Document:

EX-10.1

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

	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.

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:

	 	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

2

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:

3

	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:

4

EXHIBIT C

CAPITATION RATES

EFFECTIVE July 1, 2008 — June 30, 2009

5

EXHIBIT D

CAPITATION RATES

EFFECTIVE July 1, 2009 (Except CHOICES Rates as described below)

	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)”.

6

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.

7EX-4.1

Exhibit 4.1

FIRST SUPPLEMENTAL INDENTURE

This FIRST SUPPLEMENTAL INDENTURE (this “First Supplemental Indenture”), dated as of
May 21, 2010, between Forest City Enterprises, Inc., an Ohio corporation (the “Issuer”) and
The Bank of New York Mellon Trust Company, N.A., as trustee under the Original Indenture referred
to below (the “Trustee”).

W I T N E S S E T H :

WHEREAS, the Issuer’s Pricing Committee of its Board of Directors, at a meeting held on
October 1, 2009, pursuant to authority delegated to it by the Issuer’s Board of Directors,
authorized the Issuer to issue in a private placement up to $200 million in aggregate principal
amount of its 3.625% Puttable Equity-Linked Senior Notes due October 15, 2014 (the
“Notes”), and approved the terms of the Notes as presented to it at the meeting by
management of the Issuer and the Issuer’s financial advisor for the transaction;

WHEREAS, the Issuer’s financial advisor for the transaction communicated the terms of the
Notes, as approved by the Issuer’s Pricing Committee, to the investors, reflecting a Put Value
Price of $14.54 per share of Common Stock and a Put Value Rate of 68.7758 shares of Common Stock
per $1000 principal amount Note;

WHEREAS, the respective investors thereupon entered into Exchange Agreements or Purchase
Agreements, each dated on or about October 2, 2009, with the Issuer, pursuant to which the
respective investors agreed to acquire the Notes, incorporating a Put Value Price of $14.54 per
share of Common Stock and a Put Value Rate of 68.7758 shares of Common Stock per $1000 principal
amount Note;

WHEREAS, the Issuer filed a Current Report on Form 8-K with the Securities and Exchange
Commission on October 2, 2009 and issued a press release that disclosed the agreed Put Value Price
of the Notes of $14.54 per share of Common Stock, based on a Put Value Rate of 68.7758 shares of
Common Stock per $1000 principal amount Note;

WHEREAS, the Issuer and the Trustee entered into that certain Indenture, dated as of October
7, 2009 (the “Original Indenture”), providing for the issuance by the Issuer of its Notes;

WHEREAS, after execution by the Issuer and the Trustee of the Original Indenture, the Issuer
discovered that the definition of Put Value Rate contained in Section 13.01(a) of the Original
Indenture, which is calculated by dividing the $1,000 principal amount of each Note by the Put
Value Price of the Note of $14.54 per share of Common Stock, contained a typographical error, in
that it referenced a Put Value Rate of 66.7758 shares of Common Stock per $1000 principal amount
Note, rather than the Put Value Rate of 68.7758 shares of Common Stock per $1000 principal amount
Note agreed between the Issuer and the investors;

WHEREAS, pursuant to Section 9.01 of the Original Indenture, the Issuer and the Trustee may
enter into supplemental indentures to cure any ambiguity, omission, defect or inconsistency in the
Original Indenture in a manner that does not individually or in the aggregate adversely affect the
rights of any Noteholder in any respect;

1

WHEREAS, the Issuer wishes to correct the typographical error contained in Section 13.01(a) of
the Indenture so that the Put Value Rate is correctly presented as 68.7758;

WHEREAS, the changes contained herein do not adversely affect the rights of any Noteholder in
any respect; and

WHEREAS, the Issuer and the Trustee have duly authorized the execution and delivery of this
First Supplemental Indenture and have done all things necessary to make this First Supplemental
Indenture (together with the Original Indenture, the “Indenture”) a valid and legally
binding agreement of the parties hereto, in accordance with its terms;

NOW THEREFORE, in consideration of the foregoing and for other good and valuable
consideration, the receipt of which is hereby acknowledged, the Issuer and the Trustee mutually
covenant and agree for the equal and ratable benefit of the Noteholders as follows:

1. Definitions.

(a) Capitalized terms used herein without definition shall have the meanings assigned
to them in the Original Indenture or in the form of Note attached as Exhibit A to
the Original Indenture.

(b) For all purposes of this First Supplemental Indenture, except as otherwise herein
expressly provided or unless the context otherwise requires: (i) the terms and expressions
used herein shall have the same meanings as corresponding terms and expressions used in the
Original Indenture; and (ii) the words “herein,” “hereof” and “hereby” and other words of
similar import used in this First Supplemental Indenture refer to this First Supplemental
Indenture as a whole and not to any particular section hereof.

2. Cure of Scrivener’s Error. In Section 13.01(a) of the Original Indenture and in
the form of Note attached as Exhibit A to the Original Indenture, the number of shares of
Common Stock referenced in connection with the definition of the Put Value Rate in such Section
13.01(a) shall be corrected to read “68.7758,” instead of “66.7758” as reflected in both places the
Original Indenture.

3. Ratification of Original Indenture; Supplemental Indentures Part of Original
Indenture. Except as expressly amended hereby, the Original Indenture is in all respects
ratified and confirmed and all the terms, conditions and provisions thereof shall remain in full
force and effect. This First Supplemental Indenture shall form a part of the Original Indenture
for all purposes, and every Holder heretofore or hereafter authenticated and delivered shall be
bound hereby.

4. Governing Law. THIS SUPPLEMENTAL INDENTURE SHALL BE GOVERNED BY AND CONSTRUED IN
ACCORDANCE WITH THE LAWS OF THE STATE OF NEW YORK.

5. Trustee Makes No Representation. The Trustee shall not be responsible in any
manner whatsoever for or in respect of the validity or sufficiency of this First Supplemental
Indenture or for or in respect of the recitals contained herein, all of which are made solely by
the Issuer.

6. Multiple Counterparts. The parties may sign multiple counterparts of this First
Supplemental Indenture. Each signed counterpart shall be deemed an original, but all of them
together represent one and the same agreement.

2

7. Headings. The headings of this First Supplemental Indenture have been inserted for
convenience of reference only, are not to be considered a part hereof, and shall in no way modify
or restrict any of the terms or provisions hereof.

[Remainder of page intentionally left blank; signature page follows.]

3

IN WITNESS WHEREOF, the parties hereto have caused this First Supplemental Indenture to be
duly executed as of the date and year first above written.

FOREST CITY ENTERPRISES, INC.

By: /s/ Robert G. O’/Brien

Title: Executive Vice President and

Chief Financial Officer

THE BANK OF NEW YORK MELLON TRUST

COMPANY, N.A., as Trustee

By: /s/ D. G. Donovan

Name: D. G. Donovan

Title: Vice President

[Signature Page to First Supplemental Indenture]

4

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