Common use of Services for All Members Clause in Contracts

Services for All Members. A. Health Education 1) Contractor shall implement and maintain a health education system that includes programs, services, functions, and resources necessary to provide health education, health promotion and patient education for all Members. 2) Contractor shall ensure administrative oversight of the health education system by a qualified full-time health educator. 3) Contractor shall provide health education programs and services at no charge to Members directly and/or through Subcontracts or other formal agreements with providers that have expertise in delivering health education services to the Member population. 4) Contractor shall ensure the organized delivery of health education programs using educational strategies and methods that are appropriate for Members and effective in achieving behavioral change for improved health. 5) Contractor shall ensure that health education materials are written at the sixth grade reading level and are culturally and linguistically appropriate for the intended audience. 6) Contractor shall maintain a health education system that provides educational interventions addressing the following health categories and topics: a) Appropriate use of health care services – managed health care; preventive and primary health care; obstetrical care; health education services; and, complementary and alternative care. b) Risk-reduction and healthy lifestyles – tobacco use and cessation; alcohol and drug use; injury prevention; prevention of sexually transmitted diseases; HIV and unintended pregnancy; nutrition, weight control, and physical activity; and, parenting. c) Self-care and management of health conditions – pregnancy; asthma; diabetes; and, hypertension. 7) Contractor shall ensure that Members receive point of service education as part of preventive and primary health care visits. Contractor shall provide education, training, and program resources to assist contracting medical providers in the delivery of health education services for Members. 8) Contractor shall maintain health education policies and procedures, and standards and guidelines; conduct appropriate levels of program evaluation; and, monitor performance of providers that are contracted to deliver health education services to ensure effectiveness. 9) Contractor shall periodically review the health education system to ensure appropriate allocation of health education resources, and maintain documentation that demonstrates effective implementation of the health education requirements. 10) Contractor shall ensure that all new Members complete the individual health education behavioral assessment within 120 calendar days of enrollment as part of the initial health assessment; and that all existing Members complete the individual health education behavioral assessment at their next non-acute care visit. Contractor shall ensure: 1) that primary care providers use the DHCS standardized “Staying Healthy” assessment tools, or alternative approved tools that comply with DHCS approval criteria for the individual health education behavioral assessment; and 2) that the individual health education behavioral assessment tool is: a) administered and reviewed by the primary care provider during an office visit, b) reviewed at least annually by the primary care provider with Members who present for a scheduled visit, and c) re- administered by the primary care provider at the appropriate age- intervals. 11) Contractor shall cover and ensure provision of comprehensive case management including coordination of care services as described in Exhibit A, Attachment 11. B. The Health Information Form (HIF)/Member Evaluation Tool (MET) Contractor shall use data from the HIF and submitted through the MET to help identify newly enrolled Members who may need expedited services. C. Hospice Care 1) Contractor shall cover and ensure the provision of hospice care services as defined in Sections 1905(o)(1) of the Social Security Act. Contractor shall ensure that Members and their families are fully informed of the availability of hospice care as a covered service and the methods by which they may elect to receive these services. Services shall be limited to individuals who have been certified as terminally ill with a life expectancy of 6 months or less if the terminal illness runs its normal course, and who directly or through their representative voluntarily elect to receive such benefits in lieu of other care as specified. However, for a member under age 21, a voluntary election of hospice care shall not constitute a waiver of any rights of that member to be provided with, or to have payment made for covered services that are related to the treatment of that member’s condition for which a diagnosis of terminal illness has been made. For individuals who have elected hospice care, Contractor shall arrange for continuity of medical care, including maintaining established patient-provider relationships, to the greatest extent possible. Contractor shall cover the cost of all hospice care provided. Contractor is also responsible for all medical care not related to the terminal condition. 2) Admission to a nursing facility of a Member who has elected covered hospice services does not affect the Member's eligibility for enrollment under this Contract. Hospice services are Covered Services under this Contract and are not long term care services regardless of the Member's expected or actual length of stay in a nursing facility. D. Vision Care - Lenses Contractor shall cover and ensure the provision of eye examinations and prescriptions for corrective lenses as appropriate for all Members. Contractor shall arrange for the fabrication of optical lenses for Members through Prison Industry Authority (PIA) optical laboratories. Contractor shall cover the cost of the eye examination and dispensing of the lenses for Members. DHCS will reimburse PIA for the fabrication of the optical lenses in accordance with the contract between DHCS and PIA. E. Mental Health and Substance Use Services 1) Contractor shall cover Outpatient Mental Health Services that are within the scope of practice of Primary Care Providers and mental health care providers, in accordance with the Outpatient Mental Health Services requirements as defined in Exhibit E, Attachment 1, Definitions. Contractor’s policies and procedures shall define and describe what services are to be provided by Primary Care Providers. In addition, Contractor shall cover and ensure the provision of psychotherapeutic drugs prescribed by its Primary Care Providers or other mental health care professionals, except those specifically excluded in this Contract as stipulated below. 2) Contractor shall cover and pay for all Medically Necessary Covered Services for the Member, including the following services: a) Emergency room professional services as described in Title 22 CCR Section 53855, except services provided by psychiatrists, psychologists, licensed clinical social workers, marriage, family and child counselors, or other specialty mental health providers. b) Facility charges for emergency room visits which do not result in a psychiatric admission. c) All laboratory and radiology services when these services are necessary for the diagnosis, monitoring, or treatment of a Member's mental health condition. d) Emergency medical transportation services necessary to provide access to all Medi-Cal Covered Services, including emergency mental health services, as described in Title 22 CCR Section 51323. e) All non-emergency medical transportation services, as provided for in Title 22 CCR Section 51323, required by Members to access Medi-Cal covered mental health services, subject to a written prescription by Contractor’s mental health provider within Contractor’s mental health provider network, except when the transportation is required to transfer the Member from one facility to another, for the purpose of reducing the local Medi-Cal mental health program’s cost of providing services. f) Medically Necessary Covered Services after Contractor has been notified by a specialty mental health provider that a Member has been admitted to a psychiatric inpatient hospital, including the initial health history and physical examination required upon admission and any consultations related to Medically Necessary Covered Services. However, notwithstanding this requirement, Contractor shall not be responsible for room and board charges for psychiatric inpatient hospital stays by Members. g) All Medically Necessary Medi-Cal covered psychotherapeutic drugs for Members not otherwise excluded under this Contract. i. This includes reimbursement for covered psychotherapeutic drugs prescribed by out-of-plan psychiatrists for Members. ii. Contractor may require that covered prescriptions written by out-of-plan psychiatrists be filled by pharmacies in Contractor’s provider network. iii. Reimbursement to pharmacies for those psychotherapeutic drugs listed in the Medi-Cal Provider Manual, MCP: Two-Plan Model, Capitated /Noncapitated Drugs section, which lists excluded psychiatric drugs, shall be reimbursed through the Medi-Cal FFS program, whether these drugs are provided by a pharmacy contracting with Contractor or by an out-of-plan pharmacy provider. To qualify for reimbursement under this provision, a pharmacy must be enrolled as a Medi-Cal provider in the Medi-Cal FFS program. h) Paragraphs c), e), and f) above shall not be construed to preclude Contractor from: (1) requiring that Covered Services be provided through Contractor's provider network, to the extent possible, or (2) applying utilization review controls for these services, including prior authorization, consistent with Contractor's obligation to provide Covered Services under this Contract. 3) Contractor shall develop and implement a written internal policy and procedure to ensure that Members who need Specialty Mental Health Services (services outside the scope of practice of Primary Care Providers) are referred to and are provided mental health services by an appropriate Medi-Cal FFS mental health provider or to the local mental health plan for Specialty Mental Health Services in accordance with Exhibit A, Attachment 11, Case Management and Coordination of Care, Provision 6. Specialty Mental Health. 4) Contractor shall establish and maintain mechanisms to identify Members who require non-covered psychiatric services and ensure appropriate referrals are made. Contractor shall continue to cover and ensure the provision of primary care and other services unrelated to the mental health treatment and coordinate services between the Primary Care Provider and the psychiatric service provider(s). Contractor shall enter into a Memorandum of Understanding with the county mental health plan in accordance with Exhibit A, Attachment 12, Local Health Department Coordination, Provision 3. Local Mental Health Plan Coordination. F. Tuberculosis (TB) 1) TB screening, diagnosis, treatment and follow-up are covered under this Contract. Contractor shall provide TB care and treatment in compliance with the guidelines recommended by American Thoracic Society and the Centers for Disease Control and Prevention. 2) Contractor shall coordinate with Local Health Departments in the provision of direct observed therapy as required in Exhibit A, Attachment 11, Case Management and Coordination of Care, Provision 16. Direct Observed Therapy (DOT) for Treatment of Tuberculosis (TB) and Attachment 12, Local Health Department Coordination. G. Pharmaceutical Services and Provision of Prescribed Drugs 1) Contractor shall cover and ensure the provision of all prescribed drugs and Medically Necessary pharmaceutical services. Contractor shall provide pharmaceutical services and prescription drugs in accordance with all Federal and State laws and regulations including, but not limited to the California State Board of Pharmacy

Services for All Members. A. Health Education 1) Contractor shall implement and maintain a health education system that includes programs, services, functions, and resources necessary to provide health education, health promotion and patient education for all Members. 2) Contractor shall ensure administrative oversight of the health education system by a qualified full-time health educator. 3) Contractor shall provide health education programs and services at no charge to Members directly and/or through Subcontracts or other formal agreements with providers Providers that have expertise in delivering health education services to the Member population. 4) Contractor shall ensure the organized delivery of health education programs using educational strategies and methods that are appropriate for Members and effective in achieving behavioral change for improved health. 5) Contractor shall ensure that health education materials are written at the sixth grade reading level and are culturally and linguistically appropriate for the intended audience. 6) Contractor shall maintain a health education system that provides educational interventions addressing the following health categories and topics: a) Appropriate use of health care services – managed health care; preventive and primary health care; obstetrical care; health education services; and, complementary complimentary and alternative care. b) Risk-reduction and healthy lifestyles – tobacco use and cessation; alcohol and drug use; injury prevention; prevention of sexually transmitted diseases; HIV and unintended pregnancy; nutrition, weight control, and physical activity; and, parenting. c) Self-care and management of health conditions – pregnancy; asthma; diabetes; and, hypertension. 7) Contractor shall ensure that Members receive point of service education as part of preventive and primary health care visits. Contractor shall provide education, training, and program resources to assist contracting medical providers Providers in the delivery of health education services for Members. 8) Contractor shall maintain health education policies and procedures, and standards and guidelines; conduct appropriate levels of program evaluation; and, monitor performance of providers Providers that are contracted to deliver health education services to ensure effectiveness. 9) Contractor shall periodically review the health education system to ensure appropriate allocation of health education resources, and maintain documentation that demonstrates effective implementation of the health education requirements. 10) Contractor shall ensure that all new Members complete the individual health education behavioral assessment IHEBA within 120 calendar days of enrollment as part of the initial health assessmentIHA; and that all existing Members complete the individual health education behavioral assessment IHEBA at their next non-acute care visit. Contractor shall ensure: 1) that primary care providers Primary Care Provider use the DHCS standardized “Staying Healthy” assessment tools, or alternative approved tools that comply with DHCS approval criteria for the individual health education behavioral assessmentIHEBA; and 2) that the individual health education behavioral assessment IHEBA tool is: : a) administered and reviewed by the primary care provider Primary Care Provider during an office visit, b) reviewed at least annually by the primary care provider Primary Care Provider with Members who present for a scheduled visit, and c) re- re-administered by the primary care provider Primary Care Provider at the appropriate age- age-intervals. 11) Contractor shall cover and ensure provision of comprehensive case management including coordination of care services as described in Exhibit A, Attachment 11. B. The Health Information Form (HIF)/Member Evaluation Tool (MET) Contractor shall use data from the HIF and submitted through the MET a Health Information Form (HIF) Member Evaluation Tool (MET) to help identify newly enrolled Members who may need expedited services. In accordance with 42 CFR 438.208(b), Contractor shall, at a minimum, comply with the following: 1) Mail a DHCS approved HIF/MET to all new Members as a part of Contractor’s welcome packet and include a postage paid envelope for response. 2) Within 90 days of each new Member’s effective date of enrollment: a) Make at least two (2) telephone call attempts to remind new Members to return the HIF/MET and/or collect the HIF/MET information from new Members. This outreach can be done through head of household for Members under the care of parents, custodial parents, legal guardians, or other authorized representatives in accordance with applicable privacy laws. b) Conduct an initial screening of the Member’s needs as identified in the all HIF/METs received. To meet this requirement, Contractor may build upon any existing screening process currently used to meet requirements in Exhibit A, Attachment 10, Scope of Services, or Exhibit A, Attachment 11, Case Management and Coordination of Care. 3) Upon a Member’s disenrollment, Contractor shall make the HIF/MET assessment results available to their new Medi-Cal Managed Care Health Plan upon request. C. Hospice Care 1) Contractor shall cover and ensure the provision of hospice care services as defined in Sections 1905(o)(1) of the Social Security Act. Contractor shall ensure that Members and their families are fully informed of the availability of hospice care as a covered service and the methods by which they may elect to receive these services. Services shall be limited to individuals who have been certified as terminally ill with a life expectancy of 6 months or less if the terminal illness runs its normal course, and who directly or through their representative voluntarily elect to receive such benefits in lieu of other care as specified. However, for a member under age 21, a voluntary election of hospice care shall not constitute a waiver of any rights of that member to be provided with, or to have payment made for covered services that are related to the treatment of that member’s condition for which a diagnosis of terminal illness has been made. For individuals who have elected hospice care, Contractor shall arrange for continuity of medical care, including maintaining established patient-provider patient Provider relationships, to the greatest extent possible. Contractor shall cover the cost of all hospice care provided. Contractor is also responsible for all medical care not related to the terminal condition. 2) Admission to a nursing facility of a Member who has elected covered hospice services does not affect the Member's eligibility for enrollment under this Contract. Hospice services are Covered Services under this Contract and are not long term care services Long-Term Care (LTC) regardless of the Member's expected or actual length of stay in a nursing facility. D. Vision Care - Lenses Contractor shall cover and ensure the provision of eye examinations and prescriptions for corrective lenses as appropriate for all Members. Contractor shall arrange for the fabrication of optical lenses for Members through Prison Industry Authority (PIA) optical laboratories. Contractor shall cover the cost of the eye examination and dispensing of the lenses for Members. DHCS will reimburse PIA for the fabrication of the optical lenses in accordance with the contract between DHCS and PIA. E. Mental Health and Substance Use Disorder Services 1) Contractor shall cover Outpatient Mental Health Services that are within the scope of practice of Primary Care Providers and mental health care providersProviders, in accordance with the Outpatient Mental Health Services requirements as defined in Exhibit E, Attachment 1, Definitions. Contractor’s policies and procedures shall define and describe what services are to be provided by Primary Care Providers. In addition, Contractor shall cover and ensure the provision of psychotherapeutic drugs prescribed by its Primary Care Providers or other mental health care professionals, except those specifically excluded in this Contract as stipulated below. 2) Contractor shall cover and pay for all Medically Necessary Covered Services for the Member, including the following services: a) Emergency room professional services as described in Title 22 CCR Section 53855, except services provided by psychiatrists, psychologists, licensed clinical social workers, marriage, family and child counselors, or other specialty mental health providersProviders. b) Facility charges for emergency room visits which do not result in a psychiatric admission. c) All laboratory and radiology services when these services are necessary for the diagnosis, monitoring, or treatment of a Member's mental health condition. d) Emergency medical transportation Medical Transportation services necessary to provide access to all Medi-Cal Covered Services, including emergency mental health services, as described in Title 22 CCR Section 51323. e) All nonNon-emergency medical transportation Emergency Medical Transportation services, as provided for in Title 22 CCR Section 51323, required by Members to access Medi-Cal covered mental health services, subject to a written prescription by Contractor’s mental health provider Provider within Contractor’s mental health provider network, except when the transportation is required to transfer the Member from one facility to another, for the purpose of reducing the local Medi-Cal mental health program’s cost of providing servicesProvider Network. f) Medically Necessary Covered Services after Contractor has been notified by a specialty mental health provider Specialty Mental Health Provider that a Member has been admitted to a an inpatient psychiatric inpatient hospitalfacility, including an Institution for Mental Diseases (IMD) as defined by Title 9 CCR Section 1810.222.1, regardless of the age of the Member. These services include, but are not limited to: i. The initial health history and physical examination required upon admission and any consultations related to Medically Necessary Covered Services. ii. However, notwithstanding Notwithstanding this requirement, Contractor shall not be responsible for room and board charges for psychiatric inpatient hospital stays by Members. iii. When IMD services are provided to Members age 21 and under or age 65 and over, Contractor shall cover Skilled Nursing Facility (SNF) room and board. Contractor shall not cover other inpatient psychiatric facility/IMD room and board charges or other services that are reimbursed as part of the inpatient psychiatric facility/IMD per diem rate. g) All Medically Necessary Medi-Cal covered psychotherapeutic drugs for Members not otherwise excluded under this Contract. i. This includes reimbursement for covered psychotherapeutic drugs prescribed by out-of-plan Network psychiatrists for Members. ii. Contractor may require that covered prescriptions written by out-of-plan Network psychiatrists be filled by pharmacies in Contractor’s provider networkProvider Network. iii. Reimbursement to pharmacies for those psychotherapeutic drugs listed in the Medi-Cal Provider Manual, MCP: Two-Plan Model, Capitated /Noncapitated Drugs section, which lists excluded psychiatric drugs, shall be reimbursed through the Medi-Cal FFS program, whether these drugs are provided by a pharmacy contracting with Contractor or by an out-of-plan Network pharmacy providerProvider. To qualify for reimbursement under this provision, a pharmacy must be enrolled as a Medi-Cal provider Provider in the Medi-Cal FFS program. h) Paragraphs c), e), and f) above shall not be construed to preclude Contractor from: (1) requiring that Covered Services be provided through Contractor's provider networkProvider Network, to the extent possible, or (2) applying utilization review controls for these services, including prior authorization, consistent with Contractor's obligation to provide Covered Services under this Contract. 3) Contractor shall develop and implement a written internal policy and procedure to ensure that Members who need Specialty Mental Health Services (services outside the scope of practice of Primary Care Providers) are referred to and are provided mental health services by an appropriate Medi-Cal FFS mental health provider Provider or to the local county mental health plan for Specialty Mental Health Services in accordance with Exhibit A, Attachment 11, Case Management and Coordination of Care, Provision 6. Specialty Mental Health. 4) Contractor shall establish and maintain mechanisms to identify Members who require non-covered psychiatric services and ensure appropriate referrals are made. Contractor shall continue to cover and ensure the provision of primary care and other services unrelated to the mental health treatment and coordinate services between the Primary Care Provider and the psychiatric service provider(sProvider(s). Contractor shall enter into a Memorandum of Understanding with the county mental health plan in accordance with Exhibit A, Attachment 12, Local Health Department Coordination, Provision 3. Local , County Mental Health Plan Coordination. F. Tuberculosis (TB) 1) TB screening, diagnosis, treatment and follow-up are covered under this Contract. Contractor shall provide TB care and treatment in compliance with the guidelines recommended by American Thoracic Society and the Centers for Disease Control and Prevention. 2) Contractor shall coordinate with Local Health Departments in the provision of direct observed therapy as required in Exhibit A, Attachment 11, Case Management and Coordination of Care, Provision 16. Direct Observed Therapy (DOT) for Treatment of Tuberculosis (TB) and Attachment 12, Local Health Department Coordination. G. Pharmaceutical Services and Provision of Prescribed Drugs 1) Contractor shall cover and ensure the provision of all prescribed drugs and Medically Necessary pharmaceutical services. Contractor shall provide pharmaceutical services and prescription drugs Prescription Drugs in accordance with all Federal federal and State laws and regulations including, but not limited to Title 22 CCR Sections 53214 and 53854, Title 16, Sections 1707.1, 1707.2, and 1707.3, 42 CFR 438.3(s), and Sections 1927(d)(5) and 1927(k)(2) of the California Social Security Act. Prior authorization requirements for pharmacy services and provision of prescribed drugs must be clearly described in the Member Services Guide and Contractor’s provider manuals. 2) At a minimum, Contractor shall arrange for pharmaceutical services to be available during regular business hours. Contractor’s drug utilization review (DUR) systems should be comparable to such programs administered by the State, and are subject to requirements outlined in 42 CFR 438.3(s), Section 1927(g) of the Social Security Act, and 42 CFR 456, subpart K. 3) Contractor shall ensure access to at least a 72-hour supply of a covered outpatient drug in an emergency situation. Contractor shall meet this requirement by doing all of the following: a) Having written policies and procedures, including, if applicable, written policies and procedures of Contractor’s Network hospitals’ policies and procedures related to emergency medication dispensing, which describe the method(s) that are used to ensure that the emergency medication dispensing requirements are met, including, if applicable, specific language in Network hospital subcontracts. Written policies and procedures must describe how Contractor and/or Contractor’s Network hospitals will monitor compliance with the requirements. Compliance monitoring does not require verification of receipt of medications for each and every ER visit made by Members to an emergency room which does not result in hospitalization. b) Providing the Member, in all cases, access to at least a 72- hour supply of Medically Necessary drugs. This requirement can be met by providing a 72-hour supply of the drug to the Member, or provision of an initial dose of medication and a prescription for additional medication, which together cover the Member for the 72-hour period. Contractor's policies and procedures can describe other methods for ensuring compliance with the 72-hour requirement. c) Having a mechanism in place for informing Members of this requirement and of their right to submit a Grievance if they do not receive Medically Necessary medications in emergency situations. d) Having a procedure for investigating and resolving Grievances related to the failure of Contractor to provide Medically Necessary medications in emergency situations. e) Having policies and procedures and Grievance and Appeal logs available for inspection during any State Board of Pharmacyaudit or monitoring visit, upon request.

Services for All Members. A. Health Education 1) Contractor shall implement and maintain a health education system that includes programs, services, functions, and resources necessary to provide health education, health promotion and patient education for all Members. 2) Contractor shall ensure administrative oversight of the health education system by a qualified full-time health educator. 3) Contractor shall provide health education programs and services at no charge to Members directly and/or through Subcontracts or other formal agreements contracts with providers Providers that have expertise in delivering health education services to the Member population. 4) Contractor shall ensure the organized delivery of health education programs using educational strategies and methods that are appropriate for Members and effective in achieving behavioral change for improved health. 5) Contractor shall ensure that health education materials are written at the sixth grade reading level and are culturally and linguistically appropriate for the intended audience. 6) Contractor shall maintain a health education system that provides educational interventions addressing the following health categories and topics: a) Appropriate use of health care services – managed health care; preventive and primary health care; obstetrical care; health education services; and, complementary and alternative care. b) Risk-reduction and healthy lifestyles – tobacco use and cessation; alcohol and drug use; injury prevention; prevention of sexually transmitted diseases; HIV and unintended pregnancy; nutrition, weight control, and physical activity; and, parenting. c) Self-care and management of health conditions – pregnancy; asthma; diabetes; and, hypertension. 7) Contractor shall ensure that Members receive point of service education as part of preventive and primary health care visits. Contractor shall provide education, training, and program resources to assist contracting medical providers Providers in the delivery of health education services for Members. 8) Contractor shall maintain health education policies and procedures, and standards and guidelines; conduct appropriate levels of program evaluation; and, monitor performance of providers Providers that are contracted to deliver health education services to ensure effectiveness. 9) Contractor shall periodically review the health education system to ensure appropriate allocation of health education resources, and maintain documentation that demonstrates effective implementation of the health education requirements. 10) Contractor shall ensure that all new Members complete the individual health education behavioral assessment IHEBA within 120 calendar days of enrollment as part of the initial health assessmentIHA; and that all existing Members complete the individual health education behavioral assessment IHEBA at their next non-acute care visit. Contractor shall ensure: 1) that primary care providers Primary Care Providers use the DHCS standardized “Staying Healthy” assessment tools, or alternative approved tools that comply with DHCS approval criteria for the individual health education behavioral assessmentIHEBA; and 2) that the individual health education behavioral assessment IHEBA tool is: : a) administered and reviewed by the primary care provider Primary Care Provider during an office visit, b) reviewed at least annually by the primary care provider Primary Care Provider with Members who present for a scheduled visit, and c) re- re-administered by the primary care provider Primary Care Provider at the appropriate age- age-intervals. 11) Contractor shall cover and ensure provision of comprehensive case management including coordination of care services as described in Exhibit A, Attachment 1122. 12) Contractor shall develop a referral policy to ensure the Member is seen by a dental Provider following an initial dental health screening. The Member shall be referred to a dental Provider to address any immediate dental needs and for comprehensive dental care which will include a comprehensive oral exam. B. The Health Information Form (HIF)/Member Evaluation Tool (MET) Contractor shall use data from the HIF and submitted through the MET a Health Information Form (HIF)/Member Evaluation Tool (MET) to help identify newly enrolled Members who may need expedited services. In accordance with 42 CFR section 438.208(b), Contractor shall, at a minimum, comply with the following: 1) Mail a DHCS-approved HIF/MET to all new Members as a part of Contractor’s welcome packet and include a postage paid envelope for response. 2) Within 90 days of each new Member’s effective date of enrollment: a) Make at least two (2) telephone call attempts to remind new Members to return the HIF/MET and/or collect the HIF/MET information from new Members. This outreach can be done through head of household for Members under the care of parents, custodial parents, legal guardians, or other authorized representatives in accordance with applicable privacy laws. b) Conduct an initial screening of the Member’s needs as identified in the HIF/METs received. To meet this requirement, Contractor may build upon any existing screening process currently used to meet requirements in Exhibit A, Attachment 10, Scope of Services, or Exhibit A, Attachment 11, Case Management and External Coordination of Care. 3) Upon a Member’s disenrollment, Contractor shall make the HIF/MET assessment results available to their new Medi-Cal Managed Care Health Plan upon request. C. Hospice Care 1) Contractor shall cover and ensure the provision of hospice care services as defined in Sections 1905(o)(1) of the Social Security Act. Contractor shall ensure that Members and their families are fully informed of the availability of hospice care as a covered service and the methods by which they may elect to receive these services. Services shall be limited to individuals who have been certified as terminally ill with a life expectancy of 6 months or less if the terminal illness runs its normal course, and who directly or through their representative voluntarily elect to receive such benefits in lieu of other care as specified. However, for a member under age 21, a voluntary election of hospice care shall not constitute a waiver of any rights of that member to be provided with, or to have payment made for covered services that are related to the treatment of that member’s condition for which a diagnosis of terminal illness has been made. For individuals who have elected hospice care, Contractor shall arrange for continuity of medical care, including maintaining established patient-provider Provider relationships, to the greatest extent possible. Contractor shall cover the cost of all hospice care provided. Contractor is also responsible for all medical care not related to the terminal condition. 2) Admission to a nursing facility of a Member who has elected covered hospice services services, as described in Title 22 CCR Section 51349, does not affect the Member's eligibility for enrollment under this Contract. Hospice services are Covered Services under this Contract and are not long term care Long-Term Care (LTC) services regardless of the Member's expected or actual length of stay in a nursing facility. D. Vision Care - Lenses Contractor shall cover and ensure the provision of eye examinations and prescriptions for corrective lenses as appropriate for all Members. Contractor shall must arrange for the fabrication of optical lenses for Members through Prison Industry Authority (PIA) optical laboratories, except when the Member requires lenses not available through PIA. Contractor’s responsibility to arrange for the fabrication of optical lenses for Members through PIA optical laboratories shall be limited to Medi-Cal covered optical and optical lab services. Contractor shall cover the cost of the eye examination and dispensing of the lenses for Membersfabricated by PIA. DHCS will reimburse PIA for the fabrication of the optical lenses in accordance with the contract between DHCS and PIA. Contractor must cover the cost of lens material, fabrication, and dispensing of lenses not available through PIA. E. Mental Behavioral Health and Substance Use Services 1) Contractor shall cover Outpatient mild to moderate Non-Specialty Mental Health Services (NSMHS) that are within the scope of practice of Primary Care Providers and mental health care providers, in accordance with the Outpatient Providers. Contractor shall refer Members needing Specialty Mental Health Services requirements as defined in Exhibit E, Attachment 1, Definitionsto the county mental health plan. Contractor’s policies and procedures shall define and describe what the services are to be provided by Primary Care Providers. In addition, Contractor shall cover Providers and ensure the provision of psychotherapeutic drugs prescribed by its Primary Care Providers or other mental health care professionals, except those specifically excluded in this Contract as stipulated belowProviders. 2) Contractor shall cover and pay for all Medically Necessary Mental Health Covered Services for the Member, including the following services: a) Emergency room professional services as described in Title 22 CCR Section section 53855, except 22 CCR section 53216, and 28 CCR section 1300.67(g). The requirement to provide emergency room professional services provided also includes all professional, physical, mental, and substance use disorder treatment services, including screening examinations necessary to determine the presence or absence of an Emergency Medical Condition and, if an Emergency Medical Condition exists, for all services Medically Necessary to stabilize the Member. Emergency Services includes Facility and professional services and facility charges claimed by psychiatrists, psychologists, licensed clinical social workers, marriage, family and child counselors, or other specialty mental health providersemergency departments. b) Facility charges for emergency room visits which do not result in a psychiatric admission. c) All laboratory and radiology services when these services are necessary for the diagnosis, monitoring, or treatment of a Member's mental health condition. d) Emergency medical transportation Medical Transportation services necessary to provide access to all Medi-Cal Covered Services, including emergency mental health services, as described in Title 22 CCR Section 51323. e) All non-emergency medical transportation NEMT services, as provided for in Title 22 CCR Section 51323, required by Members to access Medi-Cal covered mental health and substance use disorder services. These services include outpatient opioid detoxification, tobacco cessation, and Alcohol Misuse Screening and Counseling (AMSC) services, and are subject to a written prescription by Contractor’s mental health provider or substance use disorder Provider within Contractor’s mental health provider networkand substance use disorder Provider Network. NEMT services are subject to a written prescription and Prior Authorization, except when for NEMT services provided between acute care hospitals immediately following an emergency room visit from which an inpatient transfer is occurring, or an inpatient stay at the transportation is required acute level of care to transfer the Member from one facility imbedded psychiatric units, free standing psychiatric inpatient hospitals, psychiatric health facilities, and any other appropriate inpatient acute psychiatric facilities. The written prescription must be contained in a Physician Certification Statement form, which must be completed by a Member’s Provider to another, for the purpose of reducing the local Medi-Cal mental health program’s cost of providing servicesrequest NEMT. f) Medically Necessary Covered Services after Contractor has been notified by a specialty mental health provider Specialty Mental Health Provider that a Member has been admitted to a an inpatient psychiatric inpatient hospitalfacility, including an Institution for Mental Diseases (IMD) as defined by Title 9 CCR Section 1810.222.1, regardless of the age of the Member. These services include, but are not limited to: i The initial health history and physical examination required upon admission and any consultations related to Medically Necessary Covered Services. However, notwithstanding this requirement, Contractor shall not be responsible for room and board charges for psychiatric inpatient hospital stays by Members. g) All Medically Necessary Medi-Cal covered psychotherapeutic drugs for Members not otherwise excluded under this Contract. i. This includes reimbursement for covered psychotherapeutic drugs prescribed by out-of-plan psychiatrists for Members. ii. Contractor may require that covered prescriptions written by out-of-plan psychiatrists be filled by pharmacies in Contractor’s provider network. iii. Reimbursement to pharmacies for those psychotherapeutic drugs listed in the Medi-Cal Provider Manual, MCP: Two-Plan Model, Capitated /Noncapitated Drugs section, which lists excluded psychiatric drugs, shall be reimbursed through the Medi-Cal FFS program, whether these drugs are provided by a pharmacy contracting with Contractor or by an out-of-plan pharmacy provider. To qualify for reimbursement under this provision, a pharmacy must be enrolled as a Medi-Cal provider in the Medi-Cal FFS program. h) Paragraphs c), e), and f) above shall not be construed to preclude Contractor from: (1) requiring that Covered Services be provided through Contractor's provider network, to the extent possible, or (2) applying utilization review controls for these services, including prior authorization, consistent with Contractor's obligation to provide Covered Services under this Contract. 3) Contractor shall develop and implement a written internal policy and procedure to ensure that Members who need Specialty Mental Health Services (services outside the scope of practice of Primary Care Providers) are referred to and are provided mental health services by an appropriate Medi-Cal FFS mental health provider or to the local mental health plan for Specialty Mental Health Services in accordance with Exhibit A, Attachment 11, Case Management and Coordination of Care, Provision 6. Specialty Mental Health. 4) Contractor shall establish and maintain mechanisms to identify Members who require non-covered psychiatric services and ensure appropriate referrals are made. Contractor shall continue to cover and ensure the provision of primary care and other services unrelated to the mental health treatment and coordinate services between the Primary Care Provider and the psychiatric service provider(s). Contractor shall enter into a Memorandum of Understanding with the county mental health plan in accordance with Exhibit A, Attachment 12, Local Health Department Coordination, Provision 3. Local Mental Health Plan Coordination. F. Tuberculosis (TB) 1) TB screening, diagnosis, treatment and follow-up are covered under this Contract. Contractor shall provide TB care and treatment in compliance with the guidelines recommended by American Thoracic Society and the Centers for Disease Control and Prevention. 2) Contractor shall coordinate with Local Health Departments in the provision of direct observed therapy as required in Exhibit A, Attachment 11, Case Management and Coordination of Care, Provision 16. Direct Observed Therapy (DOT) for Treatment of Tuberculosis (TB) and Attachment 12, Local Health Department Coordination. G. Pharmaceutical Services and Provision of Prescribed Drugs 1) Contractor shall cover and ensure the provision of all prescribed drugs and Medically Necessary pharmaceutical services. Contractor shall provide pharmaceutical services and prescription drugs in accordance with all Federal and State laws and regulations including, but not limited to the California State Board of Pharmacy

Services for All Members. A. Health Education 1) Contractor shall implement and maintain a health education system that includes programs, services, functions, and resources necessary to provide health education, health promotion and patient education for all Members. 2) Contractor shall ensure administrative oversight of the health education system by a qualified full-time health educator. 3) Contractor shall provide health education programs and services at no charge to Members directly and/or through Subcontracts or other formal agreements with providers Providers that have expertise in delivering health education services to the Member population. 4) Contractor shall ensure the organized delivery of health education programs using educational strategies and methods that are appropriate for Members and effective in achieving behavioral change for improved health. 5) Contractor shall ensure that health education materials are written at the sixth grade reading level and are culturally and linguistically appropriate for the intended audience. 6) Contractor shall maintain a health education system that provides educational interventions addressing the following health categories and topics: a) Appropriate use of health care services – managed health care; preventive and primary health care; obstetrical care; health education services; and, complementary and alternative care. b) Risk-reduction and healthy lifestyles – tobacco use and cessation; alcohol and drug use; injury prevention; prevention of sexually transmitted diseases; HIV and unintended pregnancy; nutrition, weight control, and physical activity; and, parenting. c) Self-care and management of health conditions – pregnancy; asthma; diabetes; and, hypertension. 7) Contractor shall ensure that Members receive point of service education as part of preventive and primary health care visits. Contractor shall provide education, training, and program resources to assist contracting medical providers Providers in the delivery of health education services for Members. 8) Contractor shall maintain health education policies and procedures, and standards and guidelines; conduct appropriate levels of program evaluation; and, monitor performance of providers Providers that are contracted to deliver health education services to ensure effectiveness. 9) Contractor shall periodically review the health education system to ensure appropriate allocation of health education resources, and maintain documentation that demonstrates effective implementation of the health education requirements. 10) Contractor shall ensure that all new Members complete the individual health education behavioral assessment IHEBA within 120 calendar days of enrollment as part of the initial health assessmentIHA; and that all existing Members complete the individual health education behavioral assessment IHEBA at their next non-acute care visit. Contractor shall ensure: 1) that primary care providers Primary Care Providers use the DHCS standardized “Staying Healthy” assessment tools, or alternative approved tools that comply with DHCS approval criteria for the individual health education behavioral assessmentIHEBA; and 2) that the individual health education behavioral assessment IHEBA tool is: : a) administered and reviewed by the primary care provider Primary Care Provider during an office visit, b) reviewed at least annually by the primary care provider Primary Care Provider with Members who present for a scheduled visit, and c) re- re-administered by the primary care provider Primary Care Provider at the appropriate age- age-intervals. 11) Contractor shall cover and ensure provision of comprehensive case management including coordination of care services as described in Exhibit A, Attachment 11. B. The Health Information Form (HIF)/Member Evaluation Tool (MET) Contractor shall use data from the HIF and submitted through the MET a Health Information Form (HIF)/Member Evaluation Tool (MET) to help identify newly enrolled Members who may need expedited services. In accordance with 42 CFR 438.208(b), Contractor shall, at a minimum, comply with the following: 1) Mail a DHCS-approved HIF/MET to all new Members as a part of Contractor’s welcome packet and include a postage paid envelope for response. 2) Within 90 days of each new Member’s effective date of enrollment: a) Make at least two (2) telephone call attempts to remind new Members to return the HIF/MET and/or collect the HIF/MET information from new Members. This outreach can be done through head of household for Members under the care of parents, custodial parents, legal guardians, or other authorized representatives in accordance with applicable privacy laws. b) Conduct an initial screening of the Member’s needs as identified in the HIF/METs received. To meet this requirement, Contractor may build upon any existing screening process currently used to meet requirements in Exhibit A, Attachment 10, Scope of Services, or Exhibit A, Attachment 11, Case Management and Coordination of Care. 3) Upon a Member’s disenrollment, Contractor shall make the HIF/MET assessment results available to their new Medi-Cal Managed Care Health Plan upon request. C. Hospice Care 1) Contractor shall cover and ensure the provision of hospice care services as defined in Sections 1905(o)(1) of the Social Security Act. Contractor shall ensure that Members and their families are fully informed of the availability of hospice care as a covered service and the methods by which they may elect to receive these services. Services shall be limited to individuals who have been certified as terminally ill with a life expectancy of 6 months or less if the terminal illness runs its normal course, and who directly or through their representative voluntarily elect to receive such benefits in lieu of other care as specified. However, for a member under age 21, a voluntary election of hospice care shall not constitute a waiver of any rights of that member to be provided with, or to have payment made for covered services that are related to the treatment of that member’s condition for which a diagnosis of terminal illness has been made. For individuals who have elected hospice care, Contractor shall arrange for continuity of medical care, including maintaining established patient-provider Provider relationships, to the greatest extent possible. Contractor shall cover the cost of all hospice care provided. Contractor is also responsible for all medical care not related to the terminal condition. 2) Admission to a nursing facility of a Member who has elected covered hospice services services, as described in Title 22 CCR Section 51349, does not affect the Member's eligibility for enrollment under this Contract. Hospice services are Covered Services under this Contract and are not long term care Long-Term Care (LTC) services regardless of the Member's expected or actual length of stay in a nursing facility. D. Vision Care - Lenses Contractor shall cover and ensure the provision of eye examinations and prescriptions for corrective lenses as appropriate for all Members. Contractor shall arrange for the fabrication of optical lenses for Members through Prison Industry Authority (PIA) optical laboratories. Contractor shall cover the cost of the eye examination and dispensing of the lenses for Members. DHCS will reimburse PIA for the fabrication of the optical lenses in accordance with the contract between DHCS and PIA. E. Mental Health and Substance Use Disorder Services 1) Contractor shall cover Outpatient Mental Health Services that are within the scope of practice of Primary Care Providers and mental health care providersProviders, in accordance with the Outpatient Mental Health Services requirements as defined in Exhibit E, Attachment 1, Definitions. Contractor’s policies and procedures shall define and describe what services are to be provided by Primary Care Providers. In addition, Contractor shall cover and ensure the provision of psychotherapeutic drugs prescribed by its Primary Care Providers or other mental health care professionals, except those specifically excluded in this Contract as stipulated below. 2) Contractor shall cover and pay for all Medically Necessary Covered Services for the Member, including the following services: a) Emergency room professional services as described in Title 22 CCR Section 53855, except services provided by psychiatrists, psychologists, licensed clinical social workers, marriage, family and child counselors, or other specialty mental health providersProviders. b) Facility charges for emergency room visits which do not result in a psychiatric admission. c) All laboratory and radiology services when these services are necessary for the diagnosis, monitoring, or treatment of a Member's mental health condition. d) Emergency medical transportation Medical Transportation services necessary to provide access to all Medi-Cal Covered Services, including emergency mental health services, as described in Title 22 CCR Section 51323. e) All non-emergency medical transportation NEMT services, as provided for in Title 22 CCR Section 51323, required by Members to access Medi-Cal covered mental health and substance use disorder services. These services include outpatient opioid detoxification, tobacco cessation, and Alcohol Misuse Screening and Counseling (AMSC) services, and are subject to a written prescription by Contractor’s mental health provider or substance use disorder Provider within Contractor’s mental health provider network, except when the transportation is required to transfer the Member from one facility to another, for the purpose of reducing the local Medi-Cal mental health program’s cost of providing servicesand substance use disorder Provider Network. f) Medically Necessary Covered Services after Contractor has been notified by a specialty mental health provider Specialty Mental Health Provider that a Member has been admitted to a an inpatient psychiatric inpatient hospitalfacility, including an Institution for Mental Diseases (IMD) as defined by Title 9 CCR Section 1810.222.1, regardless of the age of the Member. These services include, but are not limited to: i The initial health history and physical examination required upon admission and any consultations related to Medically Necessary Covered Services. However, notwithstanding this requirement, Contractor shall not be responsible for room and board charges for psychiatric inpatient hospital stays by Members. g) All Medically Necessary Medi-Cal covered psychotherapeutic drugs for Members not otherwise excluded under this Contract. i. This includes reimbursement for covered psychotherapeutic drugs prescribed by out-of-plan psychiatrists for Members. ii. Contractor may require that covered prescriptions written by out-of-plan psychiatrists be filled by pharmacies in Contractor’s provider network. iii. Reimbursement to pharmacies for those psychotherapeutic drugs listed in the Medi-Cal Provider Manual, MCP: Two-Plan Model, Capitated /Noncapitated Drugs section, which lists excluded psychiatric drugs, shall be reimbursed through the Medi-Cal FFS program, whether these drugs are provided by a pharmacy contracting with Contractor or by an out-of-plan pharmacy provider. To qualify for reimbursement under this provision, a pharmacy must be enrolled as a Medi-Cal provider in the Medi-Cal FFS program. h) Paragraphs c), e), and f) above shall not be construed to preclude Contractor from: (1) requiring that Covered Services be provided through Contractor's provider network, to the extent possible, or (2) applying utilization review controls for these services, including prior authorization, consistent with Contractor's obligation to provide Covered Services under this Contract. 3) Contractor shall develop and implement a written internal policy and procedure to ensure that Members who need Specialty Mental Health Services (services outside the scope of practice of Primary Care Providers) are referred to and are provided mental health services by an appropriate Medi-Cal FFS mental health provider or to the local mental health plan for Specialty Mental Health Services in accordance with Exhibit A, Attachment 11, Case Management and Coordination of Care, Provision 6. Specialty Mental Health. 4) Contractor shall establish and maintain mechanisms to identify Members who require non-covered psychiatric services and ensure appropriate referrals are made. Contractor shall continue to cover and ensure the provision of primary care and other services unrelated to the mental health treatment and coordinate services between the Primary Care Provider and the psychiatric service provider(s). Contractor shall enter into a Memorandum of Understanding with the county mental health plan in accordance with Exhibit A, Attachment 12, Local Health Department Coordination, Provision 3. Local Mental Health Plan Coordination. F. Tuberculosis (TB) 1) TB screening, diagnosis, treatment and follow-up are covered under this Contract. Contractor shall provide TB care and treatment in compliance with the guidelines recommended by American Thoracic Society and the Centers for Disease Control and Prevention. 2) Contractor shall coordinate with Local Health Departments in the provision of direct observed therapy as required in Exhibit A, Attachment 11, Case Management and Coordination of Care, Provision 16. Direct Observed Therapy (DOT) for Treatment of Tuberculosis (TB) and Attachment 12, Local Health Department Coordination. G. Pharmaceutical Services and Provision of Prescribed Drugs 1) Contractor shall cover and ensure the provision of all prescribed drugs and Medically Necessary pharmaceutical services. Contractor shall provide pharmaceutical services and prescription drugs in accordance with all Federal and State laws and regulations including, but not limited to the California State Board of Pharmacy