E SCOPE OF WORK Clause Samples

E SCOPE OF WORK. An individual or entity who is (or is affiliated with a person/entity that is) debarred, suspended, or otherwise excluded from participating in procurement activities under the Federal Acquisition Regulation or from participating in non- procurement activities under regulations issued under Executive Order No. 12549 or under guidelines implementing Executive Order No. 12549, which relates to debarment and suspension; • An individual or entity who is an affiliate, as defined in the Federal Acquisition Regulation, of a person described above; or • An individual or entity that is excluded from participation in any Federal health care program under section 1128 or 1128A of the Act. The relationships include directors, officers or partners of the Contractor, persons with beneficial ownership of five percent (5%) or more of the Contractor’s equity, network providers, subcontractors, or persons with an employment, consulting or other arrangement with the Contractor for the provision of items and services that are significant and material to the Contractor's obligations under the Contract. In accordance with Section 1932(d)(1) of the Social Security Act, 42 CFR 438.608(C)(1), 42 CFR 438.610(a), 42 CFR 438.610(b), 42 CFR 438.610(c), SMDL 6/12/08, SMDL 1/16/09, and Exec. Order No. 2549, the Contractor shall provide written disclosure of any of the prohibited relationships described above. If FSSA finds that the Contractor is in violation of this regulation, FSSA will notify the Secretary of noncompliance and determine if the Contract will be continued or terminated in accordance with 42 CFR 438.610(d).

E SCOPE OF WORK. Prior to the Contract start date, the Contractor must also obtain from an insurance company duly authorized to do business in the State, professional liability (malpractice) insurance for the Contractor and its Medical Director, as defined in IC 34-18-4-1. The Contractor shall also obtain workers’ compensation insurance and comprehensive liability insurance. No less than thirty (30) calendar days before the policy renewal effective date, the Contractor must submit to FSSA its certificate of insurance for each renewal period for review and approval.

E SCOPE OF WORK. The Contractor must make a version available in a format that is optimized for mobile phone use. The Contractor’s member portal and website shall be designed with ease of access for an aging population and caretakers in mind. The Contractor shall date each web page, change the date with each revision and allow users print access to the information. The website must include the information required in the Enrollment Packet as described in Section 4.4. Such information shall include, at minimum, the following: • The Contractor’s searchable provider network identifying each provider’s specialty, service location(s), hours of operation, phone numbers, public transportation access and other demographic information as described in Section 4.4.1. The Contractor must update the on-line provider network information every two (2) weeks, at a minimum; • The Contractor’s contact information for member inquiries, member grievances and appeals; • The Contractor’s member services phone number, TDD number, hours of operation and after-hours access numbers, including the 24-hour Nurse Call Line; • A member portal with access to electronic Explanation of Benefit (EOB) statements, • Preventive care and wellness information; • Information about the cost and quality of health care services, as further described in Section 4.7.9; • A description of the Contractor’s disease management, care management and complex case management programs; • The member’s rights and responsibilities, as enumerated in 42 CFR 438.100. Please see Section 4.10 for further details regarding member rights; • The member handbook; • Contractor-distributed literature regarding all health or wellness promotion programs that are offered by the Contractor; • Contractor’s marketing brochures and posters • The Health Insurance Portability and Accountability Act (HIPAA) privacy statement; • Links to FSSA’s website for general Medicaid, Hoosier Care Connect information, and referrals • Per 42 CFR 438.10(i), information on pharmacy locations and preferred drug lists applicable to each program and benefit package; • List of all prior authorization criteria for prescription drugs, including mental health drugs; • Transportation access information; • Information about how members may access dental services and how to access the Contractor’s dental network; • A list and brief description of each of the Contractor’s member outreach and education materials;

E SCOPE OF WORK. The Contractor shall inform members that information is available upon request in alternative formats and how to obtain them. OMPP defines alternative formats as braille, large font letters, audio recordings, languages other than English and verbal explanation of written materials. When a member has requested materials in preferred alternative format, this shall be documented in the member’s record. The Contractor shall supply future materials in the requested and preferred format to the member. The Contractor may review with the member and document the specific type the member wishes to receive in a specific format versus other formats. For example, a member may wish to receive certain materials in braille and other materials in audio recordings. Unless a member specifically states their alternative format request is a one-time request, the Contractor shall consider the request an ongoing request and supply all future materials in the preferred format to the member. For first-time or one-time requests from a member, the Contractor shall mail the alternative version of the document in no more than seven (7) business days from the date of the request. If, for example, the member received a wellness visit reminder flyer and called the Contractor to ask for the flyer to be sent in braille, the Contractor shall take no more than seven (7) business days to mail the braille version from the date of the member request call. For first-time or one-time requests from a member, when the mailing is governed by NCQA or statutory requirements, the Contract shall have two (2) additional days from the NCQA or statutory timeframe to mail the document if no mailing has yet been sent to the member. For first-time or one-time requests from a member, when the mailing is governed by NCQA or statutory requirements and the statutory notice has already been fulfilled with a regular printed letter, the Contractor shall mail the alternate version of the document in no more than seven (7) business days from the date of the request. For existing on-going alternate format requests, the Contractor shall have two (2) additional business days from when the document would normally be required to be mailed, to mail the document in the alternate format. If, for example, a member had previously requested materials in braille, and an ID card would be sent to the member in five (5) business days, the timeline would be seven (7) business days for the braille version. The additional two (2) days ...

E SCOPE OF WORK. ▪ All subcontractors shall fulfill all State and federal requirements including Medicaid laws, regulations, applicable sub-regulatory guidance and contract provisions appropriate to the services or activities delegated under the subcontract. In addition, all subcontractors shall fulfill the requirements of the Contract (and any relevant amendments) that are appropriate to any service or activity delegated under the subcontract. ▪ The Contractor shall submit a plan to the State on how the subcontractor will be monitored for debarred employees. ▪ For the purposes of an audit, evaluation, or inspection by the State, CMS, the DHHS Inspector General, the Comptroller General or their designees, the subcontractor shall make available for ten (10) years from the final date of the contract period or from the date of completion of any audit, whichever is later, its premises, physical facilities, equipment, books, records contracts, computer, or other electronic systems relating to its Medicaid enrollees per 42 CFR 438.230(c)(3)(iii) and 42 CFR 438.3(k). This contract term shall specify that if the state, CMS, or the DHHS Inspector General determine that there is a reasonable possibility of fraud or similar risk, the above State and Federal agencies may inspect, evaluate, and audit the subcontractor at any time. ▪ The Contractor shall comply with all subcontract requirements specified in 42 CFR 438.230, which contains federal subcontracting requirements. All subcontracts, provider contracts, agreements or other arrangements by which the Contractor intends to deliver services required under the Contract, whether or not characterized as a subcontract under the Contract, are subject to review and approval by FSSA and must be sufficient to assure the fulfillment of the requirements of 42 CFR 434.6, which addresses general requirements for all Medicaid contracts and subcontracts. FSSA may waive its right to review subcontracts, provider contracts, agreements or other arrangements. Such waiver shall not constitute a waiver of any subcontract requirement. ▪ The subcontract shall specify the activities and obligations, and related reporting responsibilities per 42 CFR 438.230(c)(1)(i)-(ii) and 42 CFR 438.3(k). OMPP reserves the right to audit the Contractor’s subcontractors’ self-reported data and change reporting requirements at any time with reasonable notice. OMPP may require corrective actions and will assess liquidated damages, as specified in Contrac t Exhibit

E SCOPE OF WORK. ▪ The Contractor must require any third party vendor providing claims adjudication services to provide all underlying data associated with MLR reporting to the Contractor within 180 days of the end of the MLR reporting year or within 30 days of being requested by the Contractor, whichever comes sooner. • The MLR report submitted by the Contractor for each reporting year must include the following elements, as defined in 42 CFR 438.8: ▪ Number of member months in the reporting year ▪ Premium revenue ▪ Taxes ▪ Licensing fees ▪ Regulatory fees ▪ Incurred claims ▪ Expenditures for Quality Improvement activities ▪ Expenditures for Fraud prevention activities as defined in 42 CFR 438.8(e)(4) ▪ Non-claims costs ▪ Any credibility adjustment applied ▪ Remittance owed to the State, if any ▪ A comparison of the information reported on the MLR with the audited financial report ▪ A description of the aggregation method used to calculate total incurred claims ▪ A description of the methodology used to allocate expenses ▪ An attestation as to the accuracy of the calculation, in accordance with MLR standards. • Incurred Claims: ▪ Incurred claims submitted for each reporting year should include total incurred claims for the reporting year, and should not include claims incurred in prior years, regardless of when they were paid. ▪ Incurred claims reported in the MLR should relate only to members who were enrolled with the Contractor on the dates of service, based on data and information available on the reporting date. (Claims for members who were retroactively disenrolled should be recouped from providers and excluded from MLR reporting). ▪ Under sub-capitated or sub-contracted arrangements, the Contractor may only include amounts actually paid to providers for covered services and supplies as incurred claims. The non-benefit portion of sub-capitated and sub-contracted payments should be excluded from incurred claims. The Contractor should ensure all subcontracts provide for sufficient transparency to allow for this required reporting. • Expenditures may not be duplicated across expense categories or contracts: ▪ Each expenditure must be reported under only one expense category, unless a portion of the expense fits under the definition of, or criteria for, one type of expense and the remainder fits into a different type of expense, in which case the expense must be pro-rated between types of expenses. ▪ Expenditures that benefit multiple contracts or populations must be re...

E SCOPE OF WORK. For services that may be at risk for improper payments, the Contractor must develop processes to verify with members that said targeted services billed by providers were actually received by said members, in order to obtain direct verification of services rendered and increase oversight. Processes and procedures must be identified in the Contractor’s Program Integrity Plan, identified in Section 7.4.1. Specific services for member verification may be identified by the OMPP PI Section and may change based upon fraud trends. Processes for verifying services with members shall be included in the Contractor’s Program Integrity Plan. The Contractor shall provide a member portal with access to electronic EOB statements for Hoosier Care Connect members. Provider quality information shall also be made available to members. The Contractor shall capture quality information about its network providers and must make this information available to members. In making the information available to members, the Contractor shall identify any limitations of the data. The Contractor shall also refer members to quality information compiled by credible external entities such as CMS Hospital Compare or Leapfrog Group.

E SCOPE OF WORK. The plan shall be assessed by the Contractor annually and submitted to FSSA by August 1st for calendar year 2023 and by January 31st for all remaining calendar years of the Contract period. The assessment shall provide the outcome measures used to measure progress in the prior year, and any new interventions the Contractor will incorporate in the next year. The Contractor shall follow the guidance provided by the National Committee for Quality Assurance (NCQA) regarding the stratification of HEDIS measures by race and ethnicity. The Contractor shall ensure that all subcontractor’s services and sites are physically and digitally accessible, following the Americans with Disabilities Act (ADA) and Section 508 of the Rehabilitation Act (Section 508) and that all subcontractors are culturally competent.

E SCOPE OF WORK member’s enrollment in the Contractor. This information shall be included in the member handbook. The Contractor shall notify all members of their right to request and obtain information in accordance with 42 CFR 438.10. In addition to providing the specific information required at 42 CFR 438.10(f) upon enrollment in the Welcome Packet as described in Section 4.4 the Contractor shall notify members at least once a year of their right to request and obtain this information. Individualized notice shall be given to each member of any significant change in this information at least thirty (30) days before the intended effective date of the change. Significant change is defined as any change that may impact member accessibility to the Contractor’s services and benefits. The Contractor shall comply with the information requirements at 42 CFR 438.10. All enrollment notices, informational and instructional materials must be provided in a manner and format that is easily understood. This means, written materials shall not exceed a fifth-grade reading level and be in plain language. All written materials for members or potential members shall be in a font size no smaller than 12-point. In accordance with 42 CFR 438.10(e), the State must provide potential members with general information about the basic features of managed care and information specific to each MCE operating in the potential member’s service area. At minimum, this information will include factors such as MCE service area; benefits covered; network provider information; information about the potential enrollee's/member’s right to disenroll consistent with the requirements of 42 CFR 438.56 and which explains clearly the process for exercising this disenrollment right, as well as the alternatives available to the potential enrollee/member based on their specific circumstance; which populations are excluded from enrollment, subject to mandatory enrollment, or free to enroll voluntarily in the program (for mandatory and voluntary populations, the length of the enrollment period and all disenrollment opportunities available to the member must also be specified; any cost-sharing that will be imposed by the Contractor consistent with those set forth in the State plan; and the Contractor’s responsibilities for coordination of member care. The State shall provide information on Hoosier Care Connect MCEs in a comparative chart-like format. Once available, the State also intends to include Contractor quality and ...