CTR050520_Amendment_3_Final._Fully_Executed.pdf

Contract Amendment State of Arizona Department of Child Safety

Office of Procurement 3003 N. Central St, 20th Fl.

Phoenix, AZ 85012

Contract #: CTR050520

Amendment #: Three (3)

ALL OTHER REQUIREMENTS, SPECIFICATIONS, TERMS AND CONDITIONS REMAIN UNCHANGED

This amendment shall be fully executed upon the approval electronically in the state approved e-procurement system by an authorized representative of the Contractor and applied to the contract within the e-procurement system by the

Procurement Officer or delegate.

1 | P a g e

QUALITY MANAGEMENT AND PERFORMANCE IMPROVEMENT

Pursuant to the Uniform Terms and Conditions, Section 5.1. Amendments and the Special Terms and

Conditions, Section 9. Amendments, the following sections are amended and replaced as follows:

1. Throughout the contract delete “DCS/CMDP” and replace with “DCS CHP”.

2. Throughout the Contract delete “his or her” and replace with “their”.

3. Throughout the Contract delete “himself” or herself” and replace with “themself”.

4. Under SECTION B: CAPITATION RATES AND CONTRACTOR SPECIFIC REQUIREMENTS, The calculation for the monthly rate cap for TXIX members for CYE23 is $1,193.13 PM/PM. The calculation for this rate is listed below. This rate will be reset annually.

5. Under SECTION C, Definitions, AHCCCS COMPLETE CARE CONTRACTOR, add (ACC) to the title and replace in its entirety to read: “A contracted Managed Care Organization (also known as a health plan) that is responsible for the provision of specific physical and behavioral health services

DocuSign Envelope ID: 56059C41-2E40-464C-8F94-7EC96ABD3A27

Office of Procurement 3003 N. Central St, 20th Fl.

Phoenix, AZ 85012

This amendment shall be fully executed upon the approval electronically in the state approved e-procurement system by an authorized representative of the Contractor and applied to the contract within the e-procurement system by the

2 | P a g e to certain Title XIX/XXI populations as specified in Contract No. YH19-0001 and which does not have the expanded contractual responsibilities of an ACC-RBHA under CCE No. YH20-0002.”

6. Under SECTION C, Definitions, add “AHCCCS COMPLETE CARE-REGIONAL BEHAVIORAL

HEALTH AGREEMENT (ACC-RBHA) OR (RBHA) CONTRACTOR: “An AHCCCS Complete

Care (ACC) Contractor with expanded contractual responsibilities, as specified in CCE No. YH20-

0002, for the provision of Non-Title XIX/XXI services for Title XIX/XXI and Non-Title XIX/XXI members and comprehensive Title XIX/XXI physical health and behavioral health services to eligible individuals with a Serious Mental Cognitive health Illness designation.”

7. Under SECTION C, Definitions, AHCCCS CONTRACTOR OPERATIONS MANUAL (ACOM), delete “and is available on the AHCCCS website at www.azahcccs.gov.”

8. Under SECTION C, Definitions, AHCCCS MEDICAL POLICY, delete “and is available on the

AHCCCS website at www.azahcccs.gov.”

9. Under SECTION C, Definitions, delete BEHAVIORAL HEALTH PARAPROFESSIONAL (BHPP) in its entirety.

10. Under SECTION C, Definitions, delete “BEHAVIORAL HEALTH PROFESSIONAL (BHP)” entirety and replace with, “BEHAVIORAL HEALTH PROFESSIONAL (BHP)

1. An individual licensed under A.R.S. Title 32, Chapter 33, whose scope of practice allows the individual to: Independently engage in the practice of behavioral health as defined in

A.R.S. § 32-3251, or

i. Except for a licensed substance abuse technician, engage in the practice of behavioral health as defined in A.R.S. § 32-3251 under direct supervision as defined in A.A.C. R4-6-101:

2. A psychiatrist as defined in A.R.S. § 36-501,

3. A psychologist as defined in A.R.S. § 32-2061,

4. A physician,

5. A behavior analyst as defined in A.R.S. § 32-2091, or

6. A registered nurse practitioner licensed as an adult psychiatric and mental health nurse, or

7. A registered nurse with:

a. A psychiatric-mental health nursing certification, or

b. One year of experience providing behavioral health services.”

11. Under SECTION C, Definitions add, CHANGE IN ORGANIZATIONAL STRUCTURE

Any of the following:

1. Acquisition,

2. Change in Articles of Incorporation,

3. Change in Ownership, DocuSign Envelope ID: 56059C41-2E40-464C-8F94-7EC96ABD3A27 http://www.azahcccs.gov/ http://www.azahcccs.gov/

Office of Procurement 3003 N. Central St, 20th Fl.

Phoenix, AZ 85012

This amendment shall be fully executed upon the approval electronically in the state approved e-procurement system by an authorized representative of the Contractor and applied to the contract within the e-procurement system by the

3 | P a g e

4. Change of MSA Subcontractor (to the extent management of all or substantially all plan functions has been delegated to meet AHCCCS contractual requirements).

5. Joint Venture,

6. Merger,

7. Reorganization,

8. State Agency reorganization resulting from an act of the Governor of the State of

Arizona or the Arizona State Legislature, or

9. Other applicable changes which may cause:

a. A change in the Employer Identification Number/Tax Identification Number

(EIN/TIN),

b. Changes in critical member information, including the website, member or provider handbook and member ID card, or

c. A change in legal entity name.

12. Under SECTION C, Definitions, add “CHILD AND FAMILY TEAM (CFT) A defined group of individuals that includes, at a minimum, the child and their family, or healthcare decision maker, a behavioral health representative, and any individuals important in the child’s life who are identified and invited to participate by the child and family. This may include teachers, extended family members, friends, family support partners, healthcare providers, coaches and community resource providers, representatives from churches, temples, synagogues, mosques, or other places of worship/faith, agents from other service systems like the Department of Child Safety (DCS) or the

Division of Developmental Disabilities (DDD). The size, scope, and intensity of involvement of the team members are determined by the objectives established for the child, the needs of the family in providing for the child, and by who is needed to develop an effective service plan and can therefore expand and contract as necessary to be successful on behalf of the child.”

13. Under SECTION C, Definitions, DAY-BUSINESS/WORKING, delete, “/WORKING” and “A

“business” or “working” day means a”

14. Under SECTION C, Definitions, MATERIAL CHANGE TO BUSINESS OPERATIONS, add

“Change to Organization Name”.

1. PBM,

2. Dental Benefit Manager,

3. Transportation vendor,

4. Claims Processing system,

5. System changes and upgrades,

6. Change to Organization Name,

7. Member ID Card vendor,

8. Call center system,

9. Covered benefits delivered exclusively through the mail, such as mail order pharmaceuticals or delivery of medical equipment, Office of Procurement 3003 N. Central St, 20th Fl.

Phoenix, AZ 85012

This amendment shall be fully executed upon the approval electronically in the state approved e-procurement system by an authorized representative of the Contractor and applied to the contract within the e-procurement system by the

4 | P a g e

10. MSA, and

11. Any other Administrative Services Subcontract.

15. Under SECTION C, Definitions, add “QUALIFYING CLINICAL TRIAL” “Any clinical phase of development that is conducted in relation to the prevention, detection, or treatment of any serious or life-threatening disease or condition, and is described in any of clauses (i)-(iii) of Section

1905(gg)(2)(A) of the Social Security Act. A study or investigation must be approved, conducted, peer-reviewed, or supported (including by funding through in-kind contributions) by national organizations.”

16. Under SECTION C, Definitions, delete in its entirety, “REGIONAL BEHAVIORAL HEALTH

AUTHORITY (RBHA)”

17. Under SECTION C, Definitions, REINSURANCE, delete “AHCCCS’ risk sharing program to DCS

CHP for the reimbursement of certain Contract service costs incurred for member beyond a predetermined monetary threshold.” And replace with “Reinsurance is a stop-loss program provided by AHCCCS to the Contractor for the partial reimbursement of covered medical services for the

Contract year. Reinsurance case types include but are not limited to regular, catastrophic, and transplant. These case types may have different qualifying criteria and reimbursement.”

18. Under SECTION C, Definitions, SPECIALIST, replace “physician” with “practitioner”.

19. Under SECTION C, Definitions, SPECIALTY PHYSICIAN, replace “PHYSICIAN” with

“practitioner”.

20. Under Section D, INTRODUCTION, System Values and Guiding Principles, delete “2. Culturally competent and linguistically appropriate care” and replace with “2. Culturally and linguistically competent appropriate care”

21. Under Section D, INTRODUCTION, Initiatives, delete “AHCCCS initiatives can be found on the

AHCCCS website at www.azahcccs.gov, under the AHCCCS Info tab”.

22. Under Section D, INTRODUCTION, Initiatives, delete “1. Justice System transitions; 2. Payment modernization, 3. EHR; 4. Target Investments; 5. CRS; 6. Social Determinates of Health; 7. Services for children including children in DCS custody and those diagnosed with Autism Spectrum Disorder

(ASD_ who do not qualify for services under the DES, DDD; and; 8. SUD.” And replace with, “

1. Health equity.

2. Telehealth services.

3. Accessing behavioral health services in schools.

4. Whole person care.

5. Care coordination and integration.

6. Public/private partnerships.

Office of Procurement 3003 N. Central St, 20th Fl.

Phoenix, AZ 85012

This amendment shall be fully executed upon the approval electronically in the state approved e-procurement system by an authorized representative of the Contractor and applied to the contract within the e-procurement system by the

5 | P a g e

7. Electronic Visit Verification (EVV).

8. Emergency Triage, Treat, and Transport (ET3).

9. Payment modernization.

10. HIT.

11. The Health Current Arizona Healthcare Directives Registry (AzHDR).

12. Justice System transitions.

13. Targeted investments (TI) program”

23. Under Section D, 3. Enrollment and Disenrollment, For newborns eligible for CHP delete “via the

AHCCCS web site” rand replace with “AHCCCS Online”.

24. Under Section D, 9. SCOPE OF SERVICES, COVERED SERVICES, delete “More detail on network oversight and management can be found in Section D, Paragraph 28, Network

Management.”

25. Under Section D, 9. SCOPE OF SERVICES, Dental Services, delete “as outlined in AMPM Policy

431” and replace with “as specified in 431 on the Resource page of the AHCCCS website”.

26. Under Section D, 9. SCOPE OF SERVICES, Dental Services, delete “one year of age” and replace with “six months of age or upon enrollment.’

27. Under Section D, 9. SCOPE OF SERVICES, Family Planning Services add “Members may choose to obtain Family Planning Services and Supplies from any appropriate provider regardless of whether the Family Planning Service Providers are network providers.”

28. Under Section D, 9. SCOPE OF SERVICES, Hospice Services, delete “See the AMPM for details on covered hospice services.”

29. Under Section D, 9. SCOPE OF SERVICES, Medical Equipment add “For continuous glucose monitoring device criteria, refer to AMPM Policy 320-D.”

30. Under Section D, 9. SCOPE OF SERVICES, Prescription Medications, add “Effective October 1, 2022, the Contractor’s pharmacy department or the Contractor’s Pharmacy Benefit Manager (PBM) shall follow the AHCCCS FFS criteria for Point-of-Sale and medical claims.”

31. Under Section D, 9. SCOPE OF SERVICES, Organ and Tissue Transplants, and Related

Immunosuppressant Drugs, delete “These services are covered within limitations defined in the

AMPM for members diagnosed with specified medical conditions. Services include: pre- transplant inpatient or outpatient evaluation, donor search, organ/tissue harvesting or procurement, preparation and transplantation services, and convalescent care. In addition, if a member receives a transplant covered by a source other than AHCCCS, medically necessary non-experimental services are provided, within limitations, after the discharge from the acute care hospitalization for the transplantation. AHCCCS maintains specialty Contracts with transplantation facility providers for

Office of Procurement 3003 N. Central St, 20th Fl.

Phoenix, AZ 85012

This amendment shall be fully executed upon the approval electronically in the state approved e-procurement system by an authorized representative of the Contractor and applied to the contract within the e-procurement system by the

6 | P a g e the Contractor’s use. The Contractor may subcontract with its own transplantation provider for purposes of allowing the Contractor to choose from AHCCCS specialty contractor or Contractor provider. See Section D, Paragraph 38, Specialty Contracts and AMPM Policy 310-DD.” and replace with, “AHCCCS covers medically necessary transplant services and related immunosuppressant medications in accordance with State and Federal law and regulations. Services include pre-transplant inpatient or outpatient evaluation, donor search, organ/tissue harvesting or procurement, preparation and transplantation services, and convalescent care. AHCCCS maintains specialty Contracts with transplantation facility providers for the Contractor’s use or the Contractor may select its own transplantation provider. Refer to Section D, Paragraph 52, Reinsurance. The

Contractor shall not make payments for organ transplants not provided for in the Arizona State Plan except as otherwise required pursuant to 42 USC 1396d(r)(5) for individuals receiving services under EPSDT. The Contractor shall follow the written standards that provide for similarly situated individuals to be treated alike and for any restriction on facilities or practitioners to be consistent with the accessibility of high quality care to members per Sections (1903(i) and 1903(i)(1)) of the

Social Security Act. Refer AMPM Policy 310-DD and the AHCCCS Reinsurance Policy Manual.”

32. Under Section D, 9. SCOPE OF SERVICES, Transplant Services and Immunosuppressant

Medications, delete “Transplant Services and Immunosuppressant Medications: AHCCCS covers medically necessary transplant services and related immunosuppressant medications in accordance with Federal and State law and regulations. The Contractor shall not make payments for organ transplants not provided for in the State Plan except as otherwise required pursuant to 42 USC

1396d(r)(5) for individuals receiving services under EPSDT. The Contractor must follow the written standards that provide for similarly situated individuals to be treated alike and for any restriction on facilities or practitioners to be consistent with the accessibility of high quality care to members per

Sections (1903(i) and 1903(i)(1)) of the Social Security Act. Refer AMPM Policy 310-DD.”

33. Under Section D, 9. SCOPE OF SERVICES, Vision Services/Ophthalmology/Optometry:

add “repair, or replacement of broken or lost eyeglasses without restriction.”

34. Under Section D, 9. SCOPE OF SERVICES, Well Exams: add “and physical”

35. Under Section D, 11. BEHAVIORAL HEALTH SERVICE DELIVERY, delete “6. Coordinate and provide access to peer and family delivered support services” Replace with “6. Coordination and provision of peer and family delivered support services, whether delivered within or outside of the member’s identified health home.”

36. Under Section D, 11. BEHAVIORAL HEALTH SERVICE DELIVERY, 6. Centers of Excellence’ delete “Parity Analysis Deficiency Report”, and replace with “Mental Health Parity Deficiencies

Report.”

37. Under Section D, 14. PEDIATRIC IMMUNIZATIONS AND THE VACCINES FOR CHILDREN

PROGRAM , delete “register” and replace with “enroll”. Delete “free”. Add “Providers shall enroll and re-enroll annually with the VFC program.”

Office of Procurement 3003 N. Central St, 20th Fl.

Phoenix, AZ 85012

This amendment shall be fully executed upon the approval electronically in the state approved e-procurement system by an authorized representative of the Contractor and applied to the contract within the e-procurement system by the

7 | P a g e

Delete “Due to low numbers of children in their panels, providers in certain geographical regions may choose not to provide vaccinations.” Add “within the respective GSA.” Add “Refer to AMPM

Policy 430.”

38. Under Section D, 17. MEMBER INFORMATION, 4. How members may access the services above

[42 CFR 457.1207, 42 CFR 438.10(d)(5)] delete “All written materials must also include large print taglines and information (in font size of at least 18 point) explaining how to request auxiliary aids and services, including the provision of materials in alternative formats”. Delete “Auxiliary aids and services must also be made available upon request and at no cost.” Add “in a conspicuously visible font size, explaining how to request auxiliary aids and services,” Delete “and include large print

(font size of at least 18 point)”.

39. Under Section D, 17 MEMBER INFORMATION, WEBSITE REQUIREMENTS, add, “Practice

Name or Agency Name,”. Add “The type of provider shall be based on formal licensure (e.g., Medical Doctor [MD], Psychologist), and may list additional specialty information for the practitioner (e.g., psychiatrist, developmental pediatrician, neuropsychologist, etc.). The Contractor shall ensure that any licensure type listed is based on Arizona Administrative Code (A.A.C. R4-6, A.A.C. R4-16, A.A.C. R4-26).” Add “The Contractor shall also publish a listing of providers who specialize in the treatment of individuals with ASD on its website. The web pathway for the members accessing this list shall be easily available and navigable within the Contractor’s website, using a simple key word search for autism or other similar term. This webpage shall include information for members and their families on how to access specialized treatment services. At a minimum the listing shall include the following fields: Group Practice Name (or Agency Name), Address, Phone Number, Provider Name, Treatment Type (based on types of services that can be offered within AMPM 310-B) and Specialized Age Range. The Contractor shall submit this information with the website certification as specified in Section F, Attachment F3, Contractor Chart of Deliverables.

The Contractor shall have a process in place to identify and verify that any and all agencies or providers listed on their website can deliver the services, as listed to meet the needs of individuals who may need access these specialized services.”

40. Under Section D, 17 MEMBER INFORMATION, as specified in Section F, Attachment F3, Contractor Chart of Deliverables, 21 days prior to release (includes the 6-day review by DCS CHP and the 15-day review required by AHCCCS)

The Contractor will collaborate annually with DCS on the criteria used for co-branding member information material.

41. Under Section D, 22. QUALITY MANAGEMENT AND PERFORMANCE IMPROVEMENT, Office of Procurement 3003 N. Central St, 20th Fl.

Phoenix, AZ 85012

This amendment shall be fully executed upon the approval electronically in the state approved e-procurement system by an authorized representative of the Contractor and applied to the contract within the e-procurement system by the

8 | P a g e

Delete, The CVO is also responsible for conducting annual entity site visits to ensure compliance with AHCCCS requirements.

ACCREDITATION, delete “2. Recommended actions or improvements, CAPs, and summaries of findings, and;” replace with “2. Accreditation results including summaries of findings, recommended/required actions or improvements, and Corrective Action Plans (CAPs).

Delete, “This information”. Add “The Contractor’s accreditation status (inclusive of the name of the accrediting entity, accreditation program, and accreditation level, when applicable)”

Delete, DCS/CHP and the contractor share responsibility and accountability for the performance measures. The Contractor deliverable table below indicates DCS/CHP/Contractor clinical performance measures. The data exchange requirements shall include the necessary information

DCS/CHP needs to complete all clinical performance measures (name of document, key definitions).

Operational performance measures shall be developed and delivered to DCS/CHP per a pre-determined schedule. DCS/CHP has established standards for the measures listed below. The following tables identify the MPS for each current and future measure:, replace with, DCS CHP and the contractor share responsibility and accountability for the performance measures. The data exchange requirements shall include the necessary information DCS/CHP needs to complete all

AHCCCS and DCS CHP/contractor clinical performance measures (name of document, key definitions). Operational performance measures shall be developed and delivered to DCS/CHP per a pre-determined schedule. DCS/CHP has established standards for the measures provided in the goals document. DCS CHP expects that Mercy Care will produce the AHCCCS required measures

(2022/2023 Core Set of Children’s Health Care Quality Measure for Medicaid and CHIP (Child

Core Set), including the DCS CHP required specific measures which include:

• Annual Dental Visit (ADV)

• Inpatient Utilization (IPU)

• Mental Health Utilization (MPT)

• Initial Visit within 30 days for Members Newly Identified with a CRS Condition (AHCCCS) –

Tabled

DCS CHP will clarify additional measures and will provide a performance measure goal document to Mercy Care which will serve as the minimum performance standards for the measures, please see attachment titled, “DCS CHP Performance Measure Goal document”.

Delete, the existing Clinical Performance Measure table and replace with, Clinical Performance Measures

Measure

Minimum Performance

Standard

(MPS)

DCS CHP

Measure

Contractor

Office of Procurement 3003 N. Central St, 20th Fl.

Phoenix, AZ 85012

This amendment shall be fully executed upon the approval electronically in the state approved e-procurement system by an authorized representative of the Contractor and applied to the contract within the e-procurement system by the

9 | P a g e

AAB Avoidance of Antibiotic

Treatment for Acute

Bronchitis/Bronchiolitis

* X X

ADD Follow-Up Care for

Children Prescribed ADHD

Medication: Initiation

Follow-Up Care for

Children Prescribed ADHD

Medication: Continuation

& Maintenance

* X X

ADV Annual Dental Visit * X X

AMB Ambulatory Care: Emergency

Department (ED) Visits

* X X

AMR Asthma Medication Ratio * X X

APM Metabolic Monitoring for

Children & Adolescents on

Antipsychotics: Cholesterol

Testing

Metabolic Monitoring for

Children & Adolescents on

Antipsychotics: Blood Glucose

Testing

Metabolic Monitoring for

Children & Adolescents on

Antipsychotics: Blood Glucose

& Cholesterol Testing (Total)

* X X

CCP Contraceptive Care –

Postpartum Women Ages 15 to

20: Most/Moderately Effective

(60 Days)

Contraceptive Care –

* X X

Office of Procurement 3003 N. Central St, 20th Fl.

Phoenix, AZ 85012

This amendment shall be fully executed upon the approval electronically in the state approved e-procurement system by an authorized representative of the Contractor and applied to the contract within the e-procurement system by the

10 | P a g e

Postpartum Women Ages 15 to

20: Most/Moderately Effective

(3 Days)

Contraceptive Care –

Postpartum Women Ages 15 to

20: LARC (60 Days)

Contraceptive Care –

Postpartum Women Ages 15 to 20: LARC (3 Days)

CCW Contraceptive Care – All

Women Ages 15 to 20:

Most/Moderate Effective

Contraceptive Care – All

Women Ages 15 to 20: LARC

* X X

CDF Screening for Depression and

Follow-Up Plan: Ages 12 to

* X X

CHL Chlamydia Screening in

Women

* X X

CIS Childhood Immunization

Status:

VZV (Chickenpox)

Rotavirus

Pneumococcal

Conjugate (PCV)

MMR

IPV

Influenza

HiB

Hepatitis B

Hepatitis A

DTaP

Combo 9

Combo 8

Combo 7

Combo 6

Combo 5

Combo 4

Office of Procurement 3003 N. Central St, 20th Fl.

Phoenix, AZ 85012

This amendment shall be fully executed upon the approval electronically in the state approved e-procurement system by an authorized representative of the Contractor and applied to the contract within the e-procurement system by the

11 | P a g e

Combo 3

Combo 2

Combo 10

CRS Initial Visit within 30 days for

Members Newly Identified with a CRS Condition

* X X

DEV Developmental Screening in the First Three Years of Life

* X X

FUA Follow-Up After Emergency

Department Visit for Alcohol and

Other Drug Abuse or Dependence:

7 Day

30 Day

* X X

FUH Follow-Up After Hospitalization for Mental Illness:

7 Day

30 Day

* X X

FUM Follow-Up After Emergency

Department Visit for Mental

Illness:

7 Day

30 Day

* X X

IET Initiation and Engagement of

Alcohol and Other Drug Abuse or

Dependence Treatment

* X X

IMA Immunizations for Adolescents:

Tdap

Meningococcal

HPV

Combination 2

Combination 1

* X X

LSC Lead Screening in Children * X X

MPT Mental Health Utilization:

Telehealth (Total)

Outpatient (Total)

Intensive Outpatient or

Office of Procurement 3003 N. Central St, 20th Fl.

Phoenix, AZ 85012

This amendment shall be fully executed upon the approval electronically in the state approved e-procurement system by an authorized representative of the Contractor and applied to the contract within the e-procurement system by the

12 | P a g e

Partial Hospitalization

(Total)

Inpatient (Total)

ED (Total)

Service (Total)

OEV Oral Evaluation, Dental Services * X X

PPC Prenatal and Postpartum Care:

Timeliness of Prenatal

Care

Postpartum Care

* X X

SFM Sealant Receipt on Permanent First

Molars

Rate 1: At Least One Sealant Rate

2: All Four Molars Sealed

TFL Topical Fluoride for Children:

Oral Health Service

Dental Service

Dental or Oral Health

Service

* X X

W30 Well-Child Visits in the First 30

Months of Life

Submeasure: 16-30

Months

Submeasures: 0-15

Months

* X X

WCC Weight Assessment & Counseling for Nutrition & Physical Activity for Children/Adolescents:

Physical Activity

Nutrition

BMI

* X X

WCV Child & Adolescent Well Care

Visits: 3-21 yrs

Office of Procurement 3003 N. Central St, 20th Fl.

Phoenix, AZ 85012

This amendment shall be fully executed upon the approval electronically in the state approved e-procurement system by an authorized representative of the Contractor and applied to the contract within the e-procurement system by the

13 | P a g e

Depression Screening and Follow-

Up for Adolescents and Adults

* X X

APC Use of Multiple concurrent

Antipsychotics in children and

Adolescents

* X X

CMS-416 EPSDT Participation * X X

IPU Inpatient Utilization * X X

Enhanced EPSDT Screenings –

Monthly for the first 3 months after removal for all ages, then by age:

Monthly for infant’s birth to 6 months (including at 3 and 5 mo.)

Every three months for children between 6–24 months

(including at 21 mo.)

Minimum bi-annually for children/youth 24 months to 18 years of age, though recommend 3-4 times a year and visit post placement change

* X X

Enhanced BH Services – post

Rapid Response:

Intake Appointment within 7 days of the referral from the

Rapid Response

Team/Provider

Ensure the first [direct] service begins no later than 21 days of the completed intake appointment

Ensure comprehensive assessment1 is completed with the child and family no later

* X X

Office of Procurement 3003 N. Central St, 20th Fl.

Phoenix, AZ 85012

This amendment shall be fully executed upon the approval electronically in the state approved e-procurement system by an authorized representative of the Contractor and applied to the contract within the e-procurement system by the

14 | P a g e than 45 days from the date of the intake

Monthly documented ongoing services for at least 6 months

(unless services refused or no longer in DCS custody)

Individual Service Plan must be completed no less than 90 calendar days from the intake appointment.

EPSDT within the first 30 days of entry into the health plan

* X

X

Dental Care within the first 30 days of entry into the health plan

* X

*Please see, “DCS CHP Performance Measure Goal document”.

Collaborative Management Approach between CHP & Contractor to align operational initiatives and reporting of outcomes. Contractor shall implement system improvements through analysis of data on provider performance.

Credentialing Standard Performance Measures; Initial, delete 75 days, and replace with 60.

Organizational, delete 90 and replace with 60. Load time delete 90% and replace with 95% .

Credentialing Standard Performance Measures

Provisional – including Medical Director sign off 100% within 14 days

X

Initial 100% within 60 days

Operational Performance Measures

Minimum Performance Standard

(MPS)

Future

DCS CHP

Measure

Future Contractor Measure

Re-credentialing 100% within 3 years

X

Organizational 100% within 60 days

Office of Procurement 3003 N. Central St, 20th Fl.

Phoenix, AZ 85012

This amendment shall be fully executed upon the approval electronically in the state approved e-procurement system by an authorized representative of the Contractor and applied to the contract within the e-procurement system by the

15 | P a g e

Load time – across all types of credentialing with breakdown below:

• Physical

• Behavioral

95% within

30 days from date of

Credentialing

Committee approval

Delete, Reserve Status Performance Measures: The following are measures that DCS CHP will be monitoring and may use for reporting purposes (such as to AHCCCS or CMS), but they are not considered as part of the measures subject to financial incentives. These measures may be considered for measurement and financial incentives at a future date.

ACUTE PERFORMANCE MEASURES RESERVE STATUS *

Access to Behavioral Health Services, 7

Days – Measure Tabled Until Further

Notice

75%

Access to Behavioral Health Services, 23

Days – Measure Tabled Until Further

Notice

90%

Asthma in Younger Adults Admission Rate

(PQI15)

9 Per 100,000 Member Months

Diabetes Short-Term Complications

Admissions Rate (PQI 01)

16 Per 100,000 Member Months

EPSDT Participation 68%

Heart Failure Admission Rate (PQI 08) 23 Per 100,000 Member Months

ACUTE PERFORMANCE MEASURES RESERVE STATUS *

Measure MPS

Weight Assessment and Counseling - Body

Mass Index (BMI) Assessment for

Children/ Adolescents (WCC)

55%

Office of Procurement 3003 N. Central St, 20th Fl.

Phoenix, AZ 85012

This amendment shall be fully executed upon the approval electronically in the state approved e-procurement system by an authorized representative of the Contractor and applied to the contract within the e-procurement system by the

16 | P a g e

Note: *Performance measures remain important to DCS/CHP and as such will continue to be monitored by DCS/CHP. The identified targets depict the current performance measures.

These measures might be more than currently required by AHCCCS, however DCS/CHP intends to maintain this level of performance.

42. Under Section D, 23. MEDICAL MANAGEMENT, delete “g. Clinical Practice Guidelines”. And replace with “g. Clinical Practice Guidelines developed in consultation with network providers [42

CFR Part 438.236(b)(3)].”

43. Under Section D, 26. NETWORK DEVELOPMENT, Telehealth and Telemedicine: delete “The

Contractor shall promote the use of telemedicine to support an adequate provider network.”

44. Under Section D, 29. PRIMARY CARE PROVIDER STANDARDS, delete, “The Contractor shall ensure that providers serving EPSDT-aged members utilize AHCCCS- approved EPSDT

Tracking forms” and replace with “The Contractor shall ensure that providers serving EPSDT-aged members utilize the AHCCCS-approved EPSDT Tracking forms Clinical Sample Template”.

Delete “5. Utilizing the AHCCCS-approved EPSDT Tracking form” and replace with, “5. Utilizing the AHCCCS approved EPSDT Clinical Sample Templates”.

45. Under Section D, 30. MATERNITY CARE PROVIDER REQUIREMENTS delete, “the”. Add

“Chapter 400.”

46. Under Section D, 30. MATERNITY CARE PROVIDER REQUIREMENTS delete “Licensed midwives perform deliveries only in the member’s home. Labor and delivery services may be provided in the member’s home by physicians, nurse practitioners, and certified nurse midwives who include such services within their practice”, and replace with “Per AMPM Policy 410 labor and delivery services rendered through Free Standing Birthing Centers shall be provided by a physician or by a certified nurse midwife who has hospital admitting privileges for labor and delivery services, or a licensed midwife who is following licensing and practice requirements as specified in A.A.C.

R9-16-111 through 113 Labor and delivery services may be provided in the member’s home by physicians, nurse practitioners, certified nurse midwives, and licensed midwives who include such services within their practice. Labor and delivery services may be provided in the member’s home by physicians, nurse practitioners, certified nurse midwives, and licensed midwives who include such services within their practice.”

47. Under Section D, 31. REFERRAL MANAGEMENT, delete “Refer to AMPM Policy 580;”

48. Under Section D, 32. APPOINTMENT STANDARDS, delete “this”. Add “Appointment

Availability Review”.

Office of Procurement 3003 N. Central St, 20th Fl.

Phoenix, AZ 85012

This amendment shall be fully executed upon the approval electronically in the state approved e-procurement system by an authorized representative of the Contractor and applied to the contract within the e-procurement system by the

17 | P a g e

49. Under Section D, 33. FEDERALLY QUALIFIED HEALTH CENTERS AND RURAL HEALTH

CLINICS add “Refer to AHCCCS Federally Qualified Healthcare Centers and Rural Health Clinics for a listing of the” delete “are listed on the AHCCCS website”

50. Under Section D, 35. PROVIDER REGISTRATION/TERMINATION delete “on Provider

Registration”. Add “Provider Enrollment.” Delete “website”.

51. Under Section D, 37. CLAIMS PAYMENT/HEALTH INFORMATION SYSTEM, Behavioral

Health Services for School-Aged Children: delete “The Contractor shall pay claims against DCS/CHP designated funding to provide BH services to school-aged children in school settings, as Place of

Service (POS) 03. The Contractor shall track claims against the designated funding and report on expenditures as required in Exhibit 4, Contractor Chart of Deliverables. The Contractor, at the direction of DCS/CHP, shall collaborate with schools and contracted providers to determine the extent of the services to be provided in individual schools. The Contractor shall submit an implementation plan and a quarterly deliverable as specified in Exhibit 4, Contractor Chart of Deliverables to report on a number of items regarding the services provided in this setting.” and replace with “The Contractor shall pay claims against DCS/CHP designated funding to provide BH services to school-aged children in school settings, and the use of appropriate billing and coding for these services, including place of service codes and the use of County, Town, District, Site (CTDS) numbers by the billing provider.

The Contractor shall track claims against the designated funding and report on expenditures as required in Exhibit 4, Contractor Chart of Deliverables. The Contractor, at the direction of DCS/CHP, Contractor shall work with schools and contracted providers to remove barriers to referral pathways and improve access to care in school settings. Contractors shall provide updates on efforts to provide resources and technical assistance for school-based services during quarterly school based services collaborative meetings with AHCCCS. Contractors shall also provide information to enrolled members on Behavioral Health Services in schools which shall include a list of resources available to their members on school campuses, and any provider programing offered during school breaks. The

Contractor shall submit an implementation plan and a quarterly deliverable as specified in Exhibit 4, Contractor Chart of Deliverables to report on a number of items regarding the services provided in this setting.”

52. Under Section D, 52. CAPITATION ADJUSTMENTS, add “Refer to the AHCCCS Medical

Assistance Eligibility Policy Manual Chapter 500, 525 Not an Inmate and section MA1502J of the

EPM; AHCCCS Medical Assistance Eligibility Policy Manual Chapter 1500, 1502 Types of

Changes, V. Incarcerated”

53. Under Section D, 55. Reinsurance, Replace.

Office of Procurement 3003 N. Central St, 20th Fl.

Phoenix, AZ 85012

This amendment shall be fully executed upon the approval electronically in the state approved e-procurement system by an authorized representative of the Contractor and applied to the contract within the e-procurement system by the

18 | P a g e

REINSURANCE CASE TYPE DEDUCTIBLE CO-INSURANCE

REGULAR REINSURANCE

$35,000 75%

CATASTROPHIC REINSURANCE N/A 85%

TRANSPLANT AND OTHER

CASE TYPES Refer to specific paragraphs below Refer to specific paragraphs below

Replace with:

REINSURANCE CASE TYPE DEDUCTIBLE CO-INSURANCE

REGULAR REINSURANCE

$75,000 75%

CATASTROPHIC REINSURANCE N/A 85%

TRANSPLANT AND OTHER

CASE TYPES Refer to specific paragraphs below Refer to specific paragraphs below

54. Under Section D, 55. Reinsurance, Regular Reinsurance, delete “$35,000” and replace with

“$75,000”.

55. Under Section D, 55. Reinsurance, Catastrophic Reinsurance, add “All biologic/High Cost specialty drugs must be encountered on a Form C pharmacy claim to be eligible for reinsurance. Members transitioning to different biologics and/or High Cost specialty drugs or receiving multiple biologics and/or High Cost specialty drugs must request authorization from AHCCCS/DHCM, MM for each separate drug in order to receive Reinsurance.”

56. Under Section D, 55. Reinsurance, Transplant Reinsurance, add “Transplant reinsurance will be paid for a maximum 30-day retroactive period from the date of notification to AHCCCS.”

57. Under Section D, 55. Payment of Transplant Reinsurance Cases, delete “Payment of Transplant

Reinsurance Cases “ replace with “Transplant Reinsurance Cases Payment”. Add “under rates and billing”.

58. Under Section D, 55. Reinsurance, Other Catastrophic Reinsurance, add “and Reinsurance Analyst,””

59. Under Section D, 55. Reinsurance Audits, delete “ DCS/CHP or AHCCCS may, at a later date, perform medical audits on reinsurance cases. Terms of the audit process will be disclosed prior to implementation to the audits providing the Contractor appropriate advance notice.”

Office of Procurement 3003 N. Central St, 20th Fl.

Phoenix, AZ 85012

This amendment shall be fully executed upon the approval electronically in the state approved e-procurement system by an authorized representative of the Contractor and applied to the contract within the e-procurement system by the

19 | P a g e

60. Under Section D, 60. CORPORATE COMPLIANCE, add “Administrator”.

61. Under Section D, 60. CORPORATE COMPLIANCE, Termination of Provider from Contractor

Network of Providers, add “ (as defined in 42 CFR 455.101)”

62. Under Section D, 62. SYSTEMS DATA EXCHANGE REQUIREMENTS delete “Contractor's

Chief Executive Officer”. Add “Administrator/CEO”.

63. Under Section D, 62. SYSTEMS DATA EXCHANGE REQUIREMENTS, Health Information

Exchange Add “2. Ensuring providers utilize ADT alerts to facilitate timely follow up with members after admission or discharge from hospitals and emergency rooms.”

64. Under Section D, 75. Add ” THE AMERICAN RESCUE PLAN ACT

Section 9187 of the American Rescue Plan Act (ARPA) of 2021 (Pub. L. 117-2) provides qualifying states with a temporary 10 percentage point increase to the federal medical assistance percentage

(FMAP) for certain Medicaid expenditures for Home and Community Based Services (HCBS).

AHCCCS submitted and received Centers for Medicare & Medicaid (CMS) approval of an HCBS

Spending Plan, which allows the Agency to leverage this enhanced FMAP to improve and expand the State’s HCBS and behavioral health programs. CMS extended the deadline for states to use the state funds received through enhanced 10 percent FMAP on qualifying home and community-based and behavioral health services to March 31, 2025. The HCBS Spending Plan targets delivery of member-centric strategies to support strengthening and enhancing care and advancing technology to promote greater independence and community connection for their HCBS-based populations.

AHCCCS is in the process of implementing its Spending Plan, which targets four key populations:

seniors; individuals with disabilities; individuals SMI; and children with behavioral health needs.

To be eligible for additional federal funding under ARPA Section 9817, participating states must submit a quarterly HCBS spending plan to provide information on the amount of funds attributable to the increase in FMAP that the state is claiming. States must also report on the cost of the activities they are implementing to enhance, expand, or strengthen HCBS. In addition, every other quarter, states must provide an updated spending plan narrative describing the state’s activities to enhance, expand, or strengthen HCBS.

While the Contractor will not participate directly in the development or implementation of HCBS

Spending Plans, AHCCCS recognizes that several HCBS Spending Plan initiatives may impact the

CHP population. AHCCCS will communicate any impact of the HCBS Spending Plan on CHP providers as appropriate.

Refer to Section D, Paragraph 49, Compensation for ARPA-related Directed Payments.”

65. Under EXHIBIT 1: MEMBER GRIEVANCE AND APPEAL SYSTEM STANDARDS, delete

“eighteen [18] point”. Add “conspicuously visible font size”.

Office of Procurement 3003 N. Central St, 20th Fl.

Phoenix, AZ 85012

This amendment shall be fully executed upon the approval electronically in the state approved e-procurement system by an authorized representative of the Contractor and applied to the contract within the e-procurement system by the

20 | P a g e

66. Under Attachment F3, Contractor Chart of Deliverables, add, 21 days prior to release (includes the

6-day review by DCS CHP and the 15-day review required by AHCCCS) and The Contractor will collaborate annually with DCS on the criteria used for co-branding member information material.

The effective date of this amendment is October 1, 2022. All other terms and conditions remain the same.

Mercy Care (Company Name)

(Typed Name and Title)

(Signature)

(Date)

Arizona Department of Child Safety

Jesse Atoigue, Deputy Chief Procurement Officer (Typed Name and Title)

(Signature)

(Date)

6/16/2023 | 9:23 AM MST

Lorry Bottrill (Jun 19, 2023 06:40 PDT) Lorry Bottrill

Lorry Bottrill

06/19/23 https://aetna.na1.adobesign.com/verifier?tx=CBJCHBCAABAA-6svFUdb-VOI34Iq_rvgczk3lYEJlWbw