Common use of Coordination of Care Clause in Contracts

Coordination of Care. The PH-MCO must coordinate care for its Members. The PH-MCO must provide for seamless and continuous coordination of care across a continuum of services for the Member with a focus on improving health care outcomes. The continuum of services may include the In-Plan comprehensive service package, out-of-plan services, and non-MA covered services provided by other community resources such as: • Nursing Facility Care • Intermediate Care Facility for the Intellectually Disabled/Other Related Conditions • Residential Treatment Facility • Acute Psychiatric Facilities • Extended and Extended Acute Psychiatric Facilities • Non-Hospital Residential Detoxification, Rehabilitation, and Half- Way House Facilities for Drug/Alcohol Dependence/ Addiction • Opioid Use Disorder Centers of Excellence • Aging Well PA/Level of Care Assessment and Pre-admission Screening Requirements • Juvenile Detention Centers • Children in Substitute Care Transition • Adoption Assistance for Children and Adolescents • Services to Dual Eligibles Under the Age of Twenty-one • Transitional Care Homes • Medical Xxxxxx Care Services • Early Intervention Services (note the PH-MCO must refer for Early Intervention Services any of its Members who are children from birth to age three (3) who are living in residential facilities. “Children living in residential facilities” describes children who are in a 24-hour living setting in which care is provided for one or more children.) • The OBRA waiver, a home-and-community-based waiver program for individuals who have a severe developmental physical disability requiring an Intermediate Care Facility/Other Related Conditions (ICF/ORC) level of care • Intellectual Disabilities Services (note the PH-MCO is responsible to ensure a family with a child who has or is at risk of a developmental delay is referred to the County Intellectual Disabilities office for a determination of eligibility for home and community-based services, including children living in residential facilities as described above.) • Home-and Community-Based Waiver for Persons with Intellectual Disabilities • Children in Residential Facilities • Home-and Community-Based Waiver for Persons with Autism The PH-MCO must provide the necessary related services for Members in facilities as described in Exhibit O, Description of Facilities and Related Services. Out-of-Plan Services are described in Exhibit P, Out-of-Plan Services. Recipient coverage rules are outlined in Exhibit BB, PH-MCO Recipient Coverage Document.

Coordination of Care. The PH-MCO must coordinate is responsible for coordination of care for its Membersindividuals enrolled in HealthChoices. The PH-MCO must provide for ensure seamless and continuous coordination of care across a continuum of services for the individual Member with a focus on improving health care outcomes. The continuum of services may include the Inin-Plan plan comprehensive service benefits package, out-of-plan servicesbenefits, and non-MA covered services provided by other community resources such as: •  Nursing Facility Care •  Intermediate Care Facility for the Intellectually DisabledMentally Retarded/Other Related Conditions • (ICF/MR/ORC)  Residential Treatment Facility • (RTF)  Acute Psychiatric Facilities •  Extended and and/or Extended Acute Psychiatric Facilities •  Non-Hospital Residential Detoxification, Rehabilitation, and Half- Half-Way House Facilities for Drug/Alcohol Dependence/ Addiction • Opioid Use Disorder Centers of Excellence •  Area Agencies on Aging Well PA/Level of Care (AAA)/OPTIONS Assessment and Pre-Pre- admission Screening Requirements •  Pennsylvania Department of Aging (PDA) Waiver  Juvenile Detention Centers • (JDCs)  Children in Substitute Care Transition •  Adoption Assistance for Children and Children/Adolescents •  Services to Dual Eligibles Under the Age of Twenty-one •  Transitional Care Homes •  Medical Xxxxxx Care Services •  Early Intervention Services (note that the PH-MCO must refer for Early Intervention Services any of its Members members who are children from birth to age three (3) who are living in residential facilities. “Children living in residential facilities” describes children who are in a 24-hour living setting in which care is provided for one or more children.) • The OBRA waiver, a home-and-community-based waiver program  Home and Community Based Waiver Program for individuals who have a severe developmental physical disability requiring an Intermediate Care Facility/Nursing Facility Residents with Other Related Conditions (ICFOSP/ORCOBRA Waiver) level of care • Intellectual Disabilities  Home and Community Based Waiver Program for Nursing Facility Applicants with Other Related Conditions (OSP/Independence Waiver)  Home and Community Based Waiver for Attendant Care Services (note the PH-MCO is responsible to ensure a family with a child who has or is at risk of a developmental delay is referred to the County Intellectual Disabilities office for a determination of eligibility for home OSP/AC Waiver)  Home and community-based services, including children living in residential facilities as described above.) • Home-and Community-Community Based Waiver for Persons with Intellectual Disabilities • Children in Residential Facilities • Home-and Community-Based Mental Retardation  COMMCARE Waiver for Persons with Autism a Primary Diagnosis of Traumatic Brain Injury The PH-MCO must provide the necessary related HealthChoices Program requirements covering special services for Members in facilities as described are outlined in Exhibit OO of this Agreement, Description of Facilities and Related Services. Out-of-Plan Services are described in Exhibit PP of this Agreement, Out-of-Plan Services. Recipient coverage rules are outlined in Exhibit BB, PH-MCO Recipient Coverage Document.

Coordination of Care. The PH-MCO must coordinate care for its Members. The PH-MCO must provide for seamless and continuous coordination of care across a continuum of services for the Member with a focus on improving health care outcomes. The continuum of services may include the In-Plan comprehensive service package, out-of-plan services, and non-MA covered services provided by other community resources such as: • Nursing Facility Care • Intermediate Care Facility for the Intellectually Disabled/Other Related Conditions • Residential Treatment Facility • Acute Psychiatric Facilities • Extended and Extended Acute Psychiatric Facilities • Non-Hospital Residential Detoxification, Rehabilitation, and Half- Way House Facilities for Drug/Alcohol Dependence/ Addiction • Opioid Use Disorder Centers of Excellence • Aging Well PA/Level of Care Assessment and Pre-admission Screening Requirements • Juvenile Detention Centers • Children in Substitute Care Transition • Adoption Assistance for Children and Adolescents • Services to Dual Eligibles Under the Age of Twenty-one • Transitional Care Homes • Medical Xxxxxx Care Services • Early Intervention Services (note the PH-MCO must refer for Early Intervention Services any of its Members who are children from birth to age three (3) who are living in residential facilities. “Children living in residential facilities” describes children who are in a 24-hour living setting in which care is provided for one or more children.) • The OBRA waiver, a home-and-community-based waiver program for individuals who have a severe developmental physical disability requiring an Intermediate Care Facility/Other Related Conditions (ICF/ORC) level of care • Intellectual Disabilities Services (note the PH-MCO is responsible to ensure a family with a child who has or is at risk of a developmental delay is referred to the County Intellectual Disabilities office for a determination of eligibility for home and community-based services, including children living in residential facilities as described above.) • Home-and Community-Based Waiver for Persons with Intellectual Disabilities • Children in Residential Facilities • Home-and Community-Based Waiver for Persons with Autism The PH-MCO must provide the necessary related services for Members in facilities as described in Exhibit O, Description of Facilities and Related Services. Out-of-Plan Services are described in Exhibit P, Out-of-Plan Services. Recipient coverage rules are outlined in Exhibit BB, PH-MCO Recipient Coverage Document.

Coordination of Care. ‌ The PH-MCO must coordinate is responsible for coordination of care for its Membersindividuals enrolled in HealthChoices. The PH-MCO must provide for ensure seamless and continuous coordination of care across a continuum of services for the individual Member with a focus on improving health care outcomes. The continuum of services may include the Inin-Plan plan comprehensive service benefits package, out-of-plan servicesbenefits, and non-MA covered services provided by other community resources such as: • Nursing Facility Care • Intermediate Care Facility for the Intellectually Disabled/Other Related Conditions (ICF/ ID/ORC) • Residential Treatment Facility (RTF) • Acute Psychiatric Facilities • Extended and and/or Extended Acute Psychiatric Facilities • Non-Hospital Residential Detoxification, Rehabilitation, and Half- Half-Way House Facilities for Drug/Alcohol Dependence/ Addiction • Opioid Use Disorder Centers of Excellence • Area Agencies on Aging Well PA/Level of Care (AAA)/OPTIONS Assessment and Pre-Pre- admission Screening Requirements • Pennsylvania Department of Aging (PDA) Waiver • Juvenile Detention Centers (JDCs) • Children in Substitute Care Transition • Adoption Assistance for Children and Children/Adolescents • Services to Dual Eligibles Under the Age of Twenty-one • Transitional Care Homes • Medical Xxxxxx Care Services • Early Intervention Services (note that the PH-MCO must refer for Early Intervention Services any of its Members members who are children from birth to age three (3) who are living in residential facilities. “Children living in residential facilities” describes children who are in a 24-hour living setting in which care is provided for one or more children.) • The OBRA waiver, a home-and-community-based waiver program Home and Community Based Waiver Program for individuals who have a severe developmental physical disability requiring an Intermediate Care Facility/Nursing Facility Residents with Other Related Conditions (ICFOLTL/ORCOBRA Waiver) level of care • Intellectual Disabilities Home and Community Based Waiver Program for Nursing Facility Applicants with Other Related Conditions (OLTL/Independence Waiver) • Home and Community Based Waiver for Attendant Care Services (note the PH-MCO is responsible to ensure a family with a child who has or is at risk of a developmental delay is referred to the County Intellectual Disabilities office for a determination of eligibility for home and community-based services, including children living in residential facilities as described above.OLTL/AC Waiver) • Home-Home and Community-Community Based Waiver for Persons with Intellectual Disabilities • Children in Residential Facilities • Home-and Community-Based COMMCARE Waiver for Persons with Autism a Primary Diagnosis of Traumatic Brain Injury The PH-MCO must provide the necessary related HealthChoices Program requirements covering special services for Members in facilities as described are outlined in Exhibit OO of this Agreement, Description of Facilities and Related Services. Out-of-Plan Services are described in Exhibit PP of this Agreement, Out-of-Plan Services. Recipient coverage rules are outlined in Exhibit BB, PH-MCO Recipient Coverage Document. 1. Coordination of Care/Letters of Agreement‌ The PH-MCO must coordinate the comprehensive in-plan package of services with entities providing Out-of-Plan Services. To clearly define the roles of the entities involved in the coordination of services, the PH-MCO must enter into coordination of care letters of agreement with County Children and Youth Agencies (CCYAs) and Juvenile Probation Offices (refer to Sample Model Agreement, Exhibit Q of this Agreement), and the BH-MCOs (refer to Exhibit R of this Agreement, Coordination with BH-MCOs). The Department encourages the PH-MCO to make a good faith effort to enter into coordination of care letters of agreement with school districts and other public, governmental, county, and community-based service providers. Should the PH-MCO be unable to enter into coordination of care letters of agreement as required under this Agreement, the PH- MCO must submit written justification to the Department. Justification must include all the steps taken by the PH-MCO to secure coordination of care letters of agreement, or must demonstrate an existing, ongoing, and cooperative relationship with the entity. The Department will then determine whether or not this requirement will be deemed met. All written coordination documents developed and maintained by the PH-MCO must have advance written approval by the Department and must be reviewed/revised at least annually by the PH-MCO. Coordination documents must be available for review by the Department upon request. All written coordination documents entered into between a service provider and the PH-MCO must also be approved by the Department. These written coordination documents, including the operational procedures, must be submitted for final review and approval at least thirty (30) days prior to the operational date of the Initial Term of the Contract. Any written coordination documents entered into between the PH- MCO and service Providers must contain, but are not limited to, the provisions outlined in Exhibit S of this Agreement, Written Coordination Agreements Between PH-MCO and Service

Coordination of Care. ‌ The PH-MCO must coordinate care for its Members. The PH-MCO must provide for seamless and continuous coordination of care across a continuum of services for the Member with a focus on improving health care outcomes. The continuum of services may include the In-Plan comprehensive service package, out-of-plan services, and non-MA covered services provided by other community resources such as: • Nursing Facility Care • Intermediate Care Facility for the Intellectually Disabled/Other Related Conditions • Residential Treatment Facility • Acute Psychiatric Facilities • Extended and Extended Acute Psychiatric Facilities • Non-Hospital Residential Detoxification, Rehabilitation, and Half- Way House Facilities for Drug/Alcohol Dependence/ Addiction • Opioid Use Disorder Centers of Excellence • Aging Well PAAAA/Level of Care Assessment Functional Eligibility Determination and Pre-admission Screening Requirements • PDA Waiver • Juvenile Detention Centers • Children in Substitute Care Transition • Adoption Assistance for Children and Adolescents • Services to Dual Eligibles Under the Age of Twenty-one • Transitional Care Homes • Medical Xxxxxx Care Services • Early Intervention Services (note that the PH-MCO must refer for Early Intervention Services any of its Members who are children from birth to age three (3) who are living in residential facilities. “Children living in residential facilities” describes children who are in a 24-hour living setting in which care is provided for one or more children.) • The OBRA waiver, a homeHome-andand Community-community-based waiver program Based Waiver Program for individuals who have a severe developmental physical disability requiring an Intermediate Care Facility/Nursing Facility Residents with Other Related Conditions (ICF/ORC) level of care • Intellectual Disabilities Home-and Community-Based Waiver Program for Nursing Facility Applicants with Other Related Conditions • Home-and Community-Based Waiver for Attendant Care Services (note the PH-MCO is responsible to ensure a family with a child who has or is at risk of a developmental delay is referred to the County Intellectual Disabilities office for a determination of eligibility for home and community-based services, including children living in residential facilities as described above.) • Home-and Community-Based Waiver for Persons with Intellectual Disabilities • COMMCARE Waiver for Persons with a Primary Diagnosis of Acquired Brain Injury • Children in Residential Facilities • Home-and Community-Based Waiver for Persons with Autism The PH-MCO must provide the necessary related services for Members in facilities as described in Exhibit O, Description of Facilities and Related Services. Out-of-Plan Services are described in Exhibit P, Out-of-Plan Services. Recipient coverage rules are outlined in Exhibit BB, PH-MCO Recipient Coverage Document. 1. Coordination of Care/Letters of Agreement‌ The PH-MCO must coordinate the comprehensive in-plan package with entities providing Out-of-Plan Services. To facilitate the efficient administration of the Medical Assistance Program, to enhance the treatment of Members who need Out-of-Plan services and to clearly define the roles of the entities involved in the coordination of services, the PH-MCO must enter into coordination of care letters of agreement with County Children and Youth Agencies (CCYAs), Juvenile Probation Offices (refer to Sample Model Agreement, Exhibit Q), and BH-MCOs (refer to Exhibit R, Coordination with BH- MCOs). In Addition, the PH-MCO must make a good faith effort to enter into coordination of care letters of agreement with school districts and other public, governmental, county, and community- based service providers. Should the PH-MCO be unable to enter into coordination of care letters of agreement as required under this Agreement, the PH-MCO must submit written justification to the Department. Justification must include all the steps taken by the PH-MCO to secure coordination of care letters of agreement, or must demonstrate an existing, ongoing, and cooperative relationship with the entity. The Department will determine whether to waive strict compliance with this requirement. All written coordination documents developed and maintained by the PH-MCO must have advance written approval by the Department and must be reviewed and, if necessary, revised at least annually by the PH-MCO. Coordination documents must be available for review by the Department upon request. The PH-MCO must obtain the Department’s prior written approval of all written coordination documents entered into between a service provider and the PH-MCO. These coordination documents must contain, but should not be limited to, the provisions outlined in Exhibit S, Written Coordination Agreements Between PH-MCO and Service Providers, and must be submitted for final Department review and approval at least thirty (30) days prior to the operational date of Agreement. Under no circumstances may these coordination documents contain a definition of Medically Necessary other than the definition found in this Agreement. 2. PH-MCO and BH-MCO Coordination‌ To facilitate the efficient administration of the Medical Assistance Program, to enhance the treatment of Members who need both physical health and BH services, the PH-MCO must develop and implement written agreements with each BH-MCO in the PH-MCO’s zone(s) regarding the interaction and coordination of services provided to Recipients enrolled in the HealthChoices Program. These agreements must be submitted and approved by the Department. The PH-MCOs and BH-MCOs are encouraged to develop uniform coordination agreements to promote consistency in the delivery and administration of services. The HealthChoices Program requirements covering BH Services are outlined in Exhibit U, Behavioral Health Services. The PH-MCO must work in collaboration with the BH-MCOs through participation in joint initiatives to improve overall health outcomes of its Members and those activities that are prescribed by the Department. These joint initiatives must include at a minimum: a. Information exchange including the BH utilization data provided by the Department to control avoidable hospital admissions, readmissions and emergency department usage for Members with PSMI and/or substance abuse disorders. b. Development of specific coordination mechanisms to assess and, where appropriate, reduce the use of psychotropic medications prescribed for children, especially those in substitute care. The PH-MCO will comply with the requirements regarding coordination of care, which are set forth in Section V.D, Coordination of Care, including those pertaining to behavioral health. a. The PH-MCO will, and the Department will require BH-MCOs to agree, to submit to a binding independent arbitration process in the event of a dispute between the PH-MCO and a BH-MCO concerning their respective obligations under this Agreement and the Behavioral HealthChoices agreement. The mutual agreement of the PH-MCO and a BH-MCO to such an arbitration process must be evidenced by and included in the written agreement between the PH-MCO and the BH-MCO. b. Exhibit BBB contains additional requirements specific to Outpatient Drug Services.

Coordination of Care. ‌ The PH-MCO must coordinate care for its Members. The PH-MCO must provide for seamless and continuous coordination of care across a continuum of services for the Member with a focus on improving health care outcomes. The continuum of services may include the In-Plan comprehensive service package, out-of-plan services, and non-MA covered services provided by other community resources such as: • ● Nursing Facility Care • ● Intermediate Care Facility for the Intellectually Disabled/Other Related Conditions • ● Residential Treatment Facility • ● Acute Psychiatric Facilities • ● Extended and Extended Acute Psychiatric Facilities • ● Non-Hospital Residential Detoxification, Rehabilitation, and Half- Way House Facilities for Drug/Alcohol Dependence/ Addiction • ● Opioid Use Disorder Centers of Excellence • ● Aging Well PA/Level of Care Assessment and Pre-admission Screening Requirements • ● Juvenile Detention Centers • ● Children in Substitute Care Transition • ● Adoption Assistance for Children and Adolescents • ● Services to Dual Eligibles Under the Age of Twenty-one • ● Transitional Care Homes • ● Medical Xxxxxx Care Services • ● Additional Examples given in Exhibit OO ● Early Intervention Services (note the PH-MCO must refer for Early Intervention Services any of its Members who are children from birth to age three (3) who are living in residential facilities. “Children living in residential facilities” describes children who are in a 24-hour living setting in which care is provided for one or more children.) • ● The OBRA waiver, a home-and-community-based waiver program for individuals who have a severe developmental physical disability requiring an Intermediate Care Facility/Other Related Conditions (ICF/ORC) level of care • ● Intellectual Disabilities Services (note the PH-MCO is responsible to ensure a family with a child who has or is at risk of a developmental delay is referred to the County Intellectual Disabilities office for a determination of eligibility for home and community-based services, including children living in residential facilities as described above.) • Home-and Community-Based Waiver for Persons with Intellectual Disabilities • ● Children in Residential Facilities • ● Home-and Community-Based Waiver for Persons with Autism The PH-MCO must provide the necessary related services for Members in facilities as described in Exhibit O, Description of Facilities and Related Services. Out-of-Plan Services are described in Exhibit P, Out-of-Plan Services. Recipient coverage rules are outlined in Exhibit BB, PH-MCO Recipient Coverage Document. 1. Coordination of Care/Letters of Agreement‌ The PH-MCO must coordinate the comprehensive in-plan package with entities providing Out-of-Plan Services. To facilitate the efficient administration of the Medical Assistance Program, to enhance the treatment of Members who need Out-of-Plan services and to clearly define the roles of the entities involved in the coordination of services, the PH-MCO must enter into coordination of care letters of agreement with County Children and Youth Agencies (CCYAs), Juvenile Probation Offices (refer to Sample Model Agreement, Exhibit Q), and BH-MCOs (refer to Exhibit R, Coordination with BH- MCOs). In Addition, the PH-MCO must make a good faith effort to enter into coordination of care letters of agreement with school districts and other public, governmental, county, and community- based service providers. Should the PH-MCO be unable to enter into coordination of care letters of agreement as required under this Agreement, the PH-MCO must submit written justification to the Department. Justification must include all the steps taken by the PH-MCO to secure coordination of care letters of agreement, or must demonstrate an existing, ongoing, and cooperative relationship with the entity. The Department will determine whether to waive strict compliance with this requirement. All written coordination documents developed and maintained by the PH-MCO must have advance written approval by the Department and must be reviewed and, if necessary, revised at least annually by the PH-MCO. Coordination documents must be available for review by the Department upon request. The PH-MCO must obtain the Department’s prior written approval of all written coordination documents entered into between a service provider and the PH-MCO. These coordination documents must contain, but should not be limited to, the provisions outlined in Exhibit S, Written Coordination Agreements Between PH-MCO and Service Providers, and must be submitted for final Department review and approval at least thirty (30) days prior to the operational date of Agreement. Under no circumstances may these coordination documents contain a definition of Medically Necessary other than the definition found in this Agreement. 2. PH-MCO and BH-MCO Coordination‌ To facilitate the efficient administration of the Medical Assistance Program, to enhance the treatment of Members who need both physical health and BH services, the PH-MCO must develop and implement written agreements with each BH-MCO in the PH-MCO’s zone(s) regarding the interaction and coordination of services provided to Recipients enrolled in the HealthChoices Program. These agreements must be submitted and approved by the Department. The PH-MCOs and BH-MCOs are encouraged to develop uniform coordination agreements to promote consistency in the delivery and administration of services. The HealthChoices Program requirements covering BH Services are outlined in Exhibit U, Behavioral Health Services. The PH-MCO must work in collaboration with the BH-MCOs through participation in joint initiatives to improve overall health outcomes of its Members and those activities that are prescribed by the Department. These joint initiatives must include at a minimum: a. Information exchange including the BH utilization data provided by the Department to control avoidable hospital admissions, readmissions and emergency department usage for Members with PSMI and/or substance abuse disorders. b. Development of specific coordination mechanisms to assess and, where appropriate, reduce the use of psychotropic medications prescribed for children, especially those in substitute care. The PH-MCO will comply with the requirements regarding coordination of care, which are set forth in Section V.D, Coordination of Care, including those pertaining to behavioral health. a. The PH-MCO will, and the Department will require BH-MCOs to agree, to submit to a binding independent arbitration process in the event of a dispute between the PH-MCO and a BH-MCO concerning their respective obligations under this Agreement and the Behavioral HealthChoices agreement. The mutual agreement of the PH-MCO and a BH-MCO to such an arbitration process must be evidenced by and included in the written agreement between the PH-MCO and the BH-MCO. b. Exhibit BBB contains additional requirements specific to Drug Services.

Coordination of Care. The PH-MCO must coordinate care for its Members. The PH-MCO must provide for seamless and continuous coordination of care across a continuum of services for the Member with a focus on improving health care outcomes. The continuum of services may include the In-Plan comprehensive service package, out-of-plan services, and non-MA covered services provided by other community resources such as: • ● Nursing Facility Care • ● Intermediate Care Facility for the Intellectually Disabled/Other Related Conditions • ● Residential Treatment Facility • ● Acute Psychiatric Facilities • ● Extended and Extended Acute Psychiatric Facilities • ● Non-Hospital Residential Detoxification, Rehabilitation, and Half- Way House Facilities for Drug/Alcohol Dependence/ Addiction • ● Opioid Use Disorder Centers of Excellence • ● Aging Well PA/Level of Care Assessment and Pre-admission Screening Requirements • ● Juvenile Detention Centers • ● Children in Substitute Care Transition • ● Adoption Assistance for Children and Adolescents • ● Services to Dual Eligibles Under the Age of Twenty-one • ● Transitional Care Homes • ● Medical Xxxxxx Care Services • ● Early Intervention Services (note the PH-MCO must refer for Early Intervention Services any of its Members who are children from birth to age three (3) who are living in residential facilities. “Children living in residential facilities” describes children who are in a 24-hour living setting in which care is provided for one or more children.) • ● The OBRA waiver, a home-and-community-based waiver program for individuals who have a severe developmental physical disability requiring an Intermediate Care Facility/Other Related Conditions (ICF/ORC) level of care • ● Intellectual Disabilities Services (note the PH-MCO is responsible to ensure a family with a child who has or is at risk of a developmental delay is referred to the County Intellectual Disabilities office for a determination of eligibility for home and community-based services, including children living in residential facilities as described above.) • Home-and Community-Based Waiver for Persons with Intellectual Disabilities • ● Children in Residential Facilities • ● Home-and Community-Based Waiver for Persons with Autism The PH-MCO must provide the necessary related services for Members in facilities as described in Exhibit O, Description of Facilities and Related Services. Out-of-Plan Services are described in Exhibit P, Out-of-Plan Services. Recipient coverage rules are outlined in Exhibit BB, PH-MCO Recipient Coverage Document.

Coordination of Care. The PH-MCO must coordinate is responsible for coordination of care for its Membersindividuals enrolled in HealthChoices. The PH-MCO must provide for ensure seamless and continuous coordination of care across a continuum of services for the individual Member with a focus on improving health care outcomes. The continuum of services may include the Inin-Plan plan comprehensive service benefits package, out-of-plan servicesbenefits, and non-MA covered services provided by other community resources such as: • Nursing Facility Care • Intermediate Care Facility for the Intellectually DisabledMentally Retarded/Other Related Conditions (ICF/MR/ORC) • Residential Treatment Facility (RTF) • Acute Psychiatric Facilities • Extended and and/or Extended Acute Psychiatric Facilities • Non-Hospital Residential Detoxification, Rehabilitation, and Half- Half-Way House Facilities for Drug/Alcohol Dependence/ Addiction • Opioid Use Disorder Centers of Excellence • Area Agencies on Aging Well PA/Level of Care (AAA)/OPTIONS Assessment and Pre-Pre- admission Screening Requirements • Pennsylvania Department of Aging (PDA) Waiver • Juvenile Detention Centers (JDCs) • Children in Substitute Care Transition • Adoption Assistance for Children and Children/Adolescents • Services to Dual Eligibles Under the Age of Twenty-one • Transitional Care Homes • Medical Xxxxxx Care Services • Early Intervention Services (note that the PH-MCO must refer for Early Intervention Services any of its Members members who are children from birth to age three (3) who are living in residential facilities. “Children living in residential facilities” describes children who are in a 24-hour living setting in which care is provided for one or more children.) • The OBRA waiver, a home-and-community-based waiver program Home and Community Based Waiver Program for individuals who have a severe developmental physical disability requiring an Intermediate Care Facility/Nursing Facility Residents with Other Related Conditions (ICFOSP/ORCOBRA Waiver) level of care • Intellectual Disabilities Home and Community Based Waiver Program for Nursing Facility Applicants with Other Related Conditions (OSP/Independence Waiver) • Home and Community Based Waiver for Attendant Care Services (note the PH-MCO is responsible to ensure a family with a child who has or is at risk of a developmental delay is referred to the County Intellectual Disabilities office for a determination of eligibility for home and community-based services, including children living in residential facilities as described above.OSP/AC Waiver) • Home-Home and Community-Community Based Waiver for Persons with Intellectual Disabilities Mental Retardation • Children in Residential Facilities • Home-and Community-Based COMMCARE Waiver for Persons with Autism a Primary Diagnosis of Traumatic Brain Injury The PH-MCO must provide the necessary related HealthChoices Program requirements covering special services for Members in facilities as described are outlined in Exhibit OO of this Agreement, Description of Facilities and Related Services. Out-of-Plan Services are described in Exhibit PP of this Agreement, Out-of-Plan Services. Recipient coverage rules are outlined in Exhibit BB, PH-MCO Recipient Coverage Document.

Coordination of Care. The PH-MCO must coordinate care for its Members. The PH-MCO must provide for seamless and continuous coordination of care across a continuum of services for the Member with a focus on improving health care outcomes. The continuum of services may include the In-Plan comprehensive service package, out-of-plan services, and non-MA covered services provided by other community resources such as: • Nursing Facility Care • Intermediate Care Facility for the Intellectually Disabled/Other Related Conditions • Residential Treatment Facility • Acute Psychiatric Facilities • Extended and Extended Acute Psychiatric Facilities • Non-Hospital Residential Detoxification, Rehabilitation, and Half- Half-Way House Facilities for Drug/Alcohol Dependence/ Addiction • Opioid Use Disorder Centers of Excellence • Aging Well PAAAA/Level of Care OPTIONS Assessment and Pre-admission Screening Requirements • PDA Waiver • Juvenile Detention Centers • Children in Substitute Care Transition • Adoption Assistance for Children and Adolescents • Services to Dual Eligibles Under the Age of Twenty-one • Transitional Care Homes • Medical Xxxxxx Care Services • Early Intervention Services (note that the PH-MCO must refer for Early Intervention Services any of its Members who are children from birth to age three (3) who are living in residential facilities. “Children living in residential facilities” describes children who are in a 24-hour living setting in which care is provided for one or more children.) • The OBRA waiver, a homeHome-andand Community-community-based waiver program Based Waiver Program for individuals who have a severe developmental physical disability requiring an Intermediate Care Facility/Nursing Facility Residents with Other Related Conditions (ICF/ORC) level of care • Intellectual Disabilities Home-and Community-Based Waiver Program for Nursing Facility Applicants with Other Related Conditions • Home-and Community-Based Waiver for Attendant Care Services (note the PH-MCO is responsible to ensure a family with a child who has or is at risk of a developmental delay is referred to the County Intellectual Disabilities office for a determination of eligibility for home and community-based services, including children living in residential facilities as described above.) • Home-and Community-Based Waiver for Persons with Intellectual Disabilities • COMMCARE Waiver for Persons with a Primary Diagnosis of Acquired Brain Injury • Children in Residential Facilities • Home-and Community-Based Waiver for Persons with Autism The PH-MCO must provide the necessary related services for Members in facilities as described in Exhibit O, Description of Facilities and Related Services. Out-of-Plan Services are described in Exhibit P, Out-of-Plan Services. Recipient coverage rules are outlined in Exhibit BB, PH-MCO Recipient Coverage Document.

Coordination of Care. ‌ The PH-MCO must coordinate care for its Members. The PH-MCO must provide for seamless and continuous coordination of care across a continuum of services for the Member with a focus on improving health care outcomes. The continuum of services may include the In-Plan comprehensive service package, out-of-plan services, and non-MA covered services provided by other community resources such as: •  Nursing Facility Care •  Intermediate Care Facility for the Intellectually Disabled/Other Related Conditions •  Residential Treatment Facility •  Acute Psychiatric Facilities •  Extended and Extended Acute Psychiatric Facilities •  Non-Hospital Residential Detoxification, Rehabilitation, and Half- Way House Facilities for Drug/Alcohol Dependence/ Addiction •  Opioid Use Disorder Centers of Excellence • Aging Well PA AAA/Level of Care Assessment Functional Eligibility Determination and Pre-admission Screening Requirements •  PDA Waiver  Juvenile Detention Centers •  Children in Substitute Care Transition •  Adoption Assistance for Children and Adolescents •  Services to Dual Eligibles Under the Age of Twenty-one •  Transitional Care Homes •  Medical Xxxxxx Care Services •  Early Intervention Services (note that the PH-MCO must refer for Early Intervention Services any of its Members who are children from birth to age three (3) who are living in residential facilities. “Children living in residential facilities” describes children who are in a 24-hour living setting in which care is provided for one or more children.) • The OBRA waiver, a home Home-andand Community-community-based waiver program Based Waiver Program for individuals who have a severe developmental physical disability requiring an Intermediate Care Facility/Nursing Facility Residents with Other Related Conditions (ICF/ORC) level of care • Intellectual Disabilities  Home-and Community-Based Waiver Program for Nursing Facility Applicants with Other Related Conditions  Home-and Community-Based Waiver for Attendant Care Services (note the PH-MCO is responsible to ensure a family with a child who has or is at risk of a developmental delay is referred to the County Intellectual Disabilities office for a determination of eligibility for home and community-based services, including children living in residential facilities as described above.) •  Home-and Community-Based Waiver for Persons with Intellectual Disabilities •  COMMCARE Waiver for Persons with a Primary Diagnosis of Acquired Brain Injury  Children in Residential Facilities •  Home-and Community-Based Waiver for Persons with Autism The PH-MCO must provide the necessary related services for Members in facilities as described in Exhibit O, Description of Facilities and Related Services. Out-of-Plan Services are described in Exhibit P, Out-of-Plan Services. Recipient coverage rules are outlined in Exhibit BB, PH-MCO Recipient Coverage Document. 1. Coordination of Care/Letters of Agreement‌ The PH-MCO must coordinate the comprehensive in-plan package with entities providing Out-of-Plan Services. To facilitate the efficient administration of the Medical Assistance Program, to enhance the treatment of Members who need Out-of-Plan services and to clearly define the roles of the entities involved in the coordination of services, the PH-MCO must enter into coordination of care letters of agreement with County Children and Youth Agencies (CCYAs), Juvenile Probation Offices (refer to Sample Model Agreement, Exhibit Q), and BH-MCOs (refer to Exhibit R, Coordination with BH- MCOs). In Addition, the PH-MCO must make a good faith effort to enter into coordination of care letters of agreement with school districts and other public, governmental, county, and community- based service providers. Should the PH-MCO be unable to enter into coordination of care letters of agreement as required under this Agreement, the PH-MCO must submit written justification to the Department. Justification must include all the steps taken by the PH-MCO to secure coordination of care letters of agreement, or must demonstrate an existing, ongoing, and cooperative relationship with the entity. The Department will determine whether to waive strict compliance with this requirement. All written coordination documents developed and maintained by the PH-MCO must have advance written approval by the Department and must be reviewed and, if necessary, revised at least annually by the PH-MCO. Coordination documents must be available for review by the Department upon request. The PH-MCO must obtain the Department’s prior written approval of all written coordination documents entered into between a service provider and the PH-MCO. These coordination documents must contain, but should not be limited to, the provisions outlined in Exhibit S, Written Coordination Agreements Between PH-MCO and Service Providers, and must be submitted for final Department review and approval at least thirty (30) days prior to the operational date of Agreement. Under no circumstances may these coordination documents contain a definition of Medically Necessary other than the definition found in this Agreement. 2. PH-MCO and BH-MCO Coordination‌ To facilitate the efficient administration of the Medical Assistance Program, to enhance the treatment of Members who need both physical health and BH services, the PH-MCO must develop and implement written agreements with each BH-MCO in the PH-MCO’s zone(s) regarding the interaction and coordination of services provided to Recipients enrolled in the HealthChoices Program. These agreements must be submitted and approved by the Department. The PH-MCOs and BH-MCOs are encouraged to develop uniform coordination agreements to promote consistency in the delivery and administration of services. The HealthChoices Program requirements covering BH Services are outlined in Exhibit U, Behavioral Health Services. The PH-MCO must work in collaboration with the BH-MCOs through participation in joint initiatives to improve overall health outcomes of its Members and those activities that are prescribed by the Department. These joint initiatives must include at a minimum: a. Information exchange including the BH utilization data provided by the Department to control avoidable hospital admissions, readmissions and emergency department usage for Members with PSMI and/or substance abuse disorders. b. Development of specific coordination mechanisms to assess and, where appropriate, reduce the use of psychotropic medications prescribed for children, especially those in substitute care. The PH-MCO will comply with the requirements regarding coordination of care, which are set forth in Section V.D, Coordination of Care, including those pertaining to behavioral health. a. The PH-MCO will, and the Department will require BH-MCOs to agree, to submit to a binding independent arbitration process in the event of a dispute between the PH-MCO and a BH-MCO concerning their respective obligations under this Agreement and the Behavioral HealthChoices agreement. The mutual agreement of the PH-MCO and a BH-MCO to such an arbitration process must be evidenced by and included in the written agreement between the PH-MCO and the BH-MCO. b. Exhibit BBB contains additional requirements specific to Outpatient Drug Services.

Coordination of Care. The PH-MCO must coordinate care for its Members. The PH-MCO must provide for seamless and continuous coordination of care across a continuum of services for the Member with a focus on improving health care outcomes. The continuum of services may include the In-Plan comprehensive service package, out-of-plan services, and non-MA covered services provided by other community resources such as: • ● Nursing Facility Care • ● Intermediate Care Facility for the Intellectually Disabled/Other Related Conditions • ● Residential Treatment Facility • ● Acute Psychiatric Facilities • ● Extended and Extended Acute Psychiatric Facilities • ● Non-Hospital Residential Detoxification, Rehabilitation, and Half- Way House Facilities for Drug/Alcohol Dependence/ Addiction • ● Opioid Use Disorder Centers of Excellence • ● Aging Well PA/Level of Care Assessment and Pre-admission Screening Requirements • ● Juvenile Detention Centers • ● Children in Substitute Care Transition • ● Adoption Assistance for Children and Adolescents • ● Services to Dual Eligibles Under the Age of Twenty-one • ● Transitional Care Homes • ● Medical Xxxxxx Care Services • ● Additional Examples given in Exhibit OO ● Early Intervention Services (note the PH-MCO must refer for Early Intervention Services any of its Members who are children from birth to age three (3) who are living in residential facilities. “Children living in residential facilities” describes children who are in a 24-hour living setting in which care is provided for one or more children.) • ● The OBRA waiver, a home-and-community-based waiver program for individuals who have a severe developmental physical disability requiring an Intermediate Care Facility/Other Related Conditions (ICF/ORC) level of care • ● Intellectual Disabilities Services (note the PH-MCO is responsible to ensure a family with a child who has or is at risk of a developmental delay is referred to the County Intellectual Disabilities office for a determination of eligibility for home and community-based services, including children living in residential facilities as described above.) • Home-and Community-Based Waiver for Persons with Intellectual Disabilities • ● Children in Residential Facilities • ● Home-and Community-Based Waiver for Persons with Autism The PH-MCO must provide the necessary related services for Members in facilities as described in Exhibit O, Description of Facilities and Related Services. Out-of-Plan Services are described in Exhibit P, Out-of-Plan Services. Recipient coverage rules are outlined in Exhibit BB, PH-MCO Recipient Coverage Document.

Coordination of Care. ‌ The PH-MCO must coordinate care for its Members. The PH-MCO must provide for seamless and continuous coordination of care across a continuum of services for the Member with a focus on improving health care outcomes. The continuum of services may include the In-Plan comprehensive service package, outOut-of-plan servicesPlan-Services, and non-MA covered services provided by other community resources such as: • ● Nursing Facility Care • ● Intermediate Care Facility for the Intellectually Disabled/Other Related Conditions • ● Residential Treatment Facility • ● Acute Psychiatric Facilities • ● Extended and Extended Acute Psychiatric Facilities • ● Non-Hospital Residential Detoxification, Rehabilitation, and Half- Way House Facilities for Drug/Alcohol Dependence/ Addiction • Substance Use Disorder ● Opioid Use Disorder Centers of Excellence • ● Aging Well PA/Level of Care Assessment and Pre-admission Screening Requirements • ● Juvenile Detention Centers • ● Children in Substitute Care Transition • ● Adoption Assistance for Children and Adolescents • ● Services to Dual Eligibles Under the Age of Twenty-one • ● Transitional Care Homes • ● Medical Xxxxxx Care Services • ● Early Intervention Services (note the PH-MCO must refer for Early Intervention Services any of its Members who are children from birth to age three (3) who are living in residential facilities. “Children living in residential facilities” describes children who are in a 24-hour living setting in which care is provided for one or more children.) • ● The OBRA waiver, a home-and-community-based waiver program for individuals who have a severe developmental physical disability requiring an Intermediate Care Facility/Other Related Conditions (ICF/ORC) level of care • ● Intellectual Disabilities Services (note the PH-MCO is responsible to ensure a family with a child who has or is at risk of a developmental delay is referred to the County Intellectual Disabilities office for a determination of eligibility for home and community-based services, including children living in residential facilities as described above.) • Home-Home and Community-Based Waiver Waivers for Persons with Intellectual Disabilities • or Autism ● Children in Residential Facilities • Home-and Community-Based Waiver for Persons with Autism The PH-MCO must provide the necessary related services for Members in facilities as described in Exhibit O, Description of Facilities and Related Services. Out-of-Plan Services are described in Exhibit P, Out-of-Plan Services. Recipient coverage rules are outlined in Exhibit BB, PH-MCO Recipient Coverage Document. A non-exclusive list of entities that may perform coordination of care activities may be found in Exhibit OO, Coordination of Care Entities.