Common use of Agreement to Use Electronic Signatures Clause in Contracts

Agreement to Use Electronic Signatures. I agree, and it is my intent, to sign this Contract by accessing State of Indiana Supplier Portal using the secure password assigned to me and by electronically submitting this Contract to the State of Indiana. I understand that my signing and submitting this Contract in this fashion is the legal equivalent of having placed my handwritten signature on the submitted Contract and this affirmation. I understand and agree that by electronically signing and submitting this Contract in this fashion I am affirming to the truth of the information contained therein. I understand that this Contract will not become binding on the State until it has been approved by the Department of Administration, the State Budget Agency, and the Office of the Attorney General, which approvals will be posted on the Active Contracts Database: xxxxx://xx.xxxx.xx.xxx/psp/pa91prd/EMPLOYEE/EMPL/h/?tab=PAPP_GUEST In Witness Whereof, the Contractor and the State have, through their duly authorized representatives, entered into this Contract. The parties, having read and understood the foregoing terms of this Contract, do by their respective signatures dated below agree to the terms thereof. [Contractor] Indiana Department of Administration By: _________________________________ By: _______________________________ _____________________________________ ___________________________________ Name and Title, Printed Name and Title, Printed Date: _____________________________ Date: ___________________________ Indiana Office of Technology Indiana Department of Administration By: __________________________________ (for) By: ______________________________ (for) Xxxxxx Xxxxx, Chief Information Officer Xxxxxx X. Xxxxx, Commissioner Date: _________________________________ Date: ______________________________ State Budget Office of the Attorney General By: ________________________________(for) By: _______________________________ (for) Xxxxx X. Xxxxxx, Director Xxxxxx X. Xxxx, Xx. Attorney General Date:________________________________ Date: _________________________________ This document is an exhibit to the Professional Services agreement, and is deemed to be attached to and incorporated within the Professional Services Agreement by reference. Any inconsistency, conflict, or ambiguity between this exhibit and the Professional Services agreement shall be resolved by giving precedence and effect to the Professional Services agreement. TBD

Agreement to Use Electronic Signatures. I agree, and it is my intent, to sign this Contract Amendment by accessing State of Indiana Supplier Portal using the secure password assigned to me and by electronically submitting this Contract Amendment to the State of Indiana. I understand that my signing and submitting this Contract Amendment in this fashion is the legal equivalent of having placed my handwritten signature on the submitted Contract Amendment and this affirmation. I understand and agree that by electronically signing and submitting this Contract Amendment in this fashion I am affirming to the truth of the information contained therein. I understand that this Contract Amendment will not become binding on the State until it has been approved by the Department of Administration, the State Budget Agency, and the Office of the Attorney General, which approvals will be posted on the Active Contracts Database: xxxxx://xx.xxxx.xx.xxx/psp/pa91prd/EMPLOYEE/EMPL/h/?tab=PAPP_GUEST In Witness Whereofxxxxx://xx.xxxx.xx.xxx/psp/guest/SUPPLIER/ERP/c/SOI_CUSTOM_APPS.SOI_PUBLIC_CNTRCT S.GBL By:\s1\ Title:\tC1E\O Date:\6d/11\ /2021 | 11:43 CDT Title:\tM2e\ dicaid director By:\s2\ Date:6\d/21\ /2021 | 13:11 EDT Electronically Approved by: Indiana Office of Technology By: (for) Xxxxx X. Xxxxxx, the Contractor and the State have, through their duly authorized representatives, entered into this Contract. The parties, having read and understood the foregoing terms of this Contract, do by their respective signatures dated below agree to the terms thereof. [Contractor] Indiana Chief Information Officer Electronically Approved by: Department of Administration By: _________________________________ By: _______________________________ _____________________________________ ___________________________________ Name and Title, Printed Name and Title, Printed Date: _____________________________ Date: ___________________________ Indiana Office of Technology Indiana Department of Administration By: __________________________________ (for) By: ______________________________ (for) Xxxxxx Xxxxx, Chief Information Officer Xxxxxx X. Xxxxx, Commissioner DateElectronically Approved by: _________________________________ Date: ______________________________ State Budget Agency By: (for) Xxxxxxx X. Xxxxxxx, Director Electronically Approved as to Form and Legality by: Office of the Attorney General By: ________________________________(for) By: _______________________________ (for) Xxxxx Xxxxxxxx X. Xxxxxx, Director Xxxxxx X. Xxxx, Xx. Attorney General Date:________________________________ Date: _________________________________ This document is an exhibit 1.0 Background 11 2.0 Managed Care Entity- Contractor Requirements 13 2.1 State Licensure 13 2.2 National Committee for Quality Assurance (NCQA) Accreditation 13 2.3 Administrative and Organizational Structure 13 2.4 Staffing 14 2.4.1 Key Staff 14 2.4.2 Staff Positions 20 2.4.3 Training 22 2.4.4 Debarred Individuals 23 2.5 FSSA/OMPP Meeting Requirements 24 2.6 Financial Stability 24 2.6.1 Solvency 24 2.6.2 Insurance 25 2.6.3 Reinsurance 25 2.6.4 Financial Accounting Requirements 26 2.6.5 Reporting Transactions with Parties of Interest 28 2.6.6 Medical Loss Ratio 29 2.6.7 Health Insurance Providers Fee 30 2.7 Subcontracts 31 2.8 Confidentiality of Member Medical Records and Other Information 34 2.9 Internet Quorum (IQ) Inquires 34 2.10 Material Change 34 2.11 Future Program Guidance 34 2.12 Conflict of Interest 35 2.13 Capitation Related to the Professional Services agreement, a Vacated Program 35 3.0 HIP Plan Design and is deemed to be attached to and incorporated within the Professional Services Agreement by reference. Any inconsistency, conflict, or ambiguity between this exhibit and the Professional Services agreement shall be resolved by giving precedence and effect to the Professional Services agreement. TBDMember Eligibility 35 3.1 HIP Plus 35

Agreement to Use Electronic Signatures. I agree, and it is my intent, to sign this Contract by accessing State of Indiana Supplier Portal using the secure password assigned to me and by electronically submitting this Contract to the State of Indiana. I understand that my signing and submitting this Contract in this fashion is the legal equivalent of having placed my handwritten signature on the submitted Contract and this affirmation. I understand and agree that by electronically signing and submitting this Contract in this fashion I am affirming to the truth of the information contained therein. I understand that this Contract will not become binding on the State until it has been approved by the Department of Administration, the State Budget Agency, and the Office of the Attorney General, which approvals will be posted on the Active Contracts Database: xxxxx://xx.xxxx.xx.xxx/psp/pa91prd/EMPLOYEE/EMPL/h/?tab=PAPP_GUEST In Witness Whereofxxxxx://xxxxxx.xx.xxx/apps/idoa/contractsearch/ IN WITNESS to their agreement, the Contractor persons signing this lease execute it for the Landlord and Tenant: %%VENDOR_NAME%%
%%AGENCY_NAME%%
By:\s1\ By:\s2\ Printed Name:\t1\ Title:\t2\ Date:\d1\ Date:\d2\ The above named person(s) for the State haveXxxxxxxx personally appeared before me, through their duly authorized representatives, entered into this Contract. The parties, having read a Notary Public and understood acknowledged the foregoing terms execution of this ContractLease this _____ day of ________, do by their respective signatures dated below agree to the terms thereof______. [Contractor] Indiana Department of Administration By____________________________ Notary Public ___________________________ Printed Name My Commission Expires: _______ County of Residence:___________ Prepared by _____________ (Agency Legal Counsel) I affirm, under penalties of perjury, that I have taken reasonable care to redact each Social Security number in this document, as required by law. ________________________________ Electronically Approved by: Department of Administration By: (for) Xxxxxxx Xxxxxxxx Commissioner Xxxxx to Electronic Approval History found after the final page of the Executed Contract for details. Electronically Approved by: State Budget Agency By: (for) Xxxxxx X. Xxxxx, Acting State Budget Director Refer to Electronic Approval History found after the final page of the Executed Contract for details. Electronically Approved as to Form and Legality: Office of the Attorney General By: (for) Xxxxxxxx X. Xxxxxx, Attorney General Xxxxx to Electronic Approval History found after the final page of the Executed Contract for details. Landlord shall provide, at Xxxxxxxx's sole cost and expense, improvements and renovations to the Leased Premises according to Xxxxxx's exact standards and specifications ("turnkey") and in accordance with this Work Letter. You may use the Tenant Interior Build-out Specifications attached at the end of the Manual. This Letter of Confirmation is to be attached to the Lease between ______________ (Landlord) and the State of Indiana, acting by and through the Department of Administration, for and on behalf of the ____________ (Tenant). This Letter complies with Section 2 of the Lease which states that Landlord and Tenant shall confirm the commencement and expiration dates of the Lease for ______ rentable square feet located at _______________, in the City of ______________, County of ____________, State of Indiana, by signing a Letter of Confirmation, generated by the Tenant, which shall then become an attachment to the Lease. Therefore, it is agreed by the Landlord and Tenant that the Lease commenced on ______________________ and will expire on ____________________. The total agreed rent for the entire term of this Lease shall not exceed the sum of $_______, payable in equal consecutive monthly installments of $_________, which represents an annual square foot amount of $_____. The first month's rent shall be prorated based on Tenant's actual move-in date. If required by law, Xxxxxx shall separately reimburse Landlord any real estate taxes due with respect to the Leased Premises based on Tenant's proportionate share of such real estate taxes. Rent shall be paid in arrears as described in Section 5 of the Lease titled "Method of Payment". For the Landlord: For the Tenant: ________________________ ___________________________ _____________________________________ ___________________________________ Name: Name and & Title Title, Printed Name and Title, Printed : Date: ______:_______________________ Date: ___________________________ Landlord agrees to furnish reasonable and customary cleaning in and about the premises in accordance with the following schedule attached (2 pages). All labor and materials for the services identified in the attached charts will be provided by Landlord with no additional cost to the Tenant, including light bulbs, filter, trash bag liners, hand towels, toilet paper, ice control materials and janitor's cleaning supplies. ADD APPROPRIATE JANITORIAL SERVICES ATTACHMENTS (2 PAGES) BASED ON SQUARE FOOTAGE OF THE LEASED PREMISES: OR YOU MAY USE THE JANITORIAL EXHIBIT ATTACHED AT THE END OF THE MANUAL. This Amendment #_ to that certain State of Indiana Office Lease dated as of Technology Indiana Department of Administration By: __________, 20__, and effective __________, 20__, per the commencement date stated in the Confirmation Letter (the "Lease") is entered into by and between __________ (hereinafter referred to as "Current Landlord") and the State of Indiana, acting by and through its Department of Administration for and on behalf of the ___________ (for) By: ______________________________ (for) Xxxxxx Xxxxxhereinafter referred to as "Tenant"). Hereinafter, Chief Information Officer Xxxxxx X. Xxxxxthe Current Landlord, Commissioner Date: _________________________________ Date: ______________________________ State Budget Office of Successor Landlord and Tenant may collectively be referred to as the Attorney General By: ________________________________(for) By: _______________________________ (for) Xxxxx X. Xxxxxx, Director Xxxxxx X. Xxxx, Xx. Attorney General Date:________________________________ Date: _________________________________ This document is an exhibit to the Professional Services agreement, and is deemed to be attached to and incorporated within the Professional Services Agreement by reference. Any inconsistency, conflict, "Parties" or ambiguity between this exhibit and the Professional Services agreement shall be resolved by giving precedence and effect to the Professional Services agreement. TBDindividually as a "Party".

Agreement to Use Electronic Signatures. I agree, and it is my intent, to sign this Contract Amendment by accessing State of Indiana Supplier Portal using the secure password assigned to me and by electronically submitting this Contract Amendment to the State of Indiana. I understand that my signing and submitting this Contract Amendment in this fashion is the legal equivalent of having placed my handwritten signature on the submitted Contract Amendment and this affirmation. I understand and agree that by electronically signing and submitting this Contract Amendment in this fashion I am affirming to the truth of the information contained therein. I understand that this Contract Amendment will not become binding on the State until it has been approved by the Department of Administration, the State Budget Agency, and the Office of the Attorney General, which approvals will be posted on the Active Contracts Database: xxxxx://xx.xxxx.xx.xxx/psp/pa91prd/EMPLOYEE/EMPL/h/?tab=PAPP_GUEST In Witness Whereofxxxxx://xx.xxxx.xx.xxx/psp/guest/SUPPLIER/ERP/c/SOI_CUSTOM_APPS.SOI_PUBLIC_CNTRCT S.GBL By:\s1\ Title:\tC1E\O Date:6\d/11\/2021 | 11:44 CDT Title:\Mt2e\ dicaid director By:\s2\ Date:6\d/21\ /2021 | 13:12 EDT Electronically Approved by: Indiana Office of Technology By: (for) Xxxxx X. Xxxxxx, the Contractor and the State have, through their duly authorized representatives, entered into this Contract. The parties, having read and understood the foregoing terms of this Contract, do by their respective signatures dated below agree to the terms thereof. [Contractor] Indiana Chief Information Officer Electronically Approved by: Department of Administration By: _________________________________ By: _______________________________ _____________________________________ ___________________________________ Name and Title, Printed Name and Title, Printed Date: _____________________________ Date: ___________________________ Indiana Office of Technology Indiana Department of Administration By: __________________________________ (for) By: ______________________________ (for) Xxxxxx Xxxxx, Chief Information Officer Xxxxxx X. Xxxxx, Commissioner DateElectronically Approved by: _________________________________ Date: ______________________________ State Budget Agency By: (for) Xxxxxxx X. Xxxxxxx, Director Electronically Approved as to Form and Legality by: Office of the Attorney General By: ________________________________(for) By: _______________________________ (for) Xxxxx Xxxxxxxx X. Xxxxxx, Director Xxxxxx X. Xxxx, Xx. Attorney General Date:________________________________ Date: _________________________________ This document is an exhibit to the Professional Services agreement, 1.0 Background 9 2.0 Managed Care Entity- Contractor Requirements 10 2.1 State Licensure 10 2.2 National Committee for Quality Assurance (NCQA) Accreditation 10 2.3 Administrative and is deemed to be attached to Organizational Structure 10 2.4 Staffing 11 2.4.1 Key Staff 12 2.4.2 Staff Positions 17 2.4.3 Training 18 2.4.4 Debarred Individuals 19 2.5 OMPP Meeting Requirements 20 2.6 Financial Stability 20 2.6.1 Solvency 20 2.6.2 Insurance 21 2.6.3 Reinsurance 21 2.6.4 Financial Accounting Requirements 22 2.6.5 Reporting Transactions with Parties of Interest 24 2.6.6 Medical Loss Ratio 25 2.6.7 Health Insurance Providers Fee 26 2.7 Subcontracts 27 2.8 Confidentiality of Member Medical Records and incorporated within the Professional Services Agreement by reference. Any inconsistency, conflict, or ambiguity between this exhibit and the Professional Services agreement shall be resolved by giving precedence and effect to the Professional Services agreement. TBDOther Information 29

Agreement to Use Electronic Signatures. I agree, and it is my intent, to sign this Contract by accessing State of Indiana Supplier Portal using the secure password assigned to me and by electronically submitting this Contract to the State of Indiana. I understand that my signing and submitting this Contract in this fashion is the legal equivalent of having placed my handwritten signature on the submitted Contract and this affirmation. I understand and agree that by electronically signing and submitting this Contract in this fashion I am affirming to the truth of the information contained therein. I understand that this Contract will not become binding on the State until it has been approved by the Department of Administration, the State Budget Agency, and the Office of the Attorney General, which approvals will be posted on the Active Contracts Database: xxxxx://xx.xxxx.xx.xxx/psp/pa91prd/EMPLOYEE/EMPL/h/?tab=PAPP_GUEST In Witness Whereofxxxxx://xx.xxxx.xx.xxx/psp/guest/SUPPLIER/ERP/c/SOI_CUSTOM_APPS.SOI_PUBLIC_CNTRCTS.GBL IN WITNESS to their agreement, the Contractor persons signing this lease execute it for the Landlord and the State have, through their duly authorized representatives, entered into Tenant: (Company name) (Agency Name) ___________________________ ___________________________ (Type in Landlord name (Type in Agency Head's name and title under this Contract. The parties, having read and understood the foregoing terms of signature line) under this Contract, do by their respective signatures dated below agree to the terms thereof. [Contractor] Indiana Department of Administration line) Date: _______________________ Date: ______________________ By: _________________________ (for) The above named person(s) for the Xxxxxx X. Xxxxx, Commissioner Landlord personally appeared before me, a Notary Public and acknowledged the execution of this lease Date: ______________________ this _____ day of _____, ______. State Budget Agency ____________________________ By: _______________________________ (for) Notary Public Xxxxxxx X. Xxxxxxx, Director ___________________________ Date:______________________ Printed Name My Commission Expires: _______ By: ________________________ (for) County of Residence: ___________ Xxxxxx X. Xxxx, Xx., Attorney General Prepared by _____________ (Agency Legal Counsel) I affirm, under penalties of perjury, that I have taken reasonable care to redact each social security number in this document, as required by law. _________________________________________ Revised 9/2020 INSERT LEGAL DESCRIPTION Landlord shall provide, at Landlord’s sole cost and expense, improvements and renovations to the Leased Premises according to Tenant’s exact standards and specifications (“turnkey”) and in accordance with this Work Letter. You may use the Tenant Interior Build-out Specifications attached at the end of the Manual. This Letter of Confirmation is to be attached to the Lease between ______________ (Landlord) and the State of Indiana, acting by and through the Department of Administration, for and on behalf of the ____________ (Tenant). This Letter complies with Section 2 of the Lease which states that Landlord and Tenant shall confirm the commencement and expiration dates of the Lease for ______ rentable square feet located at _______________, in the City of ______________, County of ____________, State of Indiana, by signing a Letter of Confirmation, generated by the Tenant, which shall then become an attachment to the Lease. Therefore, it is agreed by the Landlord and Tenant that the Lease commenced on ______________________ and will expire on ____________________. The total agreed rent for the entire term of this Lease shall not exceed the sum of $_______, payable in equal consecutive monthly installments of $_________, which represents an annual square foot amount of $_____. The first month’s rent shall be prorated based on Tenant’s actual move-in date. If required by law, Tenant shall separately reimburse Landlord any real estate taxes due with respect to the Leased Premises based on Tenant’s proportionate share of such real estate taxes. Rent shall be paid in arrears as described in Section 5 of the Lease titled “Method of Payment”. For the Landlord: For the Tenant: ________________________ ___________________________ __________________________ ___________________________ Name: Name and & Title Title, Printed Name and Title, Printed : Date: ______:_______________________ Date: ___________________________ Indiana Office of Technology Indiana Department of Administration ByLandlord agrees to furnish reasonable and customary cleaning in and about the premises in accordance with the following schedule attached (2 pages). All labor and materials for the services identified in the attached charts will be provided by Landlord with no additional cost to the Tenant, including light bulbs, filter, trash bag liners, hand towels, toilet paper, ice control materials and janitor’s cleaning supplies. ADD APPROPRIATE JANITORIAL SERVICES ATTACHMENTS (2 PAGES) BASED ON SQUARE FOOTAGE OF THE LEASED PREMISES: __________________________________ (for) By: ______________________________ (for) Xxxxxx Xxxxx, Chief Information Officer Xxxxxx X. Xxxxx, Commissioner Date: _________________________________ Date: ______________________________ State Budget Office of the Attorney General By: ________________________________(for) By: _______________________________ (for) Xxxxx X. Xxxxxx, Director Xxxxxx X. Xxxx, XxOR YOU MAY USE THE JANITORIAL EXHIBIT ATTACHED AT THE END OF THE MANUAL. Attorney General Date:________________________________ Date: _____________EDS # or Contract # ____________________ This document is an exhibit Amendment #_ to the Professional Services agreementthat certain State of Indiana Office Lease dated as of __________, 20__, and effective __________, 20__, per the commencement date stated in the Confirmation Letter (the “Lease”) is deemed entered into by and between __________ (hereinafter referred to be attached to and incorporated within the Professional Services Agreement by reference. Any inconsistency, conflict, or ambiguity between this exhibit as “Current Landlord”) and the Professional Services agreement shall State of Indiana, acting by and through its Department of Administration for and on behalf of the ___________ (hereinafter referred to as “Tenant”). Hereinafter, the Current Landlord, Successor Landlord and Tenant may collectively be resolved by giving precedence and effect referred to as the Professional Services agreement. TBD“Parties” or individually as a “Party”.

Agreement to Use Electronic Signatures. I agree, and it is my intent, to sign this Contract Agreement by accessing State of Indiana Supplier Portal using the secure password assigned to me and by electronically submitting this Contract Agreement to the State of Indiana. I understand that my signing and submitting this Contract Agreement in this fashion is the legal equivalent of having placed my handwritten signature on the submitted Contract Agreement and this affirmation. I understand and agree that by electronically signing and submitting this Contract Agreement in this fashion I am affirming to the truth of the information contained therein. I understand that this Contract Agreement will not become binding on the State until it has been approved by the Department of Administration, the State Budget Agency, and the Office of the Attorney General, which approvals will be posted on the Active Contracts Database: xxxxx://xx.xxxx.xx.xxx/psp/pa91prd/EMPLOYEE/EMPL/h/?tab=PAPP_GUEST In Witness Whereofxxxxx://xx.xxxx.xx.xxx/psp/guest/SUPPLIER/ERP/c/SOI_CUSTOM_APPS.SOI_PUBLIC_CNTR CTS.GBL Xxxxx Xxxxxxx, the Contractor Mayor Date: Xxxxxxxx Xxxx, Clerk Date: Xxxxx Xxxxxx, Mayor Date: Xxxxxx Xxxx, Clerk Date: Xxxxxxxxx Xxxxxx, Commissioner Date: Xxxxx Xxxxxxxxx, Commissioner Date: Xxxx Xxxxxxxxxx, Commissioner Date: Xxxxx X. Xxxxx, County Auditor Date: Xxxxx X. Xxxxxx Xxxxxxxxxx District Deputy Commissioner Indiana Department of Transportation Date: Xxxxxxx Xxxxx, Commissioner Indiana Department of Transportation Date: APPROVALS STATE OF INDIANA Office of Management and the State haveBudget By: (FOR) Xxxxxxx X Xxxxxxx, through their duly authorized representatives, entered into this Contract. The parties, having read and understood the foregoing terms of this Contract, do by their respective signatures dated below agree to the terms thereof. [Contractor] Indiana Director Date: _ STATE OF INDIANA Department of Administration By: _________________________________ By: _______________________________ _____________________________________ ___________________________________ Name and Title, Printed Name and Title, Printed Date: _____________________________ Date: ___________________________ Indiana Office of Technology Indiana Department of Administration By: __________________________________ (forFOR) By: ______________________________ (for) Xxxxxx Xxxxx, Chief Information Officer Xxxxxx X. XxxxxXxxxxxx Xxxxxxxx, Commissioner Date: _________________________________ DateApproved as to Form and Legality: ______________________________ State Budget Office of the Attorney General By: ________________________________(forFOR) ByXxxxxxxx X. Xxxxxx Attorney General of Indiana Date: _______________________________ (for) Xxxxx This instrument was prepared for the Indiana Department of Transportation, 000 X. Xxxxxx Xxxxxx, Director Xxxxxxxxxxxx, XX 00000, by the undersigned attorney. Xxxxxxxx X. Xxxxxxx, Attorney No. 21748-36 000 Xxxxx Xxxxxx X. XxxxXxxxxx Xxxxxxxxxxxx, Xx. Attorney General Date:________________________________ DateXxxxxxx 00000 PHONE: _________________________________ This document is an exhibit to the Professional Services agreement, and is deemed to be attached to and incorporated within the Professional Services Agreement by reference. Any inconsistency, conflict, or ambiguity between this exhibit and the Professional Services agreement shall be resolved by giving precedence and effect to the Professional Services agreement. TBD(000) 000-0000 EMAIL: xxxxx@xxxxx.xx.xxx

Agreement to Use Electronic Signatures. I agree, and it is my intent, to sign this Contract Amendment by accessing State of Indiana Supplier Portal using the secure password assigned to me and by electronically submitting this Contract Amendment to the State of Indiana. I understand that my signing and submitting this Contract Amendment in this fashion is the legal equivalent of having placed my handwritten signature on the submitted Contract Amendment and this affirmation. I understand and agree that by electronically signing and submitting this Contract Amendment in this fashion I am affirming to the truth of the information contained therein. I understand that this Contract Amendment will not become binding on the State until it has been approved by the Department of Administration, the State Budget Agency, and the Office of the Attorney General, which approvals will be posted on the Active Contracts Database: xxxxx://xx.xxxx.xx.xxx/psp/pa91prd/EMPLOYEE/EMPL/h/?tab=PAPP_GUEST In Witness Whereofxxxxx://xx.xxxx.xx.xxx/psp/guest/SUPPLIER/ERP/c/SOI_CUSTOM_APPS.SOI_PUBLIC_CNTRCT S.GBL By:\s1\ Title:\t1P\resident, the Contractor and the State haveIndiana Market Date:\d51/\12/2021 | 14:40 EDT By:\s2\ Title:\t2M\edicaid director Date:\d52/\12/2021 | 22:51 EDT Electronically Approved by: Indiana Office of Technology By: (for) Xxxxx X. Xxxxxx, through their duly authorized representatives, entered into this Contract. The parties, having read and understood the foregoing terms of this Contract, do by their respective signatures dated below agree to the terms thereof. [Contractor] Indiana Chief Information Officer Electronically Approved by: Department of Administration By: _________________________________ By: _______________________________ _____________________________________ ___________________________________ Name and Title, Printed Name and Title, Printed Date: _____________________________ Date: ___________________________ Indiana Office of Technology Indiana Department of Administration By: __________________________________ (for) By: ______________________________ (for) Xxxxxx Xxxxx, Chief Information Officer Xxxxxx X. Xxxxx, Commissioner DateElectronically Approved by: _________________________________ Date: ______________________________ State Budget Agency By: (for) Xxxxxxx X. Xxxxxxx, Director Electronically Approved as to Form and Legality by: Office of the Attorney General By: ________________________________(for) By: _______________________________ (for) Xxxxx Xxxxxxxx X. Xxxxxx, Director Xxxxxx X. Xxxx, Xx. Attorney General Date:________________________________ Date: _________________________________ This document is an exhibit to the Professional Services agreement, 1.0 Background 9 2.0 Managed Care Entity- Contractor Requirements 10 2.1 State Licensure 10 2.2 National Committee for Quality Assurance (NCQA) Accreditation 10 2.3 Administrative and is deemed to be attached to Organizational Structure 10 2.4 Staffing 11 2.4.1 Key Staff 12 2.4.2 Staff Positions 17 2.4.3 Training 18 2.4.4 Debarred Individuals 19 2.5 OMPP Meeting Requirements 20 2.6 Financial Stability 20 2.6.1 Solvency 20 2.6.2 Insurance 21 2.6.3 Reinsurance 21 2.6.4 Financial Accounting Requirements 22 2.6.5 Reporting Transactions with Parties of Interest 24 2.6.6 Medical Loss Ratio 25 2.6.7 Health Insurance Providers Fee 26 2.7 Subcontracts 27 2.8 Confidentiality of Member Medical Records and incorporated within the Professional Services Agreement by reference. Any inconsistency, conflict, or ambiguity between this exhibit and the Professional Services agreement shall be resolved by giving precedence and effect to the Professional Services agreement. TBDOther Information 29

Agreement to Use Electronic Signatures. I agree, and it is my intent, to sign this Contract by accessing State of Indiana Supplier Portal using the secure password assigned to me and by electronically submitting this Contract to the State of Indiana. I understand that my signing and submitting this Contract in this fashion is the legal equivalent of having placed my handwritten signature on the submitted Contract and this affirmation. I understand and agree that by electronically signing and submitting this Contract in this fashion I am affirming to the truth of the information contained therein. I understand that this Contract will not become binding on the State until it has been approved by the Department of Administration, the State Budget Agency, and the Office of the Attorney General, which approvals will be posted on the Active Contracts Database: xxxxx://xx.xxxx.xx.xxx/psp/pa91prd/EMPLOYEE/EMPL/h/?tab=PAPP_GUEST In Witness Whereofxxxxx://xx00.xxxx.xx.xxx/psp/pa91prd/EMPLOYEE/EMPL/h/?tab=PAPP_GUEST XXXXX XXXXXXXXX MENTAL HEALTH INC Indiana Family and Social Services Administration, the Contractor Division of Mental Health and the State haveAddiction Kuczora By: Title: Date: Xxxx X. Digitally signed by Xxxx X. Xxxxxxx DN: cn=Xxxx X. Xxxxxxx, through their duly authorized representativeso=Xxxxx- Xxxxxxxxx Mental Health, entered into this Contract. The partiesInc., having read and understood the foregoing terms of this Contractou=GBMH, do xxxxx=xxxxx@xxxxxxxxxxx.xxx, c=US Date: 2018.03.29 14:08:09 -04'00' By: Title: Date: Xxxxx X. Xxxxx Digitally signed by their respective signatures dated below agree to the terms thereof. [Contractor] Indiana Xxxxx X. Xxxxx Date: 2018.04.02 10:24:29 -04'00' Electronically Approved by: Department of Administration By: _________________________________ By: _______________________________ _____________________________________ ___________________________________ Name and Title, Printed Name and Title, Printed Date: _____________________________ Date: ___________________________ Indiana Office of Technology Indiana Department of Administration By: __________________________________ (for) Xxxxxxx Xxxxxxxxx, Commissioner Refer to Electronic Approval History found after the final page of the Executed Contract for details. Electronically Approved by: State Budget Agency By: ______________________________ (for) Xxxxxx XxxxxXxxxx X.Xxxxxx, Chief Information Officer Xxxxxx X. Xxxxx, Commissioner DateDirector Refer to Electronic Approval History found after the final page of the Executed Contract for details. Electronically Approved as to Form and Legality: _________________________________ Date: ______________________________ State Budget Office of the Attorney General By: ________________________________(for) By: _______________________________ (for) Xxxxx X. Xxxxxx, Director Xxxxxx X. Xxxx, Xx. ., Attorney General Date:________________________________ Date: _________________________________ This document is an exhibit Refer to Electronic Approval History found after the Professional Services agreement, and is deemed to be attached to and incorporated within final page of the Professional Services Agreement by reference. Any inconsistency, conflict, or ambiguity between this exhibit and the Professional Services agreement shall be resolved by giving precedence and effect to the Professional Services agreement. TBDExecuted Contract for details.

Agreement to Use Electronic Signatures. I agree, and it is my intent, to sign this Contract by accessing State of Indiana Supplier Portal using the secure password assigned to me and by electronically submitting this Contract to the State of Indiana. I understand that my signing and submitting this Contract in this fashion is the legal equivalent of having placed my handwritten signature on the submitted Contract and this affirmation. I understand and agree that by electronically signing and submitting this Contract in this fashion I am affirming to the truth of the information contained therein. I understand that this Contract will not become binding on the State until it has been approved by the Department of Administration, the State Budget Agency, and the Office of the Attorney General, which approvals will be posted on the Active Contracts Database: xxxxx://xx.xxxx.xx.xxx/psp/pa91prd/EMPLOYEE/EMPL/h/?tab=PAPP_GUEST xxxxx://xx.xxxx.xx.xxx/psp/guest/SUPPLIER/ERP/c/SOI_CUSTOM_APPS.SOI_PUBLIC_CNTRCTS.GBL? In Witness Whereof, the Contractor Grantee and the State have, through their duly authorized representatives, entered into this ContractGrant Agreement. The parties, having read and understood the foregoing terms of this ContractGrant Agreement, do by their respective signatures dated below agree to the terms thereof. [ContractorGrantee] [Indiana Department of Administration Agency] By: _________________________________ By: _______________________________ _____________________________________ ___________________________________ Name and Title, Printed Name and Title, Printed Date: _____________________________ Date: ___________________________ Indiana Office of Technology Indiana Department of Administration By: __________________________________ (for) By: ______________________________ (for) Xxxxxx Xxxxx, Chief Information Officer Xxxxxx X. Xxxxx, Commissioner Date: _________________________________ Date: ______________________________ State Budget Office of the Attorney General Agency By: ________________________________(for) By: _______________________________ (for) Xxxxx Xxxxxxx Xxxxxxxx, Commissioner Xxxxxxx X. XxxxxxXxxxxxx, Director Xxxxxx X. Xxxx, Xx. Attorney General Date:: ________________________________ Date: _________________________________ Office of the Attorney General ___________________________________(for) Xxxxxxxx X. Xxxxxx, Attorney General Date: _________________________________ Indiana Office of Technology By: __________________________________ (for) Xxxxx X. Xxxxxx, Chief Information Officer Date: _________________________________ Guidelines for filing the annual financial report: Filing an annual financial report called an Entity Annual Report (E-1) is required by IC 5-11-1-4. This document is done through Gateway which is an exhibit on-line electronic submission process. There is no filing fee to do this. This is in addition to the Professional Services agreement, and similarly titled Business Entity Report required by the Indiana Secretary of State. The E-1 electronical submission site is deemed found at xxxxx://xxxxxxx.xxxxxxxxx.xxx/login.aspx The Gateway User Guide is found at xxxxx://xxxxxxx.xxxxxxxxx.xxx/userguides/E1guide The State Board of Accounts may request documentation to be attached to and incorporated within support the Professional Services Agreement by reference. Any inconsistency, conflict, or ambiguity between this exhibit and information presented on the Professional Services agreement shall be resolved by giving precedence and effect to the Professional Services agreement. TBDE-1.

Agreement to Use Electronic Signatures. I agree, and it is my intent, to sign this Contract Amendment by accessing State of Indiana Supplier Portal using the secure password assigned to me and by electronically submitting this Contract Amendment to the State of Indiana. I understand that my signing and submitting this Contract Amendment in this fashion is the legal equivalent of having placed my handwritten signature on the submitted Contract Amendment and this affirmation. I understand and agree that by electronically signing and submitting this Contract Amendment in this fashion I am affirming to the truth of the information contained therein. I understand that this Contract Amendment will not become binding on the State until it has been approved by the Department of Administration, the State Budget Agency, and the Office of the Attorney General, which approvals will be posted on the Active Contracts Database: xxxxx://xx.xxxx.xx.xxx/psp/pa91prd/EMPLOYEE/EMPL/h/?tab=PAPP_GUEST In Witness Whereofxxxxx://xx.xxxx.xx.xxx/psp/guest/SUPPLIER/ERP/c/SOI_CUSTOM_APPS.SOI_PUBLIC_CNTRCT S.GBL By:\s1\ Title:\tP1r\ esident and CEO Date:\5d/11\ 3/2021 | 11:45 EDT By:\s2\ Title:\tM2e\ dicaid director Date:\5d/2\13/2021 | 12:06 EDT Electronically Approved by: Indiana Office of Technology By: (for) Xxxxx X. Xxxxxx, the Contractor and the State have, through their duly authorized representatives, entered into this Contract. The parties, having read and understood the foregoing terms of this Contract, do by their respective signatures dated below agree to the terms thereof. [Contractor] Indiana Chief Information Officer Electronically Approved by: Department of Administration By: _________________________________ By: _______________________________ _____________________________________ ___________________________________ Name and Title, Printed Name and Title, Printed Date: _____________________________ Date: ___________________________ Indiana Office of Technology Indiana Department of Administration By: __________________________________ (for) By: ______________________________ (for) Xxxxxx Xxxxx, Chief Information Officer Xxxxxx X. Xxxxx, Commissioner DateElectronically Approved by: _________________________________ Date: ______________________________ State Budget Agency By: (for) Xxxxxxx X. Xxxxxxx, Director Electronically Approved as to Form and Legality by: Office of the Attorney General By: ________________________________(for) By: _______________________________ (for) Xxxxx Xxxxxxxx X. Xxxxxx, Director Xxxxxx X. Xxxx, Xx. Attorney General Date:________________________________ Date: _________________________________ This document is an exhibit to the Professional Services agreement, 1.0 Background 12 2.0 Managed Care Entity- Contractor Requirements 14 2.1 State Licensure 14 2.2 National Committee for Quality Assurance (NCQA) Accreditation 14 2.3 Administrative and is deemed to be attached to and incorporated within the Professional Services Agreement by reference. Any inconsistency, conflict, or ambiguity between this exhibit and the Professional Services agreement shall be resolved by giving precedence and effect to the Professional Services agreement. TBDOrganizational Structure 14 2.4 Staffing 15 2.4.1 Key Staff 15 2.4.2 Staff Positions 21 2.4.3 Training 23 2.4.4 Debarred Individuals 24 2.5 FSSA/OMPP Meeting Requirements 25 2.6 Financial Stability 25 2.6.1 Solvency 25 2.6.2 Insurance 26 2.6.3 Reinsurance 26 2.6.4 Financial Accounting Requirements 27