ModifiedExecutive Office of Health and Human ServicesPolicy N/A

Amendment No. 21 to the Medicaid Managed Care Agreement (EOHHS – UnitedHealthcare of New England)

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Amendment updating program standards, contract terms, attachments, reimbursement methodologies, compliance and program integrity requirements effective July 1, 2026; affects the Contractor (UnitedHealthcare of New England), MCO operations, providers, and state program administration.

Policy Summary

PayerExecutive Office of Health and Human Services

PolicyAmendment No. 21 to Medicaid Managed Care Agreement (UnitedHealthcare of New England)

Policy CodePolicy N/A

Change TypeMultiple substantive revisions (compliance, program integrity, high-cost drug carve-outs, rates)

Effective DateJul 1, 2026

Next Review Date

Key ActionMCOs must remain responsible for prior authorization for carved-out high-cost drugs using state-developed or approved criteria.

SourceLink

POLICY UPDATE CHANGES

Insertion of 'Inclusion of EPSDT beneficiary rights' into Required Information.

Pharmacy Services paragraph replaced to carve out Cell and Gene Therapy SCD model drugs to be reimbursed at Actual Acquisition Cost outside inpatient bundles with MDRP rebates to the state and MCOs prohibited from collecting rebates.

High-cost drug carve-out requirements: listing on EOHHS website, carve out of capitation, reimbursed at FFS via pass-through, excluded from risk arrangements, with MCO responsibilities for prior authorization, care coordination, reporting, and claims adjudication.

Network composition requirement that providers meet Rhode Island Medicaid location/physical presence and telehealth requirements [210-RICR-20-00-1].

Updates to State Directed Payments table and fee schedule rows as shown in Exhibit A (rate and payment changes across multiple services).

Entire Section 2.18 Compliance deleted and replaced with new Compliance provisions (Exhibit B) including mandatory written compliance plan, Compliance Officer located in Rhode Island, reporting and auditing duties, overpayment reporting, and provider enrollment/suspension requirements.

New Section 2.19 Program Integrity inserted (Exhibit C referenced).

Contract term language updated to note CMS final approval and restate effective period and option years.

Section 3.07.03 Fraud and Abuse is deleted in its entirety.

Doula Services Scope of Benefit replaced to cover all Medicaid members when medically necessary including prenatal, labor/delivery support, and postpartum visits regardless of pregnancy outcome.

Attachment H (Capitation Rates) renamed to SFY 2027 and replaced with references to Rate Book and Tables dated April 24, 2026.

Attachment J incentive payment and risk/gain share provisions updated, specifying sharing percentages across expense bands and limiting incentives to <=105% of approved capitation per 42 CFR §438.6(b)(2).

Compliance obligations under H.R.6 (SUPPORT Act) added, requiring automated DUR safety edits for opioid refills, automated claims review to identify excess refills, monitoring concurrent prescribing (opioids with benzodiazepines/antipsychotics), MME safety edits, and concurrent utilization alerts.

7/1/2026Effective date

SFY 2027Rate book

90 daysCompliance plan deadline

60 daysOverpayment report timeframe

24 hoursPayment suspension window

<=105%Incentive cap

Coverage Criteria and Benefit Changes

Doula Services Coverage

Attachment A benefit update for Doula Services:

Doula Services are covered for all Medicaid members when medically necessary and include prenatal visits, labor and delivery supports, and post-partum visits.

High-Cost Drug Carve-Out Criteria

High-cost drug reimbursement and administrative responsibilities:

High-cost SCD Cell and Gene Therapy model drugs are carved out of capitation and must be paid outside inpatient bundles at Actual Acquisition Cost (AAC) with Medicaid Drug Rebate Program (MDRP) rebates to the State; MCOs are prohibited from collecting rebates on model drugs.

High-cost drugs listed on the EOHHS website shall be reimbursed by the MCO via an FFS pass-through mechanism, excluded from risk arrangements, and reimbursed at a cadence defined by the State that is actuarily sound.

MCO responsibilities for carved-out high-cost drugs include: prior authorization using state-developed or state‑approved criteria; care coordination and case management as needed; reporting and submission of requested data to EOHHS; and timely claims adjudication and reconciliation to seek reimbursement.

State reserved rights

State may conduct audits as necessary to ensure compliance with the pass-through model.
State may modify the structure or cadence of the pass-through model and may seek supplemental materials as needed.

Contractor must adhere to EOHHS guidance and align beneficiary access policies and reimbursement methodologies with Fee-for-Service policies and submit requested data, utilization reports, financials, or other information at the cadence defined by the State.

Disclosure and integrity criteria

Disclosure and enrollment criteria for Contractors and providers:

Contractor must submit completed ownership and control disclosure forms formatted per EOHHS and 42 CFR §455.104 at proposal submission, contract execution, renewal/extension, or within 35 days after any change in ownership.

Contractor must require each disclosing provider entity to disclose: names and addresses (including every business location and P.O. Box where applicable), date of birth and Social Security Number for individuals, tax identification numbers for corporations, names of other entities in which owners have interests, and identities of managing employees (name, address, DOB, SSN), per 42 CFR §455.104.

An individual or entity is considered to have ownership or control interest if they hold direct or indirect ownership of 5% or more, or are a managing employee exercising operational or managerial control (per section 1126(b) and 42 CFR definitions); such thresholds trigger disclosure obligations.

Providers must furnish updated disclosure information when applying, executing provider agreements, during revalidation, upon State request, and within 35 days of ownership change; the Contractor must not approve or must terminate provider agreements if required disclosures are incomplete or not provided.

Providers must disclose persons convicted of crimes related to Federal health care programs before entering into or renewing agreements or upon written request (per 42 CFR §455.106); the Contractor must notify EOHHS in writing within ten (10) business days upon identifying excluded individuals.

Providers must supply information on business transactions exceeding $25,000 in the prior 12 months within 35 days of request under 42 CFR §455.105.

Program Integrity Criteria Set

Contractor program integrity and FWA obligations

The EOHHS Office of Program Integrity oversees all Fraud, Waste, and Abuse (FWA) activities; the Contractor must comply with federal and state requirements (including 42 CFR Part 455 and 42 CFR §438.608) and follow written directions and the Program Integrity Fraud and Abuse Standard Operating Procedure for referrals and reporting.

Contractor shall implement a Fraud Prevention Program meeting federal and state requirements that includes a dedicated Fraud Prevention Officer accountable to senior leadership and participating in required EOHHS oversight meetings.

The Contractor must maintain written FWA policies and procedures including: program integrity risk assessments, annual and ad‑hoc reviews, provider screening and credentialing, ongoing exclusion checks, automated pre- and post-payment claims edits, surveillance/utilization management protocols, desk audits, investigation and follow-up procedures, and provider training and corrective action.

The Contractor must provide a written Fraud, Waste and Abuse Compliance Plan to EOHHS within 90 calendar days of contract execution and annually thereafter; revisions require submission at least 60 calendar days prior to planned implementation and EOHHS will respond within 60 days of receipt.

The Contractor must promptly investigate suspected FWA, report suspected Subcontractor/Member/Provider fraud immediately to EOHHS, cooperate with EOHHS investigations, and use the current SOP for referrals and reporting.

Staffing and operational requirements include: a minimum of five provider site audits per contract year using statistically valid samples (minimum 30 records or 10% of records, sometimes 50 for large populations), at least two additional SIU/audit staff with presence in Rhode Island, and one full-time investigator per 50,000 members located in Rhode Island.

Contractor must perform ongoing exclusion screening (quarterly or monthly checks against Federal and State lists such as OIG, SAM) and maintain an electronic database and monthly reports of owners/agents/managing employees; the Contractor must maintain a publicly available fraud reporting email and review complaints at least weekly.

The Contractor shall report all overpayments identified or recovered to the State within sixty (60) days and obtain EOHHS approval for prepayment reviews, which must be completed within twelve (12) months unless renewed with approval.

Mandatory FWA training approved by the Division of Medicaid's Office of Program Integrity is required for employees, contractors, and board members at onboarding and annually; whistleblower protections and non-retaliation policies must be maintained.

Once suspected fraud is substantiated and reported to EOHHS, the Contractor is restricted from contacting investigation subjects, negotiating settlements, or accepting funds from subjects without prior written EOHHS approval.

Payment suspension, fraud reporting, and provider exclusion criteria

Contractor obligations when EOHHS imposes payment suspensions, when credible allegations of fraud arise, and when providers are excluded/terminated.

Upon receipt of notification from EOHHS that payments to a provider have been suspended, the Contractor must suspend payments to that provider within 24 hours, include claims ready for payment unless EOHHS states otherwise, and immediately inform EOHHS of the action.

Upon receipt of notification from EOHHS that a payment suspension is lifted, the Contractor must lift the suspension within 24 hours and immediately inform the Division/EOHHS.

All information regarding ongoing payment suspensions must be reported monthly on the EOHHS Monthly Program Integrity Report.

The Contractor must report cases where due diligence and investigation reveal a credible allegation of fraud to the Office of Program Integrity immediately; the Office of Program Integrity will determine referrals to the Medicaid Fraud Control Unit per federal regulation.

EOHHS will not reimburse for services rendered by providers excluded or debarred from Medicare or Medicaid (including other states' programs) except Emergency Services; the Contractor must terminate or exclude enrollment of any provider terminated under Medicaid, Medicare, or other states' Medicaid programs.

The Contractor must review the LEIE and OIG Exclusions Database at least monthly and take appropriate provider management actions based on exclusions.

If the Contractor fails to suspend payments or to correctly report adjudicated payments on hold, EOHHS may impose contractual or other remedies, and the Contractor is responsible for returning any money paid in error to a suspended provider.

Rate calculation components

Rate calculation elements present in this excerpt

Rate calculations include population-specific Effective Rate Less CTC, CCBHC PPS PMPM, Adjusted Risk Score, Initial Risk Adjusted Rate, Budget Neutral Vaccine/Neutrality Adjustment, and Initial Budget Neutral Risk Adjusted Rate.

PMPM adjustments shown include Primary Care Assessment PMPM, Adjusted CCBHC PPS PMPM, Adjusted CTC PMPM, Premium Tax PMPM, and conversion to a Risk Adjusted Full Rate and Final Adjusted Rate.

A 0.5% withhold is applied to medical expense to derive Adjusted Rate Less Withhold; medical expense less withhold and adjusted baseline CCBHC PPS medical expense are reported per cohort.

Tables use a February 2026 enrollment snapshot and provide cohort-level numeric PMPM values and adjusted rates for the July–September 2026 period (examples include CSHCN subgroups shown with final adjusted PMPMs).

Rate table criteria and adjustments (partial)

Rate table components and adjustment items shown in the excerpt include:

Rate table cells contain demographic population groups (age/gender cohorts), February 2026 enrollment counts, Effective Rate Less CTC and CCBHC PPS PMPM, Adjusted Risk Score, Initial Risk Adjusted Rate, Vaccine Neutrality Adjustment, and Risk Adjusted Full Rate.

PMPM adjustment line items include Primary Care Assessment PMPM, Adjusted CCBHC PPS PMPM, Adjusted CTC PMPM, Premium Tax PMPM, and Budget Neutrality adjustments leading to a Final Adjusted Rate.

A 0.5% withhold is applied to medical expense, producing an Adjusted Rate Less Withhold and a Withhold‑Adjusted Rate Less Withhold reported alongside the Final Adjusted Rate.

Rate computation components

Rate computation elements included in the tables

Effective Rate Less CTC (base effective rate before CTC and CCBHC PPS) is displayed per population cohort.

CCBHC PPS PMPM adjustments are applied to cohorts as per-line PMPM amounts and incorporated into Initial Risk Adjusted Rates.

Adjusted Risk Score multipliers are applied to compute Initial Risk Adjusted Rates and subsequent Vaccine Neutrality and budget neutrality adjustments.

Vaccine neutrality adjustments and other budget neutrality multipliers are applied to produce the Neutrality-Adjusted Final Adjusted Rate prior to withhold.

Primary Care Assessment PMPM and Premium Tax PMPM amounts are added as PMPM line items when deriving Risk Adjusted Full Rates.

A 0.5% withhold is applied to medical expense to derive Medical Expense Less Adjusted Rate Less Withhold and related medical expense baseline fields are reported per cohort.

Rate component nodes (JSON-encoded)

Rate components and calculations included in the excerpt (examples):

Fields shown include Effective Rate Less CTC and CCBHC PPS PMPM, Adjusted Risk Score (example values like 1.0000 or 0.9939), and Initial Risk Adjusted Rate per cohort.

Budget Neutral Vaccine/Neutrality Adjustment factors are applied (example multiplicative factors shown) to derive Budget Neutral Risk Adjusted Rates and Neutrality-Adjusted Final Adjusted Rates.

Adjusted Premium Tax PMPM and other PMPM line items are added to derive the Risk Adjusted Full Rate; Final Adjusted Rate is reported and a Final 0.5% Withhold and Withhold‑Adjusted Rate Less Withhold are displayed.

Medical Expense components such as Baseline Medical Expense and Medical Expense Less Adjusted Baseline CCBHC PPS are reported for cohorts and used in withhold calculations.

Actuarial rate table components and notes

Rate table components and notes included in this part:

Tables present risk-adjusted rates per cohort (e.g., ME - F 19-24), adjusted risk scores, initial risk adjusted rates, vaccine neutrality adjustments, and budget-neutral adjusted rates, with PMPM adjustments (CCBHC PPS, CTC, Primary Care Assessment, Premium Tax).

Final adjusted rates include application of a 0.5% withhold; tables report both Final Adjusted Rate and Withhold‑Adjusted Rate Less Withhold, and values are rounded.

Rates use a February 2026 enrollment snapshot and SOBRA payments are excluded from the illustrated composite calculations.

Coding, Rates, and Exhibit A

Exhibit A selected service codes and ratesCPT

A0426	NEMT ALS - ambulance rate entries updated in Exhibit A
A0427	Emergency ALS - ambulance rate entries updated in Exhibit A
A0428	NEMT BLS - ambulance rate entries updated in Exhibit A
A0429	Emergency BLS - ambulance rate entries updated in Exhibit A
41899	Generic code allowed in lieu of G-Code for ambulatory dental anesthesia facility fee
G0330	Facility services for dental rehabilitation referenced in Exhibit A

Business transaction disclosure thresholdmixed

>25,000

Business transactions exceeding $25,000 in prior 12 months trigger disclosure requests under 42 CFR 455.105

Claims Edits and Surveillancemixed

No codes listed

ExclusionsmixedNot Covered

Providers excluded or debarred from Medicare/Medicaid (including other states' programs) must not be reimbursed except for Emergency Services.

Rate table (no CPT/ICD codes in window)mixed

No procedure or diagnosis codes included in this excerpt; document contains numeric rate tables only.

not_applicablemixed

No explicit CPT/HCPCS/ICD-10/NDC codes present in this excerpt.

Not applicablemixed

No procedure or diagnosis codes present in this section; content is population-level rate tables and adjustments.

Not applicable (financial/rate tables, no clinical codes in this part)mixed

No CPT/HCPCS/ICD-10/NDC codes contained in this part; document contains actuarial numeric rate cells only.

Not applicablemixed

No CPT/HCPCS/ICD-10/NDC codes contained in this part; document contains actuarial numeric rate cells only.

Uniform percentage increase — 2.6% (selected services effective 7/1/2026); Pediatric 3.2% over 10/1/2025

Uniform percentage increase2.6% increase over 7/1/2025 for selected services (effective 7/1/2026); Pediatric increase 3.2% effective over 10/1/2025.

ScopeApplies to Exhibit A fee schedule rows and State Directed Payment entries as noted in Exhibit A.

Effective datesGeneral uniform increase effective 7/1/2026; Pediatric increase tied to 10/1/2025 (per Exhibit A).

Withhold percentage — 0.5%

Withhold percentage0.5% withhold applied per contract provisions.

ApplicationApplied to medical expense components in rate tables (reduces Medical Expense Less Adjusted Rate Less Withhold).

ReportingWithhold reported alongside withhold-adjusted rate less withhold in actuarial tables (examples shown in rate tables).

Withhold percentage — 0.5%

Withhold percentage0.5% withholding applied to rates/medical expense.

DisplayFinal Adjusted Rate and Withhold-Adjusted Rate Less Withhold are both displayed in rate exhibits (examples shown).

PurposeUsed to derive adjusted rate less withhold within risk-adjusted PMPM calculations.

Withhold — 0.5% applied to medical expense to derive adjusted rate less withhold

Withhold ruleA 0.5% withhold is applied to medical expense to derive the 'Adjusted Rate Less Withhold'.

Exhibit examplesRate tables show 'Medical Expense Less 0.5% Withhold Less Withhold' and resulting adjusted values (e.g., ME cohorts and RIte Care examples).

Impact on Final RateWithhold is reported alongside the Final Adjusted Rate and the Withhold-Adjusted Rate Less Withhold in actuarial tables.

Provider Responsibilities and Operational Requirements

Prior Authorization

Prior Authorization for Carved-Out High-Cost Drugs

MCOs remain responsible for prior authorization for high-cost drugs carved out of capitation and must use criteria developed by or approved by the State.

Documentation Required

Opioid/Controlled Substances Safety Edits Required

Contractor must implement automated drug utilization review safety edits for opioid refills, automated claims review to identify refills in excess of State limits, monitor concurrent prescribing (opioids with benzodiazepines and/or antipsychotics), apply maximum daily MME safety edits, and provide concurrent utilization alerts.

Denial Risk

Fraud Referral and Payment Suspension

The Contractor must promptly refer potential fraud, waste, or abuse to the EOHHS Office of Program Integrity or Fraud Control Unit and the State may suspend payments to network providers when it determines there is a credible allegation of fraud in accordance with 42 C.F.R. §455.23.

Denial Risk

Restrictions on Contractor Actions After Reporting

Once suspected fraud is substantiated and reported to EOHHS, the Contractor shall not contact investigation subjects, negotiate settlements, or accept funds from subjects without prior written EOHHS approval.

Billing Rule

Payment Suspension — Suspend and Lift Actions within 24 Hours

Upon receipt of notification from EOHHS that payments to a provider have been suspended, the Contractor must suspend payments to the provider within twenty-four (24) hours, include claims ready for payment unless EOHHS states otherwise, and lift a suspension within twenty-four (24) hours of EOHHS notification to lift.

Inform EOHHS immediately after suspending or lifting payments.
Require Subcontractors to suspend payments to applicable providers and return any money paid in error for services to a suspended provider.

Prior Authorization

Payment Suspension and Lift Operational Steps

Suspend payments to a Provider within twenty-four (24) hours of receipt of notification from EOHHS that payments to a provider have been suspended; include claims ready for payment unless otherwise stated by EOHHS, and lift a payment suspension within twenty-four (24) hours of receipt of notification from EOHHS of a payment suspension lift.

Billing Rule

Use Risk-Adjusted Monthly PMPM Rate Tables

Risk-adjusted monthly per-member-per-month (PMPM) rates and adjustments are provided for specified beneficiary groups (CSHCN subgroups, Medicaid Expansion cohorts and other demographic cells) and must be used as the basis for payment calculations.

Billing Rule

July–September 2026 Risk-Adjusted Rate Tables (Partial)

UnitedHealthcare risk-adjusted PMPM rate tables for July–September 2026 (Medicaid Expansion cohorts shown) specify effective rates, adjusted risk scores, neutrality adjustments, CCBHC PPS PMPM, primary care assessment PMPM, premium tax PMPM, and final risk-adjusted full rates to be applied per cohort.

Billing Rule

Rate Adjustments and 0.5% Withhold Application

Adjusted components — including CCBHC PPS PMPM, CTC adjustments, premium tax PMPM, budget-neutral vaccine neutrality adjustments, and a 0.5% withhold applied to medical expense — are applied to derive final adjusted PMPM rates; example: RIte Care Children RC - MF<1 final adjusted rate $857.80 and withhold-adjusted $853.51.

0.5% withhold applied to medical expense to derive adjusted rate less withhold.
Return or reconcile funds consistent with rate adjustments and EOHHS directions.

Documentation Required

Rate Table Excerpts — Cohort-Level PMPM Components

Rate table excerpts present risk-adjusted monthly PMPM rates and components for multiple eligibility groups and age/gender cohorts (examples include RIte Care children, CSHCN subgroups, and Medicaid Expansion cohorts) and must be referenced when adjudicating payments.

Note

Contents Summary — Risk-Adjusted Rate Tables and Adjustments

Risk-adjusted rate table contents include numeric rate tables and adjustments (adjusted risk scores, vaccine neutrality adjustments, PMPM assessment and premium tax adjustments) and note that final adjusted rates include a 0.5% withhold and use a February 2026 enrollment snapshot.

Final adjusted rates include a 0.5% withhold; values are rounded.
February 2026 enrollment snapshot used; SOBRA payments excluded from composites.

Definitions and Key Terms

High-cost drugs — High-Cost Drug Carve Out

DefinitionHigh-Cost Drug Carve Out: high-cost drugs listed on EOHHS website are carved out of capitation and reimbursed at Fee-for-Service via pass-through to ensure MDRP rebates apply to the state.

MCO responsibilitiesMCOs remain responsible for prior authorization, care coordination, reporting, and adjudicating claims for carved-out drugs per state criteria.

State rightsState may audit, modify pass-through structure/cadence, and seek supplemental materials to ensure compliance.

Contractor's Compliance Plan — Compliance Plan

Compliance Plan submissionContractor must submit an electronic copy of its written Compliance Plan (including policies, procedures, workflows, org charts) to EOHHS within 90 days of execution and annually thereafter.

Required elementsPlan must include designation of a Compliance Officer located in Rhode Island, Regulatory Compliance Committee, training, monitoring/auditing procedures, overpayment reporting, corrective action processes.

Ongoing updatesRevisions to the Compliance Plan must be submitted to EOHHS for review and approval per Exhibit A requirements.

Agent means any person who has express or implied authority to obligate or act on behalf of an entity.

Agent (definition)Any person who has express or implied authority to obligate or act on behalf of an entity.

Context of useTerm used for provider and ownership disclosures required under Exhibit B (per 42 CFR §1001.2 references).

Notification requirementContractor must notify EOHHS in writing within ten (10) business days of receipt of any disclosures referencing agents.

Immediate family member includes spouse, parent, child, sibling, stepparent/stepchild/stepbrother/stepsister, in‑laws, grandparents/grandchildren, and spouses of those relatives.

Immediate family member (definition)Includes spouse; natural or adoptive parent; child or sibling; stepparent, stepchild, stepbrother, or stepsister; father-/mother-/daughter-/son-/brother-/sister-in-law; grandparent or grandchild; or spouse of a grandparent or grandchild.

Use in disclosuresTerm applied to provider ownership and relationship disclosures under Exhibit B (42 CFR §1001.2 definitions referenced).

RelevanceHelps determine reportable relationships for ownership/control and managing employee disclosures.

Ownership interest held through other entities that ultimately have an ownership interest (example provided).

Indirect ownership interest (definition)Ownership interest held through other entities that ultimately have an ownership interest (example: 10% ownership can be derived via 20% of a 50% owner).

Example providedIllustrative example shows how ownership percentages cascade through intermediary entities to determine reportable interest.

Disclosure implicationUsed when calculating whether an individual meets threshold ownership (e.g., 5%) for reporting under Exhibit B.

Individual sharing a common abode as part of a single-family unit; roomer/boarder excluded.

Member of household (definition)An individual sharing a common abode as part of a single-family unit (includes domestic employees); roomer or boarder excluded.

PurposeTerm used in provider disclosures to identify household relationships relevant to ownership/control and managing employee reporting.

Exclusion noteRoomers/boarders are explicitly excluded from 'member of household' definition.

Interest in the capital, stock, profits, or secured obligations (mortgage, deed, trust, note) of the entity.

Ownership interest (definition)Interest in the capital, stock, profits, or any mortgage, deed, trust, note, or other obligation secured by the entity's property or assets.

ScopeCovers equity interests and secured obligations that indicate financial stake in an entity for disclosure purposes.

Use in policyDetermines who must be reported as owners or persons with control under Exhibit B disclosure requirements.

Fraud Prevention Program

Fraud Prevention Program (requirement)Contractor must implement a Fraud Prevention Program meeting federal/state requirements, including a dedicated Fraud Prevention Officer and written policies/procedures for detecting, investigating, and reporting FWA.

Key elementsProgram must include risk assessments, annual/ad-hoc reviews, provider screening, ongoing exclusion checks, provider education, and a Special Investigations Unit (SIU) staffing presence in RI.

Submission timelineWritten Fraud, Waste and Abuse Compliance Plan to be provided to EOHHS within 90 days of contract execution and annually thereafter.

SIU — Special Investigations Unit (SIU)

SIU (definition)Special Investigations Unit (SIU): dedicated staff for investigations/audits with regular presence in Rhode Island; Contractor must employ at least two additional SIU/auditing staff and one full-time investigator per 50,000 members.

ResponsibilitiesConduct on-site audits, preliminary investigations of suspected FWA, cooperate with EOHHS and report credible allegations to Office of Program Integrity.

ReportingSIU activities feed into monthly Program Integrity Reports and overpayment/credible allegation reporting per Exhibit C requirements.

credible allegation of fraud — definition entry

Credible allegation of fraud (definition)When due diligence and investigation reveal a credible allegation of fraud, the Contractor must report it immediately to the Office of Program Integrity; Office will determine referral to MFCU per federal regulation.

State authorityEOHHS has statewide authority to prosecute Medicaid fraud and will refer credible allegations to MFCU in accordance with federal regulations.

TimingReport cases to Office of Program Integrity immediately upon identification following investigation/due diligence.

LEIE / OIG Exclusions — List of Excluded Individual-Entities (LEIE) and OIG Exclusions Database

LEIE / OIG Exclusions (requirement)Contractor must review the List of Excluded Individual-Entities (LEIE) and OIG Exclusions Database at least monthly.

UseMonthly checks required to identify excluded/debarred providers to prevent reimbursement (except Emergency Services) and to support enrollment/termination actions.

ReportingContractor must provide monthly reports and maintain electronic database of owners/agents/managing employees as required by Exhibit C.

Final Adjusted Rate — definition entry

Final Adjusted Rate (definition)The Final Adjusted Rate is the budget-neutral, risk- and neutrality-adjusted PMPM shown in the rate tables prior to subtraction of any withhold; examples provided in the actuarial exhibits (e.g., RIte Care and cohort cells).

ComponentsIncludes Effective Rate Less CTC, CCBHC PPS PMPM, Adjusted Risk Score, Vaccine Neutrality Adjustment, Primary Care Assessment PMPM, and Premium Tax PMPM as shown in tables.

PresentationFinal Adjusted Rate is displayed in the rate exhibits alongside withhold and withhold-adjusted values (tables show rounding and February 2026 enrollment snapshot).

0.5% Withhold — Withhold

0.5% Withhold (term)A 0.5% contractual withhold applied to medical expense components of the rate to derive 'Adjusted Rate Less Withhold'.

Exhibit usageTables show 'Final Adjusted 0.5% Withhold' and '0.5% Withhold Adjusted Rate Less Withhold' values (examples in RIte Care and ME cohorts).

EffectReduces the reported medical expense portion and is reported alongside final adjusted rates in actuarial exhibits.

per-member-per-month (PMPM) rate — PMPM

PMPM (definition)Per-member-per-month (PMPM) rate: monthly risk-adjusted rate units shown throughout actuarial tables (e.g., Final Adjusted PMPM values for cohorts and composites).

ExamplesExamples include ME cohort PMPMs (e.g., 456.44, 653.69) and All Populations composite PMPM ($771.65) in the exhibits.

ComponentsPMPM values incorporate CCBHC PPS, neutrality adjustments, premium tax PMPM, and primary care assessment PMPM as shown in tables.

Enrollment count of members fully eligible as of February 2026, including those not scored.

February 2026 Enrollment (definition)Enrollment count of members fully eligible as of February 2026, including those who were not scored — used as the snapshot for actuarial tables (e.g., All Populations composite = 68,529).

UsageFebruary 2026 snapshot drives cohort counts and composite calculations in the July–September 2026 and Oct 2026–Jun 2027 tables.

NoteValues in tables are rounded; SOBRA payments are excluded from composite calculations per notes.

SOBRA Payments are excluded for purposes of the illustrated February 2026 composites.

SOBRA exclusion (definition)SOBRA Payments are excluded for purposes of the illustrated February 2026 composites in the actuarial exhibits.

Exhibit noteActuarial notes explicitly state SOBRA payments excluded from composite calculations (see table footnotes).

EffectExclusion affects composite PMPM calculations and presentation in the rate tables for February 2026 snapshots.

0.5% Withhold — indicates a withholding applied to final adjusted rates, reported alongside the withhold-adjusted rate less withhold.

Withhold displayed in tables0.5% withhold is indicated in the actuarial tables and reported alongside the withhold-adjusted rate less withhold in exhibits (explicit labeling present in tables).

ExampleRIte Care Children RC - MF<1 shows Final Adjusted 0.5% Withhold = $857.80 and 0.5% Withhold Adjusted Rate Less Withhold = $853.51.

PurposeWithhold presentation ensures transparency of amounts withheld from Final Adjusted Rates for contract financial management.

February 2026 Enrollment reflects all members fully eligible as of February 2026, including those who were not scored.

February 2026 Enrollment (note)February 2026 Enrollment reflects all members fully eligible as of February 2026, including those who were not scored; used as the enrollment snapshot in tables.

Composite exampleAll Populations - Composite enrollment = 68,529 (February 2026) shown in tables.

RoundingActuarial note: Values have been rounded in the exhibits.

SOBRA Payments are excluded for purposes of the illustrated February 2026 composites. (duplicate)

SOBRA Payments exclusion (note)SOBRA Payments are excluded for purposes of the illustrated February 2026 composites (actuarial footnote).

ReferenceFootnotes in the rate exhibits explicitly state the SOBRA exclusion and that values are rounded.

ImpactExclusion affects composite and cohort PMPM presentations in the exhibits for February 2026 snapshot-based calculations.

Policy Summary

PayerExecutive Office of Health and Human Services

PolicyAmendment No. 21 to Medicaid Managed Care Agreement (UnitedHealthcare of New England)

Policy CodePolicy N/A

Change TypeMultiple substantive revisions (compliance, program integrity, high-cost drug carve-outs, rates)

Effective DateJul 1, 2026

Next Review Date

Key ActionMCOs must remain responsible for prior authorization for carved-out high-cost drugs using state-developed or approved criteria.

SourceLink

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Amendment No. 21 to the Medicaid Managed Care Agreement (EOHHS – UnitedHealthcare of New England)

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Coverage Criteria and Benefit Changes

Doula Services Coverage

Attachment A benefit update for Doula Services:

Doula Services are covered for all Medicaid members when medically necessary and include prenatal visits, labor and delivery supports, and post-partum visits.

High-Cost Drug Carve-Out Criteria

High-cost drug reimbursement and administrative responsibilities:

State reserved rights

State may conduct audits as necessary to ensure compliance with the pass-through model.
State may modify the structure or cadence of the pass-through model and may seek supplemental materials as needed.

Disclosure and integrity criteria

Disclosure and enrollment criteria for Contractors and providers:

Providers must supply information on business transactions exceeding $25,000 in the prior 12 months within 35 days of request under 42 CFR §455.105.

Program Integrity Criteria Set

Contractor program integrity and FWA obligations

Payment suspension, fraud reporting, and provider exclusion criteria

Contractor obligations when EOHHS imposes payment suspensions, when credible allegations of fraud arise, and when providers are excluded/terminated.

Upon receipt of notification from EOHHS that a payment suspension is lifted, the Contractor must lift the suspension within 24 hours and immediately inform the Division/EOHHS.

All information regarding ongoing payment suspensions must be reported monthly on the EOHHS Monthly Program Integrity Report.

The Contractor must review the LEIE and OIG Exclusions Database at least monthly and take appropriate provider management actions based on exclusions.

Rate calculation components

Rate calculation elements present in this excerpt

PMPM adjustments shown include Primary Care Assessment PMPM, Adjusted CCBHC PPS PMPM, Adjusted CTC PMPM, Premium Tax PMPM, and conversion to a Risk Adjusted Full Rate and Final Adjusted Rate.

A 0.5% withhold is applied to medical expense to derive Adjusted Rate Less Withhold; medical expense less withhold and adjusted baseline CCBHC PPS medical expense are reported per cohort.

Rate table criteria and adjustments (partial)

Rate table components and adjustment items shown in the excerpt include:

PMPM adjustment line items include Primary Care Assessment PMPM, Adjusted CCBHC PPS PMPM, Adjusted CTC PMPM, Premium Tax PMPM, and Budget Neutrality adjustments leading to a Final Adjusted Rate.

A 0.5% withhold is applied to medical expense, producing an Adjusted Rate Less Withhold and a Withhold‑Adjusted Rate Less Withhold reported alongside the Final Adjusted Rate.

Rate computation components

Rate computation elements included in the tables

Effective Rate Less CTC (base effective rate before CTC and CCBHC PPS) is displayed per population cohort.

CCBHC PPS PMPM adjustments are applied to cohorts as per-line PMPM amounts and incorporated into Initial Risk Adjusted Rates.

Adjusted Risk Score multipliers are applied to compute Initial Risk Adjusted Rates and subsequent Vaccine Neutrality and budget neutrality adjustments.

Vaccine neutrality adjustments and other budget neutrality multipliers are applied to produce the Neutrality-Adjusted Final Adjusted Rate prior to withhold.

Primary Care Assessment PMPM and Premium Tax PMPM amounts are added as PMPM line items when deriving Risk Adjusted Full Rates.

A 0.5% withhold is applied to medical expense to derive Medical Expense Less Adjusted Rate Less Withhold and related medical expense baseline fields are reported per cohort.

Rate component nodes (JSON-encoded)

Rate components and calculations included in the excerpt (examples):

Fields shown include Effective Rate Less CTC and CCBHC PPS PMPM, Adjusted Risk Score (example values like 1.0000 or 0.9939), and Initial Risk Adjusted Rate per cohort.

Budget Neutral Vaccine/Neutrality Adjustment factors are applied (example multiplicative factors shown) to derive Budget Neutral Risk Adjusted Rates and Neutrality-Adjusted Final Adjusted Rates.

Medical Expense components such as Baseline Medical Expense and Medical Expense Less Adjusted Baseline CCBHC PPS are reported for cohorts and used in withhold calculations.

Actuarial rate table components and notes

Rate table components and notes included in this part:

Final adjusted rates include application of a 0.5% withhold; tables report both Final Adjusted Rate and Withhold‑Adjusted Rate Less Withhold, and values are rounded.

Rates use a February 2026 enrollment snapshot and SOBRA payments are excluded from the illustrated composite calculations.

Coding, Rates, and Exhibit A

Exhibit A selected service codes and ratesCPT

A0426	NEMT ALS - ambulance rate entries updated in Exhibit A
A0427	Emergency ALS - ambulance rate entries updated in Exhibit A
A0428	NEMT BLS - ambulance rate entries updated in Exhibit A
A0429	Emergency BLS - ambulance rate entries updated in Exhibit A
41899	Generic code allowed in lieu of G-Code for ambulatory dental anesthesia facility fee
G0330	Facility services for dental rehabilitation referenced in Exhibit A

Business transaction disclosure thresholdmixed

>25,000

Business transactions exceeding $25,000 in prior 12 months trigger disclosure requests under 42 CFR 455.105

Claims Edits and Surveillancemixed

No codes listed

ExclusionsmixedNot Covered

Providers excluded or debarred from Medicare/Medicaid (including other states' programs) must not be reimbursed except for Emergency Services.

Rate table (no CPT/ICD codes in window)mixed

No procedure or diagnosis codes included in this excerpt; document contains numeric rate tables only.

not_applicablemixed

No explicit CPT/HCPCS/ICD-10/NDC codes present in this excerpt.

Not applicablemixed

No procedure or diagnosis codes present in this section; content is population-level rate tables and adjustments.

Not applicable (financial/rate tables, no clinical codes in this part)mixed

No CPT/HCPCS/ICD-10/NDC codes contained in this part; document contains actuarial numeric rate cells only.

Not applicablemixed

No CPT/HCPCS/ICD-10/NDC codes contained in this part; document contains actuarial numeric rate cells only.

Uniform percentage increase — 2.6% (selected services effective 7/1/2026); Pediatric 3.2% over 10/1/2025

Uniform percentage increase2.6% increase over 7/1/2025 for selected services (effective 7/1/2026); Pediatric increase 3.2% effective over 10/1/2025.

ScopeApplies to Exhibit A fee schedule rows and State Directed Payment entries as noted in Exhibit A.

Effective datesGeneral uniform increase effective 7/1/2026; Pediatric increase tied to 10/1/2025 (per Exhibit A).

Withhold percentage — 0.5%

Withhold percentage0.5% withhold applied per contract provisions.

ApplicationApplied to medical expense components in rate tables (reduces Medical Expense Less Adjusted Rate Less Withhold).

ReportingWithhold reported alongside withhold-adjusted rate less withhold in actuarial tables (examples shown in rate tables).

Withhold percentage — 0.5%

Withhold percentage0.5% withholding applied to rates/medical expense.

DisplayFinal Adjusted Rate and Withhold-Adjusted Rate Less Withhold are both displayed in rate exhibits (examples shown).

PurposeUsed to derive adjusted rate less withhold within risk-adjusted PMPM calculations.

Withhold — 0.5% applied to medical expense to derive adjusted rate less withhold

Withhold ruleA 0.5% withhold is applied to medical expense to derive the 'Adjusted Rate Less Withhold'.

Exhibit examplesRate tables show 'Medical Expense Less 0.5% Withhold Less Withhold' and resulting adjusted values (e.g., ME cohorts and RIte Care examples).

Impact on Final RateWithhold is reported alongside the Final Adjusted Rate and the Withhold-Adjusted Rate Less Withhold in actuarial tables.

Provider Responsibilities and Operational Requirements

Prior Authorization

Prior Authorization for Carved-Out High-Cost Drugs

MCOs remain responsible for prior authorization for high-cost drugs carved out of capitation and must use criteria developed by or approved by the State.

Documentation Required

Opioid/Controlled Substances Safety Edits Required

Denial Risk

Fraud Referral and Payment Suspension

Denial Risk

Restrictions on Contractor Actions After Reporting

Billing Rule

Payment Suspension — Suspend and Lift Actions within 24 Hours

Inform EOHHS immediately after suspending or lifting payments.
Require Subcontractors to suspend payments to applicable providers and return any money paid in error for services to a suspended provider.

Prior Authorization

Payment Suspension and Lift Operational Steps

Billing Rule

Use Risk-Adjusted Monthly PMPM Rate Tables

Billing Rule

July–September 2026 Risk-Adjusted Rate Tables (Partial)

Billing Rule

Rate Adjustments and 0.5% Withhold Application

0.5% withhold applied to medical expense to derive adjusted rate less withhold.
Return or reconcile funds consistent with rate adjustments and EOHHS directions.

Documentation Required

Rate Table Excerpts — Cohort-Level PMPM Components

Note

Contents Summary — Risk-Adjusted Rate Tables and Adjustments

Final adjusted rates include a 0.5% withhold; values are rounded.
February 2026 enrollment snapshot used; SOBRA payments excluded from composites.