FP131 Humana Insurance Company

ATTACHMENT I-A

REVISED SCOPE OF SERVICES

MEDICARE ADVANTAGE DUAL ELIGIBLE SPECIAL NEEDS PLAN (DSNP) PROGRAM

AHCA Contract No. FP131, Attachment I-A, Page 1 of 6

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, Revised 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

(2) Attachment II-A, Scope of Services - Core Contract 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, 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 Region H Region I

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 Contract Provisions.

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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

(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 Contract Provisions, and their FP XXX 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.

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

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

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

(3) HIDEs are required to follow the provisions listed in this contract, Attachment II-A, Scope of Services - Core Contract 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 42 CFR 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, below.

TABLE 2

PLAN QUALIFICATION

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

6. The Plan Benefit Package (PBP) 394 is a Dual Eligible Non-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 Revised, Scope of Services.

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.

REMAINDER OF PAGE INTENTIONALLY LEFT BLANK

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EXHIBIT I-A

MEDICAID PROVIDER IDENTIFICATION NUMBERS

MEDICAID PROVIDER IDENTIFICATION

NUMBERS

Region A 119713000 B 119713000 C 119713000 D 119713000 E 119713000 F 119713000 G H I

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.

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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. FP131, Attachment I-A, Page 6 of 6

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

HumanaChoice Florida SNP-

DE H5216-394

(PPO D-SNP)

HIDE FBDE, QDWI, QI,

QMB, QMB+,

SLMB, SLMB+

H5216 394 Alachua, Baker, Bay, Bradford, Calhoun, Charlotte, Citrus, Clay, Collier, Columbia, DeSoto, Dixie, Duval, Escambia, Flagler, Franklin, Gadsden, Gilchrist, Gulf, Hamilton, Hardee, Hendry, Hernando, Highlands, Hillsborough, Holmes, Jackson, Jefferson, Lafayette, Lake, Lee, Levy, Liberty, Madison, Manatee, Marion, Nassau, Okaloosa, Orange, Osceola, Pasco, Pinellas, Polk, Putnam, Santa Rosa, Sarasota, Seminole, St. Johns, Sumter, Suwannee, Taylor, Union, Volusia, Wakulla, Walton, Washington

ATTACHMENT II-A

REVISED SCOPE OF SERVICES - CORE PROVISIONS

AHCA Contract FP131, 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

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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.

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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.

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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

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(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.

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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.

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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.

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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.

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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.

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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.”

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(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 addition 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

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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.

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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

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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 FP131, 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 FP131, 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 FP131, 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 FP131, 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 language is not English (42 CFR 438.10(d)(4)).

3. Enrollee Toll-Free Help Line

a. The Vendor shall operate a toll-free help line equipped with caller identification, automatic call distribution equipment capable of handling the expected volume of calls, a telecommunication device for the deaf (TTY/TDD), and access to the interpreter services for non-English speaking beneficiaries. The Vendor shall operate its enrollee help line as part of an inbound call center or similar functional arrangement where agents or operators staff telephones to field incoming calls.

b. The enrollee help line agents/operators shall be trained to respond to enrollee questions in all areas.

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c. The Vendor shall develop and implement an operational manual relevant to the call center. This manual shall provide information to agents/operators on how to conduct various call center tasks and provide procedures for processing enrollee inquiries, including procedures, such as call scripts, call-handling procedures, first-call resolution, and escalation protocols.

d. If the Vendor utilizes an automated phone tree system, the Vendor’s phone tree must include the option for enrollees to bypass options in the automated phone tree system and speak with an enrollee help line representative.

e. The Vendor may use a voice mail option in an automated phone tree system for callers to leave messages between the hours of 7:00 p.m. and 8:00 a.m., in the enrollee’s time zone, Monday through Friday and at all hours on weekends and holidays. This phone tree must provide callers with clear instructions on what to do in case of an emergency.

f. If the Vendor utilizes a voice mailbox option, the Vendor shall ensure that the voice mailbox has adequate capacity to receive all messages. A Vendor representative shall respond to all messages on the next business day.

g. The Vendor shall have administrative procedures that include requirements for staffing, operations, technologies, and performance measurement. The administrative procedures shall address:

(1) Personnel management such as staff development and training, scheduling, and skill-based routing.

(2) Operational management of all call center activities such as call center shrinkage and schedule adherence, workload, and call load forecasting.

(3) Software and technologies, such as Automatic Call Distribution (ACD), telephone phone tree/Interactive Voice Response (IVR) technology and call recording systems.

(4) Call center quality control metrics and measurement for the performance of agents/operators.

h. The Vendor shall ensure that hold time messages do not include non- health related items (e.g., life insurance, disability), unless otherwise directed by the Agency. The Vendor shall submit hold time messages that promote the Vendor or include benefit information to the Agency for prior approval.

4. Cultural Competency Plan

As required by 42 CFR 438.206(c)(2), the Vendor shall participate in the State’s efforts to promote the delivery of services in a culturally competent manner to all enrollees, including those with limited English proficiency and diverse cultural and ethnic backgrounds, disabilities, and regardless of sex.

AHCA Contract FP131, Attachment II-A, Page 20 of 234

Section V. Service Administration Section V. Service Administration

Section V. Service Administration

A. Required Benefits

1. Specific Medicaid Services to be Provided In addition to the coverage and scope available through Medicare Part A, Part B, and Part D, the Vendor shall provide Medicaid covered services specified in Section 409.973, F.S., the approved federal waiver for the Medicaid program, and the following Medicaid rules and services listed on the associated fee schedules in the Florida Medicaid Policies and Rule References for Medicaid Services Table, Table 1, below:

TABLE 1

FLORIDA MEDICAID POLICIES AND RULE REFERENCES FOR MEDICAID

SERVICES

Rule No. Policy Name 59G-4.013 Allergy Services Coverage Policy 59G-4.015 Ambulance Transportation Services Coverage Policy 59G-4.020 Ambulatory Surgical Center Services Coverage Policy 59G-4.022 Anesthesia Services Coverage Policy 59G-4.025 Assistive Care Services Coverage Policy 59G-4.125 Behavior Analysis Services Coverage Policy 59G-4.028 Behavioral Health Assessment Services Coverage Policy 59G-4.031 Behavioral Health Community Support Services Coverage Policy 59G-4.370 Behavioral Health Intervention Services Coverage Policy 59G-4.029 Behavioral Health Medicaid Management Services Coverage

Policy 59G-4.027 Behavioral Health Overlay Services Coverage and Limitations

Handbook 59G-4.052 Behavioral Health Therapy Services Coverage Policy 59G-4.033 Cardiovascular Services Coverage Policy 59G-4.040 Chiropractic Services Coverage Policy 59G-4.050 Community Behavioral Health Services 59G-4.055 County Health Department Services 59G-4.060 Dental Services Coverage Policy 59G-4.105 Dialysis Services Coverage Policy 59G-4.072 Durable Medical Equipment and Medical Supply Services:

Specialized 59G-4.073 Durable Medical Equipment and Medical Supply Services:

Specialized 59G-4.074 Durable Medical Equipment and Medical Supply Services:

Respiratory 59G-4.075 Durable Medical Equipment and Medical Supply Services:

Wheelchairs, Hospital Beds, and Ambulatory Aids 59G-4.076 Durable Medical Equipment and Medical Supply Services:

Continence, Ostomy, and Wound Care 59G-4.077 Durable Medical Equipment and Medical Supply Services: Enteral and Parenteral Nutrition 59G-4.015 Emergency Transportation Services Coverage Policy 59G-4.087 Evaluation and Management Services Coverage Policy http://ahca.myflorida.com/medicaid/review/specific_policy.shtml http://ahca.myflorida.com/medicaid/review/specific_policy.shtml http://ahca.myflorida.com/medicaid/review/specific_policy.shtml http://ahca.myflorida.com/medicaid/review/specific_policy.shtml https://ahca.myflorida.com/medicaid/review/Specific/59G-4.025_Assistive_Care_Services.pdf https://ahca.myflorida.com/medicaid/review/specific_policy.shtml http://ahca.myflorida.com/medicaid/review/specific_policy.shtml http://ahca.myflorida.com/medicaid/review/specific_policy.shtml http://ahca.myflorida.com/medicaid/review/specific_policy.shtml http://ahca.myflorida.com/medicaid/review/specific_policy.shtml http://ahca.myflorida.com/medicaid/review/specific_policy.shtml http://ahca.myflorida.com/medicaid/review/specific_policy.shtml http://ahca.myflorida.com/medicaid/review/specific_policy.shtml http://ahca.myflorida.com/medicaid/review/specific_policy.shtml http://ahca.myflorida.com/medicaid/review/specific_policy.shtml http://ahca.myflorida.com/medicaid/review/specific_policy.shtml https://ahca.myflorida.com/medicaid/rules/adopted-rules-service-specific-policies http://ahca.myflorida.com/medicaid/review/specific_policy.shtml http://ahca.myflorida.com/medicaid/review/specific_policy.shtml http://ahca.myflorida.com/medicaid/review/specific_policy.shtml https://ahca.myflorida.com/content/download/23763/file/59G-4.072%20Durable%20Medical%20%20Equipment%20and%20Medical%20Supply%20Services%20Specialized.pdf https://ahca.myflorida.com/content/download/23763/file/59G-4.072%20Durable%20Medical%20%20Equipment%20and%20Medical%20Supply%20Services%20Specialized.pdf https://ahca.myflorida.com/content/download/23763/file/59G-4.072%20Durable%20Medical%20%20Equipment%20and%20Medical%20Supply%20Services%20Specialized.pdf https://ahca.myflorida.com/content/download/23763/file/59G-4.072%20Durable%20Medical%20%20Equipment%20and%20Medical%20Supply%20Services%20Specialized.pdf https://ahca.myflorida.com/content/download/23765/file/59G-4.074%20Durable%20Medical%20Equipment%20and%20Medical%20Supply%20Services%20Respiratory.pdf https://ahca.myflorida.com/content/download/23765/file/59G-4.074%20Durable%20Medical%20Equipment%20and%20Medical%20Supply%20Services%20Respiratory.pdf https://ahca.myflorida.com/content/download/23766/file/59G-4.075%20Durable%20Medical%20Equipment%20and%20Medical%20Supply%20Services%20Wheelchairs%20Hospital%20Beds%20and%20Ambulatory%20Aids.pdf https://ahca.myflorida.com/content/download/23766/file/59G-4.075%20Durable%20Medical%20Equipment%20and%20Medical%20Supply%20Services%20Wheelchairs%20Hospital%20Beds%20and%20Ambulatory%20Aids.pdf https://ahca.myflorida.com/content/download/23767/file/59G-4.076%20Durable%20Medical%20Equipment%20and%20Medical%20Supply%20Services%20Coverage%20Policy%20Continence%20Ostomy%20and%20Wound%20Care.pdf https://ahca.myflorida.com/content/download/23767/file/59G-4.076%20Durable%20Medical%20Equipment%20and%20Medical%20Supply%20Services%20Coverage%20Policy%20Continence%20Ostomy%20and%20Wound%20Care.pdf…