Amendment No. 21 — EOHHS Contract Amendments with Neighborhood Health Plan of Rhode Island
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Amendment No. 21 modifies the contract between the Rhode Island Executive Office of Health and Human Services (EOHHS) and Neighborhood Health Plan of Rhode Island governing Medicaid managed care program standards, attachments, payment rules, compliance, program integrity, and related operational requirements.
Pharmacy Services paragraph replaced to require AAC payment for high-cost SCD cell and gene therapy model drugs, with rebates to the state and MCOs prohibited from collecting rebates.
High-cost drugs are carved out of capitation, reimbursed at FFS via pass-through, and listed on the EOHHS website; MCOs retain responsibilities for PA, care coordination, reporting, and claims adjudication.
State Directed Payments table updated (see Exhibit A) including multiple fee schedule and rate changes effective 7/1/2026 and other dates.
Compliance section (2.18) deleted and replaced with a new Compliance section requiring a formal compliance plan and specific compliance program elements.
New Section 2.19 Program Integrity is inserted (referenced as Exhibit C).
Inclusion of EPSDT beneficiary rights to required information.
Network providers must meet Rhode Island Medicaid location, physical presence, and telehealth requirements referenced at 210-RICR-20-00-1.
Section 3.07.03 Fraud and Abuse is deleted in its entirety.
Doula Services scope of benefit replaced to cover services for all Medicaid members when medically necessary, including prenatal, labor/delivery support, and postpartum visits regardless of pregnancy outcome.
Attachment H (Capitation Rates SFY2026) renamed and replaced with Rate Book and Tables for SFY2027 risk adjustment and capitation materials dated April 24, 2026.
Coverage Criteria & Program Integrity Requirements
Doula services coverage amendment in Attachment A.
Covered when ALL of the following are met:
Provider participation, disclosure, and program integrity criteria
Provider participation and approval are contingent on required disclosures and program-integrity checks. Covered when ALL of the following are met:
ALL of the following
- Provider or disclosing entity submits required ownership and control disclosures when applying, executing a provider agreement, during revalidation, and within 35 days of any change in ownership or written request by the State (42 CFR references as applicable).35 days
Providers must furnish updated information within 35 days of written request.
- Contractor must terminate or refuse to approve/renew a provider agreement if the provider fails to disclose required ownership or control information.
- Contractor may refuse to enter into or renew an agreement, or may terminate an agreement, if any person with ownership or control interest, an agent, or a managing employee has been convicted of an offense related to Federal health care programs.
- Contractor must notify EOHHS within ten (10) business days upon identifying an excluded individual with ownership or control interest and take actions required by EOHHS.
Program Integrity Criteria
Contractor must implement and maintain written program integrity policies and procedures, staffing, monitoring, reporting, audits, and recoupment processes. Requirements include ALL of the following:
Prohibitions on Contractor recoupment or withholding
Contractor is prohibited from recouping or withholding funds in specific circumstances. Prohibitions apply when ANY of the following are true:
ANY of the following
- The improperly paid funds have already been recovered by the State of Rhode Island (directly by EOHHS or as part of a resolution of a state or federal investigation or lawsuit, including False Claims Act cases).
- The issues, services, or claims that are the basis for the recoupment or withhold are currently under investigation by the State of Rhode Island or are the subject of pending Federal or State litigation or investigation (limited to a specific provider, dates, and issues).
- The Contractor must confer with the Office of Program Integrity before initiating any recoupment or withhold of program-integrity related funds to ensure permissibility; if Contractor obtains funds where recovery/withhold is prohibited, Contractor must return the funds to EOHHS.
Contractor responsibilities when recovering funds and during investigations
When recovering funds or during investigations, the Contractor must follow these responsibilities (ALL apply):
Provider exclusion and termination requirements
Contractor must terminate or exclude providers in the circumstances below (ALL apply):
Risk-adjusted rate components and examples for product cells
Risk-adjusted rates include multiple components; examples below illustrate components and sample values for product cells shown in the Rate Book exhibits.
ALL of the following
- Each product cell includes component fields such as: Effective Rate Less CTC and CCBHC PPS PMPM; Adjusted Risk Score; Initial Risk Adjusted Rate; Budget Neutrality/Vaccine Neutrality Adjustment; Adjusted CCBHC/CTC PMPM; Premium Tax PMPM; Risk Adjusted Full Rate; 0.5% Withhold and 0.5% Withhold Adjusted Rate Less Withhold; Medical Expense Less Adjusted Baseline; Baseline Medical Expense.
- Example product cells in the exhibits include RIte Care children/adult composites, Medicaid Expansion, RHP composites, and CSHCN/Katie Beckett, with February 2026 enrollment counts shown as the enrollment reference month.
ALL of the following
- Examples of PMPM values from the exhibits: RIte Care Children RC - MF<1 Initial Risk Adjusted Rate $838.34 and Final Adjusted Rate $857.70 (0.5% withhold shown); RC - MF 1-5 Initial $403.02 and Final Adjusted $418.44; RIte Care Children Composite Initial $351.20 and Final Adjusted $370.68.
- Notes: a 0.5% contractual withhold is applied and shown; SOBRA payments are excluded from the illustrated composites; values have been rounded.
Coding, Rates, and Exhibits
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Provider Responsibilities and Operational Actions
Prior authorization remains MCO responsibility for carved‑out high‑cost drugs
MCOs remain responsible for prior authorization for high-cost drugs carved out of capitation and reimbursed via the State's pass‑through mechanism; PA decisions must use criteria developed by or approved by the State.
Timely claims adjudication and submission of reconciliation materials
MCOs must adjudicate claims in a timely manner as defined by the State and submit reconciliation materials to the State to seek pass‑through reimbursement for carved‑out high‑cost drugs.
- Adjudicate claims timely as defined by the State.
- Submit reconciliation materials to the State to request reimbursement under the pass‑through mechanism.
Implement automated DUR safety edits and concurrent prescribing monitoring
The Contractor must implement automated drug utilization review (DUR) safety edits for opioid refills, perform automated claims review to identify refills exceeding State limits, and monitor concurrent prescribing (opioids with benzodiazepines and/or antipsychotics).
- Automated DUR safety edits for opioid refills.
- Automated claims review to identify refills in excess of State limits.
- Monitoring of concurrent prescribing of opioids with benzodiazepines and/or antipsychotics.
SUPPORT Act: MME edits and concurrent utilization alerts required
To comply with the SUPPORT Act requirements, the Contractor must enforce maximum daily morphine equivalent (MME) safety edits and provide concurrent utilization alerts for beneficiaries concurrently prescribed opioids and benzodiazepines and/or antipsychotics.
- Enforce MME safety edits.
- Provide concurrent utilization alerts for opioid/benzodiazepine and/or antipsychotic combinations.
Restrictions on Contractor actions after reporting suspected fraud
Once suspected fraud is substantiated and reported to EOHHS, the Contractor must not contact the subject, negotiate settlements or accept any monetary or other valuable consideration without prior written EOHHS approval.
- Do not contact the subject about suspected/confirmed fraud matters.
- Do not enter into or attempt to negotiate settlements or agreements regarding suspected/confirmed fraud.
- Do not accept monetary or other valuable consideration from subjects of the investigation without prior written EOHHS approval.
Preapproval required for prepayment reviews; written request and 12‑month completion
All prepayment reviews (Contractor or subcontractor) must be pre‑approved by the Office of Program Integrity; the Contractor must submit a written request to place providers on prepayment review and complete each prepayment review within 12 months of case initiation.
- Submit a written request to the Office of Program Integrity to place providers on prepayment review.
- Ensure all prepayment reviews are pre‑approved by the Office of Program Integrity.
- Complete each prepayment review within 12 months and submit a new written request to continue beyond that period.
Overpayment repayment, retention, and collection rules
EOHHS may demand repayment of audit‑identified overpayments within 30 days or offset amounts; the Contractor may retain overpayments it identifies and collects only if EOHHS approves the investigation—otherwise the Contractor is responsible for collecting overpayments from audited providers.
- EOHHS may demand repayment within thirty (30) days or offset payments.
- Contractor may retain overpayments identified and collected if EOHHS approves the investigation.
- Contractor is responsible for collecting overpayments for any provider it audits unless EOHHS conducts the investigation.
Suspend and lift provider payments within 24 hours of EOHHS notice
Upon receipt of EOHHS notification to suspend payments, the Contractor must suspend payments to the provider within 24 hours and must lift a suspension within 24 hours of EOHHS notice of lift; the Contractor must immediately inform EOHHS of these actions.
- Suspend payments to the provider within twenty‑four (24) hours of EOHHS notification.
- Lift suspension within twenty‑four (24) hours of EOHHS notification to lift and immediately inform the Division.
- Include claims ready for payment in the suspension unless EOHHS states otherwise.
Contractor responsibility for recoupment when investigation is Contractor‑led
When EOHHS approves an investigation, the Contractor is responsible for collecting overpayments from providers it audits; if the Office of Program Integrity conducts the investigation, EOHHS will collect the overpayments.
- Collect overpayments from providers when EOHHS approves the Contractor's investigation.
- If Office of Program Integrity conducts the investigation, EOHHS will collect overpayments.
February 2026 enrollment reflects all fully eligible members
February 2026 enrollment figures used in the rate tables reflect all members fully eligible as of February 2026, including members who were not scored.
Rate schedule excerpt is informational—no authorization or denial rules included
The rate schedule excerpt is informational only and provides rate cells, adjustment factors, and enrollment counts; it does not contain prior authorization, denial rules, or provider action requirements.
No authorization or denial rules present in the rate tables excerpt
This rate excerpt contains no authorization, prior authorization, or denial rules; it consists exclusively of rate tables and adjustment factors.
Key Definitions
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