Minnesota Department of Human Services Health Care Administration

Transcription

1 Minnesota Department of Human Services Health Care Administration Request for Proposals for Qualified Grantee(s) to Provide Health Care Services to Medical Assistance and MinnesotaCare Enrollees Under Alternative Payment Arrangements Through the Integrated Health Partnerships (IHP) Demonstration Date of Publication: April 27, 2015 Americans with Disabilities Act (ADA) Statement: This information is available in accessible formats for people with disabilities by calling or by using your preferred relay service. For other information on disability rights and protections, contact your agency s Americans with Disabilities Act (ADA) coordinator. IHP RFP Revised - July 13,

2 Table of Contents I. Introduction... 4 A. Purpose of Request... 4 B. Objective of this RFP... 4 C. Background General: Eligible Populations: Excluded Populations: Other Information... 6 II. Scope of Work... 6 A. Overview System Requirements Overview of Payment Models and Risk Definitions of Total Cost of Care Attribution Methodology Quality Measures Interaction with Medicaid Managed Care Organizations (MCOs) Data Feedback to Providers B. Tasks/Deliverables III. Proposal Format A. Required Proposal Contents B. Proposal Requirements Executive Summary: Description of the Applicant Delivery System: Description of MHCP Population Served by the Delivery System: Proposed Payment Arrangement: Quality Measures: D. Required Statements IV. RFP Process A. Timeline B. Optional Individual Question and Answer Sessions C. Responders Questions IHP RFP Revised - July 13,

3 D. Proposal Submission V. Proposal Evaluation and Selection A. Overview of Evaluation Methodology B. Evaluation Team C. Evaluation Phases Phase I Required Statements Review Phase II - Evaluation of Technical Requirements of Proposals Phase III - Selection of the Successful Responder(s) D. Contract Negotiations and Unsuccessful Responder Notice VI. Required Contract Terms and Conditions VII. State s Rights Reserved Appendix A, IHP Provider Reports Reference Documentation...33 Appendix B, Model IHP Contract IHP RFP Revised - July 13,

4 I. Introduction The goal of the Integrated Health Partnerships demonstration Request for Proposal (RFP) is to improve the quality and value of the care provided to the citizens served by public health care programs. This program creates an Integrated Health Partnership (IHP) structure for provider organizations to voluntarily contract with the Minnesota Department of Humans Services (DHS) to care for Minnesota Health Care Programs (MHCP) patients in both fee for service (FFS) and managed care under a payment model that holds these organizations accountable for the total cost of care and quality of services provided to this population. Within this structure, DHS plans to implement demonstration projects in different geographic regions of the state and across different models of care delivery that will integrate health care with chemical and mental health services, safety net providers, and social service agencies. The projects will include clear incentives for quality of care and targeted savings, and will result in increased competition in the marketplace through direct contracting with providers. A. Purpose of Request The Minnesota Department of Human Services, through its Health Care Administration (State), is seeking Proposals from qualified Responders to test alternative and innovative health care delivery systems serving MHCP patients. Minnesota Statutes 256B.0755 directs the State to solicit proposals to test alternative and innovative health care delivery systems that provide services to a specified patient population for an agreed upon total cost of care or risk/gain sharing payment arrangement. It also states that the request for proposals should be developed in consultation with hospitals, primary care providers, health plans, and other key stakeholders. To this end DHS released an RFI on March 28, 2011 and held three stakeholder meetings (April 7, 8, and 15, 2011). The RFI closed on April 15, The State received 40 responses and used the information to inform the development of the IHP model. B. Objective of this RFP The objective of this RFP is to contract with qualified Responders to perform the tasks and services set forth in this RFP. It is anticipated that any contract awarded under this RFP will have a start date of January 1, 2016, and an initial term of one year. Thereafter, the Commissioner of Human Services may choose to renew any contract awarded under this RFP annually over a three year period. Proposals must be submitted by 4:00 p.m. Central Time on August 24, This RFP does not obligate the State to award a contract or complete the project, and the State reserves the right to cancel the solicitation if it is considered to be in its best interest. All costs incurred in responding to this RFP will be borne by the Responder. C. Background 1. General: Under the authority of Minnesota Statutes 256B.0755, the State is soliciting IHP RFP Revised July 13,

5 proposals for Responders to participate in alternative payment arrangements for health care services on a statewide basis as an IHP. The proposed IHP will serve the population of non-dually eligible adults and children in Medical Assistance and MinnesotaCare enrolled under both fee-for-service and managed care programs. 2. Eligible Populations: The following persons who are recipients of Medical Assistance and MinnesotaCare are eligible for attribution to the IHP: a. Medical Assistance Enrollees Including pregnant women, children under 21, adults without children, and state-funded Medical Assistance. b. MinnesotaCare Enrollees Including pregnant women, children under 21, and adults without children. Individuals must belong to an eligible group under Minnesota Statutes, chapter 256L, meet income criteria, satisfy all other eligibility requirements, and pay a premium to the State. c. Recipients receiving Medical Assistance due to blindness or disability, as determined by the U.S. Social Security Administration or the State Medical Review Team, who are not dually eligible for Medicare. 3. Excluded Populations: The following persons are excluded from attribution to the IHP: a. Recipients receiving Medical Assistance due to age, blindness or disability who are dually eligible for Medicare. b. Recipients for whom DHS receives incomplete claims data due to third-party liability coverage. c. Recipients receiving Medical Assistance under the Refugee Assistance Program pursuant to 8 U.S.C. 1522(e). d. Individuals who are Qualified Medicare Beneficiaries (QMB), as defined in Section 1905(p) of the Social Security Act, 42 U.S.C. 1396d (p), who are not otherwise receiving Medical Assistance. e. Individuals who are Service Limited Medicare Beneficiaries (SLMB), as defined in Section 1905(p) of the Social Security Act, 42 U.S.C. 1396a(a)(10)(E)(iii) and 1396d(p), and who are not otherwise receiving Medical Assistance. f. Non-citizen recipients who only receive emergency Medical Assistance under Minnesota Statutes, section 256B.06, subd. 4. g. Recipients receiving Medical Assistance on a medical spend down basis. h. Medical Assistance recipients with cost-effective employer-sponsored private health care coverage, or who are enrolled in a non-medicare individual health plan determined to be cost-effective according to Minnesota Statutes, section 256B.69, subd. 4(b)(9). IHP RFP Revised - July 13,

6 i. Medical Assistance recipients with private health care coverage through a Health Maintenance Organization (HMO) licensed under Minnesota Statutes, chapter 62D. j. Medical Assistance recipients enrolled with Metropolitan Health Plan d/b/a Hennepin Health under the Hennepin County Medicaid demonstration project for single nondisabled adults under age sixty-five. k. MinnesotaCare recipients who are enrolled in the Healthy Minnesota Contribution Program. l. The commissioner may exclude recipients enrolled in Minnesota Senior Care Plus (MSC+), other than those in (a) above. 4. Other Information Minnesota Health Care Programs Fact Sheet Center for Medicare and Medicaid Innovation Models IHP website and RFI Responses Minnesota Health Reform Initiative Attachments Included DHS IHP Provider Reports Reference Documentation (Appendix A of this document) Integrated Health Partnerships (IHP) Model Base Contract and Attachments (Appendix B of this document) II. Scope of Work A. Overview This RFP provides background information and describes the services desired by the State. It delineates the requirements for this procurement and specifies the contractual conditions required by the State. Although this RFP establishes the basis for Responder Proposals, the detailed obligations and additional measures of performance will be defined in the final negotiated contract. The purpose of the IHP demonstration is to provide opportunities for providers and other organizations to develop innovative forms of care delivery under shared savings and loss payment arrangements that reduce the cost of care, improve health outcomes, and improve patient experience. The demonstration IHP RFP Revised - July 13,

7 will be conducted over a three-year period with annual performance periods. The demonstration will be conducted statewide and is not limited to providers or MHCP participants in a specified geographic area. MHCP participants included in the demonstration are non-dually eligible Medical Assistance and MinnesotaCare enrollees attributed to the IHP for the performance period. 1. System Requirements To be considered eligible to participate as an IHP for the purposes of responding to this RFP, a successful Responder must meet the following criteria: a. Provide the full scope of primary care, and adopt methods of care delivery so that the full scope of primary care is provided and care is coordinated across the spectrum of services provided. b. All providers included in the IHP demonstration payment model must be enrolled MHCP providers. c. Demonstrate, through the care delivery model, how the IHP will affect the total cost of care of its MHCP participants regardless of whether the services are delivered by the IHP. d. Demonstrate how formal and informal partnerships with community-based organizations, social service agencies, counties, public health resources, etc. are included in the care delivery model. Responders are encouraged to propose mechanisms to incorporate these organizations directly into the payment model. e. Demonstrate how the IHP will engage and coordinate with other providers, counties, and organizations, including county-based purchasing plans, that provide services to the IHP s patients on issues related to local population health, including applicable local needs, priorities, and public health goals. Responders should describe how local providers, counties, organizations, county-based purchasing plans, and other relevant purchasers were consulted in developing the application to participate in the demonstration project. f. Demonstrate how the IHP will meaningfully engage patients and families as partners in the care they receive, as well as in organizational quality improvement activities and leadership roles. g. Demonstrate established processes to monitor and ensure the quality of care provided. Participate in quality measurement activities as required by the State and engage in quality improvement activities. h. Demonstrate the capacity to receive data from the State via secure electronic processes and use it to identify opportunities for patient engagement and to stratify its population to determine the care model strategies needed to improve outcomes. i. Nothing in the contract agreement will obviate all providers included in the IHP from meeting all MHCP fee-for-service and/or managed care organization (MCO) IHP RFP Revised - July 13,

8 requirements including, but not limited to enrollment, reporting, claims submission, and quality measures. IHPs will not administer the MHCP benefit set or pay claims under the demonstration or be required to contract for additional services outside of the services delivered by the IHP. An IHP may include an organizing entity and agreement of shared governance. This may include but is not limited to a non-profit or a county or group of counties; however any IHP payments must be provided to and/or received from an MHCP enrolled provider identified in section III.B.4.b of this RFP by the IHP. 2. Overview of Payment Models and Risk Organizations that meet the system requirements described above are eligible to participate in either a Virtual or Integrated payment mode as described below. Eligibility for each payment model will be determined by the integration and scope of services provided by the IHP as described below. The payment models outlined are based on IHP performance against a risk-adjusted total cost of care target for all qualifying MHCP participants attributed to the IHP for the performance period. The total cost of care target will be calculated using risk-adjusted MHCP fee-for-service claims and encounter claims submitted by managed care organizations (MCOs) under contract with the State. IHP financial incentives under the demonstration related to reducing total costs will be contingent on performance on quality and patient experience outcomes. All shared savings and losses payments under the models described below will be calculated and disbursed annually via a reconciliation payment. Providers will continue to receive the current MHCP fee-for-service or MCO contracted payment during the performance period. Responders are encouraged to involve community organizations, local public health, behavioral health or long term care service providers in the distribution of shared savings and losses payments as defined in Sections III and IV, and bonus points are available for such arrangements. DHS is committed to developing a credible and fair risk-sharing and performance measurement process. In developing the initial IHP model analytics, DHS compiled a significant amount of stakeholder and expert feedback and performed a variety of analyses to develop the initial proposed payment model. During previous IHP negotiation and contract development processes, the payment model was refined based on additional research, actuarial analyses and feedback, and is described below and in the supplementary documentation. To assure the credibility of the process during the three years of the Demonstration Project, the payment models and process as described below may be subject to mutually agreed-upon modifications based on additional DHS research, emerging findings or feedback from the participating IHPs. a. Type of Models Model 1: Virtual IHP i. Provider organizations eligible for the Virtual IHP payment model include primary care providers and/or multi-specialty provider groups that are not formally integrated with a hospital or integrated system via aligned financial arrangements and common clinical and information systems. Provider organizations with an MHCP population between IHP RFP Revised - July 13,

9 1,000-1,999 attributed participants are eligible only for the Virtual IHP model, regardless of their level of formal integration. ii. The payment model is a shared savings model that will distribute the difference between annual expected and actual realized total cost of care if savings are achieved, a portion of which is contingent on quality and patient experience outcomes. Model 2: Integrated IHP i. Provider organizations eligible for the Integrated IHP include an integrated delivery system that provides a broad spectrum of outpatient and inpatient care as a common financial and organizational entity. Provider organizations must serve an MHCP population of 2,000 attributed participants or greater in order to be eligible for the integrated model. ii. iii. The payment model incorporates shared risk over time and builds toward a two-way risk sharing model that distributes the difference between the annual expected and actual realized total cost of care whether savings are achieved or not, a portion of which is contingent on quality and patient experience measures. Responders are required to propose the amount of risk for the MHCP population attributed to the IHP for the purposes of this RFP. The basic terms of the risk sharing agreement are outlined below. In responding to this RFP, IHPs will be required to propose their risk sharing arrangement within these parameters. b. Total Cost of Care (TCOC) Performance Assessment Process IHP performance assessment is based on a comparison of the observed TCOC for each performance period (Calendar Year (CY) 2016, CY2017, and CY2018) to a TCOC Target. The TCOC Target is based on a base period TCOC (CY2015) after adjusting for expected trend and changes in attributed population size and relative risk from the base period to the performance periods. The Base Period Attributed Population will be developed for each IHP using 2015 claims, MCO encounter data, and the attribution process as described in this RFP. Using this attributed population, the Base Period Total Cost of Care (Base TCOC) will be developed using the services as outlined in Section II.A.3 in this RFP. Claims for an individual member that fall outside of pre-determined thresholds will be capped to adjust the per member per month (PMPM) results for catastrophic cases. In addition, the Base Period Risk Score will be assessed for the assigned members, using the Johns Hopkins ACG risk adjustment tool to determine the relative risk of the base population. In addition to developing weights based exclusively on the services included in the Base TCOC, the weights used to assess the risk of the population will be calculated using the pre-determined claim caps to adjust the weights and reduce the impact of catastrophic cases. Early in each performance period, DHS will develop an Expected Trend rate for the total cost of care based on the trend rates used to develop the annual expected cost increases for the aggregate MHCP population, with appropriate adjustments for services excluded from the Base TCOC or other factors that are applicable to the total cost of care and goals of the program. An initial TCOC Target for the IHP RFP Revised - July 13,

10 upcoming performance period can be established using the Base TCOC and Expected Trend. The target will ultimately be adjusted for the relative risk of the actual population attributed to the IHP in the performance period. At the end of each performance period, DHS will determine the Performance Period Attributed Population using retrospective claims data and the attribution process as described in this RFP. In addition, the Performance Period Total Cost of Care (Performance TCOC) will be developed, adjusting for any claims for an individual member that fall outside of pre-determined catastrophic case thresholds. The risk score for the measurement period s attributed population will be used to calculate the change in relative risk from the base period to the performance period. Using the change in relative risk, the Target TCOC will be adjusted based on the increase or decrease in the risk of the attributed populations. The Adjusted Target TCOC will be compared to the Performance TCOC for purposes of determining the performance results and the basis for the calculation of shared savings and losses. c. Total Cost of Care Performance Measurement Specifications and Requirements To assure that a participating IHP does not have the measurement of their performance inappropriately impacted by changes in the risk status of the membership, DHS will perform risk adjustment on the attributed populations in the base period and performance period and adjust the Target TCOC (the Adj. Target TCOC ) to reflect the changes in risk. To further refine the measurement process and reduce the potential variability inherent in any risk score methodology, DHS has developed the following specifications and requirements: 1. Population sizes: Successful Responders must meet a minimum attributed MHCP population size of 1,000 members. For purposes of developing the risk arrangements, DHS is defining the following MHCP sizes: a. Small Population 1,000 to 1,999 attributed patients (Virtual model only) b. Medium Population 2,000 to 4,999 attributed patients c. Large Population more than 5,000 attributed patients 2. Claim cap levels: To reduce the potential variability of the risk assessment process and the financial results, DHS will develop the risk scores and total cost of care PMPM by removing the claim costs for individual members that fall above specific thresholds. Because of the greater impact of large claimants on the results for smaller populations, DHS developed the following general guidelines for managing catastrophic risk: a. Small Population $50,000 maximum annual claims per patient (Virtual model only) b. Medium Population $100,000 maximum annual claims per patient c. Large Population $200,000 maximum annual claims per patient 3. Minimum Performance Thresholds: DHS has established a 2% minimum performance threshold that must be met prior to the distribution of any shared savings or losses payments between the State (including its contracted MCOs, as applicable) and the IHP. Specifically, the Performance TCOC must be above 102% or below 98% of the Adj. Target TCOC in the Integrated IHP for shared savings and losses payments to occur. A Virtual IHP will not receive any shared savings unless their Performance TCOC is below 98% of the Adj. Target TCOC. Once the performance IHP RFP Revised - July 13,

11 target is met, shared savings or shared losses payments are calculated back to the first dollar, i.e., any amount above or below the TCOC target. 4. Shared Savings and Shared Losses Payment Distributions: DHS is requiring Integrated IHP Responders to propose their preferred performance thresholds for shared savings or shared losses between DHS and the IHP, within some specified parameters. The performance threshold parameters gradually incorporate two-way risk sharing and increased flexibility for IHPs over the three years of the demonstration. The parameters for each year are as follows: a. Performance Period 1: IHP shares any savings equally (50/50) with the State/MCOs provided the 2% minimum performance threshold has been achieved. The maximum threshold for shared savings in Performance Period 1 must be the same in Performance Period 3 and is limited to a maximum of 85% of the TCOC Target. b. Performance Period 2: IHP assumes some downside risk, but it need not be symmetrical to the proposed shared savings threshold. The IHP has some discretion around the amount of risk it is willing to bear, but the ratio of shared savings thresholds to shared loss thresholds must be 2:1. For example, if the IHP wishes to avoid risk for claims above 106% of the TCOC Target, the maximum threshold for shared savings is 88% (6 percentage points x 2 = 12) below the TCOC Target. All shared savings and shared losses are distributed equally (50/50) with the State/MCOs. c. Performance Period 3: IHP assumes two-way risk with symmetrical risk sharing thresholds. For example, if an IHP wishes to avoid risk at 115% of the TCOC Target, the maximum threshold for shared savings must be 85%. An IHP may elect different distributions of shared savings and shared losses within the proposed thresholds. The maximum threshold for shared savings in Performance Period 3 must be the same as in Performance Period 1 and is limited to a maximum of 85% of the TCOC Target (see section 1.3 of Attachment D of the model contract in Appendix B of this document, for specific requirements and additional detail). A Virtual IHP does not have the option of proposing a schedule and will be required to share any savings (once the 2% minimum performance threshold is met) equally (50/50) with the State for all three years of the demonstration. 3. Definitions of Total Cost of Care The two payment models will use the same methodology and categories of service to calculate the riskadjusted Total Cost of Care (TCOC) target. TCOC will be calculated by the State for all MHCP patients in both fee-for-service and managed care attributed to the IHP for the performance period. Further detail on the categories of service included and the specific procedure codes included in each category is provided in Attachment E: Core Services of the IHP model contract included as an attachment to this RFP. The State reserves the right to modify the services included in the total cost of care calculation under this RFP. The Responder may propose additional Medicaid covered services for inclusion in the TCOC target. The Responder should detail in their proposal any additional services beyond the core set by major category of service and procedure code. 4. Attribution Methodology IHP RFP Revised - July 13,

12 MHCP participants will be attributed by the State to an IHP using retrospective claims data for the purposes of determining the TCOC Target and actual Performance TCOC. Participants will be attributed to one IHP at a time. All of the attributed participants care as provided in the total cost of care definition will be attributed to the IHP, regardless of whether the IHP delivered the services. An interim attributed population will be determined early in the performance period and shared with the IHP. The final attributed population for the performance period will be re-calculated following 12 months of claims run-out for purposes of accountability under the payment models. Attribution will be done using a hierarchical process that incents active outreach and retention of patients by the IHP under the following general methodology: 1 st Participants actively enrolled in care coordination through a certified Health Care Home (HCH) submitting a monthly care coordination claim. 2 nd Participants that cannot be attributed based on HCH enrollment may be attributed to the IHP based on the number of Evaluation and Management (E&M) visits (i.e., encounters) with provider who specializes in primary care. 3 rd Participants that cannot be attributed through primary care visits may be attributed to the IHP based on their E&M visits with non-primary care (specialty) providers. Because the results of the attribution method will impact the size of the population included in each IHP s demonstration payment model, the State and Responder will define contract terms based on subsequent analysis of which participants are actually attributable. 5. Quality Measures 1. Shared savings under the payment models for IHPs will be contingent in part on clinical quality and patient experience measure results. The State will align quality measures across demonstrations and with existing measures and data collection under the Statewide Quality Reporting and Measurement System (Minnesota Statutes 62U.02), and Health Care Home Outcomes (Minnesota Statutes 256B.0751, subd. 6). The core set of quality measures, reporting specifications, and the benchmarking and scoring methodology are provided in detail in Attachment F: Quality and Patient Experience Measures of the IHP model contract included as Appendix B to this RFP. Performance on quality measures will impact the amount of shared savings (if any) achieved by each IHP and is phased in over the three year demonstration as follows: a. Performance Period 1: 25% of IHP portion of shared savings based on reporting measures. b. Performance Period 2: 25% of IHP portion of shared savings based on performance (overall quality score). c. Performance Period 3: 50% of IHP portion of shared savings based on performance (overall quality score). 2. The State will determine preliminary minimum and maximum attainment thresholds for each measure for all IHPs under the demonstration before the beginning of Performance Periods 2 and 3 and will post them on the DHS website. The State will notify the IHP of final thresholds upon final calculation using the data based on the most recent quality measurement periods. IHP RFP Revised - July 13,

13 3. In addition to the core set of measures defined by the State, successful Responders are encouraged to propose additional measures and to demonstrate how the additional measures apply to the specific communities and/or population served by the IHP. These measures can include specific health outcomes measures, patient experience measures, or measures of overall population health. Proposed additional measures are subject to approval by the State. Guidelines for additional measures include: a. Utilize a state or nationally recognized quality measure specification. b. The data must be able to be collected by a third-party using an existing data collection mechanism. c. The data must be validated and audited by a third-party. d. Not be a measure that is impacted by high variability due to coding changes. e. Ensure needed appropriate care is not negatively impacted. 6. Interaction with Medicaid Managed Care Organizations (MCOs) The IHP demonstration will be implemented consistently at the delivery system level and for MHCP participants currently enrolled in either fee-for-service and managed care. The State will implement and execute the IHP payment model, quality measures and methodology, patient attribution for both MHCP enrollees in fee-for-service and in MCOs under contract with the State to provide services to non-dually eligible Medical Assistance and MinnesotaCare enrollees. The MCOs will participate as a payer in the IHP payment process via their contract requirement with the State. The MHCP participants will be attributed to an IHP regardless of whether they are enrolled in fee-forservice or in an MCO. All attributed participants will be calculated together at the delivery system level for the purposes of the Total Cost of Care and the payment model. The State will calculate the total cost of care targets and the shared savings or losses payment across both fee-for-service and managed care using retrospective claims and encounter data. The State will also calculate the quality measures and overall score using data applicable to each measure. The State (and its contracted MCOs, as applicable) will each pay its portion of the shared savings payments to the IHP (or the State and its contracted MCOs will receive shared losses payments from the IHP). MCOs (licensed health plans or County-Based Purchasing Organizations) may not participate as principal Respondents in the IHP demonstration. 7. Data Feedback to Providers DHS will make utilization and risk information for its attributed population available to IHP providers via DHS IHP and MN-ITS data portals. The data will be populated by a monthly set of risk adjustment (Johns Hopkins Adjusted Clinical Groups [ACG ]) output in the DHS data warehouse, and will include both feefor-service and MCO encounter claim data. Data will be as timely as possible given standard claims lag, and will be available via risk adjustment software output or standardized reports. Key variables available to delivery systems will be primarily from ACG output, and will include population-level data (such as the total cost of care and rates of inpatient and emergency department utilization) and participant-level data (such as medical and pharmacy utilization histories, predictive risk information, and indices of care coordination). Reference documentation to IHP provider feedback reports can be found in Appendix A. IHP RFP Revised - July 13,

14 B. Tasks/Deliverables Successful Responders will: 1. Demonstrate innovative care models and community coordination, integration or linkages. 2. Describe the care model, programs and strategies and demonstrate how they will impact the total cost of care, clinical quality, and patient experience outcomes. 3. Agree to the requirements and structure defined in the RFP and the Model Contract in Appendix B of this document. 4. Agree to enter into a three-year demonstration with DHS, with at least annual opportunities to re-negotiate key contract provisions. 5. Propose the nature of the shared savings and/or losses arrangement, including the amount and distribution of shared savings and losses, within the guidelines laid out in the RFP. 6. Provide an estimated population size included in IHP to verify minimum population participation requirements. III. Proposal Format Proposals must conform to all instructions, conditions, and requirements included in the RFP. Responders are expected to examine all documentation and other requirements. Failure to observe the terms and conditions in completion of the Proposal are at the Responder s risk and may, at the discretion of the State, result in disqualification of the Proposal for non-responsiveness. Acceptable Proposals must offer all services identified in Section II - Scope of Work and agree to the contract conditions specified throughout the RFP. A. Required Proposal Contents Within the guidelines laid out in the Scope of Work above, Responders must describe their care model capabilities and propose specific elements of the demonstration payment model. Proposals should adhere to the following format: 1. Table of Contents 2. Proposal Requirements a. Executive Summary b. Description of the Applicant Delivery System c. Description of Care Models d. Description of Community Partnerships e. Description of Patient and Family Engagement f. Description of MHCP Population Served by Delivery System g. Proposed Payment Arrangement i. Selected Payment Model and Justification IHP RFP Revised - July 13,

15 ii. Defined Provider Population and Accountable Fiscal Entity iii. Additional Service Categories Included in Total Cost of Care (if applicable) iv. MHCP Population Size v. Proposed Amount of Assumed Risk vi. Mechanism for Distributing Shared Savings and Losses Payments vii. Quality Measures h. Additional Proposed Measures (if applicable) i. Description and data of Applicability of Measures to the Population Served 3. Required Statements a. Responder Information and Declarations b. Exceptions to Terms and Conditions c. Affidavit of Non-collusion d. Trade Secret/Confidential Data Notification e. Submission of Certified Financial Audit, IRS Form 990, or Most Recent Board-Reviewed Financial Statements f. Disclosure of Funding Form g. Human Rights Compliance i. Affirmative Action Certification ii. Equal Pay Certificate h. Certification and Restriction on Lobbying 4. Appendix (If Applicable) Any additional information thought to be relevant, but not applicable to the prescribed format, may be included in an Appendix of the Responder s Proposal. Please use letter K for this Appendix and attach it at the end of the Responder s Proposal. B. Proposal Requirements The following will be considered minimum requirements of the proposal. Emphasis should be on completeness and clarity of content. 1. Executive Summary: This component of the proposal should demonstrate the Responder's understanding of the requirements in this RFP and any problems anticipated in accomplishing the work. The Executive Summary should also show the Responder s overall design of the project in response to achieving the deliverables as defined in this RFP. Specifically, the proposal should demonstrate the Responder's familiarity with the project elements, its solutions to the problems presented and knowledge of the requested services. 2. Description of the Applicant Delivery System: This section must include information on the programs and activities of the delivery system, the number of people served, geographic area served, staff experience, and/or programmatic accomplishments. Include reasons why your organization is capable to effectively complete the services outlined in the RFP. Include a brief history of your organization and all strengths that you consider are an asset to your program. The Responder should demonstrate the length, depth, and applicability of all prior experience in IHP RFP Revised - July 13,

16 providing the requested services. The Responder should also verify that the delivery system provides the full scope of primary care services (defined as overall and ongoing medical responsibility for comprehensive care for preventive care and a full range of acute and chronic conditions). The Responder should also demonstrate the skill and experience of lead staff and designate a project manager with experience in planning and providing the proposed services. a. Description of Care Models: This section should detail how the IHP expects to lower the total cost of care and maintain or improve clinical quality and patient experience through innovative care delivery models, such as health care home certification or other national certifications, community-based or collaborative initiatives (e.g., DIAMOND, RARE, etc.). Include information on approaches and methods to coordinate care across the spectrum of services included in the payment model; encourage prevention and health promotion to create healthier communities; and use of data to target care interventions, stratify patients by complexity and conduct quality improvement activities. The Responder should provide examples and summaries of experience with similar performance or risk-sharing arrangements including percentages of total patient population and primary payer break out included in these arrangements between the Responder and Medicare or other payers, if applicable. b. Description of Community Partnerships: This section should describe any existing or planned partnerships between the IHP and community-based organizations and public health resources, such as disability and aging services, social services, transportation services, and school-based services. Describe the expected impact of these partnerships on key outcomes of interest. The Responder should describe how the IHP will engage and coordinate with other providers, counties, and organizations, including county-based purchasing plans, that provide services to the IHP s patients on issues related to local population health, including applicable local needs, priorities, and public health goals. Describe how the IHP consulted with local providers, counties, organizations, county-based purchasing plans, and other relevant purchasers in developing the application to participate in the demonstration project. c. Description of Patient and Family Partnerships: This section should demonstrate the ways in which patients (and their families where appropriate) are meaningfully engaged as partners in the care they receive, as well as in organizational quality improvement activities and leadership roles. 3. Description of MHCP Population Served by the Delivery System: This section must describe the entire MHCP population currently served by the IHP, including the total number of MHCP enrollees served, the overall proportion of the payer mix represented by MHCP enrollees, and key descriptive information such as age, gender, race/ethnicity, and the diagnoses/conditions of highest prevalence. As described above, the population served must include all MHCP enrollees not specifically excluded from the demonstration payment model. 4. Proposed Payment Arrangement: IHP RFP Revised - July 13,

17 a. Selected Payment Model and Justification: This section will indicate whether the delivery system qualifies for the Virtual IHP or the Integrated IHP payment model described in Section II above. If the Responder identifies the Virtual IHP model, it must describe the organizational structure of the delivery system and demonstrate that it either does not operate within a formally integrated care system, or serves an MHCP population of 1,000 1,999 participants, or both. Features of such integration include, but are not limited to, common clinical and information systems, shared financial structure and a common parent organization. This section will also indicate the catastrophic claim cap level to be used in the payment model based on the number of qualifying MHCP participants served, as illustrated in Section II. b. Defined Provider Population and Accountable Financial Entity: This section must identify the care for which the IHP will be accountable by identifying the involved providers. This must be done in a way that allows DHS to link claims data to a defined fiscal entity or group of providers. o The Responder must specify the Group National Provider Identifiers (NPI) (type 2) for the entities participating in the IHP, and o o A complete list of individual provider NPIs participating in the IHP. Further, the Respondent must specify the billing provider NPI or Tax Identification Number (TIN) that it wishes to be the locus of accountability for the delivery system and contracting partner with the State. This will be the identified entity for the shared savings and loss payments to be transmitted to and from DHS. c. Additional Service Categories Included in Total Cost of Care (if applicable): Attachment E: Core Services of the IHP model contract included as an attachment to this RFP lists the minimum services included in the Total Cost of Care (TCOC) for all demonstration payment models. Responders are encouraged to include additional services in the TCOC in their proposal. This section should identify any additional service categories that the IHP proposes to be accountable for through their inclusion in the TCOC calculation. Responders need not complete this section if they do not wish to add services to the defined TCOC model. d. MHCP Population Size: This section should provide an estimate of the population size that the IHP expects to serve under the demonstration project, and a confirmation of the corresponding catastrophic claim cap laid out in Section II. In addition to the estimate, the methodology, assumptions and information (e.g. plan provided data, payment analysis) used by the IHP to estimate the population size should be briefly described in the response. e. Proposed Amount of Assumed Risk: This section must contain a proposal for the amount and distribution of the shared savings and/or losses payments in the model in each of the three years of the demonstration. (The Virtual Model contains a standard 50/50 split of shared savings.) Within the guidelines described in Section II above, the Respondent must propose the amount of shared savings and losses. In the Integrated IHP model, the amount of shared savings and shared loss must adhere to the following guidelines: Performance Period 1: IHP shares any savings equally (50/50) with the State/MCOs provided the 2% minimum performance threshold has been achieved. The IHP RFP Revised - July 13,

18 maximum threshold for shared savings in Performance Period 1 must be the same in Performance Period 3 and is limited to a maximum of 85% of the TCOC Target. Performance Period 2 (Integrated only): IHP assumes some downside risk, but it need not be symmetrical to the proposed shared savings threshold. The IHP has some discretion around the amount of risk it is willing to bear, but the ratio of shared savings thresholds to shared loss thresholds must be 2:1. For example, if the IHP wishes to avoid risk for claims above 106% of the TCOC Target, the maximum threshold for shared savings is 88% (6 percentage points x 2 = 12) below the TCOC Target. All shared savings and losses are distributed equally (50/50) with the State/MCOs. Performance Period 3 (Integrated only): IHP assumes two-way risk with symmetrical risk sharing thresholds. For example, if an IHP wishes to avoid risk at 115% of the TCOC Target, the maximum threshold for shared savings must be 85%. An IHP may elect different distributions of shared savings and losses within the proposed thresholds. The maximum threshold for shared savings in Performance Period 3 must be the same as the maximum threshold in Performance Period 1 and is limited to a maximum of 85% of the TCOC Target. (See section 1.3 of Attachment D of the model contract in Appendix B of this document, for additional detail on the settlement process). The table below provides a hypothetical example of a permissible 3-year risk sharing agreement under the integrated model, along with a suggested format for developing your response. Performance Period 1 Performance Period 2 Performance Period 3 Shared Savings Only Example Responder to Complete Example Responder to Complete Threshold % of Adj. Target TCOC IHP/DHS Distribution % of Adj. Target TCOC IHP/DHS Distribution % of Adj. Target TCOC IHP/DHS Distribution % of Adj. Target TCOC IHP/DHS Distribution % of Adj. Target TCOC IHP/DHS Distribution 1 112% - 115% None 110% - 115% None 112% - 115% 40% / 60% 2 110% - 112% None 110% - 112% None 110% - 112% 50% / 50% 3 106% - 110% None 106% - 110% None 106% - 110% 60% / 40% 4 102% - 106% None 102% - 106% 50% / 50% 102% - 106% 70% / 30% 5 100% - 102% None 100% - 102% 50% / 50% 100% - 102% 70% / 30% 6 98% - 100% 50% / 50% 98% - 100% 50% / 50% 98% - 100% 70% / 30% 7 94% - 98% 50% / 50% 94% - 98% 50% / 50% 94% - 98% 70% / 30% 8 90% - 94% 50% / 50% 90% - 94% 50% / 50% 90% - 94% 60% / 40% 9 88% - 90% 50% / 50% 88% - 90% 50% / 50% 88% - 90% 50% / 50% 10 85% - 88% 50% / 50% 85% - 88% None 85% - 88% 40% / 60% The % thresholds for the second and third year of the Demonstration can be modified based on the preferences of the bidding IHP. The selected shared savings/losses distributions must follow the guidelines described below. For Performance Period 2, the IHP is expected to accept downside risk, which can be capped at a threshold specified by the IHP. However, if the IHP chooses to cap the loss threshold, the amount of shared savings must be capped at a 2:1 percentage of the loss cap. For Performance Period 3, the thresholds and distribution percentages may differ from the example and can vary by year. However, the IHP/State distribution must be the same for savings and losses at the symmetric thresholds (e.g., 90 to 94% gain share distribution must equal the 106 to 110% loss share distribution). Additionally, the shared savings thresholds in Performance Period 3 must be the same as Performance Period 1. IHP RFP Revised - July 13,

19 The State may consider deviations from the threshold and distribution percentage requirements described above for Responders that include community providers or organizations or additional service beyond the core set for TCOC in the IHP payment model. The Responder should follow the requirements above for completing the financial template but include details of how they propose to include community providers or organizations and/or additional services in their proposal. Deviations from the current requirements may need further federal approval. f. Mechanism for Distributing Shared Savings and Losses Payments: This section must describe the manner in which the IHP will distribute potential shared savings payments among its component parts or entities, as well as the nature of shared responsibility for potential shared losses payments penalties in the Integrated Model. If applicable, the IHP should highlight the direct inclusion of community organizations in the payment model structure. 5. Quality Measures: As described in Section II above, a portion of shared savings that accrue to the IHP are contingent on clinical quality and patient experience measure reporting in Performance Period 1 and performance in Performance Periods 2 and 3. The core set of outcome measures for all IHPs in the demonstration are measures included in the Statewide Quality Reporting and Measurement System pursuant to Minnesota Statutes 62U.02. An IHP may propose measures in addition to the core set in accordance with the guidelines described below. a. Additional Proposed Measures (if applicable): If desired, the Responder may identify additional quality and patient experience measures to incorporate into the payment model. These additional measures do not replace the core measure set identified above. Describe how the measures are defined and collected, how they have been validated and endorsed by state and/or national organizations, and otherwise meet the guidelines described is section II.A.5. of this RFP. b. Description of Applicability of Measures to the Population Served: This section must describe how the clinical quality and patient experience measures (both the core set and any additional measures proposed) apply to the specific populations and communities served by the Respondent, as well as how the care models, community partnerships, and patient and family partnerships are expected to improve these outcomes. D. Required Statements Complete the correlating forms found in edocs by right clicking on the links below (in blue), select Copy Hyperlink and paste into your web browser and click Enter. These forms must be submitted as the Required Statements section of your proposal. You must use the current forms found in edocs. Failure to use the most current forms found in edocs in completion of the proposal are at the responder s risk and may, at the discretion of the State, result in disqualification of the proposal for nonresponsiveness. IHP RFP Revised - July 13,

20 1. Responder Information and Declarations (Responder Information/Declarations Form DHS ENG): Complete and submit the attached Responder Information and Declarations form. If you are required to submit additional information as a result of the declarations, include the additional information as part of this form. 2. Exceptions to RFP Terms (Exceptions to Terms and Conditions Form- DHS-7019-ENG): The contents of this RFP and the proposal(s) of the successful responder(s) may become part of the final contract if a contract is awarded. Each responder's proposal must include a statement of acceptance of all terms and conditions stated within this RFP or provide a detailed statement of exception for each item excepted by the responder. Responders who object to any condition of this RFP must note the objection on the attached Exceptions to RFP Terms form. If a responder has no objections to any terms or conditions, the responder should write None on the form. Responder should be aware of the State s standard contract terms and conditions in preparing its response. A sample State of Minnesota, Department of Human Services, Grant Contract is attached in the Appendix for your reference. Much of the language reflected in the contract is required by statute. If you take exception to any of the terms, conditions or language in the contract, you must indicate those exceptions in your response to the RFP. Only those exceptions indicated in your response to the RFP will be available for discussion or negotiation. Responders are cautioned that any exceptions to the terms of the standard State contract which give the responder a material advantage over other responders may result in the responder s proposal being declared nonresponsive. Proposals being declared nonresponsive will receive no further consideration for award of the Contract. Also, proposals that take blanket exception to all or substantially all boilerplate contract provisions will be considered nonresponsive proposals and rejected from further consideration for contract award. 3. Affidavit of Noncollusion (Affidavit of Noncollusion Form- DHS-7021) : Each responder must complete and submit the attached Affidavit of Noncollusion form. 4. Trade Secret/Confidential Data Notification (Trade Secret/Confidential Data Notice Form- DHS ENG): All materials submitted in response to this RFP will become property of the State and will become public record in accordance with Minnesota Statutes, section , after the evaluation process is completed. Pursuant to the statute, completion of the evaluation process occurs when the government entity has completed negotiating the contract with the successful responder. If a contract is awarded to the Responder, the State must have the right to use or disclose the trade secret data to the extent otherwise provided in the grant contract or by law. If the responder submits information in response to this RFP that it believes to be trade secret/confidential materials, as defined by the Minnesota Government Data Practices Act, Minnesota Statutes, section 13.37, and the responder does not want such data used or disclosed for any purpose other than the evaluation of this proposal, the responder must: a. clearly mark every page of trade secret materials in its proposal at the time the proposal is submitted with the words TRADE SECRET or CONFIDENTIAL in capitalized, underlined and bolded type that is at least 20 pt.; the State does not assume liability for the use or disclosure of unmarked or unclearly marked trade secret/confidential data; IHP RFP Revised - July 13,

21 b. fill out and submit the attached Trade Secret/Confidential Information Notification Form, specifying the pages of the proposal which are to be restricted and justifying the trade secret designation for each item. If no material is being designated as protected, a statement of None should be listed on the form; c. satisfy the burden to justify any claim of trade secret/confidential information. In order for a trade secret claim to be considered by the State, detailed justification that satisfies the statutory elements of Minnesota Statutes, section and the factors discussed in Prairie Island Indian Community v. Minnesota Dept. of Public Safety, 658 N.W.2d 876, (Minn.App.2003) must be provided. Use of generic trade secret language encompassing substantial portions of the proposal or simple assertions of trade secret interest without substantive explanation of the basis therefore will be regarded as nonresponsive requests for trade secret exception and will not be considered by the State in the event of a data request is received for proposal information; and d. defend any action seeking release of the materials it believes to be trade secret and/or confidential, and indemnify and hold harmless the State, its agents and employees, from any judgments awarded against the State in favor of the party requesting the materials, and any and all costs connected with that defense. This indemnification survives the State s award of a contract. In submitting a response to this RFP, the responder agrees that this indemnification survives as long as the trade secret materials are in the possession of the State. The State is required to keep all the basic documents related to its contracts, including selected responses to RFPs, for a minimum of six years after the end of the contract. Non-selected RFP proposals will be kept by the State for a minimum of one year after the award of a contract, and could potentially be kept for much longer. The State reserves the right to reject a claim if it determines responder has not met the burden of establishing that the information constitutes a trade secret or is confidential. The State will not consider prices or costs submitted by the responder to be trade secret materials. Any decision by the State to disclose information designated by the responder as trade secret/confidential will be made consistent with the Minnesota Government Data Practices Act and other relevant laws and regulations. If certain information is found to constitute a trade secret/confidential, the remainder of the Proposal will become public; only the trade secret/confidential information will be removed and remain nonpublic. The State also retains the right to use any or all system ideas presented in any proposal received in response to this RFP unless the responder presents a positive statement of objection in the proposal. Exceptions to such responder objections include: (1) public data, (2) ideas which were known to the State before submission of such proposal, or (3) ideas which properly became known to the State thereafter through other sources or through acceptance of the responder's proposal. 5. Submission of Certified Financial Audit, IRS Form 990, or Most Recent Board-Reviewed Financial Statements: The successful responder must be fiscally responsible. Therefore, responders must include in their proposals sufficient financial documentation to establish their financial stability. Depending on the responder s annual income or how long the responder has been in business, a responder is required to submit either a certified financial audit, IRS Form 990, or most recent boardreviewed financial statements. A certified financial audit is a review of an organization s financial statements, fiscal policies and control procedures by an independent third party to determine if the statements fairly represent the organization s financial position and if organizational procedures are in accordance with Generally Accepted Accounting Principles (GAAP). Minnesota nonprofit organizations IHP RFP Revised - July 13,

22 are required to have a certified financial audit completed for any fiscal year in which they have total revenue of more than $750,000. An IRS Form 990 is a federal tax return for nonprofit organizations. Nonprofit organizations that are recognized as exempt from federal income tax must file a Form 990 or Form 990 EZ if it has averaged more than $25,000 in annual gross receipts over the past three tax years. Responders must submit financial information as outlined below with their proposal: a. Responders with an annual income of under $25,000 or who have not been in existence long enough to have an audit or completed IRS Form 990 should submit their most recent board-reviewed financial statements. b. Responders with total annual revenue of under $750,000 should submit their most recent IRS Form 990. c. Grant applicants with total annual revenue of over $750,000 should submit their most recent certified financial audit. Responders may also include documentations of cash reserves to carry you through shortages or delays in receipt of revenue, and/or other documents sufficient to substantiate responsible fiscal management. In the event a responder is either substantially or wholly owned by another corporate entity, the proposal must also include the most recent detailed financial report of the parent organization, and a written guarantee by the parent organization that it will unconditionally guarantee performance by the responder in each and every term, covenant, and condition of such contract as may be executed by the parties. Please also include information about any pending major accusations that could affect your financial stability. If the responder is a county government or a multi-county human services agency that has 1.) had an audit in the last year by the State Auditor or an outside auditing firm or 2) meets the requirements of the Single Audit Act, the responder is not required to submit financial statements. However, the State reserves the right to request any financial information to assure itself of a county s financial status. The information collected from these inquiries will be used in the State s determination of the award of the contract. It may be shared with other persons within the Minnesota Department of Human Services who may be involved in the decision-making process, and/or with other persons as authorized by law. If you choose not to provide the requested information, your organization s proposal will found nonresponsive and given no further consideration. The State reserves the right to request any additional information to assure itself of a responder's financial reliability. 6. Disclosure of Funding Form (Disclosure of Funding Form- DHS-7018-ENG) Per the Federal Funding Accountability and Transparency Act of 2006 Transparency Act or FFATA (Public Law ), all entities and organizations receiving federal funds are required to report full disclosure of funding (United States Code, title 31, chapter 61, section 6101). The purpose of FFATA is to provide every American with the ability to hold the government accountable for each spending decision. The end result is to reduce wasteful spending in the government. The FFATA legislation requires information on federal awards to be made available to the public through a single, searchable website. Federal awards include grants, sub-grants, loans, awards, and delivery orders. IHP RFP Revised - July 13,

23 In order to comply with the federal statute, the Minnesota Department of Human Services is required to obtain and report by the grantee s Data Universal Numbering System (DUNS) number and determine if the grantee meets specific requirement which would require additional reporting items and to collect additional information on executive compensation if required. In order to comply with federal law and to collect this information, responders are required to fill out the Disclosure of Funding Form and submit it with their response. The form requires responders to provide their Data Universal Numbering System (DUNS) number. The Data Universal Numbering System (DUNS) number is the nine-digit number established and assigned by Dun and Bradstreet, Inc. (D&B) to uniquely identify business entities. If a responder does not already have a DUNS number, a number may be obtained from the D&B by telephone (currently ) or the Internet (currently at The responder must have a DUNS number before their response is submitted. 7. Human Rights Compliance: i. Affirmative Action (Affirmative Action Data Page- DHS-7016-ENG).For all contracts estimated to be in excess of $100,000, Responders are required to complete and submit the attached Affirmative Action Data page. As required by Minnesota Rules, part , It is hereby agreed between the parties that Minnesota Statutes, section 363A.36 and Minnesota Rules, parts are incorporated into any contract between these parties based upon this specification or any modification of it. A copy of Minnesota Statutes, section 363A.36 and Minnesota Rules, parts are available upon request from the contracting agency. ii. Equal Pay Certificate. (Equal Pay Certificate Compliance DHS ENG) 1 1. Scope. Pursuant to Minnesota Statutes, section 363A.44, the State shall not execute a contract for goods or services or an agreement for goods or services in excess of $500,000 with a business that has 40 or more full-time employees in the State of Minnesota or a state where the business has its primary place of business on a single day during the prior 12 months, unless the business has an equal pay certificate or it has certified in writing that it is exempt. This section does not apply to a business, with respect to a specific contract, if the commissioner of administration determines that the requirements of this section would cause undue hardship on the business. This section does not apply to a contract to provide goods or services to individuals under Minnesota Statutes, chapters 43A, 62A, 62C, 62D, 62E, 256B, 256I, 256L, and 268A, with a business that has a license, certification, registration, provider agreement, or provider enrollment contract that is a prerequisite to providing those good or services. 2. Application. If your response to this RFP is or could be within the scope of Minnesota Statutes, section 363A.44, you must apply for an equal pay certificate by paying a $150 filing fee and submitting an equal pay compliance statement to the Minnesota Department of Human Rights ( MDHR ). MDHR s Equal Pay Certificate Application Form can be obtained at It is your sole responsibility to submit this statement to MDHR and if required apply for an equal pay certification before the due 1 IHP RFP Revised - July 13,

24 date of this proposal and obtain the certification prior to the execution of any resulting contract. 3. Revocation of Contract. If a contract is awarded to a business that does not have an equal pay certificate as required by Minnesota Statutes, section 363A.44, or is not in compliance with the laws identified within section 363A.44, MDHR may void the contract on behalf of the state, and the contract may be abridged or terminated by DHS upon notice that the MDHR has suspended or revoked the certificate of the business. 4. Equal Pay Certificate Compliance Form. You must complete the Equal Pay Certificate of Compliance Form and submit it with your proposal. The Equal Pay Certificate of Compliance Form can be obtained at 8. Certification Regarding Lobbying (Certificate Regarding Lobbying Form- DHS-7017-ENG): Federal money will be used or may potentially be used to pay for all or part of the work under the contract, therefore the responder must complete and submit the attached Certification Regarding Lobbying form. IV. RFP Process A. Timeline This timeline outlines the RFP process for ACTIVITY DATE RFP Publication April 27, 2015 All RFP Questions Received August 3, 2015 Optional Individual Q&A Sessions with Potential Responders May 11, 2015 August 3, 2015 All RFP Questions Answered and Posted on DHS Website Anticipated August 5, 2015 Proposal Responses Due August 24, 2015 RFP Review Completed Anticipated September 4, 2015 Notice of Intent to Contract Anticipated September 9, 2015 IHP Model and Contract Overview Plenary Meetings (Two 3- September 14 October 2, 2015 hour meetings) Individual Potential IHP Contract Negotiations Begin Anticipated September 14, 2015 Performance period begins January 1, 2015 B. Optional Individual Question and Answer Sessions DHS staff is making available to all potential provider responders one optional 30-minute Question and Answer (Q&A) session May 11, 2015 through August 3, 2015 in person or via conference call. The optional Q&A sessions will serve as an opportunity for Responders to ask specific questions of State staff IHP RFP Revised - July 13,

25 concerning the project. A Q&A session is not mandatory. DHS staff will record all questions and answers provided in the individual sessions and post them to the DHS website. To schedule a Question and Answer session for your provider organization, please contact Mathew Spaan at [email protected] by July 27, Responders may attend via conference call (contact the State contact for this RFP for more information about attending by conference call). Oral answers given at the conference will be non-binding. Written responses to questions asked at the conference will be sent to all identified prospective Responders after the conference. C. Responders Questions Responders questions regarding this RFP must be submitted in writing prior by 4:00 p.m. Central Time on August 3, All questions must be addressed to: Request for Proposal Response Attention: Mathew Spaan Health Care Administration Department of Human Services PO Box St. Paul, MN Questions may also be ed to [email protected]. Other personnel are NOT authorized to discuss this RFP with Responders before the proposal submission deadline. Contact regarding this RFP with any State personnel not listed above could result in disqualification. The State will not be held responsible for oral responses to Responders. Questions will be addressed in writing and distributed to all identified prospective Responders. Every attempt will be made to provide timely answers, with the intent that they are sent no later than August 5, D. Proposal Submission One (1) original and eight (8) copies of the proposal must be submitted. Additionally, Responder shall include an electronic copy on a CD-ROM or other electronic storage with the Proposal submission. Proposals must be physically received (not postmarked) by 4:00 p.m. Central Time on August 24, 2015 to be considered. Late proposals will not be considered and will be returned unopened to the submitting party. Faxed or ed proposals will not be accepted. Clearly label the original "Proposal Original" and each copy Proposal Copy. All proposals, including required copies, must be submitted in a single sealed package or container. Proposals should be submitted in three-ring binders or spiral bound binders with each section indexed with label tabs. The main body of the proposal pages must be numbered and submitted in 12-point font on 8 ½ X 11 inch paper, single spaced. The size and/or style of graphics, tabs, attachments, margin notes/highlights, etc. are not restricted by this RFP and their use and style are at the responder s discretion. IHP RFP Revised - July 13,

26 The above-referenced packages and all correspondence related to this RFP must be delivered to: Attention: Mathew Spaan Health Care Administration Department of Human Services 444 Lafayette Road N. St. Paul, MN It is solely the responsibility of each responder to assure that their proposal is delivered at the specific place, in the specific format, and prior to the deadline for submission. Failure to abide by these instructions for submitting proposals may result in the disqualification of any non-complying proposal. V. Proposal Evaluation and Selection A. Overview of Evaluation Methodology 1. All responsive proposals received by the deadline will be evaluated by the State. Proposals will be evaluated on best value as specified below, using a 100 point scale. The evaluation will be conducted in three phases: a. Phase I Required Statements Review b. Phase II Evaluation of Proposal Requirements c. Phase III Selection of the Successful Responder(s) 2. During the evaluation process, all information concerning the proposals submitted, except identity and address of the responder, will remain non-public and will not be disclosed to anyone whose official duties do not require such knowledge. 3. Nonselection of any proposals will mean that either another proposal(s) was determined to be more advantageous to the State or that the State exercised the right to reject any or all Proposals. At its discretion, the State may perform an appropriate cost and pricing analysis of a responder's proposal, including an audit of the reasonableness of any proposal. B. Evaluation Team 1. An evaluation team will be selected to evaluate Responder Proposals. 2. State and professional staff, other than the evaluation team, may also assist in the evaluation process. This assistance could include, but is not limited to, the initial mandatory requirements review, contacting of references, or answering technical questions from evaluators. 3. The State reserves the right to alter the composition of the evaluation team and their specific responsibilities. IHP RFP Revised - July 13,

27 C. Evaluation Phases At any time during the evaluation phases, the State may, at the State s discretion, contact a responder to (1) provide further or missing information or clarification of their proposal, (2) provide an oral presentation of their proposal, or (3) obtain the opportunity to interview the proposed key personnel. Reference checks may also be made at this time. However, there is no guarantee that the State will look for information or clarification outside of the submitted written proposal. Therefore, it is important that the responder ensure that all sections of the proposal have been completed to avoid the possibility of failing an evaluation phase or having their score reduced for lack of information. 1. Phase I Required Statements Review The Required Statements will be evaluated on a pass or fail basis. Responders must "pass" each of the requirements identified in these sections to move to Phase II. The Responder may fail the Required Statements Review in the event that the Responder does not affirmatively warrant to any of the warranties in the Responder Information and Declarations. Additionally, the State reserves the right to fail a Responder in the event the Responder does not make a necessary disclosure in the Responder Information and Declarations, or makes a disclosure which evidences a conflict of interest. 2. Phase II - Evaluation of Technical Requirements of Proposals. A total of 100 points have been assigned to these component areas. Of the 100 possible points, there are 15 bonus points that represent elements that are not required proposal elements. The total possible points for these component areas are as follows: Component Total Possible Points a. Executive Summary 5 b. Description of the Applicant Delivery System 40 c. Description of MHCP Population Served by Delivery System 5 d. Proposed Payment Arrangement 30 (Including 5 possible bonus points for Direct Inclusion of Community Partners in Payment Model and 5 possible bonus points for Inclusion of Additional Service Categories in Total Cost of Care ) e. Quality Measures 20 (Including 5 possible bonus points for Additional Measures Proposed Beyond the Core Set) Total: 100 The evaluation team will review the components of each responsive Proposal submitted. Each component will be evaluated on the Responder's understanding and the quality and completeness of the Responder's approach and solution to the problems or issues presented. 3. Phase III - Selection of the Successful Responder(s) a. Only the Proposals found to be responsive under Phases I and II will be considered in Phase III. b. The evaluation team will review the scoring in making its recommendations of the Successful Responder(s). IHP RFP Revised - July 13,

28 c. The State may submit a list of detailed comments, questions, and concerns to one or more Responders after the initial evaluation. The State may require said response to be written, oral, or both. The State will only use written responses for evaluation purposes. The total scores for those Responders selected to submit additional information may be revised as a result of the new information. d. The evaluation team will make its recommendation based on the above-described evaluation process. The Successful Responder(s), if any, will be selected approximately three weeks after the Proposal submission due date. The final award decision will be made by the Commissioner or authorized designee. The Commissioner or authorized designee may accept or reject the recommendation of the evaluation team. D. Contract Negotiations and Unsuccessful Responder Notice If a Responder(s) is selected, the State will notify the Successful Responder(s) in writing of their selection and the State s desire to enter into contract negotiations. Until the State successfully completes negotiations with the selected Responder(s), all submitted Proposals remain eligible for selection by the State. In the event contract negotiations are unsuccessful with the selected Responder(s), the evaluation team may recommend another Responder(s). The final award decision will be made by the Commissioner or authorized designee. The Commissioner or authorized designee may accept or reject any subsequent recommendation of the evaluation team. After the State and chosen Responder(s) have successfully negotiated a contract, the State will notify the unsuccessful Responders in writing that their Proposals have not been accepted. All public information within Proposals will then be available for Responders to review, upon request. VI. Required Contract Terms and Conditions A. Requirements. All responders must be willing to comply with all state and federal legal requirements regarding the performance of the grant contract. The requirements are set forth throughout this RFP and are contained in the attached grant contract in the Appendix. B. Governing Law/Venue. This RFP and any subsequent contract must be governed by the laws of the State of Minnesota. Any and all legal proceedings arising from this RFP or any resulting contract in which the State is made a party must be brought in the State of Minnesota, District Court of Ramsey County. The venue of any federal action or proceeding arising here from in which the State is a party must be the United States District Court for the State of Minnesota. C. Travel. Reimbursement for travel and subsistence expenses actually and necessarily incurred by the grantee as a result of the grant contract will be in no greater amount than provided in the current "Commissioner s Plan promulgated by the commissioner of Minnesota Management and Budget. Reimbursements will not be made for travel and subsistence expenses incurred outside Minnesota IHP RFP Revised - July 13,

29 unless it has received the State s prior written approval for out of state travel. Minnesota will be considered the home state for determining whether travel is out-of-state. D. Preparation Costs. The State is not liable for any cost incurred by Responders in the preparation and production of a proposal. Any work performed prior to the issuance of a fully executed grant contact will be done only to the extent the responder voluntarily assumes risk of non-payment. E. Contingency Fees Prohibited. Pursuant to Minnesota Statutes, section 10A.06, no person may act as or employ a lobbyist for compensation that is dependent upon the result or outcome of any legislation or administrative action. F. Certification Regarding Debarment, Suspension, Ineligibility, and Voluntary Exclusion. Federal money will be used or may potentially be used to pay for all or part of the work under the contract, therefore the responder must certify the following, as required by the regulations implementing Executive Order Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion -- Lower Tier Covered Transactions Instructions for Certification 1. By signing and submitting this proposal, the prospective lower tier participant is providing the certification set out below. 2. The certification in this clause is a material representation of fact upon which reliance was placed when this transaction was entered into. If it is later determined that the prospective lower tier participant knowingly rendered an erroneous certification, in addition to other remedies available to the federal government, the department or agency with which this transaction originated may pursue available remedies, including suspension and/or debarment. 3. The prospective lower tier participant shall provide immediate written notice to the person to which this proposal is submitted if at any time the prospective lower tier participant learns that its certification was erroneous when submitted or had become erroneous by reason of changed circumstances. 4. The terms covered transaction, debarred, suspended, ineligible, lower tier covered transaction, participant, person, primary covered transaction, principal, proposal, and voluntarily excluded, as used in this clause, have the meaning set out in the Definitions and Coverages sections of rules implementing Executive Order You may contact the person to which this proposal is submitted for assistance in obtaining a copy of those regulations. 5. The prospective lower tier participant agrees by submitting this response that, should the proposed covered transaction be entered into, it shall not knowingly enter into any lower tier covered transaction with a person who is proposed for debarment under 48 C.F.R. part 9, subpart 9.4, debarred, suspended, declared ineligible, or voluntarily excluded from participation in this covered transaction, unless authorized by the department or agency with which this transaction originated. IHP RFP Revised - July 13,

30 6. The prospective lower tier participant further agrees by submitting this proposal that it will include this clause titled Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion--Lower Tier Covered Transaction, without modification, in all lower tier covered transactions and in all solicitations for lower tier covered transactions. 7. A participant in a covered transaction may rely upon a certification of a prospective participant in a lower tier covered transaction that it is not proposed for debarment under 48 C.F.R. part 9, subpart 9.4, debarred, suspended, ineligible, or voluntarily excluded from covered transactions, unless it knows that the certification is erroneous. A participant may decide the method and frequency by which it determines the eligibility of its principals. Each participant may, but is not required to, check the List of Parties Excluded from Federal Procurement and Nonprocurement Programs 8. Nothing contained in the foregoing shall be construed to require establishment of a system of records in order to render in good faith the certification required by this clause. The knowledge and information of a participant is not required to exceed that which is normally possessed by a prudent person in the ordinary course of business dealings. 9. Except for transactions authorized under paragraph 5 of these instructions, if a participant in a covered transaction knowingly enters into a lower tier covered transaction with a person who is proposed for debarment under 48 C.F.R. 9, subpart 9.4, suspended, debarred, ineligible, or voluntarily excluded from participation in this transaction, in addition to other remedies available to the federal government, the department or agency with which this transaction originated may pursue available remedies, including suspension and/or debarment. Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion - Lower Tier Covered Transactions 1. The prospective lower tier participant certifies, by submission of this proposal, that neither it nor its principals is presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by any Federal department or agency. 2. Where the prospective lower tier participant is unable to certify to any of the statements in this certification, such prospective participant shall attach an explanation to this proposal. G. Insurance Requirements 1. Responder shall not commence work under the grant contract until they have obtained all the insurance described in Appendix B, section 2.9 below and the State of Minnesota has approved such insurance. All policies and certificates shall provide that the policies shall remain in force and effect throughout the term of the grant contract. 2. Additional Insurance Conditions: Responder s policy(ies) shall be primary insurance to any other valid and collectible insurance available to the State of Minnesota with respect to any claim arising out of Responder s performance under this grant contract; IHP RFP Revised - July 13,

31 If Responder receives a cancellation notice from an insurance carrier affording coverage herein, responder agrees to notify the State of Minnesota within five (5) business days with a copy of the cancellation notice, unless responder s policy(ies) contain a provision that coverage afforded under the policy(ies) will not be cancelled without at least thirty (30) days advance written notice to the State of Minnesota; Responder is responsible for payment of grant contract related insurance premiums and deductibles; If Responder is self-insured, a Certificate of Self-Insurance must be attached; Include legal defense fees in addition to its liability policy limits; and Obtain insurance policies from an insurance company having an AM BEST rating of A- (minus); Financial Size Category (FSC) VII or better and must be authorized to do business in the State of Minnesota; and An Umbrella or Excess Liability insurance policy may be used to supplement the responder s policy limits to satisfy the full policy limits required by the grant contract. 4. The State reserves the right to immediately terminate the grant contract if the responder is not in compliance with the insurance requirements and retains all rights to pursue any legal remedies against the responder. All insurance policies must be open to inspection by the State, and copies of policies must be submitted to the State s authorized representative upon written request. 5. The successful responder is required to submit Certificates of Insurance acceptable to the State of Minnesota as evidence of insurance coverage requirements prior to commencing work under the grant contract. VII. State s Rights Reserved Notwithstanding anything to the contrary, the State reserves the right to: A. Reject any and all proposals received in response to this RFP; B. Disqualify any responder whose conduct or proposal fails to conform to the requirements of this RFP; C. Have unlimited rights to duplicate all materials submitted for purposes of RFP evaluation, and duplicate all public information in response to data requests regarding the proposal; D. Select for contract or for negotiations a proposal other than that with the lowest cost or the highest evaluation score; IHP RFP Revised - July 13,

32 E. Consider a late modification of a proposal if the proposal itself was submitted on time and if the modifications were requested by the State and the modifications make the terms of the proposal more favorable to the State, and accept such proposal as modified; F. At its sole discretion, reserve the right to waive any non-material deviations from the requirements and procedures of this RFP; G. Negotiate as to any aspect of the proposal with any responder and negotiate with more than one responder at the same time, including asking for responders Best and Final offers; H. Extend the grant contract, in increments determined by the State, not to exceed a total contract term of five years; and I. Cancel the RFP at any time and for any reason with no cost or penalty to the State. J. Correct or amend the RFP at any time with no cost or penalty to the State. If the State should correct or amend any segment of the RFP after submission of proposals and prior to announcement of the successful responder, all responders will be afforded ample opportunity to revise their proposal to accommodate the RFP amendment and the dates for submission of revised proposals announced at that time. The State will not be liable for any errors in the RFP or other responses related to the RFP. (Rest of page intentionally left blank) IHP RFP Revised - July 13,

33 Appendix A: Minnesota Department of Human Services IHP Provider Reports Reference Documentation Portal Layout Reports/dashboards are organized according to content area and displayed within portlets: TCOC (Total Cost of Care) Care Coordination Utilization Quality Performance Dashboard Common Data Elements The following data elements are common to multiple reports: Run Month The run month is the month and year the report was generated, and corresponds with the attribution date. The data contained in each report has a 3 month lag for claims run out ending in the previous month. For example, a run month of January 2015 coincides with dates of service October 1, September 30, IHP RFP Revised - July 13,

34 Measurement Period The measurement period is a twelve month period ending four months prior to run month. For example, the measurement period for Oct 13 - Sep 14 coincides with a January 2015 run month. Benchmark Population The benchmark population represents all MHCP attribution eligible individuals, including IHP attributed members. Members included in the benchmark must have: had an Evaluation and Management (E&M) or Health Care Home claim at some point during the performance period; six months of continuous enrollment or nine months of non-continuous enrollment; no disqualifying enrollment characteristics such as Medicare eligibility or enrollment in partial benefit programs such as the Family Planning Program or Emergency Medical Assistance. Dashboards Performance Dashboard The Performance Dashboard is updated every quarter and offers a high level summary of an IHP s performance trend over the course of the demonstration. Data in the dashboard is consistent with the results contained in the Performance Exhibit distributed every quarter; no data will display for IHPs who have yet to receive a Performance Exhibit (IHPs receive their first Performance Exhibit the quarter following target development). The graph displays the adjusted TCOC PMPM (bar height) as compared to the IHP s adjusted target PMPM (black tick marks). The bars change color to indicate whether an IHP is in a gain share/loss position for each measurement period. Gain share: Adjusted TCOC PMPM > 2% below the Target - GREEN No savings or losses: Adjusted TCOC PMPM within ±2% of the Target - YELLOW Loss share: Adjusted TCOC PMPM > 2% above the Target - RED The dashboard also includes a chart that shows the IHP s performance reflected as a percentage (Adjusted TCOC PMPM / Target). The most recent performance is illustrated in the key performance indicator (displayed as a dial). TCOC Reports Major Category of Service Cost Trend The Major Category of Service Cost Trend report is updated every quarter using DHS Medicaid enrollment and claims/encounter data. It shows the unadjusted PMPM for services included in the IHP s TCOC by major category of service: Inpatient, Outpatient, Pharmacy, Professional, MH/CD, and Other. The report also includes a graph showing the proportional breakdown of the total TCOC by major service category. Data is displayed for measurement periods as early as the IHP has been in existence. IHP RFP Revised - July 13,

35 I. TCOC Summary The TCOC Summary report is generated every quarter using DHS Medicaid enrollment and claims/encounter data. The data used comes directly from the DHS data warehouse and represents finalized, paid claims and encounters for the designated measurement period. This report displays the total claims and PMPM by major service category for the included and excluded services. In general, the inclusion or exclusion criteria are based on the DHS detailed service category definitions, and all services falling into the detailed service categories (e.g. anesthesia) are either included or excluded from the TCOC calculation. Certain services are excluded from the TCOC for purposes of developing the targets and determining the financial results for the measurement period. Included and excluded services may differ across IHPs; included services are specified within individual IHP contracts. The report allows users to display results- aggregated for the entire IHP attributed population, All Members, and the population excluding members with third party liability (TPL),- TPL Members Excluded. Category of Service The seven major service category classifications (inpatient, outpatient facility, etc.) are based on the definitions in DHS s data. The Inpatient, Outpatient facility, Professional, and Pharmacy claims are based on the DHS data warehouse major service category definitions, while the Long Term Care (LTC) and Mental Health / Chemical Dependency (MH/CD) and Other categories are carved out of the higher level categories based on DHS detailed service category definitions. For example, the LTC claims may include services that are administered on an inpatient, outpatient facility or professional basis, but are defined as LTC due to the specific nature of the service. Because of their cost magnitude and the fact that these services are not included in the TCOC, LTC services are shown separately from the remainder of the claim cost components in the table. Relative Risk The relative risk scores are developed using the category-specific ACG risk weights (MCO vs. SNBC and FFS) based on 2012 claim costs. II. Cost by Detailed Category of Service The Cost by Detailed Category of Service report is generated every quarter using DHS Medicaid enrollment and claims/encounter data. The data used comes directly from the DHS data warehouse and represents finalized, paid claims and encounters for the designated measurement period. This report shows the detailed service category breakdown, the amount of claims and PMPM for each detailed category of service, and whether the claims are included or excluded from the TCOC. The report has 3 separate views: claims paid to providers inside the IHP, claims paid to providers outside the IHP, and all claims paid. Only detailed service categories containing paid amounts display in the table. The report allows users to display results aggregated for the entire IHP attributed population All Members and the population excluding members with third party liability (TPL), TPL Members Excluded. With the exception of mental health, chemical dependency, and uncategorized" service categories, all claims within the category are either included or excluded from the TCOC. For mental health and chemical dependency services (categories 046 and 062), the total included and excluded services are shown as two separate lines on the exhibit. As part of the target development process, DHS reviewed the uncategorized services (category 999) in the claim files to determine which claims should be included or excluded from the TCOC. Based on this review many of these services were ultimately determined to be equivalent to other services included in the TCOC (inpatient, professional chemical dependency, etc.). Although these services are shown as "uncategorized" in the exhibit, the inpatient IHP RFP Revised - July 13,

36 III. IV. and MHCD claims could reasonably be categorized as "001 Inpatient General Hospital" and "062 CD Consolidated Treatment Fund" respectively. Inside vs. Outside Summary The Inside vs. Outside Summary report is generated every quarter using DHS Medicaid enrollment and claims/encounter data. The data used comes directly from the DHS data warehouse and represents finalized, paid claims and encounters for the designated measurement period. The report shows the total claims that were paid to providers "inside and outside" of the IHP. For some IHPs, their submitted provider rosters do not contain all providers "inside" their system. For example, an NPI for an owned pharmacy or hospitals may not be included under the expectation that no eligible E&M visits will be paid to that hospital s NPI. The list of pay-to-provider identifiers (TIN and NPIs) as previously submitted by the IHPs were used. Because these breakdowns are based on the pay-to-provider TIN and/or NPIs submitted to DHS by the IHPs, the totals on this report rely on their accuracy and completeness. As always, participating IHPs are encouraged to continue to review the information submitted and provide updates to DHS if they wish to expand or refine the group of associated entities that are included in the "Paid to IHP" totals. The report allows users to display results aggregated for the entire IHP attributed population All Members and the population excluding members with third party liability (TPL), TPL Members Excluded. Paid to IHP Information based on provider lists developed from IHP-submitted Tax Identification Numbers (TINs). Included vs. Excluded Drilldown The Included vs. Excluded Drilldown report is generated every quarter using DHS Medicaid enrollment and claims/encounter data. The data used comes directly from the DHS data warehouse and represents finalized, paid claims and encounters for the same measurement period as all other TCOC reports. It shows a detailed breakdown of claim paid amounts and number of claims incurred by the Inclusion Status (Included in TCOC vs. Excluded from TCOC) and Location ( Inside vs. Outside or Paid to IHP vs. Paid Outside IHP). The report includes drill-down capabilities (user can expand each major category of service to see claim information for detailed categories of service). Claim Cap Cost Distribution The Claim Cap Cost Distribution report is generated every quarter using DHS Medicaid enrollment and claims/encounter data. The data used comes directly from the DHS data warehouse and represents finalized, paid claims and encounters for the designated measurement period. The report summarizes the member counts and total incurred claims for specific claim cost bands and demonstrates the impact of the claim cap thresholds and the PMPM difference between the total claim costs and the costs below the contracted claim cap. The "Cap Level" shown in the report represents the lower point of the cost band, and the "Claims Above the Cap Level" represent the cap level impact for the members that fall within that cost band. "Total $$ Above the Cap Level" shows the additional impact of the members with claims above the high end of the cost band and demonstrates the cumulative impact of the cap levels. The report allows users to display results aggregated for the entire IHP attributed population All Members and the population excluding members with third party liability (TPL), TPL Members Excluded. Claims Above Cap Level The combined claims above the Cap Level for all members whose claims fall within the cost band. IHP RFP Revised - July 13,

37 Total Above Cap Level The claims above the Cap Level for all members whose claims fall within and above the cost band. V. TCOC by Member Program The TCOC by Member Program report is generated every quarter using DHS Medicaid enrollment and claims/encounter data. The data used comes directly from the DHS data warehouse and represents finalized, paid claims and encounters for the designated measurement period. This report shows the relative claim cost and risk for the primary population segment breakdowns of the attributed population (FFS, SNBC and MCO-enrolled members). FFS members are defined as those who were enrolled in FFS throughout their entire enrollment period and the SNBC members are defined as those enrolled in SNBC at some point during the year. In 2012, all SNBC members were enrolled in managed care, but their claim utilization and relative risk indicate they should be analyzed separately from the remainder of the MCO-enrolled population and grouped with the FFS members for purposes of developing the risk weights. The report allows users to display results aggregated for the entire IHP attributed population All Members and the population excluding members with third party liability (TPL), TPL Members Excluded. SNBC Members Members enrolled in SNBC at some point in their enrollment period. MCO Members Non-SNBC members enrolled in an MCO at some point during their entire enrollment period. Members enrolled in both FFS and an MCO are included in the MCO totals, so long as they did not have SNBC enrollment during the year. FFS Members Members enrolled in FFS throughout their entire enrollment period TCOC by Member Category Drilldown The TCOC by Member Category Drilldown report is generated every quarter using DHS Medicaid enrollment and claims/encounter data. The data used comes directly from the DHS data warehouse and represents finalized, paid claims and encounters for the same measurement period as all other TCOC reports. It shows a detailed breakdown of claim paid amounts and number of claims incurred by member program: SNBC, MCO, and FFS. The report includes drill-down capabilities (user can expand Major Category of Service to see claim information for Detailed Category of Service). Care Coordination Reports Care Management Report The Care Management Report mirrors the Comprehensive Patient Clinical Profile Report available from John Hopkins ACG System. The report is generated monthly using DHS Medicaid enrollment and claims/encounter data. It allows users to filter results by IHP Clinic. The areas addressed and the questions this report is able to inform include: Is this recipient potentially in need of better care coordination? What were the number and types of providers seen during the observation period? IHP RFP Revised - July 13,

38 What are the recipient s costs for the prior observation period? Summary utilization statistics for the recipient including outpatient visit counts, Emergency Room visits, and Inpatient Admissions. Predictive information for resource utilization including cost and likelihood of hospitalization based on the recipient s prior history and risk indicators. An indication of whether the recipient s diagnosis and pharmacy history indicates the presence of chronic conditions. Column Name MCO Current MCO IHP Clinic NPI Clinic Name IHP Treating Provider NPI IHP Treating Provider Name Date of Last IHP Visit Recipient ID NameLast NameFirst NameMiddleInitial Birthdate Gender County Definition The managed care organization in which the recipient was enrolled during the last month of the observation period. If the recipient was not enrolled in an MCO, the field will display FFS for fee-for-service. The managed care organization in which the recipient is enrolled during the Report month (date report was generated). If the recipient was not enrolled in an MCO, the field will display FFS for fee-for-service. If the recipient was eligible during the observation period, but in their current enrollment month is no longer in an attribution eligible group, this field will be empty. This is the Billing/Pay-To NPI (National Provider Identifier type 2) on the encounter where the recipient had their most recent E&M visit. This clinic identifier reflects where WITHIN the IHP, the attributed recipient was last seen. This is not always the clinic within the IHP where the recipient is seen most. Name of the clinic where the recipient had their most recent E&M visit. The NPI of the IHP treating provider with whom the recipient had the most recent E&M visit. The Name of the IHP treating provider with whom the recipient had the most recent E&M visit. The date of the most recent E&M visit occurring within the IHP. 8-digit (char) DHS patient identification number. Only those recipients attributed to the IHP based on the prior 12 months of claim history are included in the report. The recipients included in this report may change between reporting periods as additional claim run-out is received. Last name of recipient. First name of the recipient. Middle initial of the recipient. Birthdate of recipient. The recipient s gender (F=Female, M=Male) The county in which the recipient was a resident according to the eligibility/enrollment information for the last month in the report IHP RFP Revised - July 13,

39 Column Name HCH Claims Resource Utilization Band Rescaled Reference Weight ACG Code Recipient Member Months Prior Total Cost Prior RX Cost IHP Included Services - Total Cost Probability High Total Cost Predicted Total Cost Range Probability High RX Cost Definition observation period. If a MN county of residence is not available, the county of financial responsibility is displayed. A Yes or No indicator of whether care coordination claims (S0280/S0281) were paid for this recipient during the report observation period. The Resource Utilization Band (RUB) assigned to the patient. The RUB band is an estimate of concurrent resource use associated with the recipient s current ACG score. 0 = No Use/Only Invalid Diagnoses 1 = Healthy User 2 = Low User 3 = Moderate User 4 = High User 5 = Very High User The concurrent reference weight for this recipient rescaled so that the mean across the DHS population is 1.0. Note that this risk weight is not rescaled to the IHP s attribution eligible population as is done for the TCOC target and settlement calculations. The adjusted Clinical Group code actuarial cell assigned to the recipient. The number of months the recipient was enrolled in a Minnesota Medicaid Health Care Program during the observation period (for IHP attributed members, this will be a minimum of 6 and a maximum of 12). The recipient s total claim and reported encounter costs during the observation period. Note that cost information is a current snapshot of all dollars associated with services as reported on claims and encounter records for the observation period. As described in the IHP contracts, costs for some services will be excluded from the total cost of care for which the IHP is at risk. The recipient s pharmacy costs during the observation period. Pharmacy costs are included in the prior total cost. The claim and encounter costs during the observation period for services that are included in the core set of services for which an IHP total cost of care is measured. This total cost excludes services such as dental, transportation, long term care, residential mental health, etc. Predictive Values The probability that this patient will be in the top 5 percent of total cost in the subsequent year. The predicted total cost for this patient for the subsequent year. The probability that this patient will be in the top 5 percent of pharmacy cost in the subsequent year. IHP RFP Revised - July 13,

40 Column Name Predicted Rx Cost Range Definition The predicted pharmacy cost for this patient for the subsequent year. High Risk Unexpected Rx A flag (Y = Yes, N = No) indicating the patient has a probability > 0.4 of being high morbidity and having unexpectedly high pharmacy use. Coordination of Care Chronic Condition Count Unique Providers Seen Specialty Types Seen Generalist Seen Provider Seen Most 1 Provider Seen Most 1 Specialty Description Provider 1 Percentage of Visits Provider Seen Most 2 Provider Seen Most 2 Specialty Description Provider 2 Percentage of Visits Frailty Flag Coordination Risk Indicator The chronic condition count assigned to this patient. An indication of the number of physicians providing outpatient evaluation and management services to this patient. An indication of the number of specialists providing outpatient evaluation and management services to this patient. Y indicates that a generalist was involved in face-to-face visits for the patient. The name of the provider who had the most face-to-face visits with the recipient during the observation period per ACG. This provider is not necessarily on the IHP roster (IHP providers are aggregated for purposes of attribution). If there are providers with the same percentage of visits, up to 2 are displayed. The specialty category for the Provider Seen Most. The percentage of the outpatient visits provided by the provider(s) that saw the patient most over the observation period. If a Provider Seen Most 2 is listed, then this provider had an equal percentage of face-to-face visits with the recipient during the observation period per ACG as the Provider Seen Most 1. Additional providers may have had equal percentage of visits but only 2 are included. The specialty category for the additional Provider Seen Most. The percentage of the outpatient visits provided by the provider(s) that saw the patient most over the observation period. A flag indicating the presence of a diagnosis associated with marked functional limitations (Malnutrition, Incontinence, Dementia, Decubitus Ulcer, Fall, Difficulty Walking, etc.). A marker that can be used to stratify the likelihood of coordination issues. Values include: UCI recipient is unlikely to experience coordination issues PCI recipient may possibly experience coordination issues LCI recipient is likely to experience coordination issues Utilization IHP RFP Revised - July 13,

41 Column Name Outpatient Count ED Count Inpatient Count Major Procedure Performed Dialysis Service Nursing Service Active Drug Count Hospital Dominant Count Probability Hospital Admission in 6 months Probability IP Hospitalization Probability ICU or CCU Admission Probability Injury Related Admission Probability Long-Term Admission Definition Count of ambulatory and hospital outpatient visits (unique count of recipient, provider, and date of service where place of service is 11 or 22). Count of emergency room visits that did not lead to a subsequent acute care inpatient hospitalization. Count of acute care inpatient stays for causes that are not related to child-birth and injury. A flag (Y or N) indicating whether the patient had a major inpatient procedure performed. A flag (Y or N) indicating the patient had a dialysis service performed. A flag (Y or N) indicating the presence of nursing home services as defined by the CPT code range ( , ) for the recipient. Count of individual ingredient/route of administration combinations in the recipient s prescription regimen based on pharmacy claims. Likelihood of Hospitalization The count of ACG condition groups present for the recipient which contain trigger diagnoses for high (typically greater than 50%) probability of future admission. The probability that this patient will experience a hospitalization in the subsequent 6 months. The probability that this patient will experience a hospitalization in the subsequent 12 months. The probability that this patient will experience a ICU/CCU hospitalization in the subsequent 12 months. The probability that this patient will experience an injury-related hospitalization in the subsequent 12 months. The probability that this patient will experience an extended hospitalization (12+ days) in the subsequent 12 months. Condition Indicators Age-Related Macular Degeneration A flag indicating if this patient has this medical condition and how it was indicated (NP = Not Present, ICD = ICD Indication, Rx = Rx Indication, BTH = ICD and Rx Indication, TRT = Meets Diagnosis/Treatment criteria). Bi-Polar Disorder Ischemic Heart Disease Schizophrenia Congestive Heart Failure Depression Diabetes IHP RFP Revised - July 13,

42 Column Name Glaucoma Human Immunodeficiency Virus Disorders of Lipid Metabolism Hypertension Hyperthyroidism Immunosuppression/Transplant Osteoporosis Parkinson's Disease Persistent Asthma Rheumatoid Arthritis Seizure Disorders COPD Chronic Renal Failure Low Back Pain TPL Indicator Newly Attributed Definition Other A flag (Y or N) indicating whether the recipient had a health insurance policy for medical services at some point during the observation period in addition to Medical Assistance. A flag (Y or N) indicating whether this recipient is new to your IHP in this assessment period. Provider Alert Report The Provider Alert report is generated monthly and lists recipients for whom a claim was submitted for an emergency room visit or hospital admission in the previous month. DHS Medicaid enrollment and claims/encounter data are used to create this report. The areas addressed and the questions this report is able to inform include: Which recipients attributed to the IHP during this observation period recently had a hospitalization service? Which recipients attributed to the IHP during this observation period recently visited an emergency room? Counts of hospitalization, re-admissions, and emergency room visits for the recipient in the past year. Probability of hospitalization in the next 12 months based on ACGv10 risk models. Column Name Report Month Recipient ID Definition The month the report is generated. Report is based on enrollment and claims data through the first DHS warrant cycle of this month. 8-digit (char) DHS patient identification number. Recipients in this report: are currently enrolled in Minnesota Health Care Programs (MHCP); IHP RFP Revised - July 13,

43 Column Name First Name MI Last Name Birthdate Interpreter Needed Number of ED Visits - Month Definition had a claim/encounter for an ER or hospital service submitted in the last month or through most recent DHS warrant cycle in the Report month, and the date of service for the claim/encounter is within the past 6 months. First name of the recipient. Middle initial of the recipient. Last name of recipient. Birthdate of recipient. An indicator of the patient s need for an interpreter; based on the current month s enrollment data. A supplemental tier modifier (U3) can be used on HCH care coordination claims (S0280/S0281) for recipients with language/communication barriers. Count of emergency department visits for which a claim was submitted to DHS in the previous month or by the first warrant cycle in the reporting month and which had a date of service within 6 months of the reporting month. Number of ED Count of emergency department visits for which a claim was submitted to DHS Visits 12 Months during the prior 12 month period. Number of Admissions - Month Number of Readmission - Month Number of Admissions 12 Months Inpatient Hospital Probability HCH Claims County Clinic NPI Count of hospital admissions for which a claim was submitted to DHS in the previous month or by the first warrant cycle in the reporting month and which had a date of service within 6 months of the reporting month. Claims submitted by the following mid-month warrant cycle are included in this report. Count of hospital 30-day re-admissions (all cause) for which a claim was submitted to DHS in the previous month or by the first warrant cycle in the reporting month. Re-admit counts are a subset of the Hospital Admission counts (not mutually exclusive). Count of hospital admissions for which a claim was submitted to DHS during the prior 12 month period. The probability of an acute care inpatient hospital admission in the year following the observation period. Calculated by ACGv10Ò risk-adjustment software using a prediction model calibrated with utilization markers to identify patients with risk of future hospitalization. Observation period: Previous 12 months plus a 3 month run out (ex. Dec 2012 would contain observation period of 09/01/11 8/31/12). A Yes or No indicator of whether care coordination claims (S0280/S0281) were paid for this recipient during the report observation period. This is the county in which the recipient was a resident according to the eligibility/enrollment information for the last month in the report observation period. If a MN county of residence is not available, the county of financial responsibility is displayed. This is the Clinic NPI (National Provider Identifier type 2) where the recipient had their most recent E&M visit. This clinic identifier reflects where WITHIN the IHP, the attributed recipient was last seen. This is not always the clinic within the IHP where the recipient is seen most. IHP RFP Revised - July 13,

44 Column Name IHP Provider NPI IHP Provider Name Date of Last IHP Visit Definition The NPI of the IHP treating provider with whom the recipient had the most recent E&M visit. The Name of the IHP treating provider with whom the recipient had the most recent E&M visit. The date of the most recent E&M visit occurring within the IHP. Monthly Attribution Trend The Monthly Attribution Trend is updated monthly using DHS Medicaid enrollment and claims/encounter data. It shows the total number of attributed IHP members and monthly population percent change for the previous 12 months. The Percent Change values in the chart will change color to highlight drastic population fluctuations. Percent Change > 4% - GREEN Percent Change < -4% - RED Chronic Condition Profile The Chronic Condition Profile report is generated monthly using DHS Medicaid enrollment and claims/encounter data. It shows the prevalence of chronic conditions in an IHP population as it compares to the Benchmark population. The graph displays the 10 most prevalent chronic conditions, whose rates are expressed as a percentage of the IHP attributed population identified as having the condition. Results are aggregated based on the following Age Groups: All Ages, 18 & Over, 17 & Under. Chronic Conditions The ACG System identifies specific conditions that are high prevalence chronic conditions, commonly selected for disease management or warranting ongoing medication therapy. The conditions are identified through diagnoses, pharmacy information, and/or specific treatment criteria. The following conditions are included: Age Related Macular Degeneration, Bipolar Disorder, Chronic Obstructive Pulmonary Disease, Chronic Renal Failure, Congestive Heart Failure, Depression, Diabetes, Disorders of Lipid Metabolism, Glaucoma, Human Immunodeficiency Virus, Hypertension, Hypothyroidism, Immunosuppression Transplant, Ischemic Heart Disease, Low Back Pain, Osteoporosis, Parkinson s Disease, Persistent Asthma, Rheumatoid Arthritis, Schizophrenia, and Seizure Disorders. The report includes a table with linking capabilities. Clicking on any underlined text will display a list of ALL IHP attributed members with a particular chronic condition. For example, clicking on the underlined text: depression will display a list of all IHP members identified as having depression (clicking other data elements within the same row as depression will result in the same list). The following data elements (displayed in the linked table) are also found in the Care Management Report. Recipient ID First Name Last Name Birthdate Clinic NPI Clinic Name Condition Criteria IHP RFP Revised - July 13,

45 Utilization Reports Inpatient and ED Trends by IHP The Inpatient and ED Trends by IHP report is generated every quarter using DHS Medicaid enrollment and claims/encounter data. It displays a risk adjusted hospitalization rate and risk adjusted emergency department rate trend as it compares to the Benchmark population. Data for measurement periods up to Apr 13 - Mar 14 were gathered 6 months following the end of the period, while data for all measurement periods after March 2014 are gathered 3 months following the end of the measurement period. The difference in claim lag may result in artificially lower rates for the most recent measurement periods as opposed to the earlier measurement periods. Hospitalization Rate The hospitalization rate is based upon the ACG count of inpatient events occurring within the observation period which excludes admissions with a primary diagnosis for pregnancy, delivery, newborns, and injuries. Transfers made within and between providers count as a single hospitalization event. The hospitalization rate is reflected per 1,000 of the IHP s attributed population. ED Rate The ED Rate is the number of emergency room visits that did not lead to a subsequent acute care inpatient hospitalization during the observation period, reflected per 1,000 members of the IHP s attributed population. The ED count is calculated as part of the ACG definition which considers place of service, procedure code, and revenue code to identify emergency room visits. Risk Adjustment Methodology In order to compare utilization rates among IHPs and the benchmark population, DHS used ACG risk weights, customized by program categories (FFS+SNBC and MCO), in order to adjust for differences in aggregate risk among these populations. Although the aggregate relative risk between populations may not be fully applicable to the relative risk differential for an individual utilization rate (i.e. a population with a 10% higher overall TCOC risk, could have a different relative risk for inpatient admissions), these utilization adjustment factors should provide a reasonable, high-level way for the IHPs to understand how their population risk may be impacting their observed utilization relative to the benchmark. The risk adjustment factor is produced by first calculating the average risk scores for the individual IHPs and the overall benchmark population, based on the Category Specific ACG weights (FFS+SNBC vs. MCO) used for the IHP performance measurement and quarterly reporting. Using the risk score for the benchmark population as a reference point, the IHP utilization adjustment factors are calculated based upon the ratio between the IHP risk score and the benchmark risk score. The utilization factor represents the difference in IHP risk relative to the benchmark. For example, an IHP risk score of 1.26 and a benchmark risk score of 1.17 results in an adjustment factor of 1.08 (1.26 / 1.17 = 1.08). This factor is used to adjust the IHP utilization by dividing the unadjusted rate by the adjustment factor. Using the example above, an IHP unadjusted inpatient hospitalization rate of 85.0 per 1,000 members, results in an adjusted rate of 78.7 per 1,000 (85 / 1.08 = 78.7). Inpatient and ED Trends by Clinic The Inpatient and ED Trends by Clinic report is generated every quarter using DHS Medicaid enrollment and claims/encounter data. It displays a risk adjusted hospitalization rate and risk adjusted emergency department rate trend for an IHP clinic as it compares to the Benchmark population and IHP population. Clinics are ranked within an IHP based on their risk adjusted rates in a given measurement period. IHP RFP Revised - July 13,

46 Members are attributed to the clinic within an IHP where the most recent E&M visit occurred. Clinics whose population was less than 100 members for all measurement periods are excluded from the analysis. **Results for some clinics are unreliable due to drastic population fluctuations and small population sizes (clinics whose population > 100 for one measurement period are still included in the analysis even if their population drops dramatically in subsequent periods); in some cases clinics have no attributed members for a given measurement period. Data for measurement periods up to Apr 13 - Mar 14 were gathered 6 months following the end of the period, while data for all measurement periods after March 2014 are gathered 3 months following the end of the measurement period. The difference in claim lag may result in artificially lower rates for the most recent measurement periods as opposed to the earlier measurement periods. The same methodology is used to produce risk scores for an individual IHP clinic as it is for IHPs. The IHP ED Rate and IHP Hospitalization Rate are both risk adjusted and should match the risk adjusted rates in the Inpatient and ED Trends by IHP report. Pharmacy Summary - Utilization The Pharmacy Summary - Utilization report is generated every quarter using DHS Medicaid enrollment and claims/encounter data. The report displays the total number of prescriptions aggregated by drug class and individual drug (grouped by generic drug name). Analysis excludes over the counter prescriptions and compound drugs, but the paid amount, % of included TCOC, and Rx PMPM in the summary chart at the top of the report are calculated using all pharmacy claims and should match the pharmacy paid amount and PMPM on the TCOC Summary report. Generic vs. Brand Name Drugs are classified as generic or not based on an indicator - drug NDC (National Drug Classification) codes with a missing indicator value are classified as generic. Drug Class Drug groupings based on the AHFS (American Hospital Formulary Service) - Therapeutic Classification Pharmacy Summary - Spend The Pharmacy Summary - Spend report is generated every quarter using DHS Medicaid enrollment and claims/encounter data. The report displays prescription costs aggregated by drug class, individual drug, and specialty drug. Analysis excludes over the counter prescriptions and compound drugs, but the paid amount, % of Included TCOC, and Rx PMPM in the summary chart at the top of the report are calculated using all pharmacy claims and should match the pharmacy paid amount on the TCOC Summary report. Specialty Drug Drugs classified as high cost Specialty Description Specialty drug groupings (not the same as drug class ) Specialty Rx Scripts Total number of prescriptions for specialty drugs % Specialty Percentage of specialty drug prescriptions (denominator excludes over the the counter and compound drugs) IHP RFP Revised - July 13,

47 Specialty $$ The total paid amount for specialty drugs Quality Reports IHP HEDIS Measures The IHP HEDIS Measures report is run annually. All HEDIS measures are limited to enrollees who were attributed to an IHP in April following the measurement year, using claims for services provided during the calendar year. For example, measurement year 2013 would include members attributed in April 2014 for claims incurred during calendar year The report includes HEDIS measures for an individual IHP as well as an aggregated measure based on the entire IHP population - All IHPs. IHPs joining the demonstration after 2013 will still see data aggregated measures even if their individual scores for that year are not included. For more specific information on any measure, refer to the NCQA publication Technical Specifications for Health Plans, HEDIS 2014 Volume 2. Adults Access to Preventive/Ambulatory Health Services 1) This measure shows the percentage of members 20 years and older who had an ambulatory or preventive care visit during the measurement year. 2) This report follows HEDIS 2014, Volume 2 specifications with the exception that inpatient professional and emergency room claims were excluded. 3) Highlights of the HEDIS specifications are as follows: Limited to ages 20 and older as of December 31 of the measurement year. The denominator is the number of members meeting eligibility criteria. The numerator is the number members having received an ambulatory or preventive care visit during the measurement year. 4) There were HEDIS 2014 changes to this measure: Coding changes for Ambulatory Visits. Coding tables removed from the technical specifications and replaced coding table references with value set references. Adolescent Well Care visits 1) This measure shows the percentage of enrolled members years of age who had at least one comprehensive well care visit with a primary care practitioner (PCP) or an OB/GYN practitioner during the measurement year. 2) This report follows HEDIS 2014, Volume 2 specifications. However, DHS does not have a single code designating a provider as a PCP or OB/GYN provider. Instead a provider was classified as a PCP or OB/GYN if: One or more of 8 HEDIS-specified procedure codes, or 7 HEDIS-specified diagnosis codes was used, and The pay-to-provider type or the treating-provider type had any of a list of codes considered to encompass primary care practice or OB/GYN practice. 3) Highlights of the HEDIS specifications are as follows: IHP RFP Revised - July 13,

48 Adolescents were defined as members aged 12 through 21 on December 31 of the measurement year. For calculating the percentage, the numerator was the number of members who had 1 or more visits and the denominator was the number of members who met eligibility criteria. 4) Certain changes were made to this HEDIS measure for Report Year 2014, as follows: Five CPT codes (99381, 99382, 99391, 99392, and 99461) were added to the list of codes that help to define a visit as a visit to PCP. Three ICD-9 codes (V20.3, V20.31, and V20.32) were added to the list of codes that help to define a visit as a visit to a PCP. The means of identifying a provider as a PCP was revised to add pay-to provider type 33 ( consolidated provider ) to the list of providers that, if all other criteria were met, qualified the provider to be classified as a PCP. This revision causes a slight increase in the count of visits and hence the numerator, and the AWC performance rate, will increase somewhat compared to prior years. Breast Cancer Screening for Women 1) The BCS measure shows the percentage of women years of age who had a mammogram to screen for breast cancer. 2) This report follows HEDIS 2014, Volume 2 specifications except DHS does not have any modifier codes larger than two digits, so modifier code listed in the Bilateral Modifier Value Set is not included. 3) Highlights of the HEDIS specifications are as follows: Limited to women years as of December 31 of the measurement year 4) Certain changes were made to this HEDIS measure for Report Year 2014, as follows: The age criterion is revised to women years of age The numerator time frame is revised to one or more mammograms any time on or between October 1 two years prior to the measurement year and December 31 of the measurement year. Coding tables are removed and replaced with value set references. Children and Adolescents Access to Primary Care Practitioners 1) This measure shows the percentage of members 12 months to 19 years of age who had a visit with a Primary Care Practitioner (PCP). Four separate percentages were reported: Children months who had a visit with a PCP during the measurement year Children 25 months-6 years who had a visit with a PCP during the measurement year Children 7-11 who had a visit with a PCP during the measurement year or the year prior to the measurement year Adolescents who had a visit with a PCP during the measurement year or the year prior to the measurement year 2) This report followed HEDIS 2014 (Volume 2) specifications. Highlights of the HEDIS specifications are as follows: Limited to ages 12 months to 19 years as of December 31 of the measurement year IHP RFP Revised - July 13,

49 The numerator was the count of members included in the denominator who had an ambulatory or preventive care visit to any PCP. 3) Certain changes were made to this HEDIS measure for Report Year 2014, as follows: Four CPT codes (99386, 99387, 99396, and 99397) were added to the list of codes that help to define a visit as a visit to PCP. One HCPCS code (G0402) was added to the list of codes that help to define a visit as a visit to a PCP. Nineteen new Revenue Codes [0982, 0983, and 0510 through 0529, excluding 0518, 0523, 0524, and 0525)] were added to the list of codes that help to define a visit as a visit to PCP. Note especially: New programming code was added to classify a provider as a Primary Care Provider. Since no such attempt had been made to do this prior to 2014, the new programming language in 2014 has the effect of restricting somewhat the number of visits classified as visits to a PCP. This causes the count of such visits to go down, and hence the numerator, and the CAP performance rate, will decrease somewhat compared to prior years. Cervical Cancer Screening 1) This measure shows the percentage of women age 24 to 64 who were screened for cervical cancer using the two step criteria described in 2a below. 2) This report follows HEDIS 2014, Volume 2 specifications. Highlights of the HEDIS specifications are as follows: First identify women years of age as of December 31 of the measurement year who had cervical cytology during the measurement year or the two years prior to the measurement year. For those women who don t meet the first criteria, identify women age 30 to 64 years of age as of December 31 of the measurement year who had cervical cytology and a HPV test with service dates four of fewer days apart during the measurement year or the four years prior to the measurement year. Steps 1 and 2 are summed to obtain the rate for the measure. The numerator contains all women who had one or more Pap tests during the measurement year or during the two years prior to that year. The denominator contains all women who meet the criteria listed in the first bullet with the exception of those who had previously received a total hysterectomy. 3) HEDIS 2014 specification deleted the following CPT and ICD9PC codes, respectively: 88155, Chlamydia Screening in Women 1) This measure shows the percentage of women years of age who were identified as sexually active and who had at least one test for chlamydia during the measurement year. 2) This report followed HEDIS 2014, Volume 2 specifications. Highlights of the HEDIS specifications are as follows: Limited to ages as of December 31 of the measurement year. IHP RFP Revised - July 13,

50 Pharmacy data and claim/encounter data were used to identify the eligible population (denominator) during each measurement year. However, a member was eligible for the measure if they received contraceptives or had an encounter with a sexually active CPT, HCPCS, ICD-9 Diagnosis, ICD-9 Procedure or UB Revenue code The numerator included women who had at least one chlamydia test with a service date within the measurement year. A woman could only be counted once in each measurement year The HEDIS optional exclusion removed members who had a pregnancy test during the measurement year followed within seven days by either isotretinoin (Accutane) or an x-ray. This exclusion only applied to the members who were included in the denominator by the pregnancy test alone NDC codes and medication lists to identify contraceptives and exclusions were obtained from NCQA 3) Changes to the CHL measure for HEDIS 2014 include the deletion of the following CPT codes for sexual activity: and The following CPT codes were deleted for diagnostic radiology: 71090, 73542, 75722, 75724, and Childhood Immunization Status 1) This measure shows the percentage of children 2 years of age who had four diphtheria, tetanus and acellular pertussis (DTaP); three polio (IPV); one measles, mumps and rubella (MMR); three H influenza type B (HiB); three hepatitis B (HepB), one chicken pox (VZV); four pneumococcal conjugate (PCV); one hepatitis A (HepA); two or three rotavirus (RV); and two influenza (flu) vaccines by their second birthday. The measure calculates a rate for each vaccine and nine separate combination rates. 2) This report follows HEDIS 2014, Volume 2 specifications. Highlights of the HEDIS specifications are as follows: Limited to children who turn 2 years of age as of December 31 of the measurement year. The denominator is the same for Combination Vaccinations 2 through Combination Vaccinations 10. 3) Certain changes were made to this HEDIS measure for Report Year 2014, as follows: Removed coding tables and replaced all coding table references with value set references. Codes deleted for DTaP (99.39 ICD9PCS), Influenza (99.52 ICD9PCS), IPV (99.41 ICD9PCS), Measles (99.45 ICD9PCS), MMR (99.48 ICD9PCS), Mumps (99.46 ICDPCS), and Rubella (99.47 ICD9PCS). 4) Immunization records from the DHS Data Warehouse are supplemented with the Minnesota Department of Health immunization records. Follow up after Hospitalization for Mental Illness 1) This measure shows the percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental health disorders and who had an outpatient visit, an intensive outpatient encounter or partial hospitalization with a mental health practitioner. Two rates are reported: IHP RFP Revised - July 13,

51 The percentage of discharges for which the member received follow up within 30 days of discharge The percentage discharges for which the member received follow up within 7 days of discharge 2) This report follows HEDIS 2014, Volume 2 specifications. Highlights of the HEDIS specifications are as follows: The denominator was defined as an event. In order to count as an event, the recipient must have been discharged alive from an acute inpatient setting (including acute care psychiatric facilities) with a principal mental health diagnosis on or between January 1 and December 1 of the measurement year. The denominator for this measure was based on discharges, not members. If a given member had more than one discharge, all discharges were included if between January 1 and December 1 of the measurement year. Discharges were excluded when there were certain kinds of mental health related readmissions and/or certain non-mental health re-admissions within 30 days. Subsequent mental health discharges were then eligible to be used as events as long as they were prior to December 1st of the measurement year and as long as they were not followed by excluded re-admissions within 30 days. 3) Changes for 2014: Add CPT codes 90791, 90792, 90832, 90833, 90834, 90836, 90837, 90838, 90839, Appropriate Treatment for Children with Upper Respiratory Infection 1) The URI measure shows the percentage of children 3 months 18 years of age who were given a diagnosis of upper URI and were not dispensed an antibiotic. 2) This report follows HEDIS 2014, Volume 2 specifications. Highlights of the HEDIS specifications are as follows: Limited to children 3 months of age as of July 1 of the year prior to the measurement year to 18 years of age as June 30 of the measurement year. Eligible outpatient or emergency department visits with a diagnosis of URI are limited to a 12-month window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year. 3) There were no HEDIS 2014 changes to this measure. Well-Child Visits in the First 15 Months of Life 1) This measure shows the percentage of children who turned 15 months old during the measurement year and who had 6 or more well-child visits with a Primary Care Practitioner (PCP) during their first 15 months of life. 2) This report follows HEDIS 2014, Volume 2, technical specifications. However, the following issue may be noted: MHCP does not have a single code designating a provider as a PCP provider. Instead a provider was treated as a PCP if: IHP RFP Revised - July 13,

52 o o One or more of the HEDIS-specified procedure codes or diagnosis codes was used, AND The pay-to or treating provider had any of a list of codes considered to encompass primary care practice. The HEDIS specs call for calculating the percentage of children who had zero, 1, 2, 3, 4, 5, and 6 or more well-child visits. For MHCP purposes only the last percentage (children with 6 or more visits) is calculated. 3) Highlights of the HEDIS specifications are as follows: Limited to children who turned 15 months old during the measurement year. For calculating the percentage, the numerator was the number of members who had 6 or more visits between their date of birth and their 15-month-old date, and the denominator was the number of members who met eligibility criteria above. 4) Certain changes were made to this HEDIS measure for Report Year 2014, as follows: Six CPT codes (99383, 99384, 99385, 99393, 99394, and 99395) were added to the list of procedure codes that help to define a visit as a visit to PCP. The means of identifying a provider as a PCP was revised to add pay-to provider type 33 ( consolidated provider ) to the list of providers that, if all other criteria were met, qualified the provider to be classified as a PCP. This revision causes a slight increase in the count of visits, and hence the numerator, and the W15 performance rate, will increase somewhat compared to prior years. Well-Child Visits in the Third, Fourth, Fifth, and Sixth Years of Life (W34) 1) The W34 measure shows the percentage of enrolled members 3-6 years of age who had one or more well-child visits with a PCP during the measurement year. 2) This report follows HEDIS 2014, Volume 2, technical specifications. However the following issues may be noted: MHCP does not have a single code designating a provider as a PCP provider. Instead a provider was treated as a PCP if: o One or more of the HEDIS-specified procedure codes or diagnosis codes was used, AND o The pay-to or treating provider had any of a list of codes considered to encompass primary care practice. 3) Highlights of the HEDIS specifications are as follows: Limited to children 3, 4, 5 or 6 years old on December 31 of the measurement year. For calculating the percentage, the numerator was the number of members who had 1 or more visits and the denominator was the number of members who met the eligibility criteria above. 4) Certain changes were made to this HEDIS measure for Report Year 2014, as follows: Seven CPT codes (99381, 99384, 99385, 99391, 99394, 99395, and 99461) were added to the list of procedure codes that help to define a visit as a visit to PCP. Three ICD-9 codes (V20.3, V20.31, and V20.32) were added to the list of procedure codes that help to define a visit as a visit to PCP. IHP RFP Revised - July 13,

53 The means of identifying a provider as a PCP was revised to add pay-to provider type 33 ( consolidated provider ) to the list of providers that, if all other criteria were met, qualified the provider to be classified as a PCP. This revision causes a slight increase in the count of visits, and hence the numerator, and the W15 performance rate, will increase somewhat compared to prior years. (Rest of page intentionally left blank) IHP RFP Revised - July 13,

54 Appendix B: Sample State of Minnesota, Department of Human Services IHP Contract and Contract Attachments MINNESOTA DEPARTMENT OF HUMAN SERVICES INTEGRATED HEALTH PARTNERSHIPS CONTRACT with [NAME OF IHP] January 1, 2016 IHP RFP Revised - July 13,

55 STATE OF MINNESOTA DEPARTMENT OF HUMAN SERVICES INTEGRATED HEALTH PARTNERSHIPS CONTRACT For (IHP Name) THIS CONTRACT, and amendments and supplements thereto, is between the State of Minnesota, acting through its Department of Human Services (DHS) Health Care Administration (hereinafter STATE) and [IHP Name] (hereinafter IHP), witnesseth that: WHEREAS, the STATE, pursuant to Minnesota Statutes, , subd. 2 (a)(6) and 256B.0755, is empowered to enter into contracts for an Integrated Health Partnerships payment model that will represent a wide variety of geographic locations, patient populations, providers, and care coordination models, and will encourage formal and informal partnerships among health care delivery systems, counties, and non-profit agencies that provide services such as social services, public health, mental health, community-based projects, and continuing care; and WHEREAS, the STATE has received approval from the Centers for Medicare and Medicaid for an Integrated Care Models for Health Care Delivery Systems State Plan Amendment; and WHEREAS, the STATE is in need of contractors for the delivery of health care services under the demonstration described in Minnesota Statutes, 256B.0755, and WHEREAS, the STATE is permitted to share information with the IHP in accordance with Minnesota Statutes, 13.46, and WHEREAS, IHP has established a mechanism of shared governance as described in Minnesota Statutes, 256B.0755, subd. 1 (d), and is a [PLACEHOLDER for type of corporation] in good standing under the relevant laws of the State of Minnesota [cite to 317A, 322B, etc.]; and WHEREAS, the disclosure by STATE to (IHP Name) of protected health information that is subject to the Health Insurance Portability Accountability Act (HIPAA) is permitted by 45 C.F.R (c)(4) and (i); and WHEREAS, the IHP represents that it is duly qualified and willing to perform the services set forth herein, NOW, THEREFORE, it is agreed: Article. 1 ACRONYMS, ABBREVIATIONS AND DEFINITIONS. The following terms as used in this Contract and its Attachments shall be construed and interpreted as follows: (1) ACG means the data obtained from claims and encounters as derived from the Johns Hopkins Adjusted Clinical Groups (ACG ). IHP RFP Revised - July 13,

56 (2) Attributed Population means the Patients included in the Total Cost of Care calculations for which the IHP is accountable. (3) Attribution means the process described in Attachment A, Patient Attribution Method of determining which Patients are assigned to a particular IHP. (4) Claims Run-out means the period of time between the date a service is rendered and the date the claims or encounter data record is considered complete. (5) Contract means this Contract, its terms and conditions, attachments, documents incorporated by reference under the terms of this Contract, and any future modifying agreements made pursuant to sections 8.4 or 11.5 of this Contract. (6) Day means calendar day unless otherwise specified (for example, business day). (7) Fee For Service (FFS) means the Minnesota Health Care Programs payment method whereby a health care provider is paid directly by DHS for each service rendered. (8) Final Payment means an adjustment to the Interim Payment that occurs after the conclusion of a Performance Period based on complete data. A percentage of the Final Payment shall be affected by IHP performance on quality and patient experience measures. (9) IHP Entity means an Integrated Health Partnership that is able to deliver the full scope of primary care services and directly deliver or demonstrate the ability to coordinate with additional non-primary care providers. The IHP Entity may be a separate legal entity able to bind providers to the terms of this Contract to deliver services. The IHP Entity that is a Party to this Contract is further described in Attachment B, IHP-Specific Governance. (10) IHP Participant means a constituent part of an IHP as a health care delivery system, and includes but is not limited to clinic location(s), hospitals, physician and other provider group(s) or outpatient service locations. Each IHP Participant shall be included in the Shared Governance mechanism required by Minnesota Statutes, 256B.0755, subd. 1(d). A list of the IHP Participants and a description of the shared governance system is included in Attachment B, IHP-Specific Governance. (11) IHP Fiscal Agent means the agent or entity acting as the fiscal agent for the IHP Entity that makes, distributes or receives Interim Payments and Final Payments. (12) Integrated Health Partnership (IHP) means a health care delivery system described in Minnesota Statutes, 256B.0755, subd. 1(d). (13) Health Care Home means a provider organization certified by the Minnesota Department of Health (MDH) pursuant to Minnesota Statutes, 256B (14) Interim Payment means the payment of the Shared Savings amount that occurs after the conclusion of a demonstration Performance Period based on the most complete data available at that time. The Interim Payments shall not be affected by IHP performance on quality and patient experience measures. IHP RFP Revised - July 13,

57 (15) Managed Care Organization (MCO) means an entity that has, or is seeking to qualify for, a comprehensive risk contract with the STATE pursuant to the Minnesota PMAP program in Minnesota Statutes, 256B.69 and the MinnesotaCare program in Minnesota Statutes, Chapter 256L. (16) MinnesotaCare means the program authorized in Minnesota Statutes, Chapter 256L. (17) Minnesota Health Care Programs (MHCP) means Minnesota s Medical Assistance and MinnesotaCare programs including FFS and managed care programs. (18) Minnesota Health Care Programs Provider Agreement means the form DHS agreement, as amended, between the STATE and a provider allowing the provider to serve MHCP recipients. (19) Party means the STATE or IHP and Parties means both the STATE and IHP. (20) Patient or Attributed Patient means, for purposes of this Contract, either a recipient in the MHCP FFS program or an MCO enrollee who is included in the IHP s Attributed Population. (21) Performance Period means a period of time for the purposes of calculating the Total Cost of Care for services provided to the IHP Attributed Patients. (22) Prepaid Medical Assistance Program (PMAP) means the Medicaid program authorized under Minnesota Statutes, 256B.69 and Minnesota Rules, Parts through (23) Primary Care Provider means a health care provider whose principal specialty is among those listed as primary care or PCP in Attachment C, Provider Taxonomy. (24) Quality Measurement Period means a specific reporting period based upon dates of service, discharge dates, or visit dates for which a particular quality or patient experience measure is calculated to determine scoring and impact on Shared Savings. (25) Roster means a list of the IHP Participants and Primary Care and Specialty Providers the IHP provides to the STATE on or before the last business day of each quarter according to specifications provided by the STATE. (26) Shared Governance means a mechanism of IHP governance pursuant to Minnesota Statutes, 256B.0755, subd. 1(d). (27) Shared Losses means the amount by which the observed Performance Period Total Cost of Care is in excess of the adjusted Total Cost of Care target for the Performance Period after the IHP Entity exceeds the performance threshold as described in Attachment D, Settlement Process. (28) Shared Savings means the amount by which the observed Performance Period Total Cost of Care is below the adjusted Total Cost of Care target for the Performance Period after the IHP Entity exceeds the performance threshold as described in Attachment D, Settlement Process. IHP RFP Revised - July 13,

58 (29) Specialty Provider means a provider whose principal specialty is other than those listed as primary care in Attachment C, Provider Taxonomy. (30) Total Cost of Care means, in the context of this Contract, the cost of services as specified in Attachment D, Settlement Process, using the list of core services in Attachment E, Core Services. Article. 2 IHP REQUIREMENTS. IHP represents and warrants that it meets the requirements of Minnesota law, in that: 2.1 Legal Entity. IHP warrants it is a recognized legal entity formed under applicable state, federal, or tribal law and authorized to conduct business in the State of Minnesota. Its charter, articles, and/or bylaws allow it to: (A) Receive and distribute or make Interim and Final Payments; (B) Make Final Payments determined to be owed to the STATE or an MCO under this Contract; (C) Establish reporting, and ensure IHP Participants compliance with reporting of health care quality measures in Attachment F, Quality and Patient Experience Measures or Attachment F-1, IHP-Specific Quality and Patient Experience Measures as applicable; and (D) Fulfill other IHP functions as defined herein. 2.2 Governance. IHP warrants that IHP and its Participants have a mechanism of Shared Governance in accordance with Minnesota Statutes, 256B.0755, subd. 1(d), which is described in Attachment B, IHP-Specific Governance. In addition: (A) The IHP must make available a copy of this Contract to each IHP Participant, and other individuals and entities involved in IHP governance. (B) The IHP governing body must have a conflict of interest policy that applies to members of the governing body, IHP management and their agents who exercise operational or managerial control over the IHP. The conflict of interest policy must: (1) Require the disclosure of relevant financial interests; (2) Provide a procedure to determine whether a conflict of interest exists and set forth a process to address conflict; and (3) Address remedial action for any person or entity that fails to comply with the policy. 2.3 Legal Authority. IHP warrants that it possesses the legal authority to enter into this Contract and that it has taken all actions required by its articles, by-laws, resolutions, operating agreements and/or applicable laws to exercise that authority, and to authorize its undersigned signatories to execute this Contract, or any part thereof, and to bind IHP and IHP Participants to its terms. IHP RFP Revised - July 13,

59 2.4 Documentation of Legal Entity and Fiscal Soundness. (A) Upon request, IHP must provide copies to the STATE of all relevant documents effectuating the IHP s formation and operation relevant to the IHP demonstration, including but not limited to its articles, by-laws, resolutions, operating agreements, partnership agreements, joint venture agreements, management and consulting agreements, asset purchase agreements, financial statements and records, and resumes and other documentation for leaders of the IHP. (B) Annually and ongoing, the IHP must submit to the STATE its most recent certified financial audit, IRS Form 990, or most recent board-reviewed financial statements of its IHP Participants by the end of the second quarter following each Performance Period. 2.5 Assurance of Ability to Make Final Payments. IHP must have the ability to make a Final Payment of Shared Losses for which it may be liable. The STATE may request documentation that the IHP is capable of making a Final Payment of Shared Losses, if it is expected that a Shared Losses payment may exceed the amount that DHS FFS program would pay the IHP Fiscal Agent for 120 days services. Documentation of a repayment mechanism may include reinsurance, escrowed funds, surety bonds, a line of credit the STATE can draw upon, or another payment mechanism that will ensure its ability to repay the STATE. 2.6 Taxpayer Identification Number. IHP will designate a single Taxpayer Identification Number (TIN) of the IHP Fiscal Agent to receive any Interim or Final Payments. 2.7 Provider Rosters. IHP agrees that its IHP Participants and providers will remain as listed on the Roster reported to the STATE each quarter, except that: (A) IHP may add IHP Participant locations, clinics, groups of providers, or individual Primary Care Providers or Specialty Providers to its Roster by the last day of each quarter. IHP may add non-participant locations, clinics, regional health systems, or groups of providers only by amending Attachment B pursuant to section (B) Any changes to processes for maintaining provider Rosters and corresponding impacts to Attribution will be discussed with the IHP, and at least ninety (90) days notice will be provided to the IHP. 2.8 Statutory Eligibility. IHP warrants that it is eligible to participate in the demonstration consistent with Minnesota Statutes, 256B.0755, in that it and/or its Participants has or will: (A) Establish processes to monitor and ensure the quality of care provided; (B) Provide the full scope of primary care, and adopt methods of care delivery so that the full scope of primary care is provided and care is coordinated across the spectrum of services provided; (C) Contract and/or coordinate with necessary providers and clinics for the delivery of care; and contract or form partnerships with community-based organizations and public health resources; IHP RFP Revised - July 13,

60 (D) Develop and use processes to engage Patients and their families meaningfully in the care they receive; (E) Have the capability to use data provided by the STATE to identify opportunities for Patient engagement and to stratify its population to determine the care model strategies needed to improve outcomes; and (F) Provide consistent implementation of its care delivery model regardless of whether a Patient is enrolled in FFS or managed care in accordance with Minnesota Statutes, 256B.0755, subd. 1(c). 2.9 Insurance and Insurance Risk Management. IHP agrees that it will: (A) At all times during the term of the Contract keep in force a commercial general liability insurance policy or a program of self-insurance with the following minimum amounts: $2,000,000 per occurrence and $2,000,000 annual aggregate, protecting it from claims for damages for bodily injury, including sickness or disease, death, and for care and loss of services as well as from claims for property damage, including loss of use which may arise from operations under the Contract whether the operations are by the IHP or by a subcontractor or by anyone directly or indirectly employed by the IHP under the Contract. (B) Upon request of the STATE, purchase stop loss insurance or another form of insurance risk management pursuant to Minnesota Statutes, 256B.0755, subd. 1 (e). Article. 3 DUTIES. 3.1 Participation in Demonstration. IHP and the STATE agree to participate in the demonstration described in Minnesota Statutes, 256B Provider Enrollment. All IHP Participants and their providers must be enrolled in MHCP and comply with the provisions of the MHCP Provider Agreement, as amended. 3.3 Shared Savings or Losses. IHP understands and agrees that the demonstration requires calculation of Shared Savings or Shared Losses based upon the Attribution of Patients to the IHP. The Attribution model is described in Attachment A, Patient Attribution Method, appended and made a part of this Contract. The Shared Savings and Shared Losses calculation is described in Attachment D, Settlement Process, appended and made a part of this Contract. 3.4 Provision of Data. The Parties agree to provide data as follows: Data from IHP. IHP and/or its Participants agrees to provide necessary data in the form of claims and/or encounters, as required by its MHCP Provider Agreement with DHS or its contract with any MCO that participates in the Minnesota Health Care Programs, using standard data formats as required by state and federal law and/or the relevant contract. (A) Claims and/or encounters must be submitted within the timeframes required by the relevant provider agreement or contract. IHP RFP Revised - July 13,

61 (B) Quality and patient experience data must be submitted consistent with the data collection and submission requirements of the Minnesota Statewide Quality Reporting and Measurement System (Minnesota Rules, Chapter 4654) for measures in Attachment F, Quality and Patient Experience Measures. (C) Data collection and submission of other quality and patient experience measures is identified in Attachment F-1, IHP-Specific Quality and Patient Experience Measures, as applicable. (D) In the event the STATE identifies trends or patterns suggesting improper claim submission, discriminatory marketing activities, selective recruitment, or avoidance of atrisk patients, IHP agrees to submit additional documentation as required by the STATE for further investigation. (E) Upon request, the IHP shall provide status updates, data, or reports to the STATE associated with this demonstration to assist the STATE in meeting CMS monitoring and reporting obligations related to the status and progress of the IHP s care delivery transformation. This includes: participation in IHP learning collaboratives, tracking the progress of the IHP s analysis of utilization and ACG output data provided by the STATE as well as the IHP s clinical data, and updates on the progress of expansion and formation of relationships and coordination with community partners Data from STATE. STATE agrees to provide the following data in a secure format: (A) Clinical Data. The STATE will provide clinical data, ACG risk adjustment output and claims-level data outlined in (1) or (2) below for the IHP s Attributed Population monthly throughout the term of this Contract, unless otherwise mutually agreed by the Parties in writing. Data will be derived from the STATE data warehouse, and will include both FFS claim data and MCO encounter data in a form and format determined by the STATE. The STATE will provide IHP with at least ninety (90) days notice of changes in the data format, unless otherwise mutually agreed by the Parties. (1) Data for a rolling twelve (12) month period will be provided on a monthly basis no later than the final business day of each month, unless otherwise mutually agreed in writing by the Parties. The ACG risk adjustment output will have a three (3) month lag for Claims Run-out; claims-level data will not have a lag for Claims Run-out. (2) Data will include patient claim-level data (which must be protected according to Article. 8) including name and date of birth; procedure codes and diagnosis codes, inpatient and emergency department utilization; medical and pharmacy utilization; predictive risk information including an individual risk score; and indices of care coordination for the defined Attributed Population. All lines of claims for chemical and alcohol dependency treatment programs as governed by 42 USC 290dd-2 and 42 CFR 2.1 to 2.67 will be excluded. (B) Quarterly Total Cost of Care Data Package. The STATE will provide lists of Patients with name and date of birth who are attributed to the IHP, their Total Cost of Care, and risk score by forty-five (45) days after the end of each quarter, according to the methodology described in Attachment A, Patient Attribution Method applied to the eligible IHP RFP Revised - July 13,

62 populations described in Attachment G, Eligible and Excluded Populations and based on the Settlement Information Sets described in Attachment D, Settlement Process. (C) Annual payment-to-charge ratio or equivalent cost factor as determined by the STATE. The STATE will provide a payment-to-charge ratio or equivalent cost factor annually to the IHP and no later than forty-five (45) days after the beginning of the Performance Period. (D) IHP may reconcile its patients to its Attributed Population list. (1) In the event that IHP believes an Attributed Population list contains errors, IHP must provide notice and supporting data to the STATE, according to error report specifications provided by the STATE, no later than sixty (60) days after the receiving the Attributed Population list associated with the settlement calculation. (2) The STATE will review the possible error(s) and at least thirty (30) days before the Final Payment calculation will provide a written response of whether it will make changes based upon this review. The determination that results from the STATE s review shall be final. Any adjustment to the IHP Attributed Population based on the STATE s review will be included in the IHP s Final Payment calculation. (E) The STATE shall not provide provider- or episode-specific cost of care for any code or encounter, pursuant to Minnesota Statutes, 256B.69, subd. (9)(c) Data. The Parties will work together to anticipate and mitigate problems that may affect the data in Article Data Analysis. The STATE shall perform necessary data analysis to calculate the Attribution and settlement methods described in Attachment A, Patient Attribution Method, and Attachment D, Settlement Process respectively. 3.6 Required Reports and Notices. (A) IHP shall provide the initial Roster of its Participants and Primary Care and Specialty Providers to the STATE forty-five (45) days prior to the beginning of the Performance Period. (B) IHP shall notify the STATE of a change in its Authorized Representative, pursuant to the timeframes in section 6.2. (C) IHP shall notify the STATE within ten (10) days of the following events: (1) Material change in fiscal soundness that may impair the ability of IHP to perform its obligations under this Contract. (2) Upon being served with any legal action filed with a court or administrative agency, related to this Contract or which may materially affect the IHP s ability to perform its obligations hereunder. IHP RFP Revised - July 13,

63 (D) IHP shall notify the STATE of errors in its Attributed Population list consistent with the timeframes in above. (E) Report Certification. As a condition for receiving payment and upon request, IHP shall certify its data and reports that are utilized by the STATE for purposes including, but not limited to Total Cost of Care calculations and provider Rosters. (1) Data or reports which must be certified are: (a) Provider Rosters pursuant to section 3.6(A); (b) Alternative quality reporting (only for IHPs who have alternative quality reporting in Attachment F-1, IHP-Specific Quality and Patient Experience Measures); (c) Other data or reports requested by the STATE with notice that a certification is required; and (d) Errors in its Attributed Population list pursuant to section 3.4.2(D). (2) The certification must be signed by an officer of the IHP or an individual who has been delegated the authority to sign for the IHP chief executive officer or chief financial officer. The certification shall accompany the data or report, or IHP may submit a separate written certification due by the 5th day of the following month for any submissions in the previous month. The certification must identify each submission, the date it was submitted, and attest, based on best knowledge, information, and belief, to the accuracy, completeness and truthfulness of the data or report. 3.7 Patient Protection and Patient-Centeredness. (A) IHP shall comply with Medicaid marketing requirements: (1) The IHP, its agents and marketing representatives, may not offer or grant any reward, favor or compensation as an inducement to a MHCP recipient to receive services from the IHP or an IHP Participant. (2) The IHP, acting indirectly through publications and other marketing activity, or through mass media advertising (including the Internet), may inform MHCP recipients of the availability of IHP-related services through the IHP, the location and hours of service and other IHP characteristics, subject to all restrictions in this section. IHP shall provide the STATE with a timely advance copy of such materials. (B) Patients attributed to the IHP are free to choose any qualified provider. (C) IHP and its Participants must not discriminate among Patients on the basis of health status and must not engage in activities designed to result in selective recruitment and attribution of Patients with more favorable health status. (D) IHP and its Participants shall have processes in place to accomplish the following: (1) Promote patient engagement; IHP RFP Revised - July 13,

64 (2) Develop infrastructure for IHP Participants to internally report on quality and cost metrics that enables the IHP to monitor performance and use these results to improve care over time; and (3) Coordinate care across and among providers. Article. 4 PAYMENT. 4.1 Claims Payments and Demonstration Payments. Services shall be paid as follows: (A) IHP Participants will receive reimbursement for health care services according to and under its contract(s) with the Department of Human Services FFS program, or the relevant MCO in which the Patient is enrolled; and (B) Shared Savings or Shared Losses will be calculated by the STATE pursuant to the method in Attachment D, Settlement Process and distributed based on the method described in Attachment D-1 IHP-Specific Settlement Process. Final Payment of Shared Savings is reducible by the score calculated for quality and patient experience determined by Attachment F, Quality and Patient Experience Measures and Attachment F-1, IHP- Specific Quality and Patient Experience Measures if applicable. 4.2 Terms of Payment. Shared Savings and Shared Losses will be calculated, and paid according the timeframes in this section. (A) Interim Payments. (1) Shared Savings and Shared Losses interim settlements will be calculated by the STATE and reported to the IHP and applicable MCOs no later than the last business day of the fifth month following the close of the Performance Period, as described in 1.4 (B) of Attachment D, Settlement Process. (2) Shared Savings Interim Payments owed by the STATE to the IHP based upon FFS shall be paid by the STATE to the IHP on the next available FFS payment warrant after the notice in 4.2(A)(1) above. (3) The STATE will direct applicable MCOs to make Shared Savings Interim Payments to the IHP within thirty (30) days of the date that the STATE informs the MCOs of the amount owed. (B) Final Payment. (1) Final Payments of Shared Savings and Shared Losses will be calculated by the STATE and reported to the IHP and applicable MCOs no later than the last business day of the seventeenth (17th) month following the close of the Performance Period, as described in 1.4 (C) of Attachment D, Settlement Process. The receipt of data necessary to complete the Final Payment calculation is a condition precedent to the Final Payment. IHP RFP Revised - July 13,

65 (2) Final Payment of Shared Savings owed by the STATE to the IHP based upon FFS shall be paid by the STATE to the IHP on the next available DHS FFS payment after the notice in 4.2(B)(1) above. (3) The STATE will direct applicable MCOs to make Final Payments of Shared Savings to the IHP within thirty (30) days of the date that the STATE informs the MCOs of the amount owed. (4) Final Shared Losses, as calculated by the STATE, shall be paid by the IHP to the STATE or applicable MCO no later than one hundred and twenty (120) days after the calculation in section 4.2(B)(1) above is completed and the IHP is notified. The STATE may, at its option, offset any Shared Losses obligation by withholding payment from current payment warrants on a schedule to be agreed upon between the Parties. (C) Certain Laws not Applicable to Payments. The Parties agree that Interim and Final payments are not claims payments subject to the prompt pay laws in Minnesota Statutes, 62Q.75. The vendor payment timelines in Minnesota Statutes, 16A.124 apply to these payments only after final calculation pursuant to this Article. (D) All services provided by IHP pursuant to this Contract shall be performed to the satisfaction of the STATE, as determined at its sole discretion, and in accord with all applicable federal, state, and local laws, ordinances, rules and regulations including business registration requirements of the Office of the Secretary of State. (E) Neither Party shall pay interest on any amounts due hereunder. 4.3 Payment Errors. In the event of a payment error identified by either Party: (A) From DHS FFS system: If either Party determines that there has been a material error in its payment to or from the other Party that resulted in overpayment or underpayment due to reasons that do not include the agreed-upon methodology in the Attachments, or Fraud or Abuse by the IHP, its Participating Entities or an Attributed Patient; then the STATE or IHP may make a claim under this section within sixty (60) days from the discovery of the error. (B) From an MCO payment error: If either Party determines that there has been a material error in payment that resulted in overpayment or underpayment, which error is due to changes in or errors in claims or encounters processing by an MCO, the procedure in section 4.3(A) shall be followed except that the timeframe for initial notice shall be extended to ninety (90) days. (C) The IHP must have filed a timely and Patient-Specific appeal of Attribution under section 3.4.2(D) in order to assert any claims regarding Attribution. (D) The Party receiving the claim in (A) or (B) above shall acknowledge in writing or e- mail the receipt of the claim. (E) Neither Party shall assert any claim for or seek the payment of or make any adjustment for any erroneous payment made pursuant to this Contract more than one year after the date such payment was actually received by the receiving Party. IHP RFP Revised - July 13,

66 Article. 5 TERM AND TERMINATION; DISPUTE RESOLUTION. 5.1 Effective Dates. This Contract shall be effective on January 1, 2016, or upon the date that the final required signature is obtained by the STATE, pursuant to Minnesota Statutes, 16C.05, subd. 2, whichever occurs later, and shall remain in effect through December 31, 2016, or until all obligations set forth in this Contract have been satisfactorily fulfilled, whichever occurs first. 5.2 Automatic Renewal. Notwithstanding the termination date in section 5.1 above, this Contract shall automatically renew at the end of the current term for a successive one-year term, not to exceed a total of three years, unless the STATE or IHP gives written notice of its intention not to renew (consistent with below), at least sixty (60) days before expiration of the then-current term. 5.3 Termination Termination By STATE. (A) Without Cause. This Contract may be terminated by the STATE at any time, with or without cause, upon ninety (90) days written notice to IHP. In the event of such a termination, IHP shall be entitled to payment, determined on a pro rata basis, of Shared Savings through the effective date of termination for work or services satisfactorily performed, but IHP will not be required to make payment for Shared Losses, if any, through the effective date of termination. (B) For Cause. The STATE has the right to suspend or terminate this Contract in writing immediately when the STATE deems: (1) The health or welfare of its Patients is endangered; (2) When the STATE has reasonable cause to believe that the IHP has breached a material term of the Contract; or (3) When IHP non-compliance with the terms of the Contract may jeopardize federal financial participation in the STATE s Medicaid program. (C) Insufficient Funds. The STATE may immediately terminate this Contract if it does not obtain funding from the Minnesota Legislature, or other funding source; or if funding cannot be continued at a level sufficient to allow for payment. Termination will be by written notice to the IHP. The IHP will be entitled to or obligated to pro rata payment of Shared Savings or Shared Losses up to the date of termination for services satisfactorily performed to the extent that funds are available. The STATE will not be assessed any penalty if the contract is terminated because of the decision of the Minnesota Legislature, or other funding source, not to appropriate funds. The STATE must provide the IHP notice of the lack of funding within a reasonable time of the STATE s receiving that notice. (D) Breach. Notwithstanding any other provision of this Contract, upon STATE s knowledge of a curable material breach of the Contract by IHP, STATE shall provide IHP written notice of the breach and thirty (30) days to cure the breach from the date it IHP RFP Revised - July 13,

67 receives the notice of breach, unless a longer period is mutually agreed upon if the breach can be cured. In urgent situations, as determined by the STATE, the STATE may establish a shorter time period to cure the breach. If IHP does not cure the breach within the time allowed, IHP will be in default of this Contract and STATE may terminate the Contract immediately. If IHP has breached a material term of this Contract and cure is not possible, STATE may immediately terminate this Contract. (E) The STATE may terminate this Contract in the event the IHP: (1) Becomes insolvent, is dissolved or liquidated; (2) Files or has filed against it a petition in bankruptcy and, in the case of an involuntary petition, such petition is not dismissed within thirty (30) days; (3) Makes a general assignment for the benefit of its creditors; (4) IHP or any of its Participants, Primary Care Providers, Specialty Providers or principals is in violation of section 10.6 below, unless the IHP has promptly provided termination notice to and taken steps to disaffiliate itself from any such Participant, Primary Care Provider, Specialty Provider or principal; or (5) Ceases conducting business in the ordinary course Pre-termination Action by STATE. The STATE may, but is not required to, take one or more of the following actions if the STATE concludes termination of the Contract is warranted: (A) Provide a warning notice to the IHP regarding noncompliance; (B) Request a Corrective Action Plan for the IHP; or (C) Place the IHP on a special monitoring plan Termination by IHP. IHP may terminate this Contract under the following circumstances: (A) With Cause; Loss of an IHP Participant. IHP must notify the STATE under section 3.6 above in the event that one or more of its constituent IHP Participants will no longer be available to treat Patients under this Contract. In the event that this departing IHP Participant provides care for more than fifty percent (50%) of the IHP s most recent quarter Attributed Population, the IHP may provide written notice of termination and follow the termination procedures outlined in section The IHP will be entitled to pro rata payment of Shared Savings up to the effective date of the termination. (B) Without Cause. Upon ninety (90) days written notice to the STATE. The IHP will be entitled or obligated to pro rata payment of Shared Savings or Shared Losses up to the effective date of the termination in the second and third years of the demonstration only Termination Procedures. Upon termination of this Contract and continuing until Final Payment is complete, the IHP shall, upon request of the STATE, provide information to the STATE IHP RFP Revised - July 13,

68 that may be necessary to end data collection and determine payments owed. IHP shall cooperate with a mutually agreed-upon termination plan Dispute Resolution. In the event of a dispute between the STATE and IHP, the Parties will work together in good faith to resolve any disputes about their business relationship. (A) If the Parties are unable to resolve the dispute within thirty (30) days following the date one party sent written notice of the dispute to the other party, the Parties may submit the dispute to non-binding mediation before a single mediator prior to commencing any other forms of dispute resolution. The mediator shall accept both written and oral argument as requested, and make its recommendation within fifteen (15) days of receiving the request for recommendation unless the Parties mutually agree to a longer time period. The Commissioner of Human Services shall resolve all disputes after taking into account the recommendations of the mediator and within three (3) business days after receiving the recommendation of the mediator. The cost of mediation shall be shared equally between the Parties, and each party shall be responsible for its own expenses, including attorney s fees. Whether or not the Parties elect to submit the dispute to non-binding mediation, nothing in this paragraph shall bar either party from enforcing its rights under this Contract in any legal forum. (B) IHP may not dispute the methodologies in the Attachments. Article. 6 AUTHORIZED REPRESENTATIVE AND RESPONSIBLE AUTHORITY. 6.1 STATE. The STATE's authorized representative for the purposes of administration of this Contract is Marie Zimmerman, or her successor. If the STATE s authorized representative changes at any time during this Contract, the STATE will provide notice to the IHP. 6.2 IHP. The IHP s authorized representative is listed in Attachment B, IHP-Specific Governance. If IHP s authorized representative changes at any time during this Contract, IHP must notify the STATE within three (3) business days. Article. 7 QUALITY AND PATIENT EXPERIENCE MEASURES. The STATE and IHP agree that the following standardized set of quality measures will be used as described in Attachment F, Quality and Patient Experience Measures to affect the amount of Shared Savings, subject to any modifications described in Attachment F-1, IHP-Specific Quality and Patient Experience Measures. 7.1 Source of Measure Specifications and Reporting Requirements. The STATE will use the Minnesota Statewide Quality Reporting and Measurement System measure specifications and reporting requirements, including all updates and modifications, as published by the Minnesota Department of Health (MDH) in Minnesota Rules, Chapter 4654, for each respective measure described in Attachment F and standardized measure specifications and reporting requirements for each measure described in Attachment F-1 as applicable. 7.2 Changes in Measures. The STATE may change the measures both in response to changes promulgated by MDH and Minnesota Community Measurement (MNCM) or any other measurement organization identified in Attachment F, Quality and Patient Experience Measures or Attachment F-1, IHP RFP Revised - July 13,

69 IHP-Specific Quality and Patient Experience Measures as applicable, and as the IHP demonstration evolves. (A) The STATE will not notify IHP regarding updates and modifications that originate from MDH, MNCM, or other organization used as a source of measures when the organization publishes its measure specifications. (B) The STATE will only add to or delete from the list of measures listed in Attachment F, Quality and Patient Experience Measures or Attachment F-1, IHP-Specific Quality and Patient Experience Measures as applicable prior to a Performance Period, and will provide notice to IHP of the proposed new measure at least ninety (90) days in advance. 7.3 Changes in Calculation Methods. The STATE will notify the IHP of the thresholds described in Attachment F, Quality and Patient Experience Measures or Attachment F-1, IHP-Specific Quality and Patient Experience Measures as applicable, before the beginning of the Performance Period by publishing preliminary thresholds on the DHS public website. The STATE will notify the IHP of final thresholds upon calculation using the data based on the most recent Quality Measurement Period. The STATE will work with the IHP on any modifications to the calculation methods, quality measure thresholds, or other modifications resulting from changes to a measure or measures pursuant to section 7.1 or 7.2 to achieve the goals of the demonstration. The STATE will notify the IHP of the change. 7.4 Quality and Patient Experience Data Appeals. Appeal processes that the IHP may use for quality and patient experience data are limited to those provided by the relevant organizations receiving the data (for example, MDH and MNCM) pursuant to Minnesota Rules, Part Article. 8 INFORMATION PRIVACY AND SECURITY. 8.1 Part of the Welfare System. For purposes of executing its responsibilities and to the extent set forth in this Contract, the IHP will be considered part of the welfare system, as defined in Minnesota Statutes, 13.46, subd. (1). 8.2 Information Privacy and Security. IHP and the STATE must comply with the Minnesota Government Data Practices Act, Minnesota Statutes, Chapter 13, and the Health Insurance Portability Accountability Act (HIPAA), 45 CFR Parts 160 and 164, as it applies to all data provided by STATE under this Contract, and as it applies to all data created, collected, received, stored, used, maintained, or disseminated by IHP under this Contract. The civil remedies of Minnesota Statutes apply to data governed by the Minnesota Government Data Practices Act. The remedies of HIPAA apply to the release of data governed by HIPAA Information Covered by this Provision. In carrying out its duties under this Contract, IHP will be handling one or more types of private information, collectively referred to as protected information, concerning individual DHS clients. Protected information, for purposes of this Contract, may include any or all of the following: (A) Private data (as defined in Minnesota Statutes 13.02, subd. 12), confidential data (as defined in Minnesota Statutes, 13.02, subd. 3), welfare data (as governed by Minnesota Statutes, 13.46), medical data (as governed by Minnesota Statutes, ), and other IHP RFP Revised - July 13,

70 non-public data governed by other sections in the Minnesota Government Data Practices Act (MGDPA), Minnesota Statutes Chapter 13; (B) Health records (as governed by the Minnesota Health Records Act, Minnesota Statutes, through ); (C) Chemical health records (as governed by 42 USC 290dd-2 and 42 CFR 2.1 to 2.67); (D) Protected health information ( PHI ) as defined in and governed by the Health Insurance Portability Accountability Act (HIPAA), 45 CFR ; (E) Federal tax information ( FTI ) (as protected by 26 USC 6103); and (F) Other data subject to applicable state and federal statutes, rules, and regulations affecting the collection, storage, use, or dissemination of private or confidential information General Oversight Responsibilities. (A) Duty to ensure proper handling of information. IHP shall be responsible for ensuring proper handling and safeguarding by its employees, subcontractors, and authorized agents of protected information collected, created, used, maintained, or disclosed on behalf of STATE under this Contract. This responsibility includes ensuring that employees and agents comply with and are properly trained regarding, as applicable, the laws listed above in section 8.2. (B) Minimum necessary access to information. IHP shall comply with the minimum necessary access and disclosure rule set forth in HIPAA (45 CFR (b) and (d)) and the MGDPA (Minnesota Statutes, 13.05, subd. 3). The collection, creation, use, maintenance, and disclosure of protected information shall be limited to that necessary for the administration and management of programs specifically authorized by the legislature or local governing body or mandated by the federal government. (C) Information Requests. Pursuant to Minnesota Statutes, 13.05, subd. 11, all of the data created, collected, received, stored, used, maintained, or disseminated by the IHP in performing under this Contract is subject to the requirements of Chapter 13, and IHP must comply with those requirements as if it were a government entity. Pursuant to Laws of Minnesota 2014, Ch. 293, sec. 3, this section (C) is effective July 1, Unless provided for otherwise in this Contract, if IHP receives a request to release the information referred to in section 8.2 under this Contract, IHP must immediately notify and consult with the STATE. The STATE will give IHP instructions concerning the release of the data to the requesting party before the data are released. (D) General Use and Disclosure Provisions. Except as otherwise limited in this Contract, IHP in its role as a Business Associate (as defined in HIPAA) may use or disclose Protected Health Information ( PHI ) on behalf of, or to provide services to, the STATE for the purposes described in this section, provided that such use or disclosure of PHI does not violate the HIPAA Privacy Rule if performed by the STATE. IHP RFP Revised - July 13,

71 (E) Specific Use and Disclosure Provisions. Except as otherwise limited in this Contract, IHP may: (1) Use PHI for the proper management and administration of the IHP or to carry out the legal responsibilities of the IHP. In particular, IHP may use PHI for evaluation of risk or for program evaluation relating to the IHP demonstration. (2) Disclose PHI for the proper management and administration of the Business Associate, provided that: (a) The disclosure is required by law, or (b) The disclosure is required to perform the services provided to or on behalf of the STATE or the disclosure is otherwise authorized by the STATE; and (c) IHP obtains reasonable assurances from the entity to whom the PHI will be disclosed that the PHI will remain confidential, and will not be used or disclosed other than for the contracted services or the authorized purposes; and (d) IHP requires the entity to whom PHI is disclosed to notify IHP of any compromise to the confidentiality of PHI of which the entity becomes aware. (F) Obligations and Activities of IHP as a Business Associate. IHP agrees: (1) Not to use or disclose PHI other than as permitted or required by this Contract or as otherwise permitted or required by law. (2) To use appropriate safeguards, and comply with Subpart C of 45 CFR Part 164 (HIPAA Security Rule) with respect to electronic PHI, to prevent the use or disclosure of PHI other than as provided for by this Contract. (3) To mitigate, to the extent practicable, any harmful effect that is known to IHP of a use or disclosure of PHI by IHP in violation of the requirements of this Contract. (4) To report to the STATE, in writing, any use or disclosure of PHI not provided for by this Contract of which it becomes aware, including breaches of unsecure PHI as required at 45 CFR , and any security incident of which it becomes aware, as promptly as possible, but in no event later than five (5) business days of IHP s discovery. All notifications shall be sent to the STATE Authorized Representative and shall identify the individuals whose PHI has been or is reasonably believed to have been breached; the date of the breach and its discovery; a description of the steps taken to investigate the breach, mitigate its effects and prevent future breaches; the sanctions imposed on members of the IHP s workforce involved in the breach; and any other available information that the STATE is required to include in notification to the individual under 45 CFR (c). A breach shall be treated as discovered as of the first day on which such breach is known or reasonably should have been known by IHP as provided under 45 CFR (a)(2). IHP agrees to provide the STATE, within forty-eight (48) hours of a request, any reports necessary for the STATE to respond to any inquiries pursuant to an investigation about a breach. IHP RFP Revised - July 13,

72 (5) To ensure that any agent (including a subcontractor) to whom IHP discloses PHI received from or on behalf of the STATE, or to whom IHP employs or contracts with to create, receive, maintain or transmit PHI agrees to the same restrictions and conditions that apply through this Contract to IHP regarding such PHI, in accordance with 45 CFR (e)(1)(ii) and (b)(2). (6) If IHP maintains part of the STATE s Designated Record Set and if so requested by Covered Entity: (a) to provide the means for an individual to access, inspect, or receive copies of the individual s PHI; (b) to provide the means for an individual to make an amendment to the individual s PHI; (c) to provide the means for access and amendment in the time and manner that complies with HIPAA requirements or as otherwise directed by the STATE. (7) To make internal practices, books, and records relating to the use and disclosure of PHI subject to this Contract available to the STATE or to the Secretary of Health and Human Services, in a time and manner designated by the STATE or Secretary, for purposes of the Secretary determining the STATE s or IHP s compliance with the HIPAA Rules. (8) To document disclosures of PHI made by IHP that are subject to the accounting of disclosure requirement described in 45 CRF , and to provide to the STATE such documentation in a time and manner designated by the STATE. (9) To comply with the sections of the HIPAA Rules, and in particular to the Rules requirements for business associates that must appear in a business associate agreement under 45 CFR (e)(1), which are incorporated by reference into this Contract. (10) To reimburse the STATE for all costs incurred by the STATE in providing any notifications required by 45 CFR Part 164 Subpart D, or other actions determined by the STATE, for a breach caused by the actions of IHP or its subcontractors or agents. (G) Maintain and make available no later than fifteen (15) days after receipt of request from STATE, the information required to provide an accounting of disclosures to STATE as necessary to satisfy the STATE s obligations under 45 CFR , or upon request from STATE respond directly to individual s request for an accounting of disclosures. 8.3 STATE s Duties. The STATE shall: (A) Only release information which it is authorized by law or regulation to share with IHP. (B) Obtain any required consents, authorizations or other permissions that may be necessary for it to share information with IHP. (C) Notify IHP of limitation(s), restrictions, changes, or revocation of permission by an individual to use or disclose protected information, to the extent that such limitation(s), IHP RFP Revised - July 13,

73 restrictions, changes or revocation may affect IHP s use or permitted disclosure of protected information. (D) Not request IHP to use or disclose protected information in any manner that would not be permitted under law if done by STATE. 8.4 Effect of statutory amendments or rule changes. The Parties agree to take such action as is necessary to amend this Agreement from time to time as is necessary for compliance with the requirements of the laws listed in section or in any other applicable law. However, any requirement in this Agreement or in the STATE Information Security Policy that is based upon HIPAA Rules or upon other federal or state information privacy or security laws means the requirement as it is currently in effect, including any applicable amendment(s), regardless of whether the agreement has been amended to reflect the amendments(s). 8.5 Disposition and/or Retention of Protected Information/Data upon Completion, Expiration, or Contract Termination. Upon completion, expiration, or termination of this Contract, IHP will return to the STATE or destroy all protected information received or created on behalf of the STATE for purposes associated with this Contract. A written certification of destruction or return to Authorized Representative is required. IHP will retain no copies of such protected information, provided that if both Parties agree that such return or destruction is not feasible, or if required by the applicable regulation, rule or statutory retention schedule to retain beyond the life of this Contract, IHP will extend the protections of this Contract to the protected information and refrain from further use or disclosure of such information, except for those purposes that make return or destruction infeasible, for as long as IHP maintains the information. 8.6 Sanctions. In addition to acknowledging and accepting the general terms set forth in this Contract relating to indemnification, the Parties acknowledge that violation of the laws and protections described above could result in limitations being placed on future access to protected information, in investigation and imposition of sanctions (including but limited to civil and criminal penalties) by, among other agencies, the U.S. Department of Health and Human Services, Office for Civil Rights; the federal Internal Revenue Service (IRS); the Centers for Medicare & Medicaid Services (CMS); and the Office of the Attorney General for the State Minnesota. Article. 9 Intellectual Property Rights. 9.1 Definitions. Works means all inventions, improvements, discoveries (whether or not patentable or copyrightable), databases, computer programs, reports, notes, studies, photographs, negatives, designs, drawings, specifications, materials, tapes, and disks conceived, reduced to practice, created or originated by IHP, its employees, agents, and subcontractors, either individually or jointly with others in the performance of this Contract. Works includes Documents. Documents are the originals of any databases, computer programs, reports, notes, studies, photographs, negatives, designs, drawings, specifications, materials, tapes, disks, or other materials, whether in tangible or electronic forms, prepared by IHP, its employees, agents, or subcontractors, in the performance of this Contract. 9.2 Use of Works and Documents. IHP owns any Works or Documents developed by the IHP in the performance of this Agreement. The STATE and the U.S. Department of Health and Human Services will have royalty free, non-exclusive, perpetual and irrevocable right to reproduce, publish, IHP RFP Revised - July 13,

74 or otherwise use, and to authorize others to use, the Works or Documents for government purposes. If using STATE data for publication, IHP must cite the data, or make clear by referencing that STATE is the source. Article. 10 COMPLIANCE WITH STATE AND FEDERAL LAWS. IHP, its Participants and other individuals or entities performing functions related to IHP s activities shall comply with all applicable state and federal laws and regulations in the performance of its obligations under this Contract. Any revisions to applicable provisions of federal or state law and implementing regulations, and policy issuances and instructions, except as otherwise specified in this Contract, apply as of their effective date. If any terms of this Contract are determined to be inconsistent with rule or law, the applicable rule or law provision shall govern Compliance with Federal Laws. Notwithstanding any applicable waivers of fraud and abuse laws, the IHP shall comply with all applicable federal laws in the performance of its obligations under this Contract including, but not limited to: (A) Federal Criminal Law; (B) The False Claims Act (31 USC 3729 et seq.); (C) The anti-kickback statute (42 USC 1320a-7b(b); (D) The civil monetary penalties law (42 USC 1320a-7a); and (E) The physician self-referral law (42 USC 1395nn) Affirmative Action And Non-Discrimination Affirmative Action requirements for IHPs with more than 40 full-time employees and a contract in excess of $100,000. If IHP has had more than 40 full-time employees within the State of Minnesota on a single working day during the previous twelve months preceding the date IHP submitted its request for proposal response to the STATE, it must have an affirmative action plan, approved by the Commissioner of Human Rights of the State of Minnesota, for the employment of qualified minority persons, women and persons with disabilities. See Minnesota Statutes 363A.36. If IHP has had more than 40 full-time employees on a single working day during the previous twelve months in the state in which it has its primary place of business, then IHP must either: 1) have a current Minnesota certificate of compliance issued by the Minnesota Commissioner of Human Rights; or 2) certify that it is in compliance with federal Affirmative Action requirements Affirmative Action and Non-Discrimination requirements for all IHPs. The IHP agrees not to discriminate against any employee or applicant for employment because of race, color, creed, religion, national origin, sex, marital status, status in regard to public assistance, membership or activity in a local commission, disability, sexual orientation, or age in regard to any position for which the employee or applicant for employment is qualified. Minnesota Statutes, 363A.02. IHP agrees to take affirmative steps to employ, advance in employment, upgrade, train, and recruit minority persons, women, and persons with disabilities. IHP RFP Revised - July 13,

75 (A) The IHP must not discriminate against any employee or applicant for employment because of physical or mental disability in regard to any position for which the employee or applicant for employment is qualified. The IHP agrees to take affirmative action to employ, advance in employment, and otherwise treat qualified disabled persons without discrimination based upon their physical or mental disability in all employment practices such as the following: employment, upgrading, demotion or transfer, recruitment, advertising, layoff or termination, rates of pay or other forms of compensation, and selection for training, including apprenticeship, consistent with. Minn. Rule (B) IHP agrees to comply with the rules and relevant orders of the Minnesota Department of Human Rights issued pursuant to the Minnesota Human Rights Act. (C) Notification to employees and other affected parties. The IHP agrees to post in conspicuous places, available to employees and applicants for employment, notices in a form to be prescribed by the commissioner of the Minnesota Department of Human Rights. Such notices will state the rights of applicants and employees, and IHP s obligation under the law to take affirmative action to employ and advance in employment qualified minority persons, women, and persons with disabilities. (D) The IHP will notify each labor union or representative of workers with which it has a collective bargaining agreement or other contract understanding, that the IHP is bound by the terms of Minnesota Statutes, 363A.36 of the Minnesota Human Rights Act and is committed to take affirmative action to employ and advance in employment minority persons, women, and persons with physical and mental disabilities Compliance with Department of Human Rights Statutes. In the event of IHP s noncompliance with the provisions of this clause, actions for noncompliance may be taken in accordance with Minnesota Statutes 363A.36, and the rules and relevant orders issued pursuant to the Minnesota Human Rights Act Workers' Compensation. The IHP certifies that it is in compliance with Minnesota Statutes, , subdivision 2, pertaining to workers compensation insurance coverage. The IHP s employees and agents will not be considered employees of the STATE. Any claims that may arise under the Minnesota Workers Compensation Act on behalf of these employees or agents and any claims made by any third party as a consequence of any act or omission on the part of these employees or agents are in no way the STATE S obligation or responsibility Voter Registration Requirement. (If applicable) IHP certifies that it will comply with Minnesota Statutes, by providing voter registration services for its employees and for the public served by the IHP Federal Audit Requirements. IHP certifies it will comply with the Single Audit Act, and OMB Circular A-133, as applicable. All sub-recipients receiving $500,000 or more of federal assistance in a fiscal year will obtain a financial and compliance audit made in accordance with the Single Audit Act, or OMB Circular A-133, as applicable. Failure to comply with these requirements could result in forfeiture of federal funds Debarment Information. IHP RFP Revised - July 13,

76 (A) Debarment By State, its Departments, Commissions, Agencies or Political Subdivisions. By signing this Contract, IHP certifies that neither it nor its IHP Participants, Primary Care Providers or principals is presently debarred or suspended by the STATE, any of its departments, commissions, agencies, or political subdivisions. This certification is a material representation upon which this Contract award was based. IHP shall provide immediate written notice to the STATE S authorized representative if at any time it learns that this certification was erroneous when submitted or becomes erroneous by reason of changed circumstances. (B) Certification Regarding Debarment, Suspension, Ineligibility, and Voluntary Exclusion. Federal money will be used or may potentially be used to pay for all or part of the work under the contract, therefore IHP certifies that it is in compliance with federal requirements on debarment, suspension, ineligibility and voluntary exclusion specified in the solicitation document implementing Executive Order IHP s certification is a material representation upon which this Contract award was based Ownership and Control; Exclusions of Individuals and Entities. To the extent the IHP is not otherwise providing the following information to the STATE, the IHP as applicable shall: (A) Make full disclosure of ownership and control information as required by 42 CFR through , and upon request, full disclosure of business transactions, as is required by 42 CFR ; (B) Make full disclosure of persons convicted of program crimes as required by 42 CFR ; and (C) Ensure that IHP, all of its owners, managers, employees and subcontractors are not excluded from participation in Medicare, Medicaid or other federal health care programs. IHP must immediately report any exclusion information discovered to the STATE. Article. 11 OTHER PROVISIONS Governing Law, Jurisdiction and Venue. This Contract, and amendments and supplements thereto, shall be governed by the laws of the State of Minnesota. Venue for all legal proceedings arising out of this Contract, or breach thereof, shall be in the state or federal court with competent jurisdiction in Ramsey County, Minnesota Waiver. If either Party fails to enforce any provision of this Contract, that failure does not waive the provision or the Party s right to enforce it Contract Complete. This Contract contains all negotiations and agreements between the STATE and IHP. No other understanding regarding this Contract, whether written or oral may be used to bind either party Assignment. IHP shall neither assign nor transfer any rights or obligations under this Contract without the prior written consent of the STATE. IHP RFP Revised - July 13,

77 11.5 Amendments. Any amendments to this Contract shall be in writing, and shall be executed by the same Parties who executed the original contract, or their successors in office Indemnification. In the performance of this Contract by IHP, or IHP s agents or employees, the IHP must indemnify, save, and hold harmless the STATE, its agents, and employees, from any claims or causes of action, including attorney s fees incurred by the STATE, to the extent caused by IHP s: (A) Intentional, willful, or negligent acts or omissions; (B) Actions that give rise to strict liability; or (C) Breach of contract or warranty. The indemnification obligations of this clause do not apply in the event the claim or cause of action is the result of the STATE S sole negligence. This clause will not be construed to bar any legal remedies the IHP may have for the STATE S failure to fulfill its obligation under this Contract STATE Audits. Under Minnesota Statutes, 16C.05, subd. 5, the books, records, documents, and accounting procedures and practices of the IHP and its employees, agents, or subcontractors relevant to this Contract shall be made available and subject to examination by the STATE, including the contracting Agency/Division, Legislative Auditor, and State Auditor for a minimum of six years from the end of this Contract Right to Review before Publication. Each Party agrees to provide to the other Party a prepublication copy of materials listed below that identifiably mention the IHP and the demonstration project. Each Party agrees to provide comments, if any, within ten (10) days of receipt of the materials. IHP shall not state or imply that the STATE endorses the IHP s products or services. Each Party shall provide to the other Party copies of any formal presentation by the Party or its subcontractors, including reports, statistical or analytical materials, papers, articles, or professional publications, based on information obtained through the administration of this IHP Contract Religious-Based Counseling. IHP agrees that no religious-based counseling shall take place under the auspices of this Contract Payment to Subcontractors. As required by Minnesota Statutes, 16A.1245, the IHP must pay all subcontractors, less any retainage, within ten (10) days of the IHP s receipt of payment from the STATE for undisputed services provided by the subcontractor(s) and must pay interest at the rate of one and one-half percent per month or any part of a month to the subcontractor(s) on any undisputed amount not paid on time to the subcontractor(s). For the purposes of this clause, subcontractor does not include IHP Participants or providers Severability. If any provision or paragraph of this Contract is found by a court of competent jurisdiction to be legally invalid or unenforceable, such provision or paragraph shall be deemed to have been stricken from this Contract and the remainder of this Contract shall be deemed to be in full force and effect. IHP RFP Revised - July 13,

78 11.12 Execution in Counterparts. Each party agrees that this Contract may be executed in two or more counterparts, all of which shall be considered one and the same agreement, and which shall become effective if and when both counterparts have been signed and dated by each of the parties. It is understood that both parties need not sign the same counterpart Survival. All provisions of this Contract that, by their nature and content, should survive the termination of this Contract in order to achieve the fundamental purposes of this Contract shall survive and continue to bind the Parties. IHP s continuing obligations, after said period, include but are not limited to the following provisions: Article. 8 Information Privacy and Security; 11.1 Jurisdiction and Venue, 11.6 Indemnification, and 11.7 State Audits. Signature page follows. IHP RFP Revised - July 13,

79 IN WITNESS WHEREOF, the Parties hereto have executed this Contract. This Contract is hereby accepted and considered binding in accordance with the terms outlined in the preceding statements. STATE OF MINNESOTA (IHP) DEPARTMENT OF HUMAN SERVICES (Two corporate officers must execute) By: By: Name: Print Name: Title: Assistant Commissioner Title: Date: Date And By: Print Name: Title: Date IHP RFP Revised - July 13,

80 List of Attachments Attachment A, Patient Attribution Method Attachment B, IHP-Specific Governance Attachment C, Provider Taxonomy Attachment D, Settlement Process Attachment D-1 IHP-Specific Settlement Process Attachment E, Core Services Attachment F, Quality and Patient Experience Measures Attachment F-1, IHP-Specific Quality and Patient Experience Measures Attachment G, Eligible and Excluded Populations IHP RFP Revised - July 13,

81 ATTACHMENT A: Patient Attribution Method 1.1 Summary. This document further describes the STATE s method of how a recipient in the MHCP FFS program or a managed care organization enrollee is assigned to the IHP Attributed Population as an Attributed Patient. 1.2 Definitions. For the purposes of this Attachment: (A) Capitalized terms in this Attachment take the same meanings as in the Contract. (B) E&M refers to Evaluation and Management coding. (C) HCPCS refers to the HCFA Common Procedural Coding System. (D) Non-IHP provider means a provider not listed on a Roster submitted by an IHP. 1.3 Patients. Patients must have had at least one visit or encounter with a Roster provider during the Performance Period and such visit must be have been paid to a billing entity on the Roster to be eligible for Attribution. Certain populations are categorically excluded from the IHP model (for example, persons with dual eligibility), and are removed from the pool of MHCP Recipients who can be attributed (see Attachment G Eligible and Excluded Populations ). Attribution is based on E&M visit counts in a twelve (12) month period of a Patient s claim history. Patients who have less than six (6) months of continuous enrollment in qualifying programs or less than nine (9) total months of enrollment in qualifying programs are excluded from Attribution. Throughout the course of the Performance Period, a Patient s attribution status (either among IHPs or to no IHP) may change as the Patient s utilization pattern changes. 1.4 Attribution Steps. Once the exclusion process is completed to determine the base population eligible for Attribution, the Attribution process counts qualifying visits for each MHCP Recipient across providers on all the IHP Rosters and compares the total claim counts at each IHP to those at non-ihp providers. In performing the comparisons, there are four steps evaluated in the following order: (1) Health Care Home (HCH) claims; (2) E&M procedures by a Primary Care Provider; and (3) E&M procedures by a Specialty Provider; and (4) Tie Breaking Step. As the algorithm progresses, a MHCP recipient is either definitively assigned to an IHP and not evaluated in subsequent steps, determined to be not attributable to any IHP for this period, or passed to the next step in the Attribution decision process. ATTACHMENT A PATIENT ATTRIBUTION METHOD

82 1.4.1 STEP 1. If Health Care Home Claim Code(s) are Present: Patients with Health Care Home care coordination claims (HCPCS Code S0280 and/or S0281) are attributed to the IHP using the treating and billing provider as follows: (1) Patients with HCH codes at only one IHP are attributed to the IHP. (2) Patients with HCH codes at more than one IHP or at non-ihp provider(s) are attributed to the IHP or non-ihp provider(s) that submitted the greater number of HCH claims. (3) Patients with an equal number of HCH codes are attributed to the IHP or the non- IHP provider having the most recent date of service HCH care coordination claim.. (4) Patients with no HCH codes are assessed by the decision criteria in Step STEP 2. If Attribution From HCH Claims Has Not Occurred, but Qualifying Visit(s) to a Primary Care Provider are Present: Patients with the following E&M codes paid to an IHP billing provider and performed by an IHP Roster provider with a primary care specialty (as defined in Attachment C Provider Taxonomy ) through 99215, through 99350, through 99387, through 99397, G0402, G0438, and G0439 are attributed to the IHP as follows: (1) Patients with Primary Care Provider E&M codes at only one IHP are attributed to the IHP. (2) Patients with more Primary Care Provider E&M codes than at any other IHP or non-ihp provider(s) are attributed to the IHP that submitted the greater number of E&M codes by that IHP Primary Care Providers. (3) Patients with an equal number of Primary Care Provider E&M codes at more than one IHP or non-ihp provider are assessed by the decision criteria as described in Step 4. (4) Patients with a greater number of E&M codes at an individual non-ihp provider(s) than at any IHP are not attributed to any IHP. (5) Patients with no Primary Care Provider E&M codes at any IHP are assessed by the decision criteria in Step STEP 3. If Attribution From HCH Claims or Qualifying Visits to Primary Care Providers Has Not Occurred, but Qualifying Visits to Other Specialty Providers are Present: ATTACHMENT A PATIENT ATTRIBUTION METHOD

83 Patients with the following E&M codes performed by a Specialty Provider and paid to a billing provider from the IHP roster: through 99215, through 99350, through 99387, through 99397, G0402, G0438, and G0439 are attributed to the IHP as follows: (1) Patients with Specialty Provider E&M codes at only one IHP are attributed to the IHP. (2) Patients with Specialty Provider E&M codes at more than one IHP are attributed to the IHP that submitted the greater number of E&M codes by that IHP Specialty providers. (3) Patients with an equal number of Specialty Provider E&M codes at more than one IHP are not attributed to any IHP. (4) Patients with a greater number of E&M codes at an individual non-ihp provider(s) than at any IHP Specialty Providers are not attributed to any IHP Tie Breaking Step 4. (1) Patients with an equal number of E&M codes at more than one IHP Primary Care Providers, and having no E&M codes at IHP Specialty Providers are attributed to the IHP with the most recent date of service E&M claim. (2) Patients with an equal number of E&M codes at more than one IHP Primary Care Provider and having a greater number of E&M codes at one of those IHP Specialty Providers are attributed to the IHP with the greater number of E&M codes at Specialty Providers. (3) Patients with an equal number of E&M codes at more than one IHP Primary Care Provider, and having an equal number of E&M codes at those IHP Specialty Providers are attributed to the IHP with the most recent Primary Care Provider date of service E&M claim. (4) Patients with an equal number of E&M codes at an IHP Primary Care Provider and a non-ihp provider are attributed to the IHP if the IHP had the most recent date of service E&M claim. ATTACHMENT A PATIENT ATTRIBUTION METHOD

84 ATTACHMENT B: IHP-Specific Description and Governance 1.1 Summary. This document further defines the IHP Entity, [name of IHP] s Participants, and certain other details about the IHP as referenced in the IHP Contract. 1.2 As defined in Article 1 (9), the IHP Entity is: Provider health system(s) whose clinics and/or hospitals are owned by or under contract for the purposes of this demonstration. A separate legal entity. [Insert description of the IHP from the RFP response here. IHP should edit for any changes since the RFP response.] 1.3 As defined in Article 1 (10), the list of IHP Participants includes (as of DATE): Name: Address: MN Community Measurement ID Number* *If IHP Participant is a clinic. 1.4 As defined in Article 1 (11), the IHP Fiscal Agent is: 1.5 Description of the IHP Shared Governance System as required under section 2.2 of the Contract: (A) The IHP Shared Governance System includes the following groups of providers and suppliers as listed in Minnesota Statutes, section 256B.0755, subd. 1 (d). Professionals in group practice arrangements; Networks of individual practices of professionals; ATTACHMENT B: IHP-SPECIFIC GOVERNANCE

85 Partnerships or joint venture arrangements between hospitals and health care professionals; Hospitals employing professionals; or Other groups of providers of services and suppliers. (B) IHP contracts with a managed care plan or a county-based purchasing plan to provide administrative services: Yes No (C) List of Members of the IHP Governing Body Na me : T itl e : Expe rtise Patient Represent ative? Y/N Consu mer Advoc ate? Y/N (Add rows as needed) 1.6 Guaranteeing entity for this Contract to make a Final Payment of Shared Losses is: 1.7 Taxpayer Identification Number (TIN) of the IHP Fiscal Agent to receive any Interim or Final Payments as required in section 2.6 of the Contract: 1.8 The IHP authorized representative as required in section 6.2 of the Contract is [Name], [Title]. ATTACHMENT B: IHP-SPECIFIC GOVERNANCE

86 1.9 Insurance as required in section 2.9 of the Contract: The IHP has in force a commercial general liability policy with a minimum amount of $2,000,000 per occurrence and $2,000,000 annual aggregate; or The IHP maintains a program of self-insurance. ATTACHMENT B: IHP-SPECIFIC GOVERNANCE

87 ATTACHMENT C: Provider Taxonomy 1.1 Summary. An IHP may designate on its Roster whether a provider serves as a Primary Care Provider ( PCP ) or Specialty Provider ( SPE ) in its organization. In absence of this designation, the provider s primary taxonomy code will be used to categorize the provider according to the table below. If neither a PCP / SPE designation nor a primary taxonomy code is included on the Roster, the primary taxonomy code for that provider from the National Plan and Provider Enumeration System (NPPES) file will be used to categorize the provider according to the table below. A provider taxonomy not listed in this attachment will be considered a Specialty Provider, unless the IHP has otherwise designated the provider as a PCP on their Roster. Mapping Definitions from NUCC Database Download (Version 12.0, 1/1/12) Taxonomy PCP/SPE Type Classification Specialization 207K00000X SPE Allopathic & Osteopathic Physicians Allergy & Immunology 207L00000X SPE Allopathic & Osteopathic Physicians Anesthesiology 207LP2900X SPE Allopathic & Osteopathic Physicians Anesthesiology Pain Medicine 207LC0200X SPE Allopathic & Osteopathic Physicians Anesthesiology Critical Care Medicine 208U00000X SPE Allopathic & Osteopathic Physicians Clinical Pharmacology 208C00000X SPE Allopathic & Osteopathic Physicians Colon & Rectal Surgery 207N00000X SPE Allopathic & Osteopathic Physicians Dermatology 207P00000X SPE Allopathic & Osteopathic Physicians Emergency Medicine 207PE0004X SPE Allopathic & Osteopathic Physicians Emergency Medicine Emergency Medical Services 207PT0002X SPE Allopathic & Osteopathic Physicians Emergency Medicine Medical Toxicology 207Q00000X PCP Allopathic & Osteopathic Physicians Family Medicine 207QS0010X SPE Allopathic & Osteopathic Physicians Family Medicine Sports Medicine 207QA0000X PCP Allopathic & Osteopathic Physicians Family Medicine Adolescent Medicine 207QA0505X PCP Allopathic & Osteopathic Physicians Family Medicine Adult Medicine 208D00000X PCP Allopathic & Osteopathic Physicians Family Medicine General Practice 208M00000X SPE Allopathic & Osteopathic Physicians Hospitalist 207R00000X PCP Allopathic & Osteopathic Physicians Internal Medicine 207RR0500X SPE Allopathic & Osteopathic Physicians Internal Medicine Rheumatology 207RC0000X SPE Allopathic & Osteopathic Physicians Internal Medicine Cardiovascular Disease 207RX0202X SPE Allopathic & Osteopathic Physicians Internal Medicine Medical Oncology 207RG0100X SPE Allopathic & Osteopathic Physicians Internal Medicine Gastroenterology 207RE0101X PCP Allopathic & Osteopathic Physicians Internal Medicine Endocrinology ATTACHMENT C: PROVIDER TAXONOMY

88 Taxonomy PCP/SPE Type Classification Specialization 207RH0003X SPE Allopathic & Osteopathic Physicians Internal Medicine Hematology & Oncology 207RI0200X SPE Allopathic & Osteopathic Physicians Internal Medicine Infectious Disease 207RH0000X SPE Allopathic & Osteopathic Physicians Internal Medicine Hematology 207RP1001X SPE Allopathic & Osteopathic Physicians Internal Medicine Pulmonary Disease 207RN0300X SPE Allopathic & Osteopathic Physicians Internal Medicine Nephrology 207RI0011X SPE Allopathic & Osteopathic Physicians Internal Medicine Interventional Cardiology 207RC0200X SPE Allopathic & Osteopathic Physicians Internal Medicine Critical Care Medicine 207RC0001X SPE Allopathic & Osteopathic Physicians Internal Medicine Clinical Cardiac Electrophysiology 207RG0300X PCP Allopathic & Osteopathic Physicians Internal Medicine Geriatric Medicine 207RH0002X PCP Allopathic & Osteopathic Physicians Internal Medicine Hospice and Palliative Medicine 207SG0201X SPE Allopathic & Osteopathic Physicians Medical Genetics Clinical Genetics (M.D.) 207T00000X SPE Allopathic & Osteopathic Physicians Neurological Surgery 207V00000X PCP Allopathic & Osteopathic Physicians Obstetrics & Gynecology 207VM0101X SPE Allopathic & Osteopathic Physicians Obstetrics & Gynecology Maternal & Fetal Medicine 207VX0201X SPE Allopathic & Osteopathic Physicians Obstetrics & Gynecology Gynecologic Oncology 207W00000X SPE Allopathic & Osteopathic Physicians Ophthalmology 207X00000X SPE Allopathic & Osteopathic Physicians Orthopedic Surgery 207XS0106X SPE Allopathic & Osteopathic Physicians Orthopedic Surgery Hand Surgery 207XX0005X SPE Allopathic & Osteopathic Physicians Orthopedic Surgery Sports Medicine 207Y00000X SPE Allopathic & Osteopathic Physicians Otolaryngology 207ZP0105X SPE Allopathic & Osteopathic Physicians Pathology Clinical Pathology/Laboratory Medicine 207ZP0102X SPE Allopathic & Osteopathic Physicians Pathology Anatomic Pathology & Clinical Pathology 207ZN0500X SPE Allopathic & Osteopathic Physicians Pathology Neuropathology 207ZH0000X SPE Allopathic & Osteopathic Physicians Pathology Hematology 207ZB0001X SPE Allopathic & Osteopathic Physicians Pathology Blood Banking & Transfusion Medicine X PCP Allopathic & Osteopathic Physicians Pediatrics 2080P0205X PCP Allopathic & Osteopathic Physicians Pediatrics Pediatric Endocrinology 2080P0207X SPE Allopathic & Osteopathic Physicians Pediatrics Pediatric Hematology- Oncology ATTACHMENT C: PROVIDER TAXONOMY

89 Taxonomy PCP/SPE Type Classification Specialization 2080P0006X SPE Allopathic & Osteopathic Physicians Pediatrics Developmental Behavioral Pediatrics 2080P0202X SPE Allopathic & Osteopathic Physicians Pediatrics Pediatric Cardiology 2080N0001X SPE Allopathic & Osteopathic Physicians Pediatrics Neonatal-Perinatal Medicine 2080P0203X SPE Allopathic & Osteopathic Physicians Pediatrics Pediatric Critical Care Medicine X SPE Allopathic & Osteopathic Physicians Physical Medicine & Rehabilitation 2081P0004X SPE Allopathic & Osteopathic Physicians Physical Medicine & Spinal Cord Injury Rehabilitation 2081P0010X SPE Allopathic & Osteopathic Physicians Physical Medicine & Rehabilitation Medicine Pediatric Rehabilitation Medicine 2081P2900X SPE Allopathic & Osteopathic Physicians Physical Medicine & Pain Medicine Rehabilitation 2083X0100X SPE Allopathic & Osteopathic Physicians Preventive Medicine Occupational Medicine 2083P0901X SPE Allopathic & Osteopathic Physicians Preventive Medicine Public Health & General Preventive Medicine 2083P0500X SPE Allopathic & Osteopathic Physicians Preventive Medicine Preventive Medicine/ Occupational Environmental Medicine 2084N0400X SPE Allopathic & Osteopathic Physicians Psychiatry & Neurology Neurology 2084P0800X SPE Allopathic & Osteopathic Physicians Psychiatry & Psychiatry Neurology 2084A0401X SPE Allopathic & Osteopathic Physicians Psychiatry & Addiction Medicine Neurology 2085R0001X SPE Allopathic & Osteopathic Physicians Radiology Radiation Oncology 2085R0202X SPE Allopathic & Osteopathic Physicians Radiology Diagnostic Radiology 2085R0203X SPE Allopathic & Osteopathic Physicians Radiology Therapeutic Radiology 2085R0204X SPE Allopathic & Osteopathic Physicians Radiology Vascular & Interventional Radiology X SPE Allopathic & Osteopathic Physicians Surgery 2086S0122X SPE Allopathic & Osteopathic Physicians Surgery Plastic and Reconstructive Surgery 2086S0129X SPE Allopathic & Osteopathic Physicians Surgery Vascular Surgery 2086S0127X SPE Allopathic & Osteopathic Physicians Surgery Trauma Surgery ATTACHMENT C: PROVIDER TAXONOMY

90 Taxonomy PCP/SPE Type Classification Specialization 208G00000X SPE Allopathic & Osteopathic Physicians Thoracic Surgery (Cardiothoracic Vascular Surgery) X SPE Allopathic & Osteopathic Physicians Urology 261Q00000X PCP Ambulatory Health Care Facilities Clinic/Center 101YM0800X SPE Behavioral Health & Social Service Counselor Mental Health Providers 103T00000X SPE Behavioral Health & Social Service Psychologist Providers 1041C0700X SPE Behavioral Health & Social Service Social Worker Clinical Providers X SPE Behavioral Health & Social Service Social Worker Providers 111N00000X SPE Chiropractic Providers Chiropractor 111NI0013X SPE Chiropractic Providers Chiropractor Independent Medical Examiner 133V00000X SPE Dietary and Nutritional Service Dietitian, Registered Providers 152W00000X SPE Eye and Vision Services Providers Optometrist 291U00000X SPE Laboratories Clinical Medical Laboratory 176B00000X PCP Other Service Providers Midwife X SPE Other Service Providers Specialist 367A00000X PCP Physician Assistants & Advanced Practice Nursing Providers Advanced Practice Midwife 367H00000X SPE Physician Assistants & Advanced Practice Nursing Providers Anesthesiologist Assistant 364SM0705X PCP Physician Assistants & Advanced Clinical Nurse Medical-Surgical Practice Nursing Providers Specialist 364SP0809X SPE Physician Assistants & Advanced Clinical Nurse Psych/Mental Health Practice Nursing Providers Specialist 364S00000X PCP Physician Assistants & Advanced Practice Nursing Providers Clinical Nurse Specialist 364SA2200X PCP Physician Assistants & Advanced Clinical Nurse Adult Health Practice Nursing Providers Specialist 364SP0807X SPE Physician Assistants & Advanced Practice Nursing Providers Clinical Nurse Specialist Psych/Mental Health, Child & Adolescent 364SP0808X SPE Physician Assistants & Advanced Clinical Nurse Psych/Mental Health Practice Nursing Providers Specialist 364SN0000X SPE Physician Assistants & Advanced Clinical Nurse Neonatal Practice Nursing Providers Specialist X SPE Physician Assistants & Advanced Nurse Anesthetist Certified Registered Practice Nursing Providers 363LF0000X PCP Physician Assistants & Advanced Practice Nursing Providers Nurse Practitioner Family ATTACHMENT C: PROVIDER TAXONOMY

91 Taxonomy PCP/SPE Type Classification Specialization 363LP0200X PCP Physician Assistants & Advanced Practice Nursing Providers Nurse Practitioner 363L00000X PCP Physician Assistants & Advanced Nurse Practitioner Practice Nursing Providers 363LA2200X PCP Physician Assistants & Advanced Nurse Practitioner Practice Nursing Providers 363LW0102X PCP Physician Assistants & Advanced Nurse Practitioner Practice Nursing Providers 363LG0600X PCP Physician Assistants & Advanced Nurse Practitioner Practice Nursing Providers 363LP0808X SPE Physician Assistants & Advanced Nurse Practitioner Practice Nursing Providers 363LX0001X PCP Physician Assistants & Advanced Nurse Practitioner Practice Nursing Providers 363LN0005X SPE Physician Assistants & Advanced Nurse Practitioner Practice Nursing Providers 363LN0000X SPE Physician Assistants & Advanced Nurse Practitioner Practice Nursing Providers 363A00000X PCP Physician Assistants & Advanced Physician Assistant Practice Nursing Providers 363AM0700X PCP Physician Assistants & Advanced Physician Assistant Practice Nursing Providers 363AS0400X SPE Physician Assistants & Advanced Physician Assistant Practice Nursing Providers 363LP0222X SPE Physician Assistants & Advanced Nurse Practitioner Practice Nursing Providers 363LP2300X PCP Physician Assistants & Advanced Nurse Practitioner Practice Nursing Providers 213E00000X SPE Podiatric Medicine & Surgery Service Podiatrist Providers 213ES0103X SPE Podiatric Medicine & Surgery Service Podiatrist Providers 213ES0131X SPE Podiatric Medicine & Surgery Service Podiatrist Providers X SPE Rehabilitative & Restorative Service Developmental Providers X PCP Student in an Organized Health Care Training Program X SPE Suppliers Pharmacy Pediatrics Adult Health Women's Health Gerontology Psych/Mental Health Obstetrics & Gynecology Neonatal Critical Care Neonatal Medical Surgical Pediatrics, Critical Care Primary Care Foot & Ankle Surgery Foot Surgery Physical Therapist ATTACHMENT C: PROVIDER TAXONOMY

92 ATTACHMENT D: Settlement Process 201X Base Year 1.1 Summary. IHP performance will be measured against a Total Cost of Care target, derived from the IHP historical performance and adjusted for changes in population risk and expected trend. If the performance threshold in section 1.5 is met, and upon applicable federal approval, all Shared Savings or Shared Losses will be shared (i.e., first dollar) based upon the agreed-upon distribution between DHS and IHP described in Attachment D-1, IHP- Specific Settlement Process, subject to reductions determined by Attachment F, Quality and Patient Experience (and Attachment F-1, IHP Specific Measures, if applicable). 1.2 Definitions. (A) Capitalized terms in this Attachment take the same meanings as in the Contract. (B) Base Period means the period covering dates of service beginning January 1, 2013 and ending December 31, [Dates are illustrative and will change to reflect the actual contract awarded.] (C) Performance Period 1 means the period covering dates of service beginning January 1, 2014 and ending December 31, (D) Performance Period 2 means the period covering dates of service beginning January 1, 2015 and ending December 31, (E) Performance Period 3 means the period covering dates of service beginning January 1, 2016 and ending December 31, (F) Caps or cap means thresholds to adjust the PMPM results for catastrophic cases as follows: (1) 1,000 to 1,999 Attributed Patients in the IHP = $50,000 maximum annual claims per Patient; or (2) 2,000 to 4,999 Attributed Patients in the IHP = $200,000 maximum annual claims per Patient; or (3) 5,000 or more Attributed Patients in the IHP = $200,000 or $500,000 maximum annual claims per Patient. 1.3 Total Cost of Care (TCOC) Performance Assessment Process. Because the Attributed Population will change from the Base Period to the Performance Period(s), the STATE will adjust the Total Cost of Care target for changes in the Attributed Population and illness burden (i.e., population risk score) Base Period. ATTACHMENT D: SETTLEMENT

93 (A) Base Period Attributed Population: DHS will attribute patients to an IHP using retrospective claims and MCO encounter data available to DHS consistent with section 1.4(A). (B) Base Period Total Cost of Care (Base TCOC): (1) DHS will calculate the retrospective per patient per month (PMPM) TCOC for the Base Period Attributed Population. (2) The Base TCOC will be based on the core services outlined in Attachment E, Core Services. The services included in the TCOC may not change except under a contract amendment. (3) Claim costs for an Attributed Patient that fall outside of caps in 1.2(F) above will be capped to adjust the PMPM results for catastrophic cases. (C) Base Period Risk Score: (1) Based on the services included in the Base TCOC, a risk score will be developed for the Attributed Population to reflect the relative risk of the population. (2) DHS will use the ACG risk adjustment tool and develop category-specific risk weights based on the aggregate claims experience of the MHCP population who are eligible for attribution. In addition to developing weights based exclusively on the services included in the Base TCOC, the weights will be developed using the claim caps to adjust the weights and reduce the impact of catastrophic cases. (D) Expected Trend: (1) DHS will develop an expected trend rate for the Total Cost of Care based on the same unit cost and utilization trend rates used to develop the annual expected cost increases for the aggregate MHCP population. (2) Appropriate adjustments will be made for services excluded from the Base TCOC or other factors that are applicable to the Total Cost of Care and goals of the program. (E) Total Cost of Care Target (TCOC Target): The TCOC Target PMPM for the Performance Period will be developed based on the Base TCOC and the expected trend Performance Period. (A) Performance Period Total Cost of Care (Performance TCOC): (1) At the end of a Performance Period, DHS will calculate the Performance Period TCOC PMPM for the Performance Period Attributed Population. ATTACHMENT D: SETTLEMENT

94 (2) Claim costs for an Attributed Patient that fall outside of caps in 1.2(F) above will be capped to adjust the PMPM results for catastrophic cases. (B) Performance Period Risk Score: Based on the services included in the Total Cost of Care, a risk score will be developed for the Performance Period Attributed Population to reflect their relative risk. The risk weights will be based on the aggregate MHCP population s claims experience, based exclusively on the services included in the Total Cost of Care, and developed using the claim caps in 1.2(F) above to adjust the weights for catastrophic cases. (C) Adjusted Total Cost of Care Target (Adj. TCOC Target): (1) The Target TCOC will be adjusted based on the increase or decrease in the risk of the Attributed Populations (i.e., the change in the population risk from the Base Period to the Performance Period). (2) The Adjusted TCOC Target will be compared to the Performance Period TCOC for purposes of determining the performance results and the basis for any financial settlement. 1.4 Settlement Timing and Information. (A) Each performance period will result in the calculation of Interim Payment and Final Payment by the STATE for purposes of integrating sufficient Claims Runout information into the final Shared Savings and Shared Losses calculation. The Interim Payment will be calculated within five (5) months from the end of the Performance Period using up to three (3) months of Claims Run-out. The Final Payment will be calculated within seventeen (17) months of the end of the Performance Period using a minimum of twelve (12) months of Claims Run-out. (B) The Interim Payment will be calculated no later than five (5) months following the end of the Performance Period based on: (1) The final Base Period TCOC based on the claims incurred during the Base Period by the Attributed Population in the final Base Period Attributed Population. (2) The interim Performance Period TCOC based on the claims incurred during the Performance Period by the Attributed Population in the interim Performance Period Attributed Population. (3) The change in risk between the final Base Period Risk Score for the Attributed Population in the final Base Period Attributed Population and the interim Performance Period Risk Score for the Attributed Population in the interim Performance Period Attributed Population. (4) The Base Period TCOC will be adjusted for trend and the change in the Base Period Risk Score and the Performance Period Risk Score to develop the interim ATTACHMENT D: SETTLEMENT

95 Adjusted Target. The interim Adjusted Target will be compared to the interim Performance Period TCOC for purposes of calculating the settlement amount. (C) The Final Payment will be calculated no later than seventeen (17) months following the end of the performance period based on: (1) The final Base Period TCOC based on the claims incurred during the Base Period by the Attributed Population in the final Base Period Attributed Population. (2) The final Performance Period TCOC based on the claims incurred during the Performance Period by the Attributed Population in the final Performance Period Attributed Population. (3) The change in risk between the final Base Period Risk Score for the Attributed Population in the final Base Period Attributed Population and the final Performance Period Risk Score for the Attributed Population in the final Performance Period Attributed Population. (4) The Base Period TCOC will be adjusted for trend and the change in the Base Period Risk Score and the Performance Period Risk Score to develop the Final Adjusted Target. The Final Adjusted Target will be compared to the final Performance Period TCOC for purposes of calculating the Final Payment. 1.5 Performance Thresholds. A two percent (2%) minimum performance threshold must be met prior to any Shared Savings or Shared Losses. (A) For an integrated IHP, the Performance TCOC must be above 102% or below 98% of the Adjusted TCOC Target for Shared Losses or Shared Savings payments to occur. (B) For a virtual IHP, the Performance TCOC must be below 98% of the Adjusted TCOC Target for Shared Savings payments to occur. ATTACHMENT D: SETTLEMENT

96 ATTACHMENT E: Core Services 1.1 Summary: This document further describes the STATE s method of measuring Total Cost of Care. 1.2 Core Services. Categories of service included in Total Cost of Care are: (1) Physician services; (2) Nurse midwife; (3) Nurse practitioner; (4) Child & Teen Check-up (EPSDT); (5) Public health nurse; (6) Rural health clinic; (7) Federally qualified health center; (8) Laboratory; (9) Radiology; (10) Chiropractic; (11) Pharmacy; (12) Vision; (13) Podiatry; (14) Physical therapy; (15) Speech therapy; (16) Occupational therapy; (17) Audiology; (18) Mental health; (19) Chemical dependency; (20) Outpatient hospital; (21) Ambulatory surgical center; ATTACHMENT G: POPULATIONS

97 (22) Inpatient hospital; (23) Anesthesia; (24) Hospice; (25) Home health (excluding personal care assistant services); and (26) Private duty nursing. 1.3 Details. Procedure/revenue codes used by the STATE in calculating Total Cost of Care include (see next pages): ATTACHMENT G: POPULATIONS

98 Details: Category of Service Procedure/Revenue Codes Other Criteria 056 Ambulatory Surgery 0001T, 0002T, 0003T, 0005T, 0006T, 0007T, 0008T, 0009T, 0012T, 0013T, 0014T, 0016T, Bill Type is 83X 0017T, 0018T, 0019T, 0020T, 0021T, 0024T, 0025T,0054T, 0055T, 0056T, 0057T, 0060T, 0061T, 0092T 0095T, 0098T, 0099T, 0123T, 0124T, 0137T, 0155T-0158T, 0160T-0173T, 0176T-0177T, 0190T 0192T, , , 90870, 91010, 91033, , 93510, 93526, , , 93600, 93602, 93603, 93610,93612, 93615, 93616, 93618, 93631, , 95900, 95903, 95904, 95992, 96530, , C9716, C9724-C9728, D0120, D0140, D0150, D0160, D0180, D0210-D0350, D0416- D0418, D0421, D0431, D0460, D0470-D0471, D0475-D0479, D0481-D0485, D1110, D1120, D1201, D1203- D1205, D1351, D2110, D2120, D2130-D2131, D2140, D2150, D2160-D2161, D2210, D2330-D2332, D2335-D2337, D2380-D2382, D2385-D2388, D2390- D2394, D2710, D2712, D2750-D2752, D2780-D2783, D2790, D2794, D2910, D2915, D2920, D2930-D2934, D2940, D2950-D2952, D2954- D2955, D2960, D2970-D2971, D2975, D2980, D2999, D3211, D3220, D3222, D3230, D3240, D3310, D3320, D3330, D3346-D3348, D3351-D3353, D3410, D3421, D3425-D3426, D3430, D3470, D3920, D3950, D3999, D4210-D4211, D4220, D4240-D4241, D4245, D4260-D4261, D4265, D4271, D4273, D4275-D4276, D4321, D4341-D4342, D4355, D4381, D4910, D4999, D5850-D5851, D5955, D5982, D5986, D5991, D6053-D6054, D6094, D6190, D6194, D6205, D6214, D6240-D6242, D6253, D6624, D6634, D6710, D6750-D6752, D6794, D6930, D6972-D6973, D6975, D6980, D6999, D7110-D7111, D7120, D7130, D7140, D7210, D7220, D7230, D7240-D7241, D7250, D7260-D7261, D7270, D7280-D7283, D7285-D7286, D7288, D7310-D7311, D7321, D7411-D7415, D7472-D7473, D7485, D7510- D7511, D7520-D7521, D7671, D7771, D7880, D7953, D7963, D7972, D7999, D9110, D9420, D9910, G0104, G0105, G0121, G0127, G0186, G0242-G0243, G0247, G0259, G0260, G0268, G0269, G0289, G0338-G0340, G0364, G0392-G0393, M0050-M0054, Q1001-Q1005, Q3014, S0390, S0630, S0800, S0810, S0812, S2050-S2055, S2060-S2061, S2065, S2070, S2080, S2102-S2103, S2109, S2112, S2115, S2120, S2130, S2140, S2142, S2150, S2180, S2190, S2202, S2204-S2211, S2213, S2220, S2230, S2235, S2250, S2255, ATTACHMENT G: POPULATIONS

99 Category of Service Procedure/Revenue Codes Other Criteria S2260, S2300, S2340-S2342, S2344, S2350-S2351, S2360-S2361, S2370-S2371, S2400- S2405, S2409, S2411, S3902, S3904, S3906, S4011, S4013-S4018, S4020-S4023, S4025- S4028, S4030-S4031, S4035, S4037, S4981, S5022, S8001, S8030, S9015, S9025, S9034, S9088, S9527-S9528, X5301, V2630-V2632, V Anesthesia: Proc Code Modifiers: 47, AA, AB, AC, AD, AE (ends 12/31/2004), QK, QO, QS, QX, QZ, Z2, Z3, Z4 or Proc Code Modifier: QH or QI, (effective from 01/01/91 thru 02/28/1991) or Proc Code Modifier: QJ (ends 12/31/2002) or Proc Code Modifier: QL (ends 12/31/1998) or Proc Code Modifier: QQ (begins 12/31/2000) or Proc Code Modifier: QY (ends 12/31/1997) 058 Audiology 0208T 0212T, , (ends 04/30/2004), , , 92625, 92633, (w/o modifier GN, begins 05/01/2004), S0618, S9476, X4611-X4612, X6000-X , T1016, T1017 (with no modifier or modifier NOT EQUAL TO HE, U3), T2022, T2023 ATTACHMENT G: POPULATIONS

100 Category of Service Procedure/Revenue Codes Other Criteria Case Management - Other (w/modifier NOT HE or U3), T2041 (Begins 10/01/2004), X5401, X5424-X5425, X5455- X5456, X5476-X5477, X5491, X5566-X Chemical Dependency (99344 OR OR OR T1016 AND Pay To Provider Number = ) H0005, H0020, H2035, H2036, H0049, H0050, X0690, X5627 Primary Diag: : , H0001, H0003, H0005-H0016, H0021-H0022, H0026-H0029, H2034, H2036, H0043-H0044, Submitter ID: H0047-H0050, H2001, S9475, T1006-T1012, X0690, X5627 (CCDTF) and Claim Type "O" Outpatient/Rehabilitation 040 Child and Teen Checkup X5324, X Child and Teen Checkup Outreach 057 Chiropractic 118 Extended Occupational Therapy X5340, X5623 Not Applicable Prov Type is 37 (Chiropractor) S9129 (w/modifier UC), X Extended Physical Therapy 122 Extended Private Duty Nursing S9131 (w/modifier UC), X5426, X5453, X5468, X5579-X5580 S9124, T1002 (w/modifier UC), T1003 (w/modifier UC), X5266-X5267, X5433-X5441, X5465-X5466, X5577-X S5181 (w/modifier UC), X5430 ATTACHMENT G: POPULATIONS

101 Category of Service Procedure/Revenue Codes Other Criteria Extended Respiratory Therapy 125 Extended Speech Therapy 082 Fed Qualified Health Cntr Svc 020 Home Health Services S9128 (w/modifier UC), X , 00512, 00521, 00522, 00524, 00525, 00527, 00528, 00780, Ended 07/15/ , 99539, , , G0151-G0153, G0154 (IF Maj Prog NOT AC), G0155, G0156 (IF Wvr Type NOT F, G, H, I, J, K, L, M, P, Q, R, or S) G0157- G0164, S0270 S0274, S5180-S5181, S9035, S9061, S9097-S9098, S9122, S9126-S9129, S9131, S9200, S9208-S9214, S9220, S9225, S9230, S9300, S9308, S9310, S9335, S9339-S9343, S9370, S9372, S9395, S9420, S9423, S9425, S9524, S9526, S9529, S9533, S9535, S9537- S9539, S9542-S9543, S9545-S9546, S9550, S9555, S9558-S9560, S9562, S9590, S9800, S9802-S9803, S9810, T1004 (IF Wvr Type NOT F, G, H, I, J, K, L, M, P, Q, R, or S), T1021- T1022, T1030-T1031, X4015, X5208-X5285, X5327, X5660-X5661 Bill Type 731 or 737 Not Applicable Bill Type 32X-34X 072 Hospice Q5001-Q5010, X5210-X5228 Not Applicable Bill Type 81X or 82X 001 Inpatient Hospital General 073 Inpatient Hosp Neo- Not Applicable Not Applicable Bill Type is 11X and Prov COS is Inpatient Hospital, General Bill Type is 11X and Prov COS is Inpatient, Neonatal, ICU and ATTACHMENT G: POPULATIONS

102 Category of Service Procedure/Revenue Codes Other Criteria natal ICU Source of admission is "4 or A and Type of Admission is not "4" and DRG equals or 482 or 541 or 542 and Recipient age < 1 OR Effective 01/01/07 Bill Type is 11X and Prov COS is Inpatient, Neonatal, ICU And Recip date of birth= date of admission And One of the diagnosis codes = V30.1 or V31.1 or V32.1 or V33.1 or V34.1 or V35.1 or V36.1 or V37.1 And One of the revenue codes = 0174 OR 006 Inpatient Hosp Rehabilitation Not Applicable Effective 11/01/08 Bill Type is 11X and Prov COS is Inpatient, Neonatal, ICU and Source of admission is "6" and Type of Admission is "4" and DRG equals or 482 or 541 or 542 and Principal diagnosis code = V30.1 or V31.1 or V32.1 or V33.1 or V34.1 or V35.1 or V36.1 or V37.1 or V39.1 and Recipient age < 1 Bill Type is 11X And Prov COS is Inpatient Rehabilitation ATTACHMENT G: POPULATIONS

103 Category of Service Procedure/Revenue Codes Other Criteria 080 Laboratory 046 Mental Health 090 Nurse Midwife Services 0010T, 0023T, 0026T, 0030T, 0043T, 0058T, 0059T, 0085T, 0087T, , , , 99195, A9220, C1010-C1018, C1020- C1022, G0001, G0026-G0027, G0050-G0060, G0103 (begins 07/01/2001), G0107 (begins 07/01/2001), G0123-G0124, G0141, G0143-G0145, G0147, G0148, G0265-G0266, G0306-G0307, G0328, G0416 G0419, G0430 G0435, G9143, P2031, P3000-P3001, P7001, P7020, P9010-P9024, P9031- P9040, P9044, P9051-P9060, P9600, P9603-P9615, Q0048, Q0060-Q0061, Q0063, Q0091, Q0095-Q0102, Q0111-Q0116, Q0126, Q2022, S3600- S3601, S3618, S3620, S3625 S3626, S3628, S3630, S3645, S3650, S3652, S3655, S3700-S3701, S3708, S3711, S3717, S3800, S3818-S3820, S3822-S3823, S3828-S3831, S3833-S3835, S3837, S3840-S3853, S3855, S3860 S3862, S3865 S3866, S3870, S3890, S4036, S4040, X5328, Y8000, Y8020- Y , 90791, 90792, , , , , , M0064, , S9484, , 99354,90849, 90853, 90857, S9484 UA, S9484 UA HN Not Applicable ProvType is 66 (Nurse Midwife) 091 Nurse Practitioner Services Not Applicable ProvType is 65 (Nurse Practitioner) 054 Occupational Therapy (w/modifier GO, begins 05/01/2004), (w/modifier GO, begins 05/01/2004), (w/modifier GO, begins 05/01/2004), (w/modifier GO, begins 05/01/2004), (w/modifier GO, begins 05/01/2004), (w/modifier GO, begins 05/01/2004), (w/modifier GO, begins 05/01/2004), (w/modifier GO, begins 05/01/2004), (w/modifier GO, begins 05/01/2004), (w/modifier GO, begins 05/01/2004), (w/modifier GO, begins 05/01/2004), ATTACHMENT G: POPULATIONS

104 Category of Service Procedure/Revenue Codes Other Criteria ATTACHMENT G: POPULATIONS (w/modifier GO, begins 05/01/2004), (w/modifier GO, begins 05/01/2004), (w/modifier GO, begins 05/01/2004), (w/modifier GO, begins 05/01/2004), (w/modifier GO, begins 05/01/2004), (w/modifier GO, begins 05/01/2004), (w/modifier GO, begins 05/01/2004), (w/modifier GO, begins 05/01/2004), (w/modifier GO, begins 05/01/2004), (w/modifier GO, begins 05/01/2004), (w/modifier GO, begins 05/01/2004), (w/modifier GO, begins 05/01/2004), (w/modifier GO, begins 05/01/2004), (w/modifier GO), (w/modifier GO, begins 05/01/2004), 90901(ends 04/30/2004), (w/modifier GO, begins 05/01/2004), (w/modifier GO), (w/modifier GO), (w/modifier GO, begins 05/01/2004), (w/modifier GO, begins 05/01/2004), (w/modifier GO ), (w/modifier GO ) (w/modifier GO ), (w/modifier GO, begins 05/01/2004), (w/modifier GO, begins 05/01/2004), (w/modifier GO, begins 05/01/2004), (w/modifier GO, begins 05/01/2004), (w/modifier GO, begins 05/01/2004), (w/modifier GO, begins 05/01/2004), (with modifier GO, begins 01/01/2010), (with modifier GO, begins 01/01/2010), 96125, , (ends 04/30/2004), (w/modifier GO, begins 05/01/2004), (ends 04/30/2004), (w/modifier GO, begins 05/01/2004), (ends 04/30/2004), (w/modifier GO, begins 05/01/2004), (ends 04/30/2004), (w/modifier GO, begins 05/01/2004), (ends 04/30/2004), (w/modifier GO, begins 05/01/2004), (ends 04/30/2004), (w/modifier GO, begins 05/01/2004), (ends 04/30/2004), (w/modifier GO, begins 05/01/2004), (ends 04/30/2004), (w/modifier GO, begins 05/01/2004), (ends 04/30/2004), (w/modifier GO, begins 05/01/2004), (ends 04/30/2004), (w/modifier GO, begins 05/01/2004), (ends 04/30/2004), (w/modifier GO, begins 05/01/2004), (ends 04/30/2004), (w/modifier GO, begins 05/01/2004), (ends 04/30/2004), (w/modifier GO, begins 05/01/2004), (ends 04/30/2004), (w/modifier GO, begins 05/01/2004), (w/modifier GO, begins 05/01/2004), (ends 04/30/2004), (w/modifier GO, begins 05/01/2004), (ends 04/30/2004), (w/modifier GO,

105 Category of Service Procedure/Revenue Codes Other Criteria begins 05/01/2004), (ends 04/30/2004), (w/modifier GO, begins 05/01/2004), (ends 04/30/2004), (w/modifier GO, begins 05/01/2004), (w/modifier GO, begins 05/01/2004), 97140(ends 04/30/2004), (w/modifier GO, begins 05/01/2004), (w/modifier GO, begins 05/01/2004), (ends 04/30/2004), (w/modifier GO, begins 05/01/2004), (ends 04/30/2004), (w/modifier GO, begins 05/01/2004), (ends 04/30/2004), (w/modifier GO, begins 05/01/2004), , 97535, 97537, , (ends 04/30/2004), (w/modifier GO, begins 05/01/2004), (w/modifier GO, begins 05/01/2004), (w/modifier GO) (w/modifer GO) 97703(ends 04/30/2004), (w/modifier GO, begins 05/01/2004), (modifier EQUAL TO GO ), (w/modifier GO ), (w/modifier GO ), (w/modifier GO (w/modifier GO, begins 05/01/2004), 97770, (w/modifier GO, begins 05/01/2004), G0129, G0281 (modifier = GO ), G0282 (modifier = GO ), G0283 (modifier = GO ), H5300, H5510, H5511, Q0082, Q0109-Q0110, Q4017-Q4024 (w/modifier GO, begins 05/01/2004), Q4041-Q4049 (w/modifier GO, begins 05/01/2004), Q4051 (w/modifier GO, begins 05/01/2004), X4510-X4513, X4515-X4520, X4522-X4526, X5510- X5511, X6004- X Outpatient Hospital Services 030 Pharmacy Services Procedure codes associated with CMS-1500 claim form or , 439 Not Applicable Or 762 Bill Type is 13X or 14X Not Applicable Bill Type is 730, X5350 Or 519 Not Applicable Bill Type is 731 Claim Type P ATTACHMENT G: POPULATIONS

106 Category of Service Procedure/Revenue Codes Other Criteria 051 Physical Therapy (w/modifier GP, begins 05/01/2004), (w/modifier GP, begins 05/01/2004), (w/modifier GP, begins 05/01/2004), (w/modifier GP, begins 05/01/2004), (w/modifier GP, begins 05/01/2004), (w/modifier GP, begins 05/01/2004), (w/modifier GP, begins 05/01/2004), (w/modifier GP, begins 05/01/2004), (w/modifier GP, begins 05/01/2004), (w/modifier GP, begins 05/01/2004), (w/modifier GP, begins 05/01/2004), (w/modifier GP, begins 05/01/2004), (w/modifier GP, begins 05/01/2004), (w/modifier GP, begins 05/01/2004), (w/modifier GP, begins 05/01/2004), (w/modifier GP, begins 05/01/2004), (w/modifier GP, begins 05/01/2004), (w/modifier GP, begins 05/01/2004), (w/modifier GP, begins 05/01/2004), (w/modifier GP, begins 05/01/2004), (w/modifier GP, begins 05/01/2004), (w/modifier GP, begins 05/01/2004), (w/modifier GP, begins 05/01/2004), (w/modifier GP, begins 05/01/2004),29581 (w/modifier GP), (w/modifier GP, begins 05/01/2004), 90900, 90901(ends 04/30/2004), (w/o modifier GO, begins 05/01/2004), (w/modifier GP), (ends 04/30/2004), (w/o modifier GO, begins 05/01/2004), (ends 04/30/2004), (w/o modifier GO, begins 05/01/2004), (ends 04/30/2004), (w/o modifier GO, begins 05/01/2004), (ends 04/30/2004), (w/o modifier GO, begins 05/01/2004), , (ends 04/30/2004), (w/o modifier GO, begins 05/01/2004), (ends 04/30/2004), (w/o modifier GO, begins 05/01/2004), (with modifier GP, begins 01/01/2010), (with modifier GP, begins 01/01/2010), , , (ends 04/30/2004), (w/o modifier GO, begins 05/01/2004), 97011, (ends 04/30/2004), (w/o modifier GO, begins 05/01/2004), , (ends 04/30/2004), (w/o modifier GO, begins 05/01/2004), 97017,97018 (ends 04/30/2004), (w/o modifier GO, begins 05/01/2004), 97019, (ends 04/30/2004), (w/o modifier GO, begins 05/01/2004),97021, (ends 04/30/2004), (w/o modifier GO, begins 05/01/2004), 97023, (ends 04/30/2004), (w/o modifier GO, ATTACHMENT G: POPULATIONS

107 Category of Service Procedure/Revenue Codes Other Criteria ATTACHMENT G: POPULATIONS begins05/01/2004), 97025, (ends 04/30/2004), (w/o modifier GO, begins 05/01/2004), 97027, (ends 04/30/2004), (w/o modifier GO, begins 05/01/2004), , (ends 04/30/2004), (w/o modifier GO, begins 05/01/2004), (ends 04/30/2004), (w/o modifier GO, begins 05/01/2004), (ends 04/30/2004), (w/o modifier GO, begins 05/01/2004), (ends 04/30/2004), (w/o modifier GO, begins 05/01/2004), (ends 04/30/2004), (w/o modifier GO, begins 05/01/2004), , (ends 04/30/2004),97039 (w/o modifier GO, begins 05/01/2004), (ends 04/30/2004), (w/o modifier GO, begins 05/01/2004), 97111, (ends 04/30/2004), (w/o modifier GO, begins 05/01/2004), , (ends 04/30/2004), (w/o modifier GO, begins 05/01/2004), , (ends 04/30/2004), (w/o modifier GO, begins 05/01/2004), , (ends 04/30/2004), (w/o modifier GO, begins 05/01/2004), 97140(ends 04/30/2004), (w/o modifier GO, begins 05/01/2004), , (ends 04/30/2004), (w/o modifier GO, begins 05/01/2004), , 97250, , 97265, , (ends 04/30/2004), (w/o modifier GO, begins 05/01/2004), , (ends 04/30/2004), (w/o modifier GO, begins 05/01/2004), , (ends 04/30/2004), (w/o modifier GO, begins 05/01/2004), 97531, (ends 04/30/2004), (w/o modifier GO, begins 05/01/2004), (ends 04/30/2004), (w/o modifier GO, begins 05/01/2004), (w/o modifier GO) (w/o modifier GO), , 97703(ends 04/30/2004), (w/o modifier GO, begins 05/01/2004), , (ends 04/30/2004), (w/o modifier GO, begins 05/01/2004), 97752, (modifier NOT EQUAL TO GO ), (w/o modifier OR modifier NOT EQUAL TO GO ), (w/o modifier OR modifier NOT EQUAL TO GO ), (w/o modifier OR modifier NOT EQUAL TO GO ), (ends 04/30/2004), (w/o modifier GO, begins 05/01/2004), G0281 (modifier = GP ), G0282 (modifier = GP ), G0283 (modifier = GP ), H5220-H5299, M0005- M0008, Q0086, Q0103-Q0104, Q4017-Q4024 (w/modifier GP, begins 05/01/2004), Q4041-Q4049 (w/modifier GP, begins 05/01/2004), Q4051 (w/modifier GP, begins

108 Category of Service Procedure/Revenue Codes Other Criteria 043 Physician Services ATTACHMENT G: POPULATIONS 05/01/2004), S8940, S8945, S8948, S8990, S9033, X0715, X4521, X4600-X4601, X5515- X5516, X6006-X6008 Procedure codes listed above or , F, 0001T, 0002F, 0002T, 0003F, 0003T, 0004F, 0005F, 0005T, 0006F, 0006T, 0007F, 0007T, 0008F, 0008T, 0009F, 0009T, 0010F, 0011F, 0012F, 0012T, 0013T, 0014F, 0014T, 0015F, 0016T, 0017T, 0018T, 0019T, 0020T, 0021T, 0024T, 0025T, 0027T, 0028T, 0029T, 0031T, 0032T, 0033T, 0034T, 0035T, 0036T, 0037T, 0038T, 0039T, 0040T, 0041T, 0042T, 0044T, 0045T, 0046T, 0047T, 0048T, 0049T, 0050T, 0051T, 0052T, 0053T, 0054T, 0055T, 0056T, 0057T, 0060T, 0061T, 0062T, 0063T, 0064T, 0065T, 0068T, 0069T, 0070T, 0073T, 0074T-0084T, 0086T, 0088T, 0115T-0117T, 0120T, 0123T T, 0126T, 0130T, 0133T, 0135T, 0137T, 0140T 0143T, 0153T 0154T, 0155T-0158T, 0160T-0173T, 0176T-0181T, 0184T-0186T, 0188T 0192T 0207T, 0213T 0238T, 0243T 0275T, 0500F-0503F, 0509F, 0513F, 0514F, 0516F-0521F, 0525F, 0526F, 0528F 0529F, 0535F, 0540F, 0545F, 0575F, 1000F-1002F, 2000F, 4000F-4002F, 4006F, 4009F, 4011F, 7010F, , , , (ends 04/30/2004), (w/o modifier GO or GP, begins 05/01/2004), , (ends 04/30/2004), (w/o modifier GO or GP, begins 05/01/2004), , (ends 04/30/2004), (w/o modifier GO or GP, begins 05/01/2004), , (ends 04/30/2004), (w/o modifier GO or GP, begins 05/01/2004), , (ends 04/30/2004), (w/o modifier GO or GP, begins 05/01/2004), , (ends 04/30/2004), (w/o modifier GO or GP, begins 05/01/2004), , (ends 04/30/2004), (w/o modifier GO or GP, begins 05/01/2004), , (ends 04/30/2004), (w/o modifier GO or GP, begins 05/01/2004), , (ends 04/30/2004), (w/o modifier GO or GP, begins 05/01/2004), , (ends 04/30/2004), (w/o modifier GO or GP, begins 05/01/2004), , (ends 04/30/2004), (w/o modifier GO or GP, begins 05/01/2004), , (ends 04/30/2004), (w/o modifier GO or GP, begins 05/01/2004),

109 Category of Service Procedure/Revenue Codes Other Criteria ATTACHMENT G: POPULATIONS 29354, (ends 04/30/2004), (w/o modifier GO or GP, begins 05/01/2004), , (ends 04/30/2004), (w/o modifier GO or GP, begins 05/01/2004), , (ends 04/30/2004), (w/o modifier GO or GP, begins 05/01/2004), , (ends 04/30/2004), (w/o modifier GO or GP, begins 05/01/2004), , (ends 04/30/2004), (w/o modifier GO or GP, begins 05/01/2004), , (ends 04/30/2004), (w/o modifier GO or GP, begins 05/01/2004), , (ends 04/30/2004), (w/o modifier GO or GP, begins 05/01/2004), , (ends 04/30/2004), (w/o modifier GO or GP, begins 05/01/2004), , (ends 04/30/2004), (w/o modifier GO or GP, begins 05/01/2004), , (ends 04/30/2004), (w/o modifier GO or GP, begins 05/01/2004), , (ends 04/30/2004), (w/o modifier GO or GP, begins 05/01/2004), , (ends 04/30/2004), (w/o modifier GO or GP, begins 05/01/2004), (without modifier GO or GP), , (ends 04/30/2004), (w/o modifier GO or GP, begins 05/01/2004), , , , , , (ends 04/30/2004), (w/o modifier GO or GP, begins 05/01/2004), , , , , , , , (ends 04/30/2004), (w/o modifier GO or GN, begins 05/01/2004), (ends 04/30/2004), (w/o modifier GN, begins 05/01/2004), 92613, (ends 04/30/2004), (w/o modifier GN, begins 05/01/2004), 92615, (ends 04/30/2004), (w/o modifier GN, begins 05/01/2004), 92617, 92640, (ends 04/30/2004), , 93990, , , , , 95411, , 95803, , , , , 96020, 96040, (modifier NOT EQUAL GN, GO, GP) (modifier NOT EQUAL GN GO GP), 96115, , , , 96379, , 96567, , , (ends 04/30/2004), (w/o modifier GO or GP, begins 05/01/2004), , , , , , , , , , , , ,

110 Category of Service Procedure/Revenue Codes Other Criteria ATTACHMENT G: POPULATIONS , , , , 99499, , 99990, A4260, A9150, A9152-A9153, A9200, A9535, C8921-C8930, C8950-C8955, C8957, C9019- C9020, C9104-C9116, C9119-C9121, C9124-C9129, C9202-C9204, C9207- C9220, C9223- C9230, C9232-C9235, C9237-C9240, C9245 C9248, C9251 C9267, C9270 C9284, C9399, C9410-C9433, C9435-C9440, C9704, C9712-C9721, C9724 C9731, C9800 C9802, G0002-G0010, G0015-G0016, G0030-G0047, G0051-G0053, G0062-G0066, G0101-G102, G0103 (ends 06/30/2001), GO104-G0106, G0107 (ends 06/30/2001), G0108-G0116, G0121, G0125-G0128, G0159-G0161, G0163-G0171, G0173-G0175, G0178-G0187, G0190- G0194, G0237-G0243, G0245-G0251, G0255-G0261, G0263-G0264, G0267-G0275, G0278- G0280, G0281 (modifier NOT EQUAL GO, GP ), G0282 (modifier NOT EQUAL GO, GP ), G0283 (modifier NOT EQUAL GO, GP ), G0288-G0295, G0297-G0300, G0302-G0305, G0308-G0327, G0329, G0332-G0333, G0337-G0351, G0353-G0368, G0372, G G0377, G0392-G0393, G0396-G0400, G0402 G0415, G0420 G0429, G0436 G0441, G3001, G8006-G801, G8051-G8062, G8075-G8080, G8093-G8094, G8099-G8100, G8103- G8104, G8106-G8117, G8126-G8131, G8152-G8167, G8170-G8172, G8182-G8186, G8191- G8243, G8245-G8347, G8351, G8354, G8357, G8360, G8362, G8365, G8367, G8370- G8386, G8389-G8391, G8385-G8410, G8415-G8443, G8445-G8544, G8545 G8553, G8556 G8693, G9001-G9012, G9016 -G9036, G9050-G9142, G9147, H0033, H1000- H1005, H1010, J0100-J7020, J7040-J7042, J7050, J7052-J7130, J7140-J7170, J7184-J7199, J7300, J7302-J7304, J7306 J7312, J7315-J7317, J J7325, J7330, J7335, J J7350, J7500-J7511, J7513, J7515-J7518, J7520, J7525, J7599, J7602 J7606-J7609, J7610- J7799, J8498-J8499, J8501, J8510, J8515, J8520-J8521, J8530-J9999, K0119-K0125, K0140- K0146, K0166-K0167, K0415-K0416, K0418, K0453, K0503-K0528, K0548, M0070, M0075, M0100-M0101, M0300-M0585, M0592, M0702-M0799, M0910, M0945, M0974-M0982, P9001, P9041-P9043, P9045-P9048, P9050, Q0019-Q0032, Q0034-Q0035, Q0044, Q0059, Q0062, Q0066, Q0068, Q0081, Q0083-Q0085, Q0093-Q0094, Q0108, Q0124-Q0132, Q0134, Q0136-Q0141, Q0144, Q0156-Q0185, Q0187, Q0510-Q0515, Q1003, Q2001- Q2021, Q Q2027, Q2035- Q2044, Q3013-Q3014, Q3021-Q3026, Q3030, Q4052- Q4055, Q4075-Q4077, Q4079, Q4081-Q4092, Q4095 Q4098, Q9920-Q9944, Q9955-

111 Category of Service Procedure/Revenue Codes Other Criteria Q9957, Q9968, S0009-S0040, S0071-S0098, S0104, S0106-S0109, S0112, S0114- S0118, S0122, S0124, S0126, S0128, S0130, S0132-S0133, S0135-S0141, S0145-S0148, S0156- S0167, S S0183, S0187, S0189-S0191, S0193-S0199, S0206, S0220-S0221, S0250, S0255, S0257, S0260, S2068, S0270-S0274, S0280, S0281, S0302, S0310, S0315-S0317, S0320, S0340-S0342, S0345-S0347, S0390, S0592, S0601-S0622, S0625, S0630, S0800, S0810, S0812, S1025, S2050-S2055, S2060-S2061, S2065 S2067, S2070, S2075-S2077- S2080, S2082-S2083, S2085, S2090-S2091, S2095, S2102-S2103, S2107, S2109, S2112- S2115, S2117 S2118, S2120, S2130-S2131, S2135, S2140, S2142, S2150, S2152, S2180, S2190, S2202, S2204-S2211, S2213, S2215, S2220, S2225, S2230, S2235, S2250, S2255, S2260, S2262, S2265-S2267, S2270, S2300, S2325, S2340-S2342, S2344, S2348, S2350- S2351, S2360-S2363, S2370-S2371, S2400-S2405, S2409, S2411, S2900, S3854, S3900, S3902, S S3906, S4011, S4013-S4018, S4020-S4023, S4025-S4028, S4030-S4031, S4035, S4037, S4042, S4981, S4989, S4993, S5000-S5001, S5022, S5550-S5553, S5565- S5566, S5570-S5571, S8001, S8004, S8030, S9034, S8040, S8048-S8049, S8075, S8110 (begins 07/01/2001), S8301, S8950, S9015, S9023, S9025, S9055-S9056, S9075, S9083, S9085, S9088, S9090, S9092, S9105, S9117, S9140-S9141, S9145, S9150, S9381, S9401, S9430, S9436-S9439, S9441-S9445, S9447, S9449, S9451-S9455, S9460, S9465, S9472- S9474, S9527-S9528, S9806, S9900, S9970, S9981-S9982, S9986, S9988-S9991, T1013- T1014, T1016 (IF Maj Prog NOT AC AND Primary Diag = , 795.5, or V01.1, V12.01, V74.1,), T1023-T1029, T1502, T1503, T2042-T2047, T2050-T4520, T4544-T5000, T5002-T5998, T6000-T6515, V2630-V2632, V2785, V2790, W0100-W9999, X0995, X1000- X1018, X1030-X1031, X1050-X1395, X1410, X1420, X1520, X1672, X2300, X2390-X2393, X2395-X2396, X3100-X3102, X3120-X3121, X5355-X5356, X5493-X5501, X5509, X5659, X5698-X5699, X9001, Y0069, Y9300- Y9324 J0001-J9999, , (begins 08/01/2000) ATTACHMENT G: POPULATIONS

112 Category of Service Procedure/Revenue Codes Other Criteria 055 Podiatry Not Applicable Prov Tpe is 36 (Podiatrist) 089 Private Duty Nursing 088 Public Health Nursing 079 Radiology, Technical Component G0154 (IF Maj Prog = AC), S9216-S9218, T1000, T1002-T1003, X4020-X4021, X4029, X4031, X4033, X4035, X5641-X5642, X5646-X5649, X5662-X , S5190, S9123, S9446, T1015, X4010, X5286-X5288, X5546-X T, 0067T, 0071T, 0072T, 0082T, 0144T 0152T, 0159T, 0174T-0175T, 0182T 0183T, 0187T, 0239T 0242T, (EXCEPT 7010F, which was moved to Physician, 043 ), C8900-C8914, C8918-C8920, C8931 C8936, C9722-C9723, G0120, G0122, G0130- G0133, G0188, G0202-G0207, G0210-G0236, G0252-G0254, G0262, G0296, G0330 G0331, G0336, G0389, M0080, Q0064-Q0065, Q0067, Q0069-Q0072, Q0076, Q0092, R0065, R0070-R0076, R6129, S0820, S0830, S8035, S8037, S8042, S8055, S8080, S8085, S8092-S8093, S9022, S9024, Y1000, Y7000-Y Rural Health Clinic Services 00521, 00522, 00524, 00525, 00527, 00528, 00529, 00780, or X5325-X5326 Ended 07/15/2009 Bill Type is 71X , 92510, 92525, (if modifier NOT EQUAL to GO ), (begins ATTACHMENT G: POPULATIONS

113 Category of Service Procedure/Revenue Codes Other Criteria Speech Therapy 05/01/2004), , (ends 04/30/2004), (w/o modifier GO, begins 05/01/2004), (w/modifier GN, begins 05/01/2004), (w/modifier GN, begins 05/01/2004), (w/modifier GN, begins 05/01/2004), (w/modifier GN, begins 05/01/2004), (if modifier NOT EQUAL to GO, (if modifier NOT EQUAL to GO ), (if modifier NOT EQUAL to GO ), 96105, (with modifier GN, begins 01/01/2010), (with modifier GN, begins 01/01/2010), (w/modifier GN, begins 05/01/2004), G0195-G0201, S9152, V5301-V5364, X4610, X4613-X4614, X5517, X6002-X Vision 0065T, , 99056, 99172, , , S0592, S0625 Prov Type 35 Optometrist of 75 Optician , , 92499, G0117-G0118, G9041 G9044, S3000 ATTACHMENT G: POPULATIONS

114 ATTACHMENT F: Quality and Patient Experience Measures. 201x Base Year 1.1 Summary: This document further describes the STATE s method of measuring quality and patient experience among Attributed Patients. 1.2 Definitions. (A) Capitalized terms in this Attachment take the same meanings as in the Contract. (B) Absolute Improvement is defined as the change in performance from Baseline to follow-up. (C) Baseline means the Quality Measurement Period for the prior Performance Period (e.g., the Quality Measurement Periods for Performance Period 1 are the Baseline for the Quality Measurement Periods for Performance Period 2). (D) MNCM means Minnesota Community Measurement. (E) Relative Improvement is defined as Absolute Improvement divided by the Baseline measurement. (F) Total Population and Sample refer to use by MDH or the respective measure specification organization. (Rest of page intentionally left blank.) ATTACHMENT G: POPULATIONS

115 1.3 Measures: For the demonstration Performance Periods, the following measures will be used: Physician Clinic Measures. Measures must be submitted using the data collection mechanism identified in the following table. Measure Category Measure Name Measure Specification Organization Method of Data Collection Rate Used in Calculations Population Data Required C01 Clinical Optimal Diabetes Care (ODC) Composite: HbA1c Control Blood Pressure MNCM MDH (via MNCM portal using DDS* process); DHS shall obtain the measure results Tobacco Cessation Medicaidspecific Total Population Aspirin use for selected patients C02 Clinical Optimal Vascular Care Composite: Blood Pressure Control Tobacco Cessation Aspirin Use MNCM MDH (via MNCM portal using DDS* process) ; DHS shall obtain the measure results Medicaidspecific Total Population C03 Clinical Depression Depression Remission at Six Months MNCM MDH (via MNCM portal using DDS* process); DHS shall obtain the measure results Medicaidspecific Total Population C04 Clinical Well-Controlled MNCM ATTACHMENT G: POPULATIONS

116 Measure Category Measure Name Measure Specification Organization Method of Data Collection Rate Used in Calculations Population Data Required Optimal Asthma Control Composite: Child/Adolescent Asthma Not at Risk of Exacerbations MDH (via MNCM portal using DDS* process); DHS shall obtain the measure results Medicaidspecific Total Population C05 ** Clinical Asthma Care: Child/Adolescent Asthma Education and Self- Management MNCM MDH (via MNCM portal using DDS* process); DHS shall obtain the measure results Medicaidspecific Total Population C06 Clinical Optimal Asthma Control Composite: Adult Asthma Well-Controlled Not at Risk of Exacerbations MNCM MDH (via MNCM portal using DDS* process); DHS shall obtain the measure results Medicaidspecific Total Population C07 ** Clinical Asthma Care: Adults Asthma Education and Self- Management MNCM MDH (via MNCM portal using DDS* process); DHS shall obtain the measure results Medicaidspecific Total Population C08 C09 Patient Experience Consumer Assessment of Healthcare Providers and Timely Appointments, Care and Information How Well Providers Communicate with Patients MNCM MDH; DHS shall obtain the measure results Total Population Top Box Rate Sample or Total Population ATTACHMENT G: POPULATIONS

117 C10 Measure Category Systems Clinician & Group Survey (CG-CAHPS): 12 Month Survey Measure Name Helpful Respectful and Courteous Office Staff C11 Patient Rating of Provider as 9 or 10. Measure Specification Organization Method of Data Collection Rate Used in Calculations Population Data Required * All IHP Participant clinics must submit total population data via the direct data submission (DDS) process for these measures, except for those without an electronic medical record who may submit data based on a sample as mutually agreed upon in writing by the Parties. For those clinics that submit data based on a sample, the sample-based results will be reweighted to reflect the clinic total population. ** This measure will be included if it is required for reporting in the final administrative rule for the Minnesota Statewide Quality Reporting and Measurement System (Minnesota Administrative Rules, Chapter 4654) adopted during calendar year 2014 by the Minnesota Department of Health. (Remainder of page intentionally left blank) ATTACHMENT G: POPULATIONS

118 Hospital Measures: Measure Category Measure Name Measure Specification Organization Method of Data Collection Rate Used in Calculations Population Data Required H01 *** Clinical Heart Failure LVF Assessment Centers for Medicare & Medicaid Services (CMS), The Joint Commission MDH (via CMS Hospital Compare, Stratis Health, and Minnesota Hospital Association (MHA)); DHS shall obtain the measure results Total Population Sample or Total Population H02 *** Clinical Pneumonia Initial Antibiotic Selection CMS, The Joint Commission MDH (via CMS Hospital Compare, Stratis Health, and Minnesota Hospital Association (MHA)); DHS shall obtain the measure results Total Population Sample or Total Population H03 H04 Patient Experience Consumer Assessment of Healthcare Communication with Nurses CMS MDH (via Communication with Physicians CMS Hospital compare): Total Population Sample or Total Population ATTACHMENT G: POPULATIONS

119 H05 H06 Measure Category Providers and Systems Hospital Survey (HCAHPS): Measure Name Responsiveness of Hospital Staff Pain Management Measure Specification Organization Method of Data Collection DHS shall obtain the measure results Rate Used in Calculations Top Box Rate Population Data Required H07 Communication about Medications H08 Cleanliness of Hospital Environment H09 Quietness of Hospital Environment H10 Discharge Information H11 Overall Hospital Rating H12 Recommend the Hospital as 9 or 10 *** This measure will be removed if it is removed from reporting requirements in the final administrative rule for the Minnesota Statewide Quality Reporting and Measurement System (Minnesota Administrative Rules, Chapter 4654) adopted during calendar year 2014 by the Minnesota Department of Health. (Rest of page intentionally left blank.) ATTACHMENT G: POPULATIONS

120 Graduated Effect on Shared Savings Payments in Demonstration Performance Periods. Quality and patient experience measures will affect the IHP S portion of the Shared Savings. The amount of the Final Payment that would otherwise be available pursuant to section 4.2 (B) of the Contract shall be modified: (A) Performance Period 1. Reporting of the measures will have a twenty-five percent (25%) effect on the payment (if any) of Shared Savings; that is, 25% of the dollar amount saved in the Total Cost of Care calculation in Attachment D Settlement Process, shall be multiplied by the score calculated for quality and patient experience in section 1.5 below. (B) Performance Period 2. The measure results will have a twenty-five percent (25%) effect on the payment (if any) of Shared Savings; that is, 25% of the dollar amount saved in the Total Cost of Care calculation in Attachment D Settlement Process, shall be multiplied by the score calculated for quality and patient experience in section 1.5 below. (C) Performance Period 3. The measure results will have a fifty percent (50%) effect on the payment (if any) of Shared Savings; that is, 50% of the dollar amount saved in the Total Cost of Care calculation in Attachment D Settlement Process, shall be multiplied by the score calculated for quality and patient experience in section 1.5 below. 1.4 Calculation of Measures for Quality Performance Total Weights. The patient experience measures described in sections and above shall account for twenty-five percent (25%) of the quality performance total, as specified in Section The remaining measures in sections and above shall account for seventy-five (75%) of the quality performance total, as specified in Section 1.5.2, regardless of the number of measures agreed upon by the Parties Quality Measurement Periods. Applicable dates of service, visit dates, or discharge dates for the three Performance Periods of the demonstration are described below for each quality measure. (Remainder of page intentionally left blank) ATTACHMENT G: POPULATIONS

121 Applicable Dates of Service (DOS), Visit Dates, or Discharge Dates [Dates are illustrative and will change to reflect the actual contract awarded.] Quality Measurement Periods Measure Performance Period 1 (2015) Performance Period 2 (2016) Performance Period 3 (2017) Optimal Diabetes Care Composite January December 2015 DOS January December 2016 DOS January December 2017 DOS Optimal Vascular Care Composite January December 2015 DOS January December 2016 DOS January December 2017 DOS Depression Remission at 6 Months July 2014 June 2015 Index Contact Dates with a follow-up period of December 2014 January 2016 July 2015 June 2016 Index Contact Dates with a follow-up period of December 2015 January 2017 July 2016 June 2017 Index Contact Dates with a follow-up period of December 2016 January 2018 Optimal Asthma Control Composite July 2014 June 2015 DOS July 2015 June 2016 DOS July 2016 June 2017 DOS Adults Asthma Care Adults: Asthma July 2014 June 2015 DOS July 2015 June 2016 DOS July 2016 June 2017 DOS Education and Self-Management Optimal Asthma Control Composite July 2014 June 2015 DOS July 2015 June 2016 DOS July 2016 June 2017 DOS Children / Adolescents Asthma Care Children / July 2014 June 2015 DOS July 2015 June 2016 DOS July 2016 June 2017 DOS Adolescents: Asthma Education and Self-Management Patient Experience (CG-CAHPS) September November 2014 September November 2016 TBD visit dates visit dates Heart Failure: LVF Assessment ** October 2014 September 2015 October 2015 September 2016 October 2016 September 2017 Pneumonia: Initial Antibiotic Selection ** October 2014 September 2015 October 2015 September 2016 October 2016 September 2017 Patient Experience (HCAHPS) ** October 2014 September 2015 October 2015 September 2016 October 2016 September 2017 ** Discharge dates within these time periods. If more recent data (i.e., full calendar year that would allow alignment with Performance Period dates) is available at the time of the calculation of the final settlement calculation, it will be used in place of the discharge dates listed. (Rest of page intentionally left blank.) ATTACHMENT G: POPULATIONS

122 1.5 Cumulative Calculation Methods Awarding of Points (A) Reporting. For Performance Period 1, the IHP shall be awarded two (2) points for each measure listed in section 1.3. For each measure, the two (2) points shall be reducible by the percent of IHP Participants not reporting the quality measure in the manner specified in section 1.3. (B) Aggregating clinic-level results and hospital-level results. An IHP quality measure result will be determined for each quality measure by summing the numerators and denominators of multiple clinic-level results or hospital-level results, as applicable. (C) Performance. For Performance Periods 2 and 3, the IHP rate for each measure listed in section 1.3 shall be assessed for both achievement and improvement and the score for each measure will be the greater of the achievement or improvement score as defined below. For each measure, the points awarded shall be reducible by the percent of IHP Participants not reporting the quality measure in the manner specified in section 1.3. (1) Achievement. Each measure shall be assessed against a defined minimum attainment threshold and an upper threshold. For each measure that meets or exceeds the upper threshold, two (2) points shall be awarded. For each measure that is below the minimum attainment threshold, zero (0) points shall be awarded. For each measure that meets or exceeds the minimum attainment threshold and is below the upper threshold, between one (1) and two (2) points shall be awarded, according to the following ranges: Percentile Points Awarded 30 th -< 40 th th - < 50 th th - < 60th th - < 70 th th - < 80 th 1.8 The STATE will notify IHP, before the beginning of the Performance Period, by publishing on the DHS public website the minimum attainment and upper preliminary thresholds. The STATE will notify the IHP of final thresholds upon calculation using the data based on the most recent Quality Measurement Period. ATTACHMENT G: POPULATIONS

123 (2) Improvement. (a) Each measure shall be assessed against a Baseline rate. For each measure that has a ten percent (10%) or more Relative Improvement compared to the Baseline rate, the IHP shall be awarded two (2) points. For each measure that has less than a five percent (5%) Relative Improvement compared to the Baseline rate, the IHP shall be awarded zero (0) points. For each measure that has five percent (5%) or more and less than ten percent (10%) Relative Improvement compared to the Baseline rate, between one (1) and two (2) points shall be awarded according to the following ranges: Percent (%) Relative Improvement Points Awarded 5% - < 6% 1.0 6% - < 7% 1.2 7% - < 8% 1.4 8% - < 9% 1.6 9% - < 10% 1.8 Example calculation: Performance Period 1 (Baseline) rate = 25% Performance Period 2 rate achieved = 28% (28% - 25% = 3% Absolute Improvement; 3% 25% = 12% Relative Improvement) Improvement points earned for measure = 2 points (b) If a measure specification changes in a way that would make a year-to-year comparison statistically invalid, such as a change in the clinical target value (for example, most recent HbA1c value changes from <8.0 to <7.0 for the Optimal Diabetes Care Measure from one measurement period to the next) awarding points based on improvement will not be available for that measure. (D) For all Performance Periods, the total points earned by IHP in each measure category shall be summed and divided by the total points available for that category to produce an overall category score of the percentage of points earned versus points available for the Performance Period. The points score shall be converted to an overall quality score, considering the weights listed below and in section above. (Rest of page intentionally left blank.) ATTACHMENT G: POPULATIONS

124 Table of measures, points and weights. Measure Category Integrated Model Weights Virtual Model Weights Clinical, clinic 45% 60% Clinical, hospital 30% 15% Total Clinical 75% 75% Patient Experience, clinic 15% 20% Patient Experience, hospital 10% 5% Total Patient Experience 25% 25% Quality Effect on Payment: (A) The portion of the available Shared Savings Final Payment from section 4.2 (B) of the Contract that is affected by the quality measure and patient experience scores, for the relevant Performance Period in section above, shall be multiplied by the IHP S earned quality score percent using the table in section (B) The remainder of the available Shared Savings Final Payments shall not be reduced by the effect of the quality and patient experience scores. (C) The sum of the amount in 1.5.3(A) and 1.5.3(B) shall be paid to the IHP following the schedule in section 4.2 of the Contract. ATTACHMENT G: POPULATIONS

125 ATTACHMENT G: Eligible and Excluded Populations 1.1 Summary: This document further describes the populations who are included or excluded from Attribution and Total Cost of Care. 1.2 Eligible Populations. The following persons who are recipients of Medical Assistance and MinnesotaCare are eligible for Attribution to the IHP: (1) Medical Assistance Enrollees: Including pregnant women, children under 21, adults without children, and state-funded Medical Assistance. (2) MinnesotaCare Enrollees: Including children under 21, and adults without children. Individuals must belong to an eligible group under Minnesota Statutes, Chapter 256L, meet income criteria, satisfy all other eligibility requirements, and pay a premium to the State. (3) Recipients receiving Medical Assistance due to blindness or disability as determined by the U.S. Social Security Administration or the State Medical Review Team who are not dually eligible for Medicare. 1.3 Excluded Populations. The following persons are excluded from Attribution to the IHP: (1) Recipients receiving Medical Assistance due to age, blindness or disability who are dually eligible for Medicare. (2) Recipients for whom DHS receives incomplete claims data due to third-party liability coverage. (3) Recipients receiving Medical Assistance under the Refugee Assistance Program pursuant to 8 U.S.C. 1522(e). (4) Individuals who are Qualified Medicare Beneficiaries (QMB), as defined in Section 1905(p) of the Social Security Act, 42 U.S.C. 1396d (p), who are not otherwise receiving Medical Assistance. (5) Individuals who are Service Limited Medicare Beneficiaries (SLMB), as defined in Section 1905(p) of the Social Security Act, 42 U.S.C. 1396a(a)(10)(E)(iii) and 1396d(p), and who are not otherwise receiving Medical Assistance. (6) Non-citizen recipients who only receive emergency Medical Assistance under Minnesota Statutes, section 256B.06, subd. 4. (7) Recipients receiving Medical Assistance on a medical spend down basis. ATTACHMENT G: POPULATIONS

126 (8) Medical Assistance recipients with cost-effective employer-sponsored private health care coverage, or who are enrolled in a non-medicare individual health plan determined to be cost-effective according to Minnesota Statutes, section 256B.69, subd. 4(b)(9). (9) Medical Assistance recipients with private health care coverage through a Health Maintenance Organization (HMO) licensed under Minnesota Statutes, Chapter 62D. (10) Medical Assistance recipients enrolled with Metropolitan Health Plan d/b/a Hennepin Health under the Hennepin County Medicaid demonstration project for single non-disabled adults under age sixty-five. (11) MinnesotaCare recipients who are enrolled in the Healthy Minnesota Contribution Program. (12) The commissioner may exclude recipients enrolled in Minnesota Senior Care Plus (MSC+), other than those in section 1.3(1) above. ATTACHMENT G: POPULATIONS