Document:

EX-10.1

AMENDMENT NUMBER 8

MIDDLE GRAND REGION

CONTRACTOR RISK AGREEMENT

BETWEEN

THE STATE OF TENNESSEE,

d.b.a. TENNCARE

AND

AMERIGROUP TENNESSEE, INC.

CONTRACT NUMBER: FA- 07-16936-00

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

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

1. Section 1 shall be amended by deleting and replacing the following definitions:

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 CHOICES 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 CHOICES
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 backup 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.

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., but shall not perform activities that must
be performed by the Care Coordinator, including needs assessment, development of the plan of
care, and minimum Care Coordination contacts.

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 eligible CHOICES HCBS.

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

1. Group 1

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

2. Group 2

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

3. Group 3

Persons age sixty-five (65) and older and adults age twenty-one (21) and older with
physical disabilities who qualify for TennCare as SSI recipients, who do not meet the
nursing facility level of care, but who, in the absence of CHOICES HCBS, are
“at-risk” for nursing facility care, as defined by the State. TENNCARE has the
discretion to apply an enrollment target to this group, as described in TennCare
rules and regulations. Group 3 was not included in CHOICES on the date of CHOICES
implementation. TENNCARE intends to include CHOICES Group 3 at such time that the
State is permitted to modify nursing facility level of care based on CMS
interpretation of maintenance of effort requirements set forth in the Affordable Care
Act. . 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.

Consumer – Except when used regarding consumer direction of eligible CHOICES 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 eligible CHOICES HCBS or his/her
representative to provide one or more eligible CHOICES 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 Eligible CHOICES HCBS – The opportunity for a CHOICES member
assessed to need specified types of CHOICES 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).

Cost Neutrality Cap – The requirement that the cost of providing care to a member in
CHOICES Group 2, including CHOICES HCBS and Medicaid reimbursed home health and private duty
nursing, shall not exceed the cost of providing nursing facility services to the member, as
determined in accordance with TennCare policy. A member’s individual cost neutrality cap
shall be the average cost of Level 1 nursing facility care unless a higher cost neutrality
cap is established by TennCare based on information submitted by the AAAD or MCO (as
applicable) in the PAE application.

Disenrollment – The removal of an enrollee from participation in the CONTRACTOR’s
MCO and deletion from the outbound 834 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 specified CHOICES
HCBS and which may also be utilized for submission of claims.

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

Employer of Record – The member participating in consumer direction of eligible
CHOICES HCBS or a representative designated by the member to assume the consumer direction
of eligible CHOICES HCBS functions on the member’s behalf.

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

Fiscal Employer Agent (FEA) – An entity contracting with the State and/or an MCO
that helps CHOICES members participating in consumer direction of eligible CHOICES HCBS. The
FEA provides both financial administration and supports brokerage functions for CHOICES
members participating in consumer direction of eligible CHOICES 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 CHOICES HCBS authorized and
provided.

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

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 CHOICES
HCBS pending a final determination of eligibility. To qualify for immediate eligibility, a
person must be applying to receive covered ongoing CHOICES 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 CHOICES HCBS (no other covered services) and for a maximum of
forty-five (45) days from the effective date of eligibility.

One-Time CHOICES HCBS – Specified CHOICES HCBS which occur as a distinct event or
which may be episodic in nature (occurring at less frequent irregular intervals or on an as
needed basis for a limited duration of time). One-time HCBS include in-home respite,
in-patient respite, assistive technology, minor home modifications, and/or pest control.

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

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 eligible CHOICES 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 eligible CHOICES 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 eligible CHOICES 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.

Risk Agreement – An agreement signed by a member who will receive CHOICES HCBS (or
his/her representative) that includes, at a minimum, identified risks to the member of
residing in the community and receiving HCBS, the possible 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.

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 CHOICES 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 CHOICES HCBS s/he is authorized to receive.

Service Agreement – The agreement between a CHOICES member electing consumer
direction of eligible CHOICES 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 CHOICES HCBS that was not initiated by a member, including late and
missed visits.

Supports Broker – An individual assigned by the FEA to each CHOICES member
participating in consumer direction 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.

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

CHOICES Home and Community-Based Services (HCBS) – Services that are available
only to eligible persons enrolled in CHOICES Group 2 or Group 3 as an alternative to
long-term care institutional services in a nursing facility or to delay or prevent placement
in a nursing facility. Only CHOICES HCBS are eligible for Consumer Direction. CHOICES HCBS
do not include home health or private duty nursing services or any other HCBS that are
covered by Tennessee’s Title XIX state plan or under the TennCare demonstration for all
eligible enrollees, although such services are subject to estate recovery and shall be
counted for purposes of determining whether a CHOICES member’s needs can be safely met in
the community within his or her individual cost neutrality cap.

	3.	 	Sections 2.4.5.1 and 2.4.5.2 shall be amended by adding the words “outbound 834” in front
of the words “enrollment file”.

	4.	 	Section 2.4.6.1 shall be amended by adding the words “outbound 834” in front of the words
“enrollment files”.

	5.	 	Section 2.4.6.2 shall be amended by adding the words “(inbound 834)” after the words
“eligibility file”.

	6.	 	The first sentence of the third paragraph in the Benefit Limit description for “Non-Emergency
Medical Transportation (Including Non-Emergency Ambulance Transportation)” of Section 2.6.1.3
shall be amended by deleting the phrase “, including services”.

“The CONTRACTOR is not responsible for providing NEMT to HCBS provided through a 19
15(c) waiver program for persons with intellectual disabilities (i.e., mental retardation)
and HCBS provided through the CHOICES program.”

	7.	 	Sections 2.6.1.5 through 2.6.1.5.8.5 shall be deleted and replaced as follows:

2.6.1.5 Long-Term Care Benefits for CHOICES Members

	 	2.6.1.5.1	 	In addition to physical health benefits (see Section 2.6.1.3) and behavioral
health benefits (see Section 2.6.1.4), the CONTRACTOR shall provide long-term care
services (including CHOICES HCBS and nursing facility care) as described in this
Section 2.6.1.5 to members who have been enrolled into CHOICES by TENNCARE, as shown in
the outbound 834 enrollment file furnished by TENNCARE to the CONTRACTOR, effective
upon the CHOICES Implementation Date (see Section 1).

	 	2.6.1.5.2	 	TennCare enrollees will be enrolled by TENNCARE into CHOICES if the following
conditions, at a minimum, are met:

	 	2.6.1.5.2.1	 	TENNCARE or its designee determines the enrollee meets the categorical and
financial eligibility criteria for Group 1, 2 or 3;

	 	2.6.1.5.2.2	 	For Groups 1 and 2, TENNCARE determines that the enrollee meets nursing facility
level of care including for Group 2, that the enrollee needs ongoing CHOICES HCBS in
order to live safely in the home or community setting and to delay or prevent nursing
facility placement;

	 	2.6.1.5.2.3	 	For Group 2, the CONTRACTOR or, for new TennCare applicants, TENNCARE or its
designee, determines that the enrollee’s combined CHOICES HCBS, private duty nursing
and home health care can be safely provided at a cost less than the cost of nursing
facility care for the member;

	 	2.6.1.5.2.4	 	For Group 3, TENNCARE determines that the enrollee meets the at-risk level of
care; and

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

	 	2.6.1.5.3	 	For persons determined to be eligible for enrollment in Group 2 as a result of
Immediate Eligibility (as defined in Section 1 of this Agreement), the CONTRACTOR shall
provide a limited package of CHOICES HCBS (personal care, attendant care, homemaker
services, home-delivered meals, PERS, adult day care, and/or any other services as
specified in TennCare rules and regulations) as identified through a needs assessment
and specified in the plan of care. Upon notice that the State has determined that the
member meets categorical and financial eligibility for TennCare CHOICES, the CONTRACTOR
shall authorize additional services in accordance with Section 2.9.6.2.5. For members
residing in a community-based residential alternative at the time of CHOICES
enrollment, authorization for community- based residential alternative services shall
be retroactive to the member’s effective date of CHOICES enrollment.

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

	 	 	 	 	 	 	 
	Service and Benefit Limit	 	Group 1	 	Group 2	 	Group 3
	Nursing facility care

	 	X
	 	Short-term only

(up to 90 days)
	 	Short-term only

(up to 90 days)
	 

	 	 
	 	 
	 	 
	Community-based residential

alternatives

	 	

	 	X

	 	

	 

	 	 	 	 
	 	

	Personal care visits (up to 2

visits per day)

	 	

	 	X

	 	X

	 

	 	 	 	 
	 	 
	Attendant care (up to 1080 hours

per calendar year)

	 	

	 	X

	 	X

	 

	 	 	 	 
	 	 
	Homemaker services (up to 3

visits per week)

	 	

	 	X

	 	X

	 

	 	 	 	 
	 	 
	Home-delivered meals (up to 1

meal per day)

	 	

	 	X

	 	X

	 

	 	 	 	 
	 	 
	Personal Emergency Response

Systems (PERS)

	 	

	 	X

	 	X

	 

	 	 	 	 
	 	 
	Adult day care (up to 2080 hours

per calendar year)

	 	

	 	X

	 	X

	 

	 	 	 	 
	 	 
	In-home respite care (up to 216

hours per calendar year)

	 	

	 	X

	 	X

	 

	 	 	 	 
	 	 
	In-patient respite care (up to 9

days per calendar year)

	 	

	 	X

	 	X

	 

	 	 	 	 
	 	 
	Assistive technology (up to $900

per calendar year)

	 	

	 	X

	 	X

	 

	 	 	 	 
	 	 
	Minor home modifications (up to

$6,000 per project; $10,000 per

calendar year; and $20,000 per

lifetime)

	 	

	 	X

	 	X

	 

	 	 	 	 
	 	 
	Pest control (up to 9 units per

calendar year)

	 	

	 	X

	 	X

	 

	 	 	 	 
	 	 

	 	2.6.1.5.5	 	In addition to the benefit limits described above, in no case shall the CONTRACTOR
exceed the member’s individual cost neutrality cap (as defined in Section 1 of this
Agreement) for CHOICES Group 2 or the expenditure cap for Group 3.

	 	2.6.1.5.5.1	 	For CHOICES members in Group 2, the services that shall be compared against the
member’s individual cost neutrality cap include the total cost of CHOICES HCBS and
Medicaid reimbursed home health care and private duty nursing. The total cost of
CHOICES HCBS includes all covered CHOICES HCBS and other non-covered services that the
CONTRACTOR elects to offer as a cost effective alternative to nursing facility care
pursuant to Section 2.6.5.2 of this Agreement including, as applicable: CHOICES HCBS in
excess of specified CHOICES benefit limits, the one-time transition allowance for Group
2 and NEMT for Groups 2 and 3.

	 	2.6.1.5.5.1	 	For CHOICES members in Group 3, the total cost of CHOICES HCBS, excluding minor
home modifications, shall not exceed the expenditure cap (as defined in Section 1 of
this Agreement).

	 	2.6.1.5.6	 	CHOICES members may, pursuant to Section 2.9.7, choose to participate in consumer
direction of eligible CHOICES HCBS and, at a minimum, hire, fire and supervise workers
of eligible CHOICES HCBS.

	 	2.6.1.5.7	 	The CONTRACTOR shall, on an ongoing basis, monitor CHOICES members’ receipt and
utilization of long-term care services and identify CHOICES members who are not
receiving long-term care services. Pursuant to Section 2.30.10.5, the CONTRACTOR shall,
on a monthly basis, notify TENNCARE regarding members that have not received long-term
care services for a thirty (30) day period of time. The CONTRACTOR shall be responsible
for immediately initiating disenrollment of any member who is not receiving TennCare
reimbursed long-term care services and is not expected to resume receiving long-term
care services within the next thirty (30) days, except under extenuating circumstances
which must be reported to TennCare on the CHOICES Utilization Report. Acceptable
circumstances may include, but are not limited to, a member’s temporary hospitalization
or temporary receipt of Medicare-reimbursed skilled nursing facility care. Such
notification and/or disenrollment shall be based not only on receipt and/or payment of
claims for long-term care services, but also upon review and investigation by the
CONTRACTOR as needed to determine whether the member has received long-term care
services, regardless of whether claims for such services have been submitted or paid.

	 	2.6.1.5.8	 	The CONTRACTOR may submit to TENNCARE a request to no longer provide long-term
care services to a member due to concerns regarding the ability to safely and
effectively care for the member in the community and/or to ensure the member’s health,
safety and welfare. Acceptable reasons for this request include but are not limited to
the following:

	 	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;

	 	2.6.1.5.8.2	 	A member in Group 2 or 3 who repeatedly refuses to allow a care coordinator
entrance into his/her place of residence (Section 2.9.6);

	 	2.6.1.5.8.3	 	A member in Group 2 or 3 who refuses to receive critical HCBS as identified
through a needs assessment and documented in the member’s plan of care; and

	 	2.6.1.5.8.4	 	A member in Group 1 who fails to pay his/her patient liability and the
CONTRACTOR is unable to find a nursing facility willing to provide services to the
member (Section 2.6.7.2).

	 	2.6.1.5.8.5	 	A member in Group 2 or 3 who refuses to pay his/her patient liability and for
whom the CONTRACTOR is either: 1) in the case of persons receiving CBRA services,
unable to identify another provider willing to provide services to the member; or 2) in
the case of persons receiving non-residential HCBS or companion care, the CONTRACTOR is
unwilling to continue to serve the member, and the Bureau of TennCare has determined
that no other MCO is willing to serve the member.

	 	2.6.1.5.8.6	 	The CONTRACTOR’s request to no longer provide long-term care services to a
member shall include documentation as specified by TENNCARE. The State shall make any
and all determinations regarding whether the CONTRACTOR may discontinue providing
long-term care services to a member, disenrollment from CHOICES, and, as applicable,
termination from TennCare.

	 	2.6.1.5.9	 	The CONTRACTOR may submit to TENNCARE a request to disenroll from CHOICES a member
who is not receiving any Medicaid-reimbursed LTC services based on the CONTRACTOR’s
inability to reach the member only when the CONTRACTOR has exhausted all reasonable
efforts to contact the member, and has documented such efforts in writing, which must
be submitted with the disenrollment request. Efforts to contact the member shall
include, at a minimum:

	 	2.6.1.5.9.1	 	Multiple attempts to contact the member, his/her representative or designee (as
applicable) by phone. Such attempts must occur over a period of at least two (2) weeks
and at different times of the day and evening, including after business hours. The
CONTRACTOR shall attempt to contact the member at the phone number provided in the
outbound 834 enrollment file, any additional phone numbers the CONTRACTOR has on file,
including referral records and case management notes; and phone numbers that may be
provided in TENNCARE’s TPAES system. The CONTRACTOR shall also contact the member’s
Primary Care Provider and any contracted LTC providers that have delivered services to
the member during the previous six (6) months in order to obtain contact information
that can be used to reach the member;

	 	2.6.1.5.9.2	 	At least one (1) visit to the member’s most recently reported place of residence
except in circumstances where significant safety concerns prevent the CONTRACTOR from
completing the visit, which shall be documented in writing; and

	 	2.6.1.5.9.3	 	An attempt to contact the member by mail at the member’s most recently reported
place of residence at least two (2) weeks prior to the request to disenroll.

	8.	 	Sections 2.6.5.2.1 through 2.6.5.2.3 shall be amended by inserting the word “CHOICES”
before the word “HCBS”.

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

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

10. Sections 2.6.7.2 through 2.6.7.2.5 shall be deleted and replaced as follows:

	 	2.6.7.2	 	Patient Liability

	 	2.6.7.2.1	 	TENNCARE will notify the CONTRACTOR of any applicable patient liability amounts
for CHOICES members via the outbound 834 enrollment file.

	 	2.6.7.2.1.1	 	When TENNCARE notifies the CONTRACTOR of patient liability amounts for CHOICES
members via the outbound 834 enrollment file with an effective date any time other than
the first day of the month, the CONTRACTOR shall determine and apply the pro-rated
portion of patient liability for that month.

	 	2.6.7.2.2	 	The CONTRACTOR shall delegate collection of patient liability for CHOICES Group 1
members to the nursing facility and shall pay the facility net of the applicable
patient liability amount.

	 	2.6.7.2.2.1	 	In accordance with the involuntary discharge process, including notice and
appeal (see Section 2.12.11.3), a nursing facility may refuse to continue providing
services to a member who fails to pay his or her patient liability and for whom the
nursing facility can demonstrate to the CONTRACTOR that it has made a good faith effort
to collect payment.

	 	2.6.7.2.2.2	 	If the CONTRACTOR is notified that a nursing facility is considering discharging
a member (see Section 2.12.11.3), the CONTRACTOR shall work to find an alternate
nursing facility willing to serve the member and document its efforts in the member’s
files.

	 	2.6.7.2.2.3	 	If the CONTRACTOR is unable to find an alternate nursing facility willing to
serve the member and the member otherwise qualifies to enroll in CHOICES Group 2, the
CONTRACTOR shall determine if it can safely and effectively serve the member in the
community and within the cost neutrality cap. If it can, and the CONTRACTOR is willing
to continue serving a member who has failed to pay his or her patient liability or if
TENNCARE determines that the member would not have patient liability in the community
setting, the member shall be offered a choice of CHOICES HCBS. If the member chooses
CHOICES HCBS, the CONTRACTOR shall forward all relevant information to TENNCARE for a
decision regarding transition to Group 2 (Section 2.9.6.3).

	 	2.6.7.2.2.4	 	If the CONTRACTOR is unable to find an alternate nursing facility willing to
serve the member and the CONTRACTOR determines that it cannot safely and effectively
serve the member in the community and within the cost neutrality cap, the member
declines to enroll in Group 2, or TENNCARE determines that the member would continue to
have patient liability in the community setting and the CONTRACTOR is unwilling to
continue serving the member who has failed to pay his or her patient liability, or
TENNCARE denies enrollment in Group 2, the CONTRACTOR may, pursuant to Section
2.6.1.5.8, request to no longer provide long-term care services to the member.

	 	2.6.7.2.3	 	For CHOICES Group 2 and 3 members, patient liability shall be collected as
follows:

	 	2.6.7.2.3.1	 	The CONTRACTOR shall delegate collection of patient liability for CHOICES Group
2 members who reside in a CBRA facility to the CBRA facility and shall pay the facility
net of the applicable patient liability amount.

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

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

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

	 	2.6.7.2.3.2.3	 	The CONTRACTOR shall, upon notification in the outbound 834 enrollment file of
retroactive adjustments in patient liability amounts based on Item D deductions,
without requiring any action on the part of the member or provider, adjust the Group 2
or Group 3 member’s patient liability for the following month(s) until reimbursement of
any overpayment is accomplished, or shall refund any overpayments within thirty (30)
days of a request from the member or when the member will not continue to have patient
liability obligations going forward.

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

	 	2.6.7.2.3.4	 	The CONTRACTOR shall not waive or otherwise fail to establish and maintain
processes for collection of patient liability in accordance with this Agreement.

11. Section 2.7.2.1.2 shall be deleted and replaced as follows:

	 	2.7.2.1.2	 	The CONTRACTOR shall provide behavioral health services in accordance with
this Agreement, TennCare Rules and Regulations and TennCare policies, including Section
2.6 and Attachment I of this Agreement, and TennCare Medical Necessity Rule 1200-13-
16.

12. Section 2.7.3 shall be deleted and replaced as
follows:

	 	2.7.3	 	Self-Direction of Health Care Tasks

The CONTRACTOR shall, in accordance with TennCare rules and regulations, permit
CHOICES members the option to direct and supervise a consumer-directed worker who
is providing eligible CHOICES HCBS in the performance of health care tasks.

	 	13.	 	Section 2.8.1.2 shall be amended by adding the phrase updated as described in current
NCQA Standards” as follows:

	 	2.8.1.2	 	Each DM program shall utilize evidence-based clinical practice guidelines
(hereafter referred to as the guidelines) that have been formally adopted and updated
as described in current NCQA Standards by the CONTRACTOR’s Quality Management/Quality
Improvement (QM/QI) committee or other clinical committee as a clinical basis for
development of program content and plan of care.

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

	 	2.8.1.6	 	As part of its DM program descriptions, the CONTRACTOR shall also describe how
the organization integrates member information and coordinates with and has timely
access to MCO case management activities and other supporting entities, including but
not limited to, Utilization Management (UM), CHOICES, Health Information Lines and
Wellness programs, to assure programs are linked and enrollees receive appropriate and
timely care.

15. Section 2.8.7.2 shall be amended by deleting the word “passive”.

	 	2.8.7.2	 	The CONRACTOR shall report the participation rates (as defined by NCQA) and the
number of individuals participating in each level of each of the DM programs.

16. Sections 2.9.2.1.4 through 2.9.2.1.4.6.5 shall be deleted and replaced as follows:

	 	2.9.2.1.4	 	For covered long-term care services for CHOICES members who are transferring
from another MCO, the CONTRACTOR shall be responsible for continuing to provide covered
long-term care services, including both CHOICES HCBS authorized by the transferring MCO
and nursing facility services, without regard to whether such services are being
provided by contract or non-contract providers.

	 	2.9.2.1.4.1	 	For a member in CHOICES Group 2 or 3, the CONTRACTOR shall continue CHOICES HCBS
authorized by the transferring MCO for a minimum of thirty (30) days after the member’s
enrollment and thereafter shall not reduce these services unless a care coordinator has
conducted a comprehensive needs assessment and developed a plan of care, and the
CONTRACTOR has authorized and initiated CHOICES HCBS in accordance with the member’s
new plan of care. If a member in CHOICES Group 2 or 3 is receiving short-term nursing
facility care, the CONTRACTOR shall continue to provide nursing facility services to
the member in accordance with the level of nursing facility services (Level I or Level
II) and/or reimbursement approved by TENNCARE (see Section 2.14.1.12). For a member in
Group 1, the CONTRACTOR shall provide nursing facility services to the member in
accordance with the level of nursing facility services (Level I or Level II) and/or
reimbursement approved by TENNCARE (see Section 2.14.1.12); however, the member may be
transitioned to the community in accordance with Section 2.9.6.8 of this Agreement.

	 	2.9.2.1.4.2	 	For a member in CHOICES Group 2 or 3, within thirty (30) days of notice of the
member’s enrollment with the CONTRACTOR, a care coordinator shall conduct a face-
to-face visit (see Section 2.9.6.2.5), including a comprehensive needs assessment (see
Section 2.9.6.5), and develop a plan of care (see Section 2.9.6.6), and the CONTRACTOR
shall authorize and initiate CHOICES HCBS in accordance with the new plan of care (see
Section 2.9.6.2.5). If a member in Group 2 or 3 is receiving short- term nursing
facility care on the date of enrollment with the CONTRACTOR, a care coordinator shall
complete a face-to-face visit prior to the expiration date of the level of nursing
facility services approved by TENNCARE, but no later than thirty (30) days after
enrollment to determine appropriate needs assessment and care planning activities (see
Section 2.9.6.2.5 for members who will be discharged from the nursing facility and
remain in Group 2 or 3 and Section 2.9.6.2.4 for members who will remain in the nursing
facility and be enrolled in Group 1). If the expiration date for the level of nursing
facility services approved by TENNCARE occurs prior to thirty (30) days after
enrollment, and the CONTRACTOR is unable to conduct the face-to-face visit prior to the
expiration date, the CONTRACTOR shall be responsible for facilitating discharge to the
community or enrollment in Group 1, whichever is appropriate prior to the member’s
exhaustion of the 90-day short-term NF benefit.

	 	2.9.2.1.4.3	 	If at any time before conducting a comprehensive needs assessment for a member
in CHOICES Group 2 or 3 the CONTRACTOR becomes aware of an increase in the member’s
needs, a care coordinator shall immediately conduct a comprehensive needs assessment
and update the member’s plan of care, and the CONTRACTOR shall initiate the change in
services within ten (10) days of becoming aware of the increase in the member’s needs.

	 	2.9.2.1.4.4	 	For a member in CHOICES Group 1, a care coordinator shall conduct a face-to-face
in- facility visit within thirty (30) days of the member’s enrollment with the
CONTRACTOR and conduct a needs assessment as determined necessary by the CONTRACTOR
(see Section 2.9.6.5).

	 	2.9.2.1.4.5	 	The CONTRACTOR shall facilitate a seamless transition to new services and/or
providers, as applicable, in the plan of care developed by the CONTRACTOR without any
disruption in services.

	 	2.9.2.1.4.6	 	The CONTRACTOR shall not:

	 	2.9.2.1.4.6.1	 	Transition nursing facility residents or residents of community-based
residential alternatives to another facility unless (1) the member or his/her
representative specifically requests to transition, which shall be documented in the
member’s file, (2) the member or his/her representative provides written consent to
transition based on quality or other concerns raised by the CONTRACTOR, which shall not
include the nursing facility’s rate of reimbursement; or (3) the facility where the
member is residing is not a contract provider; if the community-based residential
facility where the member is currently residing is not a contract provider, the
CONTRACTOR shall provide continuation of services in such facility for at least thirty
(30) days, which shall be extended as necessary to ensure continuity of care pending
the facility’s contracting with the CONTRACTOR or the member’s transition to a contract
facility; if the member is transitioned to a contract facility, the CONTRACTOR shall
facilitate a seamless transition to the new facility; if the nursing facility where the
member is currently residing is a non-contract provider, the CONTRACTOR shall (a)
authorize continuation of the services pending enrollment of the facility as a contract
provider (except a facility excluded for a 2-year period when the facility has
withdrawn from Medicaid participation); (b) authorize continuation of the services
pending facilitation of the member’s transition to a contract facility, subject to the
member’s agreement with such transition; or (c) may continue to reimburse services from
the non-contract nursing facility in accordance with TennCare rules and regulations;

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

	 	2.9.2.1.4.6.3	 	Admit a member in CHOICES Group 2 to a nursing facility unless (1) the member
requires a short-term nursing facility care stay; (2) the member chooses to transition
to a nursing facility and enroll in Group 1; or (3) the CONTRACTOR determines that it
cannot safely and effectively meet the needs of the member and within the member’s cost
neutrality cap, and the member agrees to transition to a nursing facility and enroll in
Group 1;

	 	2.9.2.1.4.6.4	 	Admit a member enrolled in CHOICES Group 3 to a nursing facility unless: (1)
the member meets nursing facility level of care and is expected to require nursing
facility services for ninety (90) days or less; or (2) the member meets nursing
facility level of care, is expected to require nursing facility services for more than
ninety (90) days and chooses to transition to a nursing facility and enroll in Group 1;
or

	 	2.9.2.1.4.6.5	 	Transition members in Group 2 or 3 to another HCBS provider for continuing
services unless the current HCBS provider is not a contract provider; if the current
HCBS provider is not a contract provider, the CONTRACTOR shall provide continuation of
HCBS from that provider for at least thirty (30) days, which shall be extended as
necessary to ensure continuity of care pending the provider’s contracting with the
CONTRACTOR or the member’s transition to a contract provider; if the member is
transitioned to a contract provider, the CONTRACTOR shall facilitate a seamless
transition to the new provider.

	17.	 	Sections 2.9.2.1.5 through 2.9.2.1.5.6.4 shall be deleted in their entirety including any
references thereto.

	18.	 	Section 2.9.2.5 shall be deleted and replaced as follows:

	 	2.9.2.5	 	If the CONTRACTOR becomes aware that a CHOICES member will be transferring to
another MCO, the CONTRACTOR (including, but not limited to the member’s care
coordinator or care coordination team) shall, in accordance with protocols established
by TENNCARE, work with the other MCO in facilitating a seamless transition for that
member.

19. Section 2.9.3.3, 2.9.3.4 and 2.9.3.6 shall be deleted and replaced as follows:

	 	2.9.3.3	 	For members in Group 2 the CONTRACTOR shall continue HCBS in the member’s
approved HCBS E/D waiver plan of care except case management for a minimum of thirty
(30) days after the member’s enrollment and thereafter shall not reduce HCBS unless the
member’s care coordinator has conducted a comprehensive needs assessment and developed
a plan of care and the CONTRACTOR has authorized and initiated HCBS in accordance with
the member’s new plan of care. If a member in CHOICES Group 2 is receiving short-term
nursing facility care, the CONTRACTOR shall continue to provide nursing facility
services to the member in accordance with the level of nursing facility services (Level
I or Level II) and/or reimbursement approved by TENNCARE (see Section 2.14.1.12).

	 	2.9.3.4	 	For a member in CHOICES Group 2, within ninety (90) days of CHOICES implementation,
the member’s care coordinator shall conduct a face-to-face visit (see Section
2.9.6.2.5), including a comprehensive needs assessment (see Section 2.9.6.5), and
develop a plan of care (see Section 2.9.6.6), and the CONTRACTOR shall authorize and
initiate CHOICES HCBS in accordance with the new plan of care. If a member in Group 2
is receiving short-term nursing facility care on the date of enrollment with the
CONTRACTOR the member’s care coordinator shall complete a face-to-face visit prior to
the expiration date of the level of nursing services approved by TENNCARE, but no more
than ninety (90) days after CHOICES implementation, to determine appropriate needs
assessment and care planning activities (see Section 2.9.6.2.5 for members who will be
discharged from the nursing facility and remain in Group 2 or 3 and Section 2.9.6.2.4
for members who will remain in the nursing facility and be enrolled in Group 1). If the
expiration date for the level of nursing facility services approved by TENNCARE occurs
prior to ninety (90) days after CHOICES implementation, and the CONTRACTOR is unable to
conduct the face-to-face visit prior to the expiration date, the CONTRACTOR shall be
responsible for facilitating discharge to the community or enrollment in Group 1,
whichever is appropriate.

	 	2.9.3.6	 	The CONTRACTOR shall provide nursing facility services to a member in Group 1 in
accordance with the level of nursing facility services (Level I or Level II) and/or
reimbursement approved by TENNCARE (see Section 2.14.1.12); however, the member may be
transitioned to the community in accordance with Section 2.9.6.8 of this Agreement.

20. Section 2.9.3.9.2 and 2.9.3.9.4 shall be deleted and replaced as follows:

	 	2.9.3.9.2	 	Transition Group 1 members to CHOICES HCBS unless the member chooses to
receive CHOICES HCBS as an alternative to nursing facility care and is enrolled in
CHOICES Group 2 (see Section 2.9.6.8 for requirements regarding nursing facility to
community transition);

	 	2.9.3.9.4	 	Transition members in Group 2 or 3 to another HCBS provider for continuing
services unless the current HCBS provider is not a contract provider; if the current
HCBS provider is not a contract provider, the CONTRACTOR shall provide continuation of
CHOICES HCBS from that provider for at least thirty (30) days, which shall be extended
as necessary to ensure continuity of care pending the provider’s contracting with the
CONTRACTOR or the member’s transition to a contract provider; if the member is
transitioned to a contract provider, the CONTRACTOR shall facilitate a seamless
transition to the new provider.

	21.	 	Section 2.9.6.1 shall be amended by adding a new Section 2.9.6.1.6 and renumbering the
remaining Sections accordingly, including any references thereto.

	 	2.9.6.1.6	 	The CONTRACTOR shall compute Care Coordination CHOICES-related timelines as
follows;

	 	2.9.6.1.6.1	 	The day of the initiating event (e.g., receipt of a referral or receipt of the
outbound 834 enrollment file is not to be included in the computation;

	 	2.9.6.1.6.2	 	The Calendar Day immediately following the initiating event is day one (1) of
timelines utilizing calendar days. Each subsequent calendar day is included in the
computation; and

	 	2.9.6.1.6.3	 	The Business Day (see Section 1) immediately following the initiating event is
day one (1) of timelines utilizing business days. Each subsequent business day is
included in the computation.

	22.	 	Sections 2.9.6.2.3 through 2.9.6.2.3.8 shall be deleted and replaced as
follows:	 

2.9.6.2.3 Functions of the Single Point of Entry (SPOE)

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

	 	2.9.6.2.3.2	 	For persons identified by TENNCARE or its designee as meeting the screening
criteria, or for whom TENNCARE or its designee opts not to use a screening process,
TENNCARE or its designee will conduct a face-to-face intake visit with the applicant.
As part of this intake visit TENNCARE or its designee will, using the tools and
protocols specified by TENNCARE, conduct a level of care and needs assessment; assess
the member’s existing natural support system, including but not limited to informal
supports provided by family and other caregivers, services that may be available at no
cost to the member through other entities, and services that are reimbursable through
other public or private funding sources, such as Medicare or long-term care insurance;
and identify the long-term care services and home health and/or private duty nursing
services that may be needed by the applicant upon enrollment into CHOICES that would
build upon and not supplant a member’s existing natural support system.

	 	2.9.6.2.3.3	 	TENNCARE or its designee shall conduct the intake visit, including the level of
care and needs assessment, in the applicant’s place of residence, except under
extenuating circumstances (such as the member’s hospitalization), which shall be
documented in writing.

	 	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 CHOICES HCBS, both verbally and in writing, and obtain a
Freedom of Choice form signed and dated by the applicant or his/her representative; (5)
provide detailed information and obtain signed acknowledgement of understanding
regarding a CHOICES member’s responsibility with respect to payment of patient
liability amounts, including, as applicable, the potential consequences for non-payment
of patient liability which may include loss of the member’s current nursing facility or
CBRA provider or MCO, disenrollment from CHOICES, and to the extent the member’s
eligibility is dependent on receipt of long-term care services, possible loss of
eligibility for TennCare; and (6) for applicants who want to receive NF services,
provide information regarding the completion of all PASRR requirements prior to nursing
facility admission and conduct the level I PASRR screening; (7) for applicants who are
seeking CHOICES HCBS: (a) conduct a risk assessment using a tool and protocol specified
by TENNCARE and develop, as applicable, a risk agreement that shall be signed by the
applicant or his/her representative and which shall include identified risks to the
applicant, the consequences of such risks, strategies to mitigate the identified risks,
and the applicant’s decision regarding his/her acceptance of risk; (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, including
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
(8) 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.

	 	2.9.6.2.3.5	 	The listing of CHOICES HCBS and home health and/or private duty nursing services
the member may need shall be used by TENNCARE or its designee to determine whether
services can be provided within the member’s cost neutrality cap and may be further
refined based on the CONTRACTOR’s comprehensive needs assessment and plan of care
development processes.

	 	2.9.6.2.3.6	 	The State will be responsible for determining TennCare categorical and financial
eligibility and level of care and enrolling eligible TennCare members into CHOICES.

	 	2.9.6.2.3.7	 	TENNCARE will notify the CONTRACTOR via the outbound 834 enrollment file when a
person has been enrolled in CHOICES, the member’s CHOICES Group, and any applicable
patient liability amounts (See Section 2.6.7). For members in CHOICES Group 2, TENNCARE
will notify the CONTRACTOR of the member’s cost neutrality cap (see definition in
Section 1 and Section 2.6.1.5.2.3), which shall be the average cost of Level 1 nursing
facility care unless a higher cost neutrality cap is established by TENNCARE based on
information submitted by the AAAD or MCO (as applicable) in the level of care.

	 	2.9.6.2.3.8	 	TENNCARE or its designee will make available to the CONTRACTOR the documentation
from the intake visit, including but not limited to the member’s level of care and
needs assessment, the assessment of the member’s existing natural support system, the
member’s risk assessment and signed risk agreement (for members in CHOICES Group 2),
and the services identified by TENNCARE or its designee that the member may need upon
CHOICES enrollment.

23. Sections 2.9.6.2.4 through 2.9.6.2.4.8 shall be deleted and replaced as follows:

	 	2.9.6.2.4	 	Functions of the CONTRACTOR for Members in CHOICES Group 1

	 	2.9.6.2.4.1	 	For members enrolled in CHOICES Group 1, who are, upon CHOICES enrollment,
receiving nursing facility services, the CONTRACTOR shall reimburse such services in
accordance with the level of nursing facility services (Level I or Level II) and/or
reimbursement approved by TENNCARE (see Section 2.14.1.12), except that the CONTRACTOR
may reimburse a lesser level of service when such lesser level of service is billed by
the facility. Reimbursement for such services shall be from the current provider as of
the effective date of CHOICES enrollment. The CONTRACTOR shall not move members
enrolled in CHOICES Group 1 who are, upon CHOICES enrollment, receiving nursing
facility services, to another facility unless: (1) the member or his/her representative
specifically requests to move, which shall be documented in the member’s file; (2) the
member or his/her representative provides written consent to move based on quality or
other concerns raised by the CONTRACTOR, which shall not include the nursing facility’s
rate of reimbursement; or (3) the facility where the member is residing is not a
contract provider. If the nursing facility is a non-contract provider, the CONTRACTOR
shall (a) provide continuation of the services pending enrollment of the facility as a
contract provider (except a facility excluded for a 2-year period when the facility has
withdrawn from Medicaid participation); (b) provide continuation of the services
pending facilitation of the member’s transition to a contract facility, subject to the
member’s agreement with such transition; or (c) may continue to reimburse services from
the non-contract nursing facility in accordance with TennCare rules and regulations.

	 	2.9.6.2.4.2	 	The CONTRACTOR shall, within thirty (30) calendar days of notice of the member’s
enrollment in CHOICES, conduct a face-to-face visit with the member and perform any
additional needs assessment deemed necessary by the CONTRACTOR (see Section 2.9.6.5.1).
The care coordinator shall review the plan of care developed by the nursing facility
and may supplement the plan of care as necessary and appropriate (see Section
2.9.6.6.1).

	 	2.9.6.2.4.3	 	The CONTRACTOR shall not transition members in Group 1 to CHOICES HCBS unless
the member chooses to receive CHOICES HCBS as an alternative to nursing facility and is
enrolled in Group 2.

	 	2.9.6.2.4.4	 	For purposes of the CHOICES program, the CONTRACTOR may decide whether it will
issue service authorizations for nursing facility services, or whether it will instead
process claims for such services in accordance with the level of care and/or
reimbursement (including the duration of such level of care and/or reimbursement)
approved by TENNCARE (see Section 2.14.1.12), except that the CONTRACTOR may reimburse
a lesser level of service when such lesser level of service is billed by the facility.
        .

	 	2.9.6.2.4.5	 	For CHOICES members approved by TENNCARE for Level II (or skilled) nursing
facility services, the CONTRACTOR shall be responsible for monitoring the member’s
continued need for Medicaid reimbursed skilled and/or rehabilitation services, promptly
notifying TENNCARE when Level II nursing facility services are no longer medically
necessary, and for the submission of information needed by TENNCARE to reevaluate the
member’s level of care for nursing facility services (see also Section 2.14.1.12.2).

	24.	 	Sections 2.9.6.2.5.2 and 2.9.6.2.5.3 shall be amended by adding the word “CHOICES” in
front of the word “HCBS”.

	25.	 	Sections 2.9.6.2.5.8 through 2.9.6.2.5.13 shall be deleted and replaced as follows:

	 	2.9.6.2.5.8	 	As part of the face-to-face visit for members in CHOICES Group 2, the care
coordinator shall review, and revise as necessary, the member’s risk assessment and
risk agreement and have the member or his/her representative sign and date any revised
risk agreement.

	 	2.9.6.2.5.9	 	As part of the face-to-face visit, for members determined to need eligible
CHOICES 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 CHOICES 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.

	 	2.9.6.2.5.10	 	For purposes of CHOICES HCBS, service authorizations shall include the amount,
frequency, and duration of each service to be provided and the schedule at which such
care is needed, as applicable; the requested start date; and other relevant information
as prescribed by TENNCARE. The CONTRACTOR shall be 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, for arranging an alternative provider who is
able to initiate services as authorized on or before the requested start date.

	 	2.9.6.2.5.11	 	The member’s care coordinator/care coordination team shall provide at least
verbal notification to the member prior to initiation of CHOICES HCBS identified in the
plan of care regarding any change in providers selected by the member for each CHOICES
HCBS, including the reason such change has been made.

	 	2.9.6.2.5.12	 	If the CONTRACTOR is unable to initiate any CHOICES HCBS in accordance with the
timeframes specified herein, the CONTRACTOR shall issue written notice to the member,
documenting the service(s) that will be delayed, the reasons for the delay, and the
date the service(s) will start, and shall make good faith efforts to ensure that
services are provided as soon as practical.

	 	2.9.6.2.5.13	 	TENNCARE may establish, pursuant to policies and protocols for management of
waiting lists, alternative timeframes for completion of specified intake functions and
activities when there is a waiting list.

26. Section 2.9.6.3.1.5 through 2.9.6.3.1.5.5 shall be deleted and replaced as follows:

	 	 	 
	2.9.6.3.1.5Periodic review (at least quarterly) of:
	2.9.6.3.1.5.1

2.9.6.3.1.5.2

2.9.6.3.1.5.3

2.9.6.3.1.5.4
	 	Claims or encounter data;

Hospital admission or discharge data;

Pharmacy data; and

Data collected through the DM and/or UM processes.

	 	2.9.6.3.1.5.5	 	The CONTRACTOR may define in its policies and procedures other steps that will
be taken to better assess if the members identified through means other than referral
or notice of hospital admission will likely qualify for CHOICES, and may target its
screening and intake efforts to a more targeted list of persons that are most likely to
need and to qualify for CHOICES services.

	 	2.9.6.3.1.5.6	 	TENNCARE may establish, pursuant to policies and protocols for management
of waiting lists, alternative timeframes for completion this task when there is a
waiting list.

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

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

28. Section 2.9.6.3.3.1 shall be deleted and replaced as follows:

	 	2.9.6.3.3.1	 	Documentation of at least three (3) attempts occurring over a period of no
less than three (3) days to contact the member by phone (which shall include at least
one (1) attempt to contact the member at the number most recently reported by the
member and at least one (1) attempt to contact the member at the number provided in the
referral, if different, and which shall occur at different times of the day and
evening, including after business hours), followed by a letter sent to the member’s
most recently reported address that provides information about CHOICES and how to
obtain a screening for CHOICES, shall constitute sufficient effort by the CONTRACTOR to
assist a member who has been referred for CHOICES, regardless of referral source.
TENNCARE will review the CONTRACTOR’s referral data, including the number of referred
members the CONTRACTOR is unable to reach, and may institute additional requirements as
necessary to ensure reasonable efforts to reach the member and complete the referral
and intake process.

	29.	 	Section 2.9.6.3.7 shall be deleted and replaced as follows:

	 	2.9.6.3.7	 	If the member does not meet the telephone screening criteria, the CONTRACTOR
shall notify the member verbally and in writing in the format prescribed by TENNCARE:
(1) that he/she does not appear to meet the criteria for enrollment in CHOICES; (2)
that he/she has the right to continue with the CHOICES intake process and, if
determined not eligible, to receive notice of such denial, including the member’s due
process right to appeal; and (3) how, if the member wishes to proceed with the CHOICES
intake process, the member can submit a written request to proceed with the CHOICES
intake process to the CONTRACTOR. In the event that a member does submit such written
request, the CONTRACTOR shall process the request as a new referral and shall conduct a
face-to-face intake visit, including level of care assessment and needs assessment,
within ten (10) business days of receipt of the member’s written request, unless a
later date is requested by the member, which shall be documented in writing in the
CHOICES intake record.

	30.	 	Section 2.9.6.3.8.2 shall be amended by adding the word “CHOICES” in front of the word
“HCBS”.

	31.	 	Sections 2.9.6.3.9 through 2.9.6.3.18 shall be deleted and replaced as follows:

	 	2.9.6.3.9	 	As part of the face-to-face intake visit, the care coordinator shall: (1)
provide general 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 CHOICES HCBS, both verbally and in
writing, and obtain a Freedom of Choice form signed and dated by the member or his/her
representative; (5) provide detailed information and signed acknowledgement of
understanding regarding a CHOICES member’s responsibility with respect to payment of
patient liability amounts, including, as applicable, the potential consequences for
non-payment of patient liability which may include loss of the member’s current nursing
facility or CBRA provider or MCO, disenrollment from CHOICES, and to the extent the
member’s eligibility is dependent on receipt of long-term care services, possible loss
of eligibility for TennCare; and (6) for members who want to receive nursing facility
services, provide information regarding the completion of all PASRR requirements prior
to nursing facility admission and conduct the level I PASRR screening; (7) for members
who are seeking CHOICES HCBS, the care coordinator, shall: (a) conduct a risk
assessment using a tool and protocol specified by TENNCARE and shall develop, as
applicable, a risk agreement that shall be signed and dated by the member or his/her
representative and which shall include identified risks to the member, the consequences
of such risks, strategies to mitigate the identified risks, and the member’s decision
regarding his/her acceptance of risk; (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, and provide explanation to the member regarding
the individual cost neutrality cap, including that a change in needs or circumstances
that would result in the cost neutrality cap being exceeded or that would result in the
CONTRACTOR’s inability to safely and effectively meet the member’s needs in the
community and within the cost neutrality cap may result in the member’s disenrollment
from CHOICES Group 2, in which case, the member’s care coordinator will assist with
transition to a more appropriate care delivery setting; and (c) provide information
regarding consumer direction and obtain written confirmation of the member’s decision
regarding participation in consumer direction; and (8) 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.

	 	2.9.6.3.10	 	If the member does not meet appear to meet CHOICES enrollment criteria, the care
coordinator may advise the member verbally: (1) that he/she does not appear to meet the
criteria for enrollment in CHOICES; but shall also advise the member (2) that he/she
has the right to continue with the CHOICES intake process and, if determined not
eligible, to receive notice of such denial, including the member’s due process right to
a fair hearing.

	 	2.9.6.3.10.1	 	The decision to discontinue the CHOICES intake process must be made by the
member or the member’s representative and the CONTRACTOR shall not encourage the member
or member’s representative to discontinue the process;

	 	2.9.6.3.10.2	 	Upon the member’s decision to continue the CHOICES intake, the care coordinator
shall continue the intake process and complete all required activities, including
submission of the level of care to TENNCARE; or

	 	2.9.6.3.10.3	 	Upon the member’s decision to discontinue the CHOICES intake process, the care
coordinator shall, in the manner prescribed by TENNCARE, document the member’s decision
to terminate the CHOICES intake process, including the member’s or representative’s
signature and date. The CONTRACTOR shall maintain this documentation in the member’s
record and provide a copy to the member/representative.

	 	2.9.6.3.10.4	 	The CONTRACTOR shall provide the member with information about how to initiate
a new CHOICES screening and intake process in the future.

	 	2.9.6.3.11	 	If, during the face-to-face intake visit the member or the member’s
representative elects to terminate the intake process for any other reason (e.g.,
estate recovery, patient liability, or does not need the services available through
CHOICES), the care coordinator shall, in the manner prescribed by TENNCARE, document
the member’s decision to terminate the CHOICES intake process, including the member’s
or representative’s signature and date. The CONTRACTOR shall maintain this
documentation in the member’s record and provide a copy to the member/representative.

	 	2.9.6.3.11.1	 	The decision to discontinue the CHOICES intake process must be made by the
member or the member’s representative and the CONTRACTOR shall not encourage the member
or member’s representative to discontinue the process;

	 	2.9.6.3.11.2	 	The CONTRACTOR shall provide the member with information about how to initiate
a new CHOICES screening and intake process in the future.

	 	2.9.6.3.12	 	For CHOICES referrals by or on behalf of a potential CHOICES member, regardless
of referral source, the care coordinator shall conduct the face-to-face intake visit
and shall develop a plan of care, as appropriate (see Section 2.9.6.6), within ten (10)
business days of receipt of such referral, unless a later date is requested by the
member, which shall be documented in writing in the CHOICES intake record.

	 	2.9.6.3.13	 	For members identified by the CONTRACTOR as potentially eligible for CHOICES by
means other than referral, the care coordinator shall conduct the face-to-face intake
visit and shall develop a plan of care, as appropriate (see Section 2.9.6.6), within
thirty (30) days of identification of the member as potentially eligible for CHOICES.
For persons identified through notification of hospital admission, the CONTRACTOR shall
coordinate with the hospital discharge planner to determine whether long-term care
services may be needed upon discharge, and if so, complete all applicable screening
and/or intake processes immediately to facilitate timely transition to the most
integrated and cost effective long-term care delivery setting appropriate for the
member’s needs.

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

	 	2.9.6.3.15	 	If the member is seeking access to CHOICES HCBS through enrollment in CHOICES
Group 2 and the enrollment target for CHOICES Group 2 has been reached, the CONTRACTOR
shall notify TENNCARE, at the time of submission of the level of care and needs
assessment and plan of care, as appropriate, whether the person shall be placed on a
waiting list for CHOICES Group 2. If the CONTRACTOR wishes to enroll the person in
CHOICES Group 2 as a cost effective alternative (CEA) to nursing facility care that
would otherwise be provided, the CONTRACTOR shall submit to TENNCARE the following:

	 	2.9.6.3.15.1	 	A written summary of the CONTRACTOR’s CEA determination, including an
explanation of the member’s circumstances which warrant the immediate provision of
nursing facility services unless CHOICES HCBS are immediately available.

	 	2.9.6.3.15.2	 	TENNCARE may request additional information as needed to confirm the
CONTRACTOR’s CEA determination and/or provider capacity to meet the member’s needs, and
shall, only upon receipt of satisfactory documentation, enroll the member in CHOICES.

	 	2.9.6.3.16	 	The CONTRACTOR shall be responsible for (1) advising members who appear to meet
the nursing facility level of care that are seeking access to CHOICES HCBS through
enrollment in CHOICES Group 2 when an enrollment target has been (or will soon be)
reached; (2) advising such persons that they may choose to receive nursing facility
services if CHOICES HCBS are not immediately available; (3) determining whether the
person wants nursing facility services if CHOICES 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).

	 	2.9.6.3.17	 	The State will be responsible for determining TennCare categorical and financial
eligibility and level of care and enrolling eligible TennCare members into CHOICES.

	 	2.9.6.3.18	 	TENNCARE will notify the CONTRACTOR via the outbound 834 enrollment file when a
person has been enrolled in CHOICES and, if the member is enrolled in CHOICES, the
member’s CHOICES Group and applicable patient liability amounts (see Section 2.6.7).
For members in CHOICES Group 2, TENNCARE will notify the CONTRACTOR of the member’s
cost neutrality cap (see definition in Section 1 and see Section 2.6.1.5.2.3), which
shall be the average cost of Level 1 nursing facility care unless a higher cost
neutrality cap is established by TENNCARE based on information submitted by the AAAD or
MCO (as applicable) in the level of care.

	 	2.9.6.3.19	 	For all newly enrolled CHOICES Group 1 members, the CONTRACTOR shall reimburse NF
services in accordance with the level of nursing facility services or reimbursement
approved by TENNCARE, and as of the effective date of CHOICES enrollment, except that
the CONTRACTOR may reimburse a lesser level of service which such lesser level of
service is billed by the facility.

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

	 	2.9.6.3.20.1	 	For purposes of the CHOICES program, service authorizations for CHOICES 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. The CONTRACTOR may decide whether it will issue
service authorizations for nursing facility services, or whether it will instead
process claims for such services in accordance with the level of care and/or
reimbursement (including the duration of such level of care and/or reimbursement)
approved by TENNCARE (see Section 2.14.1.12), except that the CONTRACTOR may reimburse
a lesser level of service when such lesser level of service is billed by the facility.

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

	 	2.9.6.3.20.3	 	If the CONTRACTOR is unable to initiate any long-term care service within the
timeframes specified in this Agreement, the CONTRACTOR shall issue written notice to
the member, documenting the service(s) that will be delayed, the reasons for the delay
and the date the service(s) will start, and shall make good faith efforts to ensure
that services are provided as soon as practical.

	 	2.9.6.3.20.4	 	For members enrolled in CHOICES Groups 1 or 2 who are, upon CHOICES enrollment,
receiving nursing facility or community-based residential alternative services from a
contract provider, the CONTRACTOR shall authorize such services from the current
provider as of the effective date of CHOICES enrollment. The CONTRACTOR shall not move
members enrolled in CHOICES Groups 1 or 2 who are, upon CHOICES enrollment, receiving
services in a nursing facility or community-based residential alternative setting to
another facility unless: (1) the member or his/her representative specifically requests
to move, which shall be documented in the member’s file; (2) the member or his/her
representative provides written consent to move based on quality or other concerns
raised by the CONTRACTOR, which shall not include the nursing facility’s rate of
reimbursement; or (3) the facility where the member is residing is not a contract
provider; if the community-based residential facility where the member is currently
residing is not a contract provider, the CONTRACTOR shall provide continuation of
services in such facility for at least thirty (30) days, which shall be extended as
necessary to ensure continuity of care pending the facility’s contracting with the
CONTRACTOR or the member’s transition to a contract facility; if the member is
transitioned to a contract facility, the CONTRACTOR shall facilitate a seamless
transition to the new facility; if the nursing facility where the member is currently
residing is a non-contract provider, the CONTRACTOR shall (a) authorize continuation of
the services pending enrollment of the facility as a contract provider (except a
facility excluded for a 2-year period when the facility has withdrawn from Medicaid
participation); (b) authorize continuation of the services pending facilitation of the
member’s transition to a contract facility, subject to the member’s agreement with such
transition; or (c) may continue to reimburse services from the non-contract nursing
facility in accordance with TennCare rules and regulations.

	 	2.9.6.3.20.5	 	For members receiving nursing facility services, the care coordinator shall
participate as appropriate in the nursing facility’s care planning process (see Section
2.9.6.5.1) and may supplement the facility’s plan of care as necessary (see Section
2.9.6.6.1).

	 	2.9.6.3.20.6	 	The CONTRACTOR shall not divert or transition members in CHOICES Group 1 to
CHOICES HCBS unless the member chooses to receive CHOICES HCBS as an alternative to
nursing facility and is enrolled in Group 2.

	 	2.9.6.3.20.7	 	The CONTRACTOR shall not admit a member enrolled in CHOICES Group 2 to a
nursing facility unless: (1) the member requires a short-term nursing facility care
stay; (2) the member chooses to transition to a nursing facility and enroll in Group 1;
or (3) the CONTRACTOR determines that it cannot safely and effectively meet the needs
of the member and at a cost that is less than the member’s cost neutrality cap and the
member agrees to transition to a nursing facility and enroll in Group 1.

	 	2.9.6.3.20.8	 	The CONTRACTOR shall not admit a member enrolled in CHOICES Group 3 to a
nursing facility unless: (1) the member meets nursing facility level of care and is
expected to require nursing facility services for ninety (90) days or less; or (2) the
member meets nursing facility level of care, is expected to require nursing facility
services for more than ninety (90) days and chooses to transition to a nursing facility
and enroll in Group 1.

	 	2.9.6.3.2	 	1 TENNCARE may establish, pursuant to policies and protocols for management of
waiting lists, alternative timeframes for completion of specified intake functions and
activities for persons when there is a waiting list.

32. Section 2.9.6.4.4 shall be deleted and replaced as follows:

	 	2.9.6.4.4	 	The CONTRACTOR may utilize a care coordination team approach to performing
care coordination activities prescribed in Section 2.9.6. For each CHOICES member, the
CONTRACTOR’s care coordination team shall consist of the member’s care coordinator and
specific other persons with relevant expertise and experience appropriate to address
the needs of CHOICES members. Care coordination teams shall be discrete entities within
the CONTRACTOR’s organizational structure dedicated to fulfilling CHOICES care
coordination functions. The CONTRACTOR shall establish policies and procedures that
specify, at a minimum: the composition of care coordination teams; the tasks that shall
be performed directly by the care coordinator as specified in this Agreement, including
needs assessment, development of the plan of care, and all minimum care coordination
contacts; the tasks that may be performed by the care coordinator or the care
coordination team; measures taken to ensure that the care coordinator remains the
member’s primary point of contact for the CHOICES program and related issues;
escalation procedures to elevate issues to the care coordinator in a timely manner; and
measures taken to ensure that if a member needs to reach his/her care coordinator
specifically, calls that require immediate attention by a care coordinator are handled
by a care coordinator and calls that do not require immediate attention are returned by
the member’s care coordinator the next business day. The CONTRACTOR may elect to
utilize specialized intake coordinators or intake teams for initial needs assessment
and care planning activities. All intake activities identified as responsibilities of
the care coordinator shall be completed by an individual who meets all of the
requirements to be a care coordinator. Should the CONTRACTOR elect to utilize
specialized intake coordinators or intake teams, the CONTRACTOR shall develop policies
and procedures which specify how the contractor will coordinate a seamless transfer of
information from the intake coordinator or team to the member’s care coordinator.

33. Section 2.9.6.6.1.1 shall be amended by deleting the phrase “/care coordination team”.

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

34. Section 2.9.6.6.2.4 shall be deleted and replaced as follows:

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

	35.	 	Section 2.9.6.6.2.5.11 shall be amended by adding the words “eligible CHOICES” in front of
the word “HCBS”.

	36.	 	Section 2.9.6.6.2.6 shall be amended by adding a new sentence as follows:

	 	2.9.6.6.2.6	 	The member’s care coordinator/care coordination team shall ensure that the
member reviews, signs and dates the plan of care as well as any updates. The care
coordinator shall also sign and date the plan of care, along with any updates.

	37.	 	Sections 2.9.6.6.2.8 and 2.9.6.6.2.9 shall be deleted and replaced as follows:

	 	2.9.6.6.2.8	 	Within five (5) business days of completing a reassessment of a member’s
needs, the member’s care coordinator shall update the member’s plan of care as
appropriate, and the CONTRACTOR shall authorize and initiate CHOICES HCBS in the
updated plan of care. The CONTRACTOR shall comply with requirements for service
authorization in Section 2.9.6.2.5.10, change of provider in Section 2.9.6.2.5.11, and
notice of service delay in Section 2.9.6.2.5.12.

	 	2.9.6.6.2.9	 	The member’s care coordinator shall inform each member of his/her eligibility
end date and educate members regarding the importance of maintaining TennCare CHOICES
eligibility, that eligibility must be redetermined at least once a year, and that
members receiving CHOICES HCBS will be contacted by TENNCARE or its designee near the
date a redetermination is needed to assist them with the process, e.g., collecting
appropriate documentation and completing the necessary forms.

38. Section 2.9.6.7.2.1 shall be amended by deleting the phrase “in CHOICES Group 1”.

	 	2.9.6.7.2.1	 	Members who are waiting for placement in a nursing facility;

39. Sections 2.9.6.8 through 2.9.6.8.22 shall be deleted and replaced as follows:

	 	2.9.6.8	 	Nursing Facility-to-Community Transition 

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

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

	 	2.9.6.8.1.2	 	Identification through the care coordination process, including but not limited
to: assessments, information gathered from nursing facility staff or participation in
Grand Rounds (as defined in Section 1); and

	 	2.9.6.8.1.3	 	Review and analysis of members identified by TENNCARE based on Minimum Data Set
(MDS) data from nursing facilities.

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

	 	2.9.6.8.3	 	For identification by the CONTRACTOR by means other than referral or the care
coordination process of a member who may have the ability and/or desire to transition
from a nursing facility to the community, the CONTRACTOR shall ensure that within
ninety (90) days of such identification a care coordinator conducts an in-facility
visit with the member to determine whether or not the member is interested in and
potential ability to pursue transition to the community. The member’s care
coordinator/care coordination team shall document in the member’s case file that
transition was discussed with the member and indicate the member’s wishes as well as
the member’s potential for transition. The CONTRACTOR shall not require a member to
transition when the member expresses a desire to continue receiving nursing facility
services.

	 	2.9.6.8.4	 	If the member wishes to pursue transition to the community, within fourteen (14)
days of the initial visit (see Sections 2.9.6.8.2 and 2.9.6.8.3 above) or within
fourteen (14) days of identification through the care coordination process, the care
coordinator shall conduct an in- facility assessment of the member’s ability and/or
desire to transition using tools and protocols specified or prior approved in writing
by TENNCARE. This assessment shall include the identification of any barriers to a safe
transition.

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

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

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

	 	2.9.6.8.8	 	The care coordinator shall include other individuals such as the member’s family
and/or caregiver in the transition planning process if the member requests and/or
approves, and such persons are willing and able to participate.

	 	2.9.6.8.9	 	As part of transition planning, prior to the member’s physical move to the
community, the care coordinator shall visit the residence where the member will live to
conduct an on-site evaluation of the physical residence and meet with the member’s
family or other caregiver who will be residing with the member (as appropriate). The
care coordinator shall include in the transition plan activities and/or services needed
to mitigate any perceived risks in the residence including but not limited to an
increase in face-to-face visits beyond the minimum required contacts in Sections
2.9.6.8.18 and 2.9.6.8.17.

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

	 	2.9.6.8.11	 	The CONTRACTOR shall approve the transition plan and authorize any covered or
cost effective alternative services included in the plan within ten (10) business days
of completion of the plan. The transition plan shall be fully implemented within ninety
(90) days from approval of the transition plan, except under extenuating circumstances
which must be documented in writing.

	 	2.9.6.8.12	 	The member’s care coordinator shall also complete a plan of care that meets all
criteria described in Section 2.9.6.6 for members in CHOICES Groups 2 and 3 including
but not limited to completing a comprehensive needs assessment, completing and signing
the risk agreement and making a final determination of cost neutrality. The plan of
care shall be authorized and initiated prior to the member’s transition to the
community.

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

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

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

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

	 	2.9.6.8.17	 	For members who will live independently in the community or whose on-site visit
during transition planning indicated an elevated risk, within the first twenty-four
(24) hours, the care coordinator shall visit the member in his/her residence. During
the initial ninety (90) day post-transition period, the care coordinator shall conduct
monthly face-to-face in-home visits to ensure that the plan of care is being followed,
that the plan of care continues to meet the member’s needs, and the member has
successfully transitioned to the community.

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

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

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

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

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

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

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

	 	2.9.6.8.23.2	 	The CONTRACTOR shall, in a manner prescribed by TENNCARE notify: a) TENNCARE of
all NF discharges and elections of hospice services in a NF; b) DHS of all NF
discharges and transfers between NFs; and c) receiving NFs of all applicable level of
care information when a member is transferring between NFs.

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

	 	2.9.6.8.23.4	 	The CONTRACTOR shall monitor all short-term NF stays for Group 2 members and
shall ensure that the member is transitioned from Group 2 to Group 1 at any time a) it
is determined that the stay will not be short-term and the member will not transition
back to the community; and b) prior to exhausting the 90-day short-term NF benefit
covered for CHOICES Group 2 members.

	40.	 	Section 2.9.6.9.1.1 shall be amended by adding a new Section 2.9.6.9.1.1.5 as follows and
renumbering the existing Section 2.9.6.9.1.1 accordingly, including any references thereto.

	 	2.9.6.9.1.1.5	 	In the manner prescribed by TENNCARE, facilitate transfers between
nursing facilities which, at a minimum, includes notification to the receiving facility
of the member’s level of care, and notification to DHS; and

	41.	 	The newly renumbered Section 2.9.6.9.1.1.6 shall be amended by adding a new Section
2.9.6.9.1.1.6.5 as follows and renumbering the existing Section 2.9.6.9.1.1.6 accordingly,
including any references thereto.

	 	2.9.6.9.1.1.6.5	 	Frequent emergency department utilization; or

	42.	 	Section 2.9.6.9.2.1.2 shall be amended by adding the words “eligible CHOICES” in front of
the word “HCBS”.

	43.	 	Section 2.9.6.9.2.1.5 shall be deleted and replaced as follows:

	 	2.9.6.9.2.1.5	 	For members in CHOICES Group 2, each time a member’s plan of care is
updated to change the level or type of service, document in accordance with TENNCARE
policy that the projected total cost of CHOICES HCBS, home health care and private duty
nursing is less than the member’s cost neutrality cap. If a member’s medical condition
has changed such that a different cost neutrality cap may be appropriate, the
CONTRACTOR shall, in the manner prescribed by TENNCARE, submit to TENNCARE a request to
update the member’s cost neutrality cap, including documentation specified by TENNCARE
to support such request. The CONTRACTOR shall monitor utilization to identify members
who may exceed the cost neutrality cap and to intervene as necessary to maintain the
member’s community placement. The CONTRACTOR shall also educate members in CHOICES
Group 2 about the cost neutrality cap and what will happen if the cap is met;

	44.	 	Sections 2.9.6.9.2.1.6 and 2.9.6.9.2.1.7 shall be amended by adding the word “CHOICES” in
front of the word “HCBS”.

	45.	 	Section 2.9.6.9.2.1.15 shall be amended by adding the words “eligible CHOICES” in front of
the word “HCBS”.

	46.	 	Sections 2.9.6.9.3.1.1 and 2.9.6.9.3.1.1.1 shall be deleted and replaced as follows:

	 	2.9.6.9.3.1.1	 	In the manner prescribed by TENNCARE, conduct a level of care
reassessment at least annually and within five (5) business days of the CONTRACTOR’s
becoming aware that the member’s functional or medical status has changed in a way that
may affect level of care eligibility.

	 	2.9.6.9.3.1.1.1	 	If the level of care assessment indicates a change in the level of care or
if the assessment was prompted by a request by a member, a member’s representative or
caregiver or another entity for a change in level of services, the level of care shall
be forwarded to TENNCARE for determination;

47. Section 2.9.6.9.4.3.2 through 2.9.6.9.4.3.8 shall be deleted and replaced as follows:

	 	2.9.6.9.4.3.2	 	Members who are newly admitted to a nursing facility when the admission
has not been authorized or arranged by the CONTRACTOR, shall receive a face-to-face
visit from their care coordinator within ten (10) days of notification of admission.

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

	 	2.9.6.9.4.3.4	 	Within five (5) business days of scheduled initiation of services, the
member’s care coordinator/care coordination team shall contact members in CHOICES
Groups 2 and 3 who begin receiving CHOICES HCBS after the date of enrollment in CHOICES
to confirm that services are being provided and that the member’s needs are being met
(such initial contact may be conducted by phone).

	 	2.9.6.9.4.3.5	 	Within five (5) business days of scheduled initiation of CHOICES HCBS in the
updated plan of care, the member’s care coordinator/care coordination team shall
contact members in CHOICES Groups 2 and 3 to confirm that services are being provided
and that the member’s needs are being met (such initial contact may be conducted by
phone).

	 	2.9.6.9.4.3.6	 	Members in CHOICES Group 1 (who are residents of a nursing facility) shall
receive a face-to-face visit from their care coordinator at least twice a year with an
interval of at least one-hundred and twenty (120) days between visits.

	 	2.9.6.9.4.3.7	 	Members in CHOICES Group 2 shall be contacted by their care coordinator at
least monthly either in person or by telephone with an interval of at least fourteen
(14) days between contacts. These members shall be visited in their residence
face-to-face by their care coordinator at least quarterly with an interval of at least
sixty (60) days between visits.

	 	2.9.6.9.4.3.8	 	Members in CHOICES Group 3 shall be contacted by their care coordinator at
least quarterly either in person or by telephone with an interval of at least sixty
(60) days between contacts. These members shall be visited in their residence
face-to-face by their care coordinator a minimum of two (2) times per year with an
interval of at least one- hundred (120) days between visits.

48. Section 2.9.6.9.6.3.3 through 2.9.6.9.6.3.7 shall be deleted and replaced as follows:

	 	2.9.6.9.6.3.3	 	Written confirmation of the member’s decision regarding participation in
consumer direction of eligible CHOICES HCBS;

	 	2.9.6.9.6.3.4	 	For members in CHOICES Group 2, a completed risk assessment and a risk
agreement signed and dated by the member or his/her representative;

	 	2.9.6.9.6.3.5	 	For members in CHOICES Group 2, the cost neutrality cap provided by TENNCARE,
and a determination by the CONTRACTOR that the projected cost of CHOICES HCBS, home
health, and private duty nursing services will not exceed the member’s cost neutrality
cap; and

49. Section 2.9.6.9.6.4.1 through 2.9.6.9.6.4.3 shall be deleted and replaced as follows:

	 	2.9.6.9.6.4.1	 	For CHOICES members age 21 and older in Groups 1 and 2, a Freedom of
Choice form signed and dated by the member or his/her representative;

	 	2.9.6.9.6.4.2	 	Evidence that a care coordinator provided the member with CHOICES member
education materials (see Section 2.17.7 of this Agreement), reviewed the materials, and
provided assistance with any questions;

	 	2.9.6.9.6.4.3	 	Evidence that a care coordinator provided the member with education about the
member’s ability to use an advance directive and documentation of the member’s
decision;

50. Section 2.9.6.10 through 2.9.6.10.14 shall be deleted and replaced as follows:

	 	2.9.6.10	 	Additional Requirements for Care Coordination Regarding Consumer Direction
of eligible CHOICES 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 eligible CHOICES HCBS are fulfilled.

	 	2.9.6.10.2	 	The CONTRACTOR shall be responsible for providing all needed eligible CHOICES
HCBS using contract providers until all necessary requirements have been fulfilled in
order to implement consumer direction of eligible CHOICES 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 elects not to receive eligible CHOICES HCBS using contract providers
until all necessary requirements have been fulfilled in order to implement consumer
direction of eligible CHOICES HCBS, the CONTRACTOR shall document this decision,
including date and member/member’s representative’s signature, in the manner specified
by TENNCARE.

	 	2.9.6.10.4	 	If a member is interested in participating in consumer direction of eligible
CHOICES 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).

	 	2.9.6.10.5	 	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).

	 	2.9.6.10.6	 	For members electing to participate in consumer direction, forward to the FEA a
referral initiating the member’s participation in consumer direction of eligible
CHOICES 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.

	 	2.9.6.10.7	 	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.

	 	2.9.6.10.8	 	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 CHOICES 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

	 	2.9.6.10.9	 	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 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.

	 	2.9.6.10.10	 	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.

	 	2.9.6.10.11	 	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).

	 	2.9.6.10.12	 	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 eligible CHOICES HCBS (see Section 2.9.7.3.4).

	 	2.9.6.10.13	 	The CONTRACTOR shall establish a process that allows for the efficient
exchange of all relevant member information between the CONTRACTOR and the FEA.

	 	2.9.6.10.14	 	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.

	 	2.9.6.10.15	 	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 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 or worker shall no longer be allowed to
participate in the CHOICES program as a representative or worker. 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.

51. Section 2.9.6.11.5 shall be deleted and replaced as follows:

	 	2.9.6.11.5	 	While care coordination staffing ratios are not specified, the CONTRACTOR
shall notify TENNCARE in writing of substantive changes to its Care Coordination
Staffing Plan, including a variance of twenty (20) percent or more from the planned
staffing ratio. TENNCARE may request changes in the CONTRACTOR’s Care Coordination
Staffing Plan at any time it determines that the CONTRACTOR does not have sufficient
care coordination staff to properly and timely perform its obligations under this
Agreement.

52. Sections 2.9.6.11.12 through 2.9.6.11.12.27 shall be deleted and replaced as follows:

	 	2.9.6.11.12	 	The CONTRACTOR shall provide initial training to newly hired care
coordinators and ongoing training at least annually to care coordinators. Initial
training topics shall include at a minimum:

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

	 	2.9.6.11.12.2	 	Facilitating CHOICES enrollment for current members;

	 	2.9.6.11.12.3	 	Level of care and needs assessment and reassessment, development of a
person-centered plan of care, and updating the plan of care including training on the
tools and protocols;

	 	2.9.6.11.12.4	 	Development and implementation of back-up plans;

	 	2.9.6.11.12.5	 	Risk assessment and development of a member-specific risk agreement;
2.9.6.11.12.6 Consumer direction of eligible CHOICES HCBS;

	 	2.9.6.11.12.7	 	Self-direction of health care tasks;

	 	2.9.6.11.12.8	 	Coordination of care for duals;

	 	2.9.6.11.12.9	 	Electronic visit verification;

	 	2.9.6.11.12.10	 	Conducting a home visit and use of the monitoring checklist;

	 	2.9.6.11.12.11	 	How to immediately identify and address service gaps;

	 	2.9.6.11.12.12	 	Management of critical transitions (including hospital discharge planning);
2.9.6.11.12.13 Nursing facility diversion;

	 	2.9.6.11.12.14	 	Nursing facility to community transitions, including training on tools and
protocols;

	 	2.9.6.11.12.15	 	Management of transfers between nursing facilities and CBRA facilities,
including adult care homes;

	 	2.9.6.11.12.16	 	Facilitation of transitions between CHOICES Groups;

	 	2.9.6.11.12.17	 	For members in CHOICES Groups 1 and 2, as applicable, members’ responsibility
regarding patient liability, including the consequences of not paying patient
liability;

	 	2.9.6.11.12.18	 	Alzheimer’s, dementia and cognitive impairments; 2.9.6.11.12.19 Traumatic
brain injury;

	 	2.9.6.11.12.20	 	Physical disabilities;

	 	2.9.6.11.12.21	 	Disease management;

	 	2.9.6.11.12.22	 	Behavioral health;

	 	2.9.6.11.12.23	 	Evaluation and management of risk;

	 	2.9.6.11.12.24	 	Identifying and reporting abuse/neglect (see Section 2.24.4);

	 	2.9.6.11.12.25	 	Critical incident reporting (see Section 2.15.7); 2.9.6.11.12.26 Fraud and
abuse, including reporting fraud and abuse; 2.9.6.11.12.27 Advance directives and end
of life care;

	 	2.9.6.11.12.28	 	HIPAA/HITECH;

	 	2.9.6.11.12.29	 	Cultural competency;

	 	2.9.6.11.12.30	 	Disaster planning; and

	 	2.9.6.11.12.31	 	Available community resources for non-covered services.

	53.	 	Section 2.9.6.12.1.2 shall be amended by adding the words “level of care” in front of the
word “reassessments” as follows:

	 	2.9.6.12.1.2	 	Level of care assessments and level of care reassessments occur on
schedule and are submitted to TENNCARE in accordance with requirements in Section
2.9.6.9.3.1.1;

	54.	 	Section 2.9.6.12.3 shall be amended by adding the word “CHOICES” in front of the word
“HCBS”.

	55.	 	Section 2.9.6.12 shall be amended by adding a new Section 2.9.6.12.4 and renumbering the
existing Sections accordingly, including any references thereto.

	 	2.9.6.12.4	 	The CONTRACTOR shall require, and shall conduct readiness review activities
as necessary to confirm that the EVV system vendor has a plan in place and will be
compliant with all ICD- 10 requirements in a timely manner;

	56.	 	Section 2.9.7 through 2.9.7.1.3.10 shall be deleted and replaced as follows:

2.9.7 Consumer Direction of Eligible CHOICES HCBS

	 	2.9.7.1	 	General

	 	2.9.7.1.1	 	The CONTRACTOR shall offer consumer direction of eligible CHOICES 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 eligible CHOICES HCBS.) A
service that is not specified in TennCare rules and regulations as available for
consumer direction or that is not a CHOICES HCBS shall not be consumer directed.
Consumer direction in CHOICES affords members the opportunity to have choice and
control over how eligible CHOICES 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
eligible CHOICES HCBS is voluntary. Members may elect to participate in or withdraw
from consumer direction of eligible CHOICES 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 CHOICES HCBS or to withdraw from participation
in consumer direction of eligible CHOICES 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 eligible CHOICES HCBS.

	 	2.9.7.1.2	 	Consumer direction is a process by which eligible CHOICES HCBS are delivered; it
is not a service. If a member chooses not to direct his/her care, he/she shall receive
authorized CHOICES 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 eligible CHOICES 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	 	Evaluating worker performance and addressing any identified deficiencies or
concerns;

	 	2.9.7.1.3.6	 	Setting wages from a range of rates established by TENNCARE;

	 	2.9.7.1.3.7	 	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
approving hours worked by consumer-directed workers;

	 	2.9.7.1.3.9	 	Reviewing and ensuring proper documentation for services provided; and

	 	2.9.7.1.3.10	 	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.

	57.	 	Sections 2.9.7.2.2 and 2.9.7.2.4 shall be amended by adding the words “eligible CHOICES in
front of the word “HCBS”.

	58.	 	Sections 2.9.7.3.2, 2.9.7.3.2.1, 2.9.7.3.3, and 2.9.7.3.11.6 shall be amended by adding the
words “eligible CHOICES in front of the word “HCBS”.

	59.	 	Section 2.9.7.4 through 2.9.7.4.10.13 shall be deleted and replaced as follows:

	 	2.9.7.4	 	Needs Assessment/Plan of Care Process

	 	2.9.7.4.1	 	A CHOICES member may choose to direct needed eligible CHOICES 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 CHOICES 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 eligible
CHOICES 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 eligible CHOICES HCBS.

	 	2.9.7.4.2.1	 	The care coordinator shall assist the member in identifying which of the needed
eligible CHOICES 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 CHOICES HCBS,
throughout the period of time that consumer direction is being initiated, the
CONTRACTOR shall arrange for the provision of needed CHOICES 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 CHOICES 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 CHOICES 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
eligible CHOICES 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 eligible
CHOICES 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 eligible
CHOICES 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 eligible CHOICES 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
eligible CHOICES 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 CHOICES 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	 	The FEA and the CONTRACTOR shall each file a copy of the back-up plan for
consumer direction in the member’s file.

	 	2.9.7.4.10.9	 	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 CHOICES 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.

	 	2.9.7.4.10.10	 	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 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.

60. Section 2.9.7.5 through 2.9.7.5.10.1 shall be deleted and replaced as follows:

	 	2.9.7.5	 	Authorizations for Consumer Directed Services and Service Initiation

	 	2.9.7.5.1	 	Consumer direction of eligible CHOICES 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 eligible CHOICES 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, as appropriate, 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 eligible
CHOICES 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.

	61.	 	Sections 2.9.7.7.1, 2.9.7.7.4.1, and 2.9.7.8.5 shall be amended by adding the words
“eligible CHOICES” in front of the word “HCBS”.

	62.	 	Section 2.9.7.9 through 2.9.7.9.9 shall be amended by adding the words “eligible CHOICES” in
front of the word “HCBS” and by adding the words “outbound 834” in front of the words
“enrollment file”.

	63.	 	Section 2.9.7.9.10.2 shall be amended by adding the words “eligible CHOICES” in front of the
word “HCBS.

	64.	 	Section 2.9.14.6 shall be deleted and replaced and Section 2.9.14.7 shall be deleted in its
entirety and the remaining Section 2.9.14 shall be renumbered accordingly, including any
references thereto.

	 	2.9.14.6	 	Area Agencies on Aging and Disability (AAADs) regarding intake of members new
to both TennCare and CHOICES, and assisting CHOICES members in Groups 2 and 3 with the
TennCare eligibility redetermination process;

	65.	 	Section 2.11.1.4.1 shall be amended by adding the word “CHOICES” in front of the word
“HCBS”.

	66.	 	Section 2.11.1.8.2 shall be amended by deleting the phrase “, including services”.

	 	2.11.1.8.2	 	The CONTRACTOR is not required to provide non-emergency transportation for
HCBS provided through a 1915(c) waiver program for persons with intellectual
disabilities (i.e., mental retardation) and HCBS provided through the CHOICES program,
except as provided in Section 2.11.1.8.1 above.

	67.	 	Section 2.11.6.3, 2.11.6.4, 2.11.6.6.2, 2.11.6.6.5, 2.11.6.6.7 and 2.11.6.6.8 shall be
amended by adding the word “CHOICES” in front of the word HCBS.

68. Section 2.11.8.4 through 2.11.8.4.2 shall be deleted and replaced as follows:

	 	2.11.8.4	 	Credentialing of Long-Term Care Providers

	 	2.11.8.4.1	 	The CONTRACTOR shall develop and implement a process for credentialing and
recredentialing long-term care providers. The CONTRACTOR’s process shall, as
applicable, meet the minimum NCQA requirements as specified in the NCQA Standards and
Guidelines for the Accreditation of MCOs. In addition, the CONTRACTOR shall ensure that
all longterm care providers, including those credentialed/recredentialed in accordance
with NCQA Standards and Guidelines for the Accreditation of MCOs, meet applicable State
requirements, as specified by TENNCARE in State Rule, this Agreement, or in policies or
protocols.

	 	2.11.8.4.1.1	 	The CONTRACTOR shall develop policies that specify by HCBS provider type the
credentialing process, the recredentialing process including frequency, and ongoing
provider monitoring activities.

	 	2.11.8.4.1.1.1	 	Ongoing CHOICES HCBS providers must be recredentialed at least annually;

	 	2.11.8.4.1.1.2	 	All other CHOICES HCBS providers (e.g., pest control and assistive
technology), must be recredentialed, at a minimum, every three (3) years.

	 	2.11.8.4.1.2	 	At a minimum, credentialing of LTC providers shall include the collection of
required documents, including disclosure statements, and verification that the
provider:

	 	2.11.8.4.1.2.1	 	Has a valid license or certification for the services it will contract to
provide as required pursuant to State law or rule, or TENNCARE policies or protocols;

	 	2.11.8.4.1.2.2	 	Is not excluded from participation in the Medicare or Medicaid programs;

	 	2.11.8.4.1.2.3	 	Has a National Provider Identifier (NPI) Number, where applicable, and has
obtained a Medicaid provider number from TENNCARE.

	 	2.11.8.4.1.2.4	 	Has policies and processes in place to conduct, in accordance with Federal
and State law and rule and TENNCARE policy, criminal background checks, which shall
include a check of the Tennessee Abuse Registry, Tennessee Felony Offender Registry,
National and Tennessee Sexual Offender Registry, and List of Excluded
Individuals/Entities (LEIE), on all prospective employees who will deliver CHOICES HCBS
and to document these in the worker’s employment record;

	 	2.11.8.4.1.2.5	 	Has a process in place to provide and document initial and ongoing education
to its employees who will provide services to CHOICES members that includes, at a
minimum:

	 	2.11.8.4.1.2.5.1	 	Caring for Elderly and Disabled population;

	 	2.11.3.4.1.2.5.2	 	Abuse and neglect prevention, identification and reporting;

	 	2.11.3.4.1.2.5.3	 	Critical incident reporting;

	 	2.11.3.4.1.2.5.4	 	Documentation of service delivery;

	 	2.11.3.4.1.2.5.5	 	Use of the EVV System; and

	 	2.11.8.4.1.2.5.6	 	Any other training requirements specified by TENNCARE in State Rule, this
Agreement, or in policies or protocols.

	 	2.11.8.4.1.2.6	 	Has policies and processes in place to ensure:

	 	2.11.8.4.1.2.6.1	 	Compliance with the CONTRACTOR’s critical incident reporting and management
process; and

	 	2.11.8.4.1.2.6.2	 	Appropriate use of the EVV system.

	 	2.11.8.4.1.3	 	At a minimum, recredentialing of HCBS providers shall include verification of
continued licensure and/or certification (as applicable), and compliance with policies
and procedures identified during credentialing, including background checks and
training requirements, critical incident reporting and management, and use of the EVV.

	 	2.11.8.4.1.4	 	For both credentialing and recredentialing processes, the CONTRACTOR shall
conduct a site visit, unless the provider is located out of state, in which case the
CONTRACTOR may waive the site visit and document the reason in the provider file.

	 	2.11.8.4.1.5	 	At a minimum, the CONTRACTOR shall reverify monthly that each HCBS provider has
not been excluded from participation in the Medicare or Medicaid, and/or SCHIP
programs.

	69.	 	Section 2.12.9.38 shall be amended by adding the word “CHOICES” in front of the word

“HCBS”.

	70.	 	Section 2.12.9 shall be amended by adding a new Section 2.12.9.63 as follows:

	 	2.12.9.63	 	The provider, subcontractor or any other entity agrees to abide by the
Medicaid laws, regulations and program instructions that apply to the provider. The
provider, subcontractor or any other entity understands that payment of a claim by
TennCare or a TennCare Managed Care Contractor and/or Organization is conditioned upon
the claim and the underlying transaction complying with such laws, regulations, and
program instructions (including, but not limited to, the Federal anti-kickback statute
and the Stark law), and is conditioned on the provider’s , subcontractor’s or any other
entity’s compliance with all applicable conditions of participation in Medicaid. The
provider, subcontractor or any other entity understands and agrees that each claim the
provider, subcontractor or any other entity submits to TennCare or a TennCare Managed
Care Contractor and/or Organization constitutes a certification that the provider,
subcontractor or any other entity has complied with all applicable Medicaid laws,
regulations and program instructions (including, but not limited to, the Federal
anti-kickback statute and the Stark law), in connection with such claims and the
services provided therein.

	71.	 	Sections 2.12.12 through 2.12.12.10 and Section 2.12.13 shall be deleted and replaced as
follows:

	 	2.12.12	 	The provider agreement with a CHOICES HCBS provider shall meet the minimum
requirements specified in Section 2.12.9 above and shall also include, at a minimum,
the following requirements:

	 	2.12.12.1	 	Require the CHOICES HCBS provider to provide at least thirty (30) days advance
notice to the CONTRACTOR when the provider is no longer willing or able to provide
services to a member, including the reason for the decision, and to cooperate with the
member’s care coordinator to facilitate a seamless transition to alternate providers;

	 	2.12.12.2	 	In the event that a CHOICES HCBS provider change is initiated for a member,
require that, regardless of any other provision in the provider agreement, the
transferring HCBS provider continue to provide services to the member in accordance
with the member’s plan of care until the member has been transitioned to a new
provider, as determined by the CONTRACTOR, or as otherwise directed by the CONTRACTOR,
which may exceed thirty (30) days from the date of notice to the CONTRACTOR;

	 	2.12.12.3	 	Specify that reimbursement of a CHOICES HCBS provider shall be contingent upon the
provision of services to an eligible member in accordance with applicable federal and
state requirements and the member’s plan of care as authorized by the CONTRACTOR, and
must be supported by detailed documentation of service delivery to support the amount
of services billed, including at a minimum, the date, time and location of service, the
specific HCBS provided, the name of the member receiving the service, the name of the
staff person who delivered the service, the detailed tasks and functions performed as a
component of each service, notes for other caregivers (whether paid or unpaid)
regarding the member or his/her needs (as applicable), and the initials or signature of
the staff person who delivered the service;

	 	2.12.12.4	 	Require CHOICES HCBS providers to immediately report any deviations from a
member’s service schedule to the member’s care coordinator;

	 	2.12.12.5	 	Require CHOICES HCBS providers to use the electronic visit verification system
specified by the CONTRACTOR in accordance with the CONTRACTOR’s requirements;

	 	2.12.12.6	 	Require that upon acceptance by the CHOICES HCBS provider to provide approved
services to a member as indicated in the member’s plan of care, the provider shall
ensure that it has staff sufficient to provide the service(s) authorized by the
CONTRACTOR 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;

	 	2.12.12.7	 	Require CHOICES HCBS providers to provide back-up for their own staff if they are
unable to fulfill their assignment for any reason and ensure that back-up staff meet
the qualifications for the authorized service;

	 	2.12.12.8	 	Prohibit CHOICES HCBS providers from requiring a member to choose the provider as
provider of multiple services as a condition of providing any service to the member;

	 	2.12.12.9	 	Prohibit CHOICES HCBS providers from soliciting members to receive services from
the provider including:

	 	2.12.12.9.1	 	Referring an individual for CHOICES screening and intake with the expectation
that,, should CHOICES enrollment occur, the provider will be selected by the member as
the service provider; or

	 	2.12.12.9.2	 	Communicating with existing CHOICES members via telephone, face-to-face or
written communication for the purpose of petitioning the member to change CHOICES
providers;

	 	2.12.12.10	 	Require CHOICES HCBS providers to comply with critical incident reporting and
management requirements (see Section 2.15.7 of this Agreement); and

	 	2.12.12.11	 	Shall not require the CHOICES HCBS provider to have liability insurance in excess
of TENNCARE requirements in effect prior to the implementation of CHOICES.

	 	2.12.13	 	The provider agreement with a CHOICES HCBS provider to provide PERS, assistive
technology, minor home modifications, or pest control shall meet the requirements
specified in Sections 2.12.9, 2.12.10, and 2.12.12 except that these provider
agreements shall not be required to meet the following requirements: Section 2.12.9.9
regarding emergency services; Section 2.12.9.11 regarding delay in prenatal care;
Section 2.12.9.12 regarding CLIA; Section 2.12.9.38 regarding hospital protocols;
Section 2.12.9.40 regarding reimbursement of obstetric care; Section 2.12.9.52.2
regarding prior authorization of pharmacy; and Section 2.12.9.53 regarding coordination
with the PBM.

	72.	 	Sections 2.13.3 through 2.13.3.3 and Sections 2.13.4 through 2.13.4.4 shall be deleted and
replaced as follows:

	 	2.13.3	 	Nursing Facility Services

	 	2.13.3.1	 	The CONTRACTOR shall reimburse contract nursing facility providers at the per diem
rate specified by TENNCARE, net of any applicable patient liability amount (see Section
2.6.7).

	 	2.13.3.2	 	The CONTRACTOR shall reimburse non-contract nursing facility providers as specified
in TennCare rules and regulations, net of any applicable patient liability amount (see
Section 2.6.7).

	 	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. The CONTRACTOR may reimburse the nursing facility for
the lesser level of services only when such lesser level of services is billed by the
nursing facility or upon approval from TENNCARE of a reduction in the member’s level of
care or reimbursement as reflected on the outbound 834 enrollment file.

	 	2.13.3.4	 	The CONTRACTOR shall, upon receipt of notification from TENNCARE of a retrospective
adjustment of a nursing facility’s per diem rate(s), without requiring any action on
the part of the provider, reprocess affected claims and provide any additional payment
due within sixty (60) days of receipt of such notification. The CONTRACTOR shall, upon
notification in the outbound 834 enrollment file of retroactive patient liability
amounts or retroactive adjustments in patient liability amounts, without requiring any
action on the part of the provider, reprocess affected claims and provide any
additional payment due within thirty (30) days of receipt of such notification. The
CONTRACTOR shall not require that NFs resubmit affected claims in order to process
these adjustments.

	 	2.13.4	 	CHOICES HCBS

	 	2.13.4.1	 	For covered CHOICES HCBS and for CHOICES HCBS that exceed the specified benefit
limit and are provided by the CONTRACTOR as a cost effective alternative (see Section
2.6.5), the CONTRACTOR shall reimburse contract HCBS providers, including community-
based residential alternatives, at the rate specified by TENNCARE.

	 	2.13.4.2	 	The CONTRACTOR shall reimburse non-contract CHOICES HCBS providers as specified in
TennCare rules and regulations.

	 	2.13.4.3	 	For other HCBS that are not otherwise covered but are offered by the CONTRACTOR as
a cost effective alternative to nursing facility services (see Section 2.6.5), the
CONTRACTOR shall negotiate the rate of reimbursement.

	 	2.13.4.4	 	The CONTRACTOR shall reimburse consumer-directed workers in accordance with
Sections 2.9.6.7 and 2.26 of this Agreement.

	73.	 	Section 2.13 shall be amended by adding a new Section 2.13.8 as follows and renumbering
the existing Section 2.13.8 through 2.13.20 accordingly, including any references thereto.

2.13.8 Federally Qualified Health Centers and Rural Health Clinics (FQHCs/RHCs)

Upon notification by TENNCARE, the CONTRACTOR shall reimburse contracted FQHCs/RHCs
using prospective payment system rates and wraparound payments for qualifying visits
in accordance with TENNCARE developed policies and protocols. TENNCARE’s policies
and protocols shall be based on federal regulations.

	74.	 	The renumbered Sections 2.13.11.3 and 2.13.12.3 shall be amended by adding the words
“outbound 834” in front of the words “enrollment file”.

	75.	 	The renumbered Section 2.13.13 shall be amended by adding the phrase “in accordance with the
requirements of this agreement” to the end of the last sentence.

	2.13.13	 	Medically Necessary Services Obtained from Non-Contract Provider Referred by Contract
Provider

The CONTRACTOR shall pay for any medically necessary covered services provided to a member
by a non-contract provider at the request of a contract provider. The CONTRACTOR’s payment
shall not be less than eighty percent (80%) of the rate that would have been paid by the
CONTRACTOR if the member had received the services from a contract provider. The CONTRACTOR
shall only pay for covered long-term care services for which the member was eligible (see
Section 2.6) and that were authorized by the CONTRACTOR in accordance with the requirements
of this agreement.

	76.	 	The renumbered Section 2.13.21 shall be amended by adding the phrase “eligible CHOICES” in
front of the word “HCBS”.

	77.	 	Section 2.14.1.12 through 2.14.1.12.2 shall be deleted and replaced as follows:

	 	2.14.1.12	 	Nursing Facility 

	 	2.14.1.12.1	 	The CONTRACTOR shall ensure that reimbursement of level II nursing facility care
is provided for CHOICES members who have been determined by TENNCARE to be eligible for
Level II nursing facility care for the period specified by TENNCARE, except when a
lesser level of services is billed by the nursing facility. The CONTRACTOR shall
monitor the member’s condition, and if the CONTRACTOR determines that, prior to the end
date specified by TENNCARE, the member no longer requires Level II nursing facility
care, the CONTRACTOR may submit to TENNCARE 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. The CONTRACTOR may reimburse the nursing facility for
the lesser level of services only when such lesser level of services is billed by the
nursing facility or upon approval from TENNCARE of a reduction in the member’s level of
care or reimbursement as reflected on the outbound 834 enrollment file. .

	78.	 	Section 2.14.5 through 2.14.5.4 shall be deleted and replaced as follows:

	 	2.14.5	 	Authorization of Long-Term Care Services

	 	2.14.5.1	 	The CONTRACTOR shall have in place an authorization process for covered long-term
care services and cost effective alternative services that is separate from but
integrated with the CONTRACTOR’s prior authorization process for covered physical
health and behavioral health services (See section 2.9.6 of this Agreement).

	 	2.14.5.2	 	The CONTRACTOR may decide whether it will issue service authorizations for nursing
facility services, or whether it will instead process claims for such services in
accordance with the level of care and/or reimbursement (including the duration of such
level of care and/or reimbursement) approved by TENNCARE (see Section 2.14.1.12),
except that the CONTRACTOR may reimburse a lesser level of service when such lesser
level of service is billed by the facility.

	 	2.14.5.3	 	The CONTRACTOR shall authorize and initiate CHOICES HCBS for CHOICES members within
the timeframes specified in Sections 2.9.2, 2.9.3, and 2.9.6 of this Agreement.

	 	2.14.5.4	 	The CONTRACTOR shall not require that CHOICES HCBS be ordered by a treating
physician, but may consult with the treating physician as appropriate regarding the
member’s physical health, behavioral health, and long-term care needs and in order to
facilitate communication and coordination regarding the member’s physical health,
behavioral health, and long-term care services.

	 	2.14.5.5	 	For non-CHOICES members receiving care in non-contract nursing facilities
authorized by the CONTRACTOR as a cost-effective alternative, the CONTRACTOR shall
reimburse services in accordance with its authorization until such time that the member
is no longer eligible for services, is enrolled in CHOICES, or such care is no longer
medically necessary or cost-effective.

	79.	 	Section 2.14.8.1 shall be deleted and replaced as follows:

	 	2.14.8.1	 	The CONTRACTOR is responsible for eliciting pertinent medical history
information from the treating provider(s), as needed, for purposes of making medical
necessity determinations. With respect to CHOICES HCBS which are not primarily medical
in nature, pertinent medical history shall include assessments, case notes, and
documentation of service delivery by HCBS providers. Medical information from the
treating physician may also be pertinent in better understanding the member’s
functional needs. The CONTRACTOR shall take action (e.g., sending a CONTRACTOR
representative to obtain the information and/or discuss the issue with the provider,
imposing financial penalties against the provider, etc.), to address the problem if a
treating provider is uncooperative in supplying needed information. The CONTRACTOR
shall make documentation of such action available to TENNCARE, upon request. Providers
who do not provide requested information for purposes of making a medical necessity
determination for a particular item or service shall not be entitled to payment for the
provision of such item or service.

	80.	 	Section 2.15.1.6 shall be amended by adding new Sections 2.15.1.6.1 through
2.15.1.6.3 as follows.

	 	2.15.1.6	 	The CONTRACTOR shall take appropriate action to address service delivery,
provider, and other QM/QI issues as they are identified.

	 	2.15.1.6.1	 	The CONTRACTOR may be required to conduct special focus studies as requested by
TENNCARE.

	 	2.15.1.6.2	 	The CONTRACTOR shall collect data on race and ethnicity. As part of the QM/QI
program description, the CONTRACTOR shall include the methodology utilized for
collecting the data, as well as any interventions taken to enhance the accuracy of the
data collected.

	 	2.15.1.6.3	 	The CONTRACTOR shall include QM/QI activities to improve healthcare disparities
identified through data collection.

	81.	 	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 whenever the guidelines
change and at least every two (2) years.

	82.	 	Section 2.15.6 shall be amended by adding a new Section 2.15.6.3 as follows:

	 	2.15.6.3	 	The CONTRACTOR shall submit annually the Relative Resource Use (RRU) data to
TENNCARE within ten (10) business days of receipt from NCQA. The CONTRACTOR shall
submit both the Regional and National RRU results.

	83.	 	Sections 2.15.7 through 2.15.7.6 shall be amended by adding the word “CHOICES” in front of
the word “HCBS”.

	84.	 	Section 2.17.2 shall be amended by adding a new Section 2.17.2.10 as follows:

	 	2.17.2.10	 	All educational materials (brochures, scripts etc.) shall be reviewed and
updated concurrently with the update of the Clinical Practice Guidelines to assure the
materials reflect current evidence-based information.

	85.	 	Section 2.17.4.6, 2.17.4.7.15 and 2.17.7.3.22 shall be amended by adding the words
“eligible CHOICES” in front of the word “HCBS”.

	86.	 	Section 2.17.7.3.2, 2.17.7.3.10, 2.17.7.3.15, 2.17.7.3.16, 2.17.7.3.18, 2.17.7.3.19 and
2.17.8.6 shall be amended by adding the word “CHOICES” in front of the word “HCBS”.

	87.	 	Section 2.18.4.6 shall be deleted and replaced as follows:

	 	2.18.4.6	 	The provider service line shall be adequately staffed with staff trained to
accurately respond to questions regarding the TennCare program and the CONTRACTOR’s
MCO, including but not limited to, covered services, the CHOICES program, TENNderCare,
prior authorization and referral requirements, care coordination, and the CONTRACTOR’s
provider network. For a period of at least twelve (12) months following the
implementation of CHOICES in the Grand Region covered by this Agreement, the CONTRACTOR
shall maintain a dedicated queue to assist long-term care providers with enrollment,
service authorization, or reimbursement questions or issues and shall ensure that
long-term care providers are appropriately notified regarding how to access the
dedicated queue for assistance. Such period may be extended as determined necessary by
TENNCARE.

	88.	 	Section 2.18.5.3.3 shall be deleted and replaced as follows:

	 	2.18.5.3.3	 	Description of the CHOICES program including but not limited to who
qualifies for CHOICES (including the three CHOICES groups and enrollment targets for
CHOICES Groups 2 and 3); how to enroll in CHOICES; long-term care services available to
each CHOICES Group (including benefit limits, cost neutrality cap for members in Group
2, and the expenditure cap for members in Group 3); consumer direction of eligible
CHOICES HCBS; self-direction of health care tasks; the level of care assessment and
reassessment process; the needs assessment and reassessment processes; requirement to
provide services in accordance with an approved plan of care including the amount,
frequency, duration and scope of each service in accordance with the member’s service
schedule; service authorization requirements and processes; the role of the care
coordinator; the role and responsibilities of long-term care and other providers;
requirements regarding the electronic visit verification system and the provider’s
responsibility in monitoring and immediately addressing service gaps, including back-up
staff; how to submit clean claims; and documentation requirements for CHOICES HCBS
providers;

	89.	 	Section 2.18.5.3.13 shall be amended by adding the word “CHOICES” in front of the word
“HCBS”.

	90.	 	Section 2.18.5.3 shall be amended by adding a new Section 2.18.5.3.14 and renumbering the
existing Section accordingly, including any references thereto.

	 	2.18.5.3.14	 	Information for CHOICES HCBS providers regarding prohibition of
facilitating CHOICES referrals with the expectation of being selected as the service
provider or petitioning existing CHOICES members to change CHOICES providers.

	91.	 	Section 2.18.6.3.16 shall be amended by adding the word “CHOICES” in front of the word
“HCBS”.

	92.	 	Section 2.18.6 shall be amended by adding a new Section 2.18.6.5 and renumbering the existing
Section accordingly, including any references thereto.

	 	2.18.6.5	 	The CONTRACTOR shall develop and implement a training plan to educate
long-term care providers regarding compliance with ICD- 10 requirements;

	93.	 	The renumbered Sections 2.18.6.7 and 2.18.6.8 shall be amended by adding the word
“CHOICES” in front of the word “HCBS”.

	 	2.18.6.7	 	For a period of at least twelve (12) months following the implementation of
CHOICES in the Grand Region covered by this Agreement, the CONTRACTOR shall conduct
monthly education and training for CHOICES HCBS providers regarding the use of the EVV
system. Such period may be extended as determined necessary by TENNCARE.

	 	2.18.6.8	 	The CONTRACTOR shall provide education and training on documentation requirements
for CHOICES HCBS.

94. Section 2.21.5 through 2.21.5.2 shall be deleted and replaced
as follows:

2.2 1.5 Patient Liability

	 	2.2	 	1.5.1 TENNCARE will notify the CONTRACTOR of any applicable patient liability
amounts for members via the outbound 834 enrollment file.

	 	2.21.5.2	 	The CONTRACTOR shall delegate collection of patient liability to the nursing
facility or community-based residential alternative facility and shall pay the facility
net of the applicable patient liability amount. For members in CHOICES Groups 2 or 3
receiving non-residential CHOICES HCBS, the CONTRACTOR shall collect applicable patient
liability amounts.

	 	2.2	 	1.5.3 When TENNCARE notifies the CONTRACTOR of patient liability amounts for
CHOICES members via the outbound 834 enrollment file at any time other than the
beginning of the month, then the CONTRACTOR shall determine and apply the prorated
portion of patient liability for that month.

	95.	 	Section 2.22.4.4 through 2.22.4.4.2 shall be amended by adding the word “CHOICES” in front
of the word “HCBS”.

	96.	 	Section 2.22.6.3 and 2.22.6.4.13 shall be amended by adding the word “CHOICES” in front of
the word “HCBS”.

	97.	 	Section 2.22.6.4.5 shall be deleted and replaced as follows:

	 	2.22.6.4.5	 	Allowed payment amount agrees with contracted rate and the terms of the
provider agreement;

	98.	 	Section 2.22.7.1.8 shall be amended by adding the word “CHOICES” in front of the word
“HCBS”.

	99.	 	Section 2.23.5.1 shall be amended by adding the words “outbound 834” in front of the words
“enrollment files”.

	100.	 	Section 2.23.13.1 shall be amended by adding the words “outbound 834” in front of the words
“enrollment file”.

	101.	 	Section 2.24.3.2 shall be amended by adding the word “CHOICES” in front of the word “HCBS”.

	102.	 	Section 2.26.6 shall be amended by adding the words “eligible CHOICES” in front of the word
“HCBS.

	103.	 	Section 2.29.1 shall be amended by adding a new Section 2.29.1.11 as follows:

	 	2.29.1.11	 	The CONTRACTOR shall be required to have appropriate staff member(s) attend
certain on-site meetings held at TennCare offices or at other sites as requested and
designated by TENNCARE.

	104.	 	Sections 2.29.2 through 2.29.2.2 shall be deleted and replaced as follows:

2.29.2 Licensure and Background Checks

	 	2.29.2.1	 	Except as specified in this Section 2.29.2.1 regarding the FEA, the CONTRACTOR is
responsible for ensuring that all persons, whether they are employees, agents,
subcontractors, providers or anyone acting for or on behalf of the CONTRACTOR, are
legally authorized to render services under applicable state law. The FEA shall be
responsible for ensuring that consumer-directed workers are qualified to provide
eligible CHOICES HCBS in accordance with TENNCARE requirements.

	 	2.29.2.2	 	Except as specified in this Section 2.29.2.2 regarding the FEA, the CONTRACTOR is
responsible for conducting background checks in accordance with state law and TennCare
policy and ensuring that all employees, agents, subcontractors, providers or anyone
acting for or on behalf of the CONTRACTOR conducts background checks in accordance with
state law and TennCare policy. At a minimum, background checks shall include a check of
the Tennessee Abuse Registry, Tennessee Felony Offender Registry, National and
Tennessee Sexual Offender Registry, and List of Excluded Individuals/Entities (LEIE).
The FEA shall be responsible for conducting background checks on its staff, its
subcontractors, and consumer-directed workers.

	105.	 	Section 2.30.1.4 shall be deleted and replaced as follows:

	 	2.30.1.4	 	The CONTRACTOR shall submit all reports electronically and in the manner and
format prescribed by TENNCARE and shall ensure that all reports are complete and
accurate. The CONTRACTOR shall be subject to liquidated damages as specified in Section
4.20.2.1.1 for reports determined to be late, incorrect, incomplete or deficient, or
not submitted in the manner and format prescribed by TENNCARE until all deficiencies
have been corrected. Except as otherwise specified by TENNCARE, all reports shall be
specific to the Grand Region covered by this Agreement.

	106.	 	The lead in paragraph of Section 2.30.6.5 shall be deleted and replaced as follows:

	 	2.30.6.5	 	The CONTRACTOR shall submit a monthly CHOICES HCBS Late and Missed Visits
Report for CHOICES members regarding the following CHOICES HCBS: 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:

	107.	 	Item (2) of Section 2.30.6.6 shall be amended by adding the words “eligible CHOICES” in
front of the word “HCBS”.

	108.	 	Section 2.30.7.1 shall be amended by adding the word “CHOICES” in front of the word “HCBS”.

	109.	 	Section 2.30.7.5 shall be deleted and replaced as follows:

	 	2.30.7.5	 	The CONTRACTOR shall submit an Annual Plan for the Monitoring of Behavioral
Health Appointment Timeliness that shall include the CONTRACTOR’s plan for monitoring
behavioral health providers to ensure that they comply with the timeliness of
appointment standards that are outlined for behavioral health in Attachment III for
routine specialty MD (behavioral health) care and Attachment V for Outpatient Non-MD
behavioral health services. This plan will be submitted for approval to the Bureau of
TennCare by December 31 of each year and shall identify methods for determining how
they will monitor and evaluate providers for compliance, develop corrective action
plans for compliance, maintain records of audits for timeliness and describe efforts to
improve timeliness of appointments. The minimum data elements required are identified
in Attachment IX, Exhibit D.

	110.	 	Section 2.30.7 shall be amended by adding a new Section 2.30.7.6 and renumbering the
existing Sections 2.30.7.6 and 2.30.7.7 accordingly, including any references thereto.

	 	2.30.7.6	 	The CONTRACTOR shall submit a Quarterly Behavioral Health Appointment
Timeliness Summary Report that includes a quarterly summary of activities based on the
Annual Plan for Monitoring of Behavioral Health Appointment Timeliness (See Section
2.30.7.5) The minimum data elements required are identified in Attachment IX, Exhibit
D.

	111.	 	Section 2.30.9 shall be amended by adding a new Section 2.30.9.5 as follows:

	 	2.30.9.5	 	Upon notification by TENNCARE, the CONTRACTOR shall submit a weekly
Administrative Services Only Invoice Report for all payments to clinics designated as
Federally Qualified Health Clinics or Rural Health Clinics.

	112.	 	Section 2.30.11 shall be amended by adding a new Section 2.30.11.7 as follows:

	 	2.30.11.7	 	By October 1, 2011, the CONTRACTOR is required to submit a Data Collection
Strategy Report that describes how they intend to collect data in accordance with the
HHS initiative to implement a multifaceted health disparities data collection strategy.
(HHS Action Plan to Reduce Racial and Ethnic Health Disparities, April 8, 2011) The
report must include the CONTRACTOR’s plans for collection and reporting of data in five
specific demographic categories in accordance with the new provisions of the Affordable
Care Act: race, ethnicity, gender, primary language, and disability status. The
following OMB (minimum standards) categories for race and ethnicity (Revisions to the
Standards for the Classification of Federal Data on Race and Ethnicity, 1997) must be
used: Hispanic or Latino or Not Hispanic or Latino; American Indian or Alaska Native,
Asian, Black or African American, Hispanic or Latino, Native Hawaiian or Other Pacific
Islander, and White. CONTRACTOR plans must also include how the collected data will be
used to integrate information across systems in order to enhance TennCare data, any
system changes that will be needed, and timelines for implementation. Following review
of the CONTRACTOR’s plan, TENNCARE will set an implementation date for revised data
collection and data reporting.

	113.	 	Item (2) of Section 2.30.16.4 shall be amended by adding the word “CHOICES” in front of
the word “HCBS”.

	114.	 	Section 3.1.2 shall be amended by adding the phrase “, any payments related to FQHC/RHC
costs” as follows:

	 	3.1.2	 	The CONTRACTOR agrees that capitation payments, any payments related to
processing claims for services incurred prior to the start date of operations pursuant
to Section 3.7.1.2.1, any incentive payments (if applicable), any payments related to
FQHC/RHC costs and any payments that offset the CONTRACTOR’s cost for the development
and implementation of an electronic visit verification system (EVV) (see Section 3.13)
are payment in full for all services provided pursuant to this Agreement. TENNCARE
shall not reimburse CONTRACTOR for any costs, liquidated damages and/or penalties
incurred by the CONTRACTOR and which result from actions or inactions, including
penalties associated with CONTRACTOR’s failure to timely pay any and all expenses,
fees, taxes and other regulatory/ministerial costs associated with the requirements of
operating as an HMO in this state. The taxes, fees, expenses, and other
regulatory/ministerial costs referenced herein shall include but not be limited to
premium taxes associated with any and all obligations required by the Tennessee Health
Maintenance Organization Act of 1986 codified at TCA 56-32-101 et seq. or any
subsequent amendments thereto and/or the Tennessee Prepaid Limited Health Services Act
of 2000 codified at TCA 56-51-101 et seq. or any subsequent amendments thereto.
TENNCARE shall not share with the CONTRACTOR any financial losses realized under this
Agreement.

	115.	 	Section 3.4.3.7.1.1.1 shall be amended as follows:

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

	116.	 	Section 3.7.1 shall be amended by adding a new Section 3.7.1.5 and 3.7.1.6, deleting and
replacing the renumbered Section 3.7.1.7 as follows and updating all references accordingly.

	 	3.7.1.5	 	The CONTRACTOR shall not be entitled to a CHOICES capitation payment for any
calendar month during which a CHOICES member does not receive nursing facility services
or ongoing CHOICES HCBS, except under extenuating circumstances which must be reported
to TENNCARE on the CHOICES Utilization Report. Acceptable extenuating circumstances may
include, but are not limited to, a member’s temporary hospitalization or temporary
receipt of Medicare-reimbursed skilled nursing facility care. The determination that
the CONTRACTOR is not entitled to a CHOICES capitation payment shall be made by
TENNCARE based on information provided in monthly CHOICES Utilization Reports and/or
upon review and analysis of the CONTRACTOR’s encounter data. For any month in which the
CONTRACTOR is not entitled to the CHOICES capitation payment, the capitation payment
will be retroactively adjusted to reflect the appropriate non-CHOICES capitation rate
applicable for that month.

	 	3.7.1.6	 	The effective date of the CHOICES capitation payment may be retroactively adjusted
by TENNCARE in any instance in which the CONTRACTOR fails to initiate nursing facility
services or ongoing CHOICES HCBS within the timeframes prescribed in 2.9.6., in which
case, the effective date of the CHOICES capitation payment will be the date of
initiation of nursing facility or ongoing HCBS.

	 	3.7.1.7	 	Payment adjustments resulting in a reduction or increase of the capitation rate
shall be accomplished through the monthly capitation reconciliation process, or
pursuant to other processes as established by TENNCARE.

	117.	 	Section 3.9.2.6 shall be deleted and replaced as follows:

	 	3.9.2.6	 	The withhold amounts for subsequent months thereafter in which the CONTRACTOR
has not cured the deficiencies shall be in accordance with Section 3.9.2.1 as described
above. If the CONTRACTOR has attained a two and one half percent (2.5%) withhold and
TENNCARE subsequently determines the CONTRACTOR is not in compliance with a requirement
of this Agreement, TENNCARE will provide written notice of such determination and
TENNCARE will re-institute the retention of the withhold as described in Section
3.9.2.1 at the next capitation payment cycle. Monthly retention of the withhold amount
will continue for each subsequent month so long as the identified deficiencies have not
been corrected. These funds will not be distributed to the CONTRACTOR unless it is
determined by TENNCARE the CONTRACTOR has come into compliance with the Agreement
requirement(s) within six (6) months of TENNCARE identifying these deficiencies. For
example, if a specified deficiency(s) is corrected within four (4) months and there are
no other identified deficiencies which the CONTRACTOR has been given written notice of
by TENNCARE, the withhold for the four (4) consecutive months will be paid to the
CONTRACTOR upon TENNCARE determination that the deficiency(s) was corrected. However,
any amounts withheld by TENNCARE for six (6) consecutive months for the same or similar
compliance deficiency(s) shall be permanently retained by TENNCARE on the first day
after the sixth consecutive month period and shall not be paid to the CONTRACTOR. If
the same or similar specified deficiency(s) continues beyond six (6) consecutive
months, TENNCARE may declare the MCO ineligible for future distribution of the ten
percent (10%) incentive withhold and may continue to permanently retain any amounts
withheld by TENNCARE for six (6) consecutive months. Such ineligibility will continue
for each month TENNCARE determines the same or similar specified deficiency(s)
continues to exist. Once a CONTRACTOR corrects the deficiency(s), TENNCARE may
reinstate the MCO’s eligibility for distribution of the ten percent (10%) compliance
incentive payment of future withholds. If TENNCARE determines that distribution of the
ten percent (10%) withhold is appropriate, distribution of the ten percent (10%) shall
be made at the time of the next scheduled monthly check write which includes all other
payments due the CONTRACTOR.

	118.	 	Section 3 shall be amended by adding a new Section 3.11 as follows and renumbering the
existing Sections 3.11 through 3.14 accordingly including any references thereto.

3.11 Reimbursement of Cost related Payments for FQHCs/RHCs

Upon notification by TENNCARE, TENNCARE shall reimburse the CONTRACTOR for
FQHC/RHC cost outside of the capitation rates in accordance with TENNCARE developed
policies and protocols and based on the CONTRACTOR’s reported Administrative
Services Only weekly invoice (See Section 2.30.9.5). TENNCARE’s policies and
protocols shall be based on federal regulations.

	119.	 	The renumbered Section 3.15.1.1 shall be deleted and replaced as follows:

	 	3.15.1.1	 	In no event shall the maximum liability of the State under this Agreement
during the original term of the Agreement exceed four billion, two hundred thirty
million, nine hundred ten thousand,eight hundred sixty nine dollars
($4,230,910,869.00).

	120.	 	The opening paragraph of Section 4.1 shall be deleted and replaced as follows:

4.1 NOTICE

All notices required to be given under this Agreement shall be given in writing, and
shall be sent by United States certified mail, postage prepaid, return receipt requested; in
person; by facsimile, email or other electronic means, including but not limited to
providing notice through computer databases, software or other systems made available to the
CONTRACTOR by TENNCARE; or by other means, so long as proof of delivery and receipt is
given, and the cost of delivery is borne by the notifying party, to the appropriate party at
the address given below, or at such other address (or addresses) as may be provided by
notice given under this Section.

121. Section 4.2.1 and 4.2.2 shall be deleted and
replaced as follows: 4.2.1 Term of the Agreement

This Agreement, including any amendments and any changes made by notice to adjust the
capitation rates, shall be effective commencing on August 15, 2006 and ending on December
31, 2014.

4.2.2 Term Extension

The State reserves the right to extend this Agreement for an additional period or periods of
time representing increments of no more than one (1) year and a total term of no more than
five (5) years, provided that the State notifies the CONTRACTOR in writing of its intention
to do so at least six (6) months prior to the Agreement expiration date. In accordance with
an approved exception request, TENNCARE may extend this Agreement through December 31, 2014.
An extension of the term of this Agreement will be effected through an amendment to the
Agreement.

	122.	 	Section 4.20.2.1.1 shall be amended by adding the word “incomplete” as follows:

	 	4.20.2.1.1	 	For each day that a report or deliverable is late, incorrect, incomplete, or
deficient, the CONTRACTOR shall be liable to TENNCARE for liquidated damages in the
amount of one hundred dollars ($100) per day per report or deliverable unless specified
otherwise in this Section. Liquidated damages for late reports/deliverables shall begin
on the first day the report/deliverable is late.

	123.	 	The liquidated damage chart in Section 4.20.2.2.7 shall be amended by deleting and
replacing A.20 and adding new damages A.21 through A.26 as follows:

		 	

	124.	 	Section C of the Program Issues/Damages chart of Section 4.20.2.2.7 shall be amended by
adding a new C.3 as follows and renumbering the existing C.3 through C.7 as follows including
any references thereto.

	125.	 	Section 4.20.2.4 shall be amended by adding the word “CHOICES” in front of the word “HCBS”.

	126.	 	Section 4 shall be amended by adding new Sections 4.38 and 4.39 as follows and the existing
Sections 4.38 and 4.39 shall be renumbered accordingly including any references thereto.

4.38 Prohibition of Payments for Items or Services Outside the United States

Section 6505 of the Affordable Care Act amends section 1902(a) of the Social
Security Act (the Act), and requires that a State shall not provide any payments for
items or services provided under the State plan or under a waiver to any financial
institution or entity located outside of the United States (U.S.). This section of
the Affordable Care Act is effective January 1, 2011, unless the Secretary
determines that implementation requires State legislation, other than legislation
appropriating funds, in order for the plan to comply with this provision.

For purposes of implementing this provision, section 110 1(a)(2) of the Act defines
the term “United States” when used in a geographical sense, to mean the “States.”
Section 1 101(a)(1) of the Act defines the term “State” to include the District of
Columbia, Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands, and
American Samoa, when used under Title XIX.

Further, this provision prohibits payments to telemedicine providers located outside
of the U.S., Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands,
and American Samoa. Additionally, payments to pharmacies located outside of the
U.S., Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands, and
American Samoa are not permitted.

The Centers for Medicare & Medicaid Services (CMS) will require that, in the case of
providers that have provided medical assistance or covered items and/or services to
Medicaid beneficiaries under the State plan or under a waiver program, and are
requesting reimbursement from the State Medicaid program, such reimbursement must be
provided to financial institutions or entities located within the U.S. If it is
found that payments have been made to financial institutions or entities outside of
the U.S., States must recover these payments and must forward any Federal match for
such payments to CMS consistent with the guidelines specified in Federal regulations
at 42 CFR Part 433.

Any audits of claims by CMS to assure compliance with this provision will begin no
earlier than June 1, 2011 and will only review claims submitted on or after June 1,
2011 for compliance with this section.

4.39 Federal Funding Accountability and Transparency Act (FFATA)

This Agreement requires the CONTRACTOR to provide supplies and/or services that
are funded in whole or in part by federal funds that are subject to FFATA. The
CONTRACTOR is responsible for ensuring that all applicable requirements, including
but not limited to those set forth herein, of FFATA are met and that the CONTRACTOR
provides information to the State as required.

The CONTRACTOR shall comply with the following:

	 	4.39.1	 	Reporting of Total Compensation of the CONTRACTOR’s Executives.

	 	4.39.1.1	 	The CONTRACTOR shall report the names and total compensation of each of its five
most highly compensated executives for the CONTRACTOR’s preceding completed fiscal
year, if in the CONTRACTOR’s preceding fiscal year it received:

	 	4.39.1.1.1	 	Eighty percent (80%) or more of the CONTRACTOR’s annual gross revenues from
Federal procurement contracts and Federal financial assistance subject to the
Transparency Act, as defined at 2 CFR 170.3 20 (and sub awards); and

	 	4.39.1.1.2	 	$25,000,000 or more in annual gross revenues from Federal procurement contracts
(and subcontracts), and Federal financial assistance subject to the Transparency Act
(and sub awards); and

	 	4.39.1.1.3	 	The public does not have access to information about the compensation of the
executives through periodic reports filed under section 13(a) or 15(d) of the
Securities Exchange Act of 1934 (15 U.S.C. 78m(a), 78o(d)) or section 6104 of the
Internal Revenue Code of 1986. (To determine if the public has access to the
compensation information, see the U.S. Security and Exchange Commission total
compensation filings at http://www.sec.gov/answers/execomp.htm.).

Executive means officers, managing partners, or any other employees in
management positions.

	 	4.39.1.2	 	Total compensation means the cash and noncash dollar value earned by the executive
during the CONTRACTOR’s preceding fiscal year and includes the following (for more
information see 17 CFR 229.402(c)(2)):

	 	4.39.1.2.1	 	Salary and bonus.

	 	4.39.1.2.2	 	Awards of stock, stock options, and stock appreciation rights. Use the dollar
amount recognized for financial statement reporting purposes with respect to the fiscal
year in accordance with the Statement of Financial Accounting Standards No. 123
(Revised 2004) (FAS 123R), Shared Based Payments.

	 	4.39.1.2.3	 	Earnings for services under non-equity incentive plans. This does not include
group life, health, hospitalization or medical reimbursement plans that do not
discriminate in favor of executives, and are available generally to all salaried
employees.

	 	4.39.1.2.4	 	Change in pension value. This is the change in present value of defined benefit
and actuarial pension plans.

	 	4.39.1.2.5	 	Above-market earnings on deferred compensation which is not tax qualified.

	 	4.39.1.2.6	 	Other compensation, if the aggregate value of all such other compensation (e.g.
severance, termination payments, value of life insurance paid on behalf of the
employee, perquisites or property) for the executive exceeds $10,000.

	 	4.39.2	 	The CONTRACTOR must report executive total compensation described above to the State
by the end of the month during which this Contract is awarded.

	 	4.39.3	 	If this Agreement is amended to extend its term, the CONTRACTOR must submit an
executive total compensation report to the State by the end of the month in which the
amendment to this Agreement becomes effective.

	 	4.39.4	 	The CONTRACTOR will obtain a Data Universal Numbering System (DUNS) number and
maintain its DUNS number for the term of this Agreement. More information about
obtaining a DUNS Number can be found at: http://fedgov.dnb.com/webform/

	 	4.39.5	 	The CONTRACTOR’s failure to comply with the above requirements is a material breach
of this Agreement for which the State may terminate this Agreement for cause. The State
will not be obligated to pay any outstanding invoice received from the CONTRACTOR
unless and until the CONTRACTOR is in full compliance with the above requirements.

	127.	 	“Timely Claims Processing”, “Claims Payment Accuracy”, and “HCBS Provider Network”
Performance Measures in Attachment VII shall be amended by adding the word “CHOICES” in front
of the word “HCBS”.

	128.	 	The Performance Measure regarding “Initial appointment timeliness for behavioral health
services” in Attachment XII shall be deleted in its entirety.

	129.	 	Item 17 and 120 in Attachment VIII shall be amended by adding the words “eligible CHOICES” in
front of the word “HCBS”.

	130.	 	Attachment VIII shall be amended by deleting and replacing Items 129, 131, and 132; adding
new Items 130 and 138 as follows and renumbering the existing items accordingly.

	 	129.	 	Annual Plan for the Monitoring of Behavioral Health Appointment
Timeliness (see Section 2.30.7.5)	 

130. Quarterly Behavioral Health Appointment Timeliness Summary Report (see Section
2.30.7.6)

131. CHOICES Qualified Workforce Strategies Report (see Section 2.30.7.7)

132. FQHC Reports (see Section 2.30.7.8)

138. Administrative Services Only Invoice Report (See Section 2.30.9.5)

131. Exhibit D of Attachment IX shall be deleted and replaced as follows:

ATTACHMENT IX, EXHIBIT D

Annual Plan and Quarterly Summary for the Monitoring of Behavioral Health Appointment Timeliness

I. Annual Plan for the Monitoring of Behavioral Health Appointment Timeliness

The Annual Plan for the Monitoring of Behavioral Health Appointment Timeliness required in Section
2.30.7.5 will be submitted to the Bureau of TennCare by December 31 of each year, with the first
annual plan due for submission by December 31, 2011. This deliverable shall include, at a minimum,
the following elements:

	 	1.	 	A plan for how the CONTRACTOR monitors and evaluates behavioral health providers for
compliance with the timeliness of appointment standards that are outlined for behavioral
health in Attachment III for routine MD (behavioral health) specialty care and Attachment V
for Outpatient Non-MD behavioral health services.

2. The plan shall include a delineation of methodologies used for monitoring and evaluation:

	 	a.	 	The plan shall include at minimum, at least one method that incorporates
either a phone survey or on- site audit.

	 	b.	 	The report shall include the frequency of surveys/audits, number of site
visits, and types of providers monitored, by (MD and non-MD), and by age group (under
18 years of age and 18 years of age and over) as well as number of phone calls or
number of appointments evaluated for timeliness, by type (MD/non-MD) and (under 18
years of age and 18 years of age and over) for each provider.

	 	3.	 	This report will also include the types of correspondence with providers regarding
timeliness of appointments; number of performance reports issued to providers, number of
Corrective Action Plans (CAPs) issued to providers and results of follow-up to the CAPs.

	 	4.	 	A summary of overall findings will include a summary of results across providers; how
representative the sample of surveys/site visits are of the overall volume of services
provided; analysis of data collection and identification and resolution of problems,
including percentage of compliance with standards in Attachments III and V, as outlined in
# 1 above.

	 	5.	 	Description of record keeping, including results of audits and surveys, and requests
for corrective action plans submitted to providers.

6. A summary of other methods used to monitor the timeliness of behavioral health appointments.

II. Quarterly Summary for the Monitoring of Behavioral Health Appointment Timeliness

The Quarterly Summary for the Monitoring of Behavioral Health Appointment Timeliness as required in
Section 2.30.7.6. will be due within thirty (30) days after completion of the quarter. This
deliverable shall include, at a minimum, a summary and update of the quarterly activities and
results outlined in the Annual Plan for the Monitoring of Behavioral Health Appointment Timeliness
as required in Section 2.30.7.5, including strategies, results and outcomes of efforts to improve
timeliness of appointments.

	132.	 	Section A.4.3.2.4.1 of Attachment XI shall be amended by deleting “one-quarter (1/4th)”
and replacing it with “one-third (1/3)”.

	 	 	 	A.4.3.2.4.1 The furthest distance a member shall be required to travel to or from a
fixed route transportation stop is one-third (1/3) of a mile.

	133.	 	Sections A.12.5 and A.12.6 of Attachment XI shall be deleted and replaced as follows:

	 	 	A.12.5 The CONTRACTOR shall provide Department of Intellectual and Developmental Disabilities
(DIDD) residential and day service waiver providers the opportunity to become a NEMT provider
if the provider is qualified to provide MR waiver transportation services (either as an
individual transportation service or as a component of residential and/or day services)
pursuant to provider qualifications applicable for such providers which shall be determined by
DIDD. These providers shall only provide covered NEMT services to members receiving HCBS MR
waiver services from the provider. The CONTRACTOR shall reimburse these providers for covered
NEMT to TennCare covered services (see definition in Exhibit A) and shall not reimburse these
providers for NEMT to services provided though a HCBS MR waiver. The CONTRACTOR shall
reimburse these providers in accordance with rates paid to other NEMT providers for the
provision of NEMT services.

	 	 	A.12.6 The CONTRACTOR shall ensure that its NEMT providers are qualified to perform their duties.
Except as specified in A. 12.5, this includes, but is not limited to, meeting applicable
federal, state or local licensure, certification, or registration requirements. Failure to
comply with requirements regarding licensure requirements may result in liquidated damages as
provided in Section 4.20.2 of the Agreement.

134. Section A.14 of Attachment XI shall be amended by adding a new sentence as
follows:

A.14 PAYMENT FOR NEMT SERVICES

A.14.1 General

In addition to requirements in the Agreement regarding payment for services, when paying for
NEMT services the CONTRACTOR shall comply with the requirements in this Attachment. In
addition to the requirements of this Agreement and this Attachment, the CONTRACTOR shall
have a policy to address fuel price adjustments.

135. Item 13 of Exhibit A of Attachment XI shall be deleted and replaced as
follows:

	 	13.	 	TennCare Covered Services: The health care services available to TennCare
enrollees, as defined in TennCare rules and regulations. This includes, but is not
limited to, physical health, behavioral health, pharmacy, dental services, and
institutional services. TennCare covered services includes TENNderCare services. For
purposes of NEMT, TennCare covered services does not include CHOICES HCBS or 19 15(c)
MR waiver services.

136. Attachment XII shall be amended by adding a new Exhibit E and F as follows:

EXHIBIT E

CAPITATION RATES

AmeriGroup

EFFECTIVE July 1, 2010

1

EXHIBIT F

CAPITATION RATES

AmeriGroup

EFFECTIVE January 1, 2011

2

All of the provisions of the original Agreement not specifically deleted or modified herein shall
remain in full force and effect. Unless a provision contained in this Amendment specifically
indicates a different effective date, for purposes of the provisions contained herein, this
Amendment shall become effective July 1, 2011.

IN WITNESS WHEREOF, the parties have by their duly authorized representatives set their signatures.

3Q2 2011 - Exhibit 10.1

Exhibit 10.1 

FOURTH AMENDMENT TO CREDIT AGREEMENT

THIS FOURTH AMENDMENT TO CREDIT AGREEMENT (this “Amendment”), dated as of May 5, 2011, is entered into by and among CORE-MARK HOLDING COMPANY, INC. (“Holdings”), CORE-MARK INTERNATIONAL, INC. (“International”), CORE-MARK HOLDINGS I, INC. (“Holdings I”), CORE-MARK HOLDINGS II, INC. (“Holdings II”), CORE-MARK HOLDINGS III, INC. (“Holdings III”), CORE-MARK MIDCONTINENT, INC. (“Midcontinent”), CORE-MARK INTERRELATED COMPANIES, INC. (“Interrelated”), HEAD DISTRIBUTING COMPANY (“Head”), MINTER-WEISMAN CO. (“Minter-Weisman”; each of Holdings, International, Holdings I, Holdings II, Holdings III, Midcontinent, Interrelated, Head and Minter-Weisman shall be a “Borrower”, International shall be the “Canadian Borrower” and collectively such entities shall be the “Borrowers”), the parties hereto as lenders (each individually, a “Lender” and collectively, the “Lenders”), JPMORGAN CHASE BANK, N.A., as administrative agent for the Lenders (in such capacity, “Administrative Agent”), JPMORGAN CHASE BANK, N.A. and BANK OF MONTREAL, as Co-Lead Arrangers, JPMORGAN CHASE BANK, N.A., BANK OF MONTREAL and WELLS FARGO CAPITAL FINANCE, LLC (as successor by merger to Wachovia Capital Finance Corporation (Western)), as Joint Bookrunners, BANK OF MONTREAL and WELLS FARGO CAPITAL FINANCE, LLC (as successor by merger to Wachovia Capital Finance Corporation (Western)), as Co-Syndication Agents, and BANK OF AMERICA, N.A., as Documentation Agent.

RECITALS

		
	A.
	Borrowers, Administrative Agent and the Lenders have previously entered into that certain Credit Agreement, dated as of October 12, 2005, as amended or otherwise modified prior to the date hereof by that certain First Amendment to Credit Agreement, dated as of December 4, 2007, that certain Second Amendment to Credit Agreement, dated as of March 12, 2008, that certain letter agreement to Credit Agreement, dated January 31, 2009, and that certain Third Amendment to Credit Agreement and First Amendment to Pledge and Security Agreement, dated as of February 2, 2010 (the “Existing Credit Agreement”, and as amended by this Amendment and as the same may be further amended, supplemented, amended and restated or otherwise modified from time to time in accordance with its terms, the “Credit Agreement”), pursuant to which the Lenders have made certain loans and financial accommodations available to Borrowers.  Terms used herein without definition shall have the meanings ascribed to them in the Existing Credit Agreement.

		
	B.
	Borrowers have requested that Administrative Agent and the Lenders amend the Existing Credit Agreement and Administrative Agent and the Lenders are willing to amend the Existing Credit Agreement pursuant to the terms and conditions set forth herein.

		
	C.
	Each Borrower is entering into this Amendment with the understanding and agreement that, except as specifically provided herein, none of Administrative Agent's or any Lender's rights or remedies as set forth in the Existing Credit Agreement and the other Loan Documents are being waived or modified by the terms of this Amendment.

1

AGREEMENT
    
NOW, THEREFORE, in consideration of the foregoing and the mutual covenants herein contained, and for other good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, the parties hereby agree as follows:

		
	1.
	Amendments to Existing Credit Agreement.

		
	(a)
	The following definitions are hereby added to Section 1.01 of the Existing Credit Agreement in the appropriate alphabetical order:

“Average Modified Excess Availability” means, for any calendar quarter, the average of the amount of Modified Excess Availability as of the end of each day during such calendar quarter.  
“Fourth Amendment” means, that certain Fourth Amendment to Credit Agreement, dated as of May 5, 2011, by and among the Borrowers, the Lenders party thereto and the Administrative Agent.  

“Fourth Amendment Effective Date” means, the “Fourth Amendment Effective Date” as defined in the Fourth Amendment.

“Modified Excess Availability” means, as of any date of determination, the result of (a) Availability as of such date, plus (b) Suppressed Availability as of such date; provided, however, that the amount calculated under clause (b) shall not exceed $25,000,000 on any date. 
		
	(b)
	The definition of “Applicable Rate” in Section 1.01 of the Existing Credit Agreement is hereby amended and restated to read in its entirety as follows:

“ “Applicable Rate” means (x) at all times prior to the Third Amendment Effective Date, the margin determined in accordance with the terms of the Existing Credit Agreement (as defined in the Third Amendment), (y) from and after the Third Amendment Effect Date and prior to the Fourth Amendment Effective Date, the margin determined in accordance with the terms of the Existing Credit Agreement (as defined in the Fourth Amendment), and (z) from and after the Fourth Amendment Effective Date, for any day, with respect to any Eurodollar Revolving Loan or CDOR Revolving Loan, or with respect to the participation fees payable under Section 2.12(b) hereof, as the case may be, the applicable rate per annum set forth below under the caption “Eurodollar Spread” or “CDOR Spread”, as the case may be, based upon the Average Modified Excess Availability as of the most recent determination date:
	
		
	Average Modified Excess Availability
	Eurodollar Spread and CDOR Spread

	Category 1
≥ $125,000,000 
	1.75%

	Category 2
< $125,000,000
≥ $55,000,000
	2%

	Category 3
< $55,000,000
  
	2.25%

For purposes of the foregoing, (a) the initial Applicable Rate as of the Fourth Amendment Effective Date shall be the applicable rate per annum set forth above in Category 1, (b) thereafter, the Applicable Rate shall be determined as of the last day of each calendar quarter based upon the Borrowing Base Certificates delivered by Borrowers to Administrative Agent pursuant to Section 5.01(g) hereof for such calendar quarter, and (c) each change in the Applicable Rate, if any, resulting from a change in the Average Modified Excess Availability shall be effective on the first 

2

day of the second month after the end of each calendar quarter, provided that: (i) the Average Modified Excess Availability shall be deemed to be in Category 3 at the option of the Administrative Agent or at the request of the Required Lenders if the Borrowers fail to deliver any Borrowing Base Certificate required to be delivered by them pursuant to Section 5.01(g) hereof, during the period from the expiration of the time for delivery thereof until such Borrowing Base Certificate is delivered; and (ii) if any such Borrowing Base Certificates are subsequently determined to be incorrect in any material respect, Administrative Agent may increase the Applicable Rate retroactively to the beginning of the relevant calendar quarter to the extent that such error caused the Applicable Rate to be less than the Applicable Rate that would have been in effect if the error was not made.”
		
	(c)
	The definition of “Commitment Fee Rate” in Section 1.01 of the Existing Credit Agreement is hereby amended and restated to read in its entirety as follows:

“ “Commitment Fee Rate” means, for any day, the per annum rate set forth below, based upon the Line Usage for the prior calendar quarter:
	
			
	Level
	Line Usage
	Commitment Fee Rate

	I
	Greater than 30%
	0.375%

	II
	Less than or equal to 30%
	0.5%

The Commitment Fee Rate set forth above shall be increased or decreased based upon the Line Usage for the prior calendar quarter, as determined by Administrative Agent.”  
		
	(d)
	The definition of “Maturity Date” in Section 1.01 of the Existing Credit Agreement is hereby amended and restated to read in its entirety as follows:

“ “Maturity Date” means May 5, 2016 or any earlier date on which the Commitments are reduced to zero or otherwise terminated pursuant to the terms hereof.”

		
	(e)
	Section 1.04 of the Existing Credit Agreement is hereby amended and restated to read in its entirety as follows:

“SECTION 1.04.  Accounting Terms; GAAP.  Except as otherwise expressly provided herein, all terms of an accounting or financial nature shall be construed in accordance with GAAP, as in effect from time to time; provided that, if the Borrowers notify the Administrative Agent that the Borrowers request an amendment to any provision hereof to eliminate the effect of any change occurring after the date hereof in GAAP or in the application thereof on the operation of such provision (or if the Administrative Agent notifies the Borrowers that the Required Lenders request an amendment to any provision hereof for such purpose), regardless of whether any such notice is given before or after such change in GAAP or in the application thereof, then such provision shall be interpreted on the basis of GAAP as in effect and applied immediately before such change shall have become effective until such notice shall have been withdrawn or such provision amended in accordance herewith.  

The above shall be interpreted to read that, upon a change in GAAP, either the Borrowers or the Administrative Agent may send a notice to the other party about such change in GAAP and notifying the other party of the intention to continue using GAAP as in effect on the date hereof.  Notice may be given before or after any change in GAAP becomes effective and such notice does not require either an amendment to the Credit Agreement or an approval by the Borrowers, Administrative Agent or the Lenders.”

3

		
	2.
	Amendment Fees.  The Borrowers shall pay to Administrative Agent for the account of each Lender who executes and delivers this Amendment, a non-refundable amendment fee equal to 0.25% of such Lender's aggregate Commitment, which amendment fees shall be fully earned and due and payable on the date hereof. 

		
	3.
	Conditions Precedent to Effectiveness of this Amendment.  This Amendment and the amendments to the Existing Credit Agreement contained herein shall become effective, and shall become part of the Credit Agreement, on the date (the “Fourth Amendment Effective Date”) when each of the following conditions precedent shall have been satisfied in the sole discretion of Administrative Agent or waived by Administrative Agent:

		
	a.
	Amendment.  Administrative Agent shall have received this Amendment fully executed in a sufficient number of counterparts for distribution to all parties.

		
	b.
	Representations and Warranties. The representations and warranties set forth herein and in the Existing Credit Agreement (other than any such representations or warranties that, by their terms, are specifically made as of a date other than the date hereof) must be true and correct in all material respects, as updated by the schedules attached hereto as Annex A.

		
	c.
	Amendment Fee Letter.  Administrative Agent shall have received an Amendment Fee Letter, in form and substance satisfactory to Administrative Agent, executed by Borrowers (the “Amendment Fee Letter”).  

		
	d.
	Payment of Fees.  Administrative Agent shall have received from Borrowers all fees due and payable on or before the effective date of this Amendment, including, without limitation: (i) the amendment fees set forth in Section 2 hereof; and (ii) all fees payable in connection with this Amendment pursuant to the Amendment Fee Letter.

		
	e.
	Other Required Documentation.  Administrative Agent shall have received all other documents and legal matters in connection with the transactions contemplated by this Amendment and such documents shall have been delivered or executed or recorded and shall be in form and substance satisfactory to Administrative Agent.

		
	4.
	Representations and Warranties.    Each Borrower represents and warrants as follows:

		
	a.
	Authority.  Each Borrower has the requisite corporate power and authority to execute and deliver this Amendment, and to perform its obligations hereunder and under the Loan Documents (as amended or modified hereby) to which it is a party.  The execution, delivery, and performance by each Borrower of this Amendment have been duly approved by all necessary corporate action, have received all necessary governmental approval, if any, and do not contravene (i) any law or (ii) any contractual restriction binding on such Borrower, except for contraventions of contractual restrictions which would not, individually or in the aggregate, reasonably be expected to result in a Material Adverse Effect.  No other corporate proceedings are necessary to consummate such transactions.

		
	b.
	Enforceability.  This Amendment has been duly executed and delivered by each Borrower.  This Amendment and each Loan Document (as amended or modified hereby) (i) is the legal, valid, and binding obligation of each Borrower, enforceable against each Borrower in accordance with its terms, subject to applicable bankruptcy, insolvency, reorganization, moratorium, or other laws affecting creditors' rights generally and subject to general principles of equity, regardless of whether considered in a proceeding in equity or at law, and (ii) is in full force and effect.

		
	c.
	Representations and Warranties.  The representations and warranties contained in each Loan Document (other than any such representations or warranties that, by their terms, are specifically made as of a date other than the date hereof) are correct in all material respects on and as of the 

4

date hereof as though made on and as of the date hereof.

		
	d.
	No Default.  No event has occurred and is continuing that constitutes a Default or Event of Default.

		
	5.
	Choice of Law.  The validity of this Amendment, the construction, interpretation and enforcement hereof, and the rights of the parties hereto with respect to all matters arising hereunder or related hereto shall be determined under, governed by, and construed in accordance wit the laws of the State of New York.

		
	6.
	Counterparts.  This Amendment may be executed in any number of counterparts and by different parties and separate counterparts, each of which when so executed and delivered, shall be deemed an original, and all of which, when taken together, shall constitute one and the same instrument.  Delivery of an executed counterpart of a signature page to this Amendment by telefacsimile shall be effective as delivery of a manually executed counterpart of the Amendment.

		
	7.
	Reference to and Effect on the Loan Documents.

		
	a.
	Upon and after the Fourth Amendment Effective Date, each reference in the Existing Credit Agreement to “this Agreement”, “hereunder”, “hereof” or words of like import referring to the Credit Agreement, and each reference in the other Loan Documents to “the Credit Agreement”, “thereof” or words of like import referring to the Credit Agreement, shall mean and be a reference to the Credit Agreement as modified and amended hereby.

		
	b.
	Except as specifically amended in Section 1 of this Amendment, the Existing Credit Agreement and all other Loan Documents, are and shall continue to be in full force and effect and are hereby in all respects ratified, and confirmed and shall constitute the legal, valid, binding, and enforceable obligations of Borrowers to Administrative Agent and the Lenders without defense, offset, claim, or contribution. 

		
	c.
	The execution, delivery and effectiveness of this Amendment shall not, except as expressly provided herein, operate as a waiver of any right, power, or remedy of Administrative Agent or any Lender under any of the Loan Documents, nor constitute a waiver of any provision of any of the Loan Documents.

		
	8.
	Ratification.  Each Borrower hereby restates, ratifies and reaffirms each and every term and condition set forth in the Credit Agreement, as amended hereby, and the Loan Documents effective as of the date hereof.

		
	9.
	Estoppel.  To induce Administrative Agent and Lenders to enter into this Amendment and to induce Administrative Agent and the Lenders to continue to make advances to Borrowers under the Credit Agreement, each Borrower hereby acknowledges and agrees that, after giving effect to this Amendment, as of the date hereof, there exists no Default or Event of Default and no right of offset, defense, counterclaim, or objection in favor of any Borrower as against Administrative Agent or any Lender with respect to the Obligations.

		
	10.
	Integration.  This Amendment, together with the other Loan Documents, incorporates all negotiations of the parties hereto with respect to the subject mater hereof and is the final expression and agreement of the parties hereto with respect to the subject matter hereof.

		
	11.
	Severability.  In case any provision in this Amendment shall be invalid, illegal, or unenforceable, such provision shall be severable from the remainder of this Amendment and the validity, legality , and enforceability of the remaining provisions shall not in any way be affected or impaired thereby.

		
	12.
	Submission of Amendment.  The submission of this Amendment to the parties or their agents or 

5

attorneys for review or signature does not constitute a commitment by Administrative Agent or any Lender to waive any of their respective rights and remedies under the Loan Documents, and this Amendment shall have no binding force or effect until all of the conditions to the effectiveness of this Amendment have been satisfied as set forth herein.

[REMAINDER OF PAGE LEFT INTENTIONALLY BLANK]

6

IN WITNESS WHEREOF, the parties hereto have caused this Amendment to be duly executed and delivered by their duly authorized officers as of the day and year first above written.

CORE-MARK HOLDING COMPANY, INC.

	
		
	By:
	/S/    Greg Antholzner

	Name:
	Greg Antholzner

	Title:
	VP Finance & Treasurer

CORE-MARK INTERNATIONAL, INC.

	
		
	By:
	/S/    Greg Antholzner

	Name:
	Greg Antholzner

	Title:
	VP Finance & Treasurer

CORE-MARK HOLDINGS I, INC.

	
		
	By:
	/S/    Greg Antholzner

	Name:
	Greg Antholzner

	Title:
	VP Finance & Treasurer

CORE-MARK HOLDINGS II, INC.

	
		
	By:
	/S/    Greg Antholzner

	Name:
	Greg Antholzner

	Title:
	VP Finance & Treasurer

CORE-MARK HOLDINGS III, INC.

	
		
	By:
	/S/    Greg Antholzner

	Name:
	Greg Antholzner

	Title:
	VP Finance & Treasurer

CORE-MARK MIDCONTINENT, INC.

	
		
	By:
	/S/    Greg Antholzner

	Name:
	Greg Antholzner

	Title:
	VP Finance & Treasurer

7

CORE-MARK INTERRELATED COMPANIES, INC.

	
		
	By:
	/S/    Greg Antholzner

	Name:
	Greg Antholzner

	Title:
	VP Finance & Treasurer

HEAD DISTRIBUTING COMPANY

	
		
	By:
	/S/    Greg Antholzner

	Name:
	Greg Antholzner

	Title:
	VP Finance & Treasurer

MINTER-WEISMAN CO.

	
		
	By:
	/S/    Greg Antholzner

	Name:
	Greg Antholzner

	Title:
	VP Finance & Treasurer

8

Acknowledged and agreed to as of the date set forth above:

JPMORGAN CHASE BANK, N.A.,
as Administrative Agent and a Revolving Lender

	
		
	By:
	/S/    James Gurgone

	Name:
	James Gurgone

	Title:
	Senior Vice President

JPMORGAN CHASE BANK, N.A., TORONTO BRANCH,
as a Canadian Lender

	
		
	By:
	/S/    John P. Freeman

	Name:
	John P. Freeman

	Title:
	Senior Vice President

9

BANK OF AMERICA, N.A.,
as a Revolving Lender

	
		
	By:
	/S/    Gregory A. Jones

	Name:
	Gregory A. Jones

	Title:
	Senior Vice President

BANK OF AMERICA, N.A., (acting through its Canada branch),
as a Canadian Lender

	
		
	By:
	/S/    Medina Sales de Andrade

	Name:
	Medina Sales de Andrade

	Title:
	Vice President

10

WELLS FARGO CAPITAL FINANCE, LLC,
as a Revolving Lender

	
		
	By:
	/S/    Thomas Forbath

	Name:
	Thomas Forbath

	Title:
	Vice President

WELLS FARGO CAPITAL FINANCE CORPORATION CANADA
as a Canadian Lender

	
		
	By:
	/S/    Sean M. Noonan

	Name:
	Sean M. Noonan

	Title:
	Vice President, Relationship Manager

11

UNION BANK, N.A., 
as a Revolving Lender

	
		
	By:
	/S/    Greg Stewart

	Name:
	Greg Stewart

	Title:
	Vice President

UNION BANK, N.A., CANADA BRANCH
as a Canadian Lender

	
		
	By:
	/S/    Anne Collins

	Name:
	Anne Collins

	Title:
	Vice President

12

THE BANK OF NOVA SCOTIA, 
as a Revolving Lender and a Canadian Lender

	
		
	By:
	/S/    J. Mathews

	Name:
	J. Mathews

	Title:
	Director

13

BANK OF MONTREAL,
as a Revolving Lender 

	
		
	By:
	/S/    Craig Thistlethwaite

	Name:
	Craig Thistlethwaite

	Title:
	Director

BANK OF MONTREAL,
as a Canadian Lender

	
		
	By:
	/S/    Sean Gallaway

	Name:
	Sean Gallaway

	Title:
	Vice President

14

Source: [{"source": "alea-institute/alea-institute/kl3m-data-edgar-agreements/train-00193-of-00352.parquet"}, [{"source": "alea-institute/alea-institute/kl3m-data-edgar-agreements/train-00193-of-00352.parquet"}]]