Common use of Disease Management Clause in Contracts

Disease Management. the Contractor’s ongoing services and assistance for specific disease and/or conditions. Services include specific interventions, education and outreach targeted to Enrollees with, or at risk for, these diseases or conditions. DSRIP Performance Year (“Performance Year”) –an administrative period related to DSRIP and related purposes. For Performance Year 0, the period commencing on the Contract Effective Date and ending December 31, 2017, unless otherwise specified by EOHHS. For other Performance Years, a twelve-month period commencing January 1 and ending December 31, unless otherwise specified by EOHHS. DSRIP Program’s State Accountability Protocols – the terms of financial accountability under Massachusetts’ DSRIP agreement with the federal government, determining the percent of Massachusetts’ DSRIP spending authority that is at risk based on state performance. DSTI Glide Path Payments – DSRIP payments made to the Contractor, as appropriate, to support the transition of Participating Safety Net Hospitals. Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) – the delivery of health care services to MassHealth Standard and CommonHealth Members under the age of 21, pursuant to 42 USC 1396d(a)(4), 42 CFR Part 441, Subpart B, 130 CMR 450.140-149 and § 1115 Medicaid Research and Demonstration Waiver. Effective Date of Disenrollment - up to 11:59 p.m. on the last day, as determined by EOHHS, on which the Contractor is responsible for providing the activities described in this Contract to an Enrollee, as further defined by EOHHS. Effective Date of Enrollment – as of 12:01 a.m. on the first day on which the Contractor is responsible for providing the activities described in this Contract to an Enrollee, as further defined by EOHHS. Emergency Services Programs (ESPs) – Medically necessary services provided through designated, contracted providers, and which are available seven (7) days per week, twenty-four (24) hours per day to provide treatment of any individual who is experiencing a mental health or substance use disorder crisis, or both. An ESP encounter includes, at a minimum, crisis assessment, intervention and stabilization. In addition to contracted ESPs, ESP Encounter services (not Youth Mobile Crisis Intervention services) may also be provided by outpatient hospital emergency departments as further directed by EOHHS. Enrollee – a Member enrolled with the Contractor, either by choice, or by assignment by XXXXX. A Member shall be considered an Enrollee beginning on the Effective Date of Enrollment, including retroactive enrollment periods. A Member shall cease to be considered an Enrollee following the Effective Date of Disenrollment, including retroactive disenrollment periods. Enrollee Incentive – any compensation in cash or cash equivalent, or in-kind gifts, granted to an Enrollee as a result of engagement, or lack of engagement, in a targeted behavior, such as guideline- recommended clinical screenings, Primary Care Provider (PCP) visits, or Wellness Initiatives. Enrollees with Special Health Care Needs – Enrollees who meet the following characteristics:

Disease Management. the Contractor’s ongoing services and assistance for specific disease and/or conditions. Services include specific interventions, education and outreach targeted to Enrollees with, or at risk for, these diseases or conditions. DSRIP Performance Year (“Performance Year”) –an administrative period related to DSRIP and related purposes. For Performance Year 0, the period commencing on the Contract Effective Date and ending December 31, 2017, unless otherwise specified by EOHHS. For other Performance Years, a twelve-month period commencing January 1 and ending December 31, unless otherwise specified by EOHHS. DSRIP Program’s State Accountability Protocols – the terms of financial accountability under Massachusetts’ DSRIP agreement with the federal government, determining the percent of Massachusetts’ DSRIP spending authority that is at risk based on state performance. DSTI Glide Path Payments – DSRIP payments made to the Contractor, as appropriate, to support the transition of Participating Safety Net Hospitals. Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) – the delivery of health care services to MassHealth Standard and CommonHealth Members under the age of 21, pursuant to 42 USC 1396d(a)(4), 42 CFR Part 441, Subpart B, 130 CMR 450.140-149 and § 1115 Medicaid Research and Demonstration Waiver. Effective Date of Disenrollment - up to 11:59 p.m. on the last day, as determined by EOHHS, on which the Contractor is responsible for providing the activities described in this Contract to an Enrollee, as further defined by EOHHS. Effective Date of Enrollment – as of 12:01 a.m. on the first day on which the Contractor is responsible for providing the activities described in this Contract to an Enrollee, as further defined by EOHHS. Emergency Services Programs (ESPs) – Medically necessary Necessary services provided through designated, contracted providers, and which that are available seven (7) days per week, twenty-four (24) 24 hours per day day, to provide treatment assessment, or treatment, or stabilization, or any combination of these services to any individual Enrollee who is experiencing a mental health or substance use disorder crisisdisorder, or both. An ESP encounter includes, at a minimumincluding the Emergency Assessment, crisis assessmentMedication Management Services, intervention and stabilization. In addition to contracted ESPsShort Term Crisis Appendix C, ESP Encounter services (not Youth Mobile Crisis Intervention services) may also be provided by outpatient hospital emergency departments as further directed by EOHHSapplicable. Enrollee – a Member enrolled with the Contractor, either by choice, or by assignment by XXXXXEOHHS. A Member shall be considered an Enrollee beginning on the Effective Date of Enrollment, including retroactive enrollment periods. A Member shall cease to be considered an Enrollee following the Effective Date of Disenrollment, including retroactive disenrollment periods. Enrollee Incentive – any compensation in cash or cash equivalent, or in-kind gifts, granted to an Enrollee as a result of engagement, or lack of engagement, in a targeted behavior, such as guideline- recommended clinical screenings, Primary Care Provider (PCP) visits, or Wellness Initiatives. Enrollees with Special Health Care Needs – Enrollees who meet the following characteristics:

Disease Management. the Contractor’s ongoing services and assistance for specific disease and/or conditions. Services include specific interventions, education and outreach targeted to Enrollees with, or at risk for, these diseases or conditions. DSRIP Performance Year (“Performance Year”) –an administrative period related to DSRIP and related purposes. For Performance Year 0, the period commencing on the Contract Effective Date and ending December 31, 2017, unless otherwise specified by EOHHS. For other Performance Years, a twelve-month period commencing January 1 and ending December 31, unless otherwise specified by EOHHS. DSRIP Program’s State Accountability Protocols – the terms of financial accountability under Massachusetts’ DSRIP agreement with the federal government, determining the percent of Massachusetts’ DSRIP spending authority that is at risk based on state performance. DSTI Glide Path Payments – DSRIP payments made to the Contractor, as appropriate, to support the transition of Participating Safety Net Hospitals. Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) – the delivery of health care services to MassHealth Standard and CommonHealth Members under the age of 21, pursuant to 42 USC 1396d(a)(4), 42 CFR Part 441, Subpart B, 130 CMR 450.140-149 and § 1115 Medicaid Research and Demonstration Waiver. Effective Date of Disenrollment - up to 11:59 p.m. on the last day, as determined by EOHHS, on which the Contractor is responsible for providing the activities described in this Contract to an Enrollee, as further defined by EOHHS. Effective Date of Enrollment – as of 12:01 a.m. on the first day on which the Contractor is responsible for providing the activities described in this Contract to an Enrollee, as further defined by EOHHS. Emergency Services Programs (ESPs) – Medically necessary Necessary services provided through designated, contracted providers, and which that are available seven (7) days per week, twenty-four (24) 24 hours per day day, to provide treatment assessment, or treatment, or stabilization, or any combination of these services to any individual Enrollee who is experiencing a mental health or substance use disorder crisisdisorder, or both. An ESP encounter includes, at a minimumincluding the Emergency Assessment, crisis assessmentMedication Management Services, intervention and stabilization. In addition to contracted ESPsShort Term Crisis Appendix C, ESP Encounter services (not Youth Mobile Crisis Intervention services) may also be provided by outpatient hospital emergency departments as further directed by EOHHSapplicable. Enrollee – a Member enrolled with the Contractor, either by choice, or by assignment by XXXXX. A Member shall be considered an Enrollee beginning on the Effective Date of Enrollment, including retroactive enrollment periods. A Member shall cease to be considered an Enrollee following the Effective Date of Disenrollment, including retroactive disenrollment periods. Enrollee Incentive – any compensation in cash or cash equivalent, or in-kind gifts, granted to an Enrollee as a result of engagement, or lack of engagement, in a targeted behavior, such as guideline- recommended clinical screenings, Primary Care Provider (PCP) visits, or Wellness Initiatives. Enrollees with Special Health Care Needs – Enrollees who meet the following characteristics:

Disease Management. the Contractor’s ongoing services and assistance for specific disease and/or conditions. Services include specific interventions, education and outreach targeted to Enrollees with, or at risk for, these diseases or conditions. DSRIP Performance Year (“Performance Year”) –an administrative period related to DSRIP and related purposes. For Performance Year 0, the period commencing on the Contract Effective Date and ending December 31, 2017, unless otherwise specified by EOHHS. For other Performance Years, a twelve-month period commencing January 1 and ending December 31, unless otherwise specified by EOHHS. DSRIP Program’s State Accountability Protocols – the terms of financial accountability under Massachusetts’ DSRIP agreement with the federal government, determining the percent of Massachusetts’ DSRIP spending authority that is at risk based on state performance. DSTI Glide Path Payments – DSRIP payments made to the Contractor, as appropriate, to support the transition of Participating Safety Net Hospitals. Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) – the delivery of health care services to MassHealth Standard and CommonHealth Members under the age of 21, pursuant to 42 USC 1396d(a)(4), 42 CFR Part 441, Subpart B, 130 CMR 450.140-149 and § 1115 Medicaid Research and Demonstration Waiver. Effective Date of Disenrollment - up to 11:59 p.m. on the last day, as determined by EOHHS, on which the Contractor is responsible for providing the activities described in this Contract to an Enrollee, as further defined by EOHHS. Effective Date of Enrollment – as of 12:01 a.m. on the first day on which the Contractor is responsible for providing the activities described in this Contract to an Enrollee, as further defined by EOHHS. Emergency Services Programs (ESPs) – Medically necessary services provided through designated, contracted providers, and which are available seven (7) days per week, twenty-four (24) hours per day to provide treatment of any individual who is experiencing a mental health or substance use disorder crisis, or both. An ESP encounter includes, at a minimum, crisis assessment, intervention and stabilization. In addition to contracted ESPs, ESP Encounter services (not Youth Mobile Crisis Intervention services) may also be provided by outpatient hospital emergency departments as further directed by EOHHS. Enrollee – a Member enrolled with the Contractor, either by choice, or by assignment by XXXXXEOHHS. A Member shall be considered an Enrollee beginning on the Effective Date of Enrollment, including retroactive enrollment periods. A Member shall cease to be considered an Enrollee following the Effective Date of Disenrollment, including retroactive disenrollment periods. Enrollee Incentive – any compensation in cash or cash equivalent, or in-kind gifts, granted to an Enrollee as a result of engagement, or lack of engagement, in a targeted behavior, such as guideline- recommended clinical screenings, Primary Care Provider (PCP) visits, or Wellness Initiatives. Enrollees with Special Health Care Needs – Enrollees who meet the following characteristics:

Disease Management. the Contractor’s ongoing services and assistance for specific disease and/or conditions. Services include specific interventions, education education, and outreach targeted to Enrollees Attributed Members with, or at risk for, these diseases or conditions. DSRIP Performance Year (“Performance Year”) –– an administrative period related to DSRIP and related purposes. For Performance Year 0, the a six-month period commencing on the Contract Effective Date and ending December 31, 2017, unless otherwise specified by EOHHS. For other Performance Years, a twelve-month period commencing January 1 and ending December 31, unless otherwise specified by EOHHS. DSRIP Program’s State Accountability Protocols – the terms of financial accountability under Massachusetts’ DSRIP agreement with the federal government, determining the percent of Massachusetts’ DSRIP spending authority that is at risk based on state performance. DSTI Glide Path Payments – DSRIP payments made to the Contractor, as appropriate, certain ACOs to support the transition of Participating Safety Net Hospitals. Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) – - the delivery of health care services to MassHealth Standard and CommonHealth Members under the age of 21, pursuant to 42 USC 1396d(a)(4), 42 CFR Part 441, Subpart B, 130 CMR 450.140-149 and § 1115 Medicaid Research and Demonstration Waiver. Effective Date of Disenrollment - up to 11:59 p.m. on the last day, as determined by EOHHS, on which the Contractor is responsible for providing the activities described in this Contract to an EnrolleeAttributed Member, as further defined by EOHHS. Effective Date of Enrollment – as of 12:01 a.m. on the first day on which the Contractor is responsible for providing the activities described in this Contract to an EnrolleeAttributed Member and as reflected in the HIPAA 834 Outbound Enrollment File. Event Notification Service (ENS) – a HIway-sponsored service that provides real-time alerts about certain patient medical service encounters, for example, at the time of hospitalization, to a permitted recipient with an existing treatment relationship to the patient, such as a primary care provider. Executive Office of Health and Human Services (EOHHS) – The single state agency responsible for the administration of the MassHealth program, pursuant to M.G.L. c. 118E and Titles XIX and XXI of the Social Security Act, the Section 1115 Medicaid Research and Demonstration Waiver, and other applicable laws and waivers. External Quality Review Activities (EQR Activities) - activities performed by an entity with which EOHHS contracts in accordance with 42 CFR 438.358. External Quality Review Organization (EQRO) – the entity with which EOHHS contracts to perform External Quality Review Activities (EQR Activities), in accordance with 42 CFR 438.358. Governing Board – a board or other legal entity with sole and exclusive authority to execute the functions in this Contract, make final decisions on behalf of Contractor, and the members of which have a fiduciary duty to Contractor. Grievance – any expression of dissatisfaction by an Attributed Member or an Attributed Member’s representative about any action or inaction by the Contractor. Possible subjects for Grievances include, but are not limited to, quality of care or services provided, aspects of interpersonal relationships such as rudeness of a provider or employee of the Contractor, or failure to respect the Attributed Member’s rights. Health Information Technology (HIT) – The application of information processing involving both computer hardware and software related to the storage, retrieval, sharing, and use of health care information, data, and knowledge for communication and decision-making. Hepatitis C Virus Drugs (HCV Drugs) – Direct acting-antiviral (DAA) single and combination drugs, as further defined specified by EOHHS. Emergency Services Programs Instrumental Activities of Daily Living (ESPsIADLs) – Medically necessary services provided through designatedcertain basic environmental tasks required for daily living, contracted providersincluding the ability to prepare meals, do housework, laundry, and which are available seven (7) days per weekshopping, twenty-four (24) hours per day to provide treatment of any individual who is experiencing a mental health or substance use disorder crisis, or both. An ESP encounter includes, at a minimum, crisis assessment, intervention and stabilization. In addition to contracted ESPs, ESP Encounter services (not Youth Mobile Crisis Intervention services) may also be provided by outpatient hospital emergency departments as further directed by EOHHS. Enrollee – a Member enrolled with the Contractor, either by choice, or by assignment by XXXXX. A Member shall be considered an Enrollee beginning on the Effective Date of Enrollment, including retroactive enrollment periods. A Member shall cease to be considered an Enrollee following the Effective Date of Disenrollment, including retroactive disenrollment periods. Enrollee Incentive – any compensation in cash or cash equivalent, or in-kind gifts, granted to an Enrollee as a result of engagement, or lack of engagement, in a targeted behavior, such as guideline- recommended clinical screenings, Primary Care Provider (PCP) visits, or Wellness Initiatives. Enrollees with Special Health Care Needs – Enrollees who meet the following characteristics:get around

Disease Management. the Contractor’s ongoing services and assistance for specific disease and/or conditions. Services include specific interventions, education education, and outreach targeted to Enrollees Attributed Members with, or at risk for, these diseases or conditions. DSRIP Performance Year (“Performance Year”) –– an administrative period related to DSRIP and related purposes. For Performance Year 0, the a six-month period commencing on the Contract Effective Date and ending December 31, 2017, unless otherwise specified by EOHHS. For other Performance Years, a twelve-month period commencing January 1 and ending December 31, unless otherwise specified by EOHHS. DSRIP Program’s State Accountability Protocols – the terms of financial accountability under Massachusetts’ DSRIP agreement with the federal government, determining the percent of Massachusetts’ DSRIP spending authority that is at risk based on state performance. DSTI Glide Path Payments – DSRIP payments made to the Contractor, as appropriate, certain ACOs to support the transition of Participating Safety Net Hospitals. Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) – - the delivery of health care services to MassHealth Standard and CommonHealth Members under the age of 21, pursuant to 42 USC 1396d(a)(4), 42 CFR Part 441, Subpart B, 130 CMR 450.140-149 and § 1115 Medicaid Research and Demonstration Waiver. Effective Date of Disenrollment - up to 11:59 p.m. on the last day, as determined by EOHHS, on which the Contractor is responsible for providing the activities described in this Contract to an EnrolleeAttributed Member, as further defined by EOHHS. Effective Date of Enrollment – as of 12:01 a.m. on the first day on which the Contractor is responsible for providing the activities described in this Contract to an EnrolleeAttributed Member and as reflected in the HIPAA 834 Outbound Enrollment File. Event Notification Service (ENS) – a HIway-sponsored service that provides real-time alerts about certain patient medical service encounters, for example, at the time of hospitalization, to a permitted recipient with an existing treatment relationship to the patient, such as a primary care provider. Executive Office of Health and Human Services (EOHHS) – The single state agency responsible for the administration of the MassHealth program, pursuant to M.G.L. c. 118E and Titles XIX and XXI of the Social Security Act, the Section 1115 Medicaid Research and Demonstration Waiver, and other applicable laws and waivers. External Quality Review Activities (EQR Activities) - activities performed by an entity with which EOHHS contracts in accordance with 42 CFR 438.358. External Quality Review Organization (EQRO) – the entity with which EOHHS contracts to perform External Quality Review Activities (EQR Activities), in accordance with 42 CFR 438.358. Governing Board – a board or other legal entity with sole and exclusive authority to execute the functions in this Contract, make final decisions on behalf of Contractor, and the members of which have a fiduciary duty to Contractor. Grievance – any expression of dissatisfaction by an Attributed Member or an Attributed Member’s representative about any action or inaction by the Contractor. Possible subjects for Grievances include, but are not limited to, quality of care or services provided, aspects of interpersonal relationships such as rudeness of a provider or employee of the Contractor, or failure to respect the Attributed Member’s rights. Health Information Technology (HIT) – The application of information processing involving both computer hardware and software related to the storage, retrieval, sharing, and use of health care information, data, and knowledge for communication and decision-making. Hepatitis C Virus Drugs (HCV Drugs) – Direct acting-antiviral (DAA) single and combination drugs, as further defined specified by EOHHS. Emergency Long-Term Services Programs and Supports (ESPsLTSS) – Medically necessary a wide variety of services provided through designatedand supports that help certain members meet their daily needs for assistance and improve the quality of their lives. Examples include assistance with bathing, contracted providersdressing and other basic activities of daily life and self-care, and which are available seven (7) days per week, twenty-four (24) hours per day to provide treatment of any individual who is experiencing a mental health or substance use disorder crisis, or both. An ESP encounter includes, at a minimum, crisis assessment, intervention and stabilization. In addition to contracted ESPs, ESP Encounter services (not Youth Mobile Crisis Intervention services) may also be provided by outpatient hospital emergency departments as further directed by EOHHS. Enrollee – a Member enrolled with the Contractor, either by choice, or by assignment by XXXXX. A Member shall be considered an Enrollee beginning on the Effective Date of Enrollment, including retroactive enrollment periods. A Member shall cease to be considered an Enrollee following the Effective Date of Disenrollment, including retroactive disenrollment periods. Enrollee Incentive – any compensation in cash or cash equivalent, or in-kind gifts, granted to an Enrollee well as a result of engagement, or lack of engagement, in a targeted behavior, such as guideline- recommended clinical screenings, Primary Care Provider (PCP) visits, or Wellness Initiatives. Enrollees with Special Health Care Needs – Enrollees who meet the following characteristics:support for everyday tasks such