AMENDMENT NUMBER 3 CONTRACTOR RISK AGREEMENT

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AMERIGROUP CORP | AMERIGROUP TENNESSEE, INC

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Title: AMENDMENT NUMBER 3 CONTRACTOR RISK AGREEMENT
Date: 7/29/2008
Industry: Insurance (Accident and Health) Sector: Financial

Exhibit 10.8

AMENDMENT NUMBER 3

CONTRACTOR RISK AGREEMENT
BETWEEN
THE STATE OF TENNESSEE,
d.b.a. TENNCARE
AND
AMERIGROUP TENNESSEE, INC.

CONTRACT NUMBER: FA- 07-16936-00

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

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

1.		The “Medicaid Eligible, Age 21 and older:” designation in the “Benefit Limit” chart of Sections 2.6.1.2 and 2.6.1.4 shall be deleted and replaced with “Medicaid/Standard Eligible, Age 21 and older:”.

2.		The Non-Emergency Transportation Benefit description in Section 2.6.1.2 shall be deleted in its entirety and substituted with the following:


Non-Emergency Medical Transportation (including Non-Emergency Ambulance Transportation)		Covered non-emergency medical transportation (NEMT) services are necessary non-emergency transportation services provided to convey members to and from TennCare covered services (see definition in Exhibit A to Attachment XI). Non emergency transportation services shall be provided in accordance with federal law and the Bureau of TennCare’s rules and policies and procedures. TennCare covered services (see definition in Exhibit A to Attachment XI) include services provided to a member by a non-contract or non-TennCare provider if (a) the service is covered by Tennessee’s Medicaid State Plan or Section 1115 demonstration waiver, (b) the provider could be a TennCare provider for that service, and (c) the service is covered by a third party resource (see definition in Section 1 of the Agreement). If a member requires assistance, an escort (as defined in TennCare rules and regulations) may accompany the member; however, only one (1) escort is allowed per member (see TennCare rules and regulations). Except for fixed route and commercial carrier transport, the CONTRACTOR shall not make separate or additional

Amendment Number 3 (cont.)


		payment to a NEMT provider for an escort. Covered NEMT services include having an accompanying adult ride with a member if the member is under age eighteen (18). Except for fixed route and commercial carrier transport, the CONTRACTOR shall not make separate or additional payment to a NEMT provider for an adult accompanying a member under age eighteen (18). The CONTRACTOR is not responsible for providing NEMT to any service that is being provided to the member through a HCBS waiver. Mileage reimbursement, car rental fees, or other reimbursement for use of a private automobile (as defined in Exhibit A to Attachment XI) is not a covered NEMT service. If the member is a child, transportation shall be provided in accordance with TENNderCare requirements (see Section 2.7.5.4.6). Failure to comply with the provisions of this Section may result in liquidated damages.

3.		Section 2.6.5 shall be amended by deleting “and CMS” at the end of the paragraph.

4.		Sections 2.7.5.4.6.1 through 2.7.5.4.6.5 shall be deleted in their entirety and substituted with the following:

	2.7.5.4.6.1		The CONTRACTOR shall provide transportation assistance for a child and for the child’s escort or accompanying adult, including related travel expenses, cost of meals, and lodging en route to and from TennCare covered services. The requirement to provide the cost of meals shall not be interpreted to mean that a member (or the child’s escort or accompanying adult) can request meals while in transport to and from care. Reimbursement for meals and lodging shall only be provided when transportation for a TennCare covered service cannot be completed in one (1) day and would require an overnight stay.

	2.7.5.4.6.2		The CONTRACTOR shall offer transportation and scheduling assistance to all members under age twenty-one (21) who do not have access to transportation in order to access covered services. This may be accomplished through various means of communication to members, including but not limited to, member handbooks, TENNderCare outreach notifications, etc.

Amendment Number 3 (cont.)

Section 2.8.8 shall be deleted and replaced in its entirety.

	2.8.8		Obesity Disease Management

			In addition to the aforementioned DM program requirements, the CONTRACTOR shall have a DM program for obesity that is provided as a cost effective alternative service (see Section 2.6.5). The CONTRACTOR may fulfill this requirement by entering into a provider agreement with Weight Watchers and then referring/authorizing eligible obese and overweight members to participate in a Weight Watchers program. If the CONTRACTOR identifies another weight management program as the cost effective alternative service, the CONTRACTOR shall include a narrative of the program (including target population and description of services) as part of its quarterly disease management report (see Section 2.30.5.1) applicable to the quarter in which the program was implemented.

Section 2.9.8.1.3 shall be deleted in its entirety and substituted with the following:

2.9.8.1.3

The CONTRACTOR may require prior authorization for services related to dental services including the facility, anesthesia, and/or medical services related to the dental service. However, the CONTRACTOR may waive authorization of said services based upon authorization of the dental services by the dental benefits manager. The CONTRACTOR shall approve and arrange transportation to and from dental services in accordance with this Agreement, including but not limited to Attachment XI.

7.		Section 2.11.3.4 shall be deleted in its entirety.

8.		Section 2.11.7.5 shall be deleted and replaced in its entirety.

2.11.7.5

Weight Watchers or Other Weight Management Program

The CONTRACTOR is not required to credential the Weight Watchers or the weight management program(s) referenced in Section 2.8.8 of this Agreement.

Section 2.12.7 shall be amended by adding a new Section 2.12.7.32 and renumbering existing subparts accordingly, including any references thereto.

2.12.7.32

As a condition of reimbursement for global procedures codes for obstetric care, the provider shall submit utilization or encounter data as specified by the CONTRACTOR in a timely manner to support the individual services provided;

10.

Section 2.13 shall be amended by adding a new Section 2.13.2 and renumbering existing subparts accordingly, including any references thereto.

	2.13.2		All Covered Services

	2.13.2.1		Except as provided in Sections 2.13.2.2 and 2.13.2.3 below, the CONTRACTOR shall not reimburse providers based on a percentage of billed charges.

Amendment Number 3 (cont.)

	2.13.2.2		The CONTRACTOR may, at its discretion, pay a percentage of billed charges for covered services for which there is no Medicare reimbursement methodology.

	2.13.2.3		As part of a stop-loss arrangement with a provider, the CONTRACTOR may, at its discretion, pay the provider a percentage of billed charges for claims that exceed the applicable stop-loss threshold.

11.

Section 2.13.11 shall be deleted and replaced as follows:

2.11.1

Covered Services Ordered by Medicare Providers for Dual Eligibles

	2.13.11.1		Generally, when a TennCare enrollee is dually eligible for Medicare and TennCare and requires services that are covered under this Agreement but are not covered by Medicare, and the services are ordered by a Medicare provider who is a non-contract provider, the CONTRACTOR must pay for the ordered, medically necessary service if it is provided by a contract provider. However, if all of the following criteria are met, the CONTRACTOR may require that the ordering physician be a contracted provider:

	2.13.11.1.1		The ordered services requires prior authorization; and

	2.13.11.1.2		Dually eligible enrollees have been clearly informed of the contracted provider requirement and instructed in how to obtain assistance identifying and making an appointment with a contract provider; and

	2.13.11.1.3		The CONTRACTOR assists the enrollee in obtaining a timely appointment with a contract provider upon request of the enrollee or upon receipt of an order from a non-contract provider.

	2.13.11.2		Reimbursement shall be at the same rate that would have been paid had the service been ordered by a contract provider.

	2.13.11.3		The CONTRACTOR shall not pay for non-covered services, services that are not medically necessary, or services ordered and obtained from non-contract providers.

12.

Section 2.15.3.1 shall be deleted and replaced in its entirety.

2.15.3.1

The CONTRACTOR shall perform three (3) clinical and two (2) non-clinical PIPs.. The three (3) clinical PIPs shall include one (1) in the area of diabetes management, one (1) in the area of maternity management and one (1) in the area of behavioral health. The behavioral health PIP shall be relevant to one of the behavioral health disease management programs for bipolar disorder, major depression, or schizophrenia.

13.

Section 2.15.4.1 shall be deleted and replaced in its entirety.

2.15.4.1

The CONTRACTOR’s QM/QI program shall identify benchmarks and set achievable performance goals for the three (3) clinical PIPs and two (2) non-clinical PIPs

Amendment Number 3 (cont.)

required in Section 2.15.3. The three (3) clinical performance indicators that must show meaningful improvement are diabetes management, maternity management and behavioral health. The CONTRACTOR shall identify a relevant HEDIS measure where there is an opportunity to show improvement. The source of the benchmark should be identified, e.g., NCQA’s Quality Compass. The CONTRACTOR must demonstrate improvement against the baseline measure as indicated:


Baseline Rate		Minimum Effect Size
0-59		At least a 6 percentage point increase
60-74		At least a 5 percentage point increase
75-84		At least a 4 percentage point increase
85-92		At least a 3 percentage point increase
93-96		At least a 2 percentage point increase
97-99		At least a 1 percentage point increase

14.

Section 2.17.1.1 shall be deleted and replaced in its entirety.

2.17.1.1

The CONTRACTOR shall submit to TENNCARE for review and prior approval all materials that will be distributed to members (referred to as member materials) as well as proposed health education and outreach activities. This includes but is not limited to member handbooks, provider directories, member newsletters, identification cards, fact sheets, notices, brochures, form letters, mass mailings, member education and outreach activities as described in this Section, Section 2.17 and Section 2.7.3, system generated letters and any other additional, but not required, materials and information provided to members designed to promote health and/or educate members.

15.

Section 2.30.4.4 and 5 shall be deleted and replaced in its entirety.

	2.30.4.4		The CONTRACTOR shall submit a quarterly Behavioral Health Crisis Response Report that provides information on behavioral health crisis services (see Section 2.7.2.8) including the data elements listed in Attachment IX, Exhibit C. Specified data elements shall be reported separately for members ages eighteen (18) years and over and those under eighteen (18) years and all shall be reported for each individual crisis service provider. This report shall be provided in a standardized format as specified by the State.

	2.30.4.5		The CONTRACTOR shall submit a weekly Member CRG/TPG Assessment Report that contains information regarding the CRG assessments and TPG assessments (see Section 2.7.2.9) of members who have presented for mental health or substance abuse services or who have received CRG assessments and TPG assessments prior to obtaining such services. For purposes of this weekly Member CRG/TPG Assessment Report, the weekly report shall be due no later than 12:00 Noon, each Tuesday. The CONTRACTOR shall provide this report in the format prescribed by the State. The minimum data elements required are identified in Attachment IX, Exhibit D of this Agreement.

Amendment Number 3 (cont.)

16.

Section 2.30.4 shall be amended by adding a new 2.30.4.8 and renumbering the remaining sections.

2.30.4.8

The CONTRACTOR shall submit a quarterly Adverse Occurrences Report that summarizes all adverse occurrences and their resolutions as reported to the CONTRACTOR by its providers. This report shall be submitted in the format prescribed by TENNCARE.

17.

Section 2.30.6 shall be deleted and replaced in its entirety.

	2.30.6		Service Coordination Reports

	2.30.6.1		MCO Case Management Reports

	2.30.6.1.1		By August 15, 2007, the CONTRACTOR shall submit an annual Case Management Services Report to TENNCARE describing the CONTRACTOR’s case management services. The report shall include a description of the criteria and process the CONTRACTOR uses to identify members for case management, the process the CONTRACTOR uses to inform members and providers of the availability of case management, a description of the case management services provided by the CONTRACTOR and the methods used by the CONTRACTOR to evaluate its case management program. Annually thereafter, the CONTRACTOR shall submit a report outlining any changes to the case management program, along with justification for such changes. These reports should only contain case management activity.

	2.30.6.1.2		The CONTRACTOR shall submit a quarterly MCO Case Management Update Report that includes a brief narrative description of the MCO case management program (see Section 2.9.4); the total number of members enrolled in the MCO case management program; number of members enrolled and disenrolled in the program during the quarter; member selection criteria; the number of members who declined case management services; a description of services provided during the quarter and an evaluation of the impact of the MCO case management program during the quarter. The CONTRACTOR shall submit these reports in a format prescribed by TENNCARE. Enrollees who are enrolled in Disease Management need not be included in this report unless they are also receiving case management.

	2.30.6.2		As necessary, the CONTRACTOR shall submit a listing of members identified as potential pharmacy lock-in candidates (see Section 2.9.7).

	2.30.6.3		The CONTRACTOR shall submit a quarterly Pharmacy Services Report that includes a list of the providers and information on the interventions the CONTRACTOR has taken with the providers who appear to be operating outside industry or peer norms as defined by TENNCARE, have been identified as non-compliant as it relates to adherence to the PDL and/or generic prescribing patterns and/or are failing to follow required prior authorization processes and procedures the steps the CONTRACTOR has taken to personally contact each one as well as the outcome of these personal contacts.

	2.30.6.4		The CONTRACTOR shall submit a Pharmacy Services Report, On Request when TENNCARE requires assistance in identifying and working with providers for any

Amendment Number 3 (cont.)

reason. These reports shall provide information on the activities the CONTRACTOR undertook to comply with TENNCARE’s request for assistance, outcomes (if applicable) and shall be submitted in the format and within the time frame prescribed by TENNCARE.

18.		Section 3.4.7 shall be deleted in its entirety and subsequent sections shall be renumbered sequentially.

19.		Section 3 shall be amended by adding a new Section 3.10 and renumbering the existing sections accordingly.

	3.10		PAY-FOR-PERFORMANCE QUALITY INCENTIVE PAYMENTS

	3.10.1		General

	3.10.1.1		TENNCARE will make incentive payments to the CONTRACTOR in accordance with this Section 3.10.

	3.10.1.2		Pursuant to 42 CFR 438.6, the total of all payments made to the CONTRACTOR for a year shall not exceed one hundred and five percent (105%) of capitation payments made to the CONTRACTOR..

	3.10.1.3		In the first year that the incentives specified in Sections 3.10.2 and 3.10.3 below are available, the TennCare regional average HEDIS score (as calculated by TENNCARE using audited MCO HEDIS results) for each of the measures specified in Sections 3.10.2 and 3.10.3 for the last full calendar year prior to the year that the CONTRACTOR began operating under this Agreement will serve as the baseline. If complete TennCare HEDIS data for these measures is not available for the region for the year prior to the year that the CONTRACTOR began operating under this Agreement, then the last year for which complete data is available will serve as the baseline.

	3.10.1.4		If NCQA makes changes in any of the measures specified in Section 3.10.2 or 3.10.3 below, such that valid comparison to prior years will not be possible, TENNCARE, at its sole discretion, may elect to either eliminate the measure from pay-for-performance incentive eligibility or replace it with another measure.

	3.10.2		Physical Health HEDIS Measures

	3.10.2.1		On July 1 of the year that the first HEDIS reports are due (see Section 2.15.6), the CONTRACTOR will be eligible for a $.03 PMPM payment, applied to member months from the preceding calendar year, for each of the audited HEDIS measures specified in Section 3.10.2.2 below (calculated from the preceding calendar year’s data) for which significant improvement has been demonstrated. Significant improvement is defined using NCQA’s minimum effect size change methodology (see Section 3.10.5 below).

	3.10.2.2		Incentive payments will be available for the following audited HEDIS measures:

	3.10.2.2.1		HbA1C Testing — Diabetes measure;

Amendment Number 3 (cont.)

	3.10.2.2.2		HbA1C Control — Diabetes measure;

	3.10.2.2.3		LDL-C Screening Performed — Diabetes measure;

	3.10.2.2.4		Adolescent Well-Care Visits;

	3.10.2.2.5		Breast Cancer Screening; and

	3.10.2.2.6		Controlling High Blood Pressure.

	3.10.2.3		For HbA1C control, the reverse of the HEDIS measure (i.e. 100 minus the percentage of individuals with poorly controlled HbA1C) will serve as the measure for purposes of this section.

3.10.3

Behavioral Health HEDIS Measures

On July 1 of the year that the first HEDIS reports are due (see Section 2.15.6) the CONTRACTOR will be eligible for a $.03 PMPM payment, applied to member months from the preceding calendar year, for each of the following audited HEDIS measures (calculated from the preceding calendar year’s data) for which the CONTRACTOR scores at or above the 75 ^th national Medicaid percentile, as calculated by NCQA:

	3.10.3.1		Antidepressant Medication Management; and

	3.10.3.2		Follow-up Care for Children Prescribed ADHD Medication.

	3.10.4		Community Tenure/Hospital Readmission for Mental Illness

On July 1, of the year following the first full calendar year of operation, the CONTRACTOR will be eligible for a .$.03 PMPM payment, applied to member months from the preceding calendar year, if significant improvement has been demonstrated in the rate at which members hospitalized for mental illness remain in the community (i.e. are not readmitted to an inpatient hospital setting for treatment of mental illness) within thirty (30) days of discharge. Significant improvement is defined using NCQA’s minimum effect size change methodology (see Section 3.10.5 below). The baseline rate will be the percentage of enrollees in the region that were discharged following hospitalization for mental illness during the last full calendar year prior to the year the CONTRACTOR began operating under this Agreement, and that were not readmitted within thirty (30) days following discharge, as calculated by TennCare. The baseline rate will be compared to the percentage of the CONTRACTOR’s members that were discharged following hospitalization for mental illness during the first full calendar year of operation under this Agreement, and that were not readmitted within thirty (30 days) following discharge. The latter calculation will use methodology identical to that used in the baseline calculation performed by TENNCARE.

3.10.5

NCQA Minimum Effect Size Change Methodology

The NCQA minimum effect size change methodology is as follows:

Amendment Number 3 (cont.)


Baseline Rate		Minimum Effect Size
0-59		At least a 6 percentage point change
60-74		At least a 5 percentage point change
75-84		At least a 4 percentage point change
85-92		At least a 3 percentage point change
93-96		At least a 2 percentage point change
97-99		At least a 1 percentage point change

20.		Section 3.12.1.1 shall be amended by deleting and replacing the maximum liability with “One Billion, Five Hundred Seventy Three Million, Eight Hundred Thirty Eight Thousand, Thirty Six Dollars ($1,573,838,036.00)”.

21.		Section 4.1 shall be amended by deleting and replacing the CONTRACTOR’s contact information as follows:

C. Brian Shipp
President and Chief Executive Officer
AMERIGROUP Community Care
22 Century Blvd., Suite 310
Nashville, TN 37214

22.

Section 4.20.2.2.5 shall be deleted in its entirety and substituted with the following:

4.20.2.2.5

TENNCARE may also assess liquidated damages for failure to meet performance standards as provided in Section 2.24.3, Attachment VII, and Attachment XI of this Agreement.

23.

Item A.2 in Section 4.20.2.2.7 shall be deleted in its entirety and substituted with the following:


A.2		Failure to comply with licensure requirements in Section 2.29.2 and Attachment XI of this Agreement		$5,000 per calendar day that staff/provider/driver/agent/subcontractor is not licensed as required by applicable state or local law plus the amount paid to the staff/provider/driver/agent/subcontractor during that period

24.

Item B.23 in Section 4.20.2.2.7 shall be deleted in its entirety and substituted with the following:


B.23		Failure to maintain provider agreements in accordance with Section 2.12 and Attachment XI of this Agreement		$5000 per provider agreement found to be non-compliant with the requirements outlined in this Agreement

25.

Section 4.20.2.2.7 shall be amended by adding a new C.6 which shall read as follows:


C.6		Failure to submit a Provider Enrollment File that meets TENNCARE’s specifications (see Section 2.30.7.1)		$250 per day after the due date that the Provider Enrollment File fails to meet TENNCARE’s specifications

Amendment Number 3 (cont.)

26.

Attachment V shall be deleted and replaced and as follows:

ATTACHMENT V
ACCESS & AVAILABILITY FOR BEHAVIORAL HEALTH SERVICES


		Geographic Access Requirement	Maximum Time for
Service Type	Service Code(s)	for the Service	Admission/Appointment
Psychiatric Inpatient Hospital Services	Adult — 11, 79, 85 Child — A1 or H9	In accordance with Attachment III for Hospitals	4 hours (emergency involuntary)/24 hours (involuntary)/24 hours (voluntary)

24 Hour Psychiatric Residential Treatment	Adult — 13, 81, 82	Within 100 miles of an individual’s residence except in rural areas where community standards and documentation will apply	Within 30 calendar days
	Child — A9, H1, or H2	Within 100 miles of an individual’s residence	Within 30 calendar days

Outpatient Mental Health Services:
MD Services (Psychiatry)	Adult — 19 Child — B5	In accordance with Attachment IV for Psychiatry	Within 14 calendar days; if urgent, within 3 business days
Outpatient Non-MD Services	Adult — 20 Child — B6	Within 30 miles of an individual’s residence	Within 14 calendar days; if urgent, within 3 business days
Intensive Outpatient*	Adult — 23, 62 Child — B7, C3	Within 60 miles of an individual’s residence except in rural areas where community standards and documentation will apply	Within 14 calendar days; if urgent, within 3 business days

Inpatient, Residential & Outpatient Substance Abuse Services:
Inpatient Facility Services	Adult — 15, 17 Child — A3, A5	Within 60 miles of an individual’s residence except in rural areas where community standards and documentation will apply	Within 2 calendar days; for detoxification — within 4 hours in an emergency and 24 hours for non-emergency
24 Hour Residential Treatment Services**	Adult — 56 Child — F6	Within 100 miles of an individual’s residence except in rural areas where community standards and documentation will apply	Within 14 calendar days
Outpatient Treatment Services	Adult — 27 or 28 Child — D3 or D4	Within 30 miles of an individual’s residence except in rural areas where community standards and documentation will apply	Within 14 calendar days; for detoxification — within 24 hours

Mental Health Case Management	Adult — 31, 66, or 83 Child — C7, D7, G2, G6, or K1	Not subject to access standards	Within 7 calendar days

Psychiatric Rehabilitation Services:
Psychosocial Rehabilitation***	42 or 44	Within 60 miles of an individual’s residence	Within 14 calendar days
Supported Housing	32 and 33	Not Applicable****	Within 30 calendar days

Behavioral Health Crisis Services
Crisis Services (Mobile)	Adult — 37, 38, 39 Child — D8, D9, E1	Not subject to access standards	Face-to-face contact within 1 hour for emergency situations and 4 hours for urgent situations
Crisis Stabilization	Adult — 41	Not subject to access standards	Within 4 hours of referral

Amendment Number 3 (cont.)


*		Intensive Outpatient services may equal Adult Day Treatment, Intensive Day Treatment Program for Children & Adolescents or Partial Hospitalization.

**		24 Hour Residential Treatment Substance Abuse Services may be provided by facilities licensed by the Tennessee Department of Health as Halfway House Treatment Facilities (DOH Rule Chapter 1200-8-17), Residential Detoxification Treatment Facilities (DOH Rule Chapter 1200-8-22) or Residential Rehabilitation Treatment Facilities (DOH Rule Chapter 1200-8-23). (Effective 1/1/2008, the Tennessee Department of Mental Health and Developmental Disabilities will license these facilities.)

***		Psychosocial Rehabilitation is a consumer-centered program of services for adult recipients to enhance and support the process of recovery and may include Supported Employment, Illness Management & Recovery and Peer Support services. ((TDMHDD Rule Chapter 1940-5-29)

****		Placement of an individual more than 60 miles from his/her residence must be prior approved by the member or his/her legally appointed representative.

All providers for the following service types shall be reported on the Provider Enrollment File:


		Service Code(s) for use in
		position 330-331 of the
Service Type		Provider Enrollment File
Psychiatric Inpatient Hospital Services		Adult — 11, 79, 85
		Child — A1 or H9

24 Hour Psychiatric Residential Treatment		Adult — 13, 81, 82
		Child — A9, H1, or H2

Outpatient Mental Health Services:
MD Services (Psychiatry)		Adult — 19
		Child — B5
Outpatient Non-MD Services		Adult — 20
		Child — B6
Intensive Outpatient/ Partial Hospitalization		Adult — 23, 62
		Child — B7, C3

Inpatient, Residential & Outpatient Substance Abuse Services:
Inpatient Facility Services		Adult — 15, 17
		Child — A3, A5
24 Hour Residential Treatment Services		Adult — 56
		Child — F6
Outpatient Treatment Services		Adult — 27 or 28
		Child — D3 or D4

Mental Health Case Management		Adult — 31, 66, or 83
		Child — C7, D7, G2, G6, or K1

Psychiatric Rehabilitation Services:
Psychosocial Rehabilitation		42
Supported Employment		44
Peer Support		88
Illness Management & Recovery		91
Supported Housing		32 and 33

Behavioral Health Crisis Services
Crisis Services (Mobile)		Adult — 37, 38, 39
		Child — D8, D9, E1
Crisis Respite		Adult — 40
		Child — E2
Crisis Stabilization		Adult — 41

Amendment Number 3 (cont.)

27.

Attachment VII shall be amended by adding a new item 7, deleting and replacing the re-numbered Item 9, adding a new Item 10 and renumbering all of the Performance Measures as appropriate, including all references thereto.

PERFORMANCE

DATA

MEASUREMENT

LIQUIDATED

MEASURE

SOURCE(S)

BENCHMARK

DEFINITION

FREQUENCY

DAMAGE

Provider Network
Documentation

Provider Enrollment File and provider agreement signature pages

100% of contract providers on the Provider Enrollment File have a signed provider agreement with the CONTRACTOR

Providers listed on Provider Enrollment file with an “In Plan” indicator must have a signed agreemen t

Upon TENNCARE
request

$1,000 for each provider for which the CONTRACTOR cannot provide a signature page from the provider agreement between the provider and the CONTRACTOR

Amendment Number 3 (cont.)

PERFORMANCE

DATA

MEASUREMENT

LIQUIDATED

MEASURE

SOURCE(S)

BENCHMARK

DEFINITION

FREQUENCY

DAMAGE

Specialist Provider
Network

Provider Enrollment
File

1. Physician Specialists :
Executed specialty physician contracts in all areas required by this Agreement for the following specialists: allergy; cardiology; dermatology; endocrinology; gastroenterology; general surgery; nephrology; neurology; neurosurgery; otolaryngology; ophthalmology; orthopedics; oncology/hematology; psychiatry (adults); psychiatry (child/adolescent); and urology

2. Essential Hospital Services :
Executed contract with at least one (1) tertiary care center for each essential hospital service

3. Center of Excellence for People with AIDS :
Executed contract with at least two (2) Center of Excellence for AIDS within the CONTRACTOR’s approved Grand Region(s)

2. Center of Excellence for Behavioral Health :
Executed contract with all COEs for Behavioral Health within the CONTRACTOR’s approved Grand Region(s)

Executed contract is a signed provider agreement with a provider to participate in the CONTRACTOR’s network as a contract provider

Monthly

$25,000 if ANY of the listed standards are not met, either individually or in combination on a monthly basis

The liquidated damage may be waived for Physician Specialists if the CONTRACTOR provides sufficient documentation to demonstrate that the deficiency is attributable to a lack of physicians practicing in the area. The liquidated damage may be lowered to $5,000 in the event the CONTRACTOR provides a corrective action plan that is accepted by TENNCARE

Amendment Number 3 (cont.)

PERFORMANCE

DATA

MEASUREMENT

LIQUIDATED

MEASURE

SOURCE(S)

BENCHMARK

DEFINITION

FREQUENCY

DAMAGE

Provider
Participation
Accuracy

Provider Enrollment
File

At least 90% of listed providers confirm participation in the CONTRACTOR’s network

A statistically valid sample of participating providers on the most recent monthly provider enrollment file confirm that they are participating in the CONTRACTOR’s network

Quarterly

$25,000 per quarter if less than 90% of listed providers confirm participation. The liquidated damage may be lowered to $5,000 in the event that the CONTRACTOR provides a corrective action plan that is accepted by TENNCARE, or waived if the CONTRACTOR submits sufficient documentation to demonstrate 90% of providers in the sample are participating

Provider
Information
Accuracy

Provider Enrollment
File

Data for no more than 10% of listed providers is incorrect for each data element

Data for no more than 10% of a statistically valid sample of participating providers on the most recent monthly provider enrollment is incorrect for each element as determined by TENNCARE

Quarterly

$5,000 per quarter if data for more than 10% but fewer than 31% of providers is incorrect for each data element

$25,000 per quarter if data for more than 30% of providers is incorrect for each data element

The $25,000 liquidated damage may be lowered to $5,000 in the event that the CONTRACTOR provides a corrective action plan that is accepted by TENNCARE, or may be waived by TENNCARE if the CONTRACTOR submits sufficient documentation

Amendment Number 3 (cont.)

PERFORMANCE

DATA

MEASUREMENT

LIQUIDATED

MEASURE

SOURCE(S)

BENCHMARK

DEFINITION

FREQUENCY

DAMAGE

Distance from provider to member

Provider Enrollment
File

In accordance with
this Agreement,
including
Attachments III
through V

Time and travel distance as measured by GeoAccess

Monthly

$25,000 if ANY of the listed standards are not met, either individually or in combination on a monthly basis. The liquidated damage may be lowered to $5,000 in the event that the CONTRACTOR provides a corrective action plan that is accepted by TENNCARE

28.		Attachment VIII shall be amended by adding “Policies and procedures for delivering NEMT services, including an operating procedures manual, as provided in Section A.1 of Attachment XI” after item 175.

29.		Attachment IX, Exhibit C shall be deleted and replaced in its entirety.

ATTACHMENT IX, EXHIBIT C

BEHAVIORAL HEALTH CRISIS RESPONSE REPORT

The Behavioral Health Crisis Response Report required in Section 2.30.4.4 shall include, at a minimum, the following data elements:

	1.		Total Telephone Contacts

	2.		Type of Call: Psychiatric Emergency

	3.		Type of Call: Urgent

	4.		Type of Call: Routine

	5.		Total Face-to-Face Contacts

	6.		Face-to-Face Type: Psychiatric Emergency

	7.		Face-to-Face Type: Urgent

	8.		Face-to-Face Type: Routine

	9.		Total Face-to-Face Contacts by Payor

	10.		Face-to-Face Payor Source: TennCare

	11.		Face-to-Face Payor Source: Medicare

	12.		Face-to-Face Payor Source: Commercial

	13.		Face-to-Face Payor Source: None

	14.		Total Face-to-Face Contacts by Location

	15.		Face-to-Face Location: Onsite at CMHA

	16.		Face-to-Face Location: ER

	17.		Face-to-Face Location: Other Offsite

	18.		Total Face-to-Face Contacts by Disposition

	19.		Disposition: Total Admitted to RMHI (acute)

	20.		# Admitted to RMHI Not Mandatory Pre-Screened

	21.		Disposition: Total Admitted to Other Inpt (acute) Includes Dual Dx

	22.		# Admitted To Other Inpt Not Mandatory Pre-Screened

Amendment Number 3 (cont.)

	23.		GRAND TOTAL PSYCHIATRIC ADMISSIONS

	24.		Disposition: Admitted to IP SA Treatment

	25.		Disposition: Referred to Lower Level OP Care

	26.		Disposition: Referred to Respite Services

	27.		Average time for Admission to Crisis Respite (only when admitted to respite)

	28.		Disposition: Referred to Other Services

	29.		Disposition: Assessed / No Need for Referral

	30.		Disposition: Consumers Refusing Referral

	31.		Total Number of Face-to-Face Contacts for C&A <18 yrs of age

	32.		Total Number of Face-to-Face Contacts for C&A 18 to <21 yrs of age

	33.		Total Number of Face-to-Face Contacts for Adults 21 yrs and older

	34.		Total Number of Behavioral Health Providers notified of Crisis (only if consumer has a provider)

	35.		Average Time of Arrival in Minutes: Psychiatric Emergency

	36.		Average Time of Arrival in Minutes: Urgent

	37.		Barriers to Diversion: No Psychiatric Respite Accessible

	38.		Barriers to Diversion: No SA/Dual Respite Accessible

	39.		Barriers to Diversion: Consumer/Guardian Refused Respite

	40.		Barriers to Diversion: 6-404 Signed Prior to Assessment (when consumer could have been diverted if CON not signed)

	41.		Barriers to Diversion: Lack of Linkage w/Case Mgr (only if consumer has a CM)

	42.		Barriers to Diversion: Other (only for inappropriate admissions and barrier does not fit in any other category)

30.

Attachment XI shall be renamed Attachment XII, and a new Attachment XI shall be inserted to read as follows:

Amendment Number 3 (cont.)

ATTACHMENT XI

NEMT REQUIREMENTS

A.1		GENERAL

A.1.1		The CONTRACTOR, in its delivery of NEMT services, shall comply with all of the requirements in this Attachment XI. The requirements in this Attachment are in addition to, not instead of, requirements found elsewhere in the Agreement.

A.1.2		The CONTRACTOR shall develop written policies and procedures that describe how the CONTRACTOR, in the delivery of NEMT services, shall comply with the requirements of the Agreement, including this Attachment. Pursuant to Section 2.25.4 of the Agreement, TENNCARE will specify the policies and procedures that must be prior approved in writing by TENNCARE. As part of its policies and procedures the CONTRACTOR shall develop an operating procedures manual detailing procedures for meeting, at a minimum, requirements regarding the following:

	A.1.2.1		Requesting NEMT services (see Section A.3 of this Attachment);

	A.1.2.2		Approving NEMT services (see Section A.4 of this Attachment); and

	A.1.2.3		Scheduling, assigning and dispatching trips (see Section A.5 of this Attachment).

A.2		NEMT IMPLEMENTATION WORK PLAN AND READINESS REVIEW

A.2.1		The CONTRACTOR shall prepare and maintain throughout the implementation period (defined as the period from April 1, 2008 through July 31, 2008) an implementation work plan that details all of the tasks required to successfully implement all of the NEMT requirements of the Agreement, including this Attachment XI, by September 1, 2008. The CONTRACTOR shall submit the final implementation work plan to TENNCARE for prior written approval no later than April 1, 2008. By September 1, 2008, the CONTRACTOR shall have fully implemented the implementation work plan, and the CONTRACTOR may be subject to liquidated damages for failure to comply with the provisions herein.

A.2.2		Prior to implementation of the NEMT requirements in this Attachment, as determined by TENNCARE, the CONTRACTOR shall demonstrate to TENNCARE’s satisfaction that, in its delivery of NEMT services, the CONTRACTOR is able to meet all of the NEMT requirements of the Agreement, including but not limited to this Attachment XI.

A.2.3		The CONTRACTOR shall cooperate in a “readiness review” conducted by TENNCARE to review the CONTRACTOR’s readiness to begin providing NEMT services in accordance with the Agreement. This review may include, but is not limited to, desk and on-site review of documents provided by the CONTRACTOR, a walk-through of the CONTRACTOR’s operations, system demonstrations (including systems connectivity testing), and interviews with CONTRACTOR’s staff. The scope of the review may include any and all NEMT requirements of the Agreement as determined by TENNCARE.

A.2.4		Based on the results of the review activities, TENNCARE will issue a letter of findings and, if needed, will request a corrective action plan from the CONTRACTOR.

Amendment Number 3 (cont.)

A.3		REQUESTING NEMT SERVICES

A.3.1		Members or their representatives shall be allowed to make requests for NEMT services on behalf of members. For DCS enrollees (as defined in Exhibit A of this Attachment), representatives include the member’s DCS liaison, foster parent, adoptive parent, or provider.

A.3.2		Requests for NEMT services should be made at least seventy-two (72) hours before the NEMT service is needed. However, this timeframe does not apply to urgent trips (see Section A.5.7 of this Attachment), scheduling changes initiated by the provider, and follow-up appointments when the timeframe does not allow advance scheduling. In addition, the CONTRACTOR shall accommodate requests for NEMT services that are made within the following timeframes: three (3) hours before the NEMT service is needed when the pick-up address is in an urban area and four (4) hours before the NEMT service is needed when the pick-up address is in a non-urban area. The CONTRACTOR shall provide additional education to members who fail to request transportation seventy-two (72) hours before the NEMT service is needed (see Section A.10 of this Attachment).

A.3.3		The CONTRACTOR shall not have a time limit for scheduling transportation for future appointments. For example, if a member calls to schedule transportation to an appointment that is scheduled in two (2) months, the CONTRACTOR shall arrange for that transportation and shall not require the member to call back at a later time.

A.4		APPROVING NEMT SERVICES

A.4.1		General

	A.4.1.1		Transportation for a minor child shall not be denied pursuant to any policy that poses a blanket restriction due to member’s age or lack of accompanying adult. Any decision to deny transportation of a minor child due to a member’s age or lack of an accompanying adult shall be made on a case-by-case basis and shall be based on the individual facts surrounding the request and State of Tennessee law. Tennessee recognizes the “mature minor exception” to permission for medical treatment. The age of consent for children with mental illness is sixteen (16) (see TCA 33-8-202).

	A.4.1.2		As part of the approval process, the CONTRACTOR shall:

	A.4.1.2.1		Collect relevant information from the caller and enter it into the CONTRACTOR’s system (see Section A.5.10 of this Attachment);

	A.4.1.2.2		Verify the member’s eligibility for NEMT services;

	A.4.1.2.3		Determine the appropriate mode of transportation for the member;

	A.4.1.2.4		Determine the appropriate level of service for the member;

	A.4.1.2.5		Approve or deny the request; and

	A.4.1.2.6		Enter the appropriate information into the CONTRACTOR’s system (see Section A.5.10 of this Attachment).

Amendment Number 3 (cont.)

A.4.2

Verifying Eligibility for NEMT Services

	A.4.2.1		The CONTRACTOR shall screen all requests for NEMT services to confirm each of the following items:

	A.4.2.1.1		That the person for whom the transportation is being requested is a TennCare enrollee and enrolled in the CONTRACTOR’s MCO;

	A.4.2.1.2		That the service for which NEMT service is requested is a TennCare covered service (as defined in Exhibit A of this Attachment); and

	A.4.2.1.3		That the transportation is a covered NEMT service (see Section 2.6.1.2 of the Agreement).

A.4.3

Determining the Appropriate Mode of Transportation

	A.4.3.1		General

	A.4.3.1.1		If the criteria in Section A.4.2 of this Attachment are met, the CONTRACTOR shall determine what mode of transportation is appropriate to meet the needs of the member. The modes of transportation that shall be covered by the CONTRACTOR include, but are not limited to: fixed route, multi-passenger van, wheelchair van, invalid vehicle, and ambulance.

	A.4.3.1.2		In order to determine the appropriate mode of transportation, the CONTRACTOR shall:

	A.4.3.1.2.1		Determine whether the member is ambulatory and the member’s current level of mobility and functional independence;

	A.4.3.1.2.2		Determine whether the member will be accompanied by an escort, and, if so, whether the member requires assistance and whether the escort meets the requirements for an escort (see TennCare rules and regulations);

	A.4.3.1.2.3		Determine whether a member is under the age of eighteen (18) and will be accompanied by an adult; and

	A.4.3.1.2.4		Assess any special conditions or needs of the member, including physical or mental disabilities.

	A.4.3.2		Fixed Route

	A.4.3.2.1		The CONTRACTOR shall utilize fixed route transportation whenever available and appropriate to meet the needs of the member.

	A.4.3.2.2		The CONTRACTOR shall be familiar with schedules of fixed route transportation in communities where it is available and where it becomes available during the term of the Agreement.

	A.4.3.2.3		The CONTRACTOR shall distribute and/or arrange for the distribution of fixed route tickets, tokens or passes to members for whom fixed route transportation is available and appropriate. The CONTRACTOR shall have controls in place to track the distribution of tickets/tokens/passes. The CONTRACTOR shall use best efforts that tickets/tokens/passes are used appropriately.

Amendment Number 3 (cont.)

A.4.3.2.4

The CONTRACTOR shall consider the following when determining whether fixed route transportation is available and appropriate for a member:

	A.4.3.2.4.1		The furthest distance a member shall be required to travel to or from a fixed route transportation stop is one-quarter (1/4 ^th ) of a mile;

	A.4.3.2.4.2		The member shall not be required to change buses/trolleys more than once each leg of the trip;

	A.4.3.2.4.3		Using fixed route transportation shall not increase travel time more than sixty (60) minutes as compared to transportation directly from the pick-up location to the drop-off destination;

	A.4.3.2.4.4		The fixed route transportation schedule shall allow the member to arrive at the destination no more than sixty (60) minutes prior to the scheduled appointment time and shall be flexible on the return so that the member does not have to wait at the pick-up location more than sixty (60) minutes after the estimated time the appointment will end;

	A.4.3.2.4.5		Whether fixed route transportation is appropriate based on the member’s physical or mental disabilities; and

	A.4.3.2.4.6		Whether using fixed route for the requested trip is appropriate considering the accessibility of the stops and the safety in accessing the stops.

	A.4.3.2.5		Fixed route shall not be appropriate for a member whose physician states in writing that the member cannot use fixed route transportation.

	A.4.3.3		Ambulance

			The CONTRACTOR’s policies and procedures regarding the appropriateness of using an ambulance to provide covered NEMT services shall be based on Medicare’s medical necessity requirements (see, e.g., 42 CFR 410.40 and Medicare Benefit Policy Manual, Chapter 10 — Ambulance Services).

Amendment Number 3 (cont.)

A.4.4

Determining Level of Service

	A.4.4.1		The CONTRACTOR shall assess the member’s needs to determine whether the member requires curb-to-curb, door-to-door, or hand-to-hand service (as these terms are defined in Exhibit A of this Attachment).

	A.4.4.2		The CONTRACTOR may require a medical certification statement from the member’s provider in order to approve door-to-door or hand-to-hand service. Medical certification shall be completed within the timeframes specified in Section A.5.1.3 of this Attachment.

	A.4.4.3		The CONTRACTOR shall ensure that members receive the appropriate level of service.

	A.4.4.4		Failure to comply with requirements regarding level of service may result in liquidated damages as provided in Section 4.20.2 of the Agreement, Section A.20 of this Attachment, and/or Exhibit F of this Attachment.

A.4.5

Standing Orders

	A.4.5.1		Except as provided in this Section A.4.5, the approval of Standing Orders by the CONTRACTOR shall be consistent with the requirements in Sections A.4.1 through A.4.4.

	A.4.5.2		In order to approve a Standing Order (as defined in Exhibit A of this Attachment), the CONTRACTOR shall, at a minimum, call the provider to verify the series of appointments. The CONTRACTOR may, at its discretion, require that the member’s provider certify the series of appointments in writing.

	A.4.5.3		The CONTRACTOR shall approve Standing Orders consistent with the series of appointments. For example, if the member has a series of appointments over six (6) months, the CONTRACTOR shall approve transportation for each trip, including all legs of the trip, for the six (6) months. However, the CONTRACTOR shall verify the member’s eligibility prior to each pick-up. The CONTRACTOR may verify additional information before each pick-up as necessary.

A.4.6

Validating Requests

	A.4.6.1		The CONTRACTOR may conduct random pre-transportation validation checks prior to approving the request in order to prevent fraud and abuse.

	A.4.6.2		The CONTRACTOR may verify the need for an urgent trip with the provider prior to approving the trip.

	A.4.6.3		If requested by TENNCARE, the CONTRACTOR shall conduct pre-transportation validation checks of trips requested by specified members and/or to specific services or providers.

	A.4.6.4		All pre-transportation validation checks shall be conducted within the timeframes specified in Section A.5.1.3 of this Attachment.

Amendment Number 3 (cont.)

A.5		SCHEDULING, ASSIGNING, AND DISPATCHING TRIPS

A.5.1		General

	A.5.1.1		The CONTRACTOR shall ensure that covered NEMT services are available twenty-four (24) hours a day, three hundred and sixty-five (365) days a year.

	A.5.1.2		After approving a NEMT service to be provided by a NEMT provider (i.e., not fixed route), the CONTRACTOR shall schedule and assign the trip to an appropriate NEMT provider.

	A.5.1.3		The CONTRACTOR shall approve and schedule or deny a request for transportation (including all legs of the trip) within twenty-four (24) hours of receiving the request. This timeframe shall be reduced as necessary to ensure the member arrives in time for his/her appointment. Failure to comply with this requirement may result in liquidated damages as provided in Section 4.20.2 of the Agreement, Section A.20 of this Attachment, and/or Exhibit F of this Attachment.

	A.5.1.4		The CONTRACTOR shall ensure that trips are dispatched appropriately and meet the requirements of this Attachment. The dispatcher shall, at minimum, provide updated information to drivers, monitor drivers’ locations, and resolve pick-up and delivery issues.

A.5.2

Multi-Passenger Transportation

	A.5.2.1		The CONTRACTOR may group enrollees and trips (or legs of trips) to promote efficiency and cost effectiveness. The CONTRACTOR may contact providers if necessary to coordinate multi-passenger transportation.

	A.5.2.2		For multi-passenger trips, the CONTRACTOR shall schedule each trip leg so that a member does not remain in the vehicle for more than one (1) hour longer than the average travel time for direct transportation of that member.

A.5.3		Choice of NEMT Provider

		The CONTRACTOR is not required to use a particular NEMT provider or driver requested by the member. However, the CONTRACTOR may accommodate a member’s request to have or not have a specific NEMT provider or driver.

Amendment Number 3 (cont.)

A.5.4		Notifying Members of Arrangements

		If possible, the CONTRACTOR shall inform the member of the transportation arrangements (see below) during the phone call requesting the NEMT service. Otherwise, the CONTRACTOR shall obtain the member’s preferred method (e.g., phone call, email, fax) and time of contact, and the CONTRACTOR shall notify the member of the transportation arrangements (see below) as soon as the arrangements are in place (within the timeframe specified in Section A.5.1.3 of this Attachment) and prior to the date of the NEMT service. Information about transportation arrangements shall include but not be limited to the name and telephone number of the NEMT provider, the scheduled time and address of pick-up, and the name and address of the provider to whom the member seeks transport.

A.5.5		Notifying NEMT Providers

	A.5.5.1		The CONTRACTOR shall provide a trip manifest to each NEMT provider no later than the NEMT provider’s close of business the day before the date of the NEMT service.

	A.5.5.2		The CONTRACTOR shall have the ability to send trip manifests to a NEMT provider by a facsimile device or secure electronic transmission, at the option of the NEMT provider. The CONTRACTOR shall ensure that provision of the trip manifest is in compliance with HIPAA requirements (see Section 2.27 of the Agreement). The CONTRACTOR shall have dedicated telephone lines available at all ti

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