Exhibit 10.31.3
APPENDIX X
[Amendment Number 9]

     
Agency Code 12000
  Contract No. C020429
Period 10/1/08 — 9/30/10
  Funding Amount for Period Based on approved capitation rates

This is an AGREEMENT between THE STATE OF NEW YORK, acting by and through The
New York State Department of Health, having its principal office at Corning
Tower, Room 2001, Empire State Plaza, Albany NY 12237, (hereinafter referred to
as the STATE), and AMERIGROUP New York, LLC, (hereinafter referred to as the
CONTRACTOR), to modify Contract Number C020429 as set forth below. The effective
date of these modifications is October 1, 2008, unless otherwise noted below.

  1.   Amend “Table of Contents for Model Contract,” to delete “Section 21.23
Pharmacies — Applies to FHPlus Program Only” and add “Section 22.15 Never
Events.”     2.   Amend Subsection d) of Section 3.8 “Payment for Newborns” to
read as follows:

  d)   The Contractor cannot bill for a Supplemental Newborn Capitation Payment
unless the newborn hospital or birthing center payment has been paid by the
Contractor. The Contractor must submit encounter data evidence for the newborn
stay. Failure to have supporting records may, upon an audit result in recoupment
of the Supplemental Newborn Capitation Payment by SDOH.

  3.   Amend Subsection f) of Section 3.9 “Supplemental Maternity Capitation
Payment” to read as follows:

  f)   The Contractor may not bill a Supplemental Maternity Capitation Payment
until the hospital inpatient or birthing center delivery is paid by the
Contractor, and the Contractor must submit encounter data evidence of the
delivery, plus any other inpatient and outpatient services for the maternity
care of the Enrollee to be eligible to receive a Supplemental Maternity
Capitation Payment. Failure to have supporting records may, upon audit result in
recoupment of the Supplemental Maternity Capitation Payment by the SDOH.

  4.   Effective January 1, 2009, amend Subsection a) of Section 3.12 “Mental
Health and Chemical Dependence Stop-Loss for MMC Enrollees” to read as follows:

  a)   Effective January 1, 2009, the New York State Stop-Loss reinsurance
program will no longer cover outpatient mental health visits. Prior to
January 1, 2009, the New York State Stop-Loss reinsurance program compensated
the Contractor for medically necessary and clinically appropriate Medicaid
reimbursable mental health treatment outpatient visits by MMC Enrollees in
excess of twenty (20) visits during any calendar year at rates set forth in
contracted fee schedules. Contractors who participated in the New York State
Stop-Loss reinsurance program prior to January 1, 2009 can submit eligible
claims, as per the guidelines in the “Managed Care Manual Stop Loss Policy and
Procedures” for dates of service prior to January 1, 2009. Claims continue to be
held to a two-year limit for proper submission. Any Court-Ordered Services for
mental health treatment outpatient visits by MMC Enrollees which specify the use
of Non-Participating Providers shall be compensated at the Medicaid rate of
payment.

Appendix X
MMC/FHPlus Contract Amendment
October 1, 2008
Page 1

 

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  5.   Amend Subsection b) i) of Section 8.3 “Disenrollment Requests” to read as
follows:

  b)   Non-Routine Disenrollment Requests

  i)   Enrollees with an urgent medical need to disenroll from the Contractor’s
MMC or FHPlus product may request an expedited Disenrollment by the LDSS. An MMC
Enrollee who requests a return to Medicaid fee-for-service based on his/her HIV,
End Stage Renal Disease (ESRD), or SPMI/SED status (non-SSI Enrollees only) is
categorically eligible for an expedited Disenrollment on the basis of urgent
medical need.

  6.   Amend Subsection e) of Section 10.7 “Welfare Reform — Applies to MMC
Program Only” to read as follows:

  e)   The Contractor is not responsible for the provision and payment of
Chemical Dependence Inpatient Rehabilitation and Treatment Services for MMC
Enrollees mandated by the LDSS as a condition of eligibility for Public
Assistance under Welfare Reform (as indicated by Code 83) unless such services
are already under way as described in (d) above.

  7.   Effective January 1, 2009, amend Section 10.11 “Prenatal Care” to read as
follows:

  10.11   Prenatal Care         The Contractor is responsible for arranging for
the provision of comprehensive Prenatal Care Services to all pregnant Enrollees
including all services enumerated in Subdivision 1, Section 2522 of the PHL in
accordance with 10 NYCRR § 85.40 (Prenatal Care Assistance Program) and
including up to six (6) smoking cessation counseling sessions for each pregnant
Enrollee within any twelve (12) month period.

  8.   Amend Subsection b) “Vision Services” of Section 10.15 “Services for
Which Enrollees Can Self-Refer” to read as follows:

  b)   Vision Services         The Contractor will allow its Enrollees to
self-refer to any Participating Provider of vision services (optometrist or
ophthalmologist) for refractive vision services and, for Enrollees diagnosed
with diabetes, for an annual dilated eye (retinal) examination as described in
Appendix K of this Agreement.

  9.   Amend Subsection d) iv) of Section 10.22 “Member Needs Relating to HIV”
to read as follows:

  d) iv)   A network of providers sufficient to meet the needs of its Enrollees
with HIV. The Contractor must identify within their network HIV experienced
providers to treat Enrollees with HIV/AIDS and explicitly list those providers
in the Provider Directory. HIV experienced provider is defined as either:

  1)   an M.D. or a Nurse Practitioner providing ongoing direct clinical
ambulatory care of at least 20 HIV infected persons who are being treated with
antiretroviral therapy in the preceding twelve months, or     2)   a provider
who has met the criteria of one of the following accrediting bodies:

Appendix X
MMC/FHPlus Contract Amendment
October 1, 2008
Page 2

 

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  •   The HIV Medicine Association (HIVMA) definition of an HIV-experienced
provider, or     •   HIV Specialist status accorded by the American Academy of
HIV Medicine (AAHIVM), or     •   Advanced AIDS Credited Registered Nurse
Credential given by the HIV/AIDS Nursing Certification Board (HANCB).

      The Contractor is responsible for validating that providers meet the above
criteria. In cases where members select a non-HIV experienced provider as their
PCP and in regions where there is a shortage of HIV experienced providers, the
Contractor shall identify HIV experienced providers who will be available to
consult with non-HIV experienced PCPs of Enrollees with HIV/AIDS. The Contractor
shall inform Participating Providers about how to obtain information about the
availability of Experienced HIV Providers and HIV Specialist PCPs. In addition,
the Contractor shall include within their network and explicitly identify
Designated AIDS Center Hospitals, where available, and contracts or linkages
with providers funded under the Ryan White HIV/AIDS Treatment Act.

  10.   Delete Section 21.23 “Pharmacies — Applies to FHPlus Program Only.”    
11.   Add a new Section 22.15 “Never Events” to read as follows:

  22.15   Never Events

  a)   The Contractor is required to develop claims and payment policies and
procedures regarding “never events” or “hospital acquired conditions” that are
consistent with the Medicaid program. Specifically this includes:

  i)   Development of the capacity for claims systems to recognize the presence
or absence of valid “present on admission” (POA) indicators for each inpatient
diagnosis, using codes as described by the Centers for Medicare and Medicaid
Services for Medicare, no later than June 30, 2009;     ii)   Development of the
capacity for claims systems to reject/deny claims that do not have valid POA
indicators (corrected claims can be resubmitted), with the initiation of this
edit no later than June 30, 2009;     iii)   Development of policies and
procedures that will reject or modify any inpatient charges resulting from any
“never event” or “hospital acquired condition” (pursuant to the current list of
implemented items provided on the Department of Health and HPN websites), no
later than June 30, 2009;

  A)   The methodology for claims adjustment shall be consistent with current
Medicaid program guidance provided on the Department of Health and HPN websites.
    B)   In the event that payment for inpatient claims is not based on DRGs,
the Contractor shall develop a system that is equivalent in result to the
methodology developed by Medicaid program.

Appendix X
MMC/FHPlus Contract Amendment
October 1, 2008
Page 3

 

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  iv)   Development of an audit or review capacity to ensure that claims are
submitted accurately and adjudicated consistent with this policy.

  b)   The Contractor is required to submit inpatient claims to MEDS with valid
POA fields as of June 30, 2009.

  12.   The attached Appendix C, “New York State Department of Health
Requirements for the Provision of Family Planning and Reproductive Health
Services.” is substituted for the period beginning October 1,2008.     13.  
Amend Item 5 of Appendix G, “SDOH Requirements for the Provision of Emergency
Care and Services” to read as follows:

  5.   Emergency Transportation         When emergency transportation is
included in the Contractor’s Benefit Package, the Contractor shall reimburse the
transportation provider for all emergency transportation services, without
regard to final diagnosis or prudent layperson standards. Payment by the
Contractor for emergency transportation services provided to an Enrollee by a
Participating Provider shall be at the rate or rates of payment specified in the
contract between the Contractor and the transportation provider. Payment by the
Contractor for emergency transportation services provided to an Enrollee by a
Non-Participating Provider shall be at the Medicaid fee-for-service rate in
effect on the date the service was rendered.

  14.   Amend Item 3. d) iv) of Appendix H “New York State Department of Health
Requirements for the Processing of Enrollments and Disenrollments” to read as
follows:

  iv)   In voluntary MMC counties, the Contractor will accept Enrollment
applications for unborns if that is the mothers’ intent, even if the mothers are
not and/or will not be enrolled in the Contractor’s MMC or FHPlus product. In
all counties (mandatory and voluntary), when a mother is ineligible for
Enrollment or chooses not to enroll, the Contractor will accept Enrollment
applications for pre-enrollment of unborns who are eligible.

  15.   Amend Item 6. a) xii) C) of Appendix H “New York State Department of
Health Requirements for the Processing of Enrollments and Disenrollments” to
read as follows:

     
Reason for Disenrollment
  Effective Date of Disenrollment
C) Incarceration
  First day of the month following 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)

  16.   The attached Appendix K, “Prepaid Benefit Package Definitions of Covered
and Non-Covered Services” is substituted for the period beginning October 1,
2008.

Appendix X
MMC/FHPlus Contract Amendment
October 1, 2008
Page 4

 

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  17.   The attached Appendix L, “Approved Capitation Payment Rates,” is
substituted for the period beginning October 1, 2008.

All other provisions of said AGREEMENT shall remain in full force and effect.
Appendix X
MMC/FHPlus Contract Amendment
October 1, 2008
Page 5

 

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IN WITNESS WHEREOF, the parties hereto have executed or approved this AGREEMENT
as of the dates appearing under their signatures.

                  CONTRACTOR SIGNATURE       STATE AGENCY SIGNATURE
 
               
By:
  /s/ Robert A. Wychulis       By:    
 
               
 
  Robert A. Wychulis            
 
 
(Printed Name)
           
 
               
 
              (Printed Name)
 
               
Title:
  Preseident and Chief Executive Officer       Title:    
 
               
Date:
  2/2/09       Date:    
 
                 
 
              State Agency Certification:
 
              In addition to the acceptance of this contract, I also certify
that original copies of this signature page will be attached’ to all other exact
copies of this contract.

     
STATE OF NEW YORK
  )
 
  )               SS.:
County of ny
  )

On the 2 day of February in the year 2009 before me, the undersigned, personally
appeared Robert A. Wychulis personally known to me or proved to me on the basis
of satisfactory evidence to be the individual(s) whose name(s) is (are)
subscribed to the within instrument and acknowledged to me that he/she/they
executed the same in his/her/their/ capacity(ies), and that by his/her/their
signature(s) on the instrument, the individual(s), or the person upon behalf of
which the individual(s) acted, executed the instrument.

                  /s/ Ereen M. Waszkiewicz                           (Notary).  
         
 
              SEAL [w72825w7282504.gif]   Approved:       Approved:
 
                ATTORNEY GENERAL       Thomas P. DiNapoli
STATE COMPTROLLER
 
                         
 
               
Title:
          Title:    
 
               
 
               
Date:
          Date:    
 
               

Appendix X
MMC/FHPlus Contract Amendment
October 1, 2008
Page 6

 

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Appendix C
New York State Department of Health
Requirements for the Provision of
Family Planning and Reproductive Health Services

      C.1 Definitions and General Requirements for the Provision of Family
Planning and Reproductive Health Services         C.2 Requirements for MCOs that
Include Family Planning and Reproductive Health Services in Their Benefit
Package         C.3 Requirements for MCOs That Do Not Include Family Planning
Services and Reproductive Health Services in Their
        Benefit Package

APPENDIX C
October 1, 2008
C-1

 

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C.1
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)   medicall y-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:         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. Other pharmacy prescriptions
including emergency contraception, medical supplies, and over the

APPENDIX C
October 1, 2008
C-2

 

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      counter drugs are not the responsibility of 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 testing and
pre-and post-test counseling.

2.   Free Access to Services for MMC Enrollees

  a)   Free Access means MMC Enrollees may obtain Family Planning and
Reproductive Health services, and HIV 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 includes such services in its 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.

3.   Access to Services for FHPlus Enrollees

  a)   FHPlus Enrollees may obtain Family Planning and Reproductive Health
services, and HIV testing and pre-and post-test counseling when performed as
part of a Family Planning and Reproductive Services encounter, from either the
Contractor or through the Designated Third Party Contractor, as applicable. No
referral from the PCP or approval by the Contractor is required to access such
services.     b)   The Contractor is responsible for routine obstetric and/or
gynecologic care, including hysterectomies, pre-natal, delivery and
post-partum care, regardless of whether Family Planning and Reproductive Health
services are included in the Contractor’s Benefit Package.

APPENDIX C
October 1, 2008
C-3

 

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C.2
Requirements for MCOs that Include Family Planning and Reproductive
Health Services in Their Benefit Package

1.   Notification to Enrollees

  a)   If the Contractor includes Family Planning and Reproductive Health
services in its Benefit Package (as per Appendix M of this Agreement) the
Contractor must notify all Enrollees of reproductive age, including minors who
may be sexually active, 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)   MMC Enrollees must receive notification that they also
have the right to obtain Family Planning and Reproductive Health services in
accordance with MMC’s Free Access policy as defined in C.1. 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 MMC 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 a MMC
Enrollee obtains such services in accordance with MMC’s Free Access policy.

2.   Billing Policy

  a)   The Contractor must notify its Participating Providers that all claims
for Family Planning and Reproductive services must be billed to the Contractor
and not the Medicaid fee-for-service program.     b)   The Contractor will be
charged for Family Planning and Reproductive Health services furnished to MMC
Enrollees by
eMedNY-enrolled Non-Participating Providers at the applicable Medicaid rate or
fee. In such instances, Non-Participating Providers will bill Medicaid
fee-for-service and the SDOH will issue a confidential

APPENDIX C
October 1, 2008
C-4

 

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      charge back to the Contractor. Such charge back mechanism will comply with
all applicable patient confidentiality requirements.

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 any Enrollee’s use including a minor’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 MMC 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.

APPENDIX C.
October 1, 2008
C-5

 

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C.3
Requirements for MCOs That Do Not
Include Family Planning Services and Reproductive Health Services in Their
Benefit Package

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, Division 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
MMC Enrollees and through the Designated Third Party Contractor for FHPlus
Enrollees;     III)   No referral is needed for such services, and there will be
no cost to the Enrollee for such services.

APPENDIX C
October 1, 2008
C-6

 

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  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 MMC Enrollees
and through the Designated Third Party Contractor to FHPlus Enrollees; and that
anonymous counseling and testing services are available from SDOH, Local Public
Health Agency clinics and other 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 MMC Enrollees to secure such
services through fee-for-service Medicaid from any provider/clinic which offers
these services and who accepts Medicaid, and the right of all FHPlus Enrollees
to secure such services through the Designated Third Party Contractor.     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 MMC or
FHPlus product(s). Such information shall be prominently displayed and easily
navigated.

  C)   A description of the mechanisms to provide all new MMC Enrollees and
FHPlus 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.

APPENDIX C
October 1, 2008
C-7

 

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  II)   MMC Enrollees can use their Medicaid card to receive these non-covered
services from any doctor or clinic that provides these services and accepts
Medicaid. FHPlus Enrollees can receive these non-covered services through the
Designated Third Party Contractor using the Enrollee’s NYS Benefit
Identification card.     III)   Each MMC Enrollee and Prospective MMC 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)   The Contractor will provide the name and phone number of the
Designated Third Party Contractor or such other organization designated by the
SDOH to provide such services to FHPlus Enrollees and Prospective FHPlus
Enrollees. It is the responsibility of the Designated Third Party Contractor or
such other organization designated by the SDOH to mail to each FHPlus Enrollee
or Prospective FHPlus Enrollee who calls, a copy of the SDOH approved letter
explaining the Enrollee’s right to receive such services, and an SDOH approved
list of Family Planning Providers from which the Enrollee may access family
planning services. The Designated Third Party Contractor or such other
organization designated by the SDOH is responsible for mailing these materials
within fourteen (14) days of notice by the Contractor of a new Enrollee in the
Contractor’s FHPlus product.     V)   Enrollees can call the Contractor’s member
services number for further information about how to obtain these non-covered
services. MMC 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. FHPlus Enrollees can also call the Designated Third Party Contractor
or such other organization designated by the SDOH for a list of 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
LDSS approved list were mailed, where applicable. The Contractor will review
this log monthly and upon request, submit a copy to SDOH.

APPENDIX C
October 1, 2008
C-8

 

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  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 MMC Free Access, as defined in C.1 of this Appendix, and/or the
FHPlus Designated Third Party Contractor for FHPlus Enrollees, 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 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.     C)   The procedure(s) for informing the Contractor’s
Participating primary care providers, family practice physicians, obstetricians,
gynecologists and pediatricians 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 MMC’s
Free Access policy, as defined in C.1 of this Appendix, and/or through the
SDOH-contracted Designated Third Party for FHPlus Enrollees.     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 MMC
Enrollees, they do so as a fee-for-service Medicaid practitioner, independent of
the Contractor.     II)   if they also participate with the FHPlus Designated
Third Party Contractor and they render non-covered Family Planning and
Reproductive Health Services to FHPlus Enrollees, they do so as a participating
provider with the Designated Third Party Contractor, 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,

APPENDIX C
October 1, 2008
C-9

 

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      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 MMC Enrollees on a fee-for-service basis as an
eMedNY-enrolled provider, or to FHPlus Enrollees as a Participating Provider of
the Designated Third Party Contractor; or     II)   provide MMC Enrollees with a
copy of the SDOH approved list of Medicaid Family Planning Providers, and/or
provide FHPlus Enrollees with the name and number of the Designated Third Party
Contractor, or     III)   give Enrollees the Contractor’s member services number
to call to obtain either the list of Medicaid Family Planning Providers or the
name and number of the Designated Third Party Contractor, as applicable.

  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 or under the Designated Third Party contract
with SDOH.

  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, Division 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.     C)   A statement that the
Contractor will prepare a monthly list of MMC Enrollees who have been sent a
copy of the SDOH approved letter and the SDOH approved list of Family Planning
providers, and a list of FHPlus Enrollees who have been provided with the name
and telephone number of the Designated Third Party Contractor. This information
will be available to SDOH upon request.

APPENDIX C
October 1, 2008
C-10

 

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

 

  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.     E)   A
description of the mechanisms to provide the Designated Third Party Contractor,
SDOH, or SDOH’s subcontractor with a monthly listing of all FHPlus Enrollees
within seven (7) days of receipt of the Contractor’s monthly Enrollment Roster
and any subsequent updates or adjustments. A copy of each file will also be
provided simultaneously to the SDOH. A description of mechanisms to provide SDOH
or SDOH’s subcontractor with a list of prospective FHPlus Enrollees within two
(2) business days of the prospective Enrollee encounter, and a list of Enrollees
who call to request information within two (2) business days of an Enrollee’s
request.

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 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 and/or
the Designated Third Party Contractor 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 any Enrollee’s
use including a minor’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.

APPENDIX C
October 1, 2008
C-11

 

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APPENDIX K
PREPAID BENEFIT PACKAGE
DEFINITIONS OF COVERED AND
NON-COVERED SERVICES

     
K.1
  Chart of Prepaid Benefit Package
 
  - Medicaid Managed Care Non-SSI (MMC Non-SSI)
 
  - Medicaid Managed Care SSI (MMC SSI)
 
  - Medicaid Fee-for-Service (MFFS)
 
  - Family Health Plus (FHPlus)
 
   
K.2
  Prepaid Benefit Package
 
  Definitions of Covered Services
 
   
K.3
  Medicaid Managed Care Definitions of Non-Covered Services
 
   
K.4
  Family Health Plus Non-Covered Services

APPENDIX K
October 1, 2008
K-l

 

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APPENDIX K
PREPAID BENEFIT PACKAGE
DEFINITIONS OF COVERED AND NON-COVERED SERVICES

1.   General

  a)   The categories of services in the Medicaid Managed Care and Family Health
Plus Benefit Packages, including optional covered services, shall be provided by
the Contractor to MMC Enrollees and FHPlus Enrollees, respectively, when
medically necessary under the terms of this Agreement. The definitions of
covered and non-covered services herein are in summary form; the full
description and scope of each covered service as established by the New York
Medical Assistance Program are set forth in the applicable NYS Medicaid Provider
Manual, except for the Eye Care and Vision benefit for FHPlus Enrollees which is
described in Section 19 of Appendix K.2.     b)   All care provided by the
Contractor, pursuant to this Agreement, must be provided, arranged, or
authorized by the Contractor or its Participating Providers with the exception
of most behavioral health services to SSI or SSI related beneficiaries, and
emergency services, emergency transportation, Family Planning and Reproductive
Health services, mental health and chemical dependence assessments (one (1) of
each per year), court ordered services, and services provided by Local Public
Health Agencies as described in Section 10 of this Agreement.     c)   This
Appendix contains the following sections:

  i)   K.1 — “Chart of Prepaid Benefit Package” lists the services provided by
the Contractor to all Medicaid Managed Care
Non-SSI Enrollees, Medicaid Managed Care SSI Enrollees, Medicaid fee-for-service
coverage for carved out and wraparound benefits, and Family Health Plus
Enrollees.     ii)   K.2 — “Prepaid Benefit Package Definitions Of Covered
Services” describes the covered services, as numbered in K.1. Each service
description applies to both MMC and FHPlus Benefit Package unless otherwise
noted.     iii)   K.3 — “Medicaid Managed Care Definitions of Non-Covered
Services” describes services that are not covered by the MMC Benefit Package.
These services are covered by the Medicaid fee-for-service program unless
otherwise noted.     iv)   K.4 — “Family Health Plus Non-Covered Services” lists
the services that are not covered by the FHPlus Benefit Package. There is no
Medicaid fee-for-service coverage available for any service outside of the
FHPlus Benefit Package.

APPENDIX K
October 1, 2008
K-2

 

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K.1
PREPAID BENEFIT PACKAGE

                      *   Covered Services   MMC Non-SSI   MMC SSI   MFFS  
FHPlus**
1.
  Inpatient Hospital Services   Covered, unless admit date precedes Effective
Date of Enrollment [see § 6.8 of this Agreement]   Covered, unless admit date
precedes Effective Date of Enrollment [see § 6.8 of this Agreement]   Stay
covered only when admit date precedes Effective Date of Enrollment [see § 6.8 of
this Agreement]   Covered, unless admit date precedes Effective Date of
Enrollment [see § 6.8 of this Agreement]
 
                   
2.
  Inpatient Stay Pending Alternate Level of Medical Care   Covered   Covered    
  Covered
 
                   
3.
  Physician Services   Covered   Covered       Covered
 
                   
4.
  Nurse Practitioner Services   Covered   Covered       Covered
 
                   
5.
  Midwifery Services   Covered   Covered       Covered
 
                   
6.
  Preventive Health Services   Covered   Covered       Covered
 
                   
7.
  Second Medical/Surgical Opinion   Covered   Covered       Covered

 

* See K.2 for Scope of Benefits     ** No Medicaid fee-for service-wrap around
is available Subject to applicable co-pays.   Note: If cell is blank, there is
no coverage.  

APPENDIX K
October 1, 2008
K-3

 

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

 

                      *   Covered Services   MMC Non-SSI   MMC SSI   MFFS  
FHPlus **
8.
  Laboratory Services   Covered   Covered   HIV phenotypic, virtual phenotypic
and genotypic drug resistance tests and viral tropism testing   Covered
 
                   
9.
  Radiology Services   Covered   Covered       Covered
 
                   
10.
  Prescription and
Non- Prescription (OTC) Drugs, Medical Supplies, and Enteral Formula  
Pharmaceuticals and medical supplies routinely furnished or administered as part
of a clinic or office visit, except Risperdal Consta [see Appendix K.3, 2. b)
xi) of this Agreement]   Pharmaceuticals and medical supplies routinely
furnished or administered as part of a clinic or office visit, except Risperdal
Consta [see Appendix K.3, 2. b) xi) of this Agreement]   Covered outpatient
drugs from the list of Medicaid reimbursable prescription drugs, subject to any
applicable co-payments   Covered through the
Medicaid fee-for-service program, including prescription drugs, insulin and
diabetic supplies, smoking cessation-agents, select OTCs, hearing aid batteries
and enteral formulae.
 
                   
11.
  Smoking Cessation Products           Covered   Covered under the
Medicaid fee-for-service program.
 
                   
12.
  Rehabilitation Services   Covered   Covered       Covered for short term
inpatient, and limited to 20 visits per calendar year for outpatient PT and OT
 
                   
13.
  EPSDT Services/Child Teen
Health Program (C/THP)   Covered   Covered       Covered
 
                   
14.
  Home Health Services   Covered   Covered       Covered for 40 visits in lieu
of a skilled nursing facility stay or hospitalization, plus 2 post partum home
visits for high risk women.

 

* See K.2 for Scope of Benefits       ** No Medicaid fee-for service-wrap around
is available Subject to applicable co-pays.   Note: If cell is blank; there is
no coverage.  

APPENDIX K
October 1, 2008
K-4

 

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

 

                      *   Covered Services   MMC Non-SSI   MMC SSI   MFFS  
FHPlus**
15
  Private Duty Nursing Services   Covered   Covered       Not covered
 
                   
16
  Hospice           Covered   Covered
 
                   
17.
  Emergency Services   Covered   Covered       Covered
 
                   
 
  Post-Stabilization Care Services (see also Appendix G of this Agreement)  
Covered   Covered       Covered
 
                   
18.
  Foot Care Services   Covered   Covered       Covered
 
                   
19.
  Eye Care and Low Vision Services   Covered   Covered       Covered
 
                   
20.
  Durable Medical Equipment (DME)   Covered   Covered       Covered
 
                   
21.
  Audiology, Hearing Aids
Services & Products   Covered except for
hearing aid
batteries   Covered except for
hearing aid
batteries   Hearing aid
batteries   Covered, including
hearing aid
batteries
 
                   
22.
  Family Planning and Reproductive Health Services   Covered if included in
Contractor’s Benefit Package as per Appendix M of this Agreement   Covered if
included in Contractor’s Benefit Package as per Appendix M of Agreement  
Covered pursuant to Appendix C of Agreement   Covered if included in
Contractor’s Benefit Package as per Appendix M of this Agreement or through the
DTP Contractor
 
                   
23.
  Non-Emergency Transportation   Covered if included in Contractor’s Benefit
Package as per Appendix M of this Agreement   Covered if included in
Contractor’s Benefit Package as per Appendix M of this Agreement   Covered if
not included in Contractor’s Benefit Package   Not covered, except for
transportation to C/THP services for 19 and 20 year olds
 
                   
24
  Emergency Transportation   Covered if included in Contractor’s Benefit Package
as per Appendix M of this Agreement   Covered if included in Contractor’s
Benefit Package as per Appendix M of this Agreement   Covered if not included in
Contractor’s Benefit Package   Covered

 

* See K.2 for Scope of Benefits       ** No Medicaid fee-for service-wrap around
is available Subject to applicable co-pays.   Note: If cell is blank, there is
no coverage.    

APPENDIX K
October 1, 2008
K-5

 

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

 

                      *   Covered Services   MMC Non-SSI   MMC SSI   MFFS  
FHPlus**
25.
  Dental Services   Covered if included in Contractor’s Benefit Package as per
Appendix M of this Agreement, except orthodontia   Covered if included in
Contractor’s Benefit Package as per Appendix M of this Agreement, except
orthodontia   Covered if not included in the Contractor’s Benefit Package,
Orthodontia in all instances   Covered, if included in Contractor’s Benefit
Package as per Appendix M of this Agreement, excluding orthodontia
 
                   
26.
  Court-Ordered Services   Covered, pursuant to court order (see also §10.9 of
this Agreement)   Covered, pursuant to court order (see also §10.9 of this
Agreement)       Covered, pursuant to court order (see also §10.9 of this
Agreement)
 
                   
27.
  Prosthetic/Orthotic
Services/Orthopedic Footwear   Covered   Covered       Covered,
except orthopedic
shoes
 
                   
28.
  Mental Health Services   Covered       Covered for SSI
Enrollees   Covered subject to calendar year benefit limit of 30 days inpatient,
60 visits outpatient, combined with chemical dependency services
 
                   
29.
  Detoxification Services   Covered   Covered       Covered
 
                   
30.
  Chemical Dependence Inpatient Rehabilitation and Treatment Services   Covered
subject to stop loss       Covered for SSI
recipients   Covered subject to calendar year benefit limit 30 days combined
with mental health services
 
                   
31
  Chemical Dependence Outpatient           Covered   Covered subject to calendar
year benefit limits of 60 visits combined with mental health services
 
                   
32.
  Experimental and/or
Investigational Treatment   Covered on a case
by case basis   Covered on a case
by case basis       Covered on a case
by case basis
 
                   
33.
  Renal Dialysis   Covered   Covered       Covered
 
                   
34.
  Residential Health Care
Facility Services (RHCF)   Covered, except for
individuals in
permanent placement   Covered, except for
individuals in
permanent placement        

 

* See K.2 for Scope of Benefits       ** No Medicaid fee-for service-wrap around
is available Subject to applicable co-pays.   Note: If cell is blank, there is
no coverage.    

APPENDIX K
October 1, 2008
K-6

 

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

 

K.2
PREPAID BENEFIT PACKAGE
DEFINITIONS OF COVERED SERVICES
Service definitions in this Section pertain to both MMC and FHPlus unless
otherwise indicated.

1.   Inpatient Hospital Services       Inpatient hospital services, as medically
necessary, shall include, except as otherwise specified, the care, treatment,
maintenance and nursing services as may be required, on an inpatient hospital
basis, up to 365 days per year (366 days in leap year). Contractor will not be
responsible for hospital stays that commence prior to the Effective Date of
Enrollment (see Section 6.8 of this Agreement), but will be responsible for
stays that commence prior to the Effective Date of Disenrollment (see
Section 8.5 of this Agreement). Among other services, inpatient hospital
services encompass a full range of necessary diagnostic and therapeutic care
including medical, surgical, nursing, radiological, and rehabilitative services.
Services are provided under the direction of a physician, certified nurse
practitioner, or dentist.   2.   Inpatient Stay Pending Alternate Level of
Medical Care       Inpatient stay pending alternate level of medical care, or
continued care in a hospital, Article 31 mental health facility, or skilled
nursing facility pending placement in an alternate lower medical level of care,
consistent with the provisions of 18 NYCRR § 505.20 and
10 NYCRR Part 85.   3.   Physician Services

  a)   “Physicians’ services,” whether furnished in the office, the Enrollee’s
home, a hospital, a skilled nursing facility, or elsewhere, means services
furnished by a physician:

  i)   within the scope of practice of medicine as defined in law by the New
York State Education Department; and     ii)   by or under the personal
supervision of an individual licensed and currently registered by the New York
State Education Department to practice medicine.

  b)   Physician services include the full range of preventive care services,
primary care medical services and physician specialty services that fall within
a physician’s scope of practice under New York State law.     c)   The following
are also included without limitations:

APPENDIX K
October 1, 2008
K-7

 

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

 

  i)   pharmaceuticals and medical supplies routinely furnished or administered
as part of a clinic or office visit;     ii)   physical examinations, including
those which are necessary for employment, school, and camp;     iii)   physical
and/or mental health, or chemical dependence examinations of children and their
parents as requested by the LDSS to fulfill its statutory responsibilities for
the protection of children and adults and for children in foster care;     iv)  
health and mental health assessments for the purpose of making recommendations
regarding a Enrollee’s disability status for Federal SSI applications;     v)  
health assessments for the Infant /Child Assessment Program (ICHAP);     vi)  
annual preventive health visits for adolescents;     vii)   new admission exams
for school children if required by the LDSS;     viii)   health screening,
assessment and treatment of refugees, including completing SDOH/LDSS required
forms;     ix)   Child/Teen Health Program (C/THP) services which are
comprehensive primary health care services provided to persons under twenty-one
(21) years of age (see Section 10 of this Agreement).

  d)   Smoking cessation counseling services for pregnant women. Up to six (6)
counseling sessions are covered within any twelve (12) month period. This
Benefit Package covered service is effective beginning January 1, 2009.

4.   Certified Nurse Practitioner Services

  a)   Certified nurse practitioner services include preventive services, the
diagnosis of illness and physical conditions, and the performance of therapeutic
and corrective measures, within the scope of the certified nurse practitioner’s
licensure and collaborative practice agreement with a licensed physician in
accordance with the requirements of the NYS Education Department.     b)   The
following services are also included in the certified nurse practitioner’s scope
of services, without limitation:

  i)   Child/Teen Health Program(C/THP) services which are comprehensive primary
health care services provided to persons under twenty-one (21) (see Item 13 of
this Appendix and Section 10.4 of this Agreement);     ii)   Physical
examinations, including those which are necessary for employment, school and
camp.

APPENDIX K
October 1, 2008
K-8

 

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5.   Midwifery Services       SSA § 1905 (a)(17), Education Law § 6951(i).      
Midwifery services include the management of normal pregnancy, childbirth and
postpartum care as well as primary preventive reproductive health care to
essentially healthy women as specified in a written practice agreement and shall
include newborn evaluation, resuscitation and referral for infants. The care may
be provided on an inpatient or outpatient basis including in a birthing center
or in the Enrollee’s home as appropriate. The midwife must be licensed by the
NYS Education Department.   6.   Preventive Health Services

  a)   Preventive health services means care and services to avert
disease/illness and/or its consequences. There are three (3) levels of
preventive health services: 1) primary, such as immunizations, aimed at
preventing disease; 2) secondary, such as disease screening programs aimed at
early detection of disease; and 3) tertiary, such as physical therapy, aimed at
restoring function after the disease has occurred. Commonly, the term
“preventive care” is used to designate prevention and early detection programs
rather than restorative programs.     b)   The Contractor must offer the
following preventive health services essential for promoting health and
preventing illness:

  i)   General health education classes.     ii)   Pneumonia and influenza
immunizations for at risk populations.     iii)   Smoking cessation counseling
and treatment for pregnant women and smoking cessation classes, with targeted
outreach for adolescents and pregnant women.     iv)   Childbirth education
classes.     v)   Parenting classes covering topics such as bathing, feeding,
injury prevention, sleeping, illness prevention, steps to follow in an
emergency, growth and development, discipline, signs of illness, etc.     vi)  
Nutrition counseling, with targeted outreach for diabetics and pregnant women.  
  vii)   Extended care coordination, as needed, for pregnant women.     viii)  
HIV counseling and testing.     ix)   Asthma self-management training for newly
diagnosed asthmatics up to ten (10) hours during a continuous twelve (12) month
period and up to two (2) hours follow-up training in subsequent years. Up to ten
(10) additional hours will be covered in a continuous twelve (12) month period
to address medically complex conditions such as exacerbation of asthma, poor
asthma control, diagnosis of a complication or co-morbidity, post-surgery,
prescription for new equipment, mental health diagnosis, learning disability and
unstable medical condition. This Benefit Package covered service is effective
beginning January 1, 2009.     x)   Diabetes self-management training for newly
diagnosed diabetics up to ten (10) hours during a continuous twelve (12) month
period and up to two (2) hours follow-up training in subsequent years. Up to ten
(10) additional hours will be covered in a continuous twelve (12) month period
to address medically complex conditions such as poor diabetes control (A1c>8),
diagnosis of a complication or

APPENDIX K
October 1, 2008
K-9

 

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

 

      co-morbidity, post-surgery, prescription for new equipment such as an
insulin pump, mental health diagnosis, learning disability, unstable medical
condition, gestational diabetes and pregnancy. This Benefit Package covered
service is effective beginning January 1, 2009.

7.   Second Medical/Surgical Opinions       The Contractor will allow Enrollees
to obtain second opinions for diagnosis of a condition, treatment or surgical
procedure by a qualified physician or appropriate specialist, including one
affiliated with a specialty care center. In the event that the Contractor
determines that it does not have a Participating Provider in its network with
appropriate training and experience qualifying the Participating Provider to
provide a second opinion, the Contractor shall make a referral to an appropriate
Non-Participating Provider. The Contractor shall pay for the cost of the
services associated with obtaining a second opinion regarding medical or
surgical care, including diagnostic and evaluation services, provided by the
Non-Participating Provider.

8.   Laboratory Services       18 NYCRR § 505.7(a)

  a)   Laboratory services include medically necessary tests and procedures
ordered by a qualified medical professional and listed in the Medicaid fee
schedule for laboratory services.     b)   All laboratory testing sites
providing services under this Agreement must have a permit issued by the New
York State Department of Health and a Clinical Laboratory Improvement Act
(CLIA) certificate of waiver, a physician performed microscopy procedures
(PPMP) certificate, or a certificate of registration along with a CLIA
identification number. Those laboratories with certificates of waiver or a PPMP
certificate may perform only those specific tests permitted under the terms of
their waiver. Laboratories with certificates of registration may perform a full
range of laboratory tests for which they have been certified. Physicians
providing laboratory testing may perform only those specific limited laboratory
procedures identified in the Physician’s NYS Medicaid Provider Manual.     c)  
For MMC only: coverage for HIV phenotypic, HIV virtual phenotypic and HIV
genotypic drug resistance tests and viral tropism testing are covered by
Medicaid fee- for-service.

9.   Radiology Services       18 NYCRR § 505.17(c)(7)(d)       Radiology
services include medically necessary services provided by qualified
practitioners in the provision of diagnostic radiology, diagnostic ultrasound,
nuclear medicine, radiation oncology, and magnetic resonance imaging (MRI).
These services may only be performed upon the order of a qualified practitioner.

APPENDIX K
October 1, 2008
K-10

 

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10.   Prescription and Non-Prescription (OTC) Drugs Medical Supplies and Enteral
Formulas

  a)   For Medicaid managed care only: Enrollees are covered for prescription
drugs through the Medicaid fee-for-service program. Medically necessary
prescription and non-prescription (OTC) drugs; medical supplies and enteral
formula are covered when ordered by a qualified provider.     b)   For Family
Health Plus only: Enrollees are covered through the Medicaid fee-for-service
program. Medically necessary prescription drugs, insulin and diabetic supplies
(e.g., insulin syringes, blood glucose test strips, lancets, alcohol swabs),
smoking cessation agents, including over-the-counter (OTC) smoking cessation
products, select OTC medications covered on the Medicaid Preferred Drug List
(e.g., Prilosec OTC, Loratadine, Zyrtec), hearing aid batteries and enteral
formula are covered when ordered by a qualified provider. Medical supplies
(except for diabetic supplies and smoking cessation agents) are not covered.    
c)   For Medicaid Managed Care and Family Health Plus: Pharmaceuticals and
medical supplies routinely furnished or administered as part of a clinic or
office visit are covered by the Contractor. Self-administered injectable drugs
(including those administered by a family member) and injectable drugs
administered during a home care visit are covered by Medicaid fee-for-service if
the drug is on the list of Medicaid reimbursable drugs or covered by the
Contractor, subject to medical necessity, if the drug is not on the list of
Medicaid reimbursable prescription drugs.

11.   Smoking Cessation Products

  a)   Enrollees are covered for smoking cessation products through the Medicaid
fee-for-service program.

12.   Rehabilitation Services       18 NYCRR § 505.11

  a)   Rehabilitation services are provided for the maximum reduction of
physical or mental disability and restoration of the Enrollee to his or her best
functional level. Rehabilitation services include care and services rendered by
physical therapists, speech-language pathologists and occupational therapists.
Rehabilitation services may be provided in an Article 28 inpatient or outpatient
facility, an Enrollee’s home, in an approved home health agency, in the office
of a qualified private practicing therapist or speech pathologist, or for a
child in a school, pre-school or community setting, or in a Residential Health
Care Facility (RHCF) as long as the Enrollee’s stay is classified as a
rehabilitative stay and meets the requirements for covered RHCF services as
defined herein. For the MMC Program, rehabilitation services provided in
Residential Health Care Facilities are subject to the stop-loss provisions
specified in Section 3.13 of this Agreement. Rehabilitation services are covered
as medically necessary, when ordered by the Contractor’s Participating Provider.

APPENDIX K
October 1, 2008
K-11

 

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  b)   For Family Health Plus only: Outpatient visits for physical and
occupational therapy is limited to twenty (20) visits per calendar year.
Coverage for speech therapy services is limited to those required for a
condition amenable to significant clinical improvement within a two month
period.

13.   Early Periodic Screening Diagnosis and Treatment (EPSDT) Services Through
the Child Teen Health Program (C/THP) and Adolescent Preventive Services      
18 NYCRR § 508.8       Child/Teen Health Program (C/THP) is a package of early
and periodic screening, including inter-periodic screens and, diagnostic and
treatment services that New York State offers all Medicaid eligible children
under twenty-one (21) years of age. Care and services shall be provided in
accordance with the periodicity schedule and guidelines developed by the New
York State Department of Health. The care includes necessary health care,
diagnostic services, treatment and other measures (described in § 1905(a) of the
Social Security Act) to correct or ameliorate defects, and physical and mental
illnesses and conditions discovered by the screening services (regardless of
whether the service is otherwise included in the New York State Medicaid Plan).
The package of services includes administrative services designed to assist
families obtain services for children including outreach, education, appointment
scheduling, administrative case management and transportation assistance.

14.   Home Health Services       18 NYCRR § 505.23(a)(3)

  a)   Home health care services are provided to Enrollees in their homes by a
home health agency certified under Article 36 of the PHL (Certified Home Health
Agency - CHHA). Home health services mean the following services when prescribed
by a Provider and provided to a Enrollee in his or her home:

  i)   nursing services provided on a part-time or intermittent basis by a CHHA
or, if there is no CHHA that services the county/district, by a registered
professional nurse or a licensed practical nurse acting under the direction of
the Enrollee’s PCP;     ii)   physical therapy, occupational therapy, or speech
pathology and audiology services; and     iii)   home health services provided
by a person who meets the training requirements of the SDOH, is assigned by a
registered professional nurse to provide home health aid services in accordance
with the Enrollee’s plan of care, and is supervised by a registered professional
nurse from a CHHA or if the Contractor has no CHHA available, a registered
nurse, or therapist.

  b)   Personal care tasks performed by a home health aide incidental to a
certified home health care agency visit, and pursuant to an established care
plan, are covered.

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  c)   Services include care rendered directly to the Enrollee and instructions
to his/her family or caretaker such as teacher or day care provider in the
procedures necessary for the Enrollee’s treatment or maintenance.     d)   The
Contractor must provide up to two (2) post partum home visits for high risk
infants and/or high risk mothers, as well as to women with less than a
forty-eight (48) hour hospital stay after a vaginal delivery or less than a
ninety-six (96) hour stay after a cesarean delivery. Visits must be made by a
qualified health professional (minimum qualifications being an RN with
maternal/child health background), the first visit to occur within forty-eight
(48) hours of discharge.     e)   For Family Health Plus only: coverage is
limited to forty (40) home health care visits per calendar year in lieu of a
skilled nursing facility stay or hospitalization. Post partum home visits apply
only to high risk mothers. For the purposes of this Section, visit is defined as
the delivery of a discreet service (e.g. nursing, OT, PT, ST, audiology or home
health aide). Four (4) hours of home health aide services equals one visit.

15.   Private Duty Nursing Services – For MMC Program Only

  a)   Private duty nursing services shall be 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 must be provided in the MMC Enrollee’s home and can be provided
through an approved certified home health agency, a licensed home care agency,
or a private Practitioner.     b)   Private duty nursing services are covered
only when determined by the attending physician to be medically necessary.
Nursing services may be intermittent, part-time or continuous and must be
provided in an Enrollee’s home in accordance with the ordering physician’s or
certified nurse practitioner’s written treatment plan.

16.   Hospice Services

  a)   Hospice Services means a coordinated hospice program of home and
inpatient services which provide non-curative medical and support services for
Enrollees certified by a physician to be terminally ill with a life expectancy
of six (6) months or less.     b)   Hospice services include palliative and
supportive care provided to an Enrollee to meet the special needs arising out of
physical, psychological, spiritual, social and economic stress which are
experienced during the final stages of illness and during dying and bereavement.
Hospices must be certified under Article 40 of the New York State Public Health
Law. 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
Enrollee and the Enrollee’s family. Family members are eligible for up to five
visits for bereavement counseling.

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  c)   Medicaid Managed Care Enrollees receive coverage for hospice services
through the Medicaid fee-for-service program.

17.   Emergency Services

  a)   Emergency conditions, medical or behavioral, the onset of which is
sudden, manifesting 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 medical attention to result in
(a) 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 such
person or others in serious jeopardy; (b) serious impairment of such person’s
bodily functions; (c) serious dysfunction of any bodily organ or part of such
person; or (d) serious disfigurement of such person are covered. 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. A medical
assessment (triage) is covered for non-emergent conditions. See also Appendix G
of this Agreement.     b)   Post Stabilization Care Services means 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. These services are covered pursuant to
Appendix G of this Agreement.

18.   Foot Care Services

  a)   Covered services must include routine foot care when any Enrollee’s
(regardless of age) physical condition poses a hazard due to the presence of
localized illness, injury or symptoms involving the foot, or when performed as a
necessary and integral part of otherwise covered services such as the diagnosis
and treatment of diabetes, ulcers, and infections.     b)   Services provided by
a podiatrist for persons under twenty-one (21) must be covered upon referral of
a physician, registered physician assistant, certified nurse practitioner or
licensed midwife.     c)   Routine hygienic care of the feet, the treatment of
corns and calluses, the trimming of nails, and other hygienic care such as
cleaning or soaking feet, is not covered in the absence of a pathological
condition.

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October 1, 2008
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19.   Eye Care and Low Vision Services       18 NYCRR §505.6(b)(l-3)     SSL
§369-ee (l)(e)(xii)

  a)   For Medicaid Managed Care only:

  i)   Emergency, preventive and routine eye care services are covered. Eye care
includes the services of ophthalmologists, optometrists and ophthalmic
dispensers, and includes eyeglasses, medically necessary contact lenses and
polycarbonate lenses, artificial eyes (stock or custom-made), low vision aids
and low vision services. Eye care coverage includes the replacement of lost or
destroyed eyeglasses. The replacement of a complete pair of eyeglasses must
duplicate the original prescription and frames. Coverage also includes the
repair or replacement of parts in situations where the damage is the result of
causes other than defective workmanship. Replacement parts must duplicate the
original prescription and frames. Repairs to, and replacements of, frames and/or
lenses must be rendered as needed.     ii)   If the Contractor does not provide
upgraded eyeglass frames or additional features (such as scratch coating,
progressive lenses or photo-gray lenses) as part of its covered vision benefit,
the Contractor cannot apply the cost of its covered eyeglass benefit to the
total cost of the eyeglasses the Enrollee wants and bill only the difference to
the Enrollee. The Enrollee can choose to purchase the upgraded frames and/or
additional features by paying the entire cost of the eyeglasses as a private
customer. For example, if the Contractor covers standard bifocal eyeglasses and
the Enrollee wants no-line bifocal eyeglasses, the Enrollee must choose between
taking the standard bifocal eyeglasses or paying the full price of the no-line
bifocal eyeglasses (not just the difference between the cost of the bifocal
lenses and the no-line lenses). The Enrollee must be informed of this fact by
the vision care provider at the time that that the glasses are ordered.     iii)
  Examinations for diagnosis and treatment for visual defects and/or eye disease
are provided only as necessary and as required by the Enrollee’s particular
condition. Examinations which include refraction are limited to once every
twenty four (24) months unless otherwise justified as medically necessary.    
iv)   Eyeglasses do not require changing more frequently than once every twenty
four (24) months unless medically indicated, such as a change in correction
greater than 1/2 diopter, or unless the glasses are lost, damaged, or destroyed.
    v)   An ophthalmic dispenser fills the prescription of an optometrist or
ophthalmologist and supplies eyeglasses or other vision aids upon the order of a
qualified practitioner.     vi)   MMC Enrollees may self-refer to any
Participating Provider of vision services (optometrist or ophthalmologist) for
refractive vision services not more frequently than once every twenty four
(24) months, or if otherwise justified as

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October 1, 2008
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      medically necessary or if eyeglasses are lost, damaged or destroyed as
described above. Enrollees diagnosed with diabetes may self-refer to any
Participating Provider of vision services (optometrist or ophthalmologist) for a
dilated eye (retinal) examination not more frequently than once in any twelve
(12) month period.

b)   For Family Health Plus only:

  i)   Covered Services include emergency vision care and the following
preventive and routine vision care provided once in any twenty four (24) month
period:

  A)   one eye examination;     B)   either: one pair of prescription eyeglass
lenses and a frame, or prescription contact lenses when medically necessary; and
    C)   one pair of medically necessary occupational eyeglasses.

  ii)   An ophthalmic dispenser fills the prescription of an optometrist or
ophthalmologist and supplies eyeglasses or other vision aids upon the order of a
qualified practitioner.     iii)   FHPlus Enrollees may self-refer to any
Participating Provider of vision services (optometrist or ophthalmologist) for
refractive vision services not more frequently than once every twenty-four
(24) months. Enrollees diagnosed with diabetes may self-refer to any
Participating Provider of vision services (optometrist or ophthalmologist) for a
dilated eye (retinal) examination not more frequently than once in any twelve
(12) month period.     iv)   If the Contractor does not provide upgraded frames
or additional features that the Enrollee wants (such as scratch coating,
progressive lenses or photo-gray lenses) as part of its covered vision benefit,
the Contractor cannot apply the cost of its covered eyeglass benefit to the
total cost of the eyeglasses the Enrollee wants and bill only the difference to
the Enrollee. The Enrollee can choose to purchase the upgraded frames and/or
additional features by paying the entire cost of the eyeglasses as a private
customer. For example, if the Contractor covers standard bifocal eyeglasses and
the Enrollee wants no-line bifocal eyeglasses, the Enrollee must choose between
taking the standard bifocal glasses or paying the full price for the no-line
bifocal eyeglasses (not just the difference between the cost of bifocal lenses
and no-line lenses). The Enrollee must be informed of this fact by the vision
care provider at the time that the glasses are ordered.     v)   Contact lenses
are covered only when medically necessary. Contact lenses shall not be covered
solely because the FHPlus Enrollee selects contact lenses in lieu of receiving
eyeglasses.     vi)   Coverage does not include the replacement of lost, damaged
or destroyed eyeglasses.     vii)   The occupational vision benefit for FHPlus
Enrollees covers the cost of job-related eyeglasses if that need is determined
by a Participating Provider through special testing done in conjunction with a
regular vision examination. Such

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October 1, 2008
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      examination shall determine whether a special pair of eyeglasses would
improve the performance of job-related activities. Occupational eyeglasses can
be provided in addition to regular glasses but are available only in conjunction
with a regular vision benefit once in any twenty-four (24) month period. FHPlus
Enrollees may purchase an upgraded frame or lenses for occupational eyeglasses
by paying the entire cost as a private customer. Sun-sensitive and polarized
lens options are not available for occupational eyeglasses.

20.   Durable Medical Equipment (DME)       18 NYCRR §505.5(a)(l) and
Section 4.4 of the NYS Medicaid DME, Medical and Surgical Supplies and
Prosthetic and Orthotic Appliances Provider Manual

  a)   Durable Medical Equipment (DME) are devices and equipment, other than
medical/surgical supplies, enteral formula, and prosthetic or orthotic
appliances, and have the following characteristics:

  i)   can withstand repeated use for a protracted period of time;     ii)   are
primarily and customarily used for medical purposes;     iii)   are generally
not useful to a person in the absence of illness or injury; and     iv)   are
usually not fitted, designed or fashioned for a particular individual’s use.
Where equipment is intended for use by only
one (1) person, it may be either custom made or customized.

  b)   Coverage includes equipment servicing but excludes disposable medical
supplies.

21.   Audiology, Hearing Aid Services and Products       18 NYCRR §505.31
(a)(l)(2) and Section 4.7 of the NYS Medicaid Hearing Aid Provider Manual

  a)   Hearing aid services and products are provided in compliance with Article
37-A of the General Business Law when medically necessary to alleviate
disability caused by the loss or impairment of hearing. Hearing aid services
include: selecting, fitting and dispensing of hearing aids, hearing aid checks
following dispensing of hearing aids, conformity evaluation, and hearing aid
repairs.     b)   Audiology services include audiometric examinations and
testing, hearing aid evaluations and hearing aid prescriptions or
recommendations, as medically indicated.     c)   Hearing aid products include
hearing aids, earmolds, special fittings, and replacement parts.     d)  
Hearing aid batteries:

  i)   For Family Health Plus only: Hearing aid batteries are covered as part of
the prescription drug benefit.

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October 1, 2008
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  ii)   For Medicaid Managed Care only: Hearing aid batteries are covered
through the Medicaid fee-for-service program.

22.   Family Planning and Reproductive Health Care

  a)   Family Planning and Reproductive Health Care services means 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 pregnancy, as specified in Appendix C of this Agreement.     b)  
HIV counseling and testing is included in coverage when provided as part of a
Family Planning and Reproductive Health visit.     c)   All medically necessary
abortions are covered, as specified in Appendix C of this Agreement.     d)  
Fertility services are not covered.     e)   If the Contractor excludes Family
Planning and Reproductive Health services from its Benefit Package, as specified
in Appendix M of this Agreement, the Contractor is required to comply with the
requirements of Appendix C.3 of this Agreement and still provide the following
services:

  i)   screening, related diagnosis, ambulatory treatment, and referral to
Participating Provider as needed for dysmenorrhea, cervical cancer or other
pelvic abnormality/pathology;     ii)   screening, related diagnosis, and
referral to Participating Provider for anemia, cervical cancer, glycosuria,
proteinuria, hypertension, breast disease and pregnancy.

23.   Non-Emergency Transportation

  a)   Transportation expenses are covered for MMC Enrollees when transportation
is essential in order for a MMC 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 Medicaid fee-for-service). Non-emergent
transportation guidelines may be developed in conjunction with the LDSS, based
on the LDSS’ approved transportation plan.     b)   Transportation services
means transportation by ambulance, ambulette fixed wing or airplane transport,
invalid coach, taxicab, livery, public transportation, or other means
appropriate to the MMC Enrollee’s medical condition; and a transportation
attendant to accompany the MMC 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 MMC Enrollee’s family.

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October 1, 2008
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  c)   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.     d)  
Non-emergency transportation is covered for FHPlus Enrollees that are nineteen
(19) or twenty (20) years old and are receiving C/THP services     e)   For MMC
Enrollees with disabilities, the method of transportation must reasonably
accommodate their needs, taking into account the severity and nature of the
disability.

24.   Emergency Transportation

  a)   Emergency transportation can only be provided by an ambulance service
including air ambulance service. Emergency ambulance transportation means the
provision of ambulance transportation 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.     b)   Emergency Services
means the health care procedures, treatments or services needed to evaluate or
stabilize an Emergency Medical Condition including, but not limited to, the
treatment of trauma, burns, respiratory, circulatory and obstetrical
emergencies.     c)   Emergency ambulance transportation is transportation to a
hospital emergency room generated by a “Dial 911” emergency system call or some
other request for an immediate response to a medical emergency. Because of the
urgency of the transportation request, insurance coverage or other billing
provisions are not addressed until after the trip is completed. When the
Contractor is capitated for this benefit, emergency transportation via 911 or
any other emergency call system is a covered benefit and the Contractor is
responsible for payment. Contractor shall reimburse the transportation provider
for all emergency ambulance services without regard for final diagnosis or
prudent layperson standard.

25.   Dental Services

  a)   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. Orthodontic
services are not covered.     b)   Dental surgery performed in an ambulatory or
inpatient setting is the responsibility of the Contractor whether dental
services are included in the Benefit Package or not. The Contractor is
responsible for the cost associated with inpatient hospitalization, surgical
suites, general anesthesia, intravenous sedation, radiological services, etc.
provided in the hospital and ambulatory surgery suite. Dental provider costs are
the Contractor’s responsibility only when dental services are included in the
Benefit Package. If the Contractor does not cover dental services, it is not
responsible for the cost associated with dental providers. The Contractor shall
set up procedures to prior approve dental services provided in inpatient and
ambulatory settings.

APPENDIX K
October 1, 2008
K-19

 

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  c)   For Medicaid Managed Care only:

  i)   As described in Sections 10.15 and 10.27 of this Agreement, Enrollees may
self-refer to Article 28 clinics operated by academic dental centers to obtain
covered dental services if dental services are included in the Benefit Package.
    ii)   Professional services of a dentist for dental surgery performed in an
ambulatory or inpatient setting are billed Medicaid fee-for-service if the
Contractor does not include dental services in the benefit package.

26.   Court Ordered Services       Court ordered services are those services
ordered by a court of competent jurisdiction which are performed by or under the
supervision of a physician, dentist, or other provider qualified under State law
to furnish medical, dental, behavioral health (including treatment for mental
health and/or alcohol and/or substance abuse or dependence), or other covered
services. The Contractor is responsible for payment of those services included
in the benefit package.

27.   Prosthetic/Orthotic Orthopedic Footwear       Section 4.5, 4.6 and 4.7 of
the NYS Medicaid DME, Medical and Surgical Supplies and Prosthetic and Orthotic
Appliances Provider Manual

  a)   Prosthetics are those appliances or devices which replace or perform the
function of any missing part of the body. Artificial eyes are covered as part of
the eye care benefit.     b)   Orthotics are those appliances or devices which
are used for the purpose of supporting a weak or deformed body part or to
restrict or eliminate motion in a diseased or injured part of the body.     c)  
Medicaid Managed Care: Orthopedic Footwear means shoes, shoe modifications, or
shoe additions which are used to correct, accommodate or prevent a physical
deformity or range of motion malfunction in a diseased or injured part of the
ankle or foot; to support a weak or deformed structure of the ankle or foot, or
to form an integral part of a brace.

28.   Mental Health Services

  a)   Inpatient Services         All inpatient mental health services,
including voluntary or involuntary admissions for mental health services. The
Contractor may provide the covered benefit for medically necessary mental health
inpatient services through hospitals licensed pursuant to
Article 28 of the PHL.     b)   Outpatient Services

APPENDIX K
October 1, 2008
K-20

 

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      Outpatient services including but not limited to: assessment,
stabilization, treatment planning, discharge planning, verbal therapies,
education, symptom management, case management services, crisis intervention and
outreach services, chlozapine monitoring and collateral services as certified by
the New York State Office of Mental Health (OMH). Services may be provided
in-home, office or the community. Services may be provided by licensed OMH
providers or by other providers of mental health services including clinical
psychologists and physicians.     c)   Family Health Plus Enrollees have a
combined mental health/chemical dependency benefit limit of thirty (30) days
inpatient and sixty (60) outpatient visits per calendar year.     d)   MMC SSI
Enrollees obtain all mental health services through the Medicaid fee-for-
service program.

29.   Detoxification Services

  a)   Medically Managed Inpatient Detoxification

      These programs provide medically directed twenty-four (24) hour care on an
inpatient basis to individuals who are at risk of severe alcohol or substance
abuse withdrawal, incapacitated, a risk to self or others, or diagnosed with an
acute physical or mental co-morbidity. Specific services include, but are not
limited to: medical management, bio-psychosocial assessments, stabilization of
medical psychiatric / psychological problems, individual and group counseling,
level of care determinations and referral and linkages to other services as
necessary. Medically Managed Detoxification Services are provided by facilities
licensed by OASAS under Title 14 NYCRR § 816.6 and the Department of Health as a
general hospital pursuant to Article 28 of the Public Health Law or by the
Department of Health as a general hospital pursuant to Article 28 of the Public
Health Law.     b)   Medically Supervised Withdrawal

  i)   Medically Supervised Inpatient Withdrawal         These programs offer
treatment for moderate withdrawal on an inpatient basis. Services must include
medical supervision and direction under the care of a physician in the treatment
for moderate withdrawal. Specific services must include, but are not limited to:
medical assessment within twenty four (24) hours of admission; medical
supervision of intoxication and withdrawal conditions; bio- psychosocial
assessments; individual and group counseling and linkages to other services as
necessary. Maintenance on methadone while a patient is being treated for
withdrawal from other substances may be provided where the provider is
appropriately authorized. Medically Supervised Inpatient Withdrawal services are
provided by facilities licensed under Title 14 NYCRR §816.7.     ii)   Medically
Supervised Outpatient Withdrawal

APPENDIX K
October 1, 2008
K-21

 

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      These programs offer treatment for moderate withdrawal on an outpatient
basis. Required services include, but are not limited to: medical supervision of
intoxication and withdrawal conditions; bio-psychosocial assessments; individual
and group counseling; level of care determinations; discharge planning; and
referrals to appropriate services. Maintenance on methadone while a patient is
being treated for withdrawal from other substances may be provided where the
provider is appropriately authorized. Medically Supervised Outpatient Withdrawal
services are provided by facilities licensed under Title 14 NYCRR §816.7.

  c)   For Medicaid Managed Care only: all detoxification and withdrawal
services are a covered benefit for all Enrollees, including those categorized as
SSI or SSI-related, Detoxification Services in Article 28 inpatient hospital
facilities are subject to the inpatient hospital stop-loss provisions specified
in Section 3.11 of this Agreement.

30.   Chemical Dependence Inpatient Rehabilitation and Treatment Services

  a)   Services provided include intensive management of chemical dependence
symptoms and medical management of physical or mental complications from
chemical dependence to clients who cannot be effectively served on an outpatient
basis and who are not in need of medical detoxification or acute care. These
services can be provided in a hospital or free-standing facility. Specific
services can include, but are not limited to: comprehensive admission evaluation
and treatment planning; individual group, and family counseling; awareness and
relapse prevention; education about self-help groups; assessment and referral
services; vocational and educational assessment; medical and psychiatric
consultation; food and housing; and HIV and AIDS education. These services may
be provided by facilities licensed by the New York State Office of Alcoholism
and Substance Abuse Services (OASAS) to provide Chemical Dependence Inpatient
Rehabilitation and Treatment Services under Title 14 NYCRR Part 818. Maintenance
on methadone while a patient is being treated for withdrawal from other
substances may be provided where the provider is appropriately authorized.    
b)   Family Health Plus Enrollees have a combined mental health/chemical
dependency benefit limit of thirty (30) days inpatient and sixty (60) outpatient
visits per calendar year.

31.   Outpatient Chemical Dependency Services

  a)   Medically Supervised Ambulatory Chemical Dependence Outpatient Clinic
Programs         Medically Supervised Ambulatory Chemical Dependence Outpatient
Clinic Programs are licensed under Title 14 NYCRR Part 822 and provide chemical
dependence outpatient treatment to individuals who suffer from chemical abuse or
dependence and their family members or significant others.     b)   Medically
Supervised Chemical Dependence Outpatient Rehabilitation Programs

APPENDIX K
October 1, 2008
K-22

 

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      Medically Supervised Chemical Dependence Outpatient Rehabilitation
Programs provide full or half-day services to meet the needs of a specific
target population of chronic alcoholic persons who need a range of services
which are different from those typically provided in an alcoholism outpatient
clinic. Programs are licensed by as Chemical Dependence Outpatient
Rehabilitation Programs under Title 14 NYCRR § 822.9.     c)   Outpatient
Chemical Dependence for Youth Programs         Outpatient Chemical Dependence
for Youth Programs (OCDY) licensed under Title 14 NYCRR Part 823, establishes
programs and service regulations for OCDY programs. OCDY programs offer
discrete, ambulatory clinic services to chemically-dependent youth in a
treatment setting that supports abstinence from chemical dependence (including
alcohol and substance abuse) services.     d)   Medicaid Managed Care Enrollees
access outpatient chemical dependency services through the Medicaid
fee-for-service program.

32.   Experimental or Investigational Treatment

  a)   Experimental and investigational treatment is covered on a case by case
basis.     b)   Experimental or investigational treatment for life-threatening
and/or disabling illnesses may also be considered for coverage under the
external appeal process pursuant to the requirements of Section 4910 of the PHL
under the following conditions:

  i)   The Enrollee has had coverage of a health care service denied on the
basis that such service is experimental and investigational, and     ii)   The
Enrollee’s attending physician has certified that the Enrollee has a
life-threatening or disabling condition or disease:

  A)   for which standard health services or procedures have been ineffective or
would be medically inappropriate, or     B)   for which there does not exist a
more beneficial standard health service or procedure covered by the Contractor,
or     C)   for which there exists a clinical trial, and

  iii)   The Enrollee’s provider, who must be a licensed, board-certified or
board-eligible physician, qualified to practice in the area of practice
appropriate to treat the Enrollee’s life-threatening or disabling condition or
disease, must have recommended either:

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October 1, 2008
K-23

 

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  A)   a health service or procedure that, based on two (2) documents from the
available medical and scientific evidence, is likely to be more beneficial to
the Enrollee than any covered standard health service or procedure; or     B)  
a clinical trial for which the Enrollee is eligible; and

  iv)   The specific health service or procedure recommended by the attending
physician would otherwise be covered except for the Contractor’s determination
that the health service or procedure is experimental or investigational.

33.   Renal Dialysis       Renal dialysis may be provided in an inpatient
hospital setting, in an ambulatory care facility, or in the home on
recommendation from a renal dialysis center.

34.   Residential Health Care Facility (RHCF) Services — For MMC Program Only

  a)   Residential Health Care Facility (RHCF) Services means inpatient nursing
home services provided by facilities licensed under Article 28 of the New York
State Public Health Law, including AIDS nursing facilities. Covered services
includes the following health care services: medical supervision, twenty-four
(24) hour per day nursing care, assistance with the activities of daily living,
physical therapy, occupational therapy, and speech/language pathology services
and other services as specified in the New York State Health Law and Regulations
for residential health care facilities and AIDS nursing facilities. These
services should be provided to an MMC Enrollee:

  i)   Who is diagnosed by a physician as having one or more clinically
determined illnesses or conditions that cause the MMC Enrollee to be so
incapacitated, sick, invalid, infirm, disabled, or convalescent as to require at
least medical and nursing care; and     ii)   Whose assessed health care needs,
in the professional judgment of the MMC Enrollee’s physician or a medical team:

  A)   do not require care or active treatment of the MMC Enrollee in a general
or special hospital;     B)   cannot be met satisfactorily in the MMC Enrollee’s
own home or home substitute through provision of such home health services,
including medical and other health and health-related services as are available
in or near his or her community; and     C)   cannot be met satisfactorily in
the physician’s office, a hospital clinic, or other ambulatory care setting
because of the unavailability of medical or other health and health-related
services for the MMC Enrollee in such setting in or near his or her community.

APPENDIX K
October 1, 2008
K-24

 

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  b)   The Contractor is also responsible for respite days and bed hold days
authorized by the Contractor.     c)   The Contractor is responsible for all
medically necessary and clinically appropriate inpatient Residential Health Care
Facility services authorized by the Contractor up to a sixty (60) day calendar
year stop-loss for MMC Enrollees who are not in Permanent Placement Status as
determined by LDSS.

APPENDIX K
October 1, 2008
K-25

 

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K.3
Medicaid Managed Care Prepaid Benefit Package
Definitions of Non-Covered Services
The following services are excluded from the Contractor’s Benefit Package, but
are covered, in most instances, by Medicaid fee-for-service:

1.   Medical Non-Covered Services

  a)   Personal Care Agency Services

  i)   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. Enrollee’s
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).    
ii)   Services rendered by a personal care agency which are approved by the LDSS
are not covered under the Benefit Package. 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 to develop a
plan of care.

  b)   Residential Health Care Facilities (RHCF)
Services provided in a Residential Health Care Facility (RHCF) to an individual
who is determined by the LDSS to be in Permanent Status are not covered.     c)
  Hospice Program

  i)   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.     ii)   Hospices are organizations which
must be certified under Article 40 of the PHL. All services must be provided by
qualified employees and volunteers of the

APPENDIX K
October 1, 2008
K-26

 

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      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.     iii)   If an Enrollee 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
Medicaid fee-for-service.

  d)   Prescription and Non-Prescription (OTC) Drugs, Medical Supplies, and
Enteral Formula         Coverage for drugs dispensed by community pharmacies,
over the counter drugs, medical/surgical supplies and enteral formula are not
included in the Benefit Package and 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.

2.   Non-Covered Behavioral Health Services

  a)   Chemical Dependence Services

  i)   Outpatient Rehabilitation and Treatment Services

  A)   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 maintenance treatment do so as their principal mission and are
certified by OASAS under 14 NYCRR Part 828.     B)   Medically Supervised
Ambulatory Chemical Dependence Outpatient Clinic Programs         Medically
Supervised Ambulatory Chemical Dependence Outpatient Clinic Programs are
licensed under Title 14 NYCRR Part 822 and provide chemical dependence
outpatient treatment to individuals who suffer from chemical abuse or dependence
and their family members or significant others.

APPENDIX K
October 1, 2008
K-27

 

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  C)   Medically Supervised Chemical Dependence Outpatient Rehabilitation
Programs         Medically Supervised Chemical Dependence Outpatient
Rehabilitation Programs provide full or half-day services to meet the needs of a
specific target population of chronic alcoholic persons who need a range of
services which are different from those typically provided in an alcoholism
outpatient clinic. Programs are licensed by as Chemical Dependence Outpatient.
Rehabilitation Programs under Title 14 NYCRR § 822.9.     D)   Outpatient
Chemical Dependence for Youth Programs         Outpatient Chemical Dependence
for Youth Programs (OCDY) licensed under Title 14 NYCRR Part 823, establishes
programs and service regulations for OCDY programs. OCDY programs offer
discrete, ambulatory clinic services to chemically-dependent youth in a
treatment setting that supports abstinence from chemical dependence (including
alcohol and substance abuse) services.

  ii)   Chemical Dependence Services Ordered by the LDSS

  A)   The Contractor is not responsible for the provision and payment of
Chemical Dependence Inpatient Rehabilitation and Treatment Services ordered by
the LDSS and provided to Enrollees who have:

  I)   been assessed as unable to work by the LDSS and are mandated to receive
Chemical Dependence Inpatient Rehabilitation and Treatment Services as a
condition of eligibility for Public Assistance or Medicaid, or     II)   have
been determined to be able to work with limitations (work limited) and are
simultaneously mandated by the LDSS into Chemical Dependence Inpatient
Rehabilitation and Treatment Services (including alcohol and substance abuse
treatment services) pursuant to work activity requirements.

  B)   The Contractor is not responsible for the provision and payment of
Medically Supervised Inpatient and Outpatient Withdrawal Services ordered by the
LDSS under Welfare Reform (as indicated by Code 83).     C)   The Contractor is
responsible for the provision and payment of Medically Managed Detoxification
Services in this Agreement.     D)   If the Contractor is already providing an
Enrollee with Chemical Dependence Inpatient Rehabilitation and Treatment
Services and Detoxification Services and the LDSS is satisfied with the level of
care and services, then the Contractor will continue to be responsible for the
provision and payment of these services.

APPENDIX K
October 1, 2008
K-28

 

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  b)   Mental Health Services

  i)   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.     ii)   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.     iii)   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.     iv)   Day Treatment Programs Serving Children.         Day
treatment programs are characterized by a blend of mental health and special
education services provided in a fully integrated program. Typically these
programs include: special education in small classes with an emphasis on
individualized instruction, individual and group counseling, family services
such as family counseling, support and education, crisis intervention,
interpersonal skill development, behavior modification, art and music therapy.  
  v)   Home and Community Based Services Waiver for Seriously Emotionally
Disturbed Children         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.

APPENDIX K
October 1, 2008
K-29

 

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  vi)   Case Management         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. Please note: See generic definition of Comprehensive Medicaid Case
Management (CMCM) under Item 3— “Other Non-Covered Services”.     vii)   Partial
Hospitalization         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.     viii)   Services Provided Through OMH
Designated Clinics for Children With A Diagnosis of Serious Emotional
Disturbance (SED)         These are services provided by designated OMH clinics
to children and adolescents with a clinical diagnosis of SED.     ix)  
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.     x)   Personalized Recovery Oriented Services (PROS)      
  PROS, licensed and reimbursed pursuant to 14 NYCRR 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.

APPENDIX K
October 1, 2008
K-30

 

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  xi)   Risperdal Consta, an injectable mental health drug used for management
of patients with schizophrenia, furnished as part of a clinic or office visit.

  c)   Rehabilitation Services Provided to Residents of OMH Licensed Community
Residences (CRs) and Family Based Treatment Programs, as follows:

  i)   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.     ii)   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.       *These services are
certified by OMH under 14 NYCRR § 586.3, Part 594 and Part 595.

  d)   Office of Mental Retardation and Developmental Disabilities
(OMRDD) Services

  i)   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.

APPENDIX K
October 1, 2008
K-31

 

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  ii)   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.     iii)   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. Please note: See generic definition of Comprehensive
Medicaid Case Management (CMCM) under Item 3 “Other Non-Covered Services.”    
iv)   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 § 1915(c) waiver from DHHS.    
v)   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

APPENDIX K
October 1, 2008
K-32

 

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coordination, respite and assistive technologies. Care at Home waiver services
are authorized pursuant to a SSA § 1915(c) waiver from DHHS.

3.   Other Non-Covered Services

  a)   The Early Intervention Program (EIP) – Children Birth to Two (2) Years of
Age

  i)   This program provides early intervention services to certain children,
from birth through two (2) years of age, who have a developmental delay or a
diagnosed physical or mental condition that has a high probability of resulting
in developmental delay. All managed care providers must refer infants and
toddlers suspected of having a delay to the local designated Early-Intervention
agency in their area. (In most municipalities, the County Health Department is
the designated agency, except: New York City – the Department of Health and
Mental Hygiene; Erie County – The Department of Youth Services; Jefferson County
–the Office of Community Services; and Ulster County – the Department of Social
Services).     ii)   Early intervention services provided to this eligible
population are categorized as Non-Covered. These services, which are designed to
meet the developmental needs of the child and the needs of the family related to
enhancing the child’s development, will be identified on eMedNY by unique rate
codes by which only the designated early intervention agency can claim
reimbursement. Contractor covered and authorized services will continue to be
provided by the Contractor. Consequently, the Contractor, through its
Participating Providers, will be expected to refer any enrolled child suspected
of having a developmental delay to the locally designated early intervention
agency in their area and participate in the development of the Child’s
Individualized Family Services Plan (IFSP). Contractor’s participation in the
development of the IFSP is necessary in order to coordinate the provision of
early intervention services and services covered by the Contractor.     iii)  
SDOH will instruct the locally designated early intervention agencies on how to
identify an Enrollee and the need to contact the Contractor or the Participating
Provider to coordinate service provision.

  b)   Preschool Supportive Health Services-Children Three (3) Through Four
(4) Years of Age

  i)   The Preschool Supportive Health Services Program (PSHSP) enables counties
and New York City to obtain Medicaid reimbursement for certain educationally
related medical services provided by approved preschool special education
programs for young children with disabilities. The Committee on Preschool
Special Education in each school district is responsible for the development of
an Individualized Education Program (IEP) for each child evaluated in need of
special education and medically related health services.

APPENDIX K
October 1, 2008
K-33

 

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  ii)   PSHSP services rendered to children three (3) through four (4) years of
age in conjunction with an approved IEP are categorized as Non-Covered.     iii)
  The PSHSP services will be identified on eMedNY by unique rate codes through
which only counties and New York City can claim reimbursement. In addition, a
limited number of Article 28 clinics associated with approved pre-school
programs are allowed to directly bill Medicaid fee-for-service for these
services. Contractor covered and authorized services will continue to be
provided by the Contractor.

  c)   School Supportive Health Services-Children Five (5) Through Twenty-One
(21) Years of Age

  i)   The School Supportive Health Services Program (SSHSP) enables school
districts to obtain Medicaid reimbursement for certain educationally related
medical services provided by approved special education programs for children
with disabilities. The Committee on Special Education in each school district is
responsible for the development of an Individualized Education Program (IEP) for
each child evaluated in need of special education and medically related
services.     ii)   SSHSP services rendered to children five (5) through
twenty-one (21) years of age in conjunction with an approved IEP are categorized
as Non-Covered.     iii)   The SSHSP services are identified on eMedNY by unique
rate codes through which only school districts can claim Medicaid reimbursement.
Contractor covered and authorized services will continue to be provided by the
Contractor.

  d)   Comprehensive Medicaid Case Management (CMCM)         A program which
provides “social work” case management referral services to a targeted
population (e.g.: pregnant 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 must 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 EMEVS and informed on the need to contact
the Contractor to coordinate service provision.     e)   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

APPENDIX K
October 1, 2008
K-34

 

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      prescribed medication regimen. While the clinical management of
tuberculosis is included in the Benefit Package, TB/DOT where applicable, can be
billed directly to eMedNY by any SDOH approved Medicaid fee-for-service TB/DOT
Provider. The Contractor remains responsible for communicating, cooperating and
coordinating clinical management of TB with the TB/DOT Provider.     f)   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.     g)   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.     h)   Adult Day
Health Care

  i)   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.     ii)   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 while or in part satisfactorily by delivery of
appropriate services in such program.

APPENDIX K
October 1, 2008
K-35

 

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  i)   Personal Emergency Response Services (PERS)         Personal Emergency
Response Services (PERS) are not included in the Benefit Package. PERS are
covered on a fee-for-service basis through contracts between the LDSS and PERS
vendors.     j)   School-Based Health Centers         A School-Based Health
Center (SBHC) is an Article 28 extension clinic that is located in a school and
provides students with primary and preventive physical and mental health care
services, acute or first contact care, chronic care, and referral as needed.
SBHC services include comprehensive physical and mental health histories and
assessments, diagnosis and treatment of acute and chronic illnesses, screenings
(e.g., vision, hearing, dental, nutrition, TB), routine management of chronic
diseases (e.g., asthma, diabetes), health education, mental health counseling
and/or referral, immunizations and physicals for working papers and sports.

APPENDIX K
October 1, 2008
K-36

 

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K.4
Family Health Plus
Non-Covered Services

1.   Non-Emergent Transportation Services (except for 19 and 20 year olds
receiving C/THP Services)   2.   Personal Care Agency Services   3.   Private
Duty Nursing Services   4.   Long Term Care — Residential Health Care Facility
Services   5.   Pharmacy Items (covered through Medicaid fee-for-service
program)   6.   Medical Supplies   7.   Alcohol and Substance Abuse
(ASA) Services Ordered by the LDSS   8.   Office of Mental Health/ Office of
Mental Retardation and Developmental Disabilities Services   9.   School
Supportive Health Services   10.   Comprehensive Medicaid Case Management (CMCM)
  11.   Directly Observed Therapy for Tuberculosis Disease   12.   AIDS Adult
Day Health Care   13.   HIV COBRA Case Management   14.   Home and Community
Based Services Waiver   15.   Methadone Maintenance Treatment Program   16.  
Day Treatment   17.   IPRT   18.   Infertility Services   19.   Adult Day Health
Care   20.   School Based Health Care Services   21.   Personal Emergency
Response Systems

APPENDIX K
October 1, 2008
K-37

 

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APPENDIX L
Approved Capitation Payment Rates
APPENDIX L
October 1, 2008
L-1

 

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AMERIGROUP NEW YORK, LLC
Medicaid Managed Care Rates
****REDACTED****

 

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      AMERIGROUP NEW YORK, LLC           Family Health Plus Rates     Effective
October 1, 2008   Optional       ****REDACTED****