CN-680000-FP129-A1.pdf

FP129 Humana Medical Plan

ATTACHMENT I-A

REVISED SCOPE OF SERVICES

MEDICARE ADVANTAGE DUAL ELIGIBLE SPECIAL NEEDS PLAN (DSNP) PROGRAM

AHCA Contract No. FP129, Attachment I-A, Page 1 of 12

I. Services to be Provided

A. Overview of Contract Structure

Title 42, Chapter IV, Subchapter B, Part 422 of the Code of Federal Regulations requires the State Medicaid agency to enter into a state contract with each Medicare Advantage Dual Eligible Special Needs Plan (DSNP) authorized to operate in the state. The Contract consists of distinct parts as follows:

(1) Attachment I-A, Scope of Services, includes contract provisions that are unique to the particular DSNP.

(a) Exhibit I-A, Medicaid Provider Identification Numbers;

(b) Exhibit I-B, DSNP Rates – Not for Use Unless Approved by CMS;

(c) Exhibit I-C, D-SNP Type and Applicable Service Areas

(d) Exhibit I-D, Fully Integrated Dual Eligible Special Needs Plan (FIDE SNP) Covered Services

(2) Attachment II-A, Scope of Services - Core Provisions, includes contract provisions that apply to all managed care plans unless specifically noted otherwise.

B. Authorized Service Areas

The DSNP is authorized to provide services pursuant to this Contract in the region(s) as specified in TABLE 1., Authorized Service Areas Table, below.

TABLE 1: AUTHORIZED SERVICE AREAS

Region Service Areas Region A X Region B X Region C X Region D X Region E X Region F X Region G X Region H X Region I X

C. Medicaid Covered Services

The DSNP shall ensure the provision of covered services in accordance with the provisions of Attachment II-A, Scope of Services – Core Provisions.

AHCA Contract No. FP129, Attachment I-A, Page 2 of 12

II. Manner of Service Provision

A. Plan Qualification

1. A Fully Integrated Dual Eligible (FIDE)Special Needs Plan (SNP) means a dual-eligible special needs plan as defined in 42 Code of Federal Regulations Part 422.2.

a. The FIDE SNP shall meet all of the following:

(1) Provide aligned and coordinated Medicare and Medicaid services under a single entity that holds both an MA contract with CMS and a Medicaid managed care organization contract under section 1903(m) of the Act with the Agency

(2) Offer primary care and acute care, and for plan year 2025 and subsequent years including Medicare cost-sharing as defined in section 1905(p)(3)(B), (C), and (D) of the Act, without regard to the limitation of that definition to qualified Medicare beneficiaries;

(3) A capitated plan covering services that include:

(a) Behavioral health services;

(b) Long-term support and services or Long-term care

(LTC);

(c) Home health services; and

(d) Medical supplies, equipment and appliances.

(4) Offers delivery of covered Medicare and Medicaid services using aligned care management and specialty care network methods for high-risk beneficiaries;

(5) Employs policies and procedures approved by CMS and the State to coordinate or integrate beneficiary communication materials, enrollment, communications, grievance and appeals, and quality improvement

b. A FIDE SNP is required to follow the provisions listed in this contract, Attachment II-A, Scope of Services – Core Provisions, and their FP117 Exhibit II-B Long Term Care program contract.

2. A Highly Integrated Dual Eligible (HIDE) Special Needs Plan (SNP) means a dual eligible special needs plan as defined in 42 CFR Part 422.2.

AHCA Contract No. FP129, Attachment I-A, Page 3 of 12

a. The HIDE SNP shall meet all of the following:

(1) Operate in a manner pursuant to 42 CFR 422;

(2) Be a Medicare Advantage plan covering Medicaid benefits, including behavioral health services, under a capitated contract with the Agency; and

(3) HIDEs are required to follow the provisions listed in this contract, Attachment II, Core Provisions.

3. A Coordination Only (CO) DSNP is defined as a plan that meets the following:

a. Holds a contract with the Agency;

b. Coordinates the delivery of Medicare and Medicaid services described in 42CFR 422.107; and

c. Meets the information-sharing requirements of 42 CFR 422.107(d) and 422.107 (d)(1).

4. The Agency classifies CO DSNPs PBPs listed in Exhibit I-C as their parent company DSNP designation.

5. The DSNP is approved to provide contracted services as a qualified entity as denoted by “X” in TABLE 2., Plan Qualification Table, below.

TABLE 2

PLAN QUALIFICATION

X Fully Integrated Dual Eligible Special Needs Plan (FIDE) Highly Integrated Dual Eligible Special Needs Plan (HIDE)

6. The Plan Benefit Package (PBP) 077, 102, 209, 210, 213, 214, 226, 280, 285, 304, 314, 339, 340, 341, is a Dual Eligible Non-Zero Cost Share plan or Dual Eligible Zero Cost Share plan with a CMS approved service area eligible to enroll pursuant to the following:

a. The individual must be entitled to participate in Medicare; and

b. The individual must reside within the CMS-approved service area as found in this Contract, Attachment I-A, Scope of Services.

REMAINDER OF PAGE INTENTIONALLY LEFT BLANK

AHCA Contract No. FP129, Attachment I-A, Page 4 of 12

IV. Special Provisions

A. Order of Precedence

For all applicable regions as specified in Table 1., Authorized Regions, the DSNP shall perform its contracted duties in accordance with this Contract.

AHCA Contract No. FP129, Attachment I-A, Page 5 of 12

EXHIBIT I-A

MEDICAID PROVIDER IDENTIFICATION NUMBERS

MEDICAID PROVIDER IDENTIFICATION

NUMBERS

Region

A 102638000 B 102638000 C 102638000 D 102638000 E 102638000 F 102638000 G 102638000 H 102638000 I 102638000

The Agency will provide Medicaid Provider Identification Number to the DSNP subsequent to the Agency’s completion of a plan-specific readiness review and prior to enrolling recipients in the DSNP in each authorized region.

AHCA Contract No. FP129, Attachment I-A, Page 6 of 12

EXHIBIT I-B

DSNP RATES – NOT FOR USE UNLESS APPROVED BY CMS

DATE SPAN REGION CATEGORIES OF

MEDICAID

ELIGIBILITY

RATE

1/1/2026- 12/31/2026

Region A Region B Region C Region D Region E Region F

QMB To Be Determined

1/1/2026- 12/31/2026

Region G Region H Region I

QMB To Be Determined

1/1/2026- 12/31/2026

Region A Region B Region C Region D Region E Region F

QMB Plus, SLMB Plus, and FBDE

To Be Determined

1/1/2026- 12/31/2026

Region G Region H Region I

QMB Plus, SLMB Plus, and FBDE

To Be Determined

AHCA Contract No. FP129, Attachment I-A, Page 7 of 12

Exhibit I-C

D-SNP TYPE AND APPLICABLE SERVICE AREAS

D-SNP PLAN

NAME

D-SNP

TYPE

CATEGORIES

OF MEDICAID

ELIGIBILITY

CMS

CONTRACT

NUMBER

(H#)

PLAN

BENEFIT

PACKAGE

(PBP#)

SERVICE AREA

Humana Gold Plus SNP-DE H1036-077A

(HMO D-SNP)

HIDE FBDE, QDWI, QI,

QMB, QMB+,

SLMB, SLMB+

H1036 077 Broward, Miami- Dade, Palm Beach

Humana Gold Plus SNP-DE H1036-102

(HMO D-SNP)

HIDE FBDE, QDWI, QI,

QMB, QMB+,

SLMB, SLMB+

H1036 102 Citrus, Hardee, Hernando, Highlands, Hillsborough, Manatee, Pasco, Pinellas, Polk, Sarasota

Humana Gold Plus SNP-DE H1036-209

(HMO D-SNP)

HIDE FBDE, QDWI, QI,

QMB, QMB+,

SLMB, SLMB+

H1036 209 Flagler, Volusia

Humana Gold Plus SNP-DE H1036-210

(HMO D-SNP)

HIDE FBDE, QDWI, QI,

QMB, QMB+,

SLMB, SLMB+

H1036 210 Alachua, Baker, Bradford, Clay, Columbia, Duval, Nassau, Putnam, St. Johns

Humana Gold Plus SNP-DE H1036-213

(HMO D-SNP)

HIDE FBDE, QDWI, QI,

QMB, QMB+,

SLMB, SLMB+

H1036 213 Lake, Marion, Orange, Osceola, Seminole, Sumter

Humana Gold Plus SNP-DE H1036-214

(HMO D-SNP)

HIDE FBDE, QDWI, QI,

QMB, QMB+,

SLMB, SLMB+

H1036 214 Escambia, Santa Rosa, Walton

Humana Gold Plus SNP-DE H1036-226

(HMO D-SNP)

HIDE FBDE, QDWI, QI,

QMB, QMB+,

SLMB, SLMB+

H1036 226 Glades, Indian River, Martin, Okeechobee, St.

Lucie

Humana Fully Integrated H1036-280

(HMO D-SNP)

FIDE

AIP

FBDE, QMB+,

SLMB+

H1036 280 Broward, Citrus, Flagler, Hardee, Hernando, Highlands, Hillsborough, Lake, Manatee, Marion, Miami-Dade, AHCA Contract No. FP129, Attachment I-A, Page 8 of 12

Orange, Osceola, Palm Beach, Pasco, Pinellas, Polk, Sarasota, Seminole, Sumter, Volusia

Humana Gold Plus SNP-DE H1036-285

(HMO D-SNP)

HIDE FBDE, QDWI, QI,

QMB, QMB+,

SLMB, SLMB+

H1036 285 Charlotte, Collier, DeSoto, Lee

Humana Gold Plus SNP-DE H1036-304

(HMO D-SNP)

HIDE FBDE, QDWI, QI,

QMB, QMB+,

SLMB, SLMB+

H1036 304 Broward, Miami- Dade, Palm Beach

Humana Gold Plus SNP-DE H1036-314

(HMO D-SNP)

HIDE FBDE, QDWI, QI,

QMB, QMB+,

SLMB, SLMB+

H1036 314 Alachua, Baker, Bay, Bradford, Charlotte, Citrus, Clay, Collier, Columbia, DeSoto, Duval, Escambia, Flagler, Hardee, Hernando, Highlands, Hillsborough, Lake, Lee, Manatee, Marion, Nassau, Okaloosa, Orange, Osceola, Pasco, Pinellas, Polk, Putnam, Santa Rosa, Sarasota, Seminole, St.

Johns, Sumter, Volusia, Walton

Humana Dual Integrated

(HMO D-

SNP)

HIDE

AIP

FBDE, QMB+,

SLMB+

H1036 339 Broward, Glades, Indian River, Martin, Miami- Dade, Okeechobee, Palm Beach, St. Lucie

Humana Dual Integrated

(HMO D-

SNP)

HIDE

AIP

FBDE, QMB+,

SLMB+

H1036 340 Alachua, Baker, Bradford, Charlotte, Citrus, Clay, Collier, Columbia, DeSoto, Duval, Flagler, Hardee, Hernando, AHCA Contract No. FP129, Attachment I-A, Page 9 of 12

Highlands, Hillsborough, Lake, Lee, Manatee, Marion, Nassau, Orange, Osceola, Pasco, Pinellas, Polk, Putnam, Sarasota, Seminole, St.

Johns, Sumter, Volusia

Humana Dual Integrated

(HMO D-

SNP)

HIDE

AIP

FBDE, QMB+,

SLMB+

H1036 341 Bay, Escambia, Okaloosa, Santa Rosa, Walton

AHCA Contract No. FP129, Attachment I-A, Page 10 of 12

Exhibit I-D

FULLY INTEGRATED DUAL ELIGIBLE SPECIAL NEEDS PLAN (FIDE SNP) COVERED

SERVICES

Fully Integrated Dual Eligible Special Needs Plan Benefit Package H1036-280 will:

1. Enroll special needs individuals entitled to medical assistance under a Medicaid State plan, as defined in Section 1859(b)(6)(B)(ii) of the Act and CFR §422.2 and described in this Contract Attachment I-A, Scope of Services, Exhibit I-C, D-SNP Type and Applicable Service Area:

a. H1036-280 is a Dual Eligible Special Needs Plan open to all individuals eligible to enroll pursuant to the following:

1) The individual must be a dually eligible recipient currently enrolled in the Managed Care Plan’s Statewide Medicaid Managed Care (SMMC) Long- Term Care (LTC) Plan FP129

2) The individual must live in one of the Managed Care Plan’s currently approved SMMC LTC regions (Regions A through I);

3) The individual must be entitled to participate in Medicare; and

4) The individual must reside within the CMS-approved service area as found in this Contract, Attachment I-A, Scope of Services, Exhibit I-C, D-SNP Type and Applicable Service Areas.

2. Provide dual eligible beneficiaries access to Medicare and Medicaid benefits under a single managed care organization (MCO), including:

a. All Medicare Part C and D services;

b. The Medicaid covered services specified in this Contract, Attachment II-A, Scope of Services - Core Provisions, Section V. D1 TABLE 1, Florida Medicaid Policies and Rule References for DSNP Services; and

c. The LTC benefits specified in Agency Contract FP129.

3. Have a capitated contract with a State Medicaid agency that includes coverage of specified primary, acute and long-term care benefits and services, consistent with State policy, as demonstrated in:

a. This Contract, Attachment II-A, Scope of Services - Core Provisions, Section V.

D1 TABLE 1, Florida Medicaid Policies and Rule References for DSNP Services;

and

b. Agency Contract FP129, under which the Managed Care Plan receives the

AHCA Contract No. FP129, Attachment I-A, Page 11 of 12 capitation rate payments specified in Agency Contract FP129 Attachment II and its Exhibits, and covers all Florida Medicaid managed LTC services, including three hundred sixty-five (365) days of all-inclusive nursing facility services per year.

4. Coordinate the delivery of covered Medicare and Medicaid health and long-term care services, using aligned care management and specialty care network methods for high-risk beneficiaries, including but not limited to:

a. Providing an LTC case manager who will manage care transitions and assist members accessing the full range of medically necessary services across their Medicare and Medicaid benefits.

b. The Managed Care Plan shall provide coordination of care for its enrollees.

Coordination of care shall include, but not be limited to the following:

(1) Assist its enrollees in obtaining required services;

(2) Coordinate the delivery of benefits and services to its enrollees;

(3) Inform network providers of benefits and services which are to be provided to its enrollees;

(4) Train network providers on available benefits and services in order to ensure its enrollees receive benefits and services; and

(5) Cover all costs incurred for benefits by its enrollees as indicated in

Attachment I-A, Scope of Services, Exhibit I-C , D-SNP Type And Applicable Service Areas.

c. Managed Care Plan Enrollee Protections

(1) Cost-Sharing Protections. The Managed Care Plan and its contracted providers are prohibited from imposing cost-sharing requirements on enrollees that would exceed the amounts permitted under the Florida Medicaid State Plan for Medical Assistance, per section 1852(a)(7) of the Act and 42 CFR§422.504(g)(1)(iii).

(2) Hold Harmless Enrollee Cost-Sharing. Section 1902(n)(3)(B) of the Act prohibits a Medicare provider from billing a dual-eligible beneficiary with QMB benefits for Medicare cost-sharing amounts, including deductibles, coinsurance, and copayments. A dual eligible beneficiary with QMB benefits has no legal obligation to make further payment to a provider or to the Managed Care Plan for Medicare Part A or Part B cost sharing amounts. The Managed Care Plan’s provider agreements shall specify that a contracted Medicare provider agrees to accept the Managed Care Plan’s Medicare reimbursement as payment in full for services rendered to

AHCA Contract No. FP129, Attachment I-A, Page 12 of 12 enrollees, or to bill the appropriate Agency source if the Managed Care Plan has not assumed the Agency’s financial responsibility under an agreement between the Managed Care Plan and the Agency.

(3) Enrollee Held Harmless from Managed Care Plan and Agency Financial

Responsibility. Notwithstanding any provision in this Contract to the contrary, the Managed Care Plan shall prohibit providers, under any circumstance including but not limited to nonpayment by the Managed Care Plan, insolvency of the Managed Care Plan or breach of the Managed Care Plan’s agreement with provider, from billing, charging, collecting a deposit from, seeking compensation or remuneration from, or having any recourse against any enrollee for fees that are the responsibility of the Managed Care Plan or Agency.

5. Employ policies and procedures to coordinate or integrate member materials, including enrollment communications, grievance and appeals, and quality assurance, including but not limited to:

a. Facilitating Medicaid eligibility redeterminations, including assisting with applications for medical assistance and conducting member education regarding Medicaid eligibility, as described in this Contract;

b. The Vendor shall ensure individuals enrolled in the MA D-SNP are eligible for both Medicare and Medicaid. The Vendor shall ensure individuals enrolled in the MA D-SNP are eligible for both Medicare and Medicaid. The Vendor shall facilitate eligibility redeterminations, by providing assistance with applications for medical assistance on behalf of its members, conducting member education regarding maintaining Medicaid eligibility, or other activities designed to facilitate the process.

c. Performing integrated Medicare and Medicaid Health Risk Assessments upon enrollment and annually thereafter; and

d. Integrating member facing materials wherever possible, including integrated enrollment communications and a single member identification card for Medicare and Medicaid.

6. Cover all costs incurred for benefits by its enrollees listed in this Exhibit.

ATTACHMENT II-A

REVISED SCOPE OF SERVICES - CORE PROVISIONS

AHCA Contract FP129, Attachment II-A, Page 1 of 234

Section I. General Overview A. Purpose B. General Provisions

Section II. Eligibility and Enrollment A. General Provisions B. Eligibility C. Eligibility Verification D. Enrollment E. Disenrollment

Section III. Marketing A. General Provisions B. Prohibited Statements and Claims C. Prohibited Activities D. Marketing of Multiple Lines of Business E. Marketing Agents F. Standards for Marketing Materials G. Regional Distribution of Marketing Materials

Section IV. Enrollee Services A. General Provisions B. Enrollee Material C. Enrollee Services

Section V. Service Administration A. Required Benefits B. General Coverage Provisions

2. Hernandez Settlement Agreement Requirements

Section XV. Accountability Section XVI. Definitions and Acronyms B. Acronyms

AHCA Contract FP129, Attachment II-A, Page 2 of 234

Section I. General Overview

A. Purpose

1. Contract Period: This contract is effective January 1, 2026, through December 31, 2028.

B. General Provisions

1. The Medicare Advantage Dual Eligible Special Needs Plan (DSNP) has entered into a contract with the Centers for Medicare & Medicaid Services (CMS) to provide services to DSNP enrollees eligible for Medicare under Title XVIII of the Social Security Act (“SSA”) and entitled to medical assistance under the Florida Medicaid State Plan, in accordance with Title XIX of the SSA. Under the Medicare Improvement for Patients and Providers Act of 2008 (MIPPA) and resulting regulations, CMS requires the DSNP to enter into a Contract with the State Medicaid agency to provide or arrange for benefits to be provided, which a dually eligible individual is entitled to receive. Medicare reimbursement for the DSNP is provided in the same manner as for any other type of Medicare Advantage Plan (Medicare Part C).

2. The Bipartisan Budget Act of 2018 requires a minimum level of Medicare-Medicaid integration for all DSNPs. CMS-4185-F requires that DSNPs meet at least one of the following criteria:

a. Be a Fully Integrated DSNP (FIDE SNP);

b. Be a Highly Integrated DSNP (HIDE SNP); or

c. Be Coordination Only DSNP (CO DSNP).

3. Hereinafter, the DSNP that has entered into a Contract with the Agency for Health Care Administration to provide Medicaid covered services for its dual-eligible enrollees shall be referred to as ‘the Vendor’.

4. Under this Contract, it is the Vendor’s responsibility to: (i) Coordinate the delivery of all benefits covered by Medicare and Medicaid for enrollees who are eligible for such services, including behavioral health services; and (ii) Provide coverage of Medicaid services, including behavioral health services, for enrollees eligible for such services. FIDE SNPs providing long-term services and supports (LTSS) must also be contracted with the Agency to provide Statewide Medicaid Managed Care (SMMC) Long-Term Care (LTC) services in accordance with Chapter 409 Florida Statutes, and as described in Attachment I, Scope of Services.

5. DSNPs, including FIDE SNPs, must cover Medicaid payment of Medicare cost sharing.

AHCA Contract FP129, Attachment II-A, Page 3 of 234

6. The Vendor is responsible for coordinating the enrollee’s Medicare and Medicaid benefits, including, but not limited to discharge planning, disease management, and care management. All the benefits and coverages of services required for the Vendor to perform and included in this Contract, are covered by Medicaid, unless specified otherwise.

7. In the event of a conflict between Attachment II and the Agency’s Standard Contract, the more restrictive of the provisions shall apply.

8. The Agency and Vendor mutually acknowledge that unforeseen policy, operational, methodological, or other issues may arise throughout the course of this Contract.

Accordingly, the Agency and Vendor agree to work together in good faith to address any such circumstances and resolve them, and if necessary, will enter into amendments to this Contract on mutually agreeable terms.

AHCA Contract FP129, Attachment II-A, Page 4 of 234

Section II. Eligibility and Enrollment

A. General Provisions

B. Eligibility

The enrollees of plans subject to this Contract must be fully or partially dually eligible for Medicare and Medicaid. Such enrollees must have the following Medicaid eligibility categories: Qualified Medicare Beneficiary (QMB), Qualified Medicare Beneficiary Plus (QMB Plus), Specified Low-Income Medicare Beneficiary (SLMB), Specified Low-Income Medicare Beneficiary Plus (SLMB Plus), Qualifying Individual (QI), Qualified Disabled and Working Individual (QDWI), or Full Benefit Dual Eligible (FBDE).

C. Eligibility Verification

1. Initial Eligibility Verification. The Agency shall provide the Managed Care Plan access to information for verifying the eligibility of enrollees through the use of the Medicaid Fiscal Agent’s Provider Secured Web Portal. The Managed Care Plan shall ensure individuals enrolled in the Managed Care Plan are eligible for both Medicare and Medicaid.

2. Ongoing Eligibility Verification. The Managed Care Plan shall review its X12-834 enrollment files to ensure that all enrollees are eligible to receive services from the Managed Care Plan. The Managed Care Plan shall notify the Agency of any discrepancies in enrollment, including enrollees not residing in the same region in which they were enrolled and enrollees not eligible for the Managed Care Plan, within sixty (60) calendar days of receipt of the enrollment file. (42 CFR 438.608(a)(3), (42 CFR §422.107[c][6])

D. Enrollment

1. General Provisions

a. The Vendor shall coordinate with the Agency and its agent(s) for all enrollment functions.

b. The Vendor shall provide services to Medicaid recipients who meet eligibility requirements and are living in a service area with authorized DSNPs.

c. The Agency or its agents shall notify the Vendor of a Medicaid recipient’s selection or assignment to the Vendor by file transfer or other Agency prescribed method. Medicaid enrollment in the Vendor shall be effective at 12:01 a.m. on the effective date of enrollment provided on the Enrollment File.

2. Specific Provisions for Enrollment in FIDE DSNPs

a. Enrollment in FIDE DSNPs shall be limited to exclusively aligned enrollment

AHCA Contract FP129, Attachment II-A, Page 5 of 234

(EAE). An enrollee’s decision shall be voluntary, however, as a condition of eligibility, members may only enroll in a FIDE DSNP if they are also enrolled with the Vendor for Medicaid coverage

b. EAE limits a D-SNP’s membership to individuals whose Medicare and Medicaid benefits are provided under a single entity or affiliated entities. The Agency requires all FIDE SNPs to operate with EAE. HIDE SNPs may also operate with

EAE.

E. Disenrollment

1. General Provisions

a. The Vendor shall ensure that it does not restrict the enrollee’s right to disenroll voluntarily in any way.

b. The Agency is prohibited from assisting enrollees with plan or enrollment changes into Medicare except as specified by the Agency (42 CFR 438.56(b)(1)).

c. The Agency shall make disenrollment requests effective no later than the first day of the month immediately following receipt of the Medicare enrollment file.

d. If the Agency fails to make a disenrollment determination within the specified timeframes, the disenrollment shall be considered approved for the same effective date that would have been established had the Agency made a determination in the specified timeframe (42 CFR 438.56(e)(1) - (2); 42 CFR 438.56(d)(3)(ii); 42 CFR 438.3(q); 42 CFR 438.56(c)).

2. Medicaid Redetermination Assistance

a. The Agency shall provide the Vendor with Medicaid recipient redetermination date information.

b. The Vendor shall provide Medicaid redetermination assistance to enrollees receiving nursing facility services and home and community-based services as described in the applicable Exhibit(s).

c. For all other enrollees, the Vendor shall request prior written approval from the Agency to assist with Medicaid eligibility redetermination to enrollees in order to promote continuous Medicaid eligibility.

d. A Vendor that chooses to participate in the use of this information shall provide its procedures regarding this Sub-Section to the Agency for its approval.

3. Should any complaint or investigation by the Agency result in a finding that the Vendor has violated this Sub-Section, the Agency may sanction the Vendor in accordance with Section XII., Sanctions and Corrective Action Plans.

AHCA Contract FP129, Attachment II-A, Page 6 of 234

a. The Agency may impose a thirty (30)-day suspension of the Vendor’s use of Medicaid redetermination dates for the first such violation.

b. The Agency may impose additional sanctions for additional or subsequent violations, up to and including the Agency’s rescinding its approval to use redetermination date information.

AHCA Contract FP129, Attachment II-A, Page 7 of 234

Section III. Marketing

1. The Vendor shall ensure compliance with all State and federal Medicaid marketing requirements and Medicaid Marketing Guidelines, including monitoring and overseeing the activities of its subcontractors and all persons acting for, or on behalf of, the Vendor when marketing activities are Medicaid specific (42 CFR 438.104;

Section 409.912, F.S.; s. 641.3901, F.S.; s. 641.3903, F.S.; s. 641.386, F.S.; s.

626.112, F.S.; s. 626.342, F.S.; s. 626.451, F.S.; s. 626.471, F.S.; s. 626.511, F.S.;

s. 626.611, F.S.; s. 626.9541, F.S., and s. 626.9521, F.S.).

2. The Vendor shall neither market nor distribute any Medicaid marketing materials without first obtaining Agency approval as specified Subsection G. of this Section (42 CFR 438.104(b)(1)(i)).

3. The Vendor shall ensure that Medicaid marketing, including marketing plans and materials, is accurate and does not mislead, confuse, or defraud recipients or the Agency (42 CFR 438.104(b)(2)). The Vendor shall not distribute marketing materials that are materially inaccurate, misleading, or otherwise make material misrepresentations.

4. The Vendor shall not engage in unfair methods of competition or unfair or deceptive acts or practices as defined in s. 641.3903, F.S., and s. 626.9541, F.S.

5. In accordance with Section 409.912, F.S., marketing is prohibited to enrollees or potential enrollees in State offices or any location where eligibility is determined. The Vendor shall not use any other State office or any location where eligibility is determined in the retention of enrollees or recruitment of potential enrollees, including Department of Children and Families community partner sites.

6. The Vendor must provide an opt-out process for enrollees and potential enrollees who previously voluntarily agreed to receive email or other electronic communications to no longer receive such communications.

B. Prohibited Statements and Claims

The Vendor shall not, whether orally or in writing:

1. Claim that a Medicaid recipient must enroll in the DSNP to obtain or to not lose Medicaid benefits or any other health or welfare benefits (42 CFR 438.104(b)(2)(i)).

2. Claim that the Vendor is recommended or endorsed by CMS, the federal or State government, or similar entity (42 CFR 438.104(b)(2)(ii)). Claim that the State or the county recommends that a Medicaid recipient enroll with the Vendor.

AHCA Contract FP129, Attachment II-A, Page 8 of 234

3. Claim that marketing agents are employees of the federal, State, or county government, or of anyone other than the Vendor or the organization by whom they are reimbursed.

C. Prohibited Activities

1. The Vendor shall not enlist the assistance of any government employee, government officer, elected official, or the State’s enrollment broker in recruitment of potential enrollees or the retention of enrollees.

2. The Vendor shall not provide any gift, commission, or any form of compensation to the State’s enrollment broker, including its full-time, part-time, or temporary employees and subcontractors.

3. The Vendor shall not, directly or indirectly, engage in door-to-door, telephone, email, texting or other cold-call marketing activities or market through unsolicited contacts for its Medicaid line of business (42 CFR 438.104(b)(1)(v)).

4. The Vendor’s marketing agents shall not visit a resident of a long-term care facility (e.g., nursing homes, assisted living facilities, board and care homes), or an individual receiving services from any other facility or organization that provides residential, temporary supervision and/or health care assistance, unless requested by the individual or the individual’s guardian.

D. Marketing of Multiple Lines of Business

1. The Vendor shall not influence enrollment of a Medicaid recipient in conjunction with the sale or offering of any private insurance (42 CFR 438.104(b)(1)(iv)).

E. Marketing Agents

1. The Vendor shall only use appointed and licensed insurance agents to conduct face-to-face and telephonic marketing in the State of Florida, to market to enrollees and potential enrollees. The Vendor shall ensure all such marketing agents or representatives comply with s. 626.112, F.S.

2. The Vendor shall report new marketing agents to the Agency as specified in Section XV., Accountability, and the DSNP Report Guide, and in the manner and format determined by the Agency.

3. The Vendor shall ensure that all marketing agents (including employed agents) are trained annually on State and federal requirements and on details specific to the Vendor. Completion of AHIP certification training may be used to fulfill this requirement. The Vendor shall ensure that its training programs are made available to the Agency upon request.

AHCA Contract FP129, Attachment II-A, Page 9 of 234

4. The Vendor shall report to the Agency any marketing agent who violates any requirements of this Contract, within fifteen (15) days of knowledge of such violation.

The Vendor shall submit reports to the Agency as specified in Section XV., Accountability, and the DSNP Report Guide, and in the manner and format determined by the Agency.

5. The Vendor shall report the termination of any marketing agents to the Agency, as specified in Section XV., Accountability, and the DSNP Report Guide, and in the manner and format determined by the Agency.

6. The Vendor shall ensure that all marketing agents at marketing events display a Vendor nametag that includes the Vendor’s name, logo, and agent’s name. The Vendor shall have business cards available to attendees of events.

F. Standards for Marketing Materials

1. The Vendor shall submit Medicaid marketing material or changes in Medicaid marketing materials to the Agency for review and approval prior to use.

2. The following components constitute marketing material:

a. Enrollment information.

b. Benefit information.

c. Plan-specific information (beyond allowable plan name, logo, tagline, phone number, or website).

d. Verbiage intended to draw a potential enrollee’s attention or retain an enrollee in the DSNP.

e. Calls to action.

f. Testimonials and endorsements.

3. The following types of Medicaid marketing materials are subject to review by the Agency:

(a) Branding materials.

(b) Scripts, including marketing scripts (presentations), telephonic scripts, and broadcast scripts (television, radio, and social media).

(c) Written materials.

AHCA Contract FP129, Attachment II-A, Page 10 of 234

4. The Vendor shall submit Medicaid marketing material to the Agency by the fifth (5th) of each month before the proposed use of the marketing material or revised material, or as prescribed by the Agency.

5. The Vendor shall submit all Medicaid marketing materials in “publication ready” form, including a sample of each version if the Vendor intends to use several versions. Each material must be submitted separately to the Agency for review.

6. The Vendor shall conduct a quality check and ensure that all Medicaid materials are consistent with this Contract and State and federal requirements prior to submitting materials for review to the Agency. Generally, the Agency will not review materials for typographical or grammatical errors, unless such errors render the material inaccurate or misleading.

7. The Vendor shall ensure that all Medicaid marketing materials comply with the standards for written materials specified in Section III., Marketing, Sub-Section A., General Provisions. The Vendor shall submit readability scores with its Medicaid marketing material, denote any redacted wording, and ensure that all materials submitted for approval are written in easily understood language, per 42 CFR

438.10 d6(i). The Vendor may exclude the following from the readability score:

addresses, phone numbers, PCP, department names, required disclaimers, medical terminology, medical conditions, proper names, legal terms, and words that cannot be easily substituted.

a. The Vendor shall include the following statements and disclaimers verbatim in any marketing materials that include information on benefits:

(1) “[insert Vendor’s legal or marketing name] is a DSNP with a Florida Medicaid Contract.”

(2) “The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the DSNP.”

(3) “[Limitations, copayments, and/or restrictions] may apply.”

(4) “[Benefits, preferred drug list, pharmacy network, premium and/or co-payments/co- insurance] may change.”

b. The Vendor shall include a written statement on all marketing materials promoting drawings, prizes, or any promise of a free gift that there is no obligation to enroll in the Vendor. For example, “Eligible for a free drawing and prizes with no obligation.” or “Free drawing without obligation.”

c. The Vendor shall ensure that advertisements and invitations to marketing and enrollee educational events include the following two statements on marketing materials:

(1) “A health plan representative will be present with information.”

AHCA Contract FP129, Attachment II-A, Page 11 of 234

(2) “For accommodation of persons with special needs at marketing or enrollee educational events call <insert phone and TTY number>.”

d. The Vendor shall include a Teletypewriter Telephone (TTY) number in conjunction with the Vendor’s toll-free customer service number. This requirement does not apply to outdoor advertising, banner/banner-like ads, radio ads, or marketing and telephonic scripts.

8. The Vendor shall include the State’s Enrollment Broker number and TTY/TDD number in any marketing materials that contain Medicaid Long-term Care (LTC) enrollment or benefit information.

a. The Vendor shall ensure all written marketing materials comply with non-discrimination requirements specified in Section IX., Administration and Management, Sub-Section B., Organizational Governance and Staffing, Item 6., Non-discrimination Compliance Requirements. The Vendor shall include a statement on all marketing materials regarding their non-discrimination policies in accordance with the Nondiscrimination Final Rule, Section 1557 of the Affordable Care Act.

b. The Vendor shall make all written marketing materials available in multiple languages, as prescribed by the Agency. Upon request, the Vendor shall notify enrollees or potential enrollees that information is available in alternative formats and how to access those formats (42 CFR 438.10(d)(3)).

c. The Vendor must include the following Long-Term Care enrollment information on Long-Term Care marketing materials referencing the Medicaid Long-Term Care Plan when the materials contain enrollment information, in additional to the Enrollment Broker’s contact information:

To become an LTC member, the following steps must be completed prior to selecting a LTC Plan:

1. Screening

2. Eligibility

3. Enrollment

The following link outlines the steps to become enrolled in the LTC program:

https://ahca.myflorida.com/medicaid/statewide-medicaid-managed-care/long-term-care-program

G. Regional Distribution of Marketing Materials

If the Vendor markets, it shall distribute marketing materials to the entire Medicaid service area served by the Vendor (42 CFR 438.104(b)(1)(ii)).

https://ahca.myflorida.com/medicaid/statewide-medicaid-managed-care/long-term-care-program https://ahca.myflorida.com/medicaid/statewide-medicaid-managed-care/long-term-care-program

AHCA Contract FP129, Attachment II-A, Page 12 of 234

Section IV. Enrollee Services

The Vendor shall establish and maintain an enrollee services function with the capability to answer enrollee inquiries and ensure that enrollees are notified of their rights and responsibilities, as described in 42 CFR 438.100, and incorporated in the model enrollee handbook.

1. The Vendor shall have the capability to answer enrollee inquiries through written materials, telephone, electronic transmission, and face-to-face communication.

2. The Vendor shall provide written notice of changes affecting enrollees to those enrollees at least thirty (30) days before the effective date of change, unless otherwise specified in this Contract.

3. The Vendor shall develop and maintain processes, compliant with applicable federal and State laws (including, but not limited to, 42 CFR Part 435, and Chapters 709, 744, and 765 of the F.S.), which shall ensure that the Vendor possesses accurate and current information indicating who has legal authority to make health care decisions on behalf of an enrollee.

4. The Vendor may send notices to the enrollee’s guardian or legally authorized responsible person as applicable.

5. In accordance with Title VI of the Civil Rights Act of 1964, the Vendor shall provide language assistance services, including the provision of foreign language interpreter and translation services, and auxiliary aids and services to enrollees to achieve effective communication (42 CFR 438.10(d)(3)).

B. Enrollee Material

1. General Provisions

a. The Vendor shall submit enrollee Medicaid specific material or changes in enrollee material related to this Contract to the Agency for review and approval prior to use.

b. The Vendor shall submit enrollee material to the Agency before the proposed use of the enrollee material or revised material.

2. The Vendor shall conduct a quality check and ensure that all materials are consistent with this Contract and State and federal requirements prior to submitting materials for review to the Agency. Generally, the Agency will not review materials for typographical or grammatical errors, unless such errors render the material inaccurate or misleading.

AHCA Contract FP129, Attachment II-A, Page 13 of 234

a. Requirements for Written Material

b. The Vendor shall provide enrollee information in accordance with 42 CFR 438.10(c)(1), 42 CFR 438.10(c)(7), 42 CFR 438.10(d)(6)(ii)-(iv), 42 CFR 438.10(f)(3), and 42 CFR 438.3(i), which addresses information requirements related to written and oral information provided to enrollees.

c. The Vendor shall provide all enrollee communications, including written materials, spoken scripts, and websites in an easily understood language and format. All material should be written in 12 point font, Times New Roman or an equivalent. (42 CFR 438.10(d)(6)(i); 42 CFR 422.2267(a)(1)). Readability tests to determine whether the written materials meet this requirement are:

• Fry Readability Index

• PROSE The Readability Analyst (software developed by Education Activities, Inc.)

• Gunning FOG Index

• McLaughlin SMOG Index

• The Flesch-Kincaid Index

• Other readability tests approved by the Agency

d. The Vendor shall make all written material available in multiple languages, as prescribed by the Agency. The Vendor shall notify all enrollees and, upon request, potential enrollees that information is available in alternative formats and how to access those formats (42 CFR 438.10(d)(3)).

e. If the Vendor meets the five percent (5%) threshold for language translation, the Vendor shall place the following alternate language disclaimer on all enrollee materials, unless otherwise indicated in this Section:

“This information is available for free in other languages. Please contact our customer service number at [insert enrollee help line and TTY/TTD numbers and hours of operation].”

f. The Vendor shall include the alternate language disclaimer in both English and all non-English languages that meet the five percent (5%) threshold. The Vendor shall place the non-English disclaimer(s) below the English version and in the same font size as the English version. Information on language use may be found at https://www.census.gov/topics/population/language-use.html#tab2.

g. The Vendor shall include taglines in the prevalent non-English languages in the https://www.census.gov/topics/population/language-use.html#tab2

AHCA Contract FP129, Attachment II-A, Page 14 of 234

State, as well as large print, explaining the availability of written translation or oral interpretation to understand the information provided. Information on the top fifteen (15) non-English languages is located at https://www.cms.gov/CCIIO/Resources/Regulations-and- Guidance/Downloads/Appendix-A-Top-15.pdf.

3. Requirements for Mailing Materials to Enrollees

a. The Vendor shall provide materials to enrollees by mail or consistent with the enrollee’s preferred method of contact.

b. The Agency does not require submission of envelopes based only on the envelope size.

c. The Vendor shall ensure that its Vendor name or logo is included in every mailing to enrollees.

d. The Vendor shall include a request for address correction in mailing envelopes for enrollee materials.

e. The Vendor shall not send emails unless the enrollee has agreed to receive those emails and shall provide an opt-out process for enrollees no longer to receive email communications.

4. Enrollee Procedures and Materials

a. The Vendor shall notify, in writing, within five (5) days following the receipt of the X12-834 enrollment file from the Agency or its designee, each person who is to be newly enrolled or reinstated with the Vendor.

b. The Vendor shall furnish enrollee materials to the new enrollee:

• An enrollment notice.

• An enrollee identification (ID) card that covers the enrollee’s Medicaid and Medicare services.

• A current enrollee handbook.

• A current provider directory

5. Enrollee Handbook Requirements

a. The Vendor operating with exclusively aligned enrollment (FIDE D-SNP) shall integrate their Medicaid and Medicare enrollee materials, including their Evidence of Coverage and Summary of Benefits, into one Enrollee Handbook that meets the minimum requirements of 42 CFR 438.10 and 422.2267.

https://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/Appendix-A-Top-15.pdf https://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/Appendix-A-Top-15.pdf

AHCA Contract FP129, Attachment II-A, Page 15 of 234

b. The Vendor shall provide the enrollee handbook through one of the following methods:

(1) Mailing a printed copy of the information to the enrollee’s address.

(2) Providing the information by email, as permitted by this Contract.

(3) Advising the enrollee in paper or electronic form that the information is available on the Vendor’s website and providing the applicable internet address.

(4) Providing the information by any other method that can reasonably be expected to result in the enrollee receiving that information.

Prior to utilizing methods (2), (3), or (4) above, the Vendor shall submit a written description to the Agency Contract Manager of the process ensuring enrollees have access to a printed copy upon request.

6. Printed Provider Directory

a. The Vendor shall include in its printed provider directory the following information and materials as required by 42 CFR 438.10(h)(1)(i) - (x) and 438.10(h)(2):

(1) Provider(s) names and group affiliations, including a designated section identifying “Essential Providers”. Street address(es).

(2) Telephone number.

(3) Website URLs, if the provider has a website.

(4) Specialty credentials and other certifications, as applicable.

(5) Whether the provider will accept new enrollees.

(6) The provider’s cultural and linguistic capabilities, including languages (including American Sign Language) offered by the provider or a skilled medical interpreter at the provider’s office, and whether the provider has completed cultural competence training.

(7) Office hours (including after hours and weekend hours).

(8) Specific performance indicators.

(9) In accordance with s. 1932(b)(3) of the Social Security Act, a statement that some providers may choose not to perform certain services based on religious or moral beliefs.

(10) Whether the provider’s office/facility has accommodations for people with physical disabilities, including offices, exam room(s) and equipment (42 CFR

AHCA Contract FP129, Attachment II-A, Page 16 of 234

438.10(h)(1)(viii)).

(11) Whether the provider offers covered services via telehealth.

b. The Vendor shall arrange the provider directory by county as follows:

(1) Providers listed by name in alphabetical order, showing the provider’s specialty.

(2) Providers listed by specialty, in alphabetical order by name.

c. The Vendor shall provide a copy of the printed provider directory through one of the following methods:

(1) Mailing a printed copy to the enrollee’s address.

(2) Providing the information by email, as permitted by this Contract.

(3) Advising the enrollee in paper or electronic form that the information is available on the internet and including the applicable internet address.

(4) Providing the information by any other method that can reasonably be expected to result in the enrollee receiving that information.

d. The Vendor shall update the printable version of the provider directory at least monthly and include the date of revision (42 CFR 438.10(h)(3)).

e. When distributing printed provider directories, the Vendor shall include information stating that the most current listing of providers is available by calling the Vendor at its toll-free telephone number and at the Vendor’s website. The letter shall include the telephone number and the internet address that links directly to the online provider database.

f. The Vendor is not required to include outpatient hospital-based specialty providers in the online provider database or printed provider directory. However, the Vendor shall include these providers in the provider network file it submits to the Agency.

7. Online Enrollee Materials

a. The Vendor shall make available electronically at the Vendor’s website without requiring enrollee login, enrollee materials, the printed provider directory, and a searchable provider database.

(1) The Vendor must provide enrollee information electronically and meet the criteria as outlined in 42 CFR 438.10(c)(6)(i)-(v).

(2) The Vendor may provide a link to applications (smartphone applications, or “apps”) for enrollee use that will take enrollees directly to existing Agency-approved materials (such as the Vendor’s enrollee handbook and provider

AHCA Contract FP129, Attachment II-A, Page 17 of 234 directory) on the Vendor’s website.

(3) The online provider directory shall be made available in a machine-readable file and format in compliance with 42 CFR 438.10(h)(4).

b. The Agency lists all providers with whom the Agency has active Medicaid agreements on the Medicaid Web Portal. The Vendor will identify in its provider directory those providers that accept both Medicare and Medicaid and that are also within the Vendor’s network. The Vendor shall electronically transmit the provider network file to the Agency Contract Manager monthly, in a manner determined by the Agency. The Vendor shall include in the provider network file all network providers contracted by the Vendor to serve its enrollees.

c. The Vendor shall maintain an accurate and complete online provider database containing all the information required in the printed provider directory and as required by Section 409.967(2)(c)1, F.S. At a minimum, the online provider database must be searchable by:

(1) Name

(2) Provider type

(3) Distance from the enrollee’s address

(4) County

(5) Zip code

(6) Whether the provider is accepting new patients

(7) After hours and weekend availability

d. The Vendor shall update the online provider database at least weekly to match the most recent provider network file submitted to the Agency.

e. The Agency reserves the right to publish the information specified in Section 409.967(2)(c)1, F.S.

f. The Vendor shall provide a link to the Agency’s Medicaid PDL on the Vendor’s website without requiring enrollee login. The Vendor shall also post the list of covered drugs that are not on the Agency’s Medicaid PDL, and that are subject to prior authorization.

8. Procedures for Provider Network Changes

a. The Vendor shall have procedures to inform potential enrollees and enrollees, upon request, of any changes to service delivery and/or the provider network including either of the following:

(1) Up-to-date information about any restrictions on access to providers, including providers who are not taking new patients.

AHCA Contract FP129, Attachment II-A, Page 18 of 234

(2) Any restrictions on counseling and referral services based on moral or religious grounds within thirty (30) days after adopting the policy with respect to any service (42 CFR 438.102(b)(1)(i)(B); 42 CFR 438.10(g)(4)).

b. The Vendor shall have procedures to inform enrollees of adverse changes to its provider network.

C. Enrollee Services

1. General Provisions

a. The Vendor shall establish and maintain an enrollee services function with the capability to answer enrollee inquiries and ensure that enrollees are notified of their rights and responsibilities.

b. The Vendor shall ensure language translation quality in all enrollee materials.

2. Translation and Interpretation Services

a. The Vendor is required to provide interpretation services at all points of contact to any potential enrollee or enrollee who speaks any non-English language regardless of whether the enrollee speaks a language that meets the threshold of a prevalent non-English language. This includes written translation, oral interpretation, and the use of auxiliary aids such as TTY/TDY and American Sign Language (42 CFR 438.10(d)(4); and 42 CFR 438.406(a)).

b. The Vendor is required to notify its enrollees of the availability of interpretation services and to inform them of how to access such services. Interpretation services are required for all Vendor information provided to enrollees, including notices of adverse action. There shall be no charge to the enrollee for translation services (42 CFR 438.10(d)(5)(i)-(iii), 42 CFR 438.10(d)(4)).

c. Upon request, the Vendor shall provide, free of charge, interpreters for potential enrollees or enrollees whose primary…