Amendment No. 21 to Medicaid Managed Care Contract with Tufts Health Public Plans
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Amendment No. 21 modifies the existing contract between the Rhode Island Executive Office of Health and Human Services and Tufts Health Public Plans, updating program standards, payment methodologies, attachments, and compliance/program integrity requirements for the Medicaid managed care program.
Insertion of 'Inclusion of EPSDT beneficiary rights' into Required Information.
Pharmacy Services section amended to replace second paragraph with Cell and Gene Therapy Access Model for Sickle Cell Disease provisions including AAC payment outside inpatient bundles and state receipt of rebates.
High-cost drug carve-out and pass-through reimbursement mechanism with MCO responsibilities (PA, care coordination, reporting, claims adjudication) and state audit/modification rights.
Network providers must meet Rhode Island Medicaid location/physical presence and telehealth requirements.
State Directed Payments table updated (details in Exhibit A).
Section 2.18 Compliance deleted and replaced with new Compliance section requiring a written compliance plan and specified compliance program elements.
New Section 2.19 Program Integrity inserted.
Doula Services scope replaced to cover medically necessary prenatal, labor/delivery, and post-partum supports regardless of pregnancy outcome.
Attachment H capitation rates renamed and replaced with State Fiscal Year 2027 Rate Book and Tables.
Attachment I Rate-Setting Process replaced with references to SFY 2027 rate books and attachments.
Incentive payments definition updated and clarified regarding compliance with 42 CFR § 438.3 and intergovernmental agreement conditions.
Risk share and gain share provisions and percentages updated (detailed share tiers for ranges around baseline).
Contract term paragraph updated to state agreement subject to CMS final approval and restate term and option periods.
Section 3.07.03 Fraud and Abuse is deleted in its entirety.
Coverage and Program Requirements
Coverage and operational criteria introduced or updated in Amendment No. 21
Covered and operational updates implemented by Amendment No. 21 (Attachment/Exhibit changes and related operational requirements):
Program Integrity criteria and operational rules
Program Integrity requirements the Contractor must implement and follow (investigations, audits, reporting, staffing, and related operations):
ALL of the following
- Contractor must comply with all Federal and State requirements regarding FWA and follow written direction from the EOHHS Office of Program Integrity, using the current Program Integrity Fraud and Abuse SOP for referrals and reporting.
- Contractor cannot be owned by, hire, or contract with debarred/excluded individuals in ways that impact contractual obligations (per 42 CFR § 438.610).
ALL of the following
- Implement a Fraud Prevention Program meeting 42 CFR Part 455 and 42 CFR § 438.608 requirements, including a dedicated Fraud Prevention Officer who reports to executive leadership and attends EOHHS quarterly oversight meetings.
- Maintain written policies and procedures for detecting, investigating, and reporting FWA, including Program Integrity Risk Assessments, annual and ad-hoc reviews, provider training and corrective action, and ongoing provider monitoring including quarterly exclusion checks.
ALL of the following
- Maintain a written FWA Compliance Plan specific to Rhode Island Medicaid and submit it to the Office of Program Integrity for written approval within 90 calendar days of contract execution and annually thereafter; submit revisions at least 60 calendar days prior to implementation.
- EOHHS will notify approval/denial/modification within 60 days of receipt; Contractor shall annually review and resubmit updated plan for approval.
ALL of the following
- Complete a minimum of five EOHHS-acceptable provider site audits per contract year using statistically valid random samples (minimum 30 records per provider or 10% of records; sometimes 50 for large populations); EOHHS may waive the minimum.
- If audits identify overpayments, EOHHS may demand repayment within 30 days or offset payments; underpayments will be corrected within 30 days.
ALL of the following
- Maintain adequate SIU/audit staffing including at least one full-time investigator physically located in Rhode Island per 50,000 members (or fraction); provide designated SIU contact information to EOHHS for direct communication and access.
Program integrity operational criteria
Operational responsibilities, prohibitions, and required actions related to recoupment, payment suspension, and provider termination:
ALL of the following
- Contractor may retain overpayments identified and collected from audits only if EOHHS approves the investigation; if EOHHS conducts the investigation, EOHHS will collect the overpayments.
- Contractor is not authorized to negotiate recoupment amounts approved by EOHHS and must annually report all overpayments recovered to the Office of Program Integrity.
- Contractor is prohibited from recouping or withholding funds when the State has already recovered funds or when issues/claims are subject to pending state or federal investigation or litigation for the specific provider/dates; Contractor must confer with the Office of Program Integrity before initiating any recoupment or withhold and must return funds to EOHHS if recovery is prohibited.
ALL of the following
- Suspend payments to a Provider within 24 hours of receipt of EOHHS notification of suspension and immediately inform EOHHS; lift suspensions within 24 hours of EOHHS lift notification and notify EOHHS; require subcontractors to take equivalent suspension actions.
- Contractor is responsible for returning any money paid in error for services provided to a suspended Provider; failure to suspend or correctly report hold amounts may result in contractual remedies by EOHHS.
ALL of the following
- Report credible allegations of fraud to the Office of Program Integrity immediately after due diligence; Office of Program Integrity determines MFCU referral.
- Terminate or exclude providers who are excluded or debarred from Medicare/Medicaid (any state) except for Emergency Services; review LEIE and OIG Exclusions Database at least monthly.
ALL of the following
- All prepayment reviews must be pre-approved by the Office of Program Integrity, completed within 12 months, and may not be used to hold claims indefinitely; placement on prepayment review requires a written request to the Office of Program Integrity.
ALL of the following
- Contractor must report overpayments and underpayments to EOHHS in writing within 30 calendar days of discovery and report overpayments due to potential fraud within 60 days, per program integrity requirements.
Coverage stance (informational)
Informational coverage stance — document contains no clinical coverage criteria; primary content in these sections is actuarial and rate information:
Rate calculation and outputs
Rate calculation components and final adjusted rate outputs (per-population), including adjustments and output fields shown in the Rate Book excerpts:
ALL of the following
- Each cohort shows an Initial Risk Adjusted Rate (example: CSHCN - Katie Beckett initial risk-adjusted rate entries appear in the October 2026–June 2027 tables).
ALL of the following
- A multiplicative neutrality adjustment (budget/vaccine neutrality) is applied to initial rates (values near 0.995–1.003 in the tables), producing an adjusted intermediate rate used in further calculations.
ALL of the following
- Rate lines include additive PMPM components such as CCBHC PPS PMPM, Adjusted CTC PMPM, and Premium Tax PMPM reported per cohort (examples: CCBHC PPS PMPM = $0.20; Premium Tax PMPM examples shown in cohort rows).
ALL of the following
- Final Adjusted Rate is produced after applying adjustments and adding PMPM components; a contractual 0.5% withhold is then applied to compute the withhold-adjusted rate where shown.
ALL of the following
- Tables present additional output fields such as Medical Expense Less Adjusted Baseline and other cohort-specific medical expense PMPMs and enrollment counts used in rate calculations (examples shown in the October 2026–June 2027 excerpts).
Codes, Rate Tables, and Coding Details
| S5170 | Home Delivered Meals Rate $13.60 (variants listed with modifiers U1/U2/U4/U5/UF) |
| Rate Cell 1 | February 2026 Enrollment |
| Rate Cell 2 | Less CTC and CCBHC PPS PMPM |
| Rate Cell 3 | Adjusted Risk Score |
| Rate Cell 4 | Initial Risk Adjusted Rate / Initial Budget Neutrality |
| Rate Cell 5 | Initial Budget Neutrality Adjustment / Budget Neutral Risk Adjusted Rate |
| Rate Cell 6 | Budget Neutral Risk Adjusted Vaccine Assessment PMPM |
| Rate Cell 7 | Primary Care Assessment PMPM |
| Rate Cell 8 | Adjusted CCBHC PPS PMPM |
| Rate Cell 9 | Adjusted CTC PMPM |
| Rate Cell 10 | Adjusted Premium Tax PMPM |
| Enrollment | 260 |
| Adjusted Rate PMPM | $838.33 |
| Adjusted Risk Score | 1.0000 |
| Risk Adjusted Full Rate (Cell 11) | $856.07 |
| Final Adjusted Rate (Cell 13) | $856.07 |
| 0.5% Withhold (Cell 14) | $4.28 |
| Withhold Adjusted Rate Less Withhold (Cell 15) | $851.79 |
| Expense Less CCBHC PPS Baseline Medical Expense (Cell 16) | $754.49 |
| ME - F 19-24 | Enrollment 227; Rate $416.82; Adjusted Risk Score 0.8546; Initial Risk Adjusted Rate $356.21; Risk Adjusted Full Rate $398.30; Final Adjusted Rate $398.30; Withhold-adjusted and expense values shown (examples: Cell 16 $377.61) |
| ME - F 25-29 | (row continued in table; related subgroup rates listed together) |
| ME - F 30-39 | Example subgroup referenced elsewhere: ME - F 30-39 = $845.75 (see document summary) |
| CSHCN - Substitute Care Composite | Final Adjusted Rate $1,239.06; Withhold-adjusted PMPM example $5.98; Expense Baseline values shown (Cell 16 ~ $943.59–$946.21) |
| CCBHC PPS PMPM | $0.20 (example CCBHC PPS PMPM) |
| Adjusted CTC PMPM | $0.23 (example) |
| Premium Tax PMPM | $24.78 (example Premium Tax PMPM) |
| Budget Neutrality / Neutrality Adjustment | Final Neutrality Adjustment example producing Final Adjusted Rate $1,239.06 |
| Withhold percentage | 0.5% withhold applied to final adjusted rate (withhold-adjusted values shown) |
| ME - F 19-24 (Oct-Jun table) | Enrollment 227; CCBHC PPS PMPM $415.16 (alternate display 597.64 in table); Adjusted Risk Score 0.8547; Initial Risk Adjusted Rate $354.84 (alternate $510.80); Budget Neutrality Adjustment example 0.9959 |
Prior Authorization, Reporting, and Operational Actions Required of Contractors
Prior authorization for carved‑out high‑cost drugs
MCOs remain responsible for prior authorization for high-cost drugs carved out of capitation using criteria developed by or approved by the state; they must also manage care coordination, reporting, and claims adjudication and submit reconciliation materials to the state for pass-through FFS reimbursement.
- Prior Authorization must use state-developed or state‑approved criteria.
- MCOs must adjudicate claims in a timely manner and submit reconciliation materials to seek reimbursement.
Implement SUPPORT Act opioid/controlled‑substance safety edits
The Contractor must implement automated DUR safety edits and claims review processes required by Section 1004 of the SUPPORT Act, including automated opioid refill safety edits, automated claims review to identify refills exceeding State limits, monitoring concurrent prescribing of opioids with benzodiazepines and/or antipsychotics (including pediatric antipsychotics), maximum daily MME safety edits, and concurrent utilization alerts.
- Automated drug utilization review safety edits for opioid refills.
- Automated claims review to identify refills in excess of State limits.
- Monitoring of concurrent prescribing (opioids + benzodiazepines/antipsychotics).
- Maximum daily MME safety edits and concurrent utilization alerts.
Restrictions on contacting/negotiating after fraud is reported
After the Contractor substantiates suspected fraud and reports it to EOHHS, the Contractor must not contact the subject, negotiate settlements, or accept any consideration from the subject without prior written approval from EOHHS; the Contractor may request EOHHS actions (e.g., disenrollment) but cannot inform the Provider or Member that disenrollment from Rhode Island Medicaid will occur.
- Do not contact the subject of the investigation about matters related to suspected/confirmed fraud.
- Do not negotiate settlements or accept money/consideration from the subject without EOHHS written approval.
- Contractor may request EOHHS take action but must not indicate pending disenrollment to Provider or Member.
Prepayment reviews require Office of Program Integrity approval
All prepayment reviews (Contractor or subcontractor) require pre-approval 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 twelve months of initiation, re-evaluating cases thereafter and obtaining new written approval to continue.
- Submit written request to Office of Program Integrity to place providers on prepayment review.
- Complete each prepayment review within 12 months of case initiation.
- Reassess and submit a new written request to continue prepayment review if necessary; cannot hold claims indefinitely.
Recoupment: retention conditional on EOHHS approval and required consultation
The Contractor may retain overpayments identified and collected from audits only if EOHHS approves the investigation; the Contractor is responsible for collecting overpayments for audited providers unless the Office of Program Integrity conducts the investigation (in which case EOHHS collects), and the Contractor must confer with the Office of Program Integrity before initiating any recoupment or withhold.
- Retain overpayments only with EOHHS approval of the investigation.
- Contractor collects overpayments for providers it audits; EOHHS collects if Office of Program Integrity conducts the investigation.
- Contractor is not authorized to negotiate recoupment amounts approved by EOHHS and must consult Office of Program Integrity before any recoupment/withhold.
- Return funds to EOHHS if recovery/withhold is prohibited (e.g., State already recovered funds or matters are under investigation/litigation).
Suspend and lift payments within 24 hours of EOHHS notice; report monthly
The Contractor must suspend payments to a Provider within 24 hours of receiving EOHHS notification of a suspension and immediately inform EOHHS; the Contractor must lift suspensions within 24 hours of EOHHS lift notification, notify EOHHS, require subcontractors to take equivalent actions, and report ongoing payment suspensions monthly.
- Suspend payments within 24 hours of EOHHS notification and immediately inform EOHHS.
- Lift suspension within 24 hours of EOHHS notification of lift and inform EOHHS.
- Require subcontractors to suspend payments to affected Providers.
- Report all ongoing payment suspensions monthly on the EOHHS Monthly Program Integrity Report.
Immediate reporting of credible allegations of fraud to Office of Program Integrity
The Contractor must report cases that meet the credible allegation of fraud standard to the Office of Program Integrity immediately after due diligence and investigation; the Office of Program Integrity will determine whether to refer the matter to the MFCU.
- Report credible allegations of fraud to the Office of Program Integrity immediately after due diligence.
- Office of Program Integrity decides on referral to the Medicaid Fraud Control Unit (MFCU).
Terminate/exclude providers excluded by Medicare/Medicaid; monthly exclusion checks
The Contractor must terminate or exclude any provider who is excluded or debarred from Medicare, Medicaid, or any state's Medicaid/CHIP program (except Emergency Services) and must review the LEIE and OIG Exclusions Database at least monthly.
- Terminate/exclude participation of providers terminated under Medicare/Medicaid or other states' Medicaid/CHIP programs (except Emergency Services).
- Review the LEIE report and OIG Exclusions Database at least monthly.
Risk‑adjusted rates and adjustment factors (July–Sept 2026)
Risk‑adjusted rate tables present tabulated PMPM rates and adjustment factors for program categories (e.g., CSHCN, Medicaid Expansion) covering July–September 2026; these rows include subgroup labels and dollar rates for each cohort.
- Tables show cohort-level initial risk‑adjusted rates, multipliers, adjustments, and PMPM components.
- Rate period indicated as July–September 2026.
Enrollment and composite notes (February 2026, SOBRA exclusion, rounding)
Notes clarify that February 2026 enrollment reflects members fully eligible as of February 2026, SOBRA payments are excluded for purposes of the illustrated February 2026 composites, and reported values have been rounded.
- February 2026 enrollment includes all members fully eligible as of that month.
- SOBRA payments are excluded from the illustrated composites.
- Values in the tables have been rounded.
Rate outputs and PMPM components (informational)
Rate outputs list numerical risk‑adjusted PMPMs, PMPM components (e.g., CCBHC PPS, CTC, premium tax), neutrality adjustments, and 0.5% withhold calculations for October 2026–June 2027 cohorts; this section does not impose provider authorization, denial, documentation, billing, or step‑therapy rules.
- Includes CCBHC PPS PMPM, Adjusted CTC PMPM, Premium Tax PMPM, neutrality adjustment, final adjusted rate, and 0.5% withhold-adjusted rate.
- Covers the October 2026–June 2027 rate period.
Risk‑adjusted PMPM components for specified subpopulations (Oct 2026–Jun 2027)
Risk‑adjusted tables for October 2026–June 2027 present PMPM components for specific subpopulations (examples include CSHCN – Katie Beckett and CSHCN – SSI) and show adjusted risk scores, initial and final adjusted PMPMs, CCBHC PPS and CTC components, premium tax, neutrality adjustments, and withhold calculations.
- Provides cohort enrollment counts, adjusted risk scores, initial risk‑adjusted rates, neutrality adjustments, PMPM components, final adjusted rates, and medical expense less adjusted baseline values.
- Rate period: October 2026 through June 2027.
RHP rate table excerpt — numeric rate outputs only
Excerpted rate table rows provide numeric risk‑adjusted rates, adjusted risk scores, final adjusted rates, and medical expense components for RHP beneficiary categories; this fragment contains only rate data and no provider authorization or documentation requirements.
- Includes RHP cohort lines with adjusted risk scores, initial and final rates, neutrality adjustments, medical expense and withhold‑adjusted values.
- No authorization or provider action rules included in this excerpt.
Defined Terms and Reference Notes
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