DSHS General Terms and Conditions

1. Definitions. ................................................................................................................................................ 6

2. Amendment............................................................................................................................................... 8

3. Assignment. .............................................................................................................................................. 8

4. Billing Limitations. ................................................................................................................................... 8

5. Compliance with Applicable Law. ........................................................................................................... 8

6. Confidentiality. ......................................................................................................................................... 8

7. Debarment Certification. ........................................................................................................................ 10

8. Governing Law and Venue. .................................................................................................................... 10

9. Independent Contractor. ........................................................................................................................ 10

10. Inspection. .............................................................................................................................................. 10

11. Maintenance of Records. ....................................................................................................................... 10

12. Order of Precedence. ............................................................................................................................. 10

13. Severability. ............................................................................................................................................ 11

14. Survivability. ........................................................................................................................................... 11

15. Contract Renegotiation, Suspension or Termination Due to Change in Funding. ............................ 11

16. Waiver. .................................................................................................................................................... 12

17. Construction ........................................................................................................................................... 12

18. Contractor Certification Regarding Ethics. .......................................................................................... 12

19. Health and Safety. .................................................................................................................................. 12

20. Indemnification and Hold Harmless. ................................................................................................... 102

21. Industrial Insurance Coverage. ........................................................................................................... 102

22. Notice of Overpayment. ......................................................................................................................... 13

23. Subcontracting. .................................................................................................................................... 113

24. Subrecipients. ....................................................................................................................................... 113

25. Terminations. ........................................................................................................................................ 124

26. Treatment of Client Property. ................................................................................................................ 15

27. Treatment of Property. ......................................................................................................................... 135

28. Taxes. .................................................................................................................................................... 135

29. HIPAA Compliance. ................................................................................................................................ 16

Special Terms and Conditions

1. Purpose. ................................................................................................................................................ 203

2. Statement of Work. ............................................................................................................................... 203

3. Comprehensive Assessment Reporting Evaluation (CARE). ............................................................ 203

4. Insurance. ............................................................................................................................................. 214

5. Disputes. ............................................................................................................................................... 237

6. Force Majeure. ...................................................................................................................................... 247

7. Mergers and Acquisitions. ................................................................................................................... 248

8. Notification of Organizational Changes. ............................................................................................. 258

9. Washington Public Disclosure Act. .................................................................................................... 258

10. Notices. ................................................................................................................................................. 258

11. Enrollment. ........................................................................................................................................... 269

12. Program Integrity. .................................................................................................................................. 32

13. Payment and Rate Setting. .................................................................................................................... 41

14. Provider Complaints and Appeals ...................................................................................................... 445

15. Policies and Procedures. ....................................................................................................................... 45

16. State Administering Agency Monitroing ............................................................................................... 45

17. Subcontracts .......................................................................................................................................... 46

18. Licensure ................................................................................................................................................ 47

19. Grievance and Appeals .......................................................................................................................... 47

20. Administrative Hearings ........................................................................................................................ 48

21. Marketing. ............................................................................................................................................... 51

22. Benefits. .................................................................................................................................................. 51

23. Care Management .................................................................................................................................. 52

24. Enrollee Rights and Access. ................................................................................................................. 52

25. Self-Directed Care .................................................................................................................................. 53

26. Access-Network. .................................................................................................................................. 553

27. Individual Providers (IP) ........................................................................................................................ 55

28. Collective Bargaining Agreements. ...................................................................................................... 56

29. Coordination with State Agency ............................................................................................................ 58

30. Reporting ................................................................................................................................................ 59

Exhibit A - Data Security Requirements

1. Definitions. .............................................................................................................................................. 60

2. Authority. ................................................................................................................................................ 62

3. Administrative Controls. ........................................................................................................................ 62

4. Authorization, Authentication, and Access .......................................................................................... 62

5. Protection of Data................................................................................................................................... 64

6. System Protection .................................................................................................................................. 67

7. Data Segregation .................................................................................................................................... 67

8. Data Disposition ..................................................................................................................................... 68

9. Notification of Compromise or Potential Compromise ........................................................................ 68

10. Data Shared with Subcontractors ......................................................................................................... 68

Exhibit B – PACE Program Agreement

APPENDIX A: NAMES AND CONTACT LIST .............................................................................................. 76

APPENDIX B: ORGANIZATIONAL STRUCTURE ......................................................................................... 77

APPENDIX C: SERVICE AREA AND PACE SITE(S) .................................................................................... 78

APPENDIX D: PARTICIPANT BILL OF RIGHTS........................................................................................... 79

APPENDIX E: ELIGIBILITY AND ENROLLMENT POLICIES AND CONTINUED ELIGIBILITY CRITERIA .. 81

APPENDIX F: ADDITIONAL ENROLLMENT CRITERIA ............................................................................... 84

APPENDIX G: VOLUNTARY DISENROLLMENT POLICY ............................................................................ 85

APPENDIX H: INVOLUNTARY DISENROLLMENT POLICY ........................................................................ 87

APPENDIX I: INTERNAL GRIEVANCE AND APPEAL PROCEDURES ..................................................... 90

APPENDIX J: ADDITIONAL APPEAL RIGHTS UNDER MEDICARE OR MEDICAID................................... 95

APPENDIX K: QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT PROGRAM ................... 99

APPENDIX L: PACE QUALITY REPORTING ............................................................................................. 102

APPENDIX M: MEDICARE AND MEDICAID PAYMENT AMOUNTS .......................................................... 103

APPENDIX N: STATE ENROLLMENT/DISENROLLMENT RECONCILIATION METHODOLOGY............. 106

APPENDIX O: TERMINATION PHASE - DOWN PLAN .................................... Error! Bookmark not defined.07

APPENDIX P: SAA ENROLLMENT PROCESS .......................................................................................... 108

APPENDIX Q: SAA OVERSIGHT OF PO ADMINISTRATION OF SAFETY CRITERIA .............................. 109

APPENDIX R: INFORMATION TO BE PROVIDED BY THE SAA TO ENROLLEES .................................. 111

APPENDIX S: SAA DISENROLLMENT PROCESS .................................................................................... 112

APPENDIX T: REGULATORY WAIVERS ................................................................................................... 113

APPENDIX U: MEDICARE PART D ............................................................................................................. 114

Exhibit C - King County Per Member Per Month PACE Rates

King County Per Member Per Month PACE Rates .................................................................................... 121

Exhibit D – Data Collection Template

Washington PACE Financial Reporting Template ..................................................................................... 122

Exhibit E – Data Elements Template

PACE Data Elements Template ................................................................................................................. 123

Exhibit F – Forecast Report Template

PACE Forecast Reports Template .............................................................................................................. 124

1. Definitions.

The words and phrases listed below, as used in this Contract, shall each have the following definitions:

1.1. “Care Management” means a set of services designed to improve the health of Enrollees. Care management includes a health assessment, development of a care plan and monitoring of Enrollee status, care coordination, ongoing reassessment and consultation and crisis intervention and case conferencing as needed to facilitate improved outcomes and appropriate use of health services,. Effective care management includes the following:

Actively assisting Enrollees to navigate the health delivery system, acquire self-care

skills to improve functioning and health outcomes, and slow the progression of disease

or disability;

Utilization of evidence-based clinical practices in screening and intervention;

Coordination of care across the continuum of medical, behavioral health, oral health,

and long-term services and supports, including tracking referrals and outcomes of

referrals;

Ready access to behavioral health and physical health services; and

Use of appropriate community resources to support individual Enrollees, families and

caregivers in managing care

1.2. “Central Contract and Legal Services” means the DSHS central headquarters contracting office, or successor section or office.

1.3. “Confidential Information” or “Data” means information that is exempt from disclosure to the public or other unauthorized persons under chapter 42.56 RCW or other federal or state laws. Confidential Information includes, but is not limited to, Personal Information.

1.4. “Contract” or “Agreement” means the entire written agreement between DSHS and the Contractor, including any Exhibits, documents, or materials incorporated by reference. The parties may execute this contract in multiple counterparts, each of which is deemed an original and all of which constitute only one agreement. E-mail or Facsimile transmission of a signed copy of this contract shall be the same as delivery of an original.

1.5. “CCLS Chief” means the manager, or successor, of Central Contracts and Legal Services or successor section or office.

1.6. “Contractor” means the individual or entity performing services pursuant to this Contract and includes the Contractor’s owners, members, officers, directors, partners, employees, and/or agents, unless otherwise stated in this Contract. For purposes of any permitted Subcontract, “Contractor” includes any Subcontractor and its owners, members, officers, directors, partners, employees, and/or agents.

1.7. “Debarment” means an action taken by a Federal agency or official to exclude a person or business entity from participating in transactions involving certain federal funds.

1.8. “DSHS” or the “Department” means the state of Washington Department of Social and Health Services and its employees and authorized agents.

1.9. “Encrypt” means to encode Confidential Information into a format that can only be read by those

possessing a “key”; a password, digital certificate or other mechanism available only to authorized users. Encryption must use a key length of at least 128 bits.

1.10. “Health Care Authority” means the State of Washington Health Care Authority and its employees and authorized agents.

1.11. “Personal Information” means information identifiable to any person, including, but not limited to, information that relates to a person’s name, health, finances, education, business, use or receipt of governmental services or other activities, addresses, telephone numbers, Social Security Numbers, driver license numbers, other identifying numbers, and any financial identifiers.

1.12. “Physically Secure” means that access is restricted through physical means to authorized individuals only.

1.13. “Program Integrity” means a system of reasonable and consistent oversight of the Medicaid program. Program Integrity effectively encourages compliance; maintains accountability; protects public funds; supports awareness and responsibility; ensures providers, contractors and subcontractors meet participation requirements; ensures services are medically necessary; and ensures payments are for the correct amount and for covered services. The goal of Program Integrity is to reduce and eliminate Fraud, Waste and Abuse (FWA) in the Medicaid program. Program Integrity activities include prevention, algorithms, investigations, audits, reviews, recovery of improper payments, education, and cooperation with Medicaid Fraud Control Unit, and other state and federal agencies. See chapter 182-502A WAC.

1.14. “RCW” means the Revised Code of Washington. All references in this Contract to RCW chapters or sections shall include any successor, amended, or replacement statute. Pertinent RCW chapters can be accessed at http://apps.leg.wa.gov/rcw/.

1.15. “Regulation” means any federal, state, or local regulation, rule, or ordinance.

1.16. “Secured Area” means an area to which only authorized representatives of the entity possessing the Confidential Information have access. Secured Areas may include buildings, rooms or locked storage containers (such as a filing cabinet) within a room, as long as access to the Confidential Information is not available to unauthorized personnel.

1.17. “Subcontract” means any separate agreement or contract between the Contractor and an individual or entity (“Subcontractor”) to perform all or a portion of the duties and obligations that the Contractor is obligated to perform pursuant to this Contract.

1.18. “Tracking” means a record keeping system that identifies when the sender begins delivery of Confidential Information to the authorized and intended recipient, and when the sender receives confirmation of delivery from the authorized and intended recipient of Confidential Information.

1.19. “Trusted Systems” include only the following methods of physical delivery: (1) hand-delivery by a person authorized to have access to the Confidential Information with written acknowledgement of receipt; (2) United States Postal Service (“USPS”) first class mail, or USPS delivery services that include Tracking, such as Certified Mail, Express Mail or Registered Mail; (3) commercial delivery services (e.g. FedEx, UPS, DHL) which offer tracking and receipt confirmation; and (4) the Washington State Campus mail system. For electronic transmission, the Washington State Governmental Network (SGN) is a Trusted System for communications within that Network.

1.20. “WAC” means the Washington Administrative Code. All references in this Contract to WAC chapters or sections shall include any successor, amended, or replacement regulation. Pertinent WAC chapters or sections can be accessed at http://apps.leg.wa.gov/wac/.

2. Amendment.

This Contract may only be modified by a written amendment signed by both parties. Only personnel authorized to bind each of the parties may sign an amendment.

3. Assignment.

The Contractor shall not assign this Contract to a third party without the prior written consent of DSHS.

4. Billing Limitations.

4.1. DSHS shall pay the Contractor only for authorized services provided in accordance with this Contract.

4.2. DSHS shall not pay any claims for payment for services submitted more than twelve (12) months after the calendar month in which the services were performed.

4.3. The Contractor shall not bill and DSHS shall not pay for services performed under this Contract, if the Contractor has charged or will charge another agency of the state of Washington or any other party for the same services.

5. Compliance with Applicable Law.

At all times during the term of this Contract, the Contractor shall comply with all applicable federal, state, and local laws and regulations, including but not limited to, nondiscrimination laws and regulations.

6. Confidentiality.

6.1. The Contractor shall not use, publish, transfer, sell or otherwise disclose any Confidential Information gained by reason of this Contract for any purpose that is not directly connected with Contractor’s performance of the services contemplated hereunder, except:

6.1.1. as provided by law; or,

6.1.2. in the case of Personal Information, with the prior written consent of the person or personal representative of the person who is the subject of the Personal Information.

6.2. The Contractor shall protect and maintain all Confidential Information gained by reason of this Contract against unauthorized use, access, disclosure, modification or loss. This duty requires the Contractor to employ reasonable security measures, which include restricting access to the Confidential Information by:

6.2.1. Allowing access only to staff that have an authorized business requirement to view the Confidential Information.

6.2.2. Physically Securing any computers, documents, or other media containing the Confidential Information.

6.2.3. Ensure the security of Confidential Information transmitted via fax (facsimile) by:

6.2.3.1. Verifying the recipient phone number to prevent accidental transmittal of Confidential Information to unauthorized persons.

6.2.3.2. Communicating with the intended recipient before transmission to ensure that the

fax will be received only by an authorized person.

6.2.3.3. Verifying after transmittal that the fax was received by the intended recipient.

6.2.4. When transporting six (6) or more records containing Confidential Information, outside a Secured Area, do one or more of the following as appropriate:

6.2.4.1. Use a Trusted System.

6.2.4.2. Encrypt the Confidential Information, including:

6.2.4.2.1. Encrypting email and/or email attachments that contain the Confidential Information.

6.2.4.2.2. Encrypting Confidential Information when it is stored on portable devices or media, including but not limited to laptop computers and flash memory devices.

Note: If the DSHS Data Security Requirements Exhibit is attached to this contract, this item, 6.b.(4), is superseded by the language contained in the Exhibit.

6.2.5. Send paper documents containing Confidential Information via a Trusted System.

6.2.6. Following the requirements of the DSHS Data Security Requirements Exhibit, if attached to this Contract.

6.3. Upon request by DSHS, at the end of the Contract term, or when no longer needed, Confidential Information shall be returned to DSHS or Contractor shall certify in writing that they employed a DSHS approved method to destroy the information. Contractor may obtain information regarding approved destruction methods from the DSHS contact identified on the cover page of this Contract.

6.4. Paper documents with Confidential Information may be recycled through a contracted firm, provided the contract with the recycler specifies that the confidentiality of information will be protected, and the information destroyed through the recycling process. Paper documents containing Confidential Information requiring special handling (e.g. protected health information) must be destroyed on-site through shredding, pulping, or incineration.

6.5. Notification of Compromise or Potential Compromise. The compromise or potential compromise of Confidential Information must be reported to the DSHS Contact designated on the contract within one (1) business day of discovery. Contractor must also take actions to mitigate the risk of loss and comply with any notification or other requirements imposed by law or DSHS.

7. Debarment Certification.

The Contractor, by signature to this Contract, certifies that the Contractor is not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded by any Federal department or agency from participating in transactions (Debarred). The Contractor also agrees to include the above requirement in any and all Subcontracts into which it enters. The Contractor shall immediately notify DSHS if, during the term of this Contract, Contractor becomes Debarred. DSHS may immediately terminate this Contract by providing Contractor written notice if Contractor becomes Debarred during the term hereof.

8. Governing Law and Venue.

This Contract shall be construed and interpreted in accordance with the laws of the state of Washington and the venue of any action brought hereunder shall be in Superior Court for Thurston County.

9. Independent Contractor.

The parties intend that an independent contractor relationship will be created by this Contract. The Contractor and his or her employees or agents performing under this Contract are not employees or agents of the Department. The Contractor, his or her employees, or agents performing under this Contract will not hold himself/herself out as, nor claim to be, an officer or employee of the Department by reason hereof, nor will the Contractor, his or her employees, or agent make any claim of right, privilege or benefit that would accrue to such officer or employee.

10. Inspection.

The Contractor shall, at no cost, provide DSHS and the Office of the State Auditor with reasonable access to Contractor’s place of business, Contractor’s records, and DSHS client records, wherever located. These inspection rights are intended to allow DSHS and the Office of the State Auditor to monitor, audit, and evaluate the Contractor’s performance and compliance with applicable laws, regulations, and these Contract terms. These inspection rights shall survive for six (6) years following this Contract’s termination or expiration.

11. Maintenance of Records.

The Contractor shall maintain records relating to this Contract and the performance of the services described herein. The records include, but are not limited to, accounting procedures and practices, which sufficiently and properly reflect all direct and indirect costs of any nature expended in the performance of this Contract. All records and other material relevant to this Contract shall be retained for six (6) years after expiration or termination of this Contract.

Without agreeing that litigation or claims are legally authorized, if any litigation, claim, or audit is started before the expiration of the six (6) year period, the records shall be retained until all litigation, claims, or audit findings involving the records have been resolved.

12. Order of Precedence.

In the event of any inconsistency or conflict between the General Terms and Conditions and the Special Terms and Conditions of this Contract, the inconsistency or conflict shall be resolved by giving precedence to these General Terms and Conditions. Terms or conditions that are more restrictive, specific, or particular than those contained in the General Terms and Conditions shall not be construed as being inconsistent or in conflict.

13. Severability.

If any term or condition of this Contract is held invalid by any court, the remainder of the Contract remains valid and in full force and effect.

14. Survivability.

The terms and conditions contained in this Contract which, by their sense and context, are intended to survive the expiration or termination of the particular agreement shall survive. Surviving terms include, but are not limited to: Billing Limitations; Confidentiality, Disputes; Indemnification and Hold Harmless, Inspection, Maintenance of Records, Notice of Overpayment, Ownership of Material, Termination for Default, Termination Procedure, and Treatment of Property.

15. Contract Renegotiation, Suspension or Termination Due to Change in Funding.

If the funds DSHS relied upon to establish this Contract are withdrawn, reduced or limited, or if additional or modified conditions are placed on such funding, after the effective date of this Contract but prior to the normal completion of this Contract:

15.1. At DSHS’ discretion, the Contract may be renegotiated under the revised funding conditions.

15.2. DSHS’ discretion, DSHS may give notice to Contractor to suspend performance when DSHS determines that there is reasonable likelihood that the funding insufficiency may be resolved in a timeframe that would allow Contractor’s performance to be resumed prior to the normal completion date of this Contract.

15.2.1. During the period of suspension of performance, each party will inform the other of any conditions that may reasonably affect the potential for resumption of performance.

15.2.2. When DSHS determines that the funding insufficiency is resolved, it will give Contractor written notice to resume performance. Upon the receipt of this notice, contractor will provide written notice to DSHS informing DSHS whether it can resume performance and, if so, the date of resumption. For purposes of this subsection, “written notice” may include email.

15.2.3. If the Contractor’s proposed resumption date is not acceptable to DSHS and an acceptable date cannot be negotiated, DSHS may terminate the contract by giving written notice to contractor. The parties agree that the Contract will be terminated retroactive to the date of notice of suspension. DSHS shall be liable only for payment in accordance with the terms of this Contract for services rendered prior to the retroactive date of termination.

15.3. DSHS may immediately terminate this contract by providing written notice to the Contractor. The termination shall be effective on the date specified in the termination notice. DSHS shall be liable only for payment in accordance with the terms of this contract for service rendered prior to the effective date of termination. No penalty shall accrue to DSHS in the event the termination option in this section is exercised.

16. Waiver.

Waiver of any breach or default on any occasion shall not be deemed to be a waiver of any subsequent breach or default. Any waiver shall not be construed to be a modification of the terms and conditions of this Contract. Only the CCLS Chief or designee has the authority to waive any term or condition of this Contract on behalf of DSHS.

Additional General Terms and Conditions – Client Service Contracts

17. Construction.

The language in this Contract shall be interpreted as to its fair meaning and not strictly for or against any party. Any rule of construction to the effect that ambiguities are to be resolved against the drafting party shall not apply in interpreting this Contract.

18. Contractor Certification Regarding Ethics.

The Contractor certifies that the Contractor is now, and shall remain, in compliance with chapter 42.52 RCW, Ethics in Public Service, throughout the term of this Contract.

19. Health and Safety.

Contractor shall perform any and all of its obligations under this Contract in a manner that does not compromise the health and safety of any DSHS client with whom the Contractor has contact.

20. Indemnification and Hold Harmless.

20.1. The Contractor shall be responsible for and shall indemnify, defend, and hold DSHS harmless from any and all claims, costs, charges, penalties, demands, losses, liabilities, damages, judgments, or fines, of whatsoever kind of nature, arising out of or relating to a) the Contractor’s or any Subcontractor’s performance or failure to perform this Contract, or b) the acts or omissions of the Contractor or any Subcontractor.

20.2. The Contractor’s duty to indemnify, defend, and hold DSHS harmless from any and all claims, costs, charges, penalties, demands, losses, liabilities, damages, judgments, or fines shall include DSHS’ personnel-related costs, reasonable attorney’s fees, court costs, and all related expenses.

20.3. The Contractor waives its immunity under Title 51 RCW to the extent it is required to indemnify, defend, and hold harmless the State and its agencies, officials, agents, or employees.

20.4. Nothing in this term shall be construed as a modification or limitation on the Contractor’s obligation to procure insurance in accordance with this Contract or the scope of said insurance.

21. Industrial Insurance Coverage.

The Contractor shall comply with the provisions of Title 51 RCW, Industrial Insurance. If the Contractor fails to provide industrial insurance coverage or fails to pay premiums or penalties on behalf of its employees, as may be required by law, DSHS may collect from the Contractor the full amount payable to the Industrial Insurance accident fund. DSHS may deduct the amount owed by the Contractor to the accident fund from the amount payable to the Contractor by DSHS under this contract, and transmit the deducted amount to the Department of Labor and Industries, (L&I) Division of Insurance Services. This provision does not waive any of L&I’s rights to collect from the Contractor.

22. Notice of Overpayment.

If the Contractor receives a vendor overpayment notice or a letter communicating the existence of an overpayment from DSHS, the Contractor may protest the overpayment determination by requesting an adjudicative proceeding. The Contractor’s request for an adjudicative proceeding must:

22.1. Be received by the Office of Financial Recovery (OFR) at Post Office Box 9501, Olympia, Washington 98507-9501, within twenty-eight (28) calendar days of service of the notice;

22.2. Be sent by certified mail (return receipt) or other manner that proves OFR received the request;

22.3. Include a statement as to why the Contractor thinks the notice is incorrect; and

22.4. Include a copy of the overpayment notice.

Timely and complete requests will be scheduled for a formal hearing by the Office of Administrative Hearings. The Contractor may be offered a pre-hearing or alternative dispute resolution conference in an attempt to resolve the overpayment dispute prior to the hearing.

Failure to provide OFR with a written request for a hearing within twenty-eight (28) days of service of a vendor overpayment notice or other overpayment letter will result in an overpayment debt against the

Contractor. DSHS may charge the Contractor interest and any costs associated with the collection of this overpayment. DSHS may collect an overpayment debt through lien, foreclosure, seizure and sale of the Contractor’s real or personal property; order to withhold and deliver; or any other collection action available to DSHS to satisfy the overpayment debt.

23. Subcontracting.

Upon execution of this Contract, the Contractor shall submit a list of current subcontractors for DSHS approval. Any changes to the list must be submitted for DSHS approval within fourteen (14) days. The Contractor is responsible to ensure that all terms, conditions, assurances and certifications set forth in this Contract are included in any and all Subcontracts. Any failure of Contractor or its subcontractors to perform the obligations of this Contract shall not discharge the Contractor from its obligations hereunder or diminish DSHS’ rights or remedies available under this Contract.

24. Subrecipients.

24.1. General. If the Contractor is a subrecipient of federal awards as defined by 2 CFR Part 200 and this Contract, the Contractor shall:

24.1.1. Maintain records that identify, in its accounts, all federal awards received and expended and the federal programs under which they were received, by Catalog of Federal Domestic Assistance (CFDA) title and number, award number and year, name of the federal agency, and name of the pass-through entity;

24.1.2. Maintain internal controls that provide reasonable assurance that the Contractor is managing federal awards in compliance with laws, regulations, and provisions of contracts or grant agreements that could have a material effect on each of its federal programs;

24.1.3. Prepare appropriate financial statements, including a schedule of expenditures of federal awards;

24.1.4. Incorporate 2 CFR Part 200, Subpart F audit requirements into all agreements between the Contractor and its Subcontractors who are subrecipients;

24.1.5. Comply with the applicable requirements of 2 CFR Part 200, including any future amendments to 2 CFR Part 200, and any successor or replacement Office of Management and Budget (OMB)Circular or regulation; and

24.1.6. Comply with the Omnibus Crime Control and Safe streets Act of 1968, Title VI of the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, Title II of the Americans with Disabilities Act of 1990, Title IX of the Education Amendments of 1972, The Age Discrimination Act of 1975, and The Department of Justice Non-Discrimination Regulations, 28 C.F.R. Part 42, Subparts C.D.E. and G, and 28 C.F.R. Part 35 and 39. (Go to https://ojp.gov/about/offices/ocr.htm for additional information and access to the aforementioned Federal laws and regulations.)

24.2. Single Audit Act Compliance.

If the Contractor is a subrecipient and expends $750,000 or more in federal awards from all sources in any fiscal year, the Contractor shall procure and pay for a single audit or a program-specific audit for that fiscal year. Upon completion of each audit, the Contractor shall:

24.2.1. Submit to the DSHS contact person the data collection form and reporting package specified in 2 CFR Part 200, Subpart F, reports required by the program-specific audit

guide (if applicable), and a copy of any management letters issued by the auditor;

24.2.2. Follow-up and develop corrective action for all audit findings; in accordance with 2 CFR Part 200, Subpart F, prepare a “Summary Schedule of Prior Audit Findings” reporting the status of all audit findings included in the prior audit’s schedule of findings and questioned costs

24.3. Overpayments.

If it is determined by DSHS, or during the course of a required audit, that the Contractor has been paid unallowable costs under this Contract, DSHS may require the Contractor to reimburse DSHS in accordance with either 2 CFR Part 200.

25. Terminations.

25.1. Termination for Default.

25.1.1. Termination by Contractor. The Contractor may terminate this Contract whenever DSHS defaults in performance of the Contract and fails to cure the default within a period of one hundred twenty (120) calendar days (or such longer period as the Contractor may allow) after receipt from the Contractor of a written notice, as described in the Notices section of the General Terms and Conditions, specifying the default. For purposes of this Section, “default” means failure of DSHS to meet one or more material obligations of this Contract. In the event it is determined that DSHS was not in default, DSHS may claim damages for wrongful termination through the dispute resolution provisions of this Contract or by a court of competent jurisdiction.

25.1.2. Termination by DSHS. DSHS may terminate this Contract whenever the Contractor defaults in performance of this Contract and fails to cure the default within a period of one hundred twenty (120) calendar days (or such longer period as DSHS may allow) after receipt from DSHS of a written notice, as described in the Notices section of the General Terms and Conditions, specifying the default. For purposes of this Section, “default” means failure of the Contractor to meet one or more material obligations of this Contract. In the event it is determined that the Contractor was not in default, the Contractor may claim damages for wrongful termination through the dispute resolution provisions of this Contract or by a court of competent jurisdiction.

25.2. Termination for Convenience.

25.2.1. Termination by DSHS. Notwithstanding any other provision of this Contract, the DSHS may, by giving thirty (30) calendar days written notice, beginning on the second day after the mailing, terminate this Contract in whole or in part when it is in the best interest of DSHS, as determined by DSHS in its sole discretion. If this Contract is so terminated, DSHS shall be liable only for payment in accordance with the terms of this contract for services rendered prior to the effective date of termination.

25.2.2. Termination by Contractor. The effective date of any termination shall be ninety (90) days from the date of the Contractor's written notice, unless the Department determines that an orderly disenrollment to Medicaid fee-for-service or transfer to another managed long-term care plan can be accomplished in fewer days.

26. Treatment of Client Property.

Unless otherwise provided, the Contractor shall ensure that any adult client receiving services from the

Contractor has unrestricted access to the client’s personal property. The Contractor shall not interfere with any adult client’s ownership, possession, or use of the client’s property. The Contractor shall provide clients under age eighteen (18) with reasonable access to their personal property that is appropriate to the client’s age, development, and needs. Upon termination of services to a client, the Contractor shall immediately release to the client and/or the client’s guardian or custodian all of the client’s personal property.

27. Treatment of Property.

All property purchased or furnished by DSHS for use by the Contractor during this Contract term shall remain with DSHS. Title to all property purchased or furnished by the Contractor for which the Contractor is entitled to reimbursement by DSHS under this Contract shall pass to and vest in DSHS. The Contractor shall protect, maintain, and insure all DSHS property in its possession against loss or damage and shall return DSHS property to DSHS upon Contract termination or expiration.

28. Taxes.

28.1. Where required by statute or regulation, Contractor shall pay for and maintain in current status all taxes that are necessary for Contract performance. DSHS will pay sales or use taxes, if any, imposed on the services and materials acquired hereunder. Contractor must pay all other taxes including without limitation Washington Business and Occupation Tax, other taxes based on Contractor’s income or gross receipts, or personal property taxes levied or assessed on Contractor’s personal property. DSHS, as an agency of Washington State government, is exempt from property tax.

28.2. Contractor shall complete registration with the Washington State Department of Revenue and be responsible for payment of all taxes due on payments made under this Contract in accordance with the requirements of Title 82 RCW and Title 458 WAC. Out-of-state Contractors must contact the Department of Revenue to determine whether they meet criteria to register and establish an account with the Department of Revenue. Refer to WAC 458-20-101 (tax registration and tax reporting) and call the Department of Revenue at 800-647-7706 for additional information. When out-of-state Contractors are not required to collect and remit sales tax, DSHS shall be responsible for paying use tax, if applicable, directly to the Department of Revenue.

28.3. All payments accrued on account of payroll taxes, unemployment contributions, any other taxes, insurance, or other expenses for Contractor or Contractor’s staff shall be Contractor’s sole responsibility.

29. HIPAA Compliance.

This section of the Contract is the Business Associate Agreement as required by HIPAA.

29.1. Definitions.

29.1.1. “Business Associate,” as used in this Contract, means the “Contractor” and generally has the same meaning as the term “business associate” at 45 CFR 160.103. Any reference to Business Associate in this Contract includes Business Associate’s employees, agents, officers, Subcontractors, third party contractors, volunteers, or directors.

29.1.2. “Business Associate Agreement” means this HIPAA Compliance section of the Contract and includes the Business Associate provisions required by the U.S. Department of Health and Human Services, Office for Civil Rights.

29.1.3. “Breach” means the acquisition, access, use, or disclosure of Protected Health Information

in a manner not permitted under the HIPAA Privacy Rule which compromises the security or privacy of the Protected Health Information, with the exclusions and exceptions listed in 45 CFR 164.402.

29.1.4. “Covered Entity” means DSHS, a Covered Entity as defined at 45 CFR 160.103, in its conduct of covered functions by its health care components.

29.1.5. “Designated Record Set” means a group of records maintained by or for a Covered Entity, that is: the medical and billing records about Individuals maintained by or for a covered health care provider; the enrollment, payment, claims adjudication, and case or medical management record systems maintained by or for a health plan; or Used in whole or part by or for the Covered Entity to make decisions about Individuals.

29.1.6. “Electronic Protected Health Information (EPHI)” means Protected Health Information that is transmitted by electronic media or maintained in any medium described in the definition of electronic media at 45 CFR 160.103.

29.1.7. “HIPAA” means the Health Insurance Portability and Accountability Act of 1996, Pub. L. 104-191, as modified by the American Recovery and Reinvestment Act of 2009 (“ARRA”), Sec. 13400 – 13424, H.R. 1 (2009) (HITECH Act).

29.1.8. “HIPAA Rules” means the Privacy, Security, Breach Notification, and Enforcement Rules at 45 CFR Parts 160 and Part 164.

29.1.9. “Individual(s)” means the person(s) who is the subject of PHI and includes a person who qualifies as a personal representative in accordance with 45 CFR 164.502(g).

29.1.10. “Minimum Necessary” means the least amount of PHI necessary to accomplish the purpose for which the PHI is needed.

29.1.11. “Protected Health Information (PHI)” means individually identifiable health information created, received, maintained or transmitted by Business Associate on behalf of a health care component of the Covered Entity that relates to the provision of health care to an Individual; the past, present, or future physical or mental health or condition of an Individual; or the past, present, or future payment for provision of health care to an Individual. 45 CFR 160.103. PHI includes demographic information that identifies the Individual or about which there is reasonable basis to believe can be used to identify the Individual. 45 CFR 160.103. PHI is information transmitted or held in any form or medium and includes EPHI. 45 CFR 160.103. PHI does not include education records covered by the Family Educational Rights and Privacy Act, as amended, 20 USCA 1232g(a)(4)(B)(iv) or employment records held by a Covered Entity in its role as employer.

29.1.12. “Security Incident” means the attempted or successful unauthorized access, use, disclosure, modification or destruction of information or interference with system operations in an information system.

29.1.13. “Subcontractor” as used in this HIPAA Compliance section of the Contract (in addition to its definition in the General Terms and Conditions) means a Business Associate that creates, receives, maintains, or transmits Protected Health Information on behalf of another Business Associate.

29.1.14. “Use” includes the sharing, employment, application, utilization, examination, or analysis, of PHI within an entity that maintains such

information.

29.2. Compliance. Business Associate shall perform all Contract duties, activities and tasks in compliance with HIPAA, the HIPAA Rules, and all attendant regulations as promulgated by the U.S. Department of Health and Human Services, Office of Civil Rights.

29.3. Use and Disclosure of PHI. Business Associate is limited to the following permitted and required uses or disclosures of PHI:

29.3.1. Duty to Protect PHI. Business Associate shall protect PHI from, and shall use appropriate safeguards, and comply with Subpart C of 45 CFR Part 164 (Security Standards for the Protection of Electronic Protected Health Information) with respect to EPHI, to prevent the unauthorized Use or disclosure of PHI other than as provided for in this Contract or as required by law, for as long as the PHI is within its possession and control, even after the termination or expiration of this Contract.

29.3.2. Minimum Necessary Standard. Business Associate shall apply the HIPAA Minimum Necessary standard to any Use or disclosure of PHI necessary to achieve the purposes of this Contract. See 45 CFR 164.514 (d)(2) through (d)(5).

29.3.3. Disclosure as Part of the Provision of Services. Business Associate shall only Use or disclose PHI as necessary to perform the services specified in this Contract or as required by law, and shall not Use or disclose such PHI in any manner that would violate Subpart E of 45 CFR Part 164 (Privacy of Individually Identifiable Health Information) if done by Covered Entity, except for the specific uses and disclosures set forth below.

29.3.4. Use for Proper Management and Administration. Business Associate may Use PHI for the proper management and administration of the Business Associate or to carry out the legal responsibilities of the Business Associate.

29.3.5. Disclosure for Proper Management and Administration. Business Associate may disclose PHI for the proper management and administration of Business Associate or to carry out the legal responsibilities of the Business Associate, provided the disclosures are required by law, or Business Associate obtains reasonable assurances from the person to whom the information is disclosed that the information will remain confidential and used or further disclosed only as required by law or for the purposes for which it was disclosed to the person, and the person notifies the Business Associate of any instances of which it is aware in which the confidentiality of the information has been Breached.

29.3.6. Impermissible Use or Disclosure of PHI. Business Associate shall report to DSHS in writing all Uses or disclosures of PHI not provided for by this Contract within one (1) business day of becoming aware of the unauthorized Use or disclosure of PHI, including Breaches of unsecured PHI as required at 45 CFR 164.410 (Notification by a Business Associate), as well as any Security Incident of which it becomes aware. Upon request by DSHS, Business Associate shall mitigate, to the extent practicable, any harmful effect resulting from the impermissible Use or disclosure.

29.3.7. Failure to Cure. If DSHS learns of a pattern or practice of the Business Associate that constitutes a violation of the Business Associate’s obligations under the terms of this Contract and reasonable steps by DSHS do not end the violation, DSHS shall terminate this Contract, if feasible. In addition, If Business Associate learns of a pattern or practice of its Subcontractors that constitutes a violation of the Business Associate’s obligations under the terms of their contract and reasonable steps by the Business Associate do not end the violation, Business Associate shall terminate the Subcontract, if feasible.

29.3.8. Termination for Cause. Business Associate authorizes immediate termination of this Contract by DSHS, if DSHS determines that Business Associate has violated a material term of this Business Associate Agreement. DSHS may, at its sole option, offer Business Associate an opportunity to cure a violation of this Business Associate Agreement before exercising a termination for cause.

29.3.9. Consent to Audit. Business Associate shall give reasonable access to PHI, its internal practices, records, books, documents, electronic data and/or all other business information received from, or created or received by Business Associate on behalf of DSHS, to the Secretary of DHHS and/or to DSHS for use in determining compliance with HIPAA privacy requirements.

29.3.10. Obligations of Business Associate Upon Expiration or Termination. Upon expiration or termination of this Contract for any reason, with respect to PHI received from DSHS, or created, maintained, or received by Business Associate, or any Subcontractors, on behalf of DSHS, Business Associate shall:

29.3.10.1. Retain only that PHI which is necessary for Business Associate to continue its proper management and administration or to carry out its legal responsibilities;

29.3.10.2. Return to DSHS or destroy the remaining PHI that the Business Associate or any Subcontractors still maintain in any form;

29.3.10.3. Continue to use appropriate safeguards and comply with Subpart C of 45 CFR Part 164 (Security Standards for the Protection of Electronic Protected Health Information) with respect to Electronic Protected Health Information to prevent Use or disclosure of the PHI, other than as provided for in this Section, for as long as Business Associate or any Subcontractors retain the PHI;

29.3.10.4. Not Use or disclose the PHI retained by Business Associate or any Subcontractors other than for the purposes for which such PHI was retained and subject to the same conditions set out in the “Use and Disclosure of PHI” section of this Contract which applied prior to termination; and

29.3.10.5. Return to DSHS or destroy the PHI retained by Business Associate, or any Subcontractors, when it is no longer needed by Business Associate for its proper management and administration or to carry out its legal responsibilities.

29.3.11. Survival. The obligations of the Business Associate under this section shall survive the termination or expiration of this Contract.

29.4. Individual Rights.

29.4.1. Accounting of Disclosures

29.4.1.1. Business Associate shall document all disclosures, except those disclosures that are exempt under 45 CFR 164.528, of PHI and information related to such disclosures.

29.4.1.2. Within ten (10) business days of a request from DSHS, Business Associate shall make available to DSHS the information in Business Associate’s possession that is necessary for DSHS to respond in a timely manner to a request for an accounting of disclosures of PHI by the Business Associate. See 45 CFR 164.504(e)(2)(ii)(G) and 164.528(b)(1).

29.4.1.3. At the request of DSHS or in response to a request made directly to the Business Associate by an Individual, Business Associate shall respond, in a timely manner and in accordance with HIPAA and the HIPAA Rules, to requests by Individuals for an accounting of disclosures of PHI.

29.4.1.4. Business Associate record keeping procedures shall be sufficient to respond to a request for an accounting under this section for the six (6) years prior to the date on which the accounting was requested.

29.4.2. Access.

29.4.2.1. Business Associate shall make available PHI that it holds that is part of a Designated Record Set when requested by DSHS or the Individual as necessary to satisfy DSHS’s obligations under 45 CFR 164.524 (Access of Individuals to Protected Health Information).

29.4.2.2. When the request is made by the Individual to the Business Associate or if DSHS asks the Business Associate to respond to a request, the Business Associate shall comply with requirements in 45 CFR 164.524 (Access of Individuals to Protected Health Information) on form, time and manner of access. When the request is made by DSHS, the Business Associate shall provide the records to DSHS within ten (10) business days.

29.4.3. Amendment.

29.4.3.1. If DSHS amends, in whole or in part, a record or PHI contained in an Individual’s Designated Record Set and DSHS has previously provided the PHI or record that is the subject of the amendment to Business Associate, then DSHS will inform Business Associate of the amendment pursuant to 45 CFR 164.526(c)(3) (Amendment of Protected Health Information).

29.4.3.2. Business Associate shall make any amendments to PHI in a Designated Record Set as directed by DSHS or as necessary to satisfy DSHS’s obligations under 45 CFR 164.526 (Amendment of Protected Health Information).

29.5. Subcontracts and other Third Party Agreements. In accordance with 45 CFR 164.502(e)(1)(ii), 164.504(e)(1)(i), and 164.308(b)(2), Business Associate shall ensure that any agents, Subcontractors, independent contractors or other third parties that create, receive, maintain, or transmit PHI on Business Associate’s behalf, enter into a written contract that contains the same terms, restrictions, requirements, and conditions as the HIPAA compliance provisions in this Contract with respect to such PHI. The same provisions must also be included in any contracts by a Business Associate’s Subcontractor with its own business associates as required by 45 CFR 164.314(a)(2)(b) and 164.504(e)(5) .

29.6. Obligations. To the extent the Business Associate is to carry out one or more of DSHS’s obligation(s) under Subpart E of 45 CFR Part 164 (Privacy of Individually Identifiable Health Information), Business Associate shall comply with all requirements that would apply to DSHS in the performance of such obligation(s).

29.7. Liability. Within ten (10) business days, Business Associate must notify DSHS of any complaint, enforcement or compliance action initiated by the Office for Civil Rights based on an allegation of violation of the HIPAA Rules and must inform DSHS of the outcome of that action. Business Associate bears all responsibility for any penalties, fines or sanctions imposed against the Business Associate for violations of the HIPAA Rules and for any imposed against its

Subcontractors or agents for which it is found liable.

29.8. Breach Notification.

29.8.1. In the event of a Breach of unsecured PHI or disclosure that compromises the privacy or security of PHI obtained from DSHS or involving DSHS clients, Business Associate will take all measures required by state or federal law.

29.8.2. Business Associate will notify DSHS within one (1) business day by telephone and in writing of any acquisition, access, Use or disclosure of PHI not allowed by the provisions of this Contract or not authorized by HIPAA Rules or required by law of which it becomes aware which potentially compromises the security or privacy of the Protected Health Information as defined in 45 CFR 164.402 (Definitions).

29.8.3. Business Associate will notify the DSHS Contact shown on the cover page of this Contract within one (1) business day by telephone or e-mail of any potential Breach of security or privacy of PHI by the Business Associate or its Subcontractors or agents. Business Associate will follow telephone or e-mail notification with a faxed or other written explanation of the Breach, to include the following: date and time of the Breach, date Breach was discovered, location and nature of the PHI, type of Breach, origination and destination of PHI, Business Associate unit and personnel associated with the Breach, detailed description of the Breach, anticipated mitigation steps, and the name, address, telephone number, fax number, and e-mail of the individual who is responsible as the primary point of contact. Business Associate will address communications to the DSHS Contact. Business Associate will coordinate and cooperate with DSHS to provide a copy of its investigation and other information requested by DSHS, including advance copies of any notifications required for DSHS review before disseminating and verification of the dates notifications were sent.

29.8.4. If DSHS determines that Business Associate or its Subcontractor(s) or agent(s) is responsible for a Breach of unsecured PHI:

29.8.4.1. requiring notification of Individuals under 45 CFR § 164.404 (Notification to Individuals), Business Associate bears the responsibility and costs for notifying the affected Individuals and receiving and responding to those Individuals’ questions or requests for additional information;

29.8.4.2. requiring notification of the media under 45 CFR § 164.406 (Notification to the media), Business Associate bears the responsibility and costs for notifying the media and receiving and responding to media questions or requests for additional information;

29.8.4.3. requiring notification of the U.S. Department of Health and Human Services Secretary under 45 CFR § 164.408 (Notification to the Secretary), Business Associate bears the responsibility and costs for notifying the Secretary and receiving and responding to the Secretary’s questions or requests for additional information; and

29.8.4.4. DSHS will take appropriate remedial measures up to termination of this Contract.

29.9. Miscellaneous Provisions.

29.9.1. Regulatory References. A reference in this Contract to a section in the HIPAA Rules

means the section as in effect or amended.

29.9.2. Interpretation. Any ambiguity in this Contract shall be interpreted to permit compliance with the HIPAA Rules.

1. Purpose.

The purpose of this Contract is to provide all Medicaid-covered Services, unless specifically excluded from this Contract, as specified in Washington’s approved Medicaid State Plan, to individuals enrolled in the Program of All-Inclusive Care for the Elderly (PACE).

2. Statement of Work.

The Contractor shall provide the services and staff, and otherwise do all things necessary for or incidental to the performance of work, as set forth in this Contract and in accordance with 42 CFR 460 and the attached Exhibit A, Data Security Requirements; Exhibit B, PACE Program Agreement #H5007; and Exhibit C, Rates.

3. Comprehensive Assessment Reporting Evaluation (CARE).

DSHS will share limited information regarding PACE Enrollees from the Comprehensive Assessment Reporting Evaluation (CARE) software.

3.1. Purpose.

3.1.1. Activity for which the Data is needed: Case Management activities

3.1.2. How Data Recipient will use Data: Staff will view the Data for eligibility and care planning activities.

3.2. Description of Data.

3.2.1. Data Elements: CARE Assessments for Contractor PACE clients only.

3.2.2. Time frame(s) for Data disclosure or exchange: ongoing.

3.2.3. Conditions under which, if any, that Data disclosed or exchanged can be linked to other Data: None

3.3. Data Access or Transfer.

3.3.1. Method. DSHS shall provide the CARE application to the Contractor via VPN or Secure Access Washington (SAW). To access CARE through VPN, the Contractor is required to:

3.3.1.1. Have the current version of Java and current RSA software.

3.3.1.2. Setup, Install and test the VPN connection to access CARE.

3.3.2. Requirements for Access. Access to Data shall be limited to staff whose duties specifically require access to such Data in the performance of their assigned duties. Prior to making Data available to its staff, Data Recipient shall notify all such staff of the Use and Disclosure requirements. All staff accessing the data shall then sign a statement in which they agree to adhere to the Use and Disclosure requirements and a list of such staff and their statements, with their signatures, shall be

updated as necessary and submitted to the Data Provider upon request.

When a new user needs access, Contractor will notify the PACE Program Manager, Kelli Emans at 360-725-3213 or kelli.emans@dshs.wa.gov.

When a user no longer needs access, Contractor will notify the PACE Program Manager, Kelli Emans at 360-725-3213 or kelli.emans@dshs.wa.gov, within one (1) business day.

3.3.3. Frequency of Exchange. Ongoing.

3.4. Limitations on Use of Data. If the Data and analyses generated by Data Recipient contain personal information about DSHS clients, then any and all reports utilizing these Data shall be subject to review and approval by the Data Provider prior to publication in any medium or presentation in any forum.

4. Insurance.

The Contractor may waive the requirements as described in the Commercial General Liability Insurance, Professional Liability Insurance, Insurers and Evidence of Coverage provisions of this Section if self-insured. In the event the Contractor is self-insured, the Contractor must send to DSHS by the third Wednesday of January in each Contract year, a signed written document, which certifies that the Contractor is self-insured, carries coverage adequate to meet the requirements of this Section, will treat the State of Washington, DSHS its agents and employees as an additional insured, expressly for, and limited to, the Contractor's services provided under this Contract, and provides a point of contact for DSHS.

4.1. General Liability Insurance

The Contractor shall maintain Commercial General Liability Insurance, or Business Liability Insurance, including coverage for bodily injury, property damage, and contractual liability, with the following minimum limits: Each Occurrence - $1,000,000; General Aggregate - $2,000,000. The policy shall include liability arising out of premises, operations, independent contractors, products-completed operations, personal injury, advertising injury, and liability assumed under an insured contract. The State of Washington, Department of Social & Health Services (DSHS), its elected and appointed officials, agents, and employees of the state, shall be named as additional insured’s.

In lieu of general liability insurance mentioned above, if the contractor is a sole proprietor with less than three contracts, the contractor may choose one of the following three general liability policies but only if attached to a professional liability policy, and if selected the policy shall be maintained for the life of the contract:

Supplemental Liability Insurance, including coverage for bodily injury and property damage that will cover the contractor wherever the service is performed with the following minimum limits: Each Occurrence - $1,000,000; General Aggregate - $2,000,000. The State of Washington, Department of Social & Health Services (DSHS), its elected and appointed officials, agents, and

employees shall be named as additional insured’s.

or

Workplace Liability Insurance, including coverage for bodily injury and property damage that provides coverage wherever the service is performed with the following minimum limits: Each Occurrence - $1,000,000; General Aggregate - $2,000,000. The State of Washington, Department of Social & Health Services (DSHS), its elected and appointed officials, agents, and employees of the state, shall be named as additional insured’s.

or

Premises Liability Insurance and provide services only at their recognized place of business, including coverage for bodily injury, property damage with the following minimum limits: Each Occurrence - $1,000,000; General Aggregate - $2,000,000. The State of Washington, Department of Social & Health Services (DSHS), its elected and appointed officials, agents, and employees of the state, shall be named as Additional Insured.

4.2. Business Automobile Liability Insurance

The Contractor shall maintain a Business Automobile Policy on all vehicles used to transport clients, including vehicles hired by the Contractor or owned by the Contractor’s employees, volunteers or others, with the following minimum limits: $1,000,000 per accident combined single limit. The Contractor’s carrier shall provide DSHS with a waiver of subrogation or name DSHS as an Additional Insured.

4.3. Professional Liability Insurance (PL)

The Contractor shall maintain Professional Liability Insurance or Errors & Omissions insurance, including coverage for losses caused by errors and omissions, with the following minimum limits: Each Occurrence - $1,000,000; Aggregate - $2,000,000.

4.4. Worker’s Compensation

The Contractor shall comply with all applicable Worker’s Compensation, occupational disease, and occupational health and safety laws and regulations. The State of Washington and DSHS shall not be held responsible for claims filed for Worker's Compensation under RCW 51 by the Contractor or its employees under such laws and regulations.

4.5. Employees and Volunteers

Insurance required of the Contractor under the Contract shall include coverage for the acts and omissions of the Contractor’s employees and volunteers. In addition, the Contractor shall ensure that all employees and volunteers who use vehicles to transport clients or deliver services have personal automobile insurance and current driver’s licenses.

4.6. Subcontractors

The Contractor shall ensure that all subcontractors have and maintain insurance with the same types and limits of coverage as required of the Contractor under the Contract, unless otherwise waived by DSHS.

4.7. Separation of Insured’s

All insurance policies shall include coverage for cross liability and contain a “Separation of Insured’s” provision.

4.8. Insurers

The Contractor shall obtain insurance from insurance companies identified as an admitted insurer/carrier in the State of Washington, with a Best’s Reports’ rating of B++, Class VII, or better. Surplus Lines insurance companies will have a rating of A-, Class VII, or better.

4.9. Evidence of Coverage

The Contractor shall, upon request by DSHS, submit a copy of the Certificate of Insurance, policy, and additional insured endorsement for each coverage required of the Contractor under the Contract. The Certificate of Insurance shall identify the Washington State Department of Social and Health Services as the Certificate Holder. A duly authorized representative of each insurer, showing compliance with the insurance requirements specified in this Contract, shall execute each Certificate of Insurance. The Contractor shall maintain copies of Certificates of Insurance, policies, and additional insured endorsements for each subcontractor as evidence that each maintains insurance as required by the Contract.

4.10. Material Changes

The insurer shall give DSHS Enterprise Risk Management Office; 45 days advance written notice of cancellation or non-renewal. If cancellation is due to non-payment of premium, the insurer shall give DSHS 10 days advance written notice of cancellation.

4.11. General

By requiring insurance, the State of Washington and DSHS do not represent that the coverage and limits specified will be adequate to protect the Contractor. Such coverage and limits shall not be construed to relieve the Contractor from liability in excess of the required coverage and limits and shall not limit the Contractor’s liability under the indemnities and reimbursements granted to the State and DSHS in this Contract. All insurance provided in compliance with this Contract shall be primary as to any other insurance or self-insurance programs afforded to or maintained by the State.

5. Disputes.

When a dispute arises over an issue that pertains in any way to this Contract, the parties agree to the following process to address the dispute:

5.1. Except as otherwise provided in this Contract, when a dispute arises between DSHS and the Contractor and it cannot be resolved, the Contractor may request a dispute resolution conference with the Director. The request for a dispute resolution conference must be in writing and shall clearly state all of the following:

5.1.1. the disputed issue(s)

5.1.2. an explanation of the positions of the parties

5.1.3. any additional facts necessary to explain completely and accurately the nature of the dispute

5.2. Requests shall be mailed to the Director within 15 days of the Contractor receiving notice of the disputed issue(s)

5.3. The Director, in his or her sole discretion, will determine a time for the parties to present their views on the disputed issue(s). The conference is informal in nature and not governed by the Administrative Procedure Act, Chapter 34.05 RCW.

5.4. The Director will consider all of the information provided at the conference and will issue a written decision on the disputed issue(s) within thirty (30) calendar days after the conclusion of the conference. However, the Director retains the option of taking up to an additional sixty (60) calendar days to consider the disputed issue(s) or taking additional steps to attempt to resolve them. If the Director determines, in his or her sole discretion, that an additional period of up to sixty (60) calendar days is needed for review, he or she will notify the Contractor, in writing, of the delay and the anticipated completion date before the initial thirty-day period expires.

5.5. The Director, at his or her sole discretion, may appoint a designee to represent him or her at the dispute conference. If the Director does not appoint a designee to represent him or her at the dispute conference, the Director shall retain all final decision-making authority regarding the disputed issue(s). Under no circumstances shall the Director’s designee have any authority to issue a final decision on the disputed issue(s).

5.6. The parties hereby agree that this dispute process shall precede any judicial or quasi-judicial proceeding and is the sole administrative remedy under this Contract.

6. Force Majeure.

If the Contractor is prevented from performing any of its obligations hereunder in whole or in part as a result of a major epidemic, act of God, war, civil disturbance, court order or any other cause beyond its control, such nonperformance shall not be a ground for termination for default. Immediately upon the occurrence of any such event, the

Contractor shall commence to use its best efforts to provide, directly or indirectly, alternative and, to the extent practicable, comparable performance. Nothing in this Section shall be construed to prevent DSHS from terminating this Contract for reasons other than for default during the period of events set forth above, or for default, if such default occurred prior to such event.

7. Mergers and Acquisitions.

If the Contractor is involved in an acquisition of assets or merger with another DSHS Contractor after the effective date of this Contract, DSHS reserves the right, to the extent permitted by law, to require that each Contractor maintain its separate business lines for the remainder of the Contract period.

8. Notification of Organizational Changes.

The Contractor shall provide DSHS with ninety (90) calendar days’ prior written notice of any change in the Contractor’s ownership or legal status. The Contractor shall provide DSHS notice of any changes to the Contractor’s key personnel including, but not limited to, the Contractor’s Chief Executive Officer, the Contractor’s Chief Financial Officer, DSHS government relations contact, DSHS Account Executive, and Medical Director as soon as reasonably possible.

9. Washington Public Disclosure Act.

The Contractor acknowledges that DSHS is subject to the Public Records Act (the Act, which is codified at RCW 42.17.250, et seq.). This Contract will be a ‘public record’ as defined in RCW 42.17.020. Any documents submitted to DSHS by the Contractor may also be construed as ‘public records’ and therefore subject to public disclosure under the Act. The Contractor may label documents submitted to DSHS as ‘confidential’ or ‘proprietary’ if it so chooses; however, the Contractor acknowledges that such labels are not determinative of whether the documents are subject to disclosure under the Act. If DSHS receives a public disclosure request that would encompass any Contractor document that has been labeled by the Contractor as ‘confidential’ or ‘proprietary,’ then DSHS will notify the Contractor pursuant to RCW 42.17.330. The Contractor then will have the option, under RCW 42.17.330, of seeking judicial intervention to prevent the public disclosure of the affected document(s).

10. Notices.

Whenever one party is required to give notice to the other under this Contract, it shall be deemed given if mailed by United States Postal Services, registered or certified mail, return receipt requested, postage prepaid and addressed as follows:

10.1. In the case of notice to the Contractor, notice will be sent to:

Susan Tuller Executive Director, Providence ElderPlace Riverfront Technical Park 2810 S 102nd Street Suite 220 Tukwila WA 98168

10.2. In the case of notice to DSHS, send notice to:

PACE Program Manager DSHS/Aging and Long-Term Support Administration P.O. Box 45600 Olympia, WA 98504-5600

10.3. Notices shall be effective on the date delivered as evidenced by the return receipt or the date returned to the sender for non-delivery other than for insufficient postage.

10.4. Either party may at any time change its address for notification purposes by mailing a notice in accord with this Section, stating the change and setting for the new address, which shall be effective on the tenth (10th) day following the effective date of such notice unless a later date is specified.

11. Enrollment.

11.1. Service Area.

The Contractor shall provide the services described in this Contract to clients who are determined by DSHS to reside in the PACE service area and meet all requirements for enrollment in PACE.

11.2. Eligible Client Group. DSHS shall determine eligibility for enrollment under this Contract.

11.2.1. The Contractor may only request enrollment of Medicaid clients whom have been found functionally and financially eligible to receive Medicaid services for the month in which the Contractor is requesting enrollment and according to CFR 460.150(2) and CFR 460.152(3).

11.2.2. To be eligible for enrollment, clients must meet the functionally and financially eligible requirements for the PACE program.

11.2.3. The Contractor may only enroll private pay individuals who have been determined by the state to be functionally eligible prior to enrollment.

11.3. Enrollment Period. Subject to the enrollment provisions of this Contract, enrollment is continuously open.

11.4. Effective Date of Enrollment.

11.4.1. Enrollment with the Contractor shall be effective on the later of the following dates:

11.4.1.1. If the client is eligible and the enrollment is processed on or before the first of the next month, enrollment shall be effective the first day of the month following the month in which the enrollment is processed; or

11.4.1.2. If the enrollment is processed after the first of the month or the client is not eligible for enrollment, enrollment shall be effective the first day of the second month following the month in which the enrollment is processed.

11.4.2. Enrollments will be done prospectively except in the following cases:

11.4.2.1. Client currently resides in a facility that does not have a DSHS contract, not enrolling would result in the client losing housing.

11.4.2.2. Client will meet eligibility criteria the month of enrollment, but are not eligible on the first of the month.

11.5. Enrollment Data and Requirements for Contractor’s Response. HCA will provide the Contractor with data files with the information needed to perform the services described in this Contract.

11.5.1. Data files will be sent to the Contractor at intervals specified within the HCA 834 Benefit Enrollment and Maintenance Companion Guide, published by HCA and incorporated by reference.

11.5.2. The data file will be in the Health Insurance Portability and Accountability Act (HIPAA) compliant 834, Benefit Enrollment and Maintenance format (45 C.F.R. § 162.1503).

11.5.3. The data file will be transferred per specifications defined within HCA Companion Guides.

11.6. Enrollment Process.

11.6.1. The Contractor shall submit a list at least one week prior to the start of the month enrollment is requested.

11.6.1.1. The Contractor shall provide

11.6.1.1.1. Name

11.6.1.1.2. Social Security Number

11.6.1.1.3. ProviderOne Id

11.6.1.1.4. Date of enrollment

11.6.1.1.5. Any necessary signed disenrollment forms for other insurance

11.6.2. Enrollment will only be processed for clients who meet the following criteria:

11.6.2.1. PACE eligible recipient aid category (RAC)

11.6.2.2. Resides in the PACE service area

11.6.2.3. Does not have comparable insurance

11.7. Enrollment reconnect process.

11.7.1. The Contractor must have written processes in place to assist clients in maintaining financial eligibility for Medicaid.

11.7.2. If a client loses eligibility, when Medicaid eligibility is reinstated and covers the month in question, the Contractor may request a reconnect to plan.

11.7.3. Such requests shall be submitted as part of the monthly reconciliation process between DSHS and the Contractor.

11.8. Denial of Enrollment.

11.8.1. The Contractor must have written processes in place to determine if a client is safe to live in the community per approved safety criteria found in H5007 contract between the state, CMS and the Contractor.

11.8.2. If the Contractor denies enrollment due to safety concerns the Contractor must provide the following documentation within 14 days for state review.

11.8.2.1. A copy of the PO’s denial of enrollment letter sent to the applicant, which includes appeal rights;

11.8.2.2. Assessment/evaluation used to determine the denial;

11.8.2.3. Narrative explanation of the basis for the finding, including attempts to arrive at a safe plan for enrollment; and

11.8.2.4. The professional disciplines involved in the PO’s determination.

11.9. Disenrollment of Medicaid clients.

11.9.1. Disenrollment requests will be submitted to DSHS HCS Program Manager and HCS PACE unit by the 15th of the month prior to the month the disenrollment is requested. HCS Program Manager can make exceptions Section.

11.9.1.1. The contractor should provide:

11.9.1.1.1. Name;

11.9.1.1.2. ProviderOne id;

11.9.1.1.3. Date of disenrollment; and

11.9.1.1.4. Specific reason for disenrollment as defined by the state.

11.9.2. The Contractor must notify the HCS PACE unit of any pending disenrollments as soon as they are known. The Contractor and HCS PACE unit must have a written process for disenrollment and communication that will assist in ensuring a safe disenrollment and transition of care.

11.9.3. Voluntary disenrollment requests will be effective the first of the month.

11.9.4. Involuntary disenrollments must comply with CFR 460.164

11.9.4.1. The Contractor must submit adequate documentation of efforts made with the Enrollee to assist them in staying enrolled in the program.

11.9.4.2. If DSHS agrees with disenrollment, participant will be disenrolled the 1st day of the month following the request, if a safe disenrollment plan is in place. The Contractor will notify the beneficiary of appeal rights through DSHS.

12. Program Integrity.

12.1. General Requirements.

12.1.1. The Contractor shall have and comply with policies and procedures that guide and require the Contractor and the Contractor’s officers, employees, agents and subcontractors to comply with the requirements of this Section.

12.1.2. The Contractor shall include Program Integrity requirements in its subcontracts and provider application, credentialing and re-credentialing processes, if applicable.

12.1.3. The following are relevant citations for Program Integrity compliance. The Contractor is expected to be familiar with, comply with, and require compliance with all regulations related to Program Integrity whether or not those regulations are listed below:

12.1.3.1. Section 1902(a)(68) of the Social Security Act;

12.1.3.2. 42 C.F.R. § 460;

12.1.3.3. 42 C.F.R. § 455;

12.1.3.4. 42 C.F.R. § 1000 through 1008; and

12.1.3.5. Chapters 74.66 RCW.

12.1.4. The Contractor shall ensure compliance with the Program Integrity provisions of this Contract, including proper payments to providers or subcontractors and methods for detection and prevention of Fraud, Waste, and Abuse.

12.2. Referrals of Credible Allegations of Fraud and Provider Payment Suspensions.

12.2.1. Provider Payment Suspensions and Referrals of Potential Credible Allegations of Fraud.

The Contractor shall establish policies and procedures for suspending a provider’s payments when HCA/DSHS determines a credible allegation of fraud exists and directs that payment suspension shall occur while the matter is being investigated.

12.2.1.1. When the Contractor suspects that an incident of fraud has occurred, the Contractor shall make a fraud referral to the HCA or ALTSA within five (5) business days of the determination. The referral must be in writing and sent to MFCUreferrals@atg.wa.gov for medical provider fraud and ADSAfraud@dshs.wa.gov for social service provider fraud. Include a copy to the PACE Program Manager.

12.3. Disclosure by Contractor: Information on Ownership and Control.

The Contractor must provide to HCA the following disclosures (42 C.F.R. § 455.103, 42 C.F.R § 455.104(b), SSA §§ 1903(m)(2)(A)(viii), 1124(a)(2)(A)):

12.3.1. The identification of any person or corporation with a direct, indirect or combined direct/indirect ownership interest of five percent (5%) or more of the Contractor’s equity (or, in the case of a subcontractor’s disclosure, five percent (5%) or more of the subcontractor’s equity).

12.3.2. The identification of any person or corporation with an ownership interest of five percent (5%) or more of any mortgage, deed of trust, note or other obligation secured by the Contractor if that interest equals at least five percent (5%) of the value of the Contractor’s assets (or, in the case of a subcontractor’s disclosure, a corresponding obligation secured by the subcontractor equal to five percent (5%) of the subcontractor’s assets).

12.3.3. The name, address, date of birth, and Social Security Number of any managing employee of the Contractor. For the purposes of this Subsection “managing employee” means a general manager, business manager, administrator, corporate officer, director (i.e. member of the board of directors), or other individual who exercises operational or managerial control over, or who directly or indirectly conducts the day-to-day operation of an institution, organization, or agency.

12.3.4. The disclosures must include the following:

12.3.4.1. The name, address, and financial statement(s) of any person (individual or corporation) that has five percent (5%) or more ownership or control interest in the Contractor.

12.3.4.2. The name and address of any person (individual or

corporation) that has five percent (5%) or more ownership or control interest in any of the Contractor’s subcontractors.

12.3.4.3. Indicate whether the individual/entity with an ownership or control interest is related to any other Contractor employee such as a spouse, parent, child, or siblings; or is related to one of the Contractor’s officers, directors or other owners.

12.3.4.4. Indicate whether the individual/entity with an ownership or control interest owns five percent (5%) or greater in any other organizations.

12.3.4.5. The address for corporate entities must include, as applicable, primary business address, every business location, and P.O. Box addresses.

12.3.4.6. Date of Birth and Social Security Number (in the case of an individual).

12.3.4.7. Other tax identification number (in the case of a corporation) with an ownership or control interest in the Contractor or its subcontractor.

12.3.5. The Contractor must terminate or deny network participation if a provider, or any person with five percent (5%) or greater direct or indirect ownership interest fails to submit sets of fingerprints in a form and manner to be determined by HCA, within thirty (30) calendar days when requested by HCA or any authorized federal agency.

12.3.6. Disclosures from the Contractor are due to HCA at any of the following times:

12.3.6.1. When the Contractor submits a proposal in accordance with a DSHS procurement process.

12.3.6.2. When the Contractor executes the Contract with DSHS.

12.3.6.3. Upon renewal or extension of the Contract.

12.3.6.4. Within thirty-five (35) calendar days after any change in ownership of the Contractor. The Contractor shall report the change on HCA PIR005 – WA MCO Ownership Change Reporting Template.

12.3.6.5. Upon request by DSHS/HCA.

12.4. Disclosure by Contractor: Information on Ownership and Control, Subcontractors and Providers.

12.4.1. The Contractor shall include the following provisions in its written agreements with all subcontractors and providers who are not individual

practitioners or a group of practitioners.

12.4.1.1. Requiring the subcontractor or provider to disclose to the MCO

upon contract execution [42 C.F.R. § 455.104(c)(1)(ii)], upon request during the re-validation of enrollment process under 42 C.F.R. § 455.414 [42 C.F.R. § 455.104(c)(1)(iii)], and within thirty-five (35) business days after any change in ownership of the subcontractor or provider 42 C.F.R. § 455.104(c)(1)(iv).

12.4.1.2. The name and address of any person (individual or corporation) with an ownership or control interest in the subcontractor or provider. 42 C.F.R. § 455.104(b)(1)(i).

12.4.2. If the subcontractor or provider is a corporate entity, the disclosure must include primary business address, every business location, and PO Box address. 42 C.F.R. § 455.104(b)(1)(i).

12.4.2.1. If the subcontractor or provider has corporate ownership, the tax identification number of the corporate owner(s). 42 C.F.R. § 455.104(b)(1)(iii).

12.4.2.2. If the subcontractor or provider has a five percent (5%) ownership interest in any of its subcontractors, the tax identification number of the subcontractor(s). 42 C.F.R. § 455.104(b)(1)(iii).

12.4.2.3. Whether any person with an ownership or control interest in the subcontractor or provider is related by marriage or blood as a spouse, parent, child, or sibling to any other person with an ownership or control interest in the subcontractor/provider. 42 C.F.R. § 455.104(b)(2).

12.4.2.4. If the subcontractor or provider has a five percent (5%) ownership interest in any of its subcontractors, whether any person with an ownership or control interest in such subcontractor is related by marriage or blood as a spouse, parent, child, or sibling to any other person with an ownership or control interest in the subcontractor or provider. 42 C.F.R. § 455.104(b)(2).

12.4.2.5. Whether any person with an ownership or control interest in the subcontractor/provider also has an ownership or control interest in any other Medicaid provider, in the state’s fiscal provider or in any managed care entity. 42 C.F.R. § 455.104(b)(3).

12.4.3. Upon request, the Contractor and the Contractor’s subcontractors shall furnish to HCA, within thirty-five (35) calendar days of the request, full and complete business transaction information as follows:

12.4.3.1. The ownership of any subcontractor with whom the Contractor

or subcontractor has had business transactions totaling more than $25,000 during the 12-month period ending on the date of

the request. (42 C.F.R § 455.105(b)(1)).

12.4.3.2. Any significant business transactions between the Contractor or subcontractor and any wholly owned supplier, or between the provider and any subcontractor, during the 5-year period ending on the date of the request. (42 C.F.R § 455.105(b)(2)).

12.4.4. Upon request, the Contractor and the Contractor’s subcontractors shall furnish to the Washington Secretary of State, the Secretary of the US Department of Health and Human Services, the Inspector General of the US Department of Health and Human Services, the Washington State Auditor, the Comptroller of the Currency, and HCA a description of the transaction identified under 42 C.F.R § 455.105 between the Contractor and the other party of interest within thirty-five (35) calendar days of the request, including the following transactions 42 C.F.R. § 438.50(c)(1):

12.4.4.1. A description of transactions between the Contractor and a party in interest (as defined in section 1318(b) of the Public Health Service Act), including the following:

12.4.4.1.1. Any sale or exchange, or leasing of any property between the Contractor and such a party.

12.4.4.1.2. Any furnishing for consideration of goods, services (including management services), or facilities between the Contractor and such a party but not including salaries paid to employees for services provided in the normal course of their employment.

12.4.4.1.3. Any lending of money or other extension of credit between the Contractor and such a party. (1903(m)(4)(B); 42 C.F.R. § 438.50(c)(1)).

12.4.4.1.4. Employment.

12.4.4.1.5. Any lending of money or other extension of credit between the Contractor and such a party. (1903(m)(4)(B); 42 C.F.R. § 438.50(c)(1)).

12.5. Excluded Individuals and Entities.

The Contractor is prohibited from paying with funds received under this Contract for goods and services furnished by an excluded person, at the medical direction or on the prescription of an excluded person. The Contractor shall notify the suppliers of excluded individual and allow the suppliers a fifteen (15) day grace period from the notification to stop all prescription fills. (Social Security Act (SSA) section 1903(i)(2) of the Act; 42 C.F.R. § 455.104, 42 C.F.R. § 455.106, and 42 C.F.R. § 1001.1901(b)).

12.5.1. The Contractor shall monitor for excluded individuals and entities by:

12.5.1.1. Screening Contractor and subcontractor individuals and entities with an ownership or control interest during the initial provider application, credentialing and re-credentialing processes and prior to entering into a contractual or other relationship where the individual or entity would benefit directly or indirectly from funds received under this Contract and payable by a federal health care program.

12.5.1.2. Screening individuals during the initial provider application, credentialing and re-credentialing process and prior to entering into a contractual or other relationship where the individual would benefit directly or indirectly from funds received under this Contract or payable by a federal health care program.

12.5.1.3. Screening LEIE and SAM lists monthly for all Contractor and subcontractor individuals and entities with an ownership or control interest, and individuals defined as affiliates, in the Federal Acquisition Regulation, of an individual that is debarred, suspended, or otherwise excluded from participating in procurement activities, and individuals that would benefit from funds received under this Contract for newly added excluded individuals and entities.

12.5.2. The Contractor will not make any payments for goods or services that directly or indirectly benefit any excluded individual or entity effective with the date of exclusion. The Contractor will immediately recover any payments for goods and services that benefit excluded individuals and entities that it discovers.

12.5.3. The Contractor shall immediately terminate any employment, contractual and control relationships with any excluded individual or entity discovered during its provider screening processes, including the provider application, credentialing and re-credentialing, and shall report these individuals and entities within ten (10) business days of discovery.

12.5.4. Civil monetary penalties may be imposed against the Contractor if it employs or enters into a contract with an excluded individual or entity to provide goods or services to Enrollees. (SSA section 1128A (a)(6) and 42 C.F.R. § 1003.102(a)(2)).

12.5.5. An individual or entity is considered to have an ownership or control interest if they have direct or indirect ownership of 5 percent or more, or are a managing employee (e.g., a general manager, business manager, administrator, or director) who exercises operational or managerial control, or who directly or indirectly conducts day-to-day operations (SSA section 1126(b), and 42 C.F.R. § 455.104(a).

12.5.6. In addition, if DSHS/HCA notifies the Contractor that an individual or entity is excluded from participation by DSHS/HCA, the Contractor shall

terminate all beneficial, employment, and contractual and control relationships with the excluded individual or entity immediately (WAC 182-502-0030).

12.5.7. DSHS will validate that the Contractor is conducting all screenings required by this Section during its annual monitoring review.

12.5.8. The Contractor shall monitor for excluded individuals and entities, and certify to the DSHS/HCS on an annual basis that the organization does not knowingly employ any excluded individuals. Contractor will certify to the Department initially and immediately upon changed circumstances from the last such certification that it does not knowingly have an individual who has been debarred or suspended by the federal or state government.

12.6. Fraud, Waste and Abuse (FWA).

12.6.1. The Contractor shall implement and maintain administrative and management arrangements or procedures designed to detect and prevent fraud, waste and abuse. The arrangements or procedures must include the following:

12.6.1.1. A compliance program that includes, at a minimum, all of the following elements:

12.6.1.1.1. Written policies, procedures, and standards of conduct that articulate the organization’s commitment to comply with all applicable requirements and standards under the contract, and all applicable federal and state requirements.

12.6.1.1.2. Designation of a Compliance Officer who is accountable for developing and implementing policies and procedures, and practices designed to ensure compliance with the requirements of the contract and who directly reports to the Chief Executive Officer (CEO) and the Board of Directors.

12.6.1.1.3. Establishment of a Regulatory Compliance Committee on the Board of Directors and at the senior management level charged with overseeing the organization’s compliance program and its compliance with the requirements under Section 12 of this Contract.

12.6.1.1.4. System for training and education for the Compliance Officer, the organization’s senior management, and the organization’s employees for the federal and state standards and requirements under this Contract.

12.6.1.1.5. Effective lines of communication between the Compliance Officer and the Contractor’s staff and subcontractors.

12.6.1.1.6. Enforcement of standards through well-publicized disciplinary guidelines.

12.6.1.1.7. Establishment and implementation of procedures and a system with dedicated staff of routine internal monitoring and auditing of compliance risks, prompt response to compliance issues as they are raised, investigation of potential problems as identified in the course of self-evaluation and audits, correction of such problems promptly and thoroughly (or coordination of suspected criminal acts with law enforcement agencies) to reduce the potential for recurrence, and ongoing compliance with the requirements under this Contract.

12.6.1.2. Provision for prompt reporting of all overpayments identified and recovered, specifying the overpayments due to potential fraud, to HCA.

12.6.1.3. Provision for notification to DSHS when the Contractor receives information about a change in a network provider’s circumstances that may affect the network provider’s eligibility to participate in the managed care program, including the termination of the provider agreement with the Contractor.

12.6.1.4. The requirement for written policies for all employees of the Contractor, and of any subcontractor, agent, or provider, that provide detailed information about the False Claims Act and other federal and state laws described in Section 1902(a)(68) of the Social Security Act, the Washington false claims statutes, chapters 74.66 RCW and RCW 74.09.210, including information about rights of employees to be protected as whistleblowers, and the criminal statutes found in chapter 74.09 sections .230 through .280 RCW.

12.6.1.5. Provision for prompt referral of any potential fraud, waste or abuse that the Contractor identifies to HCA Program Integrity and any potential fraud directly to the MFCU.

12.6.1.6. Provision for the Contractor’s suspension of payments to a network provider for which HCA determines there is a credible allegation of fraud in accordance with 42 C.F.R. § 455.23.

12.6.1.7. Provision for prompt response to detected offenses, and for development of corrective action initiatives.

12.7. Education.

12.7.1. The Contractor must educate staff and subcontractors of the Program Integrity requirements in the contract annually.

12.7.2. False Claims Act Education Compliance.

12.7.2.1. Federal law requires any entity receiving annual Medicaid payments of $5 million or more to provide education regarding federal and state false claims laws for all of its employees, contractors and/or agents. If Contractor receives at least $5 million or more in annual Medicaid payments under one or more provider identification number(s), the Contractor is required to establish and adopt written policies for all employees, including management, and any contractor or agent of the entity, including detailed information about both the federal and state False Claims Acts and other applicable provisions of Section 1902(a)(68) of the Social Security Act. The law requires the following:

12.7.2.1.1. Contractor must establish written policies to include detailed information about the False Claims Act, including references to the Washington State False Claims Act;

12.7.2.1.2. Policies regarding the handling and protection of whistleblowers;

12.7.2.1.3. Policies and procedures for detecting and preventing fraud, waste, and abuse;

12.7.2.1.4. Policies and procedures must be included in an existing employee handbook or policy manual, but there is no requirement to create an employee handbook if none already exists.

12.8. Reporting.

12.8.1. If the Contractor suspects client/member/enrollee fraud:

12.8.1.1. The Contractor shall notify the HCA Office of Medicaid Eligibility and Policy (OMEP) of any cases in which the Contractor believes there is a serious likelihood of Enrollee fraud by:

12.8.1.1.1. Sending an email to

WAHeligibilityfraud@hca.wa.gov; or

12.8.1.1.2. Calling the Office of Medicaid Eligibility and Policy at 360-725-0934 and leave a detailed voice mail message; or

12.8.1.1.3. Mailing a written referral to:

Health Care Authority Attention: OMEP PO Box 45534 Olympia, WA 98504-5534

Or

12.8.1.1.4. Faxing the written complaint to Attention Washington Apple Health Eligibility Fraud at 360-725-1158.

12.8.2. Any excluded individuals and entities discovered in the screening described in the Fraud, Waste and Abuse Subsection of this Contract, including the provider application, credentialing and re-credentialing processes, must be reported to HCA within five (5) business days of discovery. The identified excluded individual/entities shall be reported using HCA PIR006- WA Excluded Individual Template.

12.8.3. The Contractor is responsible for investigating Enrollee fraud, waste and

abuse and referring Enrollee fraud to HCA OMEP. The Contractor shall provide initial allegations, investigations and resolutions of Enrollee fraud to HCA OMEP.

12.8.4. The Contractor shall investigate and disclose to HCA, within ten (10) calendar days of Contractor’s discovery or upon request of HCA, the identity of any person who has been convicted of a criminal offense related to that person's involvement in any program under Medicare, Medicaid services program since the inception of those programs and who is an agent or person who has been delegated the authority to obligate or act on behalf of the Contractor.

12.8.5. The Contractor shall, on a regular basis, check the LEIE and SAM

database to identify any excluded individuals/entities. Documentation shall be kept validating the review of the databases and provided to HCA upon request.

13. Payment and Rate Setting.

13.1. Rate setting under this Contract will comply with 460.182 and will:

13.1.1. Be set on a 2 year cycle

13.1.2. Will align with the state budget cycle

13.2. Information for Rate Setting.

13.2.1. For rate setting only, the Contractor shall annually provide information regarding its cost experience related to the provision of the services required under this Contract. The experience information shall be provided directly to an actuary designated by DSHS. The designated actuary will determine the timing, content, format and medium for such

information. DSHS sets actuarially sound managed care rates.

13.2.2. The Contractor shall send a quarterly expenditure report to the DSHS Contract Manager. The quarterly expenditure report format is identified in the Data Collection Template, attached as Exhibit D. The quarterly expenditure report is due to DSHS no late than fourteen (14) calendar days after the last day of the quarter (April, July, October, January). The expenditures reported shall represent the payments made for services under this Contract during the calendar quarter being reported.

13.2.2.1. If expenditures are recorded in “other” categories, the submission must include detailed description of the line item and quarterly expenditure for review and potential inclusion in rates.

13.2.2.2. If the other expense is listed under patient care, it must include both client id and date of service.

13.2.3. The Contractor shall provide quarterly reports on the behavioral health services provided to enrollees under this Contract in the PACE Data Elements template, attached hereto as Exhibit E.

13.3. Rates/Premiums – capitation payments.

13.3.1. DSHS shall pay a monthly premium for each Enrollee in full consideration of the work to be performed by the Contractor under this Contract. DSHS shall pay the Contractor, on or before the fifteenth (15th) calendar day of the month based on DSHS/HCA list of Enrollees whose enrollment is ongoing or effective on the first day of said calendar month.

13.3.1.1. Rates are as set forth in the attached Exhibit C.

13.3.2. The Contractor shall reconcile the electronic benefit enrollment file with the premium payment information and submit differences it finds to DSHS within 30 days. Contractor shall ensure compliance with CFR 460.68.

13.4. Modification of Rates during Contract Period.

13.4.1. Renegotiation of or Changes in Rates:

13.4.1.1. The rates set forth in the attached Exhibit C shall be subject to renegotiation during the contract period only if the DSHS, in its sole judgment, determines that:

13.4.1.1.1. it is necessary due to a change in federal or state law or other material changes, beyond the contractor’s control, which would justify such a renegotiation.

13.4.1.1.2. there is a change in benefits or provider rates during the term of the Contract that will have a

material impact on Contractor costs, DSHS may change Contractor rates to allow for the change.

13.4.1.2. Any modification to Capitation Rates during the term of the Contract, as agreed to by the Contractor, including but not limited to changes in premium groups, shall be deemed modifications by the Department. Any other modification to Capitation Rates, as agreed to by the Department and the Contractor, during the term of the Agreement, shall be deemed incorporated into this Contract by amendment, upon approval of such modifications by the Department.

13.4.1.3. Any other modification to Capitation Rates, as agreed to by the department and the Contractor, during the term of the Agreement, shall be deemed incorporated into this Contract by amendment, upon approval of such modifications by the department.

13.4.1.4. In the event that the department and the Contractor fail to reach agreement on modifications to the monthly Capitation Rates, the department will provide formal written notice to the Contractor of the amount and effective date of the modified Capitation Rates approved by the State. The Contractor shall have the option of terminating this Contract in accordance with the termination language in this Contract, if such approved modified Capitation Rates are not acceptable.

13.4.1.4.1. The Contractor shall give written notice to the DSHS per the notices provision in this Contract within thirty (30) days of the date of the formal written notice of the modified Capitation Rates from the department specifying the reasons for and effective date of termination.

13.4.1.4.2. The effective date of termination shall be in accordance with the termination section of this Contract, unless the department determines that an orderly disenrollment to Medicaid fee-for-service or transfer to another managed long-term care plan can be accomplished in fewer days.

13.4.1.4.3. During the period commencing with the effective date of the department’s modified Capitation Rates through the effective date of termination of the Contract, the Contractor shall receive capitation payments at the Capitation Rates approved by the department for the rate period.

13.4.1.5. If the Contractor fails to exercise its right to terminate in accordance with this Section, then the modified Capitation Rates, approved by the department and its actuary, shall be

deemed incorporated into this Contract.

13.5. Denial of Capitation Payments.

In the event that CMS denies payment for new or existing Enrollees under 42 CFR 460.42 or 460.48 or under other applicable federal statutes and regulations, the Department will deny capitation payments to the Contractor for the same Enrollees for the period of time for which CMS denies payment. If the Contractor prevails during an appeal and CMS restores payment for new or existing Enrollees, then the Department will also restore capitation payments to the Contractor.

13.6. Contractor Financial Liability.

The Contractor shall not be financially liable for any services rendered to an Enrollee prior to his or her Effective Date of Enrollment or subsequent to disenrollment unless the Enrollee is admitted to a hospital prior to the Effective Date of Disenrollment and is not discharged from the hospital until after the Effective Date of Disenrollment, in which case the Contractor is responsible for the entire hospital claim.

13.7. No Recourse Against Enrollees.

13.7.1. Except for the rates and payments provided for in this Contract, the Contractor hereby agrees that in no event, including but not limited to nonpayment by the Medicaid agency, insolvency of the Contractor, loss of funding for this program, or breach of this Contract, shall the Contractor or a Subcontractor bill, charge, collect a deposit from, seek compensation, remuneration, or reimbursement from, or have any recourse against any Enrollee or person acting on his behalf for Covered Services furnished in accordance with this Contract. The Contractor shall act in accordance with WAC 182-502-0160.

13.7.2. This Section shall not prohibit the Contractor or the Subcontractors as specified in their agreements from billing for and collecting any applicable surplus amounts, Net Available Monthly Income (NAMI), commercial insurance, worker’s compensation benefits, no-fault insurance, and coordination of benefit amounts.

13.8. Data Certification Requirements.

Any financial information and/or data required by this Contract and submitted to DSHS shall be certified by the Contractor as follows:

13.8.1. Source of certification: The information and/or data shall be certified by one of the following:

13.8.1.1. The Contractor’s Chief Executive Officer.

13.8.1.2. The Contractor’s Chief Financial Officer.

13.8.1.3. An individual who has delegated authority to sign for, and who reports directly to, the Contractor’s Chief Executive Officer or Chief Financial Officer.

13.8.2. Content of certification: The Contractor’s certification shall attest, based on best knowledge, information, and belief, to the accuracy, completeness and truthfulness of the information and/or data.

13.8.3. Timing of certification: The Contractor shall submit the certification concurrently with the certified information and/or data.

13.8.4. DSHS will identify the specific data that requires certification.

14. Provider Complaints.

The Contractor shall have a system in place to process, track, and record provider complaints. The Contractor shall accept, record, and process provider complaints forward to DSHS. The Contractor’s provider complaint process should include a quality improvement process. The Contractor shall provide provider complaint data to DSHS upon request.

15. Policies and Procedures.

15.1. The Contractor shall develop, implement, maintain, comply with and monitor compliance with written policies and procedures related to the requirements of this Contract. The Contractor shall provide a list of its policies and procedures related to this Contract to DSHS.

15.2. The Contractor shall complete and submit the list no later than October 1, 2018, and, thereafter, in response to corrective action and any time there is a new policy and procedure or a change to an existing policy and procedure that directly impacts the PACE program operations. The Contractor shall also submit copies of policies and procedures upon request by DSHS.

16. State Administering Agency Monitoring.

16.1. The Contractor shall submit to DSHS monitoring reviews as requested. The monitoring review process uses standards developed by DSHS and assesses the Contractor’s compliance with regulatory requirements and standards of the quality outcomes and timeliness of, and access to, services provided by the Contractor.

16.2. The Contractor shall, during a DSHS annual monitoring review of the Contractor’s compliance with Contract standards or upon request by DSHS, provide evidence of how CMS quality review findings, Contract monitoring activities, and Enrollee grievances are used to identify and correct problems and to improve care and services to Enrollees.

17. Subcontracts.

17.1. Subcontractor/Provider Relations.

The Contractor is responsible to provide the following provider services:

17.1.1. Assisting providers with prior authorization and referral protocols;

17.1.2. Assisting providers with claims payment procedures;

17.1.3. Fielding and responding to provider questions and complaints;

17.1.4. Orientation of providers and subcontractors to program goals, and

17.1.5. Provider training to improve integrations and coordination of care.

17.2. Full responsibility retained.

17.2.1. Notwithstanding any relationship(s) that the Contractor may have with Subcontractors, the Contractor maintains full responsibility for adhering to and otherwise fully complying with all applicable laws, regulations and implementing guidelines, this Contract, the PACE Program Agreement, 42 CFR 460.

17.2.2. The Contractor oversees and is accountable to the department for all functions and responsibilities that are described in this Contract and the PACE Program Agreement.

17.2.3. The Contractor may only delegate activities or functions to a Subcontractor in a manner consistent with requirements set forth in this Contract, the PACE Program Agreement and 42 CFR 460.

17.3. Required Provisions.

17.3.1. Must be in writing and identify both parties and their legal basis to work in Washington.

17.3.2. Identify the services to be performed and what can be subcontracted.

17.3.3. Requirement to comply with all program Integrity requirements

17.3.4. Require compliance with state and federal statutes.

17.3.5. Satisfactory remedies, including termination of a Subcontract when the Contractor determines that such parties have not performed adequately which includes but is not limited to egregious patient harm, significant substantiated complaints, submitting claims to the plan for services not delivered, and refusal to participate in the plan’s quality improvement program.

17.3.6. Provision for ongoing monitoring of the Subcontractor’s compliance with the Subcontract by the Contractor. Such monitoring shall specify requirements for corrective action, revocation of the Subcontract or imposing sanctions if the Subcontractor’s performance is inadequate.

17.3.7. A provision specifying how the Subcontractor shall participate in and

comply with the Contractor's quality assurance and utilization review programs, the Contractor's Enrollee grievance and appeals procedures, and the monitoring and evaluation of the Contractor's PACE Program.

17.3.8. A provision specifying how the Subcontractor will ensure that pertinent contracts, books, documents, papers and records of their operations are available, to the Department, HHS, Comptroller General of the United States and/or their respective designated representatives, for inspection, evaluation and audit, through six years from the final date of the Subcontract, or from the date of completion of any audit, or pursuant to the timeframes established in 42 CFR 460, whichever is later.

17.4. List of Covered Services and Subcontractors.

The department may request additional information about providers, related entities or Subcontractors in the network, as required. Any addition to or deletion from the network of providers, related entities, or Subcontractors shall be promptly communicated in writing to the department by the Contractor, on a quarterly basis.

18. Licensure.

The Contractor must hold and maintain a Home Health license.

19. Grievance and Appeals System.

19.1. The Contractor must have a grievance and appeals system that is compliant with 42 CFR 460.120, 460.122, 460.124.

19.2. Grievance System.

19.2.1. The Contractor must have written policies and procedures for the receipt, disposition and documentation of all grievances from PACE participants and their representatives.

19.2.2. The Contractor must assure that a participant's or his or her representative's expression of dissatisfaction, or grievance is recognized and resolved by the PACE program's staff

19.2.3. All complaints concerning denial of service, reduction of service or service coverage will be handled as appeals.

19.3. Appeal Process.

19.3.1. All denials, reductions, or terminations of services or service coverage by the Contractor must be in writing. The Contractor must make available to all PACE staff and contracted providers, information concerning client notices, appeals and hearings processes.

19.3.2. When the Contractor authorizes a course of treatment or covered service, but subsequently acts to terminate, discontinue, or reduce the course of

treatment or a covered service, the Contractor must mail a written notice to the participant at least ten (10) working days before the date of the termination or reduction of the or reduction of the covered service unless there is documentation that the participant had previously agreed to the change as part of the course of treatment.

19.3.3. The written client notice must be a Department approved format and is to be used for all denials, reductions, or terminations of services and denials of claims payment.

19.3.3.1. The notice must include the PACE participant's right to file an appeal with the Contractor and request an administrative hearing with CMS or the Department, including a statement that the PACE participant may request continuation of benefits until a decision is rendered.

19.3.4. The Contractor shall provide the state with a quarterly report of all grievances and appeals in an agreed upon format.

20. Administrative Hearings.

20.1. Only the Enrollee or the Enrollee’s authorized representative may request a hearing. A provider may not request a hearing on behalf of an Enrollee.

20.2. If an Enrollee does not agree with the Contractor’s resolution of the appeal, the Enrollee may file a request for a hearing within the following timeframes. (See WAC 182-526-0200):

20.2.1. For hearings regarding a standard service, within one hundred twenty (120) calendar days of the date of the notice of the resolution of the appeal.

20.2.2. For hearings regarding termination, suspension, or reduction of a previously authorized service, if the Enrollee requests continuation of services, within ten (10) calendar days of the date on the Contractor’s mailing of the notice of the resolution of the appeal. If the Enrollee is notified in a timely manner and the Enrollee’s request for continuation of services is not timely, the Contractor is not obligated to continue services and the timeframes for a hearing regarding a standard service apply.

20.2.3. If the Enrollee requests a hearing, the Contractor shall provide to DSHS/HCA and the Enrollee, upon request, and within three (3) business days, and for expedited appeals, within one (1) business day, all Contractor-held documentation related to the appeal, including but not limited to, any transcript(s), records, or written decision(s) from participating providers or delegated entities.

20.2.4. When medical necessity is an issue, the Contractor's medical director or designee shall review all cases where a hearing is requested and any related appeals and the outcome of any independent review.

20.2.5. The Enrollee must exhaust appeal rights prior to filing a request for a hearing with DSHS/HCA. If the Contractor fails to adhere to the appeal notice and timing requirements, the Enrollee is deemed to have exhausted the appeal process and may initiate a hearing.

20.2.6. DSHS/HCA will notify the Contractor of hearing determinations. The Contractor will be bound by the final order, whether or not the final order upholds the Contractor’s decision. Implementation of the final order shall not be the basis for termination of enrollment by the Contractor.

20.2.7. If the final order is not within the purview of this Contract, then DSHS/HCA will be responsible for the implementation of the final order.

20.2.8. The hearings process shall include as parties to the hearing, the Contractor, the Enrollee and the Enrollee’s representative, or the legal representative of the deceased Enrollee's estate and DSHS/HCA.

20.3. Independent Review.

After exhausting both the Contractor’s Appeal process and the Administration

Hearing, the Enrollee has the right to request an independent review in accordance with RCW 48.43.535 and chapter 182-538 WAC.

The Contractor will advise the HCA Appeals Administrator at P.O. Box 45504, Olympia, WA 98504-5504 when an Enrollee requests an independent review as soon as the MCO becomes aware of the request. The Contractor will forward a copy of the decision made by the Independent Review Organization to the Appeals Administrator as soon as the MCO receives the decision.

20.4. Petition for Review.

Any party may appeal the initial order from the administrative hearing to HCA Board of Appeals in accord with chapter 182-526 WAC. Notice of this right shall be included in the Initial Order from the administrative hearing.

20.5. Continuation of Services.

20.5.1. The Contractor shall continue the Enrollee’s services if all of the following apply:

20.5.1.1. An appeal, hearing, or independent review, is requested on or before the later of the following:

20.5.1.1.1. Within ten (10) calendar days of the Contractor mailing the notice of Denial or reduction of Service, for which the Denial or reduction of Service involves services previously authorized. The Notice shall be delivered by a method that certifies receipt and assures delivery within three (3) calendar days.

20.5.1.1.2. The intended effective date of the Contractor’s

proposed Denial or reduction of Service.

20.5.1.2. The appeal involves the termination, suspension, or reduction of a previously authorized course of treatment.

20.5.1.3. The original period covered by the original authorization has not expired.

20.5.1.4. The Enrollee requests an extension of services.

20.5.2. If, at the Enrollee’s request, the Contractor continues or reinstates the Enrollee’s services while the appeal, hearing, or independent review, is pending, the services shall be continued until one of the following occurs:

20.5.2.1. The Enrollee withdraws the appeal, hearing, or independent review request.

20.5.2.2. The Enrollee has not requested a hearing (with continuation of services until the hearing decision is reached) within the ten (10) calendar days after the Contractor mailed the notice of resolution of the appeal.

20.5.2.3. When the Office of Administrative Hearings issues a decision adverse to the Enrollee.

20.5.3. If the final resolution of the appeal upholds the Contractor’s Denial or reduction of Service, the Contractor may recover from the Enrollee the amount paid for the services provided to the Enrollee for the first sixty (60) calendar days during which the appeal was pending, to the extent that they were provided solely because of the requirement for continuation of services.

20.6. Effect of Reversed Resolutions of Appeals and Hearings.

20.6.1. If the Contractor, or an independent review (IR) decision by an independent review organization (IRO), or a final order from the Office of Administrative Hearings (OAH) or Board of Appeals (BOA), reverses a decision to deny, limit, or delay services that were not provided while the appeal was pending, the Contractor shall authorize or provide the disputed services promptly and as expeditiously as the Enrollee’s health condition requires, but no later than 72 hours from the date the Contractor receives notice reversing the determination.

20.6.2. If the Contractor reverses a decision to deny authorization of services, or the denial is reversed through an IR decision or a final order of OAH or the BOA, and the Enrollee received the disputed services while the appeal was pending, the Contractor shall pay for those services.

21. Marketing.

Marketing materials must:

21.1. comply with CFR 460.82

21.2. comply with the CMS marketing guide

21.3. be submitted and approved by DSHS prior to distribution

22. Benefits.

22.1. Covered Services.

22.1.1. General.

22.1.1.1. The Contractor must authorize, arrange, integrate, and coordinate the provision of all Covered Services for its Enrollees. (See Covered Services in Appendix A.) Covered Services must be available to all Enrollees, as authorized by the Contractor and as determined Medically Necessary pursuant to section 2.4. Covered Services will be managed and coordinated by the Contractor through the Interdisciplinary Care Team (IDT).

22.1.1.2. The Contractor will have discretion to use the Capitated Payment to offer Benefits, as specified in the Enrollee’s Individualized Care Plan (ICP), as appropriate to address the Enrollee’s needs.

22.1.1.3. The Contractor must provide the full range of Covered Services. If either Medicare or Washington Medicaid provides more expansive services than the other program does for a particular condition, type of illness, or diagnosis, the Contractor must provide the most expansive set of services required by either program. The Contractor may not limit or deny services to Enrollees based on Medicare or Washington Medicaid providing a more limited range of services than the other program.

22.1.2. Non-Covered Services.

22.1.2.1. The Contractor is responsible for providing all Medicaid benefits set forth in the WA Medicaid state plan, unless explicitly excluded in this Contract or 42 CFR 460.96. https://www.hca.wa.gov/about-hca/apple-health-medicaid/medicaid-title-xix-state-plan

22.1.3. Exclusions

22.1.3.1. The Contractor is not responsible for coverage of:

22.1.3.1.1. Medications covered by Medicaid for the treatment of Hepatitis C or Hemophilia.

23. Care Management.

23.1. Contractor must have in place a robust care management system to identify the service needs of all Enrollees, including Enrollees with chronic illness and Enrollees with disabilities, and ensure that medically necessary covered benefits are delivered on a timely basis.

23.2. These systems must include procedures for:

23.2.1. Coordination with HCS PACE unit on assessments,

23.2.2. standing referrals,

23.2.3. referrals to specialty centers for Enrollees who require specialized medical care over a prolonged period of time (as determined by a treatment plan approved by the Contractor in consultation with the primary care provider, the designated specialist and the Enrollee or his/her designee),

23.2.4. out-of-network referrals and continuation of existing treatment relationships with out-of-network providers during transitional period only, and

23.2.5. assisting in maintaining client eligibility.

24. Enrollee Rights & Access.

24.1. General Requirements.

The Contractor shall comply with applicable Federal and State laws that pertain to Enrollee rights and ensure that its staff and affiliated providers take those rights into account when furnishing services to Enrollees.

24.2. Cultural Considerations.

The Contractor shall participate in and cooperate with DSHS efforts to promote the delivery of services in a culturally competent manner to all Enrollees, including those with limited English proficiency and diverse cultural and ethnic backgrounds (42 C.F.R. § 460.112).

Enrollees will be given information sufficient to ensure that they understand how to access medical care through the plan, how to file a grievance or appeal, their rights etc.

24.3. This information will be made accessible to and usable by people with disabilities. (according to 42 CFR.112) Prohibition on Enrollee Charges for Contracted Services.

24.3.1. Under no circumstances shall the Contractor, or any providers used to

deliver services under the terms of this Contract, including non-participating providers, charge Enrollees for covered services as described in the (SSA 1932(b)(6), SSA 1128B(d)(1)), 42 C.F.R. § 460.182(c) and WAC 182-502-0160).

24.3.2. Prior to authorizing services with non-participating providers, the Contractor shall assure that non-participating providers fully understand and accept the prohibition against balance billing Enrollees.

24.4. Enrollee Self-Determination.

The Contractor shall ensure that all providers: obtain informed consent prior to treatment from Enrollees, or persons authorized to consent on behalf of an Enrollee as described in RCW 7.70.065; comply with the provisions of the Natural Death Act (chapter 70.122 RCW) and state and federal Medicaid rules concerning advance directives (WAC 182-501-0125 and 42 C.F.R. § 460.112(e); and, when appropriate, inform Enrollees of their right to make anatomical gifts (chapter 68.64 RCW).

25. Self-Directed Care.

25.1. The Contractor will support Enrollees in directing their own care and participation in individual care plan development.

25.2. The Contractor’s IDT will work with the Enrollees in developing an individualized care plan. Specifically Enrollees or their designated representatives will:

25.2.1. Decide how and what LTSS to receive to maintain independence and quality of life, subject to Contractor rules for Covered Services;

25.2.2. Select their health care providers in the Contractor’s network and control care planning and coordination with their health care providers and IDT;

25.2.3. Have access to services that are culturally, linguistically, and operationally sensitive to meet their needs, and that improve their health outcomes, enhance independence, and promote living in home and community settings of their choice; and

25.2.4. Be able to hire, fire, and supervise their personal care providers.

26. Access-Network.

26.1. Service Delivery Network.

In the maintenance, monitoring and reporting of its network, the Contractor must consider the following:

26.1.1. Expected enrollment for each service area in which the Contractor offers services under this Contract.

26.1.2. Adequate access to all services covered under this Contract.

26.1.3. The expected utilization of services, taking into consideration the characteristics and health care needs of the population represented by the Contractor’s Enrollees and potential Enrollees.

26.1.4. The number and types (in terms of training, experience and specialization) of providers required to furnish the contracted services, including mental health providers by provider type.

26.1.5. The number of network providers who are not accepting new Enrollees or who have placed a limit, or given the Contractor notice of the intent to limit their acceptance of Enrollees.

26.1.6. The geographic location of providers and Enrollees, considering distance, travel time, the means of transportation ordinarily used by Enrollees or potential Enrollees, and whether the location provides physical access for the Contractor’s Enrollees with disabilities.

26.1.7. The cultural, racial/ethnic composition and language needs of Enrollees and the ability of network providers to communicate with limited English proficient Enrollees in their preferred language.

26.1.8. The ability of network providers to ensure physical access, reasonable accommodations, culturally competent communications, and accessible equipment for Medicaid Enrollees with physical or mental disabilities.

26.1.9. The availability of triage lines or screening systems, as well as the use of telemedicine, e-visit, and other evolving and innovative technological solutions.

26.2. Network Capacity.

26.2.1. The Contractor shall maintain and monitor an appropriate provider network, supported by written agreements, sufficient to serve Enrollees enrolled under this Contract.

26.2.2. The network must include all provider types necessary to furnish the Benefit Package to all Enrollees.

26.3. Timely Access to Care.

The Contractor shall have contracts in place with all subcontractors that meet standards for access, taking into account the urgency of the need for services

26.4. Provider Network Changes.

The Contractor shall give DSHS a minimum of ninety (90) calendar days' prior written notice, in accord with the Notices provisions of the General Terms and Conditions Section of this Contract, of the loss of a material provider. A material provider is one whose loss would impair the Contractor's ability to provide continuity of and access to care for the Contractor’s current Enrollees and potential Enrollees.

27. Individual Providers (IP).

27.1. The Contractor will be responsible for collecting, processing and maintaining employment related forms for all IPs employed by Enrollees/representatives.

27.2. The Contractor shall implement the following for IPs:

27.2.1. Complying with all IP requirements outlined in RCW 43.20A.710 and chapter 388-71 WAC. Individuals who do not meet these requirements are not eligible for payment for Enrollee-directed personal assistance services.

27.2.2. Developing standard policies and procedures for the IP contracting process.

27.2.3. Verifying the individuals’ right to work.

27.2.4. Processing an initial name/birthdate background check through the DSHS Background Check Central Unit (BCCU) as part of the contracting process to be used to presumptively hire an IP.

27.2.4.1. The Contractor must process all background checks and mandatory fingerprinting of all individual providers through the DSHS Background Check Central Unit (BCCU) as part of the contracting process.

27.2.5. Executing IP contracts as required and approved by the DSHS.

27.2.6. Collection and review of IP time sheets to ensure accurate payment.

27.2.7. Verifying the completion of required training as specified in chapter 388-71 WAC.

27.2.8. Providing written due process notification to the IP and Enrollee at least ten (10) days prior to the training deadline when training has not been completed and termination of payment will occur in accordance with DSHS policy.

27.2.9. If the IP does not successfully complete the training within the required timelines notify the Enrollee, and terminate payment by closing the service authorization immediately.

27.2.10. Complete Authorizations in the ProviderOne system for IP services and ensure compliance with all DSHS Management Bulletins.

27.3. IP Payment Reconciliation Process:

27.3.1. The Collective Bargaining Agreement between DSHS and Service Employees International Union (SEIU) requires payment out of one system in order to track a provider’s cumulative career hours, paid time

and other bargained benefits.

27.3.1.1. To comply with this requirement DSHS pays all IPs who provide care to the Contractor’s Enrollees and bills it back to the Contractor.

27.3.2. For services provided by IPs, to the contractor’s Enrollees, DSHS bills the Contractor for:

27.3.2.1. Personal Care Hours;

27.3.2.2. Training;

27.3.2.3. Benefits and taxes; and

27.3.2.4. Transportation.

27.3.3. DSHS reconciles payments and bills back to the Contractor retrospectively.

27.3.3.1. An offset for IP billing is made as a gross adjustment in ProviderOne against the next outgoing capitated payment.

27.3.3.2. DSHS provides the Contractor with a copy of the supporting billing documents for its records.

27.3.4. IP payments and benefits are subject to change with each new collective bargaining agreement. Contractor billing will be adjusted with any applicable changes to the collective bargaining agreement.

28. Collective Bargaining Agreements.

The state shall coordinate with the Contractor to ensure compliance with all current and future collective bargaining agreements (CBAs) by and between the Governor of the State of Washington and the Service Employees International Union, (SEIU 775), in accordance with RCW 74.39A.270 and the Adult Family Home Council (AFHC), in accordance with RCW 41.56. DSHS shall provide the Contractor with copies of any future CBAs or amendments to existing agreements no less than 60 days prior to the effective date of the future agreement or amendment. Additionally, Contractor shall specifically comply as outlined below for the following requirements. 28.1. The Contractor shall establish a mechanism to directly communicate and/or

respond to employment-related inquiries made by Union representatives when acting on the worker/provider’s behalf. Such information shall exclude specific and/or confidential personal information of Enrollees unless the Contractor has the written permission of the Enrollee in question.

28.2. The Contractor agrees to pay rate(s) negotiated between the state and the Union(s) as stipulated in the respective CBAs or as specified in item 27.4 below for AFH contracted providers.

28.3. The Contractor will have in place provider contracts, policies and procedures to ensure compliance with Section 27 of this Contract.

28.4. AFHC CBA specific: Provided the state provides the AFHC with lists of providers on a monthly basis, the Contractor shall provide DSHS with list(s) of all AFH providers serving Medicaid Enrollees, through a mechanism agreed upon by DSHS and the Contractor. This list shall be provided to DSHS every 10th business day of each month and shall include all of the data elements identified in Article 3.4 Lists A through J as follows:

A. Month in which the service was provided; B. Names of all providers who received a payment in the previous

calendar month; C. Provider number; D. Mailing address; E. Telephone number, if available; F. Amount of total payment per provider; G. Email address of provider, if available; H. Fax number, if available; I. All newly contracted providers; and J. A table cross-walking provider numbers with license number.

28.4.1. PACE Base Daily Rates: Effective July 1, 2015 through June 30, 2017, the Contractor shall pay a base daily rate in accordance with Article 7.1 of the CBA, based on the DSHS CARE assessment, or a base daily rate that is higher than the rates in Article 7.1 based on the Contractor’s own assessment of the Enrollee. All other provisions of Article 7, Payments, excluding the Expanded Community Service Daily Rate and the Specialized Behavioral Support Add-On Rate, are applicable to the Contractor.

28.4.2. Exceptions to PACE Base Daily Rates: The Contractor may pay a daily rate higher than the base daily rates in item 5.4.1, if the Contractor believes an additional rate is warranted based upon the Contractor’s assessment of the Enrollee, and is in accordance with federal regulations and the Contractor’s obligation to provide all contracted Medicaid benefits in the state plan. With the specific clarification of 5.4.1, 5.4.2 and the exclusion of the Exception to the Rule, all other provisions of Article 3, AFHC Rights are applicable to the Contractor. The CBA can be found at http://www.ofm.wa.gov/labor/agreements/15-17/nse_afh.pdf.

28.5. CBA provisions Not Applicable: None of the provisions of Article 13, the Meaningful Home-Based Activities Pilot MOU, the AFHC Voluntary Contribution MOU or the Article 13 MOU are applicable to Contractor.

28.6. The Contractor will provide a one-time report on October 1, 2016, on a format provided by DSHS and agreed to by the Contractor, detailing a one-month snap shot of rates paid to adult family homes by client for homes in which the Contractor has Enrollees placed in.

29. Coordination with State Agency.

29.1. The state agency will determine functional and financial eligibility for all long term services and supports programs based on WAC 388-106-0705.

29.2. The state agency will coordinate with the Contractor to provide the assessment for prospective enrollees according to agreed upon processes.

29.3. State staff will complete an assessment at least annually or when there has been a reported significant change (for better or worse) in the client’s cognition, activities of daily living, mood and behaviors or medical condition that affects the care plan.

29.3.1. at the time of assessment, and based on current policy, state staff may allow PACE Enrollees to elect to continue enrollment in PACE regardless of improved status related to functional criteria for Nursing Facility Level of Care (NFLOC). This process is called Deeming.

29.4. The Contractor is responsible for coordinating with the state staff to provide pertinent information regarding PACE Enrollee status.

29.4.1. It is the Contractor’s role to provide information. CARE assessments are completed at the sole discretion of the state agency staff, unless there is a significant change in condition.

29.5. The Contractor shall work with the local state staff to define procedure for coordination on assessments.

29.6. The Contractor shall provide training to local state staff regarding the PACE program. The State will help coordinate training of all state caseworkers to ensure state staff have the necessary knowledge to offer enrollment in PACE as an option at the time of the assessment.

29.7. The Contractor shall establish written policy and procedure for disenrollments and transitions of care.

29.8. The parties will establish a joint quarterly meeting to include the PACE program manager, HCS PACE unit manager, and any other staff deemed appropriate by the PACE program manager and HCS PACE unit manager to review enrollment, eligibility, disenrollments, etc. Contractor will schedule the meetings

29.9. In accordance with SHB 1499 state staff will offer enrollment in PACE as an option at the time of assessment.

29.9.1. This process will be in accordance with Federal Title XIX requirements.

29.9.2. All positive responses will be distributed to contractors in the service area per current policy.

30. Reporting.

30.1. Reporting of Enrollee Abuse. The Contractor shall report all instances of suspected abuse, abandonment, neglect and/or exploitation to an Enrollee or

other alleged victim residing in King County to1-800-END HARM.

30.2. The Contractor shall have in place a standard process and effective staff training on reporting to Adult Protective Services when fraud adversely affects the health and safety of a vulnerable adult as defined by RCW 74.34.095.

30.3. Assisted Living Facilities (ALF) Report

29.3.1. The Contractor shall track and report all service days paid to licensed Assisted Living facilities, contracted with the Department, for all Enrollees.

30.3.1.1. The Contractor shall provide the report by April 1 of each year,

on a format provided by DSHS.

30.4. Caseload forecasting reports

Caseload data: to be reported by the first day of the month of May, September and January. A current count of all enrollees and living arrangement. The contractor shall provide the caseload data according to the Forecast Report Template, attached as Exhibit F.

Exhibit A – Data Security Requirements 1. Definitions. The words and phrases listed below, as used in this Exhibit, shall each

have the following definitions:

a. “AES” means the Advanced Encryption Standard, a specification of Federal Information Processing Standards Publications for the encryption of electronic data issued by the National Institute of Standards and Technology (http://nvlpubs.nist.gov/nistpubs/FIPS/NIST.FIPS.197.pdf).

b. “Authorized Users(s)” means an individual or individuals with a business need to access DSHS Confidential Information, and who has or have been authorized to do so.

c. “Business Associate Agreement” means an agreement between DSHS and a contractor who is receiving Data covered under the Privacy and Security Rules of the Health Insurance Portability and Accountability Act of 1996. The agreement establishes permitted and required uses and disclosures of protected health information (PHI) in accordance with HIPAA requirements and provides obligations for business associates to safeguard the information.

d. “Category 4 Data” is data that is confidential and requires special handling due to statutes or regulations that require especially strict protection of the data and from which especially serious consequences may arise in the event of any compromise of such data. Data classified as Category 4 includes but is not limited to data protected by: the Health Insurance Portability and Accountability Act (HIPAA), Pub. L. 104-191 as amended by the Health Information Technology for Economic and Clinical Health Act of 2009 (HITECH), 45 CFR Parts 160 and 164; the Family Educational Rights and Privacy Act (FERPA), 20 U.S.C. §1232g; 34 CFR Part 99; Internal Revenue Service Publication 1075 (https://www.irs.gov/pub/irs-pdf/p1075.pdf); Substance Abuse and Mental Health Services Administration regulations on Confidentiality of Alcohol and Drug Abuse Patient Records, 42 CFR Part 2; and/or Criminal Justice Information Services, 28 CFR Part 20.

e. “Cloud” means data storage on servers hosted by an entity other than the Contractor and on a network outside the control of the Contractor. Physical storage of data in the cloud typically spans multiple servers and often multiple locations. Cloud storage can be divided between consumer grade storage for personal files and enterprise grade for companies and governmental entities. Examples of consumer grade storage would include iTunes, Dropbox, Box.com, and many other entities. Enterprise cloud vendors include Microsoft Azure, Amazon Web Services, and Rackspace.

f. “Encrypt” means to encode Confidential Information into a format that can only be read by those possessing a “key”; a password, digital certificate or other mechanism available only to authorized users. Encryption must use a key length of at least 256 bits for symmetric keys, or 2048 bits for asymmetric keys. When a symmetric key is used, the Advanced Encryption Standard (AES) must be used if available.

g. “FedRAMP” means the Federal Risk and Authorization Management Program (see www.fedramp.gov), which is an assessment and authorization process that federal government agencies have been directed to use to ensure security is in place when accessing Cloud computing products and services.

h. “Hardened Password” means a string of at least eight characters containing at least three of the following four character classes: Uppercase alphabetic, lowercase alphabetic, numeral, and special characters such as an asterisk, ampersand, or exclamation point.

i. “Mobile Device” means a computing device, typically smaller than a notebook, which runs a mobile operating system, such as iOS, Android, or Windows Phone. Mobile Devices include smart phones, most tablets, and other form factors.

j. “Multi-factor Authentication” means controlling access to computers and other IT resources by requiring two or more pieces of evidence that the user is who they claim to be. These pieces of evidence consist of something the user knows, such as a password or PIN; something the user has such as a key card, smart card, or physical token; and something the user is, a biometric identifier such as a fingerprint, facial scan, or retinal scan. “PIN” means a personal identification number, a series of numbers which act as a password for a device. Since PINs are typically only four to six characters, PINs are usually used in conjunction with another factor of authentication, such as a fingerprint.

k. “Portable Device” means any computing device with a small form factor, designed to be transported from place to place. Portable devices are primarily battery powered devices with base computing resources in the form of a processor, memory, storage, and network access. Examples include, but are not limited to, mobile phones, tablets, and laptops. Mobile Device is a subset of Portable Device.

l. “Portable Media” means any machine readable media that may routinely be stored or moved independently of computing devices. Examples include magnetic tapes, optical discs (CDs or DVDs), flash memory (thumb drive) devices, external hard drives, and internal hard drives that have been removed from a computing device.

m. “Secure Area” means an area to which only authorized representatives of the entity possessing the Confidential Information have access, and access is controlled through use of a key, card key, combination lock, or comparable mechanism. Secure Areas may include buildings, rooms or locked storage containers (such as a filing cabinet or desk drawer) within a room, as long as access to the Confidential Information is not available to unauthorized personnel. In otherwise Secure Areas, such as an office with restricted access, the Data must be secured in such a way as to prevent access by non-authorized staff such as janitorial or facility security staff, when authorized Contractor staff are not present to ensure that non-authorized staff cannot access it.

n. “Trusted Network” means a network operated and maintained by the Contractor, which includes security controls sufficient to protect DSHS Data on that network. Controls would include a firewall between any other networks, access control lists on networking devices such as routers and switches, and other such mechanisms which protect the confidentiality, integrity, and availability of the Data.

o. “Unique User ID” means a string of characters that identifies a specific user and which, in conjunction with a password, passphrase or other mechanism, authenticates a user to an information system.

2. Authority. The security requirements described in this document reflect the applicable requirements of Standard 141.10 (https://ocio.wa.gov/policies) of the Office of the Chief Information Officer for the state of Washington, and of the DSHS Information Security Policy and Standards Manual. Reference material related to these requirements can be found here: https://www.dshs.wa.gov/fsa/central-contract-services/keeping-dshs-client-information-private-and-secure, which is a site developed by the DSHS Information Security Office and hosted by DSHS Central Contracts and Legal Services.

3. Administrative Controls. The Contractor must have the following controls in place:

a. A documented security policy governing the secure use of its computer network and systems, and which defines sanctions that may be applied to Contractor staff for violating that policy.

b. If the Data shared under this agreement is classified as Category 4, the Contractor must be aware of and compliant with the applicable legal or regulatory requirements for that Category 4 Data.

c. If Confidential Information shared under this agreement is classified as Category 4, the Contractor must have a documented risk assessment for the system(s) housing the Category 4 Data.

4. Authorization, Authentication, and Access. In order to ensure that access to the Data is limited to authorized staff, the Contractor must: a. Have documented policies and procedures governing access to systems with the

shared Data. b. Restrict access through administrative, physical, and technical controls to authorized

staff. c. Ensure that user accounts are unique and that any given user account logon ID and

password combination is known only to the one employee to whom that account is assigned. For purposes of non-repudiation, it must always be possible to determine which employee performed a given action on a system housing the Data based solely on the logon ID used to perform the action.

d. Ensure that only authorized users are capable of accessing the Data. e. Ensure that an employee’s access to the Data is removed immediately:

(1) Upon suspected compromise of the user credentials. (2) When their employment, or the contract under which the Data is made available to them, is terminated. (3) When they no longer need access to the Data to fulfill the requirements of the contract.

f. Have a process to periodically review and verify that only authorized users have access to systems containing DSHS Confidential Information.

g. When accessing the Data from within the Contractor’s network (the Data stays within the Contractor’s network at all times), enforce password and logon requirements for users within the Contractor’s network, including:

(1) A minimum length of 8 characters, and containing at least three of the following character classes: uppercase letters, lowercase letters, numerals, and special characters such as an asterisk, ampersand, or exclamation point.

(2) That a password does not contain a user’s name, logon ID, or any form of their full name.

(3) That a password does not consist of a single dictionary word. A password may be formed as a passphrase which consists of multiple dictionary words.

(4) That passwords are significantly different from the previous four passwords. Passwords that increment by simply adding a number are not considered significantly different.

h. When accessing Confidential Information from an external location (the Data will traverse the Internet or otherwise travel outside the Contractor’s network), mitigate risk and enforce password and logon requirements for users by employing measures including:

(1) Ensuring mitigations applied to the system don’t allow end-user modification.

(2) Not allowing the use of dial-up connections.

(3) Using industry standard protocols and solutions for remote access. Examples would include RADIUS and Citrix.

(4) Encrypting all remote access traffic from the external workstation to Trusted Network or to a component within the Trusted Network. The traffic must be encrypted at all times while traversing any network, including the Internet, which is not a Trusted Network.

(5) Ensuring that the remote access system prompts for re-authentication or performs automated session termination after no more than 30 minutes of inactivity.

(6) Ensuring use of Multi-factor Authentication to connect from the external end point to the internal end point.

i. Passwords or PIN codes may meet a lesser standard if used in conjunction with another authentication mechanism, such as a biometric (fingerprint, face recognition, iris scan) or token (software, hardware, smart card, etc.) in that case:

(1) The PIN or password must be at least 5 letters or numbers when used in conjunction with at least one other authentication factor

(2) Must not be comprised of all the same letter or number (11111, 22222, aaaaa, would not be acceptable)

(3) Must not contain a “run” of three or more consecutive numbers (12398, 98743 would not be acceptable)

j. If the contract specifically allows for the storage of Confidential Information on a Mobile Device, passcodes used on the device must:

(1) Be a minimum of six alphanumeric characters.

(2) Contain at least three unique character classes (upper case, lower case, letter, number).

(3) Not contain more than a three consecutive character run. Passcodes consisting of 12345, or abcd12 would not be acceptable.

k. Render the device unusable after a maximum of 10 failed logon attempts.

5. Protection of Data. The Contractor agrees to store Data on one or more of the following media and protect the Data as described:

a. Hard disk drives. For Data stored on local workstation hard disks, access to the Data will be restricted to Authorized User(s) by requiring logon to the local workstation using a Unique User ID and Hardened Password or other authentication mechanisms which provide equal or greater security, such as biometrics or smart cards.

b. Network server disks. For Data stored on hard disks mounted on network servers and made available through shared folders, access to the Data will be restricted to Authorized Users through the use of access control lists which will grant access only after the Authorized User has authenticated to the network using a Unique User ID and Hardened Password or other authentication mechanisms which provide equal or greater security, such as biometrics or smart cards. Data on disks mounted to such servers must be located in an area which is accessible only to authorized personnel,

with access controlled through use of a key, card key, combination lock, or comparable mechanism.

For DSHS Confidential Information stored on these disks, deleting unneeded Data is sufficient as long as the disks remain in a Secure Area and otherwise meet the requirements listed in the above paragraph. Destruction of the Data, as outlined below in Section 8 Data Disposition, may be deferred until the disks are retired, replaced, or otherwise taken out of the Secure Area.

c. Optical discs (CDs or DVDs) in local workstation optical disc drives. Data provided by DSHS on optical discs which will be used in local workstation optical disc drives and which will not be transported out of a Secure Area. When not in use for the contracted purpose, such discs must be Stored in a Secure Area. Workstations which access DSHS Data on optical discs must be located in an area which is accessible only to authorized personnel, with access controlled through use of a key, card key, combination lock, or comparable mechanism.

d. Optical discs (CDs or DVDs) in drives or jukeboxes attached to servers. Data provided by DSHS on optical discs which will be attached to network servers and which will not be transported out of a Secure Area. Access to Data on these discs will be restricted to Authorized Users through the use of access control lists which will grant access only after the Authorized User has authenticated to the network using a Unique User ID and Hardened Password or other authentication mechanisms which provide equal or greater security, such as biometrics or smart cards. Data on discs attached to such servers must be located in an area which is accessible only to authorized personnel, with access controlled through use of a key, card key, combination lock, or comparable mechanism.

e. Paper documents. Any paper records must be protected by storing the records in a Secure Area which is only accessible to authorized personnel. When not in use, such records must be stored in a Secure Area.

f. Remote Access. Access to and use of the Data over the State Governmental Network (SGN) or Secure Access Washington (SAW) will be controlled by DSHS staff who will issue authentication credentials (e.g. a Unique User ID and Hardened Password) to Authorized Users on Contractor’s staff. Contractor will notify DSHS staff immediately whenever an Authorized User in possession of such credentials is terminated or otherwise leaves the employ of the Contractor, and whenever an Authorized User’s duties change such that the Authorized User no longer requires access to perform work for this Contract.

g. Data storage on portable devices or media.

(1) Except where otherwise specified herein, DSHS Data shall not be stored by the Contractor on portable devices or media unless specifically authorized within the terms and conditions of the Contract. If so authorized, the Data shall be given the following protections:

(a) Encrypt the Data.

(b) Control access to devices with a Unique User ID and Hardened Password or stronger authentication method such as a physical token or biometrics.

(c) Manually lock devices whenever they are left unattended and set devices to lock automatically after a period of inactivity, if this feature is available. Maximum period of inactivity is 20 minutes.

(d) Apply administrative and physical security controls to Portable Devices and Portable Media by:

i. Keeping them in a Secure Area when not in use,

ii. Using check-in/check-out procedures when they are shared, and

iii. Taking frequent inventories.

(2) When being transported outside of a Secure Area, Portable Devices and Portable Media with DSHS Confidential Information must be under the physical control of Contractor staff with authorization to access the Data, even if the Data is encrypted.

h. Data stored for backup purposes.

(1) DSHS Confidential Information may be stored on Portable Media as part of a Contractor’s existing, documented backup process for business continuity or disaster recovery purposes. Such storage is authorized until such time as that media would be reused during the course of normal backup operations. If backup media is retired while DSHS Confidential Information still exists upon it, such media will be destroyed at that time in accordance with the disposition requirements below in Section 8 Data Disposition.

(2) Data may be stored on non-portable media (e.g. Storage Area Network drives, virtual media, etc.) as part of a Contractor’s existing, documented backup process for business continuity or disaster recovery purposes. If so, such media will be protected as otherwise described in this exhibit. If this media is retired while DSHS Confidential Information still exists upon it, the data will be destroyed at that time in accordance with the disposition requirements below in Section 8 Data Disposition.

i. Cloud storage. DSHS Confidential Information requires protections equal to or greater than those specified elsewhere within this exhibit. Cloud storage of Data is problematic as neither DSHS nor the Contractor has control of the environment in which the Data is stored. For this reason:

(1) DSHS Data will not be stored in any consumer grade Cloud solution, unless all of the following conditions are met:

(a) Contractor has written procedures in place governing use of the Cloud storage and Contractor attests in writing that all such procedures will be uniformly followed.

(b) The Data will be Encrypted while within the Contractor network.

(c) The Data will remain Encrypted during transmission to the Cloud.

(d) The Data will remain Encrypted at all times while residing within the Cloud storage solution.

(e) The Contractor will possess a decryption key for the Data, and the decryption key will be possessed only by the Contractor and/or DSHS.

(f) The Data will not be downloaded to non-authorized systems, meaning systems that are not on either the DSHS or Contractor networks.

(g) The Data will not be decrypted until downloaded onto a computer within the control of an Authorized User and within either the DSHS or Contractor’s network.

(2) Data will not be stored on an Enterprise Cloud storage solution unless either:

(a) The Cloud storage provider is treated as any other Sub-Contractor, and agrees in writing to all of the requirements within this exhibit; or,

(b) The Cloud storage solution used is FedRAMP certified.

(3) If the Data includes protected health information covered by the Health Insurance Portability and Accountability Act (HIPAA), the Cloud provider must sign a Business Associate Agreement prior to Data being stored in their Cloud solution.

6. System Protection. To prevent compromise of systems which contain DSHS Data or through which that Data passes:

a. Systems containing DSHS Data must have all security patches or hotfixes applied within 3 months of being made available.

b. The Contractor will have a method of ensuring that the requisite patches and hotfixes have been applied within the required timeframes.

c. Systems containing DSHS Data shall have an Anti-Malware application, if available, installed.

d. Anti-Malware software shall be kept up to date. The product, its anti-virus engine, and any malware database the system uses, will be no more than one update behind current.

7. Data Segregation.

a. DSHS Data must be segregated or otherwise distinguishable from non-DSHS data. This is to ensure that when no longer needed by the Contractor, all DSHS Data can be identified for return or destruction. It also aids in determining whether DSHS Data has or may have been compromised in the event of a security breach. As such, one or more of the following methods will be used for data segregation.

(1) DSHS Data will be kept on media (e.g. hard disk, optical disc, tape, etc.) which will contain no non-DSHS Data. And/or,

(2) DSHS Data will be stored in a logical container on electronic media, such as a partition or folder dedicated to DSHS Data. And/or,

(3) DSHS Data will be stored in a database which will contain no non-DSHS data. And/or,

(4) DSHS Data will be stored within a database and will be distinguishable from non-DSHS data by the value of a specific field or fields within database records.

(5) When stored as physical paper documents, DSHS Data will be physically segregated from non-DSHS data in a drawer, folder, or other container.

b. When it is not feasible or practical to segregate DSHS Data from non-DSHS data, then both the DSHS Data and the non-DSHS data with which it is commingled must be protected as described in this exhibit.

8. Data Disposition. When the contracted work has been completed or when the Data is no longer needed, except as noted above in Section 5.b, Data shall be returned to DSHS or destroyed. Media on which Data may be stored and associated acceptable methods of destruction are as follows:

Data stored on: Will be destroyed by:

Server or workstation hard disks, or

Removable media (e.g. floppies, USB flash

drives, portable hard disks) excluding optical

discs

Using a “wipe” utility which will overwrite the

Data at least three (3) times using either

random or single character data, or

Degaussing sufficiently to ensure that the

Data cannot be reconstructed, or

Physically destroying the disk

Paper documents with sensitive or

Confidential Information

Recycling through a contracted firm, provided

the contract with the recycler assures that the

confidentiality of Data will be protected.

Paper documents containing Confidential

Information requiring special handling (e.g.

protected health information)

On-site shredding, pulping, or incineration

Optical discs (e.g. CDs or DVDs) Incineration, shredding, or completely

defacing the readable surface with a coarse

abrasive

Magnetic tape Degaussing, incinerating or crosscut

shredding

9. Notification of Compromise or Potential Compromise. The compromise or potential

compromise of DSHS shared Data must be reported to the DSHS Contact designated in the Contract within one (1) business day of discovery. If no DSHS Contact is designated in the Contract, then the notification must be reported to the DSHS Privacy Officer at dshsprivacyofficer@dshs.wa.gov. Contractor must also take actions to mitigate the risk of loss and comply with any notification or other requirements imposed by law or DSHS.

10. Data shared with Subcontractors. If DSHS Data provided under this Contract is to be shared with a subcontractor, the Contract with the subcontractor must include all of the data security provisions within this Contract and within any amendments, attachments, or exhibits within this Contract. If the Contractor cannot protect the Data as articulated within this Contract, then the contract with the sub-Contractor must be submitted to the DSHS Contact specified for this contract for review and approval.

Exhibit B

PACE Program Agreement AGREEMENT No. H-5007

(Amended as of May 23, 2018)

An Agreement Between

The Secretary of the Department of Health and Human Services, who has delegated authority to the

Administrator of the Centers for Medicare and Medicaid Services, hereinafter referred to as CMS, and

the Washington State Department of Social and Health Services, the State Administering Agency,

hereinafter referred to as SAA, and Providence Health & Services Washington operates Providence

Elder-Place Seattle, hereinafter referred to as the Pace Organization.

The Secretary, in finding the PACE Organization to be an eligible organization by the Administrator

of CMS and the SAA, agrees to the following with the PACE Organization for the purposes of

enacting sections 1894 and 1934 of the Social Security Act:

ARTICLE I

TERM OF AGREEMENT §460.32(a)(3); §460.34

This Agreement is effective for the contract year beginning November 1, 2002 through January 1, 2004

and may be extended for subsequent contract years in the absence of a notice by a party (CMS, SAA,

or the PACE Organization) to terminate the agreement. This agreement supersedes any previous

understanding, agreement, arrangement or contract with respect to the provision of and/or the payment

for PACE services. This Agreement is subject to termination as contained in Article IV.

The PACE Organization agrees to comply with all regulations or general instructions or other terms

and conditions as CMS or the SAA may find necessary and appropriate from time to time for the

administration of the PACE program.

ARTICLE II

GENERAL CONDITIONS

A. Governing Body §460.32(a)(4); §460.62; §460.60

B.

(1). The name and telephone number of the PACE Organization's program director and

the names of all members of the governing body, and the name and phone number of a

governing body member who will serve as a liaison between the governing body and

CMS and the SAA is contained in Appendix A.

(2). Any changes in names or telephone numbers shall be reported to CMS and to

2 the SAA prior to the effective date of the change(s).

B. PACE Structure §460.32(a)(4); §460.60

(1). A description of the organizational structure of the PACE Organization, including

the relationship to, at a minimum, the governing body, program director, medical

director, and to any parent, affiliate or subsidiary entity is shown in Appendix B.

(2). A PACE Organization planning a change in organizational structure shall notify

CMS and the SAA, in writing, at least 14 days before the change takes effect.

C. Service Area and PACE Site(s) §460.32(a)(1)

(1). The PACE Organization shall furnish PACE services only to participants who live

within the designated service area, approved by the SAA and CMS (except as provided

in §460.70(b)(2)), which is identified by zip code, county, perimeter street boundaries,

census tract, block, or tribal jurisdictional area (as applicable).

(2). The PACE Organization shall identify the sites at which it will perform PACE

services. Any changes in the designated service area and/or the site(s) identified in this

agreement must be approved by CMS and the SAA prior to effecting such changes. The

designated service area and site(s) are included in Appendix C.

D. Participant Bill of Rights §460.32(a)(5); §460.110 and §460.112

The PACE Organization shall make available to all enrollees a list and explanation of the rights to which they are entitled. The PACE Organization shall assure that those rights and protections are provided. The participant Bill of Rights that will be used to satisfy this requirement is included in Appendix D.

E. Services §460.32(a)(8); §460.92 and §460.94

The PACE Organization agrees to make available comprehensive health care services that include, at

a minimum, all services required by 42 CFR §460.92 and 42 CFR §460.94.

F. Eligibility, Enrollment and Disenrollment §460.32(a)(7) & §460.32(b)(1); §460.150

§460.160(b)(3)(ii); §460.162; §460.164

(1). The PACE Organization shall consider for enrollment and enroll only those persons

who: are 55 years or older, are determined by the SAA to need the level of care required

under the State Medicaid plan for coverage of nursing facility services, are able to live in

a community setting without jeopardizing their health or safety, and reside in the

organization's approved designated service area.

(2). The PACE Organization's eligibility and enrollment policies, including the criteria

used to determine if persons are able to live in a community setting without jeopardizing

their health or safety, is contained in Appendix E.

(3). The SAA, in consultation with the PACE Organization, makes a determination

3 of continued eligibility based on a review of the participant’s medical record and plan of

care. The criteria used to make the determination of continued eligibility are contained

in Appendix E.

(4). The PACE Organization may establish other enrollment criteria in addition to that

found in Article II F(1) of this Agreement that support decisions to not enroll persons

because of certain circumstances. This criteria, however, shall not modify the criteria in

Article II F(1) above. All additional enrollment criteria, if any, are specified in

Appendix F. (5). The PACE Organization agrees that any participant, for any reason, may voluntarily

disenroll and, upon doing so, is not liable for any additional or penalty payments. The

voluntary disenrollment policy is contained in Appendix G.

(6). The PACE Organization may not involuntarily disenroll a participant except for

specific causes. The PACE Organization's involuntary disenrollment policy is located in

Appendix H.

G. Grievance and Appeals §460.32(a)(6); §460.122; §460.124

(1). All participants are afforded the right to grieve a PACE Organization’s medical and

non-medical decisions. They also have the right to appeal the PACE Organization's refusal

to provide a particular care-related service or its decision not to pay for a service received

by a PACE participant. Internal grievance and appeal procedures for participants are

contained in Appendix I.

(2). PACE participants will be informed, in writing, of his or her appeal rights under

Medicare or Medicaid managed care, or both. PACE participants will be assisted in

choosing which to pursue if both are applicable. The additional appeal rights procedures

under Medicare or Medicaid are contained in Appendix J.

H. Quality Assessment and Performance Improvement §460.32(a)(9),(a)(10),(a)(11); §460.130,

§460.134(c), §460.136, §460. 140; §460.202(b)

(1). A description of the PACE Organization's quality assessment and performance

improvement program is contained in Appendix K.

(2). The PACE organization shall meet or exceed minimum levels of performance on

standardized quality measures as established by CMS and the SAA. The minimum level of

performance is: The organization will achieve an immunization rate for both influenza and

pneumococcal vaccinations of 80% for the participant population that is appropriate. (Rate

will exclude those participants who have had prior immunization or the vaccine is medically

contraindicated).

(3). The PACE Organization shall furnish data and information on participant care activities,

as established by CMS and the SAA. These data are contained in Appendix L.

I. Data Collection and Reporting Requirements §460.200(a)(b)(c) and §460.204; §460.70

(1). The PACE Organization shall collect data, maintain records and submit reports as

required by CMS and the SAA. The PACE Organization shall allow CMS and the SAA

4 access to data and records including, but not limited to, participant health outcomes data,

financial books and records, medical records, personnel records, any aspect of services

furnished, reconciliation of participants, benefit liabilities and determination of Medicare

and Medicaid amounts payable.

(2). The PACE Organization agrees to require that all related entities, contractors or

subcontractors agree that the SAA, the U.S. Department of Health and Human Services,

CMS, or their designee(s) have the right to inspect, evaluate and audit any pertinent

contracts, books, documents, papers, and records of any related entity contractor(s) or

subcontractor(s) involving transactions related to this Agreement.

ARTICLE III

PAYMENT

§460.32(a)(12)

For each enrolled participant who is Medicare and/or Medicaid eligible, the PACE Organization will

be paid a prospective, monthly capitation amount.

A. For Participants Eligible for Medicare §460.180

(1). Separate rates are established for Part A and Part B. For a participant entitled to Part A

benefits and enrolled under Part B, both the Part A and Part B rates are paid. For a participant

who is entitled to Part A benefits but not enrolled under Part B, only the Part A rate is paid.

For a participant enrolled under Part B but not entitled to Part A benefits, only the Part B

rate is paid.

(2). The Medicare payment amount is described in Appendix M.

B. For Participants Eligible for Medicaid §460.182

(1). The monthly capitated Medicaid payment amount is negotiated between the PACE

Organization and the SAA. This payment amount is specified in Appendix M.

(2). The SAA shall describe the enrollment/disenrollment reconciliation procedures, to

adjust for the difference between the estimated number of participants on which the

prospective monthly payment was based and the actual number of participants claimed in

that month. The reconciliation method is contained in Appendix N.

ARTICLE IV

TERMINATION OF THE AGREEMENT

§460.32(a)(13) §460.50, §460.52, §460.54

A. CMS or the SAA may terminate this Agreement at any time for cause, including, but not limited to:

uncorrected deficiencies in the quality of care furnished to participants, the PACE Organization’s

failure to comply substantially with the conditions for a PACE program, or

5 non-compliance with the terms of this Agreement.

B. The PACE organization may terminate this agreement after timely notice to CMS, the SAA and

the participants. Notifications shall be made as follows: 90 days before termination to CMS and

the SAA and 60 days before termination to the participants.

C. The PACE Organization’s detailed written plan for phase-down, in the event of termination, is

included in Appendix O.

ARTICLE V

REQUIREMENTS OF LAWS AND REGULATION

§460.32(a)(2)

A. The PACE Organization agrees to comply with all applicable Federal, State, and local laws and

regulations, including, but not limited to:

(1). Sections 1894 and 1934 of the Social Security Act as implemented by regulations at 42 CFR

Part 460;

(2). Title VI of the Civil Rights Act of 1964 as implemented by regulations at 45 CFR Part 84;

(3). The Age Discrimination Act of 1975 as implemented by regulations at 45 CFR

Part 91;

(4). The Americans with Disabilities Act; and

(5). Other laws applicable to the receipt of Federal funds.

ARTICLE VI

CHANGES TO THE PROGRAM AGREEMENT

The Parties agree that CMS has the authority to incorporate any additional terms agreed upon by all

parties or revise any terms of this agreement and its accompanying appendices that:

(1). Are subject to periodic readjustment;

(2). Are outmoded as a result of an organizational change made by the PACE Organization;

(3). Are outmoded as a result of a contractual modification, initiated by a Party; or

(4). Is required by a change in applicable Federal, State, or local laws and regulations.

CMS shall provide the PACE Organization and the SAA with a written notification of any revisions

made to the program agreement and/or its appendices, along with the revised program agreement

pages. Upon notification, the parties shall notify CMS, in writing, of any disagreement with the terms

of the revision(s). Absent written notification to CMS that a party disagrees with the terms contained

in CMS’s notification, revisions shall become effective thirty (30) days after the date of the initial

notification to the parties.

6 ARTICLE VII

STATE ADMINISTERING AGENCY REQUIREMENTS

Compliance and State Monitoring of the PACE Program

The SAA further assures that its responsibilities under section 1934 of the Social Security Act will be

met. All relevant provisions are included in the contract with the PACE entities, either as contractor or

SAA responsibility. Both scheduled and unscheduled on-site reviews will be conducted by SAA staff.

A. Readiness Review: The SAA will perform a Readiness Review of the applicant entity that

assures the entity has fully developed its policies and procedures, obtained commitments

from key staff, developed its solvency plan and has a facility that meets State and Federal

requirements at the time of the application, in accordance with Section 460.12(b)(1).

B. Monitoring during Trial Period: During the trial period, the SAA, in cooperation with

CMS, will conduct comprehensive reviews of a PACE organization to ensure compliance

with State and Federal requirements.

At the conclusion of the trial period, the SAA, in cooperation with CMS, will continue to

conduct reviews of a PACE organization, as appropriate, taking into account the quality of

care furnished and the organization’s compliance with State and Federal requirements.

C. Annual Monitoring: The SAA assures that at least annually it will reevaluate whether a

participant meets the level of care required under the State Medicaid plan for coverage of

nursing facility services. The SAA understands that this determination may be waived if there

is no reasonable expectation of improvement or significant change in the participant’s

conditions because of the severity of a chronic condition or the degree of impairment of

functional capacity. The SAA assures that it will make reviews conducted in accordance with

Sections 460.190 and 460.192 available to the public upon request.

D. Monitoring of Corrective Action Plans: The SAA assures it will monitor the effectiveness

of corrective actions required to be taken by the PACE organization.

Enrollment and Disenrollment

A. A description of the SAA’s enrollment process, to include the criteria for deemed continued

eligibility for PACE, in accordance with Section 460.160 (b)(3), is contained in Appendix P.

B. A description of the SAA’s process for overseeing the PACE Organization’s administration

of the criteria for determining if a potential PACE enrollee is safe to live in the community is contained

in Appendix Q.

7 C. A description of the information to be provided by the SAA to enrollees, to include

information on how beneficiaries access the State’s Fair Hearings process, is contained in Appendix

R.

D. A description of the SAA’s disenrollment process is contained in Appendix S.

E. The SAA assures that before an involuntary disenrollment is effective, it will review and

determine in a timely manner that the PACE organization has adequately documented grounds for

disenrollment.

F. In the event a PACE participant disenrolls or is disenrolled from a PACE program, the SAA

will work with the PACE organization to assure the participant has access to care during the transitional

period.

G. The SAA assures it will facilitate reinstatement in other Medicaid/Medicare programs after

a participant disenrolls.

H. The SAA assures that the State PACE requirements and State procedures will specify the

process for how the PACE organization must submit participant information to the SAA.

Marketing

The SAA assures that a process is in place to review PACE marketing materials in compliance with

Section 460.82(b)(ii).

Decisions that require joint CMS/SAA Authority

A. Waivers: The SAA will determine whether regulatory waiver requests submitted by PACE

organizations will be considered by CMS and will consult with CMS on those requests.

Approved waiver requests are described in Appendix T.

B. Service Area Designations: The SAA will consult with CMS on changes proposed by the

PACE organization related to service area designation.

C. Organizational Structure: The SAA will consult with CMS on changes proposed by the

PACE organization related to organizational structure.

D. Sanctions and Terminations: The SAA will consult with CMS on termination and sanctions

of the PACE organization.

State Licensure Requirements

The SAA assures that Life Safety Code requirements are met for facilities in which the PACE

organization furnishes services to PACE participants in accordance with Section 460.72(b), unless

CMS determines that a fire and safety code imposed by State law adequately protects participants and

staff.

APPENDIX A: NAMES AND CONTACT LIST

1) Name of Program Director: Ellen M. Garcia

Telephone Number: 206-320-5325

2) Name ofGoverning body/Board of Director contact person: Sister KarinDufault

TelephoneNumber: 206-464-3355

3) Governing body/Board ofDirectors:

Don Blem

Dr. John J Collins Jr.

Sister Susanne Hartung

Dr. Frederic Herskowitz

Carol Pacini

Al Parrish

Kay Stepp

Henry G. Walker

Sister Lynn Campbell

Orcillia Forbes, Ph.D.

Sister Celestial Kobel

APPENDIX B: ORGANIZATIONAL STRUCTURE

The Board of Directors for Providence Health System has full legal authority and fiscal

responsibnityfor Providence ElderPlace-Seattle. In order to properly discharge its governante

responsibilities by assuring effective management of the entire health care system, including

Providence ElderPlace-Seattle, the Board has structured the organization into three geographic

regions. One of these regions, Providence Health System-Washington, has created an organization

with four service areas in addition to a Long Term Care Division. Providence ElderPlace-Seattle is

housed within this Long Term CareDivision. The Board has appointed a Vice President of

Continuum Development and Long Term Care. In this role, the Vice President of Continuum

Development and Long Term Care oversees the management and operations of all long-term care

and housing facilities for Providence Health System including Providence ElderPlace-Seattle. In

addition, the Vice President has delegated authority for the day-to-day operations of Providence

ElderPlace-Seattle to its Executive Director. The Executive Director directly reports to the

Providence Health System Director of Housing and Community Services as well as the Vice

President.

APPENDIX C: SERVICE AREA AND PACE SITE(S)

1. Identify all counties in the service area. King County-Partial

2. For any partial counties above, identify by county and zip code below.

King County

98001 98029 98058 98109 98144

98002 98030 98059 98112 98146

98003 98031 98072 98115 98148

98004 98032 98074 98116 98155

98005 98033 98075 98117 98158

98006 98034 98077 98118 98166

98007 98038 98101 98119 98168

98008 98040 98102 98121 98177

98009 98042 98103 98122 98178

98011 98052 98104 98125 98188

98015 98053 98105 98126 98198

98023 98055 98106 98133 98199

98027 98056 98107 98134

98028 98057 98108 98136

3. List the name of and address of all PACE centers in the service area.

Providence ElderPlace- Seattle

4515 Martin Luther King Jr. Way South

Seattle, Washington 98118

Providence ElderPlace Seattle - West

4831 35th Ave. SW

Seattle, WA 98126

Providence ElderPlace Seattle - Full Life

7829 S 1801 Street

Kent, WA 98032

Providence ElderPlace Redmond

8550-160th Avenue NE

Redmond, WA 98052

APPENDIX D: PARTICIPANT BILL OF RIGHTS

Providence ElderPlace-Seattle Participant Bill of Rights and Responsibilities

At Providence ElderPlace, we are dedicated to providing you with quality health care services so that

youmay remain as independent as possible in the Greater Seattle community. Our staff seeks to

affirm the dignity and worth of each participant by assuring the following rights:

Respect and Non-Discrimination You have the right to:

Participate in the development of your care plan.

Comprehensive health care provided in a safe and clean environment in an accessible

manner.

Receive care from professionally trained staff. ·

Know the names and responsibilities of the people providing your care. Be treated in a

respectful manner which honors your dignity and privacy.

Be free fromharm, including unnecessary physical restraint or isolation, excessive

medication, physical or mental abuse or neglect.

Know that decisions regarding your care will be made in an ethical manner. Not be required

to perform any services for Providence ElderPlace.

Receive reasonable access to a telephone.

Not be discriminated against in the delivery of PACE services based on race, ethnicity,

national origin, religion, sex, age, sexual orientation, mental or physical disabilities or source

of payment.

Information You have the right to:

Be fully informed, in writing, of your rights and responsibilities and all rules and regulations

governing participation in Providence ElderPlace. You are also entitled to receive written

information on the PACE services available to you, both before and after your enrollment.

A full explanation of the Enrollment Agreement and an opportunity to discuss it.

Examine the results of the most recent federal or state review of Providence ElderPlace.

Confidentiality You have the right to:

Have all information related to your care kept confidential within required regulations.

Be assured that your written consent will be obtained for the release of information to

persons not otherwise authorized under law to receive it.

Provide written consent to release your confidential information.

Review and copy your medical records and request amendments to those records.

Choosing Your Provider You have the right to:

Choose your own primary care provider and specialists from the Providence ElderPlace-

Seattle provider panel.

Request a specialist for women's health services or preventive women's health services.

Initiate the disenrollment process.

Emergency Care You have the right to:

Receive health care services in an emergency without prior approval from the Providence

ElderPlace multidisciplinary team. ·

Treatment Decisions You have the right to:

Have all treatment options explained to you in a respectful and culturally competent manner.

Make your own health care decisions.

Request and receive complete information.

Request a reassessment by the Providence ElderPlace multidisciplinary team. Refuse

treatment and be informed of the consequences.

Receive reasonable advance notice if you are to be transferred to another treatment selling for

medical reasons or for your welfare or the welfare of other participants. Any such actions will

be documented in your health record.

Have our staff explain advance directives to you and to establish one on your behalf, if you

desire.

Appropriate assessment and management of pain.

Exercising Your Rights

You have the right to:

Exercise your civil, legal and participant rights, including the Medicare and Medicaid appeals

processes.

Voice your complaints and recommend changes in policies and services to our staff and to

outside representatives of your choice: There will be no restraint, interference, coercion,

discrimination or reprisal by our staff if you do so.

Appeal any treatment decision made by Providence ElderPlace or our contractors through our

appeals process.

APPENDIX E: ELIGIBILITY AND ENROLLMENT POLICIES AND CONTINUED

ELIGIBILITY CRITERIA

Providence ElderPlace-Seattle will ensure that participants are eligible for the PACE Program by

screening potential participants prior to enrollment. All potential participants must meet the

following requirements:

1. Be at least 55 years of age or older

2. Be determined by the State of Washington Home and Community Services or Aging and

Disability Services to need the level of care required under the State Medicaid plan for

coverage of nursing facility services.

3. Reside within the designated service area (currently zip codes in King County, WA).

4. At the time of enrollment, an individual must be able to live in a community setting without

jeopardizing his/her health and/or safety.

The Intake Coordinator will verify that potential participants meet the eligibility requirements by

completing the following:

1. Use official documents or identification to verify the participant's age.

2. Receive authorization that the participant meets the State Medicaid eligibility criteria for

nursing facility care from either a State of Washington Home and Community Services case

manager or an Aging and Disability Services case manager. Case managers from these state

and local agencies perform a standardized comprehensive assessment to determine whether a

potential participant meets nursing facility care criteria. The form which they use, entitled the

Comprehensive Assessment Form, is included in the Documents section.

3. Use official documents and/or make an in-person visit to the potential participant's residence.

4. Have the Providence ElderPlace-Seattle interdisciplinary team evaluate the potential

participant to determine if he/she can live in a community setting without jeopardizing

his/her health or safety.

The interdisciplinary team determines whether or not a participant’s health or safety would be

jeopardized by living in a community setting based on information obtained during their initial

assessment of the participant and his/her living situation. If the team finds that no combination of

services, which Providence ElderPlace-Seattle can provide, will allow the individual to live safely in

a community setting, he/she will be denied enrollment in the PACE program. More specifically, if

the team cannot develop a feasible plan of care or take steps to assure that the

individual can live safely in a community setting; he/she will be notified in writing and referred to

alternative services, as appropriate. Providence ElderPlace- Seattle will maintain supporting

documentation of the reason for denial, notify CMS and the State administering agency, and make

the documentation available for review.

The Intake Coordinator has the chief responsibility of explaining the program to potential enrollees

and overseeing all enrollment activities. This staff member screens potential enrollees, enrolls new

participants and monitors the assessment process. Members of the interdisciplinary team who

perform initial assessments are also responsible for explaining their area of the

program to potential participants.

The enrollment and intake process follow the proceeding format:

1. When a referral is made to Providence ElderPlace-Seattle, the Intake Coordinator screens the

potential participant to verify their eligibility. This step includes contacting the Washington

Home and Community Services office or Aging and Disability Services to determine

functional and financial eligibility for clients with Medicaid. Individuals who would privately

pay the Medicaid portion of the monthly enrollment fee must also be assessed by Washington

Home and Community Services for functional eligibility.

2. If the potential participant is eligible and interested in joining the program, the Intake

Coordinator schedules a home visit with the individual.

3. During the home visit, the Intake Coordinator performs an initial evaluation of the individual

including his/her health care needs, problems, functional abilities, cognition,

community/family support network and mental health issues. The Intake Coordinator also

explains the PACE program, using a copy of the combined enrollment agreement/participant

handbook, to the individual and answers his/her questions. In addition, the Intake

Coordinator explains to the individual that if he/she decides to · enroll, Providence

ElderPlace-Seattle would become the participant's sole service provider and clarifies that

Providence ElderPlace-Seattle guarantees access to services, but not to a specific provider.

4. At this point, if the individual is still interested in joining, the Intake Coordinator arranges for

the individual to make an on-site PACE center visit. During this visit, the individual meets

with available staff from all disciplines. This includes primary care, social work, nursing,

home care, transportation, recreational therapy and rehabilitation therapy. This tour is

intended to help the individual make an informed decision about enrollment.

5. The Intake Coordinator has the potential participant sign a release to allow Providence

ElderPlace-Seattle to obtain his/her medical and financial information and eligibility status

for Medicare and Medicaid.

6. The interdisciplinary team performs an assessment on the participant to determine the potential

participant's care plan and ensure that he/she can be cared for appropriately in a community

setting. In addition, the team decides whether the individual's care needs and health status are

appropriate for enrolling in the program. At this point, the team determines whether to accept

the individual into the program or to deny his/her enrollment.

7. If the interdisciplinary team has authorized the individual's enrollment and the individual

decides to enroll in the program, the Intake Coordinator contacts the Washington Home and

Community Services case manager or Aging and Disability case manager to obtain

authorization for enrollment for Medicaid recipients. These agencies also calculates the

monthly participant fee for the individual, if any. The Intake Coordinator informs the

Washington Home and Community Services case manager or the Aging and Disability

Services case manager of the official start date.

8. Prior to enrollment, the Intake Coordinator again reviews the enrollment agreement/participant

handbook with the participant. The Intake Coordinator discusses the recommended plan of

care, monthly participant fees and Medicaid spenddown obligations if applicable, as well as

post-eligibility treatment of income. Disenrollment

policies and procedures are also reviewed, and the participant is given a list of the employees

who provide care as well as a list of contracted health care providers.

9. If the individual agrees to accept the program conditions, he/she signs the enrollment

agreement and becomes a participant of Providence ElderPlace-Seattle.

10. Once enrolled, the participating will receive a copy of the enrollment agreement, a PACE

membership card, emergency information, and stickers for Medicare and Medicaid cards.

11. If there is a change in the enrollment agreement, Providence ElderPlace-Seattle will give an

updated copy of the information to the participant and explain the changes to the participant

and his or her representative or caregiver in a manner they understand.

12. Enrollment is effective on the first day of the calendar month following the date the

participant signs the enrollment agreement.

13. Enrollment will continue until death, the participant voluntarily disenrolls, or if the

participant is involuntary disenrolled.

The individual must also meet the following criteria, which are used by the PEP-S interdisciplinary

team to determine whether an individual can be safely cared for in the community without

jeopardizing his/her health or safety:

• Participant has a safe home environment or is willing to allow the interdisciplinary team to

make home modifications to create a safe environment or is willing to move to a safe

alternative setting.

• Participant is either safe alone or has a primary caregiver or is willing to utilize an Individual

Provider worker that they have identified or is willing to accept placement in an appropriate

setting.

• Participant's behaviors do not pose a threat to self or others.

• Participant's history of criminal behavior or drug or alcohol abuse does not pose a current threat

to caregivers or other vulnerable participants.

• A safe plan of care can be established to meet participant's needs.

State process to determine continued eligibility:

The State is responsible for determining continued eligibility on an annual basis. Home and

Community Services, the State agency that certifies and recertifies a PACE participant's nursing

home level of care, completes an annual reassessment of the participant to determine if he/she is still

eligible for PACE enrollment. This reassessment is completed no later than one year after the initial

assessment or previous reassessment and includes a review of the participant's medical records and

plan of care. If the participant continues to meet the nursing home level of care in Washington,

he/she will be PACE eligible for a period of one year. In situations where Home and Community

services determines that there is no reasonable expectation of improvement or significant change in

the participant's condition because of the severity of a

.chronic condition or the degree of impairment of functional capacity, the State will permanently waive the annual recertification requirement and the participant will be deemed continued eligibility in PACE. In addition, if Home and Community services determines that a PACE participant no longer meets the nursing home level of care, the participant may be deemed to continue to be eligible for PACE until the next annual reassessment, if, in the absence of PACE services, the participant reasonably would be expected to meet the nursing home level of care within the next six months.

APPENDIX F: ADDITIONAL ENROLLMENT CRITERIA None

APPENDIX G: VOLUNTARY DISENROLLMENT POLICY

Regulatory Citations: PACE Reg. 460.162, 460.166, 460.168, 460.172;

PURPOSE: To describe the procedures for initiating voluntary disenrollment.

SCOPE: All Providence ElderPlace-Seattle (PEP-S) participants.

POLICY:

All participants have the right to voluntarily disenroll from PEP-S without cause at any time.

Enrolling in any otherMedicare orMedicaid prepayment plan or optional benefit, including hospice,

while still a PEP-S participant is considered voluntary disenrollment fromPEP-S.

PEP-S will continue to provide and arrange for the provision of all PEP-S covered services until the

effective date of disenrollment. Prior to disenrollment, PEP-S will coordinate the participant's

transfer to other appropriate health care providers.

PROCEDURE:

1. The participant must notify PEP-S staff when he/she wishes to disenroll. This can be done

either in person or by giving written notice.

2. The PEP-S interdisciplinary team works with the participant to determine if the participant's

reason(s) for disenrolling can beresolved.

3. If the reason(s) for disenrollment cannot be resolved, the participant's social worker will have

the participant and his/her representative complete the Disenrollment Form. (See copy at end

of policy)

4. The social worker determines the effective date of disenrollment by using the following

guidelines:

a. If participant is not moving out of the service area:

• If the participant signs the Disenrollment Form (or gives written notice)

disenrollment takes effect at midnight on the last day of the month.

b. If the participant is moving out of the service area before the end of the month and notifies

PEP-S after the 15th

of themonth: • SocialWorkerwill attempt to have participant sign

disenrollment formprior to participant leaving service area. If unable to obtain signed

disenrollment form, SocialWorker will document attempt in participant medicalrecord.

• .

1. The social worker notifies the interdisciplinary team of the participant's effective date of

disenrollment. The interdisciplinary team will begin work on a safe discharge plan

immediately. If necessary, the IDT will continue to coordinate a safe discharge plan after the

participant disenrolls.

2. The interdisciplinary team will facilitate the participant's reinstatement in other Medicare and

Medicaid programs after disenrollment by making appropriate referrals

and ensuring that the participant's medical records are made available to new providers in a

timely manner. The interdisciplinary team will work with CMS and DSHS to ensure that

participant's reinstatement is successful.

3. The social worker sends the official disenrollment letter to the participant and his/her

representative. (See copy of the disenrollment letter at the end of policy)

4. The IDT notifies all parties involved of the disenrollment, including the assisted living facility,

adult family home, home care agency, nursing home, and all other interested parties. (See

copy of the Disenrollment Letter to residential facility at end of policy)

5. The social worker notifies the PEP-S Business Office of the disenrollment. The Accounting

Assistant will remove the participant's name from the billing cycle and report the

disenrollment to CMS.

6. The social worker coordinates the completion of the disenrollment checklist with the IDT.

7. The social worker will also notify the participant's Home and Community Services

casemanager and financial worker that the participant will be disenrolled from PEP-S.

APPENDIX H: INVOLUNTARY DISENROLLMENT POLICY

Regulatory Citations: PACE Reg. 460.164, 460.166, 460.168, 460.172;

Purpose: To describe the procedures for initiating involuntary disenrollment.

Scope: All Providence ElderPlace-Seattle (PEP-S) participants.

Policy: For any involuntary disenrollment, the participant may file a grievance according to the PEP-S

Grievance Procedure (refer to Policy 202.01 – Participant Grievance Process).

PEP-S will continue to provide and arrange for the provision of all PEP-S covered services until the

effective date of disenrollment. Prior to disenrollment, PEP-S will coordinate the participant's

transfer to other appropriate health care providers. PEP-S is not responsible for payment of any

covered service received by a disenrolled participant after the effective date of disenrollment.

Involuntary disenrollment data will be collected, analyzed and used as part of the ElderPlace QAPI

plan.

PEP-S will pursue involuntary disenrollment of a participant if the participant meets one of the

following criteria:

1. The participant moves out of the PEP-S service area without notifying PEP-S

2. The participant is out of the service area for more than 30 consecutive days, unless PEP-S

agrees to a longer absence due to extenuating circumstances.

3. Involuntary disenrollment does not take place for a PEP-S participant on the grounds that the

participant has engaged in noncompliant behavior if the behavior is related to a mental or

physical condition of the participant unless the participant's behavior jeopardizes his or her

health or safety, or the safety of others.

4. The participant has decision-making capacity and consistently refuses to comply with his/her

individual plan of care as outlined in the PACE enrollment agreement.

5. The participant fails to pay, or make satisfactory arrangements to pay, any participation fee

due PEP-S after a 30 day grace period.

6. The participant is determined to no longer meet the State Medicaid nursing facility level of

care requirements and becomes ineligible for participation.

7. The PACE Program agreement with CMS and DSHS is not renewed or is terminated.

8. PEP-S is unable to offer health care services due to the loss of State licenses or contracts with

outside providers.

Procedures:

For Involuntary Disenrollment Due to Non-Payment of Participation Fee 1. The PEP-S Biller notifies the Social Worker and Director of Support Services if a participant

or responsible party is not paying participation.

2. The Social Worker contacts the participant/responsible party to determine why payment is not

being made. The Social Worker may provide assistance in setting up a Representative Payee,

DPOA, or Guardian for the participant if the participant requires assistance in financial

management.

3. If the participant would like to remain enrolled with PEP-S, the Social Worker helps facilitate

communication between the participant and Biller so that a payment arrangement can be set

up.

4. If the participant would no longer like to remain enrolled with PEP-S, the Social Worker

notifies the PEP-S Biller and Director of Support Services.

5. The Director of Support Services submits a request for involuntary disenrollment to the DSHS

Program Manager.

6. The DSHS Program Manager reviews the case to determine if PEP-S has adequately

documented acceptable grounds for disenrollment. The State has the authority to approve or

reject the involuntary disenrollment. The State's approval must be obtained before the

disenrollment can proceed.

7. If the State approves the involuntary disenrollment, the interdisciplinary team will proceed

with the involuntary disenrollment process.

8. The social worker notifies the interdisciplinary team of the participant's effective date of

disenrollment.

9. The social worker will also notify the participant's Home and Community Services case

manager and financial worker that the participant will be disenrolled from PEP-S.

10. The interdisciplinary team will facilitate the participant's reinstatement in other Medicare and

Medicaid programs after disenrollment by making appropriate referrals and ensuring that the

participant's medical records are made available to new providers in a timely manner. The

interdisciplinary team will work with CMS and DSHS to ensure that participant's

reinstatement is successful.

11. The social worker sends the official disenrollment letter to the participant and his/her

representative.

12. If the participant is currently residing in a nursing home, ALF, of AFH, the social worker

sends a disenrollment notification to the residential facility.

13. The social worker notifies the PEP-S Business Office of the disenrollment.

For Disenrollment Due to Other Reasons: 1. The PEP-S interdisciplinary team identifies the reason(s) for involuntarily disenrolling a

participant.

2. The interdisciplinary team makes all reasonable attempts to remedy the situation by working

with the participant to resolve the situation.

3. The interdisciplinary team documents all efforts to remedy the situation in the participant's

medical records.

4. If the interdisciplinary team feels there is an unresolved ethical dilemma relating to the

disenrollment, the team refers the case to the PEP-S Ethics Committee. The Ethics

Committee will provide its recommendation to the interdisciplinary team as quickly as

possible.

5. If the situation prompting disenrollment still cannot be resolved and the interdisciplinary team

agrees to involuntarily disenroll the participant, the IDT notifies the Director of Support

Services that the team is considering involuntary disenrollment for this participant. The

Director of Support Services will work with the IDT to determine if reason for involuntary

disenrollment meets the criteria for involuntary disenrollment and consults with Compliance

and Risk Manager if needed. If it is believed that the criteria for involuntary disenrollment is

met, the Director of Support Services will notify the IDT. The IDT will write a letter to the

DSHS Program manager thoroughly outlining the reason for involuntary disenrollment and

send to the

Director of Support Services to submit to the DSHS program manager for consideration.

6. The DSHS Program Manager reviews the case to determine if PEP-S has adequately

documented acceptable grounds for disenrollment. The State has the authority to approve or

reject the involuntary disenrollment. The State's approval must be obtained before the

disenrollment can proceed.

7. If the State approves the involuntary disenrollment, the interdisciplinary team will proceed

with the involuntary disenrollment process.

8. The social worker notifies the interdisciplinary team of the participant's effective date of

disenrollment.

9. The social worker will also notify the participant's Home and Community Services case

manager and financial worker that the participant will be disenrolled from PEP-S.

10. The interdisciplinary team will facilitate the participant's reinstatement in other Medicare and

Medicaid programs after disenrollment by making appropriate referrals and ensuring that the

participant's medical records are made available to new providers in a timely manner. The

interdisciplinary team will work with CMS and DSHS to ensure that participant's

reinstatement is successful.

11. The social worker sends the official disenrollment letter to the participant and his/her

representative.

12. If the participant is currently residing in a nursing home, ALF, of AFH, the social worker

sends a disenrollment notification to the residential facility.

13. The social worker notifies the PEP-S Business Office of the disenrollment.

·

APPENDIX I: INTERNAL GRIEVANCE AND APPEAL PROCEDURES

Regulatory Citations: PACE Reg. 460.112(g)1,460.120

WAC 246-335-075 (d,e), 246335-115 (1,2), 388-71-0742 (1)

Purpose: To ensure that systems exist within Providence ElderPlace-Seattle (PEP-S) to capture and address

grievances/complaints as reported by participants, family members, caregivers or their

representatives. As a PACE organization, PEP-S maintains, aggregates, and analyzes information

on grievance proceedings.

Monitoring grievances plays an integral role in fostering an environment of continuous quality

improvement and it complements the Quality Assessment and Performance Improvement (QAPI)

program.

All participants are informed of the grievance procedure, both verbally and in writing, upon

enrollment and at least annually thereafter.

Scope: All PEP-S participants and their designated representatives.

Definitions: Grievance – A grievance is defined as a complaint, either written or oral, expressing

dissatisfaction with service delivery or the quality of care furnished.

Policy: • PEP-S has established a formal process to document, evaluate and resolve grievances, whether

medical or non-medical in nature, by PACE participants, their family members or

representatives. All personnel (employees and contractors) who have contact with

participants should be aware of and understand the basic procedures for receiving and

documenting grievances/complaints in order to initiate the appropriate process for resolving

participant concerns.

• The site manager or investigating manager is responsible for assuring that every grievance is

handled appropriately and that there is communication between different individuals who are

responsible for reviewing or resolving grievances. Grievances must be responded to and

resolved in a timely manner to protect the participants.

• Participant dissatisfaction in the form of oral or written grievances shall be handled according

to the procedures listed below. If the participant filing the grievance does not speak English,

an interpreter will be provided to facilitate the grievance process.

• PEP-S will continue to provide care to the participant during the grievance process and

encourages participants to voice their concerns without fear of reprisal.

Procedures:

Reporting and Resolving Grievances 1. Participants and their representatives are encouraged to express grievances to any member of

the PEP-S staff. Complete information must be provided so that every grievance can be

resolved in a timely manner.

2. All grievances must be documented in Quantros.

3. If the grievance can be resolved immediately, the staff member who receives the grievance is

responsible for documenting in Quantros: the grievance, the resolution (or attempted

resolution, if any), and whether the participant and/or their legal representative were satisfied.

If the participant and/or their legal representative are satisfied with the resolution, the

grievance will be considered closed by the site manager or investigatingmanager.

4. If the participant and/or their legal representative is not satisfied with the resolution (or there

was no resolution attempted), the grievance is elevated to the appropriate manager.

5. The quality manager (or designee) is responsible for reviewing Quantros and designating the

appropriate staff member(s) to investigate and take corrective action, if needed.

6. The staff member(s) who investigates and implements a corrective action to resolve the

grievance is responsible for documenting the resolution in Quantros. The staff member(s) is

also responsible to coordinate their resolution efforts with the participant and/or their legal

representative. If the participant and/or their legal representative are satisfied with the

resolution, this is noted in Quantros and the grievance is considered closed. The staff

member(s) must contact the participant and begin the investigation within 5 working days of

receiving the grievance.

Some grievances may require additional time to be adequately addressed. If extra time is

needed, the staff member investigating will notify the participant and/or legal

representative and document the conversation inQuantros.

Unresolved Grievances 1. Any participant and/or representative who is dissatisfied with the grievance resolution can take

further action by notifying the PEP-S Executive Director in writing no later than 30 calendar

days after the date of the final action taken on the grievance.

2. The Executive Director (or responsible designee) will acknowledge the grievance in writing to

the participant within 5 calendar days of its receipt. The Executive Director will then appoint

the appropriate staff member to follow-up and document additional information in Quantros.

3. The Executive Director will convene a meeting of the Grievance Committee to review all

relevant material(s) and meet with the participant, if necessary. Decisions will be rendered in

a timely manner and the Executive Director will notify the participant verbally and in writing

of the resolution and the specific steps that will be taken to resolve the grievance, if any. The

grievance is then considered closed.

Tracking, Analysis and Reporting

1. The investigating manager is responsible for monitoring the timeliness of each grievance

investigation and assuring that the investigation and resolution are adequately documented.

2. The grievance committee will track grievances and submit grievance data to the Quality

Committee on a quarterly basis. This committee will identify any trends and opportunities for

quality improvement.

3. Quality improvement initiatives are shared with PEP-S staff and participant council at least

semi-annually.

4. Records of all grievances will be held confidentially and made available as needed to State and

Federal agencies upon request.

Regulatory Citations: PACE Reg. 460.122, 460.124;

WAC 388-71-0825; 388-08

Purpose

To assure that Providence ElderPlace-Seattle (PEP-S) participants and their designated

representatives are informed of the appeals procedure, both verbally and in writing, up exercise their

right to file an appeal in response to a denial of coverage or payment of a service. All on enrollment

and at least annually thereafter. In addition, participants will be informed of the appeals procedure in

situations where a request for service or payment has been denied. Non-coverage of services,

including denials, reduction or termination of services, may be considered within the context of the

appeals process.

Scope:

All PEP-S participants and their designated representatives.

Policy:

Participant appeals shall be dealt with according to the procedures listed below. If the participant

filing the appeal does not speak English, an interpreter will be provided to facilitate the appeals

process. In addition, all appeals related information will be maintained confidentially.

Procedures:

Appeals Procedure

Definition: An appeal is defined as a participant's action taken with respect to any instance where the

PEP-S interdisciplinary team denies coverage or payment for a service.

1. If the interdisciplinary team denies coverage or payment of a service requested by a

participant or his/her representative, the participant and/or representative will be notified of

the denial and instructed on how to file an appeal by providing the participant with a copy of

the denied services letter. If the participant and/or representative wishes to file an appeal, he or

she must notify the PEP-S Executive Director in writing within 30 calendar days of the initial

denial. In addition, the participant and/or representative has the opportunity to present

evidence related to the dispute in person as well as in writing.

The 30-day limit may be extended for good cause. The participant and/or representative must

include in the request the reason why the appeal could not be filed within the 30day time

frame.

2. The Executive Director or another designated staff member will acknowledge the appeal in

writing to the participant and/or representative within 5 calendar days of its receipt (see

Attachment – Acknowledgement of Appeal).

3. The Executive Director will assign staff involved in the appeals request to complete the first

page of the Appeals Form.

4. The Executive Director will appoint an appropriately credentialed and impartial third party to

review the participant's appeal. The third party will vary on a case-by-case depending on the

circumstances and must not have been involved in the original action or have a stake in the

outcome of the appeal. This third party will respond to and resolve the participant's appeal as

expeditiously as the participant's health condition requires, but no later than 30 calendar days

after the appeal has been received. Once the appeal has been resolved, the third party will

complete the second page of the Appeals Form.

5. During the appeals process, PEP-S will:

a. For participants receivingMedicaid: Continue to furnish the disputed services until the final

decision is made if PEP-S is proposing to terminate or reduce services currently being

furnished to the participant and the participant and/or representative requests continuation

with the understanding that he/she may be liable for the costs of the contested services if the

decision is not made in his or her favor.

b. For all participants: Continue to furnish to the participant all other required services that

were never in dispute.

6. If the impartial third party makes a determination in favor of the participant, PEP-S will

furnish the disputed service as expeditiously as the participant's health condition requires.

7. If the impartial third party makes a determination in favor of PEP-S, PEP-S will immediately

notify the participant, both verbally and in writing, regarding the final denial of service or

payment. PEP-S will also notify the Centers for Medicare and Medicaid Services (CMS) and

theWashington Department of Social and Health Services (DSHS) of the appeal denial.

8. If a decision is wholly or partially adverse to the participant, the participant and/or

representative has additional appeal rights underMedicare orMedicaid, but not both. PEP-S will

notify the participant and/or representative of these additional appeal rights both verbally and

in writing. PEP-S will also assist the participant and/or representative in choosing which

appeals process to pursue, forward the appeal to the appropriate external entity, and provide

additional assistance with the appeals process as needed.

Expedited Appeals Process

1. An expedited appeals process will be initiated for situations in which the participant and/or the

designated representative believes applying the standard appeals process, absent the

provision of disputed service, could seriously jeopardize his/her life, health or ability to

regain maximum function.

2. PEP-S will initiate action on the appeal as expeditiously as the participant's health condition

requires, but no later than 72 hours after it receives the appeal.

3. PEP-S may extend the 72-hour timeframe by up to 14 calendar days for either of the following

reasons:

a. The participant and/or representative requests the extension.

b. PEP-S justifies to the Washington DSHS the need for additional information and how the

delay is in the interest of the participant.

Additional Appeal Rights 1. If the participant and/or representative receives a wholly or partially adverse decision from PEP-S

and disagrees with the decision, he/she has additional rights to appeal under Medicare

orMedicaid, but not both.

2. PEP-S will notify the participant and/or representative of these additional appeal rights both

verbally and in writing. PEP-S will also assist the participant and/or representative in choosing

which appeals process to pursue, forward the appeal to the appropriate external entity, and

provide additional assistance with the appeals process as needed.

Tracking, Analysis and Reporting

1. The PEP-S Executive Director is responsible for monitoring the timeliness of each appeals

investigation and assuring that the investigation and resolution are adequately documented.

2. Medical Records will track appeals data by hand and submit appeal data to the Quality of Care

Committee on a regular basis. This committee will analyze the data to identify any trends and

opportunities for quality improvement.

3. Records of all appeals will be held confidentially and made available as needed to State and

Federal agencies uponrequest.

APPENDIX J: ADDITIONAL APPEAL RIGHTS UNDER MEDICARE OR MEDICAID

Regulatory Citations: PACE Reg. 460.122, 460.124;

WAC 388-71-0825; 388-08

Purpose

To assure that Providence ElderPlace-Seattle (PEP-S) participants and their designated

representatives are informed of the appeals procedure, both verbally and in writing, up exercise their

right to file an appeal in response to a denial of coverage or payment of a service. All on enrollment

and at least annually thereafter. In addition, participants will be informed of the appeals procedure in

situations where a request for service or payment has been denied. Non-coverage of services,

including denials, reduction or termination of services, may be considered within the context of the

appeals process.

Scope:

All PEP-S participants and their designated representatives.

Policy:

Participant appeals shall be dealt with according to the procedures listed below. If the participant

filing the appeal does not speak English, an interpreter will be provided to facilitate the appeals

process. In addition, all appeals related information will be maintained confidentially.

Procedures:

Appeals Procedure

Definition: An appeal is defined as a participant's action taken with respect to any instance where the

PEP-S interdisciplinary team denies coverage or payment for a service.

1. If the interdisciplinary team denies coverage or payment of a service requested by a participant

or his/her representative, the participant and/or representative will be notified of the denial

and instructed on how to file an appeal by providing the participant with a copy of the denied

services letter. If the participant and/or representative wishes to file an appeal, he or she must

notify the PEP-S Executive Director in writing within 30 calendar days of the initial denial.

In addition, the participant and/or representative has the opportunity to present evidence

related to the dispute in person as well as in writing.

The 30-day limit may be extended for good cause. The participant and/or representative must

include in the request the reason why the appeal could not be filed within the 30day

time frame.

2. The Executive Director or another designated staff member will acknowledge the appeal in

writing to the participant and/or representative within 5 calendar days of its receipt (see

Attachment – Acknowledgement of Appeal).

3. The Executive Director will assign staff involved in the appeals request to complete the first

page of the Appeals Form.

4. The Executive Director will appoint an appropriately credentialed and impartial third party to

review the participant's appeal. The third party will vary on a case-by-case depending on the

circumstances and must not have been involved in the original action or have a stake in the

outcome of the appeal. This third party will respond to and resolve the participant's appeal as

expeditiously as the participant's health condition requires, but no later than 30 calendar days

after the appeal has been received. Once the appeal has been resolved, the third party will

complete the second page of the Appeals Form.

5. During the appeals process, PEP-S will:

a. For participants receivingMedicaid: Continue to furnish the disputed services until the

final decision is made if PEP-S is proposing to terminate or reduce services currently

being furnished to the participant and the participant and/or representative requests

continuation with the understanding that he/she may be liable for the costs of the

contested services if the decision is not made in his or her favor.

b. For all participants: Continue to furnish to the participant all other required services that

were never in dispute.

6. If the impartial third party makes a determination in favor of the participant, PEP-S will

furnish the disputed service as expeditiously as the participant's health condition requires.

7. If the impartial third party makes a determination in favor of PEP-S, PEP-S will immediately

notify the participant, both verbally and in writing, regarding the final denial of service or

payment. PEP-S will also notify the Centers for Medicare and Medicaid Services (CMS) and

theWashington Department of Social and Health Services (DSHS) of the appeal denial.

8. If a decision is wholly or partially adverse to the participant, the participant and/or

representative has additional appeal rights underMedicare orMedicaid, but not both. PEP-S

will notify the participant and/or representative of these additional appeal rights both verbally

and in writing. PEP-S will also assist the participant and/or representative in choosing which

appeals process to pursue, forward the appeal to the appropriate external entity, and provide

additional assistance with the appeals process as needed.

Expedited Appeals Process

1. An expedited appeals process will be initiated for situations in which the participant and/or the

designated representative believes applying the standard appeals process, absent the

provision of disputed service, could seriously jeopardize his/her life, health or ability to

regain maximum function.

2. PEP-S will initiate action on the appeal as expeditiously as the participant's health condition

requires, but no later than 72 hours after it receives the appeal.

3. PEP-S may extend the 72-hour timeframe by up to 14 calendar days for either of the following

reasons:

a. The participant and/or representative requests the extension.

b. PEP-S justifies to the Washington DSHS the need for additional information and how the

delay is in the interest of the participant.

Part D Appeals

If a participant or his/her representative as made a request for coverage or payment of a Part D drug

benefit and the request is denied, the participant or his/her representative has the right to file a Part D

appeal within 60 calendar days after receiving the denial of coverage. There are two types of Part D

appeals that the participant can request: a standard Part D appeal or an expedited (72 hour) Part D

Appeal.

1. Standard Part D Appeal If a participant or his/her representative files a standard Part D appeal, PEP-S will make a decision on

the appeal request within 7 calendar days after receiving the appeal. The participant or his/ her

representative may file the appeal in writing or orally. If an oral appeal request is made, PEP-S will

document the oral request in writing in the participant's or his/ her representatives own words, repeat

the request back to the participant or his/her representative to confirm the accuracy, and place the

request into a tracking system. PEP-s will designate someone other than the person involved in

making the initial coverage determination to make a determination on the appeal request. If the

original denial was based on a lack of medical necessity, the appeal review will be performed by a

physician with expertise in the field of medicine that is appropriate for the drug benefits at issue. If a

determination is made in favor of the appeal. PEP-s will provide immediate coverage of the drug as

requested. If a determination is made to uphold the initial decision to deny coverage of or payment of

the requested prescription drug, the participant or his/her representative will be notified of his/her

right to ask for an independent review of PEP-S's decision. The participant or his/her representative

will have 60 days from the date of receiving the appeal determination to request an independent

review from the following entity:

MAXIMUS Federal Services

Medicare Managed Care & PACE Reconsideration Project 3750 Monroe Avenue

Suite 702

Pittsford, NY 14534-1302

Phone: 585-348-3300

2. Expedited (72 hour) Part D Appeal If the participant or his/her representative or his/her physician or other prescriber indicates that the

participant's life, health, or ability to regain maximum function could be jeopardized by using the

standard Medicare Part D appeals process, PEP-S will apply the expedited Medicare Part D appeals

process. If a participant or his/her representative files an expedited Medicare Part D appeal, PEP-S

will make a decision on the appeal request within 72 hours

after receiving the appeal. The participant or his/her representative may file the appeal in writing or

orally. If an oral appeal request is made, PEP-S will document the oral request in writing in the

participant's or his/her representative's own words, repeat the request back to the participant or

his/her representative to confirm the accuracy, and place the request into a tracking system. PEP-S

will designate someone other than the person involved in making the initial coverage determination

to make a determination on the appeal request. If the original denial was based on a lack of medical

necessity, the appeal review will be performed by a physician with expertise in the field of medicine

that is appropriate for the drug benefits at issue. If a determination is made in favor of the appeal,

PEP-S will provide immediate coverage of the drug as requested. If a determination is made to

uphold the initial decision to deny coverage of or payment of the requested prescription drug, the

participant or his/her representative will be notified of his/her right to ask for an independent review

of PEP-S's decision. The participant or his/her representative will have 60 days from the date of

receiving the appeal determination to request an independent review from the following entity:

[Note, the participant or his/her representative or physician or other prescriber can request an

expedited (72 hour) decision fromMAXIMUS].

MAXIMUS Federal Services

Medicare Managed Care & PACE Reconsideration Project 3750 Monroe Avenue

Suite 702

Pittsford, NY 14534-1302

Phone: 585-348-3300

Additional Appeal Rights 1. If the participant and/or representative receives a wholly or partially adverse decision from PEP-S

and disagrees with the decision, he/she has additional rights to appeal under Medicare

orMedicaid, but not both.

2. PEP-S will notify the participant and/or representative of these additional appeal rights both

verbally and in writing. PEP-S will also assist the participant and/or representative in choosing

which appeals process to pursue, forward the appeal to the appropriate external entity, and

provide additional assistance with the appeals process as needed.

Tracking, Analysis and Reporting

1. The PEP-S Executive Director is responsible for monitoring the timeliness of each appeals

investigation and assuring that the investigation and resolution are adequately documented.

2. Medical Records will track appeals data by hand and submit appeal data to the Quality of Care

Committee on a regular basis. This committee will analyze the data to identify any trends and

opportunities for quality improvement.

3. Records of all appeals will be held confidentially and made available as needed to State and

Federal agencies uponrequest.

APPENDIX K: QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT

PROGRAM

PROVIDENCE ELDERPLACE - SEATTLE

QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT PLAN POLICY:

Providence ElderPlace-Seattle (PEP-S) has an integrated Quality Assessment and Performance

Improvement (QAPI) program designed to: collect data on an ongoing basis; create the systems

necessary to assess, analyze and trend this data; and to serve as a framework to enhance the quality of

care provided to participants. The focus for our efforts is to create a data-driven quality improvement

program that seeks to enhance systems and processes, utilizing a streamlined Continuous Quality

Improvement (CQI) approach. Opportunities for improvement are prioritized by the Quality of Care

(QoC) committee on the basis of trends within the data, with special attention given to high volume,

problem prone and/or high risk aspects of care. Our QAPI program incorporates measures that

document the services provided through contractual arrangements.

All participant and employee documentation regarding quality assessment and performance

improvement activities are kept confidential. .All employees are responsible for participating in

efforts to assess the quality of services rendered and to improve them on an ongoing basis.

A. PURPOSE

1. To establish, maintain and document evidence of an ongoing Quality Assessment and

Performance Improvement program designed to enhance patient care outcomes.

2. To provide a system for improving processes based on the Continuous Quality Improvement

methodology. (Providence ElderPlace-Seattle utilizes a FOCUS-Plan-DoCheck-Act system.)

3. To identify systems for ongoing collection of data and the establishment of teams to· address

prioritized areas for improvement.

4. To provide education to the staff in identifying opportunities to- improve the care they provide

based on the findings of Continuous Quality Improvement efforts.

B. ORGANIZATIONAL ELEMENTS AND RESPONSIBILITIES

1. The PEP-S Quality of Care committee has overall responsibility for assuring that our quality

improvement efforts are implemented in accordance with our plan. The QoC committee

prioritizes areas for improvement annually and analyzes the results of quality improvement

efforts. They also review the QAPI plan as needed.

2. The Long Term Care Division has established the Long Term Care Community Quality Board

to provide oversight to quality activities within PEP-S; offer external review of

findings; and serve as the linkage to the Providence Health System Board of Directors relative

to the quality of care rendered at Providence ElderPlace.

3. The Quality Improvement Coordinator is responsible for coordinating CQI activities and

conducting staff education in quality improvement.

4. The Medical Director plays a pivotal role in Quality Improvement efforts by focusing activities

on assuring quality participant outcomes.

5. The clinical team collects data based on the comprehensive assessment of participant status on

a regular basis. This data is integrated by our Medical Records Coordinator on a quarterly

basis through our DataPACE reporting systems to monitor changes in our participant

population and utilization of services.

6. The Quality Improvement Coordinator is responsible for aggregating data; creating graphs

depicting data and compiling requested reports.

C. REPORTING OF QUALITY ASSESSMENT AND IMPROVEMENT ACTIVITIES

All quality assessment and performance improvement activities, results, follow-up action and

monitoring are reported quarterly to the QoC committee and as requested to the Long Term Care

Division Quality Board. Data is also shared with CMS, the State and the National PACE Association

as required. We benchmark our data against national data through use of the Medicare Health

Outcomes Study and DataPACE aggregate reports.

We are currently participating in national efforts to design a consumer satisfaction tool that meets the

specialized needs of our PACE population. Once this consumer satisfaction measurement project,

named ConSat, is field tested we will incorporate it into our performance improvement efforts and

report this data annually.

The Unusual Occurrence Report is utilized by staff members as a means of documenting incidents

that may impact the quality of care delivered to participants. Unusual Occurrence Reports are

immediately acted upon by the appropriate Manager, Executive Director and/or Medical Director.

These reports are trended on a quarterly basis and analyzed by the QoC Committee.

SCOPE

Quality assessment and performance improvement activities are integrated and coordinated among

all disciplines with PEP-S. On an ongoing basis, data is collected to monitor performance in terms of

clinical outcomes: This data may include the following measures:

Participant outcomes:

a. Skin lesions

b. Undesirable weight changes

c. Falls

d. Unanticipated deaths

e. Infections

f. Utilization of the ER and Inpatient Facilities

Participant/FamilySatisfaction

a. Complaints, Grievances and Appeals

b. Disenrollments

c. Surveys of Participant/Family Satisfaction.

Contracted Services

a. Durable Medical Equipment

b. Specialty Care Ongoing Processes·

c. Multidisciplinary Team Meetings

d. Medical Records

e. Implementation of Advanced Directives Education

D. SUMMARY

The QAPI program is based on currently accepted practices for performance improvement functions

and is designed to comply with all state and federal regulations. It is an evolving program that

focuses on priorities which are central to the delivery of high quality care for our participants.

APPENDIX L: PACE Quality Reporting

In order to comply with the PACE regulations, §460.140, §460.200(b)(1), §460.200 (c), and

§460.202, PACE Organizations (POs) must meet external quality assessment and reporting

requirements as specified by CMS and the SAA.

PACE Level I quality data elements are reported to CMS using the Health Plan Management System

(HPMS). The PACE organization should refer to HPMS for the current PACE Level I Guidance and

PACE User Guide.

PACE Level II reporting requirements apply specifically to unusual incidents that result in serious

adverse participant outcomes, or negative media coverage related to the PACE program. The PACE

Organization should refer to the PACE Level II Guidance dated July 2015. POs are required to report

incidents within 3 working days to https://dmaoportal.lmi.org with a copy to the Regional Office

(RO) and the SAA.

APPENDIX M: MEDICARE AND MEDICAID PAYMENT AMOUNTS

CMS makes a prospective monthly payment to the PACE organization of a capitation amount for

each Medicare participant in the payment area. Prospective payments are made up of the pre-ACA

county rate, unadjusted for Indirect Medical Education (IME), and multiplied by the sum of the

individual risk score and the organization frailty score. This payment methodology is described in the

PACE program agreement. We have provided a brief description of PACE payment and the

differences between PACE payment and payment for other Medicare Advantage plans below.

County Rates

The prospective payment rates for PACE are based on the applicable amount under section

1853(k)(1) of the Act, unadjusted for IME. The applicable amount is the pre-Affordable Care Act

rate, which will be phased-out under the Affordable Care Act for other Medicare Advantage plans.

The applicable amount will not be phased out for PACE. In rebasing years, this rate is the greater of:

1) the county’s FFS rate for the payment year or 2) the prior year’s applicable amount increased by

the payment year’s National Per Capita Medicare Advantage Growth Percentage. In non-rebasing

years, this rate is the prior year’s applicable amount increased by the payment year’s National Per

Capita Medicare Advantage Growth Percentage.

Section 1853 (k) (4) of the Act requires CMS to phase out indirect medical education (IME) amounts

from MA capitation rates. PACE programs are excluded from the IME payment phase out under that

section.

Effective CY 2006 and subsequent years, CMS makes advance monthly per capita payments for aged

and disabled enrollees based on the bidding methodology established by the MMA. PACE plans are

not required to bid, however.

Risk Adjustment

For the final payment rate, the county rate for the PACE organization is multiplied by the individual

participant risk score. Risk adjustment allows CMS to pay plans for the risk of the beneficiaries they

enroll, instead of an average amount for Medicare beneficiaries. The individual participant risk score

for Medicare Advantage and PACE is calculated using the CMS–HCC model (community, long-term

institutionalized, End-Stage Renal Disease (ESRD) or new enrollee) published in the Announcement

of Calendar Year (CY) 2012 Medicare Advantage Capitation Rates and Medicare Advantage and

Part D Payment Policies and Final Call Letter (Rate Announcement).

A frailty factor is added to each individual’s risk score for PACE plan payment. Risk adjustment

predicts (or explains) the future Medicare expenditures of individuals based on diagnoses and

demographics. But risk adjustment may not explain all of the variation in expenditures for frail

community populations. The purpose of frailty adjustment is to predict the Medicare expenditures of

community populations with functional impairments that are unexplained by risk adjustment. The

frailty score added to the beneficiary’s risk score is calculated at the contract-level, using the

aggregate counts of ADLs among HOS-M survey respondents enrolled in a

specific organization. More information regarding the HOS-M can be found in section 10.3.1.3.

Because the CMS-HCC model has been designed to pay appropriately for the long-term

institutionalized population, frailty adjustments are added to the risk scores only for community-

based and short-term institutionalized enrollees (i.e., the frailty adjustment for long-term

institutionalized enrollees is zero). Updated frailty factors are published in the Rate Announcement

for the payment year in which they are first used.

Additional Information

For additional, more detailed information about PACE Medicare payment, please see the following

documents:

• Payments to Medicare Advantage Organizations, Chapter 8, Medicare Managed Care Manual

• Risk Adjustment, Chapter 7, Medicare Managed Care Manual

• CMS publishes changes to the Medicare Advantage payment methodologies in the Advance

Notice of Methodological Changes for Medicare Advantage (MA) Capitation Rates and Part

C and Part D Payment Policies (Advance Notice) in mid-February at

http://www.cms.gov/MedicareAdvtgSpecRateStats/for public comment. The final payment

methodologies are published in the Announcement of Medicare Advantage Capitation Rates

and Medicare Advantage and Part D Payment Policies and Final Call Letter (Rate

Announcement) on the first Monday in April at the same website.

Medicare Part D:

In order for PACE organizations to continue to meet the statutory requirement of providing

prescription drug coverage to their enrollees, and to ensure that they receive adequate payment for

the provision of Part D drugs, beginning January 1, 2006, PACE organizations began to offer

qualified prescription drug coverage to their enrollees who are Part D eligible individuals. The MMA

did not impact the manner in which PACE organizations are paid for the provision of outpatient

prescription drugs to non-part D eligible PACE participants.

PACE organizations are required to annually submit two Part D bids: one for a Plan Benefit Package

(PBP) for dually eligible enrollees and one for a PBP for Medicare-only enrollees. The Part D

payment to PACE organizations comprises several pieces, including the direct subsidy, reinsurance

payments, and risk sharing. Payments for eligible enrollees of either PBP will include a low-income

premium subsidy and a low-income cost-sharing subsidy for basic Part D benefits. Payments for

dually eligible enrollees will also include an additional amount to cover nominal cost sharing

amounts (“2% capitation”), and an additional premium payment in situations where the PACE plan’s

basic Part D beneficiary premium is greater than the regional low-income premium subsidy amount.

Medicaid: Monthly Capitation Rates

Rate Category

July 1, 2017-June 30, 2018

Medicaid Only Age 55-64 Categorically Needy $5,172.89

Medicaid Only Age 55-64 Disabled $5,315.87

Medicaid Only Age 55-64 Newly Eligible $5,184.34

Medicaid Only Age 65+ Categorically Needy $4,497.57

Medicaid Only Age 65+ Disabled $4,640.55

Medicaid Only Age 65+ Newly Eligible $4,509.02

Dually Eligible Age 55-64 Categorically Needy $3,684.85

Dually Eligible Age 55-64 Disabled $3,827.83

Dually Eligible Age 55-64 Newly Eligible $3,696.30

Dually Eligible Age 65+ Categorically Needy $3,399.21

Dually Eligible Age 65+ Disabled $3,542.19

Dually Eligible Age 65+ Newly Eligible $3,410.66

APPENDIX N: STATE ENROLLMENT/DISENROLLMENT RECONCILLIATION

METHODOLOGY

On a monthly basis, the State sends a report to the provider that lists all the individuals who are

currently reported in the system as PACE enrollees. The provider verifies whether or not the

individual is still enrolled in the PACE program and notifies the State of any new or disenrolled

individuals. If a payment has been made to the provider prior to the date of death or disenrollment,

the provider is required to submit a claim adjustment. Conversely, the provider can also submit a

claim adjustment if the State inadvertently misses a necessary payment. The next payment is adjusted

to reflect the reported differences.

APPENDIX O: TERMINATION PHASE - DOWN PLAN

To ensure that all enrolled participants receive transitional care in the event of program termination,

Providence ElderPlace-Seattle has established the following phase-down plan. Upon receiving final·

notice of program termination, Providence ElderPlace-Seattle administrationwill initiate the

following activities:

Disclosure: The Providence ElderPlace-Seattle Leadership Team will develop standardized

guidelines on how to inform participants, the community, contractors, HCFA and the State of the

phase-down. In addition, the Leadership Team will oversee the implementation of all termination and

transition procedures. Participants and their designated representatives will be notified, in writing,

about the termination and transition procedures. Providence ElderPlace-Seattle will make every

effort to ensure that participants and their designated representatives understand the termination and

transition processes. The Marketing Coordinator will be responsible for informing the community of

the termination according to procedures developed by the Leadership Team. The Executive Director

will inform HCFA, the State and all contractors, in writing, of the program termination.

Marketing and Enrollment Activities: All marketing and enrollment activities will be immediately

terminated once Providence ElderPlace-Seattle has received final notice of its program termination.

Transitional Care: Providence ElderPlace-Seattle will assist participants in reinstating their

conventional Medicare and Medicaid benefits if they are eligible to receive them. Providence

ElderPlace-Seattle will provide assistance to each participant in obtaining necessary transitional care

through appropriate referrals. The multidisciplinary team will reassess each participant's plan of care

in order to develop a discharge plan. This discharge plan would be used to transition the participant

out of PACE to another provider. In addition, the multidisciplinary team would be responsible for

making the necessary discharge plan arrangements. This includes making the participant's medical

records available to new providers.

APPENDIX P: SAA ENROLLMENT PROCESS

The State Administering Agency assesses any potential participant including those who are not eligible

for Medicaid to ensure that the individual meets the nursing facility level of care. The PO may only

request enrollment of individuals in the state system who have been found both financially and

functionally eligible for the program. Eligible individuals may enroll any day of the month, and their

enrollment will become effective on the first of the month.

The PACE Organization shall submit a list at least once week prior to the start of the month

enrollment is requested, in an agreed upon format, so the SAA may enter enrollment in the state

MMIS system. Enrollments are processed prospectively.

The State undertakes the following steps:

At the time of enrollment, the HCS case manager sends the PACE organization proof of nursing

home certification contained in the Comprehensive Assessment document. HCS will send proof of

recertification on an annual basis upon notification from the PACE organization that recertification is

due. In addition, the HCS case manager provides the approval for enrollment for Medicaid recipients

and calculates the monthly participant fee for the enrollee, if any.

The agency will conduct a face-to-face reassessment of PACE clients every twelve (12) months and/or

whenever the client’s circumstances or physical condition substantially changes. The State

Administering Agency may deem eligibility of those individuals, who are determined ineligible at the

annual reassessment process, if the individual would be expected to meet the nursing facility level of

care requirement within the next six months based on the PACE organization’s detailed assessment

and recommendations.

APPENDIX Q: SAA OVERSIGHT OF PO ADMINISTRATION OF SAFETY CRITERIA

Description of the SAA’s process for overseeing the PACE organization’s administration of the

criteria for determining if a potential PACE enrollee is safe to live in the community.

A. Development of Enrollment Safety Criteria

1) The criteria for determining an applicant’s safety in the community must be approved by CMS, as

part of the application process.

2) Approved Safety Criteria:

a) The individual must meet the following criteria which are used by the POs multidisciplinary

team to determine whether an individual can be safely cared for in the community without

jeopardizing his/her health or safety:

1) Participant has a safe home environment or is willing to allow the multidisciplinary team to

make home modifications to create a safe environment or is willing to move to a safe

alternative setting.

2) Participant is either safe alone or has a primary caregiver or is willing to utilize an

Individual Provider worker that they have identified or is willing to accept placement in an

appropriate setting.

3) Participant’s behaviors do not pose a threat to self or others.

4) Participant’s history of criminal behavior or drug or alcohol abuse does not pose a current

threat to caregivers or other vulnerable participants.

5) A safe plan of care can be established to meet participant’s needs.

3) The PO evaluates the applicant’s ability to safely receive services in the community using the

above criteria and develops a Plan of Care to meet the Participant’s needs, ensuring, at minimum,

the following:

a. Safety of the home environment;

b. Adequate support systems;

c. Hygiene, nutrition and medical care systems adequate to meet assessed care needs;

d. Behavioral problems can be managed to prevent significant risk to self or others;

e. Safety while alone, or adequate informal supports to ensure the individual will not be left

alone;

f. Ability to be safely transported into and out of the home; and

g. Acceptance by the Participant and his/her support system of essential components of the

plan of care based on assessed needs.

4) An applicant will be denied PACE enrollment if it is determined that the individual cannot receive

services safely in the community and/or the individual demonstrates imminent danger to self or

others.

B. SAA Oversight

1. For applicants denied enrollment in PACE due to safety concerns, the PO must provide the

SAA with documentation within 14 days to include the following:

a. A copy of the PO’s denial of enrollment letter sent to the applicant, which includes

appeal rights;

b. Assessment/evaluation used to determine the denial;

c. Narrative explanation of the basis for the finding, including attempts to arrive at a safe plan

for enrollment; and

d. The professional disciplines involved in the PO’s determination.

2. The SAA may request additional information or may conduct an on-site review, if warranted.

3. The SAA monitors the PO’s compliance with enrollment safety standards through survey

review of client records, enrollment records, grievances, Reportable or Level II events, or

other documentation it deems relevant.

APPENDIX R: INFORMATION TO BE PROVIDED BY THE SAA TO ENROLLEES

Enrollees shall receive a copy of their Comprehensive Assessment, Service Plan, financial award

notices, and notice of fair hearing rights for any adverse actions. Enrollees are entitled to a fair

hearing after it has gone through the PACE organization’s internal appeal process. Medicaid fair

hearing rights shall be translated for individuals with limited English proficiency.

The State assures that the following information is provided to all enrollees prior to and at the time of

enrollment and annually thereafter, by the PACE organization in accordance with its approved

policies and procedures.

Detailed information about 460.112, Participant Rights, 460.120, 460.122, Grievance and Appeals

processes; 460.154, Enrollment Agreement; and 460.156, other enrollment procedures are contained

in the Enrollment Agreement.

The process for explaining the information contained in the Enrollment Agreement, in a manner

understandable to the enrollee, is conducted in the following manner:

In accordance with Policy Number 301.03, issued 7/13/01, the process begins with a contact by

telephone or in-person between the potential participant and the PACE Intake Coordinator. The

Intake Coordinator, after making an initial determination of eligibility, arranges a home visit. During

the home visit, the Intake Coordinator explains the PACE organization using the Enrollment

Agreement and answers any questions from the individual and/or caregiver. If the individual is

interested in joining, a site visit is arranged at which time the individual meets with members of the

multidisciplinary team and again is provided with opportunities to ask questions.

At this time, the Intake Coordinator contacts the Aging and Long-Term Services Administration

(ALTSA) Home and Community Services (HCS) office to confirm or start the process of

determining functional and financial eligibility for individuals requesting Medicaid coverage, or

contacts HCS to determine functional eligibility only for individuals who pay privately.

If the individual is determined to be eligible and if the individual agrees to accept the program

conditions, he/she signs an enrollment agreement in accordance with Policy 301.04, issued 7/13/01

which requires that all individuals who enroll in PACE must sign an enrollment agreement. Prior to

signing, the Intake Coordinator again reviews the Enrollment Agreement with the individual and

he/she receives a copy of the Enrollment Agreement from the PO for reference.

All enrollees also receive a PACE enrollment card in accordance with the requirements in 460.156

from the PO.

APPENDIX S: SAA DISENROLLMENT PROCESS

Involuntary Disenrollments:

The PACE organization will notify the state of involuntary disenrollments after the organization has

followed its approved internal process. The PO shall submit all supporting documents with the request

for involuntary disenrollment to the State. The state will respond with approval or denial within 10

business days of receiving the request for a review. The PO will notify the enrollee of the adverse

action and the right to a fair hearing.

Voluntary Disenrollments:

Enrollees may choose to voluntarily disenroll from PACE at any time of the month. The state will

assist with returning any disenrolled participant (voluntary or involuntary) to the previous Medicaid

coverage program, effective the beginning of the next month possible.

The PACE organization follows Policy Number 302.1 for Voluntary Disenrollments:

All participants have the right to voluntarily disenroll from the PACE organization without cause at

any time. The PACE Social Worker has the individual or his/her caregiver sign the disenrollment form.

The disnrollment form advises participants of the following:

• They may be contacted by HCS or CMS to verify their desire to disenroll

• Attests to the fact that they understand that they are disenrolling and

• That they have been informed that they will return to the traditional Medicare and Medicaid

systems as of the disenrollment date and no longer are required to receive services through

the PACE organization.

The social worker notifies the multidisciplinary team and the HCS program manager & case manager

regarding the anticipated date for disenrollment. The multidisciplinary team ensures that the participant

is reinstated in other Medicare and Medicaid programs after disenrollment by making appropriate

referrals, transferring medical records and coordinating with CMS and HCS to ensure participant’s

reinstatement. All services to the participant are continued during the disenrollment process.

The PO social worker sends the official disenrollment letter to the participant and his/her representative

or to the nursing home, if the participant is currently residing there. The social worker also notifies the

PACE organization business office. The Accounting Assistant in the business office will remove the

participant’s name from the billing cycle and will report the disenrollment to CMS.

SAA undertakes the following steps:

The HCS case manager inputs the information that the PACE organization participant has disenrolled.

The SAA ends PACE enrollment in the state MMIS system. An HCS representative may contact the

former enrollee to verify his/her desire to disenroll.

APPENDIX T: REGULATORY WAIVERS

CMS has granted a conditional organization-wide waiver of the following sections of the PACE

regulation:

Section 460.64(a)(3)-Personnel qualifications for staff with direct participant contact This waiver permits driver(s) to be hired without having one year experience with the frail or elderly

population.

Section 460.64(a)(5)-Personnel qualifications for staff with direct participant contact This waiver permits individuals who have documentation that is consistent with the State's

requirement for establishing an individual is medically cleared for communicable diseases and have

all immunizations up-to-date to give direct care to participants outside of the PACE Center.

Section 460.102-Interdisclplinary Team This waiver permits Nurse Practitioners (NP) to be involved as part of the Interdisciplinary Team

(IDT) along with the eleven required IDT members.

Section 460.104-Participant Assessment This waiver permits NP, in collaboration with PEP's Medical Director or PEP staff physicians to:

(1) Conduct initial comprehensive assessments.

(2) Conduct periodic reassessments.

(3) Conduct unscheduled reassessments,

(4) Participate in the development of the PACE participant's plan of care and ongoing

monitoring of participant's health status.

Section 460.182-Medicaid Payment This waiver allows the PACE organization to continue the practice of receiving Medicaid

retrospective payments from the State of Washington.

APPENDIX U- MEDICARE PART D

The Centers for Medicare & Medicaid Services (hereinafter referred to as “CMS”) and Providence Health

& Services Washington operates Providence ElderPlace-Seattle, a PACE organization (hereinafter

referred to as the PACE Organization) agree that the PACE Organization shall operate a Voluntary

Medicare Prescription Drug Plan pursuant to sections 1860D-1 through 1860D-42 (with the exception of

sections 1860D-22 and 1860D-31) of the Act.

This agreement is made pursuant to 42 CFR Part 423, Subpart K (to the extent that waivers of those

provisions have not been granted pursuant to 42 CFR §423.458(d)) and 42 CFR Part 460, Subpart C, of

the PACE regulations.

Article I

Medicare Prescription Drug Benefit

A. The PACE Organization agrees to operate a Medicare Prescription Drug Benefit as described in its

application and related materials, including but not limited to all the attestations contained therein and

all supplemental guidance provided by CMS. In addition, the PACE Organization agrees to comply

with the provisions of this Appendix, which incorporates in its entirety the Medicare Part D

Application for New PACE Organizations. The PACE Organization also agrees to operate in

accordance with sections 1860D-1 through 1860D-42 of the Act (with the exception of sections

1860D-22 and 1860D-31), the regulations at 42 CFR §423.1 through 42 CFR §423.910, with the

exception of Subparts Q, R and S and other sections of 42 CFR Part 423 specifically waived for

PACE Organizations (the PACE waivers are attached to this Appendix as Attachment A), the

abbreviated application, the PACE regulations at 42 CFR Part 460, as applicable, as well as all other

applicable Federal statutes, regulations, and policies. This Appendix is deemed to incorporate any

changes that are required by statute to be implemented during the term of this Appendix and any

regulations or policies implementing or interpreting such statutory provisions.

B. CMS agrees to perform its obligations to the PACE Organization consistent with the regulations at 42

CFR §423.1 through 42 CFR §423.910, as applicable, sections 1860D-1 through 1860D-42 of the

Social Security Act, as applicable, and the abbreviated application, as well as all other applicable

Federal statutes, regulations, and policies.

C. CMS agrees that it will not implement, other than at the beginning of a calendar year, regulations

under 42 CFR Part 423 that impose new, significant regulatory requirements on the PACE

Organization. This provision does not apply to new requirements mandated by statute.

D. This Appendix is in no way intended to supersede or modify 42 CFR, Part 423 or Part 460. Failure to

reference a regulatory requirement in this Appendix does not affect the applicability of such

requirements to the PACE Organization and CMS.

Article II

Functions to be Performed by the PACE Organization A. ENROLLMENT

Part D eligible participants enrolled in a PACE plan that offers a Medicare Prescription Drug Plan

must receive qualified prescription drug coverage through the PACE Organization’s Part D plan

pursuant to 42 CFR §423.30(c).

B. PRESCRIPTION DRUG BENEFIT

1. The PACE Organization agrees to provide the basic prescription drug coverage as defined under 42

CFR §423.100 to all Part D eligible PACE beneficiaries and, to the extent applicable,

supplemental benefits as defined in 42 CFR §423.100 and in accordance with Subpart C of 42

CFR Part 423 to all Part D eligible beneficiaries. The PACE Organization also agrees to provide

Part D benefits as described in the PACE Organization’s Part D bid(s) approved each year by

CMS.

2. The PACE Organization agrees to calculate and collect beneficiary Part D premiums, to the extent

applicable, in accordance with 42 CFR §§423.286 and 423.293.

C. DISSEMINATION OF PLAN INFORMATION

1. The PACE Organization agrees to disclose information related to Part D benefits to beneficiaries in

the manner specified in the PACE regulations at 42 CFR §460.82.

2. Any PACE Organization that utilizes a Part D formulary agrees to provide notice regarding

formulary changes and to educate participants and providers concerning its formulary in

accordance with 42 CFR §423.120(b).

3. Approval of marketing materials shall be governed by 42 CFR §460.82 of the PACE regulations.

D. QUALITY ASSURANCE/UTILIZATION MANAGEMENT

1. The PACE Organization will operate quality assurance, cost and utilization management, and

medication therapy management as required in 42 CFR §§ 460.102, 460.104, 460.106, and

Subpart H of the PACE regulations to the extent these requirements have relevance to Part D and

do not exceed the corresponding requirements under 42 CFR §§423.153 and 423.162.

2. The PACE Organization will support electronic prescribing in accordance with 42 CFR §423.159.

E. APPEALS AND GRIEVANCES

The PACE Organization agrees that any appeals and grievances regarding Part D issues will be

subject to the requirements of 42 CFR §§460.120, 460.122 and 460.124 of the PACE regulations

governing grievances and appeals.

F. PAYMENT TO PACE ORGANIZATION

The PACE Organization and CMS agree that payment paid for Part D services under this Appendix

will be governed by §1894(d) of the Act and the rules in Subpart G of 42 CFR Part 423.

G. BID SUBMISSION AND REVIEW

1. If the PACE Organization intends to participate in the Part D Program for the next program year,

the PACE Organization agrees to submit the next year’s Part D bid, including all required

information on premiums and benefits, by the applicable due date as provided in Subpart F of 42

CFR Part 423, unless a waiver is granted pursuant to 42 CFR §423.265(b), so that CMS and the

PACE Organization may conduct negotiations regarding the terms and conditions of the proposed

bid and benefit plan renewal.

H. COORDINATION WITH OTHER PRESCRIPTION DRUG COVERAGE

1. The PACE Organization agrees to comply with the coordination requirements of State Pharmacy

Assistance Programs (SPAPs) and, as applicable, agrees to comply with coordination

requirements of other plans that provide prescription drug coverage as described in 42 CFR

§§423.464(a)-(b),(d)-(e), (f)(1) and (3).

2. The PACE Organization agrees that Medicare Secondary Payer procedures will be governed by 42

CFR §460.180(d) of the PACE regulations.

I. SERVICE AREA AND PHARMACY ACCESS

1. The PACE Organization agrees to provide Part D benefits to Part D eligible PACE enrollees in the

service area for which it has been approved by CMS to offer PACE benefits.

2. The PACE Organization agrees to ensure adequate access to Part D covered drugs at out-of-

network pharmacies in accordance with 42 CFR §§460.90(b), 460.92(q) and 460.100.

3. The PACE Organization agrees to adjudicate prescription drug claims in a timely and efficient

manner in compliance with CMS standards.

J. COMPLIANCE PLAN/PROGRAM INTEGRITY

The PACE Organization agrees that it will develop and implement a compliance plan that applies

to its Part D-related operations, consistent with 42 CFR §§423.504(b)(4)(vi)(F)-(H) and 42 CFR

§§460.32, 460.60-68, 460.71 and 460.80.

K. LOW-INCOME SUBSIDY

The PACE Organization agrees that it will participate in the administration of subsidies for low-

income individuals according to Subpart P of 42 CFR Part 423.

L. BENEFICIARY FINANCIAL PROTECTIONS

The PACE Organization agrees to afford its enrollees protection from liability for payment of fees

related to Part D prescription drug coverage that are the obligation of the PACE Organization in

accordance with section 1894(b)(1)(A)(i) of the Act and 42 CFR §§460.70(e)(5) and 460.90(a).

M. RELATIONSHIP WITH RELATED ENTITIES, CONTRACTORS, AND SUBCONTRACTORS

1. The PACE Organization agrees that it maintains ultimate responsibility for adhering to, and

otherwise fully complying with, all terms and conditions of this Appendix.

2. The PACE Organization shall ensure that any contracts or agreements with subcontractors or

agents performing functions on the PACE Organization’s behalf related to the operation of the

Part D benefit are in compliance with 42 CFR §460.70 of the PACE regulation.

N. CERTIFICATION OF DATA THAT DETERMINE PAYMENT

The PACE Organization shall provide certifications in accordance with 42 CFR §423.505(k)(1-5).

Article III

Record Retention and Reporting Requirements

A. MAINTENANCE OF RECORDS

The PACE Organization agrees to maintain records and provide access in accordance with 42 CFR

§423.505(d) and 42 CFR §§460.200(a)–(e), 460.202, 460.204, 460.208 and 460.210.

B. GENERAL REPORTING REQUIREMENTS

The PACE Organization agrees to submit information to CMS according to 42 CFR 460, Subpart L

of the PACE regulations and the “Medicare Part D Reporting Requirements”, a document issued by

CMS and subject to modification each program year. The Reporting Requirements document

specifies the abbreviated list of requirements applicable to PACE organizations.

C. CMS LICENSE FOR USE OF PLAN FORMULARY

If the PACE Organization develops a formulary, then the PACE Organization agrees to submit to

CMS its formulary information, including any changes to its formularies, and hereby grants to the

Government [and any person or entity who might receive the formulary from the Government,] a

non-exclusive license to use all or any portion of the formulary for any purpose related to the

administration of the Part D program, as applicable.

Article IV

HIPAA Transactions/Privacy/Security

The PACE Organization agrees to comply with the confidentiality and enrollee record accuracy

requirements specified in 42 CFR §§460.200(d)-(e) of the PACE regulations.

Article V

Appendix Term and Renewal

A. TERM OF APPENDIX

This Appendix is effective from the date of CMS’ authorized representative’s signature through

December 31, 2018, and shall be renewable for successive one-year periods thereafter according to 42

CFR §460.34 of the PACE regulations. The PACE Organization shall begin delivering the Medicare

prescription drug benefit services upon executing the signed PACE program agreement.

B. QUALIFICATION TO RENEW APPENDIX

1. In accordance with 42 CFR §423.507, the PACE Organization will be determined qualified to

renew this Appendix annually only if—

(a) CMS informs the PACE Organization that it is qualified to renew its

Appendix; and

(b) The PACE Organization has not provided CMS with a notice of intention not to renew in

accordance with Article VII of this Appendix.

2. Although the PACE Organization may be determined qualified to renew its Appendix under this

Article, if the PACE Organization and CMS cannot reach agreement on the Part D bid under

Subpart F of 42 CFR Part 423, no renewal takes place, and the failure to reach agreement is not

subject to the appeals provisions in 42 CFR Part 423, Subpart N or 42 CFR §460.54.

Article VI

Relationship Between Appendix and PACE Program Agreement

A. In the event that the PACE Organization’s Program Agreement is terminated by any party, the

provisions of this Appendix shall also terminate. In such an event, the PACE Organization shall

provide notice to enrollees and the PACE Organization shall prepare a transitional plan of care as

described in the Program Agreement as well as in 42 CFR §460.52 of the PACE regulations.

B. The PACE Organization acknowledges that the termination or nonrenewal of this Appendix by either

party may require CMS to terminate or non-renew the PACE Program Agreement in the event that

such termination or non-renewal prevents the PACE Organization from meeting the requirements of

42 CFR §§ 460.80(a) and 460.92, in which case the PACE Organization must provide the notices as

specified in Article VI.A. of this Appendix, as well as the notices specified under 42 CFR §460.52.

The PACE Organization also acknowledges that the nonrenewal or termination of this Appendix by

either party may prevent the PACE Organization from entering into a new Program Agreement with

CMS for two years following such Appendix nonrenewal or termination where CMS determines that

such non-renewal or termination will prevent the PACE Organization from meeting the requirements

of 42 CFR §§460.80(a) and 460.92.

C. The termination of this Appendix by either party shall not, by itself, relieve the parties from their

obligations under the Program Agreement to which this document is an Appendix.

Article VII

Nonrenewal of Appendix

A. NONRENEWAL BY THE PACE ORGANIZATION

1. The PACE Organization may non-renew this Appendix in accordance with 42 CFR §423.507(a).

2. If the PACE Organization non-renews this Appendix under this Article, CMS cannot enter into a

Part D Appendix with the organization for 2 years unless there are special circumstances that

warrant special consideration, as determined by CMS.

B. NONRENEWAL BY CMS

CMS may non-renew this Appendix under the rules contained in 42 CFR §423.507(b).

Article VIII

Modification or Termination of Appendix by Written Mutual Consent

This Appendix may be modified or terminated by written mutual consent in accordance with 42 CFR

§423.508.

Article IX

Termination of Appendix by CMS

CMS may terminate this Appendix in accordance with 42 CFR 423.509.

Article X

Termination of Appendix by the PACE Organization

A. The PACE Organization may terminate this Appendix in accordance with 42 CFR §423.510.

B. CMS will not enter into a Part D Appendix with any PACE Organization that has terminated its

Appendix within the preceding two years unless there are circumstances that warrant special

consideration, as determined by CMS

C. If the Appendix is terminated under section A of this Article, the Pace Organization must ensure the

timely transfer of any data and files.

Article XI

Intermediate Sanctions

The PACE Organization shall be subject to sanctions and civil money penalties, consistent with

Subpart O of 42 CFR Part 423.

Article XII

Severability Severability of the Appendix shall be in accordance with 42 CFR §423.504(e).

Article XIII

Miscellaneous

A. DEFINITIONS: Terms not otherwise defined in this Appendix shall have the meaning given such

terms at 42 CFR Part 423 or, as applicable, 42 CFR Part 460.

B. ALTERATION TO ORIGINAL APPENDIX TERMS: The PACE Organization agrees that it has not

altered in any way the terms of the PACE Part D Appendix. The PACE Organization agrees that any

alterations to the original text of the Appendix made by the PACE Organization shall not be binding

on the parties.

C. ADDITIONAL CONTRACT TERMS: The PACE Organization agrees to include in this Appendix

other terms and conditions in accordance with 42 CFR §423.505(j).

D. CMS APPROVAL TO BEGIN PROVIDING PART D: The PACE Organization agrees that it must

complete CMS operational requirements including, but not limited to, establishing and successfully

testing connectivity with CMS systems to process enrollment applications (or contracting with an

entity qualified to perform such functions on the PACE Organization’s behalf). To establish and

successfully test connectivity, the PACE Organization must 1) establish and test physical connectivity

to the CMS data center, 2) acquire user identifications and passwords, 3) receive, store, and maintain

data necessary to perform enrollments and send and receive transactions to and from CMS, and 4)

check and receive transaction status information.

Exhibit C

Exhibit D

Exhibit E

Data Element Description

Data

Type/Length Comments/Examples

ENC_REF_ID Encounter Submission ID VARCHAR2(33)

ENC_SUB_DT Encounter Submission Date DATE MMDDYYYY

RCPT_ID Recipient ID / Member ID VARCHAR2(9)

RCPT_DOB Recipient DOB DATE MMDDYYYY

RCPT_SEX Recipient Gender CHAR(1) M = Male, F = Female

DUAL_IND Dual eligible CHAR(1) Y = Yes, N = No

MDCD_STATUS Medicaid Eligible CHAR(1) Y = Yes, N = No

PROV_ID Provider ID / NPI VARCHAR2(10) Use National Provider Identifier (NPI)

PROV_SRVC_LOC Provider Service Location NUMBER(4)

Use to distinguish multiple locations that

share one PROV_ID (e.g., "0001",

"0002"…)

SERV_START_DATE Service Date From CHAR(8) MMDDYYYY

SERV_END_DATE Service Date To CHAR(8) MMDDYYYY

SRVC_UNITS Service Units NUMBER(9)

Specify unit measure for any populated

value

SRVC_HOURS Service Hours NUMBER(9) N/A for per diem services

SRVC_DAYS Service Days NUMBER(9) N/A for hourly services

MDCD_REIMB Final Medicaid Reimbursed NUMBER(15,2) For services provided by Salaried Staff,

input 0.00. For all other services subject to

reimbursement rates, report values in a

consistent format.

TPL_PAID_AMOUNT Amount Paid by Other Insurance NUMBER(15,2)

MEDICARE_PAID_AMOUNT Amount Paid by Medicare NUMBER(15,2)

R&B_REIMB

Room and Board Amount

Reimbursed NUMBER(15,2)

PROVR_TYPE_ID Provider Type CHAR(2)

PROVR_SPECIALTY_ID Provider Specialty VARCHAR2(3)

PRIM_PROC_ID Procedure Code VARCHAR2(5) Standard CPT or HCPCS procedure code

PROC_ID_MODIFIER_1 Procedure Code Modifier 1 VARCHAR2(2)

Standard CPT or HCPCS procedure

modifier

PROC_ID_MODIFIER_2 Procedure Code Modifier 2 VARCHAR2(2)

Standard CPT or HCPCS procedure

modifier

PROC_ID_MODIFIER_3 Procedure Code Modifier 3 VARCHAR2(2)

Standard CPT or HCPCS procedure

modifier

PROC_ID_MODIFIER_4 Procedure Code Modifier 4 VARCHAR2(2)

Standard CPT or HCPCS procedure

modifier

PROC_CD_DESC Procedure Code Description TEXT Optional field to describe service

PRIM_DIAGNOSIS_ID Primary Diagnosis VARCHAR2(8) Standard ICD-10 or DSM-5 coding

SEC_DIAGNOSIS_ID Secondary Diagnosis VARCHAR2(8) Standard ICD-10 or DSM-5 coding

TERT_DIAGNOSIS_ID Tertiary Diagnosis VARCHAR2(8) Standard ICD-10 or DSM-5 coding

Exhibit F

Medicare Status Age Band Client Count

Medicaid Only 55-64 Medicaid Only 65+ Dually Eligible 55-64 Dually Eligible 65+ Total 0

Living situation mix Client count Home -Agency Provider Home - Individual Provider Adult Family Home Assisted Living Facility Total 0