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Back to Form 8-K [form8k.htm]
Exhibit 10.1
 
 

ATTESTATION

 
I Todd S. Farha, being an individual authorized to execute agreements on behalf
of WellCare of New York, Inc. (Name of Managed Care Organization)  (hereafter
"MCO"), hereby attest that the Medicaid Advantage contract submitted by MCO to
the New York City Department of Health and Mental Hygiene (DOHMH), follows the
latest model contract provided to us by the DOHMH. This executed contract
contains no deviations from the aforementioned model contract language.
 

3/17/06
(Date)
/s/ Todd S. Farha
(Signature)
 
 
Todd S. Farha
(Print Name in Full)
 
 
President and CEO
(Title)
/s/ Rebecca McNeely
(Notary Seal and Signature)
 

I Diane Daniels, attest that DOHMH has reviewed this executed contract and that
it follows the latest model contract provided to us by the New York State
Department of Health.

4/6/06
/s/ Diane Daniels
(Date)
(Signature)
 
Diane Daniels
 
(Print Name in Full)
 
Assistant Counsel
/s/ Alice Rothbaum
(Notary Seal and Signature)
(title)

 
 
 

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MEDICAID ADVANTAGE
MODEL CONTRACT

2006
 

 
New York City Model
 

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AGREEMENT BETWEEN

 
The City of New York
 
And
 
WellCare of New York, Inc.
 
This Agreement is made by and between
 
The City of New York
 
Acting through,
 
Department of Health and Mental Hygiene ["DOHMH"]
 
Located at
 
161 William Street, 5th floor
 
New York, NY 1003 8
 
And
 
WellCare of New York, Inc.
 
Located At
 
11 West 19th Street, 2nd floor
New York, NY 10011

--------------------------------------------------------------------------------

RECITALS
 
WHEREAS, pursuant to Title XIX of the Federal Social Security Act, codified as
42 U.S.C. Section 1396 et seq. (the Social Security Act), and Title 11 of
Article 5 of the New York State Social Services Law (SSL), codified as SSL
Section 363 et seq., a comprehensive program of Medical Assistance for needy
persons exists in the State of New York (Medicaid); and
 
WHEREAS, pursuant to Article 44 of the Public Health Law (PHL), the New York
State Department of Health (SDOH) is authorized to issue Certificates of
Authority to establish Health Maintenance Organizations (HMOs), PHL Section 4400
et seq., and Prepaid Health Services Plans (PHSPs), PHL Section 4403-a; and
 
WHEREAS, the State Social Services Law defines Medicaid to include payment of
part or all of the cost of care and services furnished by an HMO or a PHSP,
identified as Managed Care Organizations (MCOs) in this Agreement, to Eligible
Persons, as defined in this Agreement, residing in the geographic area specified
in Appendix M (Service Area) when such care and services are furnished in
accordance with an agreement approved by the SDOH that meets the requirements of
federal law and regulations; and
 
WHEREAS, the Contractor is a corporation organized under the laws of New York
State and is certified under Article 44 of the State Public Health Law or
Article 43 of the NYS Insurance Law; and
 
WHEREAS, the Contractor has applied to participate in the Medicaid Managed Care
Program and the SDOH and DOHMH have determined that the Contractor meets the
qualification criteria established for participation; and
 
WHEREAS, the Contractor is an entity which has been determined to be an eligible
Medicare Advantage Organization by the Administrator of the Centers for Medicare
and Medicaid Services (CMS) under 42 CFR 422.503; and has entered into a
contract with CMS pursuant to Sections 1851 through 1859 of the Social Security
Act to operate a coordinated care plan, as described in its final Plan Benefit
Package (PBP) bid submission proposal approved by CMS, in compliance with 42 CFR
Part 422 and other applicable Federal statutes, regulations and policies; and
 
WHEREAS, the Contractor is an entity that has amended its contract with CMS to
include an agreement to offer qualified Medicare Part D coverage pursuant to
sections 1860D-1 through 1860D-42 of the Social Security Act and Subpart K of 42
CFR Part 422 or is a Specialized Medicare Advantage Plan for Special Needs
Individuals which includes Medicare Part D prescription drug coverage; and
 
WHEREAS, the Contractor offers a comprehensive health services plan and
represents that it is able to make provision for furnishing the Medicare Plan
Benefit Package ( Medicare Part C benefit), the Medicare Voluntary Prescription
Drug Benefit (Medicare Part D prescription drug
 
 

 
Medicaid Advantage Contract
RECITALS
New York City 2006
Page 2 of 3
 

benefit) and the Medicaid Advantage Product as defined in this Agreement and has
proposed to provide these products to Eligible Persons as defined in this
Agreement residing in the geographic area specified in Appendix M; and
 
WHEREAS, Chapter 364-j (5)(d) of the SSL authorizes the local department of
social services in a city with a population of over two million to contract with
managed care providers who meet the qualifications for participation in the
Medicaid Managed care program and since in the City of New York such authority
has been delegated the DOHMH;
 
NOW THEREFORE, the parties agree as follows:
 

 

Medicaid Advantage Contract
RECITALS
New York City 2006
Page 3 of 3
 

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Table of Contents for Medicaid Advantage Model Contract
 
Recitals
 
Section 1 Definitions
 
Section 2 Agreement Term, Amendments, Extensions, and General Contract
Administration Provisions
2.1 Term
2.2 Amendments
2.3 Approvals
2.4 Entire Agreement
2.5 Renegotiation
2.6 Assignment and Subcontracting
2.7 Termination
a. DOHMH Initiated Termination
b. Contractor and DOHMH Initiated Termination
c. Contractor Initiated Termination
d. Termination Due to Loss of Funding
2.8 Close-Out Procedures
2.9 Rights and Remedies
2.10 Notices
2.11 Severability
 
Section 3 Compensation
3.1 Capitation Payments
3.2 Modification of Rates During Contract Period
3.3 Rate Setting Methodology
3.4 Payment of Capitation
3.5 Denial of Capitation Payments
3.6 SDOH Right to Recover Premiums
3.7 Third Party Health Insurance Determination
3.8 Contractor Financial Liability
3.9 Tracking Services Provided by Indian Health Clinics
 
Section 4 Service Area
 
Section 5 Eligibility For Enrollment in Medicaid Advantage
5.1 Eligible to Enroll in the Medicaid Advantage Program
5.2 Not Eligible to Enroll in the Medicaid Advantage Program
5.3 Change in Eligibility Status
 
Section 6 Enrollment
6.1 Enrollment Requirements
6.2 Equality of Access to Enrollment
6.3 Enrollment Decisions
6.4 Prohibition Against Conditions on Enrollment
 

 

 

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TABLE OF CONTENTS
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Table of Contents for Medicaid Advantage Model Contract
 
6.5 Effective Date of Enrollment
6.6 Contractor Liability
6.7 Roster
6.8 Automatic Re-Enrollment
6.9 Failure to Enroll in Contractor's Medicare Advantage Product
6.10 Medicaid Managed Care Enrollees Who Will Gain Medicare Eligibility
6.11 Newborn Enrollment
 
Section 7 RESERVED
 
Section 8 Disenrollment
8.1 Disenrollment Requirements
8.2 Disenrollment Prohibitions
8.3 Disenrollment Requests
a. Routine Disenrollment Requests
b. Non-routine Disenrollment Requests
8.4 Contractor Notification of Disenrollments
8.5 Contractor's Liability
8.6 Enrollee Initiated Disenrollment
8.7 Contractor Initiated Disenrollment
8.8 LDSS Initiated Disenrollment
 
Section 9 Guaranteed Eligibility
9.1 General Requirements
9.2 Right to Guaranteed Eligibility
9.3 Covered Services During Guaranteed Eligibility
9.4 Disenrollment During Guaranteed Eligibility
 
Section 10 Benefit Package, Covered and Non-Covered Services
10.1 Contractor Responsibilities
10.2 SDOH and LDSS Responsibilities
10.3 Benefit Package and Non-Covered Services Descriptions
10.4 Adult Protective Services
10.5 Court-Ordered Services
10.6 Family Planning and Reproductive Health Services
10.7 Emergency and Post Stabilization Care Services
10.8 Medicaid Utilization Thresholds (MUTS)
10.9 Services for Which Enrollees Can Self-Refer
a. Diagnosis and Treatment of Tuberculosis
b. Family Planning and Reproductive Health Services
c. Article 28 Clinics Operated by Academic Dental Centers
10.10 Coordination with Local Public Health Agencies
10.11 Public Health Services
a. Tuberculosis Screening, Diagnosis and Treatment; Directly Observed Therapy
(TB/DOT)

 
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Table of Contents for Medicaid Advantage Model Contract

b. Immunizations
c. Prevention and Treatment of Sexually Transmitted Diseases
10.12 Adults with Chronic Illnesses and Physical or Developmental Disabilities
10.13 Persons Requiring Ongoing Mental Health Services
10.14 Member Needs Relating to HIV
10.15 Persons Requiring Chemical Dependence Services
10.16 Native Americans
10.17 Urgently Needed Services
10.18 Dental Services Provided by Article 28 Clinics Operated by Academic Dental
Centers Not Participating in Contractor's Network
10.19 Coordination of Services

Section 11 Marketing
11.1 Marketing Requirements
 
Section 12 Member Services
12.1 General Functions
12.2 Translation and Oral Interpretation
12.3 Communicating with the Visually, Hearing and Cognitively Impaired
 
Section 13 Enrollee Notification
13.1 General Requirements
13.2 Member ID Cards
13.3 Member Handbooks
13.4 Enrollee Rights
 
Section 14 Organization Determinations, Actions, and Grievance System
14.1 General Requirements
14.2  Filing and Modification of Medicaid Advantage Action and Grievance System
Procedures
14.3 Medicaid Advantage Action and Grievance System Additional Provisions
14.4 Notification of Medicaid Advantage Action and Grievance System Procedures
14.5 Complaint, Complaint Appeal and Action Appeal Investigation determinations
 
Section 15 Access Requirements
 

Section 16 Quality Management and Performance Improvement
 
Section 17 Monitoring and Evaluation
17.1 Right To Monitor Contractor Performance
17.2 Cooperation During Monitoring And Evaluation
17.3 Cooperation During On-Site Reviews
17.4 Cooperation During Review of Services by External Review Agency

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Table of Contents for Medicaid Advantage Model Contract
 
Section 18 Contractor Reporting Requirements
18.1 General Requirements
18.2 Time Frames for Report Submissions
18.3 SDOH Instructions for Report Submissions
18.4 Liquidated Damages
18.5 Notification of Changes in Report Due Dates, Requirements or Formats
18.6 Reporting Requirements
18.7 Ownership and Related Information Disclosure
18.8 Public Access to Reports
18.9 Certification Regarding Individuals Who Have Been Debarred or Suspended by
Federal or State Government
18.10 Conflict of Interest Disclosure
18.11 Physician Incentive Plan Reporting
 
Section 19 Records Maintenance and Audit Rights
19.1 Maintenance of Contractor Performance Records
19.2 Maintenance of Financial Records and Statistical Data
19.3 Access to Contractor Records
19.4 Retention Periods
 
Section 20 Confidentiality
20.1 Confidentiality of Identifying Information about Enrollees, Eligible
Persons and Prospective Enrollees
20.2 Confidentiality of Medical Records
20.3 Length of Confidentiality Requirements
 
Section 21 Participating Providers
21.1 General Requirements
21.2 Medicaid Advantage Network Requirements
21.3 SDOH Exclusion or Termination of Providers
21.4 Payment in Full
21.5 Dental Networks
 
Section 22 Subcontracts and Provider Agreements for Medicaid Only Covered
Services
22.1 Written Subcontracts
22.2 Permissible Subcontracts
22.3 Provision of Services Through Provider Agreements
22.4 Approvals
22.5 Required Components
22.6 Timely Payment
22.7 Physician Incentive Plan

Section 23 Americans With Disabilities Act Compliance Plan
 
Section 24 Fair Hearings

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4

Table of Contents for Medicaid Advantage Model Contract
 
24.1 Enrollee Access to Fair Hearing Process
24.2 Enrollee Rights to a Fair Hearing
24.3 Contractor Notice to Enrollees
24.4 Aid Continuing
24.5 Responsibilities of SDOH
24.6 Contractor's Obligations
 
Section 25 External Appeal
25.1 Basis for External Appeal
25.2 Eligibility for External Appeal
25.3 External Appeal Determination
25.4 Compliance with External Appeal Laws and Regulations
25.5 Member Handbook
 
Section 26 Intermediate Sanctions
26.1 General Practices
26.2 Unacceptable Practices
26.3 Intermediate Sanctions
26.4 Enrollment Limitations
26.5 Due Process

Section 27 Environmental Compliance
 
Section 28 Energy Conservation
 
Section 29 Independent Capacity of Contractor Section 30 No Third Party
Beneficiaries
 
Section 31 Indemnification
31.1 Indemnification by Contractor
31.2 Indemnification by DOHMH
 
Section 32 Prohibition on Use of Federal Funds for Lobbying
32.1 Prohibition of Use of Federal Funds for Lobbying
32.2 Disclosure Form to Report Lobbying
32.3 Requirements of Subcontractors
 
Section 33 Non-Discrimination
 
33.1 Equal Access to Benefit Package
33.2 Non-Discrimination
33.3 Equal Employment Opportunity
33.4 Native Americans Access to Services From Tribal or Urban Indian Health
Facility
 

Medicaid Advantage Contract
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5

Table of Contents for Medicaid Advantage Mode! Contract
 
Section 34 Compliance with Applicable Laws and Regulations
34.1 Contractor and DOHMH Compliance with Applicable Laws
34.2 Nullification of Illegal, Unenforceable, Ineffectiveor Void Contract
Provisions
34.3 Certificate of Authority Requirements
34.4 Notification of Changes in Certificate of Incorporation
34.5 Contractor's Financial Solvency Requirements
34.6 Non-Liability ofEnrollees for Contractor's Debts
34.7 DOHMH Compliance with Conflict of Interest Laws
34.8 Compliance Plan

Section 35 New York State Standard Contract Clauses and New York City Standard
Clauses Signature Page

Medicaid Advantage Contract
TABLE OF CONTENTS
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6
 

Table of Contents for Medicaid Advantage Model Contract

APPENDICES

 
A.
New York State Standard Clauses

 
B.
Certification Regarding Lobbying

 
C.
New York State Department of Health Requirements for Provision of Free Access to
Family Planning and Reproductive Health Services

 
D.
New York State Department of Health Medicaid Advantage Marketing Guidelines

 
E.
New York State Department of Health Medicaid Advantage Model Member Handbook
Guidelines

 
F.
New York State Department of Health Medicaid Advantage Action and Grievance
Systems Requirements

 
G.
RESERVED

 
H.
New York State Department of Health Guidelines for the Processing of Medicaid
Advantage Enrollments and Disenrollments

 
I.
RESERVED

 
J.
New York State Department of Health Guidelines of Federal Americans with
Disabilities Act

 
K.
Medicare and Medicaid Advantage Products and Non-Covered Services

 
L.
Approved Capitation Payment Rates

 
M.
Service Area

 
N.
New York City Specific Contracting Requirements

 
O.
RESERVED

 
P.
RESERVED

 
Q.
RESERVED

 
R.
New York City Standard Clauses

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1. DEFINITIONS
 
"Capitation Rate" means the fixed monthly amount that the Contractor receives
from the State for an Enrollee to provide that Enrollee with the Medicaid
Advantage Benefit Package.
 
"Court-Ordered Services" means those services that the Contractor is required to
provide to Enrollees pursuant to orders of courts of competent jurisdiction,
provided however, that such ordered services are within the Contractor's
Medicare and Medicaid Advantage Benefit Packages.
 
"Days" means calendar days except as otherwise stated.
 
"Department of Health and Mental Hygiene" or "DOHMH" means the New York City
Department of Health and Mental Hygiene.
 
"Disenrollment" means the process by which an Enrollee's membership in the
Contractor's Medicaid Advantage Product terminates.
 
"Dually Eligible" means eligible for both Medicare and Medicaid.
 
"Effective Date of Disenrollment" means the date on which an Enrollee is no
longer a member of the Contractor's Medicaid Advantage Product.
 
"Effective Date of Enrollment" means the date on which an Enrollee is a member
of the Contractor's Medicaid Advantage Product.
 
"Eligible Person" means a person whom the LDSS, state or federal government
determines to be eligible for Medicaid and who meets all the other conditions
for enrollment in the Medicaid Advantage Program as set forth in Section 5.1 of
this Agreement.
 
"eMedNY" means the electronic Medicaid system of New York State for eligibility
verification and Medicaid provider claim submission and payments.
 
"Emergency Medical Condition" means a medical or behavioral condition, the onset
of which is sudden, that manifests itself by symptoms of sufficient severity,
including severe pain, that a prudent layperson, possessing an average knowledge
of medicine and health, could reasonably expect the absence of immediate medical
attention to result in:
(i) placing the health of the person afflicted with such condition in serious
jeopardy, or in the case of a behavioral condition, placing the health of the
person or others in serious jeopardy; or (ii) serious impairment to such
person's bodily functions; or (iii) serious dysfunction of any bodily organ or
part of such person; or (iv) serious disfigurement of such person.
 

 
Medicaid Advantage Contract
SECTION 1
(DEFINITIONS)
New York City 2006
1-1
 

"Emergency Services" means covered services that are needed to treat an
Emergency Medical Condition. Emergency services include health care procedures,
treatments or services needed to evaluate or stabilize an Emergency Medical
Condition including psychiatric stabilization and medical detoxification from
drugs or alcohol.
 
"Enrollee" means an Eligible Person who, either personally or through an
authorized representative, has enrolled in the Contractor's Medicaid Advantage
Product pursuant to Section 6 of this Agreement.
 
"Enrollment" means the process by which an Enrollee's membership in a
Contractor's Medicaid Advantage Product begins.
 
"Enrollment Broker" means the state and/or county-contracted entity that
provides enrollment, education, and outreach services; effectuates Enrollments
and Disenrollments in the Medicaid Advantage Program; and provides other
contracted services on behalf of the SDOH and the LDSS.
 
"Fiscal Agent" means the entity that processes or pays vendor claims on behalf
of the Medicaid state agency pursuant to an agreement between the entity and
such agency.
 
"Guaranteed Eligibility" means the period beginning on the Enrollee's Effective
Date of Enrollment in the Contractor's Medicaid Advantage Product and ending six
(6) months thereafter, during which the Enrollee, who remains enrolled in the
Contractor's Medicare Advantage Product, may be entitled to continued enrollment
in the Contractor's Medicaid Advantage Product despite the loss of Medicaid
eligibility as set forth in Section 9 of this Agreement.
 
"Health Provider Network" or "HPN" means a closed communication network
dedicated to secure data exchange and distribution of health related information
between various health facility providers and the SDOH. HPN functions include:
collection of Medicaid complaint and disenrollment information; collection of
Medicaid financial reports; collection and reporting of managed care provider
networks systems (PNS); and the reporting of Medicaid encounter data systems
(MEDS).
 
"Local Department of Social Services" or "LDSS" means a city or county social
services district as constituted by Section 61 of the SSL.
 
"Local Public Health Agency" or "LPHA" means the city or county government
agency responsible for monitoring the population's health, promoting the health
and safety of the public, delivering public health services and intervening when
necessary to protect the health and safety of the public.
 
"Managed Care Organization" or "MCO" means a health maintenance organization
("HMO") or prepaid health service plan ("PHSP") certified under Article 44 of
the New York State PHL.
 

 
Medicaid Advantage Contract
SECTION 1
(DEFINITIONS)
New York City 2006
1-2
 

"Marketing" means activity of the Contractor, subcontractor or individuals or
entities affiliated with the Contractor, as described in Appendix D, by which
information about the Contractor is made known to Eligible Persons for the
purpose of persuading such persons to enroll in the Contractor's Medicaid
Advantage Product.
 
"Marketing Representative" means any individual or entity engaged by the
Contractor to market on behalf of the Contractor.
 
"Medicaid Advantage Benefit Package" means the services and benefits described
in Appendix K-2 of this Agreement, plus the CMS approved Medicare supplemental
premium for the Medicare Part C benefits described in Appendix K-l of this
Agreement, if any, included in the Capitation Rate paid to the MCO by the State.
 
"Medicaid Advantage Program" means the program that the State has developed to
enroll persons who are Dually Eligible in Medicaid managed care pursuant 364-j
of the Social Services Law.
 
"Medicaid Advantage Product" means the product offered by a qualified MCO to
Eligible Persons under this Agreement as described in Appendix K-2 of this
Agreement.
 
"Medicaid Only Covered Services" means those services included in the Medicaid
Advantage Benefit Package that are covered solely by Medicaid and which are not
included in the Contractor's Plan Benefit Package Bid submission proposal as
approved by CMS.
 
"Medical Record" means a complete record of care rendered by a provider
documenting the care rendered to the Enrollee, including inpatient, outpatient,
and emergency care, in accordance with all applicable federal, state and local
laws, rules and regulations. Such record shall be signed by the medical
professional rendering the services.
 
"Medically Necessary", as applicable to services that the Contractor determines
are a Medicaid only benefit and to services that the Contractor determines are a
benefit under both Medicare and Medicaid, means health care and services that
are necessary to prevent, diagnose, manage or treat conditions in the person
that cause acute suffering, endanger life, result in illness or infirmity,
interfere with such person's capacity for normal activity, or threaten some
significant handicap.
 
"Medicare Advantage Benefit Package" means all the health care services and
supplies that are covered by the Contractor's Medicare Advantage Product,
including Medicare Part C and qualified Part D Benefits, on file with CMS, as
described in Appendix K-l of this Agreement.
 
"Medicare Advantage Organization" means a public or private organization
licensed by the State as a risk-bearing entity that is under contract with CMS
to provide the Medicare Advantage Benefit Package.
 

 
Medicaid Advantage Contract
SECTION 1
(DEFINITIONS)
New York City 2006
1-3
 

"Medicare Advantage Product" means the product offered by a qualified MCO to
Eligible Persons under this Agreement as described in Appendix K-l of this
Agreement.
 
"Member Handbook" means the publication prepared by the Contractor and issued to
Enrollees to inform them of their benefits and services, how to access health
care services and to explain their rights and responsibilities as a Medicaid
Advantage Enrollee.
 
"Native American" means, for purposes of this Agreement, a person identified in
the Medicaid eligibility system as a Native American.
 
"Nonconsensual Enrollment" means Enrollment of an Eligible Person, in a Medicaid
Advantage Product, without the consent of the Eligible Person or consent of a
person with the legal authority to act on behalf of the Eligible Person at the
time of Enrollment.
 
"Non-Participating Provider" means a provider of medical care and/or services
with which the Contractor has no Provider Agreement.
 
"Participating Provider" means a provider of medical care and/or services that
has a Provider Agreement with the Contractor.
 
"Permanent Placement Status" means the status of an individual in a Residential
Health Care Facility (RHCF) when the LDSS determines that the individual is not
expected to return home based upon medical evidence affirming the individual's
need for permanent RHCF placement.
 
"Physician Incentive Plan" or "PIP" means any compensation arrangement between
the Contractor or one of its contracting entities and a physician or physician
group that may directly or indirectly have the effect of reducing or limiting
services furnished to the Contractor's Enrollees.
 
"Prepaid Capitation Plan Roster" or "Roster" means the enrollment list generated
on a monthly basis by SDOH by which LDSS and Contractor are informed of
specifically which Eligible Persons the Contractor will be serving in the
Medicaid Advantage Program for the coming month, subject to any revisions
communicated in writing or electronically by SDOH, LDSS, or the Enrollment
Broker.
 
"Post-stabilization Care Services" means covered services, related to an
Emergency Medical Condition, that are provided after an Enrollee is stabilized
in order to maintain the stabilized condition, or to improve or resolve the
Enrollee's condition.
 
"Prospective Enrollee" means any Eligible Person as defined in this Agreement
that has not yet enrolled in the Contractor's Medicaid Advantage Product.
 
 

Medicaid Advantage Contract
SECTION 1
(DEFINITIONS)
New York City 2006
1-4
 

"Provider Agreement" means any written contract between the Contractor and a
Participating Provider to provide medical care and/or services to the
Contractor's Enrollees.
 
"Tuberculosis Directly Observed Therapy" or "TB/DOT" means the direct
observation of ingestion of oral TB medications to assure patient compliance
with the physician's prescribed medication regimen.
 
"Urgently Needed Services" means covered services that are not Emergency
Services as defined in this section, provided when an Enrollee is temporarily
absent from the Contractor's service area when the services are medically
necessary and immediately required: (1) as a result of an unforeseen illness,
injury or condition; and (2) it was not reasonable given the circumstances to
obtain the services through the Contractor's Participating Providers.
 
 

Medicaid Advantage Contract
SECTION 1
(DEFINITIONS)
New York City 2006
1-5

2.
AGREEMENT TERM, AMENDMENTS, EXTENSIONS, AND GENERAL CONTRACT ADMINISTRATION
PROVISIONS

 
2.1 Term
 

 
a)
This Agreement is effective April 1, 2006 and shall remain in effect until
December 31, 2006 or until the execution of an extension, renewal or successor
Agreement between the Contractor and the DOHMH approved by the SDOH, the
Department of Health and Human Services (DHHS), and any other entities as
required by law or regulation, whichever occurs first.

 

 
b)
This Agreement shall not be automatically renewed at its expiration. The parties
to the Agreement shall have the option to renew this Agreement for four
additional one (1) year terms, subject to the approval of the SDOH, the DHHS,
and any other entities as required by law or regulation.

 

 
c)
The maximum duration of this Agreement is five (5) years. An extension to this
Agreement beyond the five year maximum may be granted for reasons including, but
not limited to, the following:

 
i. Negotiations for a successor agreement will not be completed by the
expiration date of the current Agreement; or
 
ii. The Contractor has submitted a termination notice and transition of
Enrollees will not be completed by the expiration date of the current Agreement.
 

 
d)
Notwithstanding the foregoing, this Agreement will automatically terminate, in
its entirety, should federal financial participation for the Medicaid Advantage
program expire.

 
2.2 Amendments
 

 
a)
This Agreement may only be modified in writing. Unless otherwise specified in
this Agreement, modifications must be signed by the parties and approved by the
SDOH, and any other entities as required by law or regulation, and approved by
the DHHS prior to the end of the quarter in which the amendment is to be
effective.

 

 
b)
SDOH and DOHMH will make reasonable efforts to provide the Contractor with
notice and opportunity to comment with regard to proposed amendments of this
Agreement except when provision of advance notice would result in the SDOH and
DOHMH being out of compliance with state or federal law.

 

 
Medicaid Advantage Contract
SECTION 2
(AGREEMENT TERM, AMENDMENTS, EXTENSIONS, AND GENERAL
CONTRACT ADMINISTRATION PROVISIONS)
New York City 2006
2-1

 
c)
The Contractor will return the signed amendment or notify the SDOH and DOHMH
that it does not agree with the terms of the amendment within ten (10) business
days of the date of the Contractor's receipt of the proposed amendment.

 
2.3 Approvals
 
This Agreement and any amendments to this Agreement shall not be effective or
binding unless and until approved, in writing, by the DHHS, the SDOH and any
other entity as required in law or regulation. SDOH will provide a notice of
such approval to the Contractor and the DOHMH upon such approval.
 
2.4 Entire Agreement
 
This Agreement, including those attachments, schedules, appendices, exhibits,
and addenda that have been specifically incorporated herein and written plans
submitted by the Contractor and maintained on file by SDOH and/or DOHMH pursuant
to this Agreement, contains all the terms and conditions agreed upon by the
parties, and no other Agreement, oral or otherwise, regarding the subject matter
of this Agreement shall be deemed to exist or to bind any of the parties or vary
any of the terms contained in this Agreement. In the event of any inconsistency
or conflict among the document elements of this Agreement, such inconsistency or
conflict shall be resolved by giving precedence to the document elements in the
following order:
 
1) Appendix A, Standard Clauses for all New York State Contracts;
2) Appendix R, Local Standard Clauses for all New York City Contracts;
3) Appendix N, New York City Specific Requirements
4) The body of this Agreement;
5) The appendices attached to the body of this Agreement, other than Appendices
A, R and N;
6) The Contractor's approved:
i) Medicaid Advantage Marketing Plan, if applicable, on file with
SDOH and DOHMH
ii) Action and Grievance System Procedures on file with SDOH
iii) ADA Compliance Plan on file with SDOH and DOHMH
 
2.5 Renegotiation
 
The parties to this Agreement shall have the right to renegotiate the terms and
conditions of this Agreement in the event applicable local, state or federal
law, regulations or policy are altered from those existing at the time of this
Agreement in order to be in continuous compliance therewith. This Section shall
not limit the
 

 
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CONTRACT ADMINISTRATION PROVISIONS)
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right of the parties to this Agreement from renegotiating or amending other
terms and conditions of this Agreement. Such changes shall only be made with the
consent of the parties and the prior approval of the SDOH and the DHHS.
 
2.6
Assignment and Subcontracting

 
a) The Contractor shall not, without DOHMH and SDOH's prior written consent,
assign, transfer, convey, sublet, or otherwise dispose of this Agreement; of the
Contractor's right, title, interest, obligations, or duties under the Agreement;
of the Contractor's power to execute the Agreement; or, by power of attorney or
otherwise, of any of the Contractor's rights to receive monies due or to become
due under this Agreement. DOHMH and SDOH agree that they will not unreasonably
withhold consent of the Contractor's assignment of this Agreement, in whole or
in part, to a parent, affiliate or subsidiary corporation, or to a transferee of
all or substantially all of its assets. Any assignment, transfer, conveyance,
sublease, or other disposition without DOHMH and SDOH's consent shall be void.
 
b) Contractor may not enter into any subcontracts related to the delivery of
Medicaid Only Covered services to Enrollees, except by written agreement, as set
forth in Section 22 of this Agreement. The Contractor may subcontract for
provider services and management services. If such written agreement would be
between Contractor and a provider of health care or ancillary health services or
between Contractor and an independent practice association, the agreement must
be in a form previously approved by SDOH. If such subcontract is for management
services under 10 NYCRR Part 98, it must be approved by SDOH prior to becoming
effective. Any subcontract entered into by Contractor shall fulfill the
requirements of 42 CFR Parts 434 and 438 to the extent such regulations are or
become effective that pertain to the service or activity delegated under such
subcontract. Contractor agrees that it shall remain legally responsible to DOHMH
and SDOH for carrying out all activities under this Agreement and that no
subcontract shall limit or terminate Contractor's responsibility.
 
2.7
Termination

 
a) DOHMH Initiated Termination
 
i) DOHMH shall have the right to terminate this Agreement, in whole or in part
if the Contractor:
A) takes any action that threatens the health, safety, or welfare of its
Enrollees;
B) has engaged in an unacceptable practice under 18 NYCRR, Part 515, that
affects the fiscal integrity of the Medicaid program
 
 
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GENERAL CONTRACT ADMINISTRATION PROVISIONS)
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or engaged in an unacceptable practice pursuant to Section 26.2 of this
Agreement;

 
C)
has its Certificate of Authority suspended, limited or revoked by SDOH;

 
D)
materially breaches the Agreement or fails to comply with any term or condition
of this Agreement that is not cured within twenty (20) days, or to such longer
period as the parties may agree, of SDOH or DOHMH's written request for
compliance;

E)
becomes insolvent;

 
F)
brings a proceeding voluntarily, or has a proceeding brought against it
involuntarily, under Title 11 of the U.S. Code (the Bankruptcy Code);

 
G)
knowingly has a director, officer, partner or person owning or controlling more
than five percent (5%) of the Contractor's equity, or has an employment,
consulting, or other agreement with such a person for the provision of items
and/or services that are significant to the Contractor's contractual obligation
who has been debarred or suspended by the federal, state or local government, or
otherwise excluded from participating in procurement activities; or

 
H)
terminates or fails to renew its contract with CMS pursuant to Sections 1851
through 1859 of the Social Security Act to offer the Medicare Advantage Product,
including Medicare Part C benefits as defined in this Agreement and qualified
Medicare Part D benefits to Eligible Persons residing in the service area
specified in Appendix M. In such instances, the Contractor shall notify the
DOHMH and SDOH of the termination or failure to renew the contract with CMS
immediately upon knowledge of the impending termination or failure to renew.

 

 
ii)
The DOHMH will notify the Contractor of its intent to terminate this Agreement
for the Contractor's failure to meet the requirements of this Agreement and
provide Contractor with a hearing prior to the termination.

 

 
iii)
If SDOH suspends, limits or revokes Contractor's Certificate of Authority under
PHL § 4404, this Agreement shall expire on the date the Contractor ceases to
have authority to serve the geographic area of the LDSS. No hearing will be
required if the Agreement expires due to SDOH suspension, limitation or
revocation of the Contractor's Certificate of Authority or if the Contractor's
contract with CMS to offer the Medicare Advantage Product is terminated or not
renewed.

 

iv)  
Prior to the effective date of the termination the DOHMH shall notify Enrollees
of the termination, or delegate responsibility for such notification to the
Contractor, and such notice shall include a statement that Enrollees may
disenroll immediately from the Contractor's Medicaid Advantage Product.

 

 
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(AGREEMENT TERM, AMENDMENTS, EXTENSIONS,
AND GENERAL CONTRACT ADMINISTRATION PROVISIONS)
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b) Contractor and DOHMH Initiated Termination
 

 
i)
The Contractor and the DOHMH each shall have the right to terminate this
Agreement in the event that SDOH and the Contractor fail to reach agreement on
the monthly Capitation Rates.

 

 
ii)
The Contractor and the DOHMH shall each have the right to terminate this
Agreement in the event the Contractor terminates or fails to renew its contract
with CMS to offer the Medicare Advantage Product, as defined in this Agreement,
to Eligible Persons in the service area as specified in Appendix M.

 

 
iii)
In such events, the party exercising its right shall give the other party and
SDOH written notice specifying the reason for and the effective date of
termination, which shall not be less time than will permit an orderly
disenrollment of Enrollees from the Contractor's Medicaid Advantage Product.
However, in the event that this Agreement is terminated due to the Contractor's
failure to renew its contract with CMS to offer the Medicare Advantage Product,
or that the Contractor's Medicare Advantage contract with CMS otherwise expires
or terminates, this Agreement shall terminate on the effective date of the
termination of the Contractor's contract with CMS.

 
c) Contractor Initiated Termination
 

 
i)
The Contractor shall have the right to terminate this Agreement in the event
that DOHMH materially breaches the Agreement or fails to comply with any term or
condition of this Agreement that is not cured within twenty (20) days, or to
such longer period as the parties may agree, of the Contractor's written request
for compliance. The Contractor shall give DOHMH and SDOH written notice
specifying the reason for and the effective date of the termination, which shall
not be less time than will permit an orderly disenrollment of Enrollees from the
Contractor's Medicaid Advantage Product.

 

 
ii)
In the event that the Contractor's obligations are materially changed by
modifications to this Agreement and its Appendices by SDOH or DOHMH and the
Contractor does not agree to such material changes, the Contractor shall have
the right to terminate this Agreement. In such event. Contractor shall give
DOHMH and SDOH written notice within thirty (30) days of notification of changes
to the Agreement or

 

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(AGREEMENT TERM, AMENDMENTS, EXTENSIONS,
AND GENERAL CONTRACT ADMINISTRATION PROVISIONS)
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Appendices specifying the reason for and the effective date of termination,
which shall not be less time than will permit an orderly disenrollment of
Enrollees from the Contractor's Medicaid Advantage Product.
 

 
iii)
The Contractor shall have the right to terminate this Agreement if the
Contractor is unable to provide the Medicaid Advantage Benefit Package pursuant
to this Agreement because of a natural disaster and/or an act of God to such a
degree that Enrollees cannot obtain reasonable access to Medicaid Only Covered
Services within the Contractor's organization, and, after diligent efforts, the
Contractor cannot make other provisions for the delivery of such services. The
Contractor shall give DOHMH and SDOH written notice of any such termination that
specifies:

 
A) the reason for the termination, with appropriate documentation of the
circumstances arising from a natural disaster and/or an act of God that preclude
reasonable access to services;
B) the Contractor's attempts to make other provision for the delivery of
Medicaid Only Covered Services; and
C) the effective date of the termination, which shall not be less time than will
permit an orderly disenrollment of Enrollees from the Contractor's Medicaid
Advantage Product.
 
d) Termination Due To Loss of Funding
 
In the event that State and/or Federal funding used to pay for services under
this Agreement is reduced so that payments cannot be made in full, this
Agreement shall automatically terminate, unless both parties agree to a
modification of the obligations under this Agreement. The effective date of such
termination shall be ninety (90) days after the Contractor receives written
notice of the reduction in payment, unless available funds are insufficient to
continue payments in full during the ninety (90) day period, in which case DOHMH
shall give the Contractor written notice of the earlier date upon which the
Agreement shall terminate. A reduction in State and/or Federal funding cannot
reduce monies due and owing to the Contractor on or before the effective date of
the termination of the Agreement.
 
2.8 Close-Out Procedures
 

 
a)
Upon termination or expiration of this Agreement and in the event that it is not
scheduled for renewal, the Contractor shall comply with close-out procedures
that the Contractor develops in conjunction with DOHMH and that the DOHMH, and
the SDOH have approved. The close-out procedures shall include the following:

 
 

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AND GENERAL CONTRACT ADMINISTRATION PROVISIONS)
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i) The Contractor shall promptly account for and repay funds advanced by SDOH
for coverage of Enrollees for periods subsequent to the effective date of
termination;
 
ii) The Contractor shall give DOHMH, SDOH, and other authorized federal, state
or local agencies access to all books, records, and other documents and upon
request, portions of such books, records, or documents that may be required by
such agencies pursuant to the terms of this Agreement;
 
iii) The Contractor shall submit to DOHMH, SDOH, and other authorized federal,
state or local agencies, within ninety (90) days of termination, a final
financial statement and audit report relating to this Agreement, made by a
certified public accountant, unless the Contractor requests of DOHMH and
receives written approval from DOHMH, SDOH and all other governmental agencies
from which approval is required, for an extension of time for this submission;
 
iv) The Contractor shall establish an appropriate plan acceptable to and prior
approved by the DOHMH and SDOH for the orderly disenrollment of Enrollees from
the Contractor's Medicaid Advantage Product;
 
v) SDOH shall promptly pay all claims and amounts owed to the Contractor;
 
vi) Any termination of this Agreement by either the Contractor or DOHMH shall be
done by amendment to this Agreement, unless the Agreement is terminated by the
DOHMH due to conditions in Section 2.7 (a)(i) or Appendix A of this Agreement.
 
2.9 Rights and Remedies
 
The rights and remedies of DOHMH and the Contractor provided expressly in this
Article shall not be exclusive and are in addition to all other rights and
remedies provided by law or under this Agreement.
 
 
 

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(AGREEMENT TERM, AMENDMENTS, EXTENSIONS,
AND GENERAL CONTRACT ADMINISTRATION PROVISIONS)
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2.10 Notices
 
All notices to be given under this Agreement shall be in writing and shall be
deemed to have been given when mailed to, or, if personally delivered, when
received by the Contractor, DOHMH, and the SDOH at the following addresses:
 
For DOHMH:
New York City Department of Health and Mental Hygiene
125 Worth Street, CN # 29C
New York, NY 10013
ATTN: Assistant Commissioner
Division of Health Care Access and Improvement
 
For SDOH:
New York State Department of Health Empire State Plaza Corning Tower, Rm. 2074
Albany, NY 12237-0065
 
For the Contractor:
WellCare of New York, Inc. 11 West 19th Street, 2nd floor New York, NY 10011
ATTN: Chief Executive Officer
 
2.11  Severability
 
If this Agreement contains any unlawful provision that is not an essential part
of this Agreement and that was not a controlling or material inducement to enter
into this Agreement, the provision shall have no effect and, upon notice by
either party, shall be deemed stricken from this Agreement without affecting the
binding force of the remainder of this Agreement.
 
Medicaid Advantage Contract SECTION 2
(AGREEMENT TERM, AMENDMENTS, EXTENSIONS, AND
GENERAL CONTRACT ADMINISTRATION PROVISIONS)
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3. COMPENSATION
 
3.1 Capitation Payments
 
a) Compensation to the Contractor shall consist of a monthly capitation payment
for each Enrollee as described in this Section.
 
b) The monthly Capitation Rates are attached hereto as Appendix L and shall be
deemed incorporated into this Agreement without further action by the parties.
 
c) The monthly capitation payments to the Contractor shall constitute full and
complete payments to the Contractor for all services that the Contractor
provides pursuant to this Agreement.
 
d) Capitation Rates shall be effective for the entire contract period, except as
described in Section 3.2.
 
3.2 Modification of Rates During Contract Period
 
a) Any technical modification to Capitation Rates during the term of this
Agreement as agreed to by the Contractor, including but not limited to, changes
in reinsurance or the Medicaid Advantage Benefit Package, shall be deemed
incorporated into this Agreement without further action by the parties, upon
approval by SDOH, and upon written notice by SDOH to the DOHMH.
 
b) Any other modification to Capitation Rates, as agreed to by SDOH and the
Contractor, during the term of the Agreement shall be deemed incorporated into
this Agreement without further action by the parties upon approval of such
modifications by the SDOH and the State Division of the Budget, and upon written
notice by SDOH to the DOHMH.
 
c) In the event that SDOH and the Contractor fail to reach agreement on
modifications to the monthly Capitation Rates, the SDOH will provide formal
written notice to the Contractor and DOHMH of the amount and effective date of
the modified Capitation Rates approved by the State Division of the Budget. The
Contractor shall have the option of terminating this Agreement if such approved
modified Capitation Rates are not acceptable. In such case, the Contractor shall
give written notice to the SDOH and the DOHMH within thirty (30) days of the
date of the formal written notice of the modified Capitation Rates from SDOH
specifying the reasons for and effective date of termination. The effective date
of termination shall be ninety (90) days from the date of the Contractor's
written notice, unless the SDOH determines that an orderly disenrollment to
Medicaid fee-for-service or transfer to another MCO's Medicaid Advantage Product
can be accomplished in fewer days. During the period commencing with the
effective date of the SDOH modified Capitation Rates through the effective date
of termination of the Agreement,
 

 

 
Medicaid Advantage Contract
 SECTION 3 (COMPENSATION)
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the Contractor shall have the option of continuing to receive capitation
payments at the expired Capitation Rates or at the modified Capitation Rates
approved by SDOH and State Division of the Budget for the rate period.
 
If the Contractor fails to exercise its right to terminate in accordance with
this Section, then the modified Capitation Rates approved by SDOH and the State
Division of the Budget shall be deemed incorporated into this Agreement without
further action by the parties as of the effective date of the modified
Capitation Rates as established by SDOH and approved by State Division of the
Budget.
 
3.3 Rate Setting Methodology
 

 
a)
Capitation Rates shall be determined prospectively and shall not be
retroactively adjusted to reflect actual fee-for-service data or plan experience
for the time period covered by the rates.

 

 
b)
Capitated rates in effect as of April 1, 2006 and thereafter, shall be certified
to be actuarially sound in accordance with 42 CFR § 438.6 (c ).

 

 
c)
Notwithstanding the provisions set forth in Section 3.3 (a) and (b) above, the
DOHMH reserves the right to terminate this Agreement pursuant to Section 2.7 of
this Agreement, upon determination by SDOH that the aggregate monthly Capitation
Rates are not cost effective.

 
3.4 Payment of Capitation
 

 
a)
The monthly capitation payments for each Enrollee are due to the Contractor from
the Effective Date of Enrollment until the Effective Date of Disenrollment of
the Enrollee or termination of this Agreement, whichever occurs first. The
Contractor shall receive a full month's capitation payment for the month in
which Disenrollment occurs. The Roster generated by SDOH with any modification
communicated electronically or in writing by the LDSS or the Enrollment Broker
prior to the end of the month in which the Roster is generated, shall be the
Enrollment list for purposes of eMedNY premium billing and payment, as discussed
in Section 6.7 and Appendix H.

 

 
b)
Upon receipt by the Fiscal Agent of a properly completed claim for monthly
capitation payments submitted by the Contractor pursuant to this Agreement, the
Fiscal Agent will promptly process such claim for payment and use its best
efforts to complete such processing within thirty (30) business days from date
of receipt of the claim by the Fiscal Agent. Processing of Contractor claims
shall be in compliance with the requirements of 42 CFR 447.45. The Fiscal Agent
will also use its best efforts to resolve any billing problem relating to the
Contractor's claims as soon as possible. In accordance with Section 41 of the
State Finance Law, the State and New York City shall have no liability under
this Agreement to the Contractor or anyone else beyond funds appropriated and
available for this Agreement.

 
 
 
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SECTION 3
(COMPENSATION)
New York City 2006
3-2
 
3.5 Denial of Capitation Payments
 
If the Centers for Medicare and Medicaid Services denies payment for new
Enrollees, as authorized by SSA § 1903(m)(5) and 42CFR§ 438.730 (e), or such
other applicable federal statutes or regulations, based upon a determination
that Contractor failed substantially to provide medically necessary items and
services, imposed premium amounts or charges in excess of permitted payments,
engaged in discriminatory practices as described in SSA § 1932(e)(l)(A)(iii),
misrepresented or falsified information submitted to CMS, SDOH, LDSS or DOHMH,
the Enrollment Broker, or an Enrollee, potential Enrollee, or health care
provider, or failed to comply with federal requirements (i.e. 42 CFR § 422.208
and 42 CFR § 438.6 (h)) relating to the Physician Incentive Plans, SDOH and LDSS
will deny capitation payments to the Contractor for the same Enrollees for the
period of time for which CMS denies such payment.
 
3.6 SDOH Right to Recover Premiums
 
The parties acknowledge and accept that the SDOH has a right to recover premiums
paid to the Contractor for Enrollees listed on the monthly Roster who are later
determined for the entire applicable payment month, to have been disenrolled
from the Contractor's Medicare Advantage Product; to have been in an
institution; to have been incarcerated; to have moved out of the Contractor's
service area subject to any time remaining in the Enrollee's Guaranteed
Eligibility period; or to have died. In any event, the State may only recover
premiums paid for Medicaid Enrollees listed on a Roster if it is determined by
the SDOH that the Contractor was not at risk for provision of Benefit Package
services for any portion of the payment period.
 
3.7 Third Party Health Insurance Determination
 
The Contractor will make diligent efforts to determine whether Enrollees have
third party health insurance (TPHI). The LDSS is also responsible for making
diligent efforts to determine if Enrollees have TPHI and to maintain third party
information on the Welfare Management System (WMS)/eMedNY Third Party Resource
System. The Contractor shall make good faith efforts to coordinate benefits with
and collect TPHI recoveries from other insurers, and must inform the LDSS of any
known changes in status of TPHI insurance eligibility within thirty (30) days of
learning of a change in TPHI. The Contractor may use the Roster as one method to
determine TPHI information. The Contractor will be permitted to retain one
hundred percent (100%) of any reimbursement for Benefit Package services
obtained from TPHI. Capitation Rates are net of TPHI recoveries. In no instances
may an Enrollee be held responsible for disputes over these recoveries.

 
Medicaid Advantage Contract
SECTION 3
(COMPENSATION)
New York City 2006
3-3

3.8 Contractor Financial Liability
 
Contractor shall not be financially liable for any services rendered to an
Enrollee prior to his or her Effective Date of Enrollment in the Contractor's
Medicaid Advantage Product.
 
3.9 Tracking Services Provided by Indian Health Clinics
 
The SDOH shall monitor all services provided by tribal or Indian health clinics
or urban Indian health facilities or centers to enrolled Native Americans, so
that the SDOH can reconcile payment made for those services, should it be deemed
necessary to do so.

 
Medicaid Advantage Contract
SECTION 3
(COMPENSATION)
New York City 2006
3-4

4.
SERVICE AREA

 
The Service Area described in Appendix M of this Agreement, which is hereby made
a part of this Agreement as if set forth fully herein, is the specific
geographic area within which Eligible Persons must reside to enroll in the
Contractor's Medicaid Advantage Product.
 

 

 
Medicaid Advantage Contract
SECTION 4
(SERVICE AREA)
New York City 2006
4-1
 

5. ELIGIBILITY FOR ENROLLMENT IN MEDICAID ADVANTAGE
 
5.1 Eligible to Enroll in the Medicaid Advantage Program
 
a) Except as specified in Section 5.2, persons meeting the following criteria
shall be eligible to enroll in the Contractor's Medicaid Advantage Product:
 

 
i)
Must have full Medicaid coverage or full Medicaid coverage with Qualified
Medicare Beneficiary (QMB) eligibility;

 

 
ii)
Must have evidence of Medicare Part A & B coverage; or be enrolled in Medicare
Part C coverage;

 

iii)
 Must reside in the service area as defined in Appendix M of this Agreement;

 

iv)
 Must be 21 years of age or older; and

 

v)
 Must enroll in the Contractor's Medicare Advantage Product as defined in
Section 1 and Appendix K-l of this Agreement.

 
b) Participation in the Medicaid Advantage Program and enrollment in the
Contractor's Medicaid Advantage Product shall be voluntary for all Eligible
Persons.
 
5.2 Not Eligible to Enroll in the Medicaid Advantage Program
 
Persons meeting the following criteria are not eligible to enroll in the
Contractor's Medicaid Advantage Product:
 
a)  Individuals who are medically determined to have End Stage Renal Disease
(ESRD) at the time of enrollment, unless such individuals meet the exceptions to
Medicare Advantage eligibility rules for persons who have ESRD as found in
Section 20.2.2 of the Medicare Managed Care Manual.
 
b)  Individuals who are only eligible for the Qualified Medicare Beneficiary
(QMB), Specified Low Income Medicare Beneficiary (SLIMB) or the Qualified
Individual-1 (QI-1) and are not otherwise eligible for Medical Assistance.
 
c)  Individuals who become eligible for Medical Assistance only after spending
down a portion of their income.
 

Medicaid Advantage Contract
SECTION 5
(ELIGIBLE, EXEMPT AND EXCLUDED POPULATIONS)
New York City 2006
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d)
Individuals who are residents of State-operated psychiatric facilities or
residents of State-certified or voluntary treatment facilities for children and
youth.

 
e)
 Individuals who are residents of Residential Health Care Facilities ("RHCF") at
the time of Enrollment, and Enrollees whose stay in a RHCF is classified as
permanent upon entry in the RHCF or is classified as permanent at a time
subsequent to entry.

 

 
f)
Individuals enrolled in managed long term care demonstrations authorized under
Article 4403-fofthe New York State PHL.

 

 
g)
Individuals with access to comprehensive private health care coverage, except
for Medicare, including those already enrolled in an MCO. Such health care
coverage purchased either partially or in full, by or on behalf of the
individual, must be determined to be cost effective by the local social services
district.

 
h)  Individuals expected to be eligible for Medicaid for less than six (6)
months, except for pregnant women (e.g., seasonal agricultural workers).
 
i)  Individuals in receipt of long-term care services through Long Term Home
Health Care programs (except ICF services for the Developmentally Disabled).
 
j)  Individuals eligible for Medical Assistance benefits only with respect to TB
related services.
 
k)  Individuals placed in State Office of Mental Health licensed family care
homes pursuant to NYS Mental Hygiene Law, Section 31.03.

1)   Individuals enrolled in the Restricted Recipient Program.
 
m)   Individuals with a "County of Fiscal Responsibility" code of 99.
 

 
n)
Individuals admitted to a Hospice program prior to time of enrollment (if an
Enrollee enters a Hospice program while enrolled in the Contractor's plan,
he/she may remain enrolled in the Contractor's plan to maintain continuity of
care with his/her PCP).

 

 
o)
Individuals with a "County of Fiscal Responsibility" code of 97 (OMH in eMedNY).

 

 

 

Medicaid Advantage Contract
SECTION 5
(ELIGIBLE, EXEMPT AND EXCLUDED POPULATIONS)
New York City 2006
5-2

p)  Individuals with a "County of Fiscal Responsibility" code of 98 (OMRDD in
eMedNY) will be excluded until program features are approved by the State and
operational at the local district level to permit these individuals to
voluntarily enroll in Medicaid managed care.
 
q)  Individuals receiving family planning services pursuant to Section
366(l)(a)(ll) of the Social Services Law who are not otherwise eligible for
medical assistance and whose net available income is 200% or less of the federal
poverty level.
 
r)  Individuals who are eligible for Medical Assistance pursuant to the
"Medicaid buy-in for the working disabled" (subparagraphs twelve or thirteen of
paragraph (a) of subdivision one of Section 366 of the Social Services Law), and
who, pursuant to subdivision 12 of Section 367-a of the Social Services Law, are
required to pay a premium.
 

 
s)
Individuals who are eligible for Medical Assistance pursuant to paragraph (v) of
subdivision four of Section 366 of the Social Services Law (persons who are
under 65 years of age, have been screened for breast and/or cervical cancer
under the Centers for Disease Control and Prevention Breast and Cervical Cancer
Early Detection Program and need treatment for breast or cervical cancer, and
are not otherwise covered under creditable coverage as defined in the Federal
Public Health Service Act).

 
5.3 Change in Eligibility Status
 

 
a)
The Contractor must report to the LDSS any change in status of its Enrollees,
which may impact the Enrollee's eligibility for Medicaid or Medicaid Advantage,
within five (5) business days of such information becoming known to the
Contractor. This information includes, but is not limited to: change of address;
incarceration; permanent placement in a nursing home or other residential
institution or program rendering the individual ineligible for enrollment in
Medicaid Advantage; death; and disenrollment from the Contractor's Medicare
Advantage Product as defined in this Agreement.

 

 
b)
To the extent practicable, the LDSS will follow-up with Enrollees when the
Contractor provides documentation of any change in status which may affect the
Enrollee's Medicaid and/or Medicaid Advantage plan eligibility and enrollment.

 
 

Medicaid Advantage Contract
SECTION 5
(ELIGIBLE, EXEMPT AND EXCLUDED POPULATIONS)
New York City 2006
5-3

6. ENROLLMENT
 
6.1 Enrollment Requirements
 
The LDSS and the Contractor agree to conduct enrollment of Eligible Persons in
accordance with the policies and procedures set forth in Appendix H of this
Agreement as if set forth fully herein.
 
6.2 Equality of Access to Enrollment
 
The Contractor shall accept Enrollments of Eligible Persons in the order they
are received without regard to the Eligible Person's age, sex, race, creed,
physical or mental handicap/developmental disability, national origin, sexual
orientation, type of illness or condition, need for health services or to the
Capitation Rate that the Contractor will receive for such Eligible Person.
 
6.3 Enrollment Decisions
 
An Eligible Person's decision to enroll in the Contractor's Medicaid Advantage
Product shall be voluntary. However, as a condition of eligibility for Medicaid
Advantage, individuals may only enroll in the Contractor's Medicaid Advantage
Product if they also enroll in the Contractor's Medicare Advantage Product as
defined in this Agreement.
 
6.4 Prohibition Against Conditions on Enrollment
 
Unless otherwise required by law or this Agreement, neither the Contractor nor
LDSS shall condition any Eligible Person's enrollment in the Medicaid Advantage
Program upon the performance of any act or suggest in any way that failure to
enroll may result in a loss of Medicaid benefits.
 
6.5 Effective Date of Enrollment
 

 
a)
At the time of enrollment, the Contractor and the LDSS must notify the Enrollee
of the expected Effective Date of Enrollment.

 

 
b)
To the extent practicable, such notification must precede the Effective Date of
Enrollment.

 

 
c)
In the event that the actual Effective Date of Enrollment changes, the
Contractor and the LDSS must notify the Enrollee of the change.

 
Medicaid Advantage Contract
SECTION 6 (ENROLLMENT)
New York City 2006
6-1

 
d)
An Enrbllee's Effective Date of Enrollment shall be the first day of the month
on which the Enrollee's name appears on the Prepaid Capitation Plan Roster and
is enrolled in the Contractor's Medicare Advantage Product for that month.

 
6.6 Contractor Liability
 
As of the Effective Date of Enrollment, and until the Effective Date of
Disenrollment from the Contractor's product, the Contractor shall be responsible
for the provision and cost of the Medicaid Advantage Benefit Package as
described in Appendix K-2 of this Agreement for Enrollees whose names appear on
the Prepaid Capitation Plan Roster.
 
6.7 Roster
 

 
a)
The first and second monthly Rosters generated by SDOH in combination shall
serve as the official Contractor enrollment list for purposes of eMedNY premium
billing and payment, subject to ongoing eligibility of the Enrollees as of the
first (1st) day of the Enrollment month. Modifications to the Roster may be made
electronically or in writing by the LDSS or the Enrollment Broker. If the LDSS
or Enrollment Broker notifies the Contractor in writing or electronically of
changes in the Roster and provides supporting information as necessary prior to
the effective date of the Roster, the Contractor will accept that notification
in the same manner as the Roster.

 

 
b)
The LDSS is responsible for making data on eligibility determinations available
to the Contractor and SDOH to resolve discrepancies that may arise between the
Roster and the Contractor's enrollment files in accordance with the provisions
in Appendix H of this Agreement.

 
c) All Contractors must have the ability to receive these Rosters
electronically.
 
6.8 Automatic Re-Enrollment
 
An Enrollee who is disenrolled from the Contractor's Medicaid Advantage Product
due to loss of Medicaid eligibility and who regains eligibility within a three
(3) month period will automatically be prospectively re-enrolled with the
Contractor's Medicaid Advantage Product, provided that the individual remains
enrolled in the Contractor's Medicare Advantage Product as defined in this
Agreement unless:
 

 

Medicaid Advantage Contract
SECTION 6
(ENROLLMENT)
New York City 2006 6-2

 
i)
the Contractor does not offer a Medicaid Advantage product in the Enrollee's
county of fiscal responsibility; or

 
ii)
the Enrollee indicates in writing that he/she wishes to enroll in another MCO's
Medicaid and Medicare Advantage Products, or receive Medicaid coverage through
Medicaid fee-for-service.

 
6.9 Failure to Enroll in the Contractor's Medicare Advantage Product
 
If an Enrollee's enrollment in the Contractor's Medicare Advantage Product is
rejected by CMS, the Contractor must notify the local social services district
within five (5) business days of learning of CMS' rejection of the enrollment.
In such instances, the LDSS shall delete the Enrollee's enrollment in the
Contractor's Medicaid Advantage Product retroactive to the Effective Date of
Enrollment.
 
6.10 Medicaid Managed Care Enrollees Who Will Gain Medicare Eligibility
 
Medicaid managed care enrollees who will gain Medicare coverage may elect to
transfer to the Contractor's Medicaid and Medicare Advantage Products or to
enroll in another MCO's Medicaid and Medicare Advantage Products for dually
eligible individuals. A new enrollment must be processed by the LDSS or the
Enrollment Broker to transfer a member of the Contractor's Medicaid managed care
product to the Contractor's Medicaid Advantage Product. To the extent possible,
such enrollments shall be made effective the first day of the month that the
Enrollee's Medicare Advantage coverage is effective.
 
6.11 Newborn Enrollment
 

 
a)
A pregnant Enrollee in the Contractor's Medicaid Advantage Product may choose to
pre-enroll her unborn in any available Medicaid managed care health plan in the
social services district in which she resides.

 

 
b)
The Contractor shall notify the local district in writing of any enrollee that
is pregnant within 30 days of knowledge of the pregnancy. Notification shall
include the pregnant woman's name, CIN, and expected date of confinement.

 

 
c)
Upon the newborn's birth, the Contractor must send identification of the
infant's demographic data to the LDSS within 5 days after knowledge of the
birth. The demographic data must include the mother's name and CIN, the
newborn's name and CIN (if available), sex and the date of birth.

Medicaid Advantage Contract
SECTION 6
(ENROLLMENT)
New York City 2006
6-3
 

d)  
The SDOH'and LDSS shall be responsible for ensuring that timely Medicaid
eligibility determination and Enrollment of the newborn is effected consistent
with state laws, regulations, and policy with the newborn Enrollment
requirements set forth in Appendix H of this Agreement.

 

Medicaid Advantage Contract
SECTION 6
(ENROLLMENT)
New York City 2006
6-4
 

7. RESERVED

Medicaid Advantage Contract
SECTION 7
(LOCK-IN PROVISIONS)
New York City 2006
7-1

8. DISENROLLMENT
 
8.1 Disenrollment Requirements
 

 
a)
The Contractor agrees to conduct Disenrollment of an Enrollee in accordance with
the policies and procedures set forth in Appendix H of this Agreement.

 

 
b)
LDSSs are responsible for making the final determination concerning
Disenrollment requests.

 
8.2 Disenrollment Prohibitions
 
Enrollees shall not be disenrolled from the Contractor's Medicaid Advantage
Product based on any of the following reasons:
 

 
i)
an existing condition or a change in the Enrollee's health which would
necessitate disenrollment pursuant to the terms of this Agreement, unless the
change results in the Enrollee becoming ineligible for Medicaid Advantage
enrollment as described in Section 5 of this Agreement;

 
ii) any of the factors listed in Section 33 (Non-Discrimination) of this
Agreement; or
 
iii) the Capitation Rate payable to the Contractor.
 
8.3 Disenrollment Requests
 
a) Routine Disenrollment Requests
 
The LDSS or the Enrollment Broker is responsible for processing routine
Disenrollment requests to take effect on the first (1st) day of the next month,
to the extent possible. In no event shall the Effective Date of Disenrollment be
later than the first (1st) day of the second (2nd) month after the month in
which an Enrollee requests a Disenrollment.
 
b) Non-Routine Disenrollment Requests
 
i) Enrollees with an urgent medical need to disenroll from the Contractor's
Medicaid Advantage Product may request an expedited disenrollment by the LDSS.
Enrollees who have HIV, ESRD or SPMI/SED status are categorically eligible for
expedited Disenrollment on the basis of urgent medical need.
ii) Enrollees with a complaint of Non-consensual Enrollment may request an
expedited Disenrollment by the LDSS.

 

Medicaid Advantage Contract
SECTION 8
(DISENROLLMENT)
New York City 2006
8-1
 

iii) Homeless Enrollees residing in the shelter system may request an expedited
disenrollment by the LDSS.
iv) An expedited Disenrollment from the Contractor's Medicaid Advantage Product
may also be warranted in instances when the LDSS leams that an Enrollee is
disenrolling from the Contractor's Medicare Advantage Product. In such
instances, the LDSS will disenroll the individual effective concurrent with the
Effective Date of Disenrollment from the Contractor's Medicare Advantage
Product.
v) Retroactive Disenrollments from the Contractor's Medicaid Advantage Product
may be warranted in rare instances and may be requested of the LDSS as described
in Appendix H of this Agreement.
vi) Substantiation of non-routine Disenrollment requests by the LDSS will result
in Disenrollment in accordance with the timeframes as set forth in Appendix H of
this Agreement.
 
8.4 Contractor Notification of Disenrollments
 

 
a)
Notwithstanding anything herein to the contrary, the Roster, along with any
changes sent by the LDSS to the Contractor in writing or electronically, shall
serve as official notice to the Contractor of Disenrollment of an Enrollee. In
cases of expedited and retroactive Disenrollment, the Contractor shall be
notified of the Enrollee's Effective Date of Disenrollment by the LDSS.

 

 
b)
In the event that the LDSS intends to retroactively disenroll an Enrollee on a
date prior to the first day of the month of the disenrollment request, the LDSS
shall consult with the Contractor prior to Disenrollment. Such consultation
shall not be required in cases where it is clear that the Contractor was not a
risk for the provision of the Medicaid Advantage Benefit Package for any portion
of the retroactive period.

 

 
c)
In all cases of retroactive Disenrollment, including Disenrollments effective
the first day of the current month, the LDSS is responsible for notifying the
Contractor at the time of Disenrollment, of the Contractor's responsibility to
submit to the SDOH's Fiscal Agent voided premium claims for any months of
retroactive Disenrollment where the Contractor was not at risk for the provision
of the Medicaid Advantage Benefit Package during the month.

 
8.5 Contractor's Liability
 

 
a)
The Contractor is not responsible for providing the Medicaid Advantage Benefit
Package under this Agreement after the Effective Date of Disenrollment.

 

Medicaid Advantage Contract 
SECTION 8
(DISENROLLMENT)
New York City 2006
8-2
 

8.6 Enrollee Initiated Disenrollment
 
An Enrollee may disenroll from the Contractor's Medicaid Advantage Plan for any
reason. Disenrollments generally shall be effective on the first of the month
following receipt of the complete written Disenrollment request.
 
8.7 Contractor Initiated Disenrollment
 

 
a)
The Contractor must notify the LDSS and initiate an Enrollee's Disenrollment
from the Contractor's Medicaid Advantage Product in the following cases:

 
i) A change in residence makes the Enrollee ineligible to be a member of the
plan;
ii) The Enrollee disenrolls from the Contractor's Medicare Advantage Product as
defined in this Agreement;
iii) The Enrollee dies;
iv) The Enrollee's status changes such that he/she is no longer eligible to
participate in Medicaid Advantage as described in Section 5 of this Agreement.
 

 
b)
The Contractor may initiate an Enrollee's disenrollment from the Contractor's
Medicaid Advantage Product in the following cases:

 

 
i)
The Enrollee engages in conduct or behavior that seriously impairs the
Contractor's ability to furnish services to either the Enrollee or other
Enrollees, provided that the Contractor has made and documented reasonable
efforts to resolve the problems presented by the Enrollee.

 
ii)
The Enrollee provides fraudulent information on an enrollment form or the
Enrollee permits abuse of an enrollment card in the Medicaid Advantage Program
except when the Enrollee is no longer eligible for Medicaid and is in his/her
Guaranteed Eligibility period.

 
iii)
Consistent with 42 CFR 438.56 (b), the Contractor may not request Disenrollment
because of an adverse change in the Enrollee's health status, or because of the
Enrollee's utilization of medical services, diminished mental capacity, or
uncooperative or disruptive behavior resulting from the Enrollee's special needs
(except where continued enrollment in the Contractor's plan seriously impairs
the Contractor's ability to furnish services to either the Enrollee or other
Enrollees).

 

 
c)
Contractor-initiated Disenrollments must be carried out in accordance with the
requirements and timeframes described in Appendix H of this Agreement.

Medicaid Advantage Contract
SECTION 8
(DISENROLLMENT)
New York City 2006
8-3
 

 
d)
Once an Enrollee has been disenrolled at the Contractor's request, he/she will
not be re-enrolled with the Contractor's plan unless the Contractor first agrees
to such re-enrollment.

 
8.8 LDSS Initiated Disenrollment
 

 
a)
The LDSS is responsible for promptly initiating Disenrollment from the
Contractor's Medicaid Advantage Product when:

 
i) an Enrollee fails to enroll or stay enrolled in the Contractor's Medicare
Advantage Product as specified in Sections 6.9 and 8.3(b)(iv) of this Agreement;
or
ii) an Enrollee is no longer eligible for Medicaid or Medicaid Advantage
benefits; or
iii) the Guaranteed Eligibility period ends (See Section 9) and an Enrollee is
no longer eligible for any Medicaid benefits; or iv) an Enrollee is no longer
the financial responsibility of the LDSS; or v) an Enrollee becomes ineligible
for Enrollment pursuant to Section 5.2 of this Agreement, as appropriate.

Medicaid Advantage Contract
SECTION 8
(DISENROLLMENT)
New York City 2006
8-4
 

9. GUARANTEED ELIGIBILITY

9.1 General Requirements
 
SDOH, LDSS and the Contractor will follow the policies in this section subject
to state and federal laws and regulations.
 
9.2 Right to Guaranteed Eligibility
 
a) New Enrollees, other than those identified in Section 9.2 who would otherwise
lose Medicaid eligibility during the first six (6) months of enrollment, will
retain the right to remain enrolled in the Contractor's Medicaid Advantage
Product under this Agreement for a period of six (6) months from their Effective
Date of Enrollment as long as they also remain enrolled in the Contractor's
Medicare Advantage Product as defined in this Agreement.
 
b) Guaranteed Eligibility is not available to the following Enrollees:
 

 
i)
Enrollees who lose eligibility due to death, moving out of State, or
incarceration;

 

 
ii)
Female Enrollees with a net available income in excess of medically necessary
income but at or below two hundred percent (200%) of the federal poverty level
who are only eligible for Medicaid while pregnant and then through the end of
the month in which the sixtieth (60th) day following the end of the pregnancy
occurs.

 
c) If, during the first six (6) months of enrollment in the Contractor's
Medicaid Advantage Product, an Enrollee becomes eligible for Medicaid only as a
spend-down, the Enrollee will be eligible to remain enrolled in the Contractor's
Medicaid Advantage Product for the remainder of the six (6) month Guaranteed
Eligibility period as long as he/she also remains enrolled in the Contractor's
Medicare Advantage Product. During the six (6) month Guaranteed Eligibility
period, an Enrollee eligible for spend-down has the option of spending down to
gain full Medicaid eligibility. If the Enrollee spends down to gain full
Medicaid eligibility, the Enrollee will no longer be in guarantee status and the
LDSS will manually set coverage codes as appropriate.
 
d) Enrollees who lose and regain Medicaid eligibility within a three (3) month
period will not be entitled to a new period of six (6) months Guaranteed
Eligibility in Medicaid Advantage.
 

 
Medicaid Advantage Contract
SECTION 9
(GUARANTEED ELIGIBILITY)
New York City 2006
9-1
 

9.3 Covered Services During Guaranteed Eligibility
 
The services covered during the Guaranteed Eligibility period shall be those
contained in the Medicaid Advantage Benefit Package, as specified in Appendix
K-2, and free access to family planning and reproductive health services as set
forth in Section 10.6 of this Agreement. During the Guaranteed Eligibility
period Enrollees are also eligible for pharmacy services not covered by the
Medicare Advantage Product (Part C and Part D pharmacy benefits) on a Medicaid
fee-for-service basis.
 
9.4 Disenrollment During Guaranteed Eligibility
 

 
a)
An Enrollee-initiated disenrollment from the Contractor's Medicare or Medicaid
Advantage Product terminates the Enrollee's Guaranteed Eligibility period.

 

 
b)
During the guarantee period, an Enrollee may not change health plans. An
Enrollee may choose to disenroll from the Contractor's Medicaid Advantage
Product during the guarantee period but is not eligible to enroll in another
MCO's Medicaid Advantage Product because he/she has lost eligibility for
Medicaid.

 
 
 

Medicaid Advantage Contract
SECTION 9
(GUARANTEED ELIGIBILITY)
New York City 2006
9-2

10. BENEFIT PACKAGE, COVERED AND NON-COVERED SERVICES
 
10.1 Contractor Responsibilities
 
a) The Contractor agrees to provide the Medicare Advantage Benefit Package, as
described in Appendix K-l of this Agreement, to Enrollees of the Contractor's
Medicaid Advantage Product subject to any exclusions or limitations imposed by
federal or state law during the period of this Agreement. Such services and
supplies shall be provided in compliance with the requirements of the
Contractor's Medicare Advantage Coordinated Care Plan contract with CMS and all
applicable federal statutes, regulations and policies.
 
b) The Contractor agrees to provide the Medicaid Advantage Benefit Package, as
described in Appendix K-2 of this Agreement, to Enrollees of the Contractor's
Medicaid Advantage Product subject to any exclusions or limitations imposed by
federal or state law during the period of this Agreement. Such services and
supplies, shall be provided in compliance with the requirements of this
Agreement, the State Medicaid Plan established pursuant to Section 363-a of the
State Social Services Law, and all applicable federal and state statutes,
regulations and policies.
 
10.2 SDOH and LDSS Responsibilities
 
SDOH and LDSS shall assure that Medicaid services covered under the Medicaid
fee-for-service program as described in Appendix K-3 of this Agreement which are
not covered in the Medicare or Medicaid Advantage Benefit Packages are available
to, and accessible by, Medicaid Advantage Enrollees.
 
10.3 Benefit Package and Non-Covered Services Descriptions
 
The Medicare and Medicaid Advantage Benefit Packages and Non-Covered Services
agreed to by the Contractor and the LDSS are contained in Appendix K, which is
hereby made a part of this Agreement as if set forth fully herein.
 
10.4 Adult Protective Services
 
The Contractor shall cooperate with LDSS in the implementation of 18 NYCRR Part
457 and any subsequent amendments thereto with regard to medically necessary
health and mental health services and all Court Ordered Services for adults to
the extent such services are included in the Contractor's Medicare and Medicaid
Advantage Benefit Packages as described in Appendix K of this Agreement. The
Contractor is responsible for payment of those services as covered by the
Medicare and Medicaid Advantage Benefit Packages, even when provided by
Non-Participating Providers. Non-Participating Providers will be reimbursed at
the Medicaid fee schedule.
 
 

Medicaid Advantage Contract
SECTION 10
(BENEFIT PACKAGE, COVERED AND NON-COVERED SERVICES)
New York City 2006
10-1

10.5 Court-Ordered Services
 

 
a)
The Contractor shall provide any Medicare and Medicaid Advantage Benefit Package
services to Enrollees as ordered by a court of competent jurisdiction,
regardless of whether such services are provided by a Participating Provider or
by a Non-Participating Provider in compliance with such court order. The
Non-Participating Providers shall be reimbursed by the Contractor at the
Medicaid fee schedule. The Contractor is responsible for court-ordered services
to the extent that such court-ordered services are included in the Contractor's
Medicare and Medicaid Advantage Benefit Packages as described in Appendix K of
this Agreement.

 

 
b)
Court Ordered Services are those services ordered by the court performed by, or
under the supervision of a physician, dentist, or other provider qualified under
State law to furnish medical, dental, behavioral health (including mental health
and/or chemical dependence services), or other Medicaid covered services. The
Contractor is responsible for payment of those services as covered by the
Contractor's Medicare and Medicaid Advantage Benefit Packages, even when
provided by Non-Participating Providers.

 
10.6 Family Planning and Reproductive Health Services
 
a) Nothing in this Agreement shall restrict the right of Enrollees to receive
Family Planning and Reproductive Health Services, as defined in Appendix C of
this Agreement, which is hereby made a part of this Agreement as if set forth
fully herein.
 

 
i)
Enrollees may receive such services from any qualified Medicaid provider,
regardless of whether the provider is a Participating Provider or a
Non-Participating Provider in the Contractor's Medicare Advantage Product,
without referral from the Enrollee's PCP and without approval from the
Contractor.

 

 
b)
The Contractor shall permit Enrollees to exercise their right to obtain Family
Planning and Reproductive Health Services from either the Contractor, if Family
Planning and Reproductive Health Services are provided by the Contractor, or
from any appropriate Medicaid enrolled Non-Participating family planning
Provider, without a referral from the Enrollee's PCP and without approval by the
Contractor.

 

 
c)
If Contractor provides Family Planning and Reproductive Health Services to its
Enrollees, the Contractor shall comply with the requirements in Part C-2 of
Appendix C of this Agreement, including assuring that Enrollees are fully
informed of their rights.

 

Medicaid Advantage Contract
SECTION 10
(BENEFIT PACKAGE, COVERED AND NON-COVERED SERVICES)
New York City 2006
10-2

 
d)
If Contractor does not provide Family Planning and Reproductive Health Services
to its Enrollees, the Contractor shall comply with Part C.3' of Appendix C of
this Agreement, including assuring that Enrollees are fully informed of their
rights.

 
10.7 Emergency and Post Stabilization Care Services
 

 
a)
The Contractor shall provide Emergency and Post Stabilization Care Services in
accordance with applicable federal and state requirements, including 42
CFR§422.113.

 

 
b)
The Contractor shall ensure that Enrollees are able to access Emergency Services
twenty four (24) hours per day, seven (7) days per week.

 

 
c)
The Contractor agrees that it will not require prior authorization for services
in a medical or behavioral health emergency. The Contractor agrees to inform its
Enrollees that access to Emergency Services is not restricted and that Emergency
Services may be obtained from a Non-Participating Provider without penalty.
Nothing herein precludes the Contractor from entering into contracts with
providers or facilities that require providers or facilities to provide
notification to the Contractor after Enrollees present for Emergency Services
and are subsequently stabilized. The Contractor must pay for services for
Emergency Medical Conditions whether provided by a Participating Provider or a
Non-Participating Provider, and may not deny payments for failure of the
Emergency Services provider or Enrollee to give notice.

 

 
d)
The Contractor shall advise its Enrollees how to obtain Emergency Services when
it is not feasible for Enrollees to receive Emergency Services from or through a
Participating Provider. The Contractor shall bear the cost of providing
Emergency Services through Non-Participating Providers.

 

 
e)
Triage Fees: For emergency room services that do not meet the definition of
Emergency Medical Conditions and for which the Contractor denies the Medicare
Benefit, the Contractor shall pay the hospital a triage fee of $40.00 in the
absence of a negotiated rate. Non-participating emergency departments cannot be
denied a payment on the basis of non-notification.

 
10.8 Medicaid Utilization Thresholds (MUTS)
 
Enrollees may be subject to MUTS for services which are billed to Medicaid
fee-for-service and for dental services provided without referral at Article 28
clinics operated by academic dental centers as described in Section 10.18 of
this Agreement. Enrollees are not otherwise subject to MUTS for services
included in the Medicaid Advantage Benefit Package.
 

 
Medicaid Advantage Contract
SECTION 10
(BENEFIT PACKAGE, COVERED AND NON-COVERED SERVICES)
New York City 2006
10-3

10.9 Services for Which Enrollees Can Self-Refer
 
In addition to those services for which Medicare Advantage Enrollees can
self-refer, Medicaid Advantage Enrollees may self-refer to:
 

 
a)
Public health agency facilities for the diagnosis and/or treatment of TB as
described in Section 10.11 (a) (i) of this Agreement.

 

 
b)
Family Planning and Reproductive Health services as described in Section 10.6
and Appendix C of this Agreement.

 

 
c)
Article 28 clinics operated by academic dental centers to obtain covered dental
services as described in Section 10.18 of this Agreement.

 
10.10 Coordination with Local Public Health Agencies
 
The Contractor will coordinate its public health-related activities with the
Local Public Health Agency (LPHA) consistent with the SDOH MCO and Public Health
Guidelines. Coordination mechanisms and operational protocols for addressing
public health issues will be negotiated with the LPHA and customized to reflect
local public health priorities. Negotiations must result in agreements regarding
required Contractor activities related to public health as set forth in Appendix
N of this Agreement as if set forth fully herein.
 
10.11 Public Health Services
 
a) Tuberculosis Screening, Diagnosis and Treatment; Directly Observed
Therapy (TB\DOT):

 
i)
Consistent with New York State law, public health clinics are required to
provide or arrange for treatment to individuals presenting with tuberculosis,
regardless of the person's insurance or enrollment status.

 
ii)
It is the State's preference that Enrollees receive TB diagnosis and treatment
through the Contractor's Medicare Advantage Product, to the extent that
Participating Providers experienced in this type of care are available.

 
iii)
The SDOH will coordinate with the LPHA to evaluate the Contractor's protocols
against State and local guidelines and to review the tuberculosis treatment
protocols and networks of Participating Providers to verify their readiness to
treat tuberculosis patients. SDOH and LPHAs will also be available to offer
technical assistance to the Contractor in establishing TB policies and
procedures.

 
iv)
The Contractor shall inform participating providers of their responsibility to
report TB cases to the LPHA.

 
v)
Enrollees may self-refer to public health agency facilities for the diagnosis
and/or treatment of TB.

 
 
Medicaid Advantage Contract
SECTION 10
(BENEFIT PACKAGE, COVERED AND NON-COVERED SERVICES)
New York City 2006
10-4

 
A.
The Contractor agrees to reimburse public health clinics when physician visit
and patient management or laboratory and radiology services are rendered to
their Enrollees, within the context ofTB diagnosis and treatment.

 
B.
The Contractor will make best efforts to negotiate fees for these services with
the LPHA. If no agreement has been reached, the Contractor agrees to reimburse
the public health clinics for these services at rates determined by SDOH.

 
C.
The LPHA is responsible for: 1) giving notification to the Contractor before
delivering TB-related services, unless these services are ordered by a court of
competent jurisdiction; and 2) making reasonable efforts to verify with the
Enrollee's PCP that he/she has not already provided TB care and treatment, and
3) providing documentation of services rendered along with the claim.

 
D.
Prior authorization for inpatient hospital admissions may not be required by the
Contractor for an admission pursuant to a court order or an order of detention
issued by the local commissioner or director of public health.

 
E.
The Contractor shall provide the LPHA with access to health care practitioners
on a twenty-four (24) hour a day seven (7) day a week basis who can authorize
inpatient hospital admissions. The Contractor shall respond to the LPHA's
request for authorization within the same day.

 
F)
The Contractor will not be financially liable for treatments rendered to
Enrollees who have been institutionalized as a result of a local health
commissioner's order due to non-compliance with TB care regimens.

 

 
vi)
The Contractor will not be financially liable for Directly Observed Therapy
(DOT) costs. While all other clinical management of tuberculosis is covered by
the Contractor, TB/DOT, where applicable, may be billed to any SDOH approved
fee-for-service Medicaid provider. The Contractor agrees to make all reasonable
efforts to ensure coordination with DOT providers regarding clinical care and
services. Enrollees may use any Medicaid fee-for-service TB/DOT provider.

 

 
vii)
HIV counseling and testing provided to a Medicaid Advantage Enrollee during a TB
related visit at a public health clinic, directly operated by a LPHA will be
covered by Medicaid fee-for-service (FFS) at rates established by the SDOH.

 
b) Immunizations

 
i)
The Contractor will be required to reimburse the Local Public Health Agency when
Enrollees self-refer to Local Public Health Agencies for immunizations covered
by Contractor's Medicare Advantage Plan.

 
Medicaid Advantage Contract
 
SECTION 10
(BENEFIT PACKAGE, COVERED AND NON-COVERED SERVICES)
New York City 2006
10-5

 
ii)
The LPHA is responsible for making reasonable efforts to (1) determine the
Ehrollee's managed care membership status; and (2) ascertain the Enrollee's
immunization status. Reasonable efforts shall consist of client interviews,
medical records, and, when available, access to the Immunization Registry. When
an Enrollee presents a membership card with a PCP's name, the LPHA is
responsible for calling the PCP. If the LPHA is unable to verify the
immunization status from the PCP or learns that immunization is needed, the LPHA
is responsible for delivering the service as appropriate, and the Contractor
will reimburse the LPHA at the negotiated rate or in the absence of a negotiated
rate, at rates determined by SDOH.

 
c) Prevention and Treatment of Sexually Transmitted Diseases
 
The Contractor will be responsible for ensuring that its Participating Providers
educate their Enrollees about the risk and prevention of sexually transmitted
disease (STD). The Contractor also will be responsible for ensuring that its
Participating Providers screen and treat Enrollees for STDs and report cases of
STD to the LPHA and cooperate in contact investigation, in accordance with
existing state and local laws and regulations. HIV counseling and testing
provided to an Enrollee during a STD related visit at a public health clinic,
directly operated by a LPHA, will be covered by Medicaid fee-for-service at
rates established by the State.
 
10.12 Adults with Chronic Illnesses and Physical or Developmental Disabilities
 
a) The Contractor will implement all of the following to meet the needs of its
adult Enrollees with chronic illnesses and physical or developmental
disabilities:

 
i)
Satisfactory methods for ensuring that the Contractor is in compliance with the
ADA and Section 504 of the Rehabilitation Act of 1973. Program accessibility for
persons with disabilities shall be in accordance with Section 23 of this
Agreement.

 
ii)
Clinical case management which uses satisfactory methods/guidelines for
identifying persons at risk of or having, chronic diseases and disabilities and
determining their specific needs in terms of specialist physician referrals,
durable medical equipment, home health services, self-management education and
training, etc. The Contractor shall:

 
A)
develop protocols describing the Contractor's case management services and
minimum qualification requirements for case management staff;

 
B)
develop and implement protocols for monitoring effectiveness of case management
based on patient outcomes;

 
C
develop and implement protocols for monitoring service utilization including
emergency room visits and hospitalizations, with adjustment of severity of
patient conditions;

 
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D)
provide regular information to Participating Providers on the case management
services available to the Contractor's Enrollees and the criteria for referring
Enrollees to the Contractor for case management services.

 
iii)
Satisfactory methods/guidelines for determining which patients are in need of
case management services, including establishment of severity thresholds, and
methods for identification of patients including monitoring of hospitalizations
and ER visits, provider referrals, new Enrollee health screenings ands
self-referrals by Enrollees.

 
iv)
Guidelines for determining specific needs of Enrollees in case management,
including specialist physician referrals, durable medical equipment, home health
services, self management education and training, etc.

 
v)
Satisfactory systems for coordinating service delivery with Non-Participating
Providers, including behavioral health providers for all Enrollees.

 
10.13 Persons Requiring Ongoing Mental Health Services
 
a) The Contractor will implement all of the following for its Enrollees with
chronic or ongoing mental health service needs:

 
i)
Satisfactory methods for identifying Enrollees requiring such services and
encouraging self-referral and early entry into treatment.

 
ii)
Satisfactory case management systems or satisfactory case management.

 
iii)
Satisfactory systems for coordinating service delivery between physical health,
chemical dependence, and mental health providers, and coordinating services with
other available services, including Social Services.

 
iv)
The Contractor agrees to participate in the local planning process for serving
persons with mental health needs to the extent requested by the DOHMH. At the
DOHMH's discretion, the Contractor will develop linkages with local governmental
units on coordination, procedures and standards related to mental health
services and related activities.

 
10.14 Member Needs Relating to HIV
 

 
a)
To adequately address the HIV prevention needs of uninfected Enrollees, as well
as the special needs of individuals with HIV infection who do enroll in managed
care, the Contractor shall have in place all of the following:

 
i)
Anonymous testing may be furnished to the Enrollee without prior approval by the
Contractor and may be conducted at anonymous testing sites available to clients.
Services provided for HIV treatment may only be obtained from the Contractor
during the period the Enrollee is enrolled in the Contractor's plan.

 
ii)
Methods for promoting HIV prevention to all Plan Enrollees. HIV prevention
information, both primary, as well as secondary should be

 

 

 
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tailored to the Enrollee's age, sex, and risk factor(s), (e.g., injection drug
use arid sexual risk activities), and should be culturally and linguistically
appropriate. HIV primary prevention means the reduction or control of causative
factors for HIV, including the reduction of risk factors. HIV Primary prevention
includes strategies to help prevent uninfected Enrollees from acquiring HIV,
i.e., behavior counseling for HIV negative Enrollees with risk behavior. Primary
prevention also includes strategies to help prevent infected Enrollees from
transmitting HIV infection, i.e., behavior counseling with an HIV infected
Enrollee to reduce risky sexual behavior or providing antiviral therapy to a
pregnant, HIV infected female to prevent transmission of HIV infection to a
newborn. HIV Secondary Prevention means promotion of early detection and
treatment of HIV disease in an asymptomatic Enrollee to prevent the development
of symptomatic disease. This includes: regular medical assessments; routine
immunization for preventable infections;prophylaxis for opportunistic
infections; regular dental, optical, dermatological and gynecological care;
optimal diet/nutritional supplementation; and partner notification services
which lead to the early detection and treatment of other infected persons. All
plan Enrollees should be informed of the availability of HIV counseling,
testing, referral and partner notification (CTRPN) services.

 
iii)
Policies and procedures promoting the early identification of HIV infection in
Enrollees. Such policies and procedures shall include at a minimum: assessment
methods for recognizing the early signs and symptoms of HIV disease; initial and
routine screening for HIV risk factors through administration of sexual behavior
and drug and alcohol use assessments; and the provision of information to all
Enrollees regarding the availability of HIV CTRPN services from Participating
Providers, or as part of a Family Planning and Reproductive Health services
visit pursuant to Appendix C of this Agreement, and the availability of
anonymous CTRPN services from New York State, New York City and the LPHA.

 
iv)
Policies and procedures that require Participating Providers to provide HIV
counseling and recommend HIV testing to pregnant women in their care. The HIV
counseling and testing provided shall be done in accordance with Article 27-F of
the PHL. Such policies and procedures shall also direct Participating Providers
to refer any HIV positive women in their care to clinically appropriate services
for both the women and their newboms.

 
v)
A network of providers sufficient to meet the needs of its Enrollees with HIV.
Satisfaction of the network requirement may be accomplished by inclusion of HIV
specialists within the network or the provision of HIV specialist consultation
to non-HIV specialists serving as PCPs for persons with HIV infection; inclusion
of Designated AIDS Center Hospitals or other hospitals experienced in HIV care
in the Contractor's

 

 
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network; and contracts or linkages with providers funded under the Ryan White
CARE Act. The Contractor shall inform the providers in its network how to obtain
information about the availability of Experienced HIV Providers and HIV
Specialist PCPs

 
vi)
Case Management Assessment for Enrollees with HIV Infection. The Contractor
shall establish policies and procedures to ensure that Enrollees who have been
identified as having HIV infection are assessed for case management services.
The Contractor shall arrange for any Enrollee identified as having HIV infection
and needing case management services to be referred to an appropriate case
management services provider, including in-plan case management, and/or, with
appropriate consent of the Enrollee, COBRA Comprehensive Medicaid Case
Management (CMCM) services and/or HIV community-based psychosocial case
management services.

 
vii)
The Contractor shall require its Participating Providers to report positive HIV
test results and diagnoses and known contacts of such persons to the New York
State Commissioner of Health. In New York City, these shall be reported to the
New York City Commissioner of Health and Mental Hygiene. Access to partner
notification services must be consistent with 10 NYCRR Part 63.

 
viii)
The Contractor's Medical Director shall review Contractor's HIV practice
guidelines at least annually and update them as necessary for compliance with
recommended SDOH AIDS Institute and federal government clinical standards. The
Contractor will disseminate the HIV Practice Guidelines or revised guidelines to
Participating Providers at least annually, or more frequently as appropriate.

 
10.15 Persons Requiring Chemical Dependence Services
 
a) The Contractor will have in place all of the following for its Enrollees
requiring Chemical Dependence Services:

 
i)
Satisfactory methods for identifying persons requiring such services and
encouraging self-referral and early entry into treatment and methods for
referring Enrollees to the New York State Office of Alcohol and Substance Abuse
Services (OASAS) for appropriate services beyond the Contractor's Benefit
Package (e.g., halfway houses).

 
ii)
Satisfactory systems of care including Participating Provider networks and
referral processes sufficient to ensure that emergency services, including
crisis services, can be provided in a timely manner.

 
iii)
Satisfactory case management systems.

 
iv)
Satisfactory systems for coordinating service delivery between physical health,
chemical dependence, and mental health providers, and coordinating in-plan
services with other services, including Social Services.

 
v)
The Contractor agrees to also participate in the local planning process for
serving persons with chemical dependence, to the extent requested by the DOHMH.
At the DOHMH's discretion, the Contractor will develop linkages with local
governmental units on coordination procedures and standards related to Chemical
Dependence Services and related activities.

 

 
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10.16 Native Americans
 
If an Enrollee is a Native American and the Enrollee chooses to access primary
care or other services through their tribal health center, the PCP authorized by
the Contractor to refer the Enrollee for Medicare or Medicaid Advantage Product
benefits must develop a relationship with the Enrollee's PCP at the tribal
health center to coordinate services for said Native American Enrollee.
 
10.17 Urgently Needed Services
 
The Contractor is financially responsible for Urgently Needed Services.
 

 
10.18
Dental Services Provided by Article 28 Clinics Operated by Academic Dental
Centers Not Participating in Contractor's Network

 

 
a)
Consistent with Chapter 697 of Laws of 2003 amending Section 364 (j) of the
Social Services Law, dental services provided by Article 28 clinics operated by
academic dental centers may be accessed directly by Medicaid managed care
Enrollees without prior approval and without regard to network participation.

 

 
b)
If dental services are part of the Contractor's Medicaid Advantage Benefit
Package, the Contractor will reimburse non-participating Article 28 clinics
operated by academic dental centers for covered dental services provided to
Enrollees at approved Article 28 Medicaid clinic rates in accordance with the
protocols issued by the SDOH.

 
10.19 Coordination of Services
 
a) The Contractor shall coordinate care for Enrollees with:

i) the court system (for court ordered evaluations and treatment);
ii) specialized providers of health care for the homeless, and other providers
of services for victims of domestic violence;
iii) family planning clinics, community health centers, migrant health centers,
rural health centers;
iv) WIC;
v) programs funded through the Ryan White CARE Act;
vi) other pertinent entities that provide services out of network;
vii) Prenatal Care Assistance Program (PCAP) Providers;
viii) local governmental units responsible for public health, mental health,
mental retardation or Chemical Dependence Services; and
ix) specialized providers of long term care for people with developmental
disabilities.

 

 

 
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b)  
Coordination may involve contracts or linkage agreements (if entities are
willing to enter into such an agreement), or other mechanisms to ensure
coordinated care for Enrollees, such as protocols for reciprocal referral and
communication of data and clinical information on Enrollees.

 
 
 

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11. MARKETING
 
11.1 Marketing Requirements
 
a) The Contractor agrees to follow the Medicare Advantage Marketing
Guidelines as set forth in Chapter 3 of the CMS's Medicare Managed Care Manual
as well as all applicable statutes and regulations including and without
limitation. Section 1851 (h) of the Social Security Act and 42 CFR Sections
422.80, 422.111 and 423.50 when marketing to individuals entitled to enroll in
Medicare Advantage.
 

b)  
In developing marketing materials and conducting marketing activities for the
Medicaid Advantage Program, the Contractor shall comply with the Medicaid
Advantage Marketing Guidelines as defined in Appendix D of this document as if
set forth fully herein.

 

 

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SECTION 11
(MARKETING)
New York City 2006
11-1
 

12. MEMBER SERVICES
 
12.1 General Functions
 
a) The Contractor shall operate a Member Services function during regular
business hours, which must be accessible to Enrollees via a toll-free telephone
line. Personnel must also be available via a toll-free telephone line (which can
be the member services toll-free line or separate toll-free lines) not less than
during regular business hours to address complaints and utilization review
inquiries. In addition, the Contractor must have a telephone system capable of
accepting, recording or providing instruction in response to incoming calls
regarding complaints and utilization review during other than normal business
hours and measures in place to ensure a response to those calls the next
business day after the call was received.
 
b) Member Services staff must be responsible for the following:
 
i) Explaining the benefits and covered services offered under the Medicare and
Medicaid Advantage Products, including applicable conditions and limitations,
and any conditions associated with the receipt or use of benefits.
 
ii) Explaining the rules for obtaining Medicare and Medicaid Advantage Benefit
Package services and additional services available to the Enrollee through use
of his/her Medicaid benefit card.
 
iii) Providing information on: the providers from whom Enrollees may obtain
Medicare and Medicaid Advantage Benefit Package Services, any out-of-area
coverage provided by the plan, and coverage of emergency services and urgently
needed care.
 
iv) Fielding and responding to Enrollee questions and complaints regarding the
Contractor's Medicare and Medicaid Advantage Products and benefits, and advising
Enrollees of the prerogative to complain at any time to the CMS regarding the
Medicare Advantage Product, and to the SDOH and LDSS, regarding the Medicaid
Advantage Product.
 
v) Clarifying information in the member handbooks for Enrollees regarding the
Contractor's Medicare and Medicaid Advantage Products and benefits.
 
vi) Advising Enrollees of the Contractor's applicable complaint and appeals
programs, utilization review processes, and the Enrollee's rights to a fair
hearing or external review.
 
vii) Clarifying an Enrollee's Disenrollment rights and responsibilities under
the Contractor's Medicare and Medicaid Advantage Products.
 

 
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SECTION 12
(MEMBER SERVICES)
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12-1
 

12.2 Translation and Oral Interpretation
 

 
a)
The Contractor must make available written marketing and other informational
materials (e.g., member handbooks) in a language other than English whenever at
least five percent (5%) of the Prospective Enrollees of the Contractor in any
county of the service area speak that particular language and do not speak
English as a first language.

 

 
b)
In addition, verbal interpretation services must be made available to Enrollees
who speak a language other than English as a primary language. Interpreter
services must be offered in person where practical, but otherwise may be offered
by telephone.

 

 
c)
The SDOH will determine the need for other than English translations based on
county-specific census data or other available measures.

 
12.3 Communicating with the Visually, Hearing and Cognitively Impaired
 
The Contractor also must have in place appropriate alternative mechanisms for
communicating effectively with persons with visual, hearing, speech, physical or
developmental disabilities. These alternative mechanisms include Braille or
audio tapes for the visually impaired, TTY access for those with certified
speech or hearing disabilities, and use of American Sign Language and/or
integrative technologies.

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SECTION 12
(MEMBER SERVICES)
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12-2
 

13. ENROLLEE NOTIFICATION
 
13.1 General Requirements
 
a) The Contractor shall disclose required information to Prospective Enrollees
and Enrollees as prescribed by applicable federal and state law and regulations
found at 42 CFR 422.111, New York PHL 4408, SSL 364-j, and 42 CFR §438.10
(e),(f) and (g), and any specific guidance issued by CMS and SDOH.
 
b) The Contractor must provide Enrollees with an annual notice that this
information is available to them upon request.
 
c) The Contractor must inform Enrollees that oral interpretation service is
available for any language and that information is available in alternative
formats and how to access these formats.
 
d) Medicaid Advantage post enrollment notices and materials shall include, but
not be limited to the following:
 
Provider Directories
Member ID Cards
Member Handbooks
Notice of the Effective Date of Enrollment
Notice of the Effective Date of Benefit Package Changes
Notice of Termination, Service Area Changes and Network Changes
Summary of Benefits
 
e) Integrated post enrollment materials including member handbooks, member
notices, and summary of benefits targeted to Enrollees of the Contractor's
Medicare and Medicaid Advantage Products must be prior approved by the CMS
Regional Office; in collaboration with SDOH.
 
13.2 Member ID Cards
 
The Contractor must issue an identification card to the Enrollee that complies
with CMS and SDOH specifications.
 
13.3 Member Handbooks
 
The Contractor shall issue to a new Enrollee no later than fourteen (14) days
following the Effective Date of Enrollment a Medicaid Advantage Member Handbook,
which is approved by SDOH and consistent with the Medicaid Advantage Model
Handbook Guidelines in Appendix E, which is hereby made a part of this Agreement
as if set forth fully herein.
 

 

 

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SECTION 13
(ENROLLEE NOTIFICATION) New York City 2006
13-1
 

13.4 Enrollee Rights
 
a) The Contractor shall, in compliance with the requirements of 42 CFR
§ 438.6(i)(l) and 42 CFR Part 489 Subpart I, maintain written policies and
procedures regarding advance directives and inform each Enrollee in writing at
the time of enrollment of an individual's rights under State law to formulate
advance directives and of the Contractor's policies regarding the implementation
of such rights. The Contractor shall include in such written notice to the
Enrollee materials relating to advance directives and health care proxies as
specified in 10 NYCRR Part 98 and § 700.5. The written information must reflect
changes in State law as soon as possible, but no later than ninety (90) days
after the effective date of the change.
 

 
b)
The Contractor shall have policies and procedures that protect the Enrollee's
right to:

 
i) receive information about the Contractor and managed care;
 

 
ii)
be treated with respect and due consideration for his or her dignity and
privacy;

 

 
iii)
receive information on available treatment options and alternatives, presented
in a manner appropriate to the Enrollee's condition and ability to understand;

 

 
iv)
participate in decisions regarding his or her health care, including the right
to refuse treatment;

 

 
v)
be free from any form of restraint or seclusion used as a means of coercion,
discipline, convenience or retaliation, as specified in Federal regulations on
the use of restraints and seclusion; and

 

 
vi)
If the privacy rule, as set forth in 45 CFR Parts 160 and 164, Subparts A and E,
applies, request and receive a copy of his or her medical records and request
that they be amended or corrected, as specified in 45 CFR §§164.524 and 164.526.

 

c)  
The Contractor's policies and procedures must require that neither the
Contractor nor its Participating Providers adversely regard an Enrollee who
exercises his/her rights in 13.4(b) above.

 
 
 

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SECTION 13
(ENROLLEE NOTIFICATION)
New York City- 2006
13-2
 

14. ORGANIZATION DETERMINATIONS, ACTIONS AND GRIEVANCE SYSTEM
 

 
14.1
General Requirements

 
a) The Contractor agrees to comply with, and shall establish and maintain
written Organization Determination and Action procedures and a comprehensive
Grievance system, as described in Appendix F, which is hereby made a part of
this Agreement as if set forth fully herein, that complies with:
 
i) all procedures and requirements of 42 CFR Subpart M of Part 422 and Chapter
13 of CMS's Medicare Managed Care Manual for services that the Contractor
determines are a Medicare only benefit.
 
ii) all procedures and requirements of 42 CFR Subpart M of Part 422 and Chapter
13 of CMS's Medicare Managed Care Manual for services the Contractor determines
to be a benefit covered under both Medicare and Medicaid, except that:
A) the Contractor will determine whether services are Medically Necessary as
that term is defined in this Agreement; and
B) when the Contractor intends to reduce, suspend, or terminate a previously
authorized service within an authorization period, the notification provisions
of paragraph F.2(4)(a) of Appendix F of this Agreement shall apply.
 
iii)  all procedures and requirements of the Medicaid Advantage Action and
Medicaid Advantage Grievance System requirements described in Appendix F of this
Agreement and 42 CFR Section 438.400 et. seq., for services that the Contractor
determines are a Medicaid only benefit. With respect to Medicaid-only services,
nothing herein shall release the Contractor from its responsibilities under PHL
§ 4408-a or PHL Article 49 and 10 NYCRR Part 98 that are not otherwise expressly
established in Appendix F of this Agreement.
 
b) For services that the Contractor determines are a benefit under both Medicare
and Medicaid, the Contractor agrees to offer Enrollees the right to pursue
either the Medicare appeal procedures or the Medicaid Advantage Action Appeal
and Grievance System in the manner described and provided for in Appendix F of
this Agreement.
 

 
14.2
Filing and Modification of Medicaid Advantage Action and Grievance Systems
Procedures

 
a) The Contractor's Action and Grievance System Procedures governing services
determined by the Contractor to be a Medicaid only benefit and services
determined by the Contractor to be a benefit under both Medicare and Medicaid
shall be, approved by the SDOH, and kept on file with the Contractor/DOHMH and
SDOH.

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(COMPLAINT AND APPEAL PROCEDURE)
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b) The Contractor shall not modify its Action and Grievance System Procedures
without the prior written approval of SDOH, and shall provide SDOH and DOHMH
with a copy of the approved modifications within fifteen (15) days of its
approval.
 
14.3 Medicaid Advantage Action and Grievance System Additional Provisions
 

 
a)
The Contractor must have in place effective mechanisms to ensure consistent
application of review criteria for Service Authorization Determinations and
consult with the requesting provider when appropriate.

 

 
b)
If the Contractor subcontracts for Service Authorization Determinations and
utilization review, the Contractor must ensure that its subcontractors have in
place and follow written policies and procedures for delegated activities
regarding processing requests for initial and continuing authorization of
services consistent with Article 49 of the PHL, 10 NYCRR Part 98, 42 CFR Part
438, Appendix F of this Agreement, and the Contractor's policies and procedures.

 

 
c)
The Contractor must ensure that compensation to individuals or entities that
perform Service Authorization Determination and utilization management
activities is not structured to include incentives that would result in the
denial, limiting, or discontinuance of Medically Necessary services to
Enrollees.

 

 
d)
The Contractor or its subcontractors may not arbitrarily deny or reduce the
amount, duration, or scope of a covered service solely because of the diagnosis,
type of illness, or Enrollee's condition. The Contractor may place appropriate
limits on a service on the basis of criteria such as Medical Necessity or
utilization control, provided that the services furnished can reasonably be
expected to achieve their purpose.

 

 
e)
The Contractor shall ensure that its Medicaid Advantage Grievance System
includes methods for prompt internal adjudication of Enrollee Complaints,
Complaint Appeals and Action Appeals and provides for the maintenance of a
written record of all Complaints, Complaint Appeals and Action Appeals received
and reviewed and their disposition, as specified in Appendix F of this
Agreement.

 

 
f)
The Contractor shall ensure that persons with authority to require corrective
action participate in the Medicaid Advantage Grievance System.

 

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SECTION 14
(COMPLAINT AND APPEAL PROCEDURE)
New York City 2006
14-2

14.4 Notification of Medicaid Advantage Action and Grievance System Procedures
 

 
a)
The Contractor's specific Action and Grievance System Procedures 'for services
determined by the Contractor to be a Medicaid only benefit and services
determined by the Contractor to be a benefit under both Medicare and Medicaid
shall be described in the Contractor's Medicaid Advantage member handbook and
shall be made available to all Medicaid Advantage Enrollees.

 

 
b)
The Contractor will advise Enrollees of their right to a fair hearing as
appropriate and comply with the procedures established by SDOH for the
Contractor to participate in the fair hearing process, as set forth in Section
24 of this Agreement. Such procedures shall include the provision of a Medicaid
notice in accordance with 42 CFR Sections 438.210 and 438.404.

 

 
c)
The Contractor will also advise Enrollees of their right to an External Appeal,
related to services determined by the Contractor to be a Medicaid only benefit
or services determined by the Contractor to be a benefit under both Medicare and
Medicaid, in accordance with Section 25 of this Agreement.

 

 
d)
The Contractor will provide written notice to all Participating Providers, and
subcontractors to whom the Contractor has delegated utilization review and
Service Authorization Determination procedures, at the time they enter into an
agreement with the Contractor, of the following Medicaid Advantage Complaint,
Complaint Appeal, Action Appeal and fair hearing procedures and when such
procedures may be applicable:

 

 
i)
the Enrollee's right to a fair hearing, how to obtain a fair hearing, and
representation rules at a hearing;

 

 
ii)
the Enrollee's right to file Complaints, Complaint Appeals and Action Appeals
and the process and timeframes for filing;

 

 
iii)
the Enrollee's right to designate a representative to file Complaints, Complaint
Appeals and Action Appeals on his/her behalf;

 

 
iv)
the availability of assistance from the Contractor for filing Complaints,
Complaint Appeals and Action Appeals;

 

 
v)
the toll-free numbers to file oral Complaints, Complaint Appeals and Action
Appeals;

 

 
vi)
the Enrollee's right to request continuation of benefits while an Action Appeal
or state fair hearing is pending, and that if the Contractor's Action is upheld
in a hearing, the Enrollee may be liable for the cost of any continued benefits;

 

Medicaid Advantage Contract
SECTION 14
(COMPLAINT AND APPEAL PROCEDURE)
New York City 2006
14-3

vii)  the right of the provider to reconsideration of an Adverse Determination
pursuant to Section 4903(6) of the PHL; and
 
viii) the right of the provider to appeal a retrospective Adverse Determination
pursuant to Section 4904(1) of the PHL.
 
14.5 Complaint, Complaint Appeal and Action Appeal Investigation Determinations
 
The Contractor must adhere to determinations resulting from Complaint, Complaint
Appeal and Action Appeal investigations conducted by SDOH.
 

 

Medicaid Advantage Contract
SECTION 14
(COMPLAINT AND APPEAL PROCEDURE)
New York City 2006
14-4

15. ACCESS REQUIREMENTS
 
a) The Contractor agrees to provide Enrollees access to Medicare Advantage
Benefit Package and Medicaid Only Covered Services as described in Appendix K-l
and K-2 of this Agreement in a manner consistent with professionally recognized
standards of health care and access standards required by 42 CFR Section 422.112
and applicable state law, respectively.
 
b) The Contractor will establish and implement mechanisms to ensure that
Participating Providers comply with timely access requirements, monitor
regularly to determine compliance and take corrective action if there is a
failure to comply.
 
c) The Contractor will participate in the State's efforts to promote the
delivery of services in a culturally competent manner to all Enrollees,
including those with limited English proficiency and diverse cultural and ethnic
backgrounds.
 

Medicaid Advantage Contract
SECTION 15
(EQUALITY OF ACCESS AND TREATMENT)
New York City 2006
15-1

16. QUALITY MANAGEMENT AND PERFORMANCE IMPROVEMENT
 
16.1 The Contractor agrees to operate an ongoing quality management and
performance improvement program in accordance with Section 1852 (e) of the SSA
and 42 CFR Section 422.152.
 
16.2 The Contractor agrees to conduct a Chronic Care Improvement Program (CCIP)
relevant to its membership as directed by CMS and to submit the annual report on
the CCIP to CMS and SDOH.
 
16.3 The Contractor agrees to conduct performance improvement projects and to
measure performance using standard measures required by CMS, and to report
results to CMS and SDOH. Standard Measures will include, but not be limited to:
 
• Health Plan and Employer Data Information Set (HEDIS);
 
• Consumer Assessment of Health Plan Satisfaction (CAHPS); and
 
• Health Outcomes Survey (HOS).
 

Medicaid Advantage Contract
SECTION 16
(QUALITY ASSURANCE)
 New York City 2006
16-1
 

17. MONITORING AND EVALUATION
 
17.1 Right to Monitor Contractor Performance
 
The SDOH and/or its designee, DOHMH, and DHHS shall each have the right, during
the Contractor's normal operating hours, and at any other time a Contractor
function or activity is being conducted, to monitor and evaluate, through
inspection or other means, the Contractor's performance, including, but not
limited to, the quality, appropriateness, and timeliness of services provided
under this Agreement.
 
17.2 Cooperation During Monitoring and Evaluation
 
The Contractor shall cooperate with and provide reasonable assistance to the
SDOH and/or its designee, DOHMH, and DHHS in the monitoring and evaluation of
the services provided under this Agreement.
 
17.3 Cooperation During On-Site Reviews
 
The Contractor shall cooperate with SDOH and/or its designee, DOHMH and DHHS in
any on-site review of the Contractor's operations.
 
17.4 Cooperation During Review of Services by External Review Agency
 
The Contractor shall comply with all requirements associated with any review of
the quality of services rendered to its Enrollees to be performed by an external
review agent selected by the SDOH or DHHS.
 

 

Medicaid Advantage Contract
SECTION 17
(MONITORING AND EVALUATION)
New York City 2006
17-1

18. CONTRACTOR REPORTING REQUIREMENTS
 
18.1 General Requirements
 
a) The Contractor must maintain a health information system that collects,
analyzes, integrates and reports data. The system must be sufficient to provide
the data necessary to comply with the requirements of this Agreement.
 
b) The Contractor must take steps to ensure that data entered into the system,
particularly that received from Participating Providers, is accurate and
complete.
 
c) The Contractor must make collected information available to CMS and SDOH, as
requested under this Agreement.
 
18.2 Time Frames for Report Submissions
 
Except as otherwise specified herein, the Contractor shall prepare and submit to
SDOH the reports required under this Section in an agreed media format within
sixty (60) days of the close of the applicable semi-annual or annual reporting
period, and within fifteen (15) business days of the close of the applicable
quarterly reporting period.
 
18.3 SDOH Instructions for Report Submissions
 
SDOH, with notice to the DOHMH, will provide Contractor with instructions for
submitting the reports required by Section 18.6 (a) (i) through (x) of this
Agreement, including time frames, and requisite formats. The instructions, time
frames and formats may be modified by SDOH upon sixty (60) days written notice
to the Contractor.
 
18.4 Liquidated Damages
 
The Contractor shall pay liquidated damages of $2,500 to SDOH if any report
required pursuant to this Section is materially incomplete, contains material
misstatements or inaccurate information, or is not submitted in the requested
format. The Contractor shall pay liquidated damages of $2,500 to the SDOH if its
monthly encounter data submission is not received by the Fiscal Agent by the due
date specified in Section 18.6(a)(iv) of this Agreement. The Contractor shall
pay liquidated damages of $500 to SDOH for each day other reports required by
this Section are late. The SDOH shall not impose liquidated damages for a first
time infraction by the Contractor unless the SDOH deems the infraction to be a
material misrepresentation of fact or the Contractor fails to cure the first
infraction within a reasonable period of time upon notice from the SDOH.
Liquidated damages may be waived at the sole discretion of SDOH. Nothing in this
Section
 

 
Medicaid Advantage Contract
SECTION 18
(CONTRACTOR REPORTING REQUIREMENTS)
New York City 2006
18-1

shall limit other remedies or rights available to SDOH relating to the
timeliness, completeness and/or accuracy of Contractor's reporting submission.
 
18.5 Notification of Changes in Report Due Dates, Requirements or Formats
 
SDOH may extend due dates, or modify report requirements or formats upon a
written request by the Contractor to the SDOH, where the Contractor has
demonstrated a good and compelling reason for the extension or modification. The
determination to grant a modification or extension of time shall be made by the
SDOH.
 
18.6 Reporting Requirements
 

 
a)
The Contractor shall submit the following reports to SDOH (unless otherwise
specified). The Contractor will certify the data submitted pursuant to this
section as required by SDOH. The certification shall be in the manner and format
established by SDOH and must attest, based on best knowledge, information, and
belief to the accuracy, completeness and truthfulness of the data being
submitted.

 
i) Annual Financial Statements:
 
Contractor shall submit Annual Financial Statements to SDOH. The due date for
annual statements shall be April 1 following the report closing date.
 
ii) Quarterly Financial Statements:
 
Contractor shall submit Quarterly Financial Statements to SDOH. The due date for
quarterly reports shall be forty-five (45) days after the end of the calendar
quarter.
 
iii) Other Financial Reports:
 
Contractor shall submit financial reports, including certified annual financial
statements, and make available documents relevant to its financial condition to
SDOH and the State Insurance Department (SID) in a timely manner as required by
State laws and regulations including, but not limited to, PHL §§ 4403-a, 4404
and 4409, Title 10 NYCRR Part 98 and, when applicable, SIL §§ 304, 305, 306, and
310. The SDOH may require the Contractor to submit such relevant financial
reports and documents related to its financial condition to the DOHMH.
 
iv) Encounter Data:
 
The Contractor shall prepare and submit encounter data on a monthly basis to
SDOH through SDOH's designated Fiscal Agent. Each provider is
 

 
Medicaid Advantage Contract
SECTION 18
(CONTRACTOR REPORTING REQUIREMENTS)
New York City 2006
18-2

required to have a unique identifier. Submissions shall be comprised of
encounter records, or adjustments to previously submitted records, which the
Contractor has received and processed from provider encounter or claim records
of any contracted services rendered to the Enrollee in the current or any
preceding months, including both Medicare and Medicaid covered services. Monthly
submissions must be received by the Fiscal Agent in accordance with the time
frames specified in the MEDS II data dictionary on the HPN to assure the
submission is included in the Fiscal Agent's monthly production processing.
 
v) Quality of Care Performance Measures:
 
The Contractor shall prepare and submit reports to SDOH, as specified by CMS for
the Medicare Advantage Program including Medicare HEDIS results and Medicare
CAHPS. Reports should be duplicative of reports submitted to CMS, and separate
reports for the dual eligible population are not required.
 
vi) Complaint, Complaint Appeals and Action Appeals Reports:
 

 
A)
The Contractor must provide the SDOH on a quarterly basis, and within fifteen
(15) business days of the close of the quarter, a summary of all Complaints,
Complaint Appeals and Action Appeals subject to PHL §4408-a received during the
preceding quarter via the Summary Complaint Form on the HPN related to Medicaid
Only Covered Services and services determined by the Contractor to be a benefit
under both Medicare and Medicaid.

 

 
B)
The Contractor also agrees to provide on a quarterly basis, via the Summary
Complaint form on the HPN, the total number of Complaints, Complaint Appeals and
Action Appeals subject to PHL §4408-a and related to Medicaid Only Covered
Services and services determined by the Contractor to be a benefit under both
Medicare and Medicaid that have been unresolved for more than forty-five (45)
days. The Contractor shall maintain records on these and other Complaints,
Complaint Appeals and Action Appeals pursuant to Appendix F of this Agreement.

 

 
C)
Nothing in this Section is intended to limit the right of the DOHMH, LDSS, or
SDOH or its designee to obtain information immediately from a Contractor
pursuant to investigating a particular Enrollee or provider Complaint, Complaint
Appeal or Action Appeal.

 
vii) Fraud and Abuse Reporting Requirements:
 

 
A)
The Contractor must submit quarterly, via the HPN Complaint reporting format,
the number of Complaints of fraud or abuse made to the Contractor related to
Medicaid Only Covered Services that warrant preliminary investigation by the
Contractor.

 

 
Medicaid Advantage Contract
SECTION 18
(CONTRACTOR REPORTING REQUIREMENTS)
New York City 2006
18-3

 
 

 
B)
The Contractor must also submit to the SDOH the following on' an ongoing basis
for each confirmed case of fraud or abuse it identifies through Complaints,
organizational monitoring, contractors, subcontractors, providers,
beneficiaries, Enrollees, etc related to Medicaid Only Covered Services:

1) The name of the individual or entity that committed the fraud or abuse;
2) The source that identified the fraud or abuse;
3) The type of provider, entity or organization that committed the fraud or
abuse;
4) A description of the fraud or abuse;
5) The approximate dollar amount of the fraud or abuse;
6) The legal and administrative disposition of the case including actions taken
by law enforcement officials to whom the case has been referred; and
7) Other data/information as prescribed by SDOH.
 

 
C)
Such report shall be submitted when cases of fraud or abuse are confirmed, and
shall be reviewed and signed by an executive officer of the Contractor.

 
viii) Participating Provider Network Reports:
 
The Contractor shall submit electronically to the HPN, an updated provider
network report on a quarterly basis for providers of Medicaid Only Covered
Services as defined in this Agreement and described in Appendix K-2. The
Contractor shall submit an annual notarized attestation that the providers
listed in each submission have executed an agreement with the Contractor to
serve Contractor's Medicaid Enrollees. The report submission must comply with
the Managed Care Provider Network Data Dictionary. Networks must be reported
separately for each county in which the Contractor operates.
 
ix) Quality Assessment and Performance Improvement Projects
 
The Contractor will submit reports to SDOH on all quality assessment and
performance improvement projects directed by CMS for the Medicare Advantage
Program, including the annual report on the Contractor's Chronic Care
Improvement Program. Reports should be duplicative of reports submitted to CMS,
and separate reports for the dual eligible population are not required.
 

 

Medicaid Advantage Contract
SECTION 18
(CONTRACTOR REPORTING REQUIREMENTS)
New York City 2006
18-4

x) Additional Reports:
 
Upon request by the SDOH, or as specified by DOHMH in Appendix N, the Contractor
shall prepare and submit other operational data reports. Such requests will be
limited to situations in which the desired data is considered essential and
cannot be obtained through existing Contractor reports. Whenever possible, the
Contractor will be provided with ninety (90) days notice and the opportunity to
discuss and comment on the proposed requirements before work is begun. However,
the SDOH reserves the right to give thirty (30) days notice in circumstances
where time is of the essence.
 
18.7 Ownership and Related Information Disclosure
 
The Contractor shall report ownership and related information to SDOH and the
LDSS, and upon request to the Secretary of Health and Human Services and the
Inspector General of Health and Human Services, in accordance with 42 U.S.C. §§
1320a-3 and 1396b(m)(4) (Sections 1124 and 1903(m)(4) of the SSA).
 
18.8 Public Access to Reports
 
Any data, information, or reports collected and prepared by the Contractor and
submitted to NYS authorities in the course of performing their duties and
obligation under this program will be deemed to be owned by the State of New
York subject to and consistent with the requirements of Freedom of Information
Law. This provision is made in consideration of the Contractor's use of public
funds in collecting and preparing such data, information, and reports.
 

 
18.9
Certification Regarding Individuals Who Have Been Debarred Or Suspended By
Federal, State, or Local Government Contractor will certify to the SDOH
initially and immediately upon changed circumstances from the last such
certification that it does not knowingly have an individual who has been
debarred or suspended by the federal, state or local government, or otherwise
excluded from participating in procurement activities:

 

 
a)
as a director, officer, partner or person with beneficial ownership of more than
five percent (5%) of the Contractor's equity; or

 

 
b)
as a party to an employment, consulting or other agreement with the Contractor
for the provision of items and services that are significant and material to the
Contractor's obligations in the Medicaid managed care program, consistent with
requirements of SSA § 1932 (d)(l).

 
Medicaid Advantage Contract
SECTION 18
(CONTRACTOR REPORTING REQUIREMENTS)
New York City 2006
18-5

18.10 Conflict of Interest Disclosure
 
Contractor shall report to SDOH, in a format specified by SDOH, documentation,
including but not limited to the identity of and financial statements of,
person(s) or corporation(s) with an ownership or contract interest in the
managed care plan, or with any subcontract(s) in which the managed care plan has
a five percent (5%) or more ownership interest, consistent with requirements of
SSA § 1903 (m)(2)(a)(viii) and 42 CFR §§ 455.100 - 455.104.
 
18.11 Physician Incentive Plan Reporting
 
The Contractor shall submit to SDOH annual reports containing the information on
all of its Physician Incentive Plan arrangements in accordance with 42 CFR §
438.6 (h) or, if no such arrangements are in place, attest to that. The contents
and time frame of such reports shall comply with the requirements of 42 CFR §§
422.208 and 422.210 and be in a format provided by SDOH.
 

Medicaid Advantage Contract
SECTION 18
(CONTRACTOR REPORTING REQUIREMENTS)
New York City 2006
18-6

19. RECORDS MAINTENANCE AND AUDIT RIGHTS
 
19.1 Maintenance of Contractor Performance Records
 
a) The Contractor shall maintain and shall require its subcontractors, including
its Participating Providers, to maintain appropriate records relating to
Contractor performance under this Agreement, including:
 
i) records related to services provided to Enrollees, including a separate
Medical Record for each Enrollee;
 
ii)  all financial records and statistical data that DOHMH, LDSS, SDOH, DHHS and
any other authorized governmental agency may require including books, accounts,
journals, ledgers, and all financial records relating to capitation payments,
third party health insurance recovery, and other revenue received and expenses
incurred under this Agreement;
 
iii)  appropriate financial records to document fiscal activities and
expenditures, including records relating to the sources and application of funds
and to the capacity of the Contractor or its subcontractors, including its
Participating Providers, if applicable, to bear the risk of potential financial
losses.
 
b) The record maintenance requirements of this Section shall survive the
termination, in whole or in part, of this Agreement.
 
19.2 Maintenance of Financial Records and Statistical Data
 
The Contractor shall maintain all financial records and statistical data
according to generally accepted accounting principles.
 
19.3 Access to Contractor Records
 
The Contractor shall provide DOHMH, SDOH, the Comptroller of the State of New
York, DHHS, the Comptroller General of the United States, and their authorized
representatives with access to all records relating to Contractor performance
under this Agreement for the purposes of examination, audit, and copying (at
reasonable cost to the requesting party) of such records. The Contractor shall
give access to such records on two (2) business days prior written notice,
during normal business hours, unless otherwise provided or permitted by
applicable laws, rules, or regulations.
 
Medicaid Advantage Contract
 SECTION 19
(RECORDS MAINTENANCE AND AUDIT RIGHTS)
New York City 2006
19-1

19.4 Retention Periods
 
The Contractor shall preserve and retain all records relating to Contractor
performance under this Agreement in readily accessible form during the term of
this Agreement and for a period of six (6) years thereafter except that the
Contractor shall retain Enrollees' medical records that are in the custody of
the Contractor for six (6) years after the date of service rendered to the
Enrollee or cessation of Contractor operation, and in the case of a minor, for
six (6) years after majority. The Contractor shall require and make reasonable
efforts to assure that Enrollees' medical records are retained by providers for
six (6) years after the date of service rendered to the Enrollee or cessation of
Contractor operation, and in the case of a minor, for six (6) years after
majority. All provisions of this Agreement relating to record maintenance and
audit access shall survive the termination of this Agreement and shall bind the
Contractor until the expiration of a period of six (6) years commencing with
termination of this Agreement or if an audit is commenced, until the completion
of the audit, whichever occurs later. If the Contractor becomes aware of any
litigation, claim, financial management review or audit that is started before
the expiration of the six (6) year period, the records shall be retained until
all litigation, claims, financial management reviews or audit findings involved
in the record have been resolved and final action taken.
 

Medicaid Advantage Contract
SECTION 19
(RECORDS MAINTENANCE AND AUDIT RIGHTS)
New York City 2006
19-2

20. CONFIDENTIALITY
 

 
20.1
Confidentiality of Identifying Information about Enrollees, Eligible Persons and
Prospective Enrollees

 
All information relating to services to Enrollees, Eligible Persons and
Prospective Enrollees which is obtained by the Contractor shall be confidential
pursuant to the PHL including PHL Article 27 F, the provisions of Section 369(4)
of the SSL, 42 U.S.C. § 1396a (a) (7) (Section 1902(a)(7) of SSA), Section 33.13
of the Mental Hygiene Law, and regulations promulgated under such laws including
42 CFR § 422.118 and 42 CFR Part 2 pertaining to Alcohol and Substance Abuse
Services. Such information including information relating to services provided
to Enrollees, Eligible Persons and Prospective Enrollees under this Agreement
shall be used or disclosed by the Contractor only for a purpose directly
connected with performance of the Contractor's obligations. It shall be the
responsibility of the Contractor to inform its employees and contractors of the
confidential nature of Medicaid information.
 

 
20.2
Confidentiality of Medical Records

 
Medical records of Enrollees pursuant to this Agreement shall be confidential
and shall be disclosed to and by other persons within the Contractor's
organization including Participating Providers, only as necessary to provide
medical care, to conduct quality assurance functions and peer review functions,
or as necessary to respond to a complaint and appeal under the terms of this
Agreement.
 

 
20.3
Length of Confidentiality Requirements

 
The provisions of this Section shall survive the termination of this Agreement
and shall bind the Contractor so long as the Contractor maintains any
individually identifiable information relating to Enrollees, Eligible Persons
and Prospective Enrollees.

 
Medicaid Advantage Contract
SECTION 20
(CONFIDENTIALITY)
New York City 2006
20-1
 

21. PARTICIPATING PROVIDERS
 
21.1 General Requirements
 
a) The Contractor agrees to comply with all applicable requirements and
standards set forth at 42 CFR Section 422.112, Subpart C; Part 422, Subpart E;
Section 422.504(a)(6) and 422.504(i), Subpart K; Part 423, subpart C and other
applicable federal laws and regulations related to MCO relationships with
providers and with related entities, contractors and subcontractors for services
in the Contractor's Medicare Advantage Product.
 
b) The Contractor agrees to comply with all applicable requirements and
standards set forth at PHL Article 44, 10 NYCRR Part 98, and other applicable
federal and state laws and regulations related to MCO relationships with
providers and with related entities, contractors and subcontractors for services
in the Contractor's Medicaid Advantage Product.
 
21.2 Medicaid Advantage Network Requirements
 
a) The Contractor will establish and maintain a network of Participating
Providers that is supported by written agreements and is sufficient to provide
adequate access to covered services to meet the needs of Enrollees.
 
b) In establishing the network, the Contractor must consider the following:
anticipated Enrollment, expected utilization of Medicaid Only Covered Services
by the population to be enrolled, the number and types of providers necessary to
furnish the services in the Medicaid Advantage Benefit Package, the number of
providers who are not accepting new patients, and the geographic location of the
providers and Enrollees.
 
c) The Contractor's Medicaid Advantage Plan network must contain all of the
provider types necessary to furnish Medicaid Only Covered Services to Enrollees,
including inpatient mental health services beyond the 190-day lifetime limit;
non-Medicare covered home health services; private duty nursing services, and
dental health services and non-emergency transportation services when included
in the Contractor's Medicaid Advantage Product.
 
d) To be considered accessible, the network must contain a sufficient number and
array of providers to meet the diverse needs of the Enrollee population. This
includes being geographically accessible (meeting time/distance standards) and
being accessible for the disabled.
 
e) The Contractor shall not include in its network any provider who has been
sanctioned or prohibited from participation in Federal health care programs
under either Section 1128 or Section 1128A of the SSA, or who has had his/her
license suspended by the New York State Education Department or the SDOH Office
of Professional Medical Conduct.
 

 
Medicaid Advantage Contract
SECTION 21
(PROVIDER NETWORK AND AGREEMENTS)
New York City 2006
21-1

21.3 SDOH Exclusion or Termination of Providers
 
If SDOH excludes or terminates a provider from its Medicaid Program, the
Contractor shall, upon learning of such exclusion or termination, immediately
terminate the provider agreement with the Participating Provider with respect to
the Contractor's Medicaid Advantage Product, and agrees to no longer utilize the
services of the subject provider, as applicable. The Contractor shall access
information pertaining to excluded Medicaid providers through the SDOH HPN. Such
information available to the Contractor on the HPN shall be deemed to constitute
constructive notice. The HPN should not be the sole basis for identifying
current exclusions or termination of previously approved providers. Should the
Contractor become aware, through the HPN or any other source, of an SDOH
exclusion or termination, the Contractor shall validate this information with
the Office of Medicaid Management, Bureau of Enforcement Activities and comply
with the provisions of this Section.
 
21.4 Payment in Full
 
Contractor must limit participation to providers who agree that payment received
from the Contractor for services included in the Medicare and Medicaid Advantage
Benefit Package is payment in full for services provided to Enrollees, except
for the collection of applicable co-payments from Enrollees as provided by law.
 
21.5 Dental Networks
 
If the Contractor includes dental services in its Medicaid Advantage Benefit
Package, the Contractor's dental network shall include geographically accessible
general dentists sufficient to offer each Enrollee a choice of two (2) primary
care dentists in their Service Area and to achieve a ratio of at least one (1)
primary care dentist for each 2,000 Enrollees. Networks must also include at
least one (1) oral surgeon. Orthognathic surgery, temporal mandibular disorders
(TMD) and oral/maxillofacial prosthodontics must be provided through any
qualified dentist, either in-network or by referral. Periodontists and
endodontists must also be available by referral. The network should include
dentists with expertise in serving special needs populations (e.g., HIV+ and
developmentally disabled patients).
 
Dental surgery performed in an ambulatory or inpatient setting is covered by the
Contractor's Medicare Advantage Product.
 

Medicaid Advantage Contract
SECTION 21
(PROVIDER NETWORK AND AGREEMENTS)
New York City 2006
21-2

22.
SUBCONTRACTS AND PROVIDER AGREEMENTS FOR MEDICAID ONLY COVERED SERVICES

 
22.1 Written Subcontracts
 

 
a)
Contractor may not enter into any subcontracts related to the delivery of
Medicaid Only Covered Services to Enrollees, except by a written agreement.

 

 
b)
If the Contractor enters into subcontracts for the performance of work pursuant
to this Agreement, the Contractor shall retain full responsibility for
performance of the subcontracted services. Nothing in this subcontract shall
impair the rights of the DOHMH or the State under this Agreement. No
sub-contractual relationship shall be deemed to exist between the subcontractor
and the DOHMH or the State.

 

 
c)
The delegation by the Contractor of its responsibilities assumed by this
Agreement to any subcontractors will be limited to those specified in the
subcontracts.

 
22.2 Permissible Subcontracts
 
Contractor may subcontract for provider services as set forth in Section 2.6 and
21 of this Agreement, for management services and for other services as are
acceptable to the SDOH. The Contractor must evaluate the prospective
subcontractor's ability to perform the activities to be delegated.
 
22.3 Provisions of Services through Provider Agreements
 
All medical care and/or services covered under this Agreement, with the
exception of Emergency Services, Family Planning and Reproductive Health
Services, and services for which Enrollees can self refer, shall be provided
through Provider Agreements with Participating Providers.
 
22.4 Approvals
 

 
a)
Provider Agreements related to Medicaid Only Covered Services shall require the
approval of SDOH as set forth in PHL § 4402 and 10 NYCRR Part 98.

 

 
b)
If a subcontract is for management services under 10 NYCRR Part 98, it must be
approved by SDOH prior to its becoming effective.

 

 
c)
The Contractor shall notify SDOH of any material amendments to any such Provider
Agreement as set forth in 10 NYCRR Part 98.

 

 
Medicaid Advantage Contract
SECTION 22
(PROVIDER AGREEMENTS)
New York City 2006
22-1

22.5 Required Components
 
a) All subcontracts, including Provider Agreements entered into by the
Contractor to provide program services under this Agreement shall contain
provisions specifying:

 
i)
the activities and reporting responsibilities delegated to the subcontractor;
and provide for revoking the delegation, in whole or in part, and imposing other
sanctions if the subcontractor's performance does not satisfy standards set
forth in this Agreement, and an obligation for the provider to take corrective
action;

ii) that the work performed by the subcontractor must be in accordance
with the terms of this Agreement; and

 
iii)
that the subcontractor specifically agrees to be bound by the confidentiality
provisions set forth in this Agreement.

 
b) The Contractor shall impose obligations and duties on its subcontractors,
including its Participating Providers, that are consistent with this Agreement,
and that do not impair any rights accorded to DOHMH, LDSS, SDOH, or DHHS.
 
c) No subcontract, including any Provider Agreement shall limit or terminate the
Contractor's duties and obligations under this Agreement.
 
d) Nothing contained in this Agreement shall create any contractual relationship
between any subcontractor of the Contractor, including its Participating
Providers, and the SDOH, DOHMH, or LDSS.
 
e) Any subcontract entered into by the Contractor shall fulfill the requirements
of 42 CFR Part 438 that are appropriate to the service or activity delegated
under such subcontract.
 
f) The Contractor shall also ensure that, in the event the Contractor fails to
pay any subcontractor, including any Participating Provider in accordance with
the subcontract or Provider Agreement, the subcontractor or Participating
Provider will not seek payment from the SDOH, LDSS, DOHMH, the Enrollees, or
persons acting on an Enrollee's behalf.
 
g) The Contractor shall include in every Provider Agreement a procedure for the
resolution of disputes between the Contractor and its Participating Providers.
 
h) The Contractor must monitor the subcontractor's performance on an ongoing
basis and subject it to formal review according to time frames established by
the State, consistent with State laws and regulations, and the terms of this
Agreement. When deficiencies or areas for improvement are identified, the
Contractor and subcontractor must take corrective action.

Medicaid Advantage Contract
SECTION 22
(PROVIDER AGREEMENTS)
New York City 2006
22-2
 

22.6 Timely Payment
 
Contractor shall make payments to health care providers for items and services
included in the Contractor's Medicaid Advantage Product on a timely basis,
consistent with the claims payment procedures described in SIL § 3224-a.
 
22.7 Physician Incentive Plan
 

 
a)
If Contractor elects to operate a Physician Incentive Plan, Contractor agrees
that no specific payment will be made directly or indirectly under the plan to a
physician or physician group as an inducement to reduce or limit medically
necessary services furnished to an Enrollee. Contractor agrees to submit to SDOH
annual reports containing the information on its physician incentive plan in
accordance with 42 CFR § 438.6 (h). The contents of such reports shall comply
with the requirements of 42 CFR §§ 422.208 and 422.210 and be in a format to be
provided by SDOH.

 

 
b)
The Contractor must ensure that any agreements for contracted services covered
by this Agreement, such as agreements between the Contractor and other entities
or between the Contractor's subcontracted entities and their contractors, at all
levels including the physician level, include language requiring that the
physician incentive plan information be provided by the sub-contractor in an
accurate and timely manner to the Contractor, in the format requested by SDOH.

 

 
c)
In the event that the incentive arrangements place the physician or physician
group at risk for services beyond those provided directly by the physician or
physician group for an amount beyond the risk threshold of twenty five percent
(25%) of potential payments for covered services (substantial financial risk),
the Contractor must comply with all additional requirements listed in
regulation, such as: conduct enrollee/disenrollee satisfaction surveys; disclose
the requirements for the physician incentive plans to its beneficiaries upon
request; and ensure that all physicians and physician groups at substantial
financial risk have adequate stop-loss protection. Any of these additional
requirements that are passed on to the subcontractors must be clearly stated in
their Agreement.

 

Medicaid Advantage Contract
SECTION 22
(PROVIDER AGREEMENTS)
New York City 2006
22-3
 

23.  
AMERICANS WITH DISABILITIES ACT COMPLIANCE PLAN

Contractor must comply with Title II of the ADA and Section 504 of the
Rehabilitation Act of 1973 for program accessibility, and must develop an ADA
Compliance Plan consistent with the applicable SDOH Guidelines for Medicaid MCO
Compliance with the ADA set forth in Appendix J, which is hereby made a part of
this Agreement as if set forth fully herein. Said plan must be approved by the
SDOH, in collaboration with the DOHMH, and be filed with the SDOH and DOHMH, and
be kept on file by the Contractor.
 
24. FAIR HEARINGS
 
24.1 Enrollee Access to Fair Hearing Process
 
Enrollees in the Contractor's Medicaid Advantage Product may access the fair
hearing process related to services determined by the Contractor to be a
Medicaid only benefit or services determined by the Contractor to be a benefit
under both Medicare and Medicaid in accordance with applicable federal and state
laws and regulations. The Contractor must abide by and participate in New York
State's Fair Hearing Process and comply with determinations made by a fair
hearing officer.
 
24.2 Enrollee Rights to a Fair Hearing
 
Enrollees in the Contractor's Medicaid Advantage Product may request a fair
hearing regarding adverse LDSS determinations concerning enrollment,
disenrollment and eligibility, and regarding the denial, termination, suspension
or reduction of a service determined by the Contractor to be a Medicaid only
benefit or a benefit under both Medicare and Medicaid. For issues related to
disputed services, Enrollees must have received an adverse determination from
the Contractor or its approved utilization review agent either overriding a
recommendation to provide services by a Participating Provider or confirming the
decision of a Participating Provider to deny those services. An Enrollee may
also seek a fair hearing for a failure by the Contractor to act with reasonable
promptness with respect to such services. Reasonable promptness shall mean
compliance with the time frames established for review of grievances and
utilization review in Sections 44 and 49 of the Public Health Law, the grievance
system requirements of 42 CFR Part 438 and Appendix F of this Agreement.
 
24.3 Contractor Notice to Enrollees
 
a) Contractor must issue a written notice of Action and notice of a right to
request a Fair Hearing within applicable timeframes to any Enrollee when taking
an adverse Action and when making an Appeal determination as provided in
Appendix F of this Agreement.
 

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b)
Contractor agrees to serve notice on affected Enrollees by mail and must
maintain documentation of such.

 
24.4 Aid Continuing
 

 
a)
Contractor shall be required to continue the provision of services determined by
the Contractor to be a Medicaid only benefit or a benefit under both Medicare
and Medicaid that are the subject of the fair hearing to an Enrollee (hereafter
referred to as "aid continuing") if so ordered by the OAH under the following
circumstances:

 
i) Contractor has or is seeking to reduce, suspend or terminate such service
or treatment currently being provided;

 
ii)
Enrollee has filed a timely request for a fair hearing with OAH; and iii) There
is a valid order for the service or treatment from a Participating

Provider.
 

 
b)
Contractor shall provide aid continuing until the matter has been resolved to
the Enrollee's satisfaction or until the administrative process is completed and
there is a determination from OAH that Enrollee is not entitled to receive the
service, the Enrollee withdraws the request for aid continuing and/or the fair
hearing in writing, or the service or treatment originally ordered by the
provider has been completed, whichever occurs first.

 

 
c)
If the services and/or benefits in dispute have been terminated, suspended or
reduced and the Enrollee requests a fair hearing in a timely manner, the
Contractor shall, at the direction of either SDOH or LDSS, restore the disputed
services and/or benefits consistent with the provisions of Section 24.4 of this
Agreement.

 
24.5 Responsibilities of SDOH
 
SDOH will make every reasonable effort to ensure that the Contractor receives
timely notice in writing by fax, or e-mail, of all requests, schedules and
directives regarding fair hearings.
 
24.6 Contractor's Obligations
 

 
a)
Contractor shall appear at all scheduled fair hearings concerning its clinical
determinations and/or Contractor-initiated Disenrollments to present evidence as
justification for its determination or submit written evidence as justification
for its determination regarding the disputed benefits and/or services. If
Contractor will not be making a personal appearance at the fair hearing, the
written material must be submitted to OAH and Enrollee or Enrollee's
representative at least three (3) business days prior to the scheduled hearing.
If the hearing is scheduled fewer than three (3) business days after the
request,

 
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Contractor must deliver the evidence to the hearing site no later than one (1)
business day prior to the hearing, otherwise Contractor must appear in person.
Notwithstanding the above provisions, Contractor may be required to make a
personal appearance at the discretion of the hearing officer and/or SDOH.
 

 
b)
Despite an Enrollee's request for a State fair hearing in any given dispute,
Contractor is required to maintain and operate in good faith its own internal
Complaint and Appeal processes for services determined by the Contractor to be a
Medicaid only benefit or a benefit under both Medicare and Medicaid as required
under state and federal laws and by Section 14 and Appendix F of this Agreement.
Enrollees may seek redress of Adverse Determinations simultaneously through
Contractor's internal process and the State fair hearing process. If Contractor
has reversed its initial determination and provided the service to the Enrollee,
Contractor may request a waiver from appearing at the hearing and, in submitted
papers, explain that it has withdrawn its initial determination and is providing
the service or treatment formerly in dispute.

 

 
c)
Contractor shall comply with all determinations rendered by OAH at fair
hearings. Contractor shall cooperate with SDOH efforts to ensure that Contractor
is in compliance with fair hearing determinations. Failure by Contractor to
maintain such compliance shall constitute breach of this Agreement. Nothing in
this Section shall limit the remedies available to SDOH, DOHMH, LDSS or the
federal government relating to any non-compliance by Contractor with a fair
hearing determination or Contractor's refusal to provide disputed services.

 

 
d)
If SDOH investigates a Complaint that has as its basis the same dispute that is
the subject of a pending fair hearing and, as a result of its investigation,
concludes that the disputed services and/or benefits should be provided to the
Enrollee, Contractor shall comply with SDOH's directive to provide those
services and/or benefits and provide notice to OAH and Enrollee as required by
Section 24.6(b) of this Agreement.

 

 
e)
If SDOH, through its Complaint investigation process, or OAH, by a determination
after a fair hearing, directs Contractor to provide a service that was initially
denied by Contractor, Contractor may either directly provide the service,
arrange for the provision of that service or pay for the provision of that
service by a Non-Participating Provider. If the services were not furnished
during the period in which the fair hearing was pending, the Contractor must
authorize and furnish the disputed services promptly and as expeditiously as the
Enrollee's health condition requires.

 

 
f)
Contractor agrees to abide by changes made to this Section of the Agreement with
respect to the fair hearing. Service Authorization, Action, Action Appeal,

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Complaint and Complaint Appeal processes by SDOH in order to comply with any
amendments to applicable state or federal statutes or regulations.
 
g) Contractor agrees to identify a contact person within its organization who
will serve as a liaison to SDOH for the purpose of receiving fair hearing
requests, scheduled fair hearing dates and adjourned fair hearing dates and
compliance with State directives. Such individual shall be accessible to the
State by e-mail; shall monitor e-mail for correspondence from the State at least
once every business day; and shall agree, on behalf of Contractor, to accept
notices to the Contractor transmitted via e-mail as legally valid.
 
h) The information describing fair hearing rights, aid continuing, Service
Authorization, Action Appeal, Complaint and Complaint Appeal procedures shall be
included in all Medicaid Advantage member handbooks and shall comply with
Section 14 and Appendix F of this Agreement.
 
i) Contractor shall bear the burden of proof at hearings regarding the
reduction, suspension or termination of ongoing services determined by the
Contractor to be a Medicaid only benefit or a benefit under both Medicare and
Medicaid. In the event that Contractor's initial adverse determination is upheld
as a result of a fair hearing, any aid continuing provided pursuant to that
hearing request, may be recouped by Contractor.
 
25. EXTERNAL APPEAL
 
25.1 Basis for External Appeal
 
Enrollees in the Contractor's Medicaid Advantage Product are eligible to request
an External Appeal when one or more health care service determined by the
Contractor to be a Medicaid only benefit or a benefit under both Medicare and
Medicaid has been denied by the Contractor on the basis that the service(s) is
not medically necessary or is experimental or investigational.
 
25.2 Eligibility for External Appeal
 
An Enrollee is eligible for an External Appeal when the Enrollee has received an
adverse determination from the Contractor for an expedited internal Action
Appeal, has received a final adverse determination from the Contractor, or both
the Enrollee and the Contractor have agreed to waive internal Action Appeal
procedures in accordance with PHL § 4914(2)2(a). A provider is also eligible for
an External Appeal of retrospective denials.

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25.3 External Appeal Determination
 
The External Appeal determination is binding on the Contractor; however, a fair
hearing determination supersedes an external appeal determination for Medicaid
Advantage Enrollees.
 
25.4 Compliance with External Appeal Laws and Regulations
 
The Contractor must comply with the provisions of Sections 4910-4914 of the PHL
and 10 NYCRR Part 98 regarding the External Appeal program with respect to
services determined by the Contractor to be a Medicaid only benefit or a benefit
under both the Medicare and Medicaid programs.
 
25.5 Member Handbook
 
The Contractor shall describe its Action and utilization review policies and
procedures, including a notice of the right to an External Appeal together with
a description of the External Appeal process and the timeframes for External
Appeal in the Medicaid Advantage Handbook.
 
26. INTERMEDIATE SANCTIONS
 
26.1 General
 
Contractor is subject to the imposition of sanctions as authorized by 42 CFR
422, Subpart 0. In addition, for the Medicaid Advantage Program, the Contractor
is subject to the imposition of sanctions as authorized by state and federal law
and regulation, including the SDOH's right to impose sanctions for unacceptable
practices as set forth in 18 NYCRR Part 515 and civil and monetary penalties as
set forth in 18 NYCRR Part 516 and 43 CFR § 438.700, and such other sanctions
and penalties as are authorized by local laws and ordinances and resultant
administrative codes, rules and regulations related to the Medical Assistance
Program or to the delivery of the contracted for services.
 
26.2 Unacceptable Practices
 
a) Unacceptable practices for which the Contractor may be sanctioned include,
but are not limited to:
i) Failing to provide medically necessary services that the Contractor is
required to provide under its contract with the State.
ii) Imposing premiums or charges on Enrollees that are in excess of the premiums
or charges permitted under the Medicaid Advantage Program.
iii) Discriminating among Enrollees on the basis of their health status or need
for health care services.
 

 

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iv) Misrepresenting or falsifying information that the Contractor furnishes to
an' Enrollee, Eligible Persons, Prospective Enrollees, health care providers,
the State or to CMS. v) Failing to comply with the requirements for Physician
Incentive Plans, as set forth in 42 CFR §§ 422.208 and 422.210.
vi) Distributing directly or through any agent or independent contractor,
Marketing materials that have not been approved by CMS and the State or that
contain false or materially misleading information.
vii) Violating any other applicable requirements of SSA §§ 1903 (m) or 1932 and
any implementing regulations
viii) Violating any other applicable requirements of 18 NYCRR or 10 NYCRR Part
98.
ix) Failing to comply with the terms of this Agreement.
 
26.3 Intermediate Sanctions
 
a) Intermediate Sanctions may include, but are not limited to:
 
i) Civil and monetary penalties.
ii) Suspension of all new Enrollment, after the effective date of the sanction.
iii) Termination of the Agreement, pursuant to Section 2.7 of this Agreement.
 
 
26.4 Enrollment Limitations
 

 
a)
The DOHMH shall have the right, upon consultation with and notice to the SDOH,
to limit, suspend, or terminate Enrollment activities by the Contractor and/or
enrollment into the Contractor's Medicaid Advantage Product upon ten (10) days
written notice to the Contractor. The written notice shall specify the action(s)
contemplated and the reason(s) for such action(s) and shall provide the
Contractor with an opportunity to submit additional information that would
support the conclusion that limitation, suspension or termination of Enrollment
activities or Enrollment in the Contractor's plan is unnecessary. Nothing in
this paragraph limits other remedies available to the DOHMH under this
Agreement.

 

 
b)
The SDOH shall have the right, upon notice to the DOHMH and LDSS, to limit,
suspend or terminate Enrollment activities by the Contractor and/or Enrollment
into the Contractor's Medicaid Advantage Product upon ten (10) days written
notice to the Contractor. The written notice shall specify the action(s)
contemplated and the reason(s) for such action(s) and shall provide the
Contractor with an opportunity to submit additional information that would
support the conclusion that limitation, suspension or termination of Enrollment
activities or Enrollment in the Contractor's Medicaid Advantage

 

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Product is unnecessary. Nothing in this paragraph limit other remedies available
to SDOH or the DOHMH under this Agreement.
 
26.5 Due Process
 
The Contractor will be afforded due process pursuant to federal and state law
and regulations (42 CFR § 438.710, 18 NYCRR Part 516, and Article 44 of the
PHL).
 
27. ENVIRONMENTAL COMPLIANCE
 
The Contractor shall comply with all applicable standards, orders, or
requirements issued under Section 306 of the Clean Air Act (42 U.S.C. §
1857(h)), Section 508 of the Federal Water Pollution Control Act as amended (33
U.S.C. § 1368), Executive Order 11738, and the Environmental Protection Agency
("EPA") regulations (40 CFR, Part 15) that prohibit the use of the facilities
included on the EPA List of Violating Facilities. The Contractor shall report
violations to SDOH and to the Assistant Administrator for Enforcement of the
EPA.
 
28. ENERGY CONSERVATION
 
The Contractor shall comply with any applicable mandatory standards and policies
relating to energy efficiency that are contained in the State Energy
Conservation regulation issued in compliance with the Energy Policy and
Conservation Act of 1975 (Pub. L. 94-165) and any amendment to the Act.
 
29. INDEPENDENT CAPACITY OF CONTRACTOR
 
The parties agree that the Contractor is an independent Contractor, and that the
Contractor, its agents, officers, and employees act in an independent capacity
and not as officers or employees ofLDSS, DOHMH, SDOH or the DHHS..
 
30. NO THIRD PARTY BENEFICIARIES
 
Only the parties to this Agreement and their successors in interest and assigns
have any rights or remedies under or by reason of this Agreement.
 
31. INDEMNIFICATION
 
31.1 Indemnification by Contractor
 
a) The Contractor shall indemnify, defend, and hold harmless the SDOH and the
DOHMH, and their officers, agents, and employees and the Enrollees and their
eligible dependents from
 

 
i)
any and all claims and losses accruing or resulting to any and all Contractors,
subcontractors, materialmen, laborers, and any other person,

 
 

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firm, or corporation furnishing or supplying work, services, materials, or
supplies in connection with the performance of this Agreement
 

 
ii)
any and all claims and losses accruing or resulting to any person, firm, or
corporation that may be injured or damaged by the Contractor, its officers,
agents, employees, or subcontractors, including Participating Providers, in
connection with the performance of this Agreement;

 

 
iii)
any liability, including costs and expenses, for violation of proprietary
rights, copyrights, or rights of privacy, arising out of the publication,
translation, reproduction, delivery, performance, use, or disposition of any
data furnished under this Agreement, or based on any libelous or otherwise
unlawful matter contained in such data.

 
b) The DOHMH will provide the Contractor with prompt written notice of any claim
made against the DOHMH, and the Contractor, at its sole option, shall defend or
settle said claim. The DOHMH shall cooperate with the Contractor to the extent
necessary for the Contractor to discharge its obligation under Section 31.1.
 
c) The Contractor shall have no obligation under this section with respect to
any claim or cause of action for damages to persons or property solely caused by
the negligence of DOHMH, or their employees, or agents.
 
31.2 Indemnification by DOHMH
 
The DOHMH shall indemnify and hold harmless the Contractor and its officers,
agents, and employees from any loss or damage resulting from actions by the
DOHMH pursuant to the terms of Appendix R, Section 6.3 herein.
 
32. PROHIBITION ON USE OF FEDERAL FUNDS FOR LOBBYING
 
32.1 Prohibition of Use of Federal Funds for Lobbying
 
The Contractor agrees, pursuant to 31 U.S.C. § 1352 and 45 CFR Part 93, that no
Federally appropriated funds have been paid or will be paid to any person by or
on behalf of the Contractor for the purpose of influencing or attempting to
influence an officer or employee of any agency, a Member of Congress, an officer
or employee of Congress, or an employee of a Member of Congress in connection
with the award of any Federal contract, the making of any federal grant, the
making of any Federal loan, the entering into of any cooperative agreement, or
the extension, continuation, renewal, amendment, or modification of any Federal
contract, grant, loan, or cooperative agreement. The Contractor agrees to
complete and submit the "Certification Regarding Lobbying", Appendix B attached
hereto and incorporated herein, if this Agreement exceeds $100,000.
 
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32.2 Disclosure Form to Report Lobbying
 
If any funds other than Federally appropriated funds have been paid or will'be
paid to any person for the purpose of influencing or attempting to influence an
officer or employee of any agency, a Member of Congress, an officer or employee
of Congress, or an employee of a Member of Congress in connection with the award
of any Federal contract, the making of any Federal grant, the making of any
Federal loan, the entering into of any cooperative agreement, or the extension,
continuation, renewal, amendment, or modification of any Federal contract,
grant, loan, or cooperative agreement, and the Agreement exceeds $100,000, the
Contractor shall complete and submit Standard Form-LLL "Disclosure Form to
Report Lobbying," in accordance with its instructions.
 
32.3 Requirements of Subcontractors
 
The Contractor shall include the provisions of this section in its subcontracts,
including its Provider Agreements. For all subcontracts, including Provider
Agreements, that exceed $100,000, the Contractor shall require the
subcontractor, including any Participating Provider to certify and disclose
accordingly to the Contractor.
 
33. NON-DISCRIMINATION
 
33.1 Equal Access to Benefit Package
 
Except as otherwise provided in applicable sections of this Agreement the
Contractor shall provide the Medicaid Advantage Benefit Package to all Enrollees
in the same manner, in accordance with the same standards, and with the same
priority as Enrollees of the Contractor enrolled under any other contracts.
 
33.2 Non-Discrimination
 
The Contractor shall not discriminate against Eligible Persons or Enrollees on
the basis of age, sex, race, creed, physical or mental handicap/developmental
disability, national origin, sexual orientation, type of illness or condition,
need for health services, or Capitation Rate that the Contractor will receive
for such Eligible Persons or Enrollees.
 
33.3 Equal Employment Opportunity
 
Contractor must comply with Executive Order 11246, entitled "Equal Employment
Opportunity" as amended by Executive Order 11375, and as supplemented in
Department of Labor regulations.
 
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33.4 Native Americans Access to Services from Tribal or Urban Indian Health
Facility
 
The Contractor shall not prohibit, restrict or discourage enrolled Native
Americans from receiving care from or accessing Medicaid reimbursed health
services from or through a tribal health or urban Indian health facility or
center.
 
34. COMPLIANCE WITH APPLICABLE LAWS AND REGULATIONS
 
34.1 Contractor and DOHMH Compliance with Applicable Laws
 
Notwithstanding any inconsistent provisions in this Agreement, the Contractor
and DOHMH shall comply with all applicable requirements of the State Public
Health Law; the State Insurance Law; the State Social Services Law; and state
regulations related to the aforementioned state statutes. Such state laws and
regulations shall not be deemed to be applicable to the extent that they are
pre-empted by federal laws. The Contractor also shall comply with Titles XVIII
and XIX of the Social Security Act and regulations promulgated thereunder,
including but not limited to 43 CFR Part 422 and Part 423; Title VI of the Civil
Rights Act of 1964 and 45 C.F.R. Part 80, as amended; Section 504 of the
Rehabilitation Act of 1973 and 45 C.F.R. Part 84, as amended; Age Discrimination
Act of 1975 and 45 C.F.R. Part 91, as amended; the ADA; Title XIII of the
Federal Public Health Services Act, 42 U.S.C. § 300e et seq., and the
regulations promulgated there under; the Health Insurance Portability and
Accountability Act of 1996 (P.L. 104-191) and related regulations; and all other
applicable legal and regulatory requirements in effect at the time that this
Agreement is signed and as adopted or amended during the term of this Agreement.
The parties agree that this Agreement shall be interpreted according to the laws
of the State of New York.
 
34.2 Nullification of Illegal, Unenforceable, Ineffective or Void Contract
Provisions
 
Should any provision of this Agreement be declared or found to be illegal or
unenforceable, ineffective or void, then each party shall be relieved of any
obligation arising from such provision; the balance of this Agreement, if
capable of performance, shall remain in full force and effect.
 
34.3 Certificate of Authority Requirements
 
The Contractor must satisfy conditions for issuance of a certificate of
authority, including proof of financial solvency, as specified in 10 NYCRR Part
98.
 
34.4 Notification of Changes in Certificate of Incorporation
 
The Contractor shall notify DOHMH of any amendment to its Certificate of
Incorporation in the same manner as and simultaneously with the notice given to
SDOH pursuant to 10 NYCRR Part 98.
 
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34.5 Contractor's Financial Solvency Requirements
 
The Contractor, for the duration of this Agreement, shall remain in compliance
with all applicable state requirements for financial solvency for MCOs
participating in the Medicaid Program. The Contractor shall continue to be
financially responsible as defined in PHL § 4403 (l)(c) and shall comply with
the contingent reserve fund and escrow deposit requirements of 10 NYCRR Part 98
and must meet minimum net worth requirements established by SDOH and the State
Insurance Department. The Contractor shall make provision, satisfactory to SDOH,
for protections for SDOH, LDSS and the Enrollees in the event of HMO or
subcontractor insolvency, including but not limited to, hold harmless and
continuation of treatment provisions in all provider agreements which protect
SDOH, DOHMH, LDSSs and Enrollees from costs of treatment and assures continued
access to care for Enrollees.
 
34.6 Non-Liability of Enrollees for Contractor's Debts
 
Contractor agrees that in no event shall the Enrollee become liable for the
Contractor's debts as set forth in SSA § 1932(b)(6).
 
34.7 DOHMH Compliance with Conflict of Interest Laws
 
DOHMH and its employees shall comply with Article 18 of the General Municipal
Law and all other appropriate provisions of New York State law, local laws and
ordinances and all resultant codes, rules and regulations pertaining to
conflicts of interest.
 
34.8 Compliance Plan
 
The Contractor agrees to implement a compliance plan in accordance with the
requirements of 42 CFR § 422.503(b)(4) (vi) and 42 CFR § 438.608.
 
35.
NEW YORK STATE STANDARD CONTRACT CLAUSES AND NEW YORK CITY STANDARD CLAUSES

 
The parties agree to be bound by the standard clauses for all New York State
contracts and standard clauses, if any, for local government contracts contained
in Appendix A and R, respectively, attached to and incorporated into this
Agreement as if set forth fully herein, and any amendment thereto.

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--------------------------------------------------------------------------------

 
This Agreement is effective April 1, 2006 and shall remain in effect until
December 31, 2006 or until the execution of an extension, renewal or successor
agreement as provided for in the Agreement.
 
In Witness Whereof, the parties have duly executed this Agreement on the dates
appearing below their respective signatures.
 
By /s/ Todd S. Farha
 
By: /s/  Illegible   
Contractor
 
New York City Department of Health and Mental Hygiene
 
Date 3/17/06
 
 
Date:  4/04/06

 

 
Approval as to form and certification as to legal authority was granted by the
Corporation Counsel on: March 8, 2006.

Medicaid Advantage Contract
SIGNATURE PAGE
New York City 2006
 

--------------------------------------------------------------------------------

STATE OF FLORIDA
SS:

COUNTY OF HILLSBOROUGH

On this 17 day of March 2006, Todd S. Farha came before me known to be the
President and CEO of WellCare of New York, Inc., who is duly authorized to
execute the foregoing instrument on behalf of said corporation and s/he
acknowledged to me that s/he executed the same for the purpose therein
mentioned.
 

/s/ Rebecca McNealy
NOTARY PUBLIC

 

 
STATE OF NEW YORK)
 
SS:
 
COUNTY OF NEW YORK
 
On this 4 day of April, 2006, Thomas Frieden   came before me, to me known and
known to be the Commissioner  in the New York City Department of Health and
Mental Hygiene, who is duly authorized to execute the foregoing instrument on
behalf of the City and s/he acknowledged to me that s/he executed the same for
the purpose therein mentioned.

 
Frank Lane          
NOTARY PUBLIC

 

--------------------------------------------------------------------------------

APPENDIX A
 
 
 
New York State Standard Clauses
 
 
 

--------------------------------------------------------------------------------

 

STANDARD CLAUSES FOR NYS CONTRACTS
 
The parties to the attached contract, license, lease, amendment or other
agreement of any kind (hereinafter, "the contract" or "this contract") agree to
be bound by the following clauses which are hereby made a part of the contract
(the word "Contractor" herein refers to any party other than the State, whether
a contractor, licenser, licensee, lessor, lessee or any other party):
 
1. EXECUTORY CLAUSE. In accordance with Section 41 of the State Finance Law, the
State shall have no liability under this contract to the Contractor or to anyone
else beyond funds appropriated and available for this contract.

2. NON-ASSIGNMENT CLAUSE. In accordance with Section 138 of the State Finance
Law, this contract may not be assigned by the Contractor or its right, title or
interest therein assigned, transferred, conveyed, sublet or otherwise disposed
of without the previous consent, in writing, of the State and any attempts to
assign the contract without the State's written consent are null and void. The
Contractor may, however, assign its right to receive payment without the State's
prior written consent unless this contract concerns Certificates of
Participation pursuant to Article 5-A of the State Finance Law.'.

3. COMPTROLLER'S APPROVAL. In accordance with Section 112 of the State Finance
Law (or, if this contract is with the State University or City University of New
York, Section 355 or Section 6218 of the Education Law), if this contract
exceeds $15,000 (or the minimum thresholds agreed to by the Office of the State
Comptroller for certain S.U.N.Y. and C.U.N.Y. contracts), or if this is an
amendment for any amount to a contract which, as so amended, exceeds said
statutory amount, or if, by this contract, the State agrees to give something
other than money when the value or reasonably estimated value of such
consideration exceeds $10,000, it shall not be valid, effective or binding upon
the State until it has been approved by the State Comptroller and filed in his
office. Comptroller's approval of contracts let by the Office of General
Services is required when such contracts exceed $30,000 (State Finance Law
Section 163.6.a).

4. WORKERS' COMPENSATION BENEFITS. In accordance with Section 142 of the State
Finance Law, this contract shall be void and of no force and effect unless the
Contractor shall provide and maintain coverage during the life of this contract
for the benefit of such employees as are required to be covered by the
provisions of the Worker;;' Compensation Law.
 
5. NON-DISCRIMINATION REQUIREMENTS. To the extent required by Article 15 of the
Executive Law (also known as the Human Rights Law) and all other State and
Federal statutory and constitutional non-discrimination provisions, the
Contractor will not discriminate against any employee or applicant for
employment because of race, creed, color, sex, national origin, sexual
orientation, age, disability, genetic predisposition or carrier status, or
marital status. Furthermore, in accordance with Section 220-e of the Labor Law,
if this is a contract for the construction, alteration or repair of any public
building or public work or for the manufacture, sale or distribution of
materials, equipment or supplies, and to the extent that this contract shall be
performed within the State of New York, Contractor agrees that neither it not
its subcontractors shall, by reason of race, creed, color, disability, sex, or
national origin: (a) discriminate in hiring against any New York State citizen
who is qualified and available to perform the work; or (b) discriminate against
or intimidate any employee hired for the performance of work under this
contract. If this is a building service contract as defined in Section 230 of
the Labor Law, then, in accordance with Section 239 thereof, Contractor agrees
that neither it nor its subcontractors shall by reason of race, creed, color,
national origin, age, sex or disability: (a) discriminate in hiring against any
New York State citizen who is qualified and available to perform the work; or
(b) discriminate against or intimidate any employee hired for the performance of
work under this contract. Contractor is subject to fines of $50.00 per person
per day for any violation of Section 220-e or Section
 
 
Page 1

239 as well as possible termination of this contract and forfeiture of all
moneys due hereunder for a second or subsequent violation.
 
6. WAGE AND HOURS PROVISIONS. If this is a public work contract covered by
Article 8 of the Labor Law or a building service contract covered by Article 9
thereof, neither Contractor's employees nor the employees of its subcontractors
may be required or permitted to work more than the number of hours or days
stated in said statutes, except as otherwise provided in the Labor Law and as
set forth in prevailing wage and supplement schedules issued by the State Labor
Department. Furthermore, Contractor and its subcontractors must pay at least the
prevailing wage rate and pay or provide the prevailing supplements, including
the premium rates for overtime pay, as determined by the State Labor Department
in accordance with the Labor Law.
 
7. NON-COLLUSIVE BIDDING CERTIFICATION. In accordance with Section 139-d of the
State Finance Law, if this contract was awarded based upon the submission of
bids, Contractor warrants, under penalty of perjury, that its bid was arrived at
independently and without collusion aimed at restricting competition. Contractor
further warrants that, at the time Contractor submitted its bid, an authorized
and responsible person executed and delivered to the State a non-collusive
bidding certification on Contractor's behalf.

8. INTERNATIONAL BOYCOTT PROHIBITION. In accordance with Section 220-f of the
Labor Law and Section 139-h of the State Finance Law, if this contract exceeds
$5,000, the Contractor agrees, as a material condition of the contract, that
neither the Contractor nor any substantially owned or affiliated person, firm,
partnership or corporation has participated, is participating, or shall
participate in an international boycott in violation of the federal Export
Administration Act of 1979 (50 USC App. Sections 2401 et seq.) or regulations
thereunder. If such Contractor, or any of the aforesaid affiliates of
Contractor, is convicted or is otherwise found to have violated said laws or
regulations upon the final determination of the United States Commerce
Department or any other appropriate agency of the United States subsequent to
the contract's execution, such contract, amendment or modification thereto shall
be rendered forfeit and void. The Contractor shall so notify the State
Comptroller within five (5) business days of such conviction, determination or
disposition of appeal (2NYCKR 105.4).

9. SET-OFF RIGHTS. The State shall have all of its common law, equitable and
statutory rights of set-off. These rights shall include, but not be limited to,
the State's option to withhold for the purposes of set-off any moneys due to the
Contractor under this contract up to any amounts due and owing to the State with
regard to this contract, any other contract with any State department or agency,
including any contract for a term commencing prior to the term of this contract,
plus any amounts due and owing to the State for any other reason including,
without limitation, tax delinquencies, fee delinquencies or monetary penalties
relative thereto. The State shall exercise its set-off rights in accordance with
normal State practices including, in cases of set-off pursuant to an audit, the
finalization of such audit by the State agency, its representatives, or the
State Comptroller.

10. RECORDS. The Contractor shall establish and maintain complete and accurate
books, records, documents, accounts and other evidence directly pertinent to
performance under this contract (hereinafter, collectively, "the Records"). The
Records must be kept for the balance of the calendar year in which they were
made and for six (6) additional years thereafter. The State Comptroller, the
Attorney General and any other person or entity authorized to conduct an
examination, as well as the agency or agencies involved in this contract, shall
have access to the Records during normal business hours at an office of the
Contractor

May, 2003

STANDARD CLAUSES FOR NYS CONTRACTS APPENDIX A
 
within the State of New York or, if no such office is available, at a mutually
agreeable and reasonable venue within the State, for the term specified above
for the purposes of inspection, auditing and copying. The State shall take
reasonable steps to protect from public disclosure any of the Records which are
exempt from disclosure under Section 87 of the Public Officers Law (the
"Statute") provided that: (i) the Contractor shall timely inform an appropriate
State official, in writing, that said records should not be disclosed; and (ii)
said records shall be sufficiently identified; and (iii) designation of said
records as exempt under the Statute is reasonable. Nothing contained herein
shall diminish, or in any way adversely affect, the State's right to discovery
in any pending or future litigation.

11. IDENTIFYING INFORMATION AND PRIVACY NOTIFICATION, (a) FEDERAL EMPLOYER
IDENTIFICATION NUMBER and/or FEDERAL SOCIAL SECURITY NUMBER. All invoices or New
York State standard vouchers submitted for payment for the sale of goods or
services or the lease of real or personal property to a New York State agency
must include the payee's identification number, i.e., the seller's or lessor's
identification number. The number is either the payee's Federal employer
identification number or Federal social security number, or both such numbers
when the payee has both such numbers. Failure to include this number or numbers
may delay payment. Where the payee does not have such number or numbers, the
payee, on its invoice or New York State standard voucher, must give the reason
or reasons why the payee does not have such number or numbers.
(b) PRIVACY NOTIFICATION. (1) The authority to request the above personal
information from a seller of goods or services or a lessor of real or personal
property, and the authority to maintain such information, is found in Section 5
of the State Tax Law. Disclosure of this information by the seller or lessor to
the State is mandatory. The principal purpose for which the information is
collected is to enable the State to identify individuals, businesses and others
who have been delinquent in filing tax returns or may have understated their tax
liabilities and to generally identify persons affected by the taxes administered
by the Commissioner of Taxation and Finance. The information will be used for
tax administration purposes and for any other purpose authorized by law.
(2) The personal information is requested by the purchasing unit of the agency
contracting to purchase the goods or services or lease the real or personal
property covered by this contract or lease. The information is maintained in New
York State's Central Accounting System by the Director of Accounting Operations,
Office of the State Comptroller, AESOB, Albany, New York 12236.

12. EQUAL EMPLOYMENT OPPORTUNITIES FOR MINORITIES AND WOMEN. In accordance with
Section 312 of the Executive Law, if this contract is: (i) a written agreement
or purchase order instrument, providing for a total expenditure in excess of
$25,000.00, whereby a contracting agency is committed to expend or does expend
funds in return for labor, services, supplies, equipment, materials or any
combination of the foregoing, to be performed for, or rendered or furnished to
the contracting agency; or (ii) a written agreement in excess of S100,000.00
whereby a contracting agency is committed to expend or does expend funds for the
acquisition, construction, demolition, replacement, major repair or renovation
of real property and improvements thereon; or (iii) a written agreement in
excess of $100,000.00 whereby the owner of a Slate assisted housing project is
committed to expend or does expend funds for the acquisition, construction,
demolition, replacement, major repair or renovation of real property and
improvements thereon for such project, then:

(a) The Contractor will not discriminate against employees or applicants for
employment because of race, creed, color, national origin, sex, age, disability
or marital status, and will undertake or continue existing programs of
affirmative action to ensure that minority group members and women are afforded
equal employment opportunities without discrimination. Affirmative action shall
mean recruitment,
 
 
Page 2

 
employment, job assignment, promotion, upgrading?, demotion, transfer, layoff,
or termination and rates of pay or other forms of compensation;
 
(b) at the request of the contracting agency, the Contractor shall request each
employment agency, labor union, or authorized representative of workers with
which it has a collective bargaining or other agreement or understanding, to
furnish a written statement that such employment agency, labor union or
representative will not discriminate on the basis of race, creed, color,
national origin, sex, age, disability or marital status and that such union or
representative will affirmatively cooperate in the implementation of the
contractor's obligations herein; and

(c) the Contractor shall state, in all solicitations or advertisements for
employees, that, in the performance of the State contract, all qualified
applicants will be afforded equal employment opportunities without
discrimination because of race, creed, color, national origin, sex, age,
disability or marital status.
 
Contractor will include the provisions of "a", "b", and "c" above, in every
subcontract over $25,000.00 for the construction, demolition, replacement, major
repair, renovation, planning or design of real property and improvements thereon
(the "Work") except where the Work is for the beneficial use of the Contractor.
Section 312 does not apply to: (i) work, goods or services unrelated to this
contract; or (ii) employment outside New York State; or (iii) banking services,
insurance policies or the sale of securities. The State shall consider
compliance by a contractor or subcontractor with the requirements of any federal
law concerning equal employment opportunity which effectuates the purpose of
this section. The contracting agency shall determine whether the imposition of
the requirements of title provisions hereof duplicate or conflict with any such
federal law and if such duplication or conflict exists, the contracting agency
shall waive the applicability of Section 312 to the extent of such duplication
or conflict. Contractor will comply with all duly promulgated and lawful rules
and regulations of the Governor's Office of Minority and Women's Business
Development pertaining hereto.

13. CONFLICTING TERMS. In the event of a conflict between the terms of the
contract (including any and all attachments thereto and amendments thereof) and
the terms of this Appendix A, the terms of this Appendix A shall control.

14. GOVERNING LAW. This contract shall be governed by the laws of the State of
New York except where the Federal supremacy clause requires otherwise.

15. LATE PAYMENT. Timeliness of payment and any interest to be paid to
Contractor for late payment shall be governed by Article I)-A of the State
Finance Law to the extent required by law.

16. NO ARBITRATION. Disputes involving this contract, including the breach or
alleged breach thereof, may not be submitted to binding arbitration (except
where statutorily authorized), but must, instead, be heard in a court of
competent jurisdiction of the State of New York.

17. SERVICE OF PROCESS. In addition to the methods of service allowed by the
State Civil Practice Law & Rules ("CPLR"), Contractor hereby consents to service
of process upon it by registered or certified mail, return receipt requested.
Service hereunder shall be complete upon Contractor's actual receipt of process
or upon the State's receipt of the return thereof by [he United States Postal
Service as refused or undeliverable. Contractor must promptly notify the State,
in writing, of each and every change of address to which service of process can
be made. Service by the State to the last known address shall be sufficient.
Contractor will have thirty (30) calendar days after service hereunder is
complete in which to respond.
 
 
May,2003
 

STANDARD CLAUSES FOR NYS CONTRACTS APPENDIX A

18. PROHIBITION ON PURCHASE OF TROPICAL HARDWOODS. The Contractor certifies and
warrants that all wood products to be used under this contract award will be in
accordance with, but not limited to, the specifications and provisions of State
Finance Law §165. (Use of Tropical Hardwoods) which prohibits purchase and use
of tropical hardwoods, unless specifically exempted, by the State or any
governmental agency or political subdivision or public benefit corporation.
Qualification for an exemption under this law will be the responsibility of the
contractor to establish to meet with the approval of the State.
In addition, when any portion of this contract involving the use of woods,
whether supply or installation, is to be performed by any subcontractor, the
prime Contractor will indicate and certify in the submitted bid proposal that
the subcontractor has been informed and is in compliance with specifications and
provisions regarding use of tropical hardwoods as detailed in §165 State Finance
Law. Any such use must meet with the approval of the State; otherwise, the bid
may not be considered responsive. Under bidder certifications, proof of
qualification for exemption will be the responsibility of the Contractor to meet
with the approval of the State.
 
19. MACBRIDE FAIR EMPLOYMENT PRINCIPLES. In
accordance with: the MacBride Fair Employment Principles (Chapter 807 of the
Laws of 1992), the Contractor hereby stipulates that the Contractor either (a)
has no-business operations in Northern Ireland, or (b) shall take lawful steps
in good faith to conduct any business operations in Northern Ireland in
accordance with the MacBride Fair Employment Principles (as described in Section
165 of the New York State Finance Law), and shall permit independent monitoring
of compliance with such principles.

20. OMNIBUS PROCUREMENT ACT OF 1992. It is the policy of New York State to
maximize opportunities for the participation of New York State business
enterprises, including minority and women-owned business enterprises as bidders,
subcontractors and suppliers on its procurement contracts.

Information on the availability of New York State subcontractors and suppliers
is available from:

NYS Department of Economic Development Division for Small Business 30 South
Pearl St - 7th Floor Albany, New York 12245 Telephone: 518-292-5220

A directory of certified minority and women-owned business enterprises is
available from:
 
NYS Department of Economic Development
Division of Minority and Women's Business Development
30 South Pearl St - 2nd Floor
Albany, New York 12245
http://www.empire.state.ny.us
 
The Omnibus Procurement Act of 1992 requires that by signing this bid proposal
or contract, as applicable, Contractors certify that whenever the total bid
amount is greater than $1 million:

(a) The Contractor has made reasonable efforts to encourage the participation of
New York State Business Enterprises as suppliers and subcontractors, including
certified minority and women-owned business enterprises, on this project, and
has retained the documentation of these efforts to be provided upon request to
the Slate;

(b) The Contractor has complied with the Federal Equal Opportunity Act of 1972
(P.L. 92-261), as amended;

 

Page 3

 
(c) The Contractor agrees to make reasonable efforts to provide notification to
New York State residents of employment opportunities on this project through
listing any such positions with the Job Service Division of the New York State
Department of Labor, or providing such notification in such manner as is
consistent with existing collective

bargaining contracts or agreements. The Contractor agrees to document these
efforts and to provide said documentation to the State upon request; and
 
(d) The Contractor acknowledges notice that the State may seek to obtain offset
credits from foreign countries as a result of this contract and agrees to
cooperate with the State in these efforts.
 
21. RECIPROCITY AND SANCTIONS PROVISIONS. Bidders are hereby notified that if
their principal place of business is located in a country, nation, province,
state or political subdivision that penalizes New York State vendors, and if the
goods or services they offer will be substantially produced or performed outside
New York State, the Omnibus Procurement Act 1994 and 2000 amendments (Chapter
684 and Chapter 383, respectively) require that they be denied contracts which
they would otherwise obtain. NOTE: As of May 15, 2002, the list of
discriminatory jurisdictions subject to this provision includes the states of
South Carolina, Alaska, West Virginia, Wyoming, Louisiana and Hawaii. Contact
NYS Department of Economic Development for a current list of jurisdictions
subject to this provision.
 
22. PURCHASES OF APPAREL. In accordance with State Finance Law 162 (4-a), the
State shall not purchase any apparel from any vendor unable or unwilling to
certify that: (i) such apparel was manufactured in compliance with all
applicable labor and occupational safety laws, including, but not limited to,
child labor laws, wage and hours laws and workplace safety laws, and (ii) vendor
will supply, with its bid (or, if not a bid situation, prior to or at the time
of signing a contract with the State), if known, the names and addresses of each
subcontractor and a list of all manufacturing plants to be utilized by the
bidder.
 

 
 
May 2003
 

--------------------------------------------------------------------------------

APPENDIX B CERTIFICATION REGARDING LOBBYING
 
The undersigned certifies, to the best of his or her knowledge, that:
 
1. No Federal appropriated funds have been paid or will be paid to any person by
or on behalf of the Contractor for the purpose of influencing or attempting to
influence an officer or employee of any agency, a Member of Congress, an officer
or employee of a Member of Congress in connection with the award of any Federal
loan, the entering into of any cooperative agreement, or the extension,
continuation, renewal, amendment, or modification of any Federal contract,
grant, loan, or cooperative agreement.
 
2. If any funds other than Federal appropriated funds have been paid or will be
paid to any person for the purpose of influencing or attempting to influence an
officer or employee of any agency, a Member of Congress in connection with the
award of any Federal contract, the making of any Federal grant, the making of
any Federal loan, the entering into of any cooperative agreement, or the
extension, continuation, renewal, amendment, or modification of any Federal
contract, grant, loan, or cooperative agreement, and the Agreement exceeds
$100,000, the Contractor shall complete and submit Standard Form -LLL
"Disclosure Form to Report Lobbying", in accordance with its instructions.
 
3. The Contractor shall include the provisions of this section in all provider
Agreements
under this Agreement and require all Participating providers whose Provider
Agreements exceed $100,000 to certify and disclose accordingly to the
Contractor.
 
This certification is a material representation of fact upon which reliance was
place when this transaction was made or entered into. Submission of this
certification is a prerequisite for making or entering into this transaction
pursuant to U.S.C. Section 1352. The failure to file the required certification
shall subject the violator to a civil penalty of not less than $10,000 and not
more than $100,000 for each such failure.
 

 
DATE:  3/17/06       
 
 
SIGNATURE:  /s/ Todd S. Farha    
 
 
TITLE:  President and Chief Executive Officer    
 
 
ORGANIZATION:  WellCare of New York, Inc.   

 
Medicaid Advantage Contract
APPENDIX B
New York City 2006
B-2

--------------------------------------------------------------------------------

 

Appendix C

New York State Department of Health
Requirements for the Provision of Free Access to
Family Planning and Reproductive Health Services
 
 

 
C.I
Definitions and General Requirements for the Provision of Family Planning and
Reproductive Health Services

 

 
C.2
Requirements for MCOs that Provide Family Planning and Reproductive Health
Services

 

 
C.3
Requirements for MCOs That Do Not Provide Family Planning and Reproductive
Health Services

Medicaid Advantage Contract
APPENDIX C.
New York City 2006
C-l
 

--------------------------------------------------------------------------------

C.I
Definitions and General Requirements for the Provision of Family Planning and
Reproductive Health Services
 
1. Family Planning and Reproductive Health Services
 

 
a)
Family Planning and Reproductive Health Services mean the offering, arranging
and furnishing of those health services which enable Enrollees, including minors
who may be sexually active, to prevent or reduce the incidence of unwanted
pregnancies.

 

 
i)
Family Planning and Reproductive Health Services include the following
medically-necessary services, related drugs and supplies which are furnished or
administered under the supervision of a physician, licensed midwife or certified
nurse practitioner during the course of a Family Planning and Reproductive
Health visit for the purpose of:

 

 
A)
contraception, including all FDA-approved birth control methods, devices such as
insertion/removal of an intrauterine device (IUD)or insertion/removal of
contraceptive implants, and injection procedures involving Pharmaceuticals such
as Depo-Provera;

 
B) emergency contraception and follow up;
 
C) sterilization;
 

 
D)
screening, related diagnosis, and referral to a Participating Provider for
pregnancy;

 

 
E)
medically-necessary induced abortions, which are procedures, either medical or
surgical, that result in the termination of pregnancy. The determination of
medical necessity shall include positive evidence of pregnancy, with an estimate
of its duration.

 

 
ii)
Family Planning and Reproductive Health Services include those education and
counseling services necessary to render the services effective.

 

 
iii)
Family Planning and Reproductive Health Services include medically-necessary
ordered contraceptives and pharmaceuticals:

 

 
A)
The Contractor is responsible for pharmaceuticals and medical supplies such as
IUDS and Depo-Provera that must be furnished or administered under the
supervision of a physician, licensed midwife, or certified nurse practitioner
during the course of a Family Planning and Reproductive Health visit and for
those prescription drugs included in the Contractor's Medicare Part D
Prescription Drug Benefit. Over the counter drugs are not the responsibility of

 
 

Medicaid Advantage Contract
APPENDIX C
New York City 2006
C-2
 

the Contractor and are to be obtained when covered on the New York State list of
Medicaid reimbursable drugs by the Enrollee from any appropriate eMedNY-enrolled
health care provider of the Enrollee's choice.
 

 
b)
When clinically indicated, the following services may be provided as a part of a
Family Planning and Reproductive Health visit:

 

 
i)
Screening, related diagnosis, ambulatory treatment and referral as needed for
dysmenorrhea, cervical cancer, or other pelvic abnormality/pathology.

 

 
ii)
Screening, related diagnosis and referral for anemia, cervical cancer,
glycosuria, proteinuria, hypertension and breast disease.
 

 
iii)
Screening and treatment for sexually transmissible disease.

iv) HIV blood testing and pre- and post-test counseling.

2. Free Access to Services for Enrollees
 

 
a)
Free Access means Enrollees may obtain Family Planning and Reproductive Health
Services, and HIV blood testing and pre-and post-test counseling when performed
as part of a Family Planning and Reproductive Health encounter, from either the
Contractor, if it provides such services in its Medicare Advantage Benefit
Package, or from any appropriate eMedNY-enrolled health care provider of the
Enrollee's choice. No referral from the PCP or approval by the Contractor is
required to access such services.

 

 
b)
The Family Planning and Reproductive Health Services listed above are the only
services which are covered under the Free Access policy. Routine obstetric
and/or gynecologic care, including hysterectomies, pre-natal, delivery and
post-partum care are not covered under the Free Access policy, and are the
responsibility of the Contractor.

Medicaid Advantage Contract APPENDIX C
New York City 2006
C-3
 
 
C.2
 
Requirements for MCOs that Provide Family Planning and Reproductive Health
Services
 
1. Notification to Enrollees
 
a)  If the Contractor provides Family Planning and Reproductive Health Services,
the Contractor must notify all Enrollees of reproductive age at the time of
Enrollment about their right to obtain Family Planning and Reproductive Health
Services and supplies without referral or approval. The notification must
contain the following:
 
i) Information about the Enrollee's right to obtain the full range of Family
Planning and Reproductive Health Services, including HIV counseling and testing
when performed as part of a Family Planning and Reproductive Health encounter,
from the Contractor's Participating Provider without referral, approval or
notification.
 
ii) Enrollees must receive notification that they also have the right to obtain
Family Planning and Reproductive Health Services in accordance with the Medicaid
Free Access policy as defined in C.I of this Appendix.
 
iii) A current list of qualified Participating Family Planning Providers who
provide the full range of Family Planning and Reproductive Health Services
within the Enrollee's geographic area, including addresses and telephone
numbers. The Contractor may also provide Enrollees with a list of qualified
Non-Participating providers who accept Medicaid and who provide the full range
of these services.
 
iv) Information that the cost of the Enrollee's Family Planning and Reproductive
care will be fully covered, including when an Enrollee obtains such services in
accordance with the Medicaid Free Access policy.
 
2. Billing Policy
 

 
a)
The Contractor must notify its Participating Providers that all claims for
Family Planning and Reproductive Health Services must be billed to the
Contractor and not the Medicaid fee-for-service program.

 
b)  Non-Participating Providers will bill Medicaid fee-for-service.
 

Medicaid Advantage Contract
APPENDIX C
New York City 2006
C-4
 

3. Consent and Confidentiality
 
a) The Contractor will comply with federal, state, and local laws, regulations
and policies regarding informed consent and confidentiality and ensure
Participating Providers comply with all of the requirements set forth in
Sections 17 and 18 of the PHL and 10 NYCRR Section 751.9 and Part 753 relating
to informed consent and confidentiality.
 
b) Participating Providers may share patient information with appropriate
Contractor personnel for the purposes of claims payment, utilization review and
quality assurance, unless the provider agreement with the Contractor provides
otherwise. The Contractor must ensure that an Enrollee's use of Family Planning
and Reproductive Health Services remains confidential and is not disclosed to
family members or other unauthorized parties, without the Enrollee's consent to
the disclosure.
 
4. Informing and Standards
 
a) The Contractor will inform its Participating Providers and administrative
personnel about policies concerning Free Access as defined in C. 1 of this
Appendix, where applicable; HIV counseling and testing; reimbursement for Family
Planning and Reproductive Health encounters; Enrollee Family Planning and
Reproductive Health education and confidentiality.
 
b) The Contractor will inform its Participating Providers that they must comply
with professional medical standards of practice, the Contractor's practice
guidelines, and all applicable federal, state, and local laws. These include but
are not limited to, standards established by the American College of
Obstetricians and Gynecologists, the American Academy of Family Physicians, the
U.S. Task Force on Preventive Services and the New York State Child/Teen Health
Program. These standards and laws recognize that Family Planning counseling is
an integral part of primary and preventive care.

Medicaid Advantage Contract
APPENDIX C
New York City 2006
C-5

C.3
 
Requirements for MCOs That Do Not Provide Family Planning and Reproductive
Health Services
 
1. Requirements
 

 
a)
The Contractor agrees to comply with the policies and procedures stated in the
SDOH-approved statement described in Section 2 below.

 

 
b)
Within ninety (90) days of signing this Agreement, the Contractor shall submit
to the SDOH a policy and procedure statement that the Contractor will use to
ensure that its Enrollees are fully informed of their rights to access a full
range of Family Planning and Reproductive Health Services, using the following
guidelines. The statement must be sent to the Director, Office of Managed Care,
NYS Department of Health, Corning Tower, Room 2001, Albany, NY 12237.

 

 
c)
SDOH may waive the requirement in (b) above if such approved statement is
already on file with SDOH and remains unchanged.

 
2. Policy and Procedure Statement
 

 
a)
The policy and procedure statement regarding Family Planning and Reproductive
Health Services must contain the following:

 
i) Enrollee Notification
 

 
A)
A statement that the Contractor will inform Prospective Enrollees, new Enrollees
and current Enrollees that:

 

 
I)
Certain Family Planning and Reproductive Health Services (such as abortion,
sterilization and birth control) are not covered by the Contractor, but that
routine obstetric and/or gynecologic care, including hysterectomies, pre-natal,
delivery and post-partum care are covered by the Contractor;

 

 
II)
Such Family Planning and Reproductive Health Services that are not covered by
the Contractor may be obtained through fee-for-service Medicaid providers for
Medicaid Advantage Enrollees;

 

 
III)
No referral is needed for such services, and there will be no cost to the
Enrollee for such services;

 

Medicaid Advantage Contract
APPENDIX C
New York City 2006
C-6
 

 
IV)
HIV counseling and testing services are available through the Contractor and are
also available as part of a Family Planning and Reproductive Health encounter
when furnished by a fee-for-service Medicaid provider to Medicaid Advantage
Enrollees; and that anonymous counseling and testing services are available from
SDOH, Local Public Health Agency clinics and other New York City or county
programs.

 

 
B)
A statement that this information will be provided in the following manner:

 

 
I)
Through the Contractor's written Marketing materials, including the Member
Handbook. The Member Handbook and Marketing materials will indicate that the
Contractor has elected not to cover certain Family Planning and Reproductive
Health Services, and will explain the right of all Medicaid Advantage Enrollees
to secure such services through fee-for-service Medicaid from any
provider/clinic which offers these services and who accepts Medicaid.

 

 
II)
Orally at the time of Enrollment and any time an inquiry is made regarding
Family Planning and Reproductive Health Services.

 

 
III)
By inclusion on any web site of the Contractor which includes information
concerning its Medicaid Advantage product. Such information shall be prominently
displayed and easily navigated.

 

 
C)
A description of the mechanisms to provide all new Medicaid Advantage Enrollees
with an SDOH approved letter explaining how to access Family Planning and
Reproductive Health Services and the SDOH approved list of Family Planning
providers. This material will be furnished by SDOH and mailed to the Enrollee no
later than fourteen (14) days after the Effective Date of Enrollment.

 

 
D)
A statement that if an Enrollee or Prospective Enrollee requests information
about these non-covered services, the Contractor's Marketing or Enrollment
representative or member services department will advise the Enrollee or
Prospective Enrollee as follows:

 

 
I)
Family Planning and Reproductive Health Services such as abortion, sterilization
and birth control are not covered by the Contractor and that only routine
obstetric and/or gynecologic care, including hysterectomies, pre-natal, delivery
and post-partum care are the responsibility of the Contractor.

 

 
II)
Medicaid Advantage Enrollees can use their Medicaid card to receive these
non-covered services from any doctor or clinic that provides these services and
accepts Medicaid.

Medicaid Advantage Contract
APPENDIX C
New York City 2006
C-7

 
III)
Each Medicaid Advantage Enrollee and Prospective Enrollee who calls will be
mailed a copy of the SDOH approved letter explaining the Enrollee's right to
receive these non-covered services, and an SDOH approved list of Family Planning
Providers who participate in Medicaid in the Enrollee's community. These
materials will be mailed within two (2) business days of the contact.

 

 
IV)
Enrollees can call the Contractor's member services number for further
information about how to obtain these non-covered services. Medicaid Advantage
Enrollees can also call the New York State Growing-Up-Healthy Hotline
(1-800-522-5006) to request a copy of the list of Medicaid Family Planning
Providers.

 

 
E)
The procedure for maintaining a manual log of all requests for such information,
including the date of the call, the Enrollee's client identification number
(CIN), and the date the SDOH approved letter and SDOH or DOHMH approved list
were mailed, where applicable. The Contractor will review this log monthly and
upon request, submit a copy to SDOH.

 
ii) Participating Provider and Employee Notification
 

 
A)
A statement that the Contractor will inform its Participating Providers and
administrative personnel about Family Planning and Reproductive Health policies
under Medicaid Advantage Free Access, as defined in C.I of this Appendix, HIV
counseling and testing; reimbursement for Family Planning and Reproductive
Health encounters; Enrollee Family Planning and Reproductive Health education
and confidentiality.

 

 
B)
A statement that the Contractor will inform its Participating Providers that
they must comply with professional medical standards of practice, the
Contractor's practice guidelines, and all applicable federal, state, and local
laws. These include but are not limited to, standards established by the
American College of Obstetricians and Gynecologists, the American Academy of
Family Physicians, the U.S. Task Force on Preventive Services. These standards
and laws recognize that Family Planning counseling is an integral part of
primary and preventive care.

 

 
C)
The procedure(s) for informing the Contractor's Participating primary care
providers, family practice physicians, obstetricians, and gynecologists that the
Contractor has elected not to cover certain Family Planning and Reproductive
Health Services, but that routine obstetric and/or gynecologic care, including
hysterectomies, pre-natal, delivery and post-partum care are covered; and that
Participating Providers may provide, make referrals, or arrange for non-covered
services in accordance with Medicaid Advantage Free Access policy, as defined in
C.I of this Appendix.

 

Medicaid Advantage Contract
APPENDIX C
New York City 2006
C-8

 
D)
A description of the mechanisms to inform the Contractor's Participating
Providers that:

 

 
I)
if they also participate in the fee-for-service Medicaid program and they render
non-covered Family Planning and Reproductive Health Services to Medicaid
Advantage Enrollees, they do so as a fee-for-service Medicaid practitioner,
independent of the Contractor.

 

 
E)
A description of the mechanisms to inform Participating Providers that, if
requested by the Enrollee, or, if in the provider's best professional judgment,
certain Family Planning and Reproductive Health Services not offered through the
Contractor are medically indicated in accordance with generally accepted
standards of professional practice, an appropriately trained professional should
so advise the Enrollee and either:

 

 
I)
offer those services to Medicaid Advantage Enrollees on a fee-for-service basis
as an eMedNY-enrolled provider, or

 

 
II)
provide Medicaid Advantage Enrollees with a copy of the SDOH approved list of
Medicaid Family Planning Providers, or

 

 
III)
give Enrollees the Contractor's member services number to call to obtain the
list of Medicaid Family Planning Providers.

 

 
F)
A statement that the Contractor acknowledges that the exchange of medical
information, when indicated in accordance with generally accepted standards of
professional practice, is necessary for the overall coordination of Enrollees'
care and assist Primary Care Providers in providing the highest quality care to
the Contractor's Enrollees. The Contractor must also acknowledge that medical
record information maintained by Participating Providers may include information
relating to Family Planning and Reproductive Health Services provided under the
fee-for-service Medicaid program.

 
iii) Quality Assurance Initiatives
 

 
A)
A statement that the Contractor will submit any materials to be furnished to
Enrollees and providers relating to access to non-covered Family Planning and
Reproductive Health Services to SDOH, Office of Managed Care for its review and
approval before issuance. Such materials include, but are not limited to, Member
Handbooks, provider manuals, and Marketing materials.

 

 
B)
A description of monitoring mechanisms the Contractor will use to assess the
quality of the information provided to Enrollees.

 

 

Medicaid Advantage Contract
APPENDIX C
New York City 2006
C-9
 

 
C)
A statement that the Contractor will prepare a monthly list of Medicaid
Advantage Enrollees who have been sent a copy of the SDOH approved letter and
the SDOH approved list of Family Planning providers. This information will be
available to SDOH upon request.

 

 
D)
A statement that the Contractor will provide all new employees with a copy of
these policies. A statement that the Contractor's orientation programs will
include a thorough discussion of all aspects of these policies and procedures
and that annual retraining programs for all employees will be conducted to
ensure continuing compliance with these policies.

 
3. Consent and Confidentiality
 
a) The Contractor must comply with federal, state, and local laws, regulations
and policies regarding informed consent and confidentiality and ensure that
Participating Providers comply with all of the requirements set forth in
Sections 17 and 18 of the PHL and 10 NYCRR § 751.9 and Part 753 relating to
informed consent and confidentiality.
 
b) Participating Providers may share patient information with appropriate
Contractor personnel for the purposes of claims payment, utilization review and
quality assurance, unless the provider agreement with the Contractor provides
otherwise. The Contractor must ensure that an Enrollee's use of Family Planning
and Reproductive Health Services remains confidential and is not disclosed to
family members or other unauthorized parties, without the Enrollee's consent to
disclosure.

Medicaid Advantage Contract
APPENDIX C
New York City 2006
C-10
 

--------------------------------------------------------------------------------

Appendix D

New York State Department of Health
Medicaid Advantage Marketing Guidelines

 

Medicaid Advantage Contract
APPENDIX D
New York City 2006
D-l
 

MEDICAID ADVANTAGE MARKETING GUIDELINES
 
I. Purpose
 
The purpose of these guidelines is to provide an operational framework for the
Medicaid managed care organizations (MCOs) in the development of marketing
materials and the conduct of marketing activities for the Medicaid Advantage
Program. The marketing guidelines set forth in this Appendix do not replace the
CMS marketing requirements for Medicare Advantage Plans; they supplement them.
 
II. Marketing Materials
 
A. Definitions
 

 
1.
Marketing materials generally include the concepts of advertising, public
service announcements, printed publications, and other broadcast or electronic
messages designed to increase awareness and interest in a Contractor's Medicaid
Advantage product. The target audience for these marketing materials is Eligible
Persons as defined in Section 5.1 of this Agreement living in the defined
service area.

 

 
2.
For purposes of this Agreement, marketing materials include any information that
references the Contractor's Medicaid Advantage Product and which is intended for
distribution to Dual Eligibles, and is produced in a variety of print,
broadcast, and direct marketing mediums. These generally include: radio,
television, billboards, newspapers, leaflets, informational brochures, videos,
telephone book yellow page ads, letters, and posters. Additional materials
requiring marketing approval include a listing of items to be provided as
nominal gifts or incentives.

 
B. Marketing Material Requirements
 
In addition to meeting CMS' Medicare Advantage marketing requirements and
guidance on marketing to individuals entitled to Medicare and Medicaid:
 

 
1.
Medicaid Advantage marketing materials must be written in prose that is
understood at a fourth-to sixth-grade reading level except when the Contractor
is using language required by CMS, and must be printed in at least twelve (12)
point font.

 

 
2.
The Contractor must make available written marketing and other informational
materials (e.g., member handbooks) in a language other than English whenever at
least five percent (5%) of the Prospective Enrollees of the Contractor in any
county of the service area speak that particular language and do not speak
English as a first language. SDOH will inform the DOHMH and the DOHMH will
inform the Contractor when the 5% threshold has been reached. Marketing
materials to

Medicaid Advantage Contract
APPENDIX D
New York City 2006
D-2
 

be translated include those key materials, such as informational brochures, that
are produced for routine distribution, and which are included within the MCO's
marketing plan. SDOH will determine the need for other than English translations
based on county specific census data or other available measures.
 

 
3.
The Contractor shall advise potential Enrollees, in written materials related to
enrollment, to verify with the medical services providers they prefer, or have
an existing relationship with, that such medical services providers participate
in the selected managed care provider's network and are available to serve the
participant.

 
C. Prior Approvals
 

 
1.
The CMS and SDOH will jointly review and approve Medicaid Advantage marketing
videos, materials for broadcast (radio, television, or electronic), billboards,
mass transit (bus, subway or other livery) and statewide/regional print
advertising materials in accordance with CMS timeframes for review of marketing
materials. These materials must be submitted to the CMS Regional Office for
review. CMS will coordinate SDOH input in the review process just as SDOH will
coordinate DOHMH input in the review process.

 

 
2.
CMS and SDOH will jointly review and approve the following Medicaid Advantage
marketing materials:

 
a. Scripts or outlines of presentations and materials used at health fairs and
other approved types of events and locations;
 
b. All pre-enrollment written marketing materials - written marketing materials
include brochures and leaflets, and presentation materials used by marketing
representatives;
 
c. All direct mailing from the Contractor specifically targeted to the Medicaid
market.
 

 
3.
The Contractor shall electronically submit all materials related to marketing
Medicaid Advantage to Dually Eligible persons to the CMS Regional Office for
prior written approval. The CMS Medicare Regional Office Plan Manager will be
responsible for obtaining SDOH input in the review and approval process in
accordance with CMS timeframes for the review of marketing materials. Similarly,
SDOH will be responsible for obtaining DOHMH input in the review and approval
process.

 

 
4.
The Contractor shall not distribute or use any Medicaid Advantage marketing
materials that the CMS Regional Office and the SDOH have not jointly approved,
prior to the expiration of the required review period.

 
Medicaid Advantage Contract
APPENDIX D
New York City 2006
D-3
 

 
5.
Approved marketing materials shall be kept on file in the offices of the
Contractor, the'DOHMH, the SDOH, and CMS.

 
D. Dissemination of Outreach Materials to LDSS
 

 
1.
Upon request, the Contractor shall provide to the LDSS and/or Enrollment Broker,
sufficient quantities of approved Marketing materials or alternative
informational materials that describe coverage in the LDSS jurisdiction.

 

 
2.
The Contractor shall, upon request, submit to the LDSS or Enrollment Broker, a
current provider directory, together with information that describes how to
determine whether a provider is presently available.

 
III. Marketing Activities
 
A. General Requirements
 

 
1.
The Contractor must follow the State's Medicaid marketing rules and the
requirements of 42 CFR 438.104 to the extent applicable when conducting
marketing activities that are primarily intended to sell a Medicaid managed care
product (i.e., Medicaid Advantage). Marketing activities intended to sell a
Medicaid managed care product shall be defined as activities which are conducted
pursuant to a Medicaid Advantage marketing program in which a dedicated staff of
marketing representatives employed by the Contractor, or by an entity with which
the Contractor has subcontracted, are engaged in marketing activities with the
primary purpose of enrolling recipients in the Contractor's Medicaid Advantage
product.

 

 
2.
Marketing activities that do not meet the above criteria shall not be construed
as having a primary purpose of intending to sell a Medicaid managed care product
and shall be conducted in accordance with Medicare Advantage marketing
requirements. Such activities include but are not limited to plan sponsored
events in which marketing representatives not dedicated to the marketing of the
Medicaid Advantage product explain Medicare products offered by the Contractor
as well as the Contractor's Medicaid Advantage product.

 
B. Marketing at LDSS Offices
 
With prior LDSS approval, MCOs may distribute CMS/SDOH approved Medicaid
Advantage marketing materials in the local social services district offices and
facilities.

Medicaid Advantage Contract APPENDIX D
New York City 2006
D-4
 

C. Responsibility for Marketing Representatives
 
Individuals employed by the Contractor as marketing representatives and
employees of marketing subcontractors must have successfully completed the
Contractor's training program including training related to an Enrollee's rights
and responsibilities in Medicaid Advantage. The Contractor shall be responsible
for the activities of its marketing representatives and the activities of any
subcontractor or management entity.
 
D. Medicaid Advantage Specific Marketing Requirements
 
The requirements in Section D apply only if marketing activities for the
Medicaid Advantage Program are conducted pursuant to a Medicaid Advantage
marketing program in which a dedicated staff of marketing representatives
employed by the Contractor or by an entity with which the Contractor has a
subcontract are engaged in marketing activities with the sole purpose of
enrolling recipients in the Contractor's Medicaid Advantage product.
 
1. Approved Marketing Plan
 

 
a.
The Contractor must submit a plan of Medicaid Advantage Marketing activities
that meet the SDOH requirements to the SDOH.

 

 
b.
The SDOH, in consultation with DOHMH, is responsible for the review and approval
of Medicaid Advantage marketing plans, using a SDOH and CMS approved checklist.

 

 
c.
Approved marketing plans will set forth the terms and conditions and proposed
activities of the Medicaid Advantage dedicated staff during the contract period.
The following must be included: description of materials to be used,
distribution methods; primary types of marketing locations and a listing of the
kinds of community service events the Contractor anticipates sponsoring and/or
participating in during which it will provide information and/or distribute
Medicaid Advantage marketing materials.

 

 
d.
An approved marketing plan must be on file with the SDOH and the DOHMH prior to
the Contractor engaging in the Medicaid Advantage specific Marketing activities.

 

 
e.
The plan shall include stated marketing goal and strategies. Marketing
activities, and the training, development and responsibilities of dedicated
marketing staff.

 

 
f.
The Contractor must describe how it is able to meet the informational needs
related to marketing for the physical and cultural diversity of its potential
membership. This may include, but not be limited to, a description of the

 

Medicaid Advantage Contract
APPENDIX D
New York City 2006
D-5
 

Contractor's other than English language provisions, interpreter services,
alternate communication mechanisms including sign language, Braille, audio
tapes, and/or use of Telecommunications Devices for the Deaf (TTY) services.
 

 
g.
The Contractor shall describe measures for monitoring and enforcing compliance
with these guidelines by its Marketing representatives including the prohibition
of door to door solicitation and cold-call telephoning; a description of the
development of pre-enrollee mailing lists that maintains client confidentiality
and honors the client's express request for direct contact by the Contractor;
the selection and distribution of pre-enrollment gifts and incentives to
prospective enrollees; and a description of the training, compensation and
supervision of its Medicaid Advantage dedicated marketing representatives.

 
2. Compensation for Dedicated Medicaid Advantage Marketing Staff
 
The Contractor shall not offer compensation to Medicaid Advantage dedicated
Marketing Representatives, including salary increases or bonuses, based solely
on the number of individuals they enroll in Medicaid Advantage. However, the
Contractor may base compensation of these Marketing Representatives on periodic
performance evaluations which consider enrollment productivity as one of several
performance factors during a performance period, subject to the following
requirements:
 

 
a.
"Compensation" shall mean any remuneration required to be reported as income or
compensation for federal tax purposes;

 

 
b.
The Contractor may not pay a "commission" or fixed amount per enrollment;

 

 
c.
The Contractor may not award bonuses more frequently than quarterly, or for an
annual amount that exceeds ten percent (10%) of his/her total annual
compensation;

 

 
d.
The Contractor shall keep written documentation, including performance
evaluations or other tools it uses as a basis for awarding bonuses or increasing
the salary of Marketing Representatives and employees involved in Marketing and
make such documentation available for inspection by SDOH or the DOHMH;

 
3. Prohibition of Cold Call Marketing Activities
 
Contractors are prohibited from directly or indirectly, engaging in door to
door, telephone, or other cold-call marketing activities.

Medicaid Advantage Contract
APPENDIX D
New York City 2006
D-6
 

4. Marketing in Emergency Rooms or Other Patient Care Areas
 
Contractors may not distribute materials or assist prospective Enrollees in
completing Medicaid Advantage application forms in hospital emergency rooms, in
provider offices, or other areas where health care is delivered unless requested
by the individual.
 
5. Enrollment Incentives
 
Contractors may not offer incentives of any kind to Medicaid recipients to join
Medicaid Advantage. Incentives are defined as any type of inducement whose
receipt is contingent upon the recipients joining the Contractor's Medicaid
Advantage product.
 
E. General Marketing Restrictions
 
The following restrictions apply anytime the Contractor markets its Medicaid
Advantage product:
 

 
1.
Contractors are prohibited from misrepresenting the Medicaid program, the
Medicaid Advantage Program or the policy requirements of the LDSS or SDOH.

 

 
2.
Contractors are prohibited from purchasing or otherwise acquiring or using
mailing lists that specifically identify Medicaid recipients from third party
vendors, including providers and LDSS offices, unless otherwise permitted by
CMS. The Contractor may produce materials and cover their costs of mailing to
Medicaid recipients if the mailing is carried out by the State or LDSS, without
sharing specific Medicaid information with the Contractor.

 

 
3.
Contractors may not discriminate against a potential Enrollee based on his/her
current health status or anticipated need for future health care. The Contractor
may not discriminate on the basis of disability or perceived disability of any
Enrollee or their family member. Health assessments may not be performed by the
Contractor prior to enrollment. The Contractor may inquire about existing
primary care relationships of the applicant and explain whether and how such
relationships may be maintained. Upon request, each potential Enrollee shall be
provided with a listing of all participating providers and facilities in the
MCO's network. The Contractor may respond to a potential Enrollee's question
about whether a particular specialist is in the network. However, the contractor
is prohibited from inquiring about the types of specialists utilized by the
potential Enrollee.

 

 
4.
Contractors may not require participating providers to distribute plan prepared
communications to their patients, including communications which compare the
benefits of different health plans, unless the materials have the concurrence of
all

Medicaid Advantage Contract
APPENDIX D
New York City 2006
D-7
 

MCOs involved, and have received prior approval by SDOH, and by CMS, if Medicare
Advantage is referenced.
 

 
5.
Contractors are responsible for ensuring that their marketing representatives
engage in professional and courteous behavior in their interactions with LDSS
and DOHMH staff, staff from other health plans and Medicaid clients. Examples of
inappropriate behavior include interfering with other health plan presentations
or talking negatively about another health plan.

 
IV. Marketing Infractions
 
A. Infractions of Medicaid marketing guidelines, as found in Appendix D,
Sections III D and E, may result in the following actions being taken by the
SDOH, and/or the DOHMH to protect the interests of the program and its clients.
These actions shall be taken by the SDOH, and/or DOHMH in collaboration with the
CMS Regional Office.
 

 
1.
If the Contractor or its representative commits a first time infraction of
marketing guidelines and the SDOH and/or the DOHMH deems the infraction to be
minor or unintentional in nature, the SDOH and/or the DOHMH may issue a warning
letter to the Contractor.

 

 
2.
If the Contractor engages in Marketing activities that the SDOH and/or DOHMH
determines to be an intentional or serious breach of the Medicaid Advantage
Marketing Guidelines or the Contractor's approved Medicaid Advantage Marketing
Plan, or a pattern of minor breaches, SDOH and/or the DOHMH may require the
Contractor to and the Contractor shall prepare and implement a corrective action
plan acceptable to the SDOH and/or DOHMH within a specified timeframe. In
addition, or alternatively, SDOH and the DOHMH, in consultation with SDOH, may
impose sanctions, including monetary penalties, as permitted by law.

 

 
3.
If the Contractor commits further infractions, fails to pay monetary penalties
within the specified timeframe, fails to implement a corrective action plan in a
timely manner or commits an egregious first time infraction, the SDOH, or the
DOHMH in consultation with the SDOH, may in addition to any other legal remedy
available to the SDOH and/or DOHMH in law or equity:

 
a) direct the Contractor to suspend its Medicaid Advantage marketing activities
for a period up to the end of the Agreement period;
 
b) suspend new Medicaid Advantage Enrollments, for a period up to the remainder
of the Agreement period; or
 
c) terminate this Agreement pursuant to termination procedures described in
Section 2.7 of this Agreement.
 

 

Medicaid Advantage Contract APPENDIX D
New York City 2006
D-8
 

--------------------------------------------------------------------------------

Appendix E

New York State Department of Health
Medicaid Advantage
Model Member Handbook

Medicaid Advantage Contract
APPENDIX E
New York City 2006
E-l
 

Introduction
 
Managed care organizations (MCOs) under contract to provide a Medicaid Advantage
Product to Dually Eligible beneficiaries must provide Enrollees with a Medicaid
Advantage member handbook which is consistent with the current model Medicaid
Advantage member handbook provided by SDOH and approved by the CMS Regional
Office and the SDOH. This model handbook is to be issued by the Contractor to
Enrollees in addition to the handbook or Explanation of Coverage (EOC) required
by CMS for Medicare Advantage. The model member handbook may be revised based on
changes in the law and the changing needs of the program. Handbooks must be
approved by the CMS Regional Office and the SDOH prior to printing and
distribution by the Contractor.
 
General Format
 
Member handbooks must be written in a style and reading level that will
accommodate the reading skills of Medicaid recipients. In general the writing
should not exceed a fourth to sixth-grade reading level, taking into
consideration the need to incorporate and explain certain technical or
unfamiliar terms to assure accuracy. The text must be printed in at least twelve
(12) point font. The SDOH reserves the right to require evidence that a handbook
has been tested against the sixth-grade reading-level standard. Member handbooks
must be available in languages other than English whenever at least five percent
(5%) of the Prospective Enrollees in any county in the Contractor's service area
speak that particular language and do not speak English as a first language.
 
Model Medicaid Advantage Handbook
 
It will be the responsibility of the SDOH to provide a copy of the current model
Medicaid Advantage member handbook to the Contractor.

Medicaid Advantage Contract APPENDIX E
New York City 2006
E-2
 
 

--------------------------------------------------------------------------------

 
APPENDIX F

New York State Department of Health
Medicaid Advantage Action and Grievance System Requirements
 
F.I General Requirements
 
F.2 Medicaid Advantage Action Requirements
 
F.3 Medicaid Advantage Grievance System Requirements

Medicaid Advantage Contract
APPENDIX F
New York City 2006
F-l
 

F.I
General Requirements
 
1. Organization Determinations
 
a) Organization Determinations means any decision by or on behalf of a MCO
regarding payment or services to which an Enrollee believes he or she is
entitled. For the purposes of this Agreement, Organization Determinations are
synonymous with Action, as defined by this Appendix.
 
b) Organization Determinations regarding services determined by the Contractor
to be benefits covered solely by Medicare shall be conducted in accordance with
the procedures and requirements of 42 CFR Subpart M of Part 422, and the
Medicare Managed Care Manual.
 
c) Organization Determinations regarding services determined by the Contractor
to be benefits covered by Medicare and Medicaid shall be conducted in accordance
with the procedures and requirements of 42 CFR Subpart M of Part 422 and the
Medicare Managed Care Manual, except that:
i) the Contractor will determine whether services are Medically Necessary as
that
term is defined in this Agreement; and
ii) when the Contractor intends to reduce, suspend, or terminate a previously
authorized service within an authorization period, the notification provisions
of paragraph F.2(4)(a) of this Appendix shall apply.
 
d) Organization Determinations regarding services determined by the Contractor
to be solely covered by Medicaid shall be conducted in accordance with Appendix
F.I of this Agreement, and Articles 44 and 49 of the PHL, and 10 NYCRR Part 98,
not otherwise expressly established herein.
 
2. Notices, Action Appeals, Complaints and Complaint Appeals
 
a) Services determined by the Contractor to be benefits solely covered by
Medicare are subject to the Medicare Advantage Complaint and Appeals Process. In
these cases, the Contractor will follow such procedures to notify Enrollees, and
providers as applicable, regarding Organization Determinations and offer the
Enrollee Medicare appeal rights.
 
b) Services determined by the Contractor to be solely covered by Medicaid are
subject to the Medicaid Advantage Grievance System. In these cases, the
Contractor will follow such procedures to notify Enrollees and providers
regarding Organization Determinations and offer Action Appeal, Complaint, and
Complaint Appeals rights in accordance with Appendices F.2 and F.3 of this
Agreement and the requirements of Articles 44 and 49 of the PHL, and 10 NYCRR
Part 98, not otherwise expressly established herein.

Medicaid Advantage Contract
APPENDIX F
New York City 2006
F-2

c) For Organization Determinations regarding services determined by the
Contractor to be a benefit under both Medicare and Medicaid, the Contractor must
offer Enrollees the right to pursue either the Medicare appeal procedures or the
Medicaid Advantage Action Appeals, Complaint, and Complaint Appeals procedures.
 
i) As part of, or attached to, the appropriate Organization Determination
notice, the Contractor must provide Enrollees with a notice that informs the
Enrollee of his or her appeal rights under both the Medicare and Medicaid
Advantage programs, and of their right to select either the Medicare or Medicaid
Advantage appeals process, and instructions to make such selection. Such notice
shall inform the Enrollee that:
A) if he or she chooses to pursue the Medicare appeal procedures to challenge a
service denial, suspension, reduction, or termination, the Enrollee may not
pursue a Medicaid Advantage appeal and may not file a Fair Hearing request with
the state; and
B) if he or she chooses to pursue the Medicaid Advantage appeal procedures to
challenge a service denial, suspension, reduction, or termination, the Enrollee
has up to 60 days from the day of the Contractor's notice of denial of coverage
to pursue a Medicare appeal, regardless of the status of the Medicaid Advantage
appeal.
 
ii) The Contractor will enclose with the notice described in (i) above the
notice of Action and other attachments as may be required by Appendix F.2
(5)(a)(iii). However, the notice of Action need not duplicate information
provided in the Organization Determination notice it is attached to.
 
iii) If the Enrollee files an appeal, but fails to select either the Medicare or
Medicaid Advantage procedure, the default procedure will be the Medicaid
Advantage procedure.

Medicaid Advantage Contract
APPENDIX F
New York City 2006
F-3
 

F.2
 
Medicaid Advantage Action Requirements
 
1. Definitions
 
a) Service Authorization Request means a request by an Enrollee or a provider on
the Enrollee's behalf, to the Contractor for the provision of a service,
including a request for a referral or for a non-covered service.
 
i) Prior Authorization Request is a Service Authorization Request by the
Enrollee, or a provider on the Enrollee's behalf, for coverage of a new service,
whether for a new authorization period or within an existing authorization
period, before such service is provided to the Enrollee.
 
ii) Concurrent Review Request is a Service Authorization Request by an Enrollee,
or a provider on Enrollee's behalf, for continued, extended or more of an
authorized service than what is currently authorized by the Contractor.
 
b) Service Authorization Determination means the Contractor's approval or denial
of a Service Authorization Request.
 
c) Adverse Determination means a denial of a Service Authorization Request by
the Contractor on the basis that the requested service is not Medically
Necessary or an approval of a Service Authorization Request is in an amount,
duration, or scope that is less than requested.
 
d) An Action means an activity of a Contractor or its subcontractor that results
in:
 
i) the denial or limited authorization of a Service Authorization Request,
including the type or level of service;
 
ii) the reduction, suspension, or termination of a previously authorized
service;
 
iii)  the denial, in whole or in part, of payment for a service;
 
iv) failure to provide services in a timely manner as defined by applicable
State law and regulation and Section 15 of this Agreement; or
 
v) failure of the Contractor to act within the timeframes for resolution and
notification of determinations regarding Complaints, Action Appeals and
Complaint Appeals provided in this Appendix.

Medicaid Advantage Contract
APPENDIX F
New York City 2006
F-4

2. General Requirements

a) The Contractor's policies and procedures for Service Authorization
Determinations and utilization review determinations shall comply with 42 CFR
Part 438 and Article 49 of the PHL, including but not limited to the following:
 
i) Expedited review of a Service Authorization Request must be conducted when
the Contractor determines or the provider indicates that a delay would seriously
jeopardize the Enrollee's life or health or ability to attain, maintain, or
regain maximum function. The Enrollee may request expedited review of a Prior
Authorization Request or Concurrent Review Request. If the Contractor denies the
Enrollee's request for expedited review, the Contractor must handle the request
under standard review timeframes.
 
ii) Any determination to deny a Service Authorization Request or to authorize a
service in an amount, duration, or scope that is less than requested, must be
made by a licensed, certified, or registered health care professional. If such
Adverse Determination was based on medical necessity, the determination must be
made by a clinical peer reviewer as defined by PHL §4900(2)(a).
 
iii) The Contractor is required to provide notice by phone and in writing to the
Enrollee and to the provider of Service Authorization Determinations, whether
adverse or not, within the timeframe specified in Section 3 below. Notice to the
provider must contain the same information as the Notice of Action for the
Enrollee.
 
iv) The Contractor is required to provide the Enrollee written notice of any
Action other than a Service Authorization Determinations within the timeframe
specified in Section 4 below.
 
3. Timeframes for Service Authorization Determinations
 

 
a) For Prior Authorization Requests, the Contractor must make a Service
Authorization Determination and notice the Enrollee of the determination by
phone and in writing as fast as the Enrollee's condition requires and no more
than:
 
i) In the case of an expedited review, three (3) business days after receipt of
the Service Authorization Request; or
 
ii) In all other cases, within three (3) business days of receipt of necessary
information, but no more than fourteen (14) days after receipt of the Service
Authorization request.
 
b) For Concurrent Review Requests, the Contractor must make a Service
Authorization Determination and notice the Enrollee of the determination by
phone and in writing as fast as the Enrollee's condition requires and no more
than:

Medicaid Advantage Contract
APPENDIX F
New York City 2006
F-5
 

 
i)
In the case of an expedited review, one (1) business day after receipt of
necessary information but no more than three (3) business days after receipt of
the Service Authorization Request; or

 

 
ii)
In all other cases, within one (1) business day of receipt of necessary
information, but no more than fourteen (14) days after receipt of the Service
Authorization Request.

 
c) Timeframes for Service Authorization Determinations may be extended for up to
fourteen (14) days if:
 
i) the Enrollee, the Enrollee's designee, or the Enrollee's provider requests an
extension orally or in writing; or
 
ii) The Contractor can demonstrate or substantiate that there is a need for
additional information and how the extension is in the Enrollee's interest. The
Contractor must send notice of the extension to the Enrollee. The Contractor
must maintain sufficient documentation of extension determinations to
demonstrate, upon SDOH's request, that the extension was justified.
 
d) If the Contractor extended its review as provided in paragraph 3(c) above,
the Contractor must make a Service Authorization Determination and notice the
Enrollee by phone and in writing as fast as the Enrollee's condition requires
and within three (3) business days after receipt of necessary information for
Prior Authorization Requests or within one (1) business day after receipt of
necessary information for Concurrent Review Requests, but in no event later than
the date the extension expires.
 

 
4.
Timeframes for Notices of Actions Other Than Service Authorizations
Determinations

 

 
a)
When the Contractor intends to reduce, suspend, or terminate a previously
authorized service within an authorization period, it must provide the Enrollee
with a written notice at least ten (10) days prior to the intended Action,
except:

i) the period of advance notice is shortened to five (5) days in cases of
confirmed
Enrollee fraud; or
ii) the Contractor may mail notice not later than date of the Action for the
following:
A) the death of the Enrollee;

 
B)
a signed written statement from the Enrollee requesting service termination or
giving information requiring termination or reduction of services (where the
Enrollee understands that this must be the result of supplying the information);

 
C)
the Enrollee's admission to an institution where the Enrollee is ineligible for
further services;

 
D)
the Enrollee's address is unknown and mail directed to the Enrollee is returned
stating that there is no forwarding address;

Medicaid Advantage Contract
APPENDIX F
New York City 2006
F-6
 

 
E)
the Enrollee has been accepted for Medicaid services by another jurisdiction;

or
F) the Enrollee's physician prescribes a change in the level of medical care.
 
b) The Contractor must mail written notice to the Enrollee on the date of the
Action when the Action is denial of payment, in whole or in part, except as
provided in paragraph F.2 6(b) below.
 
c) When the Contractor does not reach a determination within the Service
Authorization Determination timeframes described above, it is considered an
Adverse Determination, and the Contractor must send notice of Action to the
Enrollee on the date the timeframes expire.
 
5. Format and Content of Notices
 
a) The Contractor shall ensure that all notices are in writing, in easily
understood language and are accessible to non-English speaking and visually
impaired Enrollees. Notices shall include that oral interpretation and alternate
formats of written material for Enrollees with special needs are available and
how to access the alternate formats.
 
i)  Notice to the Enrollee that the Enrollee's request for an expedited review
has been denied shall include that the request will be reviewed under standard
timeframes, including a description of the timeframes.
 
ii) Notice to the Enrollee regarding a Contractor-initiated extension shall
include:
A) the reason for the extension;
B) an explanation of how the delay is in the best interest of the Enrollee;
C) any additional information the Contractor requires from any source to make
its determination;
D) the revised date by which the MCO will make its determination;
E) the right of the Enrollee to file a Complaint (as defined in Appendix F.3
ofthis Agreement)regarding the extension;
F) the process for filing a Complaint with the Contractor and the timeframes
within which a Complaint determination must be made;
G) the right of an Enrollee to designate a representative to file a Complaint on
behalf of the Enrollee; and
H) the right of the Enrollee to contact the New York State Department of Health
regarding his or her Complaint, including the SDOH's toll-free number for
Complaints.
 
iii) Notice to the Enrollee of an Action shall include:
A) the description of the Action the Contractor has taken or intends to take;
B) the reasons for the Action, including the clinical rationale, if any;
C) the Enrollee's right to file an Action Appeal (as defined in Appendix F.3 of
this Agreement), including:

Medicaid Advantage Contract
APPENDIX F
New York City 2006
F-7
 

 
I)
The fact that the Contractor will not retaliate or take any discriminatory
action against the Enrollee because he/she filed an Action Appeal.

II)  The right of the Enrollee to designate a representative to file Action
Appeals on his/her behalf;
D) the process and timeframe for filing an Action Appeal with the Contractor,
including an explanation that an expedited review of the Action Appeal can be
requested if a delay would significantly increase the risk to an Enrollee's
health, a toll-free number for filing an oral Action Appeal and a form, if used
by the Contractor, for filing a written Action Appeal;
E) a description of what additional information, if any, must be obtained by the
Contractor from any source in order for the Contractor to make an Appeal
determination;
F) the timeframes within which the Action Appeal determination must be made;
G) the right of the Enrollee to contact the New York State Department of Health
with his or her Complaint, including the SDOH's toll-free number for Complaints;
and
H) the notice entitled "Managed Care Action Taken" for denial of benefits or for
termination or reduction in benefits, as applicable, containing the Enrollee's
fair hearing and aid continuing rights.
I) For Actions based on issues of Medical Necessity or an experimental or
investigational treatment, the notice of Action shall also include:

 
I)
a clear statement that the notice constitutes the initial adverse determination
and specific use of the terms "medical necessity" or
"experimental/investigational;"

 
II)
a statement that the specific clinical review criteria relied upon in making the
determination is available upon request; and

 
III)
a statement that the Enrollee may be eligible for, and timeframes for filing an
External Appeal, including that if so eligible, the Enrollee may request an
External Appeal after first filing an expedited Action Appeal with the
Contractor and receiving notice that the Contractor upholds its adverse
determination, or after filing standard Action Appeal with the Contractor and
receiving the Contractor's final adverse determination, or after the Contractor
and the Enrollee agree to waive the internal Action Appeal process.

 
6. Contractor Obligation to Notice
 
a) The Contractor must provide written Notice of Action to Enrollees and
providers in accordance with the requirements of this Appendix, including, but
not limited to, the following circumstances (except as provided for in paragraph
6(b) below):
 
i) the Contractor makes a coverage determination or denies a request for a
referral, regardless of whether the Enrollee has received the benefit;
 
ii) the Contractor determines that a service does not have appropriate
authorization;

Medicaid Advantage Contract
APPENDIX F
New York City 2006
F-8
 

 
iii)
the Contractor denies a claim for services provided by a Non-Participating
Provider for any reason;

 
iv) the Contractor denies a claim or service due to medical necessity;
 
v) the Contractor rejects a claim or denies payment due to a late claim
submission;
 

 
vi)
the Contractor denies a claim because it has determined that the Enrollee was
not eligible for Medicaid Advantage coverage on the date of service;

 

 
vii)
the Contractor denies a claim for service rendered by a Participating Provider
due to lack of a referral;

 
viii) the Contractor denies a claim because it has determined it is not the
appropriate payor; or
 

 
ix)
the Contractor denies a claim due to a Participating Provider billing for
Benefit Package services not included in the Provider Agreement between the
Contractor and the Participating Provider.

 
b) The Contractor is not required to provide written Notice of Action to
Enrollees in the following circumstances:
 

 
i)
When there is a prepaid capitation arrangement with a Participating Provider and
the Participating Provider submits a fee-for-service claim to the Contractor for
a service that falls within the capitation payment;

 

 
ii)
if a Participating Provider of the Contractor itemizes or "unbundles" a claim
for services encompassed by a previously negotiated global fee arrangement;

 

 
iii)
if a duplicate claim is submitted by the Enrollee or a Participating Provider,
no notice is required, provided an initial notice has been issued;

 

 
iv)
if the claim is for a service that is carved-out of the Benefit Package and is
provided to an Enrollee through Medicaid fee-for-service, however, the
Contractor should notify the provider to submit the claim to Medicaid;

 

 
v)
if the Contractor makes a coding adjustment to a claim (up-coding or
down-coding) and its Provider Agreement with the Participating Provider includes
a provision allowing the Contractor to make such adjustments;

 

 
vi)
if the Contractor has paid the negotiated amount reflected in the Provider
Agreement with a Participating Provider for the services provided to the
Enrollee and denies the Participating Provider's request for additional payment;
or

Medicaid Advantage Contract 
APPENDIX F
New York City 2006
F-9
 

 
vii)
if the Contractor has not yet adjudicated the claim. If the Contractor has
pended the claim while requesting additional information, a notice is not
required until the coverage determination has been made.

Medicaid Advantage Contract
APPENDIX F
New York City 2006
F-10

F.3
 
Medicaid Advantage Grievance System Requirements
 
1. Definitions
 
a) A Grievance System means the Contractor's Medicaid Advantage Complaint and
Appeal process, and includes a Complaint and Complaint Appeal process, a process
to appeal Actions, and access to the State's fair hearing system.
 
b) For the purposes of this Agreement, a Complaint means an Enrollee's
expression of dissatisfaction with any aspect of his or her care other than an
Action. A "Complaint" means the same as a "grievance" as defined by 42 CFR
§438.400 (b).
 
c) An Action Appeal means a request for a review of an Action.
 
d) A Complaint Appeal means a request for a review of a Complaint determination.
 
e) An Inquiry means a written or verbal question or request for information
posed to the Contractor with regard to such issues as benefits, contracts, and
organization rules. Neither Enrollee Complaints nor disagreements with
Contractor determinations are Inquiries.
 
2. Grievance System - General Requirements
 
a) The Contractor shall describe its Grievance System in the Member Handbook,
and it must be accessible to non-English speaking, visually, and hearing
impaired Enrollees. The handbook shall comply with The Member Handbook
Guidelines (Appendix E) of this Agreement.
 
b) The Contractor will provide Enrollees with any reasonable assistance in
completing forms and other procedural steps for filing a Complaint, Complaint
Appeal or Action Appeal, including, but not limited to, providing interpreter
services and toll-free numbers with TTY/TDD and interpreter capability.
 
c) The Enrollee may designate a representative to file Complaints, Complaint
Appeals and Action Appeals on his/her behalf.
 
d) The Contractor will not retaliate or take any discriminatory action against
the Enrollee because he/she filed a Complaint, Complaint Appeal or Action
Appeal.

Medicaid Advantage Contract
APPENDIX F
New York City 2006
F-ll
 

e) The Contractor's procedures for accepting Complaints, Complaint Appeals and
Action Appeals shall include:
 
i) toll-free telephone number;
 
ii) designated staff to receive calls;
 
iii) "live" phone coverage at least 40 hours a week during normal business
hours;
 
iv) a mechanism to receive after hours calls, including either:
A) a telephone system available to take calls and a plan to respond to all such
calls no later than on the next business day after the calls were recorded; or
B) a mechanism to have available on a twenty-four (24) hour, seven (7) day a
week basis designated staff to accept telephone Complaints, whenever a delay
would significantly increase the risk to an Enrollee's health.
 
f) The Contractor must ensure that personnel making determinations regarding
Complaints, Complaint Appeals and Action Appeals were not involved in previous
levels of review or decision-making. If any of the following applies,
determinations must be made by qualified clinical personnel as specified in this
Appendix:
i) A denial of an Action Appeal based on lack of medical necessity. ii) A
Complaint regarding denial of expedited resolution of an Action Appeal. iii) A
Complaint, Complaint Appeal, or Action Appeal that involves clinical issues.
 
3.  Action Appeals Process
 
a) The Contractor's Action Appeals process shall indicate the following
regarding resolution of Appeals of an Action:
 
i) The Enrollee, or his or her designee, will have no less than sixty (60)
business days and no more than 90 days from the date of the notice of Action to
file an Action Appeal. An Enrollee filing an Action Appeal within ten (10) days
of the notice of Action or by the intended date of an Action, whichever is
later, that involves the reduction, suspension, or termination of previously
approved services may request "aid continuing" in accordance with Section 24.4
of this Agreement.
 
ii) The Enrollee may file a written Action Appeal or an oral Action Appeal. Oral
Action Appeals must be followed by a written, signed. Action Appeal. The
Contractor may provide a written summary of an oral Action Appeal to the
Enrollee (with the acknowledgement or separately) for the Enrollee to review,
modify if needed, sign and return to the Contractor. If the Enrollee or provider
requests expedited resolution of the Action Appeal, the oral Action Appeal does
not need to be confirmed in writing.

Medicaid Advantage Contract
APPENDIX F
New York City 2006
F-12
 

The date of the oral filing of the Action Appeal will be the date of the Action
Appeal for the purposes of the timeframes for resolution of Action Appeals.
Action Appeals resulting from a Concurrent Review must be handled as an
expedited Action Appeal.
 
iii) The Contractor must send a written acknowledgement of the Action Appeal,
including the name, address and telephone number of the individual or department
handling the Action Appeal, within fifteen (15) days of receipt. If a
determination is reached before the written acknowledgement is sent, the
Contractor may include the written acknowledgement with the notice of Action
Appeal determination (one notice).
 
iv) The Contractor must provide the Enrollee reasonable opportunity to present
evidence, and allegations of fact or law, in person as well as in writing. The
Contractor must inform the Enrollee of the limited time to present such evidence
in the case of an expedited Action Appeal. The Contractor must allow the
Enrollee or his or her designee, both before and during the Action Appeals
process, to examine the Enrollee's case file, including medical records and any
other documents and records considered during the Action Appeals process. The
Contractor will consider the Enrollee, his or her designee, or legal estate
representative of a deceased Enrollee a party to the Action Appeal.
 
v) The Contractor must have a process for handling expedited Action Appeals.
Expedited resolution of the Action Appeal must be conducted when the Contractor
determines or the provider indicates that a delay would seriously jeopardize the
Enrollee's life or health or ability to attain, maintain, or regain maximum
function. The Enrollee may request an expedited review of an Action Appeal. If
the Contractor denies the Enrollee's request for an expedited review, the
Contractor must handle the request under standard Action Appeal resolution
timeframes, make reasonable efforts to provide prompt oral notice of the denial
to the Enrollee and send written notice of the denial within two (2) days of the
denial determination.
 
vi) The Contractor must ensure that punitive action is not taken against a
provider who either requests an expedited resolution or supports an Enrollee's
Appeal.
 
vii) Action Appeals of clinical matters must be decided by personnel qualified
to review the Action Appeal, including licensed, certified or registered health
care professionals who did not make the initial determination, at least one of
whom must be a clinical peer reviewer, as defined by PHL §4900(2)(a). Action
Appeals of non-clinical matters shall be determined by qualified personnel at a
higher level than the personnel who made the original determination.

Medicaid Advantage Contract
APPENDIX F
New York City 2006
F-13
 

4. Timeframes for Resolution of Action Appeals
 
a) The Contractor's Action Appeals process shall indicate the following specific
timeframes regarding Action Appeal resolution:
 
i) The Contractor will resolve Action Appeals as fast as the Enrollee's
condition requires, and no later than thirty (30) days from the date of the
receipt of the Action Appeal.
 
ii) The Contractor will resolve expedited Action Appeals as fast as the
Enrollee's condition requires, within two (2) business days of receipt of
necessary information and no later than three (3) business days of the date of
the receipt of the Action Appeal.
 
iii) Timeframes for Action Appeal resolution, in either (i) or (ii) above, may
be extended for up to fourteen (14) days if:
A) the Enrollee, his or her designee, or the provider requests an extension
orally or in writing; or
B) the Contractor can demonstrate or substantiate that there is a need for
additional information and the extension is in the Enrollee's interest. The
Contractor must send notice of the extension to the Enrollee. The Contractor
must maintain sufficient documentation of extension determinations to
demonstrate, upon SDOH's request, that the extension was justified.
 
iv) The Contractor will make a reasonable effort to provide oral notice to the
Enrollee, his or her designee, and the provider where appropriate, for expedited
Action Appeals at the time the Action Appeal determination is made.
 
v) The Contractor must send written notice to the Enrollee, his or her designee,
and the provider where appropriate, within two (2) business days of the Action
Appeal determination.
 
5. Action Appeal Notices
 
a) The Contractor shall ensure that all notices are in writing and in easily
understood language and are accessible to non-English speaking and visually
impaired Enrollees. Notices shall include that oral interpretation and alternate
formats of written material for Enrollees with special needs are available and
how to access the alternate formats.
 
i) Notice to the Enrollee that the Enrollee's request for an expedited Action
Appeal has been denied shall include that the request will be reviewed under
standard Action Appeal timeframes, including a description of the timeframes.
This notice may be combined with the acknowledgement.
 
ii) Notice to the Enrollee regarding an Contractor-initiated extension shall
include:

 
A)
the reason for the extension;

Medicaid Advantage Contract
APPENDIX F
New York City 2006
F-14
 

B) an explanation of how the delay is in the best interest of the Enrollee;
C) any additional information the Contractor requires from any source to make
its determination;
D) the revised date by which the MCO will make its determination;
E) the right of the Enrollee to file a Complaint regarding the extension;
F) the process for filing a Complaint with the Contractor and the timeframes
within which a Complaint determination must be made;
G) the right of an Enrollee to designate a representative to file a Complaint on
behalf of the Enrollee; and 
H) the right of the Enrollee to contact the New York State Department of Health
regarding his or her their Complaint, including the SDOH's toll-free number for
Complaints.
 
iii) Notice to the Enrollee of Action Appeal Determination shall include:
A) Date the Action Appeal was filed and a summary of the Action Appeal;
B) Date the Action Appeal process was completed;
C) the results and the reasons for the determination, including the clinical
rationale, if any;
D) If the determination was not in favor of the Enrollee, a description of
Enrollee's fair hearing rights, if applicable;
E) the right of the Enrollee to contact the New York State Department of Health
regarding his or her Complaint, including the SDOH's toll-free number for
Complaints; and
F) For Action Appeals involving Medical Necessity or an experimental or
investigational treatment, the notice must also include:
I) a clear statement that the notice constitutes the final adverse determination
and specifically use the terms "medical necessity" or '
'experimental/investigational;''
II) the Enrollee's coverage type;
III) the procedure in question, and if available and applicable the name of the
provider and developer/manufacturer of the health care service;
IV) statement that the Enrollee is eligible to file an External Appeal and the
timeframe for filing;
V) a copy of the "Standard Description and Instructions for Health Care
Consumers to Request an External Appeal" and the External Appeal application
form;
VI) the Contractor's contact person and telephone number;
VII) the contact person, telephone number, company name and full address of the
utilization review agent, if the determination was made by the agent;
and
VIII) if the Contractor has a second level internal review process, the notice
shall contain instructions on how to file a second level Action Appeal and a
statement in bold text that the timeframe for requesting an External Appeal
begins upon receipt of the final adverse determination of the first level Action
Appeal, regardless of whether or not a second level of Action Appeal is
requested, and that by choosing to request a second level Action appeal, the
time may expire for the Enrollee to request an External Appeal.

Medicaid Advantage Contract
APPENDIX F
New York City 2006
F-15
 
6.  Complaint Process
 
a) The Contractor' Complaint process shall include the following regarding the
handling of Enrollee Complaints:
 

 
i)
The Enrollee, or his or her designee, may file a Complaint regarding any dispute
with the Contractor orally or in writing. The Contractor may have requirements
for accepting written Complaints either by letter or Contractor supplied form.
The Contractor cannot require an Enrollee to file a Complaint in writing.

 

 
ii)
The Contractor must provide written acknowledgment of any Complaint not
immediately resolved, including the name, address and telephone number of the
individual or department handling the Complaint, within fifteen (15) business
days of receipt of the Complaint. The acknowledgement must identify any
additional information required by the Contractor from any source to make a
determination. If a Complaint determination is made before the written
acknowledgement is sent, the Contractor may include the acknowledgement with the
notice of the determination (one notice).

 

 
iii)
Complaints shall be reviewed by one or more qualified personnel.

 
iv) Complaints pertaining to clinical matters shall be reviewed by one or more
licensed, certified or registered health care professionals in addition to
whichever non-clinical personnel the Contractor designates.
 
7.  Timeframes for Complaint Resolution by the Contractor
 
a) The Contractor's Complaint process shall indicate the following specific
timeframes regarding Complaint resolution:
 
i) If the Contractor immediately resolves an oral Complaint to the Enrollee's
satisfaction, that Complaint may be considered resolved without any additional
written notification to the Enrollee. Such Complaints must be logged by the
Contractor and included in the Contractor's quarterly HPN Complaint report
submitted to SDOH in accordance with Section 18 of this Agreement.
ii) Whenever a delay would significantly increase the risk to an Enrollee's
health, Complaints shall be resolved within forty-eight (48) hours after receipt
of all necessary information and no more than seven (7) days from the receipt of
the Complaint.
iii) All other Complaints shall be resolved within forty-five (45) days after
the receipt of all necessary information and no more than sixty (60) days from
receipt of the Complaint. The Contractor shall maintain reports of Complaints
unresolved after forty-five (45) days in accordance with Section 18 of this
Agreement.

Medicaid Advantage Contract
APPENDIX F
New York City 2006
F-16
 

 
8. Complaint Determination Notices
 
a) The Contractor's procedures regarding the resolution of Enrollee Complaints
shall include the following:
 
i) Complaint Determinations by the Contractor shall be made in writing to the
Enrollee or his/her designee and include:
A) the detailed reasons for the determination;
B) in cases where the determination has a clinical basis, the clinical rationale
for the determination;
C) the procedures for the filing of an appeal of the determination, including a
form, if used by the Contractor, for the filing of such a Complaint Appeal; and
notice of the right of the Enrollee to contact the State Department of Health
regarding his or her Complaint, including SDOH's toll-free number for
Complaints.
 
ii) If the Contractor was unable to make a Complaint determination because
insufficient information was presented or available to reach a determination,
the Contractor will send a written statement that a determination could not be
made to the Enrollee on the date the allowable time to resolve the Complaint has
expired.
 
iii) In cases where delay would significantly increase the risk to an Enrollee's
health, the Contractor shall provide notice of a determination by telephone
directly to the Enrollee or to the Enrollee's designee, or when no phone is
available, some other method of communication, with written notice to follow
within three (3) business days.
 
9. Complaint Appeals
 
a) The Contractor's procedures regarding Enrollee Complaint Appeals shall
include the following:
 
i) The Enrollee or designee has no less than sixty (60) business days after
receipt of the notice of the Complaint determination to file a written Complaint
Appeal. Complaint Appeals may be submitted by letter or by a form provided by
the Contractor.
 
ii) Within fifteen (15) business days of receipt of the Complaint Appeal, the
Contractor shall provide written acknowledgment of the Complaint Appeal,
including the name, address and telephone number of the individual designated to
respond to the Appeal. The Contractor shall indicate what additional
information, if any, must be provided for the Contractor to render a
determination.
 
 
Medicaid Advantage Contract
APPENDIX F
New York City 2006
F-17

 
iii) Complaint Appeals of clinical matters must be decided by personnel
qualified to review the Appeal, including licensed, certified or registered
health care professionals who did not make the initial determination, at least
one of whom must be a clinical peer reviewer, as defined by PHL §4900(2)(a).
 
iv) Complaint Appeals of non-clinical matters shall be determined by qualified
personnel at a higher level than the personnel who made the original Complaint
determination.
v)  Complaint Appeals shall be decided and notification provided to the Enrollee
no more than:
A) two (2) business days after the receipt of all necessary information when a
delay would significantly increase the risk to an Enrollee's health; or
B) thirty (30) business days after the receipt of all necessary information in
all other instances.
 
vi) The notice of the Contractor's Complaint Appeal determination shall include:
A) the detailed reasons for the determination;
B) the clinical rationale for the determination in cases where the determination
has a clinical basis;
C) the notice shall also inform the Enrollee of his/her option to also contact
the State Department of Health with his/her Complaint, including the SDOH's
toll-free number for Complaints;
D) instructions for any further Appeal, if applicable.
 
10. Records
 
a) The Contractor shall maintain a file on each Complaint, Action Appeal and
Complaint Appeal. These records shall be readily available for review by the
SDOH, upon request. The file shall include:
 
i) date the Complaint was filed;
 
ii), copy of the Complaint, if written;
 
iii) date of receipt of and copy of the Enrollee's written confirmation, if any;
 
iv) log of Complaint determination including the date of the determination and
the titles of the personnel and credentials of clinical personnel who reviewed
the Complaint;
 
v) date and copy of the Enrollee's Action Appeal or Complaint Appeal;
 
vi) Enrollee or provider requests for expedited Action Appeals and Complaint
Appeals and the Contractor's determination;
 

Medicaid Advantage Contract
APPENDIX F
New York City 2006
F-18

vii) necessary documentation to support any extensions;
 
viii) determination and date of determination of the Action Appeals and
Complaint Appeals;
 
ix) the titles and credentials of clinical staff who reviewed the Action Appeals
and Complaint Appeals; and
 
x) Complaints unresolved for greater than forty-five (45) days.

Medicaid Advantage Contract
APPENDIX F
New York City 2006
F-19
 

--------------------------------------------------------------------------------

APPENDIX G
 

 
Reserved

Medicaid Advantage Contract
APPENDIX G
New York City 2006
G-l

--------------------------------------------------------------------------------

APPENDIX H
 
New York State Department of Health Guidelines for the Processing of Medicaid
Advantage Enrollments and Disenrollments

Medicaid Advantage Contract
APPENDIX H
New York City 2006
H-l
 

Appendix H SDOH Guidelines
For the Processing of Medicaid Advantage Enrollments and Disenrollments
 
1. General
 
The Contractor's Enrollment and Disenrollment procedures for Medicaid Advantage
shall be consistent with these requirements, except that to allow LDSS and the
Contractor flexibility in developing processes that will meet the needs of both
parties, the SDOH may allow modifications to timeframes and some procedures.
Where an Enrollment Broker exists, the Enrollment Broker may be responsible for
some or all of the LDSS responsibilities.
 
2. Enrollment
 
a) SDOH Responsibilities:
 
i) The SDOH is responsible for monitoring Local District program activities and
providing technical assistance to the LDSS and the Contractor to ensure
compliance with the State's policies and procedures.
 
ii) SDOH reviews and approves proposed Enrollment materials prior to the
Contractor publishing and disseminating or otherwise using the materials.
 
b) LDSS Responsibilities:
 
i) The LDSS has the primary responsibility for processing Medicaid Advantage
enrollments.
 
ii) Each LDSS determines Medicaid eligibility. To the extent practicable, the
LDSS will follow up with Enrollees when the Contractor provides documentation of
any change in status which may affect the Enrollee's Medicaid and/or Medicaid
Advantage eligibility.
 
iii) The LDSS is responsible for providing pre-enrollment information on
Medicaid Advantage to Dually Eligible beneficiaries, consistent with Social
Services Law, Section 364-j(4)(e)(iv) and train persons providing enrollment
counseling to Eligible Persons.
 
iv) The LDSS is responsible for informing Eligible Persons of the availability
of Medicaid Advantage Products, the scope of services covered by each, and that
enrollment is voluntary.
 
Medicaid Advantage Contract
APPENDIX H
New York City 2006
H-2

v) The LDSS is responsible for informing Eligible Persons of the right to
confidential face-to-face enrollment counseling and will make confidential
face-to-face sessions available upon request.
 
vi) The LDSS is responsible for instructing Eligible Persons, to verify with the
medical services providers they prefer, or have an existing relationship with,
that such medical services providers are Participating Providers of the selected
MCO and are available to serve the Enrollee. The LDSS includes such written
instructions to Eligible Persons in its written materials related to Enrollment.
 
vii) For Enrollments made during face-to-face counseling, if the Prospective
Enrollee has a preference for particular medical services providers, Enrollment
counselors shall verify with the medical services providers that such medical
services providers whom the prospective Enrollee prefers are Participating
Providers of the selected MCO and are available to serve the Prospective
Enrollee.
 
viii) The LDSS is responsible for the timely processing of Medicaid Advantage
Enrollment applications received from participating health plans.
 
ix) The LDSS is responsible for processing Enrollments in Medicaid Advantage
without edits for Medicare coverage in the Welfare Management System (WMS);
however the LDSS is responsible for ensuring that WMS is updated with Medicare A
and B coverage status for new Enrollees upon review of documentation provided by
the Contractor or the Enrollee.
 
x) The LDSS is responsible for determining the eligibility status of Medicaid
Advantage enrollment applications. Applications will be enrolled, pended or
denied.
 
xi) The LDSS is responsible for processing Medicaid Advantage enrollment
applications until the last day of the month preceding th-e Effective Date of
Enrollment, to the extent possible.
 
xii) The LDSS is responsible for notifying the Contractor of plan-assisted
enrollment applications that are accepted, pended or denied.
 
xiii) The LDSS is responsible for entering individual enrollment form data and
transmitting that data to the State's Prepaid Capitation Plan (PCP) Subsystem.
The transfer of enrollment information may "be accomplished by any of the
following:

Medicaid Advantage Contract
APPENDIX H
New York City 2006
H-3
 

A) LDSS directly enters data into PCP Subsystem; or
 
B) LDSS or Contractor submits a tape to the State, to be edited and entered into
PCP Subsystem; or
 
C) LDSS electronically transfers data via a dedicated line, from eMedNY to the
PCP Subsystem.
 
xiv) Extensive use of the secondary roster will be utilized to coordinate the
Effective Dates of Enrollment for Medicaid and Medicare Advantage.
 
xv) The LDSS is responsible for prospectively re-enrolling an Enrollee who is
disenrolled from the Contractor's Medicaid Advantage Product due to loss of
Medicaid eligibility, who regains eligibility within three months, in the
Contractor's Medicaid Advantage Product, provided that the individual remains
enrolled in the Contractor's Medicare Advantage Product.
 
xvi) The LDSS is responsible for processing new Enrollment applications to
transfer a member of the Contractor's Medicaid managed care product to the
Contractor's Medicaid Advantage Product if the Enrollee, upon gaining Medicare
eligibility, wishes to enroll in the Contractor's Medicaid Advantage Product. To
the extent possible, such Enrollments shall be made effective the first day of
the month that the Enrollee's Medicare Advantage Coverage is effective.
 
xvii) The LDSS is responsible for sending the following notices to Eligible
Persons:
 
A) Enrollment Confirmation Notice: This notice indicates the Effective Date of
Enrollment, the name of the Medicaid Advantage Product and the individual who is
being enrolled. This notice must also include a statement advising the
individual that if his/her Medicare Advantage enrollment is denied by CMS, the
individual's Medicaid Advantage Enrollment will be voided retroactively back to
the Effective Date of Enrollment, hi such instances, the individual may be
responsible for the cost of any Medicaid Advantage Benefit rendered during the
retroactive period if the benefit was provided by a non-Medicaid participating
provider.
 
B) Notice of Denial of Enrollment: This notice is used when an individual has
been determined by LDSS to be ineligible for enrollment into a Medicaid
Advantage Product. This notice must include fair hearing rights.

Medicaid Advantage Contract
APPENDIX H
New York City 2006
H-4
 

c) Contractor Responsibilities:
 
i) To the extent permitted by law and regulation, the Contractor is responsible
for assisting Dually Eligible persons eligible for enrollment in Medicaid
Advantage to complete the Enrollment application. The Contractor will submit
plan Enrollments to the LDSS, within a maximum of five (5) business days from
the day the Enrollment is received by the Contractor (unless otherwise agreed to
by SDOH and LDSS).
 
ii) The Contractor is responsible for obtaining documentation of Medicare A and
B coverage prior to sending the Enrollment transaction to the LDSS for
processing. In all areas where Enrollments are not processed by the Enrollment
Broker, the documentation must accompany the Enrollment form to the LDSS.
Acceptable documentation includes: a current Medicare card or other
documentation acceptable to CMS or received by the Contractor from interaction
with CMS' data systems.
 
iii) In areas where Enrollments are submitted electronically to the Enrollment
Broker, the Contractor is responsible for forwarding the documentation of
current Medicare A and B coverage to the Enrollment Broker within five (5)
business days of learning from the Enrollment Broker that evidence of Medicare A
and B coverage is not reflected in the WMS system.
 
iv) The Contractor must notify new Enrollees of their Effective Date of
Enrollment. To the extent practicable, such notification must precede the
Effective Date of Enrollment. This notice must also include a statement advising
the individual that if his/her Medicare Advantage enrollment is denied by CMS,
the individual's Medicaid Advantage Enrollment will be voided retroactively back
to the Effective Date of Enrollment. In such instances, the individual may be
responsible for the cost of any Medicaid Advantage Benefit rendered during the
retroactive period if the benefit was provided by a non-Medicaid participating
provider.
 
v) The Contractor must report any changes in status for its Enrollees to the
LDSS within five (5) business days of such information becoming known to the
Contractor. This includes, but is not limited to, factors that may impact
Medicaid or Medicaid Advantage eligibility such as address changes,
incarceration, third party insurance other than Medicare, Disenrollment from the
Contractor's Medicare Advantage Product, etc.
 
vi) If an Enrollee's Enrollment in the Contractor's Medicare Advantage Product
is rejected by CMS, the Contractor must notify the LDSS within five (5) business
days of learning of CMS' rejection of the Enrollment.

Medicaid Advantage Contract
APPENDIX H
New York City 2006
H-5
 

In such instances, the LDSS shall delete the Enrollee's Enrollment in the
Contractor's Medicaid Advantage Plan.
 
vii) The Contractor shall advise potential Enrollees, in written materials
related to enrollment, to verify with the medical services providers they
prefer, or have an existing relationship with, that such medical services
providers are Participating Providers and are available to serve the Prospective
Enrollee.
 
viii) The Contractor shall accept all Enrollments as ordered by the Office of
Temporary and Disability Assistance's Office of Administrative Hearings due to
fair hearing requests or decisions.
 
3. Newborn Enrollments:
 
a) SDOH Responsibilities:
 
i) The SDOH will update WMS with information on the newborn received from
hospitals or birthing centers, consistent with the requirements of Section 366-g
of the Social Services Law as amended by Chapter 412 of the Laws of 1999.
 
ii) Upon notification of the birth by the hospital or birthing center, the SDOH
will update WMS with the demographic data for the newborn generating appropriate
Medicaid coverage.
 
b) LDSS Responsibilities:
 
i) The LDSS is responsible for granting Medicaid eligibility for newboms for one
(1) year if born to a woman eligible for and receiving MA assistance on the date
of birth. (Social Services Law Section 366(4)(1))
 
ii) The LDSS is responsible for adding eligible unboms to all WMS cases that
include a pregnant woman as soon as the pregnancy is medically verified. (NYS
DSS Administrative Directive 85 ADM-33)
 
iii) hi the event that the LDSS learns of an Enrollee's pregnancy prior to the
Contractor, the LDSS is responsible for establishing MA eligibility and
enrolling the unborn into Medicaid managed care in cases where an enrollment
form is received or other members of the family are enrolled in a mainstream
plan.
 
iv) When a newborn is enrolled in managed care, the LDSS is responsible for
sending an Enrollment Confirmation Notice to inform the mother of the Effective
Date of Enrollment, which is the first (1st) day of the month of birth, and the
plan in which the newborn is enrolled.
 

 

 
Medicaid Advantage Contract
APPENDIX H
New York City 2006
H-6

v) The LDSS may develop a transmittal form to be used for unbom/newbom
notification between the Contractor and the LDSS.
 
c) Contractor Responsibilities:
 
i) The Contractor must notify the LDSS in writing of any Enrollee that is
pregnant within thirty (30) days of knowledge of the pregnancy. Notifications
should be transmitted to the LDSS at least monthly. The notifications should
contain the pregnant woman's name. Client ID Number (CIN), and the expected date
of confinement (EDC).
 
ii) Upon the newborn's birth, the Contractor must send verifications of infant's
demographic data to the LDSS, within five (5) days after knowledge of the birth.
The demographic data must include: the mother's name and CIN, the newborn's name
and CIN (if newborn has a CIN), sex and the date of birth.
 
4. Roster Reconciliation:
 
a) All Enrollments are effective the first of the month.
 
b) SDOH Responsibilities:
 
i) The SDOH maintains both the PCP subsystem Enrollment files and the WMS
eligibility files, using data input by the LDSS. SDOH uses data contained in
both these files to generate the Roster.
 
ii) SDOH shall send monthly to the the Contractor and LDSS (according to a
schedule established by SDOH), a complete list of all Enrollees for which the
Contractor is expected to assume medical risk beginning on the 1st of the
following month (First Monthly Roster). Notification to the Contractor and LDSS
will be accomplished via paper transmission, magnetic media, or the HPN.
 
iii) SDOH shall send monthly to the Contractor and LDSS, at the time of the
first monthly roster production; a Disenrollment Report listing those Enrollees
from the previous month's roster who were disenrolled, transferred to another
MCO, or whose Enrollments were deleted from the file. Notification to the
Contractor and LDSSs will be accomplished via paper transmission, magnetic
media, or the HPN.
 
iv) The SDOH shall also forward an error report as necessary to the Contractor
and LDSS.
 
v) On the first (1st) weekend after the first (1st) day of the month following
the generation of the first (1st) Roster, SDOH shall send the Contractor
 

 

Medicaid Advantage Contract
APPENDIX H
New York City 2006
H-7
 

and LDSS a second Roster which contains any additional Enrollees that the LDSS
has added for Enrollment for the current month. The SDOH will also include any
additions to the error report that have occurred since the initial error report
was generated.
 
c) LDSS Responsibilities:
 
i) The LDSS is responsible for notifying the Contractor electronically or in
writing of changes in the First Roster and error report, no later than the end
of the month. This includes, but is not limited to, new Enrollees whose
Enrollments in Medicaid Advantage were processed subsequent to the pull-down
date but prior to the Effective Date of Enrollment. (Note: To the extent
practicable the date specified must allow for timely notice to Enrollees
regarding their Enrollment status. The Contractor and the LDSS may develop
protocols for the purpose of resolving Roster discrepancies that remain
unresolved beyond the end of the month).
 
ii) Enrollment and eligibility issues are reconciled by the LDSS to the extent
possible, through manual adjustments to the PCP subsystem Enrollment and WMS
eligibility files, if appropriate.
 
d) Contractor Responsibilities:
 
i) The Contractor is at risk for providing Benefit Package services for those
Enrollees listed on the 1st and 2nd Rosters for the month in which the 2nd
Roster is generated. Contractor is not at risk for providing services to
Enrollees who appear on the monthly Disenrollment report.
 
ii) The Contractor must submit claims to the State's Fiscal Agent
for all Eligible Persons that are on the 1st and 2nd Rosters (see Appendix H,
page 7), adjusted to add Eligible Persons enrolled by the LDSS after Roster
production and to remove individuals disenrolled by LDSS after Roster production
(as notified to the Contractor). In the cases of retroactive Disenrollments, the
Contractor is responsible for submitting an adjustment to void any previously
paid premiums for the period of retroactive Disenrollment, where the Contractor
was not at risk for the provision of Benefit Package services. Payment of
sub-capitation does not constitute "provision of Benefit Package services."
 
5. Disenrollment:
 
a) LDSS Responsibilities:
i) Enrollees may request to disenroll from the Contractor's Medicaid Advantage
product at any time for any reason. Disenrollment requests may be made by
Enrollees to the LDSS, the Enrollment Broker, or the Contractor.
 

 
Medicaid Advantage Contract
APPENDIX H
New York City 2006
H-8

 
ii) Medicaid Advantage Plans, LDSSs, and the Enrollment Broker must utilize
State-approved Disenrollment forms.
 
iii) The LDSS will accept requests for Disenrollment directly from the Enrollee
or from the Contractor.
 
iv) Enrollees may initiate a request for an expedited Disenrollment to the LDSS.
The LDSS is responsible for expediting the Disenrollment process in those cases
where an Enrollee's request for Disenrollment involves concurrent Disenrollment
from the Contractor's Medicare Advantage Product, an urgent medical need, a
complaint of non-consensual enrollment or, in New York City, homeless
individuals in the shelter system. If approved, the LDSS will manually process
the Disenrollment through the PCP Subsystem. Enrollees who request to be
disenrolled from Medicaid Advantage based on their documented HIV, ESRD, or
SPMI/SED status are categorically eligible for an expedited Disenrollment on the
basis of urgent medical need.
 
v) The LDSS is responsible for processing routine Disenrollment requests to take
effect on the first (1st) day of the following month to the extent possible. In
no event shall the Effective Date of Disenrollment be later than the first (1st)
day of the second month after the month in wilich an Enrollee requests a
Disenrollment.
 
vi) The LDSS is responsible for disenrolling Enrollees automatically upon death,
Disenrollment from the Contractor's Medicare Acrvantage Product, or loss of
Medicaid eligibility. All such Disenrollments will be effective at the end of
the month in which the death. Effective Date of Disenrollment from the
Contractor's Medicare Advantage Product, or loss of eligibility occurs, or at
the end of the last month of Guaranteed Eligibility, where applicable.
 
vii) The LDSS is responsible for promptly disenrolling an Enrollee whose managed
care eligibility or status changes such that he/she is deemed by the LDSS to no
longer be eligible for Medicaid Advantage Enrollment. The LDSS is responsible
for providing Enrollees with a notice of their right to request a fair hearing.
 

Medicaid Advantage Contract
APPENDIX H
New York City 2006
H-9

viii) The LDSS is responsible for ensuring that Retroactive Disenrollments are
used only when absolutely necessary. Circumstances warranting a retroactive
Disenrollment are rare and include when an individual is deemed to have been
non-consensually enrolled in the Contractor's Medicaid Advantage Product, is
enrolled when ineligible for Enrollment, or when an Enrollee enters or resides
in a residential institution under circumstances which render the individual
ineligible; is incarcerated; is retroactively disenrolled from the Contractor's
Medicare Advantage Product, or dies - as long as the Contractor was not at risk
for provision of Benefit Package services for any portion of the retroactive
period. Payment of subcapitation does not constitute "provision of Benefit
Package services." The LDSS is responsible for notifying the Contractor of the
retroactive disenrollment prior to the action. The LDSS is responsible for
finding out if the Contractor has made payments to providers on behalf of the
Enrollee prior to Disenrollment. After this information is obtained, the LDSS
and Contractor will agree on a retroactive Disenrollment or prospective
Disenrollment date.
 
In all cases of retroactive Disenrollment, including Disenrollments effective
the first day of the current month, the LDSS is responsible for sending notice
to the Contractor at the time of Disenrollrnent, of the Contractor's
responsibility to submit to the SDOH's Fiscal Agent voided premium claims for
any full months of retroactive Disenrollment where the Contractor was not at
risk for the provision of Benefit Package services during the month. However,
failure by the LDSS to so notify the Contractor does not affect the right of the
SDOH to recover the premium payment as authorized by Section 3.6 of this
Agreement.

Medicaid Advantage Contract
APPENDIX H
New York City 2006
H-10
 

ix) Generally the effective dates of Disenrollment are prospective. Effective
dates for other than routine Disenrollments are described below:
 
 
Reason for Disenrollment
 
Effective Date of Disenrollment
 
• Death of Enrollee
 
• First day of the month after death
 
• Incarceration
 
• First day of the month of incarceration (note-Contractor is at risk for
covered services only to the date of incarceration and is entitled to the
capitation payment for the month of incarceration).
 
• Enrollee entered or stayed in a residential institution under circumstances
which rendered the individual ineligible for enrollment in Medicaid Advantage or
is in receipt ofwaivered services through the Long Term Home Health Care Program
(LTHHCP), including when an Enrollee is admitted to a hospital that 1) is
certified by Medicare as a long-term care hospital and 2) has an average length
of stay for all patients greater than ninety-five (95) days as reported in the
Statewide Planning and Research Cooperative System (SPARCS) Annual Report 2002.
 
• First day of the month of entry or first day of the month of classification of
the stay as permanent, subsequent to entry (note-Contractor is at risk for
covered services only to the date of entry or classification of the stay as
permanent subsequent to entry, and is entitled to the capitation payment for the
month of entry or classification of the stay as permanent subsequent to entry).
 
• Individual enrolled while ineligible for enrollment
 
• Effective Date of Enrollment in the Contractor's Plan.
 
• Non-consensual Enrollment
 
• Retroactive to the first day of the month of
 
Enrollment
 
• Enrollee moved outside of the District/County of Fiscal Responsibility
 
• First day of the month after the update of the system with the new address*
 
• Urgent medical need
 
• First day of the next month after determination except where medical need
requires an earlier Disenrollment
 
• Homeless Enrollees in Medicaid Advantage residing in the shelter system in NYC
 
• Retroactive to the first day of the month of
 
the request
 
• An Enrollee with more than one Client Identification Number (CIN) is enrolled
in the Contractor's Medicaid Advantage Product under more than one of the CINs.
 
• First day of the month the duplicate Enrollment began.

 
* In counties outside of New York City, LDSSs should work together to ensure
continuity of care through the Contractor if the Contractor's service area
includes the county to which the Enrollee has moved and the Enrollee, with
continuous eligibility, wishes to stay enrolled in the Contractor's plan. In New
York City, Enrollees, not in guaranteed status, who move out of the Contractor's

Medicaid Advantage Contract APPENDIX H
New York City 2006
H-ll
 

Service Area but not outside, of the City of New York (e.g., move from one
borough to another), will not be involuntarily disenrolled, but must request a
Disenrollment or transfer. These Disenrollments will be performed on a routine
basis unless there is an urgent medical need to expedite the Disenrollment.
 
x) The LDSS is responsible for informing Enrollees of their right to disenroll
at any time for any reason.
 
xi) The LDSS will render a decision within five (5) days of the receipt of a
fully documented request for Disenrollment.
 
xii) To the extent possible, the LDSS is responsible for processing an expedited
disenrollment within two (2) business days of its determination that an
expedited Dissenrollment is warranted.
 
xiii) The LDSS is responsible for sending the following notices to Enrollees
regarding their Disenrollment status. Where practicable, the process will allow
for timely notification to Enrollees unless there is "good cause" to disenroll
more expeditiously.
 
A) Notice of Disenrollment: These notices will advise the Enrollee of the LDSS's
determination regarding an Enrollee-initiated, LDSS-initiated or
Contractor-initiated Disenrollment and will include the Effective Date of
Disenrollment. In cases where the Enrollee is being involuntarily disenrolled,
the notice must contain fair hearing rights.
 
B) When the LDSS denies any Enrollee's request for Disenrollment pursuant to
Section 8 of this Agreement, the LDSS is responsible for informing the Enrollee
in writing explaining the reason for the denial, stating the facts upon which
the denial is based, citing the statutory and regulatory authority and advising
the Enrollee of his/her right to a fair hearing pursuant to 18 NYCRR Part 358.
 
C) Notice of Change to "Guarantee Coverage": This notice will advise the
Enrollee that his or her Medicaid coverage is ending and how this affects his or
her enrollment in the Medicaid Advantage Product. This notice contains pertinent
information regarding "Guaranteed Eligibility" benefits and dates of coverage.
If an Enrollee is not eligible for guarantee, this notice is not necessary.
 
xiv) In those instances where the LDSS approves the Contractor's request to
disenroll an Enrollee, and the Enrollee requests a fair hearing, the Enrollee
will remain in the Contractor's Medicaid Advantage Product until the disposition
of the fair hearing, if Aid to Continue is ordered by the New York State Office
of Administrative Hearings.
 

Medicaid Advantage Contract APPENDIX H
New York City 2006
H-12
 

xv) The LDSS is responsible for reviewing each Contractor requested
Disenrollment in accordance with the provisions of Section 8.7 of this
Agreement. Where applicable, the LDSS may consult with local mental health and
substance abuse authorities in the district when making the determination to
approve or disapprove the request.
 
xvi) The LDSS is responsible for establishing procedures whereby the Contractor
refers cases which are appropriate for an LDSS-initiated Disenrollment and
submits supporting documentation to the LDSS.
 
xvii) After the LDSS receives and, if appropriate, approves the request for
Disenrollment either from the Enrollee or the Contractor, the LDSS is
responsible for updating the PCP subsystem file with an end date. The Enrollee
is removed from the Contractor's Roster.
 
b) Contractor Responsibilities:
 
i) In those instances where the Contractor directly receives Disenrollment
forms, the Contractor will forward these Disenrollments to the LDSS for
processing within five (5) business days (or according to Section 5 of this
Appendix). During pull-down week, these forms may be faxed to the LDSS with the
hard copy to follow.
 
ii) The Contractor must accept and transmit all requests for voluntary
Disenrollments from its Enrollees to the LDSS, and shall not impose any barriers
to Disenrollment requests. The Contractor may require that a Disenrollment
request be in writing, contain the signature of the Enrollee, and state the
Enrollee's correct Contractor or Medicaid identification number.
 
iii) Following LDSS procedures, the Contractor will refer cases which are
appropriate for an LDSS-initiated Disenrollment and will submit supporting
documentation to the LDSS. This includes, but is not limited to, changes in
status for its enrolled members that may impact eligibility for Enrollment in an
MCO such as address changes, incarceration, death, ineligibility for Medicaid
Advantage Enrollment, change in Medicare status, etc.
 
iv) With respect to Contractor-initiated Disenrollments:
 
A) The Contractor may initiate an involuntary Disenrollment if the Enrollee:

i) engages in conduct or behavior that seriously impairs the Contractor's
ability to furnish services to either the Enrollee or other Enrollee's, provided
that the Contractor has made

 

Medicaid Advantage Contract
APPENDIX H
New York City 2006
H-13
 

and documented reasonable efforts to resolve the problems presented by the
Enrollee; or
ii) provides fraudulent information on an enrollment form or permits abuse of an
enrollment card except when the Enrollee is no longer eligible for Medicaid and
is in his/her Guaranteed Eligibility period.
 
B) The Contractor may not request Disenrollment because of an adverse change in
the Enrollee's health status, or because of the Enrollee's utilization of
medical services, diminished mental capacity, or uncooperative or disruptive
behavior resulting from the Enrollee's special needs (except where continued
enrollment in the Contractor's plan seriously impairs the Contractor's ability
to furnish services to either the Enrollee or other Enrollees).
 
C) The Contractor must make a reasonable effort to identify for the Enrollee,
both verbally and in writing, those actions of the Enrollee that have interfered
with the effective provision of covered services as well as explain what actions
or procedures are acceptable.
 
D) The Contractor shall give prior verbal and written notice to the Enrollee,
with a copy to the LDSS, of its intent to request Disenrollment. The written
notice shall advise the Enrollee that the request has been forwarded to the LDSS
for review and approval. The written notice must include the mailing address and
telephone number of the LDSS.
 
E) The Contractor shall keep the LDSS informed of decisions related to all
complaints filed by an Enrollee as a result of, or subsequent to, the notice of
intent to disenroll.
v) The Contractor will not consider an Enrollee disenrolled without confirmation
from the LDSS or the Roster (as described in Section 4 of this Appendix).

Medicaid Advantage Contract
APPENDIX H
New York
City 2006
H-14
 
 

--------------------------------------------------------------------------------

 

APPENDIX I
 
Reserved

Medicaid Advantage Contract APPENDIX I
New York City 2006
1-1
 
 
 

--------------------------------------------------------------------------------

APPENDIX J
 
New York State Department of Health Guidelines for Contractor Compliance with
the Federal Americans with Disabilities Act
 

 

 

 

 
APPENDIX J
October 1,2005
 
J-l
 
I. OBJECTIVES

Title II of the Americans With Disabilities Act (ADA) and Section 504 of the
Rehabilitation Act of 1973 (Section 504) provides that no qualified individual
with a disability shall, by reason of such disability, be excluded from
participation in or denied access to the benefits of services, programs or
activities of a public entity, or be subject to discrimination by such an
entity. Public entities include State and local government and ADA and Section
504 requirements extend to all programs and services provided by State and local
government. Since MMC and FHPlus are government programs, health services
provided through MMC and FHPlus Programs must be accessible to all that qualify
for them.

Contractor responsibilities for compliance with the ADA are imposed under Title
II and Section 504 when, as a Contractor in a MMC or FHPlus Program, a
Contractor is providing a government service. If an individual provider under
contract with the Contractor is not accessible, it is the responsibility of the
Contractor to make arrangements to assure that alternative services are
provided. The Contractor may-determine it is expedient to make arrangements with
other providers, or to describe reasonable alternative means and methods to make
these services accessible through its existing Participating Providers. The
goals of compliance with ADA Title II requirements are to offer a level of
services that allows people with disabilities access to the program in its
entirety, and the ability to achieve the same health care results as any
Enrollee.

Contractor responsibilities for compliance with the ADA are also imposed under
Title III when the Contractor functions as a public accommodation providing
services to individuals (e.g. program areas and sites such as Marketing,
education, member services, orientation. Complaints and Appeals). The goals of
compliance with ADA Title III requirements are to offer a level of services that
allows people with disabilities full and equal enjoyment of the goods, services,
facilities or accommodations that the entity provides for its customers or
clients. New and altered areas and facilities must be as accessible as possible.
Whenever Contractors engage in new construction or renovation, compliance is
also required with accessible design and construction standards promulgated
pursuant to the ADA as well as State and local laws. Title III also requires
that public accommodations undertake "readily achievable barrier removal" in
existing facilities where architectural and communications barriers can be
removed easily and without much difficulty or expense.

The State uses MCO Qualification Standards to qualify MCOs for participation in
the MMC and FHPlus Programs. Pursuant to the State's responsibility to assure
program access to all Enrollees, the Plan Qualification Standards require each
MCO to submit an ADA Compliance Plan that describes in detail how the MCO will
make services, programs and activities readily accessible and useable by
individuals with disabilities. In the event that certain program sites are not
readily accessible, the MCO must describe reasonable alternative methods for
making the services or activities accessible and usable.

APPENDIX J
October 1.2005
J-2
 

The objectives of these guidelines are threefold:
• To ensure that Contractors take appropriate steps to measure access and assure
program accessibility for persons with disabilities;
• To provide a framework for Contractors as they develop a plan to assure
compliance with the Americans with Disabilities Act (ADA); and
• To provide standards for the review of the Contractor Compliance Plans.

These guidelines include a general standard followed by a discussion of specific
considerations and suggestions of methods for assuring compliance. Please be
advised that, although these guidelines and any subsequent reviews by State and
local governments can give the Contractor guidance, it is ultimately the
Contractor's obligation to ensure that it complies with its Contractual
obligations, as well as with the requirements of the ADA, Section 504, and other
federal, state and local laws. Other federal, state and local statutes and
regulations also prohibit discrimination on the basis of disability and may
impose requirements in addition to those established under ADA. For example,
while the ADA covers those impairments that "substantially" limit one or more of
the major life activities of an individual. New York City Human Rights Law
deletes the modifier "substantially".

II. DEFINITIONS
 
A. "Auxiliary aids and services" may include qualified interpreters, note
takers, computer-aided transcription services, written materials, telephone
handset amplifiers, assistive listening systems, telephones compatible with
hearing aids, closed caption decoders, open and closed captioning,
telecommunications devices for Enrollees who are deaf or hard of hearing
(TTY/TDD), video test displays, and other effective methods of making aurally
delivered materials available to individuals with hearing impairments; qualified
readers, taped texts, audio recordings, Braille materials, large print
materials, or other effective methods of making visually delivered materials
available to individuals with visual impairments.

B. "Disability" means a mental or physical impairment that substantially limits
one or more of the major life activities of an individual; a record of such
impairment; or being regarded as having such an impairment.

 
III. SCOPE OF CONTRACTOR COMPLIANCE PLAN

The Contractor Compliance Plan must address accessibility to services at
Contractor's program sites, including both Participating Provider sites and
Contractor facilities intended for use by Enrollees.

IV. PROGRAM ACCESSIBILITY

Public programs and services, when viewed in their entirety must be readily
accessible to and useable by individuals with disabilities. This standard
includes physical access, non-discrimination in policies and procedures and
communication. Communications with individuals with disabilities are required to
be as

APPENDIX J
October 1.2005
J-3

effective as communications with others. The Contractor Compliance Plan must
include a detailed description of how Contractor services, programs, and
activities are readily accessible and usable by individuals with disabilities.
In the event that full physical accessibility is not readily available for
people with disabilities, the Contractor Compliance Plan will describe the steps
or actions the Contractor will take to assure accessibility to services
equivalent to those offered at the inaccessible facilities.

IV PROGRAM ACCESSIBILITY

A. PRE-ENROLLMENT MARKETING AND EDUCATION

STANDARD FOR COMPLIANCE

Marketing staff, activities and materials will be made available to persons with
disabilities. Marketing materials will be made available in alternative formats
(such as Braille, large print, and audiotapes) so that they are readily usable
by people with disabilities.

SUGGESTED METHODS FOR COMPLIANCE

1. Activities held in physically accessible location, or staff at activities
available to meet with person in an accessible location as necessary
2. Materials available in alternative formats, such as Braille, large print,
audio tapes
3. Staff training which includes training and information regarding attitudinal
barriers related to disability
4. Activities and fairs that include sign language interpreters or the
distribution of a written summary of the marketing script used by Contractor
marketing representatives
5. Enrollee health promotion material/activities targeted specifically to
persons with disabilities (e.g. secondary infection prevention, decubitus
prevention, special exercise programs, etc.)
6. Policy statement that Marketing Representatives will offer to read or
summarize to blind or vision impaired individuals any written material that is
typically distributed to all Enrollees
7. Staff/resources available to assist individuals with cognitive impairments in
understanding materials

COMPLIANCE PLAN SUBMISSION

1. A description of methods to ensure that the Contractor's Marketing
presentations (materials and communications) are accessible to persons with
auditory, visual and cognitive impairments
2. A description of the Contractor's policies and procedures, including
Marketing training, to ensure that Marketing Representatives neither screen
health status nor ask questions about health status or prior health care
services

 
APPENDIX J
October 1.2005
J-4

IV. PROGRAM ACCESSIBILITY

B. MEMBER SERVICES DEPARTMENT

Member services functions include the provision to Enrollees of information
necessary to make informed choices about treatment options, to effectively
utilize the health care resources, to assist Enrollees in making appointments,
and to field questions and Complaints, to assist Enrollees with the Complaint
process.

Bl. ACCESSIBILITY

STANDARD FOR COMPLIANCE
Member Services sites and functions will be made accessible to and usable by,
people with disabilities.

SUGGESTED METHODS FOR COMPLIANCE (include, but are not limited to those
identified below):
1. Exterior routes of travel, at least 36" wide, from parking areas or public
transportation stops into the Contractor's facility
2. If parking is provided, spaces reserved for people with disabilities,
pedestrian ramps at sidewalks, and drop-offs
3. Routes of travel into the facility are stable, slip-resistant, with all steps
> Vi" ramped, doorways with minimum 32" opening
4. Interior halls and passageways providing a clear and unobstructed path or
travel at least 36" wide to bathrooms and other rooms commonly used by Enrollees
5. Waiting rooms, restrooms, and other rooms used by Enrollees are accessible to
people with disabilities
6. Sign language interpreters and other auxiliary aids and services provided in
appropriate circumstances
7. Materials available in alternative formats, such as Braille, large print,
audio tapes
8. Staff training which includes sensitivity training related to disability
issues (Resources and technical assistance are available through the NYS Office
of Advocate for Persons with Disabilities - V/TTY (800) 522-4369; and the NYC
Mayor's Office for People with Disabilities - (212) 788-2830 or TTY
(212)788-2838)
9. Availability of activities and educational materials tailored to specific
conditions/illnesses and secondary conditions that affect these populations
(e.g. secondary infection prevention, decubitus prevention, special exercise
programs, etc.)
10. Contractor staff trained in the use of telecommunication devices for
Enrollees who are deaf or hard of hearing (TTY/TDD) as well as in the use of NY
Relay for phone communication
11. New Enrollee orientation available in audio or by interpreter services
12. Policy that when member services staff receive calls through the NY Relay,
they will offer to return the call utilizing a direct TTY/TDD connection
 

APPENDIX J
October 1.2005
J-5

COMPLIANCE PLAN SUBMISSION
1. A description of accessibility to the Contractor's -member services
department or reasonable alternative means to access member services for
Enrollees using wheelchairs (or other mobility aids)
2. A description of the methods the Contractor's member services department will
use to communicate with Enrollees who have visual or hearing impairments,
including any necessary auxiliary aid/services for Enrollees who are deaf or
hard of hearing, and TTY/TDD technology or NY Relay service available through a
toll-free telephone number
3. A description of the training provided to the Contractor's member services
staff to assure that staff adequately understands how to implement the
requirements of the program, and of these guidelines, and are sensitive to the
needs of persons with disabilities

IV. PROGRAM ACCESSIBILITY

B2. IDENTIFICATION OF ENROLLEES WITH DISABILITIES

STANDARD FOR COMPLIANCE
The Contractor must have in place satisfactory methods/guidelines for
identifying persons at risk of, or having, chronic diseases and disabilities and
determining their specific needs in terms of specialist physician referrals,
durable medical equipment, medical supplies, home health services etc. The
Contractor may not discriminate against a Prospective Enrollee based on his/her
current health status or anticipated need for future health care. The Contractor
may not discriminate on the basis of disability, or perceived disability of an
Enrollee or their family member. Health assessment forms may not be used by the
Contractor prior to Enrollment. Once a MCO has been chosen, a health assessment
form may be used to assess the person's health care needs.

SUGGESTED METHODS FOR COMPLIANCE
1. Appropriate post Enrollment health screening for each Enrollee, using an
appropriate health screening tool
2. Patient profiles by condition/disease for comparative analysis to national
norms, with appropriate outreach and education
3. Process for follow-up of needs identified by initial screening; e.g.
referrals, assignment of case manager, assistance with scheduling/keeping
appointments
4. Enrolled population disability assessment survey
5. Process for Enrollees who acquire a disability subsequent to Enrollment to
access appropriate services

APPENDIX J
October 1.2005
J-6

COMPLIANCE PLAN SUBMISSION

A description of how the .Contractor will identify special health care, physical
access or communication needs of Enrollees on a timely basis, including but not
limited to the health care needs of Enrollees who:

• are blind or have visual impairments, including the type of auxiliary aids and
services required by the Enrollee
• are deaf or hard of hearing, including the type of auxiliary aids and services
required by the Enrollee
• have mobility impairments, including the extent, if any, to which they can
ambulate
• have other physical or mental impairments or disabilities, including cognitive
impairments
• have conditions which may require more intensive case management

IV. PROGRAM ACCESSIBILITY

B3. NEW ENROLLEE ORIENTATION

STANDARD FOR COMPLIANCE

Enrollees will be given information sufficient to ensure that they understand
how to access medical care through the Contractor. This information will be made
accessible to and usable by people with disabilities.

SUGGESTED METHODS FOR COMPLIANCE

1. Activities held in physically accessible location, or staff at activities
available to meet with person in an accessible location as necessary
2. Materials available in alternative formats, such as Braille, large print,
audio tapes
3. Staff training which includes sensitivity training related to disability
issues (Resources and technical assistance are available through the NYS Office
of Advocate for Persons with Disabilities - V/TTY (800) 522-4369; and the NYC
Mayor's Office for People with Disabilities - (212) 788-2830 or TTY (212)788-283
8)
4. Activities and fairs that include sign language interpreters or the
distribution of a written summary of the Marketing script used by Contractor
marketing representatives
5. Include in written/audio materials available to all Enrollees information
regarding how and where people with disabilities can access help in getting
services, for example help with making appointments or for arranging special
transportation, an interpreter or assistive communication devices
6. Staff/resources available to assist individuals with cognitive impairments in
understanding materials

 
APPENDIX J
October 1.2005
J-7
 

COMPLIANCE PLAN SUBMISSION

1. A description of how the Contractor will advise Enrollees with disabilities,
during the new Enrollee orientation on how to access care
2. A description of how the Contractor will assist new Enrollees with
disabilities (as well as current Enrollees who acquire a disability) in
selecting or arranging an appointment with a Primary Care Practitioner (PCP)
• This should include a description of how the Contractor will assure and
provide notice to Enrollees who are deaf or hard of hearing, blind or who have
visual impairments, of their right to obtain necessary auxiliary aids and
services during appointments and in scheduling appointments and follow-up
treatment with Participating Providers
• In the event that certain provider sites are not physically accessible to
Enrollees with mobility impairments, the Contractor will assure that reasonable
alternative site and services are available
3. A description of how the Contractor will determine the specific needs of an
Enrollee with or at risk of having a disability/chronic disease, in terms of
specialist physician referrals, durable medical equipment (including assistive
technology and adaptive equipment), medical supplies and home health services
and will assure that such contractual services are provided
4. A description of how the Contractor will identify if an Enrollee with a
disability requires on-going mental health services and how the Contractor will
encourage early entry into treatment
5. A description of how the Contractor will notify Enrollees with disabilities
as to how to access transportation, where applicable

IV. PROGRAM ACCESSIBILITY

B4. COMPLAINTS, COMPLAINT APPEALS AND ACTION APPEALS STANDARD FOR COMPLIANCE
The Contractor will establish and maintain a procedure to protect the rights and
interests of both Enrollees and the Contractor by receiving, processing, and
resolving Complaints, Complaint Appeals and Action Appeals in an expeditious
manner, with the goal of ensuring resolution of Complaints, Complaint Appeals,
and Action Appeals and access to appropriate services as rapidly as possible.
All Enrollees must be informed about the Grievance System within their
Contractor and the procedure for filing Complaints, Complaint Appeals and Action
Appeals. This information will be made available through the Member Handbook,
SDOH toll-free Complaint line (1-(800) 206-8125) and the Contractor's Complaint
process annually, as well as when the Contractor denies a benefit or referral.
The Contractor will inform Enrollees of the Contractor's Grievance System;
Enrollees' right to contact the LDSS or SDOH with a Complaint, and to file a
Complaint Appeal,

APPENDIX J
October 1,2005
J-8

Action Appeal or request a fair hearing; the right to appoint a designee to
handle a Complaint, Complaint Appeal or Action Appeal; and the toll free
Complaint line. The Contractor will maintain designated staff to take and
process Complaints, Complaint Appeals and Action Appeals, and be responsible for
assisting Enrollees in Complaint, Complaint Appeal or Action Appeal resolution.
The Contractor will make all information regarding the Grievance System
available to and usable by people with disabilities, and will assure that people
with disabilities have access to sites where Enrollees typically file Complaints
and requests for Complaint Appeals and Action Appeals.

SUGGESTED METHODS FOR COMPLIANCE
1. Toll-free Complaint phone line with TDD/TTY capability
2. Staff trained in Complaint process, and able to provide interpretive or
assistive support to Enrollee during the Complaint process
3. Notification materials and Complaint forms in alternative formats for
Enrollees with visual or hearing impairments
4. Availability of physically accessible sites, e.g. member services department
sites
5. Assistance for individuals with cognitive impairments

COMPLIANCE PLAN SUBMISSION
1. A description of how the Contractor's Complaint, Complaint Appeals and Action
appeal procedures shall be accessible for persons with disabilities, including:
• procedures for Complaints, Complaint Appeals and Action Appeals to be made in
person at sites accessible to persons with mobility impairments
• procedures accessible to persons with sensory or other impairments who wish to
make verbal Complaints, Complaint Appeals or Action Appeals, and to communicate
with such persons on an ongoing basis as to the status or their Complaints and
rights to further appeals
• description of methods to ensure notification material is available in
alternative formats for Enrollees with vision and hearing impairments
2. A description of how the Contractor monitors Complaints, Complaint Appeals
and Action Appeals related to people with disabilities. Also, as part of the
Compliance Plan, the Contractor must submit a summary report based on the
Contractor's most recent year's Complaints, Complaint Appeals and Action Appeals
data.

IV. PROGRAM ACCESSIBILITY

C. CASE MANAGEMENT

STANDARD FOR COMPLIANCE

The Contractor must have in place adequate case management systems to identify
the service needs of all Enrollees, including Enrollees with chronic illness and
Enrollees with disabilities, and ensure that medically necessary covered
benefits are delivered on a timely basis. These systems must include procedures
for standing referrals, specialists as PCPs, and referrals to specialty centers
for Enrollees who require specialized medical

appendix J
October 1,2005
J-9

care over a prolonged period of time (as determined by a treatment plan approved
by the Contractor in consultation with the primary care provider, the designated
specialist and the Enrollee or his/her designee), out-of-network referrals and
continuation of existing treatment relationships with out-of-network providers
(during transitional period).

SUGGESTED METHODS FOR COMPLIANCE
1. Procedures for requesting specialist physicians to function as PCP
2. Procedures for requesting standing referrals to specialists and/or specialty
centers, out-of-network referrals, and continuation of existing treatment
relationships
3. Procedures to meet Enrollee needs for; durable medical equipment, medical
supplies, home visits as appropriate
4. Appropriately trained Contractor staff to function as case managers for
special needs populations, or sub-contract arrangements for case management
5. Procedures for informing Enrollees about the availability of case management
services

COMPLIANCE PLAN SUBMISSION

1. A description of the Contractor case management program for people with
disabilities, including case management functions, procedures for qualifying for
and being assigned a case manager, and description of case management staff
qualifications
2. A description of the Contractor's model protocol to enable Participating
Providers, at their point of service, to identify Enrollees who require a case
manager
3. A description of the Contractor's protocol for assignment of specialists as
PCP, and for standing referrals to specialists and specialty centers,
out-of-network referrals and continuing treatment relationships
4. A description of the Contractor's notice procedures to Enrollees regarding
the availability of case management services, specialists as PCPs, standing
referrals to specialists and specialty centers, out-of-network referrals and
continuing treatment relationships

IV. PROGRAM ACCESSIBILITY

D. PARTICIPATING PROVIDERS

STANDARD FOR COMPLIANCE
The Contractor's network will include all the provider types necessary to
furnish the Benefit Package, to assure appropriate and timely health care to all
Enrollees, including those with chronic illness and/or disabilities. Physical
accessibility is not limited to entry to a provider site, but also includes
access to services within the site, e.g., exam tables and medical equipment.

APPENDIX J
October 1,2005
J-10

SUGGESTED METHODS FOR COMPLIANCE

1. Process for the Contractor to evaluate provider network to ascertain the
degree of provider accessibility to persons with disabilities, to identify
barriers to access and required modifications to policies/procedures
2. Model protocol to assist Participating Providers, at their point of service,
to identify Enrollees who require case manager, audio, visual, mobility aids, or
other accommodations
3. Model protocol for determining needs of Enrollees with mental disabilities
4. Use of Wheelchair Accessibility Certification Form (see attached)
5. Submission of map of physically accessible sites
6. Training for providers re: compliance with Title III of ADA, e.g. site access
requirements for door widths, wheelchair ramps, accessible diagnostic/treatment
rooms and equipment; communication issues; attitudinal barriers related to
disability, etc. (Resources and technical assistance are available through the
NYS Office of Advocate for Persons with Disabilities -V/TTY (800) 522-4369; and
the NYC Mayor's Office for People with Disabilities - (212) 788-2830 or TTY
(212) 788-2838).
7. Use of NYS Office of Persons with Disabilities (OAPD) ADA Accessibility
Checklist for Existing Facilities and NYC Addendum to OAPD ADA Accessibility
Checklist as guides for evaluating existing facilities and for new construction
and/or alteration.

COMPLIANCE PLAN SUBMISSION

1. A description of how the Contractor will ensure that its Participating
Provider network is accessible to persons with disabilities. This includes the
following:
• Policies and procedures to prevent discrimination on the basis of disability
or type of illness or condition
• Identification of Participating Provider sites which are accessible by people
with mobility impairments, including people using mobility devices. If certain
provider sites are not physically accessible to persons with disabilities, the
Contractor shall describe reasonable, alternative means that result in making
the provider services readily accessible
• Identification of Participating Provider sites which do not have access to
sign language interpreters or reasonable alternative means to communicate with
Enrollees who are deaf or hard of hearing; and for those sites, a description of
reasonable alternative methods to ensure that services will be made accessible

 
•
Identification of Participating Providers which do not have adequate
communication systems for Enrollees who are blind or have vision impairments
(e.g. raised symbol and lettering or visual signal appliances), and for those
sites, a description of reasonable alternative methods to ensure that services
will be made accessible

2. A description of how the Contractor's specialty network is sufficient to meet
the needs of Enrollees with disabilities

APPENDIX J
October 1,2005
J-ll

3. A description of methods to ensure the coordination of out-of-network
providers to meet the needs of the Enrollees with disabilities
• This may include the implementation of a referral system to ensure that the
health care needs of Enrollees with disabilities are met appropriately
• The Contractor shall describe policies and procedures to allow for the
continuation of existing relationships with out-of-network providers, when in
the best interest of the Enrollee with a disability
4. Submission of the ADA Compliance Summary Report or Contractor statement that
data submitted to SDOH on the Health Provider Network (HPN) files is an accurate
reflection of each network's physical accessibility.

IV. PROGRAM ACCESSIBILITY
E. POPULATIONS WITH SPECIAL HEALTH CARE NEEDS
STANDARD FOR COMPLIANCE
The Contractor will have satisfactory methods for identifying persons at risk
of, or having, chronic disabilities and determining their specific needs in
terms of specialist physician referrals, durable medical equipment, medical
supplies, home health services, etc. The Contractor will have satisfactory
systems for coordinating service delivery and, if necessary, procedures to allow
continuation of existing relationships with out-of-network provider for course
of treatment.

SUGGESTED METHODS FOR COMPLIANCE
1. Procedures for requesting standing referrals to specialists .and/or specialty
centers, specialist physicians to function as PCP, out-of-network referrals, and
continuation "of existing relationships with out-of-network providers for course
of treatment
2. Linkages with behavioral health agencies, disability and advocacy
organizations, etc.
3. Adequate network of providers and sub-specialists (including pediatric
providers and sub-specialists) and contractual relationships with tertiary
institutions
4. Procedures for assuring that these populations receive appropriate diagnostic
work-ups on a timely basis
5. Procedures for assuring that these populations receive appropriate access to
durable medical equipment on a timely basis
6. Procedures for assuring that these populations receive appropriate allied
health professionals (Physical, Occupational and Speech Therapists,
Audiologists) on a timely basis
7. State designation as a Well Qualified Plan to serve the OMRDD population and
look-alikes 

APPENDIX J
October 1,2005
J-l2

COMPLIANCE PLAN SUBMISSION

1. A description of arrangements to ensure access to specialty care providers
and centers in and out of New York State, standing referrals, specialist
physicians to function as PCP, out-of-network referrals, and continuation of
existing relationships (out-of-network) for diagnosis and treatment of rare
disorders
 
2. A description of appropriate service delivery for children with disabilities.
This may include a description of methods for interacting with school districts,
child protective service agencies, early intervention officials, behavioral
health, and disability and advocacy organizations.
 
3. A description of the sub-specialist network, including contractual
relationships with tertiary institutions to meet the health care needs of people
with disabilities
 
V. ADDITIONAL ADA RESPONSIBILITIES FOR PUBLIC ACCOMMODATIONS
 
Please note that Title III of the ADA applies to all non-governmental providers
of health care. Title III of the Americans with Disabilities Act prohibits
discrimination on the basis of disability in the full and equal enjoyment of
goods, services, facilities, privileges, advantages or accommodations of any
place of public accommodation. A public accommodation is a private entity that
owns, leases or leases to, or operates a place of public accommodation. Places
of public accommodation identified by the ADA include, but are not limited to/
stores (including pharmacies) offices (including doctors' offices), hospitals,
health care providers, and social service centers.
 
New and altered areas and facilities must be as accessible as possible. Barriers
must be removed from existing facilities when it is readily achievable, defined
by the ADA as easily accomplishable without much difficulty or expense. Factors
to be considered when determining if barrier removal is readily achievable
include the cost of the action, the financial resources of the site involved,
and, if applicable, the overall financial resources of any parent corporation or
entity. If barrier removal is not readily achievable, the ADA requires alternate
methods of making goods and services available. New facilities must be
accessible unless structurally impracticable.
 
Title III also requires places of public accommodation to provide any auxiliary
aids and services that are needed to ensure equal access to the services it
offers, unless a fundamental alteration in the nature of services or an undue
burden would result. Auxiliary aids include, but are not limited to, qualified
sign interpreters, assistive listening systems, readers, large print materials,
etc. Undue burden is defined as "significant difficulty or expense". The factors
to be considered in determining "undue burden" include, but are not limited to,
the nature and cost of the action required and the overall financial resources
of the provider. "Undue burden" is a higher standard than "readily achievable"
in that it requires a greater level of effort on the part of the public
accommodation.

APPENDIX J
October 1,2005
J-13

 
Please note also that the ADA is not the only law applicable for people with
disabilities. In some cases, State or local laws require more than the ADA. For
example. New York City's Human Rights Law, which also prohibits discrimination
against people with disabilities, includes people whose impairments are not as
"substantial" as the narrower ADA and uses the higher "undue burden"
("reasonable") standard where the ADA requires only that which is "readily
achievable". New York City's Building Code does not permit access waivers for
newly constructed facilities and requires incorporation of access features as
existing facilities are renovated. Finally, the State Hospital code sets a
higher standard than the ADA for provision of communication (such as sign
language interpreters) for services provided at most hospitals, even on an
outpatient basis.
 

APPENDIX J
October 1,2005
J-14
 

 

--------------------------------------------------------------------------------

APPENDIX K

Medicare and Medicaid Advantage Products And Non-Covered Services

Medicaid Advantage Contract
APPENDIX K
New York City 2006
K-l

 
APPENDIX K.l
 
MEDICARE ADVANTAGE PRODUCT
 

Medicare Advantage Benefit Package for Dual Eligibles- Upstate Counties
Category of Service
Included in Medicare Capitation
Inpatient Hospital Care Including Substance Abuse and Rehabilitation Services
Up to 365 days per year (366 days for leap year). $3 00 per stay co-payment
Inpatient Mental Health
Medically necessary care. $300 per stay co-payment. 190-day lifetime limit in a
psychiatric hospital.
Skilled Nursing Facility
Care provided in a skilled nursing facility. Covered for 100 days each benefit
period. No prior hospital stay required. No co-payment.
Home Health
Medically necessary intermittent skilled nursing care, home health aide services
and rehabilitation services. $10 per visit co-payment.
PCP Office Visits
Primary care doctor office visits. Subject to $10 co-payment per visit.
Specialist Office Visits
Specialist office visits. Subject to $20 co-payment for each specialist office
visit.
Chiropractic
Manual manipulation of the spine to correct subluxation provided by
chiropractors or other qualified providers. Subject to $20 co-payment.
Podiatry
Medically necessary foot care, including care for medical conditions affecting
lower limbs, subject to $20 co-payment. Visits for routine foot care up to 4
visits per year, not subject to co-payment.
Outpatient Mental Health
Individual and group therapy visits, subject to co-payment of $20 per individual
or group visit. Enrollee must be able to self-refer for one assessment from a
network provider in a twelve (12) month period.
Outpatient Substance Abuse
Individual and group visits subject to $20 co-payment per group or individual
visit. Enrollee must be able to self-refer for one assessment from a network
provider in a twelve (12) month period.
Outpatient Surgery
Medically necessary visits to an ambulatory surgery center or outpatient
hospital facility. $35 per visit to ambulatory surgery or outpatient hospital.
Ambulance
Transportation provided by an ambulance service, including air ambulance.
Emergency transportation if for the purpose of obtaining hospital service for an
enrollee who suffers from severe, life-threatening or potentially disabling
conditions

 
 
 
Medicaid Advantage Contract
APPENDIX K
New York City 2006
K-3
 

 
Medicare Advantage Benefit Package for Dual Eligibles - Upstate Counties
Category of Service
Included in Medicare Capitation
 
which require the provision of emergency services while the enrollee is being
transported. Includes transportation to a hospital emergency room generated by a
"Dial 911". $50 co-
Emergency Room
Care provided in an emergency room subject to prudent layperson standard. $50
co-payment per visit. Co-payment waived if admitted to the hospital within 24
hours for the same condition.
Urgent Care
Urgently needed care in most cases outside the plan's service area. Subject to
$20 co-payment.
Outpatient Rehabilitation (OT, PT, Speech)
Occupational therapy, physical therapy and speech and language therapy subject
to $20 co-payment.
Durable Medical Equipment (DME)
Medicare and Medicaid covered durable medical equipment, including devices and
equipment other than medical/surgical supplies, enteral formula, and prosthetic
or orthotic appliances having the following characteristics: can withstand
repeated use for a protracted period of time; are primarily and customarily used
for medical purposes; are generally not useful to a person in the absence of
illness or injury and are usually fitted, designed or fashioned for a particular
individual's use. Must be ordered by a qualified practitioner. No homebound
prerequisite and including non-Medicare DME covered by Medicaid (e.g. tub stool;
grab bars). No co-payment or coinsurance.
Prosthetics
Medicare and Medicaid covered prosthetics, orthotics and orthopedic footwear. No
diabetic or temporary impairment prerequisite for orthotics. Not subject to
co-payment or coinsurance.
Diabetes Monitoring
Diabetes self-monitoring training and supplies including coverage for glucose
monitors, test strips, lancets and self-management training. No co-payment.
Diagnostic Testing
Diagnostic tests, x-rays, lab services and radiation therapy. No co-payment.
Bone Mass Measurement
Bone Mass Measurement for people at risk. No co-payment.
Colorectal Screening
Colorectal screening for people, age 50 and older. No co-payment.
Immunizations
Flu, hepatitis B vaccine for people who are at risk. Pneumonia vaccine.
Vaccines/Toxoids. No co-payment.
Mammograms
Annual screening for women age 40 and older. No referral necessary. No
co-payment.
Pap Smear and Pelvic Exams
Pap smears and Pelvic Exams for women. No co-payment.
Prostate Cancer Screening
Prostate Cancer Screening exams for men age 50 and older. No co-payment

Medicaid Advantage Contract
APPENDIX K
New York City 2006
K-4
 
Medicare Advantage Benefit Package for Dual Eligibles - Upstate Counties
Category of Service
Included in Medicare Capitation
Outpatient Drugs
Medicare Part B covered prescription drugs and other drugs obtained by a
provider and administered in a physician office or clinic setting covered by
Medicaid.
Hearing Services
Medicaid and Medicare hearing services and products when medically necessary to
alleviate disability caused by the loss or impairment of hearing. Services
include hearing aid selecting, fitting, and dispensing; hearing aid checks
following dispensing, conformity evaluations and hearing aid repairs; audiology
services including examinations and testing, hearing aid evaluations and hearing
aid prescriptions; and hearing aid products including hearing aids, earmolds,
special fittings and replacement parts. No co-payment or limitations.
Vision Care Services
Services of optometrists, ophthalmologists and ophthalmic dispensers including
eyeglasses, medically necessary contact lenses and poly-carbonate lenses,
artificial eyes (stock or custom-made), low vision aids and low vision services.
Coverage includes the replacement of lost or destroyed glasses. Coverage also
includes the repair or replacement of parts. Coverage also includes examinations
for diagnosis and treatment for visual defects and/or eye disease. Examinations
for refraction are limited to every two (2) years unless otherwise justified as
medically necessary. Eyeglasses do not require changing more frequently than
every two (2) years unless medically necessary or unless the glasses are lost,
damaged or destroyed. No prerequisite of cataract surgery. No co-payment
Routine Physical Exam I/year
Up to one routine physical per year. Subject to $10 co-payment per visit.
Health/Wellness Education
Coverage for the following: general health education classes, parenting classes,
smoking cessation classes, childbirth education and nutrition counseling, plus
additional benefits at plan option including but not limited to items such as
newsletters, nutritional training, congestive heart program, health club
membership/fitness classes, nursing hotline, disease management, other wellness
services. No co-payments.
Additional Part C Benefits, if any
 
Medicare Part D Prescription Drug Benefit as Approved by CMS
 

 
 

Medicaid Advantage Contract
APPENDIX K
New York City 2006
K-5
 

 
Medicare Advantage Benefit Package for Dual Eligibles
 
NYC, Nassau, Suffolk, Westchester, Rockland, Orange and Putnam Counties
Category of Service
Included in Medicare Capitation
Inpatient Hospital Care Including Substance Abuse and Rehabilitation Services
Up to 365 days per year (366 days for leap year) with no deductible or
co-payment
Inpatient Mental Health
Medically necessary care with no deductible or co-payment. 190-day lifetime
limit in a psychiatric hospital.
Skilled Nursing Facility
Care provided in a skilled nursing facility. Covered for 100 days each benefit
period. No prior hospital stay required. No co-payment.
Home Health
Medically necessary intermittent skilled nursing care, home health aide services
and rehabilitation services. No co-payment.
PCP Office Visits
Primary care doctor office visits. No co-payment.
Specialist Office Visits
Specialist office visits. Subject to $10 co-payment for each specialist office
visit.
Chiropractic
Manal manipulation of the spine to correct subluxation provided by chiropractors
or other qualified providers. Subject to $10 co-payment.
Podiatry
Medically necessary foot care, including care for medical conditions affecting
lower limbs, subject to $10 co-payment. Visits for routine foot care up to 4
visits per year, not subject to co-payment.
Outpatient Mental Health
Individual and group therapy visits, subject to co-payment of $20 per individual
or group visit. Enrollee must be able to self-refer for one assessment from a
network provider in a twelve (12) month period.
Outpatient Substance Abuse
Individual and group visits subject to $20 co-payment per group or individual
visit. Enrollee must be able to self-refer for one assessment from a network
provider in a twelve (12) month period.
Outpatient Surgery
Medically necessary visits to an ambulatory surgery center or outpatient
hospital facility. No co-payment.
Ambulance
Transportation provided by an ambulance service, including air ambulance.
Emergency transportation if for the purpose of obtaining hospital services for
an enrollee who suffers from severe, life-threatening or potentially disabling
conditions which require the provision of emergency services while the enrollee
is being transported. Includes transportation to a hospital emergency room
generated by a "Dial 9 II". No co-payment.

Medicaid Advantage Contract
APPENDIX K
New York City 2006
K-6
 

 
Medicare Advantage Benefit Package for Dual Eligibles
 
NYC, Nassau, Suffolk, Westchester, Rockland, Orange and Putnam Counties
Category of Service
Included in Medicare Capitation
Emergency Room
 
Care provided in an emergency room subject to prudent layperson standard. $50
co-payment per visit. Co-payment waived if admitted to the hospital within 24
hours for the same condition.
Urgent Care
 
Urgently needed care in most cases outside the plan's service area. Subject to
$10 co-payment.
Outpatient Rehabilitation (OT, PT, Speech)
 
Occupational therapy, physical therapy and speech and language therapy subject
to $ 10 co-payment.
Durable Medical Equipment (DME)
Medicare and Medicaid covered durable medical equipment, including devices and
equipment other than medical/surgical supplies, enteral formula, and prosthetic
or orthotic appliances having the following characteristics: can withstand
repeated use for a protracted period of time; are primarily and customarily used
for medical purposes; are generally not useful to a person in the absence of
illness or injury and are usually not fitted, designed or fashioned for a
particular individual's use. Must be ordered by a qualified practitioner. No
homebound prerequisite and including non-Medicare DME covered by Medicaid (e.g.,
tub stool; grab bar). No co-payment or coinsurance.
Prosthetics
 
Medicare and Medicaid covered prosthetics, orthotics and orthopedic footwear. No
diabetic prerequisite for orthotics. Not subject to co-payment or coinsurance.
Diabetes Monitoring
 
Diabetes self-monitoring training and supplies including coverage for glucose
monitors, test strips, lancets and self-management training. No co-payments.
Diagnostic Testing
 
Diagnostic tests, x-rays, lab services and radiation therapy. No co-payments.
Bone Mass Measurement
 
Bone Mass Measurement for people at risk. No co-payment
Colorectal Screening
 
Colorectal screening for people, age 50 and older. No co-payment.
Immunizations
 
Flu, hepatitis B vaccine for people who are at risk. Pneumonia vaccine. No
co-payment.
Mammograms
 
Annual screening for women age 40 and older. No referral necessary. No
co-payment.
Pap Smear and Pelvic Exams
Pap smears and Pelvic Exams for women. No co-payment.
Prostate Cancer Screening
 
Prostrate Cancer Screening exams for men age 50 and older. No co-payment.
Outpatient Drugs
 
Medicare Part B covered prescription drugs and other drugs obtained by a
provider and administered in a physician office or clinic setting covered by
Medicaid.
Hearing Services
 
Medicare and Medicaid hearing services and products when

 
Medicaid Advantage Contract APPENDIX K New York City 2006 K-7
 

 
Medicare Advantage Benefit Package for Dual Eligibles
 
NYC, Nassau, Suffolk, Westchester, Rockland, Orange and Putnam Counties
Category of Service
Included in Medicare Capitation
 
medically necessary to alleviate disability caused by the loss or impairment of
hearing. Services include hearing aid selecting, fitting, and dispensing;
hearing aid checks following dispensing, conformity evaluations and hearing aid
repairs; audiology services including examinations and testing, hearing aid
evaluations and hearing aid prescriptions; and hearing aid products including
hearing aids, earmolds, special fittings and replacement parts. No co-payment or
limitations.
Vision Care Services
Services of optometrists, ophthalmologists and ophthalmic dispensers including
eyeglasses, medically necessary contact lenses and poly-carbonate lenses,
artificial eyes (stock or custom-made), low vision aids and low vision services.
Coverage includes the replacement of lost or destroyed glasses. Coverage also
includes the repair or replacement of parts. Coverage also includes examinations
for diagnosis and treatment for visual defects and/or eye disease. Examinations
for refraction are limited to every two (2) years unless otherwise justified as
medically necessary. Eyeglasses do not require changing more frequently than
every two (2) years unless medically necessary or unless the glasses are lost,
damaged or destroyed. No prerequisite of cataract services. No co-payment.
Routine Physical Exam I/year
Up to one routine physical per year. No co-payment.
Health/Wellness Education
Coverage for the following: general health education classes, parenting classes,
smoking cessation classes, childbirth education and nutrition counseling, plus
additional benefits at plan option including but not limited to items such as
newsletters, nutritional training, congestive heart program, health club
membership/fitness classes, nursing hotline, disease management, other wellness
services. No co-payments.
Additional Part C Benefits, if any
 
 
Medicare Part D Prescription Drug Benefit as Approved by CMS
 

Medicaid Advantage Contract
APPENDIX K
New York City 2006
K-8
 

 
APPENDIX K.2
 
MEDICAID ADVANTAGE PRODUCT
 
 
Medicaid Advantage Benefit Package for Dual Eligibles - Upstate Counties
Category of Service
Included in Medicaid Capitation
Inpatient Hospital Care Including Substance Abuse and Rehabilitation Services
Elimination of $300 per stay co-payment.
Inpatient Mental Health
Elimination of $300 per stay co-payment, plus days in excess of the 190-day
lifetime maximum.
Home Health
Elimination of $10 co-payment per Medicare covered visit, plus value of Medicare
non-covered visits including home health aid services with nursing supervision
to medically unstable individuals.
PCP Office Visits
Elimination of $10 co-payment
Specialist Office Visits
Elimination of $20 co-payment
Podiatry
Elimination of $20 co-payment for medically necessary foot care
Outpatient Mental Health
Elimination of $20 co-payment
Outpatient Substance Abuse
Elimination of $20 co-payment
Outpatient Surgery
Elimination of $35 co-payment
Ambulance
Elimination of $50 co-payment
Emergency Room
Elimination of $50 co-payment
Urgent Care
Elimination of $20 co-payment
Outpatient Rehabilitation (OT, PT, Speech)
Elimination of $20 co-payment
Dental (Optional benefit)
Medicaid covered dental services including necessary preventive, prophylactic
and other routine dental care, services and supplies and dental prosthetics to
alleviate a serious health condition. Ambulatory or inpatient surgical dental
services subject to prior authorization.
Routine Physical Exam I/year
Elimination of $10 co-payment
Transportation - Routine (Optional benefit)
Transportation essential for an enrollee to obtain necessary medical care and
services under the plan's benefits or Medicaid fee-for-service. Includes
ambulette, invalid coach, taxicab, livery, public transportation, or other means
appropriate to the enrollee's medical condition and a transportation attendant
to accompany the enrollee, if necessary.
Private Duty Nursing
Medically necessary private duty nursing services in accordance with the
ordering physician, registered physician assistant or certified nurse
practitioner's written treatment plan.

 
Medicaid Advantage Contract
APPENDIX K-
New York City 2006
K-9
 

 
Medicaid Advantage Benefit Package for Dual Eligibles
 
NYC, Nassau, Suffolk,.Westchester, Rockland, Orange and Putnam Counties
Category of Service
Included in Medicaid Capitation
Inpatient Mental Health
Days in excess of the 190-day lifetime maximum.
Home Health
Non-Medicare covered home health services, including home health aid services
and nursing supervision to medically unstable individuals.
Specialist Office Visits
Elimination of $ 10 co-payment.
Podiatry
Elimination of $10 co-payment for medically necessary footcare.
Outpatient Mental Health
Elimination of $20 co-payment.
Outpatient Substance Abuse
Elimination of $20 co-payment.
Emergency Room
Elimination of $50 co-payment
Urgent Care
Elimination of $ 10 co-payment.
Outpatient Rehabilitation (OT, PT, Speech)
Elimination of $10 co-payment.
Dental (Optional benefit outside of NYC)
Medicaid covered dental services including necessary preventive, prophylactic
and other routine dental care, services and supplies and dental prosthetics to
alleviate a serious health condition. Ambulatory or inpatient surgical dental
services subject to prior authorization.
Transportation - Routine (Optional benefit outside of NYC)
Transportation essential for an enrollee to obtain necessary medical care and
services under the plan's benefits or Medicaid fee-for-service. Includes
ambulette, invalid coach, taxicab, livery, public transportation, or other means
appropriate to the enrollee's medical condition and a transportation attendant
to accompany the enrollee, if necessary.
Private Duty Nursing
Medically necessary private duty nursing services in accordance with the
ordering physician, registered physician assistant or certified nurse
practitioner's written treatment plan.

 
Medicaid Advantage Contract
APPENDIX K
New York City 2006
K-10
 

DESCRIPTION OF MEDICAID ONLY SERVICES IN MEDICAID ADVANTAGE BENEFIT PACKAGE:
 
Inpatient Mental Health Over 190-Day Lifetime Limit
 
All inpatient mental health services, including voluntary or involuntary
admissions for mental health services over the Medicare 190-Day Lifetime Limit.
The Contractor may provide the covered benefit for medically necessary mental
health impatient .services through hospitals licensed pursuant to Article 28 of
the New York State P.H.L.
 
Non-Medicare Covered Home Health Services
 
Medicaid covered home health services include the provision of skilled services
not covered by Medicare (e.g. physical therapist to supervise maintenance
program for patients who have reached their maximum restorative potential or
nurse to pre-fill syringes for disabled individuals •with diabetes) and /or home
health aide services as required by an approved plan of care developed by a
certified home health agency.
 
Private Duty Nursing Services
 
Private duty nursing services provided by a person possessing a license and
current registration from the NYS Education Department to practice as a
registered professional nurse or licensed practical nurse. Private duty nursing
services can be provided through an approved certified home health agency, a
licensed home care agency, or a private Practitioner. The location of nursing
services may be in the Enrollee's home or in the hospital.
 
Private duty nursing services are covered when determined by the attending
physician to be medically necessary. Nursing services may be intermittent,
part-time or continuous and provided in accordance with the ordering physician,
registered physician assistant or certified nurse practitioner's written
treatment plan.
 
Dental Services (optional benefit outside of NYC)
 
Dental care includes preventive, prophylactic and other routine dental care,
services, supplies and dental prosthetics required to alleviate a serious health
condition, including one which affects employability.
 
Dental surgery performed in an ambulatory or inpatient setting is the
responsibility of the Contractor whether dental services are a covered plan
benefit, or not. Inpatient claims and referred ambulatory claims for dental
services provided in an inpatient or outpatient hospital setting for surgery,
anesthesiology, x-rays, etc. are the responsibility of the Contractor. In these
situations, the professional services of the dentist are covered by Medicaid
fee-for-service. The Contractor should set up procedures to prior approve dental
services providedin inpatient and ambulatory settings.
 
Medicaid Advantage Contract
APPENDIX K
New York City 2006
K-ll
 

As described in Sections 10.9 and 10.18 of this Agreement, Enrollees may
self-refer to Article 28 clinics operated by academic dental centers to obtain
covered dental services.
 
If Contractor's Benefit Package excludes dental services:
 
i) Enrollees may obtain routine exams, orthodontic services and appliances,
dental office surgery, fillings, prophylaxis, and other Medicaid covered dental
services from any qualified Medicaid provider who shall claim reimbursement from
eMedNY; and
 
ii) Inpatient and referred ambulatory claims for medical services provided in an
inpatient or outpatient hospital setting in conjunction with a dental procedure
(e.g. anesthesiology, x-rays), are the responsibility of the Contractor. In
these situations, the professional services of the dentist are covered Medicaid
fee-for-service.
 
Non-Emergency Transportation (optional benefit outside ofNYC)
 
Transportation expenses are covered when transportation is essential in order
for an Enrollee to obtain necessary medical care and services which are covered
under the Medicaid program (either as part of the Contractor's Benefit Package
or by fee-for-service Medicaid). Non-emergent transportation guidelines may be
developed in conjunction with the LDSS, based on the LDSS' approved
transportation plan.
 
Transportation services means transportation by ambulance, ambulette, fixed wing
or airplane transport, invalid coach, taxicab, livery, public transportation, or
other means appropriate to the Enrollee's medical condition; and a
transportation attendant to accompany the Enrollee, if necessary. Such services
may include the transportation attendant's transportation, meals, lodging and
salary; however, no salary will be paid to a transportation- attendant who is a
member of the Enrollee's family.
 
When the Contractor is capitated for non-emergency transportation, the
Contractor is also responsible for providing transportation to Medicaid covered
services that are not part of the Contractor's Benefit Package.
 
For Contractors that cover non-emergency transportation in the Medicaid
Advantage Benefit Package, transportation costs to MMTP services may be
reimbursed by Medicaid FFS in accordance with the LDSS transportation policies
in local districts where there is a systematic method to discretely identify and
reimburse such transportation costs.
 
For Enrollees with disabilities, the method of transportation must reasonably
accommodate their needs, taking into account the severity and nature of the
disability.
 
Medicaid Advantage Contract
APPENDIX K
New York City 2006
K-12
 

 
APPENDIX K.3
 
NON COVERED SERVICES
 
The following services will not be the responsibility of the MCO under the
Medicare/Medicaid program:
 
Services Covered by Direct Reimbursement from Original Medicare
 
• Hospice services provided to Medicare Advantage members
• Other services deemed to be covered by Original Medicare by CMS
 
Services Covered by Medicaid Fee for Service
• Out of network Family Planning services under the direct access provisions of
the waiver
• Skilled Nursing Facility (SNF) days not covered by Medicare
• Personal Care Services
• Medicaid-Covered Prescription and Non-Prescription (OTC) Drugs, Medical
Supplies and Enteral Formula not covered under Medicare Part B or the
Contractor's Medicare Part D Prescription Drug Benefit approved by CMS.
• Methadone Maintenance Treatment Programs
• Certain Mental Health Services, including
o Intensive Psychiatric Rehabilitation Treatment Programs
o Day Treatment
o Continuing Day Treatment
o Case Management for Seriously and Persistently Mentally 111 (sponsored by
state or local mental health units) o Partial Hospitalizations o Assertive
Community Treatment (ACT) o Personalized Receiving Oriented Services (PROS)
• Rehabilitation Services Provided to Residents of OMH Licensed Community
Residences (CRs) and Family Based Treatment Programs
• Office of Mental Retardation and Developmental Disabilities (OMRDD) Services
• Comprehensive Medicaid Case Management
• Directly Observed Therapy for Tuberculosis Disease
• AIDS Adult Day Health Care
• HIV COBRA Case Management
• Adult Day Health Care
• Personal Emergency Response Services (PERS)
 
Medicaid Advantage Program Optional Benefits
Optional benefits will be covered Medicaid fee for service if the MCO elects not
to cover these services in their Medicaid Advantage Product. Currently the only
2 optional benefits are:
 
• Non-Emergency Transportation Services
 
• Dental Service
 
These services are mandatory in NYC.
 
Medicaid Advantage Contract
APPENDIX K
New York City 2006
K-13
 

DESCRIPTION OF NON-COVERED SERVICES
 
The following services are excluded from the Contractor's Medicare and Medicaid
Benefit Packages, and are covered, in most instances, by Medicare or Medicaid
fee-for-service:
 
1. Hospice Services Provided to Medicaid Advantage Enrollees
 
Hospice services provided to Medicare Advantage Enrollees by a Medicare approved
hospice providers are directly reimbursed by Medicare. Hospice is a coordinated
program of home and inpatient care that provides non-curative medical and
support services for persons certified by a physician to be terminally ill with
a life expectancy of six (6) months or less. Hospice programs provide patients
and families with palliative and supportive care to meet the special needs
arising out of physical, psychological, spiritual, social and economic stresses
which are experienced during the final stages of illness and during dying and
bereavement.
 
Hospices are organizations which must be certified under Article 40 of the NYS
P.H.L. and approved by Medicare. All services must be provided by qualified
employees and volunteers of the hospice or by qualified staff through
contractual arrangements to the extent permitted by federal and state
requirements. All services must be provided according to a written plan of care
which reflects the changing needs of the patient/family.
 
If an Enrollee in the Contractor's plan becomes terminally ill and receives
Hospice Program services he or she may remain enrolled and continue to access
the Contractor's Benefit Package while Hospice costs are paid for by Medicare
fee-for-service.
 
2. Other Services Deemed to be Covered by Original Medicare by CMS
 
3. Personal Care Agency Services
 
Personal care services (PCS) are the provision of some or total assistance with
personal hygiene, dressing and feeding; and nutritional and environmental
support (meal preparation and housekeeping). Such services must be essential to
the maintenance of the Enrollee's health and safety in his or her own home. The
service has to be ordered by a physician, and there has to be a medical need for
the service. Licensed home care services agencies, as opposed to certified home
health agencies, are the primary providers of PCS. Enrollees receiving PCS have
to have a stable medical condition and are generally expected to be in receipt
of such services for an extended period of time (years).
 
Services rendered by a personal care agency which are approved by the LDSS are
not covered under the Medicare or Medicaid Benefit Packages. Should it be
medically necessary for the PCP to order personal care agency services, the PCP
(or the Contractor on the physician's behalf) must first contact the Enrollee's
LDSS contact person for personal care. The district will determine the
Enrollee's need for personal care agency services and coordinate with the
personal care agency a plan of care.
 
Medicaid Advantage Contract
APPENDIX K
New York City 2006
K-14
 

4. Skilled Nursing Facility Days Not Covered by Medicare
 
    Skilled nursing facility days for Medicaid Advantage Enrollees in excess of
the first 100 days in the benefit period are covered by Medicaid on a fee for
service basis.
 
5. Prescription and Non-Prescription (OTC) Drugs, Medical Supplies, and Enteral
Formula Not Covered by Medicare Part B and the Medicare Advantage Organization's
Medicare Part D Prescription Drug Benefit approved by CMS
 
Coverage for drugs dispensed by community pharmacies, over the counter drugs,
medical/surgical supplies and enteral formula covered by Medicaid and not
included in the Contractor's Medicare Advantage Benefit Package will be paid for
by Medicaid fee-for-service. Medical/surgical supplies are items other than
drugs, prosthetic or orthotic appliances, or DME which have been ordered by a
qualified practitioner in the treatment of a specific medical condition and
which are: consumable, non-reusable, disposable, or for a specific rather than
incidental purpose, and generally have no salvageable value (e.g. gauze pads,
bandages and diapers). Pharmaceuticals and medical supplies routinely furnished
or administered as part of a clinic or office visit are covered by the
Contractor.
 
6. Out of Network Family Planning Services
 
As described in Section 10.6 and 10.9 of this Agreement, out of network family
planning services provided by qualified Medicaid providers to plan enrollees
will be directly reimbursed by Medicaid fee-for-service at the Medicaid fee
schedule. Family Planning and Reproductive Health Care services means those
health services which enable Enrollees, including minors, who may be sexually
active to prevent or reduce the incidence of unwanted pregnancy. These include:
diagnosis and all medically necessary treatment, sterilization, screening and
treatment for sexually transmissible diseases and screening for disease and
pregnancy.
 
Also included is HIV counseling and testing when provided as part of a family
planning visit. Additionally, reproductive health care includes coverage of all
medically necessary abortions. Elective induced abortions must be covered for
New York City recipients. Fertility services are not covered.
 
7. Dental (when not in benefit package)
 
(see description in Appendix K-2)
8. Non-Emergency Transportation (when not in benefit package) (see description
in Appendix K-2)
 
9. Methadone Maintenance Treatment Program (MMTP)
 
Consists of drug detoxification, drug dependence counseling, and rehabilitation
services which include chemical management of the patient with methadone.
Facilities that provide methadone
 
Medicaid Advantage Contract
APPENDIX K
New York City 2006
K-15
 

maintenance treatment do so as their principal mission and are certified by the
Office of Alcohol and Substance Abuse Services (OASAS) under Title 14 NYCRR,
Part 828.
 
10. Certain Mental Health Services
 
Contractor is not responsible for the provision and payment of the following
services which are reimbursed through Medicaid fee-for-service.
 
a. Intensive Psychiatric Rehabilitation Treatment Programs (IPRT)
 
A time limited active psychiatric rehabilitation designed to assist a patient in
forming and achieving mutually agreed upon goals in living, learning, working
and social environments, to intervene with psychiatric rehabilitative
technologies to overcome functional disabilities. IPRT services are certified by
OMH under 14 NYCRR, Part 587.
 
b. Day Treatment
 
A combination of diagnostic, treatment, and rehabilitative procedures which,
through supervised and planned activities and extensive client-staff
interaction, provides the services of the clinic treatment program, as well as
social training, task and skill training and socialization activities. Services
are expected to be of six (6) months duration. These services are certified by
OMH under 14 NYCRR, Part 587.
 
c. Continuing Day Treatment
 
Provides treatment designed to maintain or enhance current levels of functioning
and skills, maintain community living, and develop self-awareness and
self-esteem. Includes: assessment and treatment planning; discharge planning;
medication therapy; medication education; case management; health screening and
referral; rehabilitative readiness development; psychiatric rehabilitative
readiness determination and referral; and symptom management. These services are
certified by OMH under 14 NYCRR, Part 587.
 
This waiver is in select counties for children and adolescents who would
otherwise be admitted to an institutional setting if waiver services were not
provided. The services include individualized care coordination, respite, family
support, intensive in-home skill building, and crisis response.
 
d. Case Management for Seriously and Persistently Mentally 111 Sponsored by
State or Local Mental Health Units
 
The target population consists of individuals who are seriously and persistently
mentally ill (SPMI), require intensive, personal and proactive intervention to
help them obtain those services which will permit functioning in the community
and either have symptomology which is difficult to treat in the existing mental
health care system or are unwilling or unable to adapt to the existing mental
health care system. Three case management models are currently operated pursuant
to an agreement with OMH or a local governmental unit, and receive Medicaid
reimbursement pursuant to 14 NYCRR Part 506.
 
Medicaid Advantage Contract
APPENDIX K
New York City 2006
K-16
 

Please note: See generic definition of Comprehensive Medicaid Case Management
(CMCM) in this section.
 
e. Partial Hospitalization Not Covered by Medicare
 
Provides active treatment designed to stabilize and ameliorate acute systems,
serves as an alternative to inpatient hospitalization, or reduces the length of
a hospital stay within a medically supervised program by providing the
following: assessment and treatment planning; health screening and referral;
symptom management; medication therapy; medication education; verbal therapy;
case management; psychiatric rehabilitative readiness determination and referral
and crisis intervention. These services are certified by OMH under NYCRR Part
587.
 
f. Assertive Community Treatment (ACT)
 
ACT is a mobile team-based approach to delivering comprehensive and flexible
treatment, rehabilitation, case management and support services to individuals
in their natural living setting. ACT programs deliver integrated services to
recipients and adjust services over time to meet the recipient's goals and
changing needs; are operated pursuant to approval or certification by OMH; and
receive Medicaid reimbursement pursuant to 14 NYCRR Part 508.
 
g. Personalized Recovery Oriented Services (PROS)
 
PROS, licensed and reimbursed pursuant to 14 NYCCR Part 512, are designed to
assist individuals in recovery from the disabling effects of mental illness
through the coordinated delivery of a customized array of rehabilitation,
treatment, and support services in traditional settings and in off-site
locations. Specific components of PROS include Community Rehabilitation and
Support, Intensive Rehabilitation, Ongoing Rehabilitation and Support and
Clinical Treatment.
 
11. Rehabilitation Services Provided to Residents of OMH Licensed Community
Residences (CRs) and Family Based Treatment Programs, as follows:
 
a. OMH Licensed CRs*
 
Rehabilitative services in community residences are interventions, therapies and
activities which are medically therapeutic and remedial in nature, and are
medically necessary for the maximum reduction of functional and adaptive
behavior defects associated with the person's mental illness.
 
b. Family-Based Treatment*
 
Rehabilitative services in family-based treatment programs are intended to
provide treatment to seriously emotionally disturbed children and youth to
promote their successful functioning and integration into the natural family,
community, school or independent living situations. Such services are provided
in consideration of a child's developmental stage. Those children determined
eligible for admission are placed in surrogate family homes for care and
treatment.
 
Medicaid Advantage Contract
APPENDIX K
New York City 2006
K-17
 

"These services are certified by OMH under 14 NYCRR Part 586.3, 594 and 595.
 
12. Office of Mental Retardation and Developmental Disabilities (OMRDD) Services
 
a. Long Term Therapy Services Provided by Article 16-Clinic Treatment Facilities
or Article 28 Facilities
 
These services are provided to persons with developmental disabilities including
medical or remedial services recommended by a physician or other licensed
practitioner of the healing arts for a maximum reduction of the effects of
physical or mental disability and restoration of the person to his or her best
possible functional level. It also includes the fitting, training, and
modification of assistive devices by licensed practitioners or trained others
under their direct supervision. Such services are designed to ameliorate or
limit the disabling condition and to allow the person to remain in or move to,
the least restrictive residential and/or day setting. These services are
certified by OMRDD under 14 NYCRR, Part 679 (or they are provided by Article 28
Diagnostic and Treatment Centers that are explicitly designated by the SDOH as
serving primarily persons with developmental disabilities). If care of this
nature is provided in facilities other than Article 28 or Article 16 centers, it
is a covered service.
 
b. Day Treatment
 
A planned combination of diagnostic, treatment and rehabilitation Services
provided to developmentally disabled individuals in need of a broad range of
services, but who do not need intensive twenty-four (24) hour care and medical
supervision. The services provided as identified in the comprehensive assessment
may include nutrition, recreation, self-care, independent living, therapies,
nursing, and transportation services. These services are generally provided in
ICF or a comparable setting. These services are certified by OMRDD under 14
NYCRR, Part 690.
 
c. Medicaid Service Coordination (MSC)
 
Medicaid Service Coordination (MSC) is a Medicaid State Plan service provided by
OMRDD which assists persons with developmental disabilities and mental
retardation to gain access to necessary services and supports appropriate to the
needs of the needs of the individual. MSC is provided by qualified service
coordinators and uses a person centered planning process in developing,
implementing and maintaining an Individualized Service Plan (ISP) with and for a
person with developmental disabilities and mental retardation. MSC promotes the
concepts of a choice, individualized services and consumer satisfaction.
 
MSC is provided by authorized vendors who have a contract with OMRDD, and who
are paid monthly pursuant to such contract. Persons who receive MSC must not
permanently reside in an ICF for persons with developmental disabilities, a
developmental center, a skilled nursing facility or any other hospital or
Medical Assistance institutional setting that provides service coordination.
They must also not concurrently be enrolled in any other comprehensive Medicaid
long term service coordination program/service including the Care at Home
Waiver.
 
Medicaid Advantage Contract
APPENDIX K
New York City 2006
K--18
 

Please note: See generic definition of Comprehensive Medicaid Case Management
(CMCM) in this section.
 
d. Home And Community Based Services Waivers (HCBS)
 
The Home and Community-Based Services Waiver serves persons with developmental
disabilities who would otherwise be admitted to an ICF/MR if waiver services
were not provided. HCBS waivers services include residential habilitation, day
habilitation, prevocational, supported work, respite, adaptive devices,
consolidated supports and services, environmental modifications, family
education and training, live-in caregiver, and plan of care support services.
These services are authorized pursuant to a SSA Section 1915(c) waiver from
DHHS.
 
e. Services Provided Through the Care At Home Program (OMRDD)
 
The OMRDD Care at Home III, Care at Home IV, and Care at Home VI waivers, serve
children who would otherwise not be eligible for Medicaid because of their
parents' income and resources, and who would otherwise be eligible for an ICF/MR
level of care. Care at Home waiver services include service coordination,
respite and assistive technologies. Care at Home waiver services are authorized
pursuant to a SSA section 1915(c) waiver from DHHS.
 
13. Comprehensive Medicaid Case Management (CMCM)
 
A program which provides "social work" case management referral services to a
targeted population (e.g.: teens, mentally ill). A CMCM case manager will assist
a client in accessing necessary services in accordance with goals contained in a
written case management plan. CMCM programs do not provide services directly,
but refer to a wide range of service Providers. Some of these services are:
medical, social, psycho-social, education, employment, financial, and mental
health. CMCM referral to community service agencies and/or medical providers
requires the case manager to work out a mutually agreeable case coordination
approach with the .agency/medical providers. Consequently, if an Enrollee of the
Contractor is participating in a CMCM program, the Contractor should work
collaboratively with the CMCM case manager to coordinate the provision of
services covered by the Contractor. CMCM programs will be instructed on how to
identify a managed care Enrollee on eMedNY and informed on the need to contact
the Contractor to coordinate service provision.
 
14. Directly Observed Therapy for Tuberculosis Disease
 
Tuberculosis directly observed therapy (TB/DOT) is the direct observation of
oral ingestion of TB medications to assure patient compliance with the
physician's prescribed medication regimen.. While the clinical management of
tuberculosis is covered in the Benefit Package, TB/DOT where applicable, can be
billed directly to MMIS by any SDOH approved fee-for-service Medicaid TB/DOT
Provider. The Contractor remains responsible for communicating, cooperating and
coordinating clinical management of TB with the TB/DOT Provider.
 
Medicaid Advantage Contract
APPENDIX K
New York City 2006
 K-19
 

15. AIDS Adult Day Health Care
 
Adult Day Health Care Programs (ADHCP) are programs designed to assist
individuals with HIV disease to live more independently in the community or
eliminate the need for residential health care services. Registrants in ADHCP
require a greater range of comprehensive health care services than can be
provided in any single setting, but do not require the level of services
provided in a residential health care setting. Regulations require that a person
enrolled in an ADHCP must require at least three (3) hours of health care
delivered on the basis of at least one (1) visit per week. While health care
services are broadly defined in this setting to include general medical care,
nursing care, medication management, nutritional services, rehabilitative
services, and substance abuse and mental health services, the latter two (2)
cannot be the sole reason for admission to the program. Admission criteria must
include, at a minimum, the need for general medical care and nursing services.
 
16. HIV COBRA Case Management
 
The HIV COBRA (Community Follow-up Program) Case Management Program is a program
that provides intensive, family-centered case management and community follow-up
activities by case managers, case management technicians, and community
follow-up workers. Reimbursement is through an hourly rate billable to Medicaid.
Reimbursable activities include intake, assessment, reassessment, service plan
development and implementation, monitoring, advocacy, crisis intervention, exit
planning, and case specific supervisory case-review conferencing.
 
17. Adult Day Health Care
 
Adult Day Health Care means care and services provided to a registrant in a
residential health care facility or approved extension site under the medical
direction of a physician and which is provided by personnel of the adult day
health care program in accordance with a comprehensive assessment of care needs
and individualized health care plan, ongoing implementation and coordination of
the health care plan, and transportation.
 
Registrant means a person who is a nonresident of the residential health care
facility who is functionally impaired and not homebound and who requires certain
preventive, diagnostic, therapeutic, rehabilitative or palliative items or
services provided by a general hospital, or residential health care facility;
and whose assessed social and health care needs, in the professional judgment of
the physician of record, nursing staff, Social Services and other professional
personnel of the adult day health care program can be met in whole or in part
satisfactorily by delivery of appropriate services in such program.
 
18. Personal Emergency Response Services (PERS)
 
Personal Emergency Response Services (PERS) are not covered by the Benefit
Package. PERS are covered on a fee-for-service basis through contracts between
the LDSS and PERS vendors.
 
Medicaid Advantage Contract
APPENDIX K
New York City 2006
K-20
 
 

--------------------------------------------------------------------------------

 

Wellcare of New York, Inc
 
Dual Eligible Medicaid Managed Care Rates
 

MMSI ID#: 02645710
 
Effective Date: 01/01/06
Region: NYC
   
County: NYC
   
Rate Code
Premium Group
Rate Amount
2370
DUALLY ELIGIBLE SSI 21-64 MALE/FEMALE
$44.45
2371
DUALLY ELIGIBLE SSI 65+ MALE/FEMALE
$46.04
 
Optional Benefits Offered:
 
R Dental
R Non-Emergent Transportation
 
Box will be checked if the optional benefit is covered by the plan

 

 

--------------------------------------------------------------------------------

APPENDIX M
 
 
Service Area

Medicaid Advantage Contract
APPENDIX M
New York City 2006
M-l
 

--------------------------------------------------------------------------------

WellCare of New York, Inc.
 
The Contractor's Medicaid Advantage service area is comprised of the following
Counties in their entirety:
 
New York
 
Medicaid Advantage Contract
APPENDIX M
New York City 2006
M-2
 

 

--------------------------------------------------------------------------------

 
 
Appendix N
 
New York City Specific Contracting Requirements
 
 
 
 
 
APPENDIX M
New York City 2006
N-l
 

--------------------------------------------------------------------------------

Appendix N New York City Specific Contracting Requirements
 
1. General
 
a) In New York City, the Contractor will comply with all provisions of the main
body and other Appendices of this Agreement, except as otherwise expressly
established in this Appendix.
 
b) This Appendix sets forth New York City Specific Contracting Requirements and
contains the following sections:
 
N. 1 Compensation for Public Health Services
N.2 Coordination with DOHMH on Public Health Initiatives
N.3 Benefits
N.4 Additional Reporting Requirements
N.5 New York City Additional Medicaid Advantage Marketing Guidelines
N.6 Guidelines for Processing Enrollments and Disenrollments in New York City
N.7 New York City Transportation Policy Guidelines
 
Schedule 1 DOHMH Public Health Services Fee Schedule
 
APPENDIX N
New York City 2006
N-2
 

 
N.I
Compensation for Public Health Services
 
1. The Contractor shall reimburse DOHMH at the rates contained in Schedule 1 of
this Appendix for Enrollees who receive the following services from DOHMH
facilities, except in those instances where DOHMH may bill Medicaid
fee-for-service.
 
a) Diagnosis and/or treatment of TB
b) HIV counseling and testing that is not part of an STD or TB visit
c) Adult immunizations
d) Dental services
 
. 2. Notwithstanding Sections 10.11 (a) (v) (C) and (b) (ii) of this Agreement,
the following requirements concerning Contractor notification and documentation
of services shall apply in New York City:
 
a) DOHMH shall confirm the Enrollee's membership in the Contractor's Medicaid
Advantage product on the date of service through EMEDNY prior to billing for
these services.
b) DOHMH must submit claims for services provided to Enrollees no later than one
year from the date of service.
c) The Contractor shall not require pre-authorization, notification to the
Contractor or , contacts with the PCP for the above mentioned services.
d) DOHMH shall make reasonable efforts to notify the Contractor that it has
provided the above mentioned services to an Enrollee.
 
APPENDIX N
New York City 2006
N-3
 

N.2
 
Coordination with DOHMH on Public Health Initiatives
 
1. Coordination with DOHMH
 
a) The Contractor shall provide the DOHMH with existing information requested by
DOHMH to conduct epidemiological investigations.
 
2. Provider Reporting Obligations
 
a) The Contractor shall make reasonable efforts to assure timely and accurate
compliance by Participating Providers with public health reporting requirements
relating to communicable disease and conditions mandated in the New York City
Health Code pursuant to 24 RCNY §§ 1103-1107 and Article 21 of the NYS Public
Health Law.
 
b)"Reasonable efforts" shall include:
 
i) educating Participating Providers on treatment guidelines and instructions
for
reporting included in the NYC DOHMH Compendium of Public Health
Requirements and Recommendations. ii) Including reporting requirements in the
Contractor's provider manual or other
written instructions or guidelines. iii) letters from the Contractor to
Participating Providers who generated claims that
suggest that an Enrollee may have a reportable disease or condition, encouraging
such providers to report and providing information on how to report. iv) Other
methods for follow up with Participating Providers, subject to DOHMH
approval, may be employed.
 
3. Enrollee Outreach/Education
 
a) The Contractor shall provide health education to Enrollees on an on-going
basis through methods such as distribution of Enrollee newsletters, health
education classes or individual counseling on preventive health and public
health topics. Each topic below shall be covered at least once every two years.
 
i) HIV/AIDS
A) Encourage Enrollee counseling and testing
B) Inform Enrollees as to availability of sterile needles and syringes ii) STDs
A) Inform Enrollees that confidential STD services are available at DOHMH
facilities for non-enrolled sexual and needle-sharing partners at no charge iii)
Injury prevention, including age appropriate anticipatory guidance iv) Domestic
violence
 
APPENDIX N
New York City 2006
N-4
 

v) Smoking cessation
vi) Asthma
vii) Immunization-influenza and pneumococcal
viii) Mental health services
ix) Diabetes
x) Screening for Cancer
xi) Chemical Dependence
xii) Physical fitness and nutrition
xiii) Cardiovascular disease and hypertension
xiv) Injury prevention including guidance on preventing falls and poisoning
xv) Preserving oral function and oral health
xvi) Stroke recognition
 
4. Provider Education
 
a) DOHMH shall prepare a public health compendium ("Compendium") with public
health guidelines, protocols, and recommendations which it shall make available
directly to Participating Providers and to the Contractor.
 
b) The Contractor shall adapt public health guidance from the Compendium for its
internal protocols, practice manuals and guidelines.
 
c) The Contractor will assist DOHMH in its efforts to disseminate electronic
materials to its Participating Providers by providing electronic addresses if
known by Contractor (fax and/or e-mail) for its Participating Providers, updated
semi- annually.
 
d) The Contractor shall promote the use of rapid HIV testing among its
Participating Providers.
 
5. MCO Staff Responsibilities and Training
 
a) Domestic Violence
 
i) The Contractor shall designate a domestic violence coordinator who can:
A) Provide technical assistance to Participating Providers in documenting cases
of domestic violence;
B) Provide referrals to Enrollees or their Participating Providers, to obtain
protective, legal and or supportive social services; and
C) Provide consultative assistance to other staff within the Contractor's
organization.
 
ii) The Contractor shall distribute a directory of resources for victims of
domestic violence to appropriate staff, such as member services staff or case
managers.
 
6. Medical Directors
 
APPENDIX N
New York City 2006
N-5
 

a) The Contractor's Medical Director shall participate in Medical Directors'
Meetings with the medical directors of the other MCOs participating in the MMC
Program in New York City and representatives of the New York City Department of
Health and Mental Hygiene. The purpose of the Medical Directors' Meetings shall
be to share public health information and data; recommend that certain public
health information be disseminated by the MCOs to their Participating Providers;
discuss public health strategies and outreach efforts and potential
collaborative projects; encourage the development ofMCO policies that support
public health strategies; and provide a vehicle for communication between the
MCOs participating in the MMC Program and the various bureaus and divisions of
the NYC Department of Health and Mental Hygiene.
 
b) The Contractor's Medical Director shall attend all periodic meetings, which
shall not exceed one every two months. In the event that the Medical Director is
unable to attend a particular meeting, the Contractor will designate an
appropriate substitute to attend the meeting.
 
c) DOHMH, following consultation with the Medical Directors, may create
workgroups on particular public health topics. The Contractor's Medical Director
may participate in any or all of the workgroups, but shall participate in at
least one of the designated workgroups.
 
7. Take Care New York
 
a) The Contractor shall:
 
i) Educate Enrollees regarding prevention and treatment of diseases and
conditions included in the Take Care New York initiative (TCNY);
 
ii) Disseminate TCNY health passports or materials containing similar content
approved by DOHMH to Enrollees;
 
iii) Disseminate reminders to obtain recommended health screenings at age
appropriate intervals to Enrollees; and
 
iv) Educate Participating Providers on recommended clinical guidelines regarding
prevention and treatment/management of diseases and conditions described in the
TCNY initiative.
 
b) The Contractor shall select one condition annually from the TCNY initiative
and perform the following:
 
i) Identify Enrollees with the condition using information from multiple sources
(e.g., utilization data, including hospitalizations and ER visits; provider
referrals; new Enrollee screenings; self-referrals by Enrollees) and maintain
such information in a patient registry; and
 
APPENDIX N
New York City 2006
N-6
 

ii) Develop and submit to DOHMH for approval a proposal to evaluate the
effectiveness of Contractor interventions for this condition by tracking service
utilization and assessing health outcomes.
 
c) The Contractor shall, upon request by DOHMH, participate in one or more TCNY
workgroups or other activities sponsored by the DOHMH.

 

APPENDIX N
New York City 2006
N-7
 

N.3 Benefits
 
1. Transitional Home Health Services Pending Placement in Personal Care Agency
Services
 
a) Transitional home health services are home health services as defined in
Appendix K of this Agreement provided by the Contractor to a Medicaid Advantage
Enrollee while the Human Resources Administration's determination regarding a
request for the provision of personal care agency services to the Enrollee is
pending. Transitional home health services are available to Medicaid Advantage
Enrollees in addition to the home health care services otherwise covered under
the Medicare and Medicaid Advantage Benefit Packages as medically necessary.
 
b) The Contractor shall be responsible for providing transitional home health
services to Medicaid Advantage Enrollees for up to a thirty (30) day period as
follows:
 
i) For Enrollees discharged from a hospital or RHCF and for whom personal care
a-gency services have been requested by the hospital/RHCF discharge planner, the
thirty (30) day period shall commence with the day following the Enrollee's
discharge from the hospital or RHCF. Transitional home health services shall not
be available if the Enrollee: was hospitalized less than thirty (30) days, was
in receipt of personal care agency services prior to his/her admission to the
hospital or RHCF, and requires the same level and hours of personal care agency
services upon discharge. ii) For Enrollees who have been receiving Medicare or
Medicaid Advantage covered home health care services in the community and for
whom personal care agency services have been ordered by the Enrollee's
physician, the thirty (30) day period shall commence with the day following the
last day that the Contractor approved home health care services to be medically
necessary.
 
c) The Contractor shall provide reasonable assistance as requested regarding the
completion of forms required by the Human Resources Administration to initiate
the review of a request for personal care agency services. Such form, commonly
referred to as the Ml 1Q, requires physician orders, signed by the licensed
physician, to be received by HRA within thirty (30) calendar days of the
physician's examination.
 
APPENDIX N
New York City 2006
N-8
 

N.4
 
Additional Reporting Requirements
 
1. DOHMH, will provide Contractor with instructions for submitting the reports
required by paragraphs 4(c), below. These instructions shall include time
frames, and requisite formats. The instructions, time frames and formats may be
modified by DOHMH upon sixty (60) days written notice to the Contractor.
 
2. The Contractor shall submit reports that are required to be submitted to
DOHMH by this Agreement electronically.
 
3. The Contractor shall pay liquidated damages of $500 to DOHMH for any report
required by paragraphs 4(c) below which is materially incomplete, contains
material misstatements or inaccurate information or is not submitted on time in
the requested format. The DOHMH shall not impose liquidated damages for a first
time infraction by the Contractor unless DOHMH deems the infraction to be a
material misrepresentation of fact or the Contractor fails to cure the first
infraction within a reasonable period of time upon notice from the DOHMH.
Liquidated damages may be waived at the sole discretion of DOHMH.
 
4. The Contractor shall submit the following reports to DOHMH:
 
a) The Contractor shall provide DOHMH with all reports submitted to SDOH
pursuant to Sections! 8.6(a)(i), (ii), (vi) and (vii) of this Agreement.
 
b) Upon request by DOHMH, the Contractor shall submit to DOHMH reports submitted
to SDOH pursuant to Section 18.6(a) (iii) of this Agreement.
 
c) Upon request by the DOHMH, the Contractor shall prepare and submit other
operational data reports. Such requests will be limited to situations in which
the desired data is considered essential and cannot be obtained through existing
Contractor reports. Whenever possible, the Contractor will be provided with
ninety (90) days notice and the opportunity to discuss and comment on the
proposed requirements before work is begun. However, the DOHMH reserves the
right to give thirty (30) days notice in circumstances where time is of the
essence.
 
 
APPENDIX N
New York City 2006
N-9

 
 

 
N.5
 
New York City Additional Medicaid Advantage Marketing Guidelines
 
1. Contractor may not market Medicaid Advantage within a two block perimeter of
an HRA facility. Additionally, when a Medicaid community office is located in a
hospital facility, Contractor may not market Medicaid Advantage within 60 feet
of the MEedicaid community office.
 
2. Contractor shall not market in h-omeless shelters.
 
 
Appendix N
New York City 2006
N-10
 

 
N.6
 
Guidelines for Processing Enrollments and Disenrollments in New York City
 
1. Notwithstanding any contrary provisions in Appendix H, in New York City,
Enrollment error reports are generated by the Enrollment Broker to the
Contractor generally within 24-48 hours of Contractor Enrollment submissions and
the Contractor is able to resubmit corrections via the Enrollment Broker before
Roster pulldown. Changes in Enrollee eligibility or Enrollment status that occur
prior to production of the monthly Roster are reported by the State to the
Contractor with their rosters. Changes in Enrollee eligibility status that occur
subsequent to production of the monthly Roster shall be reported by the
Enrollment Broker by means of the electronic bulletin board. Reports of
Disenrollments processed by the Enrollment Broker shall be reported to the
Contractor as they occur by means of the electronic bulletin board. Reports of
Disenrollments processed by HRA shall be reported to the Contractor manually as
they occur or through the HPN. In the event that the electronic bulletin board
notification process is not available for any reason, the Contractor shall use
EMEDNY to verify loss of eligibility.
 
2. With respect to Section 5 (a) (vi) of Appendix H of this Agreement, in the
event that an Enrollee loses Medicaid eligibility, the PCP Enrollment is left on
the system and removed thereafter by SDOH if no eligibility reinstatement
occurs.
 
3. Section 3 (c) (ii) of Appendix H of this Agreement is not applicable in New
York City. The Contractor shall not send verification of the infant's
demographic data to the HRA unless thirty days has expired since the date of
birth and the Contractor has not received confirmation via the HPN of a
successful Enrollment through the automated Enrollment system. When the thirty
days has expired the Contractor shall, within 10 days, send verification of the
infant's demographic data to the HRA including: the mother's name and CIN; and
the newborn's name, CIN, sex and date of birth. Upon receipt of the data, if the
Enrollment does not appear on the system, HRA will process the retroactive
Enrollment.
 
4. In New York City, Enrollees may initiate a request for an expedited
Disenrollment to the HRA. The HRA will expedite the Disenrollment process in
those cases where: an Enrollee's request for Disenrollment involves an urgent
medical need; the Enrollee is a homeless individual residing in the shelter
system in New York City; the Enrollee has HIV, ESRD, or a SPMI/SED condition;
the request involves a complaint ofnon-consenusal Enrollment; or the Enrollee is
certified blind or disabled and meets an exemption criteria. If approved, the
HRA will manually process the Disenrollment.
 
 
APPENDIX N
New York City 2006
N-ll
 
5. Notwithstanding Section 5 (a) (viii) of Appendix H of this Agreement, in New
York City, further notification by HRA is not required prior to retroactive
Disenrollment in the following instances:
 
(a) death or incarceration of an Enrollee;
 
(b) an Enrollee has duplicate CINs and is enrolled in a Contractor's Medicaid
Advantage Product or FHPlus product under more than one of the CINs; or
 
(c) where there has been communication between the Contractor and HRA or the
Enrollment Broker regarding the date of disenrollmerit.
 
Consistent with 5 (a) (viii) of Appendix H of this Agreement, the LDSS remains
responsible for sending a notice to the Contractor at the time of Disenrollment
of the Contractor's responsibility to submit to the SDOH's Fiscal Agent voided
premium claims for any full months of retroactive Disenrollment where the
Contractor was not at risk for the provision of Benefit Package Services. Such
notice shall be completed by the LDSS to include: the Disenrollment Effective
Date, the reason for the retroactive Disenrollment, and the months for which
premiums must be repaid. The Contractor has 10 days to notify the LDSS should it
refute the Disenrollment Effective Date, based on a belief that the Contractor
was at risk for the provision of Benefit Package Services for any month for
which recoupment of premium has been requested. However failure by the LDSS to
so notify the Contractor does not affect the right of SDOH to recover premium
payment as authorized by Section 3.6 of this Agreement.
 
6. In New York City, the LDSS will only accept Medicaid Advantage plan
Enrollments submitted to the Enrollment Broker via the bulletin board with the
exception of consumers currently enrolled in a mainstream plan. For consumers
enrolled in a mainstream plan. Enrollment applications will only be accepted
when submitted to the Enrollment Broker via paper application.
 
APPENDIX N
New York City 2006
N-12
 

 
N.7
 
New York City Transportation Policy Guidelines
 
1. The Medicaid Managed Care Program contractual Benefit Package in New York
City includes non emergency transportation to all medical care and services that
are covered under the Medicare and Medicaid program, regardless of whether the
specific medical service is included in the Benefit Package or paid for on a
fee-for-service basis, except for transportation costs to Methadone Maintenance
Treatment Programs. The transportation obligation includes the cost of meals and
lodging incurred when going to and returning from a provider of medical care and
services when distance and travel time require these costs.
 
2. Generally, the Contractor may provide transportation by giving or reimbursing
the Enrollee subway/bus tokens for the round trip for their medical care and
services, if public transportation is available for such care and services. The
Contractor is not required to provide transportation if the distance to the
medical appointment is so short that the Enrollee would customarily walk to
perform other routine errands. The Contractor may adopt policies requiring a
minimum distance between an Enrollee's residence and the medical appointment,
which may not be greater than ten blocks;
 
however, the policy must provide transportation for Enrollees living a lesser
distance upon a showing of special circumstances such as a physical disability
on a case-by-case basis.
 
3. If the Enrollee has disabilities or medical conditions which prevent him or
her from utilizing public transportation, the Contractor must provide accessible
transportation which is appropriate to the disability or condition such as
livery, ambulette, or taxi. The Contractor may require pre-authorization of
non-public transportation except for emergency transportation.
 
a) The Contractor shall provide livery transportation under the following
circumstances, unless the Enrollee requires transportation by ambulette or
ambulance:
 
i) The Enrollee is able to travel independently but due to a debilitating
physical or mental condition, cannot use the mass transit system. ii) The
Enrollee is traveling to and from a location that is inaccessible by mass
transit.
 
iii) The Enrollee cannot access the mass transit system due to temporary severe
weather, which prohibits use of the normal mode of transportation.
 
b) The Contractor shall provide ambulette transportation under the following
circumstances, unless the Enrollee requires transportation by ambulance:
 
i) The Enrollee requires personal assistance from the driver in entering/exiting
the Enrollee's residence, the ambulette and the medical facility.
 

 
APPENDIX N
New York City 2006
N-13
 

 
ii) The Enrollee is wheelchair-bound (non-collapsible or requires a specially
configured vehicle).
 
iii) The Enrollee has a mental impairment and requires the personal assistance
of the ambulette driver.
 
iv) The Enrollee has a severe, debilitating weakness or is mentally disoriented
as a result of medical treatment and requires the personal assistance of the
ambulette driver.
 
v) The Enrollee has a disabling physical condition that requires the use of a
walker, cane, crutch or brace and is unable to use livery service or mass
transportation.
 
c) The Contractor shall provide non-emergency ambulance transportation when the
Enrollee must be transported on a stretcher and/or requires the administration
of life support equipment by trained medical personnel. The use of non-emergency
ambulance is indicated when the Enrollee's condition would prohibit any other
form of transport.
 
4. Emergency transportation may only be provided by accessing 911 emergency
ambulances. Urgent care transportation may be provided by any mode of
transportation so long as such mode is appropriate for the medical condition or
disability experienced by the Enrollee.
 
5. If an attendant is medically necessary to accompany the Enrollee to the
medical appointment, the Contractor is responsible for the transportation of the
attendant. A medically required attendant (authorized by the attending
physician) may include a family member, friend, legal guardian or home health
worker. When a child travels to medical care and services, and an attendant is
required, the parent or guardian of the child may act as an attendant. In these
situations, the costs of the transportation, lodging and meals of the parent or
guardian may be reimbursable, and authorization of the attending physician is
not required.
 
 
 
APPENDIX N 
New York City 2006
N-14
 

 
Schedule 1 of Appendix N
 
DOHMH Public Health Services Fee Schedule
 
 
SERVICE
FEE
TB CLINIC
$125.00
IMMUNIZATION
$ 50.00
HP/ COUNSELING AND TESTING
$ 96.47
VISIT HIV COUNSELING AND NO TESTING
$90.12
HIV POST TEST COUNSELING
$ 72.54
Visit Negative Result Visit Positive Result
$90.12
LAB TESTS
$ 12.27
HP/ 1 (ELISA Test) HIV Antibody, Confirmatory (Western Blot)
$ 26.75
DENTAL SERVICES
$ 108.00

 

APPENDIX N
New York City 2006
N-15
 

--------------------------------------------------------------------------------

APPENDIX O
Reserved

Medicaid Advantage Contract
APPENDIX 0
New York City 2006
0-1
 

--------------------------------------------------------------------------------

 
APPENDIX P
 
Reserved

APPENDIX P
New York City 2006
P-l
 

 

--------------------------------------------------------------------------------

APPENDIX Q

Reserved

Medicaid Advantage Contract
APPENDIX Q
New York City 2006
Q-l
 

--------------------------------------------------------------------------------

 
APPENDIX R
 
New York City Standard Clauses
 
 
R.1 General Provisions Governing Contracts for Consultants, Professional and
Technical Services (Not-For-Profit Entities)
 
R.2 General Provisions Governing Contracts for Consultants, Professional and
Technical Services (For-Profit Entities)
 
 
 
Medicaid Advantage Contract
APPENDIX R
New York City 2006
 R-l

 
 
 
 
APPENDIX R
 
 
New York City Standard Local Clauses
 
 
 
R.I General Provisions Governing Contracts for Consultants, Professional and
Technical Services (Not-For-Profit Entities)
 
R.2 General Provisions Governing Contracts for Consultants, Professional and
Technical Services (For-Profit Entities)

 

APPENDIX R October 1, 2005
R-l

 

--------------------------------------------------------------------------------

 
 

APPENDIX R 1
 
GENERAL PROVISIONS GOVERNING CONTRACTS FOR CONSULTANTS, PROFESSIONAL AND
TECHNICAL SERVICES (Not-For-Profit entities)

CONTENTS
Page
 
 
 
Page
ARTICLE 1.
DEFINITIONS
2
 
6.5
Waiver
12
 
 
 
 
6.6
Notice
12
ARTICLE 2.
REPRESENTATIONS AND WARRANTIES
2
 
6.7
All Legal Provisions Deemed Included
12
2.1
Procurement of Agreement
2
 
6.8
Severability
12
2.2
Conflict of interest
2
 
6.9
Political Activity
12
2.3
Fair Practices
2
 
6.10
Modification
12
 
 
 
 
6.11
Paragraph Headings
13
ARTICLE 3.
AUDIT BY DEPARTMENT
AND CITY
 
3
 
6.12
No removal of records from premises
13
 
 
 
 
6.13
Inspection at site
13
ARTICLE 4.
CONVENANTS OF THE CONTRACTOR
 
3
 
6.14
Pricing
13
4.1
Employees
3
 
ARTICLE 7.
MERGER
13
4.2
Independent Contractor Status
4
 
 
 
 
4.3
Insurance
4
 
ARTICLE 8.
CONDITIONS PRECEDENT
13
4.4
Protection of City Property.
6
 
 
 
 
4.5
Confidentiality
6
 
ARTICLE 9.
PPB RULES
14
4.6
Books and Records
6
 
 
 
 
4.7
Retention of Records
6
 
ARTICLE 10.
STATE LABOR LAW AND CITY ADMINISTRTIVE
CODE
14
4.8
Compliance with Law
6
 
 
 
 
4.9
Investigation Clause
6
 
ARTICLE 11.
FORUM PROVISION
15
4.10
Assignment
8
 
 
 
 
4.11
Subcontracting
8
 
ARTICLE 12.
EQUAL EMPLOYMENT OPPORTUNITY
15
4.12
Publicity
9
 
 
 
 
4.13
Participation in an International Boycott
9
 
ARTICLE 13.
NO DAMAGE FOR DELAY
16
4.14
Inventions, Patents, and Copyrights
9
 
ARTICLE 14.
CONSULTANT REPORT INFORMATION
16
4,15
Infringements
9
 
 
 
 
4.16
Anti-Trust
10
 
ARTICLE 15.
RESOLUTION OF DISPUTES
17
 
 
 
 
15.4
Presentation of Dispute to Agency head
17
ARTICLE 5.
TERMINATION
10
 
15.5
Presentation of dispute to the controller
18
5.1
Termination of Agreement
10
 
15.6
Contract Dispute Resolution Board
19
 
 
 
 
15.7
Petition to Contract Dispute Resolution Board
19
ARTICLE 6.
MISCELLANEOUS
11
 
 
 
 
6.1
Conflict of Laws
11
 
ARTICLE 16.
PROMPT PAYMENT
20
6.2
General Release
11
 
 
 
 
6.3
Claims and Actions Thereon
11
 
 
 
 
6.4
No Claims Against Officers, Agents, or Employees
 
11
 
     

 
 
 
 

--------------------------------------------------------------------------------

ARTICLE 1. DEFINITIONS
As used throughout this Agreement, the following terms shall have the meaning
set forth below:
a. "City" shall mean the City of New York, its departments and political
subdivisions.
 
b. "Comptroller" shall mean the Comptroller of the City of New York.
 
c. "Department" or "Agency" shall mean the DEPARTMENT OF HEALTH. AND MENTAL
HYGIENE
 
d. "Commissioner" or "Administrator" shall mean the COMMISSIONER OF HEALTH AND
MENTAL
 
HYGIENE or his duly authorized representative. The term "duly authorized
representative" shall include any
 
person or persons acting within the limits of his or her authority.
 
e. "Law" or "Laws" shall include but not be limited to the New York City
Charter, the New York City AdministrativeCode, a local law of the City of New
York, and any ordinance, rule or regulation having the Force of law.
f. "Contractor"or"ConsuItant" shall mean VENDOR
 
ARTICLE 2. REPRESENTATIONS AND WARRANTIES
2.1 PROCUREMENT OF AGREEMENT
A. The Contractor represents and warrants that no person or selling agency has
been employed or retained to solicit or secure this Agreement upon an agreement
or understanding for a commission, percentage, brokerage fee, contingent fee or
any other compensation. The Contractor further represents and warrants that no
payment, gift or thing of value has been made, given or promised to obtain this
or any other agreement between the parties. The Contractor makes such
representations and warranties to induce the City to enter into this Agreement
and the City relies upon such representations and warranties in the execution
hereof.
B. For a breach or violation of such representations or warranties, the
Administrator shall have the right to annul this Agreement without liability,
entitling the City to recover all monies paid hereunder and the Contractor shall
not make claim for, or be entitled to recover, any sum or sums due under this
Agreement. This remedy, if effected, shall not constitute the sole remedy
afforded the City for the falsity or breach, nor shall it constitute a waiver of
the City's right to claim damages or refuse payment or to take any other action
provided for by law or pursuant to this Agreement.
 
2.2 CONFLICT OF INTEREST
The Contractor represents and warrants that neither it nor any of its directors,
officers, members, partners or employees, has any interest nor shall they
acquire any interest, directly or indirectly, which would or may conflict in any
manner or degree with the performance or rendering of the services herein
provided. The Contractor further represents and warrants that in the performance
of this Agreement no person having such interest or possible interest shall be
employed by it. No elected official or other officer or employee of the City or
Department, nor any person whose salary is payable, in whole or in part, from
the City Treasury, shall participate in any decision relating to this Agreement
which affects his or her personal interest or the interest of any corporation,
partnership or association in which he or she is, directly or indirectly,
interested; nor shall any such person have any interest, direct or indirect, in
this Agreement or in the proceeds thereof.
 
2.3 FAIR PRACTICES
The Contractor and each person signing on behalf of any contractor represents
and warrants and certifies, under penalty of perjury, that to the best of its
knowledge and belief:
   A. The prices in this contract have been arrived at independently without
collusion, consultation, communication, or
agreement, for the purpose of restricting competition, as to any matter relating
to such prices with any other bidder or with any competitor;
B. Unless otherwise required by law, the prices which have been quoted in this
contract and on the proposal submitted by the Contractor have not been knowingly
disclosed by the Contractor prior to the proposal opening, directly or
indirectly, to any other bidder or to any competitor; and
C. No attempt has been made or will be made by the Contractor to induce any
other person, partnership or corporation to submit or not to submit a proposal
for the purpose of restricting competition. The fact that the Contractor (a) has
published price lists, rates, ortariffs covering items being procured, (b) has
informed prospective customers of proposed

NFP.W/P.L.
-2-

or pending publication of new or revised price lists for such items, or © has
sold the same items to other customers at the same prices being bid, does not
constitute, without more, a disclosure within the meaning of the above.
 
ARTICLE 3. AUDIT BY THE DEPARTMENT AND CITY
3.1 All vouchers or invoices presented for payment to be made hereunder, and the
books, records and accounts upon which said vouchers or invoices are based are
subject to audit by the Department and by the Comptroller of the City of New
York pursuant to the powers and responsibilities as conferred upon said
Department and said Comptroller by the New York City Charter and Administrative
Code of the City of New York, as well as all orders and regulations promulgated
pursuant thereto.
 
3.2 The Contractor shall submit any and all documentation and justification in
support of expenditures or fees under this Agreement as may be required by said
Department and said Comptroller so that they may evaluate the reasonableness
ofthe charges and shall make its records available to the Department and to the
Comptroller as they consider necessary.
 
3.3 All books, vouchers, records, reports, canceled checks and any and all
similar material may be subject to periodic inspection, review and audit by the
State of New York, Federal Government and other persons duly authorized by the
City. Such audit may include examination and review ofthe source and application
of all funds whether from the City, any State, the Federal Government, private
sources or otherwise.
 
3.4 The contractor shall not be entitled to final payment under the Agreement
until all requirements have been satisfactorily met.
 
ARTICLE 4. COVENANTS OF THE CONTRACTOR
4.1 EMPLOYEES
A. All experts or consultants or employees ofthe Contractor who are employed by
the Contractor to perform work under this contract are neither employees ofthe
City nor under contract to the City and the Contractor alone is responsible for
their work, direction, compensation and personal conduct while engaged under
this Agreement. Nothing in this contract shall impose any liability or duty on
the City for the acts, omissions, liabilities or obligations ofthe Contractor
any person, firm company, agency, association, expert, consultant, independent
contractor, specialist, trainee, employee, servant, or agent, or for taxes of
any nature including but not limited to unemployment insurance, workmen's
compensation, disability benefits and social security, or, except as
specifically stated in this contract, to any person, firm or corporation.

B. The Contractor shall be solely responsible for all physical injuries or death
to its agents, servants, or employees or to any other person or damage to any
property sustained during its operations and work on the project under this
agreement resulting from any act of omission or commission or error in judgment
of any of its officers, trustees, employees, agents, servants, or independent
contractors, and shall hold harmless and indemnify the City from liability upon
any and all claims for damages on account of such injuries or death to any such
person or damages to property on account of any neglect, fault or default ofthe
Contractor, its officers, trustees, employees, agents, servants, or independent
contractors. The Contractor shall be solely responsible for the safety and
protection of all of its employees whether due to the negligence, fault or
default ofthe Contractor or not.
 
C. Workmen's Compensation and Disability Benefits
If this Agreement be of such a character that the employees engaged thereon are
required to be insured by the provision of Chapter 615 ofthe Laws of 1922, known
as the "Workmen's Compensation Law" and acts amendatory thereto, the Agreement
shall be void and of no effect unless the Contractor shall secure compensation
for the benefit of, and keep insured during the life of this Agreement such
employees in compliance with the provisions of said law, inclusive of Disability
Benefits,; and, shall furnish the Department with two (2) certificates of these
insurance coverages.
 
D. Unemployment Insurance
Unemployment Insurance coverage shall be obtained and provided by the Contractor
for its employees.

NFP.W/P.L.
-3-
 

E. Minimum Wage 
Except for those employees whose minimum wage is required to be fixed pursuant
to Section 220 of the Labor Law of the State of New York, all persons employed
by the Contractor in the performance of this Agreement shall be paid, without
subsequent deduction or rebate, unless expressly authorized by law, not less
than the minimum wage as prescribed by law. Any breach or violation of the
foregoing shall be deemed a breach or violation of a material provision of this
Agreement.
 
4.2 INDEPENDENT CONTRACTOR STATUS
The Contractor and the Department agree that the Contractor is an independent
contractor, and not an employee of the Department or the City of New York, and
that in accordance with such status as independent contractor, the Contractor
covenants and agrees that neither it nor its employees or agents will hold
themselves out as, nor claim to be, officers or employees of the City ofNew
York, or of any department, agency or unit thereof, by reason hereof, and that
they will not, by reason hereof, make any claim, demand or application to or for
any right or privilege applicable to an officer or employee of the City ofNew
York, including, but not limited to, Workmen's Compensation coverage.
Unemployment Insurance Benefits, Social Security coverage or employee retirement
membership or credit.
 
4.3 INSURANCE
A. INSURANCE REQUIREMENTS FOR CONTRACTORS
Contractors shall procure and maintain for the duration of the contract
insurance against claims for injuries to persons or damages to property which
may arise from or in connection with the performance of the work hereunder by
the Contractor, his agents, representatives, employees or subcontractors. All
required insurance policies shall be maintained with companies that may lawfully
issue the required policy and have an A.M. Best rating of at least A-7 or a
Standard and Poor's rating of at least AA, unless prior written approval is
obtained from the Mayor's Office of Operations. The cost of such insurance shall
be included in the Contractor's bid.
 
a. Minimum Scope of Insurance
Coverage shall be at least as broad as:
1. Insurance Services Office form number GL 0002 (1/73) covering Comprehensive
General Liability and Insurance Services Office form number GL 0404 covering
Broad Form Comprehensive General Liability; or Insurance Services Office
Commercial General Liability coverage ("occurrence" form CG 0001).(ED 11/85).
2.Insurance Services Office form number CA 0001 (Ed. 1/78) covering Automobile
Liability, code 1 "any auto" and endorsements CA 2232 and CA 0112.
3. Workers' Compensation insurance as required by Labor Code of the State ofNew
York and Employers Liability insurance.
 
b. Minimum Limits of Insurance
Contractor shall maintain limits no less than:
1. Comprehensive General Liability: $1,000,000.00 combined single limit per
accident for bodily injury and property damage.
2-Professional liability: 1 Million Dollars per occurrence; Three Million
Dollars Aggregate.
3. Workers' Compensation and Employers Liability: Workers' Compensation limits
as required by the Labor Code of the State of New York Employers Liability
limits of $1,000,000.00 per accident. Pursuant to Section 57 of the NYS Workers'
Compensation Law, the vendor has submitted proof of workers' compensation and
disability benefits coverage to the agency.

 

NFP.W/P.L.
-4-
 

c. Deductibles and Self-Insured Retentions
Any deductibles and self-insured retentions must be declared to and approved by
the Agency. At the option of the Agency, either: the insurer shall reduce or
eliminate such deductibles or self-insured retentions as respects and Agency,
its officers, officials and employees; or the Contractor shall procure a bond
guaranteeing payment of losses and related investigations, claim administration
and defense expenses.
 
1. General Liability and Automobile Liability Coverages
 
a. The City, its officers, officials and employees are to be covered as insured
as respects: liability arising out of activities performed by or on behalf of
the Contractor; products and completed operations of the Contractor; premises
owned, leases or used by the Contractor; or automobiles owned, leased, hired or
borrowed by the Contractor. The coverage shall contain no special limitations on
the scope of protection afforded to the City, its officers, officials and
employees.
b. The Contractor's insurance coverage shall be primary insurance as respect the
City, its officers, officials, and employees. Any other insurance or
self-insurance maintained by the Agency, its officers, officials and employees
shall be excess of and not contribute with the Contractor's insurance.
c. Any failure to comply with reporting provisions of the policies shall not
affect coverage provided to the Agency, its officers, officials, and employees.
d. The Contractor's insurance shall apply separately to each insured against
whom claim is made or suit is brought, except with respect to the limits of the
insurers liability.
 
2. Workers' Compensation and Employers Liability Coverage
The insurer shall agree to waive all rights of subrogation against the Agency,
its officers, officials, and employees for losses arising from work performed by
the Contractor for Agency. -
 
3. All Coverages
 
Each insurance policy required by this clause shall be endorsed to state that
coverage shall not be suspended, voided, cancelled by either party, reduced in
coverage or in limits except after sixty (60) days prior written notice by
certified mail, return receipt requested, has been given to the City.
 
d. Acceptability of Insurers
Insurance is to be placed with insurers with an A.M. Best rating of at least A-7
or a Standard and Poor's rating of at least AA, unless prior written approval is
obtained from the Mayor's Office of Operations.
 
e. Verification of Coverage
Contractor shall furnish the City with Certificates of Insurance effecting
coverage required by this clause.' The Certificates for each insurance policy
are to be signed by a person authorized by that insurer to bind coverage on its
behalf. The Certificates are to be on forms provided by the Agency and are to be
received and approved by the Agency before work commences. The Agency reserves
the right to obtain complete, certified copies of all required insurance
policies, at any time.
 
f. Subcontractors
Contractor shall include all subcontractors as insured under its policies or
shall furnish separate Certificates for each subcontractor. All coverages for
subcontractors shall be subject to all of the requirements stated herein.
 
B. In the event that any claim is made or any action is brought against the City
arising out of negligent or careless acts of an employee of the Contractor,
either within or without the scope of his employment, or arising out of
Contractor's negligent performance of this Agreement, then the City shall have
the right to withhold further payments hereunder for the purpose of set-off in
sufficient sums to cover the said claim or action. The rights and remedies of
the City provided for in this clause shall not be exclusive and are in addition
to any other rights and remedies provided by law or this Agreement,

 
NFP.W/P.L.
-5-

 
4.4 PROTECTION OF CITY PROPERTY
 
A. The Contractor assumes the risk of, and shall be responsible for, any loss or
damage to City property, including property and equipment leased by the City,
used in the performance of this Agreement; and caused, either directly or
indirectly by the acts, conduct, omissions or lack of good faith of the
Contractor, its officers, managerial personnel and employees, or any person,
firm, company, agent or others engaged by the Contractor as expert, consultant,
specialist or subcontractor hereunder.
 
B. In the event that any such City property is lost or damaged, except for
normal wear and tear, then the City shall have the right to withhold further
payments hereunder for the purpose of set-off, in sufficient sums to cover such
loss or damage.
 
C. The Contractor agrees to indemnify the City and hold it harmless from any and
all liability or claim for damages due to any such loss or damage to any such
City property described in subsection A above.

D. The rights and remedies of the City provided herein shall not be exclusive
and are in addition to any other rights and remedies provided by law or by this
Agreement.
 
4.5 CONFIDENTIALITY
All of the reports, information or data, furnished to or prepared, assembled or
used by the Contractor under this Agreement are to be held confidential, and
prior to publication, the Contractor agrees that the same shall not be made
available to any individual or organization without the prior written approval
of the Department.
 
4.6 BOOKS AND RECORDS
The Contractor agrees to maintain separate and accurate books, records,
documents and other evidence and accounting procedures and practices which
sufficiently and properly reflect all direct and indirect costs of any nature
expended in the performance of this Agreement.
 
4.7 RETENTION OF RECORDS
The Contractor agrees to retain all books, records, and other documents relevant
to this Agreement for six years after the final payment or termination of this
Agreement, whichever is later. City, State and Federal auditors and any other
persons duly authorized by the Department shall have full access to and the
right to examine any of said materials during said period.
 
4.8 COMPLIANCE WITH LAW
Contractor shall render all services under this Agreement in accordance with the
applicable provisions of federal, state and local laws, rules and regulations as
are in effect at the time such services are rendered.
 
4.9 INVESTIGATION CLAUSE
1. The parties to this agreement agree to cooperate fully and faithfully with
any investigation, audit or inquiry conducted by a State of New York (State) or
City of New York (City) governmental agency or authority that is empowered
directly or by designation to compel the attendance of witnesses and to examine
witnesses under oath, or conducted by the Inspector General of a governmental
agency that is a party in interest to the transaction, submitted bid, submitted
proposal, contract, lease, permit, or license that is the subject of the
investigation, audit or inquiry.
2(a) If any person who has been advised that his or her statement, and any
information from such statement, will not be used against him or her in any
subsequent criminal proceeding refuses to testify before a grand jury or other
governmental agency or authority empowered directly or by designation to compel
the attendance of witnesses and to examine witnesses under oath concerning the
award of or performance under any transaction,

NFP.W/P.L.
-6-
 

agreement, lease, permit, contract, or license entered into with the City, the
State, or any political subdivision or public authority thereof, or the Port
Authority of New York and New Jersey, or any local development corporation
within the City, or any public benefit corporation organized under the laws of
the State of New York, or;
 
(b) If any person refuses to testify for a reason other than the assertion of
his or her privilege against self-incrimination in an investigation, audit or
inquiry conducted by a City or State governmental agency or authority empowered
directly or by designation to compel the attendance of witnesses and to take
testimony under oath, or by the Inspector General of the governmental agency
that is a party in interest in, and is seeking testimony concerning the award
of, or performance under, any transaction, agreement, lease, permit, contract .
or license entered into with the City, the State, or any political subdivision
thereof or any local development corporation within the City, then;

3(a) The commissioner or agency head whose agency is a party in interest to the
transaction, submitted bid, submitted proposal, contract, lease, permit, or
license shall convene a hearing, upon not less than five (5) days written notice
to the parties involved, to determine if any penalties should attach for the
failure of a person to testify.

3(b) If any non-governmental party to the hearing requests an adjournment, the
commissioner or agency head who convened the hearing may, upon granting the
adjournment, suspend any contract, lease, permit, or license pending the final
determination pursuant to paragraph 5 below without the City incurring any
penalty or damages for delay or otherwise.

4. The penalties which may attach after a final determination by the
commissioner or agency head may include but shall not exceed:

(a) The disqualification for a period not to exceed five (5) years from the date
of an adverse determination for any person, or any entity of which such person
was a member at the time the testimony was sought, from submitting bids for, or
transacting business with, or entering into or obtaining any contract, lease,
permit or license with or from the City; and/or

(b) The cancellation or termination of any and all such existing City contracts,
leases, permits or licenses that the refusal to testify concerns and that have
not been assigned as permitted under this agreement, nor the proceeds of which
pledged, to an unaffiliated and unrelated institutional lender for fair value
prior to the issuance of the . notice scheduling the hearing, without the City
incurring any penalty or damages on account of such cancellation or termination;
monies lawfully due for goods delivered, work done, rentals, or fees accrued
prior to the cancellation or termination shall be paid by the City.

5. The commissioner or agency head shall consider and address in reaching his or
her determination and in assessing an appropriate penalty the factors in
paragraphs (a) and (b) below. He or she may also consider, if relevant and
appropriate, the criteria established in paragraphs (c) and (d) below in
addition to any other information which may be relevant and appropriate:

(a) The party's good faith endeavors or lack thereof to cooperate fully and
faithfully with any governmental investigation or audit, including but not
limited to the discipline, discharge, or disassociation of any person failing to
testify, the production of accurate and complete books and records, and the
forthcoming testimony of all other members, agents, assignees or fiduciaries
whose testimony is sought.
 
(b) The relationship of the person who refused to testify to any entity that is
a party to the hearing, including, but not limited to, whether the person whose
testimony is sought has an ownership interest in the entity and/or the degree of
authority and responsibility the person has within the entity.
 
NFP.W/P.L.
-7-
 

(c) The nexus of the testimony sought to the subject entity and its contracts,
leases, permits or licenses with the City.

(d) The effect a penalty may have on an unaffiliated and unrelated party or
entity that has a significant interest in an entity subject to penalties under 4
above, provided that the party or entity has given actual notice to the
commissioner or agency head upon the acquisition of the interest, or at the
hearing called for in 3(a) above gives notice and proves that such interest was
previously acquired. Under either circumstance the party or entity must present
evidence at the hearing demonstrating the potential adverse impact a penalty
will have on such person or entity.

6. The term "license" or "permit" as used herein shall be defined as a license,
permit, franchise or concession not granted as a matter of right.
 
(a) The term "person" as used herein shall be defined as any natural person
doing business alone or associated with another person or entity as a partner,
director, officer, principal or employee.

b) The term "entity" as used herein shall be defined as any firm, partnership,
corporation, association, or person that receives monies, benefits, licenses,
leases, or permits from or through the City or otherwise transacts business with
the City.

(c) The term "member" as used herein shall be defined as any person associated
with another person or entity as a partner, director, officer, principal or
employee.

7. . In addition to and notwithstanding any other provision of this agreement
the Commissioner or agency head may in his or her sole discretion terminate this
agreement upon not less than three (3) days written notice in the event
contractor fails to promptly report in writing to the Commissioner of
Investigation of the City of New York any solicitation of money, goods, requests
for future employment or other benefit or thing of value, by or on behalf of any
employee of the City or other person, firm, corporation or entity for any
purpose which may be related to the procurement or obtaining of this agreement
by the contractor, or affecting the performance of this contract.
 
4.10 ASSIGNMENT
A. The Contractor shall not assign, transfer, convey or otherwise dispose of
this Agreement or of Contractor's rights, obligations, duties, in whole or in
part, or of its right to execute it, or its right, title or interest in it or
any part thereof, or assign, by power of attorney or otherwise, any of the
notices due or to become due under this contract, unless the prior written
consent of the Administrator shall be obtained. Any such assignment, transfer,
conveyance or other disposition without such consent shall be void.

B. Failure of the Contractor to obtain any required consent to any assignment,
shall be cause for termination for cause, at the option of the Administrator;
and if so terminated, the City shall thereupon be relieved and discharged from
any further liability and obligation to the Contractor, its assignees or
transferees, and all monies that may become due under the contract shall be
forfeited to the City except so much thereof as may be necessary to pay the
Contractor's employees.

C. The provisions of this clause shall not hinder, prevent, or affect an
assignment by the Contractor for the benefit of its creditors made pursuant to
the laws of the State of New York.

D. This Agreement may be assigned by the City to any corporation, agency or
instrumentality having authority to accept such assignment.
 
4.11 SUBCONTRACTING
A. The Contractor agrees not to enter into any subcontracts for the performance
of its obligations, in whole or in part, under this Agreement without the prior
written approval of the Department. Two copies of each such proposed subcontract
 
NFP.W/P.L.
 -8-
 

shall be submitted to the Department with the Contractor's written request for
approval. All such subcontracts shall contain provisions specifying:
1. that the work performed by the subcontractor must be in accordance with the
terms of the Agreement between the Department and the Contractor,
2. that nothing contained in such agreement shall impair the rights of the
Department,
3. that nothing contained herein, or under the Agreement between the Department
and the Contractor, shall create any contractual relation between the
subcontractor and the Department, and
4. that the subcontractor specifically agrees to be bound by the confidentiality
provision set forthin this Agreement between the Department and the Contractor.
B. The Contractor agrees that it is fully responsible to the Department for the
acts and omissions of the subcontractors and of persons either directly or
indirectly employed by them as it is for the acts and omissions of persons
directly employed by it.

C. The aforesaid approval is required in all cases other than individual
employer-employee contracts.

D. The Contractor shall not in any way be relieved of any responsibility under
this Contract by any subcontract.
 
4.12 PUBLICITY
A. The prior written approval of the Department is required before the
Contractor or any of its employees, servants, agents, or independent contractors
may, at any time, either during or after completion or termination of this
Agreement, make any statement to the press or issue any material for publication
through any media of communication bearing on the work performed or data
collected under this Agreement.

B. If the Contractor publishes a work dealing with any aspect of performance
under this Agreement, or of the results and accomplishments attained in such
performance, the Department shall have a royalty free, non-exclusive and
irrevocable license to reproduce, publish or otherwise use and to authorize
others to use the publication.
 
4.13 PARTICIPATION IN AN INTERNATIONAL BOYCOTT
A. The Contractor agrees that neither the Contractor nor any substantially-owned
affiliated company is participating or shall participate in an international
boycott in violation of the provisions of the Export Administration Act of 1979,
as amended, or the regulations of the United States Department of Commerce
promulgated thereunder.

B. Upon the final determination by the Commerce Department or any other agency
of the United States as to, or conviction of the Contractor or a
substantially-owned affiliated company thereof, participation in an
international boycott in violation of the provisions of the Export
Administration Act of 1979, as amended, or the regulations promulgated
thereunder, the Comptroller may, at his option, render forfeit and void this
contract.
 
C. The Contractor shall comply in all respects, with the provisions of Section
6-114 of the Administrative Code of the City of New York and the rules and
regulations issued by the Comptroller thereunder.
 
4.14 INVENTIONS. PATENTS AND COPYRIGHTS
A. Any discovery or invention arising out of or developed in the course of
performance of this Agreement shall be promptly and fully reported to the
Department, and if this work is supported by a federal grant of funds, shall be
promptly and fully reported to the Federal Government for determination as to
whether patent protection on such invention shall be sought and how the rights
in the invention or discovery, including rights under any patent issued thereon,
shall be disposed of and administered in order to protect the public interest.

B. No report, document or other data produced in whole or in part with contract
funds shall be copyrighted by the Contractor nor shall any notice of copyright
be registered by the Contractor in connection with any report, document or other
data developed for the contract.

NFP.W/P.L.
-9-
 

C. In no case shall subsections A and B of this section apply to, or prevent the
Contractor from asserting or protecting its rights in any report, document or
other data, or any invention which existed prior to or was developed or
discovered independently from the activities directly related to this Agreement.
 
4.15 INFRINGEMENTS
The Contractor shall be liable to the Department and hereby agrees to indemnify
and hold the Department harmless for any damage or loss or expense sustained by
the Department from any infringement by the Contractor of any copyright,
trademark or patent rights of design, systems, drawings, graphs, charts,
specifications orprinted matter furnished orused by the Contractor in the
performance of this Agreement.

4.16 ANTI-TRUST
The Contractor hereby assigns, sells, and transfers to the City all right, title
and interest in and to any claims and causes of action arising under the
anti-trust laws of the State of New York or of the United States relating to the
particular goods or services purchased or procured by the City under this
Agreement.
 
ARTICLES. TERMINATION
5.1 TERMINATION OF AGREEMENT
 
A. The Department and/or City shall have the right to terminate this Agreement,
inwhole or in part:
1. Under any right to terminate as specified in any section of this Agreement.
2. Upon the failure of the Contractor to comply with any of the terms and
conditions of this Agreement.
3. Upon the Contractor's becoming insolvent.
4. Upon the commencement under the Bankruptcy Act of any proceeding by or
against the Contractor, either voluntarily or involuntarily. -
5. Upon the Commissioner's determination, termination is in the best interest of
the City.

B. The Department or City shall give the Contractor written notice of any
termination of this Agreement specifying therein the applicable provisions of
subsection A of this section and the effective date thereof which shall not be
less than ten (10) days from the date the notice is received.

C. The Contractor shall be entitled to apply to the Department to have this
Agreement terminated by said Department by reason of any failure in the
performance of this Agreement (including any failure by the Contractor to make
progress in the prosecution of work hereunder which endangers such performance),
if such failure arises out of causes beyond the control and without the fault or
negligence of the Contractor. Such causes may include, but are not restricted
to: acts of God or of the public enemy; acts of the Government in either its
sovereign or contractual capacity; fires; floods; epidemics; quarantine
restrictions; strikes; freight embargoes; or any other cause beyond the
reasonable control of the Contractor. The determination that such failure arises
out of causes beyond the control and without the fault or negligence of the
Contractor shall be made by the Department which agrees to exercise reasonable
judgment therein. If such a determination is made and the Agreement terminated
by the Department pursuant to such application by the Contractor, such
termination shall be deemed to be without cause.

D Upon termination of this Agreement the Contractor shall comply with the
Department or City close-out procedures, including but not limited to:

1. Accounting for and refund to the Department or City, within thirty (30) days,
any unexpended funds which have been paid to the Contractor pursuant to this
agreement.
2. Furnishing within thirty (30) days an inventory to the Department or City of
all equipment, appurtenances and property purchased through or provided under
this Agreement carrying out any Department or City directive concerning the
disposition thereof.
3. Not incurring or paying any further obligation pursuant to this Agreement
beyond the termination date. Any obligation necessarily incurred by the
Contractor on account of this Agreement prior to receipt of notice of
termination and falling due after such date shall be paid by the Department or
City in accordance with the terms of this Agreement. In no event shall the word
"obligation as used herein,,"
 
NFP.W/P.L.
 -10-
 

be construed as including any lease agreement, oral or written, entered into
between the Contractor and its landlord.
4. Turn over to the Department or City or its designees all books, records,
documents and material specifically relating to this Agreement.
5. Submit, within ninety (90) days, a final statement and report relating to
this Agreement. The report shall be made by a certified public accountant or a
licensed public accountant.
 
E. In the event the Department or City shall terminate this Agreement, in whole
or in part, as provided in paragraphs 1,2, 3, or 4 of subsection A of this
section, the Department or City may procure, upon such terms and in such manner
as deemed appropriate, services similar to those so terminated, and the
Contractor shall continue the performance of this Agreement to the extent not
terminated hereby.
 
F. Not withstanding any other provisions of this contract, the Contractor shall
not be relieved of liability to the City for damages sustained by the City by
virtue of Contractor's breach of the contract, and the City may withhold
payments to the Contractor for the purpose of set-off until such time as the
exact amount of damages due to the City from the Contractor is determined.
 
G. The provisions of the Agreement regarding confidentiality of information
shall remain in full force and effect following any termination.
 
H. The rights and remedies of the City provided in this section shall not be
exclusive and are in addition to all other rights and remedies provided by law
or under this Agreement.
 
ARTICLE 6. MISCELLANEOUS
 
6.1 CONFLICT OF LAWS
All disputes arising out of this Agreement shall be interpreted and decided in
accordance with the laws of the State of New York.
 
6.2 GENERAL RELEASE
The acceptance by the Contractor or its assignees of the final payment under
this contract, whether by voucher, judgment of any court of competent
jurisdiction or any other administrative means, shall constitute and operate as
a general release to the City from any and all claims of and liability to the
Contractor arising out of the performance of this contract.
 
6.3 CLAIMS AND ACTIONS THEREON
A. No action at law or proceeding in equity against the City or Department shall
lie or be maintained upon any claim based upon this Agreement or arising out of
this Agreement or in any way connected with this Agreement unless the Contractor
shall have strictly complied with all requirements relating to the giving of
notice and of information with respect to such claims, all as herein provided.
B. No action shall lie or be maintained against the City by Contractor upon any
claims based upon this Agreement unless such action shall be commenced within
six (6) months after the date of filing in the Office of the Comptroller of the
City of the certificate for the final payment hereunder, or within six (6)
months of the termination or conclusion of this Agreement, or within six (6)
months after the accrual of the Cause of Action, whichever first occurs.
C. In the event any claim is made or any action brought in any way relating to
the Agreement herein, the Contractor shall diligently render to the Department
and/or the City of New York without additional compensation any and all
assistance which the Department and/or the City of New York may require of the
Contractor.
 
D. The Contractor shall report to the Department in writing within three (3)
working days of the initiation by or against the Contractor of any legal action
or proceeding in connection with or relating to this Agreement.
 
NFP.W/P.L. -11-
 

6.4 NO CLAIM AGAINST OFFICERS. AGENTS OR EMPLOYEES
No claim whatsoever shall be made by the Contractor against any officer, agent
or employee of the City for, or on account of, anything done or omitted in
connection with this contract.
 
6.5 WAIVER
Waiver by the Department of a breach of any provision of this Agreement shall
not be deemed to be a waiver of any other or subsequent breach and shall not be
construed to be a modification of the terms of the Agreement unless and until
the same shall be agreed to in writing by the Department or City as required and
attached to the original Agreement.
 
6.6 NOTICE
The Contractor and the Department hereby designate the business addresses
hereinabove specified as the places where all notices, directions or
communications from one such party to the other party shall be delivered, or to
which they shall be mailed. Actual delivery of any such notice, direction or
communication to a party at the aforesaid place, or delivery by certified mail
shall be conclusive and deemed to be sufficient service thereof upon such party
as of the date such notice, direction or communication is received by the party.
Such address may be changed at any time by an instrument in writing executed and
acknowledged by the party making such change and delivered to the other party in
the manner as specified above. Nothing in this section shall be deemed to serve
as a waiver of any requirements for the service of notice or process in the
institution of an action or proceeding as provided by law, including the Civil
Practice Law and Rules.
 
6.7 ALL LEGAL PROVISIONS DEEMED INCLUDED
It is the intent and understanding of the parties to this Agreement that each
and every provision of law required to be inserted in this Agreement shall be
and is inserted herein. Furthermore, it is hereby stipulated that every such
provision is to be deemed to be inserted herein, and if, through mistake or
otherwise, any such provision is not inserted, or is not inserted in correct
form, then this Agreement shall forthwith upon the application of either party
be amended by such insertion so as to comply strictly with the law and without
prejudice to the rights of either party hereunder.
 
6.8 SEVERABILITY
If this Agreement contains any unlawful provision not an essential part of the
Agreement and which shall not appear to have been a controlling or material
inducement to the making thereof, the same shall be deemed of no effect and
shall upon notice by either party, be deemed stricken from the Agreement without
affecting the binding force of the remainder.
 
6.9 POLITICAL ACTIVITY
There shall be no partisan political activity or any activity to further the
election or defeat of any candidate for public, political or party office as
part of or in connection with this Agreement, nor shall any of the funds
provided under this Agreement be used for such purposes.
 
6.10 MODIFICATION
This Agreement may be modified by the parties in writing in a manner not
materially affecting the substance hereof. It may not be altered or modified
orally.
 
A. CONTRACT CHANGES
Changes may be made to this contract only as duly authorized by the Agency Chief
Contracting Officer of his or her designee. Vendors deviating from the
requirements of an original purchase order or contract without a duly authorized
change order document, or written contract modification or amendment, do so at
their own risk. All such duly authorized changes, modifications and amendments
will be reflected in a written change order and become a part of the original
contract. Contract changes will be made only for work necessary to complete the
work included in the original scope of the contract, and for non-material
changes to the scope of the contract. Changes are not permitted for any material
alteration in the scope of the work. Changes may include any one or more of the
following:
- Specification changes to account for design errors or omissions;
 
NFP.W/P.L. -12-
 

 
-
changes in contract amount due to authorized additional or omitted work. Any
such changes require appropriate price and cost analysis to determine
reasonableness. In addition, except for non-construction requirements contracts,
all changes that cumulatively exceed the greater often percent of the original
contract amount or $100,000 shall be approved by the City Chief Procurement
Officer;

 
-
Extensions of a contract term for good and sufficient cause for a cumulative
period not to exceed one year from the date of expiration of this current
contract. Requirements contracts shall be subject to this limitation;

 
-
Changes in delivery location;

- Changes in shipment method; and
- Any other change not inconsistent with §4-02 of the P.P.B. Rules (ed. 9/00),
or any successor Rule.

The Contractor may be entitled to a price adjustment for extra work performed
pursuant to a written change order. If any part of the contract work is
necessarily delayed by a change order, the Contractor may be entitled to an
extension of time for performance. Adjustments to price shall be validated for
reasonableness by using appropriate price and cost analysis.
 
6.11 PARAGRAPH HEADINGS
Paragraph headings are inserted only as a matter of convenience and for
reference and in no way define, limit or describe the scope or intent of this
contract and in no way affect this contract.
 
6.12 NO REMOVAL OF RECORDS FROM PREMISES
Where performance of this Agreement involves use by the Contractor of
Departmental papers, files, data or records at Departmental facilities or
offices, the Contractor shall not remove any such papers, files, data or
records, therefrom without the prior approval of the Department's designated
official.
 
6.13 INSPECTION AT SITE
The Department shall have the right to have representatives of the Department or
of the City or of the State or Federal governments present at the site of the
engagement to observe the work being performed.
 
6.14 PRICING
A. The Contractor shall when ever required during the contract, including but
not limited to the time of bidding, submit cost or pricing data and formally
certify that, to the best of its knowledge and belief, the cost or pricing date
submitted was accurate, complete, and current as of a specified date. The
Contractor shall be required to keep its submission of cost and pricing date
current until the contract has been completed.
B. The price of any change order or contract modification subject to the
conditions of paragraph A, shall be adjusted to exclude any significant sums by
which the City finds that such price was based on cost or price data furnished
by the supplier which was inaccurate, incomplete, or not current as of the date
agreed upon between the parties.
C. Time for Certification. The Contractor must certify that the cost or pricing
data submitted are accurate, complete and current as of a mutually determined
date.
D. Refusal to Submit Data. When any contractor refuses to submit the required
data to support a price, the Contracting Officer shall not allow the price.
E. Certificate of Current Cost or Pricing Data. Form of Certificate. In those
cases when cost or pricing data is required, certification shall be made using a
certificate substantially similar to the one contained in Chapter 4 of the PPB
rules and such certification shall be retained in the agency contract file.
 
ARTICLE 7. MERGER
This written Agreement contains all the terms and conditions agreed upon by the
parties hereto, and no other agreement, oral or otherwise, regarding the subject
matter of this Agreement shall be deemed to exist or to bind any of the parties
hereto, or to vary any of the terms contained herein.
 
NFP.W/P.L. -13-
 

ARTICLE 8. CONDITIONS PRECEDENT
This contract shall neither be binding nor effective unless:
A. Approved by the Mayor pursuant to the provisions of Executive Order No. 42,
dated October 9, 1975, in the event the
Executive Order requires such approval; and
B. Certified by the Mayor (Mayor's Fiscal Committee created pursuant to
Executive Order No. 43, dated October 14,1975) that performance thereof will be
in accordance with the City's financial plan; and
C. Approved by the New York State Financial Control Board (Board) pursuant to
the New York State Financial Emergency Act for the City of New York, as amended,
(the "Act"), in the event regulations of the Board pursuant to the Act require
such approval.
 
D. It has been authorized by the Mayor and the Comptroller shall have endorsed
his certificate that there remains unexpended and unapplied a balance of the
appropriation of funds applicable thereto sufficient to pay the estimated
expense of carrying out this Agreement. The requirements of this section of the
contract shall be in addition to, and not in lieu of, any approval or
authorization otherwise required for this contract to be effective and for the
expenditure of City funds.
 
ARTICLE 9. PPB RULES
This contract is subject to the Rules of the Procurement Policy Board of the
City of New York effective August 1, 1990, as amended. In the event of a
conflict between said Rules and a provision of this contract, the Rules shall
take precedence.
 
ARTICLE 10. STATE LABOR LAW AND CITY ADMINISTRATIVE CODE
1. As required by New York State Labor Law Section 220-e:
a. That in the hiring of employees for the performance of work under this
contract or any subcontract hereunder, neither the Contractor, Subcontractor,
nor any person acting on behalf of such Contractor or Subcontractor, shall by
reason of race, creed, color, sex or national origin discriminate against any
citizen of the State of New York who is qualified and available to perform the
work to which the employment relates;
b. That neither the Contractor, subcontractor, nor any person on his behalf
shall, in any manner, discriminate against or intimidate any employee hired for
the performance of work under this contract on account of race, creed, color,
sex or national origin;
c. That there may be deducted from the amount payable to the Contractor by the
City under this contract a penalty of five dollars for each person for each
calendar day during which such person was discriminated against or intimidated
in violation of the provisions of this contract; and
d. That this contract may be canceled or terminated by the City and all monies
due or to become due hereunder may be forfeited, for a second or any subsequent
violation of the terms or conditions of this section of the contract.
e. The aforesaid provisions of this section covering every contract for or on
behalf of the State or a municipality for the manufacture, sale or distribution
of materials, equipment or supplies shall be limited to operations performed
within the territorial limits of the State of New York.
 
2. As required by New York City Administrative Code Section 6-108:
a. It shall be unlawful for any person engaged in the construction, alteration
or repair of buildings or engaged in the construction or repair of streets or
highways pursuant to a contract with the City or engaged in the manufacture,
sale or distribution of materials, equipment or supplies pursuant to a contract
with the City to refuse to employ or to refuse to continue in any employment any
person on account of the race, color or creed of such person.
b. It shall be unlawful for any person or any servant, agent or employee of any
person, described in subdivision (a) above, to ask, indicate or transmit, orally
or in writing, directly or indirectly, the race, color, creed or religious
affiliation of any person employed or seeking employment from such person, firm
or corporation.
c. Disobedience of the foregoing provisions shall be deemed a violation of a
material provision of this contract.
d. Any person, or the employee, manager or owner of or officer of such firm or
corporation who shall violate any of the provisions of this section shall, upon
conviction thereof, be punished by a fine of not more than one hundred dollars
or by imprisonment for not more than thirty days, or both.

NFP.W/P.L.
-14-

ARTICLE 11. FORUM PROVISION CHOICE OF LAW. CONSENT TO JURISDICTION AND VENUE
This Contract shall be deemed to be executed in the City of New York, State of
New York. regardless of the domicile of the Contractor, and shall be governed by
and construed in accordance with the laws of the State of New York. The parties
agree that any and all claims asserted by or against the City arising under this
Contract or related thereto shall be heard and determined either in the courts
of the United States located in New York City ("Federal Courts") or in the
courts of the State of New York ("New York State Courts") located in the City
and County of New York. To effect this Agreement and intent, the Contractor
agrees:
a. If the City initiates any action against the Contractor in Federal Court or
in New York State Court, service of process may be made on the Contractor either
in person, wherever such Contractor may be found, or by registered mail
addressed to the Contractor at its address as set forth in this Contract, or to
such other address .as the Contractor may provide to the City in writing; and
b. With respect to any action between the City and the Contractor in New York
State Court, the Contractor hereby expressly waives and relinquishes any rights
it might otherwise have (I) to move to dismiss on grounds of forum non
conveniens; (ii) to remove to Federal Court; and (iii) to move for a change of
venue to a New York State Court outside New York County.
c. With respect to any action between the City and the Contractor in Federal
Court located in New York City, the Contractor expressly waives and relinquishes
any right it might otherwise have to move to transfer the action to a United
States Court outside the City of New York.
d. If the Contractor commences any action against the City in a court located
other than in the City and State of New York, upon request of the City, the
Contractor shall either consent to a transfer of the action to a court of
competent jurisdiction located in the City and State ofNew York or, if the court
where the action is initially brought will not or cannot transfer the action,
the Contractor shall consent to dismiss such action without prejudice and may
thereafter reinstitute the action in a court of competent jurisdiction in New
York City. If any provision(s) of this Article is held unenforceable for any
reason, each and all other provision(s) shall nevertheless remain in full force
and effect.
 
ARTICLE 12. EQUAL EMPLOYMENT OPPORTUNITY
This contract is subject to the requirements of Executive Order No. 50 (1980) as
revised ("E.O. 50") and the Rules and Regulations promulgated thereunder. No
contract will be awarded unless and until these requirements have been complied
with in their entirety. By signing this contract, the contractor agrees that it:
1. will not engage in any unlawful discrimination against any employee or
applicant for employment because of race, creed, color, national origin, sex
age, disability, marital status or sexual orientation with respect to all
employment decisions including, but not limited to, recruitment, hiring,
upgrading, demotion, downgrading, transfer, training, rates of pay or other
forms of compensation, layoff, termination, and all other terms and conditions
of employment;
2. the contractor agrees that when it subcontracts it will not engage in any
unlawful discrimination in the selection of subcontractors on the basis of the
owner's race, color, creed, national origin, sex, age, disability, marital
status or sexual orientation;
3. will state in all solicitations or advertisements for employees placed by or
on behalf of the contractor that all qualified applicants will receive
consideration for employment without unlawful discrimination based on race,
creed, color, national origin, sex, age, disability, marital status or sexual
orientation, or that it is an equal employment opportunity employer;
4. will send to each labor organization or representative of workers with which
it has a collective bargaining agreement or other contract or memorandum of
understanding, written notification of its equal employment opportunity
commitments under E. 0. 50 and the rules and regulations promulgated thereunder;
and
5. will furnish all information and reports including an Employment Report
before the award of the contract which are required by E. 0. 50, the rules and
regulations promulgated thereunder, and orders of the Director of the Bureau of
Labor Services ("Bureau"), and will permit access to its books, records and
accounts by the Bureau for the purposes of investigation to ascertain compliance
with such rules, regulations, and orders. The contractor understands that in the
event of its noncompliance with nondiscrimination clauses of this contract or
with any of such rules, regulations, or orders, such noncompliance shall
constitute a material breach of the contract and noncompliance with the E. 0. 50
and the rules and regulations promulgated thereunder. After a hearing held
pursuant to the rules of the Bureau, the Director may direct the imposition by
the contracting agency held of any or all of the following sanctions:
(i) disapproval of the contractor;
 
NFP.W/P.L. -15-
 

(ii) suspension or termination of the contract;
(iii) declaring the contractor in default; or '
(iv) in lieu of any of the foregoing sanctions, the Director may impose an
employment program. The Director of the Bureau may recommend to the contracting
agency head that a Board of Responsibility be convened for purposes of declaring
a contractor who has repeatedly failed to comply with E.O. 50 and the rule and
regulations promulgated thereunder to be nonresponsible. The contractor agrees
to include the provisions of the foregoing paragraphs in every subcontract or
purchase order in excess of $50,000 to which it becomes a party unless exempted
by E.O. 50 and the rules and regulations promulgated thereunder, so that such
provisions will be binding upon each subcontractor or vendor. The contractor
will take such action with respect to any subcontract or purchase order as may
be directed by the Director of the Bureau of Labor Services as a means of
enforcing such provisions, including sanctions for noncompliance. The contractor
further agrees that it will refrain from entering into any contract or contract
modification subject to E.O. 50 and the rules and regulations promulgated
thereunder with a subcontractor who is not in compliance with the requirements
of E.O. 50 and the rules and regulations promulgated thereunder.
 
ARTICLE 13. NO DAMAGE FOR DELAY
The Contractor agrees to make no claim for damages for delay in the performance
of this Contract occasioned by any act or omission to act of the City or any of
its representatives, and agrees that any such claim shall be fully compensated
for by an extension of time to complete performance of the work as provided
herein.
 
ARTICLE 14. CONSULTANT REPORT INFORMATION
A copy of each consultant report submitted by a consultant to any City official
or to any officer, employee, agent or representative of a City department,
agency, commission or body or to any corporation, association or entity whose
expenses are paid in whole or in part from the City treasury shall be furnished
to the Commissioner of the department to which such report was submitted or, if
not a City department, then to the chief controlling officer or officers of such
other office or entity. A copy of such report shall also be furnished to the
Director of the Mayor's Office of Construction for matters related to
construction or to the Director of the Mayor's Office of Operations for all
other matters.
 
ARTICLE 15. RESOLUTION OF DISPUTES
15.1 All disputes between the City and the Contractor of the kind delineated in
this section that arise under, or by virtue of this Contract shall be finally
resolved in accordance with the provisions of this section and Section 4-09 of
the Rules of the Procurement Policy Board ("PPB Rules"), and any successor Rule.
The procedure for resolving all disputes of the kind delineated herein shall be
the exclusive means of resolving any such disputes.

a. This section shall not apply to disputes concerning matters dealt with in
other sections of the PPB Rules or to disputes involving patents, copyrights,
trademarks, or trade secrets (as interpreted by the courts of New York State)
relating to proprietary rights in computer software.

b. For construction and construction-related services this section shall apply
only to disputes about the scope of work delineated by the Contract, the
interpretation of Contract Documents, the amount to be paid for extra work or
disputed work performed in connection with the Contract, the conformity of the
Contractor's work to the Contract, and the acceptability and quality of the
Contractor's work; such disputes arise when the Engineer makes a determination
with which the Contractor disagrees.

15.2 All determinations required by this section shall be made in writing,
clearly stated, with a reasoned explanation for the determination based on the
information and evidence presented to the party making the determination.
Failure to make such determination within the time period required by this
section shall be deemed a non-determination without prejudice that will allow
appeal to the next level.
 
15.3 During such time as any dispute is being presented, heard, and considered
pursuant to this section, the contract terms shall remain in full force and
effect and the Contractor shall continue to perform work in accordance with the
Contract and as directed by the Agency Chief Contracting Officer or Engineer.
Failure of the Contractor to continue the work as directed shall constitute a
waiver by the Contractor of any and all claims being presented pursuant to this
section and a material breach of Contract.

NFP.W/P.L.
-16-
 

15.4 Presentation of Dispute to Agency Head.
 
(A) Notice of Dispute and Agency Response. The Contractor shall present its
dispute in writing ("Notice of Dispute") to the Agency Head within the time
specified herein or, if no time is specified, within thirty (30) days of
receiving notice of the determination or action that is the subject of the
dispute. This notice requirement shall not be read to replace any other notice
requirements contained in the Contract. The Notice of Dispute shall include all
the facts, evidence, documents, or other basis upon which the Contractor relies
in support of its position, as well as a detailed computation demonstrating how
any amount of money claimed by the Contractor in the dispute was arrived at.
Within thirty (30) days after receipt of the detailed written submission, the
Agency Chief Contracting Officer or, in the case of construction or
construction-related services, the Engineer shall submit to the Agency Head all
materials he or she deems pertinent to the dispute. Following initial
submissions to the Agency Head, either party may demand of the other the
production of any document or other material the demanding party believes may be
relevant to the dispute. The requested party shall produce all relevant
materials that are not otherwise protected by a legal privilege recognized by
the courts of New York State. Any question of relevancy shall be determined by
the Agency Head whose decision shall be final. Wilful failure of the Contractor
to produce any requested material whose relevancy the Contractor has not
disputed, or whose relevancy has been affirmatively determined, shall constitute
a waiver by the Contractor of its claim.

(B) Agency Head Inquiry. The Agency Head shall examine the material and may, in
his or her discretion, convene an informal conference with the Contractor and
the Agency Chief Contracting Officer and, in the case of construction or
construction-related services, the Engineer to resolve the issue by mutual
consent prior to reaching a determination. The Agency Head may seek such
technical or other expertise as he or she shall deem appropriate, including the
use of neutral mediators, and require any such additional material from either
or both parties as he or she deems fit. The Agency Head's ability to render, and
the effect of, a decision hereunder shall not be impaired by any negotiations in
connection with the dispute presented, whether or not the Agency Head
participated therein. The Agency Head may or, at the request of any party to the
dispute, shall compel the participation of any other contractor with a contract
related to the work of this Contract, and that contractor shall be bound by the
decision of the Agency Head. Any contractor thus brought into the dispute
resolution proceeding shall have the same rights to make presentations and to
seek review as the Contractor initiating the dispute.

(C) Agency Head Determination. Within thirty (30) days after the receipt of all
materials and information, or such longer time as may be agreed to by the
parties, the Agency Head shall make his or her determination and shall deliver
or send a copy of such determination to the Contractor and Agency Chief
Contracting Officer and, in the case of construction or construction-related
services, the Engineer, together with a statement concerning how the decision
may be appealed.

(D) Finality of Agency Head Decision. The Agency Head's decision shall be final
and binding on all parties, unless presented to the Contract Dispute Resolution
Board pursuant to this section. The City may not take a petition to the Contract
Dispute Resolution Board. However, should the Contractor take such a petition,
the City may seek, and the Board may render, a determination less favorable to
the Contractor and more favorable to the City than the decision of the Agency
Head.

15.5 Presentation of Dispute to the Comptroller. Before any dispute may be
brought by the Contractor to the Contract Dispute Resolution Board, the
Contractor must first present its claim to the comptroller for his or her
review, investigation, and possible adjustment.

(A) Time, Form, and Content of Notice. Within thirty (30) days of its receipt of
a decision by the Agency Head, the Contractor shall submit to the Comptroller
and to the Agency Head a Notice of Claim regarding its dispute with the Agency.
The Notice of Claim shall consist of(i) a brief written statement of the
substance of the dispute, the amount of money, if any, claimed and the reason(s)
the Contractor contends the dispute was wrongly decided by the Agency Head; (ii)
a copy of the written decision of the Agency Head, and (iii) a copy of all
materials submitted by the Contractor to the Agency, including the Notice of
Dispute. The Contractor may not present to the Comptroller any material not
presented to the Agency Head, except at-the request of the Comptroller.
(B) Agency Response. Within thirty (30) days of receipt of the Notice of Claim,
the Agency shall make available to the Comptroller a copy of all material
submitted by the Agency to the Agency Head in connection with the dispute. The
Agency may not present to the Comptroller any material not presented to the
Agency Head except at the request of the Comptroller.

NFP.W/P.L.
-17-
 

(C) Comptroller Investigation. The Comptroller may investigate the claim in
dispute and, in the course of such investigation, may exercise all powers
provided in sections 7-201 and 7-203 of the New York City Administrative Code.
In addition, the Comptroller may demand of either party, and such party shall
provide, whatever additional material the Comptroller deems pertinent to the
claim, including original business records of the Contractor. Wilful failure of
the Contractor to produce within fifteen (15) days any material requested by the
Comptroller shall constitute a waiver by the Contractor of its claim. The
Comptroller may also schedule an informal conference to be attended by the
Contractor, Agency representatives, and any other personnel desired by the
Comptroller.
 
(D) Opportunity of Comptroller to Compromise or Adjust Claim. The Comptroller
shall have forty-five (45) days from his or her receipt of all materials
referred to in 5. (C) to investigate the disputed claim. The period for
investigation and compromise may be further extended by agreement between the
Contractor and. the Comptroller, to a maximum of ninety (90) days from the
Comptroller's receipt of all the materials. The Contractor may not present its
petition to the Contract Dispute Resolution Board until the period for
investigation and compromise delineated in this paragraph has expired. In
compromising or adjusting any claim hereunder, the Comptroller may not revise or
disregard the terms of the Contract between the parties.
 
15.6 Contract Dispute Resolution Board. There shall be a Contract Dispute
Resolution Board composed of:
A. the chief administrative law judge of the Office of Administrative Trials and
Hearings ("OATH") or his/her designated OATH administrative law judge, who shall
act as chairperson, and may adopt operational procedures and issue such orders
consistent with this section as may be necessary in the execution of the
Contract Dispute Resolution Board's functions, including, but not limited to,
granting extensions of time to present or respond to submissions;

B. the City Chief Procurement Officer or a designee; or in the case of disputes
involving construction, the Director of the Office of Construction or his/her
designee; any designee shall have the requisite background to consider and
resolve the merits of the dispute and shall not have participated personally and
substantially in the particular matter that is the subject of the dispute or
report to anyone who so participated, and
 
C. a neutral person with appropriate expertise. This person shall be selected by
the presiding administrative lawjudge from a prequalified panel of individuals,
established and administered by OATH, with appropriate background to act as
decision-makers in a dispute. Such individuals may not have a contract or
dispute with the City or be an officer or employee of any company or
organization that does, or regularly represents persons, companies, or
organizations having disputes with the City.
 
15.7 Petition to Contract Dispute Resolution Board. In the event the claim has
not been settled or adjusted by the Comptroller within the period provided in
this section, the Contractor, within thirty (30) days thereafter, may petition
the Contract Dispute Resolution Board to review the Agency Head determination.

(A) Form and Content of Petition by Contractor. The Contractor shall present its
dispute to the Contract Dispute Resolution Board in the form of a Petition,
which shall include (i) a brief written statement of the substance of the
dispute, the amount of money, if any, claimed and the reason(s) the Contractor
contends that the dispute was wrongly decided by the Agency Head; (ii) a copy of
the written decision of the Agency Head; (iii) copies of all materials submitted
by the Contractor to the Agency; (iv) a copy of the written decision of the
Comptroller, if any, and (v) copies of all correspondence with, or written
material submitted by the Contractor to, the Comptroller's Office. The
Contractor shall concurrently submit four complete sets of the Petition: one to
the Corporation Counsel (Attn: Commercial and Real Estate Litigation Division),
and three to the Contract Dispute Resolution Board at oath's offices with proof
of service on the Corporation Counsel. In addition, the supplier shall submit a
copy of the statement of the substance of the dispute, cited in (i) above to
both the Agency Head and the Comptroller.
 
(B) Agency Response. Within thirty (30) days of its receipt of the Petition by
the Corporation Counsel, the Agency shall respond to the brief written statement
of the Contractor and make available to the Board at oath's offices and one to
the Contractor, all material it submitted to the Agency Head and Comptroller.
Extensions of time for submittal of the agency response shall be given as
necessary upon a showing of good cause or, upon the consent of the parties, for
an initial period of up to thirty (30) days.
 
(C) Further Proceedings. The Board shall permit the Contractor to present its
case by
 
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the submission of memoranda, briefs, and oral argument. The Board shall also
permit the Agency to present its case in response to the Contractor by the
submission of memoranda, briefs, and oral argument. If requested by the
Corporation Counsel, the Comptroller shall provide reasonable assistance in the
preparation of the Agency's case. Neither the Contractor nor the Agency may
support its case with any documentation or other material that was not
considered by the Comptroller, unless requested by the Board. The Board, at its
discretion, may seek such technical or other expertise as it shall deem
appropriate and may seek, on its own or upon application of a party, any such
additional material from any party as it deems fit. The Board, in its
discretion, may combine more than one dispute between the parties of concurrent
resolution.
 
(D) Contract Dispute Resolution Board Determination. Within forty-five (45) days
of the conclusion of all written submissions and oral arguments, the Board shall
render a written decision resolving the dispute. In an unusually complex case,
the Board may render its decision in a longer period of time, not to exceed
ninety (90) days, and shall so advise the parties at the commencement of this
period. The Board's decision must be consistent with the terms of the Contract.
In reaching its decision, the Board shall accord no precedential significance to
prior decisions of the Board involving other non-related contracts.

(E) Notification of Contract Dispute Resolution Board Decision. The Board shall
send a copy of its decision to the Contractor, the Agency Chief Contracting
Officer, the Corporation Counsel, the Comptroller, and in the case of
construction or construction-related services, the Engineer. A decision in favor
of the Contractor shall be subject to the prompt payment provisions of the PPB
Rules. The Required Payment Day shall be thirty (30) days after the date the
parties are formally notified of the Board's decision.

(F) Finality of Contract Dispute Resolution Board Decision. The Board's decision
shall be final and binding on all parties. Any party may seek review of the
Board's decision solely in the form of a challenge, made within four (4) months
of the date of the Board's decision, in a court of competent jurisdiction of the
State ofNew York, County of New York, pursuant to Article 78 of the Civil
Practice Law and Rules. Such review by the court shall be limited to the
question of whether or not the Board's decision was made in violation of lawful
procedure, was affected by an error of law, or was arbitrary and capricious or
an abuse of discretion. No evidence or information shall be introduced or relied
upon in such proceeding that was not presented to the Board in accordance with
Section 4-09 of the PPB Rules.

15.8 Any termination, cancellation, or alleged breach of the Contract prior to
or during the pendency of any proceedings pursuant to this section shall not
affect or impair the ability of the Agency Head or Contract Dispute Resolution
Board to make a binding and final decision pursuant to this section.
 
ARTICLE 16. PROMPT PAYMENT
The Prompt Payment provisions set forth in Chapter 4, Section 4-06 of the
Procurement Policy Board Rules in effect at the time for this solicitation will
be applicable to payments made under this contract. The provisions require the
payment to the contractors of interest on payments made after the required
payment date except as set forth in Section 4-06 of the Rules;

The contractor must submit a proper invoice to receive payment, except where the
contract provides that the contractor will be paid at predetermined intervals
without having to submit an invoice for each scheduled payment.

Determinations of interest due will be made in accordance with the provisions of
the Procurement Policy Board Rules and General Municipal Law Section 3-a.
 
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--------------------------------------------------------------------------------

APPENDIX R2
 
GENERAL PROVISIONS GOVERNING CONTRACTS FOR CONSULTANTS, PROFESSIONAL AND
TECHNICAL SERVICES (For-Profit Entities)
 

 
 

 CONTENTS  PAGE
ARTICLE 1.
DEFINITIONS
1
ARTICLE 2.
REPRESENTATIONS AND WARRANTIES
1
ARTICLE 3.
AUDIT BY THE DEPARTMENT AND CITY 
2
ARTICLE 4. 
COVENANTS OF THE CONTRACTOR
3
ARTICLE 5.
TERMINATION
10
ARTICLE 6
MISCELLANEOUS
12
ARTICLE 7.
MERGER
15
ARTICLE 8.
CONDITIONS PRECEDENT
15
ARTICLE 9.
PPB RULES
15
ARTICLE 10.
STATE LABOR LAW AND CITY ADMINISTRATIVE CODE
15
ARTICLE 11.
FORUM PROVISION
16
ARTICLE 12
EQUAL EMPLOYMENT OPPORTUNITY
17
ARTICLE 13
NO DAMAGE FOR DELAY
18
ARTICLE 14
CONSULTANT REPORT INFORMATION
18
ARTICLE 15.
RESOLUTION OF DISPUTES
18
ARTICLE 16.
PROMPT PAYMENT
22
ARTICLE 17.
MACBRIDE PRINCIPLES ADMINISTRATIVE CODE
22

 
 
ARTICLE 1. DEFINITIONS
As used throughout this Agreement, the following a-ms shall have the meaning set
forth below:
a. "City" shall mean the City of New York, its
departments and political subdivisions.
b. "Comptroller" shall mean the Comptroller
of the City of New York.
c.  "Department" or "Agency" shall mean the DEPARTMENT OF HEALTH AND MENTAL
HYGIENE
d. "Commissioner" or "Administrator shall mean the COMMISSIONER OF HEALTH AND
MENTAL HYGIENE or his duly authorized representative. The term "duly authorized
representative" shall include any person or persons acting within the limits of
his or her authority.
e. "Law" or "Laws" shall include but not be limited to the New York City
Charter, the New York City Administrative Code, a local law of the City of New
York, and any ordinance, rule or regulation having the force of law.
f. "Contractor"or"ConsuItant" shall mean WellCare of New York, Inc.
 
ARTICLE 2. REPRESENTATIONS AND WARRANTIES

2.1 PROCUREMENT OF AGREEMENT  
A. The Contractor represents and warrants that no person or selling agency has
been employed or retained to solicit or secure this Agreement upon an agreement
or understanding for a commission, percentage, brokerage fee, contingent fee or
any other compensation. The Contractor further represents and warrants that no
payment, gift or thing of value has been made, given or promised to obtain this
or any other agreement between the parties. The Contractor makes such
representations and warranties to induce the City to enter into this Agreement
and the City relies upon such representations and warranties in the execution
hereof.

B. For a breach or violation of such representations or warranties, the
Administrator shall have the right to annul this Agreement without liability,
entitling the City to recover all monies paid hereunder and the Contractor shall
not make claim for, or be entitled to recover, any sum or sums due under this
Agreement. This remedy, if effected, shall not constitute the sole remedy
afforded the City for the falsity or breach, nor shall it constitute a waiver of
the City's right to claim damages or refuse payment or to take any other action
provided for by law or pursuant to this Agreement.
 
2.2 CONFLICT OF INTEREST
The Contractor represents and warrants that neither it nor any of its directors,
officers, members, partners or employees, has any interest nor shall they
acquire any interest, directly or indirectly, which would or may conflict in any
manner or degree with the performance or rendering of the services herein
provided. The Contractor further represents and warrants that in the performance
of this Agreement no person having such interest or possible interest shall be
employed by it. No elected official or other officer or employee of the City or
Department, nor any person whose salary is payable, in whole or in part, from
the City Treasury, shall participate in any decision relating to this Agreement
which affects his or her personal interest or the interest of any corporation,
partnership or association in which he or she is, directly or indirectly,
interested; nor shall any such person have any interest, direct or indirect, in
this Agreement or in the proceeds thereof.

2.3 FAIR PRACTICES
The Contractor and each person signing on behalf of any contractor represents
and warrants and certifies, under penalty of perjury, that to the best of its
knowledge and belief:

A. The prices in this contract have been arrived at independently without
collusion, consultation, communication, or agreement, for the purpose of
restricting competition, as to any matter relating to such prices with any other
bidder or with any competitor;
B. Unless otherwise required by law, the prices which have been quoted in this
contract and on the proposal submitted by the Contractor have not been knowingly
disclosed by the Contractor prior to the proposal opening, directly or
indirectly, to any other bidder or to any competitor; and
C. No attempt has been made or will be made by the Contractor to induce any
other person, partnership or corporation to submit or not to submit a proposal
for the purpose of restricting competition.

The fact that the Contractor (a) has published price lists, rates, or tariffs
covering items being procured, (b) has informed prospective customers of
proposed or pending publication of new or revised price lists for such items, or
(c) has sold the same items to other customers at the same prices being bid,
does not constitute, without more, a disclosure within the meaning of the above.
 
ARTICLE 3. AUDIT BY THE DEPARTMENT AND CITY
 

3.1 All vouchers or invoices presented for payment to be made hereunder, and the
books, records and accounts upon which said vouchers or invoices are based are
subject to audit by the Department and by the Comptroller of the City of New
York pursuant to the powers and responsibilities as conferred upon said
Department and said Comptroller by the New York City Charter and Administrative
Code of the City of New York, as well as all orders and regulations promulgated
pursuant thereto.
3.2 The Contractor shall submit any and all documentation and justification in
support of expenditures or fees under this Agreement as may be required by said
Department and said Comptroller so that they may evaluate the reasonableness of
the charges and shall make its records available to the Department and to the
Comptroller as they consider necessary.

 
Profit.w/P.L.
 
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3.3 All books, vouchers, records, reports, canceled checks and any and all
similar material may be subject to periodic inspection, review and audit by the
State of New York, Federal Government and other persons duly authorized by the
City. Such audit may include examination and review of the source and
application of all funds whether from the City, any State, the Federal
Government, private sources or otherwise.
3.4 The contractor shall not be entitled to final payment under the Agreement
until all requirements have been satisfactorily met.
 
ARTICLE 4. COVENANTS OF THE CONTRACTOR

4.1 EMPLOYEES

A. All experts or consultants or employees of the Contractor who are employed by
the Contractor to perform work under this contract are neither employees of the
City nor under contract to the City and the Contractor alone is responsible for
their work, direction, compensation and personal conduct while engaged under
this Agreement. Nothing in this contract shall impose any liability or duty on
the City for the acts, omissions, liabilities or obligations of the Contractor
any person, firm company, agency, association, expert, consultant, independent
contractor, specialist, trainee, employee, servant, or agent, or for taxes of
any nature including but not limited to unemployment insurance, workmen's
compensation, disability benefits and social security, or, except as
specifically stated in this contract, to any person, firm or corporation.

B. The Contractor shall be solely responsible for all physical injuries or death
to its agents, servants, or employees or to any other person or damage to any
property sustained during its operations and work on the project under this
agreement resulting from any act of omission or commissioner error in judgment
of any of its officers, trustees, Employees, agents, servants, or independent
contractors and shall hold harmless, and indemnify the city from liability upon
any and all claims for damages on account of such injuries or death to any such
person or damages to property on account for any neglect, fault or default of
the contractor, its officers trustees, employees, agents, servants, or
independent contractors. The Contractor shall be solely responsible for the
safety and protection of all of its employees whether due to the negligence,
fault or default of the contractor or not.

C. Workmen’s Compensation and Disability Benefits:
If this agreement be of such a character that the employees engages thereon are
required to be insured by the provision of Chapter 615 of the Laws of 1992,
known as the “Workmen’s Compensation Law” and acts amendatory thereto, the
agreement shall be void and of no effect unless the Contractor shall secure
compensation for the benefit of, and keep such insured during the life of this
agreement such employees compliance with the provisions of said law, inclusive
of Disabilities Benefits; and shall furnish the Department with two (2)
certificates of these insurance coverages.

D.  
Unemployment Insurance:

Unemployment Insurance coverage shall be obtained and provided by the contractor
for its employees

E. Minimum Wage
Except for those employees whose minimum wage is required to be fixed pursuant
to Section 220 of the Labor Law of the State of New York, all persons employees
by the contractor in the performance of this agreement shall be paid, without
subsequent deduction or rebate, unless expressly authorized by the law, not less
than the minimum wage as prescribed by law. Any breach or violation of the
foregoing shall be deemed a breach or violation of a material provision of this
Agreement.
 

 

Profit.w/P.L
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4.2 INDEPENDENT CONTRACTOR STATUS The Contractor and the Department agree that
the Contractor is an independent contractor, and not an employee of the
Department or the City of New York, and that in accordance with such status as
independent contractor, the Contractor covenants and agrees that neither it nor
its employees or agents will hold themselves out as, nor claim to be, officers
or employees of the City of New York, or of any department, agency or unit
thereof, by reason hereof, and that they will not, by reason hereof, make any
claim, demand or application to or for any right or privilege applicable to an
officer or employee of the City of New York, including, but not limited to,
Workmen's Compensation coverage. Unemployment Insurance Benefits, Social
Security coverage or employee retirement membership or credit.
 
4.3 INSURANCE
A. Insurance Requirements for Contractors 
Contractors shall procure and maintain for the duration of the contract
insurance against claims for injuries to persons or damages to property which
may arise from or in connection with the performance of the work hereunder by
the Contractor, his agents, representatives, employees or subcontractors. All
required insurance policies shall be maintained with companies that may lawfully
issue the required policy and have an A.M. Best rating of at least A-7 or a
Standard and Poor's rating of at least AA, unless prior written approval is
obtained from the Mayor's Office of Operations. The cost of such insurance shall
be included in the Contractor's bid.

a. Minimum Scope of Insurance
Coverage shall be at least as broad as:

1.  
Insurance Services Office form number GL 0002 (1/73) covering Comprehensive
General Liability and Insurance Services Office form number GL 0404 covering
Broad Form Commercial General Liability; Insurance General Liability; or
Insurance Services Office Commercial General Liability coverage ("occurrence"
form CG 0001).(ED 11/85).

2.  
Insurance Services Office form number CA 0001 (Ed. 1/78) covering Automobile
Liability, code 1 "any auto" and endorsements CA 2232 and CA 0112.

3.  
Workers' Compensation insurance as required by Labor Code of the State of New
York and Employers Liability insurance.

b.  
Minimum Limits of Insurance Contractor shall maintain limits no less than:

1. Comprehensive General Liability:
$1,000,000.00 combined single limit per accident for bodily injury and property
damage.
2.  Professional liability: 1 Million Dollars per occurrence; Three Million
Dollars Aggregate.
3. Workers' Compensation and Employers Liability: Workers' Compensation limits
as required by the Labor Code of the State of New York Employers Liability
limits of $1,000,000.00 per accident. Pursuant to Section 57 of the NYS Workers'
Compensation Law, the vendor has submitted proof of workers' compensation and
disability benefits coverage to the agency.
c. Deductibles and Self-Insured Retentions. Any deductibles and self-insured
retentions must be declared to and approved by the Agency. At the option of the
Agency, either: the insurer shall reduce or eliminate such deductibles or
self-insured retentions as respects the Agency, its officers, officials and
employees; or the Contractor shall procure a bond guaranteeing payment of losses
and related investigations, claim administration and defense expenses.
1. General Liability and Automobile Liability Coverages
 
 
Profit.w/P.L.
-4-
 

a.  The City, its officers, officials and employees are to be covered as insured
as respects: liability arising out of activities performed by or on behalf of
the Contractor; products and completed operations of the Contractor; premises
owned, leases or used by the Contractor; or automobiles owned, leased, hired or
borrowed by the Contractor. The coverage shall contain no special limitations on
the scope of protection afforded to the City, its officers, officials and
employees.

b. The Contractor's insurance coverage shall be primary insurance as respect the
City, its officers, officials, and employees. Any other insurance or
self-insurance maintained by the Agency, its officers, officials and employees
shall be excess of and not contribute with the Contractor's insurance.

c.  
Any failure to comply with reporting provisions of the policies shall not affect
coverage provided to the Agency, .its officers, officials, and employees.

d.  
The Contractor's insurance shall apply separately to each insured against whom
claim is made or suit is brought, except with respect to the limits of the
insurers liability.

2.  
Workers Compensation and Employers Liability Coverage

The insurer shall agree to waive all rights of subrogation against the Agency,
its officers, officials, and employees for losses /rising from work performed by
the Contractor for Agency.

3. All Coverages
Each insurance policy required by this clause shall be endorsed to state that
coverage shall not be suspended, voided, canceled by either party, reduced in
coverage or in limits except after sixty (60) days prior written notice by
certified mail, return receipt requested, has been given to the City.

d.  
Acceptability of Insurers

Insurance is to be placed with insurers with a Best's rating of no less than an
A.M. Best rating of at least A-7 or a Standard and Poor's rating of at least AA,
unless prior written approval is obtained from the Mayor's Office of Operations.

e.  
Verification of Coverage Contractor shall furnish the City with Certificates of
Insurance effecting coverage required by this clause. The Certificates for each
insurance policy are to be signed by a person authorized by that insurer to bind
coverage on its behalf. The Certificates are to be on forms provided by the
Agency and are to be received and approved by the Agency before work commences.
The Agency reserves the right to obtain complete, certified copies of all
required insurance policies, at any time.

f.  
Subcontractors

Contractor shall include all subcontractors as insured under its policies or
shall furnish separate Certificates for each subcontractor. All coverages for
subcontractors shall be subject to all of the requirements stated herein.

 

Profit.w/P.L.
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B. In the event that any claim is made or any action is brought against the City
arising out of negligent or careless acts of an employee of the Contractor,
either within or without the scope of his employment, or arising out of
Contractor's negligent performance of this Agreement, then the City shall have
the right to withhold further payments hereunder for the purpose of set-off in
sufficient sums to cover the said claim or action. The rights and remedies of
the City provided for in this clause shall not be exclusive and are in addition
to any other rights and remedies provided by law or this Agreement.

4.4 PROTECTION OF CITY PROPERTY

A. The Contractor assumes the risk of, and shall be responsible for, any loss or
damage to City property, including property and equipment leased by the City,
used in the performance of this Agreement; and caused, either directly or
indirectly by the acts, conduct, omissions or lack of good faith of the
Contractor, its officers, managerial personnel and employees, or any person,
firm, company, agent or others engaged by the Contractor as expert, consultant,
specialist or subcontractor hereunder.
B. In the event that any such City property is lost or damaged, except for
normal wear and tear, then the City shall have the right to withhold further
payments hereunder for the purpose of set-off, in sufficient sums to cover such
loss or damage.
C. The Contractor agrees to indemnify the City and hold it harmless from any and
all liability or claim for damages due to any such loss or damage to any such
City property described in subsection A above.
D. The rights and remedies of the City provided herein shall not be exclusive
and are in addition to any other rights and remedies provided by law or by this
Agreement.

 
4.5 CONFIDENTIALITY
All of the reports, information or data, furnished to or prepared, assembled or
used by the Contractor under this Agreement are to be held confidential, and
prior to publication, the Contractor agrees that the same shall not be made
available to any individual or organization without the prior written approval
of the Department.
 
4.6 BOOKS AND RECORDS
The Contractor agrees to maintain separate and accurate books, records,
documents and other evidence and accounting procedures and practices which
sufficiently and properly reflect all direct and indirect costs of any nature
expended in the performance of this Agreement.

4.7 RETENTION OF RECORDS
The Contractor agrees to retain all books, records, and other documents relevant
to this Agreement for six years after the final payment or termination of this
Agreement, whichever is later. City, State and Federal auditors and any other
persons duly authorized by the Department shall have full access to and the
right to examine any of said materials during said period.

4.8 COMPLIANCE WITH LAW
Contractor shall render all services under this Agreement in accordance with the
applicable provisions of federal, state and local laws, rules and regulations as
are in effect at the time such services are rendered.

4.9 INVESTIGATION CLAUSE
 

 
1. The parties to this agreement agree to cooperate fully and faithfully with
any investigation, audit or ' inquiry conducted by a State of New York (State)
or City of New York (City) governmental agency or authority that is empowered
directly or by designation to compel the attendance of witnesses and to examine
witnesses under oath, or conducted by the Inspector General of a governmental
agency that is a party in interest to the transaction, submitted bid, submitted
proposal, contract, lease, permit, or license that is the subject of the
investigation, audit or inquiry.
 
2.
 
Profit.w/P.L.
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(a) If any person who has been advised that his or her statement, and any
information from such statement, will not be used against him or her in any
subsequent criminal proceeding refuses to testify before a grand jury or other
governmental agency or authority empowered directly or by designation to compel
the attendance of witnesses and to examine witnesses under oath concerning the
award of or performance under any transaction, agreement, lease, permit,
contract, or license entered into with the City, the State, or any political
subdivision or public authority thereof, or the Port Authority of New York and
New Jersey, or any local development corporation within the City, or any public
benefit corporation organized under the laws of the State of New York, or;
 

2.
(b) If any person refuses to testify for-a reason other than the assertion of
his or her privilege against self-incrimination in an investigation, audit or
inquiry conducted by a City or State governmental agency or authority empowered
directly or by designation to compel the attendance of witnesses and to take
testimony under oath, or by the Inspector General of the governmental agency
that is a party in interest in, and is seeking testimony concerning the award
of, or performance under, any transaction, agreement, lease, permit, contract,
or license entered into with the City, the State, or any political subdivision
thereof or any local development corporation within the City, then;
 
3.
(a) The commissioner or agency head whose agency is a party in interest to the
transaction, submitted bid, submitted proposal, contract, lease, permit, or
license shall convene a hearing, upon not less than five (5) days written notice
to the parties involved, to determine if any penalties should attach for the
failure of a person to testify.

3. 
(b) If any non-governmental party to the hearing requests an adjournment, the
commissioner or agency head who convened the hearing may, upon granting the
adjournment, suspend any contract, lease, permit, or license pending the final
determination pursuant to paragraph 5 below without the City incurring any
penalty or damages for delay or otherwise.

4. The penalties which may attach after a final determination by the
commissioner or agency head may include but shall not exceed:

(a) The disqualification for a period not to exceed five (5) years from the date
of an adverse determination for any person, or any entity of which such person
was a member at the time the testimony was sought, from submitting bids for, or
transacting business with, or entering into or obtaining any contract, lease,
permit or license with or from the City; and/or
(b) The cancellation or termination of any and all such existing City contracts,
leases, permits or licenses that the refusal to testify concerns and that have
not been assigned as permitted under this agreement, nor the proceeds of which
pledged, to an unaffiliated and unrelated institutional lender for fair value
prior to the issuance of the notice scheduling the hearing, without the City
incurring any penalty or damages on account of such cancellation or termination;
monies lawfully due for goods delivered, work done, rentals, ' or fees accrued
prior to the cancellation or termination shall be paid by the City.

5. The commissioner or agency head shall consider and address in reaching his or
her determination and in assessing an appropriate penalty the factors in
paragraphs (a) and (b) below. He or she may also consider, if relevant and
appropriate, the criteria established in paragraphs (c) and (d) below in
addition to any other information which may be relevant and appropriate:

 
Profit.w/P.L.
 
-7-

(a) The party's good faith endeavors or lack thereof to cooperate fully and
faithfully with any governmental investigation or audit, including but not
limited to the discipline, discharge, or disassociation of any person failing to
testify, the production of accurate and complete books and records, and the
forthcoming testimony of all other members, agents, assignees or fiduciaries
whose testimony is sought.
(b) The relationship of the person who refused to testify to any entity that is
a party to the hearing, including, but not limited to, whether the person whose
testimony is sought has an ownership interest in the entity and/or the degree of
authority and responsibility the person has within the entity.
(c) The nexus of the testimony sought to the subject entity and its contracts,
leases, permits or licenses with the City.
(d) The effect a penalty may have on an unaffiliated and unrelated party or
entity that has a significant interest in an entity subject to penalties under 4
above, provided that the party or entity has given actual notice to the
commissioner or agency head upon the acquisition of the interest, or at the
hearing called for in 3 (a) above gives notice and proves that such interest was
previously acquired. Under either circumstance the party or entity must present
evidence at the hearing demonstrating the potential adverse impact a penalty
will have on such person or entity.
 
6.
(a) The term "license" or "permit" as used herein shall be defined as a license,
permit, franchise or concession not granted as a matter of right.
(b) The term "person" as used herein shall be defined as any natural person
doing business alone or associated with another person or entity as a partner,
director, officer, principal or employee.
(c) The term "entity" as used herein shall be defined as any firm, partnership,
corporation, association, or person that receives monies, benefits, licenses,
leases, or permits from or through the City or otherwise transacts business with
the City.
(d) The term "member" as used herein shall be defined as any person associated
with another person or entity as a partner, director, officer, principal or
employee,

7. In addition to and notwithstanding any other provision of this agreement the
Commissioner or agency head may in his or her sole discretion terminate this
agreement upon not less than three (3) days written notice in the event
contractor fails to promptly report in writing to the Commissioner of
Investigation of the City of New York any solicitation of money, goods, requests
for future employment or other benefit or thing of value, by or on behalf of any
employee of the City or other person, firm, corporation or entity for any
purpose which may be related to the procurement or obtaining of this agreement
by the contractor, or affecting the performance of this contract.

4.10 ASSIGNMENT
A. The Contractor shall not assign, transfer, convey or otherwise dispose of
this Agreement or of Contractor's rights, obligations, duties, in whole or in
part, or of its right to execute it, or its right, title or interest in it or
any part thereof, or assign, by power of attorney or otherwise, any of the
notices due or to become due under this contract, unless the prior written
consent of the Administrator shall be obtained. Any such assignment, transfer,
conveyance or other disposition ' without such consent shall be void.
B. Failure of the Contractor to obtain any required consent to any assignment,
shall be cause for termination for cause, at the option of the Administrator;
and if so terminated, the City shall thereupon be relieved and discharged from
any further liability and obligation to the Contractor, its assignees or
transferees, and all monies that may become due under the contract shall be
forfeited to the City

Profit.w/P.L.
-8-

except so much thereof as may be necessary to pay the Contractor's employees.
C. The provisions of this clause shall not hinder, prevent, or affect an
assignment by the Contractor for the benefit of its creditors made pursuant to
the laws of the State of New York.
D. This Agreement may be assigned by the City to any corporation, agency or
instrumentality having authority to accept such assignment.

4.11 SUBCONTRACTING
A. The Contractor agrees not to enter into any subcontracts for the performance
of its obligations, in whole or in part, under this Agreement without the prior
written approval of the Department. Two copies of each such proposed subcontract
shall be submitted to the Department with the Contractor's written request for
approval. All such subcontracts shall contain provisions specifying:
1. that the work performed by the subcontractor must be in accordance with the
terms of the Agreement between the Department and the Contractor,
2. that nothing contained in such agreement shall impair the rights of the
Department,
3. that nothing contained herein, or under the Agreement between the Department
and the Contractor, shall create any contractual relation between the
subcontractor and the Department, and
4. that the subcontractor specifically agrees to be bound by the confidentiality
provision set forth in this Agreement between the Department and the Contractor.
B. The Contractor agrees that it is fully responsible to the Department for the
acts and omissions of the subcontractors and of persons either directly or
indirectly employed by them as it is for the acts and omissions of persons
directly employed by it.
C.  The aforesaid approval is required in all cases other than individual
employer-employee contracts.
D.  The Contractor shall not in any way be relieved of any responsibility under
this Contract by any subcontract.

4.12 PUBLICITY
A.  The prior written approval of the Department is required before the
Contractor or any of its employees, servants, agents, or independent contractors
may, at any time, either during or after completion or termination of this
Agreement, make any statement to the press or issue any material for publication
through any media of communication bearing on the work performed or data
collected under this Agreement.
B.  If the Contractor publishes a work dealing with any aspect of performance
under this Agreement, or of the results and accomplishments attained in such
performance, the Department shall have a royalty free, non-exclusive and
irrevocable license to reproduce, publish or otherwise use and to authorize
others to use the publication

4.13. PARTICIPATION IN AN INTERNATIONAL BOYCOTT
A.  The Contractor agrees that neither the Contractor nor any
substantially-owned affiliated company is participating or shall participate in
an international boycott in violation of the provisions of the Export
Administration Act of 1979, as amended, or the regulations of the United States
Department of Commerce promulgated thereunder.
B. Upon the final determination by the Commerce Department or any other agency
of the United States as to, or conviction of the Contractor or a

 
Profit.w/P.L,
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substantially-owned affiliated company thereof, participation in an
international boycott in violation of the provisions of the Export
Administration Act of 1979, as amended, or the regulations promulgated
thereunder, the Comptroller may, at his option, render forfeit and void this
contract.
C. The Contractor shall comply in all respects, with the provisions of Section
6-114 of the Administrative Code of the City of New York and the rules and
regulations issued by the Comptroller thereunder.

4.14 INVENTIONS. PATENTS AND COPYRIGHTS
A. Any discovery or invention arising out of or developed in the course of
performance of this Agreement shall be promptly and fully reported to the
Department, and if this work is supported by a federal grant of funds, shall be
promptly and fully reported to the Federal Government for determination as to
whether patent protection on such invention shall be sought and how the rights
in the invention or discovery, including rights under any patent issued thereon,
shall be disposed of and administered in order to protect the public interest.
B. No report, document or other data produced in whole or in part with contract
funds shall be copyrighted by the Contractor nor shall any notice of copyright
be registered by the Contractor in connection with any report, document or other
data developed for the contract.
C. In no case shall subsections A and B of this section apply to, or prevent the
Contractor from asserting or protecting its rights in any report, document or
other data, or any invention which existed prior to or was developed or
discovered independently from the activities directly related to this Agreement.

4.15 INFRIGEMENTS
The Contractor shall be liable to the Department and hereby agrees to indemnify
and hold the Department harmless for any damage or loss or expense sustained by
the Department from any infringement by the Contractor of any copyright,
trademark or patent rights of design, systems, drawings, graphs, charts,
specifications or printed matter furnished or used by the Contractor in the
performance of this Agreement.

4.16 ANTI-TRUST
 
The Contractor hereby assigns, sells, and transfers to the City all right, title
and interest in and to any claims and causes of action arising under the
anti-trust laws of the State of New York or of the United States relating to the
particular goods or services purchased or procured by the City under this
Agreement.
 
ARTICLE 5. TERMINATION
 

5.1 TERMINATION OF AGREEMENT
A. The Department and/or City shall have the right to terminate this Agreement,
in whole or in part:
1. Under any right to terminate as specified in any section of this Agreement.
2. Upon the failure of the Contractor to comply with any of the terms and
conditions of this Agreement.
3. Upon the Contractor's becoming insolvent.
4. Upon the commencement under the Bankruptcy Act of any proceeding by or
against the Contractor, either voluntarily or involuntarily.
5. Upon the Commissioner's determination, termination is in the best interest of
the City.
B. The Department or City shall give the Contractor written notice of any
termination of this Agreement specifying therein the applicable provisions of
subsection A of this section and the effective date thereof which shall not be

 
Profit.w/P.L.
-10-
 

less than ten (10) days from the date the notice is
 
received.
C. The Contractor shall be entitled to apply to the Department to have this
Agreement terminated by said Department by reason of any failure in the
performance of this Agreement (including any failure by the Contractor to make
progress in the prosecution of work hereunder which endangers such performance),
if such failure arises out of causes beyond the control and without the fault or
negligence of the Contractor. Such causes may include, but are not restricted
to: acts of God or of the public enemy; acts of the Government in either its
sovereign or contractual capacity; fires; floods; epidemics; quarantine
restrictions; strikes; freight embargoes; or any other cause beyond the
reasonable control of the Contractor. The determination that such failure arises
out-of causes beyond the control and without the fault or negligence of the
Contractor shall be made by the Department which agrees to exercise reasonable
judgment therein. If such a determination is made and the Agreement terminated
by the Department pursuant to such application by the Contractor, such
termination shall be deemed to be without cause.
D.  Upon termination of this Agreement the Contractor shall comply with the
Department or City close-out procedures, including but not limited to:
1. Accounting for and refund to the Department or City, within thirty (30) days,
any unexpended funds which have been paid to the Contractor pursuant to this
agreement.
2. Furnishing within thirty (30) days an inventory to the Department or City of
all equipment, appurtenances and property purchased through or provided under
this Agreement carrying out any Department or City directive concerning the
disposition thereof.

3.  
Not incurring or paying any further obligation pursuant to this Agreement beyond
the termination date. Any obligation necessarily incurred by the . Contractor on
account of this Agreement prior to receipt of notice of termination and falling
due after such date shall be paid by the Department or City in accordance with
the terms of this Agreement. In no event shall the word "obligation," as used
herein, be construed as including any lease agreement, oral or written, entered
into between the Contractor and its landlord.

4.  
Turn over to the Department or City or its designees all books, records,
documents and material specifically relating to this Agreement.

5. Submit, within ninety (90) days, a final statement and report relating to
this Agreement. The report shall be made by a certified public accountant or a
licensed public accountant.
E. In the event the Department or City shall terminate this Agreement, in whole
or in part, as provided in paragraphs 1, 2, 3, or 4 of subsection A of this
section, the Department or City may procure, upon such terms and in such manner
as deemed appropriate, services similar to those so terminated, and the
Contractor shall continue the performance of this Agreement to the extent not
terminated hereby.
F. Not withstanding any other provisions of this contract, the Contractor shall
not be relieved of liability to the City for damages sustained by the City by
virtue of Contractor's breach of the contract, and the City may withhold
payments to the Contractor for the purpose of set-off until

 
Profit.w/P.L.
 -11-
 

such time as the exact amount of damages due to the City from the Contractor is
determined.
G. The provisions of the Agreement regarding confidentiality of information
shall remain in full force and effect following any termination.
H. The rights and remedies of the City provided in this section shall not be
exclusive and are in addition to all other rights and remedies provided by law
or under this Agreement.
 
ARTICLE 6. MISCELLANEOUS

6.1 CONFLICT OF LAWS
All disputes arising out of this Agreement shall be interpreted and decided in
accordance with the laws of the State of New York.

6.2 GENERAL RELEASE
The acceptance by the Contractor or its assignees of the final payment under
this contract, whether by voucher, judgment of any court of competent
jurisdiction or any other administrative means, shall constitute and operate as
a general release to the City from any and all claims of and liability to the
Contractor arising out of the performance of this contract.

6.3 CLAIMS AND ACTIONS THEREON
A. No action at law or proceeding in equity against the City or Department shall
lie or be maintained upon any claim based upon this Agreement or arising out of
this Agreement or in any way connected with this Agreement unless the Contractor
shall have strictly complied with all requirements relating to the giving of
notice and of information with respect to such claims, all as herein provided.
B. No action shall lie or be maintained against the City by Contractor upon any
claims based upon this Agreement unless such action shall be commenced within
six (6) months after the date of filing in the Office of the Comptroller of the
City of the certificate for the final payment hereunder, or within six (6)
months of the termination or conclusion of this Agreement, or within six (6)
months after the accrual of the Cause of Action, whichever first occurs.
 
C. In the event any claim is made or any action brought in any way relating to
the Agreement herein, the Contractor shall diligently render to the Department
and/or the City of New York without additional compensation any and all
assistance which the Department and/or the City of New York may require of the
Contractor.
D. The Contractor shall report to the Department in writing within three (3)
working days of the initiation by or against the Contractor of any legal action
or proceeding in connection with or relating to this Agreement.

6.4 NO CLAIM AGAINST OFFICERS. AGENTS OR EMPLOYEES 
No claim whatsoever shall be made by the Contractor against any officer, agent
or employee of the City for, or on account of, anything done or omitted in
connection with this contract.

6.5 WAIVER
Waiver by the Department of a breach of any provision of this Agreement shall
not be deemed to be a waiver of any other or subsequent breach and shall not be
construed to be a modification of the terms of the Agreement unless and until
the same shall be agreed to in writing by the Department or City as required and
attached to the original Agreement.

6.6 NOTICE
The Contractor and the Department hereby designate the business addresses
hereinabove specified as the places where all notices, directions or
communications from one such party to the other party shall be delivered, or to
which they shall be mailed. Actual delivery of any such notice, direction or
communication to a party at the

Profit.w/P.L.
-12-

aforesaid place, or delivery by certified mail shall be conclusive and deemed to
be sufficient service thereof upon such party as of the date such notice,
direction or communication is received by the party. Such address may be changed
at any time by an instrument in writing executed and acknowledged by the party
making such change and delivered to the other party in the manner as specified
above. Nothing in this section shall be deemed to serve as a waiver of any
requirements for the service of notice or process in the institution of an
action or proceeding as provided by law, including the Civil Practice Law and
Rules.

6.7 ALL LEGAL PROVISIONS DEEMED INCLUDED
It is the intent and understanding of the parties to this Agreement that each
and every provision of law required to be inserted in this Agreement shall be
and is inserted herein. Furthermore, it is hereby stipulated that every such
provision is to be deemed to be inserted herein, and if, through mistake or
otherwise, any such provision is not inserted, or is not inserted in correct
form, then this Agreement shall forthwith upon the application of either party
be amended by such insertion so as to comply strictly with the law and without
prejudice to the rights of either party hereunder.

6.8 SEVERABILITY
If this Agreement contains any unlawful provision not an essential part of the
Agreement and which shall not appear to have been a controlling or material
inducement to the making thereof, the same shall be deemed of no effect and
shall upon notice by either party, be deemed stricken from the Agreement without
affecting the binding force of the remainder.

6.9 POLITICAL ACTIVITY
There shall be no partisan political activity or any activity to further the
election or defeat of any candidate for public, political or party office as
part of or in connection with this Agreement, nor shall any of the funds
provided under this Agreement be used for such purposes.

6.10 MODIFICATION
This Agreement may be modified by the parties in writing in a manner not
materially affecting the substance hereof. It may not be altered or modified
orally.
 
A. CONTRACT CHANGES Changes may be made to this contract only as duly authorized
by the Agency Chief Contracting Officer of his or her designee. Vendors
deviating from the requirements of an original purchase order or contract
without a duly authorized change order document, or written contract
modification or amendment, do so at their own risk. All such duly authorized
changes, modifications and amendments will be reflected in a written change
order and become a part of the original contract. Contract changes will be made
only for work necessary to complete the work included in the original scope of
the contract, and for non-material changes to the scope of the contract. Changes
are not permitted for any material alteration in the scope of the work. Changes
may include any one or more of the following:
- Specification changes to account for design errors or omissions;
- changes in contract amount due to authorized additional or omitted work. Any
such changes require appropriate price and cost analysis to determine
reasonableness. In addition, except for non-construction requirements contracts,
all changes that cumulatively exceed the greater often percent of the original
contract amount or $100,000 shall be approved by the City Chief Procurement
Officer;
- Extensions of a contract term for good and sufficient cause for a cumulative
period not to exceed one year from the date of expiration of this current
contract. Requirements contracts shall be subject to this limitation;
- Changes in delivery location;
 
- Changes in shipment method; and
- Any other change not inconsistent with

Profit.w/P.L.
-13-
 

§ 5-02 of the P.P.B. Rules (ed. 9/99), or any successor Rule.

The Contractor may be entitled to a price adjustment for extra work performed
pursuant to a written change order. If any part of the contract work is
necessarily delayed by a change order, the Contractor may be entitled to an
extension of time for performance. Adjustments to price shall be validated for
reasonableness by using appropriate price and cost analysis.

6.11 PARAGRAPH HEADINGS
Paragraph headings are inserted only as a matter of convenience and for
reference and in no way define, limit or describe the scope or intent of this
contract and in no way affect this contract.

6.12 NO REMOVAL OF RECORDS FROM PREMISES
Where performance of this Agreement involves use by the Contractor of
Departmental papers, files, data or records at Departmental facilities or
offices, the Contractor shall not remove any such papers, files, data or
records, therefrom without the prior approval of the Department's designated
official.

6.13 INSPECTION AT SITE
The Department shall have the right to have representatives of the Department or
of the City or of the State or Federal governments present at the site of the
engagement to observe the work being performed.

6.14 PRICING
A.  The Contractor shall when ever required during the contract, including but
not limited to the time of bidding, submit cost or pricing data and formally
certify that, to the best of its knowledge and belief, the cost or pricing date
submitted was accurate, complete, and current as of a specified date. The
Contractor shall be required to keep its submission of cost and pricing date
current until the contract has been completed.
B. The price of any change order or contract modification subject to the
conditions of paragraph A, shall be adjusted to exclude any significant sums by
which the City finds that such price was based on cost or price data furnished
by the supplier which was inaccurate, incomplete, or not current as of the date
agreed upon between the parties.

C.  
Time for Certification. The Contractor must certify that the cost or pricing
data submitted are accurate, complete and current as of a mutually determined
date

D. Refusal to Submit Data. When any contractor refuses to submit the required
data to support a price, the Contracting Officer shall not allow the price.
E. Certificate of Current Cost or Pricing Data.
Form of Certificate. In those cases when cost or pricing data is required,
certification shall be made using a certificate substantially similar to the one
contained in Chapter 4 of the PPB rules and such certification shall be retained
in the agency contract file.

ARTICLE 7. MERGER

This written Agreement contains all the terms and conditions agreed upon by the
parties hereto, and no other agreement, oral or otherwise, regarding the subject
matter of tills Agreement shall be deemed to exist or to bind any of the parties
hereto, or to vary any of the terms contained herein.

ARTICLE 8. CONDITIONS PRECEDENT
This contract shall neither be binding nor effective unless:
A.  Approved by the Mayor pursuant to the provisions of Executive Order No. 42,
dated October 9, 1975, in the event the Executive Order requires such approval;
and

Profit.w/P.L.
-14-

 

B.
Certified by the Mayor (Mayor's Fiscal Committee created pursuant to Executive
Order No. 43, dated October 14, 1975) that performance thereof will be in
accordance with the City's financial plan; and

C.  Approved by the New York State Financial Control Board (Board) pursuant to
the New York State Financial Emergency Act for the City of New York, as amended,
(the "Act"), in the event regulations of the Board pursuant to the Act require
such approval.
D.  It has been authorized by the Mayor and the Comptroller shall have endorsed
his certificate that there remains unexpended and unapplied a balance of the
appropriation of funds applicable thereto sufficient to pay the estimated
expense of carrying out this Agreement.

The requirements of this section of the contract shall be in addition to, and
not in lieu of, any approval or authorization otherwise required for this
contract to be effective and for the expenditure of City funds.
 
ARTICLE 9. PPB RULES
This contract is subject to the Rules of the Procurement Policy Board of the
City of New York effective August 1, 1990, as amended. In the event of a
conflict between said Rules and a provision of this contract, the Rules shall
take precedence.
 
ARTICLE 10. STATE LABOR LAW AND CITY ADMINISTRATIVE CODE
1. As required by New York State Labor Law Section 220-e:
a. That in the hiring of employees for the performance of work under this
contract or any subcontract hereunder, neither the Contractor, Subcontractor,
nor any person acting on behalf of such Contractor or Subcontractor, shall by
reason of race, creed, color, sex or national origin discriminate against any
citizen of the State of New York who is qualified and available to perform the
work to which the employment relates;
b.  That neither the Contractor, subcontractor, nor any person on his behalf
shall, in any manner, discriminate against or intimidate any employee hired for
the performance of work under this contract on account of race, creed, color,
sex or national origin;
c. That there may be deducted from the amount payable to the Contractor by the
City under this contract a penalty of five dollars for each person for each
calendar day during which such person was discriminated against or intimidated
in violation of the provisions of this contract; and
d. That this contract may be canceled or terminated by the City and all monies
due or to become due hereunder may be forfeited, for a second or any subsequent
violation of the terms or conditions of this section of the contract.
e. The aforesaid provisions of this section covering every contract for or on
behalf of the State or a municipality for the manufacture, sale or distribution
of materials, equipment or supplies shall be limited to operations performed
within the territorial limits of the State of New York.
2. As required by New York City Administrative Code Section 6-108:
a. It shall be unlawful for any person engaged in the construction, alteration
or repair of buildings or engaged in the construction or repair of streets or
highways pursuant to a contract with the City or. engaged in the manufacture,
sale or distribution of' materials, equipment or supplies pursuant to a contract
with the City to refuse to employ or to refuse to continue in any employment any
person on account of the race, color or creed of such person.
b. It shall be unlawful for any person or any servant, agent or employee of any
person, described in subdivision (a) above, to ask, indicate or transmit, orally
or in writing, directly or indirectly, the race, color, creed or religious
affiliation of any person employed or seeking employment from such person, firm
or corporation.

 
Profit.w/P.L. 15-
 

c. Disobedience of the foregoing provisions shall be deemed a violation of a
material provision of this contract.
d. Any person, or the employee, manager or owner of or officer of such firm or
corporation who shall violate any of the provisions of this section shall, upon
conviction thereof, be punished by a fine of not more than one hundred dollars
or by imprisonment for not more than thirty days, or both.
 
ARTICLE 11. FORUM PROVISION
Choice of Law, Consent to Jurisdiction and Venue This Contract shall be deemed
to be executed in the City of New York, State of New York, regardless of the
domicile of the Contractor, and shall be governed by and construed in accordance
with the laws of the State of New York.
The parties agree that any and all claims asserted by or against the City
arising under this Contract or related thereto shall be heard and determined
either in the courts of the United States located in New York City ("Federal
Courts") or in the courts of the State of New York ("New York State Courts")
located in the City and County of New York. To effect this Agreement and intent,
the Contractor agrees:
a. If the City initiates any action against the
Contractor in Federal Court or in New York State Court, service of process may
be made on the Contractor either in person, wherever such Contractor may be
found, or by registered mail addressed to the Contractor at its address as set
forth in this Contract, or to such other address as the Contractor may provide
to the City in writing; and
b. With respect to any action between the City and the Contractor in New York
State Court, the Contractor hereby expressly waives and relinquishes any rights
it might otherwise have (I) to move to dismiss on grounds of forum non
conveniens; (ii) to remove to Federal Court; and (iii) to move for a change of
venue to a New York State Court outside New York County.
c. With respect to any action between the City and the Contractor in Federal
Court located in New York City, the Contractor expressly waives and relinquishes
any right it might otherwise have to move to transfer the action to a United
States Court outside the City of New York.
d. If the Contractor commences any action against the City in a court located
other than in the City and State of New York, upon request of the City, the
Contractor shall either consent to a transfer of the action to a court of
competent jurisdiction located in the City and State of New York or, if the
court where the action is initially brought will not or cannot transfer the
action, the Contractor shall consent to dismiss such action without prejudice
and may thereafter reinstitute the action in a court of competent jurisdiction
in New York City. If any provision(s) of this Article is held unenforceable for
any reason, each and all other provision(s) shall nevertheless remain in full
force and effect.
 
ARTICLE 12. EQUAL EMPLOYMENT OPPORTUNITY
This contract is subject to the requirements of Executive Order No. 50 (1980) as
revised ("E.O. 50") and the Rules and Regulations promulgated thereunder. No
contract will be awarded unless and until these requirements have been complied
with in their entirety. By signing this contract, the contractor agrees that it:
1. will not engage in any unlawful discrimination against any employee or
applicant for employment because of race, creed, color, national origin, sex
age, disability, marital status or sexual orientation with respect to all
employment decisions including, but not limited to, recruitment, hiring,
upgrading, demotion, downgrading, transfer, training, rates of pay or other
forms of compensation, layoff, termination, and all other terms and conditions
of employmEnt;
2. the contractor agrees that when it subcontracts it will not engage in any
unlawful discrimination in
 

Profit.w/P.L.
16-
 
the selection of subcontractors on the basis of the owner's race, color, creed,
national origin, sex, age. disability, marital status or sexual orientation;
3. will state in all solicitations or advertisements for employees placed by or
on behalf of the contractor that all qualified applicants will receive
consideration for employment without unlawful discrimination based on race,
creed, color, national origin, sex, age, disability, marital status or sexual
orientation, or that it is an equal employment opportunity employer;
4. will send to each labor organization or representative of workers with which
it has a collective bargaining agreement or other contract or memorandum of
understanding, written notification of its equal employment opportunity
commitments under E. 0. 50 and the rules and regulations promulgated thereunder;
and
5. will furnish all information and reports including an Employment Report
before the award of the contract which are required by E-. 0. 50, the rules and
regulations promulgated thereunder, and orders of the Director of the Bureau of
Labor Services ("Bureau"), and will permit access to its books, records and
accounts by the Bureau for the purposes of investigation to ascertain compliance
with such rules, regulations, and orders. The contractor understands that in the
even of its noncompliance with nondiscrimination clauses of this contract or
with any of such rules, regulations, or orders, such noncompliance shall
constitute a material breach of the contract and noncompliance with the E. 0. 50
and the rules and regulations promulgated thereunder. After a hearing held
pursuant to the rules of the Bureau, the Director may direct the imposition by
the contracting agency held of any or all of the following sanctions:
(I) disapproval of the contractor;
(ii) suspension or termination of the contract;
(iii) declaring the contractor in default; or (iv) in lieu of any of the
foregoing sanctions, the Director may impose an employment program.
The Director of the Bureau may recommend to the contracting agency head that a
Board of Responsibility be convened for purposes of declaring a contractor who
has repeatedly failed to comply with E.O. 50 and the rule and regulations
promulgated thereunder to be nonresponsible. The contractor agrees to include
the provisions of the foregoing paragraphs in every subcontract or purchase
order in excess of $50,000 to which it becomes a party unless exempted by E.O.
50 and the rules and regulations promulgated thereunder, so that such provisions
will be binding upon each subcontractor or vendor. The contractor will take such
action with respect to any subcontract or purchase order as may be directed by
the Director of the Bureau of Labor Services as a means of enforcing such
provisions, including sanctions for noncompliance.
The contractor further agrees that it will refrain from entering into any
contract or contract modification subject to E.O. 50 and the rules and
regulations promulgated thereunder with a subcontractor who is not in compliance
with the requirements of E.O. 50 and the rules and regulations promulgated
thereunder.
 
ARTICLE 13. NO DAMAGE FOR DELAY
The Contractor agrees to make no claim for damages for delay in the performance
of this Contract occasioned by any act or omission to act of the City or any of
its representatives, and agrees that any such claim shall be fully compensated
for by an extension of time to complete performance of the work as provided
herein.
 
ARTICLE 14. CONSULTANT REPORT INFORMATION
 
A copy of each consultant report submitted by a consultant to any City official
or to any officer, employee, agent or representative of a City department,
agency, commission or body or to any
 

 
Profit.w/P.L.
-17-

corporation, association or entity whose expenses are paid in whole or in part
from the City treasury shall be furnished to the Commissioner of the department
to which such report was submitted or, if not a City department, then to the
chief controlling officer or officers of such other office or entity. A copy of
such report shall also be furnished to the Director of the Mayor's Office of
Construction for matters related to construction or to the Director of the
Mayor's Office of Operations for all other matters.
 
ARTICLE 15. RESOLUTION OF DISPUTES
 
15.1 All disputes between the City and the Contractor of the kind delineated in
this section that arise under, or by virtue of, this Contract shall be finally
resolved in accordance with the provisions of this section and Section 5-11 of
the Rules of the Procurement Policy Board ("PPB Rules"). The procedure for
resolving all disputes of the kind delineated herein shall be the exclusive
means of resolving any such disputes.
 
a. This section shall not apply to disputes concerning matters dealt with in
other sections of the PPB Rules or to disputes involving patents, copyrights,
trademarks, or trade secrets (as interpreted by the courts of New York State)
relating to proprietary rights in computer software.
 
b. For construction and construction-related services this section shall apply
only to
disputes about the scope of work delineated by the Contract, the interpretation
of Contract Documents, the amount to be paid for extra work or disputed work
performed in connection with the Contract, the conformity of the Contractor's
work to the Contract, and he acceptability and quality of the Contractor's work;
such disputes arise when the Engineer makes a determination with which the
Contractor disagrees.
5.2 All determinations required by this section shall be made in writing,
clearly stated, with a reasoned explanation for the determination based on the
information and evidence presented to the party making the determination.
Failure to make such determination within the time period required by this
section shall be deemed a non-determination without prejudice that will allow
appeal to the next level.
 
15.3 During such time as any dispute is being presented, heard, and considered
pursuant to this section, the contract terms shall remain in full force and
effect and the Contractor shall continue to perform work in accordance with the
Contract and as directed by the Agency Chief Contracting Officer or Engineer.
Failure of the Contractor to continue the work as directed shall constitute a
waiver by the Contractor of any and all claims being presented pursuant to this
section and a material breach of Contract.
 
15.4 Presentation of Dispute to Agency Head.
 
(A) Notice of Dispute and Agency Response. The Contractor shall present its
dispute in writing ("Notice of Dispute") to the Agency Head within the time
specified herein or, if no time is specified, within thirty (30) days of
receiving notice of the determination or action that is the subject of the
dispute. This notice requirement shall not be read to replace any other notice
requirements contained in the Contract. The Notice of Dispute shall include all
the facts, evidence, documents, or other basis upon which the Contractor relies
in support of its position, as well as a detailed computation demonstrating' how
any amount of money claimed by the Contractor in the dispute was arrived at.
Within thirty (30) days after receipt of the detailed written submission, the
Agency Chief Contracting Officer or, in the case of construction or
construction-related services, the Engineer shall submit to the Agency Head all
materials he or she deems pertinent to the dispute. Following initial
submissions to the Agency Head, either party may demand of the other the
production of any document or other material the demanding party believes may be
relevant to the dispute. The requested party shall produce all relevant
materials
 
 
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that are not otherwise protected by a legal privilege recognized by the courts
of New York State. Any question of relevancy shall be determined by the Agency
Head whose decision shall be final. Wilful failure of the Contractor to produce
any requested material whose relevancy the Contractor has not disputed, or whose
relevancy has been affirmatively determined, shall constitute a waiver by the
Contractor of its claim.
 
(B) Agency Head Inquiry. The Agency Head shall examine the material and may, in
his or her discretion, convene an informal conference with the Contractor and
the Agency Chief Contracting Officer and, in the case of construction or
construction-related services, the Engineer to resolve the issue by mutual
consent prior to reaching a determination. The Agency Head may seek such
technical or other expertise as he or she shall deem appropriate, including the
use of neutral mediators, and require any such additional material from either
or both parties as he or she deems fit. The Agency Head's ability to render, and
the effect of, a decision hereunder shall not be impaired by any negotiations in
connection with the dispute presented, whether or not the Agency Head
participated therein. The Agency Head may or, at the request of any party to the
dispute, shall compel the participation of any other contractor with a contract
related to the work of this Contract, and that contractor shall be bound by the
decision of the Agency Head. Any contractor thus brought into the dispute
resolution proceeding shall have the same rights to make presentations and to
seek review as the Contractor initiating the dispute.
 
(C) Agency Head Determination. Within thirty (30) days after the receipt of all
materials and information, or such longer time as may be agreed to by the
parties, the Agency Head shall make his or her determination and shall deliver
or send a copy of such determination to the Contractor and Agency Chief
Contracting Officer and, in the case of construction or construction-related
services, the Engineer, together with a statement concerning how the decision
may be appealed.

(D) Finality of Agency Head Decision. The Agency Head's decision shall be final
and binding on all parties, unless presented to the Contract Dispute Resolution
Board pursuant to this section. The City may not take a petition to the Contract
Dispute Resolution Board. However, should the Contractor take such a petition,
the City may seek, and the Board may render, a determination less favorable to
the Contractor and more favorable to the City than the decision of the Agency
Head.
 
15.5 Presentation of Dispute to the Comptroller. Before any dispute may be
brought by the Contractor to the Contract Dispute Resolution Board, the
Contractor must first present its claim to the comptroller for his or her
review, investigation, and possible adjustment.
 
(A) Time, Form, and Content of Notice. Within thirty
(3 0) days of its receipt of a decision by the Agency Head, the Contractor shall
submit to the Comptroller and to the Agency Head a Notice of Claim regarding its
dispute with the Agency. The Notice of Claim shall consist of (i) a brief
written statement of the substance of the dispute, the amount of money, if any,
claimed and the reason(s) the Contractor contends the dispute was wrongly
decided by the Agency Head; (ii) a copy of the written decision of the Agency
Head, and (iii) a copy of all materials submitted by the Contractor to the
Agency, including the Notice of Dispute. The Contractor may not present to the
Comptroller any material not presented to the Agency Head, except at-the request
of the Comptroller.
 
(B) Agency Response. Within thirty (30) days of receipt of the Notice of Claim,
the Agency shall make available to the Comptroller a copy of all material
submitted by the Agency to the Agency Head in connection with the dispute. The
Agency may not present to the Comptroller any material not presented to the
Agency Head except at the request of the Comptroller.
 
(C) Comptroller Investigation. The Comptroller may investigate the claim in
dispute and, in the course of such
 
 

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investigation, may exercise all powers provided in sections 7-201 and 7-203 of
the New York City Administrative Code. In addition, the Comptroller may demand
of either party, and such party shall provide, whatever additional material the
Comptroller deems pertinent to the claim, including original business records of
the Contractor. Wilful failure of the Contractor to produce within fifteen (15)
days any material requested by the Comptroller shall constitute a waiver by the
Contractor of its claim. The Comptroller may also schedule an informal
conference to be attended by the Contractor, Agency representatives, and any
other personnel desired by the Comptroller.
 
(D) Opportunity of Comptroller to Compromise or Adjust Claim. The Comptroller
shall have forty-five (45) days from his or her receipt of all materials
referred to in 5. (C) to investigate the disputed claim. The period for
investigation and compromise may be further extended by agreement between the
Contractor and the Comptroller, to a maximum of ninety (90) days from the
Comptroller's receipt of all the materials. The Contractor may not present its
petition to the Contract Dispute Resolution Board until the period for
investigation and compromise delineated in this paragraph has expired. In
compromising or adjusting any claim hereunder, the Comptroller may not revise or
disregard the terms of the Contract between the parties.
 
15.6 Contract Dispute Resolution Board. There shall be a Contract Dispute
Resolution Board composed of:
 
(a) the chief administrative law judge of the Office of Administrative Trials
and Hearings ("OATH") or his/her designated OATH administrative law judge, who
shall act as chairperson, and may adopt operational procedures and issue such
orders consistent with this section as may be necessary in the execution of the
Contract Dispute Resolution Board's functions, including, but not limited to,
granting extensions of time to present or respond to submissions;

(b) the City Chief Procurement Officer or a designee; or in the case of disputes
involving construction, the Director of the Office of Construction or his/her
designee; any designee shall have the requisite background to consider and
resolve the merits of the dispute and shall not have participated personally and
substantially in the particular matter that is the subject of the dispute or
report to anyone who so participated, and
 
(c) a neutral person with appropriate expertise. This person shall be selected
by the presiding administrative law judge from a prequalified panel of
individuals, established and administered by OATH, with appropriate background
to act as decision-makers in a dispute. Such individuals may not have a contract
or dispute with the City or be an officer or employee of any company or
organization that does, or regularly represents persons. companies, or
organizations having disputes with the City.
 
15.7 Petition to Contract Dispute Resolution Board. In the event the claim has
not been settled or adjusted by the Comptroller within the period provided in
this section, the Contractor, within thirty (30) days thereafter, may petition
the Contract Dispute Resolution Board to review the Agency Head determination.
 
(A) Form and Content of Petition by Contractor. The Contractor shall present its
dispute to the Contract Dispute Resolution Board in the form of a Petition,
which shall include (i) a brief written statement of the substance of the
dispute, the amount of money, if any, claimed and the reason(s) the Contractor
contends that the dispute was wrongly decided by the Agency Head; (ii) a copy of
the written decision of the Agency Head; (iii) copies of all materials submitted
by the Contractor to the Agency; (iv) a copy of the written decision of the
Comptroller, if any, and (v) copies of all correspondence with, or written
material submitted by the Contractor to, the Comptroller's Office. The
Contractor shall concurrently submit four complete sets of the Petition: one to
the Corporation Counsel (Attn: Commercial and

 
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Real Estate Litigation Division), and three to the Contract Dispute Resolution
Board at oath's offices with proof of service on the Corporation Counsel. In
addition, the supplier shall submit a copy of the statement of the substance of
the dispute, cited in (i) above to both the Agency Head and the Comptroller.
 
(B) Agency Response. Within thirty (30) days of its receipt of the Petition by
the Corporation Counsel, the Agency shall respond to the brief written statement
of the Contractor and make available to the Board at oath's offices and one to
the Contractor, all material it submitted to the Agency Head and Comptroller.
Extensions of time for submittal of the agency response shall be given as
necessary upon a showing of good cause or, upon the consent of the parties, for
an initial period of up to thirty (30) days.
 
(C) Further Proceedings. The Board shall permit the Contractor to present its
case by
the submission of memoranda, briefs, and oral argument. The Board shall also
permit the Agency to present its case in response to the Contractor by the
submission of memoranda, briefs, and oral argument. If requested by the
Corporation Counsel, the Comptroller shall provide reasonable assistance in the
preparation of the Agency's case. Neither the Contractor nor the Agency may
support its case with any documentation or other material that was not
considered by the Comptroller, unless requested by the Board. The Board, at its
discretion, may seek such technical or other expertise as it shall deem
appropriate and may seek, on its own or upon application of a party, any such
additional material from any party as it deems fit. The Board, in its
discretion, may combine more than one dispute between the parties of concurrent
resolution.

(D) Contract Dispute Resolution Board Determination. Within forty-five (45) days
of the conclusion of all written submissions and oral arguments, the Board shall
render a written decision resolving the dispute. In an unusually complex case,
the Board may render its decision in a longer period of time, not to exceed
ninety (90) days, and shall so advise the parties at the commencement of this
period. The Board's decision must be consistent with the terms of the Contract.
In reaching its decision, the Board shall accord no precedential significance to
prior decisions of the Board involving other non-related contracts.
 
(E) Notification of Contract Dispute Resolution Board Decision. The Board shall
send a copy of its decision to the Contractor, the Agency Chief Contracting
Officer, the Corporation Counsel, the Comptroller, and in the case of
construction or construction-related services, the Engineer. A decision in favor
of the Contractor shall be subject to the prompt payment provisions of the PPB
Rules. The Required Payment Day shall be thirty (30) days after the date the
parties are formally notified of the Board's decision.
 
(F) Finality of Contract Dispute Resolution Board Decision. The Board's decision
shall be final and binding on all parties. Any party may seek review of the
Board's decision solely in the form of a challenge, made within four (4) months
of the date of the Board's decision, in a court of competent jurisdiction of the
State of New York, County of New York, pursuant to Article 78 of the Civil
Practice Law and Rules. Such review by the court shall be limited to the
question of whether or not the Board's decision was made in violation of lawful
procedure, was affected by an error of law, or was arbitrary and capricious or
an abuse of discretion. No evidence or information shall be introduced or relied
upon in such proceeding that was not presented to the Board in' accordance with
Section 5-11 of the PPB Rules.
 
15.8 Any termination, cancellation, or alleged breach of the Contract prior to
or during the pendency of any proceedings pursuant to this section shall not
affect or impair the ability of the Agency Head or Contract Dispute Resolution
Board to make a binding and final decision pursuant to this section.
 
ARTICLE 16. PROMPT PAYMENT
 
The Prompt Payment provisions set forth in Chapter 5,
 

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Section 5-07 of the Procurement Policy Board Rules in effect at the time for
this solicitation will be applicable to payments made under this contract. The
provisions require the payment to the contractors of interest on payments made
after the required payment date except as set forth in subdivisions c(3) and
d(2), (3), (4) and (5) of Section 5-07 of the Rules.
 
The contractor must submit a proper invoice to receive payment, except where the
contract provides that the contractor will be paid at predetermined intervals
without having to submit an invoice for each scheduled payment.
 
Determinations of interest due will be made in accordance with the provisions of
the Procurement Policy Board Rules and General Municipal Law Section 3-a.
 
ARTICLE 17.
MACBRIDE PRINCIPLES PROVISIONS FOR NEW YORK CITY CONTRACTORS
 
ARTICLE I. MACBRIDE PRINCIPLES NOTICE TO ALL PROSPECTIVE CONTRACTORS
Local Law No. 34 of 1991 became effective on September 10, 1991 and added
section 6-115.1 to the Administrative Code of the City of New York. The local
law provides for certain restrictions on City contracts to express the
opposition of the people of the City of New York to employment discrimination
practices in Northern Ireland and to encourage companies doing business in
Northern Ireland to promote freedom of workplace opportunity.
Pursuant to Section 6-115. ^prospective contractors for contracts to provide
goods or services involving an expenditure of an amount greater than ten
thousand dollars, or for construction involving an amount greater than fifteen
thousand dollars, are asked to sign a rider in which they covenant and
represent, as a material condition of their contract, that any business in
Northern Ireland operations conducted by the contractor and any individual or
legal entity in which the contractor holds a ten percent or greater ownership
interest and any individual or legal entity that holds a ten percent or greater
ownership interest in the contractor will be conducted in accordance with the
MacBride Principles of nondiscrimination in employment.
Prospective contractors are not required to agree to these conditions. However,
in the case of contracts let by competitive sealed bidding, whenever the lowest
responsible bidder has not agreed to stipulate to the conditions set forth in
this notice and another bidder who has agreed to stipulate to such conditions
has submitted a bid within five percent of the lowest responsible bid for a
contract to supply goods, services or construction of comparable quality, the
contracting entity shall refer such bids to the Mayor, the Speaker or other
officials, as appropriate, who may determine, in accordance with applicable law
and rules, that it is in the best interest of the city that the contract be
awarded to other than the lowest responsible bidder pursuant to Section 313
(b)(2) of the City Charter.
In the case of contracts let by other than competitive sealed bidding, if a
prospective contractor does not agree to these conditions, no agency, elected
official or the Council shall award the contract to that bidder unless the
entity seeking to use the goods, services or construction certifies in writing
that the contract is necessary for the entity to perform its functions and there
is no other responsible contractor who will supply goods, services or
construction of comparable quality at a comparable price.
 
PART A
In accordance with section 6-115.1 of the Administrative Code of the City of New
York, the contractor stipulates that such contractor and any individual or legal
entity in which the contractor holds a ten percent or greater ownership interest
and any individual or legal entity that holds a ten percent or greater ownership
interest in the contractor either (a) have no business operations in Northern
Ireland, or (b) shall take lawful steps in good faith to conduct any business
operations they have in Northern Ireland in accordance with the MacBride
Principles, and shall permit independent monitoring of their compliance with
such principles.
 
 
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PART B
 
For purposes of this section, the following terms shall have the following
meanings:
1. "MacBride Principles" shall mean those principles relating to
nondiscrimination in employment and freedom of workplace opportunity which
require employers doing business in Northern Ireland to:
(1) increase the representation of individuals from under represented religious
groups in the work force, including managerial, supervisory, administrative,
clerical and technical jobs;
(2) take steps to promote adequate security for the protection of employees from
under represented religious groups both at the workplace and while traveling to
and from work;
(3) ban provocative religious or-political emblems from the workplace;
(4) publicly advertise all job openings and make special recruitment efforts to
attract applicants from under represented religious groups;
(5) establish layoff, recall and termination procedures which do not in practice
favor a particular religious group;
(6) abolish all job reservations, apprenticeship restrictions and different
employment criteria which discriminate on the basis of religion;
(7) develop training programs that will prepare substantial numbers of current
employees from under represented religious groups for skilled jobs, including
the expansion of existing programs and the creation of new programs to train,
upgrade and improve the skills of workers from under represented religious
groups;
(8) establish procedures to assess, identify and actively recruit employees from
under represented religious groups with potential for further advancement; and
(9) appoint a senior management staff member to oversee affirmative action
efforts and develop a timetable to ensure their full implementation.

ARTICLE II. ENFORCEMENT OF ARTICLE I.
The contractor agrees that the covenants and representation in Article I above
are material conditions to this contract. In the event the contracting entity
receives information that the contractor who made the stipulation required by
this section is in violation thereof, the contracting entity shall review such
information and give the contractor an opportunity to respond. If the
contracting entity finds that a violation has occurred, the entity shall have
the right to declare the contractor in default and/or terminate this contract
for cause and procure the supplies, services or work from another source in any
manner the entity deems proper. In the event of such termination, the contractor
shall pay to the entity, or the entity in its sole discretion may withhold from
any amounts otherwise payable to the contractor, the difference between the
contract price for the uncompleted portion of this contract and the cost to the
contracting entity of completing performance of this contract either itself or
by engaging another contractor or contractors. In the case of a requirements
contract, the contractor shall be liable for such difference in price for the
entire amount of supplies required by the contracting entity for the uncompleted
term of its contract. In the case of a construction contract, the contracting
entity shall also have the right to hold the contractor in partial or total
default in accordance with the default provisions of this contract, and/or may
seek debarment or suspension of the contractor. The rights and remedies of the
entity hereunder shall be in addition to, and not in lieu of, any rights and
remedies the entity has pursuant to this contract or by operation of law.
 
 
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