AMENDMENT NUMBER 12
MIDDLE GRAND REGION
CONTRACTOR RISK AGREEMENT
BETWEEN
THE STATE OF TENNESSEE,
d.b.a. TENNCARE
AND
AMERIGROUP TENNESSEE, INC.
CONTRACT NUMBER: FA- 07-16936-00

For and in consideration of the mutual promises herein contained and other good
and valuable consideration, the receipt and sufficiency of which is hereby
acknowledged, the parties agree to clarify and/or amend the Contractor Risk
Agreement (CRA) by and between the State of Tennessee TennCare Bureau,
hereinafter referred to as TENNCARE, and AMERIGROUP TENNESSEE, INC., hereinafter
referred to as the CONTRACTOR as specified below.

Titles and numbering of paragraphs used herein are for the purpose of
facilitating use of reference only and shall not be construed to infer a
contractual construction of language.

1.Section 1 shall be amended by deleting and replacing the following
definitions:
At-Risk — As it relates to the CHOICES program, SSI eligible adults age
sixty-five (65) and older or age twenty-one (21) or older with physical
disabilities, who do not meet the established level of care criteria for nursing
facility services, but have a lesser number or level of functional deficits in
activities of daily living as defined in TennCare rules and regulations, such
that, in the absence of the provision of a moderate level of home and community
based services, the individual's condition and/or ability to continue living in
the community will likely deteriorate, resulting in the need for more expensive
institutional placement. As it relates to Interim CHOICES Group 3, open for
enrollment only between July 1, 2012 and December 31, 2013, "at risk" is defined
as adults age sixty-five (65) and older or age twenty-one (21) or older with
physical disabilities who receive SSI or meet Nursing Financial eligibility
criteria, and also meet the Nursing Facility level of care in effect on June 30,
2012.

CHOICES Group (Group) — One of the three groups of TennCare enrollees who are
enrolled in CHOICES. There are three CHOICES groups:

1.Group 1
Medicaid enrollees of all ages who are receiving Medicaid-reimbursed care in a
nursing facility.

2.Group 2
Persons age sixty-five (65) and older and adults age twenty-one (21) and older
with physical disabilities who meet the nursing facility level of care, who
qualify for TennCare either as SSI recipients or as members of the CHOICES
217-Like HCBS Group, and who need and are receiving CHOICES HCBS as an
alternative to nursing facility care. The CHOICES 217-Like HCBS Group includes
persons who could have been eligible under 42 CFR 435.217 had the state
continued its 1915(c) HCBS waiver for elders and/or persons with physical
disabilities. TENNCARE has the discretion to apply an enrollment target to this
group, as described in TennCare rules and regulations.

3.Group 3

--------------------------------------------------------------------------------

Persons age sixty-five (65) and older and adults age twenty-one (21) and older
with physical disabilities who qualify for TennCare as SST recipients, who do
not meet the nursing facility level of care, but who, in the absence of CHOICES
HCBS, are "at-risk" for nursing facility care, as defined by the State. TENNCARE
has the discretion to apply an enrollment target to this group as described in
TennCare rules and regulations.

4.
Interim Group 3 (open for new enrollment only between July 1, 2012, through
December 31, 2013) Persons age 65 and older and adults age 21 and older with
physical disabilities who qualify for TennCare as SSI eligibles or as members of
MOE Demonstration Group and who meet the NF LOC criteria in place as of June 30,
2012. There is no enrollment target on Interim Group 3.

All requirements set forth is this agreement regarding Group 3 members are
applicable to Interim Group 3 members, except as explicitly stated otherwise.
Interim Group 3 members are not subject to an enrollment target.

Consumer Direction of Eligible CHOICES HCBS — The opportunity for a CHOICES
member assessed to need specified types of CHOICES HCBS including attendant
care, personal care, in-home respite, companion care and/or any other service
specified in TennCare rules and regulations as available for consumer direction
to elect to direct and manage (or to have a representative direct and manage)
certain aspects of the provision of such services—primarily, the hiring, firing,
and day-to-day supervision of consumer-directed workers delivering the needed
service(s).

Cost Neutrality Cap — The requirement that the cost of providing care to a
member in CHOICES Group 2, including CHOICES HCBS and Medicaid reimbursed home
health and private duty nursing, shall not exceed the cost of providing nursing
facility services to the member, as determined in accordance with TennCare
policy. A member's individual cost neutrality cap shall be the average cost of
Level I nursing facility care unless a higher cost neutrality cap is established
by TENNCARE based on information submitted by the AAAD or MCO (as applicable) in
the level of care application.

Eligible CHOICES HCBS — Attendant care, personal care, in-home respite,
companion care services and/or any other CHOICES HCBS specified in TennCare
rules and regulations as eligible for consumer direction for which a CHOICES
member is determined to need and elects to direct and manage (or have a
representative direct and manage) certain aspects of the provision of such
services — primarily the hiring, firing and day-to-day supervision of
consumer-directed workers delivering the needed service(s). Eligible CHOICES
HCBS do not include home health or private duty nursing services.

Eligible Individual — With respect to Tennessee's Money Follows the Person
Rebalancing Demonstration (MFP) and pursuant to Section 6071(b)(2) of the
Deficit Reduction Act of 2005 (DRA), (Pub. L. 109-171 (S. 1932)) (Feb. 8, 2006)
as amended by Section 2403 of the Patient Protection and Affordable Care Act of
2010 (ACA), (Pub. L. 111-148) (May 1, 2010), the State's approved MFP
Operational Protocol and TENNCARE Rules, a member who qualifies to participate
in MFP. Such person, immediately before beginning participation in the MFP
demonstration project, shall:

1.
Reside in a Nursing Facility (NF) or an Intermediate Care Facility for persons
with Mental Retardation (ICF/MR) and have resided for a period of not less than
ninety (90) consecutive days in a Qualified institution.

--------------------------------------------------------------------------------

a.
Inpatient days in an institution for mental diseases (IMDs) which includes
Psychiatric Hospitals and Psychiatric Residential Treatment Facilities (PRTF)
may be counted only to the extent that Medicaid reimbursement is available under
the State Medicaid plan for services provided by such institution. Medicaid
payments may only be applied to persons in IMDs who are over 65 or under 21
years of age.

b.
Any days that an individual resides in a Medicare certified Skilled Nursing
Facility (SW) on the basis of having been admitted solely for purposes of
receiving post-hospital short-term rehabilitative services covered by Medicare
shall not be counted for purposes of meeting the ninety (90)-day minimum stay in
a Qualified Institution established under ACA.

c.
Short-term continuous care in a nursing facility, to include Level 2 nursing
facility reimbursement, for episodic conditions to stabilize a condition rather
than admit to hospital or to facilitate hospital discharge, and inpatient
rehabilitation facility services reimbursed by the CONTRACTOR (i.e., not covered
by Medicare) as a cost-effective alternative (see Section 2.6.5) and provided in
a Qualified Institution shall be counted for purposes of meeting the ninety (90)
day minimum stay in a Qualified Institution established under ACA.

2.
Be eligible for and receive Medicaid benefits for inpatient services furnished
by the nursing facility or ICF/MR for at least one (1) day. For purposes of this
Agreement, an Eligible Individual must reside in a nursing facility and be
enrolled in CHOICES Group 1 for a minimum of one (1) day and must be eligible to
enroll and transition seamlessly into CHOICES Group 2 or CHOICES Group 3
(without delay or interruption).

3.
Meet nursing facility or ICF/MR level of care, as applicable, and, but for the
provision of ongoing CHOICES HCBS, continue to require such level of care
provided in an inpatient facility or meet at- risk level of care such that, in
the absence of the provision of a moderate level of home and community based
services, the individual's condition and/or ability to live in the community
will likely deteriorate and result in the need for institutional placement.

--------------------------------------------------------------------------------

Home and Community-Based Services (HCBS) — Services that are provided pursuant
to a Section
1915(c) waiver or the CHOICES program as an alternative to long-term care
institutional services in a nursing facility or an Intermediate Care Facility
for the Mentally Retarded (ICF/MR) or to delay or prevent placement in a nursing
facility. HCBS may also include optional or mandatory services that are covered
by Tennessee's Title XIX state plan or under the TennCare demonstration for all
eligible enrollees, including home health or private duty nursing. However, only
CHOICES HCBS are eligible for Consumer Direction. CHOICES HCBS do not include
home health or private duty nursing services or any other HCBS that are covered
by Tennessee's Title XIX state plan or under the TennCare demonstration for all
eligible enrollees, although such services are subject to estate recovery and
shall be counted for purposes of determining whether a CHOICES member's needs
can be safely met in the community within his or her individual cost neutrality
cap.

Long-Term Care (LTC)— The services of a nursing facility (NF), an Intermediate
Care Facility for the Mentally Retarded (ICF/MR), or Home and Community-Based
Services (HCBS). These services may also be called Long-Term Services and
Supports (LTSS).

Ongoing CHOICES HCBS — Specified CHOICES HCBS which are delivered on a regular
and ongoing basis, generally one or more times each week, or (in the case of
community-based residential alternatives and PERS) on a continuous basis.
Ongoing HCBS include community-based residential alternatives, personal care,
attendant care, home-delivered meals, personal emergency response systems
(PERS), and/or adult day care.

Qualified Institution — With respect to Tennessee's MFP Rebalancing
Demonstration, and pursuant to Section 6071(b)(3) of the DRA, a hospital,
nursing facility, or ICF/MR.

1.
An institution for mental diseases (IMDs) which includes Psychiatric Hospitals
and Psychiatric Residential Treatment Facilities (PRTF) shall be a Qualified
Institution only to the extent that Medicaid reimbursement is available under
the State Medicaid plan for services provided by such institution. Medicaid
payments may only be applied to persons in IMDs who are over 65 or under 21
years of age.

2.
Any days that an individual resides in a Medicare certified Skilled Nursing
Facility (SNF) on the basis of having been admitted solely for purposes of
receiving post-hospital short-term rehabilitative services covered by Medicare
shall not be counted for purposes of meeting the ninety (90)-day minimum stay in
a Qualified Institution established under the Affordable Care Act.

TENNCARE PreAdmission Evaluation System (TPAES) — A component of the State's
Medicaid Management Information System and the system of record for all
PreAdmission Evaluation (i.e., level of care) submissions and level of care
determinations, as well as enrollments into and transitions between LTC
programs, including CHOICES and the State's MFP Rebalancing Demonstration (MFP),
and which shall also be used to gather data required to comply with tracking and
reporting requirements pertaining to MFP.

Tennessee Department of Mental Health and Substance Abuse Services (TDMHSAS) —
The state agency having the authority to provide care for persons with mental
illness, substance abuse, and/or developmental disabilities.

--------------------------------------------------------------------------------

Transition Allowance — A per member allotment not to exceed two thousand dollars
($2,000) per lifetime which may, at the sole discretion of the CONTRACTOR, be
provided as a cost-effective alternative to continued institutional care for a
CHOICES Group 1 member in order to facilitate transition from a nursing facility
to the community when such member will, upon transition to CHOICES Group 2,
receive more cost-effective non-residential home and community based services or
companion care. Items that may be purchased or reimbursed are only those items
that the member has no other means to obtain and that are essential in order to
establish a community residence when such residence is not already established
and to facilitate the member's safe and timely transition, including rent and/or
utility deposits, essential kitchen appliances, basic furniture, and essential
basic household items, such as towels, linens, and dishes. A Transition
Allowance shall not be provided to members that no longer meet nursing facility
level of care and are transitioning to CHOICES Group 3.

2.
Section 1 shall be amended by adding the following new definitions:

Maintenance of Effort (MOE) — Provisions in the American Recovery and
Reinvestment Act (ARRA) (Pub. L. 111-5) (Feb. 17, 2009) and the Affordable Care
Act (ACA) to ensure that States' coverage for adults under the Medicaid program
remains in place and that "eligibility standards, methodologies, and procedures"
are not more restrictive than those in place as of July 1, 2008 for purposes of
the ARRA and March 23, 2010, for purposes of the ACA pending the establishment
of specific provisions of ACA (i.e., a fully operational Exchange) on January 1,
2014.

MOE Demonstration Group — Individuals who are age 65 and older and adults age 21
and older with disabilities who (I) meet nursing home financial eligibility, (2)
do not meet the nursing facility level of care criteria in place on July 1,
2012; and (3) in the absence of TennCare CHOICES services, are "at risk" of
institutionalization. The MOE Demonstration Group is open only between July 1,
2012, through December 31, 2013. Individuals enrolled in the MOE Demonstration
Group as of December 31, 2013, may continue to qualify in this group after
December 31, 2013, so long as they (1) continue to meet Nursing Facility
financial eligibility and the LOC criteria in place when they enrolled; and (2)
remain continuously enrolled in the MOE Demonstration Group and in CHOICES 3.

3.
Section 2.6.1.5.2.5 shall be amended by adding the phrase "but excluding Interim
Group 3," in the first sentence immediately following "3,".

2.6.1.5.2.5
For Groups 2 and 3, but excluding Interim Group 3, if there is an enrollment
target, TENNCARE determines that the enrollment target has not been met or, for
Group 2, approved the CONTRACTOR’s request to provide CHOICES HCBS as a cost
effective alternative (see Section 2.6.5). Enrollees transitioning from a
nursing facility to the community will not be subject to the enrollment target
for Group 2 but must meet categorical and financial eligibility for Group 2.

4.
Section 2.6.1.5.3 and 2.6.1.5.4 shall be deleted and replaced as follows:

2.6.1.5.3
For persons determined to be eligible for enrollment in Group 2 as a result of
Immediate Eligibility (as defined in Section 1 of this Agreement), the
CONTRACTOR shall provide a limited package of CHOICES HCBS (personal care,
attendant care, home-delivered meals, PERS, adult day care, and/or any other
services as specified in TennCare rules and regulations) as identified through a
needs assessment and specified in the plan of care.

--------------------------------------------------------------------------------

Upon notice that the State has determined that the member meets categorical and
financial eligibility for TennCare CHOICES, the CONTRACTOR shall authorize
additional services in accordance with Section 2.9.6.2.5. For members residing
in a community-based residential alternative at the time of CHOICES enrollment,
authorization for community-based residential alternative services shall be
retroactive to the member's effective date of CHOICES enrollment.

2.6.1.5.4
The following long-term care services are available to CHOICES members, per
Group,when the services have been determined medically necessary by the
CONTRACTOR.

Service and Benefit Limit
Group 1
Group 2
Group 3
Nursing facility care
X
Short-term
only (up to 90
days)
Short-term
only
(up to 90 days)
Community-based residential alternatives
 
X
 
Personal care visits (up to 2 visits per day at intervals of no less than 4
hours between visits)
 
X
X
Attendant care (up to 1080 hours per calendar year; up to 1400 hours per full
calendar year only for persons who require covered assistance with household
chores or errands in addition to hands-on assistance with self-care tasks)
 
X
X
Home-delivered meals (up to 1 meal per day)
 
X
X
Personal Emergency Response Systems (PERS)
 
X
X
Adult day care (up to 2080 hours per calendar year)
 
X
X
1n-home respite care (up to 216 hours per calendar year)
 
X
X
In-patient respite care (up to 9 days per calendar year)
 
X
X
Assistive technology (up to $900 per calendar year)
 
X
X
Minor home modifications (up to $6,000 per project; $10,000 per calendar year;
and $20,000 per lifetime)
 
X
X
Pest control (up to 9 units per calendar year)
 
X
X

--------------------------------------------------------------------------------

--------------------------------------------------------------------------------

5.
Section 2.6.5.2.5 shall be deleted and replaced as follows:

2.6.5.2.5
For CHOICES Group 1 members transitioning from a nursing facility to Group 2, a
one-time transition allowance, per member. The amount of the transition
allowance shall not exceed two thousand dollars ($2,000) and may be used for
items such as, but not limited to, the first month’s rent and/or utility
deposits, kitchen appliances, furniture, and basic household items. A Transition
Allowance shall not be provided to members that no longer meet nursing facility
level of care and are transitioning to CHOICES Group 3.

6.
Section 2.6.5.3 shall be deleted and replaced as follows:

2.6.5.3
If the CONTRACTOR chooses to provide cost effective alternative services to a
CHOICES member, in no case shall the cost of CHOICES HCBS, private duty nursing
and home health care for Group 2 exceed a member's cost neutrality cap nor the
total cost of CHOICES HCBS, excluding minor home modifications, for members in
Group 3 exceed the expenditure cap. The total cost of CHOICES HCBS includes all
covered CHOICES HCBS and other non-covered services that the CONTRACTOR elects
to offer as a cost effective alternative to nursing facility care for CHOICES
Group 2 members pursuant to Section 2.6.5.2 of this Agreement including, as
applicable: CHOICES HCBS in excess of specified benefit limits, the one-time
transition allowance for CHOICES Group 1 members who are transitioning to
CHOICES Group 2, and NEMT for Groups 2 and 3.

7.
Sections 2.6.7.2.2.3 shall be amended by deleting the reference to Section
"2.9.6.3" and replacing it with "2.9.6.8".

2.6.7.2.2.3
If the CONTRACTOR is unable to find an alternate nursing facility willing to
serve the member and the member otherwise qualifies to enroll in CHOICES Group
2, the CONTRACTOR shall determine if it can safely and effectively serve the
member in the community and within the cost neutrality cap. If it can, and the
CONTRACTOR is willing to continue serving a member who has failed to pay his or
her patient liability or if TENNCARE determines that the member would not have
patient liability in the community setting, the member shall be offered a choice
of CHOICES HCBS. If the member chooses CHOICES HCBS, the CONTRACTOR shall
forward all relevant information to TENNCARE for a decision regarding transition
to Group 2 (Section 2.9.6.8).

8.
Sections 2.6.7.2.3.2 through 2.6.7.2.3.2.2 shall be deleted and replaced as
follows:

2.6.7.2.3.2
The CONTRACTOR shall collect patient liability from CHOICES Group 2 and Group 3
members (as applicable) who receive CHOICES HCBS in his/her own home or who
receive adult day care services and from Group 2 members who receive Companion
Care.

--------------------------------------------------------------------------------

2.6.7.2.3.2.1
The CONTRACTOR shall use calculated patient liability amounts to offset the cost
of CHOICES Group 2 or CHOICES Group 3 benefits (or CEA services provided as an
alternative to covered CHOICES Group 2 or Group 3 benefits) reimbursed by the
CONTRACTOR for that month.

2.6.7.2.3.2.2
The CONTRACTOR shall not collect patient liability that exceeds the cost of
CHOICES Group 2 or CHOICES Group 3 benefits (or CEA services provided as an
alternative to CHOICES Group 2 or Group 3 benefits) reimbursed by the CONTRACTOR
for that month.

9.
Section 2.6.7.2.3.3 shall be amended by adding the phrase "or Group 3" after "If
a Group 2" as follows:

2.6.7.2.3.3
If a Group 2 or Group 3 member fails to pay required patient liability, pursuant
to Section 2.6.1.5.8.6, the CONTRACTOR may request to no longer provide
long-term care services to the member.

10.
The last sentence of Section 2.7.1.3 shall be amended by deleting the space
between the word "non-emergency".

11.
Sections 2.9.2.1.4.6.2 through 2.9.2.1.4.6.4 shall be deleted and replaced as
follows:

2.9.2.1.4.6.2
Transition Group 1 members to CHOICES HCBS unless the member chooses to receive
CHOICES HCBS as an alternative to nursing facility care and is enrolled in
CHOICES Group 2 or the member meets the at-risk level of care and is enrolled in
CHOICES Group 3 (see Section 2.9.6.8 for requirements regarding nursing facility
to community transition);

2.9.2.1.4.6.3
Admit a member in CHOICES Group 2 to a nursing facility unless the member meets
the nursing facility level of care in place at the time of admission and (1) is
expected to require short-term nursing facility services for ninety (90) days or
less; (2) the member chooses to transition to a nursing facility and enroll in
Group 1; or (3) the CONTRACTOR determines that it cannot safely and effectively
meet the needs of the member and within the member’s cost neutrality cap, and
the member agrees to transition to a nursing facility and enroll in Group 1;

2.9.2.1.4.6.4
Admit a member enrolled in CHOICES Group 3 to a nursing facility unless the
member meets the nursing facility level of care in place at the time of
admission and (1) is expected to require short-term nursing facility service for
ninety (90) days or less; or (2) the member chooses to transition to a nursing
facility and enroll in Group 1; or

12.
Section 2.9.6.1.6.1 shall be deleted and replaced as follows:

2.9.6.1.6.1
The day of the initiating event (e.g., receipt of a referral for CHOICES
screening and intake or notification of a new CHOICES member on the outbound 834
enrollment file) shall be the anchor date and is not to be included in the
timeline computation;

--------------------------------------------------------------------------------

13.
Section 2.9.6.2.3.1 shall be deleted and replaced as follows:

2.9.6.2.3.1
For persons wishing to apply to CHOICES, TENNCARE or its designee may employ a
screening process, using the tools and protocols specified by TENNCARE, to
assist with intake for persons new to both TennCare and CHOICES. Such screening
process shall assess: (1) whether the applicant appears to meet categorical and
financial eligibility criteria for CHOICES; (2) whether the applicant appears to
meet level of care eligibility for enrollment in CHOICES; and (3) for applicants
seeking access to CHOICES HCBS through enrollment in CHOICES Group 2, whether it
appears that the applicant’s needs can be safely and effectively met in the
community and at a cost that does not exceed nursing facility care.

14.
Section 2.9.6.2.3.4 and 2.9.6.2.3.5 shall be deleted and replaced as follows:

2.9.6.2.3.4
As part of the intake visit, TENNCARE or its designee shall: (1) provide general
CHOICES education and information, as specified by TENNCARE, and assist in
answering any questions the applicant may have; (2) provide information about
estate recovery; (3) complete Medicaid and level of care (i.e., PAE)
applications and provide assistance, as necessary, in gathering documentation
needed by the State to determine TennCare eligibility; (4) provide choice
counseling and facilitate the selection of an MCO by the applicant or his/her
representative; (5) for applicants seeking enrollment in CHOICES Group 1 or
Group 2, provide information regarding freedom of choice of nursing facility
versus CHOICES HCBS, both verbally and in writing, and obtain a Freedom of
Choice form signed and dated by the applicant or his/her representative; (6)
provide detailed information and obtain signed acknowledgement of understanding
regarding a CHOICES member's responsibility with respect to payment of patient
liability amounts, including, as applicable, the potential consequences for
non-payment of patient liability which may include loss of the member's current
nursing facility or CBRA provider or MCO, disenrollment from CHOICES, and to the
extent the member's eligibility is dependent on receipt of long-term care
services, possible loss of eligibility for TennCare; (7) for applicants who want
to receive NF services, provide information regarding the completion of all
PASRR requirements prior to nursing facility admission and conduct the level I
PASRR screening; (8) for applicants who are seeking CHOICES HCBS: (a) conduct a
risk assessment using a tool and protocol specified by TENNCARE and develop, as
applicable, a risk agreement that shall be signed by the applicant or his/her
representative and which shall include identified risks to the applicant, the
consequences of such risks, strategies to mitigate the identified risks, and the
applicant's decision regarding his/her acceptance of risk; and (b) provide
information regarding consumer direction and obtain signed documentation of the
applicant's interest in participating in consumer direction; (9) for applicants
who are seeking enrollment in Group 2, identify the services that may be needed
by the applicant upon enrollment in Group 2, make a determination regarding
whether the applicant’s needs can be safely and effectively met in the community
and at a cost that does not exceed nursing facility care, and provide

--------------------------------------------------------------------------------

explanation to the applicant regarding the individual cost neutrality cap,
including that a change in member’s needs or circumstances that would result in
the neutrality cap being exceeded or that would result in the MCO’s inability to
safely and effective meet a member’s needs in the community and with the cost
neutrality cap may result in the member’s disenrollment from CHOICES Group 2, in
which case, the care coordinator will assist with transition to a more
appropriate care delivery setting; (10) for applicants who are seeking
enrollment in Group 3, identify the covered HCBS that may be needed by the
applicant upon enrollment in Group 3 and provide explanation to the applicant
regarding the fifteen thousand dollars ($15,000) expenditure cap; and (11) for
all applicants, provide information regarding next steps in the process
including the need for approval by TENNCARE to enroll in CHOICES and the
functions of the CONTRACTOR, including that the CONTRACTOR will develop and
approve a plan of care.

15.
Section 2.9.6.2.4.3 shall be amended by adding new language to the end of the
existing language as follows:

2.9.6.2.4.3
The CONTRACTOR shall not transition members in Group 1 to CHOICES HCBS unless
the member chooses to receive CHOICES HCBS as an alternative to nursing facility
and is enrolled in Group 2 or a member enrolled in CHOICES on or after July 1,
2012 no longer meets nursing facility level of care but does meet the at-risk
level of care and is enrolled in Group 3.

16.
Section 2.9.6.2.5.3 shall be amended by adding the phrase "in Group 2" after the
word "enrolled" in the first sentence.

2.9.6.2.5.3
The care coordinator shall, for all other CHOICES members in Groups 2 and 3 not
specified in 2.9.6.2.5.1 — 2.9.6.2.5.2 above, within ten (10) business days of
notice of the member's enrollment in CHOICES, conduct a face-to-face visit with
the member, perform a comprehensive needs assessment (see Section 2.9.6.5),
develop a plan of care (see Section 2.9.6.6), and authorize and initiate CHOICES
HCBS, except in the case of members enrolled in Group 2 on the basis of
Immediate Eligibility in which case only the limited package of CHOICES HCBS
shall be authorized and initiated. Members enrolled on the basis of Immediate
Eligibility shall have access only to a limited package of CHOICES HCBS (see
Section 2.6.1.5.3) pending determination of categorical and financial
eligibility for TennCare CHOICES; however all needed services shall be listed in
the plan of care, and the CONTRACTOR shall immediately revise the service
authorizations as necessary upon notice that the State has determined that the
member meets categorical and financial eligibility for TennCare CHOICES and
initiate services within ten (10) business days of notice.

--------------------------------------------------------------------------------

17.
Sections 2.9.6.2.5.5 and 2.9.6.2.5.6 shall be deleted and replaced as follows:

2.9.6.2.5.5
The CONTRACTOR shall not admit a member enrolled in CHOICES Group 2 to a nursing
facility unless the member meets nursing facility level of care in place at the
time of admission and (1) is expected to require short-term nursing facility
services for ninety (90) days or less; (2) chooses to transition to a nursing
facility and enroll in Group l; or (3) the CONTRACTOR determines that it cannot
safely and effectively meet the needs of a Group 2 member and at a cost that is
less than the member's cost neutrality cap and the member agrees to transition
to a nursing facility and enroll in Group 1.

2.9.6.2.5.6
The CONTRACTOR shall not admit a member enrolled in CHOICES Group 3 to a nursing
facility unless the member meets nursing facility level of care in place at the
time of admission and: (1) is expected to require short-term nursing facility
services for ninety (90) days or less; or (2) chooses to transition to a nursing
facility and enroll in Group 1.

18.
Section 2.9.6.3.2 shall be deleted and replaced as follows:

2.9.6.3.2
As part of its identification process for members who may be eligible for
CHOICES, the CONTRACTOR may initiate a telephone screening process, using the
tool and protocols specified by TENNCARE. Such screening process shall: (1)
verify the member's current eligibility category based on information provided
by TENNCARE in the outbound 834 enrollment file; for persons seeking access to
CHOICES HCBS through enrollment in CHOICES Groups 2 or 3, identify whether the
member meets categorical eligibility requirements for enrollment in such group
based on his/her current eligibility category, and if not, whether the member
appears to meet categorical and financial eligibility criteria for the
Institutional (i.e., CHOICES 217-Like HCBS or MOE Demonstration) category; (2)
determine whether the member appears to meet level of care eligibility for
CHOICES; and (3) for members seeking access to CHOICES HCBS through enrollment
in CHOICES Group 2, determine whether it appears that the member's needs can be
safely and effectively met in the community and at a cost that does not exceed
nursing facility care. Such telephone screening shall be conducted at the time
of the initial call by the CONTRACTOR unless the member requests that the
screening be conducted at another time, which shall be documented in writing in
the CHOICES intake record.

--------------------------------------------------------------------------------

19.
Section 2.9.6.3.9 shall be deleted and replaced as follows:

2.9.6.3.9
As part of the face-to-face intake visit, the care coordinator shall: (1)
provide general CHOICE education and information, as specified by TENNCARE, to
the member and assist in answering question the member may have; (2) provide
information about estate recovery; (3) provide assistance, as necessary, in
gathering documentation needed by DHS to determine categorical/financial
eligibility for LTC; (4) for members seeking enrollment in CHOICE Group 1 or
Group 2, provide information regarding freedom of choice or nursing facility
versus CHOICES HCBS, both verbally and in writing, and obtain a Freedom of
Choice form signed and dated by the member of his/her representative; (5)
provide detailed information and signed acknowledgement of understanding
regarding a CHOICES member’s responsibility with respect to payment of patient
liability amounts, including, as applicable, the potential consequences for
non-payment of patient liability which may include loss of the member’s current
nursing facility or CBRA provider or MCO, disenrollment from CHOICES, and to the
extent the member’s eligibility is dependent on receipt of long-term services,
possible loss of eligibility for TennCare; and (6) for members who want to
receive nursing facility services, provide information regarding the completion
of all PASRR requirements prior to nursing facility admission and conduct the
level I PASRR screening; (7) for members who are seeking CHOICES HCBS, the care
coordinator, shall: (a) conduct a risk assessment using a tool and protocol
specified by TENNCARE and shall develop, as applicable, a risk agreement that
shall be signed and dated by the member or his/her representative and which
shall include identified risks to the member, the consequences of such risks,
strategies to mitigate the identified risks, and the member's decision regarding
his/her acceptance of risk; and (b) provide information regarding consumer
direction and obtain written confirmation of the member's decision regarding
participation in consumer direction; (8) for members seeking enrollment in Group
2, make a determination regarding whether the person's needs can be safely and
effectively met in the community and at a cost that does not exceed nursing
facility care, and provide explanation to the member regarding the individual
cost neutrality cap, including that a change in needs or circumstances that
would result in the cost neutrality cap being exceeded or that would result in
the CONTRACTOR's inability to safely and effectively meet the member's needs in
the community and within the cost neutrality cap may result in the member's
disenrollment from CHOICES Group 2, in which case, the member's care coordinator
will assist with transition to a more appropriate care delivery setting; (9) for
members seeking enrollment in Group 3, provide explanation to the member
regarding the fifteen thousand dollar ($15,000) expenditure cap; ; and (10) for
all members, provide information regarding choice of contract providers, subject
to the provider's availability and willingness to timely deliver services, and
obtain signed documentation of the member's choice of contract providers.

--------------------------------------------------------------------------------

20.
Section 2.9.6.3.14 shall be deleted and replaced as follows:

2.9.6.3.14
Once completed, in the manner prescribed by TENNCARE the CONTRACTOR shall submit
the level of care and, for members requesting CHOICES Group 2 HCBS,
documentation, as specified by TENNCARE, to verify that the member's needs can
be safely and effectively met in the community and within the cost neutrality
cap to TENNCARE as soon as possible but no later than five (5) business days of
the face-to- face visit. The CONTRACTOR shall make every effort to obtain
supporting documentation required for the level of care in a timely manner and
shall document in writing the cause of any delay in the submission of the
required documentation to TENNCARE, including the CONTRACTOR's actions to
mitigate such delay. The CONTRACTOR shall be responsible for ensuring that the
level of care is accurate and complete, satisfies all technical requirements
specified by TENNCARE, and accurately reflects the member's current medical and
functional status based on information gathered, at a minimum, from the member,
his or her representative, the Care Coordinator's direct observations, and the
history and physical or other medical records which shall be submitted with the
application. The CONTRACTOR shall note in the level of care any discrepancies
between these sources of information, and shall provide explanation regarding
how the CONTRACTOR addressed such discrepancies in the level of care.

21.
Section 2.9.6.3.16 shall be deleted and replaced as follows:

2.9.6.3.16
The CONTRACTOR shall be responsible for (1) advising members who appear to meet
the nursing facility level of care that are seeking access to CHOICES HCBS
through enrollment in CHOICES Group 2 when an enrollment target has been (or
will soon be reached; (2) advising such persons that they may choose to receive
nursing facility services if CHOICES Group 2 HCBS are not immediately available;
(3) determining whether the person wants nursing facility services if CHOICES
Group 2 HCBS are not immediately available; and (4) at the CONTRACTOR's sole
discretion, making a determination regarding whether enrollment in Group 2
constitutes a CEA because the immediate provision of nursing facility services
will otherwise be required and submitting appropriate documentation to TENNCARE
if there is a waiting list for CHOICES Group 2 but the CONTRACTOR chooses to
enroll a member in Group 2 as a CEA (see Section 2.9.6.3.15.1).

--------------------------------------------------------------------------------

22.
Section 2.9.6.3.20 shall be deleted and replaced as follows:

2.9.6.3.20
For the CONTRACTOR's current members enrolled into CHOICES Group 2 or Group 3,
the member's Care Coordinator shall within ten (10) business days of notice of
the member's enrollment in CHOICES Group 2 or Group 3, authorize and initiate
CHOICES HCBS.

23.
Section 2.9.6.3.20.3 shall be deleted and replaced as follows:

2.9.6.3.20.3
The CONTRACTOR shall provide at least verbal notice to the member prior to
initiation of CHOICES HCBS identified in the plan of care regarding any change
in providers selected by the member for each CHOICES HCBS; including the reason
such change has been made. If the CONTRACTOR is unable to place a CHOICES Group
I or 2 member in the nursing facility or community-based residential alternative
setting requested by the member, the care coordinator shall meet with the member
and his/her representative to discuss the reasons why the member cannot be
placed with the requested facility and the available options and identify an
alternative facility.

24.
Sections 2.9.6.3.20.7 through 2.9.6.3.20.9 shall be deleted and replaced as
follows:

2.9.6.3.20.7
The CONTRACTOR shall not divert or transition members in CHOICES Group 1 to
CHOICES HCBS unless the member chooses to receive CHOICES HCBS as an alternative
to nursing facility and is enrolled in Group 2 or a member enrolled in CHOICES
on or after July 1, 2012 no longer meets nursing facility level of care but does
meet the at-risk level of care and is enrolled in Group 3.

2.9.6.3.20.8
The CONTRACTOR shall not admit a member enrolled in CHOICES Group 2 to a nursing
facility unless the member meets the nursing facility level of care in place at
the time of admission and : (1) is expected to require a short-term nursing
facility care stay for ninety (90) days or less; (2) chooses to transition to a
nursing facility and enroll in Group I; or (3) the CONTRACTOR determines that it
cannot safely and effectively meet the needs of the member and at a cost that is
less than the member's cost neutrality cap and the member agrees to transition
to a nursing facility and enroll in Group 1.

2.9.6.3.20.9
The CONTRACTOR shall not admit a member enrolled in CHOICES Group 3 to a

nursing facility unless the member meets the nursing facility level of care in
place at the time of admission and: (1) is expected to require short-term
nursing facility services for ninety (90) days or less; or (2) chooses to
transition to a nursing facility and enroll in Group 1.

--------------------------------------------------------------------------------

25.
Section 2.9.6.4.3.2 shall be amended by deleting the reference to Section
"2.9.6.3.19" and replacing it with "2.9.6.3.20".

2.9.6.4.3.2
For CHOICES members who, upon enrollment in CHOICES, are not receiving services
in a nursing facility or a community-based residential alternative setting, the
CONTRACTOR shall assign a specific care coordinator and shall advise the member
of the name of his/her care coordinator and provide contact information prior to
the initiation of services (see Section 2.9.6.2.5.3 and 2.9.6.3.20), but no more
than ten (10) calendar days following CHOICES enrollment.

26.
Section 2.9.6.6.2.4 shall be amended by adding the phrase "in CHOICES Group 2"
in items (4) and (5) as follows:

2.9.6.6.2.4
The plan of care developed for CHOICES members in Groups 2 and 3 prior to
initiation of CHOICES HCBS shall at a minimum include: (1) pertinent demographic
information regarding the member including the name and contact information of
any representative and a list of other persons authorized by the member to have
access to health care (including long-term care) related information and to
assist with assessment, planning, and/or implementation of health care
(including long-term care) related services and supports; (2) care, including
specific tasks and functions, that will be performed by family members and other
caregivers; (3) home health, private duty nursing, and longterm care services
the member will receive from other payor sources including the payor of such
services; (4) home health and private duty nursing that will be authorized by
the CONTRACTOR, except in the case of persons enrolled in CHOICES Group 2 on the
basis of Immediate Eligibility who shall have access to services beyond the
limited package of CHOICES HCBS (see Section 2.6.1.5.3) only upon determination
of categorical and financial eligibility for TennCare; (5) CHOICES HCBS that
will be authorized by the CONTRACTOR, including the amount, frequency, duration,
and scope (tasks and functions to be performed) of each service to be provided,
and the schedule at which such care is needed, as applicable; members enrolled
in CHOICES Group 2 on the basis of Immediate Eligibility shall have access only
to a limited package of CHOICES HCBS (see Section 2.6.1.5.3) pending
determination of categorical and financial eligibility for TennCare CHOICES
however all identified needed services shall be listed in the plan of care; (6)
a detailed back-up plan for situations when regularly scheduled HCBS providers
are unavailable or do not arrive as scheduled; the back-up plan may include paid
and unpaid supports and shall include the names and telephone numbers of persons
and agencies to contact and the services provided by listed contacts; the
CONTRACTOR shall assess the adequacy of the back-up plan; and (7) for CHOICES
Group 2 members, the projected TennCare monthly and annual cost of home health
and private duty nursing identified in (4) above, and the projected monthly and
annual cost of CHOICES HCBS specified in (5) above, and for CHOICES Group 3
members, the projected total cost of CHOICES HCBS specified in (5) above,
excluding the cost of minor home modifications.

--------------------------------------------------------------------------------

27.
Section 2.9.6.8 shall be deleted and replaced as follows:

2.9.6.8        Nursing Facility-to-Community Transition

2.9.6.8.1
The CONTRACTOR shall develop and implement methods for identifying members who
may have the ability and/or desire to transition from a nursing facility to the
community. Such methods shall include, at a minimum:

2.9.6.8.1.1
Referrals, including but not limited to, treating physician, nursing facility,
other providers, community-based organizations, family, and self-referrals;

2.9.6.8.1.2
Identification through the care coordination process, including but not limited
to: assessments, information gathered from musing facility staff, participation
in Grand Rounds (as defined in Section 1) or review and assessment of members
whose nursing facility level of care is ending and who appear to meet the
at-risk level of care for Group 3. 2.9.6.8.1.3 Review and analysis of members
identified by TENNCARE based on Minimum Data Set (MDS) data from nursing
facilities.

2.9.6.8.2
Members in CHOICES Group 1 (who are residents of a nursing facility) and who are
under the age of twenty-one (21) and have requested to transition home will be
provided coordination of care by the CONTRACTOR's CHOICES and MCO Case
Management staff (see Section 2.9.5.4.1).

2.9.6.8.3
Notwithstanding the nursing facility-to-community transition requirements set
forth in this section (2.9.6.8.), the CONTRACTOR shall be responsible for
monitoring all Group 1 members' level of care eligibility (see Section
2.9.6.8.1.2.) and for completing the process to re-establish nursing facility
level of care or transition to Group 3 HCBS, as appropriate, prior to expiration
of nursing facility level of care.

2.9.6.8.4
For transition referrals by or on behalf of a nursing facility resident,
regardless of referral source, the CONTRACTOR shall ensure that within fourteen
(14) days of the referral a care coordinator conducts an in-facility visit with
the member to determine the member's interest in and potential ability to
transition to the community, and provide orientation and information to the
member regarding transition activities. The member's care coordinator/care
coordination team shall document in the member's case file that transition was
discussed with the member and indicate the member's wishes as well as the
member's potential for transition. The CONTRACTOR shall not require a member to
transition from Group 1 to Group 2 when the member expresses a desire to
continue receiving nursing facility services.

2.9.6.8.5
For identification by the CONTRACTOR by means other than referral or the care
coordination process of a member who may have the ability and/or desire to
transition from a nursing facility to the community, the CONTRACTOR shall ensure
that within ninety (90) days of such identification a care coordinator

--------------------------------------------------------------------------------

conducts an in-facility visit with the member to determine whether or not the
member is interested in and potential ability to pursue transition to the
community. The member's care coordinator/care coordination team shall document
in the member's case file that transition was discussed with the member and
indicate the member's wishes as well as the member's potential for transition.
The CONTRACTOR shall not require a member to transition when the member
expresses a desire to continue receiving nursing facility services.

2.9.6.8.6
If the member wishes to pursue transition to the community, within fourteen (14)
days of the initial visit (see Sections 2.9.6.8.3 and 2.9.6.8.4 above) or within
fourteen (14) days of identification through the care coordination process, the
care coordinator shall conduct an in- facility assessment of the member's
ability and/or desire to transition using tools and protocols specified or prior
approved in writing by TENNCARE. This assessment shall include the
identification of any barriers to a safe transition.

2.9.6.8.7
As part of the transition assessment, the care coordinator shall conduct a risk
assessment using a tool and protocol specified by TENNCARE, discuss with the
member the risk involved in transitioning to the community and shall begin to
develop, as applicable, a risk agreement that shall be signed and dated by the
member or his/her representative and which shall include identified risks to the
member, the consequences of such risks, strategies to mitigate the identified
risks, and the member's decision regarding his/her acceptance of risk as part of
the plan of care. The risk agreement shall include the frequency and type of
care coordinator contacts that exceed the minimum contacts required (see Section
2.9.6.9.4), to mitigate any additional risks associated with transition and
shall address any special circumstances due to transition. For members
transitioning to Group 2, the member's care coordinator/care coordination team
shall also make a determination regarding whether the member's needs can be
safely and effectively met in the community and at a cost that does not exceed
nursing facility care. The member's care coordinator shall explain to the member
the individual cost neutrality cap and obtain a signed acknowledgement of
understanding by the member or his/her representative that a change in a
member's needs or circumstances that would result in the cost neutrality cap
being exceeded or that would result in the CONTRACTOR's inability to safely and
effectively meet a member's needs in the community and within the cost
neutrality cap may result in the member's disenrollment from CHOICES Group 2, in
which case, the CONTRACTOR will assist with transition to a more appropriate
care delivery setting. For members transitioning to Group 3, the care
coordinator shall explain the expenditure cap.

2.9.6.8.8
For those members whose transition assessment indicates that they are not
candidates for transition to the community, the care coordinator shall notify
them in accordance with the specified transition assessment protocol.

2.9.6.8.9
For those members whose transition assessment indicates that they are candidates
for transition to the community, the care coordinator shall facilitate the
development of and complete a transition plan within fourteen (14) days of the
member's transition assessment.

--------------------------------------------------------------------------------

2.9.6.8.10
The care coordinator shall include other individuals such as the member's family
and/or caregiver in the transition planning process if the member

requests and/or approves, and such persons are willing and able to participate.

2.9.6.8.11
As part of transition planning, prior to the member's physical move to the
community, the care coordinator shall visit the residence where the member will
live to conduct an on-site evaluation of the physical residence and meet with
the member's family or other caregiver who will be residing with the member (as
appropriate). The care coordinator shall include in the transition plan
activities and/or services needed to mitigate any perceived risks in the
residence including but not limited to an increase in face-to-face visits beyond
the minimum required contacts in Sections 2.9.6.8.19 and 2.9.6.8.20.

2.9.6.8.12
The transition plan shall address all services necessary to safely transition
the member to the community and include at a minimum member needs related to
housing, transportation, availability of caregivers, and other transition needs
and supports. The transition plan shall also identify any barriers to a safe
transition and strategies to overcome those barriers.

2.9.6.8.13
The CONTRACTOR shall approve the transition plan and authorize any covered or
cost effective alternative services included in the plan within ten (10)
business days of completion of the plan. The transition plan shall be fully
implemented within ninety (90) days from approval of the transition plan, except
under extenuating circumstances which must be documented in writing.2.9.6.8.14
The member's care coordinator shall also complete a plan of care that meets all
criteria described in Section 2.9.6.6 for members in CHOICES Groups 2 and 3
including but not limited to completing a comprehensive needs assessment,
completing and signing the risk agreement and making a final determination of
cost neutrality. The plan of care shall be authorized and initiated prior to the
member's transition to the community.

2.9.6.8.14.1.
If a transitioning member is enrolled in CHOICES Group 1, any CHOICES HCBS that
must be completed prior to a member's transition from a nursing facility to the
community in order to ensure the member's health and safety upon transition (e g
, minor home modifications, adaptive equipment, or PERS installation) shall be
completed while the member is enrolled in Group 1, but shall be billed as a
Group 2 service once the member is enrolled into Group 2, with the date of
service the effective date of enrollment in CHOICES Group 2 (see State Medicaid
Director Letter, Olmstead Update No. 3, July 25, 2000).

2.9.6.8.14.2.
If a transitioning member is enrolled in CHOICES Group 2 or 3 but is receiving
short- term nursing facility care, any CHOICES HCBS that must be completed prior
to a member's transition from a nursing facility to the community in order to
ensure the member's health and safety upon transition (e.g., minor home
modifications, adaptive equipment, or PERS installation) shall be completed
while the member resides in the

--------------------------------------------------------------------------------

facility and billed as a Group 2 or Group 3 service, as applicable. However, a
member shall not be transitioned from CHOICES Group 1 into Group 2 or 3 for
receipt of short- term nursing facility services in order to provide these
services. Short-term nursing facility care is
available only to a CHOICES 2 or CHOICES 3 participant who was receiving home
and community based services upon admission to the short-term nursing facility
stay.

2.9.6.8.15
For members requesting transition from Group 1 to Group 2, the CONTRACTOR shall
not prohibit a member from transitioning to the community once the member has
been counseled regarding risk. However, the CONTRACTOR may determine that the
member's needs cannot be safely and effectively met in the community and at a
cost that does not exceed nursing facility care. In such case, the CONTRACTOR
shall seek written review and approval from TENNCARE prior to denial of any
member's request to transition to the community. If TENNCARE approves the
CONTRACTOR's request, the CONTRACTOR shall notify the member in accordance with
TennCare rules and regulations and the transition assessment protocol, and the
member shall have the right to appeal the determination (see Section 2.19.3.12
of this Agreement).

2.9.6.8.16
Once completed, the CONTRACTOR shall submit to TENNCARE documentation, as
specified by TENNCARE to verify that for members transitioning to Group 2, the
member's needs can be safely and effectively met in the community and within the
cost neutrality cap. Before transitioning a member, the CONTRACTOR shall verify
that the member has been approved for enrollment in CHOICES Group 2 or Group 3,
as applicable, effective as of the planned transition date.

2.9.6.8.17
Ongoing CHOICES HCBS and any medically necessary covered home health or private
duty nursing services needed by the member shall be initiated immediately upon
transition from a nursing facility (i.e., CHOICES Group 1) to the community
(i.e., CHOICES Group 2 or CHOICES Group 3) and as of the effective date of
transition with no gaps between the member's receipt of nursing facility
services and ongoing CHOICES HCBS.

2.9.6.8.18
The member's care coordinator/care coordination team shall monitor all aspects
of the transition process and take immediate action to address any barriers that
arise during transition.

2.9.6.8.19
For members transitioning to a setting other than a community-based residential
alternative setting, the care coordinator/care coordination team shall upon
transition utilize the EVV system to monitor the initiation and daily provision
of services in accordance with the member's new plan of care, and shall take
immediate action to resolve any service gaps (see definition in Section 1).

2.9.6.8.20
For members who will live independently in the community or whose on-site visit
during transition planning indicated an elevated risk, within the first
twenty-four (24) hours, the care coordinator shall visit the member in his/her
residence. During the initial ninety (90) day post-transition period, the care

--------------------------------------------------------------------------------

coordinator shall conduct monthly face-to-face in-home visits to ensure that the
plan of care is being followed, that the plan of care continues to meet the
member's needs, and the member has successfully transitioned to the community.

2.9.6.8.21
For members transitioning to a community-based residential alternative setting
or who will live with a relative or other caregiver, within the first
twenty-four (24) hours the care coordinator shall contact the member and within
seven (7) days after the member has transitioned to the community, the care
coordinator shall visit the member in his/her new residence. During the initial
ninety (90) day post-transition period, the care coordinator shall (1) at a
minimum, contact the member by telephone each month to ensure that the plan of
care is being followed, that the plan of care continues to meet the member's
needs, and the member has successfully transitioned to the community; and (2)
conduct additional face-to- face visits as necessary to address issues and/or
concerns and to ensure that the member's needs are met.

2.9.6.8.22
The CONTRACTOR shall monitor hospitalizations and nursing facility re-admission
for members who transition from a nursing facility to the community to identify
issues and implement strategies to improve transition outcomes.

2.9.6.8.23
The CONTRACTOR shall be permitted to coordinate or subcontract with local
community-based organizations to assist in the identification, planning and
facilitation processes related to nursing facility-to-community transitions that
are not specifically assigned to the care coordinator.

2.9.6.8.24
The CONTRACTOR shall develop and implement any necessary assessment tools,
transition plan templates, protocols, or training necessary to ensure that
issues that may hinder a member's successful transition are identified and
addressed. Any tool, template, or protocol must be prior approved in writing by
TENNCARE.

2.9.6.8.25
To facilitate nursing facility to community transition, the CONTRACTOR may elect
to use specialized transition coordinators or transition teams. All transition
activities identified as responsibilities of the care coordinator shall be
completed by an individual who meets all of the requirements to be a care
coordinator.

2.9.6.8.26
The CONTRACTOR shall implement policies and processes necessary to ensure that
it is aware when a member is admitted to or discharged from a NF in order to
facilitate care planning and as seamless a transition as possible, and to ensure
timely notification to TENNCARE and other entities (e.g., DHS) as appropriate.

2.9.6.8.26.1
The CONTRACTOR shall require NFs to notify the CONTRACTOR of all NF discharges,
transfers between NFs, or elections of hospice services in a NF.

2.9.6.8.26.2
The CONTRACTOR shall, in a manner prescribed by TENNCARE notify: a) TENNCARE of
all NF discharges and elections of hospice

--------------------------------------------------------------------------------

services in a NF; b) DHS of all NF discharges and transfers between NFs; and c)
receiving NFs of all applicable level of care information when a member is
transferring between NFs.

2.9.6.8.26.3
The CONTRACTOR shall conduct a census as frequently as deemed necessary by
TENNCARE to confirm the residency status and Group assignment of all CHOICES
members (i.e., Group 1 receiving services in a NF or Group 2 receiving HCBS or
short- term NF services). The CONTRACTOR shall take actions as necessary to
address any discrepancies when a CHOICES member is found to no longer be
receiving LTC services, or is receiving services in a different service delivery
setting, e.g., NF, HCBS, or hospice in a NF, including, as appropriate,
disenrollment from CHOICES and/or enrollment in a different CHOICES Group.

2.9.6.8.26.4
The CONTRACTOR shall authorize and/or reimburse short-term NF stays for Group 2
and Group 3 members only when (1) the member meets the nursing facility level of
care in place at the time of admission; (2) the member's stay in the facility is
expected to be less than ninety (90) days; and (3) the member is expected to
return to the community upon its conclusion. The CONTRACTOR shall monitor all
short-term NF stays for Group 2 and Group 3 members and shall ensure that the
member is transitioned from Group 2 or Group 3, as applicable, to Group I at any
time a) it is determined that the stay will not be short-term or the member will
not transition back to the community; and b) prior to exhausting the ninety
(90)-day short-term NF benefit covered for CHOICES Group 2 and Group 3 members.

2.9.6.8.26.4.1
Upon request, the CONTRACTOR shall provide to TENNCARE a member-by-member status
for each Group 2 and Group 3 member utilizing the short-term NF stay benefit,
including but not limited to the name of each Group 2 and Group 3 member
receiving short-term NF services, the NF in which s/he currently resides, the
date of admission for short-term stay, and the anticipated date of discharge
back to the community.

28.
Section 2.9.6.9.4.3.3 shall be amended by adding the phrase "or Group 3" after
the phrase "CHOICES Group 2".

2.9.6.9.4.3.3
Members in CHOICES Group 2 or Group 3 who have transitioned from a nursing
facility to the community shall be contacted per the applicable timeframe
specified in Section 2.9.6.8.

29.
Sections 2.9.6.9.4.3.7 through 2.9.6.9.4.3.9 shall be deleted and replaced as
follows:

2.9.6.9.4.3.7
Members in CHOICES Group 2 or Group 3 shall be contacted by their care
coordinator at least monthly either in person or by telephone with an interval
of at least fourteen (14) days between contacts. These members shall be visited
in their

--------------------------------------------------------------------------------

residence face-to-face by their care coordinator at least quarterly with an
interval of at least sixty (60) days between visits.

29.9.6.9.4.3.8
Members in CHOICES Group 2 or Group 3 participating in MFP shall, for at least
the first ninety (90) days following transition to the community, be visited in
their residence face-to-face by their care coordinator at least monthly with an
interval of at least fourteen (14) days between contacts to ensure that the plan
of care is being followed, that the plan of care continues to meet the member's
needs, and the member has successfully transitioned back to the community.
Thereafter, for the remainder of the member's MFP participation period, minimum
contacts shall be as described in 2.9.6.9.4.3.7 unless more frequent contacts
are required based on the member's needs and circumstances and as reflected in
the member's plan of care, or based on a significant change in circumstances
(see Sections 2.9.6.9.2.1.16. and 2.9.8.4.5) or a short-term nursing facility
stay (see Sections 2.9.8.8.5 and 2.9.8.8.7).

30.
Sections 2.9.6.9.6.3.3 and 2.9.6.9.6.3.4 shall be deleted and replaced as
follows:

2.9.6.9.6.3.3    For members whose plan of care includes eligible CHOICES HCBS,
written
confirmation of the member's decision regarding participation in consumer
direction of eligible CHOICES HCBS;

2.9.6.9.6.3.4
A completed risk assessment and a risk agreement signed and dated by the member
or his/her representative; and

31.
Section 2.9.6.11.6.1.1 shall be amended by adding the phrase "or Group 3" after
the phrase "CHOICES Group 2".

2.9.6.11.6.1.1
Upon completion of a Transition Assessment which indicates that a Group 1 member
is a candidate for transition to the community, such member shall be factored
into the weighted caseload and staffing ratio calculations using an acuity level
of two and one- half (2.5) until such time as the member is transitioned to
CHOICES Group 2 or Group 3 or the member is no longer a candidate for
transition;

32.
Section 2.9.6.11.6.2 shall be amended by adding the phrase "or Group 3" after
the phrase
"CHOICES Group 2".

2.9.6.11.6.2
Each CHOICES Group 2 or Group 3 member shall be factored into the weighted
caseload and staffing ratio calculations utilizing an acuity level of two and
one-half (2.5);

33.
Sections 2.9.6.11.6.3 and 2.9.6.11.6.4 shall be amended by deleting and
replacing the header of the charts as follows:

2.9.6.11.6.3.
Using the delineated acuity factors, the following provides examples of the
composition of caseloads with a weighted value of 125:

--------------------------------------------------------------------------------

Weighted Caseload Mix for a 1:125 Ratio
CHOICES
Group 1
(Acuity 1.0)
CHOICES
Group 2 and
Group 3
(Acuity 2.5)
Total CHOICES
Members on Caseload
125
0
125
100
10
110
75
20
95
50
30
80
25
40
65
0
50
50

2.9.6.11.6.4.
Using the delineated acuity factors, the following delineates the composition of
caseloads with a weighted value of 175:

Weighted Caseload Mix for a 1:175 Ratio
CHOICES
Group 1
(Acuity 1.0)
CHOICES
Group 2 and
Group 3
(Acuity 2.5)
Total CHOICES
Members on
Caseload
175
0
175
150
10
160
125
20
145
100
30
130
75
40
115
50
50
100
25
60
85
0
70
70

34.
Section 2.9.6.11.8 shall be deleted and replaced as follows:

2.9.6.11.8
Upon request, the CONTRACTOR shall provide to TENNCARE documentation of such
monitoring, including an itemized list by care coordinator of the total number
of members assigned, and the number of Group I members (including members in
transition and children under age 21), Group 2 and Group 3 members that comprise
each care coordinator's caseload.

35.
Section 2.9.6.11.18.1 shall be deleted and replaced as follows:

--------------------------------------------------------------------------------

2.9.6.11.18.1
The CHOICES program including a description of the CHOICES groups; eligibility
for CHOICES enrollment; enrollment in CHOICES; enrollment targets for Groups 2
and 3 (excluding Interim Group 3), including reserve capacity and administration
of waiting lists; and CHOICES benefits, including benefit limits, the individual
cost neutrality cap for Group 2, the expenditure cap for Group 3, and the
limited benefit package for Group 2 members enrolled on the basis of Immediate
Eligibility;

36.
Section 2.9.6.11.18.17 shall be deleted and replaced as follows:

2.9.6.11.18.17
For all CHOICES members, as applicable, members' responsibility regarding
patient liability, including the consequences of not paying patient liability;

37.
Section 2.9.6.13.1 shall be deleted and replaced as follows:

2.9.6.13.1
The CONTRACTOR shall use the TENNCARE PreAdmission Evaluation System (TPAES),
the system of record for CHOICES level of care determinations, to facilitate
submission of all PreAdmission Evaluation (i.e., level of care) applications,
including required documentation pertaining thereto, and to facilitate
enrollments into and transitions between LTC programs, including CHOICES. The
CONTRACTOR shall comply with all data entry and tracking processes and timelines
established by TENNCARE in policy or protocol in order to ensure efficient and
effective administration and oversight of the CHOICES program.

38.
Section 2.9.7.4.1 shall be amended by deleting the reference to "Section
2.9.6.2.4" and replacing it with the reference to "Section 2.9.6.2.5" and
Section 2.9.7.4.3.3 shall be amended by adding the phrase "or Group 3" after the
phrase "CHOICES Group 2" and Section 2.9.7.4.3.4 shall be amended by deleting
the phrase "Group 2" at the end of the sentence.

2.9.7.4.3.3
For any CHOICES Group 2 or Group 3 member electing to participate in consumer
direction that refuses to receive eligible CHOICES HCBS from contract providers
while services are initiated through consumer direction, the member's care
coordinator shall visit the member face to face at least monthly to ensure that
the member's needs are safely met, and shall continue to offer eligible CHOICES
HCBS through contract providers.

2.9.7.4.3.4
If eligible CHOICES HCBS are not initiated within sixty (60) days following
referral to the FEA, the CONTRACTOR shall notify the member that eligible
CHOICES HCBS must be initiated by contract providers unless these HCBS are not
needed on an ongoing basis in order to safely meet the member's needs in the
community, in which case, the CONTRACTOR shall submit documentation to TENNCARE
to begin the process of disenrollment from CHOICES.

--------------------------------------------------------------------------------

39.
Section 2.9.8.1.2 shall be amended by adding the phrase "or Group 3" after the
phrase "CHOICES Group 2".

2.9.8.1.2
Eligible Individuals transitioning to a Qualified Residence in the community and
consenting to participate in MFP shall be transitioned from CHOICES Group 1 into
CHOICES Group 2 or Group 3 pursuant to TENNCARE policies and protocols for
Nursing Facility-to-community transitions and shall also be enrolled into MFP.
For persons enrolled in CHOICES who are also participating in MFP, the
CONTRACTOR shall comply with all applicable provisions of this Agreement
pertaining to the CHOICES program. This section sets forth additional
requirements pertaining to the CONTRACTOR's responsibilities specifically as it
relates to MFP.

40.
Section 2.9.8.2.2 shall be amended by adding the phrase "or Group 3" after the
phrase "CHOICES Group 2".

2.9.8.2.2
The CONTRACTOR shall assess all nursing facility residents transitioning from
the NF to CHOICES Group 2 or Group 3 for participation in MFP. This includes
CHOICES Group 1 members referred for transition, as well as nursing facility
residents referred for CHOICES who are not yet enrolled in CHOICES Group 1 but
may be determined eligible for Group 1, and who have expressed a desire to move
back into the community. However, the resident must actually be enrolled into
Group I in order to qualify for MFP.

41.
Sections 2.9.8.3.3 and 2.9.8.3.4 shall be deleted and replaced as follows:

2.9.8.3.3
Only CHOICES Group I members who qualify to enroll in CHOICES Group 2 or Group 3
shall be eligible to transition to Group 2 or Group 3, as applicable, and enroll
into MFP.

2.9.8.3.4
In addition to facilitating transition from CHOICES Group 1 to CHOICES Group 2
or Group 3 pursuant to Section 2.9.6.8 of this Agreement and TENNCARE's policies
and protocols, the CONTRACTOR shall facilitate the enrollment of Eligible
Individuals who consent into MFP.

42.
Sections 2.9.8.4.6 and 2.9.8.4.12 shall be amended by adding the phrase "or
Group 3, as applicable" after the phrase "CHOICES Group 2".

2.9.8.4.6
The CONTRACTOR shall review the circumstances which resulted in the inpatient
facility admission and shall evaluate whether the services and supports provided
to the member are sufficient to safely meet his needs in the community such that
continued participation in CHOICES Group 2 or Group 3, as applicable, and in MFP
is appropriate.

2.9.8.4.12
The CONTRACTOR shall, using a template provided by TENNCARE, issue a written
notice of MFP participation to each member enrolled in MFP which shall not occur
prior to transition from CHOICES Group 1 to CHOICES Group

--------------------------------------------------------------------------------

2 or Group 3, as applicable. Such notice shall be issued within ten (10)
business days of notification from TENNCARE via the outbound 834 enrollment file
furnished by TENNCARE to the CONTRACTOR that the member is enrolled in MFP.

--------------------------------------------------------------------------------

43.
Sections 2.9.8.5.1, 2.9.8.6.1, and 2.9.8.7.1 shall be amended by adding the
phrase "or Group 3, as applicable" after the phrase "CHOICES Group 2".

2.9.8.5.1
For members participating in the MFP, the Plan of Care shall reflect that the
member is an MFP participant, including the date of enrollment into MFP (i.e.,
date of transition from CHOICES Group 1 to CHOICES Group 2 or Group 3, as
applicable).

2.9.8.6.1
A member enrolled in MFP shall be simultaneously enrolled in CHOICES Group 2 or
Group 3, as applicable, and shall be eligible to receive covered benefits as
described in 2.6.1

2.9.8.7.1
Upon completion of a person's 365-day participation in MFP, services (including
CHOICES HCBS) shall continue to be provided in accordance with the covered
benefits described in 2.6.1 and the member's plan of care. Transition from
participation in MFP and CHOICES Group 2 or Group 3, as applicable, to
participation only in CHOICES Group 2 or Group 3, as applicable, shall be
seamless to the member, except that the CONTRACTOR shall be required to issue
notice of the member's conclusion of his 365- day MFP participation period.

44.
Sections 2.9.8.8.1 and 2.9.8.8.2 shall be deleted and replaced as follows:

2.9.8.8.1
A CHOICES Group 2 or Group 3 member that meets the nursing facility level of
care in place at the time of admission may be admitted for an inpatient
short-term nursing facility stay for up to ninety (90) days and remain enrolled
in CHOICES Group 2 or Group 3, as applicable (see Section 2.6.1.5.4). The
CONTRACTOR shall ensure that the member is transitioned from Group 2 or Group 3,
as applicable, to Group 1 at any time: a) it is determined that the stay will
not be short-term and the member will not transition back to the community; and
b) prior to exhausting the ninety (90) day short-term nursing facility benefit
covered for CHOICES Group 2 or Group 3 members (see Section 2.9.6.8.26.4).

2.9.8.8.2
A CHOICES Group 2 or Group 3 member participating in MFP who meets the nursing
facility level of care in place at the time of admission may be admitted for an
inpatient short-term nursing facility stay during his 365-day participation
period and remain enrolled in MFP regardless of the number of days the member is
admitted for inpatient facility care.

45.
Sections 2.9.8.8.4 shall be deleted and replaced as follows:

2.9.8.8.4
If the short-term stay will exceed ninety (90) days, the CONTRACTOR shall
facilitate transition from CHOICES Group 2 or Group 3 if the Group 3 member
continues to meet nursing facility level of care to CHOICES Group 1.

46.
Sections 2.9.8.8.6 shall be amended by adding the phrase "or Group 3" after the
phrase "CHOICES Group 2".

--------------------------------------------------------------------------------

2.9.8.8.6
The CONTRACTOR shall conduct a Transition Assessment and develop a Transition
Plan (see Section 2.9.6.8) as necessary to facilitate the member's return to the
community. Such assessment shall include a review of the circumstances which
resulted in the nursing facility admission and shall evaluate whether the
services and supports provided to the member are sufficient to safely meet his
needs in the community such that transition back to CHOICES Group 2 or Group 3
and continued participation in MFP is appropriate. The CONTRACTOR shall update
the member's plan of care, including the member's Risk Agreement, as deemed
necessary based on the member's needs and circumstances.

47.
Section 2.9.8.11.1 shall be amended by deleting the reference to "Section
2.9.6.12.6" and replacing it with the reference to "Section 2.9.6.12.7".

48.
Section 2.9.8.13.1.5.2 shall be amended by adding the phrase "and Group 3" after
the phrase "CHOICES Group 2".

2.9.8.13.1.5.2
Immediately prior to implementation of MFP and at the beginning of each calendar
year thereafter, statewide calendar year numbers for benchmark #5 will be
allocated on a regional basis to each MCO operating in the region, based on the
number of persons in CHOICES Group 2 and Group 3. For purposes of incentive
payments (see Section 3.11), achievement of this benchmark shall be determined
on a regional basis by MCO.

49.
Sections 2.9.15.1 and 2.9.15.5 shall be deleted and replaced as follows:

2.9.15.1
Tennessee Department of Mental Health and Substance Abuse Services (TDMHSAS) and
Tennessee Department of Intellectual and Developmental Disabilities (DIDD) for
the purpose of interfacing with and assuring continuity of care and for
coordination of specialized services in accordance with federal PASRR
requirements;

2.9.15.5
Tennessee Department of Intellectual Disabilities Services (DIDD), for the
purposes of coordinating physical and behavioral health services with HCBS
available for members who are also enrolled in a Section 1915(c) HCBS waiver for
persons with intellectual disabilities, i.e., mental retardation;

50.
Section 2.13.4.4 shall be amended by deleting the reference to "Section 2.9.6.7"
and replacing it with "Section 2.9.7.6.11".

51.
Section 2.14.1.2 shall be amended by adding a new Section 2.14.1.2.1 as follows:

2.14.1.2.1
The UM program description, work plan and program evaluation shall be exclusive
to TENNCARE and shall not contain documentation from other state Medicaid
programs or product lines operated by the CONTRACTOR.

--------------------------------------------------------------------------------

52.
Section 2.15.1.1.6 shall be amended by deleting the word "and"at the end of the
sentence, Section 2.15.1.1.7 shall be amended by deleting and replacing the "."
with "; and", and Section 2.15.1.1 shall be amended by adding a new Section
2.15.1.1.8 as follows:

2.15.1.1.8
The QM/QI program description, work plan and program evaluation shall be
exclusive to TENNCARE and shall not contain documentation from other state
Medicaid programs or product lines operated by the CONTRACTOR.

53.
Section 2.17.4.7.11 shall be amended by adding the phrase "(excluding Interim
Group 3)" after the phrase "Group 2 and Group 3".

2.17.4.7.11
Shall include information on the CHOICES program, including a description of the
CHOICES groups; eligibility for CHOICES; enrollment in CHOICES, including whom
to contact at the MCO regarding enrollment in CHOICES; enrollment targets for
Group 2 and Group 3 (excluding Interim Group 3), including reserve capacity and
administration of waiting lists; and CHOICES benefits, including benefit limits,
the individual cost neutrality cap for Group 2, and the expenditure cap for
Group 3;

54.
Section 2.17.7.3.12 shall be deleted and replaced as follows:

2.17.7.3.12
Information about patient liability responsibilities including the potential
consequences of failure to comply with patient liability requirements. For Group
1 members, this may include loss of the member's nursing facility provider; for
Group 2 members, loss of the member's CBRA provider; and for all CHOICES
members, loss of the member's MCO, disenrollment from CHOICES, and to the extent
that the member's eligibility depends on receipt of long-term care services,
loss of eligibility for TennCare;

55.
Section 2.20.2 shall be deleted and replaced as follows:

2.20.2 Reporting and Investigating Suspected Fraud and Abuse

2.20.2.1
The CONTRACTOR shall cooperate with all appropriate state and federal agencies,
including TBI MFCU and/or OIG, in investigating fraud and abuse. In addition,
the CONTRACTOR shall fully comply with the TCA 71-5-2601 and 71-5-2603 in
performance of its obligations under this Agreement.

2.20.2.2
The CONTRACTOR shall have methods for identification, investigation, and
referral of suspected fraud cases (42 CFR 455.13, 455.14, 455.21).

2.20.2.3
The CONTRACTOR shall notify TBI MFCU and TennCare Office of Program Integrity
simultaneously and in a timely manner regarding all internal (such as identified
patterns of data mining outliers, audit concerns, critical incidences) and
external (such as hotline calls) tips with potential implications to TennCare
providers' billing anomalies and/or to safety of TennCare enrollees
(http://www.tbi.state.tn.us/tbi_tips.shtml; ProgramIntegrity.TennCare@tn.gov).
Along with a notification, the CONTRACTOR shall take steps to triage and/or
substantiate these tips and provide simultaneous and timely updates to TBI

--------------------------------------------------------------------------------

MFCU and the TennCare Office of Program Integrity when the concerns and/or
allegations of any tips are authenticated.

2.20.2.4
The CONTRACTOR shall report all confirmed or suspected fraud and abuse to
TENNCARE and the appropriate agency as follows:

2.20.2.4.1
Suspected fraud and abuse in the administration of the program shall be reported
to TennCare Office of Program Integrity, TBI MFCU and/or MG;

2.20.2.4.2
All confirmed or suspected provider fraud and abuse shall immediately be
reported to TBI MFCU and TennCare Office of Program Integrity; and

2.20.2.4.3
All confirmed or suspected enrollee fraud and abuse shall be reported
immediately to OIG.

2.20.2.5
The CONTRACTOR shall use the Fraud Reporting Forms in Attachment VI, or such
other form as may be deemed satisfactory by the agency to whom the report is to
be made under the terms of this Agreement.

2.20.2.6
Pursuant to TCA 71-5-2603(c) the CONTRACTOR shall be subject to a civil penalty,
to be imposed by the OIG, for willful failure to report fraud and abuse by
recipients, enrollees, applicants, or providers to TENNCARE and OIG or TBI MFCU,
as appropriate.

2.20.2.7
The CONTRACTOR shall promptly perform a preliminary investigation of all
incidents of suspected and/or confirmed fraud and abuse. Unless prior written
approval is obtained from the agency to whom the incident was reported, or to
another agency designated by the agency that received the report, after
reporting fraud or suspected fraud and/or suspected abuse and/or confirmed
abuse, the CONTRACTOR shall not take any of the following actions as they
specifically relate to TennCare claims:

2.20.2.7.1
Contact the subject of the investigation about any matters related to the
investigation;

2.20.2.7.2
Enter into or attempt to negotiate any settlement or agreement regarding the
incident; or

2.20.2.7.3
Accept any monetary or other thing of valuable consideration offered by the
subject of the investigation in connection with the incident.

2.20.2.8
The CONTRACTOR shall promptly provide the results of its preliminary
investigation to the agency to whom the incident was reported, or to another
agency designated by the agency that received the report.

2.20.2.9
The CONTRACTOR shall cooperate fully in any further investigation or prosecution
by any duly authorized government agency, whether administrative, civil, or
criminal. Such cooperation shall include providing, upon request, information,
access to records, and access to interview CONTRACTOR

--------------------------------------------------------------------------------

employees and consultants, including but not limited to those with expertise in
the administration of the program and/or in medical or pharmaceutical questions
or in any matter related to an investigation.

2.20.2.10    The State shall not transfer its law enforcement functions to the
CONTRACTOR.

2.20.2.11
The CONTRACTOR, subcontractor and providers, whether contract or non-contract,
shall, upon request and as required by this Agreement or state and/or federal
law, make available to the TBI MFCU/OIG any and all administrative, financial
and medical records relating to the delivery of items or services for which
TennCare monies are expended. In addition, the TBI MFCU/OIG shall, as required
by this Agreement or state and/or federal law, be allowed access to the place of
business and to all TennCare records of any contractor, subcontractor or
provider, whether contract or non-contract, during normal business hours, except
under special circumstances when after hour admission shall be allowed. Special
circumstances shall be determined by the TBI MFCU/OIG.

2.20.2.12
The CONTRACTOR and/or subcontractors shall include in any of its provider
agreements a provision requiring, as a condition of receiving any amount of
TennCare payment, that the provider comply with this Section, Section 2.20 of
this Agreement.

2.20.2.13
The CONTRACTOR shall notify TENNCARE when the CONTRACTOR denies a provider
credentialing application for program integrity-related reasons or otherwise
limits the ability of providers to participate in the program for program
integrity reasons.

2.20.2.14
Except as described in Section 2.11.8.2 of this Agreement, nothing herein shall
require the CONTRACTOR to ensure non-contract providers are compliant with
TENNCARE contracts or state and/or federal law.

2.20.2.15
In accordance with the Affordable Care Act and TennCare policy and procedures,
the CONTRACTOR shall report overpayments made by TENNCARE to the CONTRACTOR as
well as overpayments made by the CONTRACTOR to a provider and/or subcontractor
(See Section 2.12.9.42).

56.
Section 2.22.1 shall be amended by deleting the word "and" between the words
"filing," and "compliance" and by adding new language to the end of the section.

2.22.1    General

To the extent that the CONTRACTOR compensates providers on a fee-for-service or
other basis requiring the submission of claims as a condition of payment, the
CONTRACTOR shall process, as described herein, the provider's claims for covered
benefits provided to members consistent with applicable CONTRACTOR policies and
procedures and the terms of this Agreement including but not limited to timely
filing, compliance with all applicable state and federal laws, rules and
regulations, including the development, staff and provider education and
training, and

--------------------------------------------------------------------------------

implementation of all state and federal standardization initiatives (e.g., 5010,
ICD 10, etc.) within the designated guidelines and timeframes specified by
TENNCARE and/or CMS.

57.
Section 2.25.9 shall be deleted in its entirety.

58.
Section 2.26.1 shall be amended by adding a new Section 2.26.1.3 as follows and
renumbering the remaining Section accordingly, including any references thereto.

2.26.1.3
Effective with any new subcontracts or upon the next amendment to existing
subcontracts, the CONTRACTOR shall include a requirement that the subcontract
may be terminated by the CONTRACTOR for convenience and without cause upon a
specified number of days written notice.

59.
Section 2.29.1.3.13 shall be deleted and replaced as follows:

2.29.1.3.13
At least one full-time investigator per operating region and a staff person
responsible for all fraud and abuse detection activities, including the fraud
and abuse compliance plan, as set forth in Section 2.20 of this Agreement. The
investigator will have full knowledge with provider investigations related to
the TennCare program and will be the key staff handling day-to-day provider
investigation related inquires from TENNCARE;

60.
Section 2.29.1.3.29 shall be amended by deleting "TDMHDD" and replacing it with
"TDMHSAS".

61.
Section 2.30.4.3 shall be deleted and replaced as follows:

2.30.4.3
The CONTRACTOR shall submit a quarterly Behavioral Health Crisis Response Report
that provides information on behavioral health crisis services (see Section
2.7.2.8) including the data elements described by TENNCARE. Specified data
elements shall be reported separately for members ages eighteen (18) years and
over and those under eighteen (18) years and all data elements shall be reported
for each individual crisis service provider as described in the template
provided by TENNCARE.

62.
Sections 2.30.6.4 and 2.30.6.6 shall be amended by deleting the reference to
"Section 2.9.6.8" and replacing it with the reference to "Section 2.9.8" and
Item (1) of Section 2.30.6.9 shall be amended by adding the phrase "or Group 3"
after the phrase "CHOICES Group 2".

(1)
The total number and the name and SSN of each CHOICES Group 2 or Group 3 member
enrolled into MFP;

63.
Sections 2.30.11.5, 2.30.12.7, and 2.30.17.5 shall be amended by deleting the
reference to "Section 2.9.6.8" and replacing it with the reference to "Section
2.9.8".

64.
Section 2.30.22.1 shall be amended by adding the word "also" between the words
"shall" and "demonstrate" in the second sentence.

--------------------------------------------------------------------------------

65.
Section 3.4.3.3 shall be deleted and replaced as follows:

3.4.3.3
Health plan risk assessment scores will be recalibrated annually based upon
health status information derived from encounter data submitted to TENNCARE by
MCOs serving the Grand Region through the most recent twelve (12) month period
deemed appropriate by the State's actuary. If the health plan risk assessment
score for any MCO deviates from the profile for the Grand Region being served by
the MCO by more than one percent (1%), whether a negative or positive change in
scores, the base capitation rates as subsequently adjusted will be
proportionally adjusted, unless otherwise specified in the subsections below.

66.
Section 3.4.3.7 shall be deleted and replaced in its entirety.

3.4.3.7
For CHOICES members, only the non-long-term care component of the base
capitation rate will be adjusted for health plan risk. The long-term care
component of the base capitation rate will not be adjusted for health plan risk.
For CHOICES Groups 1 and 2 members only, the long-term care component of the
base capitation rate will be adjusted according to the relative mix of persons
receiving LTC in each service delivery setting (NF versus HCBS) in accordance
with the following:

3.4.3.7.1
Member Movement during Implementation and/or annual Open Enrollment Periods

3.4.3.7.1.1
TENNCARE will track CHOICES member change requests that occur from March 1st,
2010 through the completion of the 2010 open enrollment period for enrollees who
were enrolled in CHOICES on March 1, 2010.

3.4.3.7.1.1.1
CHOICES members that change MCOs during the open enrollment period will be
designated as either a NF enrollee (Group 1) or an HCBS enrollee (Group 2) based
upon the determination made in the outbound 834 enrollment file on the date of
their official transfer.

3.4.3.7.1.1.2
The net transfer of CHOICES Group 1 and Group 2 members from March 1, 2010
through May 31, 2010 will be compared to the mix of NF/HCBS enrollees in the
data book assumptions. If the mix of net transfers exceeds one half (1/2) of one
(1) percent different between the MCOs, rates will be adjusted accordingly.

3.4.3.7.1.2
A similar process will occur in May 2011, after the completion of the open
enrollment period for 2011 and following each Open Enrollment Period. This
process will compare the effect of net transfers for CHOICES Group 1 and 2
members only as compared to the mix before the 2011(or applicable) annual open
enrollment period.

3.4.3.7.1.3    This adjustment will be budget neutral to the state.

3.4.3.7.1.4
This adjustment described in Section 3.4.3.7.1 is intended to address changes in
CHOICES Group 1 and 2 member enrollment mix due to enrollees changing

--------------------------------------------------------------------------------

from one MCO to another and does not address changes in enrollment mix due to
other factors.
67.
The PROGRAM ISSUES Column in Items A.16 and A.29 of the Liquidated Damages Chart
in Section 4.20.2.2.7 shall be amended by adding the phrase "or 3" after the
phrase "Group 2".

LEVEL
PROGRAM ISSUES
 
DAMAGE
A.16
Failure to comply with the timeframes for developing and approving a plan of
care for transitioning CHOICES members in Group 2 or 3, authorizing and
initiating nursing facility services for transitioning CHOICES members in Group
1, or initiating long-term care services for CHOICES members (see Sections
2.9.2, 2.9.3, and 2.9.6)
 
$5,000 per month that the CONTRACTOR's performance is 85-89% by service setting
(nursing facility or HCBS)
$10,000 per month that the CONTRACTOR's performance is 80-84% by service setting
(nursing facility or HCBS)
$15,000 per month that the CONTRACTOR's performance is 75-79% by service setting
(nursing facility or HCBS)
$20,000 per month that the CONTRACTOR's performance is 70-74% by service setting
(nursing facility or HCBS)
$25,000 per month that the CONTRACTOR's performance is 69% or less by service
setting (nursing facility or HCBS)
These amounts shall be multiplied by two (2) when the CONTRACTOR has not
complied with the Caseload and Staffing recommendations as specified in Section
2.9.6.11.9 of this Agreement
A.29
Failure to initiate CHOICES HCBS or for children under age 21, EPSDT benefits
provided as an alternative to nursing facility care in accordance with the
member's plan of care and to ensure that such HCBS or EPSDT benefits are in
place immediately upon transition from a nursing facility to the community for
any person transitioning from a nursing facility (i.e.,CHOICES Group 1) to the
community (i.e., CHOICES Group 2 or 3), including persons enrolled in MFP (see
Sections 2.9.5.4.1.5 and 2.9.6.8.16)
 
$500 per day for each day that HCBS are not in place following transition from a
nursing facility (i.e., CHOICES Group 1) to the community (i.e., CHOICES Group
2) in addition to the cost of services not provided
These amounts shall be multiplied by two (2) when the CONTRACTOR has not
complied with the Caseload and Staffing recommendations as specified in Section
2.9.6.11.9 of this Agreement

--------------------------------------------------------------------------------

--------------------------------------------------------------------------------

68.
Section 4 shall be amended by adding a new Section 4.40 as follows and
renumbering the existing Sections accordingly, including any references thereto.

4.40
SOCIAL SECURITY ADMINISTRATION (SSA) REQUIRED PROVISIONS FOR DATA SECURITY

The CONTRACTOR shall comply with limitations on use, treatment, and safeguarding
of data under the Privacy Act of 1974 (5 U.S.C. §552a), as amended by the
Computer Matching and Privacy Protection Act of 1988, related Office of
Management and Budget guidelines, the Federal Information Security Management
Act of 2002 (44 U.S.C. § 3541, el seq.), and related National Institute of
Standards and Technology guidelines. In addition, the CONTRACTOR shall have in
place administrative, physical, and technical safeguards for data.

4.40.1
The CONTRACTOR shall not duplicate in a separate file or disseminate, without
prior written permission from TENNCARE, the data governed by the Agreement for
any purpose other than that set forth in this Agreement for the administration
of the TennCare program. Should the CONTRACTOR propose a redisclosure of said
data, the CONTRACTOR must specify in writing to TENNCARE the data the CONTRACTOR
proposes to redisclose, to whom, and the reasons that justify the redisclosure.
TENNCARE will not give permission for such redisclosure unless the redisclosure
is required by law or essential to the administration of the TennCare program.

4.40.2
The CONTRACTOR agrees to abide by all relevant federal laws, restrictions on
access, use, and disclosure, and security requirements in this Agreement.

4.40.3
Upon request, the CONTRACTOR shall provide a current list of the employees of
such CONTRACTOR. with access to SSA data and provide such lists to TENNCARE.

4.40.4
The CONTRACTOR shall restrict access to the data obtained from TENNCARE to only
those authorized employees who need such data to perform their official duties
in connection with purposes identified in this Agreement. The CONTRACTOR shall
not further duplicate, disseminate, or disclose such data without obtaining
TENNCARE's prior written approval.

4.40.5
The CONTRACTOR shall ensure that its employees:

4.40.5.1
Properly safeguard PHI/PII furnished by TENNCARE under this Agreement from loss,
theft or inadvertent disclosure;

4.40.5.2
Understand that they are responsible for safeguarding this information at all
times, regardless of whether or not the CONTRACTOR employee is at his or her
regular duty station;

4.40.5.3
Ensure that laptops and other electronic devices/ media containing PHI/PII are
encrypted and/or password protected;

4.40.5.4
Send mails containing PHI/PII only if encrypted or if to and from addresses that
are secure; and

4.40.5.5
Limit disclosure of the information and details relating to a PHI/PII loss only
to those with a need to know.

--------------------------------------------------------------------------------

CONTRACTOR employees who access, use, or disclose TennCare or TennCare
SSA-supplied data in a manner or purpose not authorized by this Agreement may be
subject to civil and criminal sanctions pursuant to applicable federal statutes.

--------------------------------------------------------------------------------

4.40.6
Loss or Suspected Loss of Data — If an employee of the CONTRACTOR becomes aware
of suspected or actual loss of PHI/PII, he or she must immediately contact
TENNCARE within one (1) hour to report the actual or suspected loss. The
CONTRACTOR will use the Loss Worksheet located at
http://www.tn.gov/tenncare/forms/phi_piiworksheet.pdf to quickly gather and
organize information about the incident. The CONTRACTOR must provide TENNCARE
with timely updates as any additional information about the loss of PHI/PII
becomes available.

4.40.6.1
If the CONTRACTOR experiences a loss or breach of said data, TENNCARE will
determine whether or not notice to individuals whose data has been lost or
breached shall be provided and the CONTRACTOR shall bear any costs associated
with the notice or any mitigation.

4.40.7
TENNCARE may immediately and unilaterally suspend the data flow under this
Agreement, or terminate this Agreement, if TENNCARE, in its sole discretion,
determines that the CONTRACTOR has: (1) made an unauthorized use or disclosure
of TennCare SSA-supplied data; or (2) violated or failed to follow the terms and
conditions of this Agreement.

4.40.8    Legal Authority

4.40.8.1
Federal laws and regulations giving SSA the authority to disclose data to
TENNCARE and TENNCARE's authority to collect, maintain, use and share data with
CONTRACTOR is protected under federal law for specified purposes:

4.40.8.1.1
Sections 1137, 453, and I106(b) of the Social Security Act (the Act) (42 U.S.C.
§§ 1320b-7, 653, and 1306(b)) (income and eligibility verification data);

4.40.8.1.2
26 U.S.C. § 6103(1)(7) and (8) (tax return, data);

4.40.8.1.3
Section 202(x)(3)(B)(iv) of the Act (42 U.S.C. § 401(x)(3)(B)(iv))(prisoner
data);

4.40.8.1.4
Section 205(r)(3) of the Act (42, U.S.C. § 405(r)(3)) and Intelligence Reform
and Terrorism Prevention Act of 2004, Pub. L. 108-458, 7213(a)(2) (death data);

4.40.8.1.5
Sections 402, 412, 421, and 435 of the Personal Responsibility and Work
Opportunity Reconciliation Act of 1996 (Pub. L. 104-193) (8 U.S.C. §§ 1612,
1622, 1631, and 1645) (August 22, 1996 (quarters of coverage data);

4.40.8.1.6
Children's Health Insurance Program Reauthorization Act of 2009, (Pub. L. 111-3)
(February 4, 2009) (citizenship data); and

4.40.8.1.7
Routine use exception to the Privacy Act, 5 U.S.C. § 552a(b)(3)(data necessary
to administer other programs compatible with SSA programs).

4.40.8.2
This Section further carries out Section 1106(a) of the Act (42 U.S.C. § 1306),
the regulations promulgated pursuant to that section (20 C.F.R. Part 401), the
Privacy of 1974 (5 U.S.C. § 552a), as amended by the Computer Matching and
Privacy Protection Act of 1988, related Office of Management and Budget

("OMB") guidelines, the Federal Information Security Management Act of 2002
("FISMA") (44 U.S.C. § 3541 et seq.), and related National Institute of
Standards

--------------------------------------------------------------------------------

and Technology ("NIST") guidelines, which provide the requirements that the
CONTRACTOR must follow with regard to use, treatment, and safeguarding data.

4.40.9    Definitions

4.40.9.1
"SSA-supplied data" — information, such as an individual's social security
number, supplied by the Social Security Administration to TENNCARE to determine
entitlement or eligibility for federally-funded programs (Computer Matching and
Privacy Protection Agreement between SSA and F&A; IEA between SSA and TENNCARE).

4.40.9.2
"Protected Health Information/Personally Identifiable Information" (PHI/PII) (45
CFR §160.103; OMB Circular M-06-I9 located at http
://www.whitehouse.gov/sites/default/files/omb/memoranda/fy2006/m06-19.pdf) —
Protected health information means individually identifiable health information
that is: (i) Transmitted by electronic media; (ii) Maintained in electronic
media; or (iii) Transmitted or maintained in any other form or medium.

4.40.9.3
"Individually Identifiable Health Information" — information that is a subset of
health information, including demographic information collected from an
individual, and: (1) Is created or received by a health care provider, health
plan, employer, or health care clearinghouse; and (2) relates to the past,
present, or future physical or mental health or condition of an individual; the
provision of health care to an individual; or the past, present, or future
payment for the provision of health care to an individual; and (i) identifies
the individual; or (ii) with respect to which there is a reasonable basis to
believe the information can be used to identify the individual.

4.40.9.4
Personally Identifiable Information" — any information about an individual
maintained by an agency, including, but not limited to, education, financial
transactions, medical history, and criminal or employment history and
information which can be used to distinguish or trace an individual's identity,
such as their name, Social Security Number, date and place of birth, mother's
maiden name, biometric records, including any other personal information which
can be linked to an individual.

69.
Attachment VI shall be amended by adding "TBI MFCU" in the "TO:" section along
with
"Office of Program Integrity".

70.
Exhibit C of Attachment IX shall be deleted in its entirety and replaced by
"LEFT BLANK INTENTIONALLY".

ATTACHMENT IX, EXHIBIT C LEFT BLANK INTENTIONALLY

--------------------------------------------------------------------------------

All of the provisions of the original Agreement not specifically deleted or
modified herein shall remain in full force and effect. Unless a provision
contained in this Amendment specifically indicates a different effective date,
for purposes of the provisions contained herein, this Amendment shall become
effective July 1, 2012.
The CONTRACTOR, by signature of this Amendment, hereby affirms that this
Amendment has not been altered and therefore represents the identical document
that was sent to the CONTRACTOR by TENNCARE.
IN WITNESS WHEREOF, the parties have by their duly authorized representatives
set their signatures.
[tenncareamendment12fo_image1.gif]

--------------------------------------------------------------------------------