RFP 250000002670 - Schedule A - Statement of Work - Amendment 1.docx

TABLE OF CONTENTS

Michigan.gov/MiProcurement

Michigan.gov/MiProcurement

SCHEDULE A - STATEMENT OF WORK

Request for Proposal No. 250000002670 Prepaid Inpatient Health Plan (PIHP) The State hereby enters into a Contract with the specialty Prepaid Inpatient Health Plan (PIHP) Contractor identified on the signature page of this Contract.

IMPORTANT NOTE TO CONTRACTORS/BIDDERS: In addition to responses to the Schedule J Narrative Submission Questions document, there are specific requirements for which acceptance must be simply acknowledged through a checkbox(es), and others that require further explanation. Click the appropriate checkbox and complete the entries as appropriate.

BACKGROUND

Under approval granted by the Centers for Medicare and Medicaid Services (CMS), the Michigan Department of Health and Human Services (MDHHS) operates a 1115 Behavioral Health Demonstration. Through this authority, the Medicaid Managed Care system delivers selected Medicaid State plan specialty services related to mental health and developmental disability services, as well as certain covered Substance Use Disorder (SUD) services. These services have been “carved out” (removed) from Medicaid primary physical health care plans and arrangements.

CMS has also approved a 1115 Demonstration titled the Healthy Michigan Plan (HMP) which provides health care coverage for adults who become eligible for Medicaid under Section 1902(2)(10)(A)(i)(VIII) of the Social Security Act. In Michigan, the 1115 Behavioral Health Demonstration and the Healthy Michigan Plan are managed on a shared risk basis by specialty PIHP contractors, selected through a competitive procurement process, the details of which can be found on the Specialty Behavioral Health Services website: https://www.michigan.gov/mdhhs/keep-mi-healthy/mentalhealth/specialty-behavioral-health-services.

The 2025 public survey issued as part of the competitive procurement process led to the development of four strategic pillars for PIHPs:

1. Provide high quality, timely services:

a. Ensure timely access to services through network adequacy and provider availability.

b. Deliver high-quality services that address the full continuum of care.

2. Improve choice & consistency across regions:

a. Improve choice in access to services.

b. Promote consistency across regions to ensure access to services regardless of where members reside.

3. Ensure accountability & transparency:

a. Increase accountability & transparency through enhanced oversight and outcomes-centered performance management.

b. Remove structural conflict of dual payor/ provider responsibilities.

4. Simplify the system with reduced bureaucracy:

a. Decrease bureaucracy and administrative burden, improving efficiency for providers as well as members accessing care.

Services provided under the behavioral health managed care program include treatment for people with Serious Mental Illness (SMI), Serious Emotional Disturbance (SED), Substance Use Disorder (SUD) and Intellectual and Developmental Disabilities (I/DD). Behavioral Health Services include State plan and Early Periodic Screening, Diagnosis and Treatment (EPSDT) services, 1915(i) State Plan Amendment (SPA), services, and 1915(c) State Plan Amendment (SPA) Waiver services:

· Children’s Waiver Program (CWP)

· Habilitation Supports Waiver (HSW)

· Serious Emotional Disturbance Waiver (SEDW) All the SUD services are covered under the State plan (or alternative benefit plan (ABP)) for the HMP population.

SCOPE

The purpose of this Contract is to obtain the services of Contractor to manage the 1115 Behavioral Health Demonstration Waiver Program, the Healthy Michigan Plan and relevant approved Waivers in a designated service area and to provide a comprehensive array of specialty mental health and SUD services and supports as indicated in this Contract. This is a Capitated Rate Contract paid on a price-per eligible per month (PEPM) basis. Contractor must manage its responsibilities in a manner that promotes maximum value, efficiency, and effectiveness consistent with State and federal statute and applicable waiver standards. This includes limiting managed care administrative duplication thereby reducing avoidable costs while maximizing the portion of funds to be directed to beneficiary services. Contractor must actively manage behavioral health services for its awarded region using standardized methods and measures for determination of need and appropriate delivery of service. Contractor must ensure that cost variances in services are supported by quantifiable measures of need to ensure accountability, value and efficiency. Contractor is required to hold contracts with each Community Mental Health Services Program (CMHSP) in its region(s) and must minimize duplication of contracts and reviews for providers contracting with multiple CMHSPs in the service area.

Remedies, Sanctions, or liquidated damages described in Schedule A are in addition to, and not in lieu of, the State's ability to terminate this Contract pursuant to the Contract terms. Requirements outlined in Schedule A are in addition to, and not in lieu of, any requirements set forth elsewhere in this Contract.

RESPONSIBILITIES OF THE STATE

The State will administer this Contract with Contractor, monitor Contract performance, and perform oversight. In addition, the State has the authority to take whatever action is necessary to address repeated health and welfare issues or emergencies or Contractor’s failure to provide medically necessary services timely. MDHHS is the single-state agency with final responsibility to administer and supervise Michigan’s Medicaid program. Entities contracting with the State to fulfill the State’s obligations are required under the terms of their contracts and state and federal Medicaid law to follow MDHHS’ policies, rules, and regulations and adhere to its obligations.

1. Requirements Contractor must provide deliverables/services and staff to do all things necessary to ensure the performance requirements and performance of work as required by this Contract. The requirements set forth in Schedule A and elsewhere in the Contract may collectively be referred to as “Contract Activities.” Contractor must comply with all provisions of Medicaid policy and Medicaid Waivers applicable to Contractors unless provisions of this Contract stipulate otherwise. All policies, procedures, operational plans and clinical guidelines followed by Contractor must be in writing and available to the State and CMS upon request. All medical records, report formats, information systems, liability policies, provider network information, applicable policies, and other details specific to performing the Contracted Services must be available to the State and CMS upon request.

Contractor must have sufficient administrative staff and organizational components to comply with the responsibilities reflected in this Contract. Contractor must ensure that all personnel have training, education, experience, licensing, or certification appropriate to their position and responsibilities.

1.1 General Requirements

The following sections provide an explanation of the specifications and expectations that Contractor must meet and the services that must be provided under the Contract. Contractor and its provider network are not, however, constrained from supplementing this with additional services or elements deemed necessary to fulfill the intent of the Medicaid Specialty Behavioral Health Program. Contractors are expected to provide managed care functions to beneficiaries. Those functions cannot be delegated to contracted network providers with the exception of Preadmission screening for emergency intervention services per Mental Health Code MCL 330.1409 which shall be performed by the CMHSP with Contractor authorization of inpatient admissions as indicated by the preadmission screening unit. Managed care functions include, but are not limited to, eligibility and coverage verification, utilization management, network development, contracted network provider training, claims processing, activities to improve health care quality, and fraud prevention activities. (See Schedule G, Definitions of Terms, for a complete list of managed care functions). Contractor may not directly provide or deliver health care services beyond these managed care functions. Contractor must be considered a nonprofit organization, Public body/Governmental entity, or a Public University.

Bidder must provide documentation that their organizational structure meets one of the requirements stated in the Proposal Instructions, Section 7. Mandatory Minimum Requirements labeled as, “Documentation for Mandatory Minimum Requirement”.

A. Service Area

1. Targeted Geographical Area for Implementation

a. Contractor must manage the Specialty Behavior Health Services population under the terms of this Contract for its awarded region(s). Counties included in each service area can be found at the following website: https://www.michigan.gov/mdhhs/keep-mi-healthy/mentalhealth/specialty-behavioral-health-services. Contractor must operate in one or more of three (3) regions throughout the State for the provision of Covered Services.

2. Region Expansion during Contract Term

a. The Contractor’s region includes all areas identified by MDHHS in which beneficiaries may be enrolled. Expansion of, or changes to, the Contractor’s region will be at the sole discretion of MDHHS.

3. Target Population

a. Contractor is responsible for serving beneficiaries eligible for Medicaid Specialty Behavioral Health Services:

i. In the service area described in Section 1.A.1.a. above, pursuant to the terms of this Contract.

4. Home and Community Character

a. Contractor must ensure that the residential (adult foster care, specialized residential, provider owned/controlled) and non-residential services (skill building, community living supports, and out of home non-vocational) where individuals are supported by funds from the Medicaid Home and Community Based Services (HCBS) 1915(i) State Plan Amendment (SPA) and HCBS 1915(c) waiver programs (Habilitation Supports Waiver, Children’s Waiver, and Children’s SED Waiver) maintain a home and community character setting as required by federal regulation and outlined in the HCBS Section of the Medicaid Provider Manual.

B. Customer Services Standards

1. Introduction

a. Contractor must establish a Customer Services Unit. Contactor must convey an atmosphere that is welcoming, helpful and informative. As per 42 CFR 438.66, these standards apply to the Contractor. These Customer Service Standards can be found on the MDHHS website: https://www.michigan.gov/mdhhs/keep-mi-healthy/mentalhealth/mentalhealth/practiceguidelines. Contractor must abide by all requirements within the PIHP Customer Service Standards.

2. Functions 42 CFR 438.71(d)

a. Welcome and orient individuals to the managed care system including services and benefits available, and the provider network.

b. Provide information regarding covered services to assist the beneficiary in making decisions about care options, including how to access behavioral health, primary care and other community services.

c. Provide an access point for complaints, concerns about access to covered services, enrollment and other related matters.

d. Provide outreach to beneficiaries and authorized representatives through various means when requested, including information about how to access the various rights processes.

e. Provide education on grievance and appeal rights, the State Fair Hearing process, and beneficiary rights and responsibilities, including the “Your Rights When Receiving Mental Health Services in Michigan” booklet. Reference the following website for more information: https://www.michigan.gov/mdhhs/keep-mi-healthy/mentalhealth/mentalhealth/recipientrights/information/rights-information-handbooks-and-podcast.

f. Help individuals with problems and inquiries regarding benefits.

g. Assist with navigating the appeals and grievance process, including the appeal of an Adverse Benefit Determination or State Fair Hearing and, upon request, provide sources for legal representation. See Section L. Grievance and Appeals Process for Beneficiaries.

h. Review data to identify, remediate and participate in the resolution of systemic issues for the organization. Track and report patterns of problem areas for the organization.

3. Requirements Contractor must:

a. Establish a Customer Services Unit with a minimum of one full-time equivalent (FTE).

b. Establish a toll-free customer service telephone line with access to alternative telephonic communication methods (such as teletypewriter (TTY)).

c. Ensure initial calls are answered by a live voice during normal business hours, a minimum of eight hours daily, Monday through Friday, excluding observed holidays.

d. Publish customer service numbers in agency brochures and public information material.

e. Publish how to access Customer Services information outside of normal business hours in the Customer Services Handbook and on Contractor website.

f. Develop a Customer Services Handbook in accordance with the MDHHS Customer Services Standards and 42 CFR 438.10(g)(2).

g. Provide the Customer Services Handbook to the beneficiary by one of the following methods:

i. Mailing a printed copy to the beneficiary’s mailing address.

ii. Emailing an electronic version after obtaining the beneficiary’s written approval.

iii. Notifying the beneficiary by providing a written statement that identifies where the handbook can be found on the website.

iv. Other alternate distribution method based on the request of the beneficiary.

h. Include the date of publication/revision and/or version number in each Customer Services Handbook.

i. Provide a current version of the Customer Services Handbook to the beneficiary upon first request of service and annually thereafter, or sooner if substantial revisions have been made.

j. Utilize model handbook and notices templates in accordance with the MDHHS Customer Service Standards and Appeals and Grievance Policy.

k. To the extent possible, provide each beneficiary with at least 30 days’ notice before the intended effective date of any change that the State defines as significant in the information specified in 42 CFR 438.10(g)(2). Significant is defined as any change that affects a beneficiary’s Medicaid benefits, including but not limited to: Contractor contract information, authorization for services, covered benefits and copays, how to access afterhours emergency coverage.

l. Ensure all information contained in the Customer Services Handbook follows the guidelines for written materials as indicated in N. Beneficiary Services 2. Written materials.

m. Obtain State approval, in writing, prior to publishing original and revised editions of the Customer Services Handbook.

n. Produce supplemental materials to the Customer Services Handbook, as needed, to ensure compliance with Contractual Requirements (e.g., inserts/stickers).

C. Payment Reform

1. Data Reporting

a. In order to oversee and continually improve the performance of its network providers, Contractor must collect and report data in a consistent and coordinated manner, as directed by the State.

b. Contractor agrees to work collaboratively with the State and with other Contractors to develop standard measure specifications, data collection processes, baseline data, and reports that will be provided to network providers/subcontractors and the State.

2. Responsibility for Payment of Covered Services

a. Contractor will be responsible for payment for services that Contractor authorizes, including Medicaid SUD services. This provision presumes Contractor, and its network providers and subcontractors are fulfilling their responsibility to individuals according to the terms specified in the Contract.

b. Services must not be delayed or denied as a result of a dispute of payment responsibility with or among two or more network providers/subcontractors. In the event there is an unresolved dispute between Contractor and network providers/subcontractor(s), either entity may request the State’s involvement to resolve the dispute and make a determination. However, services must not be delayed or denied as a result of or during any such dispute.

c. Contractor, or designee, must be contacted for authorization for post-stabilization care. Contractor is financially responsible for post-stabilization care services that are pre-approved by Contractor.

d. Contractor is also responsible for post-stabilization care services when they are administered to maintain, improve or resolve the beneficiary’s stabilized condition when:

i. Contractor does not respond to a request for pre-approval within one hour.

ii. Contractor cannot be contacted.

iii. Contractor’s representative and the treating physician cannot reach an agreement concerning the beneficiary's care and a Contractor physician is not available for consultation. In this situation, Contractor must give the treating physician the opportunity to consult with a Contractor physician and the treating physician may continue with care of the patient until a Contractor physician is reached or one of the criteria of 42 CFR 422.133(c) is met.

e. Financial responsibility for beneficiaries who are children is the county where the child and parents have primary residence. For temporary and permanent wards of the State or court (including tribal), financial responsibility is the county where the child currently resides in the community (i.e., licensed foster care home, relative placement, or independent living) as long as the foster care case remains open. Residential treatment facilities licensed as a Child Caring Institution (CCI) including shelter placements contracted by MDHHS child welfare are not considered “residing in the community.” If a temporary or permanent court ward is residing in the community with a foster family, the county where the child is residing is responsible for authorizing inpatient psychiatric hospitalization when medically necessary. If the child is not residing in the community and placed by child welfare in a residential treatment facility or a DHHS emergency shelter licensed as a CCI, the county of court record would be responsible for assessing and authorizing the inpatient psychiatric hospitalization and providing transition services (assessment for community-based services, Intensive Care Coordination with Wraparound, case management or supports coordination) for up to 180 days prior to discharge.

f. In accordance with 42 CFR 438.114(c)(1)(ii)(B), Contractor is prohibited from denying payment for treatment obtained by a beneficiary when a representative of Contractor instructs the beneficiary to seek emergency services. The attending emergency physician, or the provider treating the beneficiary, is responsible for determining when the beneficiary is sufficiently stabilized for transfer or discharge in accordance with 42 CFR 438.114(d)(3).

g. In accordance with 42 CFR 438.114(d)(2), Contractor may not hold an enrollee who has an emergency medical condition liable for payment of subsequent screening and treatment needed to diagnose the specific condition or stabilize the patient.

3. Liability for Payment

a. Contractor must ensure that its Medicaid beneficiaries are not held liable for Covered services provided to the beneficiary, for which the State does not pay Contractor, or Contractor does not pay the individual or health care provider that furnished the services under a contractual, referral, or other arrangement.

D. Contract Enforcement Methods (Civil Monetary Contract Remedies, Credits and Liquidated Damages

1. MDHHS will utilize a variety of means to assure compliance with Contract requirements and any applicable laws. MDHHS may impose late fees, performance credits (“civil monetary sanctions”), enrollment adjustments (including suspension of all new enrollments, suspension of auto-assigned enrollment, and redistribution of existing enrollment to other Contractors), and other contract remedies, credits and liquidated damages on Contractor. Civil monetary sanctions, contract remedies credits and liquidated damages shall collectively be referenced as (“contract enforcement methods”). MDHHS will utilize contract enforcement methods to require the Contractor to implement corrective action plans and to resolve outstanding requirements as appropriate.

2. The provisions governing a contested case under the Administrative Procedures Act of 1969, 1969 Public Act (PA) 306, MCL 24.201 to 24.328, do not apply to contract enforcement mechanisms under this section because they are not issued pursuant to the authority provided in MCL 330.1232b.

3. MDHHS may employ contract enforcement methods to address any Contractor violations and performance concerns. The use of contract enforcement methods will typically follow a progressive approach, but MDHHS reserves the right to deviate from the progression as needed, and at MDHHS’s sole discretion. The application of remedies shall be a matter of public record.

4. Contract enforcement methods include but are not limited to:

a. Requiring the Contractor to submit a plan of correction and specified status reports that become a Contract performance objective.

b. Imposing a direct dollar credit and making it a non-matchable Contractor administrative expense and reducing earned savings from that fiscal year by the same dollar amount.

c. Delaying up to 25% of scheduled payment amount to Contractor until Contractor comes into compliance as determined by MDHHS. MDHHS may apply this credit in a subsequent payment cycle and will provide prior written notice to Contractor.

5. The pursuit of any contract enforcement method does not require a Contract amendment. The Contract Compliance notice to Contractor is sufficient authority.

6. Contract enforcement methods imposed pursuant to this Contract may be collected by deducting the amount of the monetary sanction from any payments due to Contractor or by demanding immediate payment by Contractor. MDHHS, at its sole discretion, may establish an installment payment plan for payment of any civil monetary sanction. The determination of the amount of any civil monetary sanction is at the sole discretion of MDHHS, within the ranges set by MDHHS. Self-reporting by Contractor will be taken into consideration in determining the amount of any monetary sanction.

7. For instances where the specific contract compliance concerns prompting MDHHS’ outreach to the Contractor are also the subject of a Medicaid Fair Hearing, the concurrent Medicaid Fair Hearing does not preclude the Contractor from also cooperating fully with the Department’s contract compliance investigation/outreach.

8. Any contractual financial Sanctions, Credits, or Withholds may be imposed upon the Contractor and carried out by MDHHS, regardless of whether or not the contractual dispute item causing the financial Sanction, Credit, or Withhold has been, or is in the process of being, adjudicated through the dispute resolution or administrative hearings processes.

9. The Contractor will not pass-through liquidated damages imposed under this Contract to a provider and/or subcontractor, unless the provider and/or subcontractor caused the damage through its own action or inaction. Nothing described herein will prohibit a provider and/or a subcontractor from seeking judgment before an appropriate court in situations where it is unclear that the provider and/or the subcontractor caused the damage by an action or inaction. All liquidated damages imposed pursuant to this Contract, whether paid or due, will be paid by the Contractor out of administrative costs and profits.

10. Areas of noncompliance for which MDHHS may utilize contract enforcement methods include, but are not limited to noncompliance in the following areas:

a. Administration and management.

b. Standards promulgated by MDHHS.

c. Provision of medically necessary covered services.

d. Misrepresentation or falsification of information to state or federal government.

e. Appeal and grievance systems.

f. CMS 1915(c)Waivers and 1915(i)SPA reporting requirements (including as outlined in the CAP scoring metric).

g. Claims management.

h. Enrollee materials and customer services.

i. Finance, including medical loss ratio reporting.

j. Information systems, including encounter data reporting.

k. Marketing.

l. Medical management, including utilization management and case management.

m. Program integrity.

n. Provider network management, including provider directory standards.

o. Availability and accessibility of services, including network adequacy standards.

p. Quality improvement.

q. Financial statement reporting, audits, compliance examination reporting.

r. Settlement reporting.

s. Capital reserve requirements.

11. Areas related to the delivery of Long Term Services and Supports (LTSS) not otherwise included in paragraphs (10)(a) through (r) of this Section as applicable to the managed care program.

a. Administrative Subcontractor oversight.

b. All other provisions of the Contract, as appropriate.

E. Access and Availability

1. Provider Network Services Contractor is responsible for maintaining and continually evaluating an effective provider network that is adequate to fulfill the obligations of this Contract. Contractor remains the accountable party for the Medicaid beneficiaries in its service area. In compliance with 42 CFR Parts 438.414; 438.10(g)(2)(xi)(C)(D)(E) and 457.1260, Contractor must:

a. Maintain a regular means of communicating and provide information on changes in policies and procedures to its providers. This may include guidelines for answering written correspondence to providers, offering provider- dedicated phone lines, and a regular provider newsletter.

b. Have clearly written mechanisms to address provider grievances and complaints, and an appeal system to resolve disputes.

c. Provide a copy of Contractor's prior authorization policies to the provider when the provider joins Contractor's provider network. Contractor must notify providers of any changes to prior authorization policies.

d. Provide a copy of Contractor's grievance, appeal and fair hearing procedures and timeframes to the provider when the provider joins Contractor's provider network. Contractor must notify providers of any changes to those procedures or timeframes.

e. Provide, in the format specified by the State, a complete listing and description of the provider network available to recipients in the service area.

f. Assure that services are accessible, considering travel time, availability of public transportation, and other factors that may determine accessibility.

g. Assure that network providers do not segregate beneficiaries in any way from other individuals receiving their services.

2. Indian Health Care Providers (IHCP) Network Requirements

a. In accordance with 42 CFR 438.14, Contractor must demonstrate that there are sufficient Indian Health Care Providers (IHCP) participating in the provider network to ensure timely access to services available under the Contract from such providers for Indian beneficiaries who are eligible to receive services.

i. If timely access to covered services cannot be ensured due to few or no IHCPs, Contractor must:

1) Allow Indian beneficiaries to access out-of-State IHCPs; or

2) Show good cause for disenrollment from both Contractor and the State's managed care program in accordance with 42 CFR § 438.56(c).

ii. Contractor must permit Indian beneficiaries to obtain services covered under the Contract from out-of- network IHCPs from whom the beneficiary is otherwise eligible to receive such services.

iii. Contractor must permit an out-of-network IHCP to refer an Indian beneficiary to a network provider.

3. Network Adequacy Standards Information regarding Network Adequacy Standards can be found at the following MDHHS website: https://www.michigan.gov/mdhhs/keep-mi-healthy/mentalhealth/reporting

a. Pursuant to 42 CFR Parts 438.68 and 457.1218, MDHHS created a Network Adequacy Standards policy (MSA 18-49) and corresponding procedural document to effectuate network adequacy standards for Michigan’s specialty behavioral health delivery system. Contractor’s Provider Network must be supported by Provider Contracts and sufficient to provide adequate access to all Covered Services for the maximum number of beneficiaries specified under this Contract. Contractor must ensure its Provider Network can deliver Covered Services to all beneficiaries, including but not limited to beneficiaries with limited English Proficiency, Beneficiaries who are deaf or hard of hearing, beneficiaries with diverse cultural and ethnic backgrounds, and beneficiaries with physical and mental disabilities. Contractor must comply with the network adequacy standards set forth in the policy and procedure documents.

b. Contractor must comply with the standards set forth in this Contract requirement. The State will provide 90 days’ advance written notice to Contractor prior to the effective date of any changes to the Schedule I-Network Adequacy Procedure. MDHHS reserves the right to revise the network adequacy standards, as needed.

c. Contractor must submit the Network Adequacy Profile File (NAP File) quarterly to MDHHS according to the Schedule E.

d. Contractor must submit the Network Access Plan on how the standards will be effectuated. The Network Access Plan must be submitted at least annually according to Schedule E and updated anytime a provider network change occurs (as described below), or a Network Exception Request Form is submitted. The Network Access Plan must include all MDHHS requested elements (outlined in Network Access Plan Document) including but not limited to the following:

i. Maximum time and distance.

ii. Provider to enrollee ratios.

iii. Timely appointments and access to services.

iv. Language, Cultural competence, and Physical accessibility.

v. Contractor offers appropriate range of specialty behavioral health and SUD services, in accordance with this Contract, that is adequate for anticipated number of beneficiaries for the Service Area.

vi. Maintenance of a network of Providers that is sufficient in number, mix, and geographic distribution to meet the needs of the anticipated number of beneficiaries in the Service Area.

vii. Contractor must make Covered Services available 24 hours a day, seven days a week, when Clinically Necessary.

e. If Contractor's Provider Network changes such that it no longer meets network adequacy standards, the Contractor must:

i. Update and submit to MDHHS within ten business days its Network Access Plan to describe the Network non-compliance and how the Contractor is addressing it.

ii. Immediately update its assessment of capacity, as reported to MDHHS.

Failure to do (i) and (ii), above, may result in MDHHS imposing monetary Sanctions and/or other Sanctions according to Section D. Contract Enforcement Methods

f. Contractor may request Provider Network Exceptions to the time, distance and Provider-to-enrollee ratio standards identified in Schedule I Network Adequacy Procedure. Approval of any requested Provider Network Exceptions will be at the sole discretion of MDHHS. Requests must be submitted via the Provider Network Exception Request Form accompanied by an updated Network Access Plan within ten business days of identified network gap, noncompliance, or change in provider network negatively impacting network adequacy. The request must include, but is not limited to:

i. A plan for how Contractor will reasonably deliver Covered Services to beneficiaries who may be affected by the exception and how Contractor will work to increase access to the applicable provider type in the designated county or counties.

ii. How Contractor will monitor, track and report to MDHHS the delivery of Covered Services to beneficiaries potentially affected by the exception.

g. If a Provider Network Exception to a time, distance or Provider-to-enrollee ratio standard is granted by MDHHS, the exception is limited to the identified provider type and county or counties and is granted for a period of up to one year, unless otherwise specified. If the Contractor seeks to extend the network exception needs beyond the first year, Contractor must submit a revised Network Exception Request Form for approval and review.

i. Contractor must maintain a network of qualified providers in sufficient numbers, mix, and geographic locations throughout their respective service area for the provision of all covered services. Contractor may also utilize qualified providers from outside Contractor’s service area for the provision of covered services.

ii. Contractor must consider anticipated enrollment and expected utilization of services.

iii. The availability of Covered Services through telehealth may not be considered in the Contractor’s demonstration of network adequacy or its compliance with the network adequacy standards identified in the procedure document.

iv. Contractor must provide documentation on which the State bases its certification that Contractor complied with the State’s requirements for availability and accessibility of services, including the adequacy of the provider network as referenced in 42 CFR Parts 438.604(a)(5); 438.606; 438.207(b) and 438.206. Submission of documentation will take place as specified by the State but no less frequently than the following:

v. At the time Contractor enters into a contract with the State.

vi. On an annual basis.

vii. Anytime there has been significant change (as defined by the State) in Contractor operations that would affect adequacy of capacity and services, including changes in services, benefits, geographic service area, composition of or payments to its provider networks, or at the enrollment of a new population.

h. Contractor must submit any other data, documentation, or information relating to the performance of the entity’s obligations as required by the State as referenced in 42 CFR Parts 438.604(b) and 438.606.

4. Changes in Provider Network

a. Contractor must notify the State within seven days of any changes to the composition of the provider network organizations through the MDHHS Behavioral Health Customer Relationship Management (CRM). In addition, notification must be provided anytime there has been a significant change. A significant change could include, but is not limited to, contract non-renewal for network provider, provider and/or consumer relocation, warranties and representation, etc.

b. Contractor must have procedures to assess the impact of changes in its network to ensure an adequate network of providers is maintained.

c. The inability to maintain an adequate provider network may be grounds for sanctions and/or corrective action planning.

5. Out-of-Network Providers

a. Contractor must provide adequate and timely access to and authorize and reimburse Out-of-Network providers and cover Medically Necessary services for beneficiaries if such services could not reasonably be obtained by a network provider on a timely basis inside or outside the State of Michigan. Contractor must cover such Out-of-Network services for as long as Contractor’s provider network is unable to provide adequate access to covered Medically Necessary services for the identified beneficiary(ies) as referenced in 42 CFR 438.206(b)(4).

b. If Contractor cannot reasonably provide access to non-emergent Covered Services by a network provider within access requirements of this Contract, Contractor must include in its service authorization decision, the provision of Covered Services Out-of-Network.

c. Contractor must comply with all related Medicaid Policies regarding authorization and reimbursement for Out-of- Network providers.

i. Contractor must pay Out-of-Network Medicaid providers’ claims at established Medicaid fees in effect on the date of service.

ii. If Michigan Medicaid has not established a specific rate for the Covered Service, Contractor must follow Medicaid Policy to determine the correct payment amount.

6. 1115 Behavioral Health Demonstration Waiver and Healthy Michigan Programs

a. Unless otherwise noted in the Michigan Medicaid Provider Manual, mental health and intellectual/developmental disabilities services may be provided in other locations in the community, including the beneficiary's home, according to individual need and clinical appropriateness.

7. Provider Procurement

a. Contractor is responsible for the development of the service delivery system and the establishment of sufficient administrative capabilities to carry out the requirements and obligations of this Contract. Where Contractor and its provider network fulfill these responsibilities through subcontracts, they must adhere to applicable provisions of federal procurement requirements as specified in 2 CFR 200. In complying with these requirements and in accordance with 42 CFR 438.12, Contractor:

i. May not discriminate for the participation, reimbursement, or indemnification of any provider who is acting within the scope of his or her license or certification under applicable State law, solely on the basis of that license or certification.

ii. Must give those providers not selected for inclusion in the network written notice of the reason for its decision.

iii. Is not required to contract with providers beyond the number necessary to meet the needs of its beneficiaries and is not precluded from using different practitioners in the same specialty. Nor is Contractor prohibited from establishing measures that are designed to maintain quality of services and control costs and are consistent with its responsibilities to its beneficiaries. In addition, Contractor's selection policies and procedures cannot discriminate against particular providers that serve high-risk populations or specialize in conditions that require costly treatments. Also, Contractor must ensure that it does not employ or contract with providers excluded from participation in federal health care programs under either Section 1128 or Section 1128A of the Social Security Act.

iv. Contractor may not include non-compete clauses in its contract with providers.

8. Access Standards

a. Contractor must ensure timely access to covered supports and services taking into account the urgency of the need for services, as well as appointment wait time in accordance with the MDHHS Access Standards, which can be found on the MDHHS website: https://www.michigan.gov/mdhhs/keep-mi-healthy/mentalhealth/mentalhealth/practiceguidelines.

b. Contractor must ensure that services included in the contract are available 24 hours a day, seven (7) days a week, when medically necessary.

c. Contractor must ensure that network providers provide physical access, reasonable accommodations, and accessible equipment for Medicaid beneficiaries with physical or mental disabilities.

d. Contractor must participate in the State's efforts to promote the delivery of services in a culturally competent manner to all beneficiaries, including those with limited English proficiency and diverse cultural and ethnic backgrounds, disabilities, and regardless of sex which includes sex characteristics, including intersex traits; pregnancy or related conditions; sexual orientation; gender identity and sex stereotypes.

e. Contractor must Establish mechanisms to ensure compliance by network providers. 42 CFR 438.206(c)(1)(iv)

f. Contractor must monitor network providers regularly to determine compliance. 42 CFR 438.206(c)(1)(v)

g. Contractor must take corrective action if there is a failure to comply by a network provider. 42 CFR 438.206(c)(1)(vi)

h. Contractor must have written policies guaranteeing each beneficiary’s right to request and receive a copy of their medical records, and to request that they be amended or corrected.

9. Person Centered Planning

a. In accordance with 42 CFR 441.725 Person-centered service plan and the Michigan Mental Health Code, MCL 330.1712, establishes the right for all individuals to have an Individual Plan of Service (IPOS) developed through a person-centered planning process. Contractor must implement person-centered planning in accordance with the Person-Centered Planning Policy which can be found on the MDHHS website: https://www.michigan.gov/mdhhs/keep-mi-healthy/mentalhealth/mentalhealth/practiceguidelines. In accordance with 42 CFR 438.208(c), the person-centered planning process must include considerations for additional services for enrollees with special health care needs or who need LTSS.

b. As part of the person-centered planning process, Contractor must engage in family-driven and youth-guided approaches to services with children and families and engage family members and youth at the program, evaluation, and governance levels. This must be done in accordance with the Family-Driven and Youth-Guided Policy and Practice Guidelines, which can be found on the MDHHS website: https://www.michigan.gov/mdhhs/keep-mi-healthy/mentalhealth/mentalhealth/practiceguidelines.

c. Contractor must offer new and existing recipients (other than those previously terminated from self-directed service arrangements) the choice to self-direct their services.

d. Contractor must ensure that its provider network uses a specially-constituted committee, such as a behavior treatment plan review committee, to review and approve or disapprove any plans that propose to use restrictive or intrusive interventions with individuals served by the public mental health system who exhibit seriously aggressive, self-injurious or other behaviors that place the individual or others at risk of physical harm. The Committee must substantially incorporate the standards in the Technical Requirement for Behavior Treatment Plans, https://www.michigan.gov/mdhhs/-/media/Project/Websites/mdhhs/Folder4/Folder13/Folder3/Folder113/Folder2/Folder213/Folder1/Folder313/Technical_Requirement_for_Behavior_Treatment_Plans.pdf?rev=92e7d3739bf64c97991657af19362634&hash=E6D047EBF35C585C715665FF2ACD9BCD which can be found on the MDHHS website: https://www.michigan.gov/mdhhs/keep-mi-healthy/mentalhealth/mentalhealth/practiceguidelines.

10. Cultural Competence

a. The supports and services provided by Contractor (both directly and through contracted providers) must demonstrate an ongoing commitment to linguistic and cultural competence that ensures access and meaningful participation for all people in the service area. Such commitment includes acceptance and respect for the cultural values, beliefs and practices of the community, as well as the ability to apply an understanding of the relationships of language and culture to the delivery of supports and services.

b. To effectively demonstrate such commitment, the Contractor must have five components in place: (1) a method of community assessment; (2) sufficient policy and procedure to reflect Contractor's value and practice expectations; (3) a method of service assessment and monitoring; (4) ongoing training to ensure that staff are aware of, and able to effectively implement, policy; and (5) the provision of supports and services within the cultural context of the recipient.

c. Contractor must participate in the State’s efforts to promote the delivery of services in a culturally competent manner to all beneficiaries, including those with limited English proficiency and diverse cultural and ethnic backgrounds, and those who are Deaf, Hard of Hearing, and Deaf and Blind. Treatment must be modified to effectively serve individuals who are deaf, hard of hearing, and deaf and blind as determined by their language skills and preferences.

11. Self-Direction

a. Contractor must ensure compliance among their network of service providers with all elements of Participant-Directed Services outlined in the 1915(i)(1)(G)(iii), 1915(c) Appendix E HCBS waiver authorities, the Self-Direction Technical Requirement Implementation Guide, and the Self-Directed Services Technical Requirements which can be found on the MDHHS website: https://www.michigan.gov/mdhhs/keep-mi-healthy/mentalhealth/mentalhealth/practiceguidelines. This provision is not a requirement of SUD Services.

12. Choice

a. In accordance with 42 CFR 438.3(l), Contractor must ensure that the beneficiary is allowed to choose his or her health care professional, e.g., physician, therapist, etc. to the extent possible and appropriate.

13. Second Opinion

a. If the beneficiary requests, Contractor must provide for a second opinion from a qualified health care professional within the network or arrange for the beneficiary to obtain one outside the network, at no cost to the beneficiary.

14. Denials by a Qualified Professional

a. Contractor must ensure that any decision to deny a service authorization request or to authorize a service in an amount, duration, or scope that is less than requested, must be made by a health care professional who has appropriate clinical expertise in treating the beneficiary's condition.

15. Recovery Policy

a. All Supports and Services provided to individuals with mental illness, including individuals with co-occurring conditions, must be based in the principles and practices of recovery outlined in the Michigan Recovery Council document, Recovery Policy and Practice Advisory which can be found on the MDHHS website: https://www.michigan.gov/mdhhs/keep-mi-healthy/mentalhealth/drugcontrol/reportstats/reportcontent/policies-and-advisories.

16. Nursing Home Placements

a. Contractor must provide medically necessary Medicaid specialty services to facilitate placement from, or divert admissions to, a nursing home for eligible beneficiaries determined by the Omnibus Budget Reconciliation Act (OBRA) screening assessment to have a mental illness and/or developmental disability and in need of placement and/or services.

17. Nursing Home Mental Health Services

a. Residents of nursing homes with mental health needs must be given the same opportunity for access to Contractor services as other individuals covered by this Contract.

18. Payments to Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs)

a. When Contractor pays FQHCs and RHCs for specialty services included in the specialty services waivers, Contractor must ensure that payments are no less than amounts paid to non-FQHC and non-RHCs for similar services. (For additional detail regarding the coverage responsibilities under the Mental Health Framework, see section F.8, Covered Services and/or the Schedule H, Payment Responsibility Grid.)

19. Indian Health Service/Tribally Operated Facility or program/Urban Indian Clinic (I/T/U)

a. Contractor must pay any Indian Health Service, Tribal Operated Facility Organization/Program/Urban Indian Clinic (I/T/U), or I/T/U contractor, whether participating in Contractor’s provider network or not, for Contractor authorized medically necessary covered Medicaid managed care services provided to Medicaid beneficiary/Indian beneficiaries who are eligible to receive services from the I/T/U provider either (1) at a rate negotiated between Contractor and the I/T/U provider, or (2) if there is no negotiated rate, at a rate not less than the level and amount of payment that would be made if the provider were not an I/T/U provider.

b. In accordance with 42 CFR 438.14, when an Indian Health Care Provider is not enrolled in Medicaid as a FQHC, regardless of whether it participates in the network of Contractor, it has the right to receive its applicable encounter rate published annually in the Federal Register by the Indian Health Service, or in the absence of a published encounter rate, the amount it would receive if the services were provided under the state plan’s Fee for Service (FFS) payment methodology.

20. Persons Associated with the Corrections System

a. Under an arrangement between the Michigan Department of Corrections (MDOC) and MDHHS, the Contractor must be responsible for medically necessary community-based SUD treatment…