Insert Contract # PROVISIONS FOR FINANCIAL CONSEQUENCES Exhibit D

Insert Date

This Exhibit implements the provisions of Section C.11.of the Attachment I. The following payment adjustments shall be made as financial consequences for noncompliance with the following performance standards, subject to “earn back” as provided below.

Notice and Managing Entity Response: The Managing Entity shall deliver a written response to the Contract Manager within 14 days of receipt of a written notice of noncompliance with a performance standard.

Provision for Automatic Earn-Back: The Managing Entity can automatically “earn back” a Financial Consequence if:

(1)the Managing Entity’s reporting on a measure has been accurate at all times; and

(2)the Managing Entity achieves the required performance level for the standard at the next Quarterly Reconciliation and Performance Review.

If item 2) is satisfied and a payment adjustment has been made, the payment on the next invoice following achievement of item 2) will include the amount of the payment adjustment. Discovery of noncompliance with item 1) at any time will invalidate any “earn-back.”

Provision for Discretionary Earn-Back: In the event that the Managing Entity does not qualify for an automatic “earn-back” as provided above, the Managing Entity may seek Department agreement to allow it to “earn back” some or all of the Financial Consequences if the Managing Entity’s noncompliance was the result of adverse circumstance beyond the Managing Entity’s control and, where applicable, any error in reporting of a measure was inadvertent:

(1)Adverse circumstances beyond the Managing Entity’s control refers to unforeseeable events not arising from an act or omission of the Managing Entity, its officers or employees that materially impaired the Managing Entity’s ability to perform and for which there were no reasonable means to mitigate or avoid the adverse impact.

(2)Adverse circumstances arising from the acts or omissions of the Managing Entity’s subcontractors or sub-subcontractors will not be considered beyond the control of the Managing Entity unless the Managing Entity demonstrates: 1) that the subcontractor(s) or sub-subcontractor(s) had in place a Managing Entity-approved quality assurance program, with sufficient Managing Entity monitoring and controls in place to ensure achievement of performance standards; or 2) the subcontracts or sub-subcontracts included effective financial consequences and associated reporting relating to the performance standard(s) at issue.

(3)In order to be able to rely on this “earn back” provision, the Managing Entity’s representative possessing contract signature authority shall attest to and document the adverse circumstances beyond the Managing Entity’s control to the contract manager at the time that it provides its response to any notice of noncompliance or notice of financial consequences.

(4)The Managing Entity shall demonstrate that it has corrected the noncompliance as quickly as reasonably possible and detail the steps that the Managing Entity has put into place to avoid a future recurrence of the noncompliance. In addition, when applicable, the Managing Entity shall demonstrate that any error in reporting of a measure was inadvertent and detail the steps that the Managing Entity has put into place to ensure accurate reporting.

(5)Receipt of the attestation by the contract manager does not constitute acceptance of the attestation. It is specifically agreed by the parties that written acceptance by the contract manager of the sufficiency of the adverse circumstances beyond the Managing Entity’s control is a condition of agreeing to any “earn back” of any or all of the Financial Consequences provided for hereunder.

GAA/NOM[HMA1] / Non-compliance Trigger / Financial Consequence
Adult
Mental Health / 1 / Average annual days worked for pay for adults with severe and persistent mental illness / < 36 / 1% of ME operational costs
2 / Percent of adults with serious mental illness who are competitively employed / < 22% / 1% of ME operational costs
3 / Percent of adults with severe and persistent mental illnesses who live in stable housing environment / < 81% / 1% of ME operational costs
4 / Percent of adults in forensic involvement who live in stable housing environment / < 60% / 1% of ME operational costs
5 / Percent of adults in mental health crisis who live in stable housing environment / < 77% / 1% of ME operational costs
Adult Substance Abuse / 1 / Percentage change in clients who are employed from admission to discharge / < 9% / 1% of ME operational costs
2 / Percent change in the number of adults arrested 30 days prior to admission versus 30 days prior to discharge / < 14% / 1% of ME operational costs
3 / Percent of adults who successfully complete substance abuse treatment services / < 46% / 1% of ME operational costs
4 / Percent of adults with substance abuse who live in a stable housing environment at the time of discharge / < 85% / 1% of ME operational costs
Children
Mental Health / 1 / Percent of school days seriously emotionally disturbed (SED) children attended / < 77% / 1% of ME operational costs
2 / Percent of children with emotional disturbances (ED) who improve their level of functioning / < 58% / 1% of ME operational costs
3 / Percent of children with serious emotional disturbances (SED) who improve their level of functioning / < 59% / 1% of ME operational costs
4 / Percent of children with emotional disturbance (ED) who live in a stable housing environment / < 86% / 1% of ME operational costs
5 / Percent of children with serious emotional disturbance (SED) who live in a stable housing environment / < 84% / 1% of ME operational costs
6 / Percent of children at risk of emotional disturbance (ED) who live in a stable housing environment / < 86% / 1% of ME operational costs
Children Substance Abuse / 1 / Percent of children who successfully complete substance abuse treatment services / < 43% / 1% of ME operational costs
2 / Percent change in the number of children arrested 30 days prior to admission versus 30 days prior to discharge / < 18% / 1% of ME operational costs
3 / Percent of children with substance abuse who live in a stable housing environment at the time of discharge / < 84% / 1% of ME operational costs
Noncompliance Trigger / Financial Consequence
Operational Plans & Reporting / 1 / System Efficiency Plan / Plan not submitted by the stated due date / $100 per calendar day until plan is submitted
2 / Programmatic Allocation Plan
3 / Competitive Procurement Plan
4 / Fraud and Abuse Prevention Protocol
5 / Utilization Management Plan
6 / Continuous Quality Improvement Plan
7 / Information Technology Plan
8 / Incident Report Submission to IRAS / Information reported
> 24 hours after occurrence / $50 per hour, after discovery, until incident is reported to IRAS
Financial Reports / 1 / SAMH Managing Entity Cost Allocation Plan / Information not submitted by the stated due date / $100 per calendar day until information is submitted
2 / Financial & Compliance Audit
3 / SAMH Managing Entity Spending Plan for Carry Forward

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[HMA1]Please note:

The performance measures and financial consequences contained in this document need to be reviewed and approved by DFS.