Common use of HOOSIER HEALTHWISE SCOPE OF WORK Clause in Contracts

HOOSIER HEALTHWISE SCOPE OF WORK. In accordance with the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA), OMPP shall make supplemental payments to FQHCs and RHCs that subcontract (directly or indirectly) with the Contractor. These supplemental payments represent the difference, if any, between the payment to which the FQHC or RHC would be entitled for covered services under the Medicaid provisions of BIPA and the payments made by the Contractor. OMPP requires the Contractor to identify any performance incentives it offers to the FQHC or RHC. OMPP shall review and must approve any performance incentives. The Contractor shall report all such FQHC and RHC incentives which accrue during the Contract period related to the cost of providing FQHC-covered or RHC-covered services to its members along with any fee-for-service and/or capitation payments in the determination of the amount of direct reimbursement paid by the Contractor to the FQHC or RHC. If the incentives vary between the Contractor’s Hoosier Healthwise lines of business, the Contractor shall so specify in its reporting to OMPP. The Contractor shall perform quarterly claim reconciliation with each contracted FQHC or RHC to identify and resolve any billing issues that may impact the clinic’s annual reconciliation conducted by OMPP. Annually, OMPP requires the Contractor to provide the Contractor’s utilization and reimbursement data for each FQHC and RHC in each month of the reporting period. The report shall be completed in the form and manner set forth in the Hoosier Healthwise MCE Reporting Manuals, are updated annually. The data shall be submitted on an incurred claims basis, including separate reporting of Package A FFS claims, Package A capitation claims, Package C FFS claims and Package C capitation claims. The data shall be submitted on a paid claims basis. The submitted FQHC and RHC data must be accurate and complete. The Contractor shall pull the data by NPI or LPI, rather than other means, such as a Federal Tax ID number. The Contractor shall establish a process for validating the completeness and accuracy of the data, and a description of this process shall be available to OMPP upon request. The claims files should not omit claims for practitioners rendering services at the clinic nor should the files contain claims for practitioners who did not practice at the clinic. In addition, OMPP requires the FQHC or RHC and the Contractor to maintain and submit records documenting the number and types of valid encounters provided to members each month. Capitated FQHCs and RHCs shall also submit encounter data (e.g., in the form of shadow claims to the Contractor) each month. The number of encounters will be subject to audit by OMPP or its representatives. The Contractor shall work with each FQHC and RHC in assisting OMPP and/or its designee in the resolution of disputes concerning year-end reconciliations between the federally required interim payments (made by OMPP to each FQHC and RHC on the basis of provider reported encounter activity) and the final accounting that is based on the actual encounter data provided by the Contractor. EXHIBIT 1.E HOOSIER HEALTHWISE SCOPE OF WORK 5.2.10 School-based Health Care Services Contractors must plan for, develop and/or enhance relationships with school- based health centers (SBHCs) with the goal of providing accessible quality preventive and primary health care services to school-aged Hoosier Healthwise members. A school-based health center (SBHC) is a health center located in a school or on school grounds that provides on-site comprehensive preventive and primary health services including behavioral health, oral health, ancillary and enabling services. These services may include a wide variety of preventive services including general health screening or assessments, EPSDT screenings, laboratory and diagnostic screenings, immunizations, first aid, family planning counseling and services, prenatal and post-partum care, dental services, behavioral health services, drug and alcohol abuse counseling, patient education and other services based on the student’s need and on the philosophy of the school administration. SBHCs are important in delivering preventive and primary health care services to school age children and adolescents. SBHCs are in a unique position to link children and adolescents to the health care system due to students’ proximity and open access to health center services. The school setting additionally offers providers considerable opportunity and flexibility in engaging and reaching students. SBHCs’ success at providing access to critical physical and behavioral health services, reducing school absenteeism and promoting appropriate utilization of health services has been well-documented. Onsite health care providers at SBHCs generally include a nurse practitioner or physician assistant who operates under the standing orders of a physician, a consultant physician and a clinically trained behavioral health practitioner. SBHCs have varying capacities and resources to deliver health care. For purposes of this procurement, SBHCs are not permitted to serve as PMPs. However, Contractors are encouraged to be creative in their approaches to collaborating with SBHCs and to begin to develop affiliations with SBHCs with the potential of expanding those affiliations and the scope of services available in SBHCs in the future. The following are some examples of the types and levels of services acceptable in SBHCs:  The SBHC coordinates care with the child’s PMP, who assumes responsibility for care whenever the SBHC closes. The SBHC can deliver preventive and primary medical care, but may rely on its partner for year-round accessibility and twenty four (24)-hour day coverage.  The SBHC provides a limited range of services. For example, the SBHC may be able to provide services such as preventive medical care, health education, reproductive health care, behavioral health services, dental services and immunizations and may also have limited hours of operation. The SBHC refers the child back to their PMP for the majority of their primary care. Contractors’ relationships with SBHCs will vary depending on the resources available in their areas. The following list includes examples of possible Contractor relationships with Indiana SBHCs, not requirements for the Hoosier Healthwise program:

HOOSIER HEALTHWISE SCOPE OF WORK. In accordance with the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA), OMPP shall make supplemental payments to FQHCs and RHCs that subcontract (directly or indirectly) with the Contractor. These supplemental payments represent the difference, if any, between the payment to which the FQHC or RHC would be entitled for covered services under the Medicaid provisions of BIPA and the payments made by the Contractor. OMPP requires the Contractor to identify any performance incentives it offers to the FQHC or RHC. OMPP shall review and must approve any performance incentives. The Contractor shall report all such FQHC and RHC incentives which accrue during the Contract period related to the cost of providing FQHC-covered or RHC-covered services to its members along with any fee-for-service and/or capitation payments in the determination of the amount of direct reimbursement paid by the Contractor to the FQHC or RHC. If the incentives vary between the Contractor’s Hoosier Healthwise lines of business, the Contractor shall so specify in its reporting to OMPP. The Contractor shall perform quarterly claim reconciliation with each contracted FQHC or RHC to identify and resolve any billing issues that may impact the clinic’s annual reconciliation conducted by OMPP. Annually, OMPP requires the Contractor to provide the Contractor’s utilization and reimbursement data for each FQHC and RHC in each month of the reporting period. The report shall be completed in the form and manner set forth in the Hoosier Healthwise MCE Reporting Manuals, are updated annually. The data shall be submitted on an incurred claims basis, including separate reporting of Package A FFS claims, Package A capitation claims, Package C FFS claims and Package C capitation claims. The data shall be submitted on a paid claims basis. The submitted FQHC and RHC data must be accurate and complete. The Contractor shall pull the data by NPI or LPI, rather than other means, such as a Federal Tax ID number. The Contractor shall establish a process for validating the completeness and accuracy of the data, and a description of this process shall be available to OMPP upon request. The claims files should not omit claims for practitioners rendering services at the clinic nor should the files contain claims for practitioners who did not practice at the clinic. In addition, OMPP requires the FQHC or RHC and the Contractor to maintain and submit records documenting the number and types of valid encounters provided to members each month. Capitated FQHCs and RHCs shall also submit encounter data (e.g., in the form of shadow claims to the Contractor) each month. The number of encounters will be subject to audit by OMPP or its representatives. The Contractor shall work with each FQHC and RHC in assisting OMPP and/or its designee in the resolution of disputes concerning year-end reconciliations between the federally required interim payments (made by OMPP to each FQHC and RHC on the basis of provider reported encounter activity) and the final accounting that is based on the actual encounter data provided by the Contractor. EXHIBIT 1.E HOOSIER HEALTHWISE SCOPE OF WORK 5.2.10 School-based Health Care Services Contractors must plan for, develop and/or enhance relationships with school- based health centers (SBHCs) with the goal of providing accessible quality preventive and primary health care services to school-aged Hoosier Healthwise members. A school-based health center (SBHC) is a health center located in a school or on school grounds that provides on-site comprehensive preventive and primary health services including behavioral health, oral health, ancillary and enabling services. These services may include a wide variety of preventive services including general health screening or assessments, EPSDT screenings, laboratory and diagnostic screenings, immunizations, first aid, family planning counseling and services, prenatal and post-partum care, dental services, behavioral health services, drug and alcohol abuse counseling, patient education and other services based on the student’s need and on the philosophy of the school administration. SBHCs are important in delivering preventive and primary health care services to school age children and adolescents. SBHCs are in a unique position to link children and adolescents to the health care system due to students’ proximity and open access to health center services. The school setting additionally offers providers considerable opportunity and flexibility in engaging and reaching students. SBHCs’ success at providing access to critical physical and behavioral health services, reducing school absenteeism and promoting appropriate utilization of health services has been well-documented. Onsite health care providers at SBHCs generally include a nurse practitioner or physician assistant who operates under the standing orders of a physician, a consultant physician and a clinically trained behavioral health practitioner. SBHCs have varying capacities and resources to deliver health care. For purposes of this procurement, SBHCs are not permitted to serve as PMPs. However, Contractors are encouraged to be creative in their approaches to collaborating with SBHCs and to begin to develop affiliations with SBHCs with the potential of expanding those affiliations and the scope of services available in SBHCs in the future. The following are some examples of the types and levels of services acceptable in SBHCs:  ▪ The SBHC coordinates care with the child’s PMP, who assumes responsibility for care whenever the SBHC closes. The SBHC can deliver preventive and primary medical care, but may rely on its partner for year-round accessibility and twenty four (24)-hour day coverage.  ▪ The SBHC provides a limited range of services. For example, the SBHC may be able to provide services such as preventive medical care, health education, reproductive health care, behavioral health services, dental services and immunizations and may also have limited hours of operation. The SBHC refers the child back to their PMP for the majority of their primary care. Contractors’ relationships with SBHCs will vary depending on the resources available in their areas. The following list includes examples of possible Contractor relationships with Indiana SBHCs, not requirements for the Hoosier Healthwise program: