Back to Form 8-K [form8-k.htm]
Exhibit 10.2

 AMENDMENT 1
 
APPENDIX X
 

 Agency Code 12000                                                   Contract
No. C022813                                                     Period 1/1/08 -
12/31/12                                  Funding Amount for Period ____ no
change ____

  
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 Coming
Tower, Empire State Plaza, Room 1619, Albany, NY 12237, hereinafter referred to
as the STATE), and Wellcare of New York, Inc. (hereinafter referred to as the
CONTRACTOR), for modification of Contract Number C022813 as amended in attached
Appendix C.

All other provisions of said AGREEMENT shall remain in full force and effect.
 
IN WITNESS WHEREOF, the parties hereto have executed this AGREEMENT as of the
dates appearing under their signatures.
 
CONTRACTOR SIGNATURE
 
 
 
STATE AGENCY SIGANTURE
By:     /s/ Heath Schiesser    
           Heath Schiesser          
           Printed Name
 
 
 By:    /s/ Judith Arnold                             
           Judith Arnold                               
           Printed Name
Title:  President and CEO     
 
Title:  Director, Division of Coverage and Enrollment
 
Date:  8/22/08                         
 
 
Date: 9/12/08                                           
 
 
 
 
 
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 exact copies of this
contract.”

 
 
 

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STATE OF FLORIDA
)
  )SS.:     County of Hillsborugh                  )

On the 22nd day of August in the year  2008  before me, the undersigned,
personally appeared  Heath Schiesser, 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.

_Cathleen McGlynn                                                            
(Signature and office of the individual taking acknowledgement)
 

 
STATE COMPTROLLER'S SIGNATURE
 
Title:
 
Date:

 

   
 APPROVED
     
 DEPT. OF AUDIT & CONTROL
             
 DEC 4 2008
             
 /s/ Name Illegible                                   
       FOR THE STATE COMPTROLLER  

 
 
 

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APPENDIX C
PROGRAM SPECIFIC CLAUSES
 
Sections 4.4, 4.5, 4.8 and 4.10 are revised to read as follows:

4.4           Health Insurance
 
                The child must not have other health insurance coverage unless
the policy is one of the "Excepted Benefits" set forth in the federal Public
Health Service Act. These
                exceptions are as follows:
 
                A.       Accident-only coverage or disability income insurance;
                B.        Coverage issued as a supplement to liability
insurance;
                C.        Liability insurance, including auto insurance;
                D.       Workers' compensation or similar insurance;
                E.        Automobile medical payment insurance;
                F.        Credit-only insurance;
                G.        Coverage for on-site medical clinics;
                H.       Dental-only, vision-only, or long term care insurance;
                I.         Specified disease coverage;
                J.         Hospital indemnity or other fixed dollar indemnity
coverage; or
                K.       Medicare supplemental only or CHAMPUS supplemental
coverage.

Additional exceptions for otherwise eligible children are:
 
 
 ▪
Participation in the Physically Handicapped Children's Program;

 
 
 ▪
Health insurance by a non-custodial parent if the health plan's provider network
is not geographically accessible to the child; or

 
 
 ▪
Enrollment in the Medicaid Family Planning Benefit program.

                Children with other health insurance products are not eligible
for CHPlus including, but not limited to:
 
 
 ▪
A child with Medicare coverage; or

 
 
 ▪
A child insured with a college health insurance policy.

 
4.5           Public Employees
 
The parent or guardian of the applicant child shall not be a public employee of
the State or a public agency with access to family health insurance coverage by
a state health benefits plan and the State or public agency pays all or part of
the cost of the family health insurance coverage. For a listing of other than
state agencies or state operated facilities, the CONTRACTOR may use the
following website to determine if the public agency has access to a state health
benefits plan:
 
www.cs.state.ny.us/ebd/ebdonlinecenter/pamarket/directorv.cfm. If the CONTRACTOR
is uncertain if a parent has access to such coverage, the CONTRACTOR must
contact the applicant's parent or guardian to find out if the health insurance
available to the family is that described in this paragraph.

 
 

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4.8           Screen for Eligibility
 
The CONTRACTOR shall follow the following steps to assure that children are
screened for Medicaid or CHPlus eligibility.
 
New Applications
 
The CONTRACTOR must screen all new applications for Medicaid eligibility using
the STATE developed eligibility screening worksheet. CONTRACTORS shall only
enroll children who appear eligible for Medicaid based on the screening
worksheet in CHPlus on a temporary basis, as described in section 8 of this
Appendix and the CHPlus manual.

If the screen indicates the child is not eligible for Medicaid, otherwise
eligible children residing in households with gross income at or below 250
percent of the non-farm federal poverty level or, effective September 1, 2008,
400 percent of the non-farm federal poverty level, are eligible for subsidized
coverage under CHPlus. If the CONTRACTOR determines a child to be eligible for
CHPlus, the child shall be enrolled in CHPlus for a period to begin on the first
day of the month an eligible child is enrolled, based on all required
documentation, and shall continue for twelve (12) months ending on the last day
of the twelfth month as specified in section 4.9 of this Appendix.
 
Children residing in households with gross income over 250 percent of the
non-farm federal poverty level or, effective September 1, 2008, over 400 percent
of the non-farm federal poverty level, are not eligible for subsidized coverage
under CHPlus but may be enrolled in CHPlus providing that they pay the full
premium amount for the health plan in which they are enrolled.
 
4.10         Crowd-Out
 

 

 
1.          If the STATE determines that crowd-out is occurring in excess of a
percentage specified in the State Child Health Plan established under Title XXI
of the federal Social Security Act or as may be specified by the Secretary of
the federal Department of Health and Human Services based on data collected
pursuant to section 16.4 of this Appendix, the following eligibility criterion
shall be implemented for a child residing in a household with gross income at or
below two hundred fifty percent of the non-farm federal poverty level.

              
The child must not have been covered by a group health plan based upon a family
member's employment during the six (6) month period prior to the date of
application unless one of the following exceptions applies:
 
 a)          Loss of employment is due to factors other than voluntary
separation;
 
 
b)
Death of the family member which results in termination of coverage under a
group health plan under which the child is covered;

 
 
c)
Change to a new employer that does not provide an option for comprehensive
health benefits coverage;

 
 

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d)
Change of residence so that no employer-based comprehensive health benefits
coverage is available;

 
 
e)
Discontinuation of comprehensive health benefits coverage to all employees of
the applicant's employer;

 
 
f)
Expiration of the coverage periods established by COBRA or the provisions of
sections 3221(m), 4304(k) and 4305(e) of the Insurance Law;

 
                g)          Termination of comprehensive health benefits
coverage due to long-term disability;
 
 
h)
Cost of employment-based health insurance is more than five percent of the
family's income;

 
                i)           The child applying for coverage is pregnant;
 
 
j)
The child applying for coverage under this title is at or below the age of five
(5). Implementation of this exception is subject to federal approval of the
State's child health plan setting forth such exception. The STATE shall notify
the CONTRACTOR when such approval has been obtained.

2.             Effective September 1, 2008, the waiting period set forth in
paragraph 1 of this section shall be implemented for a child residing in a
household with gross income between 251 and 400 percent of the non-farm federal
poverty level, provided, however, the exceptions set forth in subparagraphs
(a)-(g) and (i) of paragraph 1 of this section shall be the only exceptions
applied to such child. The STATE shall notify the CONTRACTOR if and when federal
approval of the income expansion to 400 percent of the non-farm federal poverty
level has been obtained at which point, all the exceptions set forth in
paragraph 1 of this section shall apply to children residing in households with
gross income between 251 and 400 percent of the non-farm federal poverty level.

 
 

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Sections 5.2, 5.3 and 5.4 are revised to read as follows:

5.2           New York State Residency
 

 

 
Proof of residency must match the home address in Section A of the Growing up
Healthy or Access New York Health Care application and must be dated within six
(6) months of the application. Proof of residency shall be documented by the
following: an identification card with address, a postmarked envelope or
postcard with name and date (this cannot be used if sent to a P.O. Box), a
driver's license, a utility bill (including oil, gas or electric, water, cable,
or telephone) that includes the street address and zip code for the service (the
city name is not required on the bill), letters/correspondence from a federal,
state or local government agency, a letter or rent receipt containing the name
and street of the tenant and the amount paid each month, as well as the name and
address from the landlord and the landlord's signature, a valid lease that
contains the applicant's name, address and amount of rent from the landlord,
property tax records, a mortgage statement or a letter stating that an applying
child or family member resides with a particular individual. 

 
 

  The CONTRACTOR shall not accept cell-phone bills, magazine labels, bank
statements, an envelope or postcard without a street address (just a P.O. Box),
an envelope with a forwarding label from the Post Office, a window envelope or
Federal or state tax returns.

 
5.3           Other Health Insurance Coverage

 

  Other health insurance, if applicable, shall be documented by a copy of the
insurance policy, a certificate of insurance, a copy of the insurance card or a
copy of the Medicare card.

 

  Documentation of health insurance is necessary for CHPlus to determine if a
child's coverage or access to coverage makes them ineligible for the program.
Documentation of other health insurance is necessary for Medicaid and Family
Health Plus as a possible deduction when calculating eligibility and for
coverage of future medical bills. If the applicant indicates he/she has other
health insurance coverage, the health plan shall obtain documentation of such
coverage at initial enrollment and if different than what was stated on the
initial application, at recertification.

 

  If the CONTRACTOR receives a paycheck stub as documentation of income that
includes a deduction for health insurance, the CONTRACTOR must ask the applicant
who is covered through the employer based policy and note the response on the
stub. If the child is covered, in most cases, the child is not eligible for
CHPlus. If only the parent is covered, the child is eligible for CHPlus

 

  In most cases, if an applicant presents a State paycheck stub, the person will
have access to the State health benefits plan and the child will be ineligible
for CHPlus. If a person is employed by a local government or is a teacher, they
may have access to the State health benefits plan also. The CONTRACTOR must
determine if such coverage is through a State health benefits plan to determine
if a child is eligible for CHPlus. For a listing of other than state agencies or
state operated facilities, the CONTRACTOR may use the following website to
determine if the public agency has access to a State health benefits plan:
www.cs.state.nv.us/ebd/ebdonlinecenter/pamarket/directory.cfm. If the CONTRACTOR
is uncertain, the CONTRACTOR shall call the applicant or the employer to
determine if the child has access to the State health benefits program.

 
 

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5.4           Income

 

  Income documentation must be provided for all household members listed in
section B of the Growing up Healthy or Access New York Health Care application
who have income. Income documentation must be provided for all categories listed
below that apply. The CONTRACTOR must obtain documentation of the gross income
for the four weeks preceding the application signature date for all individuals
included in the household. Unearned income that varies from month to month (i.e.
interest income) must also be documented for the four weeks prior to
application. Documentation of unearned income which docs not vary on a month to
month basis does not have to be dated within the four weeks prior the
application as long as it reflects the current amount. Applicants may provide,
at recertification, their social security number in lieu of income
documentation. Income shall be documented by the following:

 
                a.          Wages and Salary:
 
 
1.
Paycheck stubs for the four (4) consecutive weeks preceding the application
signature date. Paychecks may only be used if they include all information
typically contained on a pay stub, including net and gross income and
deductions. Paycheck stubs must include the name of both the employer and
employee. The CONTRACTOR shall accept a paycheck stub without the employee's
name if the person provides their social security number on the application and
the paycheck stub includes the social security number.

 
2. 
In cases where the CONTRACTOR receives three weeks of paycheck stubs and is
missing one in between, the CONTRACTOR shall use the year to date income on the
subsequent paycheck to calculate the amount of the missing paycheck stub. In
this instance, the CONTRACTOR shall accept three paycheck stubs rather than
four;

 
3. 
Letter from the employer on company letterhead which is signed and dated and
includes the employer's name, address and phone number and the employee's name
and gross income. If the applicant indicates their employer does not have
letterhead, the CONTRACTOR shall accept a letter without it and note on the
letter that according to the applicant, letterhead does not exist;

 
4. 
Signed and dated income tax return (Federal form 1040) if used for applications
prior to April 1 of the following year; or
  5.  Business/payroll records.

 
The following are not acceptable documentation of earned income: quarterly wage
statements, W-2s and 1099s.

If a person has recently begun a new job or receiving some regular income and
therefore cannot document income for the last four weeks, the CONTRACTOR shall
follow the instructions in section 7 of this Appendix, presumptive eligibility.
This will involve documenting only what they have and obtaining further
documentation when the income is received.

 
 

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A joint tax return must be signed by both filers. If an electronic tax return is
used, the family may bring a signed copy of the tax return. If the return is
filed electronically, a copy of the acknowledgement form from the Internal
Revenue Service, which includes a DCN number that verifies that tax return was
accepted electronically is acceptable.
 
The CONTRACTOR shall not accept a letter from an employer that states an
"approximate" or "average" income.
 
                 b.         Self-Employment Income:
 
 
1.
Signed and dated income tax return and all schedules including Schedule C for
sole owners of a business, Schedule E for rental real estate, partnerships and S
corporations or Schedule F for farmers, Schedule K-l (Form 1065) and Form 1065
for Partnerships, and Schedule K-1 (Form 1120S) and Form 1120S for S
Corporations; (See paragraph above on electronic returns); or

 
2. 
Records of earnings and expenses/business records. The three month
"Self-Employment worksheet" used by many local social services districts may be
used as acceptable proof as long as it is consistent with other information on
the application and appears internally consistent.

 
3. 
If no other form of documentation is available, a self-declaration of income.

 
                 c.         Unemployment Benefits:
 

  1. Award letter or certificate;
 
2. 
A monthly benefit statement from the New York State Department of Labor;

 
3. 
A printout of the recipient's account information from the New York State
Department of Labor's website (www.labor.state.ny.us);

 
4. 
Correspondence from the New York State Department of Labor; or
  5.  A copy of the direct payment card with printout.

 
The CONTRACTOR shall not accept the monetary determination letter as
documentation of unemployment as it is not necessarily what the person will
receive in income. If the applicant does not have any of the above, the
CONTRACTOR shall enroll the child presumptively in accordance with section 7 of
this Appendix and follow-up accordingly.

                 d.         Private Pensions/Annuities:
 
                             1.           Statement from pension/annuity.
 
                 e.          Social Security Retirement/Survivors/Disability
Insurance:
 
                             1.           Award letter/certificate;
                             2.           Benefit check stub; or
                             3.           Correspondence from the Social
Security Administration.

 
 

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The CONTRACTOR shall not accept bank statements as documentation of this amount
since they show only net income.
 
                f.           Child Support/Alimony
 
 
1. 
Letter from person providing support which includes the name and address of the
person providing the support, the amount of the support being provided, the name
of the person receiving the support and who the support is for. The letter must
be signed and dated;
  2.  Letter from court;   3. 
Child support/alimony check stub. If the same amount of support is received each
time and it is consistent with the child support order, it is not necessary to
obtain four weeks of check stubs. If there is any dispute or discrepancy, and
the child support is not received on a consistent basis from week to week, four
weeks worth of check stubs must be submitted and averaged;
  4. 
Monthly bank statement for those recipients that choose direct deposit for their
child support;
  5. 
A copy of their child support account information from the following website:
www.newyorkchildsupport.com; or
  6.  A copy of the New York Eppicard with printout.

 
                g.          Worker's Compensation
 

  1. Award letter; or   2.  Check stub.      

 
                h.          Veteran's Benefits
 
 
1.
Award letter;

 
2.
Benefit check stub; or   3.  Correspondence from the Veteran's Administration.

 
                 i.          Military Pay
 
 
1.
Award letter; or       2.  Check stub.

 
 j.          Interest/Dividends/Royalties
 
 
1.
Recent statement from bank, credit union or financial institution;   2.  Letter
from broker;   3.  Letter from Agent; or   4.  A 1099 or tax return if no other
documentation is available.

 
                 k.          Income from Rent or Room/Board
 

1. 
Letter from roomer, boarder or tenant including the name and address of the
tenant, roomer/boarder, the name of the landlord and the amount paid. The letter
must be signed and dated; or
  2.  Check stub.

 
 

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                l.           Support from other Family members
 
                              1.          Signed statement or letter from family
member.

                m.         Self Declaration of Income

 
 
1.
CONTRACTOR shall accept a Self-Declaration of Income form found in Attachment A
of this section if the applicant has no other way to document his/her income.
The form must be completed in full and may only be accepted if no other income
documentation is available.

                n.          Student Stipends
 
 
 
1.
A letter from the school/organization providing the stipend which must include
the amount being given and any restrictions on the use of the money, if any.

 
o.          Non-Monetary Compensation
 
 
1. 
A letter from the person providing non-monetary compensation, in lieu of wages,
including the name of the person providing the service, what service is being
provided, the type of compensation being provided (i.e. rent), the value of the
compensation on the open market and the name, signature and date of the person
providing the compensation.

                p.          No income
 
 
1. 
A statement on the application or on the Declaration of No Income form found in
Attachment B of this section indicating how the person is supporting him/herself
with no income.
  2.  This form should only be used when a household has no income. It is not to
be used if one person in the household has income and one person in the
household does not.

 
 

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The following provision 9.15 is added:
 
9.15         Early Recertification Application

 

  If the CONTRACTOR receives a recertification application early (not a complete
Growing up Healthy or Access New York Health Care application at any other point
in the year), the child shall be recertified at the end of the coverage period.
Any changes in premium contribution shall not begin until the first day of the
month following the 12 month enrollment period. If the child appears eligible
for Medicaid, the CONTRACTOR shall immediately inform the family that they must
apply for Medicaid. The CONTRACTOR shall not begin the temporary enrollment
period until the first day of the month following the 12 month enrollment
period. If a child is presumptively recertified, the CONTRACTOR shall
immediately inform the family of the missing documentation. The CONTRACTOR shall
not begin the presumptive recertification period until the first day of the
month following the 12 month period.

 
 

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Section 10.1 is revised to read as follows:
 
10.1         Family Premium Contribution

 

 
The CONTRACTOR shall collect from subscribers any required family premium
contribution.   There is no family premium contribution for children whose gross
household income is less than 160 percent of the non-farm federal poverty level
or for children who are American Indians or Alaskan Natives (AI/AN) whose gross
household income is less than 250 percent of the non-farm federal poverty level.
 
 
 The family premium contribution for children whose gross household income is
between 160 percent and 222 percent of the non-farm federal poverty level is $9
per child, with a family maximum of $27 per month.
 
 
 The family premium contribution for children whose gross household income is
between 223 percent and 250 percent of the non-farm federal poverty level is $15
per child, with a family maximum of $45 per month.
 
 
The following provisions are effective for September 1, 2008 enrollment:
 
 
The family premium contribution for children whose gross household income is
between 251 percent and 300 percent of the non-farm federal poverty level is $20
per child, with a family maximum of $60 per month.
 
 
The family premium contribution for children whose gross household income is
between 301 percent and 350 percent of the non-farm federal poverty level is $30
per child, with a family maximum of $90 per month.
 
  The family premium contribution for children whose gross household income is
between 351 percent and 400 percent of the non-farm federal poverty level is $40
per child, with a family maximum of $120 per month.

 
 
 

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The following provision is added to Section 14.2:
 
 
▪
 For Child Health Plus applicants listed as undocumented immigrants, the
CONTRACTOR must review the application and the supporting documentation
submitted by the parent to determine if the child is truly undocumented. The
CONTRACTOR shall only assume a child is undocumented if the family indicates the
child does not have any valid immigration documentation and no other information
to the contrary has been provided. If the child's parent is legally employed
(provides pay stubs, an income tax return or an employer letter) and has a
social security number, the CONTRACTOR must assume that the parent has valid
immigration paperwork and that the child is not undocumented. Such cases
required additional follow up with the family prior to enrolling the child.

 
 

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The following provision in Section 16.2 is revised effective July 1, 2008 as
follows:
 
Additional Reports for Health Plans that Participate in the Facilitated
Enrollment Program:
 
New Applications- On a monthly basis, by the 1.0th business day of the month
following the end of the month when applications were taken, the CONTRACTOR
shall report, by county, the total number of new complete and incomplete
applications sent to a LDSS for an eligibility determination. The CONTRACTOR
shall report, by county, the number of new complete and incomplete applications
forwarded to a LDSS for adults only, children only and adults and children and
the total number of new applicants for Family Health Plus, adult Medicaid and
children's Medicaid.
 
Number of Facilitators - On a monthly basis by the 10th business day of the
month, the CONTRACTOR shall submit to the STATE'S Division of Managed Care and
Program Evaluation, the total number of facilitators employed by the CONTRACTOR.

 
 

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Section 18.1 is revised to read as follows:

18.1         Monthly Premium Payment
 

 
The total monthly premium shall be the amount approved by the State Insurance
Department in consultation with the STATE in effect at the time of enrollment.
 
 
The STATE shall pay the CONTRACTOR the total monthly premium for children in
families with gross household income less than 160 percent of the non-farm
federal poverty level (FPL) and children who are American Indians or Alaskan
Natives (AI/AN) whose gross household income is less than 250 percent of the
FPL.
 
 
The STATE shall pay the CONTRACTOR the total monthly premium less $9 for each of
the first three children in families with gross household income between 160
percent and 222 percent of the FPL. The STATE shall pay the total monthly
premium for each additional child.
 
 
The STATE shall pay the CONTRACTOR the total monthly premium less $15 for each
of the first three children in families with gross household income between 223
percent and 250 percent of the FPL. The STATE shall pay the total monthly
premium for each additional child.
 
 
The following provisions are effective for September 1, 2008 enrollment:
 
 
The STATE shall pay the CONTRACTOR the total monthly premium less $20 for each
of the first three children in families with gross household income between 251
percent and 300 percent of the FPL. The STATE shall pay the total monthly
premium for each additional child.
 
 
The STATE shall pay the CONTRACTOR the total monthly premium less $30 for each
of the first three children in families with gross household income between 301
percent and 350 percent of the FPL. The STATE shall pay the total monthly
premium for each additional child.
 
  The STATE shall pay the CONTRACTOR the total monthly premium less $40 for each
of the first three children in families with gross household income between 351
percent and 400 percent of the FPL. The STATE shall pay the total monthly
premium for each additional child.