AMENDMENT NUMBER 5

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 deleted and replaced as follows:

SECTION 1 — DEFINITIONS, ACRONYMS, AND ABBREVIATIONS

The terms used in this Agreement shall be given the meaning used in TennCare
rules and regulations. However, the following terms when used in this Agreement,
shall be construed and/or interpreted as follows, unless the context expressly
requires a different construction and/or interpretation. In the event of a
conflict in language between these Definitions, Attachments, and other Sections
of this Agreement, the specific language in Sections 2 through 4 of this
Agreement shall govern.

Administrative Cost – All costs to the CONTRACTOR related to the administration
of this Agreement that are non-medical in nature including, but not limited to:

  1.   Meeting general requirements in Section 2.2;

2. Enrollment and disenrollment in accordance with Sections 2.4 and 2.5;

3. Additional services and use of incentives in Section 2.6.6;

4. Health education and outreach in Section 2.7.4;

  5.   Meeting requirements for coordination of services specified in
Section 2.9, including care coordination for CHOICES members and the
CONTRACTOR’s electronic visit verification system except as otherwise provided
in Section 3;  

  6.   Establishing and maintaining a provider network in accordance with the
requirements specified in Section 2.11, Attachments III, IV and V;  

  7.   Utilization Management as specified in Section 2.14;

  8.   Quality Management/ Quality Improvement activities as specified in
Section 2.15;

  9.   Production and distribution of Member Materials as specified in
Section 2.17;

  10.   Customer service requirements in Section 2.18;

11. Complaint and appeals processing and resolution in accordance with
Section 2.19;

12. Determination of recoveries from third party liability resources in
accordance with Section 2.21.4;

13. Claims Processing in accordance with Section 2.22;

14. Maintenance and operation of Information Systems in accordance with
Section 2.23;

15. Personnel requirements in Section 2.29;

16. Production and submission of required reports as specified in Section 2.30;

17. Administration of this Agreement in accordance with policies and procedures;

  18.   All other Administration and Management responsibilities as specified in
Attachments II through IX and Sections 2.20, 2.21, 2.24, 2.25, 2.26, 2.27, and
2.28;

  19.   Premium tax; and

  20.   Costs of subcontractors engaged solely to perform a non-medical
administrative function for the CONTRACTOR specifically related to securing or
fulfilling the CONTRACTOR’s obligations to TENNCARE under the terms of this
Agreement (e.g., claims processing) are considered to be an “administrative
cost”.

Adult Protective Services (APS) – An office within the Tennessee Department of
Human Services that investigates reports of abuse, neglect (including
self-neglect) or financial exploitation of vulnerable adults. APS staff assess
the need for protective services and provide services to reduce the identified
risk to the adult.

Adverse Action – Any action taken by the CONTRACTOR to deny, reduce, terminate,
delay or suspend a covered service as well as any other acts or omissions of the
CONTRACTOR which impair the quality, timeliness or availability of such
benefits.

Affiliate – Any person, firm, corporation (including, without limitation,
service corporation and professional corporation), partnership (including,
without limitation, general partnership, limited partnership and limited
liability partnership), limited liability company, joint venture, business
trust, association or other entity or organization that now or in the future
directly or indirectly controls, is controlled by, or is under common control
with the CONTRACTOR.

Appeal Procedure – The process to resolve an enrollee’s right to contest
verbally or in writing, any adverse action taken by the CONTRACTOR to deny,
reduce, terminate, delay, or suspend a covered service as well as any other acts
or omissions of the CONTRACTOR which impair the quality, timeliness or
availability of such benefits. The appeal procedure shall be governed by
TennCare rules and regulations and any and all applicable court orders and
consent decrees.

Area Agency on Aging and Disability (AAAD) – The agency designated by the
Tennessee Commission on Aging and Disability (TCAD) to develop and administer a
comprehensive and coordinated community based system in, or serving, a defined
planning and service area.
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.

Back-up Plan – A written plan that is a required component of the plan of care
for all CHOICES members receiving companion care or non-residential HCBS in
their own home and which specifies unpaid persons as well as paid
consumer-directed workers and/or contract providers (as applicable) who are
available, have agreed to serve as back-up, and who will be contacted to deliver
needed care in situations when regularly scheduled HCBS providers or workers are
unavailable or do not arrive as scheduled. A CHOICES member or his/her
representative may not elect, as part of the back-up plan, to go without
services. The back-up plan shall include the names and telephone numbers of
persons and agencies to contact and the services to be provided by each of the
listed contacts. The member and his/her representative (as applicable) shall
have primary responsibility for the development and implementation of the
back-up plan for consumer directed services with assistance from the FEA as
needed.

Base Capitation Rate – The amount established by TENNCARE pursuant to the
methodology described in Section 3 of this Agreement as compensation for the
provision of all covered services except for behavioral services for Priority
enrollees.

Behavioral Health Assessment – Procedures used to diagnose mental health or
substance abuse conditions and determine treatment plans.

Behavioral Health Services – Mental health and/or substance abuse services.

Benefits – The package of health care services, including physical health,
behavioral health, and long-term care services, that define the covered services
available to TennCare enrollees enrolled in the CONTRACTOR’s MCO pursuant to
this Agreement.

Bureau of TennCare – The division of the Tennessee Department of Finance and
Administration (the single state Medicaid agency) that administers the TennCare
program. For the purposes of this Agreement, Bureau of TennCare shall mean the
State of Tennessee and its representatives.

Business Day – Monday through Friday, except for State of Tennessee holidays.

CAHPS (Consumer Assessment of Healthcare Providers and Systems) – A
comprehensive and evolving family of surveys that ask consumers and patients to
evaluate various aspects of health care.

Capitation Payment – The fee that is paid by TENNCARE to the CONTRACTOR for each
member covered by this Agreement. The CONTRACTOR is at financial risk as
specified in Section 3 of this Agreement for the payment of services incurred in
excess of the amount of the capitation payment. “Capitation Payment” includes
Base Capitation Rate payments and Priority Add-on rate payments, unless
otherwise specified.

Capitation Rate – The amount established by TENNCARE pursuant to the methodology
described in Section 3 of this Agreement, including the base capitation rates
and priority add-on rate.
Care Coordination Team – If an MCO elects to use a care coordination team, the
care coordination team shall consist of a care coordinator and specific other
persons with relevant expertise and experience who are assigned to support the
care coordinator in the performance of care coordination activities for a
CHOICES member as specified in this Agreement and in accordance with
Section 2.9.6.

Care Coordination Unit – A specific group of staff within the MCO’s organization
dedicated to CHOICES that is comprised of care coordinators and care coordinator
supervisors and which may also include care coordination teams.

Care Coordinator – The individual who has primary responsibility for performance
of care coordination activities for a CHOICES member as specified in the
Contractor Risk Agreement and meets the qualifications specified in
Section 2.9.6 of the Contractor Risk Agreement.

Caregiver – For purposes of CHOICES, a person who is (a) a family member or is
unrelated to the member but has a close, personal relationship with the member
and (b) routinely involved in providing unpaid support and assistance to the
member. A caregiver may be also designated by the member as a representative for
CHOICES or for consumer direction of HCBS.

CEA – Cost Effective Alternative (see Section 2.6.5 of this Agreement).

Centers of Excellence (COE) for AIDS – Integrated networks designated by the
State as able to provide a standardized and coordinated delivery system
encompassing a range of services needed by TennCare enrollees with HIV or AIDS.

Centers of Excellence (COE) for Behavioral Health – COEs that provide a limited
range of direct services to children in and at risk for state custody (i.e., not
just DCS children/youth). These services are to augment the existing service
system. Therefore, COEs for Behavioral Health typically only provide services
where there is sufficient complexity in the case to warrant the COE for
Behavioral Health resources and/or all other means to provide the service in the
TennCare network have been exhausted.

CFR – Code of Federal Regulations.

Child Protective Services (CPS) – A program division of the Tennessee Department
of Children’s Services whose purpose is to investigate allegations of child
abuse and neglect and provide and arrange preventive, supportive, and
supplementary services.

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 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 SSI recipients, who do
not meet the nursing facility level of care, but who, in the absence of 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. Group 3 will not be included in CHOICES on the
date of CHOICES implementation. TENNCARE intends to include CHOICES Group 3 on
January 1, 2011. TENNCARE will notify the CONTRACTOR at least sixty (60) days
prior to the proposed date for including Group 3 in CHOICES. As of the date
specified in that notice, the CONTRACTOR shall accept members in CHOICES Group 3
and shall implement all of the requirements in this Agreement that are
applicable to CHOICES Group 3.

CHOICES Implementation Date – The date, as determined by TENNCARE, when the
CONTRACTOR shall begin providing long-term care services to CHOICES members.

CHOICES Member – A member who has been enrolled by TENNCARE into CHOICES.

Clean Claim – A claim received by the CONTRACTOR for adjudication that requires
no further information, adjustment, or alteration by the provider of the
services in order to be processed and paid by the CONTRACTOR.

Clinical Practice Guidelines – Systematically developed tools or standardized
specifications for care to assist practitioners and patient decisions about
appropriate care for specific clinical circumstances. Such guidelines are
typically developed through a formal process and are based on authoritative
sources that include clinical literature and expert consensus.

Clinically Related Group 1: Severely and/or Persistently Mentally Ill (SPMI) –
Persons in this group are 18 years or older with a valid DSM-IV-TR (and
subsequent revisions) diagnosis excluding substance use disorders, developmental
disorders or V-codes. They are recently severely impaired and the duration of
their severe impairment totals six months or longer of the past year.

Clinically Related Group 2: Persons with Severe Mental Illness (SMI) – Persons
in this group are 18 years or older with a valid DSM-IV-TR (and subsequent
revisions) diagnosis excluding substance use disorders, developmental disorders
or V-codes. Persons in this group are recently severely impaired and the
duration of their severe impairment totals less than six months of the past
year.

Clinically Related Group 3: Persons who are Formerly Severely Impaired – Persons
in this group are 18 years or older with a valid DSM-IV-TR (and subsequent
revisions) diagnosis excluding substance use disorders, developmental disorders
or V-codes. Persons in this group are not recently severely impaired but have
been severely impaired in the past and need services to prevent relapse.

Clinically Related Group 4: Persons with Mild or Moderate Mental Disorders –
Persons in this group are 18 years or older with a valid DSM-IV-TR (and
subsequent revisions) diagnosis excluding substance use disorders, developmental
disorders or V-codes. Persons in this group are not recently severely impaired
and are either not formerly severely impaired or are formerly severely impaired
but do not need services to prevent relapse.

Clinically Related Group 5: Persons who are not in clinically related groups 1-4
as a result of their diagnosis – Persons in this group are 18 years or older
diagnosed with DSM-IV-TR (and subsequent revisions) substance use disorders,
developmental disorders or V-codes only.
CMS – Centers for Medicare & Medicaid Services.

Community-Based Residential Alternatives to Institutional Care (Community-Based
Residential Alternatives) – Residential services that offer a cost-effective,
community-based alternative to nursing facility care for persons who are elderly
and/or adults with physical disabilities. This includes, but is not limited to,
assisted care living facilities, adult care homes, and companion care.

Complaint – A written or verbal expression of dissatisfaction from a member
about an action taken by the CONTRACTOR or service provider other than an
adverse action. The CONTRACTOR shall not treat anything as a complaint that
falls within the definition of adverse action.

Confidential Information – Any non-public, confidential or proprietary
information, whether written, graphic, oral, electronic, visual or fixed in any
tangible medium or expression, which is created under this Agreement. Any such
information relating to individuals enrolled in the TennCare program (“TennCare
members”), or relating to individuals who may be potentially enrolled in the
TennCare program, which is provided to or obtained under this Agreement, shall
also be treated as “Confidential Information” to the extent that confidential
status is afforded such information under state and federal laws or regulations.
All Confidential Information shall not be subject to disclosure under the
Tennessee Public Records Act.

Consumer – Except when used regarding consumer direction of HCBS, an individual
who uses a mental health or substance abuse service.

Consumer-Directed Worker (Worker) – An individual who has been hired by a
CHOICES member participating in consumer direction of HCBS or his/her
representative to provide one or more eligible HCBS to the member. Worker does
not include an employee of an agency that is being paid by an MCO to provide
HCBS to the member.

Consumer Direction of HCBS – The opportunity for a CHOICES member assessed to
need specified types of HCBS including attendant care, personal care, homemaker,
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).

Contract Provider – A provider that is employed by or has signed a provider
agreement with the CONTRACTOR to provide covered services.

Contractor Risk Agreement (CRA) – The agreement between the CONTRACTOR and
TENNCARE regarding requirements for operation and administration of the managed
care TennCare program, including CHOICES.

Cost Neutrality Cap – The requirement that the cost of providing care to a
member in CHOICES Group 2, including HCBS, 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.

Covered Services – See Benefits.

CRA – Contractor Risk Agreement; also referred to as “Agreement.”

CRG (Clinically Related Group) – Defining and classifying consumers 18 years or
older into clinically
related groups involves diagnosis, the severity of functional impairment, the
duration of severe functional impairment, and the need for services to prevent
relapse. Based on these criteria, there are five clinically related groups:

Group 1 — Persons with Severe and Persistent Mental Illness (SPMI)

Group 2 — Persons with Severe Mental Illness (SMI)

Group 3 — Persons who were Formerly Severely Impaired and need services to
prevent relapse Group 4 — Persons with Mild or Moderate Mental Disorder

      Group 5 — Persons who are not in Clinically Related Groups 1 – 4 as a
result of their diagnosis being substance use disorder, developmental disorder,
or V-codes

Days – Calendar days unless otherwise specified.

Dental Benefits Manager (DBM) – An entity responsible for the provision and
administration of dental services, as defined by TENNCARE.

DHHS – United States Department of Health and Human Services.

Disenrollment – The removal of an enrollee from participation in the
CONTRACTOR’s MCO and deletion from the enrollment file furnished by TENNCARE to
the CONTRACTOR.

Electronic Visit Verification (EVV) System – An electronic system into which
provider staff and consumer-directed workers can check-in at the beginning and
check-out at the end of each period of service delivery to monitor member
receipt of HCBS and which may also be utilized for submission of claims.

Eligible – Any person certified by TENNCARE as eligible to receive services and
benefits under the TennCare program. As it relates to CHOICES a person is
eligible to receive CHOICES benefits only if he/she has been enrolled in CHOICES
by TENNCARE.

Eligible HCBS – Attendant care, personal care, homemaker, in-home respite,
companion care services and/or any other services 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).

Emergency Medical Condition – A physical or behavioral condition manifesting
itself by acute symptoms of sufficient severity (including severe pain) that a
prudent layperson, who possesses an average knowledge of health and medicine,
could reasonably expect the absence of immediate medical attention to result in
the following (1) placing the health of the individual (or, with respect to a
pregnant woman, the health of the woman or her unborn child) in serious
jeopardy; (2) serious impairment to bodily functions; (3) serious dysfunction of
any bodily organ or part.

Emergency Services – Covered inpatient and outpatient services that are as
follows: (1) furnished by a provider that is qualified to furnish these
services; and (2) needed to evaluate or stabilize an emergency medical
condition.
Employer of Record – The member participating in consumer direction of HCBS or a
representative designated by the member to assume the consumer direction of HCBS
functions on the member’s behalf.

Enrollee – A person who has been determined eligible for TennCare and who has
been enrolled in the TennCare program (see Member, also).

Enrollee Marketing – Any communication, from the CONTRACTOR to a TennCare
enrollee who is not enrolled in the CONTRACTOR’s MCO, that can reasonably be
interpreted as intended to influence the person to enroll in the CONTRACTOR’s
MCO, or either to not enroll in, or to disenroll from, another MCO’s TennCare
product.

Enrollment – The process by which a TennCare enrollee becomes a member of the
CONTRACTOR’s MCO.

EPSDT – The Early and Periodic Screening, Diagnostic, and Treatment
(EPSDT) service is Medicaid’s comprehensive and preventive child health program
for individuals under the age of 21. EPSDT was defined by law as part of the
Omnibus Budget Reconciliation Act of 1989 (OBRA ‘89) legislation and includes
periodic screening, vision, dental, and hearing services. In addition,
Section 1905(r)(5) of the Social Security Act (the Act) requires that any
medically necessary health care service listed at Section 1905(a) of the Act be
provided to an EPSDT recipient even if the service is not available under the
State’s Medicaid plan to the rest of the Medicaid population. The federal
regulations for EPSDT are in 42 CFR Part 441, Subpart B.

Essential Hospital Services – Tertiary care hospital services to which it is
essential for the CONTRACTOR to provide access. Essential hospital services
include, but are not limited to, neonatal, perinatal, pediatric, trauma and burn
services.

Evidence-Based Practice – A clinical intervention that has demonstrated positive
outcomes in several research studies to assist consumers in achieving their
desired goals of health and wellness; specifically, the evidence-based practices
recognized by the Substance Abuse and Mental Health Services Administration’s
(SAMHSA) Center for Mental Health Services (CMHS).

Expenditure Cap – The annual limit on expenditures for HCBS, excluding home
modifications, for CHOICES members in CHOICES Group 3. The expenditure cap is
$15,000.

Facility – Any premises (a) owned, leased, used or operated directly or
indirectly by or for the CONTRACTOR or its affiliates for purposes related to
this Agreement; or (b) maintained by a subcontractor or provider to provide
services on behalf of the CONTRACTOR.

Fee-for-Service – A method of making payment for health services based on a fee
schedule that specifies payment for defined services.

Fiscal Employer Agent (FEA) – An entity contracting with the State and/or an MCO
that helps CHOICES members participating in consumer direction of HCBS. The FEA
provides both financial administration and supports brokerage functions for
CHOICES members participating in consumer direction of HCBS. This term is used
by the IRS to designate an entity operating under Section 3504 of the IRS code,
Revenue Procedure 70-6 and Notice 2003-70, as the agent to members for the
purpose of filing certain federal tax forms and paying federal income tax
withholding, FICA and FUTA taxes. The FEA also files state income tax
withholding and unemployment insurance tax forms and pays the associated taxes
and processes payroll based on the eligible HCBS authorized and provided.
FQHC – Federally Qualified Health Center.

General Marketing – Any communication or activity that can reasonably be
interpreted as intended to promote the CONTRACTOR, including, but not limited
to, advertising, publicity, and positioning.

Grand Region – A defined geographical region that includes specified counties in
which the CONTRACTOR is authorized to enroll and serve TennCare enrollees in
exchange for a monthly capitation payment. The CONTRACTOR shall serve an entire
Grand Region. The following counties constitute the Grand Regions in Tennessee:

    East Grand Region – Anderson, Bledsoe, Blount, Bradley, Campbell, Carter,
Claiborne, Cocke, Franklin, Grainger, Greene, Grundy, Hamblen, Hamilton,
Hancock, Hawkins, Jefferson, Johnson, Knox, Loudon, Marion, McMinn, Meigs,
Monroe, Morgan, Polk, Rhea, Roane, Scott, Sequatchie, Sevier, Sullivan, Unicoi,
Union, and Washington Counties

    Middle Grand Region – Bedford, Cannon, Cheatham, Clay, Coffee, Cumberland,
Davidson, DeKalb, Dickson, Fentress, Giles, Hickman, Houston, Humphreys,
Jackson, Lawrence , Lewis, Lincoln, Macon, Marshall, Maury, Montgomery, Moore,
Overton, Perry, Pickett, Putnam, Robertson, Rutherford, Smith, Stewart, Sumner,
Trousdale, Van Buren, Warren, Wayne, White, Williamson, and Wilson Counties

    West Grand Region – Benton, Carroll, Chester, Crockett, Decatur, Dyer,
Fayette, Gibson, Hardeman, Hardin, Haywood, Henderson, Henry, Lake, Lauderdale,
Madison, McNairy, Obion, Shelby, Tipton, and Weakley Counties

Grand Rounds – As used with respect to CHOICES members residing in a nursing
facility, a planned quarterly meeting between nursing facility staff and MCO
staff, including, at minimum, the care coordinator(s) assigned to residents of
the facility conducted in order to: (1) address issues or concerns regarding
members who have experienced a potential significant change in needs or
circumstances or about whom the nursing facility or MCO has concerns (not
necessarily all members who are residents of the facility); (2) identify any
change in services or interventions for the members, including but not limited
to changes in the members’ plans of care or supplements to the members’ plans of
care; and (3) facilitate access to and coordination of physical health and/or
behavioral health services needed by the members and to ensure the proper
management of the members’ acute and/or chronic conditions. At least two of the
quarterly Grand Rounds per year shall be conducted on-site in the facility.

Healthcare Effectiveness Data and Information Set (HEDIS) – The most widely used
set of standardized performance measures used in the managed care industry,
designed to allow reliable comparison of the performance of managed health care
plans. HEDIS is sponsored, supported, and maintained by the National Committee
for Quality Assurance.

Health Maintenance Organization (HMO) – An entity certified by TDCI under
applicable provisions of TCA Title 56, Chapter 32.

HIPAA - Health Insurance Portability and Accountability Act of 1996, 45 CFR
Parts 160 and 164.

HITECH - Health Information Technology for Economic and Clinical Health Act,
Pub.L.111-5, Div. A, Title XIII, § 13001(a), Feb. 17, 2009, 123 Stat. 226.
Home and Community-Based Services (HCBS) – Services not covered by Tennessee’s
Title XIX state plan that are provided as an alternative to long-term care
institutional services in a nursing facility or an Intermediate Care Facility
for the Mentally Retarded (ICF/MR). HCBS does not include home health or private
duty nursing services.

Hospice – Services as described in TennCare rules and regulations and 42 CFR
Part 418, which are provided to terminally ill individuals who elect to receive
hospice services provided by a certified hospice agency.

Immediate Eligibility – A mechanism by which the State can, based on a
preliminary determination of a person’s eligibility for the CHOICES 217-Like
HCBS Group, enroll the person into CHOICES Group 2 and provide immediate access
to a limited package of HCBS pending a final determination of eligibility. To
qualify for immediate eligibility, a person must be applying to receive covered
HCBS, be determined by TENNCARE to meet nursing facility level of care, have
submitted an application for financial eligibility determination to DHS, and be
expected to qualify for CHOICES Group 2 based on review of the financial
information provided by the applicant. Immediate eligibility shall only be for
specified HCBS (no other covered services) and for a maximum of forty-five
(45) days.

Individually Identifiable Health Information – Any information, including
demographic information, collected from an individual, that (a) is created or
received by a health care provider, health plan, employer, or health care
clearinghouse; and (b) 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 identifies the individual; or, with respect to which
there is a reasonable basis to believe that the information can be used to
identify the individual.

Information System(s) (Systems) – A combination of computing and
telecommunications hardware and software that is used in: (a) the capture,
storage, manipulation, movement, control, display, interchange and/or
transmission of information, i.e., structured data (which may include digitized
audio and video) and documents as well as non-digitized audio and video; and/or
(b) the processing of information and non-digitized audio and video for the
purposes of enabling and/or facilitating a business process or related
transaction.

Intervention – An action or ministration that is intended to produce an effect
or that is intended to alter the course of a pathologic process.

Law – Statutes, codes, rules, regulations, and/or court rulings.

Legally Appointed Representative – Any person appointed by a court of competent
jurisdiction or authorized by legal process (e.g., power of attorney for health
care treatment, declaration for mental health treatment) to determine the legal
and/or health care interests of an individual and/or his/her estate.

Long-Term Care – The services of a nursing facility (NF), an Intermediate Care
Facility for the Mentally Retarded (ICF/MR), or Home and Community-Based
Services (HCBS).

Long-Term Care Ombudsman Program – A statewide program for the benefit of
individuals residing in long-term care facilities, which may include nursing
homes, residential homes for the aged, assisted care living facilities, and
community-based residential alternatives developed by the State. The Ombudsman
is available to help these individuals and their families resolve questions or
problems. The program is authorized by the federal Older Americans Act and
administered by the Tennessee Commission on Aging and Disability (TCAD).
Managed Care Organization (MCO) – An HMO that participates in the TennCare
program.

Mandatory Outpatient Treatment (MOT) – Process whereby a person who was
hospitalized for psychiatric reasons and who requires outpatient treatment can
be required by a court to participate in that behavioral health outpatient
treatment to prevent deterioration in his/her mental condition.

Medical Expenses – Shall be determined as follows:

  1.   Medical Expenses include the amount paid to providers for the provision
of covered physical health, behavioral health, and/or long-term care services to
members pursuant to the following listed Sections of the Agreement:

  a.   Section 2.6.1, CONTRACTOR Covered Benefits;

b. Section 2.6.4, Second Opinions;

c. Section 2.6.5, Use of Cost Effective Alternative Services;

  d.   Section 2.7, Specialized Services except TENNderCare member and provider
outreach and education, health education and outreach and advance directives;

  e.   Capitated payment to licensed providers;

  f.   Medical services directed by TENNCARE or an Administrative Law Judge; and

  g.   Net impact of reinsurance coverage purchased by the CONTRACTOR.

2. Medical Expenses do not include:

  a.   2.6.2 TennCare Benefits Provided by TENNCARE;

b. 2.6.7 Cost Sharing and Patient Liability;

c. 2.10 Services Not Covered;

d. Services eligible for reimbursement by Medicare; or

  e.   The activities described in or required to be conducted in Attachments II
through XI, which are administrative costs.

3. Medical expenses shall be net of any TPL recoveries or subrogation
activities.

4. This definition does not apply to NAIC filings.

Medical Loss Ratio (MLR) – The percentage of capitation payment received from
TENNCARE that is used to pay medical expenses.

Medical Records – All medical, behavioral health, and long-term care histories;
records, reports and
summaries; diagnoses; prognoses; records of treatment and medication ordered and
given; X-ray and
radiology interpretations; physical therapy charts and notes; lab reports; other
individualized medical,

behavioral health, and long-term care documentation in written or electronic
format; and analyses of such information.

Member – A TennCare enrollee who enrolls in the CONTRACTOR’s MCO under the
provisions of this Agreement (see Enrollee, also).

Member Month – A month of coverage for a TennCare enrollee enrolled in the
CONTRACTOR’s MCO.

Mental Health Services – The diagnosis, evaluation, treatment, residential care,
rehabilitation, counseling or supervision of persons who have a mental illness.

NAIC – National Association of Insurance Commissioners.

National Committee for Quality Assurance (NCQA) – A nonprofit organization
committed to assessing, reporting on and improving the quality of care provided
by organized delivery systems.

Non-Contract Provider – Any provider that is not directly or indirectly employed
by or does not have a provider agreement with the CONTRACTOR or any of its
subcontractors pursuant to the Agreement between the CONTRACTOR and TENNCARE.

Office of the Comptroller of the Treasury – The Comptroller of the Treasury is a
State of Tennessee constitutional officer elected by the General Assembly for a
term of two years. Statutes prescribe the comptroller’s duties, the most
important of which relate to audit of state and local government entities and
participation in the general financial and administrative management of state
government.

Office of Inspector General (OIG) – The State of Tennessee agency that
investigates and may prosecute civil and criminal fraud and abuse of the
TennCare program or any other violations of state law related to the operation
of the TennCare program administratively, civilly or criminally.

One-Time HCBS – In-home respite, in-patient respite, assistive technology, minor
home modifications, and/or pest control.

Ongoing HCBS – Community-based residential alternatives, personal care,
attendant care, homemaker services, home-delivered meals, personal emergency
response systems (PERS), and/or adult day care.

PASRR – Preadmission Screening and Resident Review.

Patient Liability – The amount of an enrollee’s income, as determined by DHS, to
be collected each month to help pay for the enrollee’s long-term care services.

Pharmacy Benefits Manager (PBM) – An entity responsible for the provision and
administration of pharmacy services.

Post-stabilization Care Services – Covered services, related to an emergency
medical condition that are provided after a member is stabilized in order to
maintain the stabilized condition, or, under the circumstances described in 42
CFR 438.114(e), to improve or resolve the member’s condition.

Prepaid Limited Health Service Organization (PLHSO) – An entity certified by
TDCI under applicable provisions of TCA Title 56, Chapter 51.

Presumptive Eligibility – An established period of time (45 days) during which
certain pregnant women are eligible for TennCare Medicaid. During this period of
time the presumptively eligible enrollee must complete an application for
Medicaid in order to stay on the program.

Primary Care Physician – A physician responsible for providing preventive and
primary health care to patients; for initiating referrals for specialist care;
and for maintaining the continuity of patient care. A primary care physician is
generally a physician who has limited his/her practice of medicine to general
practice or who is an Internist, Pediatrician, Obstetrician/Gynecologist,
Geriatrician, or Family Practitioner. However, as provided in Section 2.11.2.4
of this Agreement, in certain circumstances other physicians may be primary care
physicians if they are willing and able to carry out all PCP responsibilities in
accordance with this Agreement.

Primary Care Provider (PCP) – A primary care physician or other licensed health
practitioner practicing in accordance with state law who is responsible for
providing preventive and primary health care to patients; for initiating
referrals for specialist care; and for maintaining the continuity of patient
care. A PCP may practice in various settings such as local health departments,
FQHCs or community mental health agencies (CMHAs) provided that the PCP is
willing and able to carry out all PCP responsibilities in accordance with this
Agreement.

Prior Authorization – The act of authorizing specific services or activities
before they are rendered or occur.

Priority Add-on Rate – The amount established by TENNCARE pursuant to the
methodology described in Section 3 of this Agreement as compensation for the
provision of behavioral health services for Priority enrollees.

Priority Enrollee – A TennCare enrollee who has been assessed within the past
twelve (12) months as belonging in Clinically Related Groups (CRGs) 1, 2, or 3
if he/she is 18 years old or older, or Target Population Group (TPG) 2 if he/she
is under the age of 18 years. This assessment as a Priority enrollee expires
twelve (12) months after the assessment as been completed. In order for an
individual to remain a Priority enrollee after the twelve (12) month period
ends, he/she must be reassessed as continuing to meet the criteria to belong in
CRGs 1, 2, or 3 or TPG 2 categories. The reassessment, like the initial
assessment, expires after twelve (12) months unless another assessment is done.
Also referred to as Priority member once the enrollee is enrolled in the
CONTRACTOR’s MCO.

Privacy Breach – The acquisition, access, use, or disclosure of PHI in a manner
which compromises the security or privacy of the PHI as governed by the
provisions of HIPAA and other federal and state laws. For purposes of this
definition, “compromises the security or privacy of the protected health
information” means poses a significant risk of financial, reputational, or other
harm to the individual.

Privacy Rule – Standards for the Privacy of Individually Identifiable Health
Information at 45 CFR Part 160 and Part 164.

Protected Health Information (PHI) – Individually identifiable health
information that is transmitted by electronic media, maintained in electronic
media, or transmitted or maintained in any other form or medium.

Provider – An institution, facility, agency, physician, health care
practitioner, or other entity that is licensed or otherwise authorized to
provide any of the covered services in the state in which they are furnished.
Provider does not include consumer-directed workers (see Consumer-Directed
Worker); nor does provider include the FEA (see Fiscal Employer Agent).
Provider Agreement – An agreement, using the provider agreement template
approved by TDCI, between the CONTRACTOR and a provider or between the
CONTRACTOR’s subcontractor and a provider that describes the conditions under
which the provider agrees to furnish covered services to the CONTRACTOR’s
members.

Quality Management/Quality Improvement (QM/QI) – The development and
implementation of strategies to assess and improve the performance of a program
or organization on a continuous basis. This includes the identification of key
measures of performance, discovery and data collection processes, identification
and remediation of issues, and systems improvement activities.

Recovery – A consumer driven process in which consumers are able to work, learn
and participate fully in their communities. Recovery is the ability to live a
fulfilling and productive life despite a disability.

Regulatory Requirements – Any requirements imposed by applicable federal, state
or local laws, rules, regulations, court orders and consent decrees, a program
contract, or otherwise imposed by TENNCARE in connection with the operation of
the program or the performance required by either party under an agreement.

Representative – In general, for CHOICES members, a person who is at least
eighteen (18) years of age and is authorized by the member to participate in
care planning and implementation and to speak and make decisions on the member’s
behalf, including but not limited to identification of needs, preference
regarding services and service delivery settings, and communication and
resolution of complaints and concerns. As it relates to consumer direction of
HCBS, a person who is authorized by the member to direct and manage the member’s
worker(s), and signs a representative agreement. The representative for consumer
direction of HCBS must also: be at least eighteen (18) years of age; have a
personal relationship with the member and understand his/her support needs; know
the member’s daily schedule and routine, medical and functional status,
medication regimen, likes and dislikes, and strengths and weaknesses; and be
physically present in the member’s residence on a regular basis or at least at a
frequency necessary to supervise and evaluate workers.

Representative Agreement – The agreement between a CHOICES member electing
consumer direction of HCBS who has a representative direct and manage the
consumer’s worker(s) and the member’s representative that specifies the roles
and responsibilities of the member and the member’s representative.

Resilience – A dynamic developmental process for children and adolescents that
encompasses positive adaptation and is manifested by traits of self-efficacy,
high self-esteem, maintenance of hope and optimism within the context of
significant adversity.

Risk Agreement – An agreement signed by a member who will receive HCBS (or
his/her representative) that includes, at a minimum, identified risks to the
member of residing in the community and receiving HCBS, the consequences of such
risks, strategies to mitigate the identified risks, and the member’s decision
regarding his/her acceptance of risk. For members electing to participate in
consumer direction, the risk agreement must include any additional risks
associated with the member’s decision to act as the employer of record, or to
have a representative act as the employer of record on his/her behalf. See
Section 2.9.6 of this Agreement for related requirements.

Routine Care – Non-urgent and non-emergency medical or behavioral health care
such as screenings, immunizations, or health assessments.

Safeguarding Enrollee Information – To maintain reasonable and appropriate
administrative, technical,
and physical safeguards to ensure the integrity and confidentiality of the
information; to protect against

any reasonably anticipated threats or hazards to the security or integrity of
the information; and to protect against unauthorized uses or disclosures of the
information.

Security Incident – The attempted or successful unauthorized access, use,
disclosure, modification or destruction of information or interference with the
system operations in an information system.

Security Rule – The Final Rule adopting Security Standards for the Protection of
Electronic Health Information at 45 CFR Parts 160 and 164.

Self-Direction of Health Care Tasks – A decision by a CHOICES member
participating in consumer direction to direct and supervise a paid worker
delivering eligible HCBS in the performance of health care tasks that would
otherwise be performed by a licensed nurse. Self-direction of health care tasks
is not a service, but rather health care-related duties and functions (such as
administration of medications) that a CHOICES member participating in consumer
direction may elect to have performed by a consumer- directed worker as part of
the delivery of eligible HCBS s/he is authorized to receive.

Seriously Emotionally Disturbed (SED) – Seriously Emotionally Disturbed shall
mean persons who have been identified by the Tennessee Department of Mental
Health and Developmental Disabilities or its designee as meeting the criteria
provided below:

  1.   Person under the age of 18; and

  2.   Currently, or at any time during the past year, has had a diagnosable
mental, behavioral, or emotional disorder of sufficient duration to meet
diagnostic criteria specified within DSM-IV-TR (and subsequent revisions) of the
American Psychiatric Association with the exception of DSMIV-TR (and subsequent
revisions) V- codes, substance use, and developmental disorders, unless these
disorders co-occur with another diagnosable mental, behavioral, or emotional
disturbance other than above exclusions. All of these disorders have episodic,
recurrent, or persistent features; however, they vary in terms of severity and
disabling effects; and

  3.   The diagnosable mental, behavioral, or emotional disorder identified
above has resulted in functional impairment which substantially interferes with
or limits the child’s role or functioning in family, school, and community
activities. Functional impairment is defined as difficulties that substantially
interfere with or limit a child or adolescent in achieving or maintaining
developmentally appropriate social, behavioral, cognitive, communicative, or
adaptive skills and is evidenced by a Global Assessment of Functioning
(GAF) score of 50 or less in accordance with the DSM-IV-TR (and subsequent
revisions). Children and adolescents who would have met functional impairment
criteria during the referenced year without the benefit of treatment or other
support services are included in this definition.

Service Agreement – The agreement between a CHOICES member electing consumer
direction of HCBS (or the member’s representative) and the member’s
consumer-directed worker that specifies the roles and responsibilities of the
member (or the member’s representative) and the member’s worker.

Service Gap – A delay in initiating any long-term care service and/or a
disruption of a scheduled, ongoing HCBS that was not initiated by a member,
including late and missed visits.

Severely and/or Persistently Mentally Ill (SPMI) – Severely and/or Persistently
Mentally Ill shall mean individuals who have been identified by the Tennessee
Department of Mental Health and Developmental Disabilities or its designee as
meeting the following criteria. These persons will be identified as belonging in
one of the Clinically Related Groups that follow the criteria:

  1.   Age 18 and over; and

  2.   Currently, or at any time during the past year, has had a diagnosable
mental, behavioral, or emotional disorder of sufficient duration to meet the
diagnostic criteria specified within DSM-IVTR (and subsequent revisions) of the
American Psychiatric Association, with the exception of DSM-IV-TR (and
subsequent revisions) V-codes, substance use disorders, and developmental
disorders, unless these disorders co-occur with another diagnosable serious
mental illness other than above exclusions. All of these disorders have
episodic, recurrent, or persistent features, however, they vary in terms of
severity and disabling effects; and

  3.   The diagnosable mental, behavioral, or emotional disorder identified
above has resulted in functional impairment which substantially interferes with
or limits major life activities. Functional impairment is defined as
difficulties that substantially interfere with or limit role functioning in
major life activities including basic living skills (e.g., eating, bathing,
dressing); instrumental living skills (maintaining a household, managing money,
getting around in the community, taking prescribed medication); and functioning
in social, family, and vocational/educational contexts. This definition includes
adults who would have met functional impairment criteria during the referenced
year without the benefit of treatment or other support services.

Shall – Indicates a mandatory requirement or a condition to be met.

Span of Control – Information systems and telecommunications capabilities that
the CONTRACTOR itself operates or for which it is otherwise legally responsible
according to this Agreement. The CONTRACTOR’s span of control also includes
Systems and telecommunications capabilities outsourced by the CONTRACTOR.

Specialty Services – Includes Essential Hospital Services, services provided by
Centers of Excellence, and specialty physician services.

SSA – Social Security Administration. SSI – Supplemental Security Income.

Start Date of Operations – The date, as determined by TENNCARE, when the
CONTRACTOR shall begin providing services to members.

State – The State of Tennessee, including, but not limited to, any entity or
agency of the state, such as the Tennessee Department of Finance and
Administration, the Office of Inspector General, the Bureau of TennCare, the
Tennessee Bureau of Investigation, Medicaid Fraud Control Unit, the Tennessee
Department of Mental Health and Developmental Disabilities, the Tennessee
Department of Children’s Services, the Tennessee Department of Health, the
Tennessee Department of Commerce and Insurance, and the Office of the Attorney
General.
Subcontract – An agreement entered into by the CONTRACTOR with any other
organization or person who agrees to perform any administrative function or
service for the CONTRACTOR specifically related to securing or fulfilling the
CONTRACTOR’s obligations to TENNCARE under the terms of this Agreement (e.g.,
claims processing, disease management) when the intent of such an agreement is
to delegate the responsibility for any major service or group of services
required by this Agreement. This shall also include any and all agreements
between any and all subcontractors for the purposes related to securing or
fulfilling the CONTRACTOR’s obligations to TENNCARE under the terms of this
Agreement. Agreements to provide covered services as described in Section 2.6 of
this Agreement shall be considered provider agreements and governed by
Section 2.12 of this Agreement.

Subcontractor – Any organization or person who provides any function or service
for the CONTRACTOR specifically related to securing or fulfilling the
CONTRACTOR’s obligations to TENNCARE under the terms of this Agreement.
Subcontractor does not include provider unless the provider is responsible for
services other than those that could be covered in a provider agreement.

Substance Abuse Services – The assessment, diagnosis, treatment, detoxification,
residential care, rehabilitation, education, training, counseling, referral or
supervision of individuals who are abusing or have abused substances.

Supports Broker – An individual assigned by the FEA to each member who assists
the member/representative in performing the employer of record functions,
including, but not limited to: developing job descriptions; locating;
recruiting; interviewing; scheduling; monitoring; and evaluating workers. The
supports broker collaborates with, but does not duplicate, the functions of the
member’s care coordinator. The supports broker does not have authority or
responsibility for consumer direction. The member or member’s representative
must retain authority and responsibility for consumer direction.

System Unavailability – As measured within the CONTRACTOR’s information systems
span of control, when a system user does not get the complete, correct
full-screen response to an input command within three (3) minutes after
depressing the “Enter” or other function key.

Target Population Group (TPG) – An assessment mechanism for children and
adolescents under the age of 18 to determine an individual’s level of
functioning and severity of impairment due to a mental illness. Based on these
criteria, there are three target population groups.

1. Target Population Group 2: Seriously Emotionally Disturbed (SED)

Children and adolescents under 18 years of age with a valid DSM-IV-TR (and
subsequent revisions) diagnosis excluding substance use disorders, developmental
disorders or V-codes. These children are currently severely impaired as
evidenced by 50 or less Global Assessment of Functioning (GAF).

2. Target Population Group 3: At Risk of a (SED)

Children and adolescents under 18 years of age without a valid DSM-IV-TR (and
subsequent revisions) diagnosis excluding substance use disorders, developmental
disorders or V-codes. These children may or may not be currently seriously
impaired as evidenced by Global Assessment of Functioning (GAF). These children
have psychosocial issues that can potentially place them at risk of a SED.

3. Target Population Group 4: Persons who do not meet criteria TPG Group 2 or 3

Children and adolescents under 18 years of age without a valid DSM-IV-TR (and
subsequent
revisions) diagnosis and are not currently seriously impaired as evidenced by
Global Assessment

of Functioning (GAF). These children have no psychosocial issues that can
potentially place them at risk of a SED.

TCA – Tennessee Code Annotated.

TENNCARE – TENNCARE shall have the same meaning as “State.”

TennCare or TennCare Program – The program administered by the single state
agency, as designated by the state and CMS, pursuant to Title XIX of the Social
Security Act and the Section 1115 research and demonstration waiver granted to
the State of Tennessee and any successor programs.

TennCare CHOICES in Long-Term Care (CHOICES) – A program in which long-term care
services for elders and/or persons with physical disabilities are integrated
into TennCare’s managed care delivery system.

TennCare Medicaid Enrollee – An enrollee who qualifies and has been determined
eligible for benefits in the TennCare program through Medicaid eligibility
criteria as described in TennCare rules and regulations.

TennCare Select – TennCare Select is a statewide MCO whose risk is backed by the
State of Tennessee. TennCare Select was created to serve as a backup if other
MCOs failed or there was inadequate MCO capacity and to be the MCO for certain
populations, including children in state custody and children eligible for SSI.
Children eligible for SSI may opt out of TennCare Select and enroll in another
MCO.

TennCare Standard Enrollee – An enrollee who qualifies and has been determined
eligible for benefits in the TennCare program through eligibility criteria
designated as “TennCare Standard” as described in the approved TennCare waiver
and the TennCare rules and regulations.

TENNderCare – Tennessee’s EPSDT program; see EPSDT.

Tennessee Bureau of Investigation, Medicaid Fraud Control Unit (TBI MFCU) – The
Tennessee Bureau of Investigation’s Medicaid Fraud Control Unit has the
authority to investigate and prosecute (or refer for prosecution) violations of
all applicable state and federal laws pertaining to fraud in the administration
of the Medicaid program, the provision of medical assistance, the activities of
providers of medical assistance in the state Medicaid program (TennCare),
allegations of abuse or neglect of patients in health care facilities receiving
payments under the state Medicaid program, misappropriation of patients’ private
funds in such facilities, and allegations of fraud and abuse in board and care
facilities.

Tennessee Department of Children’s Services (DCS) – The state agency responsible
for child protective services, foster care, adoption, programs for delinquent
youth, probation, aftercare, treatment and rehabilitation programs for
identified youth, and licensing for all child-welfare agencies, except for child
(day) care agencies and child support.

Tennessee Department of Commerce and Insurance (TDCI) – The state agency having
the statutory authority to regulate, among other entities, insurance companies
and health maintenance organizations.

Tennessee Department of Finance and Administration (F&A) – The state agency that
oversees all state spending and acts as the chief corporate office of the state.
It is the single state Medicaid agency. The Bureau of TennCare is a division of
the Tennessee Department of Finance and Administration.

Tennessee Department of Health (DOH) – The state agency having the statutory
authority to provide for
health care needs in Tennessee.

Tennessee Department of Human Services (DHS) – The state agency having the
statutory authority to provide human services to meet the needs of Tennesseans
and enable them to achieve self-sufficiency. DHS is responsible for TennCare
eligibility determinations (other than presumptive eligibility and SSI).

Tennessee Department of Mental Health and Developmental Disabilities (TDMHDD) –
The state agency having the authority to provide care for persons with mental
illness, substance abuse, and/or developmental disabilities.

Third Party Liability (TPL) – Any amount due for all or part of the cost of
medical, behavioral health, or long-term care services from a third party.

Third Party Resource – Any entity or funding source other than the enrollee or
his/her responsible party, which is or may be liable to pay for all or part of
the cost of health care of the enrollee.

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 member in order to facilitate transition from a nursing facility to the
community when such member will, upon transition, 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.

Unsecured PHI – PHI information that is not rendered unusable, unreadable, or
indecipherable to unauthorized individuals through the use of a technology or
methodology specified by the Secretary of DHHS.

USC – United States Code.

Vital MCO Documents – Consent forms and notices pertaining to the reduction,
denial, delay, suspension or termination of services. All vital documents shall
be available in Spanish.

Warm Transfer – A telecommunications mechanism in which the person answering the
call facilitates transfer to a third party, announces the caller and issue, and
remains engaged as necessary to provide assistance.

Worker – See Consumer-Directed Worker.

2.   Section 2.6.1.5.4 shall be amended by adding the acronym “(PERS)” after the
reference to “Personal Emergency Response Systems”.

3.   Section 2.6.1.5.8.1 shall be deleted and replaced as follows:

  2.6.1.5.8.1   A member in Group 2 for whom the CONTRACTOR has determined that
it cannot safely and effectively meet the member’s needs at a cost that is less
than the member’ cost neutrality cap, and the member declines to transition to a
nursing facility;

4.   Section 2.6.3.1 shall be amended by deleting the word “alternatives” and
replacing it with the words “alternative services”.

5.   Section 2.7.2.10.2.1 shall be amended by deleting the phrase “seventy-two
(72)” and replacing it with the phrase “twenty-four (24)” as follows:

2.7.2.10.2.1 Psychiatric treatment for persons found by the court to require
judicial psychiatric

hospitalization (TCA 33-6 part 4 and part 5). The CONTRACTOR may apply medical
necessity criteria to the situation after twenty-four (24) hours of emergency
services, unless there is a court order prohibiting release;

6.   Section 2.7.4.2 shall be amended by adding the reference “Section 2.16.2
and” before the reference to “Section 2.17.1”.

7.   Section 2.7.5.2.2 shall be amended by deleting the word “an” and replacing
it with the word “a”.

8.   Section 2.7.6.2.2.2 shall be amended by deleting the word “EPSDT” and
replacing it with the word “TENNderCare”.

9.   Section 2.7.6.2.10.1.1 and 2.7.6.2.10.2 shall be deleted and replaced as
follows:

  2.7.6.2.10.1.1   At least thirty percent (30%) shall be conducted in rural
areas. Results of the CONTRACTOR’s CMS 416 report and HEDIS report, as well as
county demographics, shall be utilized in determining counties for targeted
activities and in developing strategies for specific populations, particularly
members who have limited English proficiency, low literacy levels, behavioral
health needs, special health care needs or who are pregnant.

  2.7.6.2.10.2   The CONTRACTOR shall contact a minimum of twenty-five
(25) state agencies or community-based organizations per quarter, to either
educate them on services available through the CONTRACTOR or to develop outreach
and educational initiatives. Collaborative activities should include those
designed to reach enrollees with limited English proficiency, low literacy
levels, behavioral health needs and special health care needs or who are
pregnant.

10.   Section 2.8.1.1 shall be amended by adding a new Section 2.8.1.1.7 and
renumbering the existing Sections accordingly, including any references thereto.
The new Section 2.8.1.1.7 shall read as follows:

2.8.1.1.7 Obesity as referenced in Section 2.8.8;

11.   Section 2.8.1.4 shall be deleted and replaced as follows:

2.8.1.4 The CONTRACTOR shall develop and maintain DM program descriptions. These
program

descriptions shall include, for each of the conditions listed above, the
following:

12. Section 2.8.1.4.3 shall be deleted and replaced as follows:

2.8.1.4.3 The guidelines as referenced in Section 2.15.4;

13. Section 2.8.1.4.6 shall be deleted in its entirety and shall be replaced as
follows:

  2.8.1.4.6   Targeted methods for informing and educating members which, for
CHOICES members, include but shall not be limited to mailing educational
materials;

14. Section 2.8.1.5 shall be deleted and replaced as follows:

2.8.1.5 As part of its DM program descriptions, the CONTRACTOR shall also
address how the DM

programs will coordinate with MCO case management activities, in particular for
members who would benefit from both.

15. Section 2.8.1.6 shall be deleted and replaced as follows:

2.8.1.6 The CONTRACTOR’s DM and care coordination program description shall
address how the

CONTRACTOR shall ensure that upon enrollment into CHOICES, disease management
activities are integrated with CHOICES care coordination processes and
functions, and that the member’s assigned care coordinator has primary
responsibility for coordination of all the member’s physical health, behavioral
health, and long-term care services, including appropriate management of
conditions specified in 2.8.1.1. If a CHOICES member has one or more of the
conditions specified in Section 2.8.1.1, the member’s care coordinator may use
the CONTRACTOR’s applicable DM tools and resources, including staff with
specialized training, to help manage the member’s condition and shall integrate
the use of these DM tools and resources with care coordination. DM staff shall
supplement but not supplant the role and responsibilities of the member’s care
coordinator/care coordination team. The CONTRACTOR’s program description shall
also include at a minimum how the CONTRACTOR will address the following for
CHOICES members:

16. Section 2.8.1.6.4 shall be deleted and replaced as follows:

  2.8.1.6.4   Ensure that the care coordinator reviews the information noted in
Section 2.8.1.6.3 above verbally with the member and with the member’s caregiver
and/or representative (as applicable) and coordinates any necessary follow-up
that may be needed regarding the DM program such as scheduling screenings or
appointments;

17. Sections 2.8.1.7 shall be deleted in its entirety.

18. Sections 2.8.7.2 through 2.8.7.2.8 shall be deleted and replaced as follows:

2.8.7.2 The CONTRACTOR shall establish measurable benchmarks and goals for each
DM program

and shall evaluate the programs using these benchmarks and goals. The
calculations for the benchmarks and goals should include non-CHOICES members
only. These benchmarks and goals shall include:

2.8.7.2.1 The rate of emergency department utilization and inpatient
hospitalization;

  2.8.7.2.2   Neonatal Intensive Care Unit (NICU) days for births associated
with members enrolled in the maternity care management program;

2.8.7.2.3 Appropriate HEDIS measures;

  2.8.7.2.4   The passive participation rates (as defined by NCQA) and the
number of individuals participating in each level of each of the DM programs;

2.8.7.2.5 Member adherence to treatment plans; and 2.8.7.2.6 Provider adherence
to the guidelines.

19.   Section 2.8.7.3 shall be deleted and the remaining Sections shall be
renumbered accordingly, including any references thereto.  

20.   Section 2.9.1.2.4 shall be deleted in its entirety including all
references thereto.

21.   Section 2.9.6.1.1 shall be amended by deleting the word “persons” and
replacing it with the word “members”.

22.   Section 2.9.6.2.3.4 shall be amended by adding the phrase “and conduct the
level I PASRR screening” to (5)(b) 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) provide choice counseling and facilitate the selection of
an MCO by the applicant or his/her representative; (4) provide information
regarding freedom of choice of nursing facility versus HCBS, both verbally and
in writing, and obtain a Freedom of Choice form signed by the applicant or
his/her representative; (5) for applicants who want to receive NF services (a)
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 provider, 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; and (b) provide information regarding
the completion of all PASRR requirements prior to nursing facility admission and
conduct the level I PASRR screening; (6) for applicants who are seeking 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; (b) 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, including explanation to the applicant regarding the
individual cost neutrality cap, and notification to and signed acknowledgement
of understanding by the applicant 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
MCO’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 care coordinator will assist with transition
to a more appropriate care delivery setting; and (c) provide information
regarding consumer direction and obtain signed documentation of the applicant’s
interest in participating in consumer direction; and (7) 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.

23.   Section 2.9.6.2.4.9 shall be deleted and replaced as follows:

2.9.6.2.4.9 If the CONTRACTOR is unable to initiate nursing facility services in
accordance with

the timeframes specified in Section 2.9.6.2.4.4, the CONTRACTOR shall issue
written notice to the member, documenting that the service will be delayed, the
reasons for the delay, and the date the service will start, and shall make good
faith efforts to ensure that services are provided as soon as practical.

24. Section 2.9.6.2.5.9 shall be deleted and replaced as follows:

2.9.6.2.5.9 As part of the face-to-face visit, for members determined to need
eligible HCBS, the care

coordinator shall verify the member’s interest in participating in consumer
direction and obtain written confirmation of the member’s decision. The care
coordinator shall also provide member education regarding choice of contract
providers for HCBS, subject to the provider’s availability and willingness to
timely deliver services, and obtain signed confirmation of the member’s choice
of contract providers.

25.   Section 2.9.6.3.8 shall be amended by deleting the last sentence so that
the amended Section 2.9.6.3.8 shall read as follows:

  2.9.6.3.8   If, through the screening process described above, or upon other
identification by the CONTRACTOR of a member who appears to be eligible for
CHOICES for whom the CONTRACTOR opts not to use such screening process, the care
coordinator shall conduct a face-to-face intake visit with the member that
includes a level of care assessment and a needs assessment (see Section 2.9.6.5)
using tool(s) prior approved by TENNCARE and in accordance with the protocols
specified by TENNCARE.

26.   Section 2.9.6.3.9 shall be amended by adding the phrase “and conduct the
level I PASRR screening” to (5)(b) as follows:  

  2.9.6.3.9   As part of the face-to-face intake visit, the care
coordinator/care coordination team shall: (1) provide general CHOICES education
and information, as specified by TENNCARE, to the member and assist in answering
questions the member may have; (2) provide information about estate recovery;
(3) provide assistance, as necessary, in facilitating gathering of
categorical/financial documentation needed by DHS; (4) provide information
regarding freedom of choice of nursing facility versus HCBS, both verbally and
in writing, and obtain a Freedom of Choice form signed by the member or his/her
representative; (5) for members who want to receive nursing facility services,
(a) provide detailed information and signed acknowledgement of understanding
regarding a CHOICES member’s responsibility with

respect to payment of patient liability amounts, including the potential
consequences for nonpayment of patient liability which may include loss of the
member’s current nursing facility provider, 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; and (b) provide information
regarding the completion of all PASRR requirements prior to nursing facility
admission and conduct the level I PASRR screening; (6) for members who are
seeking 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 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; (b) 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, including explanation to the member
regarding the individual cost neutrality cap, and notification to and signed
acknowledgement of understanding by the member or his/her representative 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; and (c) provide information regarding
consumer direction and obtain written confirmation of the member’s decision
regarding participation in consumer direction; and (7) 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.

27.   Section 2.9.6.3.13.1 shall be amended by deleting the word “and” and
replacing it with the word “an”.  

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

  2.9.6.3.14   The CONTRACTOR shall be responsible for (1) advising members who
appear to meet the nursing facility level of care that are seeking access to
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 HCBS are not immediately available;
(3) determining whether the person wants nursing facility services if 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 2.9.6.3.13.1).

29.   Section 2.9.6.3.17.1 shall be deleted and replaced as follows:

2.9.6.3.17.1 For purposes of the CHOICES program, service authorizations for
HCBS shall include

the amount, frequency, and duration of each service to be provided, and the
schedule at which such care is needed, as applicable; and other relevant
information as prescribed by TENNCARE. Service authorizations for nursing
facility services shall be for the level of nursing facility services (Level I
or Level II) approved by TENNCARE (see Section 2.14.1.12) and shall include the
duration of nursing facility services to be provided; the

requested start date; and other relevant information as prescribed by TENNCARE.
The CONTRACTOR is responsible for confirming the provider’s capacity and
commitment to initiate services as authorized on or before the requested start
date, and if the provider is unable to initiate services as authorized on or
before the requested start date, shall select an alternative provider who is
able to initiate services as authorized on or before the requested start date.

30.   Section 2.9.6.4.3.2 shall be amended by deleting and replacing the
reference “(see Section 2.9.6.2.4.4 and 2.9.6.2.5.3)” with the reference “(see
Sections 2.9.6.2.4.4, 2.9.6.2.5.3 and 2.9.6.3.17)”.

31.   Section 2.9.6.6.1.1 shall be deleted and replaced as follows:

2.9.6.6.1.1 For members in CHOICES Group 1, the member’s care coordinator/care
coordination

team may: (1) rely on the plan of care developed by the nursing facility for
service delivery instead of developing a plan of care for the member; and (2)
supplement the nursing facility plan of care as necessary with the development
and implementation of targeted strategies to improve health, functional, or
quality of life outcomes (e.g., related to disease management or pharmacy
management) or to increase and/or maintain functional abilities. A copy of any
supplements to the nursing facility plan of care, and updates to such
supplements, shall be maintained by the CONTRACTOR in the member’s file.

32.   Section 2.9.6.10 shall be deleted and replaced as follows:

2.9.6.10 Additional Requirements for Care Coordination Regarding Consumer
Direction of HCBS

  2.9.6.10.1   In addition to the roles and responsibilities otherwise specified
in this Section 2.9.6, the CONTRACTOR shall ensure that the following additional
care coordination functions related to consumer direction of HCBS are fulfilled.

  2.9.6.10.2   The CONTRACTOR shall be responsible for providing all needed
eligible HCBS using contract providers until all necessary requirements have
been fulfilled in order to implement consumer direction of HCBS, including but
not limited to: the FEA verifies that workers for these services meet all
necessary requirements (see Section 2.9.7.6.1 of this Agreement); service
agreements are completed and signed; and authorizations for consumer directed
services are in place. The CONTRACTOR, in conjunction with the FEA, shall
facilitate a seamless transition between contract providers and workers and
ensure that there are no interruptions or gaps in services.

  2.9.6.10.3   If a member is interested in participating in consumer direction
of HCBS and the member does not intend to appoint a representative, the care
coordinator shall determine the extent to which the member may require
assistance to direct his/her services (see Section 2.9.7.4.5). If the care
coordinator determines that the member requires assistance to direct his/her
services, based upon the results of a completed self-assessment instrument
developed by TENNCARE, the care coordinator shall inform the member that he/she
will need to designate a representative to assume the consumer direction
functions on his/her behalf (see Section 2.9.7.4.5.1).

  2.9.6.10.4   The member’s care coordinator/care coordination team shall ensure
that the person identified to serve as the representative meets all
qualifications (see Section 2.9.7.2.1) and that a representative agreement is
completed and signed by the member prior to forwarding a referral to the FEA
(see Section 2.9.7.4.7).

  2.9.6.10.5   For members electing to participate in consumer direction,
forward to the FEA a referral initiating the member’s participation in consumer
direction of HCBS: (1) within two (2) business days of signing the
representative agreement; or (2) if a representative is not designated by the
member, within two (2) business days of completion of the self-assessment
instrument and the care coordinator determines that the member does not require
a representative to assist the member in directing his/her care.

  2.9.6.10.6   For members electing to participate in consumer direction, the
member’s care coordinator shall integrate the member’s back-up plan for
consumer-directed workers (including any updates thereto) into the member’s
back-up plan for services provided by contract providers, as applicable, and the
member’s plan of care. The care coordinator shall review the back-up plan
developed by the member or his/her representative (as applicable) for consumer
direction to determine its adequacy to address the member’s needs, and shall
monitor for late and missed visits and to ensure that the back-up plan was
implemented timely and that the member’s needs are being met.

  2.9.6.10.7   For members electing to participate in consumer direction, the
member’s care coordinator shall reassess the adequacy of the member’s back-up
plan for consumer direction on at least an annual basis which shall include any
time there are changes in the type, amount, duration, scope of eligible HCBS or
the schedule at which such services are needed, changes in consumer- directed
workers (when such workers also serve as a back-up to other workers) or changes
in the availability of paid or unpaid back-up workers to deliver needed care

  2.9.6.10.8   For members electing to participate in consumer direction, the
member’s care coordinator shall develop and/or update, as applicable, a risk
agreement which takes into account the member’s decision to participate in
consumer direction, and which identifies any additional risks associated with
the member’s decision to direct his/her services, the potential consequences of
such risk, as well as measures to mitigate these risks. The member’s
representative (if applicable) shall participate in the risk assessment process.
The new or updated risk agreement, as applicable, shall be signed by the care
coordinator and the member (or the member’s representative, as applicable). The
CONTRACTOR shall provide a copy of the risk agreement to the
member/representative and the FEA.

  2.9.6.10.9   On an ongoing basis, the CONTRACTOR shall ensure that needs
reassessments and updates to the plan of care occur per requirements specified
in Sections 2.9.6.9 of this Agreement. The care coordinator shall ensure that,
for members participating in consumer direction, the member’s supports broker is
invited to participate in these meetings.

  2.9.6.10.10   Within two (2) business days of receipt of the notification from
the FEA indicating that all requirements have been fulfilled and the date that
the consumer direction can begin for a member, the CONTRACTOR shall forward to
the FEA an authorization for consumer directed services for that member. Each
authorization for consumer directed services shall include authorized service,
authorized units of service, including amount, frequency and

duration and the schedule at which services are needed, start and end dates, and
service code(s).

  2.9.6.10.11   The member’s care coordinator/care coordination team shall work
with and coordinate with a member’s supports broker in implementing and
monitoring consumer direction of HCBS (see Section 2.9.7.3.4).

2.9.6.10.12 The CONTRACTOR shall establish a process that allows for the
efficient exchange of all

relevant member information between the CONTRACTOR and the FEA.

  2.9.6.10.13   The care coordinator shall determine a member’s interest in
enrolling in or continuing to participate in consumer direction annually and
shall document the member’s decision in the member’s plan of care.

  2.9.6.10.14   If at anytime abuse or neglect is suspected, the member’s care
coordinator or the FEA shall report the allegations to the CONTRACTOR within 24
hours in accordance with the CONTRACTOR’s abuse and neglect plan protocols. The
notification shall include at a minimum: the member name; date of allegation
reported and/or identified; description of issue; measures taken to mitigate
risk; status of reporting to CPS or APS, as appropriate. If the allegation is in
reference to a worker or representative, the FEA shall contact the
member/representative to immediately release the worker or representative from
his/her duties until the investigation is complete. The FEA shall notify the
CONTRACTOR regarding this communication with the member/representative and the
member or representative’s decision. The care coordinator shall work the member
to find a new representative and the FEA shall work with the member to find a
suitable replacement worker, if applicable. If the allegations are substantiated
as a result of the investigation, the representative and/or worker shall no
longer be allowed to participate in the CHOICES program in any capacity. If the
investigation is inconclusive, the member may elect to retain the worker or
representative. The member’s care coordinator, with appropriate assistance from
the FEA, shall make any updates to the member’s plan of care and/or risk
assessment/risk agreement deemed necessary to help ensure the member’s health
and safety, and the CONTRACTOR may initiate action to involuntary disenroll the
member from consumer direction at any time the CONTRACTOR feels that the
member’s decisions or actions constitute unreasonable risk such that the
member’s needs can no longer be safely and effectively met in the community
while participating in consumer direction.

33.   Section 2.9.6.12.3.1 shall be amended by inserting “an” before
“individual” and deleting the text “consumer direction” before the word
“worker”.  

34.   Section 2.9.6.12.3.10 shall be deleted and replaced as follows:

  2.9.6.12.3.10   The CONTRACTOR shall ensure that the EVV system creates and
makes available to providers and to the FEA on at least a daily basis an
electronic claims submission file in the 837 format, including exceptions which
have been resolved, which may be submitted to the CONTRACTOR for claims
processing at the appropriate frequency.

35.   Section 2.9.6.12.3.11 shall be deleted in its entirety.

36. Section 2.9.7 shall be deleted and replaced as follows:

2.9.7 Consumer Direction of HCBS

2.9.7.1 General

  2.9.7.1.1   The CONTRACTOR shall offer consumer direction of HCBS to all
CHOICES Group 2 and 3 members who are determined by a care coordinator, through
the needs assessment/reassessment process, to need attendant care, personal
care, homemaker, in-home respite, companion care services and/or any other
service specified in TennCare rules and regulations as available for consumer
direction. (Companion care is only available for persons electing consumer
direction of HCBS.) A service that is not specified in TennCare rules and
regulations as available for consumer direction shall not be consumer directed.
Consumer direction in CHOICES affords members the opportunity to have choice and
control over how eligible HCBS are provided, who provides the services and how
much workers are paid for providing care, up to a specified maximum amount
established by TENNCARE (see Section 2.9.7.6.11). Member participation in
consumer direction of HCBS is voluntary. Members may elect to participate in or
withdraw from consumer direction of HCBS at any time, service by service,
without affecting their enrollment in CHOICES. To the extent possible, the
member shall provide his/her care coordinator ten (10) days advance notice
regarding his/her intent to no longer direct one or more eligible HCBS or to
withdraw from participation in consumer direction of HCBS entirely. The
CONTRACTOR shall respond to the member’s request in keeping with the timeframes
and processes set forth in this Section, in order to facilitate a seamless
transition to appropriate service delivery. TENNCARE may establish reasonable
limitations on the frequency with which members may opt into and out of consumer
direction of HCBS.

  2.9.7.1.2   Consumer direction is a process by which eligible HCBS are
delivered; it is not a service. If a member chooses not to direct his/her care,
he/she shall receive authorized HCBS through contract providers. While the
denial of a member’s request to participate in consumer direction or the
termination of a member’s participation in consumer direction gives rise to due
process including the right to fair hearing, such appeals shall be processed by
the TennCare Division of Long Term Care rather than the TennCare Solutions
Units, which manages medical appeals pertaining to TennCare benefits (i.e.,
services).

  2.9.7.1.3   Members who participate in consumer direction of HCBS choose
either to serve as the employer of record of their workers or to designate a
representative (see definition below in Section 2.9.7.2.1) to serve as the
employer of record on his/her behalf. As the employer of record the member or
his/her representative is responsible for the following:

      2.9.7.1.3.1
2.9.7.1.3.2
2.9.7.1.3.3
2.9.7.1.3.4  
Recruiting, hiring and firing workers;
Determining workers’ duties and developing job descriptions;
Scheduling workers;
Supervising workers;

      2.9.7.1.3.5
2.9.7.1.3.6
2.9.7.1.3.7  
Evaluating worker performance and addressing any identified deficiencies or
concerns;
Setting wages up to a specified maximum amount established by TENNCARE;
Training workers to provide personalized care based on the member’s needs and
preferences;
2.9.7.1.3.8 Ensuring that workers deliver only those services authorized, and
reviewing and 2.9.7.1.3.9
2.9.7.1.3.10
2.9.7.2 Representative  
approving hours worked by consumer-directed workers;
Reviewing and ensuring proper documentation for services provided; and
Developing and implementing as needed a back-up plan to address instances when a
scheduled worker is not available or fails to show up as scheduled.

 

  2.9.7.2.1   A member may designate, or have appointed by a guardian, a
representative to assume the consumer direction responsibilities on his/her
behalf. A representative shall meet, at minimum the following requirements: be
at least 18 years of age, have a personal relationship with the member and
understand his/her support needs; knows the member’s daily schedule and routine,
medical and functional status, medication regimen, likes and dislikes, and
strengths and weaknesses; and be physically present in the member’s residence on
a regular basis or at least at a frequency necessary to supervise and evaluate
each worker.

  2.9.7.2.2   In order to participate in consumer direction of HCBS with the
assistance of a representative, one of the following must apply: (1) the member
must have the ability to designate a person to serve as his/her representative
or (2) the member has a legally appointed representative who may serve as the
member’s representative.

  2.9.7.2.3   The care coordinator shall, based on a self-assessment completed
by the member, determine if the member requires assistance in carrying out the
responsibilities required for consumer direction and therefore requires a
representative. The member’s care coordinator/care coordination team shall
verify that a representative meets the qualifications as described in
Section 2.9.7.2.1 above.

  2.9.7.2.4   A member’s representative shall not receive payment for serving in
this capacity and shall not serve as the member’s worker for any consumer
directed service. The CONTRACTOR shall use a representative agreement developed
by TENNCARE to document a member’s choice of a representative for consumer
direction of HCBS and the representative’s contact information, and to confirm
the individual’s agreement to serve as the representative and to accept the
responsibilities and perform the associated duties defined therein. The
CONTRACTOR shall notify the FEA within three (3) business days when it becomes
aware of any changes to a representative’s contact information.

  2.9.7.2.5   The representative agreement shall be signed by the member (or
person authorized to sign on member’s behalf) and the representative in the
presence of the care coordinator. The care coordinator shall include the
representative agreement in the member’s file and provide copies to the member
and/or the member’s representative and the FEA.

  2.9.7.2.6   A member may change his/her representative at any time. The member
shall immediately notify his/her care coordinator and his/her supports broker
when he/she intends to change representatives. The care coordinator shall verify
that the new representative meets the qualifications as described above. A new
representative agreement shall be completed and signed, in the presence of a
care coordinator, prior to the new representative assuming their respective
responsibilities. The care coordinator shall immediately notify the FEA in
writing when a member changes his/her representative and provide a copy of the
representative agreement. The CONTRACTOR shall facilitate a seamless transition
to the new representative, and ensure that there are no interruptions or gaps in
services. As part of the needs assessment and plan of care process, the care
coordinator shall educate the member about the importance of notifying the care
coordinator prior to changing a representative.

        .

  2.9.7.2.7   The FEA shall ensure that the new representative signs all service
agreements (see Section 2.9.7.6.6).

2.9.7.3 Fiscal Employer Agent (FEA)

  2.9.7.3.1   The CONTRACTOR shall enter into a contract with the FEA specified
by TENNCARE to provide assistance to members choosing consumer direction.

  2.9.7.3.2   The FEA shall fulfill, at a minimum, the following financial
administration and supports brokerage functions, as specified in the
CONTRACTOR’s contract with the FEA and the FEA’s contract with TENNCARE, for all
CHOICES members electing consumer direction of HCBS:

            2.9.7.3.2.1    
Assign a supports broker to each CHOICES member electing to participate in
consumer
direction of HCBS; 2.9.7.3.2.2
2.9.7.3.2.3  
Assist in identifying and addressing in the risk assessment and plan of care
processes any
additional risk associated with the member participating in consumer direction;
Provide initial and ongoing training to members and their representatives (as
applicable)

          on consumer direction and other relevant issues (see Section 2.9.7.7
of this Agreement);   2.9.7.3.2.4    
Verify worker qualifications, including, as specified by TENNCARE, conduct

background checks on workers, enroll workers into Medicaid, assign provider
Medicaid ID numbers, and hold Medicaid provider agreements (see Section
2.9.7.6.1 of this Agreement);

2.9.7.3.2.5 Provide initial and ongoing training to workers on consumer
direction and other relevant

issues (see Section 2.9.7.7 of this Agreement);

      2.9.7.3.2.6
2.9.7.3.2.7
2.9.7.3.2.8
2.9.7.3.2.9
2.9.7.3.2.10
2.9.7.3.2.11
2.9.7.3.2.12
2.9.7.3.2.13
2.9.7.3.2.14  
Assist the member and/or representative in developing and updating service
agreements
(see Section 2.9.7.6.6);
Receive, review and process electronically captured visit information;
Resolve discrepancies regarding electronically captured visit information;
Obtain documentation from the member and/or representative to ensure that
services
were provided prior to payment of workers;
Withhold, file and pay applicable: federal, state and local income taxes;
employment and
unemployment taxes; and worker’s compensation;
Pay workers for authorized services rendered within authorized timeframes;
Facilitate resolution of any disputes regarding payment to workers for services
rendered;
Monitor quality of services provided by workers; and
Report to the CONTRACTOR on worker and/or staff identification of, response to,

participation in and/or investigation of critical incidents (see
Section 2.15.8).

  2.9.7.3.3   The FEA shall also fulfill, at a minimum, the following financial
administration and supports brokerage functions for CHOICES members electing
consumer direction of HCBS on an as needed basis:

      2.9.7.3.3.1
2.9.7.3.3.2
2.9.7.3.3.3
2.9.7.3.3.4
2.9.7.3.3.5
2.9.7.3.3.6
2.9.7.3.4  
Assist the member and/or representative in developing job descriptions;
Assist the member and/or representative in locating and recruiting workers;
Assist the member and/or representative in interviewing workers (developing
questions,
evaluating responses);
Assist the member and/or representative in scheduling workers;
Assist the member and/or representative in managing and monitoring payments to
workers; and
Assist the member and/or representative in monitoring and evaluating the
performance of
workers.
The CONTRACTOR’s care coordination functions shall not duplicate the supports

brokerage functions performed by the FEA or its subcontractor. A member’s care
coordinator shall work with and coordinate with a member’s supports broker in
implementing and monitoring consumer direction.

2.9.7.3.5 The CONTRACTOR’s contract with the FEA shall include the provisions
specified by

TENNCARE in the model CONTRACTOR-FEA contract.

2.9.7.3.6 The CONTRACTOR in collaboration with the FEA shall establish a process
that allows

for the efficient exchange of all relevant member information regarding members
electing to participate in consumer direction between the CONTRACTOR and the
FEA.

      2.9.7.3.7
2.9.7.3.8  
The CONTRACTOR and FEA shall develop a protocol for interfaces and transfers of
customer service inquiries per the requirements of Section 2.18 of this
Agreement.
The CONTRACTOR shall provide to the FEA copies of all relevant initial and
updated

member documents, including at a minimum, plans of care, representative
agreements and risk agreements. The CONTRACTOR shall provide to the FEA all
relevant documentation prior to service delivery.

2.9.7.3.9 The CONTRACTOR shall require that the EVV system: (1) provide
functionality and

access to the FEA for purposes of scheduling workers who will deliver services
in accordance with the schedule determined by the CONTRACTOR and for monitoring
service delivery; and (2) facilitate access by the FEA to electronically
captured visit information in order to process exceptions, to process payroll
for workers, and for purposes of claims submission to the CONTRACTOR once
exceptions have been resolved.

2.9.7.3.10 The FEA shall screen monthly to determine if workers have been
excluded from

participation in Medicare, Medicaid, SCHIP, or any Federal health care programs
(as defined in Section 1 128B(f) of the Social Security Act) and not employ or
contract with an individual or entity that has been excluded. If a worker has
been excluded, the FEA shall notify the member regarding the worker’s status and
work with the member to find a replacement worker. The FEA shall notify the
CONTRACTOR regarding the worker status. The CONTRACTOR shall work with the
member to obtain a replacement contract provider until a replacement worker can
be found and all worker requirements are fulfilled and verified.

2.9.7.3.11 FEA Training

2.9.7.3.11.1 The CONTRACTOR shall provide education and training to the FEA and
its staff and

subcontracted supports brokers (as applicable) regarding key requirements of
this Agreement and the contract between the CONTRACTOR and the FEA.

2.9.7.3.11.2 The CONTRACTOR shall provide to the FEA, in electronic format
(including but not

limited to CD or access via a web link), a member handbook and updates
thereafter annually or any time material changes are made.

2.9.7.3.11.3 The CONTRACTOR shall conduct initial education and training to the
FEA and its staff

at least thirty (30) days prior to implementation of CHOICES in the Grand Region
covered by this Agreement. This education and training shall include, but not be
limited to, the following:

2.9.7.3.11.3.1   The role and responsibilities of the care coordinator,
including as it relates to members electing to participate in consumer
direction;

  2.9.7.3.11.3.2   CHOICES needs assessment and care planning development,
implementation, and monitoring processes, including the development and
activation of a back-up plan for members participating in consumer direction;

  2.9.7.3.11.3.3   The FEA’s responsibilities for communicating with the
CONTRACTOR, members, representatives and workers and TENNCARE, and the process
by which to do this;

2.9.7.3.11.3.4 Customer service requirements;

2.9.7.3.11.3.5 Requirements and processes regarding referral to the FEA;

  2.9.7.3.11.3.6   Requirements and processes, including timeframes for
authorization of consumer directed HCBS;

  2.9.7.3.11.3.7   Requirements and processes, including timeframes, for claims
submission and payment and coding requirements;

2.9.7.3.11.3.8 Systems requirements and information exchange requirements;
2.9.7.3.11.3.9 Requirements regarding the EVV system;

  2.9.7.3.11.3.10   Requirements and role and responsibility regarding abuse and
neglect plan protocols, and critical incident reporting and management;

  2.9.7.3.11.3.11   The FEA’s role and responsibility in implementing the
CONTRACTOR’s fraud and abuse plan;

          2.9.7.3.11.3.12 CHOICES program quality requirements; and
2.9.7.3.11.3.13 The CONTRACTOR’s member complaint and appeal processes.  
2.9.7.3.11.4    
The CONTRACTOR shall provide ongoing FEA education, training and technical

assistance as deemed necessary by the CONTRACTOR or TENNCARE in order to ensure
compliance with this Agreement and the contract between the CONTRACTOR and the
FEA.

2.9.7.3.11.5 The CONTRACTOR shall require the Electronic Visit Verification
(EVV) vendor to

provide training to the FEA and its supports brokers regarding the EVV system,
and a training curriculum that shall be utilized by the FEA in training
consumer-directed workers.

2.9.7.3.11.6 The FEA shall provide training to the CONTRACTOR’s care
coordinators regarding

consumer direction of HCBS and the role and responsibilities of the FEA
(including financial administration and supports brokerage functions)

2.9.7.4 Needs Assessment/Plan of Care Process

  2.9.7.4.1   A CHOICES member may choose to direct needed eligible HCBS at
anytime: during CHOICES intake, through the needs assessment/reassessment and
plan of care and plan of care update processes; and outside of these processes.
The care coordinator shall assess the

member’s needs for eligible HCBS per requirements in Sections 2.9.6.2.4, 2.9.6.3
and 2.9.6.5, as applicable. The care coordinator shall use the plan of care
process (including updates) to identify the eligible services that the member
will direct and to facilitate the member’s enrollment in consumer direction of
HCBS.

  2.9.7.4.2   The CONTRACTOR shall obtain from the member a signed statement
regarding the member’s decision to participate in consumer direction of HCBS.

  2.9.7.4.2.1   The care coordinator shall assist the member in identifying
which of the needed eligible HCBS shall be consumer directed, provided by
contract providers or a combination of both, in which case, there must be a set
schedule which clearly defines when contract providers will be utilized. The
CONTRACTOR shall not be expected or required to maintain contract providers “on
standby” to serve in a back-up capacity for services a member has elected to
receive through consumer direction.

  2.9.7.4.3   If the member intends to direct one or more needed eligible HCBS,
throughout the period of time that consumer direction is being initiated, the
CONTRACTOR shall arrange for the provision of needed HCBS through contract
providers in accordance with 2.9.6. The care coordinator shall obtain from the
member his/her choice of contract providers who will provide HCBS until such
time as workers are secured and ready to begin delivering care through consumer
direction.

  2.9.7.4.3.1   If a member has been assessed to need companion care services,
the CONTRACTOR shall identify non-residential services that will offer interim
support to address the member’s needs and assist the member in obtaining
contract providers for these services.

  2.9.7.4.4   The CONTRACTOR shall be responsible for providing all needed
eligible HCBS using contract providers, including a back-up plan for such
services, until all necessary requirements have been fulfilled in order to
implement consumer direction of HCBS, including but not limited to: the FEA
verifies that workers for these services meet all necessary requirements (see
Section 2.9.7.6.1 of this Agreement); service agreements are completed and
signed; and authorizations for consumer directed services are in place. The
CONTRACTOR, in conjunction with the FEA, shall facilitate a seamless transition
between contract providers and workers and ensure that there are no
interruptions or gaps in services.

  2.9.7.4.5   The care coordinator shall determine if the member will appoint a
representative to assume the consumer direction functions on his/her behalf. If
the member does not intend to appoint a representative, the care coordinator
shall determine the extent to which a member requires assistance to participate
in consumer direction of HCBS, based upon the results of the member’s responses
to the self-assessment instrument developed by TENNCARE. The self- assessment
instrument shall be completed by the member with assistance from the member’s
care coordinator as appropriate. The care coordinator shall file the completed
self-assessment in the member’s file.

  2.9.7.4.5.1   If, based on the results of the self-assessment the care
coordinator determines that a member requires assistance to direct his/her
services, the care coordinator shall inform the member that he/she will need to
designate a representative to assume the consumer direction functions on his/her
behalf.

2.9.7.4.5.2 The CONTRACTOR shall forward to TENNCARE for disposition, pursuant
to TennCare

policy, any cases in which the CONTRACTOR plans to deny participation in
consumer direction because a care coordinator has determined that the health,
safety and welfare of the member would be in jeopardy if the member participates
in consumer direction without a representative but the member does not want to
appoint a representative to assist in directing his/her services. The CONTRACTOR
shall abide by TENNCARE’s decision.

2.9.7.4.6   The member’s care coordinator/care coordination team shall ensure
that the person identified to serve as the representative meets all
qualifications (see Section 2.9.7.2.1 of this Agreement) and that a
representative agreement is completed and signed by the member and the person
prior to forwarding a referral to the FEA (see Section 2.9.7.4.7 below).

2.9.7.4.7   Within two (2) business days of signing the representative agreement
or completion of the self-assessment instrument if the member has not designated
a representative and the care coordinator determines that the member does not
require a representative to assist the member in directing his/her care, the
CONTRACTOR shall forward to the FEA a referral initiating the member’s
participation in consumer direction of HCBS. The referral shall include at a
minimum: the date of the referral; the member’s name, address, telephone number,
and social security number (SSN); the name of the representative and telephone
number (if applicable); member’s MCO ID number; member’s CHOICES enrollment
date; eligible selected HCBS, including amount, frequency and duration of each
by type; and care coordinator’s name and contact information. The CONTRACTOR
shall also forward to the FEA a copy of the written confirmation of the member’s
decision to participate in consumer direction of HCBS. Referrals shall be
submitted electronically on a daily basis using the agreed upon data interface
(either a standard electronic file transfer or the FEA’s web portal technology
or both) and process. Referrals shall be submitted on a member-by-member basis.

2.9.7.4.8   Within two (2) business days of receipt of the referral, the FEA
shall assign a supports broker to the member, notify the care coordinator of the
assignment and provide the name and contact information of the supports broker.

2.9.7.4.9   Within five (5) days of receipt of the referral, the FEA shall
contact the member to inform the member of his/her assigned supports broker,
provide contact information for the supports broker, and to begin the process of
initiating consumer direction of HCBS.

2.9.7.4.10 Back-up Plan for Consumer Direction and Updated Risk Assessment/Risk
Agreement

2.9.7.4.10.1 The FEA shall assist the member/representative as needed in
developing a back-up plan

for consumer direction that adequately identifies how the member/representative
will address situations when a scheduled worker is not available or fails to
show up as scheduled. The member/representative (as applicable) shall have
primary responsibility for the development and implementation of the back-up
plan for consumer directed services.

2.9.7.4.10.2 The member/representative (as applicable) may not elect, as part of
the back-up plan, to

go without services.

2.9.7.4.10.3   The back-up plan for consumer direction shall include the names
and telephone numbers of contacts (workers, agency staff, organizations,
supports) for alternate care, the order in which each shall be notified and the
services to be provided by contacts. Back-up contacts may include paid and
unpaid supports; however, it is the responsibility of the member electing
consumer direction and/or his/her representative to secure paid (as well as
unpaid) back-up contacts who are willing and available to serve in this
capacity. The CONTRACTOR shall not be expected or required to maintain contract
providers “on standby” to serve in a back-up capacity for services a member has
elected to receive through consumer direction.

2.9.7.4.10.4   All persons and/or organizations noted in the back-up plan for
consumer direction shall be contacted by the member/representative to determine
their willingness and availability to serve as back-up contacts. The FEA shall
confirm with these persons and/or organizations to confirm their willingness and
availability to provide care when needed, document confirmation in the member’s
file and forward a copy of the documentation to the CONTRACTOR.

2.9.7.4.10.5 The member’s care coordinator shall integrate the member’s back-up
plan for consumer-

directed workers (including any updates thereto) into the member’s back-up plan
for services provided by contract providers, as applicable, and the member’s
plan of care. The care coordinator shall review the back-up plan developed by
the member or his/her representative (as applicable) for consumer direction to
determine its adequacy to address the member’s needs, and shall monitor for late
and missed visits and to ensure that the back-up plan was implemented timely and
that the member’s needs are being met.

2.9.7.4.10.6 The FEA shall assist the member or his/her representative (as
applicable) in

implementing the back-up plan for consumer direction as needed, monitor to
ensure that the back-up plan is implemented and effectively working to address
the member’s needs, and notify the care coordinator immediately regarding any
concerns with the back-up plan or the member’s care.

2.9.7.4.10.7 The FEA shall assist the member or his/her representative (as
applicable) in reviewing

and updating the back-up plan for consumer direction at least annually and as
frequently as necessary, which shall include any time there are changes in the
type, amount, duration, scope of eligible HCBS or the schedule at which such
services are needed, changes in workers (when such workers also serve as a
back-up to other workers) and changes in the availability of paid or unpaid
back-up workers to deliver needed care. As part of the annual review of the
back-up plan, the member or his/her representative and the FEA shall confirm
that each person specified in the back-up plan continues to be willing and
available to serve as back-up workers to deliver needed care and to perform the
tasks and functions needed by the member. Any updates to the back-up plan for
consumer direction shall be provided to the member’s care coordinator.

      2.9.7.4.10.8
2.9.7.4.10.9  
The FEA and the CONTRACTOR shall each file a copy of the back-up plan for
consumer direction in the member’s file.
The member’s care coordinator shall reassess the adequacy of the member’s
back-up plan

for consumer direction on at least an annual basis which shall include any time
there are
changes in the type, amount, duration, scope of eligible HCBS or the schedule at
which
such services are needed, changes in consumer-directed workers (when such
workers also

serve as a back-up to other workers) or changes in the availability of paid or
unpaid backup workers to deliver needed care.

  2.9.7.4.10.10   The CONTRACTOR shall develop and/or update, as applicable, a
risk agreement which takes into account the member’s decision to participate in
consumer direction, and which identifies any additional risks associated with
the member’s decision to direct his/her services, the potential consequences of
such risk, as well as measures to mitigate these risks. The
member/representative shall participate in the process. The member’s
representative (if applicable) shall participate in the risk assessment process.
Once a referral has been made to the FEA for consumer direction, the member’s
supports broker should be involved in risk assessment and risk planning
activities whenever possible. The new or updated risk agreement, as applicable,
shall be signed by the care coordinator and the member or his/her representative
(as applicable). The CONTRACTOR, member/representative and FEA shall receive a
copy of the risk agreement. The CONTRACTOR and the FEA shall each file a copy of
the risk agreement in the member’s file.

  2.9.7.4.10.11   The FEA shall notify the member’s care coordinator immediately
when there are changes in the member’s needs and/or circumstances which warrant
a reassessment of needs and/or risk, or changes to the plan of care or risk
agreement.

  2.9.7.4.10.12   The FEA shall assist the CONTRACTOR in identifying and
addressing in the risk assessment and plan of care processes any additional risk
associated with the member participating in consumer direction.

  2.9.7.4.10.13   On an ongoing basis, the CONTRACTOR shall ensure that needs
reassessments and updates to the plan of care occur per requirements specified
in Sections 2.9.6.9 of this Agreement. The care coordinator shall ensure that
the member’s supports broker is invited to participate in these meetings.

2.9.7.5 Authorizations for Consumer Directed Services and Service Initiation

2.9.7.5.1 Consumer direction of HCBS shall not be initiated until all
requirements are fulfilled

including but not limited to the following: (1) the FEA verifies that the
member’s employer and related documentation is in order; (2) the FEA verifies
that workers meet all qualifications, including participation in required
training; (3) there is a signed service agreement specific to each individual
worker (see Section 2.9.7.6.6 of this Agreement); and (4) the CONTRACTOR issues
to the FEA an authorization for consumer directed services (see 2.9.7.5.6 below)
for each service.

2.9.7.5.2 The FEA shall work with the member to determine the appropriate level
of assistance

necessary to recruit, interview and hire workers and provide the assistance.

  2.9.7.5.3   Once potential workers are identified, the FEA shall verify that a
potential worker meets all applicable qualifications (see Section 2.9.7.6.1 of
this Agreement).

  2.9.7.5.4   The FEA shall ensure that a service agreement is signed between
the member or member’s representative and his/her worker within five
(5) business days following the FEA’s verification that a worker meets all
qualifications.

  2.9.7.5.5   The FEA shall periodically update the member’s care coordinator of
the status of completing required functions necessary to initiate consumer
direction, including obtaining completed paperwork from the
member/representative and obtaining workers for each identified consumer
directed service and any anticipated timeframes by which qualified workers shall
be secured and consumer directed services may begin.

  2.9.7.5.6   The provision of consumer directed services shall begin as soon as
possible but no longer than sixty (60) days from the date of the CONTRACTOR’s
referral to the FEA, except due to circumstances beyond the control of the FEA.
Prior to beginning the provision of consumer directed services, the FEA shall
notify the CONTRACTOR that all requirements have been fulfilled, including
verification of all worker qualifications, criminal background checks, signed
service agreements, and that the member is ready to begin consumer direction of
HCBS. Within two (2) business days of receipt of the notification from the FEA,
the CONTRACTOR shall forward to the FEA an authorization for consumer directed
services. Each authorization for consumer directed services shall include
authorized service; authorized units of service, including amount, frequency and
duration and the schedule at which services are needed; start and end dates; and
service code(s). Authorized units of service in a service authorization should
reflect the units of measure specified by TENNCARE for the benefit (e.g. visits,
hours, days). The CONTRACTOR shall submit authorizations electronically on at
least a daily basis using the agreed upon data interface (which may include a
standard electronic file transfer, the FEA’s web portal technology, the EVV
system, or any combination thereof).

  2.9.7.5.7   If initiation of consumer directed services does not begin within
sixty (60) days from the date of the CONTRACTOR’s referral to the FEA, the FEA
shall contact the CONTRACTOR regarding the cause of the delay and provide
appropriate documentation to demonstrate efforts to meet the timeframe. The
CONTRACTOR shall determine the appropriate next steps, including but not limited
to whether additional time is needed or if the member is still interested in
participating in consumer direction of HCBS.

  2.9.7.5.8   Upon the scheduled start date of consumer directed services, the
member’s care coordinator/care coordination team shall begin monitoring to
ensure that services have been initiated and continue to be provided as
authorized. This shall include ongoing monitoring via electronic visit
verification to ensure that services are provided in accordance with the
member’s plan of care, including the amount, frequency, duration and scope of
each service, in accordance with the member’s service schedule. Upon the
identification of any gaps in care, the member’s care coordinator/care
coordination team shall contact the FEA who shall assist the member or his/her
representative as needed in implementing the member’s back-up plan for consumer
direction.

  2.9.7.5.9   Within five (5) business days of the scheduled start date of
consumer directed services as specified in the authorization of consumer
directed services, a member of the care coordinator team shall contact the
member or his/her representative to confirm that services are being provided and
that the member’s needs are being met.

  2.9.7.5.10   On an ongoing basis, in addition to requirements specified above
in 2.9.7.5.3 – 2.9.7.5.9 above:

2.9.7.5.10.1 The CONTRACTOR shall develop and forward to the FEA a new
authorization for

consumer directed services when the following occur: a change in the number of
service

units, or the frequency or duration of service delivery, or a change in the
schedule at which services are needed; or a change in the services to be
provided through consumer direction, including the provision of a new service
through consumer direction or termination of a service through consumer
direction.

2.9.7.6 Worker Qualifications

  2.9.7.6.1   As prescribed in the FEA’s contract with TENNCARE, the FEA shall
ensure that workers meet all requirements prior to the worker providing
services. The FEA shall ensure that workers: meet all TennCare established
requirements for providers of comparable, non- consumer directed services; pass
a background check which includes criminal background check (including
fingerprinting), or, as an alternative, a background check from a licensed
private investigation company, verification that the person’s name does not
appear on the State abuse registry, verification that the person’s name does not
appear on the state and national sexual offender registries and licensure
verification, as applicable; complete all required training, including the
training specified in Section 2.9.7.7 of this Agreement; complete all required
applications to become a TennCare provider; sign an abbreviated Medicaid
agreement; are assigned a Medicaid provider ID number; and sign a service
agreement.

            2.9.7.6.1.1    
A member cannot waive a background check for a potential worker. The following
findings shall disqualify a person from serving as a worker:
  2.9.7.6.1.1.1    
Conviction of an offense involving physical, sexual or emotional abuse, neglect,
financial

exploitation or misuse of funds, misappropriation of property, theft from any
person, violence against any person, or manufacture, sale, possession or
distribution of any drug;

2.9.7.6.1.1.2 Entering of a plea of nolo contendere or when a jury verdict of
guilty is rendered but

adjudication of guilt is withheld with respect to a crime reasonably related to
the nature of the position sought or held;

      2.9.7.6.1.1.3
2.9.7.6.1.1.4
2.9.7.6.1.1.5
2.9.7.6.1.1.6
2.9.7.6.1.2  
Identification on the abuse registry;
Identification on the state or national sexual offender registry;
Failure to have a required license; and
Refusal to cooperate with a background check.
If a worker fails the background check, the FEA shall make the decision
regarding

exceptions to disqualification in accordance with TennCare policy. In the event
a member chooses to hire a worker that has failed a background check but has met
all of the conditions for an exception to disqualification, as prescribed by
TennCare, and the FEA has granted the exception, the FEA shall notify the
member’s care coordinator prior to initiation of services provided by that
worker. Exceptions to disqualification may be granted at the member’s discretion
and only if all of the following conditions are met:

2.9.7.6.1.2.1 Offense is a misdemeanor;

2.9.7.6.1.2.2 Offense occurred more than five (5) years ago;

      2.9.7.6.1.2.3
2.9.7.6.1.2.4
2.9.7.6.1.2.5
2.9.7.6.2  
Offense is not related to physical or sexual or emotional abuse of another
person;
Offense does not involve violence against another person or the manufacture,
sale, or
distribution of drugs; and
There is only one disqualifying offense.
Workers are not required to be contract providers. The CONTRACTOR shall not
require

a worker to sign a provider agreement or any other agreement not specified by
TENNCARE.

      2.9.7.6.3
2.9.7.6.4  
Members shall have the flexibility to hire persons with whom they have a close
personal
relationship to serve as a worker, such as a neighbor or a friend.
Members may hire family members, excluding spouses, to serve as a worker. A
family

member shall not be reimbursed for a service that he/she would have otherwise
provided without pay. The CONTRACTOR shall use the needs assessment process (see
Section 2.9.6.5) to assess the member’s available existing supports, including
supports provided by family members.

2.9.7.6.5 A member may have multiple workers or both a worker and a contract
provider for a

given service, in which case, there must be a set schedule which clearly defines
when contract providers will be utilized. A member may elect to have a worker
provide more than one service.

2.9.7.6.6 A member shall develop a service agreement with each worker. The
service agreement

template shall be developed by TENNCARE and shall include, at a minimum: the
roles and responsibilities of the worker and the member; the worker’s schedule
(as developed by the member and/or representative), including hours and days;
the scope of each service, i.e., the specific tasks and functions the worker is
to perform; the service rate; and the requested start date for services. The
service agreement shall serve as the worker’s written confirmation of his/her
commitment to initiate services on or before the date specified and to provide
services in accordance with specified terms (including the tasks and functions
to be performed and the schedule at which care is needed). If necessary, the FEA
shall assist in this process. Service agreements shall be updated anytime there
is a change in any of the terms or conditions specified in the agreement.
Service agreements shall be signed by the new representative when there is a
change in representatives.

2.9.7.6.7 The service agreement shall also stipulate if a worker will provide
one or more self-

directed health care tasks, the specific task(s) to be performed, and the
frequency of each self-directed health care task (see Section 2.7 3).

      2.9.7.6.8
2.9.7.6.9  
The FEA shall ensure that a service agreement is in place for each worker prior
to the
worker providing services.
A copy of each service agreement shall be provided to the member and/or
representative.

The FEA shall give a copy of the service agreement to the worker and shall
maintain a copy for its files.

2.9.7.6.10 A member may terminate a worker at any time if he/she feels that the
worker is not

adhering to the terms of the service agreement and/or is not providing quality
services. If the FEA or care coordinator has concerns that a worker is unable to
deliver appropriate care as prescribed in the service agreement and the plan of
care, but the member and/or representative chooses to continue to employ the
worker, the care coordinator shall note the concern and the member’s choice to
continue using the worker in the member’s plan of care, and shall update the
risk assessment and/or risk agreement as needed. The FEA and care coordinator
shall collaborate to develop strategies to address identified issues and
concerns. The FEA shall inform the member and/or representative of any potential
risks associated with continuing to use the worker. The CONTRACTOR shall forward
to TENNCARE for disposition, pursuant to TennCare policy, any cases in which the
CONTRACTOR plans to disenroll the member from consumer direction because a care
coordinator has determined that the health, safety and welfare of the member may
be in jeopardy if the member continues to employ a worker but the member and/or
representative does not want to terminate the worker. The CONTRACTOR and FEA
shall abide by TENNCARE’s decision.

2.9.7.6.11 A member shall have the flexibility to choose from a range of
TENNCARE specified

reimbursement levels for all eligible consumer directed HCBS, excluding
companion care services which shall be reimbursed at the rate specified by
TENNCARE.

2.9.7.6.12 In order to receive payment for services rendered, all workers must:

2.9.7.6.12.1 Deliver services in accordance with the schedule of services
specified in the member’s

plan of care and in the MCO’s service authorization, and in accordance with
worker assignments determined by the member or his/her representative. The FEA
shall input the member/representative’s assignment of individual workers into
the EVV; and

2.9.7.6.12.2 Maintain and submit documentation of service delivery (i.e.,
documentation of the tasks

and functions performed during the provision of services), and any other
documentation, as required, for units of service delivered; and

2.9.7.6.12.3 Provide no more than forty (40) hours of services within a
consecutive seven (7) day

period, unless explicitly permitted by program guidelines and in accordance with
service authorizations.

2.9.7.6.13   The FEA shall enter worker schedules into the EVV system in
accordance with the CONTRACTOR’s guidelines and the schedule at which services
are needed by the member, based on the member’s plan of care and the
CONTRACTOR’s service authorization.

2.9.7.7 Training

2.9.7.7.1   The CONTRACTOR shall require all members electing to enroll in
consumer direction of HCBS and/or their representatives to receive relevant
training. The FEA shall be responsible for providing or arranging for initial
and ongoing training of members/representatives. When training is not directly
provided by the FEA, the FEA shall validate completion of training. Initial
training shall be completed prior to initiation of consumer-directed services.

2.9.7.7.2   At a minimum, consumer direction training for members and/or
representatives shall address the following issues:

      2.9.7.7.2.1
2.9.7.7.2.2
2.9.7.7.2.3
2.9.7.7.2.4
2.9.7.7.2.5
2.9.7.7.2.6
2.9.7.7.2.7
2.9.7.7.2.8  
Understanding the role of members and representatives in consumer direction;
Understanding the role of the care coordinator and the FEA;
Selecting workers;
Abuse and neglect prevention and reporting;
Being an employer, evaluating worker performance and managing workers;
Fraud and abuse prevention and reporting;
Performing administrative tasks such as reviewing and approving electronically
captured
visit information; and
Scheduling workers and back-up planning.

2.9.7.7.3   Ongoing training shall be provided by the FEA to members and/or
representatives upon request and/or if a care coordinator or FEA, through
monitoring, determines that additional training is warranted.

2.9.7.7.4   The FEA shall be responsible for providing or arranging for initial
and ongoing training of all workers. When training is not directly provided by
the FEA, the FEA shall validate completion of training. Initial training shall
be completed prior to initiation of services. At a minimum, training shall
consist of the following required elements:

      2.9.7.7.4.1
2.9.7.7.4.2
2.9.7.7.4.3
2.9.7.7.4.4
2.9.7.7.4.5
2.9.7.7.4.6
2.9.7.7.4.7
2.9.7.7.4.8  
Overview of the CHOICES program and consumer direction of HCBS;
Caring for elderly and disabled populations;
Abuse and neglect identification and reporting;
CPR and first aid certification;
Critical incident reporting;
Submission of required documentation and withholdings;
Use of the EVV system; and
As appropriate, administration of self-directed health care task(s).

2.9.7.7.5   The FEA shall assist the member/representative in determining to
what extent the member/representative shall be involved in the above-specified
training. The member/ representative) shall provide additional training to the
worker regarding individualized service needs and preference.

2.9.7.7.6   The FEA shall verify that workers have successfully completed all
required training prior to service initiation and payment for services.

  2.9.7.7.7   Ongoing, the FEA shall ensure that workers maintain CPR and first
aid certification and receive required refresher training as a condition of
continued employment and shall arrange for the appropriate training. Additional
training components may be provided to a worker to address issues identified by
the FEA, care coordinator, member and/or the representative or at the request of
the worker.

  2.9.7.7.8   Refresher training may be provided more frequently if determined
necessary by the FEA, care coordinator, member and/or representative or at the
request of the worker.

2.9.7.8 Monitoring

  2.9.7.8.1   The CONTRACTOR shall monitor the quality of service delivery and
the health, safety and welfare of members participating in consumer direction
through the CHOICES care coordination functions.

2.9.7.8.2 The CONTRACTOR shall monitor for late or missed visits by
consumer-directed workers.

  2.9.7.8.3   The CONTRACTOR shall require that the EVV system include
functionality to provide prompt (i.e., “real time”) notification 24 hours/day,
7 days/week via automated email, as defined in business rules, to the MCO and to
the FEA if a consumer directed worker does not arrive as scheduled, or otherwise
deviates from the authorized schedule so that gaps in care are immediately
identified and addressed. Alerts will be provided via email, the monitoring
alert dashboard, and text messaging.

  2.9.7.8.4   The CONTRACTOR shall monitor implementation of the back-up plan by
the member or his/her representative, with assistance provided to the
member/representative by the FEA Supports Broker as needed.

  2.9.7.8.5   The CONTRACTOR shall monitor a member’s participation in consumer
direction of HCBS to determine, at a minimum, the success and the viability of
the service delivery model for the member. The CONTRACTOR shall note any
patterns, such as frequent turnover of representatives and changing between
consumer direction of HCBS and contract providers that may warrant intervention
by the CONTRACTOR. The CONTRACTOR may submit a request to TENNCARE, pursuant to
TennCare policy, to involuntarily withdraw the member from consumer direction of
HCBS if the CONTRACTOR has concerns about its ability to protect the health,
safety and welfare of the member (see Section 2.9.7.9.4).

  2.9.7.8.6   If at any time abuse or neglect is suspected, the member’s care
coordinator or the FEA shall report the allegations to the CONTRACTOR within 24
hours in accordance with the abuse and neglect plan protocols developed by the
CONTRACTOR. The notification shall include at a minimum: the member name; date
of allegation reported and/or identified; description of issue; measures taken
to mitigate risk; status of reporting to CPS or APS, as appropriate. If the
allegation is in reference to a worker or representative, the FEA shall contact
the member/representative to immediately release the worker or representative
from his/her duties until the investigation is complete. The FEA shall notify
the CONTRACTOR regarding this communication with the member/representative and
the member or representative’s decision. The care coordinator shall work with
the member to find a new representative and the FEA shall work with the member
to find a suitable replacement worker, if applicable. If the allegations are
substantiated as a result of the investigation, the representative and/or worker
shall no longer be allowed to participate in the CHOICES

program in any capacity. If the investigation is inconclusive, the member may
elect to retain the worker or representative. The member’s care coordinator,
with appropriate assistance from the FEA, shall make any updates to the member’s
plan of care and/or risk assessment/risk agreement deemed necessary to help
ensure the member’s health and safety, and the CONTRACTOR may initiate action to
involuntary disenroll the member from consumer direction at any time the
CONTRACTOR feels that the member’s decisions or actions constitute unreasonable
risk such that the member’s needs can no longer be safely and effectively met in
the community while participating in consumer direction.

2.9.7.9 Withdrawal from Consumer Direction of HCBS

  2.9.7.9.1   A member may voluntarily withdraw from consumer direction of HCBS
at any time. The member and/or representative shall notify the care coordinator
as soon as he/she determines that he/she is no longer interested in
participating in consumer direction of HCBS.

  2.9.7.9.2   Upon receipt of a member’s request to withdraw from consumer
direction of HCBS, the CONTRACTOR shall conduct a face-to-face visit and update
the member’s plan of care, as appropriate, to initiate the process to transition
the member to contract providers.

  2.9.7.9.3   In the event that the FEA or care coordinator has concerns that a
worker is unable to deliver appropriate care as prescribed in the service
agreement and the plan of care, but the member and/or representative chooses to
continue to employ the worker, note the concern and the member’s choice to
continue using the worker in the member’s plan of care, and shall update the
risk assessment and/or risk agreement as needed.

  2.9.7.9.4   The CONTRACTOR shall forward to TENNCARE for disposition, pursuant
to TennCare policy, any cases in which the CONTRACTOR plans to disenroll a
member from consumer direction. The CONTRACTOR may initiate involuntary
withdrawal of a member from consumer direction of HCBS:

2.9.7.9.4.1 If a member’s representative fails to perform in accordance with the
terms of the

representative agreement and the health, safety and welfare of the member is at
risk, and the member wants to continue to use the representative.

2.9.7.9.4.2 If a member has consistently demonstrated that he/she is unable to
manage, with

sufficient supports (including appointment of a representative) his/her services
and the care coordinator or FEA has identified health, safety and/or welfare
issues.

2.9.7.9.4.3 A care coordinator has determined that the health, safety and
welfare of the member may

be in jeopardy if the member continues to employ a worker but the member and/or
representative does not want to terminate the worker.

2.9.7.9.4.4 Other significant concerns regarding the member’s participation in
consumer direction

which jeopardize the health, safety or welfare of the member.

  2.9.7.9.5   If TENNCARE approves the CONTRACTOR’s request, the CONTRACTOR
shall notify the member in accordance with TennCare rules and regulations, and
the member shall have the right to appeal the determination (see
Section 2.19.3.12 of this Agreement).

  2.9.7.9.6   The CONTRACTOR, in conjunction with the FEA, shall facilitate a
seamless transition from workers to contract providers and ensure there are no
interruptions or gaps in services.

  2.9.7.9.7   Voluntary or involuntary withdrawal of a member from consumer
direction of HCBS shall not affect a member’s eligibility for long-term care
services or enrollment in CHOICES.

  2.9.7.9.8   The CONTRACTOR shall notify the FEA within one business day of
processing the enrollment file when a member voluntarily withdraws from consumer
direction of HCBS, when a member is involuntarily withdrawn from consumer
direction of HCBS, and when a member is disenrolled from CHOICES or from
TennCare. The notification should include the effective date of withdrawal
and/or disenrollment, as applicable.

  2.9.7.9.9   Members who have been involuntarily withdrawn may request to be
reinstated in consumer direction of HCBS. The care coordinator shall work with
the FEA to ensure that the issues previously identified as reasons for
withdrawal have been adequately addressed prior to reinstatement. All members
shall be required to participate in consumer direction training programs prior
to re-instatement in consumer direction of HCBS.

2.9.7.9.10 Claims Submission and Payment

2.9.7.9.10.1 The CONTRACTOR shall ensure that the EVV system creates and makes
available to

the FEA on at least a daily basis an electronic claims submission file in the
837 format, including exceptions which have been resolved, which may be
submitted to the CONTRACTOR for claims processing at the appropriate frequency.

2.9.7.9.10.2 The CONTRACTOR shall reimburse the FEA for authorized HCBS provided
by workers

at the appropriate rate for the consumer-directed services, which includes
applicable payroll taxes.

2.9.7.9.10.3 The CONTRACTOR shall process and pay claims submitted by the FEA
within fourteen

(14) calendar days of receipt.

37. Section 2.9.8.1 shall be deleted and replaced as follows:

  2.9.8.1   As provided in Section 2.6.1 of this Agreement, the CONTRACTOR shall
be responsible for providing a full continuum of physical health, behavioral
health, and long-term care services. The CONTRACTOR shall also be responsible
for ensuring continuity and coordination between covered physical health,
behavioral health, and long-term care services and ensuring collaboration
between physical health, behavioral health, and long-term care providers. The
CONTRACTOR shall develop policies and procedures that address key elements in
meeting this requirement. These elements include, but are not limited to,
screening for behavioral health needs (including the screening tool), referral
to physical health and behavioral health providers, screening for long-term care
needs, exchange of information, confidentiality, assessment, treatment plan and
plan of care development and implementation, collaboration, MCO case

management, care coordination (for CHOICES members) and disease management,
provider training, and monitoring implementation and outcomes.

38.   The second sentence in Section 2.9.8.2 shall be amended by deleting the
reference “2.9.8.2” and replacing it with the reference “2.9.8.1”.  

39. Section 2.9.14 shall be deleted and replaced in its entirety. 2.9.14
Inter-Agency Coordination

The CONTRACTOR shall coordinate with other state and local departments and
agencies to ensure that coordinated care is provided to members. This includes,
but is not limited to, coordination with:

2.9.14.1 Tennessee Department of Mental Health and Developmental Disabilities
(TDMHDD) for the

purpose of interfacing with and assuring continuity of care and for coordination
of specialized services in accordance with federal PASRR requirements;

      2.9.14.2
2.9.14.3
2.9.14.4
2.9.14.5  
Tennessee Department of Children’s Services (DCS) for the purpose of interfacing
with and
assuring continuity of care;
Tennessee Department of Health (DOH), for the purposes of establishing and
maintaining
relationships with member groups and health service providers;
Tennessee Department of Human Services (DHS) and DCS Protective Services
Section, for
the purposes of reporting and cooperating in the investigation of abuse and
neglect;
The Division of Intellectual Disabilities Services (DIDS), for the purposes of
interfacing with

and assuring continuity of care and for coordination of specialized services in
accordance with federal PASRR requirements;

  2.9.14.6   Area Agencies on Aging and Disability (AAADs) regarding intake of
members new to both TennCare and CHOICES, assisting CHOICES members in Groups 2
and 3 with the TennCare eligibility redetermination process, and facilitating
the transition of members during CHOICES implementation and when members are
moving to a Grand Region where CHOICES has not yet been implemented;

            2.9.14.7    
Tennessee Commission on Aging and Disability (TCAD) regarding TCAD’s role in
monitoring the performance of the AAADs in conducting SPOE functions;   2.9.14.8
   
Tennessee Department of Education (DOE) and local education agencies for the
purposes of

coordinating educational services in compliance with the requirements of
Individuals with Disabilities Education Act (IDEA) and to ensure school-based
services for students with special needs are provided;

  2.9.14.8.1   The CONTRACTOR is responsible for the delivery of medically
necessary covered services to school-aged children. MCOs are encouraged to work
with school-based providers to manage the care of students with special needs.
The State has implemented a process, referred to as TENNderCARE Connection, to
facilitate notification of MCOs when a school- aged child enrolled in TennCare
has an Individualized Education Plan (IEP) that identifies a need for medical
services. In such cases, the school is responsible for obtaining parental

consent to share the IEP with the MCO and for subsequently sending a copy of the
parental consent and IEP to the MCO. The school is also responsible for clearly
delineating the services on the IEP that the MCOs are to consider for payment.
If a school-aged member, needing medical services, is identified by the
CONTRACTOR by another means, the CONTRACTOR shall request the IEP from the
appropriate school system.

  2.9.14.8.2   The CONTRACTOR shall designate a contact person to whom
correspondence concerning children with medical services included in their IEPs
will be directed. After receipt of an IEP, the CONTRACTOR shall:

2.9.14.8.2.1 Either accept the IEP as indication of a medical problem and treat
the IEP as a request for

service or assist in making an appointment to have the child evaluated by the
child’s PCP or another contract provider. If the CONTRACTOR does not accept the
documentation provided with the IEP as indication of a medical problem, the
CONTRACTOR shall have the child re-evaluated in order to make a decision about
the appropriateness of the requested service.

2.9.14.8.2.2 Send a copy of the IEP and any related information (e.g. action
taken by the MCO in

response to receipt of the IEP, action the MCO expects the PCP to take) to the
PCP.

2.9.14.8.2.3 Notify the designated school contact of the ultimate disposition of
the request (e.g. what

services have been approved for the child, what arrangements have been made for
service delivery) within 14 days of the CONTRACTOR’s receipt of the IEP.

2.9.14.9 Local law enforcement agencies and hospital emergency rooms for the
purposes of crisis

service provider relationships, and the transportation of individuals certified
for further assessment for emergency psychiatric hospitalization.

40.   Section 2.12.9.26 shall be amended by adding a new sentence to the end of
the Section as follows:  

  2.12.9.26   Make full disclosure of the method and amount of compensation or
other consideration to be received from the CONTRACTOR. However, the agreement
shall not include rate methodology that provides for an automatic increase in
rates;

41.   Section 2.13.1.1 shall be amended by adding a new second sentence as
follows:

2.13.1.1 The CONTRACTOR shall agree to reasonable reimbursement standards to
providers for

covered services, to be determined in conjunction with actuarially sound rate
setting. The CONTRACTOR shall not agree to reimbursement rate methodology that
provides for an automatic increase in rates. All reimbursement paid by the
CONTRACTOR to providers and amounts paid by the CONTRACTOR to any other entity
is subject to audit by the State.

42.   Section 2.13.3.3 shall be deleted and replaced as follows:

2.13.3.3 If, prior to the end date specified by TENNCARE in its approval of
Level II nursing facility

services, the CONTRACTOR determines that the nursing facility is providing Level
I and not Level II nursing facility services, the CONTRACTOR shall notify
TENNCARE and, as appropriate, shall submit a request to modify the member’s
level of nursing facility services. The CONTRACTOR shall submit documentation as
specified by TENNCARE to support the
request. Upon approval from TENNCARE, the CONTRACTOR may adjust payment to the
nursing facility to reflect the level of nursing facility services actually
provided to the member and shall maintain documentation as specified by TENNCARE
to support the payment adjustment.

43.   Section 2.13.20 shall be amended by deleting the word “subcontract” and
replacing it with the word “contract” and deleting the reference to
“Section 2.26.6”.  

44.   Section 2.14.1.3 shall be amended by deleting the word “network” and
replacing it with the word “contract”.

45.   Section 2.14.1.7 shall be amended by deleting the reference to
“Section 2.6.1.3” and replacing it with a reference to “Section 2.6.1.4”.  

46.   Section 2.14.4.5 shall be amended by deleting the references to
“Section 2.9.2.1” and replacing them with the references “Section 2.9.2”.  

47.   Section 2.15.1.1 shall be deleted and replaced as follows:

2.15.1.1 The CONTRACTOR shall have a written Quality Management/Quality
Improvement

(QM/QI) program that clearly defines its quality improvement structures and
processes and assigns responsibility to appropriate individuals. This document
shall include a separate section on CHOICES care coordination and must include
all of the elements listed below. This QM/QI program shall use as a guideline
the current NCQA Standards and Guidelines for the Accreditation of MCOs and
shall include the CONTRACTOR’s plan for improving patient safety. This means at
a minimum that the QM/QI program shall:

48.   Section 2.15.1.4 shall be deleted and replaced as follows:

2.15.1.4 Any changes to the QM/QI program structure, including that of CHOICES,
shall require prior

written approval from TENNCARE. The QM/QI program description, associated work
plan, and annual evaluation of the QM/QI Program shall be submitted to TENNCARE
as required in Section 2.30.11.1, Reporting Requirements. All three of these
documents shall include CHOICES information.

49.   Section 2.15.3.1.2 shall be deleted and replaced as follows:

  2.15.3.1.2   Two (2) of the three (3) non-clinical PIPs shall be in the area
of long-term care. The CONTRACTOR shall use existing processes, methodologies,
and protocols, including the CMS protocols.

50. Section 2.15.4 shall be deleted and replaced as follows: 2.15.4 Clinical
Practice Guidelines

The CONTRACTOR shall utilize evidence-based clinical practice guidelines in its
disease management programs. The guidelines shall be reviewed and revised at
least every two (2) years or whenever the guidelines change.

51.   Section 2.15.6.1 and 2.15.6.2 shall be deleted and replaced as follows:

2.15.6.1 Annually, beginning with HEDIS 2009, the CONTRACTOR shall complete all
HEDIS

measures designated by NCQA as relevant to Medicaid. The only exclusion from the
complete Medicaid HEDIS data set shall be dental measures. The HEDIS measure
results shall be reported separately for each Grand Region in which the
CONTRACTOR operates. The CONTRACTOR shall contract with an NCQA certified HEDIS
auditor to validate the processes of the CONTRACTOR in accordance with NCQA
requirements. Audited HEDIS results shall be submitted to TENNCARE, NCQA and
TENNCARE’s EQRO annually by June 15 of each calendar year beginning in 2009.

  2.15.6.2   Annually, beginning in 2009, the CONTRACTOR shall conduct a CAHPS
survey. The CONTRACTOR shall enter into an agreement with a vendor that is
certified by NCQA to perform CAHPS surveys. The CONTRACTOR’s vendor shall
perform the CAHPS adult survey, CAHPS child survey and the CAHPS children with
chronic conditions survey. Survey results shall be reported to TENNCARE
separately for each required CAHPS survey listed above. The survey results shall
be reported separately for each Grand Region in which the CONTRACTOR operates.
Survey results shall be submitted to TENNCARE, NCQA and TENNCARE’s EQRO annually
by June 15 of each calendar year beginning in 2009.

52.   Section 2.15.7 shall be deleted in its entirety and the remaining Sections
shall be renumbered accordingly, including any references thereto.

53.   The renumbered Sections 2.15.7.4.6 and 2.15.7.4.7 shall be deleted and
replaced as follows:

  2.15.7.4.6   Defining the role and responsibilities of the fiscal employer
agent (see definition in Section 1) in reporting, responding to, documenting,
and investigating any critical incidents, which shall include reporting
incidents to the CONTRACTOR using the process developed in a accordance with
Section 2.15.8.4.1, investigating critical incidents, submitting a report on
investigations to the CONTRACTOR and reporting to the CONTRACTOR within 24 hours
in accordance with the abuse and neglect plan protocols anytime there is a
suspicion of abuse or neglect (see Section 2.9.7.8.6); training employees,
contractors of the FEA (including supports brokers), and consumer-directed
workers regarding reporting, responding to, documenting, and cooperating with
the investigation of any critical incidents; and training consumers and
caregivers regarding critical incident reporting and management. Such role and
responsibilities shall be defined in a manner that is consistent with
requirements in this Section 2.15.8.4 as well as TENNCARE’s contract with the
fiscal employer agent and the model contract between the CONTRACTOR and the FEA.

  2.15.7.4.7   Reviewing the FEA’s reports and investigations regarding critical
incidents and follow-up with the FEA as necessary regarding corrective actions
determined by the member and/or his/her representative to help ensure the
member’s health and safety.

54. Section 2.16 shall be deleted and replaced as follows:

          2.16 MARKETING     2.16.1 The CONTRACTOR shall not conduct any
enrollee marketing activities, as defined in Section 1 of this Agreement. This
prohibition includes, but is not limited to the following information and
activities:   2.16.1.1    
Materials and/or activities that mislead, confuse or defraud or that are unfair
or deceptive

practices or that otherwise violate federal or state consumer protection laws or
regulations. This includes materials which mislead or falsely describe covered
or available services, membership or availability of network providers, and
qualifications and skills of network providers.

      2.16.1.2
2.16.1.3
2.16.1.4
2.16.1.5
2.16.1.6
2.16.1.7
2.16.1.8
2.16.1.9  
Overly aggressive solicitation, such as repeated telephoning or continued
recruitment
after an offer for enrollment is declined, or similar techniques;
Offers of gifts or material or financial gain as incentives to enroll;
Compensation arrangements with marketing personnel that utilize any type of
payment
structure in which compensation is tied to the number of persons enrolled;
Direct solicitation of prospective enrollees;
Directly or indirectly, engage in door-to-door, telephone, or other cold-call
marketing
activities;
Assertions or statements (whether oral or written) that the enrollee must enroll
with the
CONTRACTOR in order to obtain benefits or in order not to lose benefits;
Assertions or statements (whether written or oral) that the CONTRACTOR is
endorsed
by CMS, the federal or state government or similar entity;
Use of independent marketing agents in connection with marketing activities.

Independent marketing agents shall not mean staff necessary to develop or
produce

marketing materials or advertising or other similar functions; and

  2.16.1.10   Seeking to influence enrollment in conjunction with the sale or
offering of any private insurance.

2.16.2   The prohibition on enrollee marketing shall not apply to health
education and outreach activities (see Section 2.7.3) that are prior approved in
writing by TENNCARE. All health education and outreach activities must be prior
approved in writing by TENNCARE.

2.16.3   The CONTRACTOR shall not use the name of the CONTRACTOR’s TennCare MCO
in any form of general marketing (as defined in Section 1) without TENNCARE’s
prior written approval.

55.   Section 2.17.2 shall be amended by adding a new Sub-Section 2.17.2.9 which
shall read as follows:

2.17.2.9 The CONTRACTOR shall use the approved glossary of required Spanish
terms in the

Spanish translation of all member materials.

56.   Section 2.17.4.7.36 shall be amended by deleting the reference to
“Section 2.17.8.2” and replacing it with the reference “Section 2.17.9.2”.

57.   Section 2.18.1.9 shall be deleted and replaced as follows:

2.18.1.9 The CONTRACTOR shall ensure that calls received during normal business
hours that

require immediate attention by a care coordinator are immediately transferred to
a care coordinator as a “warm transfer”; that calls received after normal
business hours that require immediate attention are immediately addressed or
transferred to a care coordinator in accordance with Section 2.18.1.6; that
calls for a member’s care coordinator or care coordination team during normal
business hours are handled in accordance with Section 2.9.6.11.7; that calls
transferred to the FEA during business hours are “warm transfers”; that calls to
other CONTRACTOR staff, at a minimum, occur without the caller having to
disconnect or place a second call; and that messages to care coordinators and
other CONTRACTOR are returned by the next business day.

58.   Section 2.18.4.10.2 shall be amended by deleting the reference to
“Section 2.30.12.1” and replacing it with the reference “Section 2.30.12”.  

59.   Section 2.18.5.3.15 shall be amended by deleting the reference to
“Section 2.12.9.3.7” and replacing it with the reference “Section 2.12.9.37”.  

60.   Section 2.18.6.2 shall be amended by adding a period “.” to the end of the
text.

61.   Section 2.18.6.3.15 shall be amended by deleting the comma “,” and adding
the text “/CPS” after the acronym “APS”.

62.   Section 2.18.6.11 shall be amended by deleting the reference to
“Section 2.18.6.5” and replacing it with the reference “Section 2.18.6.11”.  

63.   Section 2.18.7.4 shall be deleted and replaced as follows:

2.18.7.4 The CONTRACTOR shall conduct an annual survey to assess provider
satisfaction, including

satisfaction with provider enrollment, provider communication, provider
education, provider complaints, claims processing, claims reimbursement, care
coordination, and utilization management processes, including medical reviews.
The CONTRACTOR shall include questions specified by TENNCARE. The CONTRACTOR
shall submit an annual report on the survey to TENNCARE as required in
Section 2.30.12.4. The CONTRACTOR shall take action to address opportunities for
improvement identified through the survey. The survey shall be structured so
that behavioral health provider satisfaction results and physical health
provider satisfaction results can be separately stratified.

64.   Section 2.18.7 shall be amended by adding a new Sub-Section 2.18.7.5 which
shall read as follows:  

2.18.7.5 The CONTRACTOR shall conduct an annual satisfaction survey of CHOICES
long-term

care providers that shall include any questions specified by TENNCARE.
Instructions specific to the CHOICES survey will be provided by TENNCARE within
the first three (3) months of CHOICES implementation.

65. Section 2.18.9 shall be deleted and replaced as follows: 2.18.9 FEA
Education and Training

The CONTRACTOR shall provide education and training to the FEA and its staff and
subcontracted support brokers (as applicable) regarding key requirement in this
Agreement and the contract between the CONTRACTOR and the FEA (see
Section 2.9.7.3 of this Agreement).

66.   Section 2.21.8.2 shall be amended by deleting the word “subcontract” and
replacing it with the word “contract” and by deleting the reference “(see
Section 2.26.6)”.

67.   Section 2.21.11.1 shall be amended by deleting the reference to
“Section 2.30.15.4.3” and replacing it with the reference “Section 2.30.15.4.5”.

68.   Section 2.22.4.4.2 shall be amended by adding the word “services” after
the words “nursing facility”.

69.   Section 2.22.8.4 shall be amended by deleting the reference to
“Section 2.22.8” and replacing it with the reference “Section 2.22.7”.

70.   Section 2.23.2 shall be amended by adding a new 2.23.2.1 and renumbering
the existing Sections accordingly including all references thereto.

2.23.2.1 HIPAA and HITECH

The parties warrant that they are familiar with the Federal regulations under
HIPAA and HITECH and agree to comply with the provisions as amended and to the
extent the following apply: “Individually Identifiable Health Information,”
“Protected Health Information,” “Unsecured PHI,” “Safeguarding Enrollee
Information,” and “Privacy Breach”.

71.   The last sentence of Section 2.24.4.3 shall be amended by deleting and
replacing the word “subcontract” with the word “contract”.  

72.   Section 2.25.9 shall be amended by deleting Sub-Sections 2.25.9.2 through
2.25.9.4.

73. Section 2.25.10.1 through 2.25.10.14 shall be deleted and replaced as
follows:

  2.25.10.1   Quarterly and annual monitoring to ensure that CHOICES members
receive appropriate disease management interventions and the adequacy and
appropriateness of these interventions based on stratification and setting. (See
Section 2.30.5).

  2.25.10.2   Quality of care activities will be monitored through information
obtained in a quarterly CHOICES Care Coordination Report (see Section 2.30.6.7)
and through activities performed by the Quality Oversight Division of TennCare.
These activities may include monitoring and technical assistance through site
visits to the CONTRACTOR, chart audits, phone calls, etc. TENNCARE may validate
the CHOICES Care Coordination report and may conduct a more in-depth review
and/or request additional information for instances where the CONTRACTOR does
not adhere to required timeframes. TENNCARE may require a corrective action plan
and/or impose sanctions to address non-compliance issues and to improve
CONTRACTOR performance.

  2.25.10.3   Quarterly monitoring to determine the CONTRACTOR’s adherence to
the requirements in this Agreement regarding processes for identifying,
assessing, and transitioning CHOICES who may have the ability and/or desire to
transition from a nursing facility to the community. TENNCARE will review the
CHOICES Nursing Facility to Community Transition reports submitted by the
CONTRACTOR (see Section 2.30.6.4) to determine the CONTRACTOR’s performance on
specified measures. TENNCARE may validate the report and may conduct a more
in-depth review and/or request additional information. TENNCARE may require a
corrective action plan and/or impose sanctions to address non-compliance issues
and to improve CONTRACTOR performance.

  2.25.10.4   Monthly monitoring regarding missed and late visits. TENNCARE will
review the CHOICES HCBS Late and Missed Visits reports submitted by the
CONTRACTOR (see Section 2.30.6.5) to determine the CONTRACTOR’s performance on
specified measures. TENNCARE may validate the report and may conduct a more
in-depth review and/or request additional information. TENNCARE may require a
corrective action plan and/or impose sanctions to address non-compliance issues
and to improve CONTRACTOR performance.

  2.25.10.5   Periodic case reviews will be conducted at the discretion of
TENNCARE in order to assess the CONTRACTOR’s needs assessment and care planning
processes..

2.25.10.6 Quarterly monitoring of the CONTRACTOR’s provider network file (see
Section 2.30.7) to
ensure that CHOICES provider network requirements are met (see Section 2.11.6).

  2.25.10.7   Annual monitoring of the CONTRACTOR’s long-term care provider
network development plan to ensure that the CONTRACTOR is making sufficient
progress towards meeting its network development and expansion goals (see
Section 2.11.6.6). TENNCARE will review the plan provided by the CONTRACTOR (see
Section 2.30.7.6) and will evaluate the adequacy of the CONTRACTOR’s long-term
care network and the CONTRACTOR’s efforts to improve the network where
deficiencies exist.

  2.25.10.8   Quarterly monitoring of critical incidents. TENNCARE will review
the CHOICES HCBS Critical Incidents reports submitted by the CONTRACTOR (see
Section 2.30.11.7) to

identify potential performance improvement activities. TENNCARE may conduct a
more in- depth review and/or request additional information.

  2.25.10.9   Quarterly monitoring of the CONTRACTOR’s member complaints process
to determine compliance with timeframes prescribed in Section 2.19.2 of this
Agreement and appropriateness of resolutions. TENNCARE will review the Member
Complaints reports submitted by the CONTRACTOR (see Section 2.30.13), to
determine the CONTRACTOR’s performance on specified measures. TENNCARE may
validate the report and may conduct a more in-depth review and/or request
additional information. TENNCARE may require a corrective action plan and/or
impose sanctions to address non-compliance issues and to improve CONTRACTOR
performance.

  2.25.10.10   Review of all reports from the CONTRACTOR (see Section 2.30) and
any related follow-up activities.

74.   Section 2.26.5 shall be deleted and replaced as follows: 2.26.5
Subcontracts for Assessments and Plans of Care  

If the CONTRACTOR subcontracts with an entity specifically to conduct care
coordination functions, including level of care or needs assessments or
reassessments and/or developing or authorizing plans of care (see
Section 2.9.6), such subcontractor shall not provide any direct long-term care
services. This does not preclude nursing facilities or hospitals contracted with
the CONTRACTOR to deliver services from completing and submitting pre-admission
evaluations.

75.   Section 2.26.6 shall be deleted and replaced as follows: 2.26.6 Contract
with Fiscal Employer Agent (FEA)  

As required in Section 2.9.7.3, the CONTRACTOR shall contract with TENNCARE’s
designated FEA to provide assistance to members choosing consumer direction of
HCBS. The CONTRACTOR shall not be liable for any failure, error, or omission by
the FEA related to the FEA’s verification of worker qualifications.

76.   Section 2.26.12.1 shall be deleted and replaced as follows:

2.26.12.1 All claims for services furnished to a TennCare enrollee filed with a
CONTRACTOR

shall be processed by either the CONTRACTOR or by one (1) subcontractor retained
by the organization for the purpose of processing claims. However, another
entity can process claims related to behavioral health, vision, lab, or
transportation if that entity has been retained by the CONTRACTOR to arrange and
provide for the delivery of said services. However, all claims processed by any
subcontractor shall be maintained and submitted by the CONTRACTOR.

77.   The first sentence of Section 2.27.2.13.3 shall be amended by adding the
word “of” after the word “days”.

78. Section 2.28 shall be deleted and replaced as follows:

2.28 NON-DISCRIMINATION COMPLIANCE REQUIREMENTS

2.28.1   The CONTRACTOR shall comply with Section 4.32 of this Agreement
regarding non-discrimination, proof of non-discrimination, and notices of
non-discrimination.

2.28.2   In order to demonstrate compliance with federal and state regulations
of Title VI of the Civil Rights Act of 1964, Section 504 of the Rehabilitation
Act of 1973, Title II of the Americans with Disabilities Act of 1990, the Age
Discrimination Act of 1975 and the Omnibus Budget Reconciliation Act of 1981
(P.L. 97- 35), the Church Amendments (42 U.S.C. 300a-7), Section 245 of the
Public Health Service Act (42 U.S.C. 238n.), and the Weldon Amendment
(Consolidated Appropriations Act 2008, Public Law 110-161, Div. G, Sec. 508 (d),
121 Stat. 1844, 2209), the CONTRACTOR shall designate a staff person to be
responsible for non-discrimination compliance as required in Section 2.29.1.
This person shall provide instruction to all CONTRACTOR staff, providers and
direct service subcontractors regarding the CONTRACTOR’s non-discrimination
policies and procedures and all applicable non-discrimination compliance
requirements of the TennCare program. The CONTRACTOR shall be able to show
documented proof of such instruction.

2.28.3   The CONTRACTOR shall develop written policies and procedures that
demonstrate non-discrimination in the provision of services to members. The
policy shall also demonstrate non-discrimination in the provision of services
for members with Limited English Proficiency and those requiring communication
assistance in alternative formats (see Section 2.18.2). These policies and
procedures shall be prior approved in writing by TENNCARE.

2.28.4   The CONTRACTOR shall, at a minimum, emphasize non-discrimination in its
personnel policies and procedures as it relates to hiring, promoting,
operational policies, contracting processes and participation on
advisory/planning boards or committees.

2.28.5   The CONTRACTOR shall ask all staff to provide their race or ethnic
origin and sex. The CONTRACTOR is required to request this information from all
CONTRACTOR staff. CONTRACTOR staff response is voluntary. The CONTRACTOR is
prohibited from utilizing information obtained pursuant to such a request as a
basis for decisions regarding employment or in determination of compensation
amounts.

2.28.6   The CONTRACTOR shall ask all providers for their race or ethnic origin.
Provider response is voluntary. The CONTRACTOR is prohibited from utilizing
information obtained pursuant to such a request as a basis for decision
regarding participation in the CONTRACTOR’s provider network or in determination
of compensation amounts.

2.28.7   The CONTRACTOR shall track and investigate all complaints alleging
discrimination filed by employees, enrollees, providers and subcontractors
related to the provision of and access to TennCare covered services provided by
the CONTRACTOR. The CONTRACTOR shall track and investigate all complaints
alleging discrimination filed by employees (when the complaint is related to the
TennCare program), enrollees, providers and subcontractors in which
discrimination is alleged in the CONTRACTOR’s TennCare MCO. The CONTRACTOR shall
track, at a minimum, the following elements: identity of the party filing the
complaint; the complainant’s relationship to the CONTRACTOR; the circumstances
of the complaint; date complaint filed; CONTRACTOR’s resolution, if resolved;
and name of CONTRACTOR staff person responsible for adjudication of the
complaint.

2.2   8.8 The CONTRACTOR shall develop and have available a standardized
complaint form to provide to a complainant upon request. This complaint form
shall be in a format specified by TENNCARE.

2.28.9 The CONTRACTOR shall report on non-discrimination activities as described
in Section 2.30.21.

79.   The second sentence of Section 2.29.1.3.5 shall be amended by adding a
period “.” after the word “TENNCARE”.

80.   Section 2.29.1.3.9 shall be deleted and replaced as follows:

2.29.1.3.9 A staff person to serve as the CONTRACTOR’s Non-discrimination
Compliance

Coordinator. This person shall be responsible for compliance with Title VI of
the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973,
Title II of the Americans with Disabilities Act of 1990, the Age Discrimination
Act of 1975 and the Omnibus Budget Reconciliation Act of 1981 (P.L. 97-35), the
Church Amendments (42 U.S.C. 300a-7), Section 245 of the Public Health Service
Act (42 U.S.C. 238n.), and the Weldon Amendment (Consolidated Appropriations Act
2008, Public Law 110-161, Div. G, Sec. 508 (d), 121 Stat. 1844, 2209) on behalf
of the CONTRACTOR. The CONTRACTOR shall report to TENNCARE in writing, to the
attention of the Director of Non-Discrimination Compliance/Health Care
Disparities, within ten (10) calendar days of the commencement of any period of
time that the CONTRACTOR does not have a designated staff person for
non-discrimination compliance. The CONTRACTOR shall report to TENNCARE at such
time that the function is redirected as required in Section 2.29.1.2;

81.   Section 2.29.1.3.12 shall be deleted and replaced as follows:

2.29.1.3.12 A full-time staff person dedicated to the TennCare CHOICES program
responsible for

educating and assisting long-term care providers and the FEA regarding
appropriate claims submission processes and requirements, coding updates,
electronic claims transactions and electronic funds transfer; for the
development and maintenance of CONTRACTOR resources such as CHOICES provider
manuals, website, fee schedules, etc.; for technical assistance regarding
long-term care claims submission and resolution processes; and for prompt
resolution of long-term care claims issues or inquiries as specified in
Section 2.22.5. This person shall develop strategies to assess the effectiveness
of the CONTRACTOR’s claims education and technical assistance activities, gather
feedback regarding the extent to which CHOICES long-term care providers are
informed about appropriate claims submission processes and practices, and
identify trends and guide the development of strategies to improve the
efficiency of long-term care claims submission and resolution processes, as well
as provider satisfaction;

82.   Section 2.29.1.3.15 and Section 2.29.1.4 shall both be amended by deleting
the words “quality management” and replacing them with “QM/QI”.

83.   Section 2.30.4.9 shall be deleted in its entirety and the remaining
Sub-Sections shall be renumbered accordingly, including any references thereto.

84.   Section 2.30.4.11 shall be deleted in its entirety.

85.   Section 2.30.5 shall be deleted and replaced as follows: 2.30.5 Disease
Management Reports  

2.30.5.1 The CONTRACTOR shall submit a quarterly Disease Management Update
Report that

includes, for each disease management program (see Section 2.8), a brief
narrative description of the program, the total number of members in the
program, the total number of members enrolled and disenrolled during the
quarter, and a description of the specific provider and member interventions
performed during the quarter. The report shall include a chart and narrative for
CHOICES members in DM to include the total number of members receiving DM
interventions, by DM condition; the total number of CHOICES members starting and
terminating DM interventions during the quarter, a description of any specific
provider and member interventions that were new during the quarter, the number
of member and provider activities/interventions, and a written analysis of data
provided.

  2.30.5.2   The CONTRACTOR shall submit on July 1 an annual Disease Management
Report that includes, for each disease management programs, a narrative
description of the eligibility criteria and the method used to identify and
enroll eligible members, the passive participation rate as defined by NCQA (the
percentage of identified eligible members who have received an intervention
divided by the total population who meet the criteria for eligibility), the
total number of active members having one or more of the diagnosis codes (ICD-9
Codes) relating to each of the disease management programs, a description of
stratification levels for each DM program including member criteria and
associated interventions, a discussion of barriers and challenges to include
resources, program structure, member involvement and provider participation, a
summary of member satisfaction with the DM program, a written analysis of the
data presented, a description of proposed changes to program, and information on
the programs’ activities, benchmarks and goals as described in Section 2.8.7.
The report shall include a separate chart(s) and narrative for CHOICES members
in DM to include a narrative description of the eligibility criteria and the
method used to identify and enroll eligible CHOICES members, a description of
stratification levels based on the setting in which the member resides; total
number of CHOICES members identified as having a DM condition, total number of
members receiving DM activities/interventions, and the number of CHOICES members
by level of stratification; a discussion of barriers and challenges to include
resources, program structure, member involvement, and provider participation
along with a description of proposed changes.

  2.30.5.3   The CONTRACTOR shall submit annually an updated Disease Management
Program Description to include at a minimum the disease management components
listed in Sections 2.8.1.4 through 2.8.1.6 of this Agreement.

86. Section 2.30.6 shall be deleted and replaced as follows:

2.30.6 Service Coordination Reports

2.30.6.1 MCO Case Management Reports

  2.30.6.1.1   The CONTRACTOR shall submit annually an updated MCO Case
Management Program Description to TENNCARE describing the CONTRACTOR’s MCO case
management services. The report shall include a description of the criteria and
process the CONTRACTOR uses to identify members for MCO case management, the
process the CONTRACTOR uses to inform members and providers of the availability
of MCO case management, a description of the MCO case management services
provided by the CONTRACTOR and the methods used by the CONTRACTOR to evaluate
its MCO case management program. CHOICES information shall also be included in
this report.

2.30.6.1.2 The CONTRACTOR shall submit an annual MCO Case Management Services
Report that
addresses the activities in Section 2.9.5 of this Agreement by July 1 of each
year.

  2.30.6.1.3   The CONTRACTOR shall submit a quarterly MCO Case Management
Update Report. Enrollees who are enrolled in Disease Management need not be
included in this report unless they are also receiving case management.

2.30.6.2 For the first six (6) months after implementation of CHOICES in the
Grand Region covered

by this Agreement, or as long as determined necessary by TENNCARE, the
CONTRACTOR shall submit a monthly Status of Transitioning CHOICES Members Report
that provides information regarding transitioning CHOICES members (see
Section 2.9.3). The report shall include information on the CONTRACTOR’s current
and cumulative performance on various measures.

The performance measures shall include but not be limited to the following:

  (1)   Of CHOICES Group 1 members who were enrolled in CHOICES as of the
CHOICES implementation date, the number and percent for whom the CONTRACTOR
has/has not conducted a face-to-face visit (see Section 2.9.3.7)

  (2)   Of CHOICES Group 2 members who were enrolled in CHOICES as of the
CHOICES implementation date, the number and percent for whom the CONTRACTOR
has/has not conducted face-to-face visit and a comprehensive needs assessment
and developed and authorized a new plan of care

  2.30.6.3   The CONTRACTOR shall submit a semi-annual CHOICES Nursing Facility
Diversion Activities Report. The report shall provide a description of the
CONTRACTOR’s nursing facility diversion activities by each of the groups
specified in Section 2.9.6.7, including a detailed description of the
CONTRACTOR’s success in identifying members for diversion, in diverting members,
and in maintaining members in the community, as well as lessons learned,
including a description of factors affecting the CONTRACTOR’s ability to divert
members, identified issues, strategies to address identified issues, and
opportunities for systemic improvements in the CONTRACTOR’s nursing facility
diversion process(es).

  2.30.6.4   The CONTRACTOR shall submit a quarterly CHOICES Nursing Facility to
Community Transition Report. The report shall include information, by month, on
specified measures, which shall include but not be limited to the following:

(1) Number of CHOICES members transitioned from a nursing facility

(2) Of members who transitioned from a nursing facility, the number and percent
of

members who transitioned to:

  (a)   A community-based residential alternative facility

(b) A residential setting where the member will be living independently

  (c)   A residential setting where the member will be living with a relative or
other caregiver

(3) Of members who transitioned from a nursing facility, the number and percent
of

members who:

(a) Are still in the community
(b) Returned to a nursing facility within ninety (90) days after transition
(c) Returned to a nursing facility more than ninety (90) days after transition

(4) Number of CHOICES members identified as potential candidates for transition
from

a nursing facility

(5) Of members identified as potential candidates for transition, the number and
percent

of members who were identified:

  (a)   By referral (by type of referral, including but not limited to referral
by treating physician, nursing facility, community-based organization, family,
self, and other)

  (b)   Via the MDS

  (c)   Via care coordination

  (d)   By other source

The CONTRACTOR shall submit its first report following the second calendar
quarter after CHOICES implementation, and that report shall include information
for the period from CHOICES implementation through the second calendar quarter
after CHOICES implementation.

  2.30.6.5   The CONTRACTOR shall submit a monthly CHOICES HCBS Late and Missed
Visits Report for CHOICES members regarding the following HCBS services:
personal care, attendant care, homemaker services, and home-delivered meals. The
report shall include information on specified measures, which shall include but
not be limited to the following:

  (1)   Total number of members enrolled in Group 2, Group 3, and in Groups 2
and 3 combined

  (2)   Total number of CHOICES members with scheduled visits for each service
type (personal care, attendant care, homemaker, and home-delivered meals), by
provider type (agency provider or consumer-directed worker)

  (3)   Total number of scheduled visits for each service type, by provider type

(4) Of the total number of scheduled visits for each service type, by provider
type; the

percent that were:

(a) On-time
(b) Late
(c) Missed

(5) Of the total number of late visits for each service type, by provider type;
the percent

that were:

(a) Member-initiated
(b) Provider-initiated
(c) Due to weather/natural disaster

(6) Of the total number of late visits for each service type, by provider type;
the number

that were:

(a) Member-initiated, by reason code
(b) Provider-initiated, by reason code
(c) Due to weather/natural disaster

(7) Of the total number of missed visits for each service type, by provider
type; the

percent that were:

(a) Member-initiated
(b) Provider-initiated
(c) Due to weather/natural disaster

(8) Of the total number of missed visits for each service type, by provider
type; the

number that were:

(a) Member-initiated, by reason code
(b) Provider-initiated, by reason code
(c) Due to weather/natural disaster

(9) Of the total number of missed visits for each service type, by provider
type; the

number and percent that were:

(a) Made-up by paid support – provider staff
(b) Made-up by paid support – worker
(c) Made-up by unpaid support
(d) Not made-up

2.3   0.6.6 The CONTRACTOR shall submit a quarterly CHOICES Consumer Direction
of HCBS Report. The report shall include current information, by month, on
specified measures, which shall include but not be limited to the following:

  (1)   Total number of members enrolled in Group 2, Group 3, and in Groups 2
and 3 combined

  (2)   The number and percent of members in Groups 2 and 3 (combined) enrolled
in consumer direction of HCBS

  (3)   Number of members referred to the FEA (for enrollment in consumer
direction)

  (4)   Maximum and average time from FEA referral to receipt of
consumer-directed services

  (5)   Number and percent of members enrolled in consumer direction who began
initial enrollment in consumer direction (for each month in the reporting
period)

  (6)   Number and percent of members enrolled in consumer direction who
withdrew from consumer direction (for each month in the reporting period)

  (7)   Number and percent of members enrolled in consumer direction who have a
representative to assist the member in consumer direction

  (8)   The number and percent of member receiving consumer-directed services by
type of consumer-directed service (attendant care, companion care, homemaker,
in-home respite, or personal care)

The CONTRACTOR shall submit its first report following the second calendar
quarter after CHOICES implementation, and that report shall include information
for the period from CHOICES implementation through the second calendar quarter.

  2.3   0.6.7 The CONTRACTOR shall submit a quarterly CHOICES Care Coordination
Report, in a format specified by TENNCARE that includes, but is not limited to,
information on care coordination staffing, enrollment and care coordination
contacts, ongoing assessment, care planning and service initiation, and
self-directed healthcare tasks. The report shall also include a narrative of
quarterly activities.

2.30.6.8 As necessary, the CONTRACTOR shall submit a listing of members
identified as potential

pharmacy lock-in candidates (see Section 2.9.10.3.2).

  2.30.6.9   The CONTRACTOR shall submit a quarterly Pharmacy Services Report
that includes a list of the providers and information on the interventions the
CONTRACTOR has taken with the providers who appear to be operating outside
industry or peer norms as defined by TENNCARE, have been identified as
non-compliant as it relates to adherence to the PDL and/or generic prescribing
patterns and/or are failing to follow required prior authorization processes and
procedures the steps the CONTRACTOR has taken to personally contact each one as
well as the outcome of these personal contacts.

  2.30.6.10   The CONTRACTOR shall submit a Pharmacy Services Report, On Request
when TENNCARE requires assistance in identifying and working with providers for
any reason. These reports shall provide information on the activities the
CONTRACTOR undertook to comply with TENNCARE’s request for assistance, outcomes
(if applicable) and shall be submitted in the format and within the time frame
prescribed by TENNCARE.

87. Section 2.30.7.3 shall be deleted and replaced as follows:

  2.30.7.3   The CONTRACTOR shall submit a quarterly PCP Assignment Report that
provides the following information for non-dual members: Provider Name, Provider
Medicaid I.D. Number, NPI Number, Number of Enrollees assigned by Enrollee Age
Category. The enrollee age categories shall be consistent with the following:
Age Under 1, Age 1 – 13, Age 14 – 20, Age 21- 44, Age 45 – 64, Age 65 +. (See
Section 2.11.2.)

88.   Section 2.30.7.8 shall be deleted and replaced as follows:

  2.30.7.8   The CONTRACTOR shall submit an annual CHOICES Qualified Workforce
Strategies Report that describes the CONTRACTOR’s strategies to assist in the
development of an adequate qualified workforce for covered long-term care
services, increase the available qualified direct care staff, and improve the
retention of qualified direct care staff (see Section 2.11.6.7). At a minimum,
the report shall include a brief description of each of the CONTRACTOR’s
strategies; activities associated with each of the CONTRACTOR’s strategies,
including associated partnerships; timeframes for implementing each strategy and
associated activities; the status of each strategy and associated activities;
and a brief summary of the current and anticipated impact of each strategy and
associated activities.

89. Section 2.30.9.4 shall be deleted and replaced as follows:

2.30.9.4 The CONTRACTOR shall provide a monthly Reconciliation Report for the
total paid

amounts between the funds released for payment to providers and the FEA (for
consumer- directed workers), the supporting claims data extract, and the
encounter data submissions for the relevant adjudication cycle. The
Reconciliation Report shall be submitted the month after the claims data extract
is submitted.

90. Section 2.30.10.5 shall be deleted and replaced as follows:

  2.30.10.5   The CONTRACTOR shall submit a monthly CHOICES Utilization Report.
The report shall include a summary overview that includes the number of CHOICES
member who have not received any long-term care services within thirty (30) to
fifty-nine (59) days, within sixty (60) to eighty-nine (89) days, or in ninety
(90) days or more. The report shall also include detailed member data for
members who have not received services in the last thirty (30) days, including
the member’s name, social security number, CHOICES group, and CHOICES enrollment
date; date of last long-term care service; length of time without long-term care
services; whether and when long-term care services will resume; and the
reason/explanation why the member has not received long-term care services.

91. Section 2.30.11.5 shall be deleted and replaced as follows:

  2.30.11.5   The CONTRACTOR shall submit an annual Report of Audited CAHPS
Results and Audited HEDIS Results by June 15 of each year (see Sections 2.15.6).
 

92.   Section 2.30.11.6 shall be deleted in its entirety and the remaining
Sub-Sections in Section 2.30.11 shall be renumbered accordingly, including any
references thereto.  

93.   The renumbered Section 2.30.11.6 shall be deleted and replaced as follows:

  2.30.11.6   The CONTRACTOR shall submit a quarterly CHOICES HCBS Critical
Incidents Report (see Section 2.15.8) that provides information, by month
regarding specified measures, which shall include but not be limited to the
following:

(1) The number of members in Group 2, Group 3, and Groups 2 and 3 combined

(2) The number of critical incidents, overall and by:

(a) Type of incident
(b) Setting
(c) Type of provider (provider agency or consumer directed worker)

(3) The percent of incidents by type of incident

(4) The percent of members in Groups 2 and 3 with an incident

94. Section 2.30.12.1.1 shall be deleted and replaced in its entirety.

  2.30.12.1.1   The CONTRACTOR shall submit a quarterly Member Services,
Provider Services, and Utilization Management Phone Line Report. The data in the
report shall be recorded by month and shall include the detailed rate
calculations. The CONTRACTOR shall submit the report in the format specified in
Attachment IX, Exhibit M.

95. Section 2.30.12.4 shall be deleted and replaced as follows:

  2.30.12.4   The CONTRACTOR shall submit an annual Provider Satisfaction Survey
Report that encompasses behavioral and physical health as well as survey results
for CHOICES long-term care providers. The report shall summarize the provider
survey methods and findings for each of the three groups and must provide an
analysis of opportunities for improvement (see Section 2.18.7.4 and 2.18.7.5) in
addition to CHOICES items specified in the protocols provided by TENNCARE.

96. Section 2.30.13 shall be deleted and replaced as follows

2.30.13 Member Complaints

Upon receipt of a reporting template from TENNCARE and in accordance with
specified timeframes for implementing the new report, the CONTRACTOR shall begin
submitting a quarterly Member Complaints Report (see Section 2.19.2) that
includes information, by month, regarding specified measures, which shall
include but not be limited to the following:

  (1)   The number of complaints received in the month, overall, by type, and by
CHOICES Group (if the member is a CHOICES member)

  (2)   The number and percent of complaints for which the CONTRACTOR met/did
not meet the specified timeframe for resolution (see Section 2.19.2.5).

The report shall also include identification of any trends regarding complaints
(e.g., the type or number of complaints) and any action steps to address these
trends, including quality improvement activities.

97. Section 2.30.15.2 shall be deleted in its entirety and the remaining
Sections shall be

renumbered accordingly, including any references thereto.

98. Renumbered Section 2.30.15.2.1 shall be amended by deleting the reference to

“September” and replacing it with the reference “August”.

99. Renumbered Section 2.30.15.2.3 shall be amended by deleting the reference to
“Section

2.30.48” and replacing it with the reference to “Section 2.21.10”.

100.   Renumbered Section 2.30.15.3.3 shall be amended by deleting the reference
to “TCA 56-32- 208” and replacing it with the reference “TCA 56-32-108”.

101.   Renumbered Section 2.30.15.3.4 shall be amended by deleting the reference
to “September 1” and replacing it with the reference “August 15”.

102.   Section 2.30.16.4 through 2.30.16.6 shall be deleted and the remaining
Section 2.30.16.7 shall be renumbered as 2.30.16.4 including any references
thereto.

103. The renumbered Section 2.30.16.4 shall be deleted and replaced as follows:

  2.30.16.4   The CONTRACTOR shall submit a quarterly CHOICES Cost Effective
Alternatives Report that provides information on cost effective alternative
services provided to CHOICES members (see Section 2.6.5.2). The report shall
provide information regarding specified measures, including but not limited to
the following:

  (1)   The number of members in Group 2, Group 3, and Groups 2 and 3 combined

  (2)   The number and percent of members authorized to receive cost effective
alternative (CEA) HCBS in excess of a benefit limit, overall and by service

  (3)   For members transitioning from a nursing facility to the community, the
number of members authorized to receive a transition allowance as a CEA, the
total amount of transition allowances authorized, the average transition
allowance authorized

  (4)   A summary of items purchased with a transition allowance, including the
most frequent categories of expenditure

  (5)   The number and percent of members authorized to receive other
non-covered HCBS as a CEA

  (6)   A summary of other non-covered HCBS authorized as a CEA, identifying the
most frequently authorized services

The CONTRACTOR shall submit its first report following the second calendar
quarter after CHOICES implementation, and that report shall include information
for the period from CHOICES implementation through the second calendar quarter.

104. Section 2.30.18.2 shall be deleted and replaced as follows:

  2.30.18.2   The CONTRACTOR shall submit a semi-annual Report on the Activities
of the CHOICES Advisory Group regarding the activities of the CHOICES advisory
group established pursuant to Section 2.24.3. This report shall include the
membership of the advisory group (name, address, and organization represented),
a description of any orientation and/or ongoing training activities for advisory
group members, and information on advisory group meetings, including

the date, time, location, meeting attendees, and minutes from each meeting.
These reports shall be submitted to TENNCARE on March 1 and September 1 of each
year.

105.   Section 2.30.21 shall be deleted and replaced as follows: 2.30.21
Non-Discrimination Compliance Reports  

  2.30.2   1.1 On an annual basis the CONTRACTOR shall submit a copy of the
CONTRACTOR’s nondiscrimination policy that demonstrates non-discrimination in
the provision of services to members. The policy shall demonstrate
non-discrimination in the provision of services for members with Limited English
Proficiency and those requiring communication assistance in alternative formats.
This shall include a report that lists all interpreter/translator services used
by the CONTRACTOR in providing services to members with Limited English
Proficiency or that need communication assistance in an alternative format. The
listing shall identify the provider by full name, address, phone number,
languages spoken, and hours services are available.

  2.30.21.2   The CONTRACTOR shall submit an annual Summary Listing of Servicing
Providers that includes race or ethnic origin of each provider. The listing
shall include, at a minimum, provider name, address, race or ethnic origin and
shall be sorted by provider type (e.g., pediatrician, surgeon, etc.). The
CONTRACTOR shall use the following race or ethnic origin categories: American
Indian or Alaskan Native, Asian or Pacific Islander, Hispanic origin and other
race/ethnic origin as indicated by TENNCARE.

  2.30.21.3   The CONTRACTOR shall annually submit its Non-Discrimination
Compliance Plan and Assurance of Non-Discrimination to TENNCARE. The signature
date of the CONTRACTOR’s Plan shall coordinate with the signature date of the
CONTRACTOR’s Assurance of Non-Discrimination.

  2.30.21.4   The CONTRACTOR shall submit a quarterly Non-discrimination
Compliance Report which shall include the following:

  2.30.21.4.1   A summary listing totaling the number of supervisory personnel
by race or ethnic origin and sex. This report shall provide the number of male
supervisors who are White, Black (not of Hispanic origin), American Indian or
Alaskan Native, Asian or Pacific Islander, Hispanic origin and other
race/ethnicity as indicated by TENNCARE and number of female supervisors who are
White, Black (not of Hispanic origin), American Indian or Alaskan Native, Asian
or Pacific Islander, Hispanic origin and other race/ethnic origin females as
indicated by TENNCARE:

  2.30.21.4.2   A listing of all complaints filed by employees, members,
providers and subcontractors in which discrimination is alleged related to the
provision of and/or access to TennCare covered services provided by the
CONTRACTOR. Such listing shall include, at a minimum, the identity of the party
filing the complaint, the complainant’s relationship to the CONTRACTOR, the
circumstances of the complaint, date complaint filed, the CONTRACTOR’s
resolution, if resolved, and the name of the CONTRACTOR staff person responsible
for adjudication of the complaint; and

  2.30.21.4.3   A listing of all member requests for language and communication
assistance. The report shall list the member, the member’s identification
number, the date of the request, the date the service was provided and the name
of the service provider.

106.   Section 3.7.1.3 shall be amended by deleting the reference to
“Section 2.6.7.2” and replacing it with the reference “Section 2.6.7”.

107.   Section 3.10.1.3 shall be deleted and replaced as follows:

3.10.1.3 In the first year that the incentives specified in Sections 3.10.2 are
available, the TennCare

regional average HEDIS score (as calculated by TENNCARE using audited MCO HEDIS
results) for each of the measures specified in Sections 3.10.2 for the last full
calendar year prior to the year that the CONTRACTOR began operating under this
Agreement will serve as the baseline. If complete TennCare HEDIS data for these
measures is not available for the region for the year prior to the year that the
CONTRACTOR began operating under this Agreement, then the last year for which
complete data is available will serve as the baseline.

108.   Section 3.10.3 shall be deleted and replaced as follows:  

3.10.3.3 Behavioral Health HEDIS Measures

3.10.3.1 Beginning on July 1, 2010, on July 1 of each year, the CONTRACTOR will
be eligible for a

$.03 PMPM payment, applied to member months from the preceding calendar year,
for each of the following audited HEDIS measures (calculated from the preceding
calendar year’s data) for which significant improvement has been demonstrated.
The CONTRACTOR’s HEDIS result for the reporting period prior to the current
reporting period will serve as the baseline. To be eligible for incentive
payment for a measure, the CONTRACTOR must demonstrate significant improvement
for both rates comprising the measure. Significant improvement is defined using
NCQA’s minimum effect size change methodology (see Section 3.10.4 below).

3.10.3.2 Audited HEDIS Measures:

3.10.3.2.1 Antidepressant Medication Management;

3.10.3.2.2 Follow-up Care for Children Prescribed ADHD Medication; and
3.10.3.2.3 Follow-Up After Hospitalization for Mental Illness.

109.   Section 3.10.4 shall be deleted in its entirety and the remaining
Sub-Section of Section 3.10 shall be renumbered accordingly, including any
references thereto.  

110.   Section 3.14.1.1 shall be deleted and replaced as follows:

3.14.1.1 In no event shall the maximum liability of the State under this
Agreement during the original

term of the Agreement exceed Three Billion, Two Hundred Seventy-Six Million,
Four Hundred Fifty-Three Thousand, Two Hundred Fifty-Eight Dollars
($3,276,453,258.00).

111.   Section 4.2.1 shall be amended by deleting the reference to “June 30,
2010” and replacing it with the reference to “June 30, 2011”.

112.   Section 4.3 shall be amended by adding new Section 4.3.11, 4.3.12, and
4.3.13 as described below and renumbering existing sub-Sections accordingly,
including any references thereto.

4.3.11 The Church Amendments (42 U.S.C. 300a-7).

4.3.12 Section 245 of the Public Health Service (PHS) Act (42 U.S.C. 238n).

4.3.13   Weldon Amendment (Consolidated Appropriations Act 2008, Public Law
110-161, Div. G, Sec. 508 (d), 121 Stat. 1844, 2209).

113.   The renumbered Section 4.3.19 and Section 4.3.20 shall be amended by
deleting and replacing the TCA citations as follows:

4.3.19 Requests for approval of material modification as provided at TCA
56-32-101 et seq. 4.3.20 Investigatory Powers of TDCI pursuant to TCA 56-32-132.

114.   Section 4.20.1.1 shall be amended by deleting the reference to
“Section 2.25.9” and replacing it with the reference “Section 2.25.11”.

115.   Section 4.20.1.2.8 shall be amended by deleting and replacing the word
“recipients” with the word “members”.

116.   Sections 4.20.2.2.1 through 4.20.2.2.4 shall be deleted and replaced as
follows:

4.20.2.2.1 Liquidated damages for failure to perform specific responsibilities
or requirements as described in

this Agreement are shown in the chart below. Damages are grouped into three
categories: Level A, Level B, and Level C program issues.

4.20.2.2.2 Failure to perform specific responsibilities or requirements
categorized as Level A are those

which pose a significant threat to patient care or to the continued viability of
the TennCare program

4.20.2.2.3 Failure to perform specific responsibilities or requirements
categorized as Level B are those

which pose threats to the integrity of the TennCare program, but which do not
necessarily imperil patient care.

4.20.2.2.4 Failure to perform specific responsibilities or requirements
categorized as Level C are those

which represent threats to the smooth and efficient operation of the TennCare
program but which do not imperil patient care or the integrity of the TennCare
program.

117.   Section 4.20.2.2.7 shall be deleted and replaced as follows, updating all
references accordingly, including any references thereto.

4.20.2.2.7 Liquidated Damages Chart

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118.   Section 4.27 shall be amended by deleting the word “which” and replacing
it with the word “that”.

119.   Section 4.32.1 shall be amended by adding the word “, beliefs” after the
word “religion”.

120. Section 4.34 shall be deleted and replaced as follows: 4.34 PROHIBITION OF
ILLEGAL IMMIGRANTS

4.34.1   The requirements of Public Acts of 2006, Chapter Number 878, of the
state of Tennessee, addressing the use of illegal immigrants in the performance
of any contract to supply goods or services to the state of Tennessee, shall be
a material provision of this Agreement, a breach of which shall be grounds for
monetary and other penalties, up to and including termination of this Agreement.

4.34.2   The CONTRACTOR hereby attests, certifies, warrants, and assures that
the CONTRACTOR shall not knowingly utilize the services of an illegal immigrant
in the performance of this Agreement and shall not knowingly utilize the
services of any subcontractor who will utilize the services of an illegal
immigrant in the performance of this Agreement. The CONTRACTOR shall reaffirm
this attestation, in writing, by submitting to the State a completed and signed
copy of the document as Attachment X, hereto, semiannually during the period of
this Agreement. Such attestations shall be maintained by the CONTRACTOR and made
available to state officials upon request.

4.34.3   Prior to the use of any subcontractor in the performance of this
Agreement, and semi-annually thereafter, during the period of this Agreement,
the CONTRACTOR shall obtain and retain a current, written attestation that the
subcontractor shall not knowingly utilize the services of an illegal immigrant
to perform work relative to this Agreement and shall not knowingly utilize the
services of any subcontractor who will utilize the services of an illegal
immigrant to perform work relative to this Agreement. Attestations obtained from
such subcontractors shall be maintained by the CONTRACTOR and made available to
state officials upon request.

4.34.4   The CONTRACTOR shall maintain records for all personnel used in the
performance of this Agreement. Said records shall be subject to review and
random inspection at any reasonable time upon reasonable notice by the State.

4.34.5   The CONTRACTOR understands and agrees that failure to comply with this
Section will be subject to the sanctions of Public Chapter 878 of 2006 for acts
or omissions occurring after its effective date. This law requires the
Commissioner of Finance and Administration to prohibit a contractor from
contracting with, or submitting an offer, proposal, or bid to contract with the
State of Tennessee to supply goods or services for a period of one year after a
contractor is discovered to have knowingly used the services of illegal
immigrants during the performance of this Agreement.

4.34.6   For purposes of this Agreement, “illegal immigrant” shall be defined as
any person who is not either a United States citizen, a Lawful Permanent
Resident, or a person whose physical presence in the United States is authorized
or allowed by the federal Department of Homeland Security and who, under federal
immigration laws and/or regulations, is authorized to be employed in the U.S. or
is otherwise authorized to provide services under the Agreement.

121.   Attachment V shall be deleted in its entirety and replaced with the
following:  

1

ATTACHMENT V

ACCESS & AVAILABILITY FOR BEHAVIORAL HEALTH SERVICES

The CONTRACTOR shall adhere to the following behavioral health network
requirements to ensure
access and availability to behavioral health services for all members (adults
and children). For the purpose of assessing behavioral health provider network
adequacy, TENNCARE will evaluate the CONTRACTOR’s provider network relative to
the requirements described below. Providers serving adults will be evaluated
separately from those serving children.

Access to Behavioral Health Services

The CONTRACTOR shall ensure access to behavioral health providers for the
provision of covered services. At a minimum, this means that:

The CONTRACTOR shall have provider agreements with providers of services listed
in the table below and meet the geographic and time for admission an/appointment
requirements.

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When the above standards are not met, an acceptable Corrective Action Plan will
be requested which details the CONTRACTOR’s intended course of action to resolve
any deficiency (ies) identified. The Bureau of TennCare will evaluate Corrective
Action Plans and, at its sole discretion, determine network adequacy considering
any alternate measures and documentation of unique market conditions.

At a minimum, providers for the following service types shall be reported on the
Provider Enrollment File:

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  122.   Attachment VI, Performance Standards shall be amended by deleting and
replacing the existing Items 3 through 6 with new Items 3 through 10 and
renumbering the remaining Items accordingly, including any references thereto.  

                                                                               
         
 
                            PERFORMANCE                      
 
      MEASUREMENT                     MEASURE       DATA SOURCE(S)      
BENCHMARK      
DEFINITION
      FREQUENCY       LIQUIDATED DAMAGE                                    
 
                  3         Telephone Response
Time/Call Answer
Timeliness-Member
Services Line       Member Services and
Provider Services
Phone Line Report       85% of all calls to
each line are
answered by a live
voice within thirty
(30) seconds or the
prevailing
benchmark
established by NCQA      
The number of calls
answered by a live
voice within 30
seconds, divided by
the number of calls
received by the
phone line (during
hours of operation)
during the
measurement period
 

   

Quarterly  

   

$25,000 for each
full percentage
point below 85% per
month                                    
 
                  4         Telephone Response
Time/Call Answer
Timeliness-Provider
Services
Line       Member Services and
Provider Services
Phone Line Report       85% of all calls to
each line are
answered by a live
voice within thirty
(30) seconds or the
prevailing
benchmark
established by NCQA      
The number of calls
answered by a live
voice within 30
seconds, divided by
the number of calls
received by the
phone line (during
hours of operation)
during the
measurement period
 

   

Quarterly  

   

$25,000 for each
full percentage
point below 85% per
month   5         Telephone Response
Time/Call Answer
Timeliness-Utilization
Management
Line       Member Services and
UM Phone Line
Report       85% of all calls to
each line are
answered by a live
voice within thirty
(30) seconds or the
prevailing
benchmark
established by NCQA      
The number of calls
answered by a live
voice within 30
seconds, divided by
the number of calls
received by the
phone line (during
hours of operation)
during the
measurement period
 

   

Quarterly  

   

$25,000 for each
full percentage
point below 85% per
month   6         Telephone Response
Time/Call Answer
Timeliness-Nurse
Triage/Nurse Advice
Line       Nurse Triage/Nurse
Advice Line Report       85% of all calls to
each line are
answered by a live
voice within thirty
(30) seconds or the
prevailing
benchmark
established by NCQA      
The number of calls
answered by a live
voice within 30
seconds, divided by
the number of calls
received by the
phone line (during
hours of operation)
during the
measurement period
 

   

Quarterly  

   

$25,000 for each
full percentage
point below 85% per
month                                    
 
                  7         Telephone Call
Abandonment Rate
(unanswered calls)
—Member Services
Line       Member Services and
Provider Services
Phone Line Report       Less than 5% of
telephone calls are
abandoned      
The number of calls
abandoned by the
caller or the
system before being
answered by a live
voice divided by
the number of calls
received by the
phone line (during
open hours of
operation) during
the measurement
period
 

   

Quarterly  

   

$25,000 for each
full percentage
point above 5% per
month                                    
 
                  8         Telephone Call
Abandonment Rate
(unanswered calls) —
Provider Services Line       Member Services and
Provider Services
Phone Line Report       Less than 5% of
telephone calls are
abandoned      
The number of calls
abandoned by the
caller or the
system before being
answered by a live
voice divided by
the number of calls
received by the
phone line (during
open hours of
operation) during
the measurement
period
 

   

Quarterly  

   

$25,000 for each
full percentage
point above 5% per
month                                    
 
                  9         Telephone Call
Abandonment Rate
(unanswered calls) —
UM Line       Member Services and
UM Phone Line
Report       Less than 5% of
telephone calls are
abandoned      
The number of calls
abandoned by the
caller or the
system before being
answered by a live
voice divided by
the number of calls
received by the
phone line (during
open hours of
operation) during
the measurement
period
 

   

Quarterly  

   

$25,000 for each
full percentage
point above 5% per
month   10         Telephone Call
Abandonment Rate
(unanswered calls) —
Nurse Triage/Nurse
Advice Line       Nurse Triage/Nurse
Advice Line Report       Less than 5% of
telephone calls are
abandoned      
The number of calls
abandoned by the
caller or the
system before being
answered by a live
voice divided by
the number of calls
received by the
phone line (during
open hours of
operation) during
the measurement
period
 

   

Quarterly  

   

$25,000 for each
full percentage
point above 5% per
month

123. The Deliverable Items in Attachment VIII shall be deleted and replaced as
follows:

ATTACHMENT VIII
DELIVERABLE REQUIREMENTS

GENERAL

This is a preliminary list of deliverables. The CONTRACTOR and TENNCARE shall
agree to the appropriate deliverables, deliverable format/submission
requirements, submission and approval time frames, and technical assistance as
required. Deliverables shall be submitted to the TennCare Bureau unless
otherwise specified.

TENNCARE will require that some or all deliverables be reviewed and/or approved
by TENNCARE during the readiness review and/or during operations. As specified
by TENNCARE, material modifications to certain deliverables must be reviewed
and/or approved by TENNCARE.

DELIVERABLE ITEMS

1.   Evidence of TDCI license for CONTRACTOR and subcontractors (as applicable)
to ensure compliance with Section 2.1.1  

2.   Notification that a member may satisfy any of the conditions for
termination from the TennCare program in accordance with Section 2.5.4

3.   Request for prior approval/notice of use of cost effective alternative
services in accordance with Section 2.6.5  

4.   Request for prior approval of incentives in accordance with Section 2.6.6

5.   Policies and procedures for patient liability that ensure compliance with
Section 2.6.7.2

6.   Policies and procedures for self-direction of health care tasks in
accordance with Section 2.7.3

7.   Description of health education and outreach programs and activities to
ensure compliance with Section 2.7.4  

8.   TENNderCare policies and procedures that ensure compliance with the
requirements of Section 2.7.6

9.   Policies and procedures for advance directives that ensure compliance with
Section 2.7.7

10.   Disease management program policies and procedures that ensure compliance
with Section 2.8

11.   Service coordination policies and procedures that ensure compliance with
Section 2.9.1

12.   Policies and procedures for transition of new members that ensure
compliance with the requirements of Section 2.9.2  

13.   Policies and procedures for transition of member receiving long-term care
services at the time of CHOICES implementation that ensure compliance with
Section 2.9.3

14.   Transition of care polices and procedures that ensure compliance with
Section 2.9.4

  15.   MCO case management policies and procedures that ensure compliance with
Section 2.9.5

16. Care coordination policies and procedures that ensure compliance with
Section 2.9.6

17. Policies and procedures for consumer direction of HCBS that ensure
compliance with Section 2.9.7

  18.   Policies and procedures for coordination of physical health, behavioral
health, and long-term care services that ensure compliance with Section 2.9.8

  19.   If CONTRACTOR subcontracts for the provision of behavioral health
services, agreement with the subcontractor in accordance with Section 2.9.8.2 to
ensure compliance with Section 2.9.8  

  20.   Policies and procedures for coordination among behavioral health
providers that ensure compliance with Section 2.9.9  

  21.   Policies and procedures for coordination of pharmacy services that
ensure compliance with Section 2.9.10

  22.   Policies and procedures for coordination of dental services that ensure
compliance with Section 2.9.11

  23.   Identification of members serving on the claims coordination committee
in accordance with Section 2.9.11.5.3  

  24.   Policies and procedures for coordination with Medicare that ensure
compliance with Section 2.9.12

  25.   Policies and procedures for inter-agency coordination that ensure
compliance with Section 2.9.14

  26.   Polices and procedures regarding non-covered services that ensure
compliance with Section 2.10

  27.   Policies and procedures to develop and maintain a provider network that
ensure compliance with Section 2.11.1, including policies and procedures for
selection and/or retention of providers  

  28.   Policies and procedures for PCP selection and assignment that ensure
compliance with Section 2.11.2, including policies and procedures regarding
change of PCP and use of specialist as PCP  

  29.   Plan to identify, develop, or enhance existing inpatient and residential
treatment capacity for adults and adolescents with co-occurring mental health
and substance abuse disorders to ensure compliance with Section 2.11.5.2  

  30.   Credentialing manual and policies and procedures that ensure compliance
with Section 2.11.8

  31.   Policies and procedures that ensure compliance with notice requirements
in Section 2.11.9

  32.   Notice of provider and subcontractor termination and additional
documentation as required by Section 2.11.9.2  

  33.   Provider agreement template(s) and revisions to TDCI as required in
Section 2.12

  34.   Indemnity language in provider agreements if different than standard
indemnity language (see Section 2.12.9.49)  

  35.   Intent to use a physician incentive plan (PIP) to TennCare Bureau and
TDCI (see Section 2.13.8)

  36.   Any provider agreement templates or subcontracts that involve a PIP for
review as a material modification (to TDCI) as required by (see Section 2.13.8)

  37.   Pricing policies for emergency services provided by non-contract
providers that ensure compliance with Section 2.13.9.1  

  38.   Policies and procedures for PCP profiling to ensure compliance with
Section 2.14.9

  39.   Information on PCP profiling as requested by TENNCARE (see
Section 2.14.9)

  40.   QM/QI policies and procedures to ensure compliance with Section 2.15

  41.   Copy of signed contract with NCQA approved vendor to perform CAHPS as
required by Section 2.15.5

  42.   Copy of signed contract with NCQA approved vendor to perform HEDIS audit
as required by Section 2.15.5  

  43.   Evidence that NCQA accreditation application submitted and fee paid
(Section 2.15.5.1)

  44.   HEDIS BAT as required by Section 2.15.6

  45.   Copy of signed NCQA survey contract as required by Section 2.15.5.1

  46.   Notice of date for ISS submission and NCQA on-site review as required by
Section 2.15.5.1

  47.   Notice of final payment to NCQA as required by Section 2.15.5.1

  48.   Notice of submission of ISS to NCQA as required by Section 2.15.5.1

  49.   Copy of completed NCQA survey and final report as required by
Section 2.15.5.1

  50.   Notice of any revision to NCQA accreditation status

  51.   Policies and procedures regarding critical incident management and
reporting to ensure compliance with Section 2.15.8  

  52.   If applicable, information on the use of the name of the CONTRACTOR’s
TennCare MCO pursuant to Section 2.16.3  

  53.   Member materials as described in Section 2.17, including but not limited
to, member handbook, quarterly member newsletters, identification card, and
provider directory along with any required supporting materials  

  54.   Member services phone line policies and procedures that ensure
compliance with Section 2.18.1

  55.   Policies and procedures regarding interpreter and translation services
that ensure compliance with Section 2.18.2  

  56.   Provider service and phone line policies and procedures that ensure
compliance with Section 2.18.4

  57.   Description of 24/7 ED Assistance Line (see Section 2.18.4.7)

58. Provider handbook that is in compliance with requirements in Section 2.18.5

59. Provider education and training plan and materials that ensure compliance
with Section 2.18.6

60. Provider relations policies and procedures in compliance with Section 2.18.7

  61.   Protocols regarding one-on-one assistance to long-term care providers
that ensure compliance with Section 2. 18.7.2

  62.   Policies and procedures to monitor and ensure provider compliance with
the Agreement (see Section 2.18.7.3)  

  63.   Policies and procedures for a provider complaint system that ensure
compliance with Section 2.18.8

  64.   FEA education and training plan and materials that ensure compliance
with Section 2.18.9

  65.   Policies and procedures regarding member involvement with behavioral
health services that ensure compliance with Section 2.18.10  

  66.   Appeal and complaint policies and procedures that ensure compliance with
Section 2.19

  67.   Fraud and abuse policies and procedures that ensure compliance with
Section 2.20

  68.   Report all confirmed or suspected fraud and abuse to the appropriate
agency as required in Section 2.20.2

  69.   Fraud and abuse compliance plan (see Section 2.20.3)

  70.   TPL policies and procedures that ensure compliance with Section 2.21.4

  71.   Accounting policies and procedures that ensure compliance with
Section 2.21.7

  72.   Proof of insurance coverage (see Section 2.21.8)

  73.   Executed agreement for audit accounts that contains the required
language (see Section 2.21.11)

  74.   Claims management policies and procedures that ensure compliance with
Section 2.22

  75.   Internal claims dispute procedure (see Section 2.22.5)

  76.   EOB policies and procedures to ensure compliance with Section 2.22.8

  77.   Systems policies and procedures, manuals, etc. to ensure compliance with
Section 2.23 (see Section 2.23.10)  

  78.   Proposed approach for remote access in accordance with Section 2.23.6.10

  79.   Information security plan as required by Section 2.23.6.11

  80.   Notification of Systems problems in accordance with Section 2.23.7

81. Systems Help Desk services in accordance with Section 2.23.8

82. Notification of changes to Systems in accordance with Section 2.23.9

  83.   Notification of changes to membership of behavioral health advisory
committee and current membership lists in accordance with Section 2.24.2  

  84.   Notification of changes to membership of CHOICES Advisory Group and
current membership lists in accordance with Section 2.24.3  

  85.   An abuse and neglect plan in accordance with Section 2.24.4

  86.   Medical record keeping policies and procedures that ensure compliance
with Section 2.24.6

  87.   Subcontracts (see Section 2.26)

  88.   HIPAA policies and procedures that ensure compliance with Section 2.27

  89.   Accounting of disclosures in accordance with Section 2.27.2.10

  90.   Notification of use or disclosure in accordance with
Section 2.27.2.13.3.3

  91.   Notification of any unauthorized acquisition of enrollee PHI in
accordance with Section 2.27.2.13.3

  92.   Third (3rd) party certification of HIPAA transaction compliance in
accordance with Section 2.27.2.27

  93.   Notification of any security incident in accordance with Section 2.27.3

  94.   Non-discrimination policies and procedures as required by Section 2.28

  95.   Names, resumes, and contact information of key staff as required by
Section 2.29.1.2

  96.   Changes to key staff as required by Section 2.29.1.2

  97.   Staffing plan as required by Section 2.29.1.8

  98.   Changes to location of staff from in-state to out-of-state as required
by Section 2.29.1.9

  99.   Background check policies and procedures that ensure compliance with
Section 2.29.2.1

  100.   List of officers and members of Board of Directors (see Section 2.29.3)

  101.   Changes to officers and members of Board of Directors (see
Section 2.29.3)

  102.   Eligibility and Enrollment Data (see Section 2.30.2.1)

  103.   Monthly Enrollment/Capitation Payment Reconciliation Report (see
Section 2.30.2.2)

  104.   Quarterly Member Enrollment/Capitation Payment Report (see
Section 2.30.2.3)

105. Information on members (see Section 2.30.2.4)

106. Psychiatric Hospital/RTF Readmission Report (see Section 2.30.4.1)

107. Mental Health Case Management Report (see Section 2.30.4.2)

108. Supported Employment Report (see Section 2.30.4.3)

109. Behavioral Health Crisis Response Report (see Section 2.30.4.4)

110. Member CRG/TPG Assessment Report (see Section 2.30.4.5)

111. Rejected CRG/TPG Assessment Report (see Section 2.30.4.6)

112. CRG/TPG Assessments Audit Report (see Section 2.30.4.7)

113. Methodology for conducting CRG/TPG assessment audits (see Section 2.30.4.8)

114. TENNderCare Report (see Section 2.30.4.9)

115. Disease Management Update Report (see Section 2.30.5.1)

116. Disease Management Report (see Section 2.30.5.2)

117. Disease Management Program Description (see Section 2.30.5.3)

118. MCO Case Management Program Description (see Section 2.30.6.1.1)

119. MCO Case Management Services Report (see Section 2.30.6.1.2)

120. MCO Case Management Update Report (see Section 2.30.6.1.3)

121. Status of Transitioning CHOICES Member Report (see Section 2.30.6.2)

122. CHOICES Nursing Facility Diversion Activities Report (see Section 2.30.6.3)

123. CHOICES Nursing Facility to Community Transition Report (see
Section 2.30.6.4)

124. CHOICES HCBS Late and Missed Visits Report (see Section 2.30.6.5)

125. CHOICES Consumer Direction of HCBS Report (see Section 2.30.6.6)

126. CHOICES Care Coordination Report (see Section 2.30.6.7)

127. Members identified as potential pharmacy lock-in candidates (see
Section 2.30.6.8)

128. Pharmacy Services Report (see Section 2.30.6.9)

129. Pharmacy Services Report, On Request (see Section 2.30.6.10)
130. Provider Enrollment File (see Section 2.30.7.1)

131. Provider Compliance with Access Requirements Report (see Section 2.30.7.2)

132. PCP Assignment Report (see Section 2.30.7.3)

133. Report of Essential Hospital Services (see Section 2.30.7.4)

134. Behavioral Health Initial Appointment Timeliness Report (see
Section 2.30.7.5)

135. Long-Term Care Provider Network Development Plan (see Section 2.30.7.6)

136. Long-Term Care Provider Capacity Performance Report (see Section 2.30.7.7)

137. CHOICES Qualified Workforce Strategies Report (see Section 2.30.7.8)

138. FQHC Reports (see Section 2.30.7.9)

139. Institutions for Mental Diseases (IMD) Out-of-State Report (see
Section 2.30.7.10)

140. Single Case Agreements Report (see Section 2.30.8)

141. Related Provider Payment Report (see Section 2.30.9.1)

142. Check Run Summaries Report (see Section 2.30.9.2)

143. Claims Data Extract Report (see Section 2.30.9.3)

144. Reconciliation Payment Report (see Section 2.30.9.4)

145. UM program description, work plan, and evaluation (see Section 2.30.10.1)

146. Cost and Utilization Reports (see Section 2.30.10.2)

147. Cost and Utilization Summaries (see Section 2.30.10.3)

148. Identification of high-cost claimants (see Section 2.30.10.4)

149. CHOICES Utilization Report (see Section 2.30.10.5)

150. Prior Authorization Reports (see Section 2.30.10.6)

151. Referral Provider Listing and supporting materials (see Section 2.30.10.7)

152. ED Threshold Report (see Section 2.30.10.8)

153. QM/QI Program Description, Associated Work Plan and Annual Evaluation (see
Section 2.30.11.1)

154. Report on Performance Improvement Projects (see Section 2.30.11.2)

155.   NCQA Accreditation Report (see Section 2.30.11.3)

156. NCQA revaluation of accreditation status based on HEDIS scores (see
Section 2.30.11.4)

157. Reports of Audited CAHPS Results and Audited HEDIS Results (see
Section 2.30.11.5)

158. CHOICES HCBS Critical Incidents Report (see Section 2.30.11.6)

159.   Member Services, Provider Services, and Utilization Management Phone Line
Report (see Section 2.30. 12. 1. 1)  

160.   24/7 Nurse Triage Line Report (see Section 2.30.12.1.2)

161.   ED Assistance Tracking Report (see Section 2.30.12.1.3)

162.   Translation/Interpretation Services Report (see Section 2.30.12.3)

163.   Provider Satisfaction Survey Report (see Section 2.30.12.4)

164.   Provider Complaints Report (see Section 2.30.12.5)

165.   Member Complaints Report (see Section 2.30.13)

166.   Fraud and Abuse Activities Report (see Section 2.30.14.1)

167.   Policies in compliance with Section 1902(a)(68) of the Social Security
Act (see Section 2.30.14.3)

168.   Recovery and Cost Avoidance Report (see Section 2.30.15.1.1)

169.   Other Insurance Report (see Section 2.30.15.1.2)

170.   Medical Loss Ratio (MLR) Report (see Section 2.30.15.3.1)

171.   Ownership and Financial Disclosure Report (see Section 2.30.15.3.2)

172.   Annual audit plan (see Section 2.30.15.3.3)

173.   Financial Plan and Projection of Operating Results Report (to TDCI) (see
Section 2.30.15.4.1)

174.   Comparison of Actual Revenues and Expenses to Budgeted Amounts Report (to
TDCI) (see Section 2.30.15.4.2)

175.   Annual Financial Report (to TDCI) (see Section 2.30.15.4.3)

176.   Quarterly Financial Report (to TDCI) (see Section 2.30.15.4.4)

177.   Audited Financial Statements (to TDCI) (see Section 2.30.15.4.5)

178.   Claims Payment Accuracy Report (see Section 2.30.16.1)

179.   EOB Report (see Section 2.30.16.2)

180.   Claims Activity Report (see Section 2.30.16.3)

181. CHOICES Cost Effective Alternatives Report (see Section 2.30.16.4)

182. Systems Refresh Plan (see Section 2.30.17.1)

183. Encounter Data Files (see Section 2.30.17.2)

184. Electronic version of claims paid reconciliation (see Section 2.30.17.3)

185. Information and/or data to support encounter data submission (see
Section 2.30.17.4)

186. Systems Availability and Performance Report (see Section 2.30.17.5)

187. Business Continuity and Disaster Recovery Plan (see Section 2.30.17.6)

188.   Reports on the Activities of the CONTRACTOR’s Behavioral Health Advisory
Committee (see Section 2.30.18. 1)

189.   Report on the Activities of the CONTRACTOR’s CHOICES Advisory Group (see
Section 2.30.18.2)

190.   Subcontracted claims processing report (see Section 2.30.19.1)

191.   Security Incident Report (see Section 2.30.20)

192.   Non-discrimination policy (see Section 2.30.2 1.1)

193.   Summary Listings of Servicing Providers (see Section 2.30.2 1.2)

194.   Non-Discrimination Compliance Plan and Assurance of Non-Discrimination
(see Section 2.30.21.3)

195.   Non-Discrimination Compliance Report (see Section 2.30.21.4)

196.   Provider reimbursement rates for services incurred prior to the start
date of operations in accordance with Section 3.7.1.2.1  

197.   Disclosure of conflict of interest (see Section 2.30.22.1)

198.   Attestation Re: Personnel Used in Contract Performance (see
Section 2.30.22.2)

199.   Return of funds in accordance with Section 3.14.5

200.   Termination plan in accordance with Section 4.4.8.2.8

201.   Policies and procedures for delivering NEMT services, including an
operating procedures manual, as provided in Section A. 1 of Attachment XI

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124. Exhibit M of Attachment IX shall be deleted and replaced as follows:

ATTACHMENT IX, EXHIBIT M
MEMBER SERVICES, PROVIDER SERVICES, AND UTILIZATION MANAGEMENT
PHONE LINE REPORT

MCO Name:

Report Submission Date:
Reporting Quarter:

[e30293-101451417555112a1c_14.jpg]

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125.   Attachment XI, NEMT Requirements, Section A.19.6.4.2 shall be amended by
deleting the reference to “Section A.14.4” and replacing it with the reference
“Section A.14.3”.

126.   Attachment XI, NEMT Requirements, Exhibit B, Item 4 shall be amended by
deleting the text “/BHO”.

127.   Attachment XII, CAPITATION RATES, shall be amended by deleting and
replacing the existing Exhibit C and adding a new Exhibit D to read as follows:

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EXHIBIT C
CAPITATION RATES
EFFECTIVE July 1, 2008 — June 30, 2009

[e30293-101451417555112a1c_15.jpg]

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EXHIBIT D
CAPITATION RATES
EFFECTIVE July 1, 2009 (Except CHOICES Rates as described below)

[e30293-101451417555112a1c_16.jpg]

128.   All references throughout the Agreement to the “Division of Mental
Retardation Services (DMRS)” shall be deleted and replaced with the reference
“Division of Intellectual Disabilities Services (DIDS)”.

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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 March 1, 2010.

IN WITNESS WHEREOF, the parties have by their duly authorized representatives
set their signatures.

[e30293-101451417555112a1c_17.jpg]

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