DCSCHP_MercyCare_ContractAmendment_CY2025_Fully_Executed.pdf

Integrated Healthcare Delivery Services State of Arizona

Department of Child Safety Office of Procurement

3003 N. Central Avenue, 20th Fl.

Phoenix, AZ 85012

Contract #: CTR050520

Amendment #: 6

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. Under SECTION B: CAPITATION RATES AND CONTRACTOR SPECIFIC REQUIREMENTS, the calculation for the monthly rate cap for TXIX members for CYE25 is $1,468.70 PM/PM. The calculation for this rate is listed below. This rate will be reset annually.

2. Throughout the contract change all references to “A.R.S” to “ARS”

3. Throughout the Contract change “A.A.C.” to “AAC”

4. Throughout the Contract change “U.S.C.” to “USC”

5. Throughout the Contract change “BH” to “behavioral health”

6. Throughout the Contract change “MH” to “mental health”

Docusign Envelope ID: 9847C535-9EDC-4A86-942F-FEDD00ED1FCC

Office of Procurement

3003 N. Central Avenue, 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. Throughout the Contract change “PH” to “physical health”

8. Under SECTION C, Definitions, added new definition, ABUSE OF THE AHCCCS PROGRAM. Added

“Provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in an unnecessary cost to the AHCCCS program, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care, noncompliance with licensure standards, misuse of billing numbers, or misuse or abuse of billing privileges. It also includes beneficiary practices that result in unnecessary cost to the AHCCCS program [42 CFR 455.2].

9. Under SECTION C, Definitions, added new definition, ABUSE (OF A CHILD). Added “As specified in

ARS 8-201(2), abuse of a child is defined as follows: The infliction of allowing of physical injury , impairment or bodily function or disfigurement or the infliction of or allowing another person to cause serious emotional damage as evidenced by sever anxiety, depression, withdrawal, or untoward aggressive behavior and which emotional damage is diagnosed by a medical doctor or psychologist and is caused by the acts or omissions of an individual who has the care, custody, and control of a child. Abuse includes:

1. Inflicting or allowing sexual abuse, sexual conduct with a minor, sexual assault, molestation of a child, commercial sexual exploitation of a minor, incest, or child sex trafficking as those acts are specified in ARS Title 13, Chapter 14.

2. Physical injury that results from permitting a child to enter or remain in any structure or vehicle in which volatile, toxic or flammable chemicals are found, or equipment is possessed by any person for the purpose of manufacturing a dangerous drug as defined in ARS 13-

3401.

3. Unreasonable confinement of a child.

10. Under SECTION C, Definitions, ABUSE (OF A MEMBER), deleted definition in entirety and replaced with: “Abuse of a Vulnerable Adult or the Abuse of a Child who is a member as specified in ASRS 45-

451(A)(1), ARS 8-201(2), ARS 46-451(A)(10).”

11. Under SECTION C, Definitions, ABUSE (BY A PROVIDER), definition was removed.

12. Under SECTION C, Definitions, ABUSE (OF A VULNERABLE ADULT), deleted definition in entirety and replaced with: “As specified in ARS 45-451(A), (i) An intentional infliction of physical harm, (ii)

Injury caused by negligent acts or omissions, (iii) Unreasonable confinement, or (iv) Sexual abuse or sexual assault.

13. Under SECTION C, Definitions, ACTIVE TREATMENT, deleted definition in entirety and replaced with: “A current need for treatment. The treatment is identified on the member’s service plan to treat a serious and chronic physical, developmental, or behavioral condition requiring medically necessary services of a type or amount beyond that generally required by members that lasts, or is expected to last one year or longer, and requires ongoing care not generally provided by a primary care provider.”

Office of Procurement

3003 N. Central Avenue, 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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14. Under SECTION C, Definitions, added new definition, ACTIVE TREATMENT – CHILDREN’S

REHABILITATIVE SERVICE’S (CRS). Added “A current need for treatment. The treatment is identified on the member’s service plan to treat a serious and chronic physical, developmental, or behavioral condition requiring medically necessary services of a type or amount beyond that generally required by members that lasts, or is expected to last one year or longer, and requires ongoing care not generally provided by a primary care provider.”

15. Under SECTION C, Definitions, added new definition, ACTUARY. Added “An individual who meets qualification standards established by the American Academy of Actuaries for an actuary and follows the practice standards established by the Actuarial Standards Board. An actuary develops and certifies the capitation rates (42 CFR 438.2].”

16. Under SECTION C, Definitions, added new definition, ACUTE CARE ONLY (ACO). Added “The enrollment status of a member who is otherwise financially and medically eligible for Arizona Long Term

Care Services (ALTCS) but who:

a. Refuses Home and Community Based Services (HCBS) offered by the Case Manager,

b. Has made an uncompensated transfer that makes him or her ineligible,

c. Resides in a setting in which Long Term Care Services and Supports (LTSS) cannot be provided, or

d. Has an equity value in a home that exceeds $713,000

17. Under SECTION C, Definitions, ADMINISTRATIVE SERVICES

SUBCONTRACT/SUBCONTRACTOR was edited. CHP was replaced with “Comprehensive Health

Plan (CHP)”.

18. Under SECTION C, Definitions, added new definition, AFFILIATED ORGANIZATION. Added “A party that, directly or indirectly through one or more intermediaries, controls, is controlled by, or is under common control with an entity.”

19. Under SECTION C, Definitions, AHCCCS (ARIZONA HEALTH CARE COST CONTAINMENT

SYSTEM), definition was removed.

20. Under SECTION C, Definitions, added new definition, AHCCCS ELIGIBILITY DETERMINATION.

Added “The process of determining through an application and required verification whether an applicant meets the criteria for Title XIX/XXI funded services.”

21. Under SECTION C, Definitions, AHCCCS MEDICAL POLICY MANUAL (AMPM), deleted definition in its entirety and replaced with: “The AMPM provides information to Contractors and Providers regarding services that are covered within the AHCCCS program. The AMPM is applicable to both

Managed Care Organizations (MCOs) and Fee-For-Services (FFS) Programs and Providers.”

Office of Procurement

3003 N. Central Avenue, 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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22. Under SECTION C, Definitions, AHCCCS MEMBER, deleted definition in its entirety and replaced with: “REFER TO “MEMBER”.”

23. Under SECTION C, Definitions, AHCCCS RULES, deleted definition in its entirety and replaced with:

“REFER TO “ARIZONA ADMINISTRATIVE CODE”.”

24. Under SECTION C, Definitions, added new definition, ALTERNATIVE HOME AND COMMUNITY

BASED SERVICES (HCBS) SETTING. Added “A living arrangement where a member may reside and receive HCBS. The setting shall be approved by the director, and either:

1. Licensed by or certified by a regulatory agency of the State,

2. Operated by the Indian tribe or tribal organization, or an urban Indian organization, and has met all the applicable standards for State Licensure, regardless of whether it has actually been obtained the license.

The possible types of settings include:

1. For an individual with an intellectual/developmental disability:

a. Community residential settings,

b. Group homes,

c. State-operated group homes,

d. Group foster homes,

e. Adult Behavioral Health Therapeutic Homes (ABHTH), and

f. Behavioral health respite homes

2. For an individual who is Elderly and/or have a Physical Disability (E/PD):

a. Adult foster care homes,

b. Assisted living homes or assisted living centers, units only,

c. Adult Behavioral Health Therapeutic Homes (ABHTH), and

d. Behavioral Health respite homes.

25. Under SECTION C, Definitions, AMERICAN INDIAN HEALTH FACILITY (ITUS), deleted definition in its entirety.

26. Under SECTION C, Definitions, AMERICANS WITH DISABILITIES ACT (ADA). Deleted definition in its entirety and replaced with: “The ADA prohibits discrimination on the basis of disability and ensures equal opportunity for individuals with disabilities in employment, state and local government services, public accommodations, commercial facilities transportation, and telecommunications. Refer to the

Americans with Disabilities Act of 1990, as amended in 42 USC 126 and 47 USC 5.

27. Under SECTION C, Definitions, AMERICAN INDIAN HEALTH PLAN (AIHP), deleted definition in its entirety.

Office of Procurement

3003 N. Central Avenue, 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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28. Under SECTION C, Definitions, APPEAL. Title changed to: “APPEAL (AS REQUIRED BY CMS 42

CFR 457.1207, 42 CFR 438.10(C)(I)). Deleted definition in its entirety, replaced with: “To ask for review of a decision that denies or limits a service.”

29. Under SECTION C, Definitions, ARIZONA ADMINISTRATIVE CODE (AAC). Amended definition.

Removed “State regulations established pursuant to relevant statutes.”. Added: “The official publication of Arizona’s codified Rules and published by the Administrative Rules Division. Referred to in this

Contract as “Rules.””

30. Under SECTION C, Definitions, added new definition, ARIZONA DEPARTMENT OF CHILD

SAFETY (DCS). Added “The department established pursuant to ARS 8-451 to protect children and to perform the following:

1. Investigate reports of abuse and neglect.

2. Assess, promote, and support the safety of a child in a safe and stable family or other appropriate placement in response to allegations of abuse or neglect.

3. Work cooperatively with law enforcement regarding reports that include criminal conduct allegations.

4. Without compromising child safety, coordinate services to achieve and maintain permanency on behalf of the child, strengthen the family, and provide prevention, intervention, and treatment services pursuant to ARS Title 8, Chapter 4.”

31. Under SECTION C, Definitions, added new definition, ARIZONA DEPARTMENT OF CHILD

SAFETY (DCS) COMPREHENSIVE HEALTH PLAN (CHP). Added, “A 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) (ARS 8-512).

32. Under SECTION C, Definitions, ARIZONA DEPARTMENT OF HEALTH SERVICES (ADHS).

Deleted definition in its entirety and replaced with: “The State agency that has the powers and duties set forth in ARS 36-104 and ARS Title 36, Chapter 5 and 34.

33. Under SECTION C, Definitions, ARIZONA DEPARTMENT OF JUVENILE CORRECTIONS (ADJC).

Deleted definition in its entirety and replaced with: “The State agency responsible for all juveniles adjudicated as delinquent and committed to its jurisdiction by the County juvenile courts.”

34. Under SECTION C, Definitions, added new definition, ASSESSMENT. Added “An analysis of a patient’s needs for physical health services or behavioral health services to determine which services a health care institution shall provide to the patient as specified in AAC R9-10-101.”

35. Under SECTION C, Definitions, added definition, ATTACHMENT. Added “Any item labeled as an

Attachment in the Contractor or placed in the Attachments section of the Contract.

Office of Procurement

3003 N. Central Avenue, 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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36. Under SECTION C, Definitions, AUTHORIZED REPRESENTATIVE. Definition deleted in its entirety and replaced with: “An individual who is authorized to apply for medical assistance or act on behalf of another individual (AAC R9-22-101, AAC R9-28-401).”

37. Under SECTION C, Definitions, BED HOLD. Definition amended to remove “and AMPM Chapter 100.”

38. Under SECTION C, Definitions, BEHAVIORAL HEALTH (BH). Definition deleted in its entirety, replaced with: “Mental health and substance use collectively.”

39. Under SECTION C, Definitions, added definition, BEHAVIORAL HEALTH PARAPROFESSIONAL

(BHPP). Added: “As specified in AAC R9-10-100 et seq, an individual who is not a behavioral health professional who provides behavioral health services at or for an Arizona Department of Health Services

(ADHS) licensed health care institution according to the health care institution’s policies and procedures that:

1. If the behavioral health services were provided in a setting other than an ADHS licensed health care institution, the individual would be required to be licensed as a behavioral health professional under ARS Title 32, Chapter 33.

2. Are provided under supervision by a behavioral health professional.”

40. Under SECTION C, Definitions, BEHAVIORAL HEALTH PROFESSIONAL (BHP). Definition deleted in its entirety and replaced with:

1. An individual licensed under ARS Title 32, Chapter 33, whose scope of practice allows the individual to:

a. Independently engage in the practice of behavioral health as defined in ARS 32-3251, or

b. Except for a licensed substance abuse technician, engage in the practice of behavioral health as defined in ARS 32-3251 under direct supervision as defined in AAC R4-6-

2. A psychiatrist as defined in ARS 36-501

3. A psychologist as defined in ARS 32-2061

4. A physician,

5. A behavior analyst as defined in ARS 32-2091

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

41. Under SECTION C, Definitions, added definition, BEHAVIORAL HEALTH TECHNICIAN (BHT).

Added, “An individual who is not a behavioral health professional who provides the following services to a patient to address the patient’s behavioral health issue:

1. With clinical oversight by a behavioral health professional, services that, if provided in a setting other than an Arizona Department of Health Services (ADHS) licensed health care institution, would be required to be provided by an individual licensed under ARS Title 32, Chapter 33.

Office of Procurement

3003 N. Central Avenue, 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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2. Health-related services.

42. Under SECTION C, Definitions, CARE MANAGEMENT PROGRAM (CMP). Definition deleted in its entirety, replaced with: “Activities to identify the top tier of high-need/high cost Title XIX members receiving services within an AHCCCS contracted health plan; including the design of clinical interventions or alternative treatments to reduce risk, cost, and help member achieve better health care outcomes. Care Management is an administrative function performed by the health plan. Distinct from

Case Management, Care Managers should not perform the day-to-day duties of service delivery.”

43. Under SECTION C, Definitions, CENTERS FOR MEDICARE AND MEDICAID SERVICES (CMS).

Definition deleted in its entirety, replaced with: “The federal agency within the United States Department of Health and Human Services (HHS), which administers the Medicare (Title XVIII) and Medicaid (Title

XIX) programs, and the State Children’s Health Insurance Program (Title XXI).”

44. Under SECTION C, Definitions, CLIENT INFORMATION SYSTEMS (CIS). Definition deleted in its entirety.

45. Under SECTION C, Definitions, added new definition, CLINICAL OVERSIGHT. Added “Monitoring the behavioral health services provided by a Behavioral Health Technician (BHT) to ensure that the BHT is providing the behavioral health services according to the health care institution’s policies and procedures and, if applicable:

1. A patient’s treatment plan.

2. Providing on-going review of BHTs skills and knowledge related to the provision of behavioral health services

3. Providing guidance to improve a BHTs skills and knowledge related to the provision of behavioral health services.

4. Recommending training for a BHT to improve the BHT’s skills and knowledge related to the provision of behavioral health services.”

46. Under SECTION C, Definitions, CONTRACT SERVICES. Definition deleted in its entirety

47. Under SECTION C, Definitions, CULTURAL COMPETENCY. Definition removed in its entirety, added: “A set of congruent behaviors, attitudes and policies that come together in a system, agency, or among professionals, which enables that system, agency, or those professionals to work effectively in cross-culture situations. Culture refers to integrated patterns of human behavior that include the language, thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious, or social groups. Competence implies having the capacity to function effectively as an individual an organization within the context of the cultural beliefs, behaviors, and needs presented by consumers and their communities. This includes consideration of health status, national origin, sex, gender, gender identity, sexual orientation, and age.”

48. Under SECTION C, Definitions, DAY, Definition amended to remove “day means a”.

Office of Procurement

3003 N. Central Avenue, 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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49. Under SECTION C, Definitions, DAY — BUSINESS, Definition amended to remove “State”

50. Under SECTION C, Definitions, DESIGNATED REPRESENTATIVE (DR), Definition amended to include

“supporter”.

51. Under SECTION C, Definitions, added new definition, DEVELOPMENTAL DISABILITY. Added: “A strongly demonstrated potential that a child under six years of age has an intellectual/developmental disability or will become a child with an intellectual/developmental disability, as determined by a test performed as specified in ARS 36-551 and ARS 36-694, by other appropriate tests, or a sever, chronic disability that:

1. Is attributable to Cognitive Disability, Cerebral Palsy, Epilepsy, Autism, or Down Syndrome.

2. Is manifested before age eighteen.

3. Is likely to continue indefinitely.

4. Results in substantial functional limitations in three or more of the followings areas of major life activity:

i. Self-care,

ii. Receptive and expressive language,

iii. Learning,

iv. Mobility,

v. Self-direction,

vi. Capacity for independent living, and

vii. Economic self-sufficiency.

5. Reflects the need for a combination and sequence of individually planned or coordinated special, interdisciplinary, or generic care, treatment or other services that are of lifelong or extended duration.”

52. Under SECTION C, Definitions, DIVISION OF MEMBER SERVICES (DMS). Definition removed in its entirety.

53. Under SECTION C, Definitions, DUAL ELIGIBLE SPECIAL NEEDS PLAN (D-SNP). Definition removed in its entirety.

54. Under SECTION C, Definitions, ELECTRONIC MEDICAL. Definition removed in its entirety.

55. Under SECTION C, Definitions, ELECTRONIC VISIT VERIFICATION (EVV). Definition removed in its entirety, replaced with: “A computer-based system that electronically verifies the occurrence of authorized service visits by electronically documenting the precise time a service delivery visit begins and ends, the individuals receiving and providing the service, and type of service performed.”

56. Under SECTION C, Definitions, EXCLUDED SERVICES. Changed title to “EXCLUDED”. Removed language: “Limitations and exclusions, other than the requirement for medical necessity and cost effectiveness, do not apply to EPSDT services.”

Office of Procurement

3003 N. Central Avenue, 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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57. Under SECTION C, Definitions, added new definition, FEE-FOR-SERVICES (FFS) MEMBER. Added

“A Title XIX or Title XXI eligible individual who is not enrolled with an AHCCCS Contractor.”

58. Under SECTION C, Definitions, added new definition, FIRST EPISODE PSYCHOSIS (FEP)

PROGRAM. Added: “A program focused on the early identification and provision of evidence-based treatment and support services to adults and adolescents who have experienced an FEP within the past two years. Evidence-based FEP programs have been shown to improve symptoms, reduce relapse, and lead to better outcomes. A commonly used evidenced based model is Coordinated Specialty Care, which is a recovery-based approach that uses shared decision making and offers case management, psychotherapy, medication management, family education and support and supported education or employment. “

59. Under SECTION C, Definitions, FISCAL YEAR. Definition removed in its entirety.

60. Under SECTION C, Definitions, FQHC Look ALIKE. Definition removed in its entirety.

61. Under SECTION C, Definitions, added new definition, HABILITATION. Added: The process by which an individual is assisted to acquire and maintain those life skills that enable the individual to cope more effectively with personal and environmental demands and to raise the level of the individual’s physical, mental, and social efficiency [ARS 36-551 (18)].”

62. Under SECTION C, Definitions, added new definition, HEALTH CARE DECISION MAKER (HCDM).

Added: “An individual who is authorized to make health care treatment decisions for the patient. As applicable to the situation, this may include a parent of an unemancipated minor or a person lawfully authorized to make health care treatment decisions pursuant to ARS Title 14, Chapter 5, article 2 or 3; or

ARS 8-514.05, 36-3221, 36-3231, or 36-3281.”

63. Under SECTION C, Definitions, added new definition, HEALTH HOME. Added “A provider that either provides or coordinates and monitors the provision of all primary, physical health, behavioral health, and service and supports to treat the whole person. A Health Home can be an Outpatient Behavioral Health

Clinic, a Federally Qualified Health Center, Primary Care Provider, or an Integrated Care Provider.

Members may or may not be formally assigned a Health Home.”

64. Under SECTION C, Definitions, HEALTH PLAN. Removed definition in its entirety, replaced with:

“REFER TO CONTRACTOR”.

65. Under SECTION C, Definitions, added new definition, HOME AND COMMUNITY BASED

SERVICES (HCBS). Added: “Home and community-based services, as defined in ARS 36-2931 and

ARS 36-2939.

66. Under SECTION C, Definitions, HOME HEALTH CARE. Added, “REFER TO “HOME HEALTH

SERVICES”.” Removed, “HCBS, as defined in A.R.S. 36-2931 and A.R.S. 36-2939(B)(2) and (C).”

Office of Procurement

3003 N. Central Avenue, 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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67. Under SECTION C, Definitions, HOME HEALTH SERVICES. Added “or beginning March 1, 2020, ordered by the member’s nurse practitioner, physician assistant, or clinical nurse specialist, as part of the plan of care and is reviewed by the practitioner annually as part of a written plan of care [42 CFR

440.70].”

68. Under SECTION C, Definitions, HOMEMAKER. Definition removed in its entirety.

69. Under SECTION C, Definitions, added new definition, HUMAN IMMUNODEFICIENCY VIRUS

(HIV). Added: “A Sexually Transmitted Infection (STI) that damages white blood cell that are very important in helping the body fight infection and disease.”

70. Under SECTION C, Definitions, added new definition, HUMAN IMMUNODEFICIENCY VIRUS

(HIV) EARLY INTERVENTION SERVICES. Added: “Appropriate pretest counseling, testing for HIV, including tests to confirm the presence of HIV, to diagnose the extent of the deficiency in the immune system, and to provide information on appropriate therapeutic measures for preventing and treating the deterioration of the immune system, and for preventing and treating conditions arising from the disease.

Appropriate post-test counseling and Therapeutic measure will also be provided [42 USC 300x-

24(b)(7)].”

71. Under SECTION C, Definitions, INTEGRATED CLINICS (ICS). Definition removed in its entirety.

72. Under SECTION C, Definitions, INTEGRATED RAPID RESPONSE. Definition removed in its entirety, replaced with; “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 and physical health needs and to refer the child for additional assessments through the behavioral health system.”

73. Under SECTION C, Definitions, MEDICAID. Added, “and State funded health care coverage”.

Removed, “Known in Arizona as AHCCCS.”

74. Under SECTION C, Definitions, added new definition, MEDICAL PRACTIONER. Added: “A physician, physician assistant or registered nurse practitioner.”

75. Under SECTION C, Definitions, MEDICAL RECORDS. Definition removed in its entirety, replaced with: “All communications related to a patient’s physical or mental health or condition that are recorded in any form or medium and that are maintained for purposes of evaluation or treatment, including records that are prepared by a health care provider or by other providers. Records do not include material that are prepared in connection with utilization review, peer review, or quality assurance activities (ARS 12-

2291).”

76. Under SECTION C, Definitions, new definition added, MEDICAL SERVICES. Added: “Medical care and treatment provided by a Primary Care Provider (PCP), attending physician, or dentist or by a nurse

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3003 N. Central Avenue, 20th Fl.

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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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77. Under SECTION C, Definitions, NON-CONTRACTING PROVIDER. Definition removed in its entirety, replaced with: “An individual or entity that provides services as prescribed in ARS 36-2901 who does not have a subcontract with an AHCCCS Contractor.”

78. Under SECTION C, Definitions, added new definition, OFFICE OF INDIVIDUAL AND FAMILY

AFFAIRS (OIFA). Added: “An area that promotes recovery, resiliency, and wellness for individuals with mental health and substance use challenges.”

79. Under SECTION C, Definitions, added new definition, OFFICE OF INDIVIDUAL AND FAMILY

AFFAIRS (OIFA) ALLIANCE. Added: “The OIFA alliance promotes the growth and expansion of peer support and family support services across the state; and engages with peers, family members, and other stakeholders to ensure their voices are included in system transformation.”

80. Under SECTION C, Definitions, PERSON-CENTERED CARE changed to PERSON-CENTERED.

Definition removed in its entirety, added: “An approach to planning designed to assist the member to plan their life and supports. This model enables individuals to increase their personal self-determination and improve their own independence.”

81. Under SECTION C, Definitions, added new definition, POSTPARTUM. Added: “For individuals determined eligible for 12-months postpartum coverage, postpartum is the period that begins on the last day of pregnancy and extends through the end of the month in which the 12-month period following termination of pregnancy ends. For individuals determined eligible for 60-days postpartum coverage, postpartum is the period that begins on the last day of pregnancy and extends through the end of the month in which the 60-day period following termination of pregnancy ends. Quality measures used in maternity care quality improvement may utilize different criteria for the postpartum period.”

82. Under SECTION C, Definitions, added new definition, POSTPARTUM CARE. Added: “Health care provide din the postpartum period to assess and treat the member’s physical, psychological, and social well-being after pregnancy, regardless of how a pregnancy ends. Services include but are not limited to, address the chronic medical conditions (e.g., hypertension, diabetes, mood disorders) family planning, and a plan to transition to parenthood, ad well-woman, or preventive care. Postpartum care visits are an ongoing process that should align with recommendations from the American College of Obstetricians and Gynecologists (ACOG).”

83. Under SECTION C, Definitions, PRE-ADMISSION SCREENING (PAS) PREMIUM, Removed definition in its entirety.

84. Under SECTION C, Definitions, added new definition, PRENATAL CARE. Added: “The provision of health services during pregnancy which is composed of three major components:

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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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1. Early and continuous risk assessment

2. Health education and promotion

3. Medical monitoring, intervention and follow-up”

85. Under SECTION C, Definitions, PRESCRIPTION DRUGS. Retitled, PRESCRIPTION DRUGS

(DEFINED PER CMS). Definition removed in its entirety, replaced with: “Medications ordered by a health care professional practitioner, and given by a pharmacist.”

86. Under SECTION C, Definitions, PRESCRIPTION DRUG COVERAGE. Definition removed in its entirety, replaced with: “Prescription drugs and medications paid for by your health plan.”

87. Under SECTION C, Definitions, PRIMARY CARE PHYSICIAN. Retitled, PRIMARY CARE

PHYSICIAN (DEFINED PER CMS). Definition removed in its entirety, replaced with: “A doctor who is responsible for managing and treating the member’s health.”

88. Under SECTION C, Definitions, PRIMARY CARE PROVIDER. Retitled, PRIMARY CARE

PROVIDER (DEFINED PER CMS). Definition removed in its entirety, replaced with: “A person who is responsible for the management of the member’s health care. A PCP may be a:

a. Person licensed as an allopathic or osteopathic physician;

b. Practitioner defined as a licensed physician assistant, or

c. Certified nurse practitioner.

89. Under SECTION C, Definitions, PRIOR QUARTER COVERAGE. Definition removed in its entirety, replaced with: “The period of time prior to an individual’s month of application for AHCCCS coverage, during which a member (limited to children under 19, individuals who are pregnant, and individuals who are in the 60-day postpartum period beginning the last day of pregnancy) may be eligible for covered services. Prior Quarter Coverage is limited to the three-month time period prior to the month of application. An applicant may be eligible during any of the three months prior to application if the applicant:

1. Received one or more covered services as specified in 9 AAC 22, Article 2 and Article 12, and 9 AAC 28, Article 2 during the month.

2. Would have qualified for Medicaid at the time services were received if the individual had applied regardless of whether the individual is alive when the application is made. Refer to

AAC R9-2-303.

AHCCCS Contractors are not responsible for payment for covered services received during the prior quarter.

90. Under SECTION C, Definitions, added new definition, QUALITY MANAGEMENT (QM). Added;

“The evaluation and assessment of member care and services to ensure adherence to standards of care and appropriateness of services; can be assessed at a member, provider, or population level.”

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91. Under SECTION C, Definitions, added new definition, QUALITY OF CARE (QOC). Added; “An expectation that, and the degree to which the health care services provided to individuals and patient populations improve desired health outcomes and are consistent with current professional recognized standards of care.”

92. Under SECTION C, Definitions, added new definition, QUALITY OF CARE (QOC) CONCERN.

Added; “An allegation that any aspect of care or treatment utilization of behavioral health services or utilization of physical health care services that caused or could have caused an acute medical or psychiatric condition or an exacerbation of a chronic medical or psychiatric condition and may ultimately cause the risk of harm to an AHCCCS member.”

93. Under SECTION C, Definitions, RAPID RESPONSE. Definition was removed in its entirety.

94. Under SECTION C, Definitions, added new definition, REFERRAL. Added; “A verbal, written, telephonic, electronic, or in-person request for health services.”

95. Under SECTION C, Definitions, added new definition, SANCTION. Added; “A monetary and/or non-monetary penalty assessed or applied for failure to demonstrate compliance in one or more areas of contractual responsibility.”

96. Under SECTION C, Definitions, SERIOUS EMOTIONAL DISTURBANCE (SED). Added, “with a qualifying mental, behavioral, or emotional diagnosis as specified in most recent”. Removed, “who currently or at any time during the past year have had a diagnosable mental or emotional disorder of sufficient duration to met diagnostic criteria specified within the current”.

97. Under SECTION C, Definitions, added new definition, SPECIALIST SUPPORT AND

REHABILITATION SERVICES PROVIDERS. Added; “Provider who provide either a limited scope of

Support and Rehabilitation Services (such as primarily specializing in respite services or skills training services) and/or services that may be designed for a specific population, age, gender, frequency, duration, or some other factor (such as a service specializing in working with teenagers or those with a history of displaying harmful sexual behaviors).

98. Under SECTION C, Definitions, added a new definition, SPECIALTY PHYSICIAN. Added; “A physician who is specially trained in a certain branch of medicine related to specific services or procedures, certain age categories of patients, certain body systems, or certain types of diseases.”

99. Under SECTION C, Definitions, SPECIALTY PRACTITIONER. Definition removed in its entirety.

100. Under SECTION C, Definitions, added new definition, SPECIALTY PROVIDER. Added; “REFER TO

“SPECIALIST”.”

101. Under SECTION C, Definitions, SUBCONTRACTOR. Removed definition in its entirety, replaced with:

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1. A provider of health care who agrees to furnish covered services

2. An individual, agency, or organization with which the Contractor, or its subcontractor has contracted or delegated some of its management/administrative functions or responsibilities.

3. An individual, agency, or organization with which a fiscal agent has entered into a Contract, agreement, purchase order or lease (or leases of real property) to obtain space, supplies equipment or services provided under the AHCCCS agreement”

102. Under SECTION C, Definitions, added new definition, TELEDENTISTRY. Added; “The acquisition and transmission of all necessary subjective and objective diagnostic data through interactive audio, video, or data communications by an AHCCCS registered dental provider to a dentist at a distant site for triage, dental treatment planning, and referral.”

103. Under SECTION C, Definitions, added new definition, TELEHEALTH. Added; “Healthcare services delivered via asynchronous, audio-only, remote patient monitoring, teledentistry, or telemedicine.”

104. Under SECTION C, Definitions, added new definition, TELEMEDICINE. Added; “The practice of synchronous (real-time) health care delivery, diagnosis, consultation, and treatment and the transfer of medical data through interactive audio and video communications that occur in the physical presence of the member.

105. Under SECTION C, Definitions, added new definition, TELEHEALTH – ASYNCHRONOUS (STORE

AND FORWARD). Added; “Transmission of recorded health history (e.g., pre-recorded videos, digital data, or digital images, such as x-rays and photos) through a secure electronic communications system between a practitioner, usually a specialist, and a member or other practitioner, in order to evaluate the case or to render consultative and/or therapeutic services outside of a synchronous (real-time) interaction.

As compared to a real-time member care, asynchronous care allows practitioners to assess, evaluate, consult, or treat conditions using secure digital transmission services, data storage services, and software solutions.

106. Under SECTION C, Definitions, added new definition, TELEHEALTH – DISTANT SITE. Added: “Site at which the provider is located at the time the services is provided via telehealth.”

107. Under SECTION C, Definitions, added new definition. TELEHEALTH – ORIGINATING SITE. Added, “Location of the AHCCCS member at the time the service is being furnished via telehealth or where the asynchronous service originates.”

108. Under SECTION C, Definitions, added new definition, TELEHEALTH – AUDIO ONLY. Added; “The practice of synchronous (real-time) health care delivery, through interactive audio-only communications.”

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109. Under SECTION C, Definitions, added new definition, TELEHEALTH-E-CONSULTANTS. Added;

“Asynchronous, non-face-to-face consultations between a primary care provider and a specialist, to discuss a member’s health condition(s) and treatment, using a secure electronic communication platform.

They include the transmission of a member’s health information without being in the presence of the member.”

110. Under SECTION C, Definitions, THERAPEUTIC FOSTER CARE (TFC). Definition removed in its entirety, replaced with: “A family-based placement option for children with serious behavioral or emotional needs who can be served in the community with intensive support.”

111. Under SECTION C, Definitions, added new definition, TREATMENT PLAN. Added; “A written plan of services and therapeutic interventions based on a complete assessment of a member’s developmental and health status, strengths and needs that are designed and periodically updated by the multi-specialty interdisciplinary team.”

112. Under SECTION C, Definitions, TRIBAL ARIZONA LONG TERM CARE SYSTEM (TRIBAL

ALTCS). Removed, “reservation”. Replaced with, “land”.

113. Under SECTION C, Definitions, TRIBAL REGIONAL BEHAVIORAL HEALTH AUTHORITY

(TRBHA). Definition removed in its entirety, replaced with: “A tribal entity that has an intergovernmental agreement with the administration, the primary purpose of which is to coordinate the delivery of comprehensive behavioral health services to all eligible individuals assigned by the administration to the tribal entity. Tribal governments, through an agreement with the State, may operate a TRBHA for the provision of behavioral health services to American Indian members. Refer to ARS 36-3401 and ARS

36-3407.”

114. Under SECTION C, Definitions, added new definition, WASTE. Added; “Over-utilization or inappropriate utilization of services, misuse of resources, or practices that result in unnecessary costs to the Medicaid Program.”

115. Under SECTION D, SCOPE OF WORK, PURPOSE, APPLICABILITY, AND INTRODUCTION, Integrated Services. Add, “4. Providers of integrated care shall operate as a team that functions as the single-point of whole health treatment and care for all of the member’s health care needs. Co-location or making referrals without coordinate care through a team approach does not equate to integrated care.”

116. Under SECTION D, SCOPE OF WORK, 1. PURPOSE, APPLICABILITY, AND INTRODUCTION, Integrated Services. Add, “5. Implementing practices to address the impact that HRSN can have on a member’s whole person health and well-being.”

117. Under SECTION D, SCOPE OF WORK, 1. PURPOSE, APPLICABILITY, AND INTRODUCTION, Integrated Services. Add, “7. Operating a single nurse triage line available for all members for physical and behavioral health services.”

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118. Under SECTION D, SCOPE OF WORK, 1. PURPOSE, APPLICABILITY, AND INTRODUCTION, Integrated Services 10. Add, “Using the following strategies to achieve system goals: a. Early screening, identification and intervention that reduces the incidence and severity of serious physical, and mental illness, b. Use of health education and health promotion services, c. Increased use of primary care prevention strategies d. Use of validated screening tools, e. Focused, targeted, consultations for behavioral health conditions, f. Cross-specialist collaboration, g. Enhanced discharge planning and follow up care between provider visits, h. Ongoing outcome measurement and treatment plan modification, i.

Care coordination through effective provider communication and management of treatment, j. Training of Contractor staff and contracted providers, and k. Member, family, and community education.”

119. Under SECTION D, SCOPE OF WORK, 2. ELIGIBILITY CATEGORIES. Removed: “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.

120. Under SECTION D, SCOPE OF WORK, 2. ELIGIBILITY CATEGORIES. Added to bullet 5, “including the Child and Adolescent Level of Care Utilization System (CALOCUS) for SED, if applicable”.

121. Under SECTION D, SCOPE OF WORK, 2. ELIGIBILITY CATEGORIES, Serious Emotional

Disturbance and Serious Mental Illness Removal of Designation. Added, “The Contractor shall compliance with the SED/SMI Eligibility Determination vendor’s established policy related to the requests for Removal of SED or SMI Designations that include a verification process of claims history for a period of six months and response back to the vendor within seven business days if any qualifying claims have occurred in the previous six months.”

122. Under SECTION D, SCOPE OF WORK, 3. ENROLLMENT AND DISENROLLMENT, ALTCS

Eligibility Determination During Hospitalization. Added “Pending ALTCS eligibility may not be used as a reason to delay or deny other medically necessary services.”

123. Under SECTION D, SCOPE OF WORK, 9. SCOPE OF SERVICES, Authorization of Service. Added, “The Contractor’s ability to ensure the delivery of services requires a complete and thorough understanding of the intricate, multi-layered service delivery system in order to create an ISOC that address the members needs. The type, amount, duration, scope of services, and method of service delivery depends on a wide variety of factors including: 1. Eligible populations. 2. Covered service benefit package. 3. Approach. 4. Funding. 5. Member need. The Contractor is required to comply with all terms in this Contract and all applicable requirements in each document guide and manual; however particular attention should be paid to the AMPM and ACOM with respect to requirements for effective service delivery.”

124. Under SECTION D, SCOPE OF WORK, 9. SCOPE OF SERVICES, Behavioral Health Services. Added, “310-B, AMPM Exhibit 300-2A, and the AHCCCS Covered Behavioral Health Services Guide.

Behavioral Health Services included but are not limited to the following: Behavior Analysis: Behavioral

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Analysis services are an AHCCCS covered benefit for individuals with Autism Spectrum Disorder

(ASD)( and other diagnoses as justified by medical necessity. Refer to AMPM Policy 320-S.

125. Under SECTION D, SCOPE OF WORK, 9. SCOPE OF SERVICES, Behavioral Health Services. Added, “The Contractor shall ensure compliance with AAC R9-10 Article 7 and AHCCCS policies. Refer to

AMPM 320-V. The Contractor shall develop admission criteria, continued stay criteria, and discharge readiness criteria for medical necessity which at a minimum includes the elements as specified in AMPM

Policy 320-V. The Contractor shall submit the BHRF Medical Necessity Criteria for prior approval as specified in Exhibit 4, Contractor Chart of Deliverables.

126. Under SECTION D, SCOPE OF WORK, 9. SCOPE OF SERVICES, Crisis Services. Added, “The

Contractor shall ensure the following: 1. A robust system of care and sufficient provider network of facilities to transition a member from receiving crisis services, such as behavioral Health Residential

Facilities (BHRF), Residential Treatment Centers (RTCs), respite care, and other ongoing care options, when continuing services are required. 2. Timely follow up and care coordination for Medication Assisted

Treatment (MAT), including Medications for Opioid Use Disorder (MOUD) for members after receiving crisis services to ensure stabilization of the member and appropriate delivery of ongoing necessary treatment and services. 3. Prior Authorization (PA) is not required for emergency behavioral health services (AAC R9-22-210.01), including crisis services. 4. Develops policies and procedures to ensure timely communication with ACC-RBHAs for members that have engaged in crisis services. 5. Contractor staff are available 24 hours per day, seven days per week to receive notification of member engagement in crisis services and to provide member post-24-hour crisis stabilization services, care coordination, and discharge planning, as appropriate. 6. Documented follow-up to the member within 72 hours after the member receives services provided by the Crisis Call Center, Mobile Crisis Team or discharges from a

Crisis Stabilization Center as specified in AMPM Policy 590. 7. Engage peer and family support services when responding to post-crisis situations, as preferred and identified by the member. 8. Tracks member crisis system utilization and refer repeat and/or frequent users of crisis services to the Contractor’s Care

Management and/or high needs/high-cost program. 9. Addresses preventable crisis system and inpatient psychiatric utilization through various strategies, including but not limited to, extended availability of outpatient treatment services, after hours member care options, development of member specific safety plans, and ensuring engagement of outpatient treatment providers in responding to post-crisis care and treatment. 10. Cooperate with DCS CHP, AHCCCS, the State designated HIO, and any applicable vendors to enhance crisis-related data sharing and availability through the HIE or other applicable data or Information Systems (IS). 11. Relay crisis contact notifications received from an ACC-RBHA or a crisis provider on behalf of an ACC-RBHA to DCS CHP.”

127. Under SECTION D, SCOPE OF…