CTR050520_Amendment_5_Final_10.20.23_encrypted_Fully_Executed.pdf

Integrated Healthcare Delivery Services State of Arizona

Department of Child Safety Office of Procurement

3003 N. Central St, 20th Fl.

Phoenix, AZ 85012

Contract #: CTR050520

Amendment #: FIVE (5)

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.

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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 change all references to “CHP” or “DCS/CHP” to “DCS CHP”.

2. Throughout the Contract change “state and federal”, “federal”, “ state” and replace with “Federal and

State”, “Federal”, “State”.

3. Throughout the Contract delete “mother or father” and replace with “parent”.

4. Throughout the Contract change miscellaneous lowercase words to capital and capital to lowercase.

5. Throughout the Contract add, “(AI/AN)”, “COC)”, “(E/PD)”, “(HMO)”, “(PA)”,” (PT)”,”(OT)”, “(CY)”

6. Throughout the Contract change, “Division of Developmental Disabilities (DDD)” to, “Department of

Economic Security/Division of Developmental Disabilities (DES/DDD).”

7. Throughout the Contract change, “Centers for Medicare and Medicaid Services (CMS)”

8. Throughout the Contract change, “Children’s Rehabilitation Services (CRS)”

9. Throughout the Contract change, “Section 1115 Waiver Demonstration” to, “1115 Waiver”

10. Throughout the Contract change, “Hospital Presumptive Eligibility” to “HPE”.

11. Throughout the Contract add/delete, “or”, “and”, “the"

12. Throughout the Contract change, “registered nurse” to “RN”

13. Throughout the Contract change, “Contract term” to “Term of Contract”

14. Throughout the Contract change, “DHCM” to, “DHCS”

15. Throughout the Contract change, “ARPA” to “ARP”

16. Throughout the Contract change, AHCCCS DMS to AHCCCS/Division of Member and Provider

Services (DMPS).

17. Throughout the Contract change, RBHA to ACC-RBHA

DocuSign Envelope ID: 28EFAD07-30C5-478D-A52D-9D49A5D527CE

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 Procurement

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18. Under SECTION B: CAPITATION RATES AND CONTRACTOR SPECIFIC REQUIREMENTS, the calculation for the monthly rate cap for TXIX members for CYE24 is $1,185.25 PM/PM. The calculation for this rate is listed below. This rate will be reset annually.

19. Under SECTION C, Definitions, ADMINISTRATIVE SERVICES SUBCONTRACT/

SUBCONTRACTOR, delete in its entirety and replace with, “An agreement that delegates any of the requirements of the Contract with AHCCCS, including, but not limited to the following:

a. Claims processing, including pharmacy claims,

b. Pharmacy Benefit Manager (PBM),

c. Dental Benefit Manager,

d. Credentialing, including those for only primary source verification (i.e., Credential Verification

Organization [CVO]),

e. Medicaid Accountable Care Organization (ACO),

f. Service Level Agreements with any Division or Subsidiary of a corporate parent owner, and

g. CHP and DES/DDD Subcontracted Health Plan.

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 Procurement

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A person (individual or entity) who holds an Administrative Services Subcontract is an Administrative

Services Subcontractor. Providers are not Administrative Services Subcontractors.”

20. Under SECTION C, Definitions, ADULT, change, “A person” to, “An individual”

21. Under SECTION C, Definitions, AHCCCS COMPLETE CARE (ACC) CONTRACTOR, insert

“Competitive Contract Extension (CCE)”

22. Under SECTION C, Definitions, AHCCCS COMPLETE CARE (ACC) CONTRACTOR, insert “An” and Change, “Serious Cognitive health Illness” to “Serious Mental Illness (SMI)”.

23. Under SECTION C, Definitions, AHCCCS CONTRACTOR OPERATIONS MANUAL (ACOM), delete in its entirety and replace with, “Administrative, Claims, Financial, and Operational Policies of the

AHCCCS Administration. The ACOM provides information to Contractors and subcontractors who have delegated responsibilities under the contract.”

24. Under SECTION C, Definitions, ARIZONA DEPARTMENT OF CHILD SAFETY (DCS), delete in its entirety and replace with, “ARIZONA DEPARTMENT OF CHILD SAFETY (DCS) /Comprehensive

Health Plan (DCS/CHP) The Contractor that is responsible for the provision of covered, medically necessary AHCCCS services for foster children in Arizona. Prior to April 1 2021, CHP was the

Comprehensive Medical and Dental Program (CMDP) (A.R.S. § 8-512).”

25. Under SECTION C, Definitions, ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM, delete in its entirety and replace with, “ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM

(AHCCCS) Arizona’s Medicaid Program, approved by the Centers for Medicare and Medicaid Services

(CMS) as Section 1115 Demonstration Waiver, and specified in A.R.S. Title 36, Chapter 29.

26. Under SECTION C, Definitions, CHANGE IN ORGANIZATIONAL STRUCTURE, change, “2.

Change in Articles of Incorporation,” to “2. Change in organizational documents (e.g., Amendments to

Articles of Incorporation, Amendments to Partnership Agreements;

27. Under SECTION C, Definitions, add, “CLOSED-LOOP REFERRAL SYSTEM, The AHCCCS-approved statewide technology platform for screening and referring members to address their health-related social needs.”

28. Under SECTION C, Definitions, add, COMMUNITY RESOURCE GUIDE, A handbook with listings of local community resources that help address Health-Related Social Needs (HRSN) and Social

Determinants of Health (SDOH). The Guide contains referral resources that are specific to the region in which members are served. The Community Resource Guide serves as a supplement to the CLRS for members who are not actively engaged with health care providers that utilize the system. The Guide can be custom-made by a provider or health plan, or it can be publicly available regional handbook of resources.

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 Procurement

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29. Under SECTION C, Definitions, CONTRACTOR, add, “and policies”.

30. Under SECTION C, Definitions, add, “DESIGNATED REPRESENTATIVE (DR) An individual parent, guardian, relative, advocate, friend, or other individual, designated orally or in writing by a member or guardian who, upon request of the member, assists the member in protecting the member’s rights and voicing the member’s service needs.”

31. Under SECTION C, Definitions, DIVISION OF HEALTH CARE MANAGEMENT (DHCM), delete in its entirety.

32. Under SECTION C, Definitions, FAMILY OR FAMILY MEMBER, change, “mother or father” to, “parent”

33. Under SECTION C, Definitions, FEDERALLY QUALIFIED HEALTH CENTER (FQHC), add

“Centers for Medicare and Medicaid Services (CMS)”

34. Under SECTION C, Definitions, FIELD CLINIC add “Children’s Rehabilitation Services (CRS).”

35. Under SECTION C, Definition, HEALTH CARE PROFESSIONAL, add, “licensed behavior analyst,”

36. Under SECTION C, Definitions, HEALTH INFORMATION EXCHANGE (HIE), delete in its entirety.

37. Under SECTION C, Definitions, add, “HEALTH INFORMATION EXCHANGE (HIE)/ HEALTH

INFORMATION ORGANIZATION (HIO) A State designated non-profit Health Information

Organization (HIO), that provides the statewide exchange of patient health information among disparate health care organizations and providers not owned, operated, or controlled by the health information exchange organization as defined in A.R.S. § 36-3801. Pursuant to A.A.C. R9-22-701.”

38. Under SECTION C, Definitions, add, “HEALTH INFORMATION TECHNOLOGY (HIT), The application of information process involving both computer hardware and software that deals with the storage, retrieval, sharing, and use of health care information, data, and knowledge for communication and decision making.”

39. Under SECTION C, Definitions, add, “HEALTH-RELATED SOCIAL NEEDS (HRSN), Non-medical factors that impact health outcomes including but not limited to increasing access to safe and affordable housing, nutritious food, utility assistance, education, employment, transportation, connection to others in the community, as well as physical, environmental, and interpersonal safety. Also known as Social

Determinants of Health (SDOH) or Social Risk Factors of Health (SRFOH).”

40. Under SECTION C, Definitions, delete, HOME, A residential dwelling that is owned, rented, leased, or occupied, including a house, a mobile home, an apartment or other similar shelter. A home is not a facility, a setting or an institution, or a portion of any of these, licensed or certified by a regulatory agency of the

State as defined in A.A.C. R9-28-101 and replace with, “HOME, A residential dwelling that is owned, 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 Procurement

5 | P a g e rented, leased, or occupied by a member, at no cost to the member, including a house, a mobile home, an apartment, or other similar shelter. A home is not a facility, a setting or an institution, or a portion of any of these, that is licensed or certified by a regulatory agency of the State as:

1. Health care institution as specified in A.R.S. § 36-401.

2. Residential care institution as specified in A.R.S. § 36-40.

3. Community residential setting as specified in A.R.S. § 36-551.

4. Behavioral health facility as specified in A.A.C. R9-28-101.”

41. Under SECTION C, Definitions, add, “INDIVIDUAL WITH AN INTELLECTUAL DISABILITY/

DEVELOPMENTAL DISABILITY (IID/DD). An individual who meets the Arizona definition as specified in A.R.S. § 36-551 and is determined eligible for services through the Department of Economic

Security/Division of Developmental Disabilities (DES/DDD). Services for AHCCCS-enrolled members with intellectual/developmental disabilities determined eligible for services through DES/DDD are managed through the DES Division of Developmental Disabilities.”

42. Under SECTION C, Definitions, INSTITUTION FOR MENTAL DISEASES (IMD), add, “and

Developmental Disabilities (IDD).”

43. Under SECTION C, Definitions, INTEGRATED MEDICAL RECORD , delete “listed in

Chapter 900 of the AMPM”.

44. Under SECTION C, Definitions add, JUVENILE PROBATION OFFICER (JPO), An officer within the Arizona Department of Juvenile Corrections (ADJC) assigned to a juvenile upon release from a secure facility. Having close supervision and observation over juvenile’s who are ordered to participate in the intensive probation program including visual contact at least four times per week and weekly contact with the school, employer, community restitution agency or treatment program (A.R.S. §

8-353).

45. Under SECTION C, Definitions, delete “MATERIAL CHANGE TO BUSINESS OPERATIONS” in its entirety and replace with, “Any change in overall operations that affects, or can reasonably be foreseen to affect, the Contractor’s ability to meet the performance standards as required in Contract including, but not limited to, any change that would impact or is likely to impact more than 5% of total membership and/or provider network in a specific Geographic Service Area (GSA). Changes to business operations may include, but are not limited to, policy, process, and protocol, such as Prior Authorization (PA) or retrospective review. Additional changes may also include the addition or change in:

1. Pharmacy Benefit Manager (PBM).

2. Dental Benefit Manager.

3. Transportation vendor.

4. Claims Processing system.

5. System changes and upgrades.

6. Change to Organization Name.

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 Procurement

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7. Member Identification (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.

10. Management Service Agreement (MSA).

11. Any other Administrative Services Subcontract.”

46. Under SECTION C, Definitions, MATERIAL CHANGE TO PROVIDER NETWORK, add, “in a

Geographic Service Area (GSA)”

47. Under SECTION C, Definitions, MEDICATION ASSISTED TREATMENT (MAT), delete in its entirety.

48. Under SECTION C, Definitions, add, “MEDICATION FOR OPIOID USE DISORDER (MOUD) An evidence-based approach that uses medication to treat individuals with Opioid Use Disorder (OUD).”

49. Under SECTION C, Definitions, NATIONAL PROVIDER IDENTIFIER (NPI), add, “Centers for

Medicare and Medicaid Services (CMS)”

50. Under SECTION C, Definitions, PERFORMANCE IMPROVEMENT PROJECT, add (PIP) to the title and remove rom the definition. Change. “QOC” to, “quality of care”.

51. Under SECTION C, Definitions, add, “PERFORMANCE MEASURE PERFORMANCE STANDARDS

(PMPS), The minimal expected level of performance by the Contractor, previously referred to as the

Minimum Performance Standard. Beginning Contract Year Ending (CYE) 2021, official performance measure results shall be evaluated based upon the National Committee for Quality Assurance (NCQA)

Healthcare Effectiveness Data and Information Set (HEDIS®) Medicaid Mean or Centers for Medicare and Medicaid Services (CMS) Medicaid Median (for selected CMS Core Set-Only Measures), as identified by AHCCCS, as well as the Line of Business (LOB) aggregate rates, as applicable.”

52. Under SECTION C, Definitions, PRESCRIPTION DRUG COVERAGE add,” registered”.

53. Under SECTION C, Definitions, add, “PRE-ADMISSION SCREENING (PAS) A process of determining an individual’s risk of institutionalization at a Nursing Facility (NF) or Intermediate Care

Facility (ICF) level of care as specified in 9 A.A.C. 28 Article 1.”

54. Under SECTION C, Definitions, add, “RAPID RESPONSE, A process that occurs when a child enters into Department of Child Safety (DCS) custody. When this occurs, a behavioral health service provider is referred and then dispatched within 72 hours to assess a child’s immediate behavioral health needs and to refer the child for additional assessments through the behavioral health system.”

55. Under SECTION C, Definitions, RURAL HEALTH CLINIC (RHC), delete, “by the Bureau of Census as rural, and by the Secretary of the DHHS as medically underserved or having an insufficient number of

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 Procurement

7 | P a g e physicians, which meets the requirements under” , and change to “that is located in a rural area designated as a shortage area, is not a rehabilitation agency or a facility primarily for the care and treatment of mental diseases, and meets all other requirements as specified in 42 CFR 491”

56. Under SECTION C, Definitions, add, “SERIOUS EMOTIONAL DISTURBANCE (SED), A designation for individuals from birth up to age 18 who currently or at any time during the past year have had a diagnosable mental or emotional disorder of sufficient duration to meet diagnostic criteria specified within the current version of the Diagnostic and Statistical Manual of Mental Disorders that resulted in functional impairment, which substantially interferes with or limits the child’s role or functioning in family, school, or community activities.”

57. Under SECTION C, Definitions, add, “SERIOUS EMOTIONAL DISTURBANCE (SED)

ELIGIBILITY DETERMINATION, A determination as to whether or not an individual meets the diagnostic and functional criteria established for the purpose of determining an individual’s eligibility for receiving all medically necessary behavioral health services.”

58. Under SECTION C, Definitions, SMI ELIGIBILITY DETERMINATION, delete in its entirety and replace with, “SERIOUS MENTAL ILLNESS (SMI) ELIGIBILITY DETERMINATION, A determination as to whether or not an individual meets the diagnostic and functional criteria established by AHCCCS for the purpose of determining an individual’s eligibility for services for the SMI.”

59. Under SECTION C, Definitions, add, “SOCIAL DETERMINANTS OF HEALTH (SDOH), The World

Health Organization defines SDOH as the conditions of the community in which an individual is born, grows, works, lives, and ages, and the wider set of forces and systems shaping their conditions of daily life, including economic policies and systems, development agendas, social norms, social policies, and political systems. These are also known as Social Risk Factors of Health (SRFOH).

60. Under SECTION C, Definitions, STATE CHILDREN’S HEALTH, change to, “STATE CHILDREN’S

HEALTH INSURANCE PROGRAM (SCHIP), add, “Children’s Health Insurance Program”, “(Also known as Children’s Health Insurance Program [CHIP]).” and delete, “CHIP”, “INSURANCE

PROGRAM (CHIP)”.

61. Under SECTION C, Definitions, SUPPLEMENTAL SECURITY INCOME (SSI) AND SSI-RELATED

GROUPS, add, “Federal Poverty Level (FPL).”

62. Under SECTION C, Definitions, add, “TRIBAL ARIZONA LONG TERM CARE SYSTEM (TRIBAL

ALTCS), A program managed by AHCCCS to provide covered, medically necessary ALTCS services to

ALTCS American Indian members who reside on a Tribal reservation in Arizona or resided on a reservation immediately before being placed in a nursing facility or alternative Home and Community

Based Services (HCBS) setting off reservation.

63. Under Section D, SCOPE OF WORK, 1. PURPOSE, APPLICABILITY AND INTRODUCTION, Introduction, System Values and Guiding Principles: Change “Embraces” to, “Commitment to”.

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 Procurement

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64. Under Section D, SCOPE OF WORK, 1. PURPOSE, APPLICABILITY AND INTRODUCTION, Introduction, Initiatives, 10. HIT, add, “Health Information Technology (HIT)”, change “11. The

Current Arizona Healthcare Directives Registry (AzHDR)” to “Health Information Exchange

(HIF) Arizona Healthcare Directives Registry (AzHDR).”

65. Under Section D, SCOPE OF WORK, 1. PURPOSE, APPLICABILITY AND INTRODUCTION, , 2.

Eligibility CATEGORIES, Other Member Eligibility Categories, SMI Eligibility (Assessments and Determinations), delete, “members”, “who may meet the SMI eligibility criteria are identified and assessed by qualified clinicians in accordance with AHCCCS Policy on SMI Eligibility

Determinations. See AMPM Policy 320-P. Payment for evaluations conducted for the purpose of an SMI eligibility determination is the responsibility of the Contractor and may not be conducted by DCS CHP or Contractor staff. The Contractor shall ensure evaluations and all required documentation are referred timely and comprehensively to the AHCCCS designee which conducts SMI eligibility determinations.” add, “the identification and assessment of enrolled”, “by qualified clinicians to identify those individuals who may meet the Serious Emotional

Disturbance (SED) or Serious Mental Illness (SMI) eligibility criteria as specified in AMPM Policy

320-P.”, “Payment for evaluations conducted for the purpose of an SED or SMI Eligibility Determination is the responsibility of the Contractor and may not be conducted by DCS CHP or Contractor staff. The

Contractor is responsible for coordinating SED or SMI eligibility evaluations, including urgent evaluations, when a member is hospitalized for psychiatric reasons, if one has not been completed within the last six months. The Contractor shall ensure SED or SMI eligibility evaluations (including removal of designation), and all required documentation is completed accurately and referred timely and comprehensively to the DCS CHP designee authorized to render SED and SMI Eligibility

Determinations.

As part of the Contractor’s care management and/or high needs/high cost program, as specified in Section

D, Paragraph 23, Medical Management, the Contractor shall have a robust process to identify and refer members who may meet SED or SMI eligibility criteria to receive an SED or SMI eligibility assessment as specified in AMPM Policy 320-P. The Contractor shall ensure SED and SMI Eligibility Determination

Evaluation Packets include at a minimum, the following documentation:

1. SED or SMI Determination Form, as applicable. Refer to AMPM Policy 320-P.

2. Consent Form(s).

3. Comprehensive Assessment, including the CALOCUS for SED, if applicable.

4. Waiver to extend three day SED or SMI Eligibility Determination timeframe, as applicable.

5. Additional records available for consideration.

6. Signed Release(s), if appropriate.

The Contractor shall cooperate with DCS CHP and the SED or SMI Eligibility Determination designee by establishing and implementing systems or processes for communication, consultation, data sharing, and the exchange of information. The Contractor shall immediately establish SED or SMI services and ensure effective and comprehensive care coordination based on the presenting needs of the member once an SED or SMI Eligibility Determination has been rendered that shall also include connection of member

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 Procurement

9 | P a g e to ACC-RBHAs or other resource providers for necessary services that are not covered under the

Contractor's TXIX plan.

The Contractor shall comply with all requirements specified in AMPM Policy 320-P.

Adherence to these requirements may be subject to review through AHCCCS audits and/or Operational

Reviews (ORs).

Serious Emotional Disturbance and Serious Mental Illness Removal of Designation: SED and SMI

Removal of Designation is the process that results in the removal of the SED or SMI behavioral health category designation from the member’s record. Refer to AMPM Policy 320-P. Once an SED or SMI

Eligibility Determination or Removal of Designation decision is made and submitted to DCS CHP, DCS

CHP will update the member’s Behavioral Health Category to add/remove SED or SMI respectively and will provide the documentation to the MCO of enrollment or AIHP, as applicable, via the AHCCCS SFTP server. The Behavioral Health Category can then be viewed in the AHCCCS Online system via the

AHCCCS Online Provider Website.”

66. Under Section D, SCOPE OF WORK, 7. ACCOMMODATING MEMBERS

Change, “individuals with disabilities” to, “a member with a disability”.

67. Under Section D, SCOPE OF WORK, 9. SCOPE OF SERVICES, Covered Services, add “Biomarker

Testing: Biomarker testing for the purposes of diagnosis, treatment, appropriate management, or ongoing monitoring of a member’s disease or condition to guide treatment decisions as specified in

AMPM Policy 310-KK.”

68. Under Section D, SCOPE OF WORK, 9. SCOPE OF SERVICES, Covered Services, Integrated Rapid

Response, add, “The Contractor shall obtain from DCS a monthly listing of children placed in DCS custody. The Contractor shall reconcile the DCS report with the Contractor’s list of children who have received a rapid response. For any identified members in DCS custody who have not received a Rapid

Response , the Contractor shall ensure that a rapid response is delivered. The Contractor shall report reconciliation activities to AHCCCS on the Rapid Response Reconciliation Reporting as specified in

ACOM 449 and Section F, Attachment F3, Contractor Chart of Deliverables. The Contractor shall monitor monthly reconciliation reports for trends and address any identified systemic issues that prevent members in DCS custody from receiving Rapid Response within 72 hours.

The Contractor shall submit a narrative and data summary (Behavioral Health Utilization and Timeframes for Members in the custody of DCS), as specified in ACOM Policy 449 and Section F, Attachment F3, Contractor Chart of Deliverables, that specifically addresses successes and barriers associated with behavioral health service delivery to CHP members. Data elements should include utilization data as well as any identified trends related to CHP members, including but not limited to Quality of Care (QOC), access, timeliness, and availability.

https://azweb.statemedicaid.us/Account/Login.aspx?ReturnUrl=%2f https://azweb.statemedicaid.us/Account/Login.aspx?ReturnUrl=%2f

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 Procurement

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The Contractor shall submit deliverables regarding member’s access to behavioral health services and provider requests to terminate (DCS and Adopted Children Services Reporting: Access to Service) as specified in ACOM Policy 449 and as specified in Section F, Attachment F3, Contractor Chart of

Deliverables.

The Contractor shall submit a deliverable to report the number of calls and emails received by the

Children’s Services Liaison and the after-hours line related to children in the custody of DCS (DCS and

Adopted Children Services Reporting: Calls and Emails) as specified in ACOM Policy 449 and as specified in Section F, Attachment F3, Contractor Chart of Deliverables.

The Contractor is required to perform recurring review of identified members in shelter care or other out of home placement to determine appropriateness of current placement and supports, with the goal of achieving increased stability/permanency. Services and supports shall be provided as needed to either stabilize current placement or support transition to a more appropriate setting/level of care.”

69. Under Section D, SCOPE OF WORK, 9. SCOPE OF SERVICES, Covered Services, add, “Certified

Community Health Worker/Community Health Representative Services: A certified Community Health

Worker/Community Health Representative (CHW/CHR), who obtains certification through the Arizona

Department of Health Services (ADHS) as specified in A.A.C. R9-16-802, may provide AHCCCS-covered member education and preventive services to eligible members.”

70. Under Section D, SCOPE OF WORK, 9. SCOPE OF SERVICES, Covered Services, Dental Services, replace, “The Contractor, or their Administrative Services Subcontractor for dental services in accordance with Section D, Paragraph 36, Subcontracts, shall adhere to the Dental Uniform Prior

Authorization List (List) and the Uniform Warranty List as specified 431 on the Resources page of the

AHCCCS website. Requests for changes to the List must be submitted to DCS CHP as specified in

Exhibit 4, Contractor Chart of Deliverables.”, with, “The Contractor, or their Administrative Services

Subcontractor for dental services in accordance with Section D, Paragraph 36, Subcontracts, shall adhere to the Uniform Warranty List as specified 431 on the Resources page of the AHCCCS website. Requests for changes to the List must be submitted to DCS CHP as specified in Exhibit 4, Contractor Chart of

Deliverables. DCS CHP in accordance to AHCCCS Medical Policy Manual 431, section III, D, 10 DCS

CHP is excluded from the “Dental Uniform Prior Authorization List” requirement.”

71. Under Section D, SCOPE OF WORK, 9. SCOPE OF SERVICES, Early and Periodic Screening, Diagnostic and Treatment Services: add, “The Contractor shall coordinate with DCS CHP and maintain records of attendance and training of the completed curriculum of their network of providers that include the use of the Comprehensive Health Assessment-EPSDT visits within 30 days of enrollment with DCS

CHP which shall be produced upon request from AHCCCS.”

72. Under Section D, SCOPE OF WORK, 9. SCOPE OF SERVICES, Covered Services, Home Health

Services, delete in its entirety and replace with, “Home Health Services: This service shall be provided under the direction of a physician or physician assistant, Nurse Practitioner (NP), Clinical Nurse

Specialist (CNS), to prevent hospitalization or institutionalization and may include nursing, therapies, 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 Procurement

11 | P a g e supplies and home health aide services. It shall be provided on a part-time or intermittent basis. The

Contractor is prohibited from paying for an item or service (other than an emergency item or service, not including items or services furnished in an emergency room of a hospital) for home health care services provided by an agency or organization, unless AHCCCS Provider Enrollment verifies compliance with the Surety Bond requirements specified in Sections 1861(o)(7) and 1903(i)(18) of the Social Security

Act. Refer to AMPM Policy 310-I.”

73. Under Section D, SCOPE OF WORK, 9. SCOPE OF SERVICES, Covered Services, Immunizations, add, “Pharmacists, and pharmacy interns and technicians under the supervision of a pharmacist, within their scope of practice, may administer AHCCCS covered immunizations to adults 19 years and older as specified in A.R.S. § 32-1974. Pharmacists, and pharmacy interns and technicians under the supervision of a pharmacist, within their scope of practice, may administer AHCCCS influenza and COVID immunizations to children who are three years through 18 years of age.”

74. Under Section D, SCOPE OF WORK, 9. SCOPE OF SERVICES, Covered Services, Incontinence Briefs, delete, “In general”, “not”, “unless”, “to treat a medical condition.”, “However”, “See A.A.C. R9-22-

212 and AMPM Chapters 300 and 400.” and add, “when”, “Refer to AMPM Policy 310-P and AMPM

Policy 430.”

75. Under Section D, SCOPE OF WORK, 9. SCOPE OF SERVICES, Covered Services, Medical

Equipment, Medical Supplies and Prosthetic Devices: delete, “For continuous glucose monitoring device criteria, refer to AMPM Policy 320-D.”, “customized” and add, “medical appliances, medical supplies”, “Refer to AMPM Policy 310-P.”

76. Under Section D, SCOPE OF WORK, 9. SCOPE OF SERVICES, Covered Services, Prescription

Medications: delete, “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.” Add, “The Contractor is required to follow the AHCCCS FFS PA criteria for all physician administered drugs including those billed on medical claims and point-of-sale prescription drug claims. The requirement to adhere to the FFS PA criteria applies to Contractors that provide PA services from within their organization or use a subcontractor, i.e., a Pharmacy Benefit Manager (PBM).”

77. Under Section D, SCOPE OF WORK, 9. SCOPE OF SERVICES, Covered Services, PCP Services:, delete, “The PCP is responsible for maintaining the member’s primary medical record, which contains documentation of all health risk assessments and health care services of which they are aware whether or not they were provided by the PCP.”, add, “The Contractor shall ensure that the

PCP maintains the member’s primary medical record and includes all documentation of all health risk assessments and health care services whether or not they were provided by the PCP.”

78. Under Section D, SCOPE OF WORK, 9. SCOPE OF SERVICES, Covered Services, Respiratory

Therapy; delete “See AMPM Policy 310-Y.”

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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

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79. Under Section D, SCOPE OF WORK, 9. SCOPE OF SERVICES, Covered Services, Organ and Tissue

Transplants, and Related Immunosuppressant Drugs: delete in its entirety.

80. Under Section D, SCOPE OF WORK, 9. Scope of Services, Covered Services, add, “Transplant Services and Immunosuppressant Medications: AHCCCS covers medically necessary transplant services and related immunosuppressant medications in accordance with Federal and State 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 to AMPM

Policy 310-DD and the AHCCCS Reinsurance Policy Manual.”

81. Under Section D, SCOPE OF WORK, 11. BEHAVIORAL HEALTH SERVICE DELIVERY, Children’s System of Care: change to “Children’s Integrated System of Care:”.

82. Under Section D, SCOPE OF WORK, 11. BEHAVIORAL HEALTH SERVICE DELIVERY, Community Service Agencies: add, “some”.

83. Under Section D, SCOPE OF WORK, 11. BEHAVIORAL HEALTH SERVICE DELIVERY, Specific Requirements for Services to American Indians: add, “living off reservation who are enrolled with the Contractor.”, delete, “whether they live on or off reservation.”

84. Under Section D, SCOPE OF WORK, 12. DCS CHP AND AHCCCS GUIDELINES, POLICIES, AND

MANUALS, add, “(Guides and Manuals for Health Plans and Providers)”

85. Under Section D, SCOPE OF WORK, 15. STAFFING REQUIREMENTS, add, “Should the Contractor experience staff inadequacy which prevents the Contractor from meeting contractual requirements, the

Contractor shall notify DCS CHP and QM of the staffing concerns, including a description”.

86. Under Section D, SCOPE OF WORK, 15. STAFFING REQUIREMENTS, Healthcare

Administrator/Chief Medical Officer, add, “The CMO/Medical Director shall actively provide oversight and management of the Quality Management (QM), QI, and Programs.”

87. Under Section D, SCOPE OF WORK, 15. STAFFING REQUIREMENTS, Key Staff Positions. add, “13. EPSDT Coordinator who is located in Arizona and who is an Arizona licensed nurse, physician or physician's assistant in good standing; or has a master's degree in health services, public health, health care administration or other related field, and/or a Certified Professional in Healthcare Quality (CPHQ) or

Certified in Health Care Quality and Management (CHCQM) certification. Staff reporting to this position

DocuSign Envelope ID: 28EFAD07-30C5-478D-A52D-9D49A5D527CE https://www.azahcccs.gov/PlansProviders/GuidesManualsPolicies/index.html https://www.azahcccs.gov/PlansProviders/GuidesManualsPolicies/index.html

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 Procurement

13 | P a g e shall be appropriate to meet the AHCCCS Maternal and Child Health (MCH)/EPSDT contractual and policy requirements, and quality and performance measure goals, and shall be located in Arizona. EPSDT staff shall either report directly to the EPSDT Coordinator or the EPSDT Coordinator shall have the ability to ensure that AHCCCS EPSDT requirements are met. The EPSDT Coordinator may also serve as the MCH

Coordinator.”

The primary functions of the EPSDT Coordinator are:

a. Ensure receipt of EPSDT services,

b. Promote preventive health strategies,

c. Promote access to oral health care services,

d. Identify and coordinate assistance for identified member needs, and

e. Interface with community partners.

88. Under Section D, SCOPE OF WORK, 15. STAFFING REQUIREMENTS, Key Staff Positions, 22.

Justice System Liaison, delete in its entirety and replace with, “Justice System Liaison who is located in

Arizona and is the single point of contact for justice system stakeholders (e.g., jails/prisons/detention facilities, courts, law enforcement, and community supervision agencies). This position is responsible for ensuring care coordination of justice-involved members and for oversight and reporting of Justice

System Reach-in Care Coordination activities. This position also serves as the single point of contact for justice system stakeholders engaged programmatically in arrest diversion or incarceration alternative initiatives intended to reduce the number of individuals from entering the justice system. This includes, but is not limited to, sequential intercept modeling, crisis system utilization, and specialty court programs

(e.g., opioid/drug, mental health, homeless, domestic violence, and veterans courts) and conducting outreach and specialized training to local law enforcement accommodating, interacting, and communicating with individuals or subpopulations who, due to the nature of their condition, may have an atypical response to law enforcement including individuals with intellectual and developmental disabilities.”

89. Under Section D, SCOPE OF WORK, 15. STAFFING REQUIREMENTS, Key Staff Positions, 25.

Individual and Family Affairs Administrator, delete in its entirety and replace with, “Office of Individual and Family Affairs Administrator who is located in Arizona and has lived experience receiving behavioral health services and/or lived experience as a family member who is a primary caregiver or natural support and experienced in navigating a public behavioral health system. This individual shall have experience working with individuals including members, families, youth, advocates, and other community members.

As an advocacy department, this individual shall work with the Contractor to promote a vision of recovery, resiliency, empowerment, and wellness. The OIFA Administrator shall take an overarching approach to incorporate the perspective of lived experience with behavioral health challenges in all programs, policies, and procedures. This individual shall oversee Contractor OIFA activities in support of the AHCCCS OIFA mission, and the OIFA Alliance initiatives. This individual shall ensure staff members directly reporting to this position are sufficient to fulfill the responsibilities of the role. This position shall report directly to the Executive/Senior Leadership Team and be an integral member of the

Contractor Leadership Team.

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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

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The Contractor may choose to engage Subcontractor staff which perform functions under Contract related to OIFA as needed for assistance with activities required under the OIFA Administrator role, while still maintaining the OIFA Administrator role under the Contractor. Staff shall report directly to the OIFA

Administrator.

At a minimum the following staff shall report directly to the OIFA Administrator:

a. The Child Behavioral Health Member Liaison with lived experience (self or family).

In support of the OIFA mission, the OIFA Administrator, and sufficient staff under this position, shall:

a. Direct and educate on the vision for the OIFA Department ensuring its mission is integrated into the programs, policies, and practices of the Contractor,

b. Cultivate new relationships and nurture existing relationships with individuals, families, youth, and community members to promote recovery, resiliency, and wellness,

c. Assemble and facilitate a Member Advocacy Council and assist and participate in the

Contractor’s Governance Committee.

d. Identify and create other opportunities for member and family member participation including boards, committees, workgroups, and meetings to ensure representation of the peer and family perspective in programs and services,

e. Advocate for service delivery and environments that are supportive, welcoming, person-centered, trauma-informed, and recovery-focused,

f. Communicate and collaborate with members and families to identify concerns and remove barriers affecting service delivery or member satisfaction,

g. Oversee the provision, and ensure the availability of, peer support services and family support services by having access to utilization reports and other necessary means to monitor, track, and trend these services,

h. Guide the development, implementation, and monitoring of PROs and FROs as defined in the

AHCCCS Contract and Policy Dictionary.

i. Create an OIFA strategic plan in alignment with the AHCCCS OIFA strategic plan and submit as specified in Section F, Attachment F3, Contractor Chart of Deliverables,

k. Work with other Contractor’s OIFAs in recognition of the interconnected relationships that providers have with multiple health plans,

l. Participate and collaborate as a member of the OIFA Alliance on all projects, initiatives and events with AHCCCS/DCAIR, OIFA, and

m. Oversee OIFA deliverables specified in Section F, Attachment F3, Contractor Chart of

Deliverables.”

90. Under Section D, SCOPE OF WORK, 15. STAFFING REQUIREMENTS, Additional Required Staff, Concurrent Review Staff, delete, “who are located in Arizona and”

91. Under Section D, SCOPE OF WORK, 15. STAFFING REQUIREMENTS, add, Quality Management

Manager who is located in Arizona, and an Arizona licensed registered nurse, physician or physician's

Office of Procurement

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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

15 | P a g e assistant in good standing or is a CPHQ by the NAHQ and/or CHCQM by the American Board of Quality

Assurance and Utilization Review Providers. The QM Manager shall have experience in quality management and clinical investigations. The QM Manager shall have a direct reporting relationship to the Contractor’s CMO/Medical Director. The QM Manager shall not hold any other position other than the QM Manager position but is able to oversee multiple lines of business should the Contractor hold multiple Contracts. QM shall have sufficient local staffing who are licensed clinical or BHPs to meet the requirements of the QM program. The Contractor may choose to engage Subcontractor staff which perform functions under Contract related to Quality Management/Performance Improvement as needed for assistance with activities required under the Performance/QI Manager role, while still maintaining the

Performance/QI Manager role under the Contractor. Staff shall report directly to the Quality Management

Manager.

The primary functions of the Quality Management Manager position are:

a. Ensure individual and systemic QOC,

b. Conduct comprehensive quality-of-care investigations,

c. Conduct onsite quality management visits/reviews,

d. Conduct Care Needed Today/ IJ investigations,

e. Integrate quality throughout the organization,

f. Implement QI as it pertains to QM related focus areas, and

g. Resolve, track, and trend QOC grievances.

92. Under Section D, SCOPE OF WORK, 15. STAFFING REQUIREMENTS, Performance/Quality

Improvement (QI) Manager, delete in its entirety and replace with, “Performance/Quality Improvement

(QI) Manager who is located in Arizona, has a direct reporting relationship (or direct hierarchical reporting relationship) to the Contractor’s CMO/Medical Director and:

a. Is a CPHQ through the National Association for Health Care Quality (NAHQ),

b. Is CHCQM through the American Board of Quality Assurance and Utilization Review Physicians, or

c. Has comparable education and experience in health plan data and outcomes measurement.

The Performance/QI Manager is responsible for QI activities as well as staff conducting QI work as outlined in Contract and policy. Staff reporting to this position shall be located in Arizona, have knowledge of both physical and behavioral health service delivery, and be appropriately qualified

(education/certification/ professional experience) to meet the AHCCCS QI contractual and policy requirements. The Performance/QI Manager shall not hold any other position other than the

Performance/QI Manager position but is able to oversee multiple LOB should the Contractor hold multiple Contracts.

Quality/Performance Improvement Manager shall work collaboratively and at the direction of DCS CHP and maintain the appropriate level of qualified staff to support the following primary functions:

• Ensure individual and systemic QOC;

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 Procurement

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• Focus organizational efforts on improving quality measure;

• Conduct comprehensive quality-of-care investigations;

• Conduct onsite quality management visits/reviews;

• Conduct Care Needed Today/Immediate Jeopardy investigations;

• Integrate quality throughout the DCS CHP program;

• Implement process improvement;

• Resolve, track and trend QOC grievances;

• Focus organizational efforts on improving clinical quality performance measures;

• Develop and implement PIPs and QI related CAPs;

• Utilize data to develop intervention strategies to improve outcomes; member satisfaction and

• Report quality improvement/performance outcomes.

93. Under Section D, SCOPE OF WORK, 17. MEMBER INFORMATION, Member Handbook and Provider

Directory: add, “The Contractor shall include information in the Member Handbook and other printed documents to educate members about the availability and accessibility of covered services and that behavioral health conditions may be treated by the member’s PCP within their scope of practice. The

Contractor shall have information available for potential members as specified in ACOM Policy 404 and

ACOM Policy 406, and 42 CFR 438.10(e)(2).”

94. Under Section D, SCOPE OF WORK, 17. MEMBER INFORMATION, Website Requirements, add, “The treatment type may include more than Behavior Analysis. Reference types of services that can be offered within AMPM Policy 310-B., “as part of its”, “deliverable”, “to”, “DCS CHP may, at its discretion, request evidence that the Contractor verify the accuracy of website provider information and services as listed.”

95. Under Section D, SCOPE OF WORK, 18. Surveys, add, “Surveys are not subject to the file and use review process.”

96. Under Section D, SCOPE OF WORK, 22. QUALITY MANAGEMENT AND PERFORMANCE

IMPROVEMENT, Credentialing, add, “AzAHP”, “the Contractor’s”.

97. Under Section D, SCOPE OF WORK, 22. QUALITY MANAGEMENT AND PERFORMANCE

IMPROVEMENT, Accreditation: 2., add, “as provided/made available through the accreditation entity” and change, ” Should the Contractor renew or lose its accreditation, the Contractor shall provide

DCS CHP written notification or copy of the renewal certificate, as applicable, within 15 calendar days of notification or receipt from the accrediting entity., to ´ Should the Contractor renew or lose its accreditation, the Contractor shall provide DCS CHP written notification or copy of the renewal certificate, as applicable, within 10 calendar days of notification or receipt from the accrediting entity.”

98. Under Section D, SCOPE OF WORK, 22. QUALITY MANAGEMENT AND PERFORMANCE

IMPROVEMENT, Performance Measures: delete “2022/2023 and replace with “2023/2024”

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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

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99. Under Section D, SCOPE OF WORK, 22. QUALITY MANAGEMENT AND PERFORMANCE

IMPROVEMENT, Performance Measures, replace, “The Contractor shall require its providers to participate in immunization audits, as required by DCS CHP, to verify the provider performance.”, with

“The contractor shall require its providers to participate in immunization audits, as required by DCS…