INNOVATIVE RESOURCE GROUP, LLC dba APS Healthcare Midwest, LLC

09-86163 Page 1

Exhibit A Scope of Work

1. Service Overview Contractor agrees to provide to the Department of Health Care Services (DHCS) the services described herein. The Contractor shall develop, test, implement and maintain a Coordinated Care Management Program-Serious Mental Illness (CCMP-SMI). Coordinated Care Management (CCM) services will be provided to Seniors and Persons with Disabilities (SPD) with chronic health conditions and Serious Mental Illnesses (SMI). The Contractor shall be responsible for, but not limited to, providing the following services: a. b. c. d. e. Contract Administration Management Information Systems (MIS) Quality Improvement System (QIS) Utilization Monitoring (UM) Member Services 1) Member Rights 2) Marketing 3) Scope of Services 4) Access and Availability f. Provider Services g. Implementation Plan and Deliverables 2. Service Location CCM services shall be delivered to members that reside in Kern, Kings, Madera, Stanislaus and Tulare counties. DHCS retains the sole and exclusive right under this Contract to expand the service location of this Contract beyond Kern, Kings, Madera, Stanislaus and Tulare counties. Any determination to expand the service location of this contract outside of Kern, Kings, Madera, Stanislaus and Tulare counties to any additional counties from which DHCS may identify Potential Members and CCM services shall be delivered by Contractor, shall be at the sole discretion of DHCS, and may be based upon an insufficient number of Potential Members in Kern, Kings, Madera, Stanislaus and Tulare counties, or for any other reason.

3.

Service Hours The health advice service will be operated 24 hours a day, 7 days a week. All other services shall be provided during normal Contractor working hours, Monday through Friday, excluding national holidays.

INNOVATIVE RESOURCE GROUP, LLC dba APS Healthcare Midwest, LLC

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Exhibit A Scope of Work

4.

Project Representatives A. The project representatives during the term of this agreement will be: Department of Health Care Services Luis Rico, Chief Telephone: (916) 449-5240 Fax: (916) 552-9244 E-mail: Luis.Rico@dhcs.ca.gov B. Direct all inquiries to: Department of Health Care Services Systems of Care Division Attention: Luis Rico Mail Station Code 4517 1501 Capitol Avenue P.O. Box 997419 Sacramento, CA 95899-7419 Telephone: (916) 449-5240 Fax: (916) 552-9244 E-mail: Luis.Rico@dhcs.ca.gov Innovative Resource Group, LLC dba APS Healthcare Midwest Attention: Richard Surles 44 South Broadway, Suite 1200 White Plains, NY 10601 Telephone: (800) 305-3720 x3119 Fax: (914) 288-4605 E-mail: publicsector@apshealthcare.com Innovative Resource Group, LLC dba APS Healthcare Midwest Richard Surles, Chief Development Officer Telephone: (800) 305-3720x3119 Fax: (914) 288-4605 E-mail: publicsector@apshealthcare.com

C. Either party may make changes to the information above by giving written notice to the other party. Said changes shall not require an amendment to this agreement. D. All notices to be given under this Contract will be in writing and will be deemed given when mailed to DHCS or the Contractor: Department of Health Care Services Attention: Luis Rico Mail Station 4517 1501 Capitol Avenue P.O. Box 997413 Sacramento, CA 95899-7419 Innovative Resource Group, LLC dba APS Healthcare, Inc. Attn: Richard Surles 44 South Broadway, Suite 1200 White Plains, NY 10601

INNOVATIVE RESOURCE GROUP, LLC dba APS Healthcare Midwest, LLC

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Exhibit A Scope of Work

5. Scope of Work Contract Performance A. Contract Administration Contractor shall maintain the organizational and administrative capabilities to perform its duties and responsibilities under the Contract. This will include, at a minimum, the following: . Organization and Staffing Contractor shall maintain the organization and staffing for implementing and operating the Contract. Contractor shall ensure the following: a. Organization has an accountable governing body; b. Staffing in medical and other health services, and in fiscal and administrative services, is sufficient to result in the effective conduct of the organizations business; and c. Written procedures for the conduct of the business of the organization, which provides effective controls. 2. Medical Oversight a. Contractor shall ensure that medical decisions, including those by subcontractors, are not unduly influenced by fiscal and administrative management. b. Contractor shall maintain a physician as Medical Director, who is licensed in California but is not required to be located in California. Responsibilities of the Medical Director shall include, but not be limited to, the following: 1) Ensuring that medical decisions are rendered by qualified medical personnel; 2) Ensuring that medical decisions are not influenced by fiscal or administrative management considerations; 3) Ensuring that medical protocols and rules of conduct for medical personnel are followed; 4) Resolving disputes related to the Member and provider services; and 5) Direct involvement in the implementation of Quality Improvement activities. c. Contractor shall report to DHCS any changes in the status of the Medical Director within ten (10) calendar days.

INNOVATIVE RESOURCE GROUP, LLC dba APS Healthcare Midwest, LLC

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Exhibit A Scope of Work

3. Reporting Requirements Many of the data elements required below may be combined into grouped reports of related elements. Additionally, the Contractor may use electronic spreadsheets to track and report necessary data elements. All reports provided to DHCS must be user friendly (easily viewable and printable) and not contain excessive amounts of unsolicited data. The Contractor will submit the following reports: a. Monthly Reports The Contractor shall send monthly reports to DHCS that include the following information. DHCS must receive these monthly reports by the tenth calendar day of each month. 1) Identification of Potential Members, including but not limited to the listing provided by DHCS, and the method and date of initial contact with the Potential Member; 2) Identification of Members enrolled in the CCMP-SMI, or the date the Potential Member opted-out; 3) Identification of Provider/Primary Care Provider (PCP) providing CCM services to CCMP-SMI Members; 4) Identification of individual Member 30-day assessment, due dates and completion dates; 5) Identification of individual Member 60-day Individual Treatment Plan (ITP) deadline date and ITP initiation date; 6) Identification of Members who have been disenrolled, disenrollment date and the reasons for disenrollment. (This report is intended to report disenrollments after they have occurred. All Contractor requests for disenrollment must be approved by DHCS through a separate process. See Member Services - Scope of Services - Enrollment/Disenrollment below); 7) Health advice service activity, including the number and type of calls; 8) Identification of Members Care Manager and/or Care Management team; 9) Risk level assessment; and 10) Other reports to be determined by DHCS.

INNOVATIVE RESOURCE GROUP, LLC dba APS Healthcare Midwest, LLC

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Exhibit A Scope of Work

b. Quarterly Reports The Contractor shall send quarterly reports to DHCS that include the following information. DHCS must receive these quarterly reports within thirty (30) calendar days after the end of the operational quarter. 1) Provider training; 2) Quality Improvement activities; 3) Quality Improvement Project; 4) Incidence of sentinel events and mortality; and 5) Other reports to be determined by DHCS. c. Semi-Annual Reports The Contractor shall send semi-annual reports to DHCS that include the following information. DHCS must receive semi-annual reports within sixty (60) calendar days after the end of each 6-month operational period: 1) Member status reports (e.g. progress, participation, education received, referrals made, etc.); and 2) Other reports to be determined by DHCS. d. Annual Report The Contractor shall send annual reports to DHCS that include the following information. DHCS must receive these annual reports within ninety (90) calendar days after the end of each twelve (12) month operational period: 1) Quality improvement summary; 2) Contractor operational self-assessment; and 3) Other reports to be determined by DHCS. e. Performance Measures The Contractor is required to provide performance measurement data on claims-based outcomes, process and clinically-based outcome measures, and other non-clinical outcome measures. (See Appendix 4 for a list of Potential CCMP-SMI Performance Measures). 1) Contractor will develop measures and provide individual member level data on a minimum of three outcome measures for each

INNOVATIVE RESOURCE GROUP, LLC dba APS Healthcare Midwest, LLC

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Exhibit A Scope of Work

eligible chronic disease and each eligible serious mental illness listed in Provision 5.G.2.c & d below. (Note: A sample of the measures developed will serve as the basis for the Pay for Performance Calculation Methodology described in Exhibit B, Attachment I, Provision 9). 2) Only one outcome measure per eligible chronic disease/mental illness may be a claims-based measure. 3) Contractor will provide a minimum of two (2) laboratory values on at least three (3) eligible chronic conditions and at least three (3) mental illnesses for a specified percentage of the enrolled population per 12 month operational period. a. The specified percentage of the enrolled population and methodology for reporting laboratory values will be agreed on by the Contractor, the Evaluator, and DHCS. DHCS will have final approval of the percentage and reporting methodology which shall not be unreasonably withheld. 4) The independent evaluator will report on the selected claims-based measures using administrative claims data. 5) Contractor will provide baseline data on all non claims-based measures. 6) Measures will be agreed on by the Contractor, the Evaluator, and DHCS. DHCS shall have final approval of all measures and approval shall not be unreasonable withheld. B. Management Information Systems 1. General Requirements Contractor shall develop a Management Information System (MIS) on behalf of the DHCS and shall have processes that support the interactions between Financial, Member and Provider, Eligibility, Encounter Claims, Quality Improvement, Utilization Monitoring and Report Generation subsystems. The interactions of the subsystems must be compatible, efficient and successful. Contractor shall develop and maintain a MIS that provides, at a minimum: a. DHCS reporting requirements as specified in Exhibit A, Provision 5.A.3; b. All CCMP-SMI eligibility data including but not limited to data contained in Exhibit A, Provision 5.G.2; c. Information on Members enrolled in the CCMP-SMI, such as Member assessments, status, care management activities, and outcomes;

INNOVATIVE RESOURCE GROUP, LLC dba APS Healthcare Midwest, LLC

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Exhibit A Scope of Work

d. Financial information as specified in Exhibit E, Provision 27; and e. Utilization data sufficient to identify under or over utilization of medication, services or durable medical equipment. 2. MIS/Data Correspondence Upon receipt of written notice by DHCS of any problems related to the submittal of data to DHCS, or any changes or clarifications related to Contractors MIS system, Contractor shall submit to DHCS a Corrective Action Plan with measurable benchmarks within thirty (30) calendar days from the date of the postmark of DHCS written notice to Contractor. Within thirty (30) calendar days of DHCS receipt of Contractors Corrective Action Plan, DHCS shall approve the Corrective Action Plan or request revisions. Within fifteen (15) calendar days after receipt of a request for revisions to the Corrective Action Plan, Contractor shall submit a revised Corrective Action Plan for DHCS approval. 3. Health Insurance Portability and Accountability Act of 1996 (HIPAA) Contractor shall comply with Exhibit G - HIPAA Business Associate Addendum requirements and all Federal and State regulations promulgated from this Act, as they become effective. C. Quality Improvement System 1. General Requirements Contractor shall implement an effective Quality Improvement System (QIS). Contractor shall monitor and evaluate all services delivered to Members to ensure contract requirements are met and to evaluate the quality of CCM services rendered. Contractor shall be accountable to address any needed improvements in meeting contract requirements, CCMP-SMI goals, and improvements in quality of CCMP-SMI services regardless of the number of contracting and subcontracting layers between the Contractor and Member. This provision does not create a cause of action against the Contractor on behalf of a CCMP-SMI Member for malpractice committed by a Subcontractor. 2. Written Description Contractor shall develop and implement a written description of its QIS that shall include the following: a. Organizational commitment to the delivery of quality CCMP-SMI services as evidenced by goals and objectives, which are approved by Contractors governing body and periodically evaluated and updated; b. Quality Improvement Committee meets at least quarterly;

INNOVATIVE RESOURCE GROUP, LLC dba APS Healthcare Midwest, LLC

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Exhibit A Scope of Work

c. System for provider review of QIS findings, which at a minimum, demonstrates provider and other appropriate professional involvement and includes provisions for providing feedback to staff and providers regarding QIS study outcomes; d. Designates a senior-level management member with the authority and responsibility for the overall operation of the quality management program; and e. Activities designed to assure the provision of care management and coordination of services Including but not limited to: 1) Identification of key indicators and measures of consumer and Member service, which may include clinical care, complaint rates, and adverse events; 2) Action plans to improve or correct identified problems; 3) Mechanisms to communicate the results of such activities to the governing body and staff; and 4) Tracking and trending of data related to Member service and health care services. 3. Delegation of Quality Improvement Activities a. Contractor is accountable for all quality improvement functions and responsibilities (e.g. Utilization Monitoring, reports, and outcome measures) that are delegated to Subcontractor(s). If Contractor delegates quality improvement functions, Contractor and delegated entity (Subcontractor) shall include in their Subcontract, at a minimum: 1) Quality improvement responsibilities, and specific delegated functions and activities of the Contractor and Subcontractor; 2) Contractors oversight, monitoring, and evaluation processes and Subcontractors agreement to such processes; 3) Contractors reporting requirements and approval processes. The agreement shall include Subcontractors responsibility to report findings and actions taken as a result of the quality improvement activities at least quarterly; and 4) Contractors action/remedies if Subcontractors obligations are not met. b. Contractor shall maintain a system to ensure accountability for delegated quality improvement activities, that at a minimum:

INNOVATIVE RESOURCE GROUP, LLC dba APS Healthcare Midwest, LLC

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Exhibit A Scope of Work

1) Evaluates, on an annual basis, the Subcontractors ability to perform the delegated activities including an initial review to assure that the Subcontractor has the administrative capacity, task, experience, and budgetary resources to fulfill its responsibilities; 2) Ensures Subcontractor meets standards set forth by Contractor and DHCS; and 3) Includes the continuous monitoring, evaluation and approval of the delegated functions.

4. Quality Improvement Annual Report

Contractor shall develop a quality improvement report for submission to DHCS on an annual basis. The annual report shall include: a. A comprehensive assessment of the quality improvement activities undertaken and an evaluation of areas of success and needed improvements in services rendered within the quality improvement program, including but not limited to, the collection of aggregate data on utilization; the review of quality of services rendered; performance measures as referenced in Exhibit A, Provision 5.A.3.e; and outcomes/findings from Quality Improvement projects. b. Copies of all final reports of non-governmental accrediting agencies (e.g. JCAHO, NCQA, URAC) relevant to the Contractors Medi-Cal line of business, including accreditation status and any deficiencies noted. Include the corrective action plan developed to address noted deficiencies. c. An assessment of subcontractors performance of delegated quality improvement activities. 5. Provider Participation Contractor shall maintain and implement appropriate procedures to keep providers serving CCMP-SMI Members informed of the written QIS, its activities, and outcomes. 6. Quality Improvement Projects (QIPs) a. For this contract, Contractor is required to maintain and conduct two Quality Improvement Projects (QIPs) approved by DHCS. b. Among the two QIPs: 1) One must be clinical (i.e. to improve services or interventions) such as development of practice guidelines, assessment tools, etc.).

INNOVATIVE RESOURCE GROUP, LLC dba APS Healthcare Midwest, LLC

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Exhibit A Scope of Work

2) One must be non-clinical (i.e. availability, accessibility or cultural competency of services, etc.). c. Appropriate timelines will be determined based on the nature of the problem and interventions selected. QI projects will typically last 12-30 months; rapid cycle improvement projects are permissible and encouraged. d. After obtaining DHCS approval, an initial QIP report is to be submitted within three months of QIP initiation. Thereafter, QIP reports will be due on a quarterly basis, or according to a timeline agreed upon by the Contractor and DHCS. At a minimum, the Contractor must submit annual QIP reports. 7. Monitoring and Evaluation DHCS will arrange for an independent assessment/evaluation of the CCMP-SMI. The measures to be evaluated will include, but not be limited to, cost effectiveness and process and outcome measures for clinical, financial, humanistic, program implementation and plan operation variables. The final list of measures within each category will be agreed on by the Contractor, DHCS and the independent evaluation contractor. The DHCS will have final approval of all evaluation measures and approval shall not be unreasonably withheld. The Contractor will cooperate with the independent assessment/evaluation process by providing necessary data and furnishing information on program operations as required by DHCS or the independent evaluator. D. Utilization Monitoring Utilization Monitoring (UM) allows an organization to monitor the provision of services. Reports and data on service utilization can provide the Contractor with vital information about the delivery of services. Utilization data can determine where health care dollars are being spent, which health care practitioners are providing the most appropriate health care, where Medi-Cal beneficiaries seem to prefer to access health care services, what services are being accessed, and what services may be utilized or delivered inappropriately. The CCMP-SMI emphasizes utilization monitoring as an important tool in detecting areas that need improvement. Contractor shall develop and implement strategies based on utilization monitoring to minimize under/over utilization of emergency department services, acute care hospitalizations, specialist services, medication and other goods and services. At a minimum, the Contractor will track and trend the following: 1. Utilization per member per month in total, by diagnosis and type of service; 2. Gaps in care (recommended treatment/preventive care versus actual treatment); and 3. Inappropriate use of medications (per applicable clinical guidelines).

INNOVATIVE RESOURCE GROUP, LLC dba APS Healthcare Midwest, LLC

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Exhibit A Scope of Work

Contractor will not have the authority to approve, modify or deny services to Members. All Treatment Authorization Requests (TARs) will be processed through the existing Medi-Cal prior authorization system. E. Member Services Member Rights 1. Member Rights and Responsibilities Contractor shall develop, implement and maintain written policies that address Member rights and responsibilities and shall communicate these to its Members. a. Contractors written policies regarding Member rights shall include the following: 1) To be treated with respect, giving due consideration to the Members right to privacy and the need to maintain confidentiality of the Members medical information; 2) DHCS approved policy for resolving disputes; 3) To be provided with information about the organization and its services; 4) To receive oral interpretation services for identified threshold languages as listed in Appendix 1-Glossary; 5) To have access to, and when legally appropriate, receive copies of, amend or correct their Member record; 6) To disenroll at any time; 7) To receive written materials in alternative formats, including threshold language, Braille, large size print, and audio format within fourteen (14) days of request; and 8) To be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation. b. Contractors written policy regarding Member responsibilities shall include, but not limited to, the following: 1) Providing accurate information to staff; 2) Treating staff with respect; 3) Cooperating with care management processes; 4) Participating in the development and the implementation of their ITP; 5) Cooperating with their health care providers; and

INNOVATIVE RESOURCE GROUP, LLC dba APS Healthcare Midwest, LLC

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Exhibit A Scope of Work

6) Cooperating with the process to resolve member disputes. c. Contractor shall develop, implement and maintain policies and procedures to ensure the Members right to confidentiality of medical information. 1) Contractor shall develop, implement and maintain procedures that guard against disclosure of confidential information to unauthorized persons. 2) Contractor shall inform Members of their right to confidentiality and Contractor shall obtain Members consent prior to release of confidential information, unless such authorization is not required. d. Contractor shall maintain the capability to provide Member services to CCMP-SMI Members through sufficient assigned and knowledgeable staff. e. Contractor shall ensure Member services staff is trained and knowledgeable on all contractually required Member service functions including, policies, procedures, and scope of benefits of this Contract. f. Contractor shall provide all new CCMP-SMI Members with a written Member Services Guide. In addition, the Contractor shall provide Potential Members with a written Member Services Guide upon request. 1) Contractor shall distribute the Member information no later than seven (7) calendar days after the effective date of the Members Enrollment. Contractor shall revise this information, at least annually, and distribute it annually to each Member. 2) Contractor shall ensure that all written Member information is provided to Members at a sixth grade reading level or as determined appropriate by existing Medi-Cal standards. 3) The written member informing materials shall be translated into the identified threshold languages upon request by the Member or Potential Member (Provision H - Member Services, Access and Availability, Linguistic Services). 4) The written member informing materials shall be provided in alternative formats, threshold languages, including Braille, large size print, and audio format, within fourteen (14) days of request. g. Contractor shall develop and provide each Member a Member Services Guide that constitutes a fair disclosure of the provisions of the covered CCMP-SMI services. The Member Services Guide shall be submitted to DHCS for review and subsequent approval prior to distribution to Members. The Member Services Guide shall include the following information:

INNOVATIVE RESOURCE GROUP, LLC dba APS Healthcare Midwest, LLC

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Exhibit A Scope of Work

1) Description of the CCMP-SMI covered services and benefits and how to access them; 2) The importance of establishing a medical home and information on how to contact the Contractor for assistance in this process; 3) Information explaining the importance and value of scheduling and keeping appointments; 4) Procedures for obtaining emergency health care; 5) Procedures for obtaining any transportation services available through the Medi-Cal program, and how to obtain such services. Include a description of both medical and non-medical transportation services and the conditions under which non-medical transportation is available; 6) The causes for which a Member shall lose entitlement to receive services under this Contract as stipulated in Provision G - Member Services Scope of Services, Enrollment/Disenrollment; 7) Procedures for Disenrollment, including an explanation of the Members right to disenroll without cause at any time; 8) Information on the availability of, and procedures for obtaining, services at Federally Qualified Health Clinics (FQHC) and Rural Health Clinics (RHC); and 9) Any other information determined by DHCS to be essential for the proper receipt of CCMP-SMI services. h. Contractor shall develop and provide each Member a Provider Directory with information on Providers/Specialists currently providing services to Medi-Cal beneficiaries in the Contract area. The Provider Directory shall be updated annually and submitted to DHCS both electronically and in hard copy for review and subsequent approval prior to distribution to Members. The Provider Directory shall include the following information: 1) Name of provider; 2) Professional license number; 3) Medi-Cal identification and/or National Provider Identifier (NPI) number; 4) Group name: Name of physician group affiliation or if Physician is independent; 5) Type of service as determined by board certification and eligibility; 6) Hospital at which the Physician has admitting staff privileges;

INNOVATIVE RESOURCE GROUP, LLC dba APS Healthcare Midwest, LLC

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Exhibit A Scope of Work

7) Professional address of the physician; 8) Languages other than English spoken at the office; 9) Hours of operation and hours that the Physician is physically at this location; 10) Whether the practice is open or closed to accepting Medi-Cal FFS clients; 11) Number of full-time equivalent non-physician medical practitioners under the supervision of the Physician; and 12) Areas of accessibility for CCMP-SMI Members with disabilities and chronic conditions including: a) b) c) d) e) f) g) h) i) Building walkway/access Parking Reception/waiting area Exam room Restrooms Accessible scales Exam table Auxiliary aides and services Public transportation access

2. Members Records Contractor shall develop, implement and maintain written procedures pertaining to Members records that address the following areas: a. Collection, processing, maintenance, storage, retrieval, identification, and distribution; b. Ensuring that Members records are protected and confidential in accordance with all Federal and State laws; c. Release of information; and d. Ensuring the maintenance of Members records in a legible, current, detailed, organized and comprehensive manner (records may be electronic or paper copy).

INNOVATIVE RESOURCE GROUP, LLC dba APS Healthcare Midwest, LLC

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Exhibit A Scope of Work

F. Member Services - Marketing 1. Marketing Plan Contractor shall develop a marketing plan as specified below. The marketing plan shall be specific to the CCMP-SMI only. Contractor shall implement and maintain the marketing plan only after approval from DHCS. Contractor shall ensure that the marketing plan, procedures, and materials are accurate and do not mislead, confuse, or defraud. Contractor shall submit a marketing plan to DHCS for review and approval on an annual basis. The marketing plan, whether new, revised, or updated, shall describe the Contractors current marketing procedures, activities, and methods. No marketing activity shall occur until the marketing plan has been approved by DHCS; approvals will not be unnecessarily withheld. The marketing plan shall have a table of contents section that divides the marketing plan into chapters and sections. Each page shall be dated and numbered so chapters, sections, or pages when revised, can be easily identified and replaced with revised submissions. Contractors marketing plan shall contain the following items and exhibits: a. Mission Statement or Statement of Purpose for the marketing plan; b. Organizational chart and narrative description; The organizational chart shall include the marketing directors name, address, telephone and facsimile number and key staff positions. The description shall explain how the Contractors internal marketing department operates, identifying key staff positions, roles and responsibilities, and reporting relationships. c. Marketing Locations; All sites for proposed marketing activities such as annual health fairs, and community events, in which the Contractor proposes to participate, shall be listed. d. Marketing Activities; All marketing methods and activities Contractor expects to use, or participate in, shall be described. Contractor shall include a letter or other document that verifies cooperation or agreement between the Contractor and an organization to undertake a marketing activity together and certify or otherwise demonstrate that permission for use of the marketing activity/event site has been granted.

INNOVATIVE RESOURCE GROUP, LLC dba APS Healthcare Midwest, LLC

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Exhibit A Scope of Work

e. Marketing Materials; Copies of all marketing materials the Contractor will use for both English and non-English speaking populations shall be included; and f. Marketing Distribution Methods A description of the methods the Contractor will use for distributing marketing materials shall be included. 2. Miscellaneous DHCS reserves the right to review, approve and/or deny all marketing activities. DHCS approvals shall not be unreasonably withheld. In addition, DHCS reserves the right to request additional documentation as needed to assess the Contractors marketing program. G. Member Services - Scope of Services Contractor shall provide or arrange for all CCMP-SMI covered services to CCMPSMI Members. Contractor will develop policies and procedures to provide CCMPSMI services which include outreach and assessment, enrollment/disenrollment, care management, health advice service, and member education. Contractor will assist Members with referrals to appropriate medical, mental health, chemical dependency service providers, and other social services to meet needs identified in assessment. The Contractor will allow DHCS, upon request, to review all programming logic and algorithms used in the provision of Member Services. 1. Outreach and Assessment a. Outreach Contractor will develop policies and procedures for outreach to Members, providers and community resources regarding program information and operation. b. Assessment Members enrolled in the CCMP-SMI must be assessed initially and periodically, not less than semi-annually, for information about their medical, mental and social condition including, but not limited to: comorbidities, history of substance abuse, support system, risk level, readiness to participate, special needs; and social, cultural, educational and economic issues. The Contractor will be responsible for developing the assessment tool(s). The assessment tool(s) and any subsequent changes to it must be approved by the DHCS and approval shall not be unreasonable withheld. The assessment shall form the basis for developing an Individual Treatment Plan (ITP) and determine the type and intensity of interventions that are

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Exhibit A Scope of Work

appropriate. The Member Assessment will be completed within thirty (30) days of enrollment, and updated at periodic intervals, not less than semiannually, based on risk level and/or change in health status. Assessment information may be compiled from various sources, including but not limited to: telephone contact, claims data, medical record review or survey methodology, but shall not be obtained through the provision of face-to-face direct clinical medical services from the Contractor. 2. Enrollment/Disenrollment DHCS will supply the Contractor with an initial list and, during the program operations phase, with monthly lists, of potential Members. The Contractor shall develop an introductory letter and notify, by mail, all potential Members of their eligibility for CCMP-SMI. The DHCS approved letter shall be the initial contact to the Potential Member. If a potential Member chooses not to be enrolled, they will have thirty (30) days from the postmarked date on the letter sent by the Contractor to opt-out of the program. In addition to the initial contact letter, the Contractor must document three (3) attempts to contact all Potential Members on the lists provided by DHCS with information regarding CCMP-SMI benefits, services and enrollment/disenrollment procedures. At the beginning of the first month following the end of the initial thirty (30) day opt-out period, Potential Members who have not opted-out will be enrolled as CCMP-SMI Members. The Contractor shall enroll a minimum of five hundred (500) CCMP-SMI Members to ensure that there is a statistically valid sample size to evaluate program effectiveness. The total maximum enrollment allowed will be determined by the annual CCMP-SMI funding available and the agreed per member per month (pmpm) administrative fee. The Contractor will provide CCM services to those persons who meet all of the following requirements: a. Are Medi-Cal eligible; b. Are 21 years of age or older; and c. Have a primary or secondary diagnosis of: 1) Cancer; 2) Cerebrovascular Disease (CVD); 3) Congestive heart failure (CHF); 4) Coronary artery disease (CAD); 5) Diabetes mellitus (Diabetes); 6) Asthma; 7) Chronic obstructive pulmonary disease (COPD); 8) Hypertension (HTN); 9) Arthritis; 10) Obesity; 11) Substance Abuse (in the presence of at least one chronic disease listed above);

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Exhibit A Scope of Work

d. Additionally, Seniors and Persons with Disabilities with a chronic condition listed above must also have at least one claim in a thirty (30) month period for one of the following serious mental illnesses: 1) 2) 3) 4) 5) 6) 7) Depression Bipolar Disorder Schizophrenia Dementia Delusional Disorder Nonorganic psychoses Anxiety, Dissociative and Somatoform disorder

e. All Medi-Cal beneficiaries receiving full scope Medi-Cal benefits without a share of cost requirement who meet the qualifications noted above will be considered a Potential Member for the CCMP-SMI, except those who: 1) Have restricted/emergency only Medi-Cal; 2) Are Medicare eligible; 3) Have other insurance that provides comparable CCMP-SMI services (e.g., Medi-Cal Managed Care); 4) Reside in nursing facilities (NF); (in the most recent sic (6) months prior to enrollment); 5) Reside in all levels of Intermediate Care Facilities for the Developmentally Disabled (ICF/DD) in the most recent 6 months prior to enrollment; 6) Have a Medi-Cal eligibility period that is only retroactive; 7) Participate in Medicaid waiver programs, including Home and Community Based, Freedom of Choice and Research and Demonstration waivers; 8) Are enrolled in a hospice program: or 9) Have an HIV diagnosis on a Medi-Cal claim since June 1, 2005 f. As part of the enrollment process noted below, DHCS will screen out MediCal beneficiaries who are not eligible for the program by generating a list of Potential Members according to the actual number of Members will be less than the number of Potential Members that opt-out of the CCMP-SMI and other data irregularities that are not within the control of DHCS. Referrals to the CCMP-SMI from other sources such as self, caregiver, family member, guardian or provider must be approved by DHCS prior to enrollment by the contractor.

g. The minimum number of Members that will be enrolled in the CCMP-SMI are based on the quotas as described in provision G.2 above. The maximum number of Members enrolled in the CCMP-SMI will be limited by the availability of funding. If membership exceeds CCMP-SMI availability, DHCS will develop and implement a process for an enrollment waiting list. h. A Member who, during the time of CCMP-SMI membership, enters a nursing facility for a short-term stay of thirty (30) days or less will not be disenrolled except at the Members request.

INNOVATIVE RESOURCE GROUP, LLC dba APS Healthcare Midwest, LLC

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Exhibit A Scope of Work

i. The Contractor shall complete a Member Assessment within thirty (30) days from the date of enrollment. Through the Member assessment, the Contractor shall determine the Members health status and include confirmation that the Member is qualified for the program (e.g. diagnosed with one of the identified disease conditions). If the Contractor determines that the Member is not medically qualified for the program, as noted above, the Contractor shall coordinate disenrollment with the Contract Administrator. DHCS shall retain control of disenrollment from the CCMP-SMI. j. Within seven (7) business days of receiving a request for disenrollment of a Member or Potential Member from the Contractor or beneficiary, DHCS will make a determination and notify the Contractor. Subsequently, the Contractor shall notify the Member or Potential Member within seven (7) business days of the disenrollment or denial of a request for enrollment with a Notice containing, at a minimum, the following information: 1) Action taken by the Contractor; and 2) Reason for the action taken. k. Members will have the option to end their enrollment each month. To request disenrollment, Members shall notify the Contractor verbally or in writing. The Contractor shall notify DHCS within two (2) business days of the Members request. Disenrollment will occur on the first day of the month following the month the request was made. Former Members who disenrolled voluntarily may reenroll at any time by making a verbal or written request to the Contractor. Reenrollment will take place on the first day of the month following the month the reenrollment request is made. 3. Care Management The Contractor will adopt standards to improve the health of Members by providing CCMP-SMI services based on an Individualized Treatment Plan (ITP) that utilizes evidence-based practice guidelines and includes promoting collaborative relationships with providers, providing Member and Provider education, and employing reporting and feedback loops for decision making with Providers and Members. The Contractor shall assign a Care Manager to each Member to oversee and coordinate CCM activities that include, but are not limited to the following: a. Development and implementation of interventions for the management of serious mental illnesses including chronic illness and disability; b. Development and implementation of interventions for end-of-life assessment and care to facilitate death with dignity in an appropriate setting of the Members choice;

INNOVATIVE RESOURCE GROUP, LLC dba APS Healthcare Midwest, LLC

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Exhibit A Scope of Work

c. Development and implementation of interventions to coordinate Clinical and social services; d. Medication management The Contractor shall develop and implement policies and procedures for the following elements: 1) Medication profiling; 2) Medication monitoring; 3) Feedback to Provider/PCP and/or pharmacist; and 4) Member and Provider education. e. Development of an ITP - Based on the Member assessment, the Contractor shall assure and coordinate the development of the Individual Treatment Plan (ITP) to be completed and in place within sixty (60) days of enrollment. The Member or the Members designee, the Provider/PCP and Care Manager should be actively involved in the development and periodic review of the ITP; 1) The ITP must include specific provisions for periodic (not less than semiannual) review and updates to the plan as appropriate. Intervals of periodic review and ITP updates should be established based on the severity of the Members condition. 2) Participants of the review should include, but not be limited to, the following: a) Member; b) Care Manager; c) Provider/PCP; and d) Representatives providing services to the Member as identified in the ITP (e.g. nutritionist or psychiatrist). 3) The ITP shall take into account: a) b) c) d) e) f) g) h) i) Clinical history, including comorbidities; Health status and risk for secondary disabilities or complications; Risk level; Age; Diagnosis/diagnoses; Functional and/or cognitive status; Mental health; Nutrition and weight management; Language/comprehension barriers;

INNOVATIVE RESOURCE GROUP, LLC dba APS Healthcare Midwest, LLC

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Exhibit A Scope of Work

j) k) l) m) n) o) p) q) r) s) t) u) v) w) Lifestyle issues; Cultural/linguistic needs, preference or limitations; Level of intensity of care management; Immediate service needs; Barriers to care; Use of prior authorized services; Follow-up schedule; Family members/caregiver/facilitator resources and contact information (if appropriate); Local community resources; Psychosocial support resources; Access/availability of needed medical equipment/accessible medical equipment; Self-management skills; Assessment of progress, including input from family if appropriate; Accommodation needs (e.g. appointment time), alternative formats (e.g. Braille, large print, disks, audio, electronic) and auxiliary aids and services; Program, Member and caregiver goals; and Evidenced-based clinical guidelines as available.

x) y) f.

Coordination/Continuity of Care Contractor shall develop and implement policies and procedures related to establishing relationships, developing referral processes, and sharing information with the Provider/PCP, discharge planners, facility staff, Specialists, and State or Community agencies to enable Members to access needed services and ensure continuity of care. The Contractor will ensure continuity of care in collaboration with the Provider/PCP by: 1) Coordinating care so that an ongoing course of treatment is not interrupted or delayed due to the change in new providers; 2) Assisting with the transfer of medical record information to new providers in a timely fashion; 3) Assisting with development and implementation of a patient/disease registry capable of being shared with other providers; 4) Monitoring the referral and follow-up of Members in need of specialty care and routine health care services; 5) Documentation of referral and follow-up services in Members record 6) Documentation in Members record of emergency medical encounters with the appropriate follow-up as medically indicated; 7) Documentation and follow-up in Members record of planned health care services; and

INNOVATIVE RESOURCE GROUP, LLC dba APS Healthcare Midwest, LLC

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Exhibit A Scope of Work

8) Assigning a Care Manager or Care Management team to each Member. g. The Contractor will establish and make available lines of communication to allow interaction between the Contractor, Member, and the Provider/PCP; h. Staffing - at a minimum, the Care Manager will be a licensed registered nurse or other healthcare professional as defined in Section 4999.2 of the California Business and Professions Code. The Contractor shall also employ the services of a licensed psychiatrist, psychologist, or licensed/certified mental health specialist, as needed, to address the behavioral and/or mental health concerns of the Member. All health care personnel providing services to CCMP-SMI Members must be licensed to practice in California. Staff case loads shall not exceed current industry standards for disease or care management organizations; i. j. Development and implementation of interventions for crisis management; Member Advocacy The ITP shall be developed and implemented to be Member-centered. The Contractor shall advocate on behalf of the member, as necessary, to ensure optimal care for the Member; and

k. Collaboration with other disease and/or care management programs to ensure services provided to Members are complementary and not duplicative (e.g. California Mental Health Care Management Program [CalMEND]). 4. Health Advice Service The Contractor must offer a toll-free telephonic health advice service staffed by health care professionals, as defined in California Business and Professions Code Section 4999.2. The service must be operated twenty four (24) hours per day, seven days a week. Operators of the advice service will provide general and personalized health care information. The advice service will also provide education and assistance for CCMP-SMI Members and/or their caregivers. This line must be operated in accordance with current managed care program rules for comparable advice services, including provisions for interpreter services (Business and Professions Code Section 4999.2 and 4999.7 and Section 1348.8 of the Health and Safety Code). The Contractor must develop and implement a timely method of communicating the Member telephone contact information with the Members care manager and ensure the advice service is operated in an efficient and effective manner. 5. Member Education a. 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.

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Exhibit A Scope of Work

b. 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. c. 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 (See Glossary Threshold Language).

d. Contractor shall maintain a health education system that provides

educational interventions addressing the following health categories and topics: 1) Appropriate use of health care services; 2) Risk-reduction and healthy lifestyles; 3) Self-care and management of health conditions; and 4) Advanced Directives for healthcare. e. Contractor shall maintain health education policies and procedures, standards and guidelines; conduct appropriate levels of program evaluation; and, monitor performance of providers that are contracted to deliver health education services to maximize effectiveness. f. Contractor shall periodically, not less than annually, 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.

H.

Member Services - Access and Availability The Contractor shall establish accessibility standards, which include, but are not limited to, the following: 1. Access Requirements a. Assisting Members in finding a medical home b. Telephone Procedures - Contractor shall maintain procedures for triaging Members telephone calls, providing telephone advice and accessing telephone interpreters. c. Contractor shall ensure that all non-English-speaking, or limited English proficient (LEP) CCMP-SMI Members receive 24-hour oral interpreter services, either through interpreters or telephone language services. Contractor shall arrange or provide, at minimum, the following linguistic services at no cost to the CCMP-SMI Members:

INNOVATIVE RESOURCE GROUP, LLC dba APS Healthcare Midwest, LLC

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Exhibit A Scope of Work

1) Fully translated written informational materials, including but not limited to the Member Service Guide, enrollee information, welcome packets, marketing information, and form letters. Contractor shall provide translated written informing materials to all non-English speaking or LEP members that speak the identified threshold language (See Glossary Threshold Language), upon request; 2) Referrals to culturally and linguistically appropriate community service programs; 3) Telecommunications Device for the Deaf (TDD); and 4) Relay service (TTY/711) for persons with speech disabilities. 2. Assist Members to resolve access and disability competency issues 3. Identify areas of provider accessibility for Members with disabilities and chronic conditions including: a. Building walkway/access; b. Parking; c. Reception/waiting area; d. Exam room; e. Restrooms; f. Accessible scales;

g. Exam table; h. Auxiliary aides and services; and i. Public transportation access.

4. Changes in Availability or Location of DM Services Contractor shall provide notification to DHCS sixty (60) calendar days prior to making any substantial change in the availability or location of services to be provided under this Contract. In the event of an emergency or other unforeseeable circumstance, Contractor shall provide notice of the emergency or other unforeseeable circumstance to DHCS as soon as possible.

INNOVATIVE RESOURCE GROUP, LLC dba APS Healthcare Midwest, LLC

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Exhibit A Scope of Work

I.

Provider Services
1. Provider Education Contractor shall provide education and training to Provider/PCP to include, but not be limited to, the following: a. Information on all Member rights, Member services, and the right to actively participate in health care decisions; b. Use of evidence-based practice guidelines; c. Resource tools developed by the Contractor to facilitate the use of evidencebased practice guidelines by the Provider/PCP; d. Evaluation and appropriate treatment or referral of mental health issues; e. The Medi-Cal Treatment Authorization Request (TAR) process; f. Identification and utilization of community resources; and

g. Disability cultural competency and sensitivity training, including information about: 1) Various types of chronic conditions and disabilities prevalent among Medi-Cal beneficiaries; 2) Awareness of personal prejudices; 3) Legal obligations to comply with the Americans with Disabilities Act (ADA); 4) Scope of benefits, including how to refer people to services covered by other state agencies; 5) Definitions and concepts such as communication access, medical equipment access, physical access, and access to programs; and 6) The types of barriers that adults with physical, sensory, communication disabilities, developmental or mental health needs face in the health care arena and the resulting access and accommodation needs. 2. Provider Feedback Contractor shall develop and implement system(s), which will provide information to the Provider/PCP relating to Members adherence to the ITP. Contractor shall employ feedback techniques to the Provider/PCP to improve the quality and appropriateness of the care provided to the Member. J. Implementation Plan and Deliverables The Implementation Plan and Deliverables section describes DHCS requirements for specific deliverables, activities, and timeframes that the Contractor must complete during the Implementation Period before beginning operations.

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Exhibit A Scope of Work

Deliverables are those policies and procedures necessary for the conduct of business including but not limited to those listed in Appendix 5, Summary of Readiness Review Submissions. Once the Contract is awarded, the Contractor has thirty (30) calendar days after the contract effective date to submit a Workplan for each region/county that describes in detail how and when the Contractor will complete and submit the deliverables, including but not limited to those listed in Appendix 5, Summary of Readiness Review Submissions, to DHCS. The Contractors Workplan(s) will include a timetable to accomplish the activities to assure timely start-up of operations and contingency plan(s) in the event of implementation delays. The Contractors workplan(s) will identify all of the deliverables, milestones, and timeframes to achieve an orderly sequence of events that will lead to compliance with all contract requirements. DHCS will review and approve each workplan(s). However, Contractor shall not delay the submission of deliverables required in the workplan(s) while waiting for DHCS approval of previously submitted deliverables required by the workplan(s). Contractor will continue to submit deliverables based on the milestones and timeframes set forth in the approved DHCS workplan(s). In the event the Contractor fails to submit all deliverables in accordance with the milestones and timeframes in the approved DHCS workplan(s), DHCS may impose Liquidated Damages in accordance with Exhibit E - Additional Provisions, Section 20 Liquidated Damages Provisions. The Implementation Period begins with the contract effective date and extends to the beginning of the Operations Period (approximately 4 months after the effective date of the Contract). The Operations Period is the period of time beginning with the effective date of the first month of operations and continues through the last month of services to the Members. Phaseout requirements are identified in Exhibit E, Additional Provisions, Provision 18, Phaseout Requirements. Upon successful completion of the Implementation Plan and Deliverables section requirements and Readiness Review Submissions, DHCS will authorize, in writing, that the Contractor may begin the Operation Period.