Common use of Care Management Level of Service Clause in Contracts

Care Management Level of Service. The care management level of service is intended for members who need assistance with care coordination, making preventive care appointments or accessing care to address the members’ chronic health condition(s). Care management is provided to help guide the member with access to care for needed health or social services to address the member’s chronic health condition(s). Care management is a purposeful plan to reach members and impact their health and health care utilization, and to coordinate all services provided to members. Through care management, the Contractor assists members in improving their health outcomes. Members who are at risk for an acute or catastrophic episode in the future may be prioritized for complex case management services. In the interim care management services will be provided as a preventive measure. The Contractor will provide comprehensive coordination services that are tailored to the individual, rely on sound medical practices, and include Medicaid-covered services. All members identified for care management services will receive all of the benefits of disease management services in addition to the additional care management supports. Newly referred members and persons with newly diagnosed conditions, increasing health services or emergency services utilization, emergency room utilization at least three (3) standard deviations outside of the mean for the population group, evidence of pharmacy non-compliance for chronic conditions and identification of special health care needs shall be considered for care management. Care management services include direct consumer contacts to assist members with scheduling, location of specialists and specialty services, transportation needs, twenty-four (24)-hour nurse call line use, general preventive (e.g. mammography) and disease specific reminders, pharmacy refill reminders, tobacco cessation and education regarding use of primary care and emergency services. The Contractor must make every effort to contact members in care management by telephone. Materials should be delivered to the member in a manner in accordance with the member’s selection as outlined in Section 4.6.2, either through postal or electronic mail direct to the consumer. Educational materials and telephonic contacts may utilize web-based education materials inclusive of clinical practice guidelines. Materials shall be developed at the fifth grade reading level and in accordance with all member communication requirements outlined in Section 4.7.2, and should be sent to members no less than quarterly. The Contractor will be required to submit quarterly and annual data to document the number of persons receiving care management services, including the number of active and passive contacts made to the member. At the time they are enrolled, members may already be receiving case management services through the CMHCs. As such, the Contractor will work with the member and CMHC to determine where and how the member should receive care coordination or case management services. For example, the Contractor will work with the member and/or the member’s provider(s) to decide whether the member will receive care coordination and case management services from the Contractor, from the CMHC, or both. In all cases, the CMHC and Contractor should work closely together to ensure the member receives appropriate services that are not duplicated.

Care Management Level of Service. The care management level of service is intended for members who need assistance with care coordination, making preventive care appointments or accessing care to address the members’ chronic health condition(s). Care management is provided to help guide the member with access to care for needed health or social services to address the member’s chronic health condition(s). Care management is a purposeful plan to reach members and impact their health and health care utilization, and to coordinate all services provided to members. Through care management, the Contractor assists members in improving their health outcomes. Members who are at risk for an acute or catastrophic episode in the future may be prioritized for complex case management services. In the interim care management services will be provided as a preventive measure. The Contractor will provide comprehensive coordination services that are tailored to the individual, rely on sound medical practices, and include Medicaid-covered services. All members identified for care management services will receive all of the benefits of disease management services in addition to the additional care management supports. Newly referred members and persons with newly diagnosed conditions, increasing health services or emergency Emergency services utilization, emergency Emergency room utilization at least three (3) standard deviations outside of the mean for the population group, evidence of pharmacy non-non- compliance for chronic conditions and identification of conditions, members with special health care needs needs, individuals recently discharged from an Institution for Mental Disease (IMD), and individuals with conditions of interest that FSSA has identified to the Contractor shall be considered referred and contacted telephonically or in person by a care manager or community health worker for enrollment in care management. Care management services include including direct consumer contacts to assist members with scheduling, location of specialists and specialty services, transportation needs, twenty-four (24)-hour nurse call line use, general preventive (e.g. mammography) and disease specific reminders, pharmacy refill reminders, tobacco cessation and education regarding use of primary care and emergency Emergency services. The Contractor must make every effort to contact members in care management by telephone. The Contractor shall use community health workers to physically make contact when members cannot be reached via telephone within a predetermined, State approved timeframe. Should such attempts fail, the Contractor shall develop a plan for how to reach members (including outreach to providers, repeated physical outreach, etc.). Materials should be delivered to the member in a manner in accordance with the member’s selection as outlined in Section 4.6.2, either through postal or electronic mail means direct to the consumer. Educational materials and telephonic contacts may utilize web-based education materials inclusive of clinical practice guidelines. Materials shall be developed at the fifth fifth-grade reading level and in accordance with all member communication requirements outlined in Section 4.7.2, and should be sent to members no less than quarterly. The Contractor shall consider utilizing the services of community health workers, as appropriate, to outreach to and provide information to those members participating in care management. The Contractor will be required to submit quarterly and annual data to document the number of persons receiving care management services, including the number of active and passive contacts made to the member. At the time they are enrolled, members may already be receiving case management services through the CMHCs. As such, the Contractor will work with the member and CMHC to determine where and how the member should receive care coordination or case management services. For example, the Contractor will work with the member and/or the member’s provider(s) to decide whether the member will receive care coordination and case management services from the Contractor, from the CMHC, or both. In all cases, the CMHC and Contractor should work closely together to ensure the member receives appropriate services that are not duplicated.

Care Management Level of Service. The care management level of service is intended for members who need assistance with care coordination, making preventive care appointments or accessing care to address the members’ chronic health condition(s). Care management is provided to help guide the member with access to care for needed health or social services to address the member’s chronic health condition(s). Care management is a purposeful plan to reach members and impact their health and health care utilization, and to coordinate all services provided to members. Through care management, the Contractor assists members in improving their health outcomes. Members who are at risk for an acute or catastrophic episode in the future may be prioritized for complex case management services. In the interim care management services will be provided as a preventive measure. The Contractor will provide comprehensive coordination services that are tailored to the individual, rely on sound medical practices, and include Medicaid-Medicaid- covered services. All members identified for care management services will receive all of the benefits of disease management services in addition to the additional care management supports. Newly referred members and persons with newly diagnosed conditions, increasing health services or emergency Emergency services utilization, emergency Emergency room utilization at least three (3) standard deviations outside of the mean for the population group, evidence of pharmacy non-compliance for chronic conditions and identification of conditions, members with special health care needs needs, individuals recently discharged from an Institution for Mental Disease (IMD), individuals with conditions of interest that FSSA has identified to the Contractor and/or members with member request that indicate the need for real-time, proactive intervention shall be considered referred and contacted telephonically or in person by a care manager or community health worker for enrollment in care management. Care management services include including direct consumer contacts to assist members with scheduling, location of specialists and specialty services, transportation needs, twenty-four (24)-hour 24)- hour nurse call line use, general preventive (e.g. mammography) and disease specific reminders, pharmacy refill reminders, tobacco cessation and education regarding use of primary care and emergency Emergency services. The Contractor must make every effort to contact members in care management by telephone. The Contractor shall use community health workers to physically make contact when members cannot be reached via telephone within a predetermined, State approved timeframe. Should such attempts fail, the Contractor shall develop a plan for how to reach members (including outreach to providers, repeated physical outreach, etc.). Materials should be delivered to the member in a manner in accordance with the member’s selection as outlined in Section 4.6.24.3, either through postal or electronic mail means direct to the consumer. Educational materials and telephonic contacts may utilize web-based education materials inclusive of clinical practice guidelines. Materials shall be developed at the fifth fifth-grade reading level and in accordance with all member communication requirements outlined in Section 4.7.24.3, and should be sent to members no less than quarterly. The Contractor shall consider utilizing the services of community health workers, as appropriate, to outreach to and provide information to those members participating in care management. The Contractor will be required to submit quarterly and annual data to document the number of persons receiving care management services, including the number of active and passive contacts made to the member. At the time they are enrolled, members may already be receiving case management services through the CMHCs. As such, the Contractor will work with the member and CMHC to determine where and how the member should receive care coordination or case management services. For example, the Contractor will work with the member and/or the member’s provider(s) to decide whether the member will receive care coordination and case management services from the Contractor, from the CMHC, or both. In all cases, the CMHC and Contractor should work closely together to ensure the member receives appropriate services that are not duplicated.

Care Management Level of Service. The care management level of service is intended for members who need assistance with care coordination, making preventive care appointments or accessing care to address the members’ chronic health condition(s). Care management is provided to help guide the member with access to care for needed health or social services to address the member’s chronic health condition(s). Care management is a purposeful plan to reach members and impact their health and health care utilization, and to coordinate all services provided to members. Through care management, the Contractor assists members in improving their health outcomes. Members who are at risk for an acute or catastrophic episode in the future may be prioritized for complex case management services. In the interim care management services will be provided as a preventive measure. The Contractor will provide comprehensive coordination services that are tailored to the individual, rely on sound medical practices, and include Medicaid-covered services. All members identified for care management services will receive all of the benefits of disease management services in addition to the additional care management supports. Newly referred members and persons with newly diagnosed conditions, increasing health services or emergency Emergency services utilization, emergency Emergency room utilization at least three (3) standard deviations outside of the mean for the population group, evidence of pharmacy non-compliance for chronic conditions and identification of conditions, members with special health care needs needs, members designated as medically frail, individuals recently discharged from an Institution for Mental Disease (IMD), individuals with conditions of interest that FSSA has identified to the Contractor and/or members with member request that indicate the need for real-time, proactive intervention shall be considered referred and contacted telephonically or in person by a care manager or community health worker for enrollment in care management. Care management services include including direct consumer contacts to assist members with scheduling, location of specialists and specialty services, transportation needs, twenty-four (24)-hour nurse call line use, general preventive (e.g. e. g. mammography) and disease specific reminders, pharmacy refill reminders, tobacco cessation and education regarding use of primary care and emergency Emergency services. The Contractor must make every effort to contact members in care management by telephone. The Contractor shall use community health workers to physically make contact when members cannot be reached via telephone within a predetermined, State approved timeframe. Should such attempts fail, the Contractor shall develop a plan for how to reach members (including outreach to providers, repeated physical outreach, etc.). Materials should be delivered to the member in a manner in accordance with the member’s selection as outlined in Section 4.6.24.3, either through postal or electronic mail means direct to the consumer. Educational materials and telephonic contacts may utilize web-based education materials inclusive of clinical practice guidelinesand EXHIBIT 1. Materials shall be developed at the fifth grade reading level and in accordance with all member communication requirements outlined in Section 4.7.2, and should be sent to members no less than quarterly. The Contractor will be required to submit quarterly and annual data to document the number of persons receiving care management services, including the number of active and passive contacts made to the member. At the time they are enrolled, members may already be receiving case management services through the CMHCs. As such, the Contractor will work with the member and CMHC to determine where and how the member should receive care coordination or case management services. For example, the Contractor will work with the member and/or the member’s provider(s) to decide whether the member will receive care coordination and case management services from the Contractor, from the CMHC, or both. In all cases, the CMHC and Contractor should work closely together to ensure the member receives appropriate services that are not duplicated.A SCOPE OF WORK

Care Management Level of Service. The care management level of service is intended for members who need assistance with care coordination, making preventive care appointments or accessing care to address the members’ chronic health condition(s). Care management is provided to help guide the member with access to care for needed health or social services to address the member’s chronic health condition(s). Care management is a purposeful plan to reach members and impact their health and health care utilization, and to coordinate all services provided to members. Through care management, the Contractor assists members in improving their health outcomes. Members who are at risk for an acute or catastrophic episode in the future may be prioritized for complex case management services. In the interim care management services will be provided as a preventive measure. The Contractor will provide comprehensive coordination services that are tailored to the individual, rely on sound medical practices, and include Medicaid-covered services. All members identified for care management services will receive all of the benefits of disease management services in addition to the additional care management supports. Newly referred members and persons with newly diagnosed conditions, increasing health services or emergency Emergency services utilization, emergency Emergency room utilization at least three (3) standard deviations outside of the mean for the population group, evidence of pharmacy non-compliance for chronic conditions and identification of conditions, members with special health care needs needs, individuals recently discharged from an Institution for Mental Disease (IMD), individuals with conditions of interest that FSSA has identified to the Contractor and/or members with member request that indicate the need for real-time, proactive intervention shall be considered referred and contacted telephonically or in person by a care manager or community health worker for enrollment in care management. Care management services include including direct consumer contacts to assist members with scheduling, location of specialists and specialty services, transportation needs, twenty-four (24)-hour nurse call line use, general preventive (e.g. mammography) and disease specific reminders, pharmacy refill reminders, tobacco cessation and education regarding use of primary care and emergency Emergency services. The Contractor must make every effort to contact members in care management by telephone. The Contractor shall use community health workers to physically make contact when members cannot be reached via telephone within a predetermined, State approved timeframe. Should such attempts fail, the Contractor shall develop a plan for how to reach members (including outreach to providers, repeated physical outreach, etc.). Materials should be delivered to the member in a manner in accordance with the member’s selection as outlined in Section 4.6.24.3, either through postal or electronic mail means direct to the consumer. Educational materials and telephonic contacts may utilize web-based education materials inclusive of clinical practice guidelines. Materials shall be developed at the fifth fifth-grade reading level and in accordance with all member communication requirements outlined in Section 4.7.24.3, and should be sent to members no less than quarterly. The Contractor shall consider utilizing the services of community health workers, as appropriate, to outreach to and provide information to those members participating in care management. The Contractor will be required to submit quarterly and annual data to document the number of persons receiving care management services, including the number of active and passive contacts made to the member. At the time they are enrolled, members may already be receiving case management services through the CMHCs. As such, the Contractor will work with the member and CMHC to determine where and how the member should receive care coordination or case management services. For example, the Contractor will work with the member and/or the member’s provider(s) to decide whether the member will receive care coordination and case management services from the Contractor, from the CMHC, or both. In all cases, the CMHC and Contractor should work closely together to ensure the member receives appropriate services that are not duplicated.

Care Management Level of Service. The care management level of service is intended for members who need assistance with care coordination, making preventive care appointments or accessing care to address the members’ chronic health condition(s). Care management is provided to help guide the member with access to care for needed health or social services to address the member’s chronic health condition(s). Care management is a purposeful plan to reach members and impact their health and health care utilization, and to coordinate all services provided to members. Through care management, the Contractor assists members in improving their health outcomes. Members who are at risk for an acute or catastrophic episode in the future may be prioritized for complex case management services. In the interim care management services will be provided as a preventive measure. The Contractor will provide comprehensive coordination services that are tailored to the individual, rely on sound medical practices, and include Medicaid-covered services. All members identified for care management services will receive all of the benefits of disease management services in addition to the additional care management supports. Newly referred members and persons with newly diagnosed conditions, increasing health services or emergency Emergency services utilization, emergency Emergency room utilization at least three (3) standard deviations outside of the mean for the population group, evidence of pharmacy non-compliance for chronic conditions and identification of conditions, members with special health care needs needs, members designated as medically frail, individuals recently discharged from an Institution for Mental Disease (IMD), individuals with conditions of interest that FSSA has identified to the Contractor and/or members with member request that indicate the need for real-time, proactive intervention shall be considered referred and contacted telephonically or in person by a care manager or community health worker for enrollment in care management. Care management services include including direct consumer contacts to assist members with scheduling, location of specialists and specialty services, transportation needs, twenty-four (24)-hour nurse call line use, general preventive (e.g. mammography) and disease specific reminders, pharmacy refill reminders, tobacco cessation and education regarding use of primary care and emergency Emergency services. The Contractor must make every effort to contact members in care management by telephone. The Contractor shall use community health workers to physically make contact when members cannot be reached via telephone within a predetermined, State approved timeframe. Should such attempts fail, the Contractor shall develop a plan for how to reach members (including outreach to providers, repeated physical outreach, etc.). Materials should be delivered to the member in a manner in accordance with the member’s selection as outlined in Section 4.6.24.3, either through postal or electronic mail means direct to the consumer. Educational materials and telephonic contacts may utilize web-based education materials inclusive of clinical practice guidelines. Materials shall be developed at the fifth fifth-grade reading level and in accordance with all member communication requirements outlined in Section 4.7.24.3, and should be sent to members no less than quarterly. The Contractor shall consider utilizing the services of community health workers, as appropriate, to outreach to and provide information to those members participating in care management. The Contractor will be required to submit quarterly and annual data to document the number of persons receiving care management services, including the number of active and passive contacts made to the member. At the time they are enrolled, members may already be receiving case management services through the CMHCs. As such, the Contractor will work with the member and CMHC to determine where and how the member should receive care coordination or case management services. For example, the Contractor will work with the member and/or the member’s provider(s) to decide whether the member will receive care coordination and case management services from the Contractor, from the CMHC, or both. In all cases, the CMHC and Contractor should work closely together to ensure the member receives appropriate services that are not duplicated.

Care Management Level of Service. The care management level of service is intended for members who need assistance with care coordination, making preventive care appointments or accessing care to address the members’ chronic health condition(s). Care management is provided to help guide the member with access to care for needed health or social services to address the member’s chronic health condition(s). Care management is a purposeful plan to reach members and impact their health and health care utilization, and to coordinate all services provided to members. Through care management, the Contractor assists members in improving their health outcomes. Members who are at risk for an acute or catastrophic episode in the future may be prioritized for complex case management services. In the interim care management EXHIBIT 1.A. SCOPE OF WORK services will be provided as a preventive measure. The Contractor will provide comprehensive coordination services that are tailored to the individual, rely on sound medical practices, and include Medicaid-covered services. All members identified for care management services will receive all of the benefits of disease management services in addition to the additional care management supports. Newly referred members and persons with newly diagnosed conditions, increasing health services or emergency Emergency services utilization, emergency Emergency room utilization at least three (3) standard deviations outside of the mean for the population group, evidence of pharmacy non-compliance for chronic conditions and identification of conditions, members with special health care needs needs, individuals recently discharged from an Institution for Mental Disease (IMD), and individuals with conditions of interest that FSSA has identified to the Contractor shall be considered referred and contacted telephonically or in person by a care manager or community health worker for enrollment in care management. Care management services include including direct consumer contacts to assist members with scheduling, location of specialists and specialty services, transportation needs, twenty-four (24)-hour nurse call line use, general preventive (e.g. mammography) and disease specific reminders, pharmacy refill reminders, tobacco cessation and education regarding use of primary care and emergency Emergency services. The Contractor must make every effort to contact members in care management by telephone. The Contractor shall use community health workers to physically make contact when members cannot be reached via telephone within a predetermined, State approved timeframe. Should such attempts fail, the Contractor shall develop a plan for how to reach members (including outreach to providers, repeated physical outreach, etc.). Materials should be delivered to the member in a manner in accordance with the member’s selection as outlined in Section 4.6.2, either through postal or electronic mail means direct to the consumer. Educational materials and telephonic contacts may utilize web-web- based education materials inclusive of clinical practice guidelines. Materials shall be developed at the fifth fifth-grade reading level and in accordance with all member communication requirements outlined in Section 4.7.2, and should be sent to members no less than quarterly. The Contractor shall consider utilizing the services of community health workers, as appropriate, to outreach to and provide information to those members participating in care management. The Contractor will be required to submit quarterly and annual data to document the number of persons receiving care management services, including the number of active and passive contacts made to the member. At the time they are enrolled, members may already be receiving case management services through the CMHCs. As such, the Contractor will work with the member and CMHC to determine where and how the member should receive care coordination or case management services. For example, the Contractor will work with the member and/or the member’s provider(s) to decide whether the member will receive care coordination and case management services from the Contractor, from the CMHC, or both. In all cases, the CMHC and Contractor should work closely together to ensure the member receives appropriate services that are not duplicated.

Care Management Level of Service. The care management level of service is intended for members who need assistance with care coordination, making preventive care appointments or accessing care to address the members’ chronic health condition(s). Care management is provided to help guide the member with access to care for needed health or social services to address the member’s chronic health condition(s). Care management is a purposeful plan to reach members and impact their health and health care utilization, and to coordinate all services provided to members. Through care management, the Contractor assists members in improving their health outcomes. Members who are at risk for an acute or catastrophic episode in the future may be prioritized for complex case management services. In the interim care management services will be provided as a preventive measure. The Contractor will provide comprehensive coordination services that are tailored to the individual, rely on sound medical practices, and include Medicaid-covered services. All members identified for care management services will receive all of the benefits of disease management services in addition to the additional care management supports. Newly referred members and persons with newly diagnosed conditions, increasing health services or emergency services utilization, emergency room utilization at least three (3) standard deviations outside of the mean for the population group, evidence of pharmacy non-compliance for chronic conditions and identification of special health care needs shall be considered for care management. Care management services include direct consumer contacts to assist members with scheduling, location of specialists and specialty services, transportation needs, twenty-four (24)-hour nurse call line use, general preventive (e.g. mammography) and disease specific reminders, pharmacy refill reminders, tobacco cessation and education regarding use of primary care and emergency services. The Contractor must make every effort to contact members in care management by telephone. Materials should be delivered to the member in a manner in accordance with the member’s selection as outlined in Section 4.6.2, either through postal or electronic mail direct to the consumer. Educational materials and telephonic contacts may utilize web-based education materials inclusive of clinical practice guidelines. Materials shall be developed at the fifth grade reading level and in accordance with all member communication requirements outlined in Section 4.7.2, and should be sent to members no less than quarterly. The Contractor will be required to submit quarterly and annual EXHIBIT 1.M SCOPE OF WORK data to document the number of persons receiving care management services, including the number of active and passive contacts made to the member. At the time they are enrolled, members may already be receiving case management services through the CMHCs. As such, the Contractor will work with the member and CMHC to determine where and how the member should receive care coordination or case management services. For example, the Contractor will work with the member and/or the member’s provider(s) to decide whether the member will receive care coordination and case management services from the Contractor, from the CMHC, or both. In all cases, the CMHC and Contractor should work closely together to ensure the member receives appropriate services that are not duplicated.

Care Management Level of Service. The care management level of service is intended for members who need assistance with care coordination, making preventive care appointments or accessing care to address the members’ chronic health condition(s). Care management is provided to help guide the member with access to care for needed health or social services to address the member’s chronic health condition(s). Care management is a purposeful plan to reach members and impact their health and health care utilization, and to coordinate all services provided to members. Through care management, the Contractor assists members in improving their health outcomes. Members who are at risk for an acute or catastrophic episode in the future may be prioritized for complex case management services. In the interim care management services servic es will be provided as a preventive measure. The Contractor will provide comprehensive coordination services that are tailored to the individual, rely on sound medical practices, and include Medicaid-covered services. All members identified for care management services will receive all of the benefits of disease management services in addition to the additional care management supports. Newly referred members and persons with newly diagnosed conditions, increasing health services or emergency Emergency services utilization, emergency Emergency room utilization at least three (3) standard deviations outside of the mean for the population group, evidence of pharmacy non-non- compliance for chronic conditions and identification of conditions, members with special health care needs needs, individuals recently discharged from an Institution for Mental Disease (IMD), individuals with conditions of interest that FSSA has identified to the Contractor and/or members with member request that indicate the need for real-time, proactive intervention shall be considered referred and contacted telephonically or in person by a care manager or community health worker for enrollment in care management. Care management services include including direct consumer contacts to assist members with scheduling, location of specialists and specialty services, transportation needs, twenty-four (24)-hour nurse call line use, general preventive (e.g. mammography) and disease specific reminders, pharmacy refill reminders, tobacco cessation and education regarding use of primary care and emergency Emergency services. The Contractor must make every effort to contact members in care management by telephone. The Contractor shall use community health workers to physically make contact when members cannot be reached via telephone within a predetermined, State approved timeframe. Should such attempts fail, the Contractor shall develop a plan for how to reach members (including outreach to providers, repeated physical outreach, etc.). Materials should be delivered to the member in a manner in accordance with the member’s selection as outlined in Section 4.6.24.3, either through postal or electronic mail means direct to the consumer. Educational materials and telephonic contacts may utilize web-based education materials inclusive of clinical practice guidelines. Materials shall be developed at the fifth fifth-grade reading level and in accordance with all member communication requirements outlined in Section 4.7.24.3, and should be sent to members no less than quarterly. The Contractor shall consider utilizing the services of community health workers, as appropriate, to outreach to and provide information to those members participating in care management. The Contractor will be required to submit quarterly and annual data to document the number of persons receiving care management services, including the number of active and passive contacts made to the member. At the time they are enrolled, members may already be receiving case management services through the CMHCs. As such, the Contractor will work with the member and CMHC to determine where and how the member should receive care coordination or case management services. For example, the Contractor will work with the member and/or the member’s provider(s) to decide whether the member will receive care coordination and case management services from the Contractor, from the CMHC, or both. In all cases, the CMHC and Contractor should work closely together to ensure the member receives appropriate services that are not duplicated.

Care Management Level of Service. The care management level of service is intended for members who need assistance with care coordination, making preventive care appointments or accessing care to address the members’ chronic health condition(s). Care management is provided to help guide the member with access to care for needed health or social services to address the member’s chronic health condition(s). Care management is a purposeful plan to reach members and impact their health and health care utilization, and to coordinate all services provided to members. Through care management, the Contractor assists members in improving their health outcomes. Members who are at risk for an acute or catastrophic episode in the future may be prioritized for complex case management services. In the interim care management services will be provided as a preventive measure. The Contractor will provide comprehensive coordination services that are tailored to the individual, rely on sound medical practices, and include Medicaid-covered services. All members identified for care management services will receive all of the benefits of disease management services in addition to the additional care management supports. Newly referred members and persons with newly diagnosed conditions, increasing health services or emergency Emergency services utilization, emergency Emergency room utilization at least three (3) standard deviations outside of the mean for the population group, evidence of pharmacy non-compliance for chronic conditions and identification of conditions, members with special health care needs needs, members designated as medically frail, individuals recently discharged from an Institution for Mental Disease (IMD), individuals with conditions of interest that FSSA has identified to the Contractor and/or members with member request that indicate the need for real-time, proactive intervention shall be considered referred and contacted telephonically or in person by a care manager or community health worker for enrollment in care management. Care management services include including direct consumer contacts to assist members with scheduling, location of specialists and specialty services, transportation needs, twenty-four (24)-hour nurse call line use, general preventive (e.g. e. g. mammography) and disease specific reminders, pharmacy refill reminders, tobacco cessation and education regarding use of primary care and emergency Emergency services. The Contractor must make every effort to contact members in care management by telephone. The Contractor shall use community health workers to physically make contact when members cannot be reached via telephone within a predetermined, State approved timeframe. Should such attempts fail, the Contractor shall develop a plan for how to reach members (including outreach to providers, repeated physical outreach, etc.). Materials should be delivered to the member in a manner in accordance with the member’s selection as outlined in Section 4.6.24.3, either through postal or electronic mail means direct to the consumer. Educational materials and telephonic contacts may utilize web-based education materials inclusive of clinical practice guidelines. Materials shall be developed at the fifth grade reading level and in accordance with all member communication requirements outlined in Section 4.7.2, and should be sent to members no less than quarterly. The Contractor will be required to submit quarterly and annual data to document the number of persons receiving care management services, including the number of active and passive contacts made to the member. At the time they are enrolled, members may already be receiving case management services through the CMHCs. As such, the Contractor will work with the member and CMHC to determine where and how the member should receive care coordination or case management services. For example, the Contractor will work with the member and/or the member’s provider(s) to decide whether the member will receive care coordination and case management services from the Contractor, from the CMHC, or both. In all cases, the CMHC and Contractor should work closely together to ensure the member receives appropriate services that are not duplicated.and

Care Management Level of Service. The care management level of service is intended for members who need assistance with care coordination, making preventive care appointments or accessing care to address the members’ chronic health condition(s). Care management is provided to help guide the member with access to care for needed health or social services to address the member’s chronic health condition(s). Care management is a purposeful plan to reach members and impact their health and health care utilization, and to coordinate all services provided to members. Through care management, the Contractor assists members in improving their health outcomes. Members who are at risk for an acute or catastrophic episode in the future may be prioritized for complex case management services. In the interim care management services will be provided as a preventive measure. The Contractor will provide comprehensive coordination services that are tailored to the individual, rely on sound medical practices, and include Medicaid-covered services. All members identified for care management services will receive all of the benefits of disease management services in addition to the additional care management supports. Newly referred members and persons with newly diagnosed conditions, increasing health services or emergency Emergency services utilization, emergency Emergency room utilization at least three (3) standard deviations outside of the mean for the population group, evidence of pharmacy non-compliance for chronic conditions and identification of conditions, members with special health care needs needs, individuals recently discharged from an Institution for Mental Disease (IMD), individuals with conditions of interest that FSSA has identified to the Contractor and/or members with member request that indicate the need for real-time, proactive intervention shall be considered referred and contacted telephonically or in person by a care manager or community health worker for enrollment in care management. Care management services include including direct consumer contacts to assist members with scheduling, location of specialists and specialty services, transportation needs, twenty-four (24)-hour 24)- hour nurse call line use, general preventive (e.g. mammography) and disease specific reminders, pharmacy refill reminders, tobacco cessation and education regarding use of primary care and emergency Emergency services. The Contractor must make every effort to contact members in care management by telephone. The Contractor shall use community health workers to physically make contact when members cannot be reached via telephone within a predetermined, State approved timeframe. Should such attempts fail, the Contractor shall develop a plan for how to reach members (including outreach to providers, repeated physical outreach, etc.). Materials should be delivered to the member in a manner in accordance with the member’s selection as outlined in Section 4.6.24.3, either through postal or electronic mail means direct to the consumer. Educational materials and telephonic contacts may utilize web-based education materials inclusive of clinical practice guidelines. Materials shall be developed at the fifth fifth-grade reading level and in accordance with all member communication requirements outlined in Section 4.7.24.3, and should be sent to members no less than quarterly. The Contractor shall consider utilizing the services of community health workers, as appropriate, to outreach to and provide information to those members participating in care management. The Contractor will be required to submit quarterly and annual data to document the number of persons receiving care management services, including the number of active and passive contacts made to the member. At the time they are enrolled, members may already be receiving case management services through the CMHCs. As such, the Contractor will work with the member and CMHC to determine where and how the member should receive care coordination or case management services. For example, the Contractor will work with the member and/or the member’s provider(s) to decide whether the member will receive care coordination and case management services from the Contractor, from the CMHC, or both. In all cases, the CMHC and Contractor should work closely together to ensure the member receives appropriate services that are not duplicated. Complex case management with member focus involves the active coordination of care and services with the member and between providers while navigating the extensive systems and resources required for the member. It includes comprehensive assessment, determination of available benefits, development and implementation of a complex case management plan directed at the member’s chronic health conditions. Complex case management targets members with two (2) or more disease states who need assistance with care coordination, making preventive care appointments or accessing care to address the members’ chronic health condition or members who have had an inpatient hospital stay in the last ninety (90) days or members with high dollar claims of over fifty thousand $50,000 thousand dollars (>$50,000) in six (6) months. The focus is on working with the providers to meet the needs of the individual through communication with the member, PMP (if applicable), other providers, and the member’s natural support system. The member’s active involvement will help members gain optimum health or improved functional capability, in the right setting and in a cost-effective manner. At a minimum, the Contractor must provide complex case management services for members discharged from an inpatient psychiatric or substance abuse hospitalization, for no fewer than ninety (90) calendar days following that inpatient hospitalization. The Contractor must also provide complex case management services for any member at risk for inpatient psychiatric, drug overdose, or substance abuse re-hospitalization. Care managers must contact members during an inpatient hospitalization, or as soon as practicable upon receiving notification of a member’s inpatient behavioral health hospitalization. The care manager must work with the hospital discharge planner, behavioral health provider case manager and/or natural supports (i.e. family) to ensure that an outpatient follow-up appointment is scheduled to occur no later than seven (7) calendar days following the inpatient behavioral health hospitalization discharge. The Contractor must ensure that lack of transportation is not a barrier to the member attending the appointment. Complex case management includes all of the services and benefits from disease management and care management. The Contractor shall use community health workers, to physically make contact when members cannot be reached via telephone within a predetermined, State approved timeframe. Should such attempts fail, the Contractor shall develop a plan for how to reach members (including outreach to providers, repeated physical outreach, etc.). All members in complex case management with member focus must receive materials no less than monthly. Avoidance of unnecessary Emergency department and inpatient hospitalizations and increased use of preventive health care are goals for complex case management.

Care Management Level of Service. The care management level of service is intended for members who need assistance with care coordination, making preventive care appointments or accessing care to address the members’ chronic health condition(s). Care management is provided to help guide the member with access to care for needed health or social services to address the member’s chronic health condition(s). Care management is a purposeful plan to reach members and impact their health and health care utilization, and to coordinate all services provided to members. Through care management, the Contractor assists members in improving their health outcomes. Members who are at risk for an acute or catastrophic episode in the future may be prioritized for complex case management services. In the interim care management services will be provided as a preventive measure. The Contractor will provide comprehensive coordination services that are tailored to the individual, rely on sound medical practices, and include Medicaid-covered services. All members identified for care management services will receive all of the benefits of disease management services in addition to the additional care management supports. Newly referred members and persons with newly diagnosed conditions, increasing health services or emergency Emergency services utilization, emergency Emergency room utilization at least three (3) standard deviations outside of the mean for the population group, evidence of pharmacy non-compliance for chronic conditions and identification of conditions, members with special health care needs needs, members designated as medically frail, individuals recently discharged from an Institution for Mental Disease (IMD), individuals with conditions of interest that FSSA has identified to the Contractor and/or members with member request that indicate the need for real-time, proactive intervention shall be considered referred and contacted telephonically or in person by a care manager or community health worker for enrollment in care management. Care management services include including direct consumer contacts to assist members with scheduling, location of specialists and specialty services, transportation needs, twenty-four (24)-hour nurse call line use, general preventive (e.g. mammography) and disease specific reminders, pharmacy refill reminders, tobacco cessation and education regarding use of primary care and emergency Emergency services. The Contractor must make every effort to contact members in care management by telephone. The Contractor shall use community health workers to physically make contact when members cannot be reached via telephone within a predetermined, State approved timeframe. Should such attempts fail, the Contractor shall develop a plan for how to reach members (including outreach to providers, repeated physical outreach, etc.). Materials should be delivered to the member in a manner in accordance with the member’s selection as outlined in Section 4.6.24.3, either through postal or electronic mail means direct to the consumer. Educational materials and telephonic contacts may utilize web-based education materials inclusive of clinical practice guidelines. Materials shall be developed at the fifth fifth-grade reading level and in accordance with all member communication requirements outlined in Section 4.7.24.3, and should be sent to members no less than quarterly. The Contractor shall consider utilizing the services of community health workers, as appropriate, to outreach to and provide information to those members participating in care management. The Contractor will be required to submit quarterly and annual data to document the number of persons receiving care management services, including the number of active and passive contacts made to the member. At the time they are enrolled, members may already be receiving case management services through the CMHCs. As such, the Contractor will work with the member and CMHC to determine where and how the member should receive care coordination or case management services. For example, the t he Contractor will work with the member and/or the member’s provider(s) to decide whether the member will receive care coordination and case management services from the Contractor, from the CMHC, or both. In all cases, the CMHC and Contractor should work closely together to ensure the member receives appropriate services that are not duplicated.

Care Management Level of Service. The care management level of service is intended for members who need assistance with care coordination, making preventive care appointments or accessing care to address the members’ chronic health condition(s). Care management is provided to help guide the member with access to care for needed health or social services to address the member’s chronic health condition(s). Care management is a purposeful plan to reach members and impact their health and health care utilization, and to coordinate all services provided to membersmembers . Through care management, the Contractor assists members in improving their health outcomes. Members who are at risk for an acute or catastrophic episode in the future may be prioritized for complex case management services. In the interim care management services will be provided as a preventive measure. The Contractor will provide comprehensive coordination services that are tailored to the individual, rely on sound medical practices, and include Medicaid-covered services. All members identified for care management services will receive all of the benefits of disease management services in addition to the additional care management supports. Newly referred members and persons with newly diagnosed conditions, increasing health services or emergency Emergency services utilization, emergency Emergency room utilization at least three (3) standard deviations outside of the mean for the population group, evidence of pharmacy non-compliance for chronic conditions and identification of conditions, members with special health care needs needs, individuals recently discharged from an Institution for Mental Disease (IMD), individuals with conditions of interest that FSSA has identified to the Contractor and/or members with member request that indicate the need for real-time, proactive intervention shall be considered referred and contacted telephonically or in person by a care manager or community health worker for enrollment in care management. Care management services include including direct consumer contacts to assist members with scheduling, location of specialists and specialty services, transportation needs, twenty-four (24)-hour nurse call line use, general preventive (e.g. mammography) and disease specific reminders, pharmacy refill reminders, tobacco cessation and education regarding use of primary care and emergency Emergency services. The Contractor must make every effort to contact members in care management by telephone. The Contractor shall use community health workers to physically make contact when members cannot be reached via telephone within a predetermined, State approved timeframe. Should such attempts fail, the Contractor shall develop a plan for how to reach members (including outreach to providers, repeated physical outreach, etc.). Materials should be delivered to the member in a manner in accordance with the member’s selection as outlined in Section 4.6.24.3, either through postal or electronic mail means direct to the consumer. Educational materials and telephonic contacts may utilize web-based education materials inclusive of clinical practice guidelines. Materials shall be developed at the fifth fifth-grade reading level and in accordance with all member communication requirements outlined in Section 4.7.24.3, and should be sent to members no less than quarterly. The Contractor shall consider utilizing the services of community health workers, as appropriate, to outreach to and provide information to those members participating in care management. The Contractor will be required to submit quarterly and annual data to document the number of persons receiving care management services, including the number of active and passive contacts made to the member. At the time they are enrolled, members may already be receiving case management services through the CMHCs. As such, the Contractor will work with the member and CMHC to determine where and how the member should receive care coordination or case management services. For example, the Contractor will work with the member and/or the member’s provider(s) to decide whether the member will receive care coordination and case management services from the Contractor, from the CMHC, or both. In all cases, the CMHC and Contractor should work closely together to ensure the member receives appropriate services that are not duplicated.

Care Management Level of Service. The care management level of service is intended for members who need assistance with care coordination, making preventive care appointments or accessing care to address the members’ chronic health condition(s). Care management is provided to help guide the member with access to care for needed health or social services to address the member’s chronic health condition(s). Care management is a purposeful plan to reach members and impact their health and health care utilization, and to coordinate all services provided to members. Through care management, the Contractor assists members in improving their health outcomes. Members who are at risk for an acute or catastrophic episode in the future may be prioritized for complex case management services. In the interim care management services will be provided as a preventive measure. The Contractor will provide comprehensive coordination services that are tailored to the individual, rely on sound medical practices, and include Medicaid-covered services. All members identified for care management services will receive all of the benefits of disease management services in addition to the additional care management supports. Newly referred members and persons with newly diagnosed conditions, increasing health services or emergency Emergency services utilization, emergency Emergency room utilization at least three (3) standard deviations outside of the mean for the population group, evidence of pharmacy non-compliance for chronic conditions and identification of conditions, members with special health care needs needs, members designated as medically frail, individuals recently discharged from an Institution for Mental Disease (IMD), individuals with conditions of interest that FSSA has identified to the Contractor and/or members with member request that indicate the need for real-time, proactive intervention shall be considered referred and contacted telephonically or in person by a care manager or community health worker for enrollment in care management. Care management services include including direct consumer contacts to assist members with scheduling, location of specialists and specialty services, transportation needs, twenty-four (24)-hour nurse call line use, general preventive (e.g. mammography) and disease specific reminders, pharmacy refill reminders, tobacco cessation and education regarding use of primary care and emergency Emergency services. The Contractor must make every effort to contact members in care management by telephone. The Contractor shall use community health workers to physically make contact when members cannot be reached via telephone within a predetermined, State approved timeframe. Should such attempts fail, the Contractor shall develop a plan for how to reach members (including outreach to providers, repeated physical outreach, etc.). Materials should be delivered to the member in a manner in accordance with the member’s selection as outlined in Section 4.6.24.3, either through postal or electronic mail means direct to the consumer. Educational materials and telephonic contacts may utilize web-based education materials inclusive of clinical practice guidelines. Materials shall be developed at the fifth grade reading level and in accordance with all member communication requirements outlined in Section 4.7.2, and should be sent to members no less than quarterly. The Contractor will be required to submit quarterly and annual data to document the number of persons receiving care management services, including the number of active and passive contacts made to the member. At the time they are enrolled, members may already be receiving case management services through the CMHCs. As such, the Contractor will work with the member and CMHC to determine where and how the member should receive care coordination or case management services. For example, the Contractor will work with the member and/or the member’s provider(s) to decide whether the member will receive care coordination and case management services from the Contractor, from the CMHC, or both. In all cases, the CMHC and Contractor should work closely together to ensure the member receives appropriate services that are not duplicated.

Care Management Level of Service. The care management level of service is intended for members who need assistance with care coordination, making preventive care appointments or accessing care to address the members’ chronic health condition(s). Care management is provided to help guide the member with access to care for needed health or social services to address the member’s chronic health condition(s). Care management is a purposeful plan to reach members and impact their health and health care utilization, and to coordinate all services provided to members. Through care management, the Contractor assists members in improving their health outcomes. Members who are at risk for an acute or catastrophic episode in the future may be prioritized for complex case management services. In the interim care management services will be provided as a preventive measure. The Contractor will provide comprehensive coordination services that are tailored to the individual, rely on sound medical practices, and include Medicaid-covered services. All members identified for EXHIBIT 1.M SCOPE OF WORK care management services will receive all of the benefits of disease management services in addition to the additional care management supports. Newly referred members and persons with newly diagnosed conditions, increasing health services or emergency services utilization, emergency room utilization at least three (3) standard deviations outside of the mean for the population group, evidence of pharmacy non-compliance for chronic conditions and identification of special health care needs shall be considered for care management. Care management services include direct consumer contacts to assist members with scheduling, location of specialists and specialty services, transportation needs, twenty-four (24)-hour nurse call line use, general preventive (e.g. mammography) and disease specific reminders, pharmacy refill reminders, tobacco cessation and education regarding use of primary care and emergency services. The Contractor must make every effort to contact members in care management by telephone. Materials should be delivered to the member in a manner in accordance with the member’s selection as outlined in Section 4.6.2, either through postal or electronic mail direct to the consumer. Educational materials and telephonic contacts may utilize web-based education materials inclusive of clinical practice guidelines. Materials shall be developed at the fifth grade reading level and in accordance with all member communication requirements outlined in Section 4.7.2, and should be sent to members no less than quarterly. The Contractor will be required to submit quarterly and annual data to document the number of persons receiving care management services, including the number of active and passive contacts made to the member. At the time they are enrolled, members may already be receiving case management services through the CMHCs. As such, the Contractor will work with the member and CMHC to determine where and how the member should receive care coordination or case management services. For example, the Contractor will work with the member and/or the member’s provider(s) to decide whether the member will receive care coordination and case management services from the Contractor, from the CMHC, or both. In all cases, the CMHC and Contractor should work closely together to ensure the member receives appropriate services that are not duplicated.