THE CITY OF NEW YORK     DEPARTMENT OF HEALTH AND MENTAL HYGIENE

 
   
Michael R. Bloomberg
Mayor
  Thomas R. Frieden, M.D., M.P.H.
Commissioner

nyc.gov/health December 22, 2004

Ms. Karin Ajmani
Executive Director
CarePlus, L.L.C.
360 West 31st Street, Fifth Floor New York, NY 10001

Dear Ms. Ajmani:

Enclosed please find, for your files, one (1) fully executed Contract Extension
of Agreement between the City of New York and CarePlus, L.L.C.

If you have any questions you may reach me at (212) 788-5533 or contact Liane
Daniels at (212) 788-5657.

Sincerely,

Vivian Toan, Counsel
NYCDOHMH-Health Care Access & Improvement

Enclosure

1

MEDICAID MANAGED CARE

MODEL CONTRACT

2

October 1, 2004
AGREEMENT BETWEEN

The City of New York

And

CarePlus, L.L.C.

This Agreement is made by and between

The City of New York

Acting through,

New York City Department of Health and Mental Hygiene [“DOHMH”]

Located at

161 William Street, 5th floor

New York, NY 10038

And

CarePlus, L.L.C

Located At

360 West 31St Street, Fifth Floor

New York, NY 10001
RECITALS
October 1, 2004
Page 1 of 2
RECITALS

Pursuant to Title XIX of the Federal Social Security Act, codified as 42 U.S.C.
Section 1396 et seq. (the “Social Security Act”), and Title 11 of Article 5 of
the New York State Social Services Law (“SSL”), codified as N.Y.S.S.L.
Section 363 et seq., a comprehensive program of Medical Assistance for needy
persons exists in the State of New York (“Medicaid”).

Pursuant to Article 44 of the Public Health Law (“PHL”), the New York State
Department of Health (“SDOH”) is authorized to issue Certificates of Authority
to establish Health Maintenance Organizations (“HMOs”), PHL Section 4400 et
seq., and Prepaid Health Services Plans (“PHSPs”), PHL Section 4403-a.

The State Social Services Law defines Medicaid to include payment of part or all
of the cost of care. and services furnished by an HMO or a PHSP, identified as
Managed Care Organizations (“MCOs”) in this Agreement, to Eligible Persons, as
defined in this Agreement, residing in the geographic area specified in
Appendix M (Service Area) when such care and services are furnished in
accordance with an agreement approved by the SDOH that meets the requirements of
federal law and regulations.

The Contractor is a corporation organized under the laws of New York State and
is certified under Article 44 of the State Public Health Law or Article 43 of
the NYS Insurance Law.

The Contractor offers a comprehensive health services plan and represents that
it is able to make provision for furnishing medical and health service benefits
and has proposed to New York City Department of Health and Mental Hygiene to
provide these services to Eligible Persons; and

The Contractor has applied to participate in the Medicaid Managed Care Program
and the SDOH and City of New York have determined that the Contractor meets the
qualification criteria established for participation.

NOW THEREFORE, the parties agree as follows:

RECITALS
October 1, 2004
Page 2 of 2

3

Table of Contents for Model Contract

Recitals

Section 1 Definitions

Section 2 Agreement Term, Amendments, Extensions, and General Contract
Administration Provisions

     
2.1
2.2
2.3
2.4
2.5
2.6
2.7
  Term
Amendments and Extensions
Approvals
Entire Agreement
Renegotiation
Assignment and Subcontracting
Termination

a. LDSS Initiated Termination of Contract
b. Contractor and LDSS Initiated Termination
c. Contractor Initiated Termination
d. Termination Due to Loss of Funding

2.8 Close-Out Procedures
2.9 Rights and Remedies 2.10 Notices

         
Section 3
  2.11
Compensation
3.1
3.2
3.3
3.4
3.5
3.6
3.7
3.8   Severability

Capitation Payments
Modification of Rates During Contract Period
Rate Setting Methodology
Payment of Capitation
Denial of Capitation Payments
SDOH Right to Recover Premiums
Third Party Health Insurance Determination
Payment for Newborns

3.9 Supplemental Maternity Capitation Payment 3.10 Contractor Financial
Liability
3.11 Inpatient Hospital Stop-Loss Insurance
3.12 Mental Health and Chemical Dependence Stop-Loss 3.13 Enrollment Limitations
3.14 Tracking Visits Provided by Indian Health Clinics

         
Section 4
  Service Area  

 
        Section 5   Eligible, Exempt and Excluded Populations

 
       
 
  5.1
5.2
5.3
5.4
5.5   Eligible Populations
Exempt Populations
Excluded Populations
Family Health Plus
Family Enrollment

TABLE OF CONTENTS

October 1, 2004 1

                  Table of Contents for Model Contract
Section 6
  Enrollment
6.1
6.2
6.3
6.4
6.5
6.6
6.7
6.8
6.9
6.10  
Enrollment Guidelines
Equality of Access to Enrollment
Enrollment Decisions
Auto Assignment
Prohibition Against Conditions on Enrollment
Family Enrollment
Newborn Enrollment
Effective Date of Enrollment
Roster
Automatic Re-Enrollment
 
       
Section 7
  Lock-In Provisions
7.1
7.2
7.3
7.4  
Lock-In Provisions in Voluntary Counties
Lock-In Provisions in Mandatory Counties and New York City
Disenrollment During Lock-In Period
Notification Regarding Lock-In and End of Lock-In Period
 
       
Section 8
  Disenrollment
8.1
8.2
8.3
8.4  
Disenrollment Guidelines
Disenrollment Prohibitions
Reasons for Voluntary Disenrollment
Processing of Disenrollment Requests

a. Routine Disenrollment
b. Expedited Disenrollment
c. Retroactive Disenrollment

     
8.5
8.6
8.7
  Contractor Notification of Disenrollments
Contractor’s Liability
Enrollee Initiated Disenrollment

a. Disenrollment for Good Cause

         
 
  8.8
8.9   Contractor Initiated Disenrollment
LDSS Initiated Disenrollment
 
       
Section 9
  Guaranteed Eligibility  

 
        Section 10   Benefit Package, Covered and Non-Covered Services

 
       
 
  10.1
10.2
10.3   Contractor Responsibilities
Compliance with State Medicaid Plan and Applicable Laws
Definitions

  10.4   Provision of Services Through Participating and Non-Participating
Providers

10.5 Child Teen Health Program / Adolescent Preventive Services 10.6 Foster Care
Children
10.7 Child Protective Services
10.8 Welfare Reform

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October 1, 2004 2

          Table of Contents for Model Contract
10.9
10.10
10.11
10.13
10.14
10.15
10.16
  Adult Protective Services
Court-Ordered Services
Family Planning and Reproductive Health Services 10.12 Prenatal Care
Direct Access
Emergency Services
Medicaid Utilization Thresholds (MUTS)
Services for Which Enrollees Can Self-Refer

a. Mental Health and Chemical Dependence Services
b. Vision Services
c. Diagnosis and Treatment of Tuberculosis
d. Family Planning and Reproductive Health Services
e. Article 28 Clinics Operated by Academic Dental Centers

10.17 Second Opinions for Medical or Surgical Care
10.18 Coordination with Local Public Health Agencies
10.19 Public Health Services

  a.   Tuberculosis Screening, Diagnosis and Treatment; Directly Observed
Therapy (TB/DOT)  

b. Immunizations
c. Prevention and Treatment of Sexually Transmitted Diseases
d. Lead Poisoning

10.20 Adults with Chronic Illnesses and Physical or Developmental Disabilities
10.21 Children with Special Health Care Needs

         
 
  10.22
10.23
10.24
10.25
10.26
10.27
10.28
10.29
10.30   Persons Requiring Ongoing Mental Health Services
Member Needs Relating to HIV
Persons Requiring Chemical Dependence Services
Native Americans
Women, Infants, and Children (WIC)
Urgently Needed Services
Dental Services Provided by Article 28 Clinics Operated by Academic
Dental Centers Not Participating in Contractor’s Network
Coordination of Services
Prospective Benefit Package Change for Retroactive SSI Determinations
 
       
Section 11
  Marketing
11.1
11.2
11.3
11.4
11.5  
Marketing Plan
Marketing Activities
Prior Approval of Marketing Materials, Procedures, Subcontracts
Marketing Infractions
LDSS Option to Adopt Additional Marketing Guidelines
 
       
Section 12
Section 13
  Member Services
12.1
12.2
12.3
Enrollee Notification
13.1
13.2
13.3
13.4
13.5
13.6
13.7
13.8  
General Functions
Translation and Oral Interpretation
Communicating with the Visually, Hearing and Cognitively Impaired

Provider Directories/Office Hours for Participating Providers
Member ID Cards
Member Handbooks
Notification of Effective Date of Enrollment
Notification of Enrollee Rights
Enrollee’s Rights to Advance Directives
Approval of Written Notices
Contractor’s Duty to Report Lack of Contact

13.9 Contractor Responsibility to Notify Enrollee of Expected Effective Date of
Enrollment

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October 1, 2004

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3
Table of Contents for Model Contract

13.10 LDSS Notification of Enrollee’s Change in Address
13.11 Contractor Responsibility to Notify Enrollee of Effective Date of Benefit
Package Change
13.12 Contractor Responsibility to Notify Enrollee of Termination, Service Area
Changes and Network Changes

          Section 14   Complaint and Appeal Procedure

 
       
 
  14.1
14.2
14.3
14.4   Contractor’s Program to Address Complaints
Notification of Complaint and Appeal Program
Guidelines for Complaint and Appeal Program
Complaint Investigation Determinations
 
       
Section 15
  Access Requirements
15.1
15.2
15.3
15.4  
Appointment Availability Standards
Twenty-Four (24) Hour Access
Appointment Waiting Times
Travel Time Standards

a. Primary Care
b. Other Providers

15.5 Service Continuation

a. New Enrollees
b. Enrollees Whose Health Care Provider Leaves Network

         
 
  15.6
15.7
15.8   Standing Referrals
Specialist as a Coordinator of Primary Care
Specialty Care Centers
 
       
Section 16
  Quality Assurance
16.1
16.2  
Internal Quality Assurance Program
Standards of Care
 
       
Section 17
  Monitoring and Evaluation
17.1
17.2
17.3
17.4  
Right To Monitor Contractor Performance
Cooperation During Monitoring And Evaluation
Cooperation During On-Site Reviews
Cooperation During Review of Services by External Review Agency
 
        Section 18   Contractor Reporting Requirements

 
       
 
  18.1
18.2
18.3
18.4
18.5   Time Frames for Report Submissions
SDOH Instructions for Report Submissions
Liquidated Damages
Notification of Changes in Report Due Dates, Requirements or Formats
Reporting Requirements

a. Annual Financial Statements
b. Quarterly Financial Statements
c. Other Financial Reports
d. Encounter Data
e. Quality of Care Performance Measures
f. Complaint Reports
g. Fraud and Abuse Reporting Requirements
h. Participating Provider Network Reports
i. Appointment Availability/Twenty-Four Hour (24) Access and Availability
Surveys
j. Clinical Studies
k. Independent Audits
l. New Enrollee Health Screening Completion Report
m. Additional Reports
n. LDSS Specific Reports

TABLE OF CONTENTS

October 1, 2004 4

                  Table of Contents for Model Contract
 
  18.6
18.7
18.8
18.9
18.10
18.11
18.12   Ownership and Related Information Disclosure
Revision of Certificate of Authority
Public Access to Reports
Professional Discipline
Certification Regarding Individuals Who Have Been Debarred or
Suspended by Federal or State Government
Conflict of Interest Disclosure
Physician Incentive Plan Reporting
 
        Section 19   Records Maintenance and Audit Rights

 
       
 
  19.1
19.2
19.3
19.4   Maintenance of Contractor Performance Records
Maintenance of Financial Records and Statistical Data
Access to Contractor Records
Retention Periods
 
       
Section 20
  Confidentiality
20.1
20.2
20.3
20.4  
Confidentiality of Identifying Information about Medicaid Recipients and
Applicants
Medical Records of Foster Children
Confidentiality of Medical Records
Length of Confidentiality Requirements

              Section 21   Participating Providers

 
            21.1
  Network Requirements

 
             
  a. b. c. d.   Sufficient Number Absence of Appropriate Network Provider
Suspension of Enrollee Assignments to Providers Notice of Provider Termination
 
            21.2
  Credentialing

 
             
  a. Licensure b. Minimum Standards c. Credentialing/Recredentialing Process d.
Application Procedure

 
            21.3
  SDOH Exclusion or Termination of Providers

 
            21.4
  Evaluation Information

 
            21.5
  Payment In Full

 
            21.6
  Choice/Assignment of PCPs

 
            21.7
  PCP Changes

 
            21.8
  Provider Status Changes

 
            21.9
  PCP Responsibilities

 
            21.10
  Member to Provider Ratios

 
            21.11
  Minimum Office Hours

 
             
  a. General Requirements b. Medical Residents

 
            21.12
  Primary Care Practitioners

 
             
  a. b. c. d.e.   General Limitations Specialists and Sub-specialists as PCPs
OB/GYN Providers as PCPs Certified Nurse Practitioners as PCPs Registered
Physician’s Assistants as Physician Extenders
 
            21.13
  PCP Teams

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5

Table of Contents for Model Contract

a. General Requirements
b. Medical Residents

21.14 Hospitals

a. Tertiary Services
b. Emergency Services

             
 
  21.15
21.16
21.17
21.19
21.20   Dental Networks
Presumptive Eligibility Providers
Mental Health and Chemical Dependence Services Providers 21.18
Federally Qualified Health Centers (FQHCs)
Provider Services Function  

Laboratory Procedures

 
            Section 22   Subcontracts and Provider Agreements
   
 
           
 
  22.1
22.2
22.3
22.4   Written Subcontracts
Permissible Subcontracts
Provision of Services Through Provider Agreements
Approvals  

 
           
 
  22.5
22.6
22.7
22.8
22.9
22.10
22.11
22.12   Required Components
Timely Payment
Restrictions on Disclosure
Transfer of Liability
Termination of Health Care Professional Agreements
Health Care Professional Hearings
Non-Renewal of Provider Agreements
Physician Incentive Plan  

 
           
Section 23
  Fraud and Abuse Prevention Plan  
 

 
            Section 24   Americans With Disabilities Act Compliance Plan
   
 
           
Section 25
  Fair Hearings
25.1
25.2
25.3
25.4
25.5
25.6  
Enrollee Access to Fair Hearing Process
Enrollee Rights to a Fair Hearing
Contractor Notice to Enrollees
Aid Continuing
Responsibilities of SDOH
Contractor’s Obligations  

 
           
Section 26
  External Appeal
26.1
26.2
26.3
26.4  
Basis for External Appeal
Eligibility For External Appeal
External Appeal Determination
Compliance With External Appeal Laws and Regulations  

 
           
Section 27
  Intermediate Sanctions  
 

 
           
Section 28
  Environmental Compliance  
 

 
           
Section 29
  Energy Conservation  
 

 
           
Section 30
  Independent Capacity of Contractor  
 

 
           
Section 31
  No Third Party Beneficiaries  
 

 
           
Section 32
  Indemnification
32.1
32.2  
Indemnification by Contractor
Indemnification by LDSS  

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October 1, 2004
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6

Table of Contents for Model Contract

          Section 33   Prohibition on Use of Federal Funds for Lobbying

 
       
Section 34
  33.1
33.2
33.3
Non-Discrimination
34.1
34.2
34.3   Prohibition of Use of Federal Funds for Lobbying
Disclosure Form to Report Lobbying
Requirements of Subcontractors

Equal Access to Benefit Package
Non-Discrimination
Equal Employment Opportunity

34.4 Native Americans Access to Services From Tribal or Urban Indian Health
Facility

              Section 35   Compliance with Applicable Laws
 
           
 
    35.1     Contractor and LDSS Compliance With Applicable Laws

35.2 Nullification of Illegal, Unenforceable, Ineffective or Void Contract
Provisions

     
 
  35.3 Certificate of Authority Requirements
35.4 Notification of Changes In Certificate of Incorporation
35.5 Contractor’s Financial Solvency Requirements
35.6 Compliance With Care For Maternity Patients
35.7 Informed Consent Procedures for Hysterectomy and Sterilization
35.8 Non-Liability of Enrollees For Contractor’s Debts
35.9 LDSS Compliance With Conflict of Interest Laws
35.10 Compliance With PHL Regarding External Appeals
 
   
Section 36
  New York State Standard Contract Clauses
 
   
Section 37
  Insurance Requirements

Signature Page

TABLE OF CONTENTS
October I. 2004
7

      Table of Contents for Model Contract APPENDICES  

A. New York State Standard Clauses and Local Standard Clauses, if applicable
B. Certification Regarding Lobbying

  C.   New York State Department of Health Guidelines for the Provision of
Family Planning and Reproductive Health Services  

D. New York State Department of Health Marketing Guidelines
E. New York State Department of Health Member Handbook Guidelines

  F.   New York State Department of Health Medicaid Managed Care Complaint and
Appeals Requirements  

  G.   New York State Department of Health Guidelines for the Provision of
Emergency Care and Services  

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

I. New York State Department of Health Guidelines for Use of Medical Residents

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

K. Prepaid Benefit Package Definitions of Covered and Non-Covered Services
L. Approved Capitation Payment Rates
M. Service Area

N. Contractor-County Specific Agreements

TABLE OF CONTENTS
October 1, 2004
8

7

“Auto-assignment” means a process by which an Eligible Person, who is mandated
to enroll in managed care, but who has not chosen to enroll within sixty
(60) days of receipt of the mandatory notice, is assigned to a MCO contracted
with the LDSS as a Medicaid Managed Care Provider in accordance with the
auto-assignment algorithm determined by the SDOH.

“Behavioral Health Services” means services to address mental health disorders
and/or chemical dependence.

“Benefit Package” means the covered services described in Appendix K of this
Agreement to be provided to the Enrollee, as Enrollee is hereinafter defined, by
or through the Contractor.

“Capitation Rate” means the fixed monthly amount that the Contractor receives
for an Enrollee to provide that Enrollee with the Benefit Package.

“Chemical Dependence Services” means examination, diagnosis, level of care
determination, treatment, rehabilitation, or habilitation of persons suffering
from chemical abuse or dependence, and includes the provision of alcohol and/or
substance abuse services.

“Child/Teen Health Program” or “C/THP” means the program of early and periodic
screening, including inter-periodic, diagnostic and treatment services
(EPSDT) that New York State offers all Medicaid eligible children under
twenty-one (21) years of age. Care and services are provided in accordance with
the periodicity schedule and guidelines developed by the New York State
Department of Health. The services include administrative services designed to
help families obtain services for children including outreach, information,
appointment scheduling, administrative case management and transportation
assistance, to the extent that transportation is included in the Benefit
Package.

“Comprehensive HIV Special Needs Plan, or HIV SNP” means a Managed Care
Organization certified pursuant to Section forty-four hundred three-c (4403-c)
of Article 44 of the Public Health Law (Article 44) which, in addition to
providing or arranging for the provision of comprehensive health services on a
capitated basis, including those for which Medical Assistance payment is
authorized pursuant to Section three hundred sixtyfive-a (365-a) of the Social
Services Law, also provides or arranges for the provision of comprehensive and
specialized HIV care to HIV positive persons eligible to receive benefits under
Title XIX of the federal Social Security Act or other public programs.

“Court-Ordered Services” means those services that the Contractor is required to
provide to Enrollees pursuant to orders of courts of competent jurisdiction,
provided however, that such ordered services are within the Contractor’s
Medicaid managed care Benefit Package and reimbursable under Title XIX of the
Federal Social Security Act (SSL 364-j(4)(r)).

“Days” means calendar days except as otherwise stated.
“Detoxification Services” means Medically Managed Detoxification Services; and
Medically Supervised Inpatient and Outpatient Withdrawal Services as defined in
Appendix K.

“Disenrollment” means the process by which an Enrollee’s membership in the
Contractor’s plan terminates.

“Effective Date of Disenrollment” means the date on which an Enrollee may no
longer receive services from the Contractor, pursuant to Section 8.6 and
Appendix H of this Agreement.

“Effective Date of Enrollment” means the date on which an Enrollee may receive
services from the Contractor, pursuant to Section 6.8(b) and Appendix H of this
Agreement.

“Eligible Person” means a person whom the LDSS, state or federal government
determines to be eligible for Medicaid and who meets all the other conditions
for enrollment in Medicaid managed care as set forth in this Agreement.

SECTION 1

(DEFINITIONS)

October 1, 2004

1-1

8

“Emergency Medical Condition” means a medical or behavioral condition, the onset
of which is sudden, that manifests itself by symptoms of sufficient severity,
including severe pain, that a prudent layperson, possessing an average knowledge
of medicine and health, could reasonably expect the absence of immediate medical
attention to result in: (i) placing the health of the person afflicted with such
condition in serious jeopardy, or in the case of a behavioral condition, placing
the health of the person or others in serious jeopardy; or (ii) serious
impairment to such person’s bodily functions; or (iii) serious dysfunction of
any bodily organ or part of such person; or (iv) serious disfigurement of such
person.

“Emergency Services” means covered medical services that are required to treat
an Emergency Medical Condition.

“Enrollee” means an Eligible Person who, either personally or through an
authorized representative, has enrolled (or who has been auto-assigned) in the
Contractor’s plan pursuant to Section 6 of this Agreement.

“Enrollment” means the process by which an Enrollee’s membership in a
Contractor’s Plan begins.

“Enrollment Broker” means the state and/or county-contracted entity that
provides enrollment, education, and outreach services; effectuates enrollments
and disenrollments in Medicaid managed care; and provides other contracted
services on behalf of the SDOH and the LDSS.

“Experienced HIV Provider” means an entity grant-funded by the SDOH AIDS
Institute to provide clinical and/or supportive services or an entity licensed
or certified by the SDOH to provide HIV/AIDS services.

“Family” means a mother and child(ren), a father and child(ren), a father and
mother and child(ren), or a husband and wife residing in the same household or
persons included in the same case for purposes of family enrollment in mandatory
counties.

“Fiscal Agent” means the entity that processes or pays vendor claims on behalf
of the Medicaid state agency pursuant to an agreement between the entity and
such agency.

“Guaranteed Eligibility” means the period beginning on the Enrollee’s Effective
Date of Enrollment with the Contractor and ending six (6) months thereafter,
during which the Enrollee may be entitled to continued enrollment in the
Contractor’s plan despite the loss of Medicaid eligibility as set forth in
Section 9 of this Agreement.

“Health Provider Network” or “HPN” means a closed communication network
dedicated to secure data exchange and distribution of health related information
between various health facility providers .and the SDOH. HPN functions include:
collection of Medicaid complaint and disenrollment information; collection of
Medicaid financial reports; collection and reporting of managed care provider
networks systems (PNS); and the reporting of Medicaid encounter data systems
(MEDS).

“HIV Specialist PCP” means a Primary Care Provider that meets the following
criteria:

• Direct clinical management of persons with HIV as part of a postgraduate
program, clinic, hospital-based or private practice during the last two years.
Primary ambulatory care of HIV-infected patients should include the management
of, patients receiving antiretroviral therapy over an extended period of time.
This experience should equal twenty patient- years experience, and

• Ten hours annually of Continuing Medical Education (CME) that includes
information on the use of antiretroviral therapy in the ambulatory care setting.

“Inpatient Stay Pending Alternate Level of Medical Care” means continued care in
a hospital pending placement in an alternate lower medical level of care,
consistent with the provisions of 18 NYCRR 505.20 and 10 NYCRR, Part 85.

“Institution for Mental Disease” or “IMD” means a hospital, nursing facility, or
other institution of more than sixteen (16) beds that is primarily engaged in
providing diagnosis, treatment or care of persons with mental diseases,
including medical attention, nursing care and related services. Whether an
institution is an Institution for Mental Disease is determined by its overall
character as that of a facility established and maintained primarily for the
care and treatment of individuals with mental diseases, whether or not it is
licensed as such. An institution for the mentally retarded is not an Institution
for Mental Diseases.

SECTION 1 (DEFINITIONS) October 1, 2004

1-2 .

9

“Local Public Health Agency” means The New York City Department of Health and
Mental Hygiene or its successor.

“Lock-In Period” means the period of time during which the Enrollee may not
disenroll from the Contractor’s plan, unless the Enrollee becomes eligible for
an exclusion or an exemption or can demonstrate good cause as established in
state law and in 18 NYCRR § 360-10.13.

“Managed Care Organization” or “MCO” means a health maintenance organization
(“HMO”) or prepaid health service plan (“PHSP”) certified under Article 44 of
the New York State PHL.

“Marketing” means any activity of the Contractor, subcontractor or individuals
or entities affiliated with the Contractor by which information about the
Contractor is made known to Eligible Persons for the purpose of persuading such
persons to enroll with the Contractor.

“Marketing Representative” means any individual or entity engaged by the
Contractor to market on behalf of the Contractor.

“Medicaid Management Information System” or “MMIS” means the Medical Assistance
Information and Payment System of the SDOH.

“Medical Record” means a complete record of care rendered by a provider
documenting the care rendered to the Enrollee, including inpatient, outpatient,
and emergency care, in accordance with all applicable federal, state and local
laws, rules and regulations. Such record shall be signed by the medical
professional rendering the services.

“Medically Necessary” means health care and services that are necessary to
prevent, diagnose, manage or treat conditions in the person that cause acute
suffering, endanger life, result in illness or infirmity, interfere with such
person’s capacity for normal activity, or threaten some significant handicap.

“Native American” means, for purposes of this contract, a person identified in
the Medicaid eligibility system as a Native American.

“Nonconsensual Enrollment” means Enrollment of an Eligible Person, other than
through Auto-assignment, newborn enrollment or case addition, in a Managed Care
Organization without the consent of the Eligible Person or consent of a person
with the legal authority to act on behalf of the Eligible Person at the time of
Enrollment.

“Non-Participating Provider” means a provider of medical care and/or services
with which the Contractor has no Provider Agreement.

“Participating Provider” means a provider of medical care and/or services that
has a Provider Agreement with the Contractor.

“Physician Incentive Plan” or “PIP” means any compensation arrangement between
the Contractor or one of its contracting entities and a physician or physician
group that may directly or indirectly have the effect of reducing or limiting
services furnished to Medicaid recipients enrolled by the MCO.

“Prepaid Capitation Plan Roster” or “Roster” means the enrollment list generated
on a monthly basis by SDOH by which LDSS and Contractor are informed of
specifically which recipients the Contractor will be serving for the coming
month, subject to any revisions communicated in writing or electronically by
SDOH, LDSS, or the Enrollment Broker.

“Presumptive Eligibility Provider” means a provider designated by the SDOH as
qualified to determine the presumptive eligibility for pregnant women to allow
them to receive prenatal services immediately. Such providers assist recipients
with the completion of the full application for Medicaid and they may be
comprehensive Prenatal Care Programs, Local Public Health Agencies, Certified
Home Health Agencies, Public Health Nursing Services, Article 28 facilities, and
individually licensed physicians and certified nurse practitioners.

“Preventive Care” means the care or services rendered to avert disease/illness
and/or its consequences. There are three levels of preventive care: primary,
such as immunizations, aimed at preventing disease; secondary, such as disease
screening programs aimed at early detection of disease; and 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 treatment programs.

SECTION 1

(DEFINITIONS)

October 1, 2004

1-3

“Primary Care Provider” or “PCP” means a qualified physician, or certified nurse
practitioner or team of no more than four (4) qualified physicians/nurse
practitioners which provides all required primary care services contained in the
Benefit Package to Enrollees.

“Provider Agreement” means any written contract between the Contractor and
participating Providers to provide medical care and/or services to Contractor’s
Enrollees.

“School Based Health Centers” or “SBHC” are SDOH approved centers which provide
comprehensive primary and mental health services including health assessments,
diagnosis and treatment of acute illnesses, screenings and immunizations,
routine management of chronic diseases, health education, mental health
counseling and treatment on-site in schools. Services are offered by
multi-disciplinary staff from sponsoring Article 28 licensed hospitals and
community health centers.

“Seriously Emotionally Disturbed” or “SED” means, a child through seventeen
(17) years of age who has utilized the following during the twelve (12) month
period prior to scheduled enrollment:

  •   ten (10) or more encounters, including visits to a mental health clinic,
psychiatrist or psychologist, and inpatient hospital days relating to a
psychiatric diagnosis; or

  •   one (1) or more specialty mental health visits (i.e., psychiatric
rehabilitation treatment program; day treatment; continuing day treatment;
comprehensive case management; partial hospitalization; rehabilitation services
provided to residents of Office of Mental Health (OMH) licensed community
residences and family-based treatment; and mental health clinics for seriously
emotionally disturbed children).

“Seriously and Persistently Mentally Ill” or “SMPI” means an adult eighteen
(18) years or older who has utilized the following during the twelve (12) month
period prior to scheduled enrollment:

• ten (10) or more encounters, including visits to a mental health clinic,
psychiatrist or psychologist, and inpatient hospital days relating to a
psychiatric diagnosis; or

• one (1) or more specialty mental health visits (i.e., psychiatric
rehabilitation treatment program; day treatment; continuing day treatment;
comprehensive case management; partial hospitalization; rehabilitation services
provided to residents of OMH licensed community residences and family-based
treatment; and mental health clinics for seriously emotionally disturbed
children).

“Supplemental Maternity Capitation Payment” means the fixed amount paid to the
Contractor for the prenatal and postpartum physician care and hospital or
birthing center. delivery costs, limited to those cases in which the plan has
paid the hospital or birthing center for the maternity stay, and can produce
evidence of such payment.

“Supplemental Newborn Capitation Payment” means the fixed amount paid to the
Contractor for the inpatient birthing costs for a newborn enrolled in the plan,
limited to those cases in which the plan has paid the hospital or birthing
center for the newborn stay, and can produce evidence of such payment.

“Tuberculosis Directly Observed Therapy” or “TB/DOT” means the direct
observation of ingestion of oral TB medications to assure patient compliance
with the physician’s prescribed medication regimen.

“Urgently Needed Services” means covered services that are not Emergency
Services as defined in this Section, provided when an Enrollee is temporarily
absent from the Contractor’s service area, when the services are medically
necessary and immediately required: (1) as a result of an unforeseen illness,
injury, or condition; and (2) it was not reasonable given the circumstances to
obtain the services through the Contractor’s plan.

SECTION I

(DEFINITIONS)

October 1, 2004

      1

10

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

2.1 Term

a) This Agreement is effective October 1, 2004 and shall remain in effect until
September 30, 2005; or until the execution of an extension, renewal or successor
Agreement approved by the SDOH and the Department of Health and Human Services
(DHHS); or until the effective date of an executed agreement between the
Contractor and SDOH for Contractor’s participation in the Medicaid managed care
program; whichever occurs first.

b) The. parties to the Agreement shall have the option to renew this Agreement
for additional two (2) year and or one (1) year terms, subject to the approval
of the LDSS, SDOH, DHHS and any other entities as required by law or regulation.

c) However, in no event, shall the maximum duration of this Agreement exceed
five (5) years.

2.2 Amendments and Extensions

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

  b)   This Agreement shall not be automatically renewed at its expiration. This
Agreement may be extended by written amendment, in accordance with the
procedures set forth in this Section.

c) An extension to this Agreement may be granted for reasons including, but not
limited, to the following:

i) Negotiations for a successor Agreement will not be completed by the
expiration date of the current contract; or

ii) The Contractor has submitted a termination notice and transition of
Enrollees will not be completed by the expiration date of the current contract.

d) The parties will submit, to the extent practicable, the proposed signed and
dated extensions, including all necessary local government approvals, to SDOH
prior to the scheduled expiration date of this Agreement.

2.3 Approvals

This Agreement and any amendments to this Agreement shall not be effective or
binding unless and until approved, in writing, by the DHHS, the SDOH and any
other entity as required in law and regulation. SDOH will provide a notice of
each such approval to the Contractor and the LDSS upon such approval.

2.4 Entire Agreement

This Agreement shall supersede all prior Agreements between the Contractor and
the LDSS. This Agreement, including those attachments, schedules, appendices,
exhibits, and addenda that have been specifically incorporated herein and
written plans submitted by the Contractor and maintained on file by SDOH and/or
LDSS pursuant to this Agreement, contains all the terms and conditions agreed
upon by the parties, and no other Agreement, oral. or otherwise, regarding the
subject matter of this Agreement shall be deemed to exist or to bind any of the
parties or vary any of the terms contained in this Agreement. In the event of
any inconsistency or conflict among the document elements of this Agreement,
such inconsistency or conflict shall be resolved by giving precedence to the
document elements in the following order:

SECTION 2

(AGREEMENT TERM, AMENDMENTS. EXTENSIONS.

AND GENERAL CONTRACT ADMINISTRATION PROVISIONS)

October 1, 2004

2-l

11

1) Appendix A, Standard Clauses for all New York State Contracts;
2) Local Standard Clauses, if any;
3) The body of this Agreement;
4) The appendices attached to the body of this Agreement, other than Appendix A;
5) The Contractor’s approved:
i) Marketing Plan on file with SDOH and LDSS

     
ii)
iii)
iv)
  Complaint and Appeals Procedure on file with SDOH and LDSS
Quality Assurance Plan on file with SDOH and LDSS
Americans with Disabilities Act Compliance Plan on file with SDOH and LDSS

v) Fraud and Abuse Prevention Plan on file with SDOH and LDSS.

2.5 Renegotiation

The parties to this Agreement shall have the right to renegotiate the terms and
conditions of this Agreement in the event applicable local, state or federal
law, regulations or policy are altered from those existing at the time of this
Agreement in order to be in continuous compliance therewith. This Section shall
not limit the right of the parties to this Agreement from renegotiating or
amending other terms and conditions of this agreement. Such changes shall only
be made with the consent of the parties and the prior approval of the SDOH and
the DHHS.

2.6 Assignment and Subcontracting

  a)   The Contractor shall not, without LDSS and SDOH’s prior written consent,
assign, transfer, convey, sublet, or otherwise dispose of this Agreement; of the
Contractor’s right, title, interest, obligations, or duties under the Agreement;
of the Contractor’s power to execute the Agreement; or, by power of attorney or
otherwise, of any of the Contractor’s rights to receive monies due or to become
due under this Agreement. Any assignment, transfer, conveyance, sublease, or
other disposition without LDSS and SDOH’s consent shall be void.

b) Contractor may not enter into any subcontracts related to the delivery of
services to Enrollees, except by written agreement, as set forth in Section 22
of this Agreement. The Contractor may subcontract for provider services and
management services. If such written agreement would be between Contractor and a
provider of health care or ancillary health services or between Contractor and
an independent practice association, the agreement must be in a form previously
approved by SDOH. If such subcontract is for management services under 10 NYCRR
§ 98-1.11, it must be approved by SDOH prior to its becoming effective. Any
subcontract entered into by Contractor shall fulfill the requirements of 42 CFR
Parts 434 and 438 that are appropriate to the service or activity delegated
under such subcontract. Contractor agrees that it shall remain legally
responsible to LDSS for carrying out all activities under this Agreement and
that no subcontract shall limit or terminate Contractor’s responsibility.

2.7 Termination

a) LDSS Initiated Termination of Contract

i) LDSS shall have the right to terminate this Agreement, in whole or in part if
the Contractor:

  A)   takes any action that threatens the health, safety, or welfare of its
Enrollees;  

B) has engaged in an unacceptable practice under 18 NYCRR, Part 515, that
affects the

fiscal integrity of the Medicaid program;

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

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

E) becomes insolvent;

SECTION 2
(AGREEMENT TERM. AMENDMENTS, EXTENSIONS,
AND GENERAL CONTRACT ADMINISTRATION PROVISIONS)
October I, 2004
2-2

12

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

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

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

iii) If SDOH suspends, limits or revokes Contractor’s Certificate of Authority
under PHL § 4404, this Agreement shall expire on the date the Contractor ceases
to have authority to serve the geographic area of the LDSS. No hearing will be
required if the contract expires due to SDOH suspension, limitation or
revocation of the Contractor’s Certificate of Authority.

iv) Prior to the effective date of the termination the LDSS shall notify
Enrollees of the termination, or delegate responsibility for such notification
to the Contractor, and such notice shall include a statement that Enrollees may
disenroll immediately without cause.

b) Contractor and LDSS Initiated Termination

The Contractor and the LDSS each shall have the right to terminate this
Agreement in the event that SDOH and the Contractor fail to reach agreement on
the monthly Capitation Rates. In such event, the party exercising its right
shall give the other party, LDSS, and SDOH written notice specifying the reason
for and the effective date of termination, which shall not be less time than
will permit an orderly disenrollment of Enrollees to the Medicaid
fee-for-service payment mechanism or transfer to another MCO, as determined by
LDSS, but no more than ninety (90) days.

c) Contractor Initiated Termination

i) The Contractor shall have the right to terminate this Agreement in the event
that LDSS materially breaches the Agreement or fails to comply with any term or
condition of this Agreement that is not cured within twenty (20) days, or to
such longer period as the parties may agree, of the Contractor’s written request
for compliance. The Contractor shall give LDSS written notice specifying the
reason for and the effective date of the termination, which shall not be less
time than will permit an orderly disenrollment of Enrollees to the Medicaid
fee-for- service payment mechanism or transfer to another managed care program,
as determined by LDSS, but no more than ninety (90) days.

ii) The Contractor shall have the right to terminate this Agreement in the event
that its obligations are materially changed by modifications to this Agreement
and its Appendices by SDOH or LDSS. In such event, Contractor shall give LDSS
and SDOH written notice within thirty (30). days of notification of changes to
the Agreement or Appendices specifying the reason and the effective date of
termination, which shall not be less time .than will permit an orderly
disenrollment of Enrollees to the Medicaid fee-for-service program or transfer
to another MCO, as determined by the LDSS, but no more than ninety (90) days.

SECTION 2
(AGREEMENT TERM. AMENDMENTS. EXTENSIONS.
AND GENERAL CONTRACT ADMINISTRATION PROVISIONS)
October I , 2004
2-3

13

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

  A)   the reason for the termination, with appropriate documentation of the
circumstances arising from a natural disaster and/or an act of God that preclude
reasonable access to services;

  B)   the Contractor’s attempts to make other provision for the delivery of
services; and

  C)   the effective date of the termination, which shall not be less time than
will permit an orderly disenrollment of Enrollees to the Medicaid
fee-for-service payment mechanism or transfer to another MCO, as determined by
LDSS, but no more than ninety (90) days.

d) Termination Due To Loss of Funding

In the event that State and/or Federal funding used to pay for services under
this Agreement is reduced so that payments cannot be made in full, this
Agreement shall automatically terminate, unless both parties agree to a
modification of the obligations under this Agreement. The effective date of such
termination shall be ninety (90) days after the Contractor receives written
notice of the reduction in payment, unless available funds are insufficient to
continue payments in full during the ninety (90) day period, in which case LDSS
shall give the Contractor written notice of the earlier date upon which the
Agreement shall terminate. A reduction in State and/or Federal funding cannot
reduce monies due and owing to the Contractor on or before the effective date of
the termination of the Agreement.

2.8 Close-Out Procedures

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

  a)   The Contractor shall promptly account for and repay funds advanced by
SDOH for coverage of Enrollees for periods subsequent to the effective date of
termination;

  b)   The Contractor shall give LDSS, SDOH, and other authorized federal, state
or local agencies access to all books, records, and other documents and upon
request, portions of such books, records, or documents that may be required by
such agencies pursuant to the terms of this Agreement;  

  c)   The Contractor shall submit to LDSS, SDOH, and other authorized federal,
state or local agencies, within ninety (90) days of termination, a final
financial statement and audit report relating to this Agreement, made by a
certified public accountant or a licensed public accountant, unless the
Contractor requests of LDSS and receives written approval from LDSS, SDOH and
all other governmental agencies from which approval is required, for an
extension of time for this submission;  

  d)   The Contractor shall furnish to SDOH immediately upon receipt all
information related to any request for reimbursement of any medical claims that
result from services delivered after the date of termination of this Agreement;

SECTION 2

(AGREEMENT TERM. AMENDMENTS, EXTENSIONS,

AND GENERAL CONTRACTADMINLSTRATION PROVISIONS)

October 1, 2004

2-4

14

  e)   The Contractor shall establish an appropriate plan acceptable to and
prior approved by the LDSS and SDOH for the orderly disenrollment of Enrollees
to the Medicaid fee-for-service program or enrollment into another MCO. This
plan shall include the provision of pertinent information to identified
Enrollees who are: pregnant; currently receiving treatment for a chronic or life
threatening condition; prior approved for services or surgery; or whose care is
being monitored by a case manager to assist them in making decisions which will
promote continuity of care.

f) SDOH shall promptly pay all claims and amounts owed to the Contractor;

  g)   Any termination of this Agreement by either the Contractor or LDSS shall
be done by amendment to this Agreement, unless the contract is terminated by the
LDSS due to conditions in Section 2.7 a.(i) or Appendix A of this Agreement.

2.9 Rights and Remedies

The rights and remedies of LDSS and the Contractor provided expressly in this
Article shall not be exclusive and are in addition to all other rights and
remedies provided by law or under this Agreement.

2.10 Notices

All notices to be given under this Agreement shall be in writing and shall be
deemed to have been given when mailed to, or, if personally delivered, when
received by the Contractor, DOHMH, and the SDOH at the following addresses:

For DOHMH:

New York City Department of Health and Mental Hygiene 125 Worth Street, CN # 29C
New York, NY 10013
ATTN: Assistant Commissioner
Division of Health Care Access and Improvement

For SDOH:

New York State Department of Health Empire State Plaza
Coming Tower, Rm. 2074
Albany, NY 12237-0065

For the Contractor:

Executive Director
CarePlus, L.L.C.
360 West 31St Street, Fifth Floor New York, NY 10001

2.11 Severability

If this Agreement contains any unlawful provision that is not an essential part
of this Agreement and that was not a controlling or material inducement to enter
into this Agreement, the provision shall have no effect and, upon notice by
either party, shall be deemed stricken from this Agreement without affecting the
binding force of the remainder of this Agreement.

SECTION 2
(AGREEMENT TERM, AMENDMENTS. EXTENSIONS,
. AND GENERAL CONTRACT ADMINISTRATION PROVISIONS)
October I, 2004
2-5

15

3. COMPENSATION

3.1 Capitation Payments

Compensation to the Contractor shall consist of a monthly capitation payment for
each Enrollee and the Supplemental Capitation Payments as described in
Sections 3.1 (c) and 3.1 (d), where applicable.

  a)   In no event shall monthly capitation payments to the Contractor for the
Benefit Package exceed the cost of providing the Benefit Package on a
fee-for-service basis to an actuarially equivalent, non-enrolled population
group Upper Payment Limit (UPL) as determined by SDOH.  

  b)   The monthly Capitation Rates are attached hereto as Appendix L and shall
be deemed incorporated into this Agreement without further action by the
parties.  

  c)   The monthly capitation payments and the Supplemental Newborn Capitation
Payment and the Supplemental Maternity Capitation Payment to the Contractor
shall constitute full and complete payments to ‘the. Contractor for all services
.that the Contractor provides pursuant to this Agreement subject to stop-loss
provisions set forth in. Section 3.11 and 3.12 of this Agreement.  

  d)   Capitation Rates shall be effective for the entire contract period,
except as described in Section 3.2.  

3.2 Modification of Rates During Contract Period

  a)   Any technical modification to Capitation Rates during the term of the
Agreement as agreed to by the Contractor, including but not limited to, changes
in reinsurance or the Benefit Package, shall be deemed incorporated into this
Agreement without further action by the parties, upon approval by SDOH, and upon
written notice by SDOH to the LDSS.  

  b)   Any other modification to Capitation Rates, as agreed to by SDOH and the
Contractor, during the term of the Agreement shall be deemed incorporated into
this Agreement without further action by the parties upon approval of such
modifications by the SDOH and the State Division of the Budget, and upon written
notice by SDOH to the LDSS.  

  c)   In the event that SDOH and the Contractor fail to reach agreement on
modifications to the monthly Capitation Rates, the SDOH will provide formal
written notice to the Contractor and LDSS of the amount and effective date of
the modified Capitation Rates approved by the State Division of the Budget. The
Contractor shall have the option of terminating this Agreement if such approved
modified Capitation Rates are not acceptable. In such case, the Contractor shall
give written notice to the SDOH and the LDSS within thirty (30) days of the date
of the formal written notice of the modified Capitation Rates from SDOH
specifying the reasons for and effective date of termination. The effective date
of termination shall be ninety (90) days from the date of the Contractor’s
written notice, unless the SDOH determines that an orderly disenrollment to
Medicaid fee-for-service or transfer to another MCO can be accomplished in fewer
days. During the period commencing with the effective date of the SDOH modified
Capitation Rates through the effective date of termination of the Agreement, the
Contractor shall have the option of continuing to receive capitation payments at
the expired Capitation Rates or at the modified Capitation Rates approved by
SDOH and State Division of the Budget for the rate period.  

If the Contractor fails to exercise its right to terminate in accordance with
this Section, then the modified Capitation Rates approved by SDOH and the State
Division of the Budget shall be deemed incorporated into this Agreement without
further action by the parties as of the effective date of the modified
Capitation Rates as established by SDOH and approved by State Division of the
Budget.

SECTION 3

(COMPENSATION)

October I, 2004

3-1

16

3.3 Rate Setting Methodology

Capitation Rates are determined using a prospective methodology whereby cost,
utilization and other rate-setting data available for the time period prior to
the time period covered by the rates are used to establish premiums. Capitation
rates will not be retroactively adjusted to reflect actual fee-for-service data
or plan experience for the time period covered by the rates.

3.4 Payment of Capitation

  a)   The monthly capitation payments for each Enrollee are due to the
Contractor from the Effective Date of Enrollment until the Effective Date of
Disenrollment of the Enrollee or termination of this Agreement, whichever occurs
first. The Contractor shall receive a full month’s capitation payment for the
month in which disenrollment occurs. The Roster generated by SDOH with any
modification communicated electronically or in writing by the LDSS or the
Enrollment Broker prior to the end of the month in which the Roster is
generated, shall be the enrollment list for purposes of MMIS premium billing and
payment, as discussed in Section 6.9 and Appendix H.

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

3.5 Denial of Capitation Payments

If the Centers for Medicare and Medicaid Services denies payment for new
Enrollees, as authorized by Social Security Act (SSA) § 1903(m)(5) and 42 CFR §
434.67, or such other applicable federal statutes or regulations, based upon a
determination that Contractor failed substantially to provide medically
necessary items and services, imposed premium amounts or charges in excess of
permitted payments, engaged in discriminatory practices as described in SSA §
1932(e)(l)(A)(iii), misrepresented or falsified information submitted to CMS,
SDOH, LDSS, the Enrollment Broker, or an Enrollee, potential Enrollee, or health
care provider, or failed to comply with federal requirements (i.e. 42 CFR §
417.479 and 42 CFR § 434.70) relating to the Physician Incentive Plans, SDOH and
LDSS will deny capitation payments to the Contractor for the same Enrollees for
the period of time-for which CMS denies such payment.

3.6 SDOH Right to Recover Premiums

The parties acknowledge and accept that the SDOH has a right to recover premiums
paid to the Contractor for Enrollees listed on the monthly Roster who are later
determined for the entire applicable payment month, to have been in an
institution; to have been incarcerated; to have moved out of the Contractor’s
service area subject to any time remaining in the Enrollee’s Guaranteed
Eligibility period; or to have died. In any event, the State may only recover
premiums paid for Medicaid Enrollees listed on a Roster if it is determined by
the SDOH that the Contractor was not at risk for provision of Benefit Package
services for any portion of the payment period.

3.7 Third Party Health Insurance Determination

The Contractor and the LDSS will make diligent efforts to determine whether
Enrollees have third party health insurance (TPHI). The LDSS shall use its best
efforts to maintain third party information on the WMS/MMIS Third Party Resource
System. The Contractor shall make good faith efforts to coordinate benefits with
and collect TPHI recoveries from other insurers, and must inform the LDSS of any
known changes in status of TPHI insurance eligibility within thirty (30) days of
learning of a change in TPHI. The Contractor may use the Roster as one method to
determine TPHI information. The Contractor will be permitted to retain
100 percent of any reimbursement for Benefit Package services obtained

SECTION 3
(COMPENSATION)
October 1, 2004
3-3

17

from TPHI. Capitation Rates are net of TPHI recoveries. In no instances may an
Enrollee be held responsible for disputes over these recoveries.

3.8 Payment For Newborns

  a)   The Contractor shall be responsible for all costs and services included
in the Benefit Package associated with the Enrollee’s newborn, unless the child
is excluded from Medicaid Managed Care.

  b)   The Contractor shall receive a capitation payment from the first day of
the newborn’s month of birth and, in instances where the plan pays the hospital
or birthing center for the newborn stay, a Supplemental Newborn Capitation
Payment.

  c)   Capitation Rate and Supplemental Newborn Capitation Payment for a newborn
will begin the month following certification of the newborn’s eligibility and
enrollment, retroactive to the first day of the month in which the child was
born:  

  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 maintain on file evidence of payment to the
hospital or birthing center of the claim for the newborn stay. Failure to have
supporting records may, upon an audit, result in recoupment of the Supplemental
Newborn Capitation Payment by SDOH.  

3.9 Supplemental Maternity Capitation Payment

  a)   The Contractor shall be responsible for all costs and services included
in the Benefit Package associated with the maternity care of an Enrollee.  

  b)   In instances where the Enrollee is enrolled in the Contractor’s plan on
the date of the delivery of a child, the Contractor shall be entitled to receive
a Supplemental Maternity Capitation Payment. The Supplemental Maternity
Capitation Payment reimburses the Contractor for the inpatient and outpatient
costs of services normally provided as part of maternity care including
antepartum care, delivery and post-partum care. The Supplemental Maternity
Capitation Payment is in addition to the monthly Capitation Rate paid by the
SDOH to the Contractor for the Enrollee.  

  c)   In instances where the Enrollee was enrolled in the Contractor’s plan for
only part of the pregnancy, but was enrolled on the date of the delivery of the
child, the plan shall be entitled to receive the entire Supplemental Maternity
Capitation Payment. The Supplemental Capitation payment shall not be pro-rated
to reflect that the Enrollee was not a member of the Contractor’s plan for the
entire duration of the pregnancy.  

  d)   In instances where the Enrollee was enrolled in the Contractor’s plan for
part of the pregnancy, but was not enrolled on the date of the delivery of the
child, the Contractor shall not be entitled to receive the Supplemental
Maternity Capitation Payment, or any portion thereof.

  e)   Costs of inpatient and outpatient care associated with maternity cases
that end in termination or miscarriage shall be reimbursed to the Contractor
through the monthly Capitation Rate for the Enrollee and the Contractor shall
not receive the Supplemental Maternity Capitation Payment.

SECTION 3

(COMPENSATION)

October I, 2004

3-4

18

  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 maintain on file evidence of payment 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.

3.10 Contractor Financial Liability

Contractor shall not be financially liable for any services rendered to an
Enrollee prior to his or her Effective Date of Enrollment in the Contractor’s
plan.

3.11 Inpatient Hospital Stop-Loss Insurance

The Contractor must obtain stop-loss coverage for inpatient hospital services. A
Contractor may elect to purchase stop-loss coverage from New York State. In such
cases, the Capitation Rates paid to the Contractor shall be adjusted to reflect
the cost of such stop-loss coverage. The cost of such coverage shall be
determined by SDOH.

Under NYS stop-loss coverage, if the hospital inpatient expenses incurred by the
Contractor for an individual Enrollee during any calendar year reaches $50,000,
the Contractor shall be compensated for 80% of the cost of hospital inpatient
services in excess of this amount up to a maximum of $250,000. Above that
amount, the Contractor will be compensated for 100% of cost. All compensation
shall be based on the lower of the Contractor’s negotiated hospital rate or
Medicaid rates of payment.
• The Contractor has elected to have NYS provide stop-loss reinsurance.
OR
x Contractor has not elected to have NYS provide stop-loss reinsurance.

3.12 Mental Health and Chemical Dependence Stop-Loss

  a)   The Contractor will be compensated for medically necessary and clinically
appropriate Medicaid reimbursable mental health treatment outpatient visits in
excess of twenty (20) visits during any calendar year at rates set forth in
contracted fee schedules. Any Court Ordered Services for mental health treatment
outpatient visits which specify the use of Non-Participating Providers shall be
compensated at the Medicaid rate of payment.

  b)   The Contractor will be compensated for medically necessary and clinically
appropriate inpatient mental health services and/or Chemical Dependence
Inpatient Rehabilitation and Treatment Services as defined in Appendix K in
excess of a combined total of thirty (30) days during a calendar year at the
lower of the Contractor’s negotiated inpatient rate or Medicaid rate of payment.

  c)   Detoxification Services in Article 28 inpatient hospital facilities are
subject to the stop-loss provisions specified in Section 3.11 of this.
Agreement.

SECTION 3

(COMPENSATION)

October 1, 2004

3-5

19

3.12 Mental Health and Chemical Dependence Stop-Loss

  a)   The Contractor will be compensated for medically necessary and clinically
appropriate Medicaid reimbursable mental health treatment outpatient visits in
excess of twenty (20) visits during any calendar year at rates set forth in
contracted fee schedules. Any Court Ordered Services for mental health treatment
outpatient visits which specify the use of Non-Participating Providers shall be
compensated at the Medicaid rate of payment.

  b)   The Contractor will be compensated for medically necessary and clinically
appropriate inpatient mental health services and/or Chemical Dependence
Inpatient Rehabilitation and Treatment Services as defined in Appendix K in
excess of a combined total of thirty (30) days during a calendar year at the
lower of the Contractor’s negotiated inpatient rate or Medicaid rate of payment.

  c)   Detoxification Services in Article 28 inpatient hospital facilities are
subject to the stop-loss provisions specified in Section 3.11 of this.
Agreement.

3.13 Enrollment Limitations

  a)   The Contractor may enroll up to the county specific provider network
capacity limits determined by SDOH, provided that the Contractor’s statewide
enrollment does not exceed the MCO’s financial capacity as determined annually
by SDOH, or more frequently as deemed necessary by SDOH.

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

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

3.14 Tracking Visits Provided by Indian Health Clinics

The SDOH shall monitor all visits provided by tribal or Indian health clinics or
urban Indian health facilities or centers to enrolled Native Americans, so that
the SDOH can reconcile payment made for those services, should it be deemed
necessary to do so.

SECTION 3

(COMPENSATION)

October I. 2004

20

3-6

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

SECTION 4
(SERVICE AREA)
October 1, 2004
4-1

21

  5.   ELIGIBLE, EXEMPT AND EXCLUDED POPULATIONS  

5.1 Eligible Populations

  a)   Except as specified in Section 5.1(b) and 5.3 below, all persons in the
following Medicaid-eligible beneficiary categories who reside in the service
area shall be eligible for enrollment in the Contractor’s plan:

i) Singles/Childless Couples — Cash and Medicaid only
ii) Low Income Families with Children — Cash and Medicaid only
iii) Aid to Families with Dependent Children — Medicaid only

  iv)   Pregnant women whose net available income is at or below two hundred
percent (200%) of the federal poverty level for the applicable household size.

  v)   Children aged one (1) year or below whose family’s net available income
is at or below two hundred percent (200%) of the federal poverty level for the
applicable household size.

  vi)   Children between ages one (1) and five (5), whose family’s net available
income is at or below one hundred and thirty-three percent (133%) of the federal
poverty level for the applicable household size.

  vii)   Children age six (6) up to age nineteen (19), whose family’s net
available income is at or below one hundred and thirty-three percent (133%) of
the federal poverty level for the applicable household size.

viii) Transitional Medical Assistance Beneficiaries

  ix)   Supplemental Security Income (cash) and Supplemental Security Income
Related (Medicaid only).

Medicaid eligible individuals in the following categories may be eligible for
enrollment in the Contractor’s plan at the LDSS’ option, as indicated by an X
below.

i) Foster care children in the direct care of LDSS.

     Mandatory county — children in LDSS direct care are mandatorily enrolled.
     Mandatory OR voluntary county — children in LDS S direct care are enrolled
on a case-by-case basis.

      _X      Mandatory OR voluntary county — all foster care children are
excluded from managed care.  

ii) Homeless persons living in shelters outside of New York City may be eligible
for

enrollment if so determined by the LDSS.

Mandatory county — homeless persons are mandatorily enrolled.
Mandatory OR voluntary county — homeless persons are enrolled on a case-by- case
basis.

Mandatory OR voluntary county — all homeless persons are excluded from managed
care.

5.2 Exempt Populations

The following populations are exempt from mandatory enrollment in Medicaid
managed care, but may enroll on a voluntary basis, if otherwise eligible.

a) Individuals who are HIV+ or have AIDS.

  b)   Individuals who are Seriously and Persistently Mentally Ill or Seriously
Emotionally Disturbed.

SECTION 5
(ELIGIBLE, EXEMPT AND EXCLUDED POPULATIONS)
October 1, 2004
5-1

22

  c)   Individuals for whom a Managed Care Provider is not geographically
accessible so as to reasonably provide services: To qualify for this exemption,
an individual must demonstrate that no participating .MCO has a provider located
within thirty (30) minutes travel time/thirty (30) miles travel distance from
the individual’s home, who is accepting new patients, and that there is a
fee-for-service Medicaid provider available within the thirty (30) minutes
travel time/thirty (30) miles travel distance.

  d)   Pregnant women who are already receiving prenatal care from a provider
authorized to provide such care not participating in any Medicaid managed care
plan. This status will last through a woman’s pregnancy, extend through the
sixty (60) day post-partum period and end at the end of the month in which the
sixtieth (60th) day occurs.

Individuals with a chronic medical condition who, for at least six (6) months,
have been under active treatment with a non-participating sub-specialist
physician who is not a network provider for any MCO participating in the
Medicaid managed care program service area. This status will last as long as the
individual’s chronic medical condition exists or until the physician joins a
participating MCO’s network. The SDOH’s Office of Managed Care, Medical Director
will, upon the request of an individual or his/her guardian or legally
authorized representative (health care agent authorized through a health care
proxy), review cases of individuals with unusually severe chronic care needs for
a possible exemption from mandatory enrollment in managed care if such
individuals are not otherwise eligible for an exemption (i.e., meet one of the
seventeen (17) criteria listed here). The SDOH’s 01N/1C Medical Director may
also authorize a plan disenrollment for such individuals. Disenrollment requests
should be made in a manner consistent with the overall disenrollment request
process for “good cause” disenrollment.

f) Individuals with End Stage Renal Disease (ESRD).

  g)   Individuals who are residents of Intermediate Care Facilities for the
Mentally Retarded (“ICF/MR”).

  h)   Individuals with characteristics and needs similar to those who are
residents of — ICF/MRs based on criteria cooperatively established by the State
Office of Mental Retardation and Developmental Disabilities (OMRDD) and the
SDOH.

  i)   Individuals already scheduled for a major surgical. procedure (within
thirty (30) days of scheduled enrollment) with a provider who is not a
participant in the network of a Medicaid MCO under contract with the LDSS. This
exemption will only apply until such time as the individual’s course of
treatment is complete.

  j)   Individuals with a developmental or physical disability who receive
services through a Medicaid Home-and-Community-Based Services Waiver or Medicaid
Model ‘Waiver (care-at-home) through a Section 1915c waiver, or individuals
having characteristics and needs similar to such individuals (including
individuals on the waiting list), based on criteria cooperatively established by
OMRDD and SDOH.

  k)   Individuals who are residents of Alcohol and Substance Abuse or Chemical
Dependence Long Term Residential Treatment Programs.

  l)   In New York City, all homeless individuals are exempt. In areas outside
of NYC, exemption of homeless individuals residing in the shelter system is at
the discretion of the local district. — See Section 5.1 (b).

m) Native Americans

  n)   Individuals who cannot be served by a managed care provider due to a
language barrier which exists when the individual is not capable of effectively
communicating his or her medical needs in English or in a secondary language for
which PCPs are available within the Medicaid managed care program. Individuals
with a language barrier will be deemed able to be served if they have a choice,
within time and distance standards, of three (3) PCPs who are able to
communicate in the primary language of the eligible individual or who have a
person on his/her staff capable of translating medical terminology. Individuals
will be eligible for an exemption when:

SECTION 5

(ELIGIBLE. EXEMPT AND EXCLUDED POPULATIONS)

October 1.2004

5-2

23

  i)   The individual has a relationship with a Medicaid fee-for-service Primary
Care Provider who:  

A) has the language capability to serve the individual;

  B)   does not participate in any of the Medicaid managed care plans contracted
for a service area which includes the individual’s residence;

  C)   is located within a thirty (30) minute /thirty (30) mile radius of the
eligible individual’s residence;  

AND

D) there are fewer than three (3) participating PCPs available within the thirty

(30) minute/thirty (30) mile radius who arc able to communicate in the
primary language of the eligible individual or who have a person on
his/her staff capable of translating medical terminology.

OR

  ii)   The individual has a relationship with a Medicaid fee-for-service
Primary Care Provider who:  

A) has the language capability to service the individual;

  B)   does not participate in any of the Medicaid managed care plans contracted
for a service area which includes the individual’s residence;  

  C)   is located outside a thirty (30) minute/thirty (30) mile radius of the
eligible individual’s residence;  

AND

  D)   there are fewer than three (3) participating PCPs available within or
outside the thirty (30) minute/thirty (30) mile radius who are able to
communicate in the primary language .of the eligible individual or who have a
person on his/her staff capable of translating medical terminology.

  •   ) Individuals temporarily residing out of district, (e.g., college
students) will be exempt until the last day of the month in which the purpose of
the absence is accomplished. The definition of temporary absence is set forth in
Social Services regulations 18 NYCRR §360-1.4(p).  

  p)   SSI and SSI-related beneficiaries are considered exempt and may enroll on
a voluntary basis.  

  q)   Individuals with a “County of Fiscal Responsibility” code of 98 (OMRDD in
MMIS) are exempt in counties where program features are approved by the State
and operational at the local district level to permit these individuals to
voluntarily enroll in Medicaid managed care.  

  •   State-approved program features are in place and operational at the local
district level to permit individuals with a “County of Fiscal Responsibility”
code of 98 to voluntarily enroll in Medicaid managed care.  

OR

      x State-approved program features are not in place and operational at the
local district level, therefore individuals with a “County of Fiscal
Responsibility” code of 98 are excluded from enrollment in Medicaid managed
care.  

r) Individuals who are eligible for Medical Assistance pursuant to the “Medicaid
buy-in for the working disabled” (subparagraphs twelve or thirteen of paragraph
(a) of subdivision one of Section 366 of the Social Services Law), and who,
pursuant to subdivision 12 of Section 367-a of the Social Services Law, are not
required to pay a premium.

SECTION 5

(ELIGIBLE, EXEMPT AND EXCLUDED POPULATIONS)

October I. 2004

5-3

24

5.3 Excluded Populations

The following populations are ineligible for enrollment in Medicaid managed
care.

a) Individuals who are Dually Eligible for Medicare/Medicaid.

  b)   Individuals who become eligible for Medicaid only after spending down a
portion of their income (Spend-down).

  c)   Individuals who are residents of State-operated psychiatric facilities or
residents of State-certified or voluntary treatment facilities for children and
youth.

  d)   Individuals who are residents of Residential Health Care Facilities
(“RHCF”) at the time of Enrollment,:an4 Enrollees whose stay in a RHCF is
classified as permanent upon entry into the RHCF or is classified as permanent
at a time subsequent to entry.

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

f) Medicaid-eligible infants living with incarcerated mothers.

  g)   Infants weighing less than 1200 grams at birth and other infants under
six (6) months of age who meet the criteria for the SSI or SSI related category
(shall not be enrolled or shall be disenrolled retroactive to date of birth).  

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

i) Foster children in the placement of a voluntary agency.

  j)   Certified blind or disabled children living or expected to be living
separate and apart from the parent for thirty (30) days or more.  

  k)   Individuals expected to be eligible for Medicaid for less than six (6)
months, except for pregnant women (e.g., seasonal agricultural workers).  

  l)   Foster children in direct care (unless LDSS opts to enroll them see
Section 5.1(b)).

  m)   Youths in the care and custody of the Commissioner of the NYS Office of
Children and Family Services.

  m)   Individuals in receipt of long-term care services through Long Term Home
Health Care programs, or Child Care Facilities (except ICF services for the
Developmentally Disabled).

  n)   Individuals eligible for Medical assistance benefits only with respect to
TB related services.

  •   ) Individuals placed in State Office of Mental Health licensed family care
homes pursuant to NYS Mental Hygiene Law, Section 3-1.03.

SECTION 5

(ELIGIBLE. EXEMPT AND EXCLUDED POPULATIONS)

October 1, 2004
5-4

25

  p)   Individuals enrolled in the Restricted Recipient Program.

r) Individuals with a “County of Fiscal Responsibility” code of 99.

  s)   Individuals admitted to a Hospice program prior to time of enrollment (if
an Enrollee enters a Hospice program while enrolled in the Contractor’s plan,
he/she may remain enrolled in the Contractor’s plan to maintain continuity of
care with his/her PCP). Hospice services are accessed through the
fee-for-service Medicaid Program.  

t) Individuals with a “County of Fiscal Responsibility” code of 97 (OMH in
MMIS).

  u)   Individuals with a “County of Fiscal Responsibility” code of 98 (OMRDD in
MMIS) will be excluded until program features are approved by the State and
operational at the local district level to permit these individuals to
voluntarily enroll in Medicaid managed care.  

  v)   Individuals receiving family planning services pursuant to
Section 366(1)(a)(11) of the Social Services Law who are not otherwise eligible
for medical assistance and whose net available income is 200% or less of the
federal poverty level.  

  w)   Individuals who are eligible for Medical Assistance pursuant to the
`”Medicaid buy-in for the working disabled” (subparagraphs twelve or thirteen of
paragraph (a) of subdivision one of Section 366 of the Social Services Law), and
who, pursuant to subdivision 12 of Section 367-a of the Social Services Law, are
required to pay a premium.  

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

5.4 Family Health Plus

Individuals eligible for Medicaid (Family Health Plus) pursuant to Title 11-D of
the Social Services Law are not eligible for enrollment in Medicaid managed care
under this Agreement.

5.5 Family Enrollment

In local social service districts where enrollment in. managed care is
mandatory, the Contractor agrees that members of the same family (defined as
mother and her child(ren), father and his child(ren), a husband, wife and
child(ren) or a husband and wife residing in the same household, or persons
included in the same case) will be required to enroll in the same health plan,
in accordance with Section 6.6 of this Agreement.

SECTION 5

(ELIGIBLE. EXEMPT AND EXCLUDED POPULATIONS)

October I , 2004

5-5

26

6.1 Enrollment Guidelines

  a)   The LDSS may employ a variety of methods and programs for enrollment of
Eligible Persons including, but not limited to enrollment assisted by the
Contractor, enrollment assisted by an Enrollment Broker, enrollment by LDSS, or
a combination of such. The policies and procedural guidelines which will be used
for enrollment are set forth in Appendix H, which is hereby made a part of this
Agreement as if set forth fully herein.

  b)   The LDSS and the Contractor agree to .conduct enrollment of eligible
individuals in accordance with the guidelines set forth in Appendix H.

  c)   The SDOH and LDSS, upon mutual agreement, may make modifications to the
guidelines set forth in Appendix H. The parties further acknowledge that such
modifications shall be effective and made a part of this Agreement without
further action by the parties upon sixty (60) days written notice to the LDSS
and the Contractor.

6.2 Equality of Access to Enrollment

Eligible Person’s shall be enrolled in the Contractor’s plan, in accordance with
the requirements set forth in Appendix H, Section A. In those instances in which
the Contractor is directly involved in enrolling eligible recipients, the
Contractor shall accept enrollments in the order they are received without
regard to the Eligible Person’s age, sex, race, creed, physical or mental
handicap/developmental disability, national origin, sexual orientation, type of
illness or condition, need for health services or to the Capitation Rate that
the Contractor will receive for such Eligible Person.

6.3 Enrollment Decisions

An Eligible Person’s decision to enroll in the Contractor’s plan shall be
voluntary except as otherwise provided in Section 6.4 of the Agreement.

6.4 Auto Assignment

An Eligible Person whose enrollment in a MCO is mandatory and who fails to
select a MCO within sixty (60) days of receipt of notice of mandatory enrollment
may be assigned by the LDSS to the Contractor’s plan pursuant to NYS Social
Services Law § 364-j and in accordance with Appendix H.

6.5 Prohibition Against Conditions on Enrollment

Unless otherwise required by law or this Agreement, neither the Contractor nor
LDSS shall condition any Eligible Person’s enrollment upon the performance of
any act or suggest in any way that failure to enroll may result in a loss of
Medicaid benefits.

6.6 Family Enrollment

  a)   In local social service districts where enrollment in managed care is
mandatory, all eligible members of the Eligible Person’s Family shall be
enrolled into the same plan.

  b)   In local social service districts where enrollment in managed care is
mandatory, the LDSS must inform Enrollees who have Family members enrolled in
other MCOs that if anyone in the Family wishes to change plans, all members of
the Family must enroll together in the newly-selected plan. The LDSS shall also
notify the Enrollee that all members of the Family will be required to enroll
together in a single MCO at the time of their next recertification for Medicaid
eligibility unless waiver of this requirement is approved by the LDSS.

SECTION 6
(ENROLLMENT)
October 1, 2004
6-1

27

c) Notwithstanding the foregoing,

  i)   the LDSS may, on a case-by-case basis, waive the same family rule
specified in Sections 6.6 (a) and (b) to preserve continuity of care:

  1)   if one or more members of the Family are receiving prenatal care and/or
continuing care for a complex chronic medical condition from Non-Participating
Providers; or  

if one or more members of the Family transition from one government-sponsored
insurance program to another.

  ii)   the LDSS must allow HIV SNP-eligible individuals within a family to
enroll in an HIV SNP, in Service Areas in which an HIV SNP exists.  

6.7 Newborn Enrollment

  i)   All newborn children not in an excluded category shall be enrolled in the
MCO of the mother, effective from the first day of the child’s month of birth.

  ii)   b) In addition to the responsibilities set forth in Appendix H, the
Contractor is responsible for doing all of the following with respect to
newborns:

i) Coordinating with the LDSS the efforts to ensure that all newborns are

enrolled in the managed care plan;

  ii)   Issuing a letter informing parent(s) about newborn child’s enrollment or
a member identification card within 14 days of the date on which the Contractor
becomes aware of the birth;

  iii)   Assuring that enrolled pregnant women select a PCP for an infant prior
to birth and the mother to make an appointment with the PCP immediately upon
birth; and

  iv)   Ensuring that the newborn is linked with a PCP prior to discharge from
the hospital, in those instances in which the Contractor has received
appropriate notification of the birth prior to discharge.

  c)   The LDSS shall be responsible for ensuring that timely Medicaid
Eligibility determination and enrollment of the newborns is effected consistent
with state laws, regulations, and policy and with the newborn enrollment
guidelines set forth in Appendix H, Section B of this Agreement.

6.8 Effective Date of Enrollment

  a)   The Contractor and the LDSS must notify the Enrollee of the expected
Effective Date of Enrollment. This may be accomplished through a “Welcome
Letter”. To the extent practicable, such notification must precede the Effective
Date of Enrollment. In the event that the actual Effective Date of Enrollment
changes, the Contractor and the LDSS must notify the Enrollee of the change.

  b)   As of the Effective Date of Enrollment, and until the Effective Date of
Disenrollment from the Contractor’s plan, the Contractor shall be responsible
for the provision and cost of all care and services covered by the Benefit
Package and provided to Enrollees whose names appear on the Prepaid Capitation
Plan Roster, except as hereinafter provided.

SECTION 6

(ENROLLMENT)
October 1.2004
6-2

28

  i)   Contractor shall not be liable for the cost of any services rendered to
an Enrollee prior to his or her Effective Date of Enrollment.

  ii)   Contractor shall not be liable for any part of the cost of a hospital
stay for an Enrollee who is admitted to the hospital prior to the Effective Date
of Enrollment in the Contractor’s plan and who remains hospitalized on the
Effective Date of Enrollment; except when the Enrollee, on or after the
Effective Date of Enrollment, 1) is transferred from one hospital to another; or
2) is discharged from one unit in the hospital to another unit in the same
facility and under Medicaid fee for service payment rules, the method of payment
changes from: a) DRG

case-based rate of payment per discharge to a per diem rate of payment exempt
from DRG case-based payment rates, or b) from a per diem payment rate exempt
from DRG case-based payment rates either to another per diem rate, or a DRG
case-based payment rate. In such instances, the Contractor shall be liable for
the cost of the consecutive stay.

  iii)   Except for newborns, an Enrollee’s Effective Date of Enrollment shall
be the first day of the month on which the Enrollee’s name appears on the PCP
roster for that month.

6.9 Roster

  a)   The first and second monthly Rosters generated by SDOH in combination
shall serve as the official Contractor enrollment list for purposes of MMIS
premium billing and payment, subject to ongoing eligibility of the Enrollees as
of the first (I”) day of the enrollment month. Modifications to the first (1”)
Roster may be made electronically or in writing by the LDSS or the Enrollment
Broker prior to the end of the month in which the Roster is generated.

  b)   The LDSS shall make data on eligibility determinations available to the
Contractor and SDOH to resolve discrepancies that may arise between the Roster
and the Contractor’s enrollment files in accordance with the provisions in
Appendix H, Section D.

  c)   If LDSS or Enrollment Broker notifies the Contractor in writing or
electronically of changes in the first (1st) Roster and provides supporting
information as necessary prior to the effective date of the Roster, the
Contractor will accept that notification in the same manner as the Roster.

d) All Contractors must have the ability to receive these Rosters
electronically.

6.10 Automatic Re-Enrollment

The Contractor agrees that Eligible Persons who are disenrolled from the
Contractor’s plan due to loss of Medicaid eligibility and who regain eligibility
within three (3) months will automatically be prospectively re-enrolled with the
Contractor’s plan, subject to availability of enrollment capacity in the plan.

SECTION 6

(ENROLLMENT)

October t. 2004

6-3

29

7. LOCK-IN PROVISIONS

7.1 Lock-In Provisions in Voluntary Counties

All Enrollees in local social service districts where enrollment in managed care
is voluntary shall be subject to a Lock-In Period under this Agreement if so
required by the LDSS as indicated by an x below:

  •   Enrollees are subject to a twelve (12) month Lock-In Period following the
Effective Date of Enrollment in the Contractor’s plan with an initial ninety
(90) day grace period to disenroll from the Contractor’s plan without cause.

• Enrollees are not subject to a Lock-In Period.

7.2 Lock-In Provisions in Mandatory Counties and New. York City

All Enrollees in local social service districts where enrollment in managed care
is mandatory and in New York City are subject to a twelve (12) month Lock-In
period following the Effective Date of Enrollment in the Contractor’s plan, with
an initial ninety (90) day grace period in which to disenroll from the
Contractor’s plan without cause, .regardless of whether the- Enrollee selected
or was auto-assigned to the Contractor’s plan.

7.3 Disenrollment During Lock-In Period

An Enrollee, subject to Lock-In, may disenroll from the Contractor’s plan during
the Lock-In period for “good cause” as established in 18 NYCRR Subpart 360-10
or, if the Enrollee becomes eligible for an exemption or exclusion from Medicaid
managed care as set forth in Sections 5.2 and 5.3 of this Agreement.

7.4 Notification Regarding Lock-In and End of Lock-in Period

LDSS, either directly or through the Enrollment Broker, shall notify Enrollees
of their right to change MCOs in the enrollment confirmation notice sent to
individuals after they have selected a MCO or been auto-assigned (the latter
being applicable to areas where the mandatory program is in effect). LDSS and
the Enrollment Broker will be responsible for providing a notice of end of
Lock-In and the right to change MCOs at least sixty (60) days prior to the first
plan enrollment anniversary date.

SECTION 7
(LOCK-IN PROVISIONS)
October 1.2004

30

8. DISENROLLMENT

8.1 Disenrollment Guidelines

  a)   Disenrollment of an Enrollee from the Contractor’s Plan may be initiated
by the Enrollee, LDSS or the Contractor under the conditions specified in
Sections 8.4, 8.7, 8.8 and 8.9 and as detailed in Appendix H, Section E and F of
this Agreement.

The LDSS and the Contractor agree to conduct disenrollment in accordance with
the guidelines set forth in Appendix H, Section E and F of this Agreement.

The SDOH and LDSS, upon mutual agreement, may modify Appendix H of this
Agreement upon sixty (60) days prior written notice to the Contractor and such
modifications shall become binding and incorporated into this Agreement without
further action by the parties.

d) LDSS shall make the final determination concerning disenrollment.

8.2 Disenrollment Prohibitions

Disenrollment shall not be based in whole or in part on any of the following
reasons:

  a)   an existing condition or a change in the Enrollee’s health which would
necessitate disenrollment pursuant to the terms of this Agreement, unless the
change

  i)   results in the Enrollee being reclassified into an excluded category for
Medicaid — managed care as listed in Section 5.3 of this Agreement;

  ii)   results in the Enrollee being reclassified into an exempt category as
listed in Section 5.2 of this Agreement and the Enrollee wants to disenroll from
managed care.  

b) any of the factors listed in Section 34 — Non-Discrimination of this
Agreement; or
c) on the Capitation Rate payable to the Contractor related to the Enrollee’s
participation with

the Contractor.

8.3 Reasons for Voluntary Disenrollment

The LDSS or the Contractor, as agreed upon between the LDSS and Contractor,
shall provide Enrollees who disenroll voluntarily with an opportunity to
identify, in writing, their reason(s) for disenrollment.

8.4 Processing of Disenrollment Requests

a) Routine Disenrollment

Unless otherwise specified in Appendix H, Section F disenrollment requests will
be processed to take effect on the first (1st) day of the next month if the
request is made before the date specified in Appendix H. In no event shall the
Effective Date of Disenrollment be later than the first (lst) day of the second
(2nd) month after the month in which an Enrollee requests a disenrollment.

SECTION K

(DISENROLLMENT)

October 1, 2004

8-1

b) Expedited Disenrollment

  i)   Enrollees with an urgent medical need to disenroll from the Contractor’s
plan may request an expedited disenrollment by the LDSS. Substantiation of the
request by the LDSS will result in an expedited disenrollment in accordance with
the guidelines and timeframes as set forth in Appendix H. Individuals who are to
be disenrolled from managed care based on their HIV, ESRD or SPMI/SED status are
categorically eligible for an expedited disenrollment on the basis of urgent
medical need.

  ii)   Enrollees may request an expedited disenrollment by the LDSS based on a
complaint of Non-consensual Enrollment. Substantiation of such a request by the
LDSS shall result in an expedited disenrollment retroactive to the first day of
the month of enrollment.

  iii)   In New York City and other districts where homeless individuals are
exempt, homeless Enrollees residing in the shelter system may request an
expedited disenrollment by the LDSS. Substantiation of such a request by the
LDSS will result in an expedited disenrollment in accordance with the guidelines
and timeframes as set forth in Appendix H.

c) Retroactive Disenrollment

  i)   Retroactive disenrollments may be warranted in rare instances and include
when an individual is enrolled or autoassigned while meeting exlusion criteria
or when an Enrollee enters or stays in a residential institution under
circumstances which render the individual excluded from managed care; is
incarcerated; is an SSI infant less than six months of age; or dies — as long as
the Contractor was not at risk for provision of Benefit Package services for any
portion of the retroactive period.

8.5 Contractor Notification of Disenrollments

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

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

In all cases of retroactive disenrollment, including disenrollments effective
the first day of the current month, the LDSS must notice the plan at the time of
disenrollment, of the Contractor’s responsibility to submit to the SDOH’s Fiscal
Agent voided premium claims for any months of retroactive disenrollment where
the Contract was not at risk for the provision of Benefit Package services
during the month.

8.6 Contractor’s Liability

  a)   The Contractor is not responsible for providing the Benefit Package under
this Agreement after the Effective Date of Disenrollment except as hereinafter
provided:

SECTION
(DISENROLLMENT)
October 1, 2004
8-2

  i)   The Contractor shall be liable for any part of the cost of a hospital
stay for an Enrollee who is admitted to the hospital prior to the Effective Date
of Disenrollment in the Contractor’s plan and who remains hospitalized on the
Effective Date of Disenrollment; except when the Enrollee, on or after the
Effective Date of Disenrollment, 1) is transferred from one hospital to another;
or 2) is discharged from one unit in the hospital to another unit in the same
facility and under Medicaid fee for service payment rules, the method of payment
changes from: a) DRG case-based rate of payment per discharge to a per diem rate
of payment exempt from DRG case-based payment rates, or b) from a per diem
payment rate exempt from DRG case-based payment rates to either another per diem
rate, or a DRG case-based payment rate. In such instances, the Contractor shall
not be liable for the cost of the consecutive stay. For the purposes of this
Section, “hospital stay” does not include a stay in a hospital that is a)
certified by Medicare as a long-term care hospital and b) has an average length
of stay for all patients greater than ninety-five (95) days as reported in the
Statewide Planning and Research Cooperative System (SPARCS) Annual Report 2002;
in such instances, Contractor liability will cease on the Effective Date of
Disenrollment.  

  b)   The Contractor shall notify the LDSS that the Enrollee remains in the
hospital and provide the LDSS with information regarding his or her medical
status. The Contractor is required to cooperate with the Enrollee and the new
MCO (if applicable) on a timely basis to ensure a smooth transition and
continuity of care.

8.7 Enrollee Initiated Disenrollment

a) Disenrollment For Good Cause

  ii)   An Enrollee subject to Lock-In may initiate disenrollment from the
Contractor’s plan for “good cause” as defined in 18 NYCRR § 360-10 at any time
during the Lock-In period and may disenroll for any reason at any time after the
twelfth (12th) month following the Effective Date of Enrollment.  

  iii)   An Enrollee subject to Lock-In may initiate disenrollment for “good
cause” by filing a written request with the LDSS or the Contractor. The
Contractor must notify the LDSS of the request. The LDSS must respond with a
determination within thirty (30) days after receipt of the request. The
Contractor must respond timely to LDSS inquiries regarding “good cause”
disenrollment requests to enable the LDSS to make a determination within 30 days
of the receipt of the request from the Enrollee.  

  iv)   Enrollees granted disenrollment for “good cause” in a voluntary county
may join another plan, if one is available, or participate in Medicaid
fee-for-service program. In mandatory counties, unless the Enrollee becomes
exempt or excluded, he/she may be required to enroll with another MCO.  

  v)   In the event that the LDSS denies an Enrollee’s request for disenrollment
for “good cause”, the LDSS must inform the Enrollee of the denial of the request
with a written notice which explains the reason for the denial, states the facts
upon which denial is based, cites the statutory and regulatory authority and
advises the recipient of his or her right to a fair hearing pursuant to 18 NYCRR
Part 358. In the event that the Enrollee’s request to disenroll is approved, the
notice must state the Effective Date of Disenrollment.  

vi) Once the Lock-In Period has expired, an Enrollee may disenroll from

the Contractor’s plan at any time, for any reason.

SECTION 8

(DISENROLLMENT)

October 1, 2004

8-3

31 8.8 Contractor Initiated Disenrollment

  a)   The Contractor may initiate an involuntary disenrollment if the Enrollee
engages in conduct or behavior that seriously impairs the Contractor’s ability
to furnish services to either the Enrollee or other Enrollees, provided that the
Contractor has made and documented reasonable efforts to resolve the problems
presented by the Enrollee.

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

  c)   The Contractor must make a reasonable effort to identify for the
Enrollee, both ‘verbally and in. writing, those actions of the Enrollee that
have interfered with the effective provision of covered services as well as
explain what actions or procedures are acceptable.

  d)   The Contractor shall give prior verbal and written notice to the
Enrollee, with a copy to the LDSS, of its intent to request disenrollment. The
written notice shall advise the Enrollee that the request has been forwarded to
the LDSS for review and approval. The written notice must include the mailing
address and telephone number of the LDSS.

  e)   The Contractor shall keep the LDSS informed of decisions related to all
complaints filed by an Enrollee as a result of, or subsequent to, the notice of
intent to disenroll.  

  f)   LDSS will review each Contractor initiated disenrollment request in
accordance with the provisions of this Section. Where applicable, the LDSS may
consult with local mental health and substance abuse authorities in the district
when making the determination to approve or disapprove a Contractor initiated
disenrollment request.  

The LDSS will render a decision within fifteen (15) days of receipt of the fully
documented request for disenrollment. Final written determination will be
provided to the Enrollee and the Contractor. If the LDSS determination upholds
the Contractor’s request to disenroll, the LDSS’s written determination must
inform the Enrollee of the Effective Date of Disenrollment and include a notice
of rights to a fair hearing. Should an Enrollee request a fair hearing as a
result of the LDSS determination, the LDSS shall inform the Contractor of the
fair hearing request and the Enrollee will remain enrolled in the Contractor’s
plan until disposition of the fair hearing.

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

8.9 LDSS Initiated Disenrollment

a) LDSS will promptly initiate disenrollment when:

i) an Enrollee is no longer eligible for any Medicaid benefits; or

  ii)   the Guaranteed Eligibility period ends (See Section 9) and an Enrollee
is no longer eligible for any Medicaid benefits; or  

iii) an Enrollee is no longer the financial responsibility of the LDSS; or

  iv)   an Enrollee becomes ineligible for enrollment pursuant to Section 5.3 of
this Agreement, as appropriate; or  

  v)   an Enrollee resides outside the Service Area covered by this Agreement,
unless Contractor can demonstrate that the. Enrollee has made an informed choice
to continue enrollment with Contractor and that Enrollee will have sufficient
access to Contractor’s provider network.  

SECTION 8

(DISENROLLMENT)

October 1, 2004

8-4

32

9. GUARANTEED ELIGIBILITY

Except as may otherwise be required by law:

  9.1   New Enrollees, other than those identified in Sections 9.2 who would
otherwise lose Medicaid eligibility during the first six (6) months of
enrollment will retain the right to remain enrolled in the Contractor’s plan
under this Agreement for a period of six (6) months from their Effective Date of
Enrollment.

  9.2   Guaranteed eligibility is not available to Enrollees who lose Medicaid
eligibility for one of the following reasons:

a) death, moving out of State, or incarceration;

  b)   being a woman with a net available income in excess of medically
necessary income but at or below 200% of the federal poverty level who is only
eligible for Medicaid while she is pregnant and then through the end of the
month in which the sixtieth (60th) day following the end of the pregnancy
occurs.

  9.3   If, during the first six (6) months of enrollment in the Contractor’s
plan, an Enrollee becomes eligible for Medicaid only as a spend-down, the
Enrollee will be eligible to remain enrolled in the Contractor’s plan for the
remainder of the six (6) month guarantee period. During the six (6) month
guarantee period, an Enrollee eligible for spend-down and in need of wraparound
services has the option of spending down to gain full Medicaid eligibility for
the wraparound services. In this situation, the LDSS will monitor the Enrollee’s
need for wrap around services and manually set coverage codes as appropriate.

  9.4   The services covered during the Guaranteed Eligibility period shall be
those contained in the Benefit Package, as specified in Appendix K, including
free access to family planning services as set forth in Section 10.12 of this
Agreement. During the Guaranteed Eligibility period Enrollees are also eligible
for pharmacy services on a Medicaid fee-for-service basis.

  9.5   An Enrollee-initiated disenrollment from the Contractor’s plan
terminates the Guaranteed Eligibility period.

  9.6   Enrollees who lose and regain Medicaid eligibility within a three
(3) month period will not be entitled to a new period of six (6) months
Guaranteed Eligibility.

  9.7   During the guarantee period, an Enrollee may not change health plans. An
Enrollee may choose to disenroll from the Contractor’s Plan during the guarantee
period but is not eligible to enroll in any other MCO because he/she has lost
eligibility for Medicaid.

SECTION 9

(GUARANTEED ELIGIBILITY)

October 1, 2004

9-1

33

  10.   BENEFIT PACKAGE. COVERED AND NON-COVERED SERVICES  

10.1 Contractor Responsibilities

Contractor must provide all services set forth in the Benefit Package (Appendix
K) that are covered under the Medicaid fee for service program except for
services specifically excluded by the contract, or enacted or affected by
Federal or State Law during the period of this agreement. SDOH and LDSS shall
assure the continued availability and accessibility of Medicaid services not
covered in the Benefit Package.

10.2 Compliance with State Medicaid Plan and Applicable Laws

Benefit Package services provided by the Contractor under this Agreement shall
comply with all standards of the State Medicaid Plan established pursuant to
Section 363-a of the State Social Services Law and shall satisfy all applicable
requirements of the State Public Health and Social Services Laws.

10.3 Definitions

Benefit Package and Non-Covered Service definitions agreed to by the Contractor
and the LDSS are contained in Appendix K, which is hereby made a part of this
contract as if set forth fully herein.

10.4 Provision of Services Through Participating and Non-Participating Providers

With the exception of Emergency services described in Section 10.14 of this
Agreement, Family Planning Services described in Section 10.11 of this
Agreement, and services for which Enrollees can self refer as described in
Section 10.16 of this Agreement, the Benefit Package must be provided and
authorized by the Contractor through Provider Agreements with Participating
Providers, as specified in Section 22 of this Agreement. A plan may also arrange
for specialty or other services for Enrollees with Non-Participating Providers,
in accordance with Section 21.1(b) of this Agreement.

10.5 Child Teen Health Program/Adolescent Preventive Services

  a)   The Contractor and its Participating Providers are required to provide
the Child Teen Health Program C/THP services outlined in Appendix K (Benefit
Package) and comply with applicable EPSDT requirements specified in 42 CFR, Part
441, sub-part B, 18NYCRR, Part 508 and the New York State Department of Health
C/THP manual. The Contractor and its Participating Providers are required to
provide C/THP services to Medicaid Enrollees under 21 years of age when:

i) The care or services are essential to prevent, diagnose, prevent the
worsening of, alleviate or ameliorate the effects of an illness, injury,
disability, disorder or condition.

ii) The care or services are essential to the overall physical, cognitive and
mental growth and developmental needs of the child.

iii) The care or service will assist the individual to achieve or maintain
maximum functional capacity in performing daily activities, taking into account
both the functional capacity of the individual and those functional capacities
that are appropriate for individuals of the same age.

The Contractor shall base its determination on medical and other relevant
information provided by the Enrollee’s PCP, other health care providers, school,
local social services, and/or local public health officials that have evaluated
the child.

  b)   The Contractor and its Participating Providers must comply with the C/THP
program standards and must do at least the following with respect to all
Enrollees under age 21:

SECTION 10

(BENEFIT PACKAGE. COVERED AND NON-COVERED SERVICES)

October 1, 2004

I 0-1

34

  i)   Educate pregnant women and families with under age 21 Enrollees about the
program and its importance to a child’s or adolescent’s health.

  ii)   Educate network providers about the program and their responsibilities
under it.

  iii)   Conduct outreach, including by mail, telephone, and through home visits
(where appropriate), to ensure children are kept current with respect to their
periodicity schedules.

  iv)   Schedule appointments for children and adolescents pursuant to the
periodicity schedule, assist with referrals, and conduct follow-up with children
and adolescents who miss or cancel appointments.

  v)   Ensure that all appropriate diagnostic and treatment services, including
specialist referrals, are furnished pursuant to findings from a C/THP screen.

  vi)   Achieve and maintain an acceptable compliance rate for screening
schedules during the contract period.

  c)   In addition to C/THP requirements, the Contractor and its Participating
Providers are required to comply with the American Medical Association’s
Guidelines for Adolescent Preventive Services which require annual well
adolescent preventive visits which focus on health guidance, immunizations, and
screening for physical, emotional, and behavioral conditions.

10.6 Foster Care Children

The Contractor shall comply with the health requirements for foster children
specified in 18 NYCRR Section 441.22 and Part 507 and any subsequent amendments
thereto. These requirements include thirty (30) day obligations for a
comprehensive physical and behavioral health assessment and assessment of the
risk that the child may be HIV+ and should be tested.

10.7 Child Protective Services

      The Contractor shall comply with the requirements specified for child
protective examinations, provision of medical information to the child
protective services investigation and court ordered services as specified in 18
NYCRR Section 432, and any subsequent amendments thereto. Medically necessary
services, whether provided in or out of plan, must be provided. Out of plan
providers will be reimbursed at the Medicaid fee schedule by the Contractor.

10.8 Welfare Reform

  a)   The LDSS must determine whether each public assistance or combined public
assistance/Medicaid applicant is incapacitated or can participate in work
activities. As part of this work determination process, the LDSS may require
medical documentation and/or an initial mental and/or physical examination to
determine whether an individual has a mental or physical impairment that limits
his/her ability to engage in work (12 NYCRR § 1300.2(d)(13)(i)). The LDSS may
not require the Contractor to provide the initial district mandated or requested
medical examination necessary for an Enrollee to meet welfare reform work
participation requirements.

  b)   The Contractor shall require that its Participating Providers, upon
Enrollee consent, provide medical documentation and health, mental health and
chemical dependence assessments as follows:  

  i)   Within ten (10) days of a request of an Enrollee or a former Enrollee,
currently receiving public assistance or who is applying for public assistance,
the Enrollee’s or former Enrollee’s PCP or specialist provider, as appropriate,
shall provide medical documentation concerning the Enrollee or former Enrollee’s
health or mental health status to the LDSS or to the LDSS’ designee. Medical
documentation includes but is not limited to drug prescriptions and reports from
the Enrollee’s PCP or specialist provider. The Contractor shall include the
foregoing as a responsibility of the PCP and specialist provider in its provider
contracts or in their provider manuals.  

SECTION 10

(BENEFIT PACKAGE, COVERED AND NON-COVERED SERVICES)

October 1.2004

10-2

  ii)   Within ten (10) days of a request of an Enrollee, who has already
undergone, or is scheduled to undergo, an initial LDSS required mental and/or
physical examination, the Enrollee’s PCP shall provide a health, or mental
health and/or chemical dependence assessment, examination or other services as
appropriate to identify or quantify an Enrollee’s level of incapacitation. Such
assessment must contain a specific diagnosis resulting from any medically
appropriate tests and specify any work limitations. The LDSS, may, upon written
notice to the Contractor, specify the format and instructions for such an
assessment.  

  c)   The Contractor shall designate a Welfare Reform liaison who shall work
with the LDSS or its designee to (1) ensure that Enrollees receive timely access
to assessments and services specified in this Agreement and (2) ensure
completion of reports containing medical documentation required by the LDSS:

  d)   The Contractor will continue to be responsible for the provision and
payment of Chemical Dependence Services in the Benefit Package for Enrollees
mandated by the LDSS under Welfare Reform if such services are already underway
and the LDSS is satisfied with the level of care and services.

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

  f)   The Contractor is not responsible for the-provision and payment of
Medically Supervised Inpatient and Outpatient Withdrawal Services for Enrollees
mandated by the LDSS under Welfare Reform (as indicated by Code 83) unless such
services are already under way as described in (c) above.

  g)   The Contractor is responsible for the provision and payment of Medically
Managed Detoxification Services ordered by the LDSS under Welfare Reform.

  h)   The Contractor is responsible for the provisions of Sections 10.10, 10.16
(a) and 10.24 of this Agreement for Enrollees requiring LDSS mandated Chemical
Dependence Services.

10.9 Adult Protective Services

The Contractor shall cooperate with LDSS in the implementation of 18 NYCRR
Part 457 and any subsequent amendments thereto with regard to medically
necessary health and mental health services and all Court Ordered Services for
adults. These services are to be provided in or out of plan. Out of plan
providers will be reimbursed at the Medicaid fee schedule.

10.10 Court-Ordered Services

  a)   The Contractor shall provide any Benefit Package services to Enrollees as
ordered by a court of competent jurisdiction, regardless of whether such
services are provided by Participating Providers within the plan or by a
Non-Participating Provider in compliance with such court order. The
Non-Participating Provider shall be reimbursed by the Contractor at the Medicaid
fee schedule. The Contractor is responsible for court-ordered services to the
extent that such court-ordered services are covered by and reimbursable by
Medicaid.

SECTION 10

(BENEFIT PACKAGE, COVERED AND NON-COVERED SERVICES)

October 1, 2004

10-3

35

  b)   Court Ordered Services are those services ordered by the court performed
by, or under the supervision of a physician, dentist, or other provider
qualified under State Law to furnish medical, dental, behavioral health
(including mental health and/or Chemical Dependence), or other Medicaid covered
services. The Contractor is responsible for payment of those Medicaid services
as covered by the Benefit Package, even when the providers are not in the
Contractor’s provider network.

10.11 Family Planning and Reproductive Health Services

  a)   Nothing in this Agreement shall restrict the right of Enrollees to
receive Family Planning and Reproductive Health Services from any qualified
Medicaid provider, regardless of whether the provider is a participating
provider or a non-participating provider, without referral from the Enrollee’s
PCP and without approval from the Contractor.  

  b)   The Contractor agrees to permit Enrollees to exercise their right to
obtain Family Planning and Reproductive Health Services as defined in Part C-I
of Appendix C, which is hereby made a part of this contract as if set forth
fully herein, from either the Contractor, if family planning is a part of the
Contractor’s Benefit Package, or from any appropriate Medicaid enrolled
Non-Participating Family Planning Provider without a referral from the
Enrollee’s PCP and without approval by the Contractor.  

  c)   The Contractor agrees to permit Enrollees to obtain pre and post-test HIV
counseling and blood testing when performed as part of a Family Planning
encounter from the Contractor, if Family Planning is a part of the Contractor’s
Benefit Package, or from any appropriate Medicaid enrolled Non-Participating
family planning Provider without a referral from the Enrollee’s PCP and without
approval by the Contractor.  

  d)   The Contractor will inform Enrollees about the availability of in-plan
HIV counseling and testing services, out-of-plan HIV counseling and testing
services when performed as part of a Family Planning encounter and anonymous
counseling and testing services available from SDOH, Local Public Health Agency
clinics and other county programs. Counseling and testing rendered outside of a
Family Planning encounter, as well as services provided as the result of an HIV+
diagnosis, will be furnished by the Contractor in accordance with standards of
care.  

  e)   Contractor must comply with federal, state, and local laws, regulations
and policies regarding informed consent and confidentiality. Providers who are
employed by the Contractor may share patient information with appropriate
Contractor personnel for the purposes of claims payment, utilization review and
quality assurance. Providers who have a contract with the Contractor, with an
appropriate consent, may share patient information with the Contractor for
purposes of claims payment, utilization review and quality assurance. Contractor
must ensure that an individual’s use of family planning services remains
confidential and is not disclosed to family members or other unauthorized
parties.  

  f)   Contractor must inform its practitioners and administrative personnel
about policies concerning free access to family planning services, HIV
counseling and testing, reimbursement, enrollee education and confidentiality.
Contractor must inform its 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 Physician, the U.S. Task Force on
Preventive Services and the New York State Child/Teen Health Program: These
standards and laws indicate that family planning counseling is an integral part
of primary and preventive care.

SECTION 10
(BENEFIT PACKAGE, COVERED AND NON-COVERED SERVICES)
October 1.2004
10-4

g) The Contractor agrees that if Family Planning is part of the Contractor’s
Benefit Package, the Contractor will be charged for the services of out of
network providers at the applicable Medicaid rate or fee. In such instances, out
of network providers will bill Medicaid and the SDOH will issue a confidential
charge back to the Contractor. Such charge back mechanism will comply with all
applicable patient confidentiality requirements.

h) If Contractor includes family planning and reproductive health services in
its benefits package, the Contractor shall comply with the requirements for
informing Enrollees about family planning and reproductive health services set
forth in Part C-2 of Appendix C, which is hereby made a part of this contract as
if set forth herein.

i) If Contractor does not include family planning and reproductive health
services in its Benefit Package, within ninety (90) days of signing this
Agreement, Contractor must submit to the SDOH and LDSS a statement of the policy
and procedure 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. Refer to Part C-3 of Appendix C for the SDOH
Guidelines for Plans That Do Not Provide Family Planning Services in their
Capitation. Contractor shall ensure that prospective Enrollees and Enrollees are
advised of the family planning services which are not provided by the Contractor
and of their right of access to such services in accordance with the provisions
of Part C-3 of Appendix C, which is hereby made a part of this contract as if
set forth fully herein.

j) SDOH with DHHS approval may issue modifications to Appendix (C) consistent
with relevant provisions of federal and state statutes and regulations. Once
issued and upon sixty (60) days notice to the LDSS and Contractor, such
modifications shall be deemed incorporated into this Agreement without further
action by the parties.

10.12. 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 Public Health Law in
accordance with 10 NYCRR Part 85.40 (Prenatal Care Assistance Program).  

10.13 Direct Access

The Contractor shall offer female Enrollees direct access to primary and
preventive obstetrics and gynecology services, follow-up care as a result of a
primary and preventive visit, and any care related to pregnancy from the
Contractor’s network providers without referral from the PCP as set forth in
Public Health Law Section 4406-b(1).

10.14 Emergency Services

  a)   The Contractor shall maintain coverage utilizing a toll free telephone
number twenty-four (24) hours per day seven (7) days per week, answered by a
live voice, to advise Enrollees of procedures for accessing services for
Emergency Medical Conditions and for accessing Urgently Needed Services.
Emergency mental health calls must be triaged via telephone by a trained mental
health professional.  

  b)   The Contractor agrees that it will not require prior authorization for
services in a medical or behavioral health emergency. The Contractor agrees to
inform its Enrollees that access to Emergency Services is not restricted and
Emergency Services may be obtained from a Non-Participating Provider without
penalty. The Contractor may require Enrollees to notify the plan or their PCP
within a specified time frame after receiving emergency care and to obtain prior
authorization for any follow-up care delivered pursuant to the emergency, as
stated in Appendix G. Nothing herein precludes the Contractor from entering into
contracts with providers or facilities that require providers or facilities to
provide notification to the Contractor after Enrollees present for Emergency
Services and are subsequently stabilized. Except as otherwise  

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otherwise provided by contractual agreement between the Contractor and a
Participating Provider, the Contractor must pay for services for Emergency
Medical Conditions whether provided by a Participating Provider or a
Non-Participating Provider, and may not deny payments if notification is not
timely.

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

  d)   The Contractor agrees to abide by guidelines for the provision and
payment of Emergency Care and Services which are specified in Appendix G, which
is hereby made a part of this contract as if set forth fully herein.

  e)   When emergency transportation is included in the Contractor’s Benefit
Package, the Contractor shall reimburse for all emergency ambulance services
without regard to final diagnosis or prudent layperson standards.

10.15 Medicaid Utilization Thresholds (MUTS)

Enrollees may be subject to MUTS for outpatient pharmacy services which are
billed Medicaid fee-for-service and for dental services provided without
referral at Article 28 clinics operated by academic dental centers as described
in Section 10.28 of this Agreement. Enrollees are not otherwise subject to MUTS
for services included in the Benefit Package.

10.16 Services for Which Enrollees Can Self-Refer

a) Mental Health and Chemical Dependence Services

The Contractor will allow Enrollees or LDSS officials on the Enrollee’s behalf
to make self referral or referral for one mental health assessment from a
Participating Provider and one chemical dependence assessment from a
Detoxification or Chemical Dependence Inpatient Rehabilitation and Treatment
Participating Provider in any calendar year period without requiring
preauthorization or referral from the Enrollee’s Primary Care Provider. In the
case of children, such self-referrals may originate at the request of a school
guidance counselor (with parental or guardian consent, or pursuant to procedures
set forth in Section 33.21 of the Mental Hygiene Law), LDSS Official, Judicial
Official, Probation Officer, parent or similar source.

  i)   The Contractor shall make available to all Enrollees a complete listing
of their participating mental health and Chemical Dependence Services providers.
The listing should specify which provider groups or practitioners specialize in
children’s mental health services.

  ii)   The Contractor will also ensure that its Participating Providers have
available and use formal assessment instruments to identify Enrollees requiring
mental health and Chemical Dependence Services, and to determine the types of
services that should be furnished.

  iii)   The Contractor will implement policies and procedures to ensure that
Enrollees receive follow-up Benefit Package services from appropriate providers
based on the findings of their mental health and/or Detoxification or Chemical
Dependence Inpatient Rehabilitation and Treatment assessment(s).

  iv)   The Contractor will implement policies and procedures to ensure that
Enrollees are referred to appropriate Chemical Dependence outpatient
rehabilitation and treatment providers based on the findings of the Chemical
Dependence assessment by the Contractor’s Participating Provider.

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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. (See Appendix K).

c) Diagnosis and Treatment of Tuberculosis

Enrollees may self-refer to public health agency facilities for the diagnosis
and/or treatment of TB as described in Section 10.19 (a)(i) of this Agreement.

d) Family Planning and Reproductive Health Services.

Enrollees may self-refer to family planning and reproductive health services as
described in Section 10.11 and Appendix C of this Agreement.

e) Article 28 Clinics Operated by Academic Dental Centers

Enrollees may self-refer to Article 28 clinics operated by academic dental
centers to obtain covered dental services as described in Section 10.28 of this
Agreement.

10.17 Second Opinions for Medical or Surgical Care

The Contractor will allow Enrollees to obtain a second opinion within the
Contractor’s network of providers for diagnosis of a condition, treatment or
surgical procedure.

10.18 Coordination with Local Public Health Agencies

The Contractor will coordinate its public health-related activities with the
Local Public Health Agency. Coordination mechanisms and operational protocols
for addressing public health issues will be negotiated with the Local Public
Health and Social Services Departments and be customized to reflect County
public health priorities. Negotiations must result in agreements regarding
required health plan activities related to public health. The outcome of
negotiations may take the form of an informal agreement among the parties which
may include memos; a separate memorandum of understanding signed by the Local
Public Health Agency, LDSS, and the Contractor; or an appendix to the contract
between the LDSS and the Contractor which shall be included in Appendix N as if
set forth fully herein.

10.19 Public Health Services

    a)   Tuberculosis Screening, Diagnosis and Treatment; Directly Observed
Therapy(TB DOT):

  i)   Consistent with New York State law, public health clinics are required to
provide or arrange for treatment to individuals presenting with tuberculosis,
regardless of the person’s insurance or enrollment status. It is the State’s
preference that the Contractor’s Enrollees receive TB diagnosis and treatment
through the Contractor’s plan, to the extent that providers experienced in this
type of care are available in the Contractor’s network of Participating
Providers, although Enrollees may self-refer to public health agency facilities
for the diagnosis and/or treatment of TB. The Contractor agrees to reimburse
public health clinics when physician visit and patient management or laboratory
and radiology services are rendered to their Enrollees, within the context of TB
diagnosis and treatment.

  ii)   The Contractor’s Participating Providers must report TB cases to the
Local Public Health Agency. The LDSS will have the Local Public Health Agency
review the tuberculosis treatment protocols and networks of Participating
Providers of the Contractor, to verify their readiness to treat Tuberculosis
patients. The Contractor’s protocols will be evaluated against State and local
guidelines. State and local departments of health also will be available to
offer technical assistance to the Contractor in establishing TB policies and
procedures.  

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  iii)   The Contractor may require the Local Public Health Agency to give
notification before delivering services, unless these services are ordered by a
court of competent jurisdiction. The Local Public Health Agency will: 1) make
reasonable efforts to verify with the Enrollee’s PCP that he/she has not already
provided TB care and treatment, and 2) provide documentation of services
rendered along with the claim.  

  iv)   The Contractor may use locally negotiated fees. In addition, SDOH will
establish fee schedules for these services, which the Contractor may use in the
absence of locally negotiated fees.

  v)   Contractors may require prior authorization for non-emergency inpatient
hospital admissions, except that prior authorization will not be required for an
admission pursuant to a court order or an order of detention issued by the local
commissioner or director of public health.

  vi)   The Contractor shall provide the Local Public Health Agency with access
to health care practitioners on a twenty-four (24) hour a day, seven (7) day a
week basis who can authorize inpatient hospital admissions. The Contractor shall
respond to the Local Public Health Agency’s request for authorization within the
same day.

  vii)   The Contractor will not be capitated or financially liable for Directly
Observed Therapy (DOT) costs. The Contractor agrees to make all reasonable
efforts to ensure coordination with DOT providers regarding clinical care and
services. HIV counseling and testing during a TB related visit at a public
health clinic, directly operated by a county health department or the New York
City Department of Health and Mental Hygiene, will be covered by Medicaid
fee-for-service (FFS) at rates established by the State. The Contractor also
will not be financially liable for treatments rendered to Enrollees who have
been: institutionalized as a result of a local health commissioner’s order due
to non-compliance with TB care regimens.

viii) While all other clinical management of tuberculosis is covered by the
Contractor, TB/DOT where applicable, can be billed directly to Medicaid by any
SDOH approved fee-for-service Medicaid TB/DOT provider. The Contractor remains
responsible for communicating, cooperating, and coordinating clinical management
of TB with the TB/DOT provider. The Enrollee reserves the right to use any
fee-for-service DOT provider because TB/DOT is a non-covered benefit.

b) Immunizations

  i)   Immunizations for adults and administration of immunizations for children
will be included in the Benefit Package and the Contractor will be required to
reimburse the Local Public Health Agency when Enrollees self-refer.

  ii)   In order to be eligible for reimbursement, a Local Public Health Agency
must make reasonable efforts to (1) determine the Enrollee’s managed care
membership status; and (2) ascertain the Enrollee’s immunization status. Such
efforts shall consist of client interviews and, when available, access to the
Immunization Registry. When an Enrollee presents a membership card with a PCP’s
name, the Local Public Health Agency shall call the PCP. If the agency is unable
to verify the immunization status from the PCP or learns that immunization is
needed, the agency shall proceed to deliver the service as appropriate, and the
Contractor will reimburse the Local Public Health Agency at the negotiated rate
or at a fee schedule to be used in the absence of a negotiated rate. Upon
implementation of the immunization registry, the Local Public Health Agency
shall not be required to contact the PCP.

  iii)   If the immunization is administered by the PCP, immunization materials
for children should be obtained free of charge from the “Vaccine For Children
Program”. The Contractor will be reimbursed only for administering the vaccine
to children.

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38 c) Prevention and Treatment of Sexually Transmitted Diseases

The Contractor will be responsible for ensuring that its Participating Providers
educate their Enrollees about the risk and prevention of sexually transmitted
disease (STD). The Contractor also will be responsible for ensuring that its
Participating Providers screen and treat Enrollees for STDs and report cases of
STD to the Local Public Health Agency and cooperate in contact investigation, in
accordance with existing state and local laws and regulations. HIV counseling
and testing provided during a STD related visit at a public health clinic,
directly operated by a county health department or the New York City Department
of Health and Mental Hygiene, will be covered by Medicaid FFS at rates
established by the State.

d) Lead Poisoning

The Contractor will be responsible for carrying out and ensuring that its
Participating Providers comply with lead poisoning screening and follow-up as
specified in 10 NYCRR, Sub-part 67.1. The Contractor shall coordinate the care
of such children with Local Public Health Agencies to assure appropriate
follow-up in terms of environmental investigation, risk management and reporting
requirements.

10.20 Adults with Chronic Illnesses and Physical or Developmental Disabilities

The Contractor will implement all of the following to meet the needs of their
adult Enrollees with chronic illnesses and physical or developmental
disabilities:

  a)   Satisfactory methods for ensuring that the Contractor is in compliance
with the Americans with Disabilities Act (“ADA”) and Section 504 of the
Rehabilitation Act of 1973. Program accessibility for persons with disabilities
shall be in accordance with Section 24 of this Agreement.

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

i) develop protocols describing the Contractor’s case management services

     
ii)
  and minimum qualification requirements for case management staff;
develop and implement protocols for monitoring effectiveness of case

management based on patient outcomes;

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

  iv)   provide regular information to network providers on the case management
services available to the Contractor’s Enrollees and the criteria for referring
Enrollees to the Contractor for case management services.

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

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

  e)   Satisfactory systems for coordinating service delivery with
out-of-network providers, including behavioral health providers for all
Enrollees.

  f)   Policies and procedures to allow for the continuation of existing
relationships with out-of-network providers, consistent with PHL 4403 6(e) and
Section 15.5 of this Agreement.

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39

10.21 Children with Special Health Care Needs

Children with special health care needs are those who have or are suspected of
having a serious or chronic physical, developmental, behavioral, or emotional
condition and who also require health and related services of a type or amount
beyond that required by children generally. The Contractor will be responsible
for performing all of the same activities for this population as for adults. In
addition, the Contractor will implement the following for these children:

  a)   Satisfactory methods for interacting with school districts, preschool
services, child protective service agencies, early intervention officials,
behavioral health, and developmental disabilities service organizations for the
purpose of coordinating and assuring appropriate service delivery.

  b)   An adequate network of pediatric providers and sub-specialists,
contractual relationships with tertiary institutions, to meet their medical
needs.

  c)   Satisfactory methods for assuring that children with serious, chronic,
and rare disorders receive appropriate diagnostic work-ups on a timely basis.

  d)   Satisfactory arrangements for assuring access to specialty centers in and
out of New York State for diagnosis and treatment of rare disorders.

  e)   A satisfactory approach for assuring access to allied health
professionals (Physical Therapists, Occupational Therapists, Speech Therapists,
and Audiologists) experienced in dealing with children and families.

10.22 Persons Requiring Ongoing Mental Health Services

The Contractor will implement all of the following for its Enrollees with
chronic or ongoing mental health service heeds:

  a)   Inclusion of all of the required provider types listed in Section 21 of
this Agreement.

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

c) Satisfactory case management systems or satisfactory case management.

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

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

10.23 Member Needs Relating to HIV

Persons with HIV infection are exempt from mandatory enrollment; however, they
will be permitted to enroll voluntarily into Managed Care Organizations. The
Contractor must inform Enrollees newly diagnosed with HIV infection or AIDS,
known to the Contractor, of their enrollment options including the ability to
return to fee-for-service or to disenroll from the Contractor’s plan and to
enroll into HIV Special Needs Plans (SNPs) as such plans become available.

The Contractor agrees that anonymous testing may be furnished to the Enrollee
without prior approval by the Contractor and may be conducted at anonymous
testing sites available to clients. Services provided for HIV treatment may only
obtained from the Contractor during the period the

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Enrollee is enrolled in the Contractor’s plan.

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

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

  b)   Policies and procedures promoting the early identification of HIV
infection in Enrollees. Such policies and procedures shall include at a minimum:
assessment methods for recognizing the early signs and symptoms of HIV disease;
initial and routine screening for HIV risk factors through administration of
sexual behavior and drug and alcohol use assessments; and the provision of
information to all Enrollees regarding the availability of in-plan HIV CTRPN
services, out of plan CTRPN services as part of a family planning visit, and
anonymous CTRPN services from New York State, New York City and Local Public
Health Agencies.  

  c)   The Contractor shall comply with the requirements set forth in Title 10
NYCRR (including Part 98 and in Subpart 69-1) which mandate that HIV counseling
with testing, presented as a-clinical recommendation, be provided to all women
in prenatal care and their newborns. Consistent with these requirements, the
Contractor shall ensure that Participating Providers refer such Enrollees
determined to have HIV infection for clinically appropriate services.  

  d)   Network Sufficiency. A network of providers sufficient to meet the needs
of its Enrollees with HIV. Satisfaction of the network requirement may be
accomplished by inclusion of HIV specialists within the network or the provision
of HIV specialist consultation to non-HIV specialists serving as PCPs for
persons with HIV infection; inclusion of Designated AIDS Center Hospitals or
other hospitals experienced in HIV care in the Contractor’s network; and
contracts or linkages with providers funded under the Ryan White CARE Act. The
Contractor shall inform the providers in its network how to obtain information
about the availability of Experienced HIV Providers and HIV Specialist PCPs  

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

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

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

10.24 Persons Requiring Chemical Dependence Services

The Contractor will have in place all of the following for its Enrollees
requiring Chemical Dependence Services:

  a)   Participating Provider networks consisting of licensed providers, as
defined in Section 21.17 of this contract.  

  b)   Satisfactory methods for identifying persons requiring such services and
encouraging self-referral and early entry into treatment. In the case of
pregnant women, having methods for referring to OASAS for appropriate services
beyond the Contractor’s Benefit Package (e.g., halfway houses).  

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

d) Satisfactory case management systems.

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

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

10.25 Native Americans

If the Contractor’s Enrollee is a Native American and’ the Enrollee chooses to
access primary care services through their tribal health center, the PCP
authorized by the Contractor to refer the Enrollee for plan benefits must
develop a relationship with the Enrollee’s PCP at — the tribal health center to
coordinate services for said Native American Enrollee.

10.26 Women, Infants, and Children (WIC)

The Contractor shall develop linkage agreements or other mechanisms to ensure
women and children enrollees are referred to WIC services if qualified to
receive such services. The Contractor shall refer pregnant women and children,
younger than five (5) years of age, to WIC local agencies for nutritional
assessments and supplements.

10.27 Urgently Needed Services

a) The Contractor is responsible for Urgently Needed Services.

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  b)   Urgently Needed Services are covered only in the United States, the
Commonwealth of Puerto Rico, the U.S. Virgin Islands, Guam, American Samoa, the
Northern Mariana Islands and Canada.  

  c)   The Contractor must disclose to all Enrollees the procedures to be
followed to obtain Urgently Needed Services.  

  d)   The Contractor may require Enrollees or the Enrollee’s designee to
coordinate with the Contractor or the Enrollee’s PCP prior to receiving care, to
ensure that the needed care will be authorized and covered by the plan as
Urgently Needed Services.

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

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

  b)   If dental services are part of the Contractor’s Benefit Package, the
Contractor will reimburse non-participating Article 28 clinics operated by
academic dental centers for covered dental services provided to Enrollees on or
after November 19, 2003 at approved Article 28 Medicaid clinic rates in
accordance with the protocols issued by the SDOH.

10.29 Coordination of Services

a) The Contractor shall coordinate care for Enrollees with:

i) the court system (for court ordered evaluations and treatment);

  ii)   specialized providers of health care for the homeless, and other
providers of services for victims of domestic violence;  

  iii)   family planning clinics, community health centers, migrant health
centers, rural health centers;  

iv) WIC, Head Start, Early Intervention;

v) special needs plans;

     
vi)
  programs funded through the Ryan White CARE Act;
 
   
vii)
  other pertinent entities that provide services out of network;
 
   
viii)
  Prenatal Care Assistance Program (PCAP) Providers;

  ix)   local governmental units responsible for public health, mental health,
mental retardation or Chemical Dependence Services;  

  x)   specialized providers of long term care for people with developmental
disabilities; and

xi) School-based health centers.

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

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October 1, 2004
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10.30 Prospective Benefit Package Change for Retroactive SSI Determinations

The managed care Benefit Package and associated Capitation Rate for Enrollees
who become SSI or SSI related retroactively shall be changed prospectively as of
the effective date of the Roster on which the Enrollee’s status change appears.

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43

11.1 Marketing Plan

The Contractor shall have a Marketing Plan, that has been prior-approved by the
SDOH and/or LDSS, that describes the Marketing activities the Contractor will
undertake within the local district during the term of this Agreement.

The Marketing Plan and all marketing activities must be consistent with the
Marketing Guidelines which are set forth in Appendix D, which is hereby made a
part of this Agreement as if set forth fully herein.

The Marketing Plan shall be kept, on file in the offices of the Contractor,
LDSS, and the SDOH. The Marketing Plan may be modified by the Contractor subject
to prior written approval by the SDOH and/or the LDSS. The LDSS or SDOH must
take action on the changes submitted within sixty (60) calendar days of
submission or the Contractor may deem the changes approved.

     
11.2
  Marketing Activities
 
   
 
  Marketing activities by the Contractor shall conform to the approved Marketing
Plan.
 
   
11.3
  Prior Approval of Marketing Materials, Procedures, Subcontracts

The Contractor shall submit all subcontracts, procedures, and materials related
to Marketing to Eligible Persons to the SDOH and/or LDSS for prior written
approval. The Contractor shall not enter into any subcontracts or use any
marketing subcontractors, procedures, or materials that the SDOH and/or LDSS has
not approved.

11.4 Marketing Infractions

Infractions of the Marketing Guidelines may result in the following actions
being taken by the LDSS to protect the interests of the program and its clients.
These actions shall be taken at the sole discretion of the LDSS.

  a)   If an MCO or its representative commits a first time infraction of
marketing guidelines and the LDSS deems the infraction to be minor or
unintentional in nature, the LDSS may issue a warning letter to the MCO.

For subsequent or more serious infractions, the LDSS may impose liquidated
damages of $2,000 or other appropriate non-monetary sanction for each
infraction.
The LDSS may require the MCO to prepare a corrective action plan with a
specified deadline for implementation.

  d)   If the MCO commits further infractions, fails to pay liquidated damages
within the specified timeframe, fails to implement a corrective action plan in a
timely manner or commits an egregious first-time infraction, the LDSS may:

  i)   prohibit the plan from conducting any marketing activities for a period
up to the end of the contract period;

  ii)   suspend new enrollments, other than newborns, for a period up to the
remainder of the contract; or

  iii)   terminate the contract pursuant to termination procedures described
therein.

11.5 LDSS Option to Adopt Additional Marketing Guidelines

The LDSS may adopt, subject to SDOH approval, additional and/or more restrictive
terms in the Marketing Guidelines to the extent appropriate to local conditions
and circumstances, which shall be appended to Appendix D, Section E.

SECTION 11
(MARKETING)
October 1, 2004
11-1

44

12. MEMBER SERVICES

12.1 General Functions

      The Contractor shall operate a Member Services function during regular
business hours, which must be accessible to Enrollees via a toll-free telephone
line. Personnel must also be available via a toll-free telephone line (which can
be the member services toll-free line or separate toll-free lines) not less than
during regular business hours to address complaints and utilization review
inquiries. In addition, the Contractor must have a telephone system capable of
accepting, recording or providing instruction to incoming calls regarding
complaints and utilization review during other than normal business hours and
measures in place to ensure a response to those calls the next business day
after the call was received. At a minimum, the Member Services Department must
be staffed at a ratio of at least one (1) full time equivalent Member Service
Representative for every 4,000 or fewer Enrollees. Member Services staff must be
responsible for the following:

  a)   Explaining the Contractor’s rules for obtaining services and assisting
Enrollees in making appointments.

b) Assisting Enrollees to select or change Primary Care Providers.

  c)   Fielding and responding to Enrollee questions and complaints, and
advising Enrollees of the prerogative to complain to the SDOH and LDSS at any
time.

d) Clarifying information in the member handbook for Enrollees.

  e)   Advising Enrollees of the Contractor’s complaint and appeals program, the
utilization review process, and Enrollee’s rights to a fair hearing or external
review.  

  f)   Clarifying for potential Enrollees current categories of exemptions and
exclusions. The Contractor may refer to the LDSS or the Enrollment Broker, where
one is in place, if necessary, for more information on exemptions and
exclusions.  

12.2 Translation and Oral Interpretation

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

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

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

12.3 Communicating with the Visually, Hearing and Cognitively Impaired

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

SECTION 12
(MEMBER SERVICES)
October 1.2004
12-1

45

13. ENROLLEE NOTIFICATION

13.1 Provider Directories/Office Hours for Participating Providers

  a)   The Contractor shall maintain and update, on a quarterly basis, a listing
by specialty of the names, addresses and telephone numbers of all Participating
Providers, including facilities. Such a list/directory shall include names,
office addresses, telephone numbers, board certification for physicians, and
information on language capabilities and wheelchair accessibility of
Participating Providers.

  b)   New Enrollees, and upon request, prospective Enrollees, must receive the
most current complete listing, in hardcopy, along with any updates to such
listing.

  c)   Enrollees must be notified of updates in writing at least annually in one
of the following methods: provide updates in hardcopy; provide a new complete
listing/directory in hardcopy; or provide written notification that a new
complete listing/directory. is available and will be provided upon request
either in hardcopy, or electronically if the Contractor has the capability of
providing such data in an -electronic format and the data is requested in that
format by an Enrollee.

  d)   In addition, the Contractor must make available to the LDSS the office
hours for Participating Providers. This requirement may be satisfied by
providing a copy of the list or Provider Directory described in this Section
with the addition of office hours or by providing a separate listing of office
hours for Participating Providers.

13.2 Member ID Cards

  a)   The Contractor must issue an identification card to the Enrollee
containing the following information:

i) the name of the Enrollee’s clinic (if applicable);
ii) the name of the Enrollee’s PCP and the PCP’s telephone number;
iii) the member services toll free telephone number;

  iv)   the twenty-four (24) hour toll free telephone number that Enrollees may
use to access information on obtaining services when his/her PCP is not
available; and

  v)   for ID Cards issued after October 1, 2004, the Enrollee’s Client
Identification Number (C1N).

  b)   If an Enrollee is being served by a PCP team, the name of the individual
shown on the card should be the lead provider. PCP information may be embossed
on the card or affixed to the card by a sticker.

  c)   The Contractor shall issue an identification card within fourteen
(14) days of an Enrollee’s Effective Date of Enrollment. If unforeseen
circumstances, such as the lack of identification of a PCP, prevent the MCO from
forwarding the official identification card to new Enrollees within the fourteen
(14) day period, alternative measures by which Enrollees may identify themselves
such as use of a Welcome Letter or a temporary identification card shall be
deemed acceptable until such time as a PCP is either chosen by the Enrollee or
auto assigned by the Contractor. The Contractor agrees to implement an
alternative method by which individuals may identify themselves as Enrollees
prior to receiving the card (e.g., using a “welcome letter” from the plan) and
to update PCP information on the identification card. Newborns of Enrollees need
not present ID cards in order to be seen by the MCO and its Participating
Providers.

13.3 Member Handbooks

The Contractor shall issue to a new Enrollee within fourteen (14) days of the
Effective Date of Enrollment a Member Handbook, which is consistent with the
SDOH guidelines described in Appendix E, which is hereby made a part of this
Agreement as if set forth fully herein.

SECTION 13
(ENROLLEE NOTIFICATION)
October 1.2004
13-1

46

13.4 Notification of Effective Date of Enrollment

The Contractor shall inform each Enrollee in writing within fourteen (14) days
of the Effective Date of Enrollment of any restriction on the Enrollee’s right
to terminate enrollment. The initial enrollment information and the Member
Handbook shall be adequate to convey this notice.

13.5 Notification of Enrollee Rights

The Contractor agrees to make all reasonable efforts to contact new Enrollees,
in person, by telephone, or by mail, within thirty (30) days of their Effective
Date of Enrollment. “Reasonable efforts” are defined to mean at least three
(3) attempts, with more than one method of contact being employed. Upon
contacting the new Enrollee(s), the Contractor agrees to do at least the
following:

  a)   Inform the Enrollee about the Contractor’s policies with respect to
obtaining medical services, including services for which the Enrollee may
self-refer, and what to do in an emergency.  

  b)   Conduct a brief health screening to assess the Enrollee’s need for any
special health care (e.g., prenatal or behavioral health services) or
language/communication needs. If a special need is identified, the Contractor
shall assist the Enrollee in arranging for an appointment with his/her PCP or
other appropriate provider.  

  c)   Offer assistance in arranging an initial visit to the Enrollee’s PCP for
a baseline physical and other preventive services, including an assessment of
the Enrollee’s potential risk, if any, for specific diseases or conditions.  

  d)   Inform new Enrollees about their rights for continuation of certain
existing services.  

  e)   Provide the Enrollee with the Contractor’s toll free telephone number
that may be called twenty-four (24) hours a day, seven (7) days a week if the
Enrollee has questions about obtaining services and cannot reach his/her PCP
(this telephone number need not be the Member Services line and need not be
staffed to respond to Member Services-related inquiries). The Contractor must
have appropriate mechanisms in place to accommodate Enrollees who do not have
telephones and therefore cannot readily receive a call back.  

  f)   Advise Enrollee about opportunities available to learn about MCO policies
and benefits in greater detail (e.g., welcome meeting, Enrollee orientation and
education sessions).  

  g)   Provide the Enrollee with a complete list of network providers that may
be accessed directly, without referral. The list should group providers by
service type and must include addresses and telephone numbers.  

  h)   Assist the Enrollee in selecting a primary care provider if one has not
already been chosen.  

13.6 Enrollee’s Rights to Advance Directives

The Contractor shall, in compliance with the requirements of 42 CFR 434.28,
maintain written policies and procedures regarding advance directives and inform
each Enrollee in writing at the time of enrollment of an individual’s rights
under State law to formulate advance directives and of the Contractor’s policies
regarding the implementation of such rights. The Contractor shall include in
such written notice to the Enrollee materials relating to advance directives and
health care proxies as specified in 10 NYCRR Sections 98.14(0 and 700.5.

13.7 Approval of Written Notices

The Contractor shall submit the format and content of all written notifications
described in this Section to LDSS for review and prior approval by LDSS or SDOH.
All written notifications must be written at a fourth (4th) to sixth (6th) grade
level and in at least ten (10) point print.

SECTION I3
(ENROLLEE NOTIFICATION)
October 1, 2004
13-23

47

13.8 Contractor’s Duty to Report Lack of Contact

The Contractor must inform the LDSS of any Enrollee they are unable to contact
within ninety (90) days of enrollment using reasonable efforts as defined in
Section 13.5 of the Agreement and who have not presented for any health care
services through the Contractor or its Participating Providers.

13.9 Contractor Responsibility to Notify Enrollee of Expected Effective Date of
Enrollment

The Contractor must notify the Enrollee of the expected Effective Date of
Enrollment. In the event that the actual Effective Date of Enrollment is
different from that given to the Enrollee the Contractor must notify the
Enrollee of the actual date of enrollment. This may be accomplished through a
Welcome Letter. To the extent practicable, such notification must precede the
Effective Date of Enrollment.

13.10 LDSS Notification of Enrollee’s Change in Address

The LDSS must notify the Contractor of any known change in address of Enrollees
in the Contractor’s plan.

13.11 Contractor Responsibility to Notify Enrollee of Effective Date of Benefit
Package Change

The Contractor must provide written notification of the effective date of any
Contractor-initiated, SDOH and LDSS-approved benefit package change to Enrollees
in the Contractor’s plan. Notification to Enrollees must be provided at least
30 days in advance of the effective date of such change.

  13.12   Contractor Responsibility to Notify Enrollee of Termination, Service
Area Changes and Network Changes  

With prior notice to and approval of the SDOH and LDSS, the Contractor shall
inform each Enrollee in writing of any withdrawal by the Contractor from the
Medicaid managed care program pursuant to Section 2.7, withdrawal from the
Service Area encompassing the Enrollee’s zip code, and/or significant changes to
the Contractor’s provider network pursuant to Section 21.1(d), except that the
Contractor need not notify Enrollees who will not be affected by such changes.

The Contractor shall provide the notifications within the timeframes specified
by SDOH and LDSS, and shall obtain the prior approval of the notification from
SDOH and LDSS.

SECTION 13

(ENROLLEE NOTIFICATION)

October I, 2004

13-4

14. COMPLAINT AND APPEAL PROCEDURE

14.1 Contractor’s Program to Address Complaints

  a)   The Contractor shall establish and maintain a comprehensive program
designed to address clinical and other complaints, and appeals of complaint
determinations, which may be brought by Enrollees, consistent with Articles 44
and 49 of the New York State PEEL,

  b)   The program must include methods for prompt internal adjudication of
Enrollee complaints and appeals and provide for the maintenance of a written
record of all complaints and appeals received and reviewed and their
disposition.

  c)   The Contractor shall ensure that persons with authority to require
corrective action participate in the complaint and appeal process.

14.2 Notification of Complaint and Appeal Program

  a)   The Contractor’s specific complaint and appeal program shall be described
in the Contractor’s member handbook and ‘shall be made available to all
Enrollees.

  b)   The Contractor will advise Enrollees of their right to a fair hearing as
appropriate and comply with the procedures established by SDOH for the
Contractor to participate in the fair hearing process, as set forth in
Section 25 of this Agreement. The Contractor will also advise Enrollees of their
right to an external appeal, in accordance with Section 26 of this Agreement.

14.3 Guidelines for Complaint and Appeal Program

  a)   The Contractor’s complaint and appeal program will comply with the
Managed Care Complaint and Appeals Program Guidelines described in Appendix F,
which is hereby made a part of this Agreement as if set forth fully herein. The
SDOH and LDSS may modify Appendix F of this Agreement upon sixty (60) days prior
written notice to the Contractor and such modifications shall become binding and
incorporated into this Agreement without further action by the parties.  

  b)   The Contractor’s complaint and appeal procedures shall be approved by the
SDOH and LDSS and kept on file with the Contractor, LDSS and SDOH.  

  c)   The Contractor shall not modify its complaint and appeals procedure
without the prior written approval of SDOH, in consultation with LDSS, and shall
provide LDSS and SDOH with a copy of the approved modification within fifteen
(15) days after its approval.  

14.4 Complaint Investigation Determinations

The MCO must adhere to determinations resulting from complaint investigations
conducted by SDOH.

SECTION 14
(COMPLAINT AND APPEAL PROCEDURE)
October 1, 2004
14-1

48

15. ACCESS REQUIREMENTS

15.1 Appointment Availability Standards

The Contractor shall comply with the following appointment availability
standards1.

a) For emergency care: immediately upon presentation at a service delivery site.

b) For urgent care: within twenty-four (24) hours of request.

c) Non-urgent “sick” visit: within forty-eight (48) to seventy-two (72) hours of
request, as clinically indicated.

d) Routine non-urgent, preventive appointments: within four (4) weeks of
request.

e) Specialist referrals (not urgent): within four (4) to six (6) weeks of
request.

f) Initial prenatal visit: within three (3) weeks during first trimester, within
two (2) weeks during the second trimester and within one (1) week during the
third trimester.

g) Adult .Baseline and •routine .physicals: within twelve (12) weeks from
enrollment. (Adults >21).

h) Well child care: within four (4) weeks of request:

i) Initial family planning visits: within two (2) weeks of request.

j) In-plan mental health or substance abuse follow-up visits (pursuant to an
emergency or hospital discharge): within five (5) days of request, or as
clinically indicated.

k) In-plan, non-urgent mental health or substance abuse visits: within two
(2) weeks of request.

l) Initial PCP office visit for newborns: within two (2) weeks of hospital
discharge.

m) Provider visits to make health, mental health and substance abuse assessments
for the purpose of making recommendations regarding a recipient’s ability to
perform work when requested by a LDSS: within ten (10) days of request by an
Enrollee, in accordance with Section 10.8 of this Agreement.

15.2 Twenty-Four (24) Hour Access

  a)   The Contractor must provide access to medical services and coverage to
Enrollees, either directly or through their PCPs and 0B/GYNs, on a twenty-four
(24) hour a day, seven (7) day a week basis. The Contractor must instruct
Enrollees on what to do to obtain services after business hours and on weekends.
 

  b)   The Contractor may satisfy the requirement in Section 15.2(a) by
requiring their PCPs and OB/GYNs to have primary responsibility for serving as
an after hours “on-call” telephone resource to members with medical problems.
Under no circumstances may the Contractor routinely refer calls to an emergency
room.  

15.3 Appointment Waiting Times

Enrollees with appointments shall not routinely be made to wait longer than one
hour.

1 These are general standards and are not intended to supersede sound clinical
judgment as to the necessity for care and services on a more expedient basis,
when judged clinically necessary and appropriate.

SECTION IS

(EQUALITY OF ACCESS AND TREATMENT)

October I. 2004

I5-1

49

15.4 Travel Time Standards

The Contractor will maintain a network that is geographically accessible to the
population to be served.

a) Primary Care

Travel time/distance to primary care sites shall not exceed thirty (30) minutes
in metropolitan areas or thirty (30) minutes/thirty (30) miles in
non-metropolitan areas. Transport time and distance in rural areas to primary
care sites may be greater than thirty (30) minutes/thirty (30) miles if based on
the community standard for accessing care or if by Enrollee choice.

Enrollees may, at their discretion, select participating PCPs located farther
from their homes as long as they are able to arrange and pay for transportation
to the PCP themselves.

b) Other Providers

Travel time/distance to specialty care, hospitals, mental health, lab and x-ray
providers shall not exceed thirty (30) minutes/thirty (30) miles. Transport time
and distance in rural areas to specialty care, hospitals, mental health, lab and
x-ray providers may be greater than thirty (30) minutes/thirty (30) miles if
based on the community standard for accessing care or if by Enrollee choice.

15.5 Service Continuation

a) New Enrollees

If a new Enrollee has an existing relationship with a health care provider who
is not a member of the Contractor’s provider network, the contractor shall
permit the Enrollee to continue an ongoing course of treatment by the
Non-Participating Provider during a transitional period of up to sixty (60) days
from the Effective Date of Enrollment, if, (I) the Enrollee has a
life-threatening disease or condition or a degenerative and disabling disease or
condition, or (2) the Enrollee has entered the second trimester of pregnancy at
the Effective Date of Enrollment, in which case the transitional period shall
include the provision of post-partum care directly related to the delivery up
until sixty (60) days post partum. If the Enrollee elects to continue to receive
care from such Non-Participating Provider, such care shall be authorized by the
Contractor for the transitional period only if the Non-Participating Provider
agrees to:

i) accept reimbursement from the Contractor at rates established by the
Contractor as payment in full, which rates shall be no more than the level of
reimbursement applicable to similar providers within the Contractor’s network
for such services; and
ii) adhere to the Contractor’s quality assurance requirements and agrees to
provide to the Contractor necessary medical information related to such care;
and
iii) otherwise adhere to the Contractor’s policies and procedures including, but
not limited to procedures regarding referrals and obtaining pre-authorization in
a treatment plan approved by the Contractor.

In no event shall this requirement be construed to require the Contractor to
provide coverage for benefits not otherwise covered.

SECTION 15
(EQUALITY OF ACCESS AND TREATMENT)
October 1. 2004
15-2

b) Enrollees Whose Health Care Provider Leaves Network

The Contractor shall permit an Enrollee, whose health care provider has left the
Contractor’s network of providers, for reasons other than imminent harm to
patient care, a determination of fraud or a final disciplinary action by a state
licensing board that impairs the health professional’s ability to practice, to
continue an ongoing course of treatment with the Enrollee’s current health care
provider during a transitional period, consistent with New York State PHL
Section 4403(6)(e).

The transitional period shall continue up to ninety (90) days from the date of
notice to the Enrollee of the provider’s disaffiliation from the network; or, if
the Enrollee has entered the second trimester of pregnancy, for a transitional
period that includes the provision of post-partum care directly related to the
delivery through sixty (60) days post partum. If the Enrollee elects to continue
to receive care from such Non-Participating Provider, such care shall be
authorized by the Contractor for the transitional period only if the
Non-Participating Provider agrees to:

  i)   accept reimbursement from the Contractor at rates established by the
Contractor as payment in full, which rates shall be no more than the level of
reimbursement applicable to similar providers within the Contractor’s network
for such services;  

  ii)   adhere to the Contractor’s quality assurance requirements and agrees to
provide to the. Contractor necessary medical information related to such care;
and  

  iii)   otherwise adhere to the Contractor’s policies and procedures including,
but not limited to procedures regarding referrals and obtaining
pre-authorization in a treatment plan approved by the Contractor.  

In no event shall this requirement be construed to require the Contractor to
provide coverage for benefits not otherwise covered.

15.6 Standing Referrals

The Contractor will implement policies and procedures to allow for standing
referrals to specialist physicians for Enrollees who have ongoing needs for care
from such specialists, consistent with PHL Section 4403(6)(b).

15.7 Specialist as a Coordinator of Primary Care

The Contractor will implement policies and procedures to allow Enrollees with a
life-threatening or degenerative and disabling disease or condition, which
requires prolonged specialized medical care, to receive a referral to a
specialist, who will then function as the coordinator of primary and specialty
care for that Enrollee, consistent with PHL Section 4403(6)(c).

15.8 Specialty Care Centers

The Contractor will implement policies and procedures to allow Enrollees with a
life-threatening or a degenerative and disabling condition or disease, which
requires prolonged specialized medical care to receive a referral to an
accredited or designated specialty care center with expertise in treating the
life-threatening or degenerative and disabling disease or condition, consistent
with New York State PHL Section 4403(6)(d).

SECTION IS
(EQUALITY OF ACCESS AND TREATMENT)
October 1, 2004
15-3

50

16. QUALITY ASSURANCE

16.1 Internal Quality Assurance Program

  a)   Contractor must operate a quality assurance program which is approved by
SDOH and which includes methods and procedures to control the utilization of
Medicaid services consistent with PHL Article 49 and 42 CFR Part 456.
Recipients’ records must include information needed to perform utilization
review as specified in 42 CFR §§ 456.111 and 456.211. The Contractor’s approved
quality assurance program must be kept on file by the Contractor and the LDSS.
The Contractor shall not modify the quality assurance program without the prior
written approval of the SDOH, and notice to the LOSS.

  b)   The Contractor shall incorporate the findings from reports in Section 18
of this Agreement into its quality assurance program. Where performance is less
than the statewide average or another standard as defined by the SDOH and
developed in consultation with plans and appropriate clinical experts, the
Contractor will be required to develop and implement a plan for improving
performance that is approved by the SDOH and LDSS and that specifies the
expected level of improvement and timeframes for actions expected to result in
such improvement. In the event that such approved plan does not result in the
expected level of improvement, the Contractor shall work with the SDOH and the
LDSS to develop and implement alternative plans to achieve improvement. The
Contractor agrees to meet with the SDOH and LDSS to review improvement plans and
quality performance.

16.2 Standards of Care

The Contractor must adopt practice guidelines consistent with current standards
of care, complying with recommendations of professional specialty groups or the
guidelines of programs such as the American Academy of Pediatrics, the American
Academy of Family Physicians, the U.S. Task Force on Preventive Care, the New
York State Child/Teen Health Program (C/THP) standards for provision of care to
individuals under age 21, the American Medical Association’s Guidelines for
Adolescent and Preventive Services, the US Department of Health and Human
Services Center for Substance Abuse Treatment, the American College of
Obstetricians and Gynecologists, the American Diabetes Association, and the AIDS
Institute clinical standards for adult, adolescent, and pediatric care. The
Contractor must have mechanisms in place to disseminate any changes in practice
guidelines to its network providers at least annually, or more frequently, as
appropriate. The Contractor shall develop and implement protocols for
identifying providers who do not adhere to practice guidelines and for making
reasonable efforts to improve the performance of these providers. Annually, the
Contractor shall select a minimum of two practice guidelines and monitor
performance of appropriate providers (or a sample of providers) against such
guidelines.

SECTION 16
(QUALITY ASSURANCE)
OCTOBER 1, 2004
16-1

51

17. MONITORING AND EVALUATION

17.1 Right to Monitor Contractor Performance

The SDOH, LDSS, and DHHS shall each have the right, during the Contractor’s
normal operating hours, and at any other time a Contractor function or activity
is being conducted, to monitor and evaluate, through inspection or other means,
the Contractor’s performance, including, but not limited to, the quality,
appropriateness, and timeliness of services provided under this Agreement.

17.2 Cooperation During Monitoring and Evaluation

The Contractor shall cooperate with and provide reasonable assistance to the
SDOH, LDSS, and DHHS in the monitoring and evaluation of the services provided
under this Agreement.

17.3 Cooperation During On-Site Reviews

The Contractor shall cooperate with SDOH and LDSS in any on-site review of the
MCO’s operations. SDOH shall give the Contractor notification of the date(s) and
survey format for any full operational review at least forty-five (45) days
prior to the site visit. This requirement shall not preclude LDSS or SDOH from
site visits upon shorter notice for other monitoring purposes.

17.4 Cooperation During Review of Services by External Review Agency

The Contractor shall comply with all requirements associated with any review of
the quality of services rendered to its Enrollees to be performed by an external
review agent selected by the SDOH.

SECTION 17
(MONITORING AND EVALUATION)
October 1, 2004
17-1

52

  18.   CONTRACTOR REPORTING REQUIREMENTS  

18.1 Time Frames for Report Submissions

Except as otherwise specified herein, the Contractor shall prepare and submit to
SDOH and the LDSS the reports required under this Agreement in an agreed media
format within sixty (60) days of the close of the applicable semi-annual or
annual reporting period, and within fifteen (15) business days of the close of
the applicable quarterly reporting period.

18.2 SDOH Instructions for Report Submissions

SDOH, with prior notice to the LDSS, will provide Contractor with instructions
for submitting the reports required by Section 18.5 (a) through (n), including
time frames, and requisite formats. The instructions, time frames and formats
may be modified by SDOH with prior notice to the LDSS, and thereafter upon sixty
(60) days written notice to the Contractor. The LDSS, with prior notice to SDOH,
shall provide the Contractor with instructions for submitting the reports,
required by Section 18.5(o) including time frames and requisite formats.

18.3 Liquidated Damages

The Contractor shall pay liquidated damages of $2,500 if any report required
pursuant to this Section is materially incomplete, contains material
misstatements or inaccurate information, or is not submitted on time in the
requested format. The Contractor shall pay liquidated damages of $2,500 to the
LDSS if its monthly encounter data submission is not received by the Fiscal
Agent by the due date specified in Section 18.5(d). The Contractor shall pay
liquidated damages of $500 to the LDSS for each day other reports required by
this Section are late. The LDSS shall not impose liquidated damages for a first
time infraction by the Contractor unless the LDSS deems the infraction to be a
material misrepresentation of fact or the Contractor fails to cure the first
infraction within a reasonable period of time upon notice from the LDSS.
Liquidated damages may be waived at the sole discretion of LDSS. Nothing in this
Section shall limit other remedies or rights available to LDSS and SDOH relating
to the timeliness, completeness and/or accuracy of Contractor’s reporting
submission.

18.4 Notification of Changes in Report Due Dates, Requirements or Formats

SDOH or LDSS may extend due dates, or modify report requirements or formats upon
a written request by the Contractor to the SDOH or LDSS with a copy of the
request to the other agency, where the Contractor has demonstrated a good and
compelling reason for the extension or modification. The determination to grant
a modification or, extension of time shall be made by SDOH with regard to annual
and quarterly statements, complaint reports, audits, encounter data, change of
ownership, clinical studies, QARR, and provider network reports. The
determination to grant a modification or extension of time shall be made by the
LDSS with respect to No-Contact, PCP auto assignment, and reports required by
Sections 18.5 (n) and (o) of the Agreement.

18.5 Reporting Requirements

The Contractor shall submit the following reports to SDOH and to the LDSS except
in those instances in which this Agreement specifies the reports shall be
submitted solely to SDOH:

a) Annual Financial Statements:

Contractor shall submit Annual Financial Statements to SDOH. The due date for
annual statements shall be April 1 following the report closing date.

b) Quarterly Financial Statements:

Contractor shall submit Quarterly Financial Statements to SDOH. The due date for
quarterly reports shall be forty-five (45) days after the end of the calendar
quarter.

SECTION 18

(CONTRACTOR REPORTING REQUIREMENTS)

October 1, 2004

18-1

53

  c)   Other Financial Reports:

Contractor shall submit financial reports, including certified annual financial
statements, and make available documents relevant to its financial condition to
SDOH and the State Insurance Department (SID) in a timely manner as required by
State laws and regulations including but not limited to PHL§§ 4403-a, 4404 and
4409, Title 10 NYCRR §§ 98.11, 98.16 and 98.17 and applicable Insurance Law §§
304, 305, 306, and 310. The LDSS reserves the right to require Contractor to
submit such relevant financial reports and documents related to the financial
condition of the MCO to the LDSS, as set forth in Section 18.5(o) of this
Agreement.

d) Encounter Data:

The Contractor shall prepare and submit encounter data on a monthly basis to
SDOH through its designated Fiscal Agent. Each provider is required to have a
unique identifier. Submissions shall be comprised of encounter records, or
adjustments to previously submitted records, which the Contractor has received
and processed from provider encounter or claim records of any contracted
services rendered to the Enrollee in the current or any preceding months.
Monthly submissions must be received by the Fiscal Agent by the Tuesday before
the last Monday of the month to assure the submission is included in the Fiscal
Agent’s monthly production processing.

e) Quality of Care Performance Measures:.

The Contractor shall prepare and submit reports to SDOH, as specified in the
Quality Assurance Reporting Requirements (QARR). The Contractor must arrange for
an NCQA-certified entity to audit the QARR data prior to its submission to the
SDOH, unless this requirement is specifically waived by the SDOH. The SDOH will
select the measures which will be audited

f) Complaint Reports:

The Contractor must provide the SDOH on a quarterly basis, and within fifteen
(15) business days. of the close of the quarter, a summary of all complaints
received during the preceding quarter on the Health Provider Network (“HPN”).

The Contractor also agrees to provide on a quarterly basis, via the HPN, the
total number of complaints that have been unresolved. for more than forty-five
(45) days. The Contractor shall maintain records on these and other complaints
which shall include all correspondence related to the complaint, and an
explanation of disposition. These records shall be readily available for review
by the SDOH or LDSS upon request.

Nothing in this Section is intended to limit the right of the SDOH and the LDSS
to obtain information immediately from a Contractor pursuant to investigating a
particular Enrollee or provider complaint.

The LDSS reserves the right to require the Contractor to submit a hardcopy of
complaint reports in Section 18.5(o) of this Agreement.

g) Fraud and Abuse Reporting Requirements:

i) The Contractor must submit quarterly, via the HPN complaint reporting format,
the number of complaints of fraud or abuse made to the Contractor that warrant
preliminary investigation by the Contractor.
ii) The Contractor must also submit to the SDOH the following on an ongoing
basis for each confirmed case of fraud and abuse it identifies through
complaints, organizational monitoring, contractors, subcontractors, providers,
beneficiaries, Enrollees, etc:

SECTION 18

(CONTRACTOR REPORTING REQUIREMENTS)
October I, 2004
18-2

A) The name of the individual or entity that committed the fraud

or abuse;

B) The source that identified the fraud or abuse;
C) The type of provider, entity or organization that committed the fraud or
abuse;
D) A description of the fraud or abuse;
E) The approximate range of dollars involved;

F) The legal and administrative disposition of the case including actions taken
by law enforcement officials to whom the case has been referred; and

G) Other data/information as prescribed by SDOH.

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

h) Participating Provider Network Reports:

The Contractor shall submit electronically, to the HPN, an updated provider
network report on a. quarterly basis. The Contractor shall submit an annual
notarized attestation that the providers listed in each submission have executed
an agreement with the Contractor to serve Contractor’s Medicaid Enrollees. The
report submission must comply with the Managed Care Provider Network Data
Dictionary. Networks must be reported separately for each county in which the
Contractor operates.

  i)   Appointment Availability/Twenty-four (24) Hour Access and Availability
Surveys: .

The Contractor will conduct a county specific (or service area if appropriate)
review of appointment availability and twenty-four (24) hour access and
availability surveys annually. Results of such surveys must be kept on file and
be readily available for review by the SDOH or LDSS, upon request. Guidelines
for such studies may be obtained by contacting the SDOH, Office of Managed Care,
Bureau of Certification and Surveillance.

The LDSS reserves the right to require the Contractor to conduct appointment
availability and twenty-four (24) hour access studies twice a year, and to
submit these reports to the LDSS, as stated in Section 18.5(o) of this
Agreement.

j) Clinical Studies:

The Contractor will participate in up to four (4) SDOH sponsored focused
clinical studies annually. The purpose of these studies will be to promote
quality improvement within the MCO.

The Contractor will be required to conduct at least one (1) internal focused
clinical study each year in a priority topic area of its choosing, from a list
to be generated through the mutual agreement of the SDOH and the Contractor’s
Medical Director. The Contractor may conduct its internal focused clinical study
in conjunction with one or more MCOs. The purpose of these studies will be to
promote quality improvement within the MCO. SDOH will provide guidelines which
address study structure and plan collaboration. Results of these studies will be
provided to the SDOH and the LDSS.

k) Independent Audits:

The Contractor must submit copies of all certified financial statements and a
QARR validation audit by independent auditors of their plan to the SDOH and the
LDSS within thirty (30) days of receipt by the Contractor.

SECTION 18
(CONTRACTOR REPORTING REQUIREMENTS)
October 1, 2004

18-3

54 1) New Enrollee Health Screening Completion Report:

The Contractor shall submit a quarterly report within thirty (30) days of the
close of the quarter showing the percentage of new Enrollees for which the
Contractor was able to complete a health screening consistent with
Section 13.5(b) of this Contract.

m) Additional Reports:

Upon request by the SDOH and/or the LDSS, the Contractor shall prepare and
submit other operational data reports. Such requests will be limited to
situations in which the desired data is considered essential and cannot be
obtained through existing Contractor reports. Whenever possible, the Contractor
will be provided with ninety (90) days notice and the opportunity to discuss and
comment on the proposed requirements before work is begun. However, the SDOH and
the LDSS reserve the right to give thirty (30) days notice in circumstances
where time is of the essence.

n) DOHMH Specific Reports:

i) The Contractor shall provide DOHMH with hard copies of the Quarterly HPN
Complaint Reports that it submits to SDOH pursuant to Section 18.5 (f) of the
Agreement.

ii) The Contractor shall provide DOHMH with a hard copy of all reports submitted
to SDOH pursuant to Sections 18.5 (g) (i) and (ii) of the Agreement.

iii) The Contractor shall conduct a service area specific review of appointment
availability and twenty-four (24) hour access and availability semi-annually
(twice per year) and submit reports to DOHMH on the results of these reviews.
The Contractor shall conform to DOHMH guidelines for performing appointment
availability and twenty-four hour access surveys.
iv) The Contractor shall conduct annual member satisfaction surveys of its
Medicaid enrollees in New York City and report to DOHMH on the results of these
surveys. The surveys must follow guidelines established by DOHMH and the
methodology must be approved by DOHMH. Surveys should exclude data from non-NYC
counties, but sample all boroughs within the Contractor’s service area. During
those calendar years during which a member satisfaction survey is conducted by
SDOH, the Contractor shall not be required to conduct a separate survey.
v) The Contractor shall provide existing aggregate data and other existing
information requested by DOHMH Division of Mental Hygiene.
vi) The Contractor shall submit semi-annually to DOHMH a report showing the
percentage of PCP assignments for Enrollees which were made automatically by the
Contractor rather than by the Enrollee.
vii) Upon thirty days notice from DOHMH, the Contractor shall submit reports
which are required to be’ submitted to DOHMH by this Agreement in a machine
readable medium, e.g., computer diskette, zip disk or e-mail attachment.

18.6 Ownership and Related Information Disclosure

The Contractor shall report ownership and related information to SDOH and the
LDSS, and upon request to the Secretary of Department of Health and Human
Services and the Inspector General of Health and Human Services, in accordance
with 42 U.S.C. Section 1320a-3 and 1396b(m)(4) (Sections 1124 and 1903(m)(4) of
the Federal Social Security Act).

18.7 Revision of Certificate of Authority

The Contractor shall give prompt written notice to LDSS of any revisions of its
Certificate of Authority issued pursuant to Article 44 of the State Public
Health Law.

SECTION 18
(CONTRACTOR REPORTING REQUIREMENTS)
October 1, 2004
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55

18.8 Public Access to Reports

Any data, information, or reports collected and prepared by the Contractor and
submitted to NYS authorities in the course of performing their duties and
obligation under this program will be deemed to be owned by the State of New
York subject to and consistent with the requirements of Freedom of Information
Law. This provision is made in consideration of the Contractor’s use of public
funds in collecting and preparing such data, information, and reports.

18.9 Professional Discipline

  a)   Pursuant to PHL Section 4405-b, the Contractor shall have in place
policies and procedures to report to the appropriate professional disciplinary
agency within thirty (30) days of occurrence, any of the following:

  i)   the termination of a health care provider contract pursuant to
Section 4406-d of the Public Health Law for reasons relating to alleged mental
and physical impairment, misconduct or impairment of patient safety or welfare;

  ii)   the voluntary or involuntary termination of a contract or employment or
other affiliation with such Contractor to avoid the imposition of disciplinary
measures; or

  iii)   the termination of a health care provider contract in the case of a
determination of fraud or in a case of imminent harm to patient health.

  b)   The Contractor shall make a report to the appropriate professional
disciplinary agency within thirty (30) days of obtaining knowledge of any
information that reasonably appears to show that a health professional is guilty
of professional misconduct as defined in Articles 130.and 131(a) of the State
Education Law.

  18.10   Certification Regarding Individuals Who Have Been Debarred Or
Suspended By Federal or State Government  

Contractor will certify to the SDOH and LDSS initially and immediately upon
changed circumstances from the last such certification that it does not
knowingly have an individual who has been debarred or suspended by the federal
or state government, or otherwise excluded from participating in procurement
activities:

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

  b)   as a party to an employment, consulting or other agreement with the
Contractor for the provision of items and services that are significant and
material to the Contractor’s obligations in the Medicaid managed care program,
consistent with requirements of SSA § 1932 (d)(1).

18.11 Conflict of Interest Disclosure

Contractor shall report to SDOH, in a format specified by SDOH, documentation,
including but not limited to the identity of and financial statements of,
person(s) or corporation(s) with an ownership or contract interest in the
managed care plan, or with any subcontract(s) in which the managed care plan has
a 5% or more ownership interest, consistent with requirements of SSA § 1903
(m)(2)(a)(viii) and 42 CFR §§ 455.100 — 455.104.

18.12 Physician Incentive Plan Reporting

The Contractor shall submit to SDOH annual reports containing the information on
all of its Physician Incentive Plan arrangements in accordance with 42 CFR §
434.70 or, if no such arrangements are in place, attest to that. The contents
and time frame of such reports shall comply with the requirements of 42 CFR §
417.479 and be in a format provided by’ SDOH.

SECTION 18
(CONTRACTOR REPORTING REQUIREMENTS)
October 1, 2004
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56

  19.   RECORDS MAINTENANCE AND AUDIT RIGHTS  

19.1 Maintenance of Contractor Performance Records

The Contractor shall maintain and shall require its subcontractors, including
its Participating Providers, to maintain appropriate records relating to
Contractor performance under this Agreement, including:

  a)   records related to services provided to Enrollees, including a separate
Medical Record for each Enrollee;

  b)   all financial records and statistical data that LDSS, SDOH and any other
authorized governmental agency may require including books, accounts, journals,
ledgers, and all financial records relating to capitation payments, third party
health insurance recovery, and other revenue received and expenses incurred
under this Agreement;

  c)   appropriate financial records to document fiscal activities and
expenditures, including records relating to the sources and application of funds
and to the capacity of the Contractor or its subcontractors, including its
Participating Providers, if. relevant, to bear the risk of potential financial
losses.

  19.2   Maintenance of Financial Records and Statistical Data  

The Contractor shall maintain all financial records and statistical data
according to generally accepted accounting principles.

19.3 Access to Contractor Records

The Contractor shall provide LDSS, SDOH, the Comptroller of the State of New
York, DHHS, the Comptroller General of the United States, and their authorized
representatives with access to all records relating to Contractor performance
under this Agreement for the purposes of examination, audit, and copying (at
reasonable cost to the requesting party) of such records. The Contractor shall
give access to such records on two (2) business days prior written notice,
during normal business hours, unless otherwise provided or permitted by
applicable laws, rules, or regulations.

19.4 Retention Periods

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

SECTION 19

(RECORDS MAINTENANCE. AND AUDIT RIGHTS)

October 1, 2004

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57

20. CONFIDENTIALITY

  20.1   Confidentiality of Identifying Information about Medicaid Recipients
and Applicants

All information relating to services to Medicaid recipients and applicants which
is obtained by the Contractor shall be confidential pursuant to the New York
State Public Health Law including PHL Article 27 F, the provisions of
Section 369(4) of the NYS Social Services Law, 42 U.S.C. Section 1396a(a)(7)
(Section 1902(a)(7) of the Federal Social Security Act), Section 33.13 of the
Mental Hygiene Law, and regulations promulgated under such laws including 42 CFR
Part 2 pertaining to Alcohol and Substance Abuse Services. Such information
including information relating to services to Medicaid recipients and applicants
as these relate to the provision of services to the recipient or applicant under
this Agreement shall be used or disclosed by the, Contractor only for a purpose
directly connected with performance of the Contractor’s obligations. It shall be
the responsibility of the Contractor to inform its employees and contractors of
the confidential nature of Medicaid information.

20.2 Medical Records of Foster Children

Medical records of enrolled Medicaid recipients enrolled in foster care programs
shall be disclosed to local social service officials in accordance with State
Social Services Law including Sections 358-a, 384-a and 392 and 18 NYCRR
Section 507.1.

20.3 Confidentiality of Medical Records

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

20.4 Length of Confidentiality Requirements

The provisions of this Section shall survive the termination of this Agreement
and shall bind the Contractor so long as the Contractor maintains any
individually identifiable information relating to Medicaid recipients and
applicants.

SECTION 20
(CONFIDENTIALITY)
October 1, 2004
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58

21. PARTICIPATING PROVIDERS

21.1 Network Requirements

a) Sufficient Number

  i)   The Contractor will establish and maintain a network of Participating
Providers.

  ii)   The Contractor’s network must contain all of the provider types
necessary to furnish the prepaid Benefit Package, including but not limited to:
hospitals, physicians (primary care and specialists), mental health and
substance abuse providers, allied health professionals, ancillary providers, DME
providers and home health providers.

  iii)   To be considered accessible, the network must contain a sufficient
number and array of providers to meet the diverse needs of the Enrollee
population. This includes being geographically accessible (meeting time/distance
standards) and being accessible for the disabled.

  iv)   The Contractor shall not include in its network any provider who has
been . sanctioned or prohibited from serving Medicaid recipients or receiving
Medical Assistance payments.

b) Absence of Appropriate Network Provider

In the event that the Contractor determines that it does not have a
Participating Provider with appropriate training and experience to meet the
particular health care needs of an Enrollee, the Contractor shall make a
referral to an appropriate Non-Participating Provider, pursuant to a treatment
plan approved by the Contractor in consultation with the Primary Care Provider,
the Non-Participating Provider and the Enrollee or the Enrollee’s designee. The
Contractor shall pay for the cost of the services in the treatment plan provided
by the Non-Participating Provider.

c) Suspension of Enrollee Assignments To Providers

The Contractor shall ensure that there is sufficient capacity, consistent with
SDOH standards, to serve Enrollees under this Agreement. In the event any of the
Contractor’s Participating Providers are no longer able to accept assignment of
new Enrollees due to capacity limitations, as determined by the SDOH and the
LDSS, the Contractor will suspend assignment of any additional Enrollees to such
Participating Provider until it is capable of further accepting Enrollees. When
a Participating Provider has more than one (1) site, the suspension will be made
by site.

d) Notice of Provider Termination

The Contractor shall notify LDSS and SDOH of any notice of termination of

an IPA, hospital or medical group provider agreement which affects an Enrollee’s
access to care.

Such notification to the LDSS and the SDOH shall be made ninety (90) days prior
to the effective date of the termination of the provider agreement or
immediately upon notice from such provider if less than ninety (90) days.

The Contractor shall also notify LDSS and SDOH in the event that the Contractor
and the providers have failed to re-execute a renewal provider agreement
forty-five (45) days prior to the expiration of the agreement.

The Contractor shall submit a contingency plan to LDSS and SDOH, at least
forty-five (45) days prior to the termination of expiration of the agreement,
identifying the number of Enrollees affected by the potential withdrawal, if
applicable, and specifying how services previously furnished by the
participating providers will be provided in the event of their withdrawal. If
the provider is a participating hospital, the Contractor shall identify the
number of doctors who would not have admitting privileges in the absence of such
participating hospital.

SECTION 21
(PROVIDER NETWORK AND AGREEMENTS)
October 1,2004
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59

The Contractor shall develop. a transition plan for patients of the departing
providers subject to approval by LDSS and SDOH. SDOH and LDSS may direct the
Contractor to provide notice to the patients of PCPs or specialists including
available options for the patients, and availability of continuing care,
consistent with §13.7, not less than thirty (30) days prior to the termination
of the provider agreement. In the event that provider agreements are terminated
with less than the notice period required by this section, the Contractor shall
immediately notify LDSS and SDOH, and develop a transition plan on an expedited
basis and provide notice to patients subject to the consent of LDSS and SDOH.

Upon Contractor notice of failure to re-execute, or termination of, a provider
agreement, the SDOH and the LDSS, in their sole discretion, may waive the
requirement of submission of a contingency plan upon a determination by the SDOH
and the LDSS that:

i) the impact upon Enrollees is not significant, and/or
ii) the Contractor and provider arc continuing to negotiate in good faith and
consent to extend the provider agreement for a period of time necessary to
provide not less than thirty (30) days notice to Enrollees.

SDOH and the LDSS reserve the right to take any other actions permitted by this
Agreement and under regulatory or statutory authority, including but not limited
to contract termination.

21.2 Credentialing

a) Licensure

The Contractor shall ensure, in accordance with Article 44 of the Public Health
Law, that persons and entities providing care and services for the Contractor in
the capacity of physician, dentist, physician’s assistant, registered nurse,
other medical professional or paraprofessional, or other such person or entity
satisfy all applicable licensing, certification, or qualification requirements
under New York law and that the functions and responsibilities of such persons-
and entities in providing Benefit Package services under this Agreement do not
exceed those permissible under New York law.

b) Minimum Standards

The Contractor agrees. that all network physicians will meet at least one (1) of
• the following standards, except as specified in Section 21.13(b) and Appendix
[ of this agreement:

i) Be board-certified or -eligible in their area of specialty;
ii) Have completed an accredited residency program; or

  iii)   Have admitting privileges at one (1) or more hospitals participating in
the Contractor’s network.  

c) Credentialing’Recredentialing Process

The Contractor shall have in place a formal process for credentialing
Participating Providers on a periodic basis (not less than once every three
(3) years) and for monitoring Participating Providers performance.

d) Application Procedure

The Contractor shall establish a written application procedure to be used by a
health care professional interested in serving as a Participating Provider with
the Contractor. The criteria for selecting providers, including the minimum
qualification requirements that a health care professional must meet to be
considered by the Contractor, must be defined in writing and developed in
consultation with appropriately qualified health care professionals. Upon
request, the application procedures and minimum qualification requirements must
be made available to health care professionals.

SECTION 21
(PROVIDER NETWORK AND AGREEMENTS)
October 1.2004
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60

21.3 SDOH Exclusion or Termination of Providers

If SDOH excludes or terminates a provider from its Medicaid Program, the
Contractor shall, upon learning of such exclusion or termination, immediately
terminate the provider agreement with the Participating Provider as it pertains
to the Contractor’s Medicaid program, and agrees to no longer utilize the
services of the subject provider, as applicable. The Contractor shall access
information pertaining to excluded Medicaid providers through the SDOH Health
Provider -Network (HPN). Such information available to the Contractor on the HPN
shall be deemed to constitute constructive notice. The HPN should not be the
sole basis for identifying current exclusions or termination of previously
approved providers. Should the Contractor become aware, through the HPN or any
other source, of an SDOH exclusion or termination, the Contractor shall validate
this information with the Office of Medicaid Management, Bureau of Enforcement
Activities and comply with the provisions of this Section.

21.4 Evaluation Information

The Contractor shall develop and implement policies and procedures to ensure
that health care professionals are regularly advised of information maintained
by the Contractor to evaluate the performance or practice of health care
professionals. The Contractor shall consult with health care professionals in
developing methodologies to collect and analyze health care professional
profiling data. The Contractor shall provide any such information and profiling
data and analysis to health care professionals. Such information, data or
analysis shall be provided on a periodic basis appropriate to the nature and
amount of data and the volume and scope of services provided. Any profiling data
used to evaluate the performance or practice of a health care professional shall
be measured against stated criteria and an appropriate group of health care
professionals using similar treatment modalities serving a comparable patient
population. Upon presentation of such information or data, each health care
professional shall be given the opportunity to discuss the unique nature of the
health care professional’s patient population which may have a bearing on the
health care professional’s profile and to work cooperatively with the Contractor
to improve performance.

21.5 Payment In Full

Contractor must limit participation to providers who agree that payment received
from the Contractor for services included in the Benefit Package is payment in
full for services provided to Enrollees.

21.6 Choice/Assignment of PCP’s

  a)   The Contractor shall offer each Enrollee the choice of no fewer than
three (3) Primary Care Providers within program distance/travel time standards.
Contractor must assign a PCP to individuals that fail to select a PCP. The
assignment of a PCP by the Contractor may occur after written notification of
Contractor by LDSS of the enrollment (through Roster or other method) and after
written notification of the Enrollee by the Contractor but in no event later
than thirty (30) days after notification of enrollment, and only after the
Contractor has made reasonable efforts as set forth in Section 13.5 of this
Agreement to contact the Enrollee and inform him/her of his/her right to choose
a PCP.

b) PCP assignments should be made taking into consideration the following:

i) Enrollee’s geographic location;
ii) any special health care needs, if known by the Contractor; and
iii) any special language needs, if known by the Contractor.

  c)   In circumstances where the Contractor operates or contracts with a
multi-provider clinic to deliver primary care services, the Enrollee must
choose-or be assigned a specific provider or provider team within the clinic to
serve as his/her PCP. .This “lead” provider will be held accountable for
performing the PCP duties.

SECTION 21
(PROVIDER NETWORK AND AGREEMENTS)
October I. 2004
21-3

21.7 PCP Changes

  a)   The Contractor must allow Enrollees the freedom to change PCPs, without
cause, within thirty (30) days of the Enrollee’s first appointment with the PCP.
After the first thirty (30) days PCP may be changed once every six (6) months
without cause.

  b)   The Contractor must process a request to change PCPs and advise the
Enrollee of the effective date of the change within forty-five (45) days of
receipt of the request. The change must be effective no later than the first
(1st) day of the second (2nd) month following the month in which the request is
made.

  c)   The Contractor will provide Enrollees with an opportunity to select a new
PCP in the event that the Enrollee’s current PCP leaves the network or otherwise
becomes unavailable. Such changes shall not be considered in the calculation of
changes for cause allowed within a six (6) month period.

  d)   In the event that an assignment of a new PCP is necessary due to the
unavailability of the Enrollee’s former PCP, such assignment shall be made in
accordance with the requirements of Section 21.6 of this Agreement.

  e)   In addition to those conditions and circumstances under which the
Contractor may assign an Enrollee a PCP when the Enrollee fails to make an
affirmative choice of a PCP, the Contractor may initiate a PCP change for an
Enrollee under the following circumstances:

  i)   The Enrollee requires specialized care for an acute or chronic condition
and the Enrollee and Contractor agree that reassignment to a different PCP is in
the Enrollee’s interest.

  ii)   The Enrollee’s place of residence has changed such that he/she has moved
beyond the PCP travel time/distance standard.

iii) The Enrollee’s PCP ceases to participate in the Contractor’s network.

  iv)   The Enrollee’s behavior toward the PCP is disruptive and the PCP has
made all reasonable efforts to accommodate the Enrollee..

v) The Enrollee has taken legal action against the PCP.

  f)   Whenever initiating a change, the Contractor must offer affected
Enrollees the opportunity to select a new PCP in the manner described in this
Section.

21.8 Provider Status Changes

1) PCP Changes

The Contractor agrees to notify its Enrollees of any of the following PCP
changes:

  a)   Enrollees will be notified within fifteen (15) days from the date on
which the Contractor becomes aware that such Enrollee’s PCP has changed his or
her office address or telephone number.  

  b)   If a PCP ceases participation in the Contractor’s network, the Contractor
shall provide written notice within fifteen (15) days from the date that the
Contractor becomes aware of such change in status to each Enrollee who has
chosen the provider as their PCP. In such cases, the notice shall describe the
procedures for choosing an alternative PCP and, in the event that the Enrollee
is in an ongoing course of treatment, the procedures for continuing care
consistent with subdivision 6 (e) of PI-IL Section 4403.  

  c)   Where an Enrollee’s PCP ceases participation with the Contractor, the
Contractor must ensure that a new PCP is assigned within thirty (30) days of the
date of the notice to the Enrollee.  

2) Other Provider Changes

In the event that an Enrollee is in an ongoing course of treatment with another
Participating Provider who becomes unavailable to continue to provide

SECTION 21
(PROVIDER NETWORK AND AGREEMENTS)
October I, 2004
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61

services to such Enrollee, the Contractor shall provide written notice to the
Enrollee within fifteen (15) days from the date on which the Contractor becomes
aware of the Participating Provider’s unavailability to the Enrollee. In such
cases, the notice shall describe the procedures for continuing care consistent
with subdivision 6 (e) of PHL Section 4403 and for choosing an alternative
provider.

21.9 PCP Responsibilities

In conformance with the Benefit Package, the PCP shall provide health counseling
and advice; conduct baseline and periodic health examinations; diagnose and
treat conditions not requiring the services of a specialist; arrange inpatient
care, consultation with specialists, and laboratory and radiological services
when medically necessary; coordinate the findings of consultants and
laboratories; and interpret such findings to the Enrollee and the Enrollee’s
family,. subject to the confidentiality provisions of Section 20 of this
Agreement, and maintain a current medical record for the Enrollee. The PCP shall
also be responsible for determining the urgency of a consultation with a
specialist and shall arrange for all consultation appointments within
appropriate time frames.

21.10 Member to Provider Ratios

The Contractor .agrees to adhere to the member-to-PCP ratios shown below. These
ratios are for Medicaid Enrollees only, are Contractor-specific, and assume the
practitioner is a full time equivalent (FTE) (defined as a provider practicing
forty (40) hours per week for the Contractor):

  i)   No more than 1,500 Medicaid Enrollees for each physician, or 2,400 for a
physician practicing in combination with a registered physician assistant or a
certified nurse practitioner.

ii) No more than 1,000 Medicaid Enrollees for each certified nurse practitioner.

The Contractor agrees that these ratios will be prorated for Participating
Providers who represent less than a FTE to the Contractor.

21.11 Minimum Office Hours

a) General Requirements

A PCP must practice a minimum of sixteen (16) hours a week at each primary care
site.

  b)   The minimum office hours requirement may be waived under certain
circumstances. A request for a waiver must be submitted by the MCO to the
Medical Director of the Office of Managed Care for review and approval; and the
physician must be available at least eight hours/week; and the physician must be
practicing in a Health Provider Shortage Area (HPSA) or other similarly
determined shortage area; and the physician must be able to fulfill the other
responsibilities of a PCP (as described in this Section); and the waiver request
must demonstrate there are systems in place to guarantee continuity of care and
to meet all access and availability standards, (24-hr/7 day week coverage,
appointment availability, etc.). SDOH shall notify the LDSS when a waiver has
been granted.  

21.12 Primary Care Practitioners

a) General Limitations

The Contractor agrees to limit its PCPs to the following primary. care
specialties: Family Practice, General Practice, General Pediatrics, General
Internal Medicine, except as specified in (b), (c), (d) and (e) of this Section.

b) Specialist and Sub-specialist as PCPs

The Contractor is permitted to use specialist and sub-specialist physicians as
PCPs when such an action is considered by the Contractor to be medically
appropriate and cost-effective. As an alternative, the, Contractor may restrict
it’s PCP network to primary care specialties only, while relying on standing
referrals to specialists and sub-specialists for Enrollees who require regular
visits to such physicians.

SECTION 21
(PROVIDER NETWORK AND AGREEMENTS)
October I, 2004
21-5

c) OB/GYN Providers as PCPs

The Contractor, at its option, is permitted to use OB/GYN’ providers as PCPs,
subject to SDOH qualifications.

d) Certified Nurse Practitioners as PCPs

The Contractor is permitted to use certified nurse practitioners as PCPs,
subject to their scope of practice limitations under New York State Law.

e) Registered Physician’s Assistants as Physician Extenders

The Contractor is permitted to use registered physician’s assistants as
physician-extenders, subject to their scope of practice limitations under New
York State Law.

21.13 PCP Teams

a) General Requirements

The Contractor may designate teams of physicians/certified nurse practitioners
to serve as PCPs for Enrollees. Such teams may include no more than four (4)
physicians/certified nurse practitioners and, when an Enrollee chooses or is
assigned to a team, one of the practitioners must be designated as “lead
provider” for that Enrollee. In the case of teams comprised of medical residents
under the supervision of an attending physician, the attending physician must be
designated as the lead physician.

b) Medical Residents

The Contractor shall comply with SDOH Guidelines for use of Medical. Residents
as found in Appendix I, which is hereby made a part of this Agreement as if set
forth fully herein.

21.14 Hospitals

a) Tertiary Services

The Contractor will establish hospital networks capable of furnishing the full
range of tertiary services to Enrollees. Contractors shall ensure that all
Enrollees have access to at least one (1) general acute care hospital within
thirty (30) minutes/thirty (30) miles travel time (by car or public
transportation) from the Enrollee’s residence, unless none are located within
such a distance. If none are located within thirty (30) minutes travel time!
thirty (30) miles travel distance, the Contractor must include the next closest
site in its network.

b) Emergency Services

The Contractor shall ensure and demonstrate that it maintains relationships with
hospital emergency facilities, including comprehensive psychiatric emergency
programs (where available) within and around its Service Area to provide
Emergency Services.

21.15 Dental Networks

If the Contractor includes dental services in its Benefit Package, the
Contractor’s dental network shall include geographically accessible general
dentists sufficient to offer each Enrollee a choice of two (2) primary care
dentists in their Service Area and to achieve a ratio of at least one
(1) primary care dentist for each 2,000 Enrollees. Networks must also include at
least one (I) pediatric dentist and one (1) oral surgeon. Orthognathic surgery,
temporal mandibular disorders (TMD) and oral/maxillofacial prosthodontics must
be provided through any qualified dentist, either in-network

SECTION 21

(PROVIDER NETWORK AND AGREEMENTS)

October 2004

21-6

62

or by referral. Periodontists and endodontists must also be available by
referral. The network should include dentists with expertise in serving special
needs populations (e.g., HIV+ and developmentally disabled patients).

Dental surgery performed in an ambulatory or inpatient setting is the
responsibility of the Contractor whether dental services are a covered benefit
or not, as set forth in Appendix K-Il — B-Optional Service, Dental Services.

21.16 Presumptive Eligibility Providers

Contractors must offer Presumptive Eligibility Providers the opportunity to
contract at terms which are at least as favorable as the terms offered to other
providers performing equivalent services (prenatal care). Contractors need not
contract with every Presumptive Eligibility Provider in their County, but must
include a sufficient number in their networks of Participating Providers to meet
the distance/travel time standards defined for primary care.

21.17 Mental Health and Chemical Dependence Services Providers

The Contractor will include a full array of mental health and Chemical
Dependence Services providers in its networks, in sufficient numbers to assure
accessibility to Benefit Package services on the part of both children and
adults, using either individual, appropriately licensed practitioners or New
York State Office of Mental Health (OMH) and Office of Alcohol and Substance
Abuse Services (OASAS) licensed programs and clinics, or both.

The State defines mental health and Chemical Dependence Services providers to
include the following: Individual Practitioners, Psychiatrists, Psychologists,
Psychiatric Nurse Practitioners, Psychiatric Clinical Nurse Specialists,
Licensed Certified Social Workers, OMH and OASAS Programs and Clinics, and
providers of mental health and/or Chemical Dependence Services certified or
licensed pursuant to Article 31 or 32 of the Mental Hygiene Law, as appropriate.

21.18 Laboratory Procedures

The Contractor agrees to restrict its laboratory provider network to entities
having either a CLIA certificate of registration or a CLIA certificate of
waiver.

21.19 Federally Qualified Health Centers (FQHCs)

In voluntary counties, the Contractor is not required to contract with FQHCs.

However, when an FQHC is part of the provider network (voluntary or mandatory
counties) the Provider Agreement must include a provision whereby the Contractor
agrees to compensate the FQHC for services provided to Enrollees at a payment
rate that is not less than the level and amount for a similar set of services
which the Contractor would make to a provider that is not an FQHC.

In mandatory counties, the Contractor shall contract with FQHCs operating in its
Service Area. However, the Contractor has the option to make a written request
to the SDOH for an exemption from the FQHC contracting requirement, if the
Contractor can demonstrate, with supporting documentation, that it has adequate
capacity and will provide a comparable level of clinical and enabling services
(e.g., outreach, referral services, social support services, culturally
sensitive services such as training for medical and administrative staff,
medical and non-medical and case management services) to vulnerable populations
in lieu of contracting with an FQHC in its Service Area. Written requests for
exemption from this requirement are subject to approval by HCFA.

When the Contractor is participating in a county where an MCO that is sponsored,
owned and/or operated by one or more FQHCs exists, the Contractor is not
required to include any FQHCs within its network in that county.

SECTION 21

(PROVIDER NETWORK AND AGREEMENTS)

October 1, 2004

21-7

63

Contractor agrees to compensate the FQHC for services provided to Enrollees at a
payment rate that is not less than the level and amount for a similar set of
services which the Contractor would make to a provider that is not an FQHC.

In mandatory counties, the Contractor shall contract with FQHCs operating in its
Service Area. However, the Contractor has the option to make a written request
to the SDOH for an exemption from the FQHC contracting requirement, if the
Contractor can demonstrate, with supporting documentation, that it has adequate
capacity and will provide a comparable level of clinical and enabling services
(e.g., outreach, referral services, social support services, culturally
sensitive services such as training for medical and administrative staff,
medical and non-medical and case management services) to vulnerable populations
in lieu of contracting with an FQHC in its Service Area. Written requests for
exemption from this requirement are subject to approval by HCFA.

When the Contractor is participating in a county where an MCO that is sponsored,
owned and/or operated by one or more FQHCs exists, the Contractor is not
required to include any FQHCs within its network in that county.

21.20 Provider Services Function

The Contractor will operate a Provider Services function during regular business
hours. At a minimum, the Contractor’s Provider Services staff must be
responsible for the following:

a) Assisting providers with prior authorization and referral protocols.
b) Assisting providers with claims payment procedures.
c) Fielding and responding to provider questions-and complaints.

SECTION 21
(PROVIDER NETWORK AND AGREEMENTS)
October 1, 2004

              21-822. SUBCONTRACTS AND PROVIDER AGREEMENTS    
 
    22.1     Written Subcontracts

Contractor may not enter into any subcontracts related to the delivery of
services to Enrollees, except by a written agreement.

22.2 Permissible Subcontracts

Contractor may subcontract for provider services as set forth in Section 2.6 and
21 of this contract and management services including, but not limited to,
marketing, quality assurance and utilization review activities and such other
services as are acceptable to the SDOH.

22.3 Provisions of Services through Provider Agreements

All medical care and/or services covered under this Agreement, with the
exception of seldom used subspecialty and Emergency Services, Family Planning
Services, and services for which Enrollees can self refer, shall be provided
through Provider Agreements with Participating Providers.

22.4 Approvals

  a)   Provider Agreements shall require the approval of SDOH as set forth in
PHL 4402 and 10 NYCRR Part 98.

  b)   If a subcontract is for management services under 10 NYCRR § 98-1.11, it
must be approved by SDOH prior to its becoming effective.

The Contractor shall notify SDOH of any material amendments to any Provider
Agreement as set forth in 10 NYCRR § 98-1.8.

22.5 Required Components

  a)   The Contractor shall impose obligations and duties on its subcontractors,
including its Participating Providers, that are consistent with this Agreement,
and that do not impair any rights accorded to LDSS, SDOH, or DHHS.

  b)   No subcontract, including any Provider Agreement shall limit or terminate
the Contractor’s duties and obligations under this Agreement.

  c)   Nothing contained in this Agreement between LDSS and the Contractor shall
create any contractual relationship between any subcontractor of the Contractor,
including Participating Providers, and the County or LDSS.

  d)   Any subcontract entered into by the Contractor shall fulfill the
requirements of 42 CFR Part 434 that are appropriate to the service or activity
delegated under such subcontract.

  e)   The Contractor shall also ensure that, in the event the Contractor fails
to pay any subcontractor, including any Participating Provider in accordance
with the subcontract or Provider Agreement, the subcontractor or Participating
Provider will not seek payment from the LOSS, the Enrollees, or their eligible
dependents.

  f)   The Contractor shall include in every Provider Agreement a procedure for
the resolution of disputes between the Contractor and its Participating
Providers.

  g)   g) The Contractor-shall ensure that all Provider Agreements entered into
with Providers require acceptance of a woman’s enrollment in the MCO as
sufficient to provide services to her newborn, unless the newborn is excluded
from participating in Medicaid managed care.

SECTION 22
(PROVIDER AGREEMENTS)
October 1.2004
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64

22.6 Timely Payment

Contractor shall make payments td health care providers for items and services
covered under this Agreement on a timely basis, consistent with the claims
payment procedures described in NYS Insurance Law § 3224-a.

22.7 Restrictions on Disclosure

The Contractor shall not by contract or written policy or written procedure
prohibit or restrict any health care provider from the following:

  a)   disclosing to any subscriber, Enrollee, patient, designated
representative or, where appropriate, prospective Enrollee any information that
such provider deems appropriate regarding:

  i)   a condition or a course of treatment with such subscriber, Enrollee,
patient, designated representative or prospective Enrollee, including the
availability of other therapies, consultations, or tests; or  

  ii)   The provisions, terms, or requirements of the Contractor’s products as
they relate to the Enrollee, where applicable.  

  b)   filing a complaint, making a report or comment to an appropriate
governmental body regarding the policies or practices of the Contractor when
they believe that the policies or practices negatively impact upon the quality
of, or access to, patient care.  

  c)   advocating to the Contractor on behalf of the Enrollee for approval or
coverage of a particular treatment or for the provision of health care services.
 

22.8 Transfer of Liability

No contract or agreement between the Contractor and a health care provider shall
contain any clause purporting to transfer to the health care provider, other
than a medical group, by indemnification or otherwise, any liability relating to
activities, actions or omissions of the Contractor as opposed to those of the
health care provider.

22.9 Termination of Health Care Professional Agreements

The Contractor shall not terminate a contract with a health care professional
unless the Contractor provides to the health care professional a written
explanation of the reasons for the proposed termination and an opportunity for a
review or hearing as hereinafter provided. For purposes of this Section a health
care professional is an individual licensed, registered or certified pursuant to
Title 8 of the Education Law.

These requirements shall not apply in cases involving imminent harm to patient
care, a determination of fraud, or a final disciplinary action by a state
licensing board or other governmental agency that impairs the health care
professional’s ability to practice.

When the Contractor desires to terminate a contract with a health care
professional, the notification of the proposed termination by the Contractor to
the health care professional shall include:

a) the reasons for the proposed action;

  b)   notice that the health care professional has the right to request a
hearing or review, at the provider’s discretion, before a panel appointed by the
Contractor;

  c)   a time limit of not less than thirty (30) days within which a health care
professional may request a hearing; and  

  d)   a time limit for a hearing date which must be held within thirty
(30) days after the date of receipt of a request for a hearing.  

SECTION 22
(PROVIDER AGREEMENTS)
October 1, 2004
22-2

No contract or agreement between the Contractor and a health care professional
shall contain any provision which shall supersede or impair a health care
professional’s right to notice of reasons for termination and the opportunity
for a hearing or review concerning such termination.

22.10 Health Care Professional Hearings

A health care professional that has been notified of his or her proposed
termination must be allowed a hearing. The procedures for this hearing must meet
the following standards:

  a)   The hearing panel shall be comprised of at least three persons appointed
by the Contractor. At least one person on such panel shall be a clinical peer in
the same discipline and the same or similar specialty as the health care
professional under review. The hearing panel may consist of more than three
persons, provided however that the number of clinical peers on such panel shall
constitute one-third or more of the total membership of the panel.

  b)   The hearing panel shall render a decision on the proposed action in a
timely manner. Such decision shall include reinstatement of the health care
professional by the Contractor, provisional reinstatement subject to conditions
set forth by the Contractor or termination of the health care professional. Such
decision shall be provided in writing to the health care professional.

  c)   A decision by the hearing panel to terminate a health care professional
shall be effective not less than thirty (30) days after the receipt by the
health care professional: of the .hearing panel’s decision. Notwithstanding the
termination of a health care professional for cause or pursuant to a hearing, a
plan shall permit an Enrollee to continue an on-going course of treatment for a
transition period of up to ninety (90) days, and post-pat-turn care, subject to
provider agreement, pursuant to PHL § 4406(6)(e).  

  d)   In no event shall termination be effective earlier than sixty (60) days
from the receipt of the notice of termination.  

22.11 Non-Renewal of Provider Agreements

Either party to a contract may exercise a right of non-renewal at the expiration
of the contract period set forth therein or, for a contract without a specific
expiration date, on each January first occurring after the contract has been in
effect for at least one year, upon sixty (60) days notice to the other party;
provided, however, that any non-renewal shall not constitute a termination for
the purposes of this Section.

22.12 Physician Incentive Plan

If Contractor elects to operate a Physician Incentive Plan, Contractor agrees
that no specific payment will be made directly or indirectly under the plan to a
physician or physician group as an inducement to reduce or limit medically
necessary services furnished to an Enrollee. Contractor agrees to submit to SDOH
annual reports containing the information on its physician incentive plan in
accordance with 42 CFR § 434.70. The contents of such reports shall comply with
the requirements of 42 CFR § 417.479 and be in a format to be provided by SDOH.

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

In the event that the incentive arrangements place the physician or physician
group at risk for services beyond those provided directly by the physician or
physician group for an amount beyond the risk threshold of 25% of: potential
payments for covered services (substantial financial risk), the

SECTION 22
(PROVIDER AGREEMENTS)
October 1, 2004
22-3

Contractor must comply with all additional requirements listed in regulation,
such as: conduct enrollee/disenrollee satisfaction surveys; disclose the
requirements for the physician incentive plans to its beneficiaries upon
request; and ensure that all physicians and physician groups at substantial
financial risk have adequate stop-loss protection. Any of these additional
requirements that are passed on to the subcontractors must be clearly stated in
their Agreement.

SECTION 22
(PROVIDER AGREEMENTS)
October 1, 2004
22-4

65

23. FRAUD AND ABUSE PREVENTION PLAN

A Fraud and Abuse Prevention Plan for the detection, investigation and
prevention of fraudulent activities must be filed by the Contractor with the
Commissioner of Health to the extent required by SDOH regulations. A copy of
this plan must be submitted to the LDSS, upon request of the LDSS.

24. AMERICANS WITH DISABILITIES ACT COMPLIANCE PLAN

Contractor must comply with Title II of the Americans with Disabilities Act
(ADA) and Section 504 of the Rehabilitation Act of 1973 for program
accessibility, and must develop an ADA Compliance Plan consistent with the SDOH
Guidelines for Medicaid MCO Compliance with the ADA which are set forth in
Appendix J, which is hereby made a part of this Agreement as if set forth fully
herein. Said plan must be approved by the SDOH and/or the LDSS, and filed with
the ‘Contractor, SDOH and the LDSS.

25. FAIR HEARINGS
25.1 Enrollee Access To Fair Hearing Process

Enrollees may access the: fair hearing process in. accordance with applicable
federal and state:laws and regulations. Contractors must abide by and
participate in New York State’s Fair Hearing Process and comply with
determinations made by a fair hearing officer.

25.2 Enrollee Rights to a Fair Hearing

Enrollees may request a fair hearing regarding adverse LDSS determinations
concerning enrollment, disenrollment and eligibility, and regarding the denial,
termination, suspension or reduction of a clinical treatment or other Benefit
Package services by the Contractor. For issues related to disputed services,
Enrollees must have received an adverse determination from the Contractor or its
approved utilization review agent either overriding a recommendation to provide
services by a Participating Provider or confirming the decision of a
Participating Provider to deny those services. An Enrollee may also seek a fair
hearing for a failure by the Contractor to act with reasonable promptness with
respect to such services. Reasonable promptness shall mean compliance with the
time frames established for review of grievances and utilization review in
Sections 44 and 49 of the Public Health Law.

25.3 Contractor Notice to Enrollees

  a)   Contractor must issue a written Notice of Adverse Determination and Fair
Hearing Rights to any Enrollee:  

  i)   When Contractor or its utilization review agent has denied a request to
approve a Benefit Package service ordered by an MCO provider; or

  ii)   When an Enrollee is denied a requested service or benefit by an MCO
provider and has exhausted the Contractor’s approved internal complaint and
appeal procedures or utilization review processes; or

  iii)   At least 10 days before the effective date of Contractor’s termination,
suspension or reduction of a benefit or treatment already in progress for that
Enrollee.

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

c) Contractor’s Notice of Adverse Determination and Notice of a Right to Request
a Fair Hearing shall include the following:

  i)   the description of the action Contractor intends to take;

     
ii)
iii)
iv)
  the reasons for the determination including the clinical rationale, if any;
the process for filing a grievance/complaint with the organization;
the timeframes within which a grievance/complaint must be made;

SECTION 23 — SECTION 37
October 1, 2004
- 1-

  v)   the right of an Enrollee to designate a representative to file a
grievance/complaint on behalf of the Enrollee;

  vi)   the notice of the right of the Enrollee to contact the New York State
Department of Health (800 206-8125) with their complaint; and

  vii)   the notice entitled “Managed Care. Action Taken” containing the
Enrollee’s fair hearing and aid continuing rights.

d) The Contractor’s Notice of Adverse Determination and Notice of a Right to
Request a Fair Hearing for Article 49 Utilization Review Determinations shall
include the following:

  i)   a description of the action Contractor intends to take;

  ii)   the reasons for the determination including the clinical rationale, if
any;

  iii)   instructions on how to initiate standard and expedited appeals pursuant
to section 4904 of the Public Health Law (PHL);

  iv)   instructions on how to initiate an external appeal pursuant to section
4914 of the PHL;

  v)   notice of availability of the clinical review criteria relied upon to
make such determination;

  vi)   the additional, if any, necessary information to be provided to, or
obtained by, the UR agent in order to render a decision on the appeal;

  vii)   notice of the right of the Enrollee to contact the New York State
Department of Health (800 206-8125) with their complaint; and

  viii)   the notice entitled “Managed Care Action Taken” containing the
Enrollee’s fair hearing and aid continuing rights.

25.4 Aid Continuing

Contractor shall be required to continue the provision of the Benefit Package
services that are the subject of the fair hearing to an Enrollee (hereafter
referred to as “aid continuing”) if so ordered by the OAH under the following
circumstances:

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

ii) Enrollee has tiled a timely request for a fair hearing with OAH; and

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

  iv)   If the services and/or benefits in dispute have been terminated,
suspended or reduced and the Enrollee timely requests a fair hearing, Contractor
shall, at the direction of either SDOH or LDSS, restore the disputed services
and/or benefits consistent with the provisions of Section 25.4(iii) of this
Agreement.

25.5 Responsibilities of SDOH

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

25.6 Contractor’s Obligations

  a)   Contractor shall appear at all scheduled fair hearings concerning its
clinical determinations and/or Contractor-initiated disenrollments to present
evidence as justification for its determination or submit written evidence as
justification for its determination regarding the disputed benefits and/or
services. If Contractor will not be making a personal appearance at the fair
hearing, the written material must be submitted to OAH and Enrollee or
Enrollee’s representative at least three (3) business days prior to the
scheduled hearing. If the hearing is scheduled fewer than three (3) business
days after the request, Contractor must deliver the evidence to the hearing site
no later than one (1) business day prior to the hearing, otherwise Contractor
must appear in person. Notwithstanding the above provisions, Contractor may be
required to make a personal appearance at the discretion of the hearing officer
and/or SDOH.

SECTION 23 — SECTION 37
October 1. 2004
- 2 -

  b)   Despite an Enrollee’s request for a State fair hearing in any given
dispute, Contractor is required to maintain and operate in good faith its own
internal complaint and appeal process as required under state and federal laws
and by Section 14 and Appendix F of this Agreement. Enrollees may seek redress
of adverse determinations simultaneously through Contractor’s internal process
and the State fair hearing process. If Contractor has reversed its initial
determination and provided the service to the Enrollee, Contractor may request a
waiver from appearing at the hearing and, in submitted papers, explain that it
has withdrawn its initial determination and is providing the service or
treatment formerly in dispute.

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

  d)   If SDOH investigates a complaint that has as its basis the same dispute
that is the subject of a pending fair hearing and, as a result of its
investigation, concludes that the disputed services and/or benefits. should be
provided to the Enrollee, Contractor shall comply with SDOH’s directive to
provide those services and/or benefits and provide notice to OAH and Enrollee as
required by Section 25.6(b) of this Agreement.

  e)   If SDOH, through its complaint investigation process, or OAH, by a
determination after a fair hearing, directs Contractor to provide a service that
was initially denied by Contractor, Contractor may either directly provide the
service, arrange for the provision of that service or pay for the provision of
that service by a Non-Participating Provider.

  f)   Contractor agrees to abide by changes made to this Section of the
Agreement with respect to the fair hearing, grievance and complaint processes by
SDOH in order to comply with any amendments to applicable state or federal
statutes or regulations. Such changes shall become effective without need for
any further action by the parties to this Agreement.

  g)   Contractor agrees to identify a contact person within its organization
who will serve as a liaison to SDOH for the purpose of receiving fair hearing
requests, scheduled fair hearing dates and adjourned fair hearing dates and
compliance with State directives. Such individual: shall be accessible to the
State by e-mail; shall monitor e-mail for correspondence from the State at least
once every business day; and shall agree, on behalf of Contractor, to accept
notices to Contractor transmitted via e-mail as legally valid.

  h)   The information describing fair hearing rights, aid continuing, complaint
procedures and utilization review appeals shall be included in all Medicaid
managed care member handbooks and shall comply with SDOH’s member handbook
guidelines.

  i)   Contractor shall bear the burden of proof at hearings regarding the
reduction, suspension or termination of ongoing services. In the event that
Contractor’s initial adverse determination is upheld as a result of a fair
hearing, any aid continuing provided pursuant to that hearing request, may be
recouped by Contractor.

26. EXTERNAL APPEAL

26.1 Basis for External Appeal

Managed care Enrollees are eligible to request an external appeal when one or
more covered health care services have been denied by the Contractor on the
basis that the service(s) is not medically necessary or is experimental or
investigational.

26.2 Eligibility for External Appeal

An Enrollee is eligible for an external appeal when the Enrollee has exhausted
the Contractor’s internal utilization review procedure or both the Enrollee and
the Contractor have agreed to waive internal appeal procedures in accordance
with New York State P.H.L. § 4914(2)2(a). A provider is also eligible for an
external appeal of retrospective denials.

SECTION 23 — SECTION 37
October 1. 2004
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26.3 External Appeal Determination

The external appeal determination is binding on the Contractor, however, a fair
hearing determination supercedes an external appeal determination for Medicaid
Enrollees.

26.4 Compliance with External Appeal Laws and Regulations

MCOs must comply with the provisions of New York State P.H.L. Sections 4910-4914
and Title 10 of NYCRR Subpart 98-2 regarding the external appeal program.

27. INTERMEDIATE SANCTIONS

Contractor is subject to the imposition of sanctions as authorized by State law
including the SDOH’s right to impose sanctions for unacceptable practices as set
forth in Title 18 of the Official Compilation of Codes, Rules and Regulations of
the State of New York (NYCRR) Part 515 and civil and monetary penalties pursuant
to 18 NYCRR Part 516 and such other sanctions and penalties as are authorized by
local laws and ordinances and resultant administrative codes, rules and
regulations related to the Medical Assistance Program or to the delivery of the
contracted for services.

28. ENVIRONMENTAL COMPLIANCE

The Contractor shall comply with all applicable standards, orders, or
requirements issued under Section 306 of the Clean Air Act 42 U.S.C.
Section 1857(h), Section 508 of the Clean Water Act (33 U.S.C. Section 1368),
Executive Order 11738, and the Environmental Protection Agency (“EPA”)
regulations (40 CFR, Part 15) that prohibit the use of the facilities included
on the EPA List of Violating Facilities. The Contractor shall report violations
to SDOH and to the Assistant Administrator for Enforcement of the EPA.

29. ENERGY CONSERVATION

The Contractor shall comply with any applicable mandatory standards and policies
relating to energy efficiency that are contained in the State Energy
Conservation regulation issued in compliance with the Energy Policy and
Conservation Act of 1975 (Pub. L. 94-165) and any amendment to the Act.

30. INEPENDENT CAPACITY OF CONTRACTOR

The parties agree that the Contractor is an independent Contractor, and that the
• Contractor, its agents, officers, and employees act in an independent capacity
and not as officers or employees of LDSS, DHHS or the SDOH.

31. NO THIRD PARTY BENEFICIARIES

Only the parties to this Agreement and their successors in interest and assigns
have any rights or remedies under or by reason of this Agreement.

32. INDEMNIFICATION

32.1 Indemnification by Contractor

The Contractor shall indemnify, defend, and hold harmless the LDSS, its
officers, agents, and employees and the Enrollees and their eligible dependents
from:

  a)   any and all claims and losses accruing or resulting to any and all
Contractors, subcontractors, materialmen, laborers, and any other person, firm,
or corporation furnishing or supplying work, services, materials, or supplies in
connection with the performance of this Agreement;  

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

SECTION 23 — SECTION 37
October I, 2004
-4-

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

  i)   The LDSS will provide the Contractor with prompt written notice of any
claim made against the LDSS, and the Contractor, at its sole option, shall
defend or settle said claim. The LDSS shall cooperate with the Contractor to the
extent necessary. for the Contractor to discharge its obligation under
Section 32.1:

  ii)   The Contractor shall have no obligation under this section with respect
to any claim or cause of action for damages to persons or property solely caused
by the negligence of LDSS, its employees, or agents.

32.2 Indemnification by LDSS

The LDSS shall indemnify and hold harmless the Contractor and its officers,
agents, and employees from any and all claims for damages resulting from actions
by the LDSS or their Contractors in connection with their performance under this
Agreement, except for such damages, costs, and expenses resulting from the
negligence or culpable act of the Contractor, its officers, agents, employees,
or subcontractors, including Participating Providers.

33. PROHIBITION ON USE OF FEDERAL FUNDS FOR LOBBYING

33.1 Prohibition of Use of Federal Funds for Lobbying

The Contractor agrees, pursuant to 31 U.S.C. Section 1352 and 45 CFR Part 93,
that no Federally appropriated funds have been paid or will be paid to any
person by or on behalf of the Contractor for the purpose of influencing or
attempting to influence an officer or employee of any agency, a Member of
Congress, an officer or employee of Congress, or an employee of a Member of
Congress in connection with the award of any Federal contract, the making of any
federal grant, the making of     any Federal loan, the entering into of any
cooperative agreement, or the extension, continuation, renewal, amendment, or
modification of any Federal contract, grant, loan, or cooperative agreement. The
Contractor agrees to complete and submit the “Certification Regarding Lobbying”,
Appendix B attached hereto and incorporated herein, if this Agreement exceeds
$100,000.

33.2 Disclosure Form to Report Lobbying

If any funds other than Federally appropriated funds have been paid or will be
paid to any person for the purpose of influencing or attempting to influence an
officer or employee of any agency, a Member of Congress, an officer or employee
of Congress, or an employee of a Member of Congress in connection with the award
of any Federal contract, the making of any Federal grant, the making of any
Federal loan, the entering into of any cooperative agreement, or the extension,
continuation, renewal, amendment, or modification of any Federal contract,
grant, loan, or cooperative agreement, and the Agreement exceeds $100,000, the
Contractor shall complete and submit Standard Form-LLL “Disclosure Form to
Report Lobbying,” in accordance with its instructions.

33.3 Requirements of Subcontractors

The Contractor shall include the provisions of this section in its subcontracts,
including its Provider Agreements. For all subcontracts, including Provider
Agreements, that exceed $100,000; the Contractor shall require the
subcontractor, including any Participating Provider to certify and disclose
accordingly to the Contractor.

SECTION 23 — SECTION 37
October 1, 2004
-5-

34. NON-DISCRIMINATION

34.1 Equal Access to Benefit Package

Except as otherwise provided in applicable sections of this Agreement the
Contractor shall provide the Benefit Package to all Enrollees in the same
manner, in accordance with the same standards, and with the same priority as
Enrollees of the Contractor under any other contracts.

34.2 Non-Discrimination

The Contractor shall not discriminate against Eligible Persons or Enrollees on
the basis of age, sex, race, creed, physical or mental handicap/developmental
disability, national origin, sexual orientation, type of illness or condition,
need for health services, or Capitation Rate that the Contractor will receive
for such Eligible Persons or Enrollees.

34.3 Equal Employment Opportunity

Contractor must comply with Executive Order 11246, entitled “Equal Employment
Opportunity”, as amended by Executive Order 11375, and as supplemented in
Department of Labor regulations.

34.4 Native Americans Access to Services From Tribal or Urban Indian Health
Facility

The Contractor shall not prohibit, restrict or discourage enrolled Native
Americans from receiving care from or accessing Medicaid reimbursed health
services from or through a tribal health or urban Indian health facility or
center.

35. COMPLIANCE WITH APPLICABLE LAWS

35.1 Contractor and LDSS Compliance With Applicable Laws

Notwithstanding any inconsistent provisions in this Agreement, the Contractor
and LDSS shall comply with all applicable requirements of the State Public
Health Law; the State Social Services Law; Title XIX of the Social Security Act;
Title VI of the Civil Rights Act of 1964 and 45 C.F.R. Part 80, as amended;
Section 504 of the Rehabilitation Act of 1973 and 45 C.F.R. Part 84, as amended;
Age Discrimination Act of 1975 and 45 C.F.R. Part 91, as amended; the Americans
with Disabilities Act; Title XIII of the Federal Public Health Services Act, 42
U.S.C. Section 300e et seq., regulations promulgated there under; the Health
Insurance Portability and Accountability Act of 1996 (P.L. 104-191) and related
regulations; and all other applicable legal and regulatory requirements in
effect at the time that this Agreement is signed and as adopted or amended
during the term of this Agreement.

35.2 Nullification of Illegal, Unenforceable, Ineffective or. Void Contract
Provisions

Should any provision of this Agreement be declared or found to be illegal or
unenforceable, ineffective or void, then each party shall be relieved of any
obligation arising from such provision; the balance of this Agreement, if
capable of performance, shall remain in full force and effect.

35.3 Certificate of Authority Requirements

The Contractor must satisfy conditions for issuance of a certificate of
authority, including proof of financial solvency, as specified in 10 NYCRR, §
98.6.

35.4 Notification of Changes in Certificate of Incorporation

The Contractor shall notify LDSS of any amendment to its Certificate of
Incorporation in the same manner as and simultaneously with the notice given to
SDOH pursuant to 10 NYCRR Section 98.4(a).

SECTION 23 — SECTION 37
October 1, 2004
-6-

35.5 Contractor’s Financial Solvency Requirements

The Contractor, for the duration of this Agreement, shall remain in compliance
with all applicable state requirements for financial solvency for MCOs
participating in the Medicaid Program. The Contractor shall continue to be
financially responsible as defined in PHL § 4403(1)(c) and shall comply with the
contingent reserve fund and escrow deposit requirements of 10 NYCRR §§ 98.11(d)
and 98.11(e), respectively, and must meet minimum net worth requirements
established by SDOH and the State Insurance Department. The Contractor shall
make provision, satisfactory to SDOH, for protections for SDOH, LDSS and the
Enrollees in the event of HMO or subcontractor insolvency, including but not
limited to, hold harmless and continuation of treatment provisions in all
provider agreements which protect SDOH, LDSS and Enrollees from costs of
treatment and assures continued access to care for Enrollees.

35.6 Compliance With Care for Maternity Patients

Contractor must comply with § 2803-n of the Public Health Law and § 3216 (i)
(10) (a) of the State Insurance Law related to hospital care for maternity
patients.

35.7 Informed Consent Procedures for Hysterectomy and Sterilization

The Contractor is required and shall require Participating Providers to comply
with the informed consent procedures for Hysterectomy and Sterilization
specified in 42 CFR, Part 441, sub-part F, and 18 NYCRR Section 505.13.

35.8 Non-Liability of Enrollees for Contractor’s Debts

Contractor agrees that in no event shall the Enrollee become liable for the
Contractor’s debts as set forth in SSA § 1932(b)(6).

35.9 LDSS Compliance With Conflict of Interest Laws

LDSS and its employees shall comply with General Municipal Law Article 18 and
all other appropriate provisions of New York State law, local laws and
ordinances and all resultant codes, rules and regulations pertaining to
conflicts of interest.

35.10 Compliance With PHL Regarding External Appeals

Contractor must comply with Article 49 Title Il of the Public Health Law
regarding external appeal of adverse determinations.

36. NEW YORK STATE STANDARD CONTRACT CLAUSES

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

37. INSURANCE REQUIREMENTS

The LDSS may propose insurance requirements based on the contract practices of
its County. Such requirements must be reasonable and consistent with the
attainment of managed care program objectives.

X The LDSS has insurance requirements (attached) as Section 37 of this Agreement

The Contractor shall comply with the insurance requirements stated in
Appendix A, Part II (General Provisions Governing contracts for Consultants,
Professional and Technical Services, Section 4.3)

• The LDSS does not have insurance requirements.

SECTION 23 — SECTION 37
October 1, 2004
-7-

66

This Agreement is effective October 1, 2004 and shall remain in effect until
September 30, 2005 or until the execution of an extension, renewal or successor
agreement as provided for in the Agreement.

In Witness Whereof, the parties have duly executed this Agreement on the dates
appearing below their respective signatures.
By /s/ K Ajmani By CarePlus, L.L.C. New York City Department of Health

      Karin Ajmani, President and Mental HygieneDate 10/8/04 Date

Approval as to form and certification as to legal authority was granted by the
Corporation Counsel on: 11/10/04

SIGNATURE PAGE
October 1, 2004

STATE OF NEW YORK)

SS:

COUNTY OF NEW YORK

      On this 17 day of November 2004, Thomas Friedman, M.D. came

 
     

 
   
before me, to me known and known to be the
  Commissioner
 
   

in the New York City Department of Health and Mental Hygiene, who is duly
authorized to execute the foregoing instrument on behalf of the City and s/he
acknowledged to me that s/he executed the same for the purpose therein
mentioned.

/s/ Frank Lane

      NOTARY PUBLIC

FRANK LANE

Notary Public, State of New York

No. 01 LA5014224

Qualified in Queens County

Commission Expires Nov. 3, 2005

STATE OF NEW YORK)

SS:

COUNTY OF NEW YORK

On this 8th day of October , 2004, Karin Ajmani came before me, to me known and
known to be the President of CarePlus, LLC , who is duly authorized to executive
the foregoing instrument on behalf of said corporation and s/he acknowledged to
me that s/he executed the same for the purpose therein mentioned.

/s/ Evelyn Huang

      NOTARY PUBLIC

Evelyn Huang

Notary Public State of New York

Lic.No. 02HU6001118

Qualified in New York County

67

Commission Expires March 13, 2006APPENDIX A

New York State Standard Clauses

And Local Standard Clauses

APPENDIX A October I. 2004

68

STANDAND CLAUSES FOR NYS CONTRACTS

STANDARD CLAUSES FOR NYS CONTRACTS

The parties to the attached contract, license, lease, amendment or other
agreement of any kind (hereinafter, “the contract” or this contract”) agree to
be bound by the following clauses which are hereby made a part of the contract
(the word “Contractor” herein refers to any party other than the State, whether
a contractor, licenser, licensee, lessor, lessee or any other party):

I. EXECUTORY CLAUSE. In accordance with Section 41 of the State Finance Law, the
State shall have no liability under this contract to the Contractor or to anyone
else beyond funds appropriated and available for this contract.

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

3. COMPTROLLER‘S APPROVAL. In accordance with Section 112 of the State Finance
Law (or, if this contract is with the State University or City University of New
York, Section 355 or Section 6218 of the Education Law),. if. this contract
exceeds 515,000 (or the minimum thresholds agreed to by the Office of the State
Comptroller for certain S.U.N.Y. and C.U.N.Y. contracts), or if this is an
amendment for any amount to a contract which, as so amended, exceeds said
statutory amount, or if, by this contract, the State agrees to give something
other than money when the value or reasonably estimated value of such
consideration exceeds 510,000, it shall not be valid, effective or binding upon
the State until it has been approved by the State Comptroller and filed in his
office. Comptroller’s approval of contracts let by the Office of General
Services is required when such contracts exceed $30,000 (State Finance Law
Section I 63.6.a).

4. WORKERS’ COMPENSATION BENEFITS. In accordance with Section 142 of the State
Finance Law, this contract shall be void and of no force and effect unless the
Contractor shall provide and maintain coverage during the life of this contract
for the benefit of such employees as are required to be covered by the
provisions of the Workers’ Compensation Law.

5. NON-DISCRIMINATION REQUIREMENTS. To the extent required by Article 15 of the
Executive Law (also known as the Human Rights Law) and all other State and
Federal statutory and constitutional non-discrimination provisions, the
Contractor will not discriminate against any employee or applicant for
employment because of race, creed, color, sex, national origin, sexual
orientation, age, disability, genetic predisposition or carrier status, or
marital status. Furthermore, in accordance with Section 220-e of the Labor Law,
if this is a contract for the construction, alteration or repair of any public
building or public work or for the manufacture, sale or distribution of
materials, equipment or supplies, and to the extent that this contract shall be
performed within the State of New York, Contractor agrees that neither ii not
its subcontractors shall, by reason of race, creed, color, disability, sex, or
national origin: (a) discriminate in hiring against any New York State citizen
who is qualified and available to perform the work; or (b) discriminate against
or intimidate any employee hired for the performance of work under this
contract. If this is a building service contract as defined in Section 230 of
the Labor Law, then, in accordance with Section 239 thereof, Contractor agrees
that neither it nor its subcontractors shall by reason of race, creed, color,
national origin, age, sex or disability: (a) discriminate in hiring against any
New York State citizen who is qualified and available to perform the work; or
(b) discriminate against or intimidate any employee hired for the

Page 1

APPENDIX A

performance of work under this contract. Contractor is subject to fines of
$50.00 per person per day for any violation of Section 220-c or Section 239 as
well as possible termination of this contract and forfeiture of all moneys due
hereunder for a second or subsequent

violation.

6. WAGE AND HOURS PROVISIONS. If this is a public work contract covered by
Article 8 of the Labor Law or a building service contract covered by Article 9
thereof, neither Contractor’s employees nor the employees of its subcontractors
may be required or permitted to work more than the number of hours or days
stated in said statutes, except as otherwise provided in the Labor Law and as
set forth in prevailing wage and supplement schedules issued by the State Labor
Department. Furthermore, Contractor and its subcontractors must pay at least the
prevailing wage rate and pay or provide the prevailing supplements, including
the premium rates for overtime pay, as determined by the State Labor Department
in accordance with the Labor Law.

7. NON-COLLUSIVE BIDDING CERTIFICATION. In accordance with Section 139-d of the
State Finance Law, if this contract was awarded based upon the submission of
bids, Contractor warrants, under penalty of perjury, that its bid was arrived at
independently and without collusion aimed at restricting competition. Contractor
further warrants that, at the time Contractor submitted its bid, an authorized
and responsible person executed and delivered to the State a non-collusive
bidding certification on Contractor’s behalf.

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

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

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

May, 2003

69

STANDAND CLAUSES FOR NYS CONTRACTS APPENDIX A

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

11. IDENTIFYING INFORMATION AND PRIVACY NOTIFICATION. (a) FEDERAL EMPLOYER
IDENTIFICATION NUMBER and/or FEDERAL SOCIAL SECURITY NUMBER. All invoices or New
York State standard vouchers submitted for payment for the sale of goods or
services or the lease of real or personal property to a New York State agency
must include the payee’s identification number, i.e., the seller’s or lessor’s
identification number. The number is either the payee’s Federal employer
identification number or Federal social security number, or both such numbers
when the payee has both such numbers. Failure to include this number or numbers
may delay payment. Where the payee does not have such number or numbers, the
payee, on its invoice or New York State standard voucher, must give the reason
or reasons why the payee does not have such number or numbers.

(b) PRIVACY NOTIFICATION. (1) The authority to request the above personal
information from a seller of goods or services or a lessor of real or personal
property, and the authority to maintain such information, is found in Section 5
of the State Tax Law. Disclosure of this information by the seller or lessor to
‘the State is mandatory. The principal purpose for which the information is
collected is to enable the State to identify individuals, businesses and others
who have been delinquent in filing tax returns or may have understated their tax
liabilities and to generally identify persons affected by the taxes administered
by the Commissioner of Taxation and Finance. The information will be used for
tax administration purposes and for any other purpose authorized by law.
(2) The personal information is requested by the purchasing unit of the agency
contracting to purchase the goods or services or lease the real or personal
property covered by this contract or lease. The information is maintained in New
York State’s Central Accounting System by the Director of Accounting Operations,
Office of the State Comptroller, AESOB, Albany, New York 12236.

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

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

Page 2

employment, job assignment, promotion, upgradings, demotion, transfer, layoff,
or termination and rates of pay or other forms of compensation;

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

(c) the Contractor shall state, in all solicitations or advertisements for
employees, that, in the performance of the State contract, all qualified
applicants will be afforded equal employment opportunities without
discrimination because of race, creed, color, national origin, sex, age,
disability or marital status.

Contractor, will include the provisions of “a”, “b”, and “c” above, in every
subcontract. over $25,000.00 for the construction, demolition, replacement,
major repair, renovation, planning or design of real property and improvements
thereon (the “Work”) except where the Work is for the beneficial use of the
.Contractor. Section 312 does not apply to: (i) work, goods or services
unrelated to this contract; or (ii) employment outside New York State; or (iii)
banking services, insurance policies or the sale of securities. The State shall
consider compliance by a contractor or subcontractor with the requirements of
any federal law concerning equal employment opportunity which effectuates the
purpose of this section. The contracting agency shall determine whether the
imposition of the requirements of the provisions hereof duplicate or conflict
with any such federal law and if such duplication or conflict exists, the
contracting agency shall waive the applicability of Section 312 to the extent of
such duplication or conflict. Contractor will comply with all duly promulgated
and lawful rules and regulations of the Governor’s Office of Minority and
Women’s Business Development pertaining hereto.

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

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

15. LATE PAYMENT. Timeliness of payment and any interest to be paid to
Contractor for late payment shall be governed by Article 11-A of the State
Finance Law to the extent required by law.

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

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

May, 2003

70

STANDARD CLAUSES F0R NYS CONTRAUCTS APPENDIX A

18. PROHIBITION ON PURCHASE OF TROPICAL HARDWOODS. The Contractor certifies and
warrants that all wood products to be used under this contract award will be in
accordance with, but not limited to, the specifications and provisions of State
Finance Law §I65. (Use of Tropical Hardwoods) which prohibits purchase and use
of tropical hardwoods, unless specifically exempted, by the State or any
governmental agency or political subdivision or public benefit corporation.
Qualification for an exemption under this law will be the responsibility of the
contractor to establish to meet with the approval of the State.

In addition, when any portion of this contract involving the use of woods,
whether supply or installation, is to be performed by any subcontractor, the
prime Contractor will indicate and certify in the submitted bid proposal that
the subcontractor has been informed and is in compliance with specifications and
provisions regarding use of tropical hardwoods as detailed in § 165 State
Finance Law. Any such use must meet with the approval of the State; otherwise,
the bid may not be considered responsive. Under bidder certifications, proof of
qualification for exemption will be the responsibility of the Contractor to meet
with the approval of the State.

19. MACBRIDE FAIR EMPLOYMENT PRINCIPLES. In accordance with the MacBride Fair
Employment Principles (Chapter 807 of the Laws of 1992), the Contractor hereby
stipulates that the Contractor either (a) has no business operations in Northern
Ireland, or (b) shall take lawful steps in good faith to conduct any business
operations in Northern Ireland in accordance with the MacBride Fair Employment
Principles (as described in Section 165 of the New York State Finance Law), and
shall permit independent monitoring of compliance with suck principles.

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

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

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

A directory of certified minority and women-owned business enterprises is
available from:

NYS Department of Economic Development

Division of Minority and Women’s Business Development
30 South Pearl St — 2nd Floor Albany, New York 12245
http://www.empire.state.ny.us

The Omnibus Procurement Act of 1992 requires that by signing this bid proposal
or contract, as applicable, Contractors certify that whenever the total bid
amount is greater than SI million:

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

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

(c)
The Contractor agrees to make reasonable efforts to provide notification to New
York State residents of employment opportunities on this project through listing
any such positions with the Job Service Division of the New York State
Department of Labor, or providing such notification in such manner as is
consistent with existing collective bargaining contracts or agreements. The
Contractor agrees to document these efforts and to provide said documentation to
the State upon request; and

(d) The Contractor acknowledges notice that the State may seek to obtain offset
credits from foreign countries as a result of this contract and agrees to
cooperate with the State in these efforts.

21. RECIPROCITY AND SANCTIONS PROVISIONS. Bidders are hereby notified that if
their principal place of business is located in a country, nation, province,
state or political subdivision that penalizes New York State vendors, and if the
goods or services they offer will be substantially produced or performed outside
New York State, the Omnibus Procurement Act 1994 and 2000 amendments
(Chapter 684 and Chapter 383, respectively) require that they be denied
contracts which they would otherwise obtain. NOTE: As of May 15, 2002, the list
of discriminatory jurisdictions subject to this provision includes the states of
South Carolina, Alaska, West Virginia, Wyoming, Louisiana and Hawaii. Contact
NYS Department of Economic Development for a current list of jurisdictions
subject to this provision.

22. PURCHASES OF APPAREL. In accordance with State Finance Law 162 (4-a), the
State shall not purchase any apparel from any vendor unable or unwilling to
certify that: (i) such apparel was manufactured in compliance with all
applicable labor and occupational safety laws, including, but not limited to,
child labor laws, wage and hours laws and workplace safety laws, and (ii) vendor
will supply, with its bid (or, if not a bid situation, prior to or at the time
of signing a contract with the State), if known, the names and addresses of each
subcontractor and a list of all manufacturing plants to be utilized by the
bidder.

21.

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APPENDIX A-PART II

City of New York

GENERAL PROVISIONS GOVERNING CONTRACTS FOR

CONSULTANTS, PROFESSIONAL AND TECHNICAL SERVICES (Not-For- Profit entities)

                  CONTENTS                
ARTICLE 1. DEFINITIONS
    2          
ARTICLE 2. REPRESENTATIONS AND WARRANTIES
            2  
2.1Procurement of Agreement
    2          
2.2Conflict of Interest
    2          
2.3Fair Practices
    2          
ARTICLE 3. AUDIT BY THE DEPARTMENT AND CITY
            3  
ARTICLE 4. COVENANTS OF THE CONTRACTOR
    3          
4.1Employees
    3          
4.2Independent Contractor Status
    4          
4.3Insurance
    4          
4.4Protection of City Property
    6          
4.5Confidentiality
    6          
4.6 Books and Records
    6          
4.7Retention of Records
    6          
4.8 Compliance with Law
    6          
4.9Investigation Clause
    6          
4.10 Assignment
    8          
4.11 Subcontracting
    8          

4.12 Publicity 9 4.13 Participation in an International Boycott 9

                  4.14 Inventions, Patents and Copyrights
    9   4.15 Infringements
    9   4.16 Anti-trust
    10   ARTICLE 5. TERMINATION
    10  
5.1
  Termination of Agreement ...........
    10   ARTICLE 6. MISCELLANEOUS
    11  
6.1
  Conflict of Laws ...................
    11  
6.2
  General Release ....................
    11  
6.3
  Claims and Actions Thereon .........
    11  
6.4
  No Claim Against Officers, Agents or
       
 
  Employees ..........................
    11  

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6.5Waiver
    12          
6.6Notice
    12          
6.7All Legal Provisions Deemed Included
    12          
6.8Severability
    12          
6.9Political Activity
    12          
6.10 Modification
    12          
6.11 Paragraph Headings
    13          
6.12 No Removal of Records from Premises
    13          
6.13 Inspection at Site
    13          
6.14 Pricing
    13          
ARTICLE 7. MERGER
    13          
ARTICLE 8. CONDITIONS PRECEDENT
    13          
ARTICLE 9. PPB RULES
    14          
ARTICLE 10. STATE LABOR LAW AND CITY ADMINISTRATIVE CODE
            14  
ARTICLE 11. FORUM PROVISION
    15          
ARTICLE 12. EQUAL EMPLOYMENT OPPORTUNITY
    15          
ARTICLE 13. NO DAMAGE FOR DELAY
    16          
ARTICLE 14. CONSULTANT REPORT INFORMATION
    16          
ARTICLE 15.RESOLUTION OF DISPUTES
    17          
15.4 Presentation of Dispute to Agency Head
    17          
15.5 Presentation of Dispute to the Comptroller
    18          
15.6 Contract Dispute Resolution Board
    19          
15.7 Petition to Contract Dispute Resolution Board
    19          
ARTICLE 16.PROMPT PAYMENT
    20          

72

ARTICLE 1. DEFINITIONS
As used throughout this Agreement, the following terms shall have the meaning
set forth below:

a. “City” shall mean the City of New York, its departments and political
subdivisions.
b. “Comptroller” shall mean the Comptroller of the City of New York.
c. “Department” or “Agency” shall mean the DEPARTMENT OF HEALTH. AND MENTAL
HYGIENE
d. “Commissioner” or “Administrator” shall mean the COMMISSIONER OF HEALTH AND
MENTAL

HYGIENE or his duly authorized representative. The term “duly authorized
representative” shall include any
person or persons acting within the limits of his or her authority.

  e.   “Law” or “Laws” shall include but not be limited to the New York City
Charter, the New York City Administrative Code, a local law of the City of New
York, and any ordinance, rule or regulation having the force of law.

f. “Contractor” or ”Consultant” shall mean VENDOR

ARTICLE 2. REPRESENTATIONS AND WARRANTIES
2.1 PROCUREMENT OF AGREEMENT

  A.   The Contractor represents and warrants that no person or selling agency
has been employed or retained to solicit or secure this Agreement upon an
agreement or understanding for a commission, percentage, brokerage fee,
contingent fee or any other compensation. The Contractor further represents and
warrants that no payment, gift or thing of value has been made, given or
promised to obtain this or any other agreement between the parties. The
Contractor makes such representations and warranties to induce the City to enter
into this Agreement and the City relies upon such representations and warranties
in the execution hereof.

  B.   For a breach or violation of such representations or warranties, the
Administrator shall have the right to annul this Agreement without liability,
entitling the City to recover all monies paid hereunder and the Contractor shall
not make claim for, or be entitled to recover, any sum or sums due under this
Agreement. This remedy, if effected, shall not constitute the sole remedy
afforded the City for the falsity or breach, nor shall it constitute a waiver of
the City’s right to claim damages or refuse payment or to take any other action
provided for by law or pursuant to this Agreement.

2.2 CONFLICT OF INTEREST

The Contractor represents and warrants that neither it nor any of its directors,
officers, members, partners or employees, has any interest nor shall they
acquire any interest, directly or indirectly, which would or may conflict in any
manner or degree with the performance or rendering of the services herein
provided. The Contractor further represents and warrants that in the performance
of this Agreement no person having such interest or possible interest shall be
employed by it. No elected official or other officer or employee of the City or
Department, nor any person whose salary is payable, in whole or in part, from
the City Treasury, shall participate in any decision relating to this Agreement
which affects his or her personal interest or the interest of any corporation,
partnership or association in which he or she is, directly or indirectly,
interested; nor shall any such person have any interest, direct or indirect, in
this Agreement or in the proceeds thereof.

2.3 FAIR PRACTICES

The Contractor and each person signing on behalf of any contractor represents
and warrants and certifies, under penalty of perjury, that to the best of its
knowledge and belief:

  A.   The prices in this contract have been arrived at independently without
collusion, consultation, communication, or agreement, for the purpose of
restricting competition, as to any matter relating to such prices with any other
bidder or with any competitor;

  B.   Unless otherwise required by law, the prices which have been quoted in
this contract and on the proposal submitted by the Contractor have not been
knowingly disclosed by the Contractor prior to the proposal opening, directly or
indirectly, to any other bidder or to any competitor; and

  C.   No attempt has been made or will be made by the Contractor to induce any
other person, partnership or corporation to submit or not to submit a proposal
for the purpose of restricting competition. The fact that the Contractor (a) has
published price lists, rates, or tariffs covering items being procured, (b) has
informed prospective customers of proposed or pending publication of new or
revised price lists for such items, or © has sold the same items to other
customers at the same prices being bid, does not constitute, without more, a
disclosure within the meaning of the above.

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ARTICLE 3. AUDIT BY THE DEPARTMENT AND CITY

  3.1   All vouchers or invoices presented for payment to be made hereunder, and
the books, records and accounts upon which said vouchers or invoices are based
are subject to audit by the Department and by the Comptroller of the City of New
York pursuant to the powers and responsibilities as conferred upon said
Department and said Comptroller by the New York City Charter and Administrative
Code of the City of New York, as well as all orders and regulations promulgated
pursuant thereto.

  3.2   The Contractor shall submit any and all documentation and justification
in support of expenditures or fees under this Agreement as may be required by
said Department and said Comptroller so that they may evaluate the
reasonableness of the charges and shall make its records available to the
Department and to the Comptroller as they consider necessary.

  3.3   All books, vouchers, records, reports, canceled checks and any and all
similar material may be subject to periodic inspection, review and audit by the
State of New York, Federal Government and other persons duly authorized by the
City. Such audit may include examination and review of the source and
application of all funds whether from the City, any State, the Federal
Government, private sources or otherwise.

  3.4   The contractor shall not be entitled to final payment under the
Agreement until all requirements have been satisfactorily met.

          ARTICLE 4. COVENANTS OF THE CONTRACTOR    
4.1
  EMPLOYEES   V
 
     

  A.   All experts or consultants or employees of the Contractor who are
employed by the Contractor to perform work under this contract are neither
employees of the City nor under contract to the City and the Contractor alone is
responsible for their work, direction, compensation and personal conduct while
engaged under this Agreement. Nothing in this contract shall impose any
liability or duty on the City for the acts; omissions, liabilities or
obligations of the Contractor any person, firm company, agency, association,
expert, consultant, independent contractor, specialist, trainee, employee,
servant, or agent, or for taxes of any nature including but not limited to
unemployment insurance, workmen’s compensation, disability benefits and social
security, or, except as specifically stated in this contract, to any person,
firm or corporation.

  B.   The Contractor shall be solely responsible for all physical injuries or
death to its agents, servants, or employees or to any other person or damage to
any property sustained during its operations and work on the project under this
agreement resulting from any act of omission or commission or error in judgment
of any of its officers, trustees, employees, agents, servants, or independent
contractors, and shall hold harmless and indemnify the City from liability upon
any and all claims for damages on account of such injuries or death to any such
person or damages to property on account of any neglect, fault or default of the
Contractor, its officers, trustees, employees, agents, servants, or independent
contractors. The Contractor shall be solely responsible for the safety and
protection of all of its employees whether due to the negligence, fault or
default of the Contractor or not.

C. Workmen’s Compensation and Disability Benefits

If this Agreement be of such a character that the employees engaged thereon are
required to be insured by the provision of Chapter 615 of the Laws of 1922,
known as the “Workmen’s Compensation Law” and acts amendatory thereto, the
Agreement shall be void and of no effect unless the Contractor shall secure
compensation for the benefit of, and keep insured during the life of this
Agreement such employees in compliance with the provisions of said law,
inclusive of Disability Benefits,; and, shall furnish the Department with two
(2) certificates of these insurance coverages.

  D.   Unemployment Insurance Unemployment Insurance coverage shall be obtained
and provided by the Contractor for its employees.  

E. Minimum Wage

Except for those employees whose minimum wage is required to be fixed pursuant
to Section 220 of the Labor Law of the State of New York, all persons employed
by the Contractor in the performance of this Agreement shall be paid, without
subsequent deduction or rebate, unless expressly authorized by law, not less
than the minimum wage as prescribed by law. Any breach or violation of the
foregoing shall be deemed a breach or violation of a material provision of this
Agreement.

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74

4.2 INDEPENDENT CONTRACTOR STATUS

The Contractor and the Department agree that the Contractor is an independent
contractor, and not an employee of the Department or the City of New York, and
that in accordance with such status as independent contractor, the Contractor
covenants and agrees that neither it nor its employees or agents will hold
themselves out as, nor claim to be, officers or employees of the City of New
York, or of any department, agency or unit thereof, by reason hereof, and that
they will not, by reason hereof, make any claim, demand or application to or for
any right or privilege applicable to an officer or employee of the City of New
York, including, but not limited to, Workmen’s Compensation coverage,
Unemployment Insurance Benefits, Social Security coverage or employee retirement
membership or credit.

4.3 INSURANCE
A. INSURANCE REQUIREMENTS FOR CONTRACTORS

Contractors shall procure and maintain for the duration of the contract
insurance against claims for injuries to persons or damages to property which
may arise from or in connection with the performance of the work hereunder by
the Contractor, his agents, representatives, employees or subcontractors. All
required insurance policies shall be maintained with companies that may lawfully
issue the required policy and have an A.M. Best rating of at least A-7 or a
Standard and Poor’s rating of at least AA, unless prior written approval is
obtained from the Mayor’s Office of Operations. The cost of such insurance shall
be included in the Contractor’s bid.

a. Minimum Scope of Insurance

Coverage shall be at least as broad as:

      1.Insurance Services Office form number GL 0002 (1/73) covering
Comprehensive General Liability and Insurance Services Office form number GL
0404 covering Broad Form Comprehensive General Liability; or Insurance Services
Office Commercial General Liability coverage (“occurrence” form CG 0001).(ED
11/85).

      2.Insurance Services Office form number CA 0001 (Ed. 1/78) covering
Automobile Liability, code 1 “any auto” and endorsements CA 2232 and CA 0112.

  3.   Workers’ Compensation insurance as required by Labor Code of the State of
New York and Employers Liability insurance.

  b.   Minimum Limits of Insurance Contractor shall maintain limits no less
than:  

      1.Comprehensive General Liability: $1,000,000.00 combined single limit per
accident for bodily injury and property damage.

2.Professional liability: 1 Million Dollars per occurrence; Three Million
Dollars Aggregate.

  3.   Workers’ Compensation and Employers Liability: Workers’ Compensation
limits as required by the Labor Code of the State of New York Employers
Liability limits of $1,000,000.00 per accident. Pursuant to Section 57 of the
NYS Workers’ Compensation Law, the vendor has submitted proof of workers’
compensation and disability benefits coverage to the agency.

c. Deductibles and Self-Insured Retentions

Any deductibles and self-insured retentions must be declared to and approved by
the Agency. At the option of the Agency, either: the insurer shall reduce or
eliminate such deductibles or self-insured retentions as respects and Agency,
its officers, officials and employees; or the Contractor shall procure a bond
guaranteeing payment of losses and related investigations, claim administration
and defense expenses.
1.General Liability and Automobile Liability Coverages

  a.   The City, its officers, officials and employees are to be covered as
insured as respects: liability arising out of activities performed by or on
behalf of the Contractor; products and completed operations of the Contractor;
premises owned, leases or used by the Contractor; or automobiles owned, leased,
hired or borrowed by the Contractor. The coverage shall contain no special
limitations on the scope of protection afforded to the City, its officers,
officials and employees.

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75

  b.   The Contractor’s insurance coverage shall be primary insurance as respect
the City, its officers, officials, and employees. Any other insurance or
self-insurance maintained by the Agency, its officers, officials and employees
shall be excess of and not contribute with the Contractor’s insurance.

  c.   Any failure to comply with reporting provisions of the policies shall not
affect coverage provided to the Agency, its officers, officials, and employees.

  d.   The Contractor’s insurance shall apply separately to each insured against
whom claim is made or suit is brought, except with respect to the limits of the
insurers liability.

2. Workers’ Compensation and Employers Liability Coverage

The insurer shall agree to waive all rights of subrogation against the Agency,
its officers, officials, and employees for losses arising from work performed by
the Contractor for Agency.

3.All Coverages

Each insurance policy required by this clause shall be endorsed to state that
coverage shall not be suspended, voided, cancelled by either party, reduced in
coverage or in limits except after sixty (60) days prior written notice by
certified mail, return receipt requested, has been given to the City.

d. Acceptability of Insurers

Insurance is to be placed with insurers with an A.M. Best rating of at least A-7
or a Standard and Poor’s rating of at least AA, unless prior written approval is
obtained from the Mayor’s Office of Operations.

e. Verification of Coverage

Contractor shall furnish the City with Certificates of Insurance effecting
coverage required by this clause. The Certificates for each insurance policy are
to be signed by a person authorized by that insurer to bind coverage on its
behalf. The Certificates are to be on forms provided by the Agency and are to be
received and approved by the Agency before work commences. The Agency reserves
the right to obtain complete, certified copies of all required insurance
policies, at any time.

f. Subcontractors

Contractor shall include all subcontractors as insured under its policies or
shall furnish separate Certificates for each subcontractor: All coverages for
subcontractors shall be subject to all of the requirements stated herein.

B. In the event that any claim is made or any action is brought against the City
arising out of negligent or careless acts of an employee of the Contractor,
either within or without the scope of his employment, or arising out of
Contractor’s negligent performance of this Agreement, then the City shall have
the right to withhold further payments hereunder for the purpose of set-off in
sufficient sums to cover the said claim or action. The rights and remedies of
the City provided for in this clause shall not be exclusive and are in addition
to any other rights and remedies provided by law or this Agreement.

4.4 PROTECTION OF CITY PROPERTY,

  A.   The Contractor assumes the risk of, and shall be responsible for, any
loss or damage to City property, including property and equipment leased by the
City, used in the performance of this Agreement; and caused, either directly or
indirectly by the acts, conduct, omissions or lack of good faith ofthe
Contractor, its officers, managerial personnel and employees, or any person,
firm, company, agent or others engaged by the Contractor as expert, consultant,
specialist or subcontractor hereunder.  

  B.   In the event that any such City property is lost or damaged, except for
normal wear and tear, then the City shall have the right to withhold further
payments hereunder for the purpose of set-off, in sufficient sums to cover such
loss or damage.  

  C.   The Contractor agrees to indemnify the City and hold it harmless from any
and all liability or claim for damages due to any such loss or damage to any
such City property described in subsection A above.  

  D.   The rights and remedies of the City provided herein shall not be
exclusive and are in addition to any other rights and remedies provided by law
or by this Agreement.  

     
4.5
  NFP.W/P.L.
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CONFIDENTIALITY
 
   

All of the reports, information or data, furnished to or prepared, assembled or
used by the Contractor. under this Agreement are to be held confidential, and
prior to publication, the Contractor agrees that the same shall not be made
available to any individual or organization without the prior written approval
of the Department.

4.6 BOOKS AND RECORDS

The Contractor agrees to maintain separate and accurate books, records,
documents and other evidence and accounting procedures and practices which
sufficiently and properly reflect all direct and indirect costs of any nature
expended in the performance of this Agreement.

4.7 RETENTION OF RECORDS

The Contractor agrees to retain all books, records, and other documents relevant
to this Agreement for six years after the final payment or termination of this
Agreement, whichever is later. City, State and Federal auditors and any other
persons duly authorized by the Department shall have full access to and the
right to examine any of said materials during said period.

4.8 COMPLIANCE WITH LAW

Contractor shall render all services under this Agreement in accordance with the
applicable provisions of federal, state and local laws, rules and regulations as
are in effect at the time such services are rendered.

4.9 INVESTIGATION CLAUSE

  1.   The parties to this agreement agree to cooperate fully and faithfully
with any investigation, audit or inquiry conducted by a State of New York
(State) or City of New York (City) governmental agency or authority that is
empowered directly or by designation to compel the attendance of witnesses and
to examine witnesses under oath, or conducted by the Inspector General of a
governmental agency that is a party in interest to the transaction, submitted
bid, submitted proposal, contract, lease, permit, or license that is the subject
of the investigation, audit or inquiry.  

2(a) If any person who has been advised that his or her statement, and any
information from such statement, will not be used against him or her in any
subsequent criminal proceeding refuses to testify before a grand jury or other
governmental agency or authority empowered directly or by designation to compel
the attendance of witnesses and to examine witnesses under oath concerning the
award of or performance under any transaction, agreement, lease, permit,
contract, or license entered into with the City, the State, or any political
subdivision or public authority thereof, or the Port Authority of New York and
New Jersey, or any local development corporation within the City, or any public
benefit corporation organized under the laws of the State of New York, or;

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

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

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

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

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

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76

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

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

  (a)   The party’s good faith endeavors or lack thereof to cooperate fully and
faithfully with any governmental investigation or audit, including but not
limited to the discipline, discharge, or disassociation of any person failing to
testify, the production of accurate and complete books and records, and the
forthcoming testimony of all other members, agents, assignees or fiduciaries
whose testimony is sought.

  (b)   The relationship of the person who refused to testify to any entity that
is a party to the hearing, including, but not limited to, whether the person
whose testimony is sought has an ownership interest in the entity and/or the
degree of authority and responsibility the person has within the entity.

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

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

6. The term “license” or “permit” as used herein shall be defined as a license,
permit, franchise or concession not

granted as a matter of right.

  (a)   The term “person” as used herein shall be defined as any natural person
doing business alone or associated with another person or entity as a partner,
director, officer, principal or employee.

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

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

  7.   In addition to and notwithstanding any other provision of this agreement
the Commissioner or agency head may in his or her sole discretion terminate this
agreement upon not less than three (3) days written notice in the event
contractor fails to promptly report in writing to the Commissioner of
Investigation of the CityofNew York any solicitation of money, goods, requests
for future employment or other benefit or thing of value, by or on behalf of any
employee of the City or other person, firm, corporation or entity for any
purpose which may be related to the procurement or obtaining of this agreement
by the contractor, or affecting the performance of this contract.

4.10 ASSIGNMENT

  A.   The Contractor shall not assign, transfer, convey or otherwise dispose of
this Agreement or of Contractor’s rights, obligations, duties, in whole or in
part, or of its right to execute it, or its right, title or interest in it or
any part thereof, or assign, by power of attorney or otherwise, any of the
notices due or to become due under this contract, unless the prior written
consent of the Administrator shall be obtained. Any such assignment, transfer,
conveyance or other disposition without such consent shall be void.

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77

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

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

  D.   This Agreement may be assigned by the City to any corporation, agency or
instrumentality having authority to accept such assignment.

4.11 SUBCONTRACTING

  A.   The Contractor agrees not to enter into any subcontracts for the
performance of its obligations, in whole or in part, under

this Agreement without the prior written approval of the Department. Two copies
of each such proposed subcontract shall be submitted to the Department with the
Contractor’s written request for approval. All such subcontracts shall contain
provisions specifying:

  1.   that the work performed by the subcontractor must be in accordance with
the terms of the Agreement between the Department and the Contractor,

2. that nothing contained in such agreement shall impair the rights of the
Department,

  3.   that nothing contained herein, or under the Agreement between the
Department and the Contractor, shall create any contractual relation between the
subcontractor and the Department, and

  4.   that the subcontractor specifically agrees to be bound by the
confidentiality provision set forth in this Agreement between the Department and
the Contractor.

  B.   The Contractor agrees that it is fully responsible to the Department for
the acts and omissions of the subcontractors and of persons either directly or
indirectly employed by them as it is for the acts and omissions of persons
directly employed by it.

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

D. The Contractor shall not in any way be relieved of any responsibility under
this Contract by any subcontract.

4.12 PUBLICITY

  A.   The prior written approval of the Department is required before the
Contractor or any of its employees,. servants, agents, or independent
contractors may, at any time, either during or after completion or termination
of this Agreement, make any statement to the press or issue any material for
publication through any media of communication bearing on the work performed or
data collected under this Agreement.

  B.   If the Contractor publishes a’ work dealing with any aspect of
performance under this Agreement, or of the results and accomplishments attained
in such performance, the Department shall have a royalty free, non-exclusive and
irrevocable license to reproduce, publish or otherwise use and to authorize
others to use the publication.

4.13 PARTICIPATION IN AN INTERNATIONAL BOYCOTT

  A.   The Contractor agrees that neither the Contractor nor any
substantially-owned affiliated company is participating or shall participate in
an international boycott in violation of the provisions of the Export
Administration Act of 1979, as amended, or the regulations of the United States
Department of Commerce promulgated thereunder.

  B.   Upon the final determination by the Commerce Department or any other
agency of the United States as to, or conviction of the Contractor or a
substantially-owned affiliated company thereof, participation in an
international boycott in violation of the provisions of the Export
Administration Act of 1979, as amended, or the regulations promulgated
thereunder, the Comptroller may, at his option, render forfeit and void this
contract.

  C.   The Contractor shall comply in all respects, with the provisions of
Section 6-114 of the Administrative Code of the City of New York and the rules
and regulations issued by the Comptroller thereunder.

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4.14 INVENTIONS, PATENTS AND COPYRIGHTS

  A.   Any discovery or invention arising out of or developed in the course of
performance of this Agreement shall be promptly and fully reported to the
Department, and if this work is supported by a federal grant of funds, shall be
promptly and fully reported to the Federal Government for determination as to
whether patent protection on such invention shall be sought and how the rights
in the invention or discovery, including rights under any patent issued thereon,
shall be disposed of and administered in order to protect the public interest.

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

  C.   In no case shall subsections A and B of this section apply to, or prevent
the Contractor from asserting or protecting its rights in any report, document
or other data, or any invention which existed prior to or was developed or
discovered independently from the activities directly related to this Agreement.

4.15 INFRINGEMENTS

The Contractor shall be liable to the Department and hereby agrees to indemnify
and hold the Department harmless for any damage or loss or expense sustained by
the Department from any infringement by the Contractor of any copyright,
trademark or patent rights of design, systems, drawings, graphs, charts,
specifications or printed matter furnished or used by the Contractor in the
performance of this Agreement.

4.16 ANTI-TRUST

The Contractor hereby assigns, sells, and transfers to the City all right, title
and interest in and to any claims and causes of action arising under the
anti-trust laws of the State of New York or of the United States relating to the
particular goods or services purchased or procured by the City under this
Agreement.

ARTICLE 5. TERMINATION
5.1 TERMINATION OF AGREEMENT

A. The Department and/or City shall have the right to terminate this Agreement,
in whole or in part:

1. Under any right to terminate as specified in any section of this Agreement.
2. Upon the failure of the Contractor to comply with any of the terms and
conditions of this Agreement.
3. Upon the Contractor’s becoming insolvent.

  4.   Upon the commencement under the Bankruptcy Act of any proceeding by or
against the Contractor, either voluntarily or involuntarily.

5. Upon the Commissioner’s determination, termination is in the best interest of
the City.

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

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

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

  1.   Accounting for and refund to the Department or City, within thirty
(30) days, any unexpended funds which have been paid to the Contractor pursuant
to this agreement.

  2.   Furnishing within thirty (30) days an inventory to the Department or City
of all equipment, appurtenances and property purchased through or provided under
this Agreement carrying out any Department or City directive concerning the
disposition thereof.

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Not incurring or paying any further obligation pursuant to this Agreement beyond
the termination date. Any obligation necessarily incurred by the Contractor on
account of this Agreement prior to receipt of notice of termination and falling
due after such date shall be paid by the Department or City in accordance with
the terms of this Agreement. In no event shall the word “obligation,” as used
herein, be construed as including any lease agreement, oral or written, entered
into between the Contractor and its landlord.

  4.   Turn over to the Department or City or its designees all books, records,
documents and material specifically relating to this Agreement.

  5.   Submit, within ninety (90) days, a final statement and report relating to
this Agreement. The report shall be made by a certified public accountant or a
licensed public accountant.

  E.   In the event the Department or City shall terminate this Agreement, in
whole or in part, as provided in paragraphs 1, 2, 3, or 4 of subsection A of
this section, the Department or City may procure, upon such terms and in such
manner as deemed appropriate, services similar to those so terminated, and the
Contractor shall continue the performance of this Agreement to the extent not
terminated hereby.

  F.   Not withstanding any other provisions of this contract, the Contractor
shall not be relieved of liability to the City for damages sustained by the City
by virtue of Contractor’s breach of the contract, and the City may withhold
payments to the Contractor for the purpose of set-off until such time as the
exact amount of damages due to the City from the Contractor is determined.

  G.   The provisions of the Agreement regarding confidentiality of information
shall remain in full force and effect following any termination.

  H.   The rights and remedies of the City provided in this section shall not be
exclusive and are in addition to all other rights and remedies provided by law
or under this Agreement,

      ARTICLE 6. MISCELLANEOUS
6.1
  CONFLICT OF LAWS
 
   

All disputes arising out of this Agreement shall be interpreted and decided in
accordance with the laws of the State of New York.

6.2 GENERAL RELEASE

The acceptance by the Contractor or its assignees of the final payment under
this contract, whether by voucher, judgment of any court of competent
jurisdiction or any other administrative means, shall constitute and operate as
a general release to the City from any and all claims of and liability to the
Contractor arising out of the performance of this contract.

6.3 CLAIMS AND ACTIONS THEREON

  A.   No action at law or proceeding in equity against the City or Department
shall lie or be maintained upon any claim based upon this Agreement or arising
out of this Agreement or in any way connected with this Agreement unless the
Contractor shall have strictly complied with all requirements relating to the
giving of notice and of information with respect to such claims, all as herein
provided.

  B.   No action shall lie or be maintained against the City by Contractor upon
any claims based upon this Agreement unless such action shall be commenced
within six (6) months after the date of filing in the Office of the Comptroller
of the City of the certificate for the final payment hereunder, or within six
(6) months of the termination or conclusion of this Agreement, or within six
(6) months after the accrual of the Cause of Action, whichever first occurs.

  C.   In the event any claim is made or any action brought in any way relating
to the Agreement herein, the Contractor shall diligently render to the
Department and/or the City of New York without additional compensation any and
all assistance which the Department and/or the City of New York may require of
the Contractor.

  D.   The Contractor shall report to the Department in writing within three
(3) working days of the initiation by or against the Contractor of any legal
action or proceeding in connection with or relating to this Agreement.

6.4 NO CLAIM AGAINST OFFICERS, AGENTS OR EMPLOYEES

No claim whatsoever shall be made by the Contractor against any officer, agent
or employee of the City for, or on account of, anything done or omitted in
connection with this contract.

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6.5 WAIVER

Waiver by the Department of a breach of any provision of this Agreement shall
not be deemed to be a waiver of any other or subsequent breach and shall not be
construed to be a modification of the terms of the Agreement unless and until
the same shall be agreed to in writing by the Department or City as required and
attached to the original Agreement.

6.6 NOTICE

The Contractor and the Department hereby designate the business addresses
hereinabove specified as the places where all notices, directions or
communications from one such party to the other party shall be delivered, or to
which they shall be mailed. Actual delivery of any such notice, direction or
communication to a party at the aforesaid place, or delivery by certified mail
shall be conclusive and deemed to be sufficient service thereof upon such party
as of the date such notice, direction or communication is received by the party.
Such address may be changed at any time by an instrument in writing executed and
acknowledged by the party making such change and delivered to the other party in
the manner as specified above. Nothing in this section shall be deemed to serve
as a waiver of any requirements for the service of notice or process in the
institution of an action or proceeding as provided by law, including the Civil
Practice Law and Rules.

6.7 ALL LEGAL PROVISIONS DEEMED INCLUDED

It is the intent and understanding of the parties to this Agreement that each
and every provision of law required to be inserted in this Agreement shall be
and is inserted herein. Furthermore, it is hereby stipulated that every such
provision is to be deemed to be inserted herein, and if, through mistake or
otherwise, any such provision is not inserted, or is not inserted in correct
form, then this Agreement shall forthwith upon the application of either party
be amended by such insertion so as to comply strictly with the law and without
prejudice to the rights of either party hereunder.

6.8 SEVERABILITY

If this Agreement contains any unlawful provision not an essential part of the
Agreement and which shall not appear to have been a controlling or material
inducement to the making thereof, the same shall be deemed of no effect and
shall upon notice by either party, be deemed stricken from the Agreement without
affecting the binding force of the remainder.

6.9 POLITICAL ACTIVITY

There shall be no partisan political activity or any activity to further the
election or defeat of any candidate for public, political or party office as
part of or in connection with this Agreement, nor shall any of the funds
provided under this Agreement be used for such purposes.

6.10 MODIFICATION

This Agreement may be modified by the parties in writing in a manner not
materially affecting the substance hereof. It may not be altered or modified
orally.

A. CONTRACT CHANGES

Changes may be made to this contract only as duly authorized by the Agency Chief
Contracting Officer of his or her designee. Vendors deviating from the
requirements of an original purchase order or contract without a duly authorized
change order document, or written contract modification or amendment, do so at
their own risk. All such duly authorized changes, modifications and amendments
will be reflected in a written change order and become a part of the original
contract. Contract changes will be made only for work necessary to complete the
work included in the original scope of the contract, and for non-material
changes to the scope of the contract. Changes are not permitted for any material
alteration in the scope of the work. Changes may include any one or more of the
following:

- Specification changes to account for design errors or omissions;

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

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

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

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The Contractor may be entitled to a price adjustment for extra work performed
pursuant to a written change order. If any part of the contract work is
necessarily delayed by a change order, the Contractor may be entitled to an
extension of time for performance. Adjustments to price shall be validated for
reasonableness by using appropriate price and cost analysis.

6.11 PARAGRAPH HEADINGS

Paragraph headings are inserted only as a matter of convenience and for
reference and in no way define, limit or describe the scope or intent of this
contract and in no way affect this contract.

6.12 NO REMOVAL OF RECORDS FROM PREMISES

Where performance of this Agreement involves use by the Contractor of
Departmental papers, files, data or records at Departmental facilities or
offices, the Contractor shall not remove any such papers, files, data or
records, therefrom without the prior approval of the Department’s designated
official.

6.13 INSPECTION AT SITE

The Department shall have the right to have representatives of the Department or
of the City or of the State or Federal governments present at the site of the
engagement to observe the work being performed.

6.14 PRICING

  A.   The Contractor shall when ever required during the contract, including
but not limited to the time of bidding, submit cost or pricing data and formally
certify that, to the best of its knowledge and belief, the cost or pricing date
submitted was accurate, complete, and current as of a specified date. The
Contractor shall be required to keep its submission of cost and pricing date
current until the contract has been completed.

  B.   The price of any change order or contract modification subject to the
conditions of paragraph A, shall be adjusted to exclude any significant sums by
which the City finds that such price was based on cost or price data furnished
by the supplier which was inaccurate, incomplete, or not current as of the date
agreed upon between the parties.

  C.   Time for Certification. The Contractor must certify that the cost or
pricing data submitted are accurate, complete and current as of a mutually
determined date.

  D.   Refusal to Submit Data. When any contractor refuses to submit the
required data to support a price, the Contracting Officer shall not allow the
price.

  E.   Certificate of Current Cost or Pricing Data. Form of Certificate. In
those cases when cost or pricing data is required, certification shall be made
using a certificate substantially similar to the one contained in Chapter 4 of
the PPB rules and such certification shall be retained in the agency contract
file.

ARTICLE 7.MERGER
This written Agreement contains all the, terms and conditions agreed upon by the
parties hereto, and no other agreement, oral or otherwise, regarding the subject
matter of this Agreement shall be deemed to exist or to bind any of the parties
hereto, or to vary any of the terms contained herein.

ARTICLE 8.CONDITIONS PRECEDENT
This contract shall neither be binding nor effective unless:

  A.   Approved by the Mayor pursuant to the provisions of Executive Order
No. 42, dated October 9, 1975, in the event the Executive Order requires such
approval; and

  B.   Certified by the Mayor (Mayor’s Fiscal Committee created pursuant to
Executive Order No. 43, dated October 14, 1975) that performance thereof will be
in accordance with the City’s financial plan; and

  C.   Approved by the New York State Financial Control Board (Board) pursuant
to the New York State Financial Emergency Act for the City of New York, as
amended, (the “Act”), in the event regulations of the Board pursuant to the Act
require such approval.

  D.   It has been authorized by the Mayor and the Comptroller shall have
endorsed his certificate that there remains unexpended and unapplied a balance
of the appropriation of funds applicable thereto sufficient to pay the estimated
expense of carrying out this Agreement. The requirements of this section of the
contract shall be in addition to, and not in lieu of, any approval or
authorization otherwise required for this contract to be effective and for the
expenditure of City funds.

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ARTICLE 9.PPB RULES
This contract is subject to the Rules of the Procurement Policy Board of the
City of New York effective August 1, 1990, as amended. In the event of a
conflict between said Rules and a provision of this contract, the Rules shall
take precedence.

ARTICLE 10. STATE LABOR LAW AND CITY ADMINISTRATIVE CODE

1. As required by New York State Labor Law Section 220-e:

      a: That in the hiring of employees for the performance of work under this
contract or any subcontract hereunder, neither the Contractor, Subcontractor,
nor any person acting on behalf of such Contractor or Subcontractor, shall by
reason of race, creed, color, sex or national origin discriminate against any
citizen of the State of New York who is qualified and available to perform the
work to which the employment relates;

  b.   That neither the Contractor, subcontractor, nor any person on his behalf
shall, in any manner, discriminate against or intimidate any employee hired for
the performance of work under this contract on account of race, creed, color,
sex or national origin;

  c.   That there maybe deducted from the amount payable to the Contractor by
the City under this contract a penalty of five dollars for each person for each
calendar day during which such person was discriminated against or intimidated
in violation of the provisions of this contract; and

  d.   That this contract may be canceled or terminated by the City and all
monies due or to become due hereunder may be forfeited, for a second or any
subsequent violation of the terms or conditions of this section of the contract.

  e.   The aforesaid provisions of this section covering every contract for or
on behalf of the State or a municipality for the manufacture, sale or
distribution of materials, equipment or supplies shall be limited to operations
performed within the territorial limits of the State of New York.

2. As required by New York City Administrative Code Section 6-108:

  a.   It shall be unlawful for any person engaged in the construction,
alteration or repair of buildings or engaged in the construction or repair of
streets or highways pursuant to a contract with the City or engaged in the
manufacture, sale or distribution of materials, equipment or supplies pursuant
to a contract with the City to refuse to employ or to refuse to continue in any
employment any person on account of the race, color or creed of such person.

  b.   It shall be unlawful for any person or any servant, agent or employee of
any person, described in subdivision (a) above, to ask, indicate or transmit,
orally or in writing, directly or indirectly, the race, color, creed or
religious affiliation of any person employed or seeking employment from such
person, firm or corporation.

c. Disobedience of the foregoing provisions shall be deemed a violation of a
material provision of this contract.

  d.   Any person, or the employee, manager or owner of or officer of such firm
or corporation who shall violate any of the provisions of this section shall,
upon conviction thereof, be punished by a fine of not more than one hundred
dollars or by imprisonment for not more than thirty days, or both.

ARTICLE 11. FORUM PROVISION CHOICE OF LAW, CONSENT TO JURISDICTION AND VENUE
This Contract shall be deemed to be executed in the City of New York, State of
New York, regardless of the domicile of the Contractor, and shall be governed by
and construed in accordance with the laws of the State of New York. The parties
agree that any and all claims asserted by or against the City arising under this
Contract or related thereto shall be heard and determined either in the courts
of the United States located in New York City (“Federal Courts”) or in the
courts of the State of New York (“New York State Courts”) located in the City
and County of New York. To effect this Agreement and intent, the Contractor
agrees:

  a.   If the City initiates any action against the Contractor in Federal Court
or in New York State Court, service of process may be made on the Contractor
either in person, wherever such Contractor may be found, or by registered mail
addressed to the Contractor at its address as set forth in this Contract, or to
such other address as the Contractor may provide to the City in writing; and

  b.   With respect to any action between the City and the Contractor in New
York State Court, the Contractor hereby expressly waives and relinquishes any
rights it might otherwise have (I) to move to dismiss on grounds of forum non
conveniens; (ii) to remove to Federal Court; and (iii) to move for a change of
venue to a New York State Court outside New York County.

  c.   With respect to any action between the City and the Contractor in Federal
Court located in New York City, the Contractor expressly waives and relinquishes
any right it might otherwise have to move to transfer the action to a United
States Court outside the City of New York.

  d.   If the Contractor commences any action against the City in a court
located other than in the City and State of New York, upon request of the City,
the Contractor shall either consent to a transfer of the action to a court of
competent jurisdiction located in the City and State of New York or, if the
court where the action is initially brought will not or cannot transfer the
action, the Contractor shall consent to dismiss such action without prejudice
and may thereafter reinstitute the action in a court of competent jurisdiction
in New York City. If any provision(s) of this Article is held unenforceable for
any reason, each and all other provision(s) shall nevertheless remain in full
force and effect.

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ARTICLE 12. EQUAL EMPLOYMENT OPPORTUNITY .
This contract is subject to the requirements of Executive Order No. 50 (1980) as
revised (“E.O. 50”) and the Rules and Regulations promulgated thereunder. No
contract will be awarded unless and until these requirements have been complied
with in their entirety. By signing this contract, the contractor agrees that it:

  1.   will not engage in any unlawful discrimination against any employee or
applicant for employment because of race, creed, color, national origin, sex
age, disability, marital status or sexual orientation with respect to all
employment decisions including, but not limited to, recruitment, hiring,
upgrading, demotion, downgrading, transfer, training, rates of pay or other
forms of compensation, layoff, termination, and all other terms and conditions
of employment;

  2.   the contractor agrees that when it subcontracts it will not engage in any
unlawful. discrimination in the selection of subcontractors on the basis of the
owner’s race, color, creed, national origin, sex, age, disability, marital
status or sexual orientation;

  3.   will state in all solicitations or advertisements for employees placed by
or on behalf of the contractor that all qualified applicants will receive
consideration for employment without unlawful discrimination based on race,
creed, color, national origin, sex, age, disability, marital status or sexual
orientation, or that it is an equal employment opportunity employer;

  4.   will send to each labor organization or representative of workers with
which it has a collective bargaining agreement or other contract or memorandum
of understanding, written notification of its equal employment opportunity
commitments under E. O. 50 and the rules and regulations promulgated thereunder;
and

  5.   will furnish all information and reports including an Employment Report
before the award of the contract which are required by E. O. 50, the rules and
regulations promulgated thereunder, and orders of the Director of the Bureau of
Labor Services (“Bureau”), and will permit access to its books, records and
accounts by the Bureau for the purposes of investigation to ascertain compliance
with such rules, regulations, and orders. The contractor understands that in the
event of its noncompliance with nondiscrimination clauses of this contract or
with any of such rules, regulations, or orders, such noncompliance shall
constitute a material breach of the contract and noncompliance with the E. O. 50
and the rules and regulations promulgated thereunder. After a hearing held
pursuant to the rules of the Bureau, the Director may direct the imposition by
the contracting agency held of any or all of the following sanctions:

(i) disapproval of the contractor;

(ii) suspension or termination of the contract;
(iii) declaring the contractor in default; or

  (iv)   in lieu of any of the foregoing sanctions, the Director may impose an
employment program. The Director of the Bureau may recommend to the contracting
agency head that a Board of Responsibility be convened for purposes of declaring
a contractor who has repeatedly failed to comply with E.O. 50 and the rule and
regulations promulgated thereunder to be nonresponsible. The contractor agrees
to include the provisions of the foregoing paragraphs in every subcontract or
purchase order in excess of $50,000 to which it becomes a party unless exempted
by E.O. 50 and the rules and regulations promulgated thereunder, so that such
provisions will be binding upon each subcontractor or vendor. The contractor
will take such action with respect to any subcontract or purchase order as may
be directed by the Director of the Bureau of Labor Services as a means of
enforcing such provisions, including sanctions for noncompliance. The contractor
further agrees that it will refrain from entering into any contract or contract
modification subject to E.O. 50 and the rules and regulations promulgated
thereunder with a subcontractor who is not in compliance with the requirements
of E.O. 50 and the rules and regulations promulgated thereunder.

ARTICLE 13. NO DAMAGE FOR DELAY
The Contractor agrees to make no claim for damages for delay in the performance
of this Contract occasioned by any act or omission to act of the City or any of
its representatives, and agrees that any such claim shall be fully compensated
for by an extension of time to complete performance of the work as provided
herein.

ARTICLE 14. CONSULTANT REPORT INFORMATION
A copy of each consultant report submitted by a consultant to any City official
or to any officer, employee, agent or . representative of a City department,
agency, commission or body or to any corporation, association or entity whose
expenses are paid in whole or in part from the City treasury shall be furnished
to the Commissioner of the department to which such report was submitted or, if
not a City department, then to the chief controlling officer or officers of such
other office or entity. A copy of such report shall also be furnished to the
Director of the Mayor’s Office of Construction for matters related to
construction or to the Director of the Mayor’s Office of Operations for all
other matters.

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ARTICLE 15. RESOLUTION OF DISPUTES

15.1 All disputes between the City and the Contractor of the kind delineated in
this section that arise under, or by virtue of, this Contract shall be finally
resolved in accordance with the provisions of this section and Section 4-09 of
the Rules of the Procurement Policy Board (“PPB Rules”), and any successor Rule.
The procedure for resolving all disputes of the kind delineated herein shall be
the exclusive means of resolving any such disputes.

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

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

15.2 All determinations required by this section shall be made in writing,
clearly stated, with a reasoned explanation for the determination based on the
information and evidence presented to the party making the determination.
Failure to make such determination within the time period required by this
section shall be deemed a non-determination without prejudice that will allow
appeal to the next level.

15.3 During such time as any dispute is being presented, heard, and considered
pursuant to this section, the contract terms shall remain in full force and
effect and the Contractor shall continue to perform work in accordance with the
Contract and as directed by the Agency Chief Contracting Officer or Engineer.
Failure of the Contractor to continue the work as directed shall constitute a
waiver by the Contractor of any and all claims being presented pursuant to this
section and a material breach of Contract.

15.4 Presentation of Dispute to Agency Head.

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

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

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

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(D) Finality of Agency Head Decision. The Agency Head’s decision shall be final
and binding on all parties, unless presented to the Contract Dispute Resolution
Board pursuant to this section. The City may not take a petition to the Contract
Dispute Resolution Board. However, should the Contractor take such a petition,
the City may seek, and the Board may render, a determination less favorable to
the Contractor and more favorable to the City than the decision of the Agency
Head.

15.5 Presentation of Dispute to the Comptroller. Before any dispute may be
brought by the Contractor to the Contract Dispute Resolution Board, the
Contractor must first present its claim to the comptroller for his or her
review, investigation, and possible adjustment.

(A) Time, Form, and Content of Notice. Within thirty (30) days of its receipt of
a decision by the Agency Head, the Contractor shall submit to the Comptroller
and to the Agency Head a Notice of Claim regarding its dispute with the Agency.
The Notice of Claim shall consist of (i) a brief written statement of the
substance of the dispute, the amount of money, if any, claimed and the reason(s)
the Contractor contends the dispute was wrongly decided by the Agency Head;
(ii) a copy of the written decision of the Agency Head, and (iii) a copy of all
materials submitted by the Contractor to the Agency, including the Notice of
Dispute. The Contractor may not present to the Comptroller any material not
presented to the Agency Head, except at-the request of the Comptroller.

(B) Agency Response. Within thirty (30) days of receipt of the Notice of Claim,
the Agency shall make available to the Comptroller a copy of all material
submitted by the Agency to the Agency Head in connection with the dispute. The
Agency may not present to the Comptroller any material not presented to the
Agency Head except at the request of the Comptroller.

(C) Comptroller Investigation. The Comptroller may investigate the claim in
dispute and, in the course of such investigation, may exercise all powers
provided in sections 7-201 and 7-203 of the New York City Administrative Code.
In addition, the Comptroller may demand of either party, and such party shall
provide, whatever additional material the Comptroller deems pertinent to the
claim, including original business records of the Contractor. Willful failure of
the Contractor to produce within fifteen (15) days any material requested by the
Comptroller shall constitute a waiver by the Contractor of its claim. The
Comptroller may also schedule an informal conference to be attended by the
Contractor, Agency representatives, and any other personnel desired by the
Comptroller.

(D) Opportunity of Comptroller to Compromise or Adjust Claim. The Comptroller
shall have forty-five (45) days from his or her receipt of all materials
referred to in 5. (C) to investigate the disputed claim. The period for
investigation and compromise may be further extended by agreement between the
Contractor and the Comptroller, to a maximum of ninety (90) days from the
Comptroller’s receipt of all the materials. The Contractor may not present its
petition to the Contract Dispute Resolution Board until the period for
investigation and compromise delineated in this paragraph has expired. In
compromising or adjusting any claim hereunder, the Comptroller may not revise or
disregard the terms of the Contract between the parties.

15.6 Contract Dispute Resolution Board. There shall be a Contract Dispute
Resolution Board composed of:

  A.   the chief administrative law judge of the Office of Administrative Trials
and Hearings (“OATH”) or his/her designated OATH administrative law judge, who
shall act as chairperson, and may adopt operational procedures and issue such
orders consistent with this section as may be necessary in the execution of the
Contract Dispute Resolution Board’s functions, including, but not limited to,
granting extensions of time to present or respond to submissions;

  B.   the City Chief Procurement Officer or a designee; or in the case of
disputes involving construction, the Director of the Office of Construction or
his/her designee; any designee shall have the requisite background to consider
and resolve the merits of the dispute and shall not have participated personally
and substantially in the particular matter that is the subject of the dispute or
report to anyone who so participated, and

  C.   a neutral person with appropriate expertise. This person shall be
selected by the presiding administrative law judge from a prequalified panel of
individuals, established and administered by OATH, with appropriate background
to act as decision-makers in a dispute. Such individuals may not have a contract
or dispute with the City or be an officer or employee of any company or
organization that does, or regularly represents persons. companies, or
organizations having disputes with the City.  

15.7 Petition to Contract Dispute Resolution Board. In the event the claim has
not been settled or adjusted by the Comptroller within the period provided in
this section, the Contractor, within thirty (30) days thereafter, may petition
the Contract Dispute Resolution Board to review the Agency Head determination.

(A) Comptroller’s Office. The Contractor shall concurrently submit four complete
sets of the Petition: one to the Corporation Counsel (Attn: Commercial and Real
Estate Litigation Division), and three to the Contract Dispute Resolution Board
at OATH’s offices with proof of service on the Corporation Counsel. In addition,
the supplier shall submit a copy of the statement of the substance of the
dispute, cited in (i) above to both the Agency Head and the Comptroller.

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(B) Agency Response. Within thirty (30) days of its receipt of the Petition by
the Corporation Counsel, the Agency shall respond to the brief written statement
of the Contractor and make available to the Board at OATH’s offices and one to
the Contractor. all material it submitted to the Agency Head and Comptroller.
Extensions of time for submittal of the agency response shall be given as
necessary upon a showing of good cause or, upon the consent of the parties, for
an initial period of up to thirty (30) days.

(C) Further Proceedings. The Board shall permit the Contractor to present its
case by the submission of memoranda, briefs, and oral argument. The Board shall
also permit the Agency to present its case in response to the Contractor by the
submission of memoranda, briefs, and oral argument. If requested by the
Corporation Counsel, the Comptroller shall provide reasonable assistance in the
preparation of the Agency’s case. Neither the Contractor nor the Agency may
support its case with any documentation or other material that was not
considered by the Comptroller, unless requested by the Board. The Board, at its
discretion, may seek such technical or other expertise as it shall deem
appropriate and may seek, on its own or upon application of a party, any such
additional material from any party as it deems fit. The Board, in its
discretion, may combine more than one dispute between the parties of concurrent
resolution.

(D) Contract Dispute Resolution Board Determination. Within forty-five (45) days
of the conclusion of all written submissions and oral arguments, the Board shall
render a written decision resolving the dispute. In an unusually complex case,
the Board may render its decision in a longer period of time, not to exceed
ninety (90) days, and shall so advise the parties at the commencement of this
period. The Board’s decision must be consistent with the terms of the Contract.
In reaching its decision, the Board shall accord no precedential significance to
prior decisions of the Board involving other non-related contracts.

(E) Notification of Contract Dispute Resolution Board Decision. The Board shall
send a copy of its decision to the Contractor, the Agency Chief Contracting
Officer, the Corporation Counsel, the Comptroller, and in the case of
construction or construction-related services, the Engineer. A decision in favor
of the Contractor shall be subject to the prompt payment provisions of the PPB
Rules. The Required Payment Day shall be thirty (30) days after the date the
parties are formally notified of the Board’s decision.

(F) Finality of Contract Dispute Resolution Board Decision. The Board’s decision
shall be final and binding on all parties. Any party may seek review of the
Board’s decision solely in the form of a challenge, made within four (4) months
of the date of the Board’s decision, in a court. Such review by the court shall
be limited to the question of whether or not the Board’s decision was made in
violation of lawful procedure, was affected by an error of law, or was arbitrary
and capricious or an abuse of discretion. No evidence or information shall be
introduced or relied upon in such proceeding that was not presented to the Board
in accordance with Section 4-09 of the PPB Rules.

15.8 Any termination, cancellation, or alleged breach of the Contract prior to
or during the pendency of any proceedings pursuant to this section shall not
affect or impair the ability of the Agency Head or Contract Dispute Resolution
Board to make a binding and final decision pursuant to this section.

ARTICLE 16. PROMPT PAYMENT
The Prompt Payment provisions set forth in Chapter 4, Section 4-06 of the
Procurement Policy Board Rules in effect at the time for this solicitation will
be applicable to payments made under this contract. The provisions require the
payment to the contractors of interest on payments made after the required
payment date except as set forth in Section 4-06 of the Rules.

The contractor must submit a proper invoice to receive payment, except where the
contract provides that the contractor will be paid at predetermined intervals
without having to submit an invoice for each scheduled payment.

Determinations of interest due will be made in accordance with the provisions of
the Procurement Policy Board Rules and General Municipal Law Section 3-a.

NFP.W/P.L.

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86

APPENDIX A -PART II

City of New York

GENERAL PROVISIONS GOVERNING CONTRACTS FOR CONSULTANTS,

PROFESSIONAL AND TECHNICAL SERVICES (For -Profit entities)

                  CONTENTS Page         ARTICLE 1. DEFINITIONS
    1   ARTICLE 2. REPRESENTATIONS AND
    1  
 
  WARRANTIES
       
ARTICLE 3.
  AUDIT BY THE DEPARTMENT
    2  
ARTICLE 4.
  AND CITY
    3  
 
  COVENANTS OF THE
       
ARTICLE 5.
  CONTRACTOR
    10  
 
  TERMINATION
       
ARTICLE 6.
  MISCELLANEOUS
    12  
ARTICLE 7.
  MERGER
    15  
ARTICLE 8.
  CONDITIONS PRECEDENT
    15  
ARTICLE 9.
  PPB RULES
    15  

ARTICLE 10. STATE LABOR LAW AND CITY 15 ADMINISTRATIVE CODE

         
ARTICLE 11. FORUM PROVISION
    16  
ARTICLE 12. EQUAL EMPLOYMENT
    17  
OPPORTUNITY ARTICLE 13. NO DAMAGE FOR DELAY
    18  
ARTICLE 14. CONSULTANT REPORT
    18  
INFORMATION ARTICLE 15. RESOLUTION OF DISPUTES
    18  
ARTICLE 16. PROMPT PAYMENT
    22  
ARTICLE 17. MACBRIDE PRINCIPLES
    22  

ARTICLE 1. DEFINITIONS

As used throughout this Agreement, the following

terms shall have the meaning set forth below:

a. “City” shall mean the City of New York, its

departments and political subdivisions.

b. “Comptroller” shall mean the Comptroller

of the City of New York.

c. “Department” or “Agency” shall mean the

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DEPARTMENT OF HEALTH AND MENTAL HYGIENE.
“Commissioner” or “Administrator” shall mean the COMMISSIONER OF HEALTH AND
MENTAL HYGIENE or his duly authorized. representative. The term “duly authorized
representative” shall include any person or persons acting within the limits of
his or her authority.
“Law” or “Laws” shall include but not be limited to the New York City Charter,
the New York City Administrative Code, a local law of the City of New York, and
any ordinance, rule or regulation having the force of law.
“Contractor”or”Consultant” shall mean

ARTICLE 2. REPRESENTATIONS AND WARRANTIES

2.1 PROCUREMENT OF AGREEMENT

  A.   The Contractor represents and warrants that no person or selling agency
has been employed or retained to solicit or secure this Agreement upon an
agreement or understanding for a commission, percentage, brokerage fee,
contingent fee or any other compensation. The Contractor further represents and
warrants that no payment, gift or thing of value has been made, given or
promised to obtain this or any other agreement between the parties. The
Contractor makes such representations and warranties to induce the City to enter
into this Agreement and the City relies upon such representations and warranties
in the execution hereof.

B. For a breach or violation of such representations or warranties, the
Administrator shall have the right to annul this Agreement without liability,
entitling the City to recover all monies paid hereunder and the Contractor shall
not make claim for, or be entitled to recover, any sum or sums due under this
Agreement. This remedy, if effected, shall not constitute the sole remedy
afforded the City for the falsity or breach, nor shall it constitute a waiver of
the City’s right to claim damages or refuse payment or to take any other action
provided for by law or pursuant to this Agreement.

87

2.2 CONFLICT OF INTEREST

The Contractor represents and warrants that neither it nor any of its directors,
officers, members, partners or employees, has any interest nor shall they
acquire any interest, directly or indirectly, which would or may conflict in any
manner or degree with the performance or rendering of the services herein
provided. The Contractor further represents and warrants that in the performance
of this Agreement no person having such interest or possible interest shall be
employed by it. No elected official or other officer or employee of the City or
Department, nor any person whose salary is payable, in whole or in part, from
the City Treasury, shall participate in. any decision relating to this Agreement
which affects his or her personal interest or the interest of any corporation,
partnership or association in which he or she is, directly or indirectly,
interested; nor shall any such person have any interest, direct or indirect, in
this Agreement or in the proceeds thereof.

2.3 FAIR PRACTICES

The Contractor and each person signing on behalf of any contractor represents
and warrants and certifies, under penalty of perjury, that to the best of its
knowledge and belief:

A. The prices in this contract have been arrived at independently without
collusion, consultation, communication, or agreement, for the purpose of
restricting competition, as to any matter relating to such prices with any other
bidder or with any competitor;

  B.   Unless otherwise required by law, the prices which have been quoted in
this contract and on the proposal submitted by the Contractor have not been
knowingly disclosed by the Contractor prior to the proposal opening, directly or
indirectly, to any other bidder or to any competitor; and  

  C.   No attempt has been made or will be made by the Contractor to induce any
other person, partnership or corporation to submit or not to submit a proposal
for the purpose of restricting competition.

The fact that the Contractor (a) has published price lists, rates, or tariffs
covering items being procured, (b) has. informed prospective customers of
proposed or pending publication of new or revised price lists for such items, or
(c) has sold the same items to other customers at the same prices being bid,
does not constitute, without more, a disclosure within the meaning of the above.

Agreement as may be required by said Department and said Comptroller so that
they may evaluate the reasonableness of the charges and shall make its records
available to the Department and to the Comptroller as they consider necessary.

  3.3   All books, vouchers, records, reports, canceled checks and any and all
similar material may be subject to periodic inspection, review and audit by the
State of New York, Federal Government and other persons duly authorized by the
City. Such audit may include examination and review of the source and
application of all funds whether from the City, any State, the Federal
Government, private sources or otherwise.

Profit.w/P.L. -2-

  3.4   The contractor shall not be entitled to final payment under the
Agreement until all requirements have been satisfactorily met.  

ARTICLE 4. COVENANTS OF THE CONTRACTOR
4.1 EMPLOYEES

  A.   All experts or consultants or employees of the Contractor who are
employed by the Contractor to perform work under this contract are neither
employees of the City nor under contract to the City and the Contractor alone is
responsible for their work, direction, compensation and personal conduct while
engaged under this Agreement. Nothing in this contract shall impose any
liability or duty on the City for the acts, omissions, liabilities or
obligations of the Contractor any person, firm company, agency, association,
expert, consultant, independent contractor, specialist, trainee, employee,
servant, or agent, or for taxes of any nature including but not limited to
unemployment insurance, workmen’s compensation, disability benefits and social
security, or, except as specifically stated in this contract, to any person,
firm or corporation.

The Contractor shall be solely responsible for all physical injuries or death to
its agents, servants, or employees or to any other person or damage to any
property sustained during its operations and work on the project under this
agreement resulting from any act of omission or commission or error in judgment
of any of its officers, trustees, employees, agents, servants, or independent
contractors, and shall hold harmless and indemnify the City from liability upon
any and all claims for damages on account of such injuries or death to any such
person or damages to property on account of any neglect, fault or default of the
Contractor, its officers, trustees, employees, agents, servants, or independent
contractors. The Contractor shall be solely responsible for the safety and
protection of all of its employees whether due to the negligence, fault or
default of the Contractor or not.

B. Workmen’s Compensation and Disability Benefits

If this Agreement be of such a character that the employees engaged thereon are
required to be insured by the provision of Chapter 615 of the Laws of 1922,
known as the “Workmen’s Compensation Law” and acts amendatory thereto, the
Agreement shall be void and of no effect unless the Contractor shall secure
compensation for the benefit of, and keep insured during the life of this
Agreement such employees in compliance with the provisions of said law,
inclusive of Disability Benefits,; and, shall furnish the Department with two
(2) certificates of these insurance coverages.

C. Unemployment Insurance

Unemployment Insurance coverage shall be obtained and provided by the Contractor
for its employees.

D. Minimum Wage

Except for those employees whose minimum wage is required to be fixed pursuant
to Section 220 of the Labor Law of the State of New York, all persons employed
by the Contractor in the performance of this Agreement shall be paid, without
subsequent deduction or rebate, unless expressly authorized by law, not less
than the minimum wage as prescribed by law. Any breach or violation of the
foregoing shall be deemed a breach or violation of a material provision of this
Agreement.

4.2 INDEPENDENT CONTRACTOR STATUS

The Contractor and the Department agree that the Contractor is an independent
contractor, and not an employee of the Department or the City of New York, and
that in accordance with such status as independent contractor, the Contractor
covenants and agrees that neither it nor its employees or agents will hold
themselves out as, nor claim to be, officers or employees of the City of New
York, or of any department, agency or unit thereof, by reason hereof, and that
they will not, by reason hereof, make any claim, demand or application to or for
any right or privilege applicable to an officer or employee of the City of New
York, including, but not limited to, Workmen’s Compensation coverage,
Unemployment Insurance Benefits, Social Security coverage or employee retirement
membership or credit.

4.3 INSURANCE
A. Insurance Requirements for Contractors

Contractors shall procure and maintain for the duration of the contract
insurance against claims for injuries to persons or damages to property which
may arise from or in connection with the performance of the work hereunder by
the Contractor, his agents, representatives, employees or subcontractors. All
required insurance policies shall be maintained with companies that may lawfully
issue the required policy and have an A.M. Best rating of at least A-7 or a
Standard and Poor’s rating of at least AA, unless prior written approval is
obtained from the Mayor’s Office of Operations. The cost of such insurance shall
be included in the Contractor’s bid.
a. Minimum Scope of Insurance

Coverage shall be at least as broad as:

  1.   Insurance Services Office form number GL 0002 (1/73) covering
Comprehensive General Liability and Insurance Services Office form number GL
0404 covering Broad Form Commercial General Liability Insurance General
Liability; or Insurance Services Office Commercial General Liability coverage
(“occurrence” form CG 0001).(ED 11/85).  

  2.   Insurance Services Office form number CA 0001 (Ed. 1/78) covering
Automobile Liability, code 1 “any auto” and endorsements CA 2232 and CA 0112.

  3.   Workers’ Compensation insurance as required by Labor Code of the State of
New York and Employers Liability insurance

b. Minimum Limits of Insurance

Contractor shall maintain limits no less than:
Comprehensive General Liability: $1,000,000.00 combined single limit per
accident for bodily injury and property damage.

Profit.w/P.L.
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1. Professional liability: 1 Million Dollars per occurrence; Three Million
Dollars Aggregate.
2. Workers’ Compensation and Employers Liability.

  3.   Workers’ Compensation limits as required by the Labor Code of the State
of New York Employers Liability limits of $1,000,000.00 per accident. Pursuant
to Section 57 of the NYS Workers’ Compensation Law, the vendor has submitted
proof of workers’ compensation and disability benefits coverage to the agency.

  c.   Deductibles and Self-Insured Retentions Any deductibles and self-insured
retentions must be declared to and approved by the Agency. At the option of the
Agency, either: the insurer shall reduce or eliminate such deductibles or
self-insured retentions as respects the Agency, its officers, officials and
employees; or the Contractor shall procure a bond guaranteeing payment of losses
and related investigations, claim administration and defense expenses.

1. General Liability and Automobile Liability Coverages

  a.   The City, its officers, officials and employees are to be covered as
insured as respects: liability arising out of activities performed by or on
behalf of the Contractor; products and completed operations of the Contractor;
premises owned, leases or used by the Contractor; or automobiles owned, leased,
hired or borrowed by the Contractor. The coverage shall contain no special
limitations on the scope of protection afforded to the City, its officers,
officials and employees.

  b.   The Contractor’s insurance coverage shall be primary insurance as respect
the City, its officers, officials, and employees. Any other insurance or
self-insurance maintained by the Agency, its officers, officials and employees
shall be excess of and not contribute with the Contractor’s insurance.

  c.   Any failure to comply with reporting provisions of the policies shall not
affect coverage provided to the Agency, its officers, officials, and employees.

  d.   The Contractor’s insurance shall apply separately to each insured against
whom claim is made or suit is brought, except with respect to the limits of the
insurers liability.

2. Workers Compensation and Employers Liability Coverage

The insurer shall agree to waive all rights of subrogation against the Agency,
its officers, officials, and employees for losses /rising from work performed by
the Contractor for Agency.

3. All Coverages

Each insurance policy required by this clause shall be endorsed to state that
coverage shall not be suspended, voided, canceled by either party, reduced in
coverage or in limits except after sixty (60) days prior written notice by
certified mail, return receipt requested, has been given to the City.

d. Acceptability of Insurers

Insurance is to be placed with insurers with a

88

Best’s rating of no less than an A.M. Best rating of at least A-7 or a Standard
and Poor’s rating of at least AA, unless prior written approval is obtained from
the Mayor’s Office of Operations.

e. Verification of Coverage

Contractor shall furnish the City with Certificates of Insurance effecting
coverage required by this clause. The Certificates for each insurance policy are
to be signed by a person authorized by that insurer to bind coverage on its
behalf. The Certificates are to be on forms provided by the Agency and are to be
received and approved by the Agency before work commences. The Agency reserves
the right to obtain complete, certified copies of all required insurance
policies, at any time.

f. Subcontractors

Contractor shall include all subcontractors as insured under its policies or
shall furnish separate Certificates for each subcontractor. All coverages for
subcontractors shall be subject to all of the requirements stated herein.

  B.   In the event that any claim is made or any action is brought against the
City arising out of negligent or careless acts of an employee of the Contractor,
either within or without the scope of his employment, or arising out of
Contractor’s negligent performance of this Agreement, then the City shall have
the right to withhold further payments hereunder for the purpose of set-off in
sufficient sums to cover the said claim or action. The rights and remedies of
the City provided for in this clause shall not be exclusive and are in addition
to any other rights and remedies provided by law or this Agreement.

4.4 PROTECTION OF CITY PROPERTY

  A.   The Contractor assumes the risk of, and shall be responsible for, any
loss or damage to City property, including property and equipment leased by the
City, used in the performance of this Agreement; and caused, either directly or
indirectly by the acts, conduct, omissions or lack of good faith of the
Contractor, its officers, managerial personnel and employees, or any person,
firm, company, agent or others engaged by the Contractor as expert, consultant,
specialist or subcontractor hereunder.

  B.   In the event that any such City property is lost or damaged, except for
normal wear and tear, then the City shall have the right to withhold further
payments hereunder for the purpose of set-off, in sufficient sums to cover such
loss or damage.

  C.   The Contractor agrees to indemnify the City and hold it harmless from any
and all liability or claim for damages due to any such loss or damage to any
such City property described in subsection A above.

  D.   The rights and remedies of the City provided herein shall not be
exclusive and are in addition to any other rights and remedies provided by law
or by this Agreement.

     
4.5
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CONFIDENTIALITY
 
   

All of the reports, information or data, furnished to or prepared, assembled or
used by the Contractor under this Agreement are to be held confidential, and
prior to publication, the Contractor agrees that the same shall not be made
available to any individual or organization without the prior written approval
of the Department.

4.6 BOOKS AND RECORDS

The Contractor agrees to maintain separate and accurate books, records,
documents and other evidence and accounting procedures and practices which
sufficiently and properly reflect all direct and indirect costs of any nature
expended in the performance of this Agreement.

4.7 RETENTION OF RECORDS

The Contractor agrees to retain all books, records, and other documents relevant
to this Agreement for six years after the final payment or termination of this
Agreement, whichever is later. City, State and Federal auditors and any other
persons duly authorized by the Department shall have full access to and the
right to examine any of said materials during said period.

4.8 COMPLIANCE WITH LAW

Contractor shall render all services under this Agreement in accordance with the
applicable provisions of federal, state and local laws, rules and regulations as
are in effect at the time such services are rendered.

INVESTIGATION CLAUSE

4.9

1. The parties to this agreement agree to cooperate fully and faithfully with
any investigation, audit or inquiry conducted by a State of New York (State) or
City of New York (City) governmental agency or authority that is empowered
directly or by designation to compel the attendance of witnesses and to examine
witnesses under oath, or conducted by the Inspector General of a governmental
agency that is a party in interest to the transaction, submitted bid, submitted
proposal, contract, lease, permit, or license that is the subject of the
investigation, audit or inquiry.
2.

(a) If any person who has been advised that his or her statement, and any
information from such statement, will not be used against him or her in any
subsequent criminal proceeding refuses to testify before a grand jury or other
governmental agency or authority empowered directly or by designation to compel
the attendance of witnesses and to examine witnesses under oath concerning the
award of or performance under any transaction, agreement, lease, permit,
contract, or license entered into with the City, the State, or any political
subdivision or public authority thereof, or the Port Authority of New York and
New Jersey, or any local development corporation within the City, or any public
benefit corporation organized under the laws of the State of New York, or;

2.
(b) If any person refuses to testify for a reason other than the assertion of
his or her privilege against self- incrimination in an investigation, audit or
inquiry conducted by a City or State governmental agency or authority empowered
directly or by designation to compel the attendance of witnesses and to take
testimony under oath, or by the Inspector General of the governmental agency
that is a party in interest in, and is seeking testimony concerning the award
of, or performance under, any transaction, agreement, lease, permit, contract,
or license entered into with the City, the State, or any political subdivision
thereof or any local development corporation within the City, then;
3.
(a) The commissioner or agency head whose agency is a party in interest to the
transaction, submitted bid, submitted proposal, contract, lease, permit, or
license shall convene a hearing, upon not less than five (5) days written notice
to the parties involved, to determine if any penalties should attach for the
failure of a person to testify.
(b) If any non-governmental party to the hearing requests an adjournment, the
commissioner or agency head who convened the hearing may, upon granting the
adjournment, suspend any contract, lease, permit, or license pending the final
determination pursuant to paragraph 5 below without the City incurring any
penalty or damages for delay or otherwise.

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

(a) The disqualification for a period not to

exceed five (5) years from the date of an adverse determination for any person,
or any

entity of which such person was a member at the time the testimony was sought,
from submitting bids for, or transacting business with, or entering into or
obtaining any contract, lease, permit or license with or from the City; and/or

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

  5.   The commissioner or agency head shall consider and address in reaching
his or her determination and in assessing an appropriate penalty the factors in
paragraphs (a) and (b) below. He or she may also

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any other information consider, if relevant and appropriate, the criteria
established in paragraphs (c) and (d) below in addition to which may be relevant
and appropriate:

(a) The party’s good faith endeavors or lack thereof to cooperate fully and
faithfully with any governmental investigation or audit, including but not
limited to the discipline, discharge, or disassociation of any person failing to
testify, the production of accurate and complete books and records, and the
forthcoming testimony of all other members, agents, assignees or fiduciaries
whose testimony is sought.

  (b)   The relationship of the person who refused to testify to any entity that
is a party to the hearing, including, but not limited to, whether the person
whose testimony is sought has an ownership interest in the entity and/or the
degree of authority and responsibility the person has within the entity.

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

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

6.

  (a)   The term “license” or “permit” as used herein shall be defined as a
license, permit, franchise or concession not granted as a matter of right.

  (b)   The term “person” as used herein shall be defined as any natural person
doing business alone or associated with another person or entity as a partner,
director, officer, principal or employee.

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

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

  7.   In addition to and notwithstanding any other provision of this agreement
the Commissioner or agency head may in his or her sole discretion terminate this
agreement upon not less than three (3) days written notice in the event
contractor fails to promptly report in writing to the Commissioner of
Investigation of the City of New York any solicitation of money, goods,
requests. for future employment or other benefit or thing of value, by or on
behalf of any employee of the City or other person, firm, corporation or entity
for any purpose which may be related to the procurement or obtaining of this
agreement by the contractor, or affecting the performance of this contract.

4.10 ASSIGNMENT

  A.   The Contractor shall not assign, transfer, convey or otherwise dispose of
this Agreement or of Contractor’s rights, obligations, duties, in whole or in
part, or of its right to execute it, or its right, title or interest in it or
any part thereof, or assign, by power of attorney or otherwise, any of the
notices due or to become due under this contract, unless the prior written
consent of the Administrator shall be obtained. Any such assignment, transfer,
conveyance or other disposition without such consent shall be void.

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

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

  D.   This Agreement may be assigned by the City to any corporation, agency or
instrumentality having authority to accept such assignment.

4.11 SUBCONTRACTING

  A.   The Contractor agrees not to enter into any subcontracts for the
performance of its obligations, in whole or in part, under this Agreement
without the prior written approval of the Department. Two copies of each such
proposed subcontract shall be submitted to the Department with the Contractor’s
written request for approval. All such subcontracts shall contain provisions
specifying:

  1.   that the work performed by the subcontractor must be in accordance with
the terms of the Agreement between the Department and the Contractor,  

2. that nothing contained in such agreement shall impair the rights of the
Department,

  3.   that nothing contained herein, or under the Agreement between the
Department and the Contractor, shall create any contractual relation between the
subcontractor and the Department, and  

  4.   that the subcontractor specifically agrees to be bound by the
confidentiality provision set forth in this Agreement between the Department and
the Contractor.  

  B.   The Contractor agrees that it is fully responsible to the Department for
the acts and omissions of the  

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subcontractors and of persons either directly or indirectly employed by them as
it is for the acts and omissions of persons directly employed by it.

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

  D.   The Contractor shall not in any way be relieved of any responsibility
under this Contract by any subcontract.  

4.12 PUBLICITY

  A.   The prior written approval of the Department is required before the
Contractor or any of its employees, servants, agents, or independent contractors
may, at any time, either during or after completion or termination of this
Agreement, make any statement to the press or issue any material for publication
through any media of communication bearing on the work performed or data
collected under this Agreement.

  B.   If the Contractor publishes a work dealing with any aspect of performance
under this Agreement, or of the results and accomplishments attained in such
performance, the Department shall have a royalty free, non-exclusive and

irrevocable license to reproduce, publish or otherwise use and to authorize
others to use the publication.

4.13 PARTICIPATION IN AN INTERNATIONAL BOYCOTT

  A.   The Contractor agrees that neither the Contractor nor any
substantially-owned affiliated company is participating or shall participate in
an international  

boycott in violation of the provisions of the Export Administration Act of 1979,
as amended, or the regulations of the United States Department of Commerce
promulgated thereunder.

B. Upon the final determination by the Commerce Department or any other agency
of the United States as to, or conviction of the Contractor or a
substantially-owned affiliated company thereof, participation in an
international boycott in violation of the provisions of the Export
Administration Act of 1979, as amended, or the regulations promulgated
thereunder, the Comptroller may, at his option, render forfeit and void this
contract.

  C.   The Contractor shall comply in all respects, with the provisions of
Section 6-114 of the Administrative Code of the City of New York and the rules
and regulations issued by the Comptroller thereunder.

4.14 INVENTIONS, PATENTS AND COPYRIGHTS

  A.   Any discovery or invention arising out of or developed in the course of
performance of this Agreement shall be promptly and fully reported to the
Department, and if this work is supported by a federal grant of funds, shall be
promptly and fully reported to the Federal Government for determination as to
whether patent protection on such invention shall be sought and how the rights
in the invention or discovery, including rights under any patent issued thereon,
shall be disposed of and administered in order to protect the public interest.

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

  C.   In no case shall subsections A and B of this section apply to, or prevent
the Contractor from asserting or protecting its rights in any report, document
or other data, or any invention which existed prior to or was developed or
discovered independently from the activities directly related to this Agreement.

4.15 INFRINGEMENTS

The Contractor shall be liable to the Department and hereby agrees to indemnify
and hold the Department harmless for any damage or loss or expense sustained by
the Department from any infringement by the Contractor of any copyright,
trademark or patent rights of design, systems, drawings, graphs, charts,
specifications or printed matter furnished or used by the Contractor in the
performance of this Agreement.

4.16 ANTI-TRUST

The Contractor hereby assigns, sells, and transfers to the City all right, title
and interest in and to any claims and causes of action arising under the
anti-trust laws of the State of New York or of the United States relating to the
particular goods or services purchased or procured by the City under this
Agreement.

      ARTICLE 5.TERMINATION
5.1
  TERMINATION OF AGREEMENT
 
   

  A.   The Department and/or City shall have the right to terminate this
Agreement, in whole or in part:  

1. Under any right to terminate as specified in any section of this Agreement.

  2.   Upon the failure of the Contractor to comply with any of the terms and
conditions of this Agreement.  

3. Upon the Contractor’s becoming insolvent.

  4.   Upon the commencement under the Bankruptcy Act of any proceeding by or
against the Contractor, either voluntarily or involuntarily.  

5. Upon the Commissioner’s determination, termination is in the best interest of
the City.

         
B.
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The Department or City shall give the Contractor  

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

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

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

  1.   Accounting for and refund to the Department or City, within thirty
(30) days, any unexpended funds which have been paid to the Contractor pursuant
to this agreement.

  2.   Furnishing within thirty (30) days an inventory to the Department or City
of all equipment, appurtenances and property purchased through or provided under
this Agreement carrying out any Department or City directive concerning the
disposition thereof.

  3.   Not incurring or paying any further obligation pursuant to this Agreement
beyond the termination date. Any obligation necessarily incurred by the
Contractor on account of this Agreement prior to receipt of notice of
termination and falling due after such date shall be paid by the Department or
City in accordance with the terms of this Agreement. In no event shall the word
“obligation,” as used herein, be construed as including any lease agreement,
oral or written, entered into between the Contractor and its landlord.

  4.   Turn over to the Department or City or its designees all books, records,
documents and material specifically relating to this Agreement.

  5.   Submit, within ninety (90) days; a final statement and report relating to
this Agreement. The report shall be made by a certified public accountant or a
licensed public accountant.

  E.   In the event the Department or City shall terminate this Agreement, in
whole or in part, as provided in paragraphs 1, 2, 3, or 4 of subsection A of
this section, the Department or City may procure, upon such terms and in such
manner as deemed appropriate, services similar to those so terminated, and the
Contractor shall continue the performance of this Agreement to the extent not
terminated hereby.

F. Not withstanding any other provisions of this contract, the Contractor shall
not be relieved of liability to the City for damages sustained by the City by
virtue of Contractor’s breach of the contract, and the City may withhold
payments to the Contractor for the purpose of set-off until such time as the
exact amount of damages due to the City from the Contractor is determined.

  G.   The provisions of the Agreement regarding confidentiality of information
shall remain in full force and effect following any termination.  

  H.   The rights and remedies of the City provided in this section shall not be
exclusive and are in addition to all other rights and remedies provided by law
or under this Agreement.

ARTICLE 6. MISCELLANEOUS

6.1 CONFLICT OF LAWS

All disputes arising out of this Agreement shall be interpreted and decided in
accordance with the laws of the State of New York.

6.2 GENERAL RELEASE

The acceptance by the Contractor or its assignees of the final payment under
this contract, whether by voucher, judgment of any court of competent
jurisdiction or any other administrative means, shall constitute and operate as
a general release to the City from any and all claims of and liability to the
Contractor arising out of the performance of this contract.

6.3 CLAIMS AND ACTIONS THEREON

  A.   No action at law or proceeding in equity against the City or Department
shall lie or be maintained upon any claim based upon this Agreement or arising
out of this Agreement or in any way connected with this Agreement unless the
Contractor shall have strictly complied with all requirements relating to the
giving of notice and of information with respect to such claims, all as herein
provided.

B. No action shall lie or be maintained against the City by Contractor upon any
claims based upon this Agreement unless such action shall be commenced within
six (6) months after the date of filing in the Office of the Comptroller of the
City of the certificate for the final payment hereunder, or within six
(6) months of the termination or conclusion of this Agreement, or within six
(6) months after the accrual of the Cause of Action, whichever first occurs.

Contractor shall diligently render to the

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  C.   In the event any claim is made or any action brought in any way relating
to the Agreement herein, the Department and/or the City of New York without
additional compensation any and all assistance which the Department and/or the
City of New York may require of the Contractor. The Contractor shall report to
the Department in writing within three (3) working days of the initiation by or
against the Contractor of any legal action or proceeding in connection with or
relating to this Agreement.

6.4 NO CLAIM AGAINST OFFICERS, AGENTS OR EMPLOYEES

No claim whatsoever shall be made by the Contractor against any officer, agent
or employee of the City for, or on account of, anything done or omitted in
connection with this contract.

6.5 WAIVER

Waiver by the Department of a breach of any provision of this Agreement shall
not be deemed to be a waiver of any other or subsequent breach and shall not be
construed to be a modification of the terms of the Agreement unless and until
the same shall be agreed to in writing by the Department or City as required and
attached to the original Agreement.

6.6 NOTICE

The Contractor and the Department hereby designate the business addresses
hereinabove specified as the places where all notices, directions or
communications from one such party to the other party shall be delivered, or to
which they shall be mailed. Actual delivery of any such notice, direction or
communication to a party at the aforesaid place, or delivery by certified mail
shall be conclusive and deemed to be sufficient service thereof upon such party
as of the date such notice, direction or communication is received by the
party. Such address may be changed at any time by an instrument in writing
executed and acknowledged by the party making such change and delivered to the
other party in the manner as specified above. Nothing in this section shall be
deemed to serve as a waiver of any requirements for the service of notice or
process in the institution of an action or proceeding as provided by law,
including the Civil Practice Law and Rules.

6.7 ALL LEGAL PROVISIONS DEEMED INCLUDED

It is the intent and understanding of the parties to this Agreement that each
and every provision of law.required to be inserted in this Agreement shall be
and is inserted herein. Furthermore, it is hereby stipulated that every such
provision is to be deemed to be inserted herein, and if, through mistake or
otherwise, any such provision is not inserted, or is not inserted in correct
form, then this Agreement shall forthwith upon the application of either party
be amended by such insertion so as to comply strictly with the law and without
prejudice to the rights of either party hereunder.

6.8 SEVERABILITY

If this Agreement contains any unlawful provision not an essential part of the
Agreement and which shall not appear to have been a controlling or material
inducement to the making thereof, the same shall be deemed of no effect and
shall upon notice by either party, be deemed stricken from the Agreement without
affecting the binding force of the remainder.

6.9 POLITICAL ACTIVITY

There shall be no partisan political activity or any activity to further the
election or defeat of any candidate for public, political or party office as
part of or in connection with this Agreement, nor shall any of the funds
provided under this

      Agreement be used for such purposes.

 
   
6.10
  MODIFICATION
 
   

This Agreement may be modified by the parties in writing in a manner not
materially affecting the substance hereof It may not be altered or modified
orally.

A. CONTRACT CHANGES
Changes may be made to this contract only as duly authorized by the Agency Chief
Contracting Officer of his or her designee. Vendors deviating from the
requirements of an original purchase order or contract without. a duly
authorized change order document, or written contract modification or amendment,
do so at their own risk. All such duly authorized changes, modifications and
amendments will be reflected in a written change order and become a part of the
original contract. Contract changes will be made only for work necessary to
complete the work included in the original scope of the contract, and for
non-material changes to the scope of the contract.. Changes are not permitted
for any material alteration in the scope of the work. Changes may include any
one or more of the following:

- Specification changes to account for design errors or omissions;

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

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

- Changes in delivery location;

- Changes in shipment method; and

- Any other change not inconsistent with §5-02 of the P.P.B. Rules (ed. 9/99),
or any successor Rule.

The Contractor may be entitled to a price adjustment for extra work performed
pursuant to a written change order. If any part of the contract work is
necessarily delayed by a change order, the Contractor may be entitled to an
extension of time for performance. Adjustments to price shall be validated for
reasonableness by using appropriate price and cost analysis.

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6.11 PARAGRAPH HEADINGS

Paragraph headings are inserted only as a matter of convenience and for
reference and in no way define, limit or describe the scope or intent of this
contract and in no way affect this contract.

6.12 NO REMOVAL OF RECORDS FROM

PREMISES

Where performance of this Agreement involves use by the Contractor of
Departmental papers, files, data or records at Departmental facilities or
offices, the Contractor shall not remove any such papers, files, data or
records, therefrom without the prior approval of the Department’s designated
official.

6.13 INSPECTION AT SITE

The Department shall have the right to have representatives of the Department or
of the City or of the State or Federal governments present at the site of the
engagement to observe the work being performed.

6.14 PRICING

  A.   The Contractor shall when ever required during the contract, including
but not limited to the time of bidding, submit cost or pricing data and formally
certify that, to the best of its knowledge and belief, the cost or pricing date
submitted was accurate, complete, and current as of a specified date. The
Contractor shall be required to keep its submission of cost and pricing date
current until the contract has been completed.

  B.   The price of any change order or contract modification subject to the
conditions of paragraph A, shall be adjusted to exclude any significant sums by
which the City finds that such price was based on cost or price data furnished
by the supplier which was inaccurate, incomplete, or not current as of the date
agreed upon between the parties.

  C.   Time for Certification. The Contractor must certify that the cost or
pricing data submitted are accurate, complete and current as of a mutually
determined date.

  D.   Refusal to Submit Data. When any contractor refuses to submit the
required data to support a price, the Contracting Officer shall not allow the
price.  

E. Certificate of Current Cost or Pricing Data.

Form of Certificate. In those cases when cost or pricing data is required,
certification shall be made using a certificate substantially similar to the one
contained in Chapter 4 of the PPB rules and such certification shall be retained
in the agency contract file.

ARTICLE 7. MERGER

This written Agreement contains all the terms and conditions agreed upon by the
parties hereto, and no other agreement, oral or otherwise, regarding the subject
matter of this Agreement shall be deemed to exist or to bind any of the parties
hereto, or to vary any of the terms contained herein.

ARTICLE 8. CONDITIONS PRECEDENT
This contract shall neither be binding nor effective unless:

A. Approved by the Mayor pursuant to the provisions of Executive Order No. 42,
dated October 9, 1975, in the event the Executive Order requires such approval;
and

  B.   Certified by the Mayor (Mayor’s Fiscal Committee created pursuant to
Executive Order No. 43, dated October 14, 1975) that performance thereof will be
in accordance with the City’s financial plan; and

  C.   Approved by the New York State Financial Control Board (Board) pursuant
to the New York State Financial Emergency Act for the City of New York, as
amended, (the “Act”), in the event regulations of the Board pursuant to the Act
require such approval.

  D.   It has been authorized by the Mayor and the Comptroller shall have
endorsed his certificate that there remains unexpended and unapplied a balance
of the appropriation of funds applicable thereto sufficient to pay the estimated
expense of carrying out this Agreement.

.The requirements of this section of the contract shall be in addition to, and
not in lieu of, any approval or authorization otherwise required for this
contract to be effective and for the expenditure of City funds.

ARTICLE 9. PPB RULES

This contract is subject to the Rules of the Procurement Policy Board of the
City of New York effective August 1, 1990,as amended. In the event of a conflict
between said Rules and a provision of this contract, the Rules shall take
precedence.

ARTICLE 10. STATE LABOR LAW AND CITY ADMINISTRATIVE CODE

1. As required by New York State Labor Law Section 220-e:

a. That in the hiring of employees for the performance of work under this
contract or any subcontract hereunder, neither the Contractor, Subcontractor,
nor any person acting on behalf of such Contractor or Subcontractor, shall by
reason of race, creed, color, sex or national origin discriminate against any
citizen of the State of New York who is qualified and available to perform the
work to which the employment relates;

  b.   That neither the Contractor, subcontractor, nor any person on his behalf
shall, in any manner, discriminate against or intimidate any employee hired for
the performance of work under this contract on account of race, creed, color,
sex or national origin;

  b.   That there may be deducted from the amount payable to the Contractor by
the City under this contract a penalty of five dollars for each person for each
calendar day during which such person was discriminated against or intimidated
in violation of the provisions of this contract; and

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  c.   That this contract may be canceled or terminated by the City and all
monies due or to become due hereunder may be forfeited, for a second or any
subsequent violation of the terms or conditions of this section of the contract.

  d.   The aforesaid provisions of this section covering every contract for or
on behalf of the State or a municipality for the manufacture, sale or
distribution of materials, equipment or supplies shall be limited to operations
performed within the territorial limits of the State of New York.  

2. As required by New York City Administrative Code Section 6-108:

  a.   It shall be unlawful for any person engaged in the construction,
alteration or repair of buildings or engaged in the construction or repair of
streets or highways pursuant to a contract with the City or engaged in the
manufacture, sale or distribution of materials, equipment or supplies pursuant
to a contract with the City to refuse to employ or to refuse to continue in any
employment any person on account of the race, color or creed of such person.

  b.   It shall be unlawful for any person or any servant, agent or employee of
any person, described in subdivision (a) above, to ask, indicate or transmit,
orally or in writing, directly or indirectly, the race, color, creed or
religious affiliation of any person employed or seeking employment from such  

person, firm or corporation.

  c.   Disobedience of the foregoing provisions shall be deemed a violation of a
material provision of this contract.

  d.   Any person, or the employee, manager or owner of or officer of such firm
or corporation who shall violate any of the provisions of this section shall,
upon conviction thereof, be punished by a fine of not more than one hundred
dollars or by imprisonment for not more than thirty days, or both.

ARTICLE 11. FORUM PROVISION

Choice of Law, Consent to Jurisdiction and Venue This Contract shall be deemed
to be executed in the City of New York, State of New York, regardless of the
domicile of the Contractor, and shall be governed by and construed in accordance
with the laws of the State of New York.

The parties agree that any and all claims asserted by or against the City
arising under this Contract or related thereto shall be heard and determined
either in the courts of the United States located in New York City (“Federal
Courts”) or in the courts of the State of New York (“New York State Courts”)
located in the City and County of New York. To effect this Agreement and intent,
the Contractor agrees:

  a.   If the City initiates any action against the Contractor in Federal Court
or in New York State Court, service of process may be made on the Contractor
either in person, wherever such Contractor may be found, or by registered mail
addressed to the Contractor at its address as set forth in this Contract, or to
such other address as the Contractor may provide to the City in writing; and

  b.   With respect to any action between the City and the Contractor in New
York State Court, the Contractor hereby expressly waives and relinquishes any
rights it might

otherwise have (I) to move to dismiss on grounds of forum non conveniens;
(ii) to remove to Federal Court; and (iii) to move for a change of venue to a
New York State Court outside New York County.

  c.   With respect to any action between the City and the Contractor in Federal
Court located in New York City, the Contractor expressly waives and relinquishes
any right it might otherwise have to move to transfer the action to a United
States Court outside the City of New York.

  d.   If the Contractor commences any action against the City in a court
located other than in the City and State of New York, upon request of the City,
the Contractor shall either consent to a transfer of the action to a court of
competent jurisdiction located in the City and State of New York or, if the
court. where the action is initially brought will not or cannot transfer the
action, the Contractor shall consent to dismiss such action without prejudice
and may thereafter reinstitute the action in a court of competent jurisdiction
in New York City. If any provision(s) of this Article is held unenforceable for
any reason, each and all other provisions) shall nevertheless remain in full
force and effect.

ARTICLE 12. EOUAL EMPLOYMENT OPPORTUNITY

This contract is subject to the requirements of Executive Order No. 50 (1980) as
revised (“E.O. 50”) and the Rules and Regulations promulgated thereunder. No
contract will be awarded unless and until these requirements have been complied
with in their entirety. By signing this contract, the contractor agrees that it:

  1.   will not engage in any unlawful discrimination against any employee or
applicant for employment because of race, creed, color, national origin, sex
age, disability, marital status or sexual orientation with respect to all
employment decisions including, but not limited to, recruitment, hiring,
upgrading, demotion, downgrading, transfer, training, rates of pay or other
forms of compensation, layoff, termination, and all other terms and conditions
of employment;  

  2.   the contractor agrees that when it subcontracts it will not engage in any
unlawful discrimination in the selection of subcontractors on the basis of the
owner’s race, color, creed, national origin, sex, age, disability, marital
status or sexual orientation;

  3.   will state in all solicitations or advertisements for employees placed by
or on behalf of the contractor that all qualified applicants will receive
consideration for employment without unlawful discrimination based on race,
creed, color, national origin, sex, age, disability, marital status or sexual
orientation, or that it is an equal employment opportunity employer;

  4.   will send to. each labor organization or representative of workers with
which it has a collective bargaining agreement or other contract or memorandum
of understanding, written notification of its equal employment opportunity
commitments under E. O. 50 and the rules and regulations promulgated thereunder;
and

Profit.w/P.L. -11-

  3.   will furnish all information and reports including an Employment Report
before the award of the contract which are required by E. O. 50, the rules and
regulations promulgated thereunder, and orders of the Director of the Bureau of
Labor Services (“Bureau”), and will permit access to its books, records and
accounts by the Bureau for the purposes of investigation to ascertain compliance
with such rules, regulations, and orders.

The contractor understands that in the even of its noncompliance with
nondiscrimination clauses of this contract or with any of such rules,
regulations, or orders, such noncompliance shall constitute a material breach of
the contract and noncompliance with the E. O. 50 and the rules and regulations
promulgated thereunder. After a hearing held pursuant to the rules of the
Bureau, the Director may direct the imposition by the contracting agency held of
any or all of the following sanctions:
(I) disapproval of the contractor;
(ii) suspension or termination of the contract;
(iii) declaring the contractor in default; or

in lieu of any of the foregoing sanctions, the Director may impose an employment
program.

The Director of the Bureau may recommend to the contracting agency head that a
Board of Responsibility be convened for purposes of declaring a contractor who
has repeatedly failed to comply with E.O. 50 and the rule and regulations
promulgated thereunder to be nonresponsible. The contractor agrees to include
the provisions of the foregoing paragraphs in every subcontract or purchase
order in excess of $50,000 to which it becomes a party unless exempted by E.O.
50 and the rules and regulations promulgated thereunder, so that such provisions
will be binding upon each subcontractor or vendor. The contractor will take such
action with respect to any subcontract or purchase order as may be directed by
the Director of the Bureau of Labor Services as a means of enforcing such
provisions, including sanctions for noncompliance. .
The contractor further agrees that it will refrain from entering into any
contract or contract modification subject to E.O. 50 and the rules and
regulations promulgated thereunder with a subcontractor who is not in compliance
with the requirements of E.O. 50 and the rules and regulations promulgated
thereunder.

ARTICLE 13. NO DAMAGE FOR DELAY The Contractor agrees to make no claim for
damages for delay in the performance of this Contract occasioned by any act or
omission to act of the City or any of its representatives, and agrees that any
such claim shall be fully compensated for by an extension of time to complete
performance of the work as provided herein.

ARTICLE 14. CONSULTANT REPORT INFORMATION
A copy of each consultant report submitted by a consultant to any City official
or to any officer, employee, agent or representative of a City department,
agency, commission or body or to any corporation, association or entity whose
expenses are paid in whole or in part from the City treasury shall be furnished
to the Commissioner of the department to which such report was submitted or, if
not a City department, then to the chief controlling officer or officers of such
other office or, entity. A copy of such report shall also be furnished to the
Director of the Mayor’s Office of Construction for matters related to
construction or to the Director of the Mayor’s Office of Operations for all
other matters.

ARTICLE 15. RESOLUTION OF DISPUTES

15.1 All disputes between the City and the Contractor of the kind delineated in
this section that arise under, or by virtue of, this Contract shall be finally
resolved in accordance with the provisions of this section and Section 5-11 of
the Rules of the Procurement Policy Board (“PPB Rules”). The procedure for
resolving all disputes of the kind delineated herein shall be the exclusive
means of resolving any such disputes.

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

b. For construction and construction-related services this section shall apply
only to

disputes about the scope of work delineated by the Contract, the interpretation
of Contract Documents, the amount tp be paid for extra work or disputed work
performed in connection with the Contract, the conformity of the Contractor’s
work to the Contract, and the acceptability and quality of the Contractor’s
work; such disputes arise when the Engineer makes a determination with which the
Contractor disagrees.

15.2 All determinations required by this section shall be made in writing,
clearly stated, with a reasoned explanation for the determination based on the
information and evidence presented to the party making the determination.
Failure to make such determination within the time period required by this
section shall be deemed a non-determination without prejudice that will allow
appeal to the next level.

15.3 During such time as any dispute is being presented, heard, and considered
pursuant to this section, the contract terms shall remain in full force and
effect and the Contractor shall continue to perform work in accordance with the
Contract and : as directed by the Agency Chief Contracting Officer or Engineer.
Failure of the Contractor to continue the work as directed shall constitute a
waiver by the Contractor of any and all claims being presented pursuant to this
section and a material breach of Contract.

15.4 Presentation of Dispute to Agency Head.

(A) Notice of Dispute and Agency Response. The Contractor shall present its
dispute in writing (“Notice of Dispute”)

to the agency Head within the time specified herein or, if no time is specified,
within thirty (30) days of receiving

Profit.w/P.L.

-12-

notice of the determination or action that is the subject of the dispute. This
notice requirement shall not be read to replace any other notice requirements
contained in the Contract. The Notice of Dispute shall include all the facts,
evidence, documents, or other basis upon which the Contractor relies in support
of its position, as well as a detailed computation demonstrating how any amount
of money claimed by the Contractor in the dispute was arrived at. Within thirty
(30) days after receipt of the detailed written submission, the Agency Chief
Contracting Officer or, in the case of construction or construction-related
services, the Engineer shall submit to the Agency Head all materials he or she
deems pertinent to the dispute. Following initial submissions to the Agency
Head, either party may demand of the other the production of any document or
other material the demanding party believes may be relevant to the dispute.

The requested party shall produce all relevant materials that are not otherwise
protected by a legal privilege recognized by the courts of New York State. Any
question of relevancy shall be determined by the Agency Head whose decision
shall be final. Wilful failure of the Contractor to produce any requested
material whose relevancy the Contractor has not disputed, or whose relevancy has
been affirmatively determined, shall constitute a waiver by the Contractor of
its claim.

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

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

      (B)

89

(D) Finality of Agency Head Decision. The Agency Head’s decision shall be final
and binding on all parties, unless presented to the Contract Dispute Resolution
Board pursuant to this section. The City may not take a petition to the Contract
Dispute Resolution Board. However, should the Contractor take such a petition,
the City may seek, and the Board may render, a determination less favorable to
the Contractor and more favorable to the City than the decision of the Agency
Head.

15.5 Presentation of Dispute to the Comptroller. Before any dispute may be
brought by the Contractor to the Contract Dispute Resolution Board, the
Contractor must first present its claim to the comptroller for his or her
review, investigation, and possible adjustment.

  (A)   Time, Form, and Content of Notice. Within thirty (30) days of its
receipt of a decision by the Agency Head, the Contractor shall submit to the
Comptroller and to the Agency Head a Notice of Claim regarding its dispute with
the Agency. The Notice of Claim shall consist of (i) a brief written statement
of the substance of the dispute, the amount of money, if any, claimed and the
reason(s) the Contractor contends the dispute was wrongly decided by the Agency
Head; (ii) a copy of the written decision of the Agency Head, and (iii) a copy
of all materials submitted by the Contractor to the Agency, including the Notice
of Dispute. The Contractor may not present to the Comptroller any material not
presented to the Agency Head, except at-the request of the Comptroller.

  (B)   Agency Response. Within thirty (30) days of receipt of the Notice of
Claim, the Agency shall make available to the Comptroller a copy of all material
submitted by the Agency to the Agency Head in connection with the dispute. The
Agency may not present to the Comptroller any material not presented to the
Agency Head except at the request of the Comptroller.

(C) Comptroller Investigation. The Comptroller may

investigate the claim in dispute and, in the course of such investigation, may
exercise all powers provided in sections 7-201 and 7-203 of the New York City
Administrative Code. In addition, the Comptroller may demand of either party,
and such party shall provide, whatever additional material the Comptroller deems
pertinent to the claim, including original business records of the Contractor.
Wilful failure of the Contractor to produce within fifteen (15) days any
material requested by the Comptroller shall constitute a waiver by the
Contractor of its claim. The Comptroller may also schedule an informal
conference to be attended by the Contractor, Agency representatives, and any
other personnel desired by the Comptroller.

(D) Opportunity of Comptroller to Compromise or Adjust Claim. The Comptroller
shall have forty-five (45) days from his or her receipt of all materials
referred to in 5. (C) to investigate the disputed claim. The period for
investigation and compromise may be further extended by agreement between the
Contractor and the

Profit.w/P.L.
-13-

Comptroller, to a maximum of ninety (90) days from the Comptroller’s receipt of
all the materials. The Contractor may not present its petition to the Contract
Dispute Resolution Board until the period for investigation and compromise
delineated in this paragraph has expired. In compromising or adjusting any claim
hereunder, the Comptroller may not revise or disregard the terms of the Contract
between the parties.

15.6 Contract Dispute Resolution Board. There shall be a Contract Dispute
Resolution Board composed of:

(a) the chief administrative law judge of the Office of Administrative Trials
and Hearings (“OATH”) or his/her designated OATH administrative law judge, who
shall act as chairperson, and may adopt operational procedures and issue such
orders consistent with this section as may be necessary in the execution of the
Contract Dispute Resolution Board’s functions, including, but not limited to,
granting extensions of time to present or respond to submissions;

(b) the City Chief Procurement Officer or a designee; or in the case of disputes
involving construction, the Director of the Office of Construction or his/her
designee; any designee shall have the requisite background to consider and
resolve the merits of the dispute and shall not have participated personally and
substantially in the particular matter that is the subject of the dispute or
report to anyone who so participated, and

(c) a neutral person with appropriate expertise. This person shall be selected
by the presiding administrative law judge from a prequalified panel of
individuals, established and administered by OATH, with appropriate background
to act as decision-makers in a dispute. Such individuals may not have a contract
or dispute with the City or be an officer or employee of any company or
organization that does, or regularly represents persons. companies, or
organizations having disputes with the City.

15.7 Petition to Contract Dispute Resolution Board. In the event the claim has
not been settled or adjusted by the Comptroller within the period provided in
this section, the Contractor, within thirty (30) days thereafter, may petition
the Contract Dispute Resolution Board to review the Agency Head determination.

(A) Form and Content of Petition by Contractor. The Contractor shall present its
dispute to the Contract Dispute Resolution Board in the form of a Petition,
which shall include (i) a brief written statement of the substance of the
dispute, the amount of money, if any, claimed and the reason(s) the Contractor
contends that the dispute was wrongly decided by the Agency Head; (ii)a copy of
the written decision of the Agency Head; (b)copies of all materials submitted by
the Contractor to the Agency; (iv) a copy of the written decision of the
Comptroller, if any, and (v) copies of all correspondence with, or written
material submitted by the Contractor to, the Comptroller’s Office. The
Contractor shall concurrently submit four complete sets of the Petition: one to
the Corporation Counsel (Attn: Commercial and Real

(ii)

90 Estate Litigation Division), and three to the Contract Dispute Resolution
Board at OATH’s offices with proof of service on the Corporation Counsel. In
addition, the supplier shall submit a copy of the statement of the substance of
the dispute, cited in (i) above to both the Agency Head and the Comptroller.

(B) Agency Response. Within thirty (30) days of its receipt of the Petition by
the Corporation Counsel, the Agency shall respond to the brief written statement
of the Contractor and make available to the Board at OATH’s offices and one to
the Contractor. all material it submitted to. the Agency Head and Comptroller.
Extensions of time for submittal of the agency response shall be given as
necessary upon a showing of good cause or, upon the consent of the parties, for
an initial period of up to thirty (30) days.

(C) Further Proceedings. The Board shall permit the Contractor to present its
case by the submission of memoranda, briefs, and oral argument. The Board shall
also permit the Agency to present its case in response. to the Contractor by the
submission of memoranda, briefs, and oral argument. If requested by the
Corporation Counsel, the Comptroller shall provide reasonable assistance in the
preparation of the Agency’s case. Neither the Contractor nor the Agency may
support its case with any documentation or other material that was not
considered by the Comptroller, unless requested by the Board. The Board, at its
discretion, may seek such technical or other expertise as it shall deem
appropriate and may seek, on its own or upon application of a party, any such
additional material from any party as it deems fit. The Board, in its
discretion, may combine more than one dispute between the parties of concurrent
resolution.

Contract Dispute Resolution Board Determination. Within forty-five (45) days of
the conclusion of all written submissions and oral arguments, the Board shall
render a written decision resolving the dispute. In an unusually complex case,
the Board may render its decision in a longer period of time, not to exceed
ninety (90) days, and shall so advise the parties at the commencement of this
period. The Board’s decision must be consistent with the terms of the Contract.
In reaching its decision, the Board shall accord no precedential significance to
prior decisions of the Board involving other non-related contracts.

(D) Notification of Contract Dispute Resolution Board Decision. The Board shall
send a copy of its decision to the Contractor, the Agency Chief Contracting
Officer, the Corporation Counsel, the Comptroller, and in the case of
construction or construction-related services, the Engineer. A decision in favor
of the Contractor shall be subject to the prompt payment provisions of the PPB
Rules. The Required Payment Day shall be thirty (30) days after the date the
parties are formally notified of the Board’s decision.

Profit.w/P.L.
-14-

(E) Finality of Contract Dispute Resolution Board Decision. The Board’s decision
shall be final and binding on all parties. Any party may seek review of the
Board’s decision solely in the form of a challenge, made within four (4) months
of the date of the Board’s decision, in a court of competent jurisdiction of the
State of New York, County of New York, pursuant to Article 78 of the Civil
Practice Law and Rules. Such review by the court shall be limited to the
question of whether or not the Board’s decision was made in violation of lawful
procedure, was affected by an error of law, or was arbitrary and capricious or
an abuse of discretion. No evidence or information shall be introduced or relied
upon in such proceeding that was not presented to the Board in accordance with
Section 5-11 of the PPB Rules.

15.8 Any termination, cancellation, or alleged breach of the Contract prior to
or during the pendency of any proceedings pursuant to this section shall not
affect or impair the ability of the Agency Head or Contract Dispute Resolution
Board to make a binding and final decision pursuant to this section.

ARTICLE 16. PROMPT PAYMENT
The Prompt Payment provisions set forth in Chapter 5, Section 5-07 of the
Procurement Policy Board Rules in effect at the time for this solicitation will
be applicable to payments made under this contract. The provisions require the
payment to the contractors of interest on payments made after the required
payment date except as set forth in subdivisions c(3) and d(2), (3), (4) and
(5) of Section 5-07 of the Rules.

The contractor must submit a proper invoice to receive payment, except where the
contract provides that the contractor will be paid at predetermined intervals
without having to submit an invoice for each scheduled payment.

Determinations of interest due will be made in accordance with the provisions of
the Procurement Policy Board Rules and General Municipal Law Section 3-a.

ARTICLE 17. .

MACBRIDE PRINCIPLES PROVISIONS FOR NEW YORK CITY CONTRACTORS

ARTICLE I. MACBRIDE PRINCIPLES NOTICE TO ALL PROSPECTIVE CONTRACTORS

Local Law No. 34 of 1991 became effective on September 10, 1991 and added
section 6-115.1 to the Administrative Code of the City of New York. The local
law provides for certain restrictions on City contracts to express the
opposition of the people of the City of New York to employment discrimination
practices in Northern Ireland and to encourage companies doing business in
Northern Ireland to promote freedom of workplace opportunity.

Pursuant to Section 6-115.1, prospective contractors for contracts to provide
goods or services involving an expenditure of an amount greater than ten
thousand dollars, or for construction involving an amount greater than fifteen
thousand dollars, are asked to sign a rider in which they covenant and
represent, as a material

condition of their contract, that any business in Northern Ireland operations
conducted by the contractor and any individual or legal entity in which the
contractor holds a ten percent or greater ownership interest and any individual
or legal entity that holds a ten percent or greater ownership interest in the
contractor will be conducted in accordance with the MacBride Principles of
nondiscrimination in employment.
Prospective contractors are not required to agree to these conditions. However,
in the case of contracts let by competitive sealed bidding, whenever the lowest
responsible bidder has not agreed to stipulate to the conditions set forth in
this notice and another bidder who has agreed to stipulate to such conditions
has submitted a bid within five percent of the lowest responsible bid for a
contract to supply: goods, services or construction of comparable quality, the
contracting entity shall refer such bids to the Mayor, the Speaker or other
officials, as appropriate, who may determine, in accordance with applicable law
and rules, that it is in the best interest of the city that the contract be
awarded to other than the lowest responsible bidder pursuant to
Section 313(b)(2) of the City Charter.
In the case of contracts let by other than competitive sealed bidding, if a
prospective contractor does not agree to these conditions, no agency, elected
official or the Council shall award the contract to that bidder unless the
entity seeking to use the goods, services or construction certifies in writing
that the contract is necessary for the entity to perform its functions and there
is no other responsible contractor who will supply goods, services or
construction of comparable quality at a comparable price.

PART A

In accordance with section 6-115.1 of the Administrative Code of the City of New
York, the contractor stipulates that such contractor and any individual or legal
entity in which the contractor holds a ten percent or greater ownership interest
and any individual or legal entity that holds a ten percent or greater ownership
interest in the contractor either (a) have no business operations in Northern
Ireland, or (b) shall take lawful steps in good faith to conduct any business
operations they have in Northern Ireland in accordance with the MacBride
Principles, and shall permit independent monitoring of their compliance with
such principles.

PART B

For purposes of this section, the following terms shall have the following
meanings:

1. “MacBride Principles” shall mean those

principles relating to nondiscrimination in employment and freedom of workplace
opportunity which require employers doing business in Northern Ireland to:

(1) increase the representation of individuals from under represented religious
groups in the work force, including managerial, supervisory, administrative,
clerical and technical jobs;

Profit.w/P.L. -15-

(2) take steps to promote adequate security for the protection of employees from
under represented religious groups both at the workplace and while traveling to
and from work;
(3) ban provocative religious or political emblems from the workplace;
(4) publicly advertise all job openings and make special recruitment efforts to
attract applicants from under represented religious groups;
(5) establish layoff, recall and termination procedures which do not in practice
favor a particular religious group;
(6) abolish all job reservations, apprenticeship restrictions and different
employment criteria which discriminate on the basis of religion;
(7) develop training programs that will prepare substantial numbers of current
employees from under represented religious groups for skilled jobs, including
the expansion of existing programs and the creation of new programs to train,
upgrade and improve the skills of workers from under represented religious
groups;

  (8)   establish procedures to assess, identify and actively recruit employees
from under represented religious groups with potential for further advancement;
and

(9) appoint a senior management staff member to oversee affirmative action
efforts and develop a timetable to ensure their full implementation.

ARTICLE II. ENFORCEMENT OF ARTICLE I.
The contractor agrees that the covenants and representation in Article I above
are material conditions to this contract. In the event the contracting entity
receives information that the contractor who made the stipulation required by
this section is in violation thereof, the contracting entity shall review such
information and give the contractor an opportunity to respond. If the
contracting entity finds that a violation has occurred, the entity shall have
the right to declare the contractor in default and/or terminate this contract
for cause and procure the supplies, services or work from’ another source in any
manner the entity deems proper. In the event of such termination, the contractor
shall pay to the entity, or the entity in its sole discretion may withhold from
any amounts otherwise payable to the contractor, the difference between the
contract price for the uncompleted portion of this contract and the cost to the
contracting entity of completing performance of this contract either itself or
by engaging another contractor or contractors. In the case of a requirements
contract, the contractor shall be liable for such difference in price for the
entire amount of supplies required by the contracting entity for the uncompleted
term of its contract. In the case of a construction contract, the contracting
entity shall also have the right to hold the contractor in partial or total
default in accordance with the default provisions of this contract, and/or may
seek debarment or suspension of the contractor. The rights and remedies of the
entity hereunder shall be in addition to, and not in lieu of, any rights and
remedies the entity has pursuant to this contract or by
operation of law.

91

APPENDIX B

92

Certification Regarding Lobbying
APPENDIX B
October 1, 2004
B•1
APPENDIX B
CERTIFICATION REGARDING LOBBYING

The undersigned certifies, to the best of his or her knowledge, that:

  1.   No Federal appropriated funds have been paid or will be paid to any
person by or on behalf of the Contractor for the purpose of influencing or
attempting to influence an officer or employee of any agency, a Member of
Congress, an officer or employee of a Member of Congress in connection with the
award of any Federal loan, the entering into of any cooperative agreement, or
the extension, continuation, renewal, amendment, or modification of any Federal
contract, grant, loan, or cooperative agreement.  

  2.   If any funds other.than Federal appropriated funds have been paid or will
be paid to any person for the purpose of influencing or attempting to influence
an officer or employee of any agency, a Member of Congress in connection with
the award of any Federal contract, the making of any Federal grant, the making
of any Federal loan, the entering into of any cooperative agreement, or the
extension, continuation, renewal, amendment, or mo.dification of any Federal
contract, grant, loan, or cooperative agreement, and the . Agreement exceeds
$100,000, the Contractor shall complete and submit Standard Form - LLL
“Disclosure Form to Report Lobbying”, in accordance with its instructions.

The Contractor shall include the provisions of this section in all provider
Agreements under this Agreement and require all Participating providers whose
Provider Agreements exceed $100,000 to certify and disclose accordingly to the
Contractor.

This certification is a material representation of fact upon which reliance was
place when this transaction was made or entered into. Submission of this
certification is a prerequisite for making or entering into this transaction
pursuant to U.S.C. Section 1352. The failure to file the required certification
shall subject the violator to a civil penalty of not less than $10,000 and not
more than $100,000 for each such failure.

DATE: 10/8/04

     
SIGNATURE: /s/ K Ajmani
 

 
   
TITLE: Karin Ajmani, President
 

 
     

 
   
ORGANIZATION:
  CarePlus LLC
 
   

93

APPENDLX B
October 1, 2004
B-2
Appendix C

New York State Department of Health

Guidelines for the Provision of

94

Family Planning and Reproductive Health Services
APPENDIX C
October 1, 2004
C-1
C.1
Guidelines for the Provision of
Family Planning and Reproductive Health Services

Enrollees may obtain family planning and or reproductive health services and HIV
blood testing and pre-and post-test counseling when performed as part of a
family planning encounter from either the Contractor or from any appropriate
MMIS-enrolled health care provider of the Enrollee’s choice. Pharmacy
prescriptions, Medical Supplies, and over the counter drugs are to be billed
fee-for-service by all providers.

Family planning services means the offering, arranging and furnishing of those
health services which enable individuals, including minors who may be sexually
active, to prevent or reduce the incidence of unwanted pregnancies.

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 or certified nurse
practitioner during the course of a family planning visit for the purpose of:-

  •   contraception, including insertion/removal of an intrauterine device
(IUD), insertion/renoval of Norplant, and injection procedures involving
Pharmaceuticals such as Depo-Provera;

     
-
  sterilization;
 
   
-
  screening, related diagnosis, and referral to participating provider for
pregnancy;
 
   
-
  medically-necessary induced abortions and for New York City recipients,
elective induced abortions.

Such services include those education and counseling services to render the
services effective. Medically-necessary induced abortions are procedures, either
medical or surgical, which result in the termination of pregnancy. The
determination of medical necessity shall include positive evidence of pregnancy,
with an estimate of its duration.

When clinically indicated, the following services may be provided as a part of a
family planning and reproductive health visit:

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

  •   screening, related diagnosis and referral for anemia, cervical cancer,
glycosuria, proteinuria, hypertension and breast disease.  

  •   screening and treatment for sexually transmissible disease.  

Providers of family planning and reproductive health care shall comply with all
of the requirements set forth in Sections 17 and 18 of the New York State Public
Health Law, and 10 NYCRR Section 751.9 and Part 753 relating to informed consent
and confidentiality.

The above family planning and reproductive health services 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 if they are covered contract services

95

APPENDIX C
October I, 2004
C-2
C.2
Guidelines for Plans that Include Family Planning and Reproductive Health
Services in Their Benefit Package

If the Contractor includes family planning and reproductive health services in
its benefit package, 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 from any network or non-network provider without referral or approval.
The notification must contain the following:

  1)   notification of the Medicaid 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 encounter) from either a
Contractor’s participating provider or any qualified non-network provider who
accepts Medicaid who undertakes to provide such services to them, without
referral, approval or notification;

  2)   a current list of qualified network family planning providers, within the
geographic area, including addresses and telephone numbers, who provide the full
range of family planning and reproductive health services. Contractor may also
choose to provide a list of qualified non-network Medicaid providers who provide
the full range of family planning and reproductive health services;

      3)’. information that the cost of the Enrollee’s care will be fully
covered by Medicaid, when services are obtained in accordance with #1 above,
regardless of where the Enrollee obtains services.

The Contractor must notify its participating providers that all claims for
family planning services must be billed to the Contractor and not the Medicaid
fee-for-service program.

96

APPENDIX C
October I, 2004
C-3
C.3
Guidelines For Policy And Procedures For Plans That Do Not
Include Family Planning Services In Their Capitation

Any Contractor who does not include family planning services in its Benefit
Package must notify all Enrollees and prospective Enrollees that these services
are not covered through the plan and submit a statement of the policy and
procedure they will use to inform Enrollees, prospective Enrollees, and network
providers using the following guidelines. The statement must be sent to
Director, Office of Managed Care, NYS Department of Health, Corning Tower,
Room 2001, Albany, NY 12237 before signing the contract.

The policy and procedure statement regarding family planning services must
contain the following:

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

  a.   Certain family planning and reproductive health services (such as
abortion, sterilization and birth control). are not covered by the Contractor.

  b.   Such services may be obtained through fee-for-service Medicaid from any
provider who accepts Medicaid.

  c.   No referral is needed for such services, and that there will be no cost
to the Enrollee for such services.

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

  a.   Through the Contractor’s written marketing materials, including the
member handbook.

  b.   Orally at the time of enrollment and any time an inquiry is made
regarding family planning and reproductive health services.

  c.   Included on any web site of the Contractor which includes information
concerning its Medicaid managed care program. Such information shall be
prominently displayed and easily navigated.

  3)   The procedure for informing the Contractor‘s primary care providers,
obstetricians, and gynecologists that the Contractor has elected not to cover
certain reproductive and family planning services, but that such Participating
Providers may provide, make referrals, or arrange for these services in
accordance with MA fee-for-service billing policies, 4) Mechanisms to inform the
Contractor’s providers who also participate in the fee-for-service Medicaid
program that, if they render non-covered reproductive health and family planning
services, they do so as a fee-for-service Medicaid practitioner, independent of
the Contractor.

  5)   The member handbook and marketing materials indicating that the
Contractor has elected not to cover certain reproductive health and family
planning services, and explaining the right of all Enrollees to secure such
services through fee-for-service Medicaid from any Medicaid provider/clinic
which offers these services.

  6)   With the advent of mandatory enrollment and auto-assignment, mechanisms
to provide all new Enrollees with an SDOH approved letter explaining how to
access family planning services and the SDOH approved or LDSS approved list of
family planning providers. This material will be furnished by SDOH or LDSS to
the plan and mailed with the first new member communication, prior to the
enrollment effective date.

  7)   If an Enrollee or prospective Enrollee requests information about these
non-covered services, the Contractor’s marketing or enrollment staff or member
services department will advise the Enrollee or prospective Enrollee as follows:
 

  a.   Family planning and reproductive health services such as abortion,
sterilization and birth control are not covered through the plan.  

APPENDIX C
October I, 2004
C-4

  b.   Enrollees can receive these non-covered services using their Medicaid
card from any doctor or clinic that provides these services and accepts
Medicaid.  

  c.   The Contractor will mail to each Enrollee or prospective Enrollee who
calls, a copy of the SDOH or LDSS approved letter explaining the Enrollee’s
right to receive these non-covered services and an SDOH approved or LDSS
approved list of family planning providers, who participate in Medicaid in the
Enrollee’s community. The Contractor will mail these materials within 48 hours
of the contact.  

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

  8)   The procedure for maintaining a manual log of all requests for such
information, including the date of the call, the Enrollee’s ID number, and the
date the SDOH approved letter and SDOH or LDSS approved list were mailed. The
Contractor will review this log monthly and upon request, submit a copy to SDOH
or the LDSS.  

Mechanisms to inform participating providers that, if requested by the Enrollee,
or, if in the provider’s best professional judgement, certain reproductive
health and family planning 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: (1) offer those services on a fee-for-service basis; or
(2) provide the Enrollee with a copy of the SDOH approved or LDSS approved list
of Medicaid family planning providers, or (3) give the Enrollee the member
services number to call to obtain this listing.

  10)   The Contractor must recognize 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 will
assist primary care providers in providing the highest quality care to the
Contractor’s Enrollees. The Contractor must acknowledge that medical record
information maintained by network providers may include information relating to
family planning services provided under the fee-for-service Medicaid program.

  11)   Quality assurance initiatives to ensure compliance with this policy.
These should include the following procedures:

  a.   The Contractor will submit any materials to be furnished to Enrollees and
providers relating to access to non-covered reproductive health and family
planning services to SDOH, Office of Managed Care for its review and approval
before issuance. Such . materials include, but are not limited to, member
handbooks, provider manuals, and marketing materials.

  b.   Monitoring calls to member services and providers will be conducted to
assess the quality of the information provided. These calls will be performed
weekly by the manager/director or his or her designee.

  c.   Every month, the plan will prepare a list of Enrollees who have been sent
a copy of the SDOH approved letter and the SDOH approved or LDSS approved list
of family planning providers. This information will be submitted to the Chief
Operating Officer and President/CEO on a monthly basis.

  d.   The Contractor will provide all new employees with a copy of this policy.
The Contractor’s orientation programs will include a thorough discussion of all
aspects of this policy and procedure. Annual retraining programs for all
employees will also be conducted to ensure continuing compliance with this
policy.

97

APPENDIX C
October I, 2004
C-5
Appendix D

New York State Department of Health

98

Marketing Guidelines
APPENDIX D
October 2004
D- l
MARKETING GUIDELINES
INTRODUCTION

The purpose of these guidelines is to provide an operational framework for
localities and Medicaid managed care organizations (MCOs) in the development of
MCO marketing plans, materials, and activities and to describe SDOH’s marketing
rules, MCO marketing requirements, and prohibited practices.

The guidelines are consistent with those issued to all states by the Health Care
Financing Administration (HCFA), U.S. Department of Health and Human Services
(DHHS) in August 1994. These guidelines are consistent with the requirements of
New York State.

APPENDIX D
October 1, 2004
D-2

99

A. Marketing Plans

  1.   The MCO shall develop a marketing plan that meets SDOH guidelines and any
local requirements as approved by the State Department of Health (SDOH).

  2.   The LDSS is responsible for the review and approval of MCO marketing
plans, using a SDOH approved checklist.

  3.   Approved marketing plans set forth the allowable terms and conditions and
the proposed activities that the MCO intends to undertake during the contract
period. Locally determined variations, as specified in Section E of this
Appendix, must be described in the MCO’s specific marketing plan for each LDSS
the MCO contracts with.

  4.   The MCO must have on file with the SDOH and each LDSS with which it will
contract, an approved marketing plan, prior to the contract award date or before
marketing and enrollment begin, whichever is sooner. Subsequent changes to, the
plan must be submitted to the LDSS or SDOH for approval at least sixty (60) days
before implementation.

  5.   The plan shall include: a stated marketing goal and strategies; marketing
activities; and staff training, development and responsibilities. The following
must be included in the plan’s description of materials to be used: distribution
methods; primary marketing locations, and a listing of the kinds of community
service events the MCO anticipates sponsoring and/or participating in, during
which it will provide information and/or distribute marketing materials.

  6.   The MCO must describe how it is able to meet the informational needs,
related to marketing, for the physical and cultural diversity of its potential
membership. This may include, but not be limited to, a description of the MCO’s
other-than English language provisions, interpreter services, alternate
communication mechanisms, including sign language, Braille, audio tapes, and/or
use of Telecommunications Device for the Deaf (TDD)/TTY services.

  7.   The MCO shall describe measures for monitoring and enforcing compliance
with the guidelines by its marketing representatives and its providers
including: the prohibition of door-to-door solicitation and cold-call
telephoning; a description of the development of pre-enrollee mailing lists,
that maintains client confidentiality and that honors the client’s express
request for direct contact by the MCO; the selection and distribution of
pre-enrollment gifts and incentives to consumers; and a description of the
training, compensation and supervision of its marketing representatives.

B. Marketing Materials

1. Definitions

  a)   Marketing materials generally include the concepts of advertising, public
service announcements, printed publications, and other broadcast or electronic
messages designed to increase awareness and interest in Medicaid managed care
and/or a MCO’s Medicaid managed care product. The target audience for these
marketing materials is Medicaid-eligible persons who are not enrolled in a
Medicaid managed care plan, and who are living in a defined service area.

  b)   Marketing materials include any information that references the Medicaid
managed care program, is intended for general distribution, and is produced in a
variety of print, broadcast, and direct marketing mediums. These generally
include: radio, television, billboards, newspapers, leaflets, informational
brochures, videos, telephone book yellow page ads, letters, and posters.
Additional materials requiring marketing approval include a listing of items to
be provided as nominal gifts or incentives.

2. Marketing Material Requirements

  a)   Marketing materials must be written in prose that is understood at a
fourth-to sixth-grade reading level and must be printed in at least ten
(10) point type.

APPENDIX D
October I, 2004
D-3

  b)   The Contractor must make available written marketing and other
informational materials (e.g., member handbooks) in a language other than
English whenever at least five percent (5%) of the potential Enrollees of the
Contractor in any county of the service area speak that particular language and
do not speak English as a first language. SDOH will inform the LDSS and LDSS
will inform the Contractor when the 5% threshold has been reached. Marketing
materials to be translated include those key materials, such as informational
brochures, that are produced for routine distribution, and which are included
within the MCO’s marketing plan. SDOH will determine the need for other than
English translations based on county specific census data or other available
measures.

  c)   Alternate forms of communications must be provided for persons with
visual, hearing, speech, physical, or developmental disabilities. These
alternate forms include Braille or audiotapes for the visually impaired, TTY
access for those with certified speech or hearing disabilities, and use of
American Sign Language and/or integrative technologies.  

  d)   The plan name, mailing address (and location, if different), and toll
free phone number must be prominently displayed on the cover of all multi-paged
marketing materials.  

  e)   Marketing materials must not contain false, misleading, or ambiguous
information—such as “You have been pre-approved for the XYZ Health Plan,” or “If
you do not choose a plan you will lose your Medicaid coverage,” or “You get
free, unlimited visits.” Materials must not use broad, sweeping statements— for
example, “If you are eligible for Medicaid, you are eligible for Medicaid
Managed Care and/or the XYZ Health Plan.”  

  f)   The material must accurately reflect general information, which is
applicable to the average consumer of Medicaid managed care.  

g) The Contractor may not use logos or wording used by government agencies if
such use could imply or cause confusion about a connection between a
governmental agency and the Contractor.

h) Marketing materials may not make reference to incentives that may be
available to Enrollees after they join a plan, such as “If you join the XYZ
Plan, you will receive a free baby carriage after you complete eight prenatal
visits.”

  i)   Marketing materials that are prepared for distribution or presentation by
the LDSS or enrollment broker must be provided in a manner that is easily
understood and appropriate to the target audience. The material covered must
include sufficient information to assist the individual in making an informed
choice of MCO.

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

3. Prior Approvals

  a)   The SDOH will review and approve MCO, marketing videos, materials for
broadcast (radio, television, or electronic), billboards, mass transit (bus,
subway or other livery) and statewide/regional print advertising materials.
These materials must be submitted to the SDOH for review. A copy must be
simultaneously provided to the LDSS.

b) The LDSS will review and approve the following marketing material:

i) MCO marketing plans;

  ii)   Scripts or outlines of presentations and materials used at health fairs
and other LDSS approved events and locations;  

APPENDIX D
October I, 2004
D-4

  iii)   All pre-enrollment written marketing materials — written marketing
materials include brochures and leaflets, and presentation materials used by
marketing representatives;  

  iv)   County specific MCO informational brochures to be included in LDSS
enrollment packets; and

v) All direct mailing from MCOs targeted to the Medicaid market.

  c)   Both SDOH and LDSS will adhere to a sixty (60) day “file and use” policy,
whereby materials submitted by the MCO must be reviewed and commented on within
sixty (60) days of submission or the MCO may assume the materials have been
approved if the reviewer has not submitted any written comment.

  d)   The Contractor shall submit all subcontracts, procedures, and materials
related to Marketing to Eligible Persons to the SDOH and/or LDSS for prior
written approval. The Contractor shall not enter into any subcontracts or use
any marketing subcontractors, procedures, or materials that the SDOH and/or LDSS
has not approved.

4. Dissemination of LDSS Outreach Materials

The Contractor shall provide to the LDSS and/or Enrollment Broker upon request,
a marketing/informational brochure or alternative :informational document that
describes coverage in the county specific service area.

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

C. Marketing Activities

1. Definitions

  a)   Marketing activities are occasions during which marketing information and
material regarding Medicaid managed care and information about a particular
MCO’s affiliated products are presented. Typically, such information is
presented both in verbal exchanges and through the distribution of written
materials, together with the giving away of nominal gifts. The informal nature
of the marketing activity requires MCOs to be forthright in their presentations
to allow potential Enrollees the exercise of informed choice, and localities
must provide the best assurances that marketing practices are consistent with
established guidelines. Any exchange of verbal marketing information must
include the following:

  i)   if the plan is not capitated for family planning services, the
representative must tell potential Enrollees that:

  a)   certain family planning and reproductive health services (such as
abortion, sterilization and birth control) are not covered by the Contractor;

  b)   whenever needed, such services may be obtained through fee-for-service
Medicaid from any provider who accepts Medicaid;

c) no referral is needed for such services;
d) there will be no cost to the enrollee for such services.

With prior local approval MCO’s may engage in. marketing activities that include
community-sponsored social gatherings, provider-hosted informational sessions,
or MCO-sponsored events. Events may include such activities as health fairs
workshops on health promotion, holiday parties, after school programs, raffles,
etc. These events must not be restricted to Medicaid Recipients only.

Media campaigns are the distribution of information/materials regarding the
Medicaid managed care program and/or a specific MCO for the purpose of
encouraging Medicaid recipients to join a managed care plan. All
mediums—including television, radio, billboards, subway and bus posters, and
electronic messages—must be pre-approved by the SDOH at least thirty (30) days
prior to the campaign. A copy must be simultaneously submitted to the SDOH and
the LDSS.

APPENDIX D
October1, 2004
D-5

2. Marketing Sites

  a)   With prior LDSS approval, MCOs may distribute approved marketing material
in such places as, an income support maintenance center, community centers (if
the center agrees and allows all MCOs to use the center), markets, pharmacies,
hospitals and other provider sites, schools, health fairs, a resource center
established by the LDSS or the enrollment counseling contractor, and other areas
where potential Enrollees are likely to gather.  

  b)   MCOs are PROHIBITED from door-to-door solicitation of potential
Enrollees, or distribution of material, and may not engage in “cold calling”
inquiries or solicitation.

  c)   MCOs are PROHIBITED from direct marketing or distribution of material in
hospital emergency rooms including emergency room waiting areas. Marketing may
not take place in patient rooms or treatment areas (except for waiting areas) or
other prohibited sites unless requested by the individual. LDSS may not allow
MCO to market in individual homes without permission of the individual.

  d)   MCOs may not require its Participating Providers to distribute
plan-prepared communications to their patients.

Participating Providers may display the marketing materials of their contracting
MCOs provided that appropriate notice is conspicuously posted for all other MCOs
with whom the Provider has a contract.

Participating Providers are encouraged to communicate with their patients about
managed care options and to advise their’ patients in determining the MCO that
best meets the health _needs of the patient and his/her family. Such advice,
whether presented verbally. or in writing, must be individually based and not
merely a promotion of one plan over another. Providers who wish to let their
patients know of their affiliation with one or more MCOs must list each MCO with
whom they hold contracts. In the event marketing material is included with such
communication, the material, together with the intended communication, must be
pre-approved by the LDSS before distribution.

  g)   In the event a provider is no longer affiliated with a particular MCO but
remains affiliated with other participant MCOs, the provider may notify
his/her/its patients of the new status and the impact of such change on the
patient.  

3 Restricted Marketing Activities

  a)   MCOs are PROHIBITED from misrepresenting the Medicaid program, the
Medicaid managed care program, or the program or policy requirements of the LDSS
or the SDOH.  

  b)   MCOs are PROHIBITED from purchasing or otherwise acquiring or using
mailing lists of Medicaid recipients from third party vendors, including
providers and LDSS offices.  

  c)   MCOs are PROHIBITED from using raffle tickets and event attendance or
sign-in sheets to develop mailing lists of potential Enrollees.  

d) MCOs may not discriminate against a potential Enrollee based on his/her
current health status or anticipated need for future health care. The MCO may
not discriminate on the basis of disability or perceived disability of an
Enrollee or their family member. Health assessments may not be performed by MCOs
prior to enrollment. MCOs may inquire about existing primary care relationships
of the applicant and explain whether and how such relationships may be
maintained. Upon request, each potential Enrollee shall be provided with a
listing of all Participating Providers including specialists and facilities in
the MCO’s network. The 1’v1CO may respond to a potential Enrollee’s question
about whether a particular specialist is in the network. However, MCOs are
prohibited from inquiring about the types of specialists utilized by the
potential Enrollee.

e) MCOs may not offer incentives of any kind to Medicaid recipients to join a
health plan. “Incentives” are defined as any type of inducement whose receipt is
contingent upon the recipients joining the plan..

APPENDIX D
October 1, 2004
D-6

100

  f)   MCOs are responsible for ensuring that their marketing representatives
engage in professional and courteous behavior in their interactions with LDSS
staff, staff from other health plans, and Medicaid clients. Examples of
inappropriate behavior include interfering with other health plan presentations,
talking negatively about another health plan, and participating with Medicaid
clients during the verification interview with LDSS staff.

  g)   MCOs may offer nominal gifts of not more than $5.00 in fair-market value
as part of a health fair or other marketing activity to stimulate interest in
managed care and/or the MCO. Such gifts must be pre-approved by the LDSS, and
offered without regard to enrollment. The MCO must submit a listing of intended
items to be distributed at marketing activities as nominal gifts. The submission
of actual samples or photographs of intended nominal gifts will not be routinely
required, but must be made available upon request by the state or local
reviewer. Listings of item donors or co-sponsors must be submitted along with
the description of items.

  h)   MCOs may offer its Enrollees rewards for completing a health goal, such
as finishing all prenatal visits, participating in a smoking cessation session,
attending initial ‘ orientation sessions upon enrollment, and timely completion
of immunizations or other health related programs. Such rewards may not exceed
$50.00 in fair-market value per Enrollee over a twelve (12) month period, and
must be related to a health goal. MCOs may not make reference to these rewards
in their pre-enrollment marketing materials or discussions and all such rewards
must be approved by the LDSS.  

  i)   MCOs may not offer compensation to marketing representatives, including
salary increases or bonuses, based solely on the number of individuals they
enroll. However, MCOs may base compensation of marketing representatives on
periodic performance evaluations which consider enrollment productivity as one
of several performance factors during a performance period, subject to the
following requirements:

  1)   “Compensation” shall mean any remuneration required to be reported as
income or compensation for federal tax purposes;

2) MCOs may not pay a “commission” or fixed amount per enrollment;

  3)   Bonuses may not be awarded more frequently than quarterly, and the annual
amount awarded as bonus compensation to a marketing representative may not
exceed 10% of his/her total annual compensation;

  4)   Performance evaluations used as a basis for such bonus or salary increase
shall be set forth in writing and available for inspection by SDOH or the LDSS;

  5)   Other appropriate factors which may be considered by an MCO in awarding
merit salary increase or bonuses to marketing representatives include but are
not limited to:

  •   Ratio of “clean” or successful enrollments submitted; quality of
applications;

  •   Attendance; adherence to marketing schedules; timeliness

  •   Observed marketing behavior; absence/paucity of complaints regarding
marketing conduct

  6)   Affiliated providers engaged in marketing on behalf of an MCO shall be
considered “marketing

representatives” for purposes of Section C (3)(i) of Appendix D.

  j)   Individuals employed by MCO’s as marketing representatives, and employees
of marketing subcontractors must have successfully completed a training program
about the basic concepts of managed care and the Medicaid recipients’ rights and
responsibilities relating to membership in managed care. MCOs must submit a copy
of the training curriculum for their marketing representatives to SDOH and the
LDSS as part of the marketing plan. The MCO shall be responsible for the
activities of its marketing representatives and the activities of any
subcontractor or management entity. A marketing representative means any
individual or entity engaged by the Contractor to market on behalf of the
Contractor.  

APPENDIX D
October 1, 2004
D-9

101

D. Marketing Infractions

  1.   Infractions of the marketing guidelines may result in the following
actions being taken by the LDSS to protect the interests of the program and its
clients. These actions shall be taken at the sole discretion of the LDSS.

  a)   If an MCO or its representative commits a first time infraction of
marketing guidelines and the LDSS deems the infraction to be minor or
unintentional in nature, the LDSS may issue a warning letter to the MCO.

  b)   For subsequent or more serious infractions, the LDSS may impose
liquidated damages of $2,000.00, or other appropriate non-monetary sanctions for
each infraction.

  c)   The LDSS may require the MCO to prepare- a corrective action plan. with a
specified deadline for implementation.

  d)   If the MCO commits further infractions, fails to pay liquidated damages
within the specified tirneframe or fails to implement a corrective action plan
in a timely manner or commits an egregious first-time infraction, the LDSS may:

  i)   prohibit the plan from conducting any marketing activities for a period
up to the end of the contract period;

  ii)   suspend new enrollments, other than newborns, for a period up to the
remainder of the contract; or

  iii)   terminate the contract pursuant to termination procedures described
therein.  

APPENDIX D
October 1, 2004
D-10

E. NEW YORK CITY SPECIFIC MARKETING GUIDELINES LDSS Name: City of New York

1. Marketing Definition

  a)   Notwithstanding any other definition of “marketing” contained in this
Agreement, in New York City “marketing” shall be defined to mean any activity of
the Contractor, subcontractor or individuals or entities affiliated with the
Contractor by which information about the Contractor is made known to potential
enrollees for the purpose of persuading such persons to enroll with the
Contractor.

2. Marketing Schedules

  a)   Contractor shall submit to the New York City Department of Health and
Mental Hygiene, Division of Health Care Access and Improvement, (“HCAI”), a
schedule of all marketing activities in accordance with instructions for
submitting the schedule and requisite formats provided by HCAI. The
instructions, time frames and formats may be modified by-HCAI with thirty days
prior notice to the Contractor.

b) HCAI may, in its sole discretion, waive the reporting of certain activities.

  c)   Contractor shall submit to HCAI a monthly calendar of events by the last
Monday of the preceding month, identifying major anticipated marketing events.  

3. Marketing Materials

a) One Page marketing flyers, newspaper print ad flyers, banners and posters
whose primary purpose is to promote name recognition of the Contractor’s plan
should contain the following:

     
[i]
  Contractor’s name and toll free telephone number and TTY
 
   
[ii]
  A contact telephone number for New York Medicaid CHOICE

b) One page marketing flyers should contain the following:

     
[i]
  Contractor’s name and toll free telephone number and TTY
 
   
[ii]
  A contact telephone number for New York Medicaid CHOICE

      [iii] General description of the Plan (i.e., identification of Contractor
as a Medicaid health plan, or health plan accepting Medicaid members, service
area)  

  c)   Multi-page marketing brochures should contain, in addition to the
information described in § 3(b)(i)-(iii) above, the following:  

      [i] General description of the benefit package, including optional
services not covered in the benefit package but available on a fee-for-service
basis (e.g. family planning, dental); description of how to obtain these carved
out services

[ii] The following information:

  (1)   the potential enrollee has a choice among several alternative managed
care plans in his/her neighborhood

  (2)   the potential enrollee will have a choice among at least three primary
care providers

  (3)   upon enrollment in a managed care plan, the enrollee will be required to
use his/her primary care provider and other plan providers exclusively for
medical care, except in certain limited circumstances  

APPENDIX D

October 1, 2004

NYC Speciflic Marketing Guidelines

  (4)   Upon enrollment in a managed care plan, the enrollee will have 90 days
to disenroll without cause, and thereafter will not be allowed to disenroll or
transfer without good cause for the next nine months

  (5)   All members of a family who enroll must enroll in the same plan except
in special cases

(6) Newborns will automatically be enrolled in the mother’s health plan

  (7)   Language advising prospective members to verify with the provider of
their choice that the provider participates in the Contractor’s network and is
available to serve the member  

  (8)   If the Contractor is not capitated for family planning services, the
marketing brochure must tell prospective members that:  

  •   Certain family planning and reproductive health services (such as
abortion, sterilization and birth control) are not covered by the Contractor;  

  •   Such services may be obtained through fee-for-service Medicaid from any
provider who accepts Medicaid; and  

  •   No referral is needed for such services and that there will be no cost to
the Enrollee for such services.

d) Foreign language translations of marketing materials need not be
independently reviewed by HCAI if Contractor uses a translation service
authorized by HCAI, and submits a letter by the Service attesting that it has
used its best efforts to accurately translate the marketing material into the
specified languages. At a minimum, the translation service must perform a
reverse translation, (translate the foreign language version back into English
and compare to original document). Translated materials must meet the
readability standards described in Section 13.7 of the Agreement.

e) The SDOH and LDSS will review and approve the following MCO marketing
materials submitted by MCOs whose service area and target population is limited
to NYC: marketing videos, materials for broadcast (radio, television, or
electronic), billboards, mass transit (bus, subway or other livery), and print
advertising materials. These materials must be submitted to the SDOH and LDSS
for review.

4. Marketing Encounters

  a)   Marketing encounters must clearly inform potential enrollees of the
Partnership Plan policies described in Section E 3(c)(ii) (1) through (8).  

  b)   Marketing representatives shall ask prospective enrollees whether they
are currently enrolled in another health plan, and shall not market to persons
who are enrolled in another health plan.

  c)   Marketing representatives must give a copy of the document, “What Managed
Care Plans are available .in my neighborhood” to prospective enrollees in each
marketing encounter.

  d)   Marketing representatives shall ask prospective enrollees whether they
currently have a provider whom they would like to continue to see, and shall
assist him/her in making sure that this provider is part of the Contractor’s
network.

  e)   Marketing representatives shall give a business card, identifying the
name of the representative, the name of the health plan, and a telephone contact
number (which may be the member services number for the health plan) to each
prospective enrollee so that he/she may ask follow-up questions. In the
alternative, the representative may have this information printed or stamped on
health plan marketing flyers or brochures which are distributed to each
prospective enrollee.  

APPENDIX D

October 1, 2004

NYC Speciflic Marketing Guidelines

5. Marketing In HRA Facilities

  a)   Contractor may conduct marketing activities within HRA facilities with
the prior approval of NYC HRA and must adhere to HRA procedures. HRA shall give
Contractor an allotted number of allowable marketing representatives at each HRA
facility, and Contractor shall not exceed this allotment. No other marketing
representatives for Contractor may market within a two block perimeter of an HRA
facility. At no time may a Contractor representative have access to HRA computer
systems. Marketing representatives are expected to adhere to LDSS policy
concerning confidentiality of all communications and information relating to
persons served by HRA.  

  b)   Marketing managers and or supervisors will be allowed to monitor their
staff at HRA facilities subject to reasonable limitations specified by HRA.
Managers/supervisors must wear visible identification and are prohibited from
actively marketing to clients.

6. Marketing Sites

  a)   The Contractor may not market at sites which were not reported on its
marketing schedule to HCAI.  

b) The Contractor shall not market in homeless shelters.

  c)   The Contractor shall not market in low income housing projects unless
permission is requested by the Contractor for a special event in the public
areas of the project, and approval is received in writing from the facility, and
a copy sent to HCAI with the marketing schedule.  

  d)   The Contractor shall not market within a two block perimeter of an HRA
facility (except as authorized by § 5(a) of these guidelines).  

e) The Contractor may not market in the same room or immediate proximity of
MAXIMUS presentations.

7. Marketing Conduct

  a)   All marketing activities shall be conducted in an orderly, non-disruptive
manner and shall not interfere with the privacy of potential enrollees or the
general community.  

8. Marketing Representatives

  a)   The Contractor’s marketing representatives must attend marketing training
sessions provided by HCAI, upon request from HCAI.  

  b)   Marketing representatives must wear visible badges with the name of the
plan and the representative’s name during all marketing activities.  

Marketing representatives may not wear any additional identification badge from
a participating facility or provider which is likely to confuse enrollees or
lead them to believe that the representative is an employee of such
organization. The Contractor shall obtain prior approval from HCAI to wear
identification badges bearing the name of any other organization.

  c)   Marketing representatives employed by a subcontractor of the Contractor
or affiliated with a community based organization which performs outreach,
education and enrollment on behalf of the Contractor shall attend a training
session conducted by the Contractor consistent with the training curriculum
approved by HCAI.  

APPENDIX D

October 1, 2004

NYC Specific Marketing Guidelines

102

9. Marketing Plans

  a)   In addition to requirements stated in § A of this Appendix, a marketing
plan shall include:

  •   A copy of the Contractor’s policies and procedures relating to marketing;

  •   A copy of the training curriculum for the Contractor’s marketing
representatives; and

  •   A description of the minimum qualifications for the Contractor’s marketing
staff.

•

103

APPENDIX D
October 1, 2004
NYC Specific Marketing Guidelines
Appendix E

New York State Department of Health

104

Member Handbook Guidelines
APPENDIX E
October 2004
El
Introduction

This document contains member handbook guidelines for use by managed care
organizations (MCOs) under contract to serve New York Medicaid beneficiaries.
These guidelines may be revised from time to time based on changes in the law
and the changing needs of the program. The guidelines reflect the review
criteria used by the SDOH Office of Managed Care in its review of all Medicaid
managed care member handbooks. Handbooks and addenda must be approved by SDOH
prior to printing and distribution by MCOs. In addition, the SDOH has developed
a model member handbook at the fourth to sixth grade reading level for use by
MCOs. The model member handbook contains language to address required disclosure
regarding free access for family planning; self referral policies; obtaining
OB/GYN services; the definitions of medical necessity and emergency services;
protocols for complaints, utilization review, external appeals, fair hearings
and newborn enrollments; and listing of member entitlements, including benefits,
rights and responsibilities, and information available upon request. MCOs must
use the language provided in these required disclosure areas in their member
handbooks. A copy of the model handbook is available from the Office of Managed
Care, Bureau of Intergovernmental Affairs.

General Format

Member handbooks must be written in a style and reading level that will
accommodate the reading skills of many Medicaid recipients. In general the
writing should be at no higher than a sixth-grade level, taking into
consideration the need to incorporate and explain certain technical or
unfamiliar terms to assure accuracy. The text must be printed in at least ten
(10) point font. The SDOH reserves the right to require evidence that a handbook
has been tested against the sixth-grade reading-level standard. Member handbooks
must be available in languages other than English whenever at least five
(5) percent of the potential enrollees of the MCO in any county in the MCO’s
service area speak a language other than English as a first language.

Handbook Requirements

a) General Overview (how the plan works)

i) Explanation of the plan, including what happens when you become a member.

  ii)   Explanation of the plan ID card, obtaining routine medical care, help by
telephone, and general information pertaining to the plan, i.e., location of the
plan, providers, etc.

  iii)   Invitation to attend scheduled orientation sessions and other
educational and outreach activities.  

b) Provider Listing including Site Locations

Note: The information described here can be included in the handbook or as an
insert to the handbook, or can be produced as a separate document and referenced
in the handbook.

i) A current listing of providers, including facilities.

     
ii)
iii)
  For physicians, separate listings of primary care practitioners and specialty
providers; include location, phone number, and board certification status.
Listing also must include a notice of how to determine whether a participating

provider is accepting new patients.

c) Voluntary or Mandatory Enrollment

i) Must indicate whether enrollment is voluntary or mandatory.

  ii)   If plan participates in both mandatory and voluntary counties,
explanation of the difference, i.e., disenrollment, family members in the same
plan, etc.

d) Choice of Primary Care Provider (including how to make an appointment)

  i)   Explanation of the role of PCP as a coordinator of care, giving some
examples, and how to choose one for self and family.

APPENDIX E

October 1, 2004

E-2

  ii)   How to make an appointment with the PCP, importance of base line
physical, immunizations and well-child care.

  iii)   Explanation of different types of PCPs, i.e., family practice,
pediatricians, internists, etc.

Notification that the plan will assign the member to a PCP if one is not chosen:
in thirty (30) days.

v) OB/GYN choice rules for women

e) Changing Primary Care Provider

i) Explanation of plan policy, time frames, and process related to changing PCP.
ii) Explanation of process for changing OB’GYN when applicable.
iii) Explanation of requirements for choosing a specialist as PCP.

f) Referrals to Specialists (in and out-of-plan)

i) Explanation of specialist care and how referrals are accomplished.
ii) Explanation of process for changing specialists.

  iii)   Explanation of self-referral services, i.e., OB/GYN services, HIV
counseling and testing, eye exams, etc.  

  iv)   Notice that Enrollee may obtain a referral to a Non-Participating
Provider when the plan does not have a Participating Provider with appropriate
training or experience to meet the needs of the Enrollee; and the procedure for
obtaining such referrals.  

  v)   Notice that an Enrollee with a condition that requires ongoing care from
a specialist may request a standing referral to such a specialist; procedure for
obtaining such referrals.  

  vi)   Notice that an Enrollee with a life-threatening condition or disease, or
a degenerative and disabling condition or disease, either of which require
specialized medical care over a prolonged period of time, may request access to
a specialist responsible for providing or coordinating the Enrollee’s medical
care; and the procedure for obtaining such a specialist.  

  vii)   Notice that an Enrollee with a life-threatening condition or disease,
or a degenerative and disabling condition or disease, either of which require
specialized medical care over a prolonged period of time, may request access to
a specialty care center; and the procedure for obtaining such access.  

g) Covered and Non-Covered Services

  i)   Benefits and services covered by the plan, including benefit maximums and
limits.

  ii)   Definition of medical necessity used to determine whether benefits will
be covered (same as plan-county contract definition).

  iii)   Medicaid services not covered by the plan or excluded from managed
care; how to access these services.

iv) Prior authorization and other requirements for treatments and services.
v) Family planning and reproductive health services free access policy.
vi) HIV counseling and testing free access policy.

  vii)   Direct access policy fol. dental services provided at Article 28
clinics operated by academic dental centers when dental is in the Benefit
Package.

  viii)   Plan policy relating to transportation, including who to call and what
to do if plan does not cover transportation.

ix) Plan toll-free number for Enrollee to call for more information.

h) Out of Area Coverage

  i)   Explanation of what to do and who to call if medical care is required
when beneficiary is out of plan’s service area.

i) Emergency Care Access

  i)   Definition of emergency services, as defined in law including examples of
situations that constitute an emergency and situations that do not.

  ii)   What to do in an emergency, including notice that services in a true
emergency are not subject to prior approval.

iii) A phone number to call if PCP is not available.
iv) Explanation of what to do in non-emergency situations (PCP, urgent care,
etc.).

APPENDIX E

October 1, 2004
E-3

j) Utilization Review

i) Circumstances under which utilization review will be undertaken.
ii) Toll-free telephone number of the utilization review agent.

  iii)   Time frames under which UR decisions must, be made for prospective,
retrospective, and concurrent decisions.  

iv) Right to reconsideration.

  v)   Right to an appeal, including expedited and standard appeals processes
and the time frames for such appeals.

vi) Right to designate a representative.

  vii)   A notice that all denials of claims will be made by qualified clinical
personnel and that all notices will include information about the basis of the
decision, and further appeal rights (if any).

k) Enrollment and Disenrollment Procedures

  i)   Where appropriate, explanation of Lock-In requirements, and initial grace
period when person may change plans, or return to fee-for-service in voluntary
areas.

  ii)   Choice of PCP (each person can have his/her own PCP and can change
thirty (30) days after the initial appointment with their PCP, and once every
six months thereafter).

iii) Procedures for disenrollment.
iv) Opportunities for change

  v)   LDSS/or enrollment broker phone number for information on enrollment and
disenrollment.

l) Rights and Responsibilities of Enrollees

  i)   Explanation of what an Enrollee has the right to expect from the
Contractor in the way of medical care and treatment of the Enrollee.

ii) Responsibilities of the Enrollee (general).

  iii)   Enrollee’s financial responsibility for payment when services are
furnished by a provider who is not part of the Contractor’s network or by any
provider without required authorization or when a procedure, treatment, or
service is not a covered benefit; also note exceptions such as family planning
and HIV counseling/testing.

iv) Enrollee’s rights under State law to formulate advance directives.

  v)   The manner in which Enrollees may participate in the development of plan
policies.

m) Language

  i)   Description of how the Contractor addresses the needs of non-English
speaking Enrollees.  

n) Grievance Procedures (complaints)

  i)   Right to file a grievance regarding any dispute between the Contractor
and an Enrollee.  

     
ii)
iii)
iv)
  Right to file a grievance orally when the dispute is about referrals or
covered benefits.
Explanation of who in the plan to call, along with the Contractor’s toll-free
number.
Time frames and circumstances for expedited and standard grievances.

  v)   Right to appeal a grievance determination and the procedures for filing
such an appeal.

vi) Time frames and circumstances for expedited and standard appeals.
vii) Right to designate a representative.

  viii)   A notice that all decisions involving clinical disputes will be made
by qualified clinical personnel and that all notices will include information
about the basis of the decision, and further appeal rights (if any).

ix) NYSDOH number for medically related complaints (1-800-206-8125).

  x)   New York State Insurance Department number for certain complaints
relating to billing.

  •   ) Fair Hearing Explain that:  

  i)   Enrollee has a right to a State Fair Hearing and Aid to Continuing in
some situations.

APPENDIX E
October 1, 2004
E-4

105

  ii)   Describe situations when the Enrollee may ask for a fair hearing as
described in Section 25 of this Agreement including State or LDSS decision about
staying in or leaving the plan; decision the Contractor makes that stops or
limits Medicaid benefits; Contractor decision agreeing with doctor who will not
order services .(must complain to the plan first).

  iii)   Describe how to request a fair hearing (assistance through member
services, LDSS, State fair hearing contact).

p) External Appeals

i) Description of circumstances where a person may request an external appeal

     
ii)
iii)
iv)
  Time frames for applying for appeal and for decision-making
How and where to apply
Describe expedited appeal time frame

v) Process for Contractor and Enrollee to agree on waiving the UR appeal
process.

q) Payment Methodologies

  i)   Description prepared annually of the types of methodologies the plan uses
to reimburse providers, specifying the type of methodology used to reimburse
particular types of providers or for the provision of particular types of
services.

r) Physician Incentive Plan Arrangements

  i)   The Member Handbook must contain a statement indicating the Enrollees and
potential Enrollees are entitled to ask if the MCO has special financial
arrangements with physicians that can affect the use of referrals and other
services that they might need and how to obtain this information.  

s) How and Where to Get More Information

i) How to access a member services representative through a toll-free number.
ii) How and when to contact LDSS for assistance.

Other Information Available Upon Enrollee’s Request

  a)   . List of the names, business addresses, and official positions of the
membership of the board of directors, officers, controlling persons, owners or
partners of the Contractor.

  b)   Copy of the most recent annual certified financial statement of the
Contractor, including a balance sheet and summary of receipts and disbursements
prepared by a CPA.

c) Copy of the most recent individual, direct pay subscriber contracts.

  d)   Information relating to consumer complaints compiled pursuant to
Section 210 of the insurance law.

  e)   Procedures for protecting the confidentiality of medical records and
other Enrollee information.

  f)   Written description of the organizational arrangements and ongoing
procedures of the Contractor’s quality assurance program.

  g)   Description of the procedures followed by the Contractor in making
decisions about the experimental or investigational nature of medical devices,
or treatments in clinical trials.

h) Individual health practitioner affiliations with participating hospitals.

  i)   Specific written clinical review criteria relating to a particular
condition or disease and, where appropriate, other clinical information which
the plan might consider in its utilization review process.

  j)   Written application procedures and minimum qualification requirements for
health care providers to be considered by the plan.

APPENDIX E
October 1, 2004
E-5

  k)   Upon request, MCOs are required to provide the following information on
the incentive arrangements affecting the MCO’s physicians to current, previous
and prospective Enrollees:

  1.   Whether the MCO’s contract or subcontracts include Physician Incentive
Plans that affect the use of referral services.

2. Information on the type of incentive arrangements used.
3. Whether stop-loss protection is provided for physicians and physicians
groups.

  4.   If the.MCO is at substantial financial risk, as defined in the PIP
regulations, a summary of the required customer satisfaction survey results.

106

APPENDIX E
October 1, 2004
E-6APPENDIX F

New York State Department of Health

Medicaid Managed Care Complaint and Appeals Requirements
APPENDIX F
October I, 2004
F-I

107

I. Overall Objectives

The Medicaid managed care program complaint process accomplishes four
objectives:

  a)   Ensures that each MCO resolves its Enrollees’ problems promptly and at
the lowest level of formality, wherever possible.

  b)   Ensures that the MCO reports the full extent of complaint activity to
governmental oversight entities.

  c)   Ensures that the MCO uses complaint information to assess and improve
program performance.

  d)   Provides an independent process for complaint resolution when issues are
not resolved by. the MCO.

II. Definitions

  a)   A complaint is a written or verbal contact to the MCO in which the
Enrollee or designee describes a dissatisfaction with the MCO, its employees,
benefits, providers: or contractors, including but not limited to:

  •   a determination made by the MCO;

  •   treatment experienced through the MCO, its providers, or contractors.

Medical necessity determinations pursuant to Article 49 of the Public Health Law
are not included in the definition of a complaint.

  b)   An inquiry is a written or verbal question or request for information
posed to the MCO with regard to such issues as benefits, contracts, and
organization rules. Inquiries do not reflect Enrollee complaints or
disagreements with MCO determinations.

  c)   Summary Complaint Forms are forms developed by the State that categorize
the type of complaints received. These forms should be submitted via the HPN on
a quarterly basis to the SDOH.

III. Complaint Procedures

  a)   The MCO shall describe its complaint and appeal procedure in the member
handbook, and it must be accessible to non-English speaking, visually, and
hearing impaired Enrollees. The handbook shall comply with Section 13.3 and The
Member Handbook Guidelines (Appendix E) of this Agreement.  

  b)   Anytime the MCO denies access to a referral; denies or reduces benefits
or services; determines that a requested benefit is not covered in the MCO’s
benefit package, or denies payment of a claim for services, the MCO shall
provide written notice of the procedures for the Enrollee to file a complaint,
including:  

i) the description of the action Contractor intends to take;

     
ii)
iii)
iv)
  the reasons for the determination including the clinical rationale, if any;
the process for filing a grievance/complaint with the organization;
the timeframes within which a grievance/complaint determination must be made;

  v)   the right of an Enrollee to designate a representative to file a
grievance/complaint on behalf of the Enrollee;

  vi)   the notice of the right of the member to contact the New York State
Department of Health (800 206-8125) with their complaint; and

  vii)   the notice entitled “Managed Care Action Taken” containing the member’s
fair hearing and aid continuing rights.

  c)   If the MCO immediately resolves a verbal complaint to the Enrollee’s
satisfaction, that complaint may be considered resolved without any additional
written notification to the Enrollee. Such complaints must be logged by the MCO:
and included in the MCO’s quarterly HPN complaint report submitted to SDOH.

APPENDIX F

October 1, 2004

F-2

108

d) MCO procedures for accepting complaints shall include:

i) toll-free telephone number;

     
ii)
iii)
iv)
  designated staff to receive calls;
“live” phone coverage at least 40 hours a week, during. normal business hours;
a mechanism to receive after hours calls including either:

  A)   telephone system available to take calls and a plan to respond to all
such calls no later than on the next business day after. •the call was recorded.

Or

  B)   a mechanism to have available on a twenty-four (24) hour, seven (7) day a
week basis designated staff to accept telephone complaints, whenever a delay
would significantly increase the risk to an Enrollee’s health.

  e)   Determinations of all clinical complaints involving clinical decisions
shall be made by qualified clinical personnel.

  f)   Upon receipt of a complaint, the MCO shall send a notice to the Enrollee
specifying what information must be provided to the MCO in order for a
determination to be made.

IV. Notice to Enrollee Procedures

Upon receipt of the following type of complaints; 1) anytime that the MCO denies
access to a referral; 2) denies or reduces benefits or services; 3) determines
that a requested benefit is not covered by the MCO’s benefit package, the MCO
shall send a notice to the Enrollee. The notice shall describe:

a) The Enrollee’s right to file a complaint regarding any dispute with the MCO.

b) The information to be provided to the MCO in order for a determination to be
made.

  c)   The fact that the MCO will not retaliate or take any discriminatory
action against the Enrollee because he/she filed a complaint or appeal.

  d)   The right of the Enrollee to designate a representative to file
complaints and appeals on his/her behalf.

  e)   The MCO’s requirements for accepting written complaints, which can be
either a letter or MCO supplied form.

The Enrollee’s right to file a verbal complaint when the dispute is about
referrals or covered benefits. The MCO must list a toll-free number which
Enrollee may use to file a verbal complaint.

For verbal complaints, whether the Enrollee is required to sign an
acknowledgment and description of the complaint prepared by the MCO. The
acknowledgment must clearly advise the Enrollee that the Enrollee may amend the
description but must sign and return it in order to initiate the complaint.

V. Timeframes for Complaint Resolution by the MCO.

Procedures should indicate the following specific timeframes regarding complaint
resolution:

  a)   The MCO has to provide written acknowledgment of the complaint including
the name, address and telephone number of the individual or department handling
the complaint within fifteen (15) days of receipt of the complaint.

  b)   Complaints shall be resolved whenever a delay would significantly
increase the risk to an Enrollee’s health within forty-eight (48) hours after
receipt of all necessary information.

  c)   Complaints shall be resolved in the case of requests for referrals or
determinations concerning benefits covered by the contractual benefit package
within thirty (30) days after the receipt of all necessary information.

APPENDIX F
October 1, 2004
F-3

  d)   All other complaints shall be resolved within forty-five (45) days after
the receipt of all necessary information. The MCO shall maintain reports of
complaints unresolved after forty-five (45) days in accordance with Section 18
of this Agreement.

VI. Complaint Determinations

      Procedures regarding the resolution of Enrollee complaints should include
the following: a) Complaints shall a) be reviewed by one or more qualified
personnel.  

  b)   Complaints pertaining to clinical matters shall be reviewed by one or
more licensed, certified or registered health care professionals in addition to
whichever non-clinical personnel the MCO designates.

  c)   Determinations by the MCO shall be made in writing to the Enrollee or
his/her designee and include:

i) the detailed reasons for the determination;

  ii)   in cases where the determination has a clinical basis, the clinical
rationale for the determination;

  iii)   the procedures for the filing of an appeal of the determination,
including a form for the filing of such an appeal;

  iv)   notice of the right of the Enrollee to contact the State Department of
Health (800 206-8125) with their complaint; and

  v)   if applicable, the notice entitled “Managed Care Action Taken,”
containing the Enrollee’s fair hearing and aid continuing rights if not provided
with the initial action.

  d)   Notices of determinations shall be sent to the Enrollee or the Enrollee’s
designee within three (3) business days after a .determination is made.

  e)   In cases where delay would significantly increase the risk to an
Enrollee’s health, notice of a determination shall. be made by telephone
directly to the Enrollee or to the Enrollee’s designee, or when no phone is
available some other method of communication, with written notice to follow
within three (3) business days.

VII. Appeals

Procedures regarding Enrollee appeals of MCO complaint determinations should
include the following:

  a)   The Enrollee or designee has no less than sixty (60) business days after
receipt of the notice of the complaint determination to file a written appeal.
Appeals may be submitted by letter or by form provided by the MCO.  

  b)   Within fifteen (15) business days of receipt of the appeal, the MCO shall
provide written acknowledgment of the appeal including the name, address and
telephone number of the individual designated to respond to the appeal. The MCO
shall indicate what additional information, if any, must be provided for the MCO
to render a decision.  

  c)   Appeals of clinical matter must be decided by personnel qualified to
review the appeal including licensed, certified or registered health care
professionals who did not make the initial determination, at least one of whom
must be a clinical peer reviewer. Clinical peer reviewers may be physicians who
possess a current and valid non-restricted license to practice medicine. A
clinical peer reviewer also may be a health care professional, who where
applicable, possesses a current and valid non-restricted license, certification
or registration, or where no provision for a license, certification, or
registration exists, is credentialed by the national accrediting body
appropriate to the profession. The clinical peer reviewer must be a physician or
other health care professional practicing in the same professional specialty as
the healthcare provider who typically manages the medical condition, procedure
or treatment under review.  

  d)   Appeals of non-clinical matters shall be determined by qualified
personnel at a higher level than the personnel who made the original complaint
determination.

APPENDIX F

October 1, 2004

F-4

  d)   Appeals shall be decided and notification provided to the Enrollee no
more than:

  i)   two (2) business days after the receipt of all necessary information when
a delay would significantly increase the risk to an Enrollee’s health;

  ii)   thirty (30) business days after the receipt of all necessary information
in all other instances.

f) The notice of an appeal determination shall include:

  i)   the detailed reasons for the determination and the clinical rationale for
the determination;  

ii) if applicable, a notice containing fair hearing rights;

  iii)   the notice shall also inform the Enrollee of his/her option to also
contact the State. Department of Health (800-206-8125) with his/her complaint;  

iv) instructions for any further appeal.

VIII. Right to an External Appeal

The MCO shall describe its utilization review policies and procedures including
a notice of the right to an external appeal together with a description of the
external appeal process and the timeframes for external appeal, in the member
handbook. It must be accessible to non-English speaking, visually, and hearing
impaired Enrollees. The handbook shall comply with Section 13 and The Member
Handbook Guidelines (Appendix E) of this Agreement.

IX. Records

      The MCO shall maintain a file on each complaint and appeal, if any. The
file. shall include:  

a) date the complaint was filed;

b) copy of the complaint, if written;

c) date of receipt of and copy of the Enrollee’s acknowledgment, if any;

  d)   log of complaint determination including the date of the determination
and the titles of the personnel and credentials of clinical personnel who
reviewed the complaint;  

e) date and copy of the Enrollee’s appeal;
f) determination and date of determination of the appeal;
g) the titles, and credentials of clinical staff who reviewed the appeal.

In addition, the Contractor shall maintain a list of the following:

a) complaints unresolved for greater than 45 days;

b) complaints referred for external appeal.

109

APPENDIX F
October 1, 2004
F-5
APPENDIX G

NYSDOH Guidelines For The Provision

Of Emergency Care and Services
APPENDIX G
October I, 2004
G-1

110

NYSDOH Guidelines for the Provision of Emergency Care and Services Definition of
an “Emergency Medical Condition”

The term “Emergency Medical Condition” means a medical or behavioral condition,
the onset of which is sudden, that manifests itself by symptoms of sufficient
severity, including severe pain, that a prudent layperson, possessing an average
knowledge of medicine and health, could reasonably expect the absence of
immediate medical attention to result in:

  i.   Placing the health of the person afflicted with such condition in serious
jeopardy or, in the case of a behavioral condition, placing the health of the
person or others in serious jeopardy; or

ii. serious impairment to such person’s bodily functions; or

  iii.   serious dysfunction of any bodily organ or part of such person; or
serious disfigurement of such person.  

Emergency Medical 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:

Protocols for Notification/Authorization

Preauthorization for treatment of an Emergency Medical Condition is never
required.

In circumstances where notification of arrival in the emergency department
(ED) is requested by the managed care organization following the assessment and
stabilization of the Enrollee, the notification process for the participating ED
should require no more than one (1) phone call (or fax), and include a limited
amount of standard clinical and demographic information.

Protocol for Acceptable Transfer Between Facilities

All relevant COBRA requirements must be met.

MCOs must provide for an appropriate (as determined by the ED physician)
transfer method/level with personnel as needed.

MCOs must contact/arrange for an available, accepting physician and patient bed
at the receiving institution.

If a patient is not transferred within eight (8) hours to an appropriate
inpatient setting, after the decision to admit has been made, then admission at
the original facility is deemed authorized.

Protocols for Disposition

If, pursuant to a screening evaluation, ED staff determines that a patient
requires further services (other than emergency medical services), the MCO will
have two (2) hours to respond to a call from the ED with the appropriate person
to discuss thgicase. If such response is longer than two (2) hours, that
admission or treatment is deemed “authorized” for purposes of payment.

APPENDIX G
October 1, 2004
G-2

In the event that the MCO/provider suggests a level of care for a specific
patient deemed inappropriate by the attending physician in the ED, and no
agreement as to disposition can be reached, a physician from the plan must
physically come to the ED and evaluate/take responsibility for this patient.

Triage Fees

For emergency room services that do not meet the definition of Emergency Medical
Condition, the MCO shall pay the hospital a triage fee of $40.00 in the absence
of a negotiated rate.

Non-participating EDs cannot be denied payment on the basis of non-notification.

111

APPENDIX G
October 1, 2004
G-3
APPENDIX H

New York State Department of Health Guidelines for the

112

Processing of Enrollments and Disenrollments
APPENDIX H
October 1, 2004
H-1
Appendix H
SDOH Guidelines
For the Processing of Enrollments and Disenrollments

This appendix is intended to provide general guidelines to LDSS and MCOs for the
processing of enrollments and disenrollments. Where an enrollment broker exists,
the enrollment broker may be responsible for some or all of the LDSS
responsibilities. To allow LDSS and MCOs flexibility in developing processes
that will meet the needs of both parties, SDOH may allow modifications to
timeframes and some procedures. Modifications are to be specified in Section G
of this Appendix and must be agreed to by both parties and receive prior
approval from SDOH.
A. Enrollment SDOH Responsibilities:

  1.   The SDOH is responsible for monitoring Local District program activities
and providing technical assistance to the LDSS and MCOs to ensure compliance
with the State’s policies and procedures.

  2.   SDOH reviews and approves proposed enrollment materials prior to MCOs
publishing and disseminating or otherwise using the materials.

LDSS Responsibilities:

The LDSS has the primary responsibility for the enrollment process.

  1.   Each local district determines Medicaid eligibility. To the extent
practicable, the LDSS will follow up with Enrollees when the MCO provides
documentation of any change in status which may affect the Enrollee’s Medicaid
and/or managed care eligibility.  

  2.   LDSS will provide pre-enrollment information to beneficiaries, consistent
with Social Services Law, . Section 364-j(4)(e)(iv) and train persons providing
enrollment counseling to beneficiaries.  

  3.   The LDSS must inform beneficiaries of the availability of MCOs and HIV
SNPs and the scope of services covered by each.  

  4.   LDSS will inform beneficiaries of the right to confidential face-to-face
enrollment counseling and will make confidential face-to-face sessions available
upon request.  

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

  6.   For enrollments made during face-to-face counseling, if the participant
has a preference for particular medical services providers, enrollment
counselors shall verify with the medical services providers that such medical
services providers whom the participant prefers participate in the MCO’s network
and are available to serve the participant.

  7.   The LDSS is responsible for the timely processing of managed care
enrollment applications, exemptions, and exclusions and ensuring attestations
are on file for all Enrollees.

  8.   The LDSS will determine the status of enrollment applications.
Applications will be enrolled, pended or denied.

APPENDIX H

October 1, 2004

H-2

  9.   The LDSS will notify the Contractor of plan-assisted enrollment
applications that are denied.

  10.   The LDSS enters individual enrollment form data and transmits that data
to the State’s Prepaid Capitation Plan (PCP) Subsystem. The transfer of
enrollment information may be accomplished by any of the following: .

i) LDSS directly enters data into PCP Subsystem; or

  ii)   LDSS or Contractor submits-a tape to the State, to be edited and entered
into PCP Subsystem; or  

  iii)   LDSS electronically transfers data, via a dedicated line or Medicaid
Eligibility Verification System (MEVS) to the PCP Subsystem.  

11. The LDSS is required to send the following notices to Eligible Persons:

  i)   Initial Notification Letter: This letter informs the Eligible Persons
about the mandatory program and the timeframes for choosing a plan. Included
with the letter are managed care brochures, an enrollment form, and information
on their rights and responsibilities under this program, including the option
for HIV/AIDS infected individuals who are categorically exempt from the
mainstream Medicaid Managed Care program to enroll in an HIV SNP on a voluntary
basis in districts where HIV SNPs exist. (Mandatory Program Only)  

  ii)   Reminder Letter: A letter to all Eligible Persons in a mandatory
category who have not responded by submitting a completed enrollment form within
thirty (30) days of being sent or given an enrollment packet. (Mandatory Program
Only)  

  iii)   Enrollment Confirmation Notice: This notice indicates the Effective
Date of Enrollment, the name of the MCO and all individuals who are being
enrolled. This notice should also be used for case additions and re-enrollments
into the same plan.  

  iv)   Notice of Denial of Enrollment: This notice is used when an individual
has been determined by LDSS to be ineligible for enrollment into a Medicaid
managed care plan. This notice must include fair hearing rights. Note: This
notice is not required when Medicaid eligibility is being denied (or closed).  

  v)   Exemption and Exclusion Request Forms: Exemption forms are provided to
Eligible Persons upon request if they wish to apply for an exemption. Exclusion
forms are provided to individuals in New York City who self-identify as
qualifying for an exclusion. Individuals precoded on the system as meeting
exemption or exclusion criteria do not need to complete an exemption or
exclusion request form.

  vi)   Exemption and Exclusion Request Approval or Denial: This notice is
designed to inform a recipient who applied for an exemption or exclusion of the
LDSS’s disposition of the request, including the right to a fair hearing if the
request for exemption or exclusion is denied.

MCO Responsibilities:

  1.   In those instances in which the Contractor is marketing to persons
already in receipt of Medicaid, the Contractor will submit plan enrollments to
the. LDSS, within a maximum of five (5) business days from the day the
enrollment is received by the Contractor (unless otherwise agreed to by SDOH and
LDSS).

  2.   The Contractor must notify new Enrollees of their Effective Date of
Enrollment. To the extent practicable, such notification must precede the
Effective Date of Enrollment. (Section 13 of the Model Contract).

  3.   The Contractor must report any changes in status for its enrolled members
to the LDSS within five (5) business days of such information becoming known to
the

  ..   Contractor. This includes, but is not limited to, factors that may impact
Medicaid eligibility such as address changes, verification of pregnancy,
incarceration, third party insurance, etc.

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

  5.   The Contractor shall accept all enrollments as ordered by the Office of
Temporary and Disability Assistance’s Office of Administrative Hearings due to
fair hearing requests or decisions.  

APPENDIX H

October 1, 2004

H-3

B. Newborn Enrollments:

The Contractor agrees to enroll and provide coverage for eligible newborn
children of Enrollees effective from the time of birth.

SDOH Responsibilities:

  1.   The SDOH will update WMS with information on the newborn received from
hospitals, consistent with. the requirements of Section 366-g of the Social
Services Law as amended by Chapter 412 of the Laws of 1999.  

  2.   Upon notification of the birth by the hospital or birthing center, the
SDOH will update WMS with the demographic data for the newborn and enroll the
newborn in the mother’s MCO if not already enrolled. The newborn will be
retroactively enrolled back to the first (1St) day of the month of birth. Based
on the transaction date of the enrollment of the newborn on the PCP subsystem,
the newborn will appear on either the next month’s roster or the subsequent
month’s roster. On plan rosters for upstate and NYC, the “PCP Effective From
Date” will indicate the first day of the month of birth, as described in 01 OM`.
MJ ADM 5 “Automatic Medicaid Enrollment for Newborns.”

LDSS Responsibilities:

  1.   Grant Medicaid eligibility for newborns for one (1) year if born to a
woman eligible for and receiving MA assistance on the date of birth. (Social
Services Law Section 366 (4) (1))

  2.   LDSS must add eligible unborns to all WMS cases that include a pregnant
woman as soon as the pregnancy is medically verified. (NYS DSS Administrative
Directive 85 ADM-33)

  3.   In the event that the LDSS learns` of an Enrollee’s pregnancy prior to
the Contractor, the LDSS is to establish MA eligibility and enroll the unborn in
the Contractor’s plan.

  4.   The LDSS is responsible for newborn enrollment should it not be
successfully competed under the “SDOH Responsibilities” process as outlined in
#2 above.

  5.   When a newborn is enrolled in managed care, the LDSS must send an
Enrollment Confirmation Notice to inform the mother of the Effective Date of
Enrollment, which is the first (1St) day of the month of birth, and the plan in
which the newborn is enrolled.

  6.   The LDSS may develop a transmittal form to be used for unborn/newborn
notification between the Contractor and the LDSS.  

MCO Responsibilities:

  1.   The Contractor must notify the LDSS in writing of any Enrollee that is
pregnant within thirty (30) days of knowledge of the pregnancy. Notifications
should be transmitted to the LDSS at least monthly. The notifications should
contain the pregnant woman’s name, Client ID Number (CIN), and the expected date
of confinement (EDC).  

  2.   Upon the newborn’s birth, the Contractor must send verifications of
infant’s demographic data to the LDSS, within five (5) days after knowledge of
the birth. The  

demographic data must include: the mother’s name and CIN, the newborn’s name and
CIN (if newborn has a CIN), sex and the date of birth.

  3.   In districts that use an Enrollment Broker, the Contractor shall not
submit electronic enrollments of newborns to the Enrollment Broker, as this will
interfere with the retroactive enrollment of the newborn back to the first (1St)
day of the month of birth. For newborns whose mothers are not enrolled in the
Contractor’s plan and who were not pre-enrolled into the plan as an unborn, the
Contractor may submit an electronic enrollment of the newborn to the Enrollment
Broker. In such cases, the Effective Date of Enrollment will be prospective.

APPENDIX H

October 1, 2004

H-4

  4.   In voluntary counties, the Contractor will accept applications for
unborns if that is the mother’s intent, even if the mother is not and/or will
not be enrolled in the Contractor’s plan. In all Counties when a mother is
ineligible for enrollment or chooses not to enroll, the Contractor will accept
applications for pre-enrollment of unborns who are eligible.

  5.   The Contractor is responsible for provision of services to the newborn
and payment of the hospital or birthing center bill, if the mother is an
Enrollee at the time of the newborn’s birth, even if the newborn is not yet on
the Roster.

      6: — The Contractor will reimburse the hospital or birthing center at the
Medicaid rate (or at another rate if contractually agreed to between the
Contractor and the hospital or birthing center) for this episode of care.
Hospitals and birthing centers have been — advised by SDOH to expeditiously bill
MCOs to allow MCOs to arrange for care for the Enrollees. However, the
Contractor may not deny the inpatient hospital or birthing center costs if
billing/notification is not timely except as otherwise provided by contractual
agreement by the Contractor and hospital or birthing center.

  7.   Within fourteen (14) days of the date on which the Contractor becomes
aware of the birth, the Contractor will issue a letter informing parent(s) about
the newborn’s enrollment and how to access care or a member identification card.
 

  8.   In those cases in which the Contractor is aware of the pregnancy, the
Contractor will ensure that enrolled pregnant women select a PCP for their
infants prior to birth.  

  9.   The Contractor will ensure that the newborn is linked with a PCP prior to
discharge from the hospital or birthing center, in those instances in which the
Contractor has received appropriate notification of birth prior to discharge.  

C. Auto-Assignment Process (Mandatory Program Only):

This section only applies to a LDSS where CMS has given approval and the LDSS
has begun mandatory enrollment. The details of the auto-assignment process are
contained in Section 12 of the State’s Operational Protocol.

SDOH Responsibilities:

  1.   SDOH will provide information to LDSS on a daily basis of those
individuals who have been added to the tickler file through the Potential
Auto-Assign List.

  2.   SDOH, LDSS or Enrollment Broker will assign eligible individuals not
pre-coded in WMS as exempt or excluded, who have not chosen an MCO in the
required time period to an MCO using an algorithm as specified in State Law SSL
§ 364-j(4)(d).

  3.   SDOH will ensure the auto-assignment process automatically updates the
PCP Subsystem, and will notify the MCO of auto-assigned individuals
electronically.

  4.   SDOH will notify the LDSS electronically on a daily basis of those
individuals for whom the State has selected a health plan through the Automated
PCP Update Report. Note: This will not apply in Local Districts that utilize an
enrollment broker.

LDSS Responsibilities:

1. The LDSS is responsible for tracking an individual’s choice period.

  2.   The LDSS will use the information contained in the Potential Auto-Assign
List for education and outreach purposes.

APPENDIX H

October 1, 2004

H-5

  3.   The LDSS will send at least one reminder notice to individuals who fail
to return the enrollment application within thirty (30) days. The LDSS may
employ other methods during the choice period to encourage individuals to choose
an MCO prior to auto-assignment.

  4.   The LDSS is responsible for providing notification to individuals
regarding their enrollment status as specified in Section A of this Appendix.

MCO Responsibilities:

  1)   The Contractor is also responsible for providing notification to
individuals regarding their enrollment status as specified in Section A of this
Appendix.  

D. Roster Reconciliation:

All enrollments are effective the first of the month.

SDOH Responsibilities:

  2)   The SDOH maintains both the PCP subsystem enrollment files and the WMS
eligibility files, using data input by the LDSS. SDOH uses data contained in
both these files to generate the Roster.  

  3)   SDOH shall send each MCO and LDSS monthly (according to a schedule
established by SDOH), a complete list of all Enrollees for which the Contractor
is expected to assume medical risk beginning on the 1” of the following month
(First Monthly Roster). Notification to MCOs and LDSS will be accomplished via
paper transmission, magnetic media, or the HPN.

  4)   SDOH shall send each MCO and LDSS monthly, at the time of the first
monthly roster production, a Disenrollment Report listing those Enrollees from
the previous month’s roster who were disenrolled, transferred to another MCO, or
whose enrollments were deleted from the file. Notification to the MCOs and LDSSs
will be accomplished via paper transmission, magnetic media, or the HPN.

5) The SDOH shall also forward an error report as necessary to each MCO and
LDSS.

  6)   On the first (1St) weekend after the first (1st) day of the month
following the generation of the first (1St) Roster, SDOH shall send MCOs and
LDSS a second Roster which contains any additional Enrollees that the LDSS has
added for enrollment for the current month. The SDOH will also include any
additions to the error report that have occurred since the initial error report
was generated.

LDSS Responsibilities:

  1)   LDSS must notify the Contractor electronically or in writing of changes
in the First Roster and error report, no later than the end of the month. (Note:
To the extent practicable the date specified must allow for timely notice to
Enrollees regarding their enrollment status. MCOs and the LDSS may develop
protocols for the purpose of resolving Roster discrepancies that remain
unresolved beyond the end of the month. These protocols should be contained in
Section G of this Appendix.)

  2)   Enrollment and eligibility issues are reconciled by the LDSS to the
extent possible, through manual adjustments to the PCP subsystem enrollment and
WMS eligibility files, if appropriate.  

MCO Responsibilities:

1) The Contractor is at risk for providing Benefit Package services for those
Enrollees listed on the 1St and 2nd rosters for the month in which the 2”d
Roster is generated. Contractor is not at risk for providing services to
Enrollees who appear on the monthly disenrollment report.

  2)   The Contractor must submit claims to the State’s Fiscal Agent for all
Eligible Persons that are on the 1” and 2nd Rosters (see Appendix H, page 7),
adjusted to add Eligible Persons enrolled by the LDSS after Roster production
and to remove individuals disenrolled by LDSS after Roster production (as
notified to the Contractor). In the cases of retroactive disenrollments, the
Contractor is responsible for submitting an adjustment to void any previously
paid premiums for the period of retroactive disenrollment, where the Contractor
was not at risk for the provision of Benefit Package services. Payment of
subcapitation  

APPENDIX H
October 1,2004
H-6

113

does not constitute `”provision of Benefit Package services.”

E. Disenrollment: LDSS Responsibilities:

  1.   The LDSS will accept requests for disenrollment directly from Enrollees
and may not require Enrollees to approach the MCO for a disenrollment form.
Where an LDSS is authorized to mandate enrollment, all requests for
disenrollment must be directed to the LDSS or the enrollment broker. LDSSs and
the enrollment broker must utilize the State-approved Disenrollment forms.

  2.   Enrollees may initiate a request for an expedited disenrollment to the
LDSS. The LDSS will expedite the disenrollment process in those cases where an
Enrollee’s request for disenrollment involves an urgent medical need, a
complaint of non-consensual enrollment or, in New York City and other local
districts where homeless individuals are exempt, homeless individuals in the
shelter system. If approved, the LDSS will manually process the disenrollment
through the PCP Subsystem.

  3.   The LDSS will process routine disenrollment requests to take effect on
the first (1st) day of the following month if the request is made before the
fifteenth (15th) day of the month. In no event shall the Effective .Date of
Disenrollment be later than the first (1St) day of the second month after the
month in which an Enrollee requests a disenrollment.

  4.   The LDSS will disenroll Enrollees automatically upon death or loss of
Medicaid eligibility. All such disenrollments will be effective at the end of
the month in which the death or loss of eligibility occurs or at the end of the
last month of guaranteed eligibility, where applicable.

  5.   In districts where the LDSS has the authority to operate a mandatory
program, and in voluntary counties that enforce lock-in, the LDSS will disenroll
Enrollees who request disenrollment upon determination that they meet good cause
requirements as specified in Section 7.3 and 8.7 of this Agreement. The LDSS
will provide Enrollees with notice of their right to request a fair hearing if
their disenrollment request is denied. This notice must outline the reason(s)
for the denial.  

  6.   The LDSS will promptly disenroll an Enrollee whose managed care
eligibility or health status changes such that he/she is deemed by the LDSS to
meet the exclusion criteria. The LDSS will provide Enrollees with a notice of
their right to request a fair hearing.  

  7.   In instances where an Enrollee requests disenrollment due to exclusion,
the LDSS must notify the Enrollee of the approval or denial of
exclusion/disenrollment status, including fair hearing rights if disenrollment
is denied.

  8.   The LDSS agrees that retroactive disenrollments are to be used only when
absolutely necessary. Circumstances warranting a retroactive disenrollment are
rare and include when an individual is enrolled or autoassigned while meeting
exclusion criteria or when an Enrollee enters or resides in a residential
institution under circumstances which render the individual excluded from
managed care; is incarcerated; is an SSI infant less than six (6) months of age;
or dies as long as the Contractor was not at risk for provision of Benefit
Package services for any portion of the retroactive period. Payment of
subcapitation does not constitute “provision of Benefit Package services.” The
LDSS must notify the Contractor of the retroactive disenrollment prior to the
action. The LDSS must find out if the Contractor has made payments to providers
on behalf of the Enrollee prior to disenrollment. After this information is
obtained, the LDSS and Contractor will agree on a retroactive disenrollment or
prospective disenrollment date.

In all cases of retroactive disenrollment, including disenrollments effective
the first day of the current month, the local district must notice the
Contractor at the time of disenrollment, of the Contractor’s responsibility to
submit to the SDOH’s Fiscal Agent voided premium claims for any full months of
retroactive disenrollment where the Contractor was not at risk for the provision
of Benefit Package services during the month.

APPENDIX H
October 1, 2004
H-7

However, failure by the LDSS to so notify the Contractor does not affect the
right of the SDOH to recover the premium payment as authorized by Section 3.6 of
this Agreement.

  9.   Generally the effective dates of disenrollment are prospective. Effective
dates for other than routine disenrollments are described below:

      Reason for Disenrollment   Effective Date of Disenrollment
• Infants weighing less than 1200 grams
at birth and other infants under six (6)
months of age who meet the criteria for
the SSI or SSI related category
 
• First Day of the month of birth or the
month of onset of disability, whichever
is later
 
   
 
   
• Death of Enrollee
  • First day of the month after death
 
   
 
   
• Incarceration
  • First day of the month after
incarceration
 
   
 
   
• Enrollee entered or stayed in a
residential institution under
circumstances which rendered the
individual excluded from managed
care, including when an Enrollee is
admitted to a hospital that 1) is certified
by Medicare as a long-term care .
hospital and 2) has an average length of
stay for all patients greater than ninety-
five (95) days as reported in the
Statewide Planning and Research
Cooperative System (SPARCS) Annual
Report 2002.
 

• First day of the month following entry
or first day of the month following
classification of the stay as permanent,
subsequent to entry’
 
   
 
   
• Individual enrolled or autoassigned
while meeting exclusion criteria
  • Effective Date of Enrollment in the
Contractor’s Plan.
 
   
 
   
Move by Enrollee
 

 
 

 
   
• (Non-NYC)-Enrollee moved
outside of the Service Area of
the contract
 
• First day of the month after the update
of the system with the new address2
 
   
 
   
• (NYC)-Enrollee moved outside
of New York City
  • First day of month after the update of
the system with the new address’
 
   

1Local districts shall make adjustments as necessary to allow a residential
institution to be reimbursed by SDOH’s Fiscal Agent for services provided by the
residential institution if such stay is under circumstances which render the
Enrollee excluded from managed care. However in such instances, if the
Contractor was at risk for providing Benefit Package services to the Enrollee
for a portion of the month, the Contractor is entitled to keep the capitation
payment for the month.

2 In counties outside of New York City, LDSSs should work together to ensure
continuity of care through the Contractor if the Contractor’s service area
includes the county to which the Enrollee has moved and the Enrollee, with
continuous eligibility, wishes to stay enrolled in the Contractor’s plan.

APPENDIX H
October 1, 2004
H-8

114

3In New York City, Enrollees, not in guaranteed status, who move out of the
Contractor’s Service Area but not outside, of the City of New York (e.g., move
from one borough to another), will not be involuntarily disenrolled, but must
request a disenrollment or transfer. These disenrollments will be performed on a
routine basis unless there is an urgent medical need to expedite the
disenrollment.

  10.   The LDSS is responsible for informing Enrollees of their right to change
MCOs including any applicable lock-in restrictions. For those LDSSs that have
implemented a mandatory enrollment program, families or members of a case
wishing to change MCOs will be required to do so as a unit, unless the LDSS
determines a “good cause” reason to waive this requirement as specified in
Section 6.6 (c) (i) of this Agreement.

  11.   The LDSS will render a decision within thirty (30) days of the receipt
of a fully documented request for disenrollment, except for Contractor-initiated
disenrollments where the LDSS decision must be made within fifteen (15) days as
specified in Section 8.8 (g) of this Agreement.

  12.   The LDSS is responsible for sending the following notices to Enrollees
regarding their disenrollment status. Where practicable, the process will allow
for timely notification to Enrollees unless there is “good cause” to disenroll
more expeditiously.

  a)   Notice of Disenrollment: These notices will advise the Enrollee of the
LDSS’s determination regarding an Enrollee-initiated, LDSS-initiated or
Contractor-initiated disenrollment and will include the Effective Date of
Disenrollment. In cases where the Enrollee is being involuntarily disenrolled,
the notice must contain fair hearing rights.  

  b)   When the LDSS denies any Enrollee’s request for disenrollment pursuant to
Section 8 of the contract, the LDSS must inform the Enrollee in writing
explaining the reason for the denial, stating the facts upon which the denial is
based, citing the statutory and regulatory authority and advising the Enrollee
of his/her right to a fair hearing pursuant to 18NYCRR Part 358.  

  c)   End of Lock-In Notice: Where Lock-In provisions are enforced, Enrollees
must be notified sixty (60) days before the end of their Lock-In Period.  

  d)   Notice of Change to “Guarantee Coverage”: This notice will advise the
Enrollee that his or her Medicaid coverage is ending and how this affects his or
her enrollment in Medicaid managed care. This notice contains pertinent
information regarding “guaranteed eligibility” benefits and dates of coverage.
If an Enrollee is not eligible for guarantee, this notice is not necessary.  

  13.   The LDSS may require that an individual that has been disenrolled at the
request of the Contractor be returned to the Medicaid fee-for-service program.

  14.   In those instances where the LDSS approves the Contractor’s request to
disenroll an Enrollee, and the Enrollee requests a fair hearing, the Contractor
will continue to keep the Enrollee in the plan until the disposition of the fair
hearing, when Aid to Continue is ordered by OAH.

  15.   The LDSS will review each Contractor requested disenrollment in
accordance with the provisions of Section 8.8 of this Agreement. Where
applicable, the LDSS may consult with local mental health and substance abuse
authorities in the district when making the determination to approve or
disapprove the request.

  16.   The LDSS shall establish procedures whereby the Contractor refers cases
which are appropriate. for an LDSS-initiated. disenrollment and submits
supporting documentation to the LDSS.

  17.   After the LDSS receives and, if appropriate, approves the request for
disenrollment either from the Enrollee or the Contractor, the LDSS will update
the PCP subsystem file with an end date. MEVS and the Fiscal Agent are then.
updated to reflect the Enrollee’s return to fee-for-service processing. The
Enrollee is removed from the Contractor’s Roster.

APPENDIX H
October 1, 2004
H- 9

MCO Responsibilities:

  1.   In those instances where the Contractor directly receives disenrollment
forms, the Contractor will forward these disenrollments to the LDSS for
processing within five (5) business days (or according to Section F of this
Appendix). During pulldown week, these forms may be faxed to the LDSS with the
hard copy to follow.

  2.   The Contractor must accept and transmit all requests for voluntary
disenrollments from its Enrollees to the LDSS, and shall not impose any barriers
to disenrollment requests. The Contractor may require that a disenrollment
request be in writing, contain the signature of the Enrollee, and state the
Enrollee’s correct MCO or Medicaid identification number.

  3.   Following LDSS procedures, the Contractor will refer cases which are
appropriate for an LDSS-initiated disenrollment and will submit supporting
documentation to the LDSS. This includes, but is not limited to, changes in
status for its enrolled members that may impact eligibility for enrollment in an
MCO such as address changes, incarceration, death, exclusion from managed care,
etc.

4. With respect to Contractor-initiated disenrollments:

  a)   The Contractor may initiate an involuntary disenrollment if the Enrollee
engages in conduct or behavior that seriously impairs the Contractor’s ability
to furnish services to either the Enrollee or other Enrollee’s, provided that
the Contractor has made and documented reasonable efforts to resolve the
problems presented by the Enrollee.

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

  c)   The Contractor must make a reasonable effort to identify for the
Enrollee, both verbally and in writing, those actions of the Enrollee that have
interfered with the effective provision of covered services as well as explain
what .actions or procedures are acceptable.

  d)   The Contractor shall give prior verbal and written notice to the
Enrollee, with a copy to the LDSS, of its intent to request disenrollment. The
written notice shall advise the Enrollee that the request has been forwarded to
the LDSS for review and approval. The written notice must include the mailing
address and telephone number of the LDSS.

  e)   The Contractor shall keep the LDSS informed of decisions related to all
complaints filed by an Enrollee as a result of, or subsequent to, the notice of
intent to disenroll.

  5.   The Contractor will not consider an Enrollee disenrolled without
confirmation from the LDSS or the Roster (as described in Section D of this
Appendix).  

F. Expedited Disenrollments

Enrollees may request an expedited disenrollment if they have an urgent medical
need to disenroll, if they were non-consensually enrolled in a managed care
plan, or, if they are homeless and residing in the shelter system in New York
City or other local districts where homeless individuals are exempt. Individuals
who request to be disenrolled from managed care based on their documented HIV,
ESRD, or SPMI/SED status are categorically eligible for an expedited
disenrollment on the basis of urgent medical need.

APPENDIX H
October 2004
H-10

LDSS Responsibilities:

  1.   The LDSS, to the extent possible, will process an expedited disenrollment
within two business days of its determination that an expedited disenrollment is
warranted. A disenrollment notice must be sent to the Enrollee outlining
approval of the disenrollment request, including the Effective Date of
Disenrollment.  

2. The Effective Date of Disenrollments resulting from expedited processing are
as follows:

          Reason for Disenrollment   Effective Date of Disenrollment
Urgent medical need
  •   First day of the next month after
determination except where medical
need requires an earlier disenrollment
 
       
 
       
Non-consensual enrollment
  •   Retroactive to the first day of the month
of enrollment
 
       
 
       
Homeless individuals residing in the shelter
system in NYC or in other districts where
homeless individuals are exempt
 
•  
Retroactive to the first day of the month
of the request
 
       

G. LDSS and Plan Specific Addenda to Appendix H.

LDSS Name

MCO Name

G. LDSS and Plan Specific Addenda to Appendix H.
LDSS Name: New York City

  1.   In New York City, the state-contracted Enrollment Broker will perform the
following LDSS functions:  

  a)   Developing enrollment materials and training persons to provide
counseling to beneficiaries;  

  b)   Informing Enrollees of the right to confidential face to face counseling
and making confidential face-to-face counseling sessions available upon request;

  c)   Informing Enrollees of the availability of contracted MCOs and HIV SNPs
and the scope of services covered by each;  

d) Processing enrollment applications, exemptions and exclusions;

  e)   Notifying the MCO of the enrollment applications that are enrolled or
denied and other transactions affecting the MCO’s Enrollees;  

  f)   Entering individual enrollment form data and transmitting the data to the
State’s Prepaid Capitation Plan (PCP) Subsystem;  

  g)   Sending all notices to beneficiaries required of an LDSS pursuant to the
terms of this Agreement, including the notices described in this Appendix H;

APPENDIX H
October 1, 2004
H-11

  h)   Performing all tasks identified in § C of this Appendix as LDSS
responsibilities with respect to the auto-assignment process;  

  i)   Notifying the Contractor electronically of changes in the Capitation
Roster. To the extent possible, the Enrollment Broker shall notify the
Contractor prior to the first day of the month in which the Roster becomes
effective;  

      j) Accepting requests for disenrollments from Enrollees and processing all
routine disenrollments. Determining, in consultation with HRA, whether a
retroactive or expedited disenrollment is required, and referring any such cases
to HRA for processing; and

  j)   Informing Enrollees of their right to change MCOs including any
applicable lock-in restrictions.  

  2.   Section D (Roster Reconciliation) In New York City, enrollment error
reports are generated by the Enrollment Broker to MCOs generally within 24-48
hours of MCO enrollment submissions and MCOs are able to resubmit corrections
via the Enrollment Broker before Roster pulldown. Changes in Enrollee
eligibility or enrollment status that occur prior to production of the monthly
Roster are reported by the State to MCOs with their rosters. Changes in Enrollee
eligibility. status that occur subsequent to production of the monthly Roster
shall be reported by the Enrollment Broker by means of the electronic bulletin
board. Reports of disenrollments processed. by the Enrollment Broker shall be
reported to MCOs as they occur by means of the electronic bulletin board.
Reports of disenrollments processed by HRA shall be reported to MCOs manually as
they occur. In the event that the electronic bulletin board notification process
is not available for any reason, EMEVS may be used as electronic notification of
loss of eligibility.

                              3.   Section E (LDSS Responsibilities), # 4 is not
applicable in New York City. In the
               
 
                                event that an Enrollee loses Medicaid
eligibility, the PCP enrollment is left on
               
 
                                the system for 90 days and removed thereafter by
SDOH if no eligibility
               
 
                           
 
  reinstatement occurs.  
 
 
 
 
 

 
                            4.   Section B (MCO Responsibilities), #2 is not
applicable in New York City. The Contractor shall not send verification of the
infant’s demographic data to the LDSS unless thirty days
  birth.
 
                                has expired since the date of birth and the
Contractor has not received confirmation via the HPN of a successful enrollment
through the automated enrollment system. When the
   
 
                                thirty days has expired the Contractor shall,
within 10 days, send verification of the infant’s demographic data to the LDSS
including: the mother’s name and CIN, the newborn’s
   
 
                                name and CIN (if newborn has a CIN), sex and the
date of
                   
 
                            5.   In New York City,   request an   in an
expedited disenrollment in accordance with the guidelines and time frames as set
forth in Appendix H.
   
 
                                Enrollees with an   expedited   Individuals who
are to be disenrolled from managed care based on their certified blind or
disabled, HIV, ESRD or
   
 
                                urgent medical need   disenrollment by  
SPMI/SED status are categorically eligible for an expedited disenrollment on the
basis of urgent medical need.
   
 
                           
6.
  to disenroll from
the Contractor’s
plan may
In New York City,
Enrollees may
initiate a request
for an expedited
disenrollment to
the LDSS. The   the LDSS.
Substantiation of
the request by the
LDSS will result
LDSS will
expedite the
disenrollment
process in those
cases where an
Enrollee’s request
for  

disenrollment
involves an urgent
medical need, the
Enrollee is a
homeless individual
residing in the  

shelter system in
New York City, the
Enrollee has HIV,
ESRD, a SPMI/SED
condition, or is
certified  

blind or disabled
or involves a
complaint of
non-consenusal
enrollment. If
approved, the LDSS
will  

manually process
the disenrollment.

 

APPENDIX H

October 1, 2004

115

NYC Specific Addenda
APPENDIX I

New York State Department of Health Guidelines for Use of Medical Residents

APPENDIX I
October 1, 2004
I- 1
APPENDIX I
Medical Residents

  (a)   Medical Residents as Primary Care Providers. MCOs may utilize medical
residents as participants (but not designated as ‘primary care providers’) in
the care of Enrollees as long as all of the following conditions are met:

  1)   Residents are a part of patient care teams headed by fully licensed and
MCO credentialed attending physicians serving patients in one or more training
sites in an “up weighted” or “designated priority” residency program. Residents
in a training program which was disapproved as a designated priority program
solely due to the outcome measurement requirement for graduates may be eligible
to participate in such patient care teams.

  2)   Only the attending physicians and nurse practitioners on the training
team, not residents, may be credentialed to the MCO and may be empanelled with
Enrollees. Enrollees must be assigned an attending physician or certified nurse
practitioner to act as their .PCP, though residents on the team may perform all
or many of the visits to the Enrollee as long as the majority of these visits
are under the direct supervision of the Enrollee‘s designated PCP. Enrollees
have the right to request care by their PCP in addition or instead of being seen
by a resident.

  3)   Residents may work with attending physicians and certified nurse
practitioners to provide continuity of care to patients under the supervision of
the patient’s PCP. Patients must be made aware of the resident attending
relationship and be informed of their rights to be cared for directly by their
PCP.

Residents eligible to be involved in a continuity relationship with patients
must be available at least 20% of the total training time in the continuity of
care setting and no less than 10% of training time in any training year must be
in the continuity of care setting and no fewer than nine (9) months a year must
be spent in the continuity of care setting.

  5)   Residents meeting these criteria provide increased capacity for
enrollment to their team according to the following formula:  

     
PGY-1
PGY-2
PGY-3
PGY-4
  300 per FTE
750 per FTE
1 125 per FTE
1500 per FTE

Only hours spent routinely scheduled for patient care in the continuity of care
training site may count as providing capacity and are based on 1.0 FTE=40 hours.

  6)   In order for a resident to provide continuity of care to an Enrollee,
both the resident and the attending PCP must have regular hours in the
continuity site and must be scheduled to be in the site together the majority of
the time.  

  7)   A preceptor/attending is required to be present a minimum of sixteen (16)
hours of combined precepting and direct patient care in the primary care setting
to be counted as a team supervising PCP and accept an increased number of
Enrollees based upon the residents working on his/her team. Time spent in
patient care activities at other clinical sites or in other activities off-site
is not counted towards this requirement.

  8)   A sixteen (16) hour per week attending may have no more than four (4)
residents on their team. Attendings spending twenty-four (24) hours per week in
patient care/supervisory activity at the continuity site could have six
(6) residents per team. Attendings spending thirty-two (32) hours per week could
have eight (8) residents on their team. Two (2) or more attendings may join
together to form a larger team as long as the ratio of attending to residents
does not exceed 1:4 and all attendings comply with the sixteen (16) hour
minimum.

APPENDIX I

October 1, 2004

I -2

  9)   Specialty consults must be performed or directly supervised by a MCO
credentialed specialist. The specialist may be assisted by a resident or fellow.

  10)   Responsibility for the care of the Enrollee remains with the attending
physician. All attending/resident teams must provide adequate continuity of
care, twenty-four (24) hour a day, seven (7) day a week coverage, and
appointment and availability access.

  11)   Residents who do not qualify to act as continuity providers as part of
an attending/resident team may still participate in the episodic care of
Enrollees as long as that care is under the supervision of an attending
physician credentialed to a MCO. Such residents would not add to the capacity of
that attending to empanel Enrollees, however.  

  12)   Certified nurse practitioners and registered physician’s assistants may
not act as attending preceptors for resident physicians.  

(b) Medical Residents as Specialty Care Providers

  (1)   Residents may participate in the specialty care of Medicaid managed care
patients in all settings supervised by fully licensed and MCO/PHSP credentialed
specialty attending physicians.  

  (2)   Only the attending physicians, not residents or fellows, may be
credentialed by the MCO. Each attending must be credentialed by each MCO with
which they will participate. Residents may perform all or many of the clinical
services for the Enrollee as long as these clinical services are under the
supervision of an appropriately credentialed specialty physician. Even when
residents are credentialed by their program in particular procedures, certifying
their competence to perform and teach those procedures, the overall care of each
Enrollee remains the responsibility of the supervising MCO-credentialed
attending.  

  (3)   It is understood that many Enrollees will identify a resident as their
specialty provider but the responsibility for all clinical decision-making
remains with the attending physician of record.  

  (4)   Enrollees must be given the name of the responsible attending physician
in writing and be told how they may contact their attending physician or
covering physician, if needed. This allows Enrollees to assist in the
communication between their primary care provider and specialty attending and
enables them to reach the specialty attending if an emergency arises in the
course of their care. Enrollees must be made aware of the resident/attending
relationship and must have a right to be cared for directly by the responsible
attending physician, if requested.  

  (5)   Enrollees requiring ongoing specialty care must be cared for in a
continuity of care setting. This requires the ability to make follow-up
appointments with a particular resident/attending physician,. or if that
provider team is not available, with a member of the provider’s coverage group
in order to insure ongoing responsibility for the patient by his/her MCO
credentialed specialist. The responsible specialist and his/her specialty
coverage group must be identifiable to the patient as well as to the referring
primary care provider.  

  (6)   Attending specialists must be available for emergency consultation and
care during non-clinic hours. Emergency coverage may be provided by residents
under adequate supervision. The attending or a member of the attending’s
coverage group must be available for telephone and/or in-person consultation
when necessary.  

  (7)   All training programs participating in Medicaid managed care must be
accredited by the appropriate academic accrediting agency.  

APPENDIX I

October 1.2004

1-3

  (8)   All sites in which residents train must produce legible (preferably
typewritten) consultation reports. Reports must be transmitted such they are
received in a time frame consistent with the clinical condition of the patient,
the urgency of the problem and the need for follow-up by the primary care
physician. At a minimum, reports should be transmitted so that they arc received
no later than two (2) weeks from the date of the specialty visit.  

  (9)   Written reports are required at the time of initial consultation and
again with the receipt of all major significant diagnostic information or
changes in therapy. In addition, specialists must promptly report to the
referring primary care physician any significant findings or urgent changes in
therapy which result from the specialty consultation.

All training sites must deliver the same standard of care to all patients
irrespective of payor. Training sites must integrate the care of Medicaid,
uninsured and private patients in the same settings.

APPENDIX I

October 1, 2004

116

I-4
APPENDIX J

New York State Department of Health Guidelines of Federal

117

Americans with Disabilities Act
APPENDIX J
October 1. 2004
J-1
GUIDELINES FOR M EDICAID MCO COMPLIANCE

WITH THE AMERICANS WITH DISABILITIES ACT (ADA)

I. Objectives Title 11 of the Americans With Disabilities Act (ADA) and
Section 504 of the Rehabilitation Act of 1973 (Section 504) provides that no
qualified individual with a disability shall, by reason of such disability, be
excluded from participation in or denied access to the benefits of services,
programs or activities of a public entity, or be subject to discrimination by
such an entity. Public entities include State and local government and ADA and
Section 504 requirements extend to all programs and services provided by State
and local government. Since Medicaid is a government program, health services
provided through Medicaid Managed Care must be accessible to all who qualify for
the program.

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

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

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

The objectives of these guidelines are threefold:

• to ensure that MCOs take appropriate steps to measure access and assure
program. accessibility for persons with disabilities;

  •   to provide a framework for managed care organizations (MCOs) as they
develop a plan to assure compliance with the Americans with Disabilities Act
(ADA); and  

  •   to provide standards for the review of MCO Compliance Plans.  

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

APPENDIX J
October 1, 2004
J-2

11. Definitions

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

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

III. Scope of MCO Compliance Plan

The MCO Compliance Plan must address accessibility to services at the MCO’s
program sites, including both participating provider sites and MCO facilities
intended for use by enrollee.

IV. Program Accessibility

     
IV.
  Public programs and services, when viewed in their entirety,
must be readily accessible to and useable by individuals with
disabilities. This standard includes physical access,
non-discrimination in policies and procedures and communication.
Communications with individuals with disabilities are required
to be as effective as communications with others. The MCO
Compliance Plan must include a detailed description of how MCO
services, programs and activities are readily accessible and
usable by individuals with disabilities. In the event that full
physical accessibility is not readily available for people with
disabilities, the MCO Compliance Plan will describe the steps or
actions the MCO will take to assure accessibility to services
equivalent to those offered at the inaccessible facilities.
Program Accessibility

A. Pre-enrollment Marketing and Education

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

Suggested Methods for Compliance

  1.   Activities held in physically accessible location, or staff at activities
available to meet with person in an accessible location as necessary  

2. Materials available in alternative formats, such as Braille, large print,
audio tapes

3. Staff training which includes training and information regarding attitudinal
barriers related to disability

4. Activities and fairs that include sign language interpreters or the
distribution of a written summary of the marketing script used by plan marketing
representatives

5. Enrollee health promotion material/activities targeted specifically to
persons with disabilities (e.g. secondary infection prevention, decubitus
prevention, special exercise programs, etc.)

  6.   Policy statement that marketing representatives will offer to read or
summarize to blind or vision impaired individuals any written material that is
typically distributed to all enrollees  

7. Staff/resources available to assist individuals with cognitive impairments in
understanding materials

APPENDIX J
October 1, 2004
J-3

Compliance Plan Submission

  1.   A description of methods to ensure that the MCO’s marketing presentations
(materials and communications) are accessible to persons with auditory, visual
and cognitive impairments  

2. A description of the MCO’s policies and procedures, including marketing
training, to ensure that marketing representatives neither screen health status
nor ask questions about health status or prior health care services

      1V.   Program Accessibility
A1.
  Member Services Department

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

          B 1.Accessibility         Standard for Compliance:        
Member Services sites and functions will be made accessible to, and usable by,
people with disabilities.
    —  

Suggested Methods for Compliance (include, but are not limited to those
identified below)

  1.   Exterior routes of travel, at least 36” wide, from parking areas or
public transportation stops into the MCO’s facility  

  2.   If parking is provided, spaces reserved for people with disabilities,
pedestrian ramps at sidewalks, and dropoffs  

  3.   Routes of travel into the facility are stable, slip-resistant, with all
steps > ''/2” ramped, doorways with minimum 32” opening  

  4.   Interior halls and passageways providing a clear and unobstructed path or
travel at least 36” wide to bathrooms and other rooms commonly used by enrollees
 

  5.   Waiting rooms, restrooms, and other rooms used by enrollees are
accessible to people with disabilities  

  6.   Sign language interpreters and other auxiliary aids and services provided
in appropriate circumstances  

7. Materials available in alternative formats, such as Braille, large print,
audio tapes

  8.   Staff training which includes sensitivity training related to disability
issues [Resources and technical assistance are available through the NYS Office
of Advocate for Persons with Disabilities — V/TTY (800) 522- 4369; and the NYC
Mayor’s Office for People with Disabilities — (212) 788-2830 or TTY
(212)788-2838]  

9. Availability of activities and educational materials tailored to specific
conditions/illnesses and secondary conditions that affect these populations
(e.g. secondary infection prevention, decubitus prevention, special exercise
programs, etc.)

10. MCO staff trained in the use of telecommunication devices for enrollees who
are deaf or hard of hearing (TTY/TDD) as well as in the use of NY Relay for
phone communication

11. New enrollee orientation available in audio or by interpreter services

  12.   Policy that when member services staff receive calls through the NY
Relay, they will offer to return the call utilizing a direct TTY/TDD connection
 

Compliance Plan Submission

  1.   A description of accessibility. to the member services department or
reasonable alternative means to access member services for enrollees using
wheelchairs (or other mobility aids)  

  2.   A description of the methods the member services department will use to
communicate with enrollees who have visual or hearing impairments, including any
necessary auxiliary aid/services for enrollees who are deaf or hard of hearing,
and TTY/TDD technology or NY Relay Service available through a toll-free
telephone number  

  3.   A description of the training provided to member services staff to assure
that staff adequately understands how to implement the requirements of the
program, and of these guidelines, and are sensitive to the needs of persons with
disabilities  

APPENDIX J
October 1, 2004
J-4

IV. PROGRAM ACCESSIBILITY

B2. Identification of Enrollees with Disabilities

Standard for Compliance:
MCOs must have in place satisfactory methods/guidelines for identifying persons
at risk of, or having, chronic diseases and disabilities and determining their
specific needs in terms of specialist physician referrals, durable medical
equipment, medical supplies, home health services etc. MCOs may not discriminate
against a potential enrollee based on his/her current health status or
anticipated need for future health care. MCOs may not discriminate on the basis
of disability, or perceived disability of an enrollee or their family member.
Health assessment forms may not be used by plans prior to enrollment. (Once a
plan has been chosen, a health assessment form may be used to assess the
person’s health care needs.)

Suggested Methods for Compliance

  1.   Appropriate post enrollment health screening for each enrollee, using an
appropriate health screening tool  

  2.   Patient profiles by condition/disease for comparative analysis to
national norms, with appropriate outreach and education  

  3.   Process for follow-up of needs identified by initial screening; e.g.
referrals, assignment of case manager, assistance with scheduling/keeping
appointments  

4. Enrolled population disability assessment survey

  5.   Process for enrollees who acquire a disability subsequent to enrollment
to access appropriate services  

Compliance Plan Submission

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

• are blind or have visual impairments, including the type of auxiliary aids and
services required by the enrollee

  •   are deaf or hard of hearing, including the type of auxiliary aids and
services required by the enrollee  

  •   have mobility impairments, including the extent, if any, to which they can
ambulate  

  •   have other physical or mental impairments or disabilities, including
cognitive impairments  

  •   have conditions which may require more intensive case management  

      IV. PROGRAM ACCESSIBILITY

 
   
B3.
  New Enrollee Orientation

Standard for Compliance:

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

Suggested Methods for Compliance

  1.   Activities held in physically accessible location, or staff at activities
available to meet with person in an accessible location as necessary  

2. Materials available in alternative formats, such as Braille, large print,
audio tapes

  3.   Staff training which includes sensitivity training related to disability
issues [Resources and technical assistance are available through the NYS Office
of Advocate for Persons with Disabilities — V/TTY (800) 522-4369; and the NYC
Mayor’s Office for People with Disabilities — (212) 788-2830 or TTY
(212)788-2838].  

  4.   Activities and fairs that include sign language interpreters or the
distribution of a written summary of the marketing script used by plan marketing
representatives  

  5.   Include in written/audio materials available to all enrollees information
regarding how and where people with disabilities can access help in getting
services, for example help with making appointments or for arranging special
transportation, an interpreter or assistive communication devices  

  6.   Staff/resources available to assist individuals with cognitive
impairments in understanding materials  

APPE NDIX J
October 1, 2004
J-5

118

Compliance Plan Submission

  1.   A description of how the MCO will advise enrollees with disabilities,
during the new enrollee orientation on how to access care  

  2.   A description of how the MCO will assist new enrollees with disabilities
(as well as current enrollees who acquire a disability) in selecting or
arranging an appointment with a Primary Care Practitioner (PCP)  

• This should include a description of how the MCO will assure and provide
notice to enrollees who are deaf or hard of hearing, blind or who have visual
impairments, of their right to obtain necessary auxiliary aids and services
during appointments and in scheduling appointments and follow-up treatment with
participating providers
• In the event that certain provider sites are not physically accessible to
enrollees with mobility impairments, the MCO will assure that reasonable
alternative site and services are available

  3.   A description of how the MCO will determine the specific needs of an
enrollee with or at risk of having a disability/chronic disease, in terms of
specialist physician referrals, durable medical equipment (including assistive
technology and adaptive equipment), medical supplies and home health services
and will assure that such contractual services are provided  

  4.   A description of how the MCO will identify if an enrollee with a
disability requires on-going mental health services and how am MCO will
encourage early entry into treatment  

5. A description of how the MCO will notify enrollees with disabilities as to
how to access transportation, where

applicable

IV. PROGRAM ACCESSIBILITY

Standard for Compliance:

The MCO will establish and maintain a procedure to protect the rights and
interests of both enrollees and managed care plans by receiving, processing, and
resolving grievances and complaints in an expeditious manner, with the goal of
ensuring resolution of complaints and access to appropriate services as rapidly
as possible.

All enrollees must be informed about the complaint process within their plan and
the procedure for filing complaints. This information will be made available
through the member handbook, the SDOH toll-free complaint line [1-(800)
206-8125] and the plan’s complaint process annually, as well as when the MCO
denies a benefit or referral. The MCO will inform enrollees of: the MCO’s
complaint procedure; enrollees’ right to contact the local district or SDOH with
a complaint, and to file.an appeal or request a fair hearing; the right to
appoint a designee to handle a complaint or appeal; the toll free complaint
line. The MCO will maintain designated staff to take and process complaints, and
be responsible for assisting enrollees in complaint resolution.

The MCO will make all information regarding the complaint process available to
and usable by people with disabilities, and will assure disabilities have access
to sites where enrollees typically file complaints and requests for appeals.

Suggested Methods for Compliance

1. 800 complaint phone line with TDD/TTY capability

2. Staff trained in complaint process, and able to provide interpretive or
assistive support to enrollee during the complaint process

3. Notification materials and complaint forms in alternative formats for
enrollees with visual or hearing impairments

4. Availability of physically accessible sites, e.g. member services department
sites
5. Assistance for individuals with cognitive impairments

APPENDIX J

October 1, 2004

J -6

Compliance Plan Submission

1. A description of how MCO’s complaint and appeal procedures shall be
accessible for persons with disabilities, including:

• procedures for complaints and appeals to be made in person at sites accessible
to persons with mobility impairments

• procedures accessible to persons with sensory or other impairments who wish to
make verbal complaints, and to communicate with such persons on an ongoing basis
as to the status or their complaints and rights to further appeals

• description of methods to ensure notification material is available in
alternative formats for enrollees with vision and hearing impairments

  3.   A description of how MCOs monitor complaints and grievances related to
people with disabilities. Also, as part of the Compliance Plan, MCOs must submit
a summary report based on the MCO’s most recent year’s complaint data.  

IV. PROGRAM ACCESSIBILITY

C. Case Management

Standard for Compliance:
MCOs must have in place adequate case management systems to identify the service
needs of all enrollees, including enrollees with chronic illness and enrollees
with disabilities, and ensure that medically necessary covered benefits are
delivered on a timely basis. These systems must include procedures for standing
referrals, specialists as PCPs, and referrals to specialty centers for enrollees
who require specialized medical care over a prolonged period of time (as
determined by a treatment plan approved by the MCO in consultation with the
primary care provider, the designated specialist and the enrollee or his/her
designee), out of plan referrals and continuation of existing treatment
relationships with out-of-plan providers (during transitional period).

Suggested Methods for Compliance

1. Procedures for requesting specialist physicians to function as PCP

  2.   Procedures for requesting standing referrals to specialists and/or
specialty centers, out of plan referrals, and continuation of existing treatment
relationships  

  3.   Procedures td meet enrollee needs for, durable medical equipment, medical
supplies, home visits as appropriate  

  4.   Appropriately trained MCO staff to function as case managers for special
needs populations, or sub-contract arrangements for case management  

  5.   Procedures for informing enrollees about the availability of case
management services  

Compliance Plan Submission

1. A description of the MCO case management program for people with
disabilities, including case management functions, procedures for qualifying for
and being assigned a case manager ; and description of case management staff
qualifications

2. A description of the MCO’s model protocol to enable participating providers,
at their point of service, to identify enrollees who require a case manager

  3.   A description of the MCO’s protocol for assignment of specialists as PCP,
and for standing referrals to specialists and specialty centers, out-of-plan
referrals and continuing treatment relationships  

4. A description of the MCO’s notice procedures to enrollees regarding the
availability of case management services, specialists as PCPs, standing
referrals to specialists and specialty centers, out-of-plan referrals and
continuing treatment relationships

APPENDIX J
October 1, 2004
J-7

Suggested Methods for Compliance

  1.   Process for MCO to evaluate provider network to ascertain the degree of
provider accessibility to persons with disabilities, to identify barriers to
access and required modifications to policies/procedures  

  2.   Model protocol to assist participating providers, at their point of
service, to identify enrollees who require case manager, audio, visual, mobility
aids, or other accommodations  

3. Model protocol for determining needs of enrollees with mental disabilities
4. Use of Wheelchair Accessibility Certification Form (see attached)
5. Submission of map of physically accessible sites
6. Training for providers re: compliance with Title III of ADA, e.g. site access
requirements for door widths, wheelchair ramps, accessible diagnostic/treatment
rooms and equipment; communication issues; attitudinal barriers related to
disability, etc. [Resources and technical assistance are available through the
NYS Office of Advocate for Persons with Disabilities -V/TTY (800) 522-4369; and
the NYC Mayor’s Office for People with Disabilities - (212) 788- 2830 or TTY
(212)788-2838]
7. Use of ADA Checklist for Existing Facilities and NYC Addendum to OAPD ADA
Accessibility Checklist as guides for evaluating existing facilities and for new
construction and/or alteration.

Compliance Plan Submission

  1.   A description of how MCO will ensure that its participating provider
network is accessible to persons with disabilities. This includes the following:
 

• Policies and procedures to prevent discrimination on the basis of disability
or type of illness or condition
• Identification of participating provider sites which are accessible by people
with mobility impairments, including people using mobility devices. If certain
provider sites are not physically accessible to persons with disabilities, the
MCO shall describe reasonable, alternative means that result in making the
provider services readily accessible.
• Identification of participating provider sites which do not have access to
sign language interpreters or reasonable alternative means to communicate with
enrollees who are deaf or hard of hearing; and for those sites describe
reasonable alternative methods to ensure that services will be made accessible

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

2. A description of how the MCO’s specialty network is sufficient to meet the
needs of enrollees with disabilities
3. A description of methods to ensure the coordination of out-of-network
providers to meet the needs of the enrollees with disabilities

  •   This may include the implementation of a referral system to ensure that
the health care needs of enrollees with disabilities are met appropriately  

  •   MCO shall describe policies and procedures to allow for the continuation
of existing relationships with out-of-network providers, when in the best
interest of the enrollee with a disability  

  4.   Submission of ADA Compliance Summary Report (see attached — county
specific/borough specific for NYC) or MCO statement that data submitted to SDOH
on the Health Provider Network (HPN) files is an accurate reflection of each
network’s physical accessibility  

IV. PROGRAM ACCESSIBILITY

E. Populations Special Health Care Needs

Standard for Compliance:

MCOs will have satisfactory methods for identifying persons at risk of, or
having, chronic disabilities and determining their specific needs in terms of
specialist physician referrals, durable medical equipment, medical supplies,
home health services,. etc. MCOs will have satisfactory systems for coordinating
service delivery and, if necessary, procedures to allow continuation of existing
relationships with out-of-network provider for course of treatment.

APPENDIX J
October 1, 2004
J-8

Suggested Methods for Compliance

  1.   Procedures for requesting standing referrals to specialists and/or
specialty centers, specialist physicians to function as PCP, out of plan
referrals, and continuation of existing relationships with out-of-network
providers for course of treatment  

2. Contracts with school-based health centers

  3.   Linkages with preschool services, child protective agencies, early
intervention officials, behavioral health agencies, disability and advocacy
organizations, etc.  

  4.   Adequate network of providers and subspecialists (including pediatric
providers and sub-specialists) and contractual relationships with tertiary
institutions  

5. Procedures for assuring that these populations receive appropriate diagnostic
workups on a timely basis
6. Procedures for assuring that these populations receive appropriate access to
durable medical equipment on a timely basis

  7.   Procedures for assuring that these populations receive appropriate allied
health professionals (Physical, Occupational and Speech Therapists,
Audiologists) on a timely basis  

8. State designation as a Well Qualified Plan to serve OMRDD population and
look-alikes

Compliance Plan Submission

      1. A description of arrangements to ensure access to specialty care
providers and centers in and out of New York State, standing referrals,
specialist physicians to function as PCP, out of plan referrals, and
continuation of existing relationships (out-of-plan) for diagnosis and treatment
of rare disorders.  

  2.   A description of appropriate service delivery for children with
disabilities. This may include a description of methods for interacting with
school districts, preschool services, child protective service agencies, early
intervention officials, behavioral health, and disability and advocacy
organizations and School Based Health Centers.  

  3.   A description of the pediatric provider and sub-specialist network,
including contractual relationships with tertiary institutions to meet the
health care needs of children with disabilities  

V. ADDITIONAL ADA RESPONSIBILITIES FOR PUBLIC ACCOMMODATIONS

Please note that Title Ill of the ADA applies to all non-governmental providers
of health care. Title III of the Americans With Disabilities Act prohibits
discrimination on the basis of disability in the full and equal enjoyment of
goods, services, facilities, privileges, advantages or accommodations of any
place of public accommodation: A public accommodation is a private entity that
owns, leases or leases to, or operates a place of public accommodation. Places
of public accommodation identified by the ADA include, but are not limited to,
stores (including pharmacies) offices (including doctors’ offices), hospitals,
health care providers, and social service centers.

New and altered areas and facilities must be as accessible as possible. Barriers
must be removed from existing facilities when it is readily achievable, defined
by the ADA as easily accomplishable without much difficulty or expense. Factors
to be considered when determining if barrier removal is readily achievable
include the cost of the action, the financial resources of the site involved,
and, if applicable, the overall financial resources of any parent corporation or
entity. If barrier removal is not readily achievable, the ADA requires alternate
methods of making goods and services available. New facilities must be
accessible unless structurally impracticable.

Title III also requires places of public accommodation to provide any auxiliary
aids and services that are needed to ensure equal access to the services it
offers, unless a fundamental alteration in the nature of services or an undue
burden would result. Auxiliary aids include but are not limited to qualified
sign interpreters, assistive listening systems, readers, large print materials,
etc. Undue burden is defined as “significant difficulty or expense”. The factors
to be considered in determining “undue burden” include, but are not limited to,
the nature and cost of the action required and the overall financial resources
of the provider. “Undue burden” is a higher standard than “readily achievable”
in that it requires a greater level of effort on the part of the public
accommodation.

Please note also that the ADA is not the only law applicable for people with
disabilities. In some cases, State or local laws require more than the ADA. For
example, New York City’s Human Rights Law, which also prohibits discrimination
against

APPENDIX J
October 1, 2004
J-8

people with disabilities, includes people whose impairments are not as
“substantial” as the narrower ADA and uses the higher “undue burden”
(“reasonable”) standard where the ADA requires only that which is “readily
achievable”. New York City’s Building Code does not permit access waivers for
newly constructed facilities and requires incorporation of access features as
existing facilities are renovated. Finally, the State Hospital code sets a
higher standard than the ADA for provision of communication (such as sign
language interpreters) for services provided at most hospitals, even on an
outpatient basis.

119

APPENDIX J
October 1, 2004
J-9APPENDIX K

PREPAID BENEFIT PACKAGE

DEFINITIONS OF COVERED AND

NON-COVERED SERVICES

120

APPENDIX K
October 1, 2004
K- 1
APPENDIX K
PREPAID BENEFIT PACKAGE.
DEFINITIONS OF COVERED AND NON-COVERED SERVICES

The categories of services in the Medicaid Managed Care Benefit Package, when
listed as covered services shall be provided by the Contractor to Enrollees when
medically necessary under the terms of this Agreement. The definitions of
covered and non-covered services therein are in summary form; the full
description and scope of each Medicaid covered service as established by the New
York Medical Assistance Program are set forth in the applicable MMIS Provider
Manual.

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 (see Benefit Package K-2), and emergency services,
emergency transportation, family planning, 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.

This Appendix contains the following two (2) charts:

     
K-1
K-2
  A summary of services provided by the Contractor to all Non-SSI Enrollees.
A summary of services provided by the Contractor to all SSI Enrollees.

Also included:

Prepaid Benefit Package Definitions of Covered Services
A) Medical Services

1. Inpatient Hospital Services
1 a. Inpatient Stay Pending Alternate Level of Medical Care
2. Professional Ambulatory Services
3. Physician Services
4. Home Health Services
5. Private Duty Nursing Services
6. Emergency Room Services
7. Services of Other Practitioners
8. Eye Care and Low Vision Services
9. Laboratory Services

10. Radiology Services
11. Early Periodic Screening Diagnosis and Treatment (EPSDT) Services Through
the Child Teen Health Program (C/THP) and Adolescent Preventive Services
12. Durable Medical Equipment (DME)
13. Audiology, Hearing Aid Services and Products
14. Preventive Care
15. Prosthetic/Orthotic Orthopedic Footwear
16. Renal Dialysis

17. Experimental or Investigational Treatment

B) Behavioral Health Services

1. Chemical Dependence Services

a) Detoxification Services

i) Medically Managed Inpatient Detoxification
ii) Medically Supervised Withdrawal

  b)   Chemical Dependence Inpatient Rehabilitation and Treatment Services  

c) Chemical Dependence Assessment Self-Referral

2. Mental Health Services

a) Inpatient Services
b) Outpatient Services

APPENDIX K

October I, 2004
K-2

C) Other Covered Services

1. Federally Qualified Health Center (FQHC) Services

  II.   Optional Covered Services (at discretion of LDSS and/or Contractor) [See
Schedule A of Appendix K for Coverage Status]  

A) Family Planning and Reproductive Health Care
B) Dental Services
C) Transportation Services

1. Non-Emergency Transportation

2. Emergency Transportation

III. Definitions of Non-Covered Services

A) Medical Non-Covered Services

1. Personal Care Agency Services
2. Residential Health Care Facilities (RHCF)
3. Hospice Program

  4.   Prescription and Non-Prescription (OTC) Drugs, Medical Supplies, and
Enteral Formula

B) Non-Covered Behavioral Health Services

1. Chemical Dependence Services

a) Outpatient Rehabilitation and Treatment Services

i) Methadone Maintenance Treatment Program (MMTP) Medically Supervised
Ambulatory Chemical Dependence Outpatient Clinic Programs
ii) Medically Supervised Chemical Dependence Outpatient Rehabilitation Programs

iii) Outpatient Chemical Dependence for Youth Programs b) Chemical Dependence
Services Ordered by the LDSS

2. Mental Health Services

a) Intensive Psychiatric Rehabilitation Treatment Programs (IPRT)

b) Day Treatment
c) Continuing Day Treatment
d) Day Treatment Programs Serving Children

  e)   Home and Community Based Services Waiver for Seriously Emotionally
Disturbed Children  

f) Case Management
g) Partial Hospitalization

  h)   Services Provided through OMH Designated Clinics for Children With a
Diagnosis of Serious Emotional Disturbance (SED)

i) Assertive Community Treatment (ACT)
j) Personalized Recovery Oriented Services (PROS)

  3.   Rehabilitation Services Provided to Residents of OMH Licensed Community
Residences (CRs) and Family Based Treatment Programs  

a) OMH Licensed CRs
b) Family-Based Treatment

Office of Mental Retardation and Developmental Disabilities (OMRDD) Services

  a)   Long Term .Therapy Services Provided by Article 16-Clinic Treatment
Facilities or Article 28 Facilities  

b) Day Treatment
c) Medicaid Service Coordination (MSC)
d) Home and Community Based Services Waivers (HCBS)

  e)   Services Provided Through the Care at Home Program (OMRDD)  

APPENDIX K

October 1, 2004

K- 3

121

C) Other Non-Covered Services

  1.   The Early Intervention Program (EIP) — Children Birth to Two (2) Years of
Age

2. Preschool Supportive Health Services — Children Three (3)

Through Four (4) Years of Age

3. School Supportive Health Services — Children Five (5) Through

Twenty-One (21) Years of Age

4. Comprehensive Medicaid Case Management (CMCM)
5. Directly Observed Therapy for Tuberculosis Disease
6. AIDS Adult Day Health Care
7. HIV COBRA Case Management
8. Fertility Services
9. Adult Day Health Care
10. Personal Emergency Response Systems (PERS)
11. School-Based Health Centers

  IV.   Schedule A of Appendix K, Prepaid Benefit Package, Coverage Status of
Optional Covered Services  

APPENDIX K

October 1, 2004

122

K- 4
APPENDIX K-1

MANAGED CARE PLAN PREPAID BENEFIT PACKAGE

                  Covered Services   Managed Care Plan Scope of Benefit  
Covered by Medicaid Fee-For-Service
 
  Up to 365 medically necessary days per year (366 for leap year) in accordance
       
 
  with the stop-loss provisions of Section 3.10 of this Agreement. Includes
inpatient
       
 
  detoxification services provided in Article 28 hospitals for all Enrollees.
Inpatient
       
Inpatient Hospital Services
  dental services are covered. (See dental definition)
                     
 
  Continued care in a hospital pending placement in an alternate lower medical
level
       
Inpatient Stay Pending Alternate
  of care, consistent with the provisions of 18 NYCRR 505.20 and 10 NYCRR, Part
       
Level of Medical Care
    85.          
 
               
 
  Provided through ambulatory care facilities including hospital outpatient
       
 
  departments, D&T centers, and emergency rooms. Services include medical,
       
 
  surgical, preventive, primary, rehabilitative, specialty care, mental health,
family
       
 
  planning, C/THPservices and ambulatory dental surgery. Covered as needed
       
Professional Ambulatory Services
  based on medical necessity.
                     
 
  Care or service to avert disease/illness and/or its consequences. Preventive
care
       
 
  includes primary care, secondary care and tertiary care. Coverage includes
general
       
 
  health education classes, smoking cessation classes, childbirth education
classes,
       
 
  parenting classes and nutrition counseling (with targeted outreach to persons
with
       
 
  diabetes and pregnant women). HIV counseling and testing is a covered service
for
       
Preventive Health Services
  all Enrollees.
                     
 
  Covered when medically necessary as ordered by a qualified medical
professional,
  HIV phenotypic, HIV virtual phenotypic and HIV

 
  and when listed in the Medicaid fee schedule. Coverage excludes HIV
  genotypic drug resistance tests with a Provider's

Laboratory Services
  phenotypic, FIN virtual phenotypic and HIV genotypic drug resistance tests.
  order.
         
 
  Covered when medically necessary as ordered by a qualified medical
professional,
       
Radiology Services
  and when ordered and provided by a qualified medical
professional/practitioner.
                     
 
  EPSDT is a package of early and periodic screening, including inter-periodic
       
 
  screens and, diagnostic and treatment services that are offered to all
Medicaid
  Services not included in the managed care Benefit

EPSDT Services/Child Teen
  eligible children under twenty-one.(2l) years of age known in New York State
as
  Package ordered by the child's physician based on

Health Program (C/THP)
  the Child Teen Health Program (C/THP).
  the results of a screening.
         

APPENDIX K

October 1, 2004

K-5

          Covered Services Managed Care Plan Scope of Benefit Covered by
Medicaid Fee-For-Service         Services rendered by a personal care agency
which     Home health care services include medically necessary nursing, home
health aide   are approved by the Local Social Services District     services,
equipment and appliances, physical therapy, speech/language pathology,   when
ordered by the Enrollee's Primary Care     occupational therapy, social work
services or nutritional services provided by a   Provider (PCP). The district
will determine the     home health care agency pursuant to an established care
plan. Personal care tasks   applicant's need for personal care agency services  
  performed by a home health aide in connection with a home health care agency  
and coordinate a plan of care with the personal care Home Health Services  
visit, and pursuant to an established care plan, are covered.   agency.    
Covered service when medically necessary in accordance with the ordering        
physician, registered physician assistant or certified nurse practitioner's
written     Private Duty Nursing Services   treatment plan.         Covered for
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. Emergency services include health care
procedures,         treatments or services, including psychiatric stabilization
and medical         detoxification from drugs or alcohol that are provided for
an emergency medical ,     Emergency Room Services .   condition. A medical
assessment (triage) is covered for non-emergent conditions.         Foot care
when the Enrollee's (any 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     Foot Care Services   the diagnosis and treatment of diabetes,
ulcers, and infections.    
Eye Care and Low Vision
Services
  Eye care includes the services of an ophthalmologist, optometrist’ and an
ophthalmic dispenser and coverage for contact lenses, polycarbonate lenses,
artificial eyes and replacement of lost or destroyed glasses (including repairs)
when medically necessary.
Artificial eyes are covered as ordered by a Contractor’s Participating Provider.
 

APPENDIX K
October 1, 2004
K-6

          Covered Services Managed Care Plan Scope of Benefit Covered by
Medicaid Fee-For-Service     DME are devices and equipment other than
medical/surgical supplies, enteral         formula, and prosthetic or orthotic
appliances. Covered when medically necessary         as ordered by a
Contractor's Participating Provider and procured from a   Excluded services,
such as disposable Durable Medical Equipment   Participating Provider. Coverage
excludes disposable medical/surgical supplies   medical/surgical supplies and
enteral formula with a (DME)   and enteral formula.   Provider's order.    
Provided when medically necessary to alleviate disability caused by the loss or
        impairment of hearing. Hearing aid products include hearing aids,
earmolds,   Excluded services, such as hearing aid batteries Hearing Aids
Services   special fittings, and replacement parts. Coverage excludes hearing
aid batteries.   with a Provider's order.
Family Planning and
Reproductive Health Services
See Schedule A of Appendix K
for Coverage Status
  Family planning means the offering, arranging, and furnishing of those health
services which enable individuals, including minors, who may be sexually active,
to prevent or.reduce the incidence of unintended pregnancies and includes the
screening, diagnosis and treatment, as medically necessary, for sexually
transmissible diseases, sterilization services and screening for pregnancy.
Reproductive health services also includes all medically necessary abortions.  

Enrollees may always obtain family planning and
HIV testing.and counseling services, when part of a
family planning visit, outside of the plan’s network
from any Provider that accepts Medicaid.

APPENDIX K

October 1, 2004
K-7

          Covered Services Managed Care Plan Scope of Benefit Covered by
Medicaid Fee-For-Service
 
  Non-Emergency Transportation:  

Transportation Services
Non-Emergency Transportation
See Schedule A of Appendix K
for Coverage Status
Emergency Transportation
See Schedule A of Appendix K
for Coverage Status
  Transportation expenses are covered when transportation is essential in order
for
an Enrollee to obtain necessary medical care and services which are covered
under
this Benefit Package (or by fee-for-service Medicaid for carved-out services).
Non-emergent transportation guidelines may be developed in conjunction with the
LDSS, based on the LDSS’ approved transportation plan.
Transportation services means transportation by ambulance, ambulette or invalid
coach, taxicab, livery, public transportation, or other means appropriate to the
Enrollee’s medical condition; and a transportation attendant to accompany the
Enrollee, if necessary. Such services may include the transportation attendant’s
transportation, meals, lodging and salary; however, no salary will be paid to a
transportation attendant who is a member of the Enrollee’s family.
For Enrollees with disabilities, the method of transportation must reasonably  
For Contractors that do not cover transportation
services, these services are paid for fee-for-service.
Non-emergent transportation requests should be
referred to the LDSS.
For Contractors that cover non-emergency
transportation in the Benefit Package, transportation
costs to MMTP services may be reimbursed by
Medicaid fee-for-service in accordance with the
LDSS transportation polices in local districts where
there is a systematic method to discretely identify
and reimburse such transportation costs.
 
     

 
       
 
  accommodate their needs, taking into account the severity and nature of the  

 
     

 
       
 
  disability.  

 
     

 
       
 
  Emergency Transportation
Emergency transportation can only be provided by an ambulance service.
Emergency transportation is covered for Enrollees suffering from severe, life-
threatening or potentially disabling conditions which require the provision of
emergency medical services while the Enrollee is being transported.  

 
     

 
       
 
  Optional Benefit Package dental services include:  

Dental Services
See Schedule A of Appendix K
for Coverage Status
  • Medically necessary preventive, prophylactic and other routine dental care,
services and supplies and dental prosthetics required to alleviate a serious
health condition, including one which affects employability.
As described in Sections 10.16 and 10.28 of this Agreement, Enrollees may self-
refer to Article 28 clinics operated by academic dental centers to obtain
covered
dental services.
All Contractors must cover the following, even if dental services is not a plan
covered benefit:
• Ambulatory or inpatient surgical services (subject to prior authorization by
the
Contractor).
Coverage excludes the professional services of the dentist if dental services
are not
covered by the Contractor’s Benefit Package.  

Routine exams, orthodontic services and appliances,
dental office surgery, fillings, prophylaxis, provided
to Enrollees of plans not electing to cover dental
services.
Orthodontic services are always covered by fee-for-
service.
 
       

APPENDIX K

October 1, 2004

K-8

          Covered Services Managed Care Plan Scope of Benefit Covered by
Medicaid Fee-For-Service
Court-Ordered Services
  Coverage includes such services ordered by a court of competent jurisdiction
if the
services are in the Contractor’s Benefit Package.  

 
     

 
       
Prosthetic/Orthotic
Services/Orthopedic Footwear
  Covered when medically necessary as ordered by the Contractor’s Participating
Provider.  

 
     

 
       
Mental Health Services
  Covered when medically necessary, in accordance with the stop-loss provisions
as
described in Section 3.12 of this Agreement. Enrollees must be allowed to self-
refer for one (1) mental health assessment from a Contractor’s Participating
Provider in a twelve (12) month period. In the case of children, such
self-referrals
may originate at the request of a school guidance counselor or similar source.  
All services in excess of twenty (20) outpatient
visits and thirty (30) inpatient days in accordance
with the stop-loss provisions in Section 3.12 of this
Agreement. Contractor continues to reimburse
mental health service providers and coordinate care.
The Contractor is reimbursed for payment through
the stop-loss provisions.
 
       
 
       
Detoxification Services
  Covered when medically necessary on either an inpatient or outpatient basis.
Such
services are referred to as “Medically Managed Detoxification Services” when
provided in facilities licensed under Title 14 NYCRR Part 816.6 or Article 28 of
the Public Health Law; and “Medically Supervised Inpatient and Outpatient
Withdrawal Services” when provided in facilities licensed under Title 14 NYCRR
Part 816.7.  

Medically Supervised Inpatient and Outpatient
Withdrawal Services, when ordered by the LDSS
under Welfare Reform (as indicated by “code 83”).
 
       
 
       
Chemical Dependence Inpatient
Rehabilitation and Treatment
Services
  Covered when medically necessary in accordance with the stop-loss provisions
described in Section 3.12 of this Agreement.   Chemical Dependence Inpatient
Rehabilitation and
Treatment Services when ordered by the LDSS
under Welfare Reform (as indicated by “code 83”)
 
       
 
       
Chemical Dependence
Assessment Self-Referral
  Enrollees must be allowed to self refer for one (1) assessment from a
Contractor’s
participating provider in a twelve (12) month period.  

 
     

 
       
Experimental and/or
Investigational Treatment
  Covered on a case by case basis in accordance with the provisions of
Section 4910
of the New York State P.H.L.  

 
     

 
       
Renal Dialysis
  Renal dialysis is covered when medically necessary as ordered by a qualified
medical professional. 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.  

 
     

APPENDIX K

October 1, 2004

123

K-9
K-2

MANAGED CARE PLAN PREPAID HEALTH ONLY BENEFIT PACKAGE

For SSI and SSI Related Recipients

                  Covered Services   Managed Care Plan Scope of Benefit.  
Covered by Medicaid Fee-For-Service
 
  Up to 365 medically necessary days per year (366 for leap year) in accordance
       
 
  with the stop-loss provisions of Section 3.10 of this Agreement. Includes
inpatient
       
 
  detoxification services provided in Article 28 hospitals for all Enrollees.
Inpatient
       
Inpatient Hospital Services
  dental services are covered.
                     
 
  Continued care in a hospital pending placement in an alternate lower medical
level
       
Inpatient Stay Pending Alternate
  of care, consistent with the provisions of 18 NYCRR 505.20 and 10 NYCRR, Part
       
Level of Medical Care
    85.          
 
               
 
  Provided. through ambulatory care facilities including hospital outpatient
       
 
  departments, D&T centers, and emergency rooms. Services include medical,
       
 
  surgical, preventive, primary, rehabilitative, specialty care, family
planning,
       
 
  C/THPservices and ambulatory dental surgery. Covered as needed based on      
 
Professional Ambulatory Services
  medical necessity.
  Mental Health and Chemical Dependence services.
         
 
  EPSDT is a package of early and periodic screening, including inter-periodic
       
 
  screens and diagnostic and treatment services that are offered to all Medicaid
  Services not included in the managed care Benefit

EPSDT Services/ Child Teen
  eligible children under twenty-one (21) years of age, known in New York State
as
  Package ordered by the child's physician based on

Health Program (C/THP)
  the Child Teen Health Plan (C/THP).
  the results of a screening.
         
 
  Care and services to avert disease/illness and/or its consequences. Preventive
care
       
 
  includes primary care, secondary care and tertiary care. Coverage includes
general
       
 
  health education classes, smoking cessation classes, childbirth education
classes,
       
 
  parenting classes and nutrition counseling (with targeted outreach to persons
with
       
 
  diabetes and pregnant women). HIV counseling and testing is a covered service
for
       
Preventive Health Services
  all Enrollees. .
                     
 
          Services rendered by a personal care agency which

 
  Home health care services include medically necessary nursing, home health
aide
  are approved by the Local Social Services District

 
  services, equipment and appliances, physical therapy, speech/language
pathology,
  when ordered by the Enrollee's Primary Care

 
  occupational therapy, social work services or nutritional services provided by
a
  Provider (PCP). The district will determine the

 
  home health care agency pursuant to an established care plan. Personal care
tasks
  applicant's need for personal care agency services

_
  performed by a home health aide in connection with a home health care agency
  and coordinate with the personal care agency a plan

Home Health Services
  visit, and pursuant to an established care plan, are covered.
  of care.
         

APPENDIX K

October 1, 2004

K-10

          Covered Services Managed Care Plan Scope of Benefit Covered by
Medicaid Fee-For-Service
Private Duty Nursing Services
  Covered service when medically necessary in accordance with the ordering
physician, registered physician assistant or certified nurse practitioner’s
written
treatment plan.  

 
     

 
       
Emergency Room Services
  Covered for 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. Emergency services include health care procedures,
treatments or services, including psychiatric stabilization and medical
detoxification from drugs or alcohol that are provided for an emergency medical
condition. A medical assessment (triage) is covered for non-emergent conditions.
 

 
     

 
       
Foot Care Services
  Foot care when the Enrollee’s (of any 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.  

 
     

 
       
Eye Care and Low Vision
Services
  Eye care includes the services of an ophthalmologist, optometrist and an
ophthalmic dispenser and coverage for contact lenses, polycarbonate lenses,
artificial eyes and replacement of lost or destroyed glasses (including repairs)
when medically necessary.
Artificial eyes are covered as ordered by the Contractor’s Participating
Provider.  

 
     

APPENDIX K October 1, 2004
K-11

          Covered Services Managed Care Plan Scope of Benefit Covered by
Medicaid Fee-For-Service
 
  Optional Benefit Package dental services include:  

Dental Services
See Schedule A of Appendix K
for Coverage Status
  • Medically necessary preventive, prophylactic and other routine dental care,
services and supplies and dental prosthetics required to alleviate a serious
health condition, including one which affects employability.
As described in Sections 10.16 and 10.28 of this Agreement, Enrollees may self-
refer to Article 28 clinics operated by academic dental centers to obtain
covered
dental services.
All Contractors must cover the following, even if dental services is not a plan
covered benefit:
• Ambulatory or inpatient surgical services (subject to prior authorization by
the
Contractor).  

Routine exams, orthodontic services and appliances,
dental office surgery, fillings, prophylaxis, provided
to Enrollees of MCOs not electing to cover dental
services.
 
       
 
  Coverage excludes the professional services of the dentist if dental services
are not
covered by the Contractor’s Benefit Package.  

 
     

 
       
Family Planning and
  Family planning means the ‘offering, arranging; and furnishing of those health
  Enrollees may always obtain family planning and
 
       
Reproductive Health Services
  services which enable individuals, including minors, who may be sexually
active,   HW testing and counseling services, when part of a
 
       
See Schedule A of Appendix K
  to prevent or reduce the incidence of unintended pregnancies and includes the
screening, diagnosis and treatment, as medically necessary, for sexually  
family planning visit, outside of the Contractor’s
network from any Provider that accepts Medicaid.
 
       
for Coverage Status
  transmissible diseases, sterilization services and screening for pregnancy.
Reproductive health services also includes all medically necessary abortions.  

 
     

APPENDIX K
October 1, 2004
K-12

          Covered Services Managed Care Plan Scope of Benefit Covered by
Medicaid Fee-For-Service     Non-Emergency Transportation:    
Transportation Services
Non-Emergency Transportation:
See Schedule A of Appendix K
for Coverage Status
Emergency Transportation:
See Schedule A of Appendix K
for Coverage Status
  Transportation expenses are covered when transportation is essential in order
for
an Enrollee to obtain necessary medical care and services which are covered
under
this Benefit Package (or by fee-for-service Medicaid for carved-out services).
Non-emergent transportation guidelines may be developed in conjunction with the
LDSS, based on the LDSS’ approved transportation plan.
Transportation services means transportation by ambulance, ambulette or invalid
coach, taxicab, livery, public transportation, or other means appropriate to the
Enrollee’s medical condition; and a transportation attendant to accompany the
Enrollee, if necessary. Such services may include the transportation attendant’s
transportation, meals, lodging and salary; however, no salary will be paid to a
transportation attendant who is a member of the Enrollee’s family.
For Enrollees with disabilities, the method of transportation must reasonably
accommodate their needs, taking into account the severity and nature of the
disability.
Emergency Transportation
Emergency transportation can only be provided by an ambulance service.
Emergency transportation is covered for Enrollees suffering from severe, life-
threatening or potentially disabling conditions which require the provision of
emergency medical services while the Enrollee is being transported.  

For Contractors that do not cover transportation
services, these services are paid for fee-for-service.
Non-emergent transportation requests should be
referred to the LDSS.
For Contractors that cover non-emergency
transportation in the Benefit Package, transportation
costs to MMTP services may be reimbursed by
Medicaid fee-for-service in accordance with the
LDSS transportation polices in local districts where
there is a systematic method to discretely identify
and reimburse such transportation costs.
 
       
 
       
Laboratory Services
  Covered when medically necessary as ordered by a medical professional, and
when listed in the Medicaid fee schedule. Coverage excludes HIV phenotypic,
HIV virtual phenotypic and HIV genotypic drug resistance tests.   HN phenotypic,
HIV virtual phenotypic and HIV
genotypic drug resistance tests with a Provider’s
order.
 
       
 
       
Radiology Services
  Covered when medically necessary as ordered by a medical professional, and
when ordered and provided by a qualified medical professional/practitioner.  

 
     

 
       
Durable Medical Equipment
(DME)
  DME are devices and equipment other than medical/surgical supplies enteral
formula, and prosthetic or orthotic appliances. Covered when medically necessary
as ordered by the Contractor’s Participating Provider and procured from a
Participating Provider. Coverage excludes disposable medical/surgical supplies
and enteral formula.  

Excluded services, such as disposable
medical/surgical supplies and enteral formula with a
Provider’s order.
 
       

APPENDIX K

October 1, 2004

K-13

          Covered Services Managed Care Plan Scope of Benefit Covered by
Medicaid Fee-For-Service
Hearing Aid Services
  Provided when medically necessary to alleviate disability caused by the loss
or
impairment of hearing. Hearing aid products include hearing aids, earmolds,
special fittings, and replacement parts. Coverage excludes hearing aid
batteries.  
Excluded services, such as hearing aid batteries
with a Provider’s order.
 
       
 
       
Court-Ordered Services
  Coverage includes such services ordered by a court of competent jurisdiction
if the
services are in the Contractor’s Benefit Package.  

 
     

 
       
Prosthetic/Orthotic Services/Orthotic
Footwear
  Covered when medically necessary as ordered by a managed care plan qualified
medical professional.  

 
     

 
       
Renal Dialysis
  Renal dialysis is covered when medically necessary as ordered by a qualified
medical professional. 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.  

 
     

 
       
Experimental and/or
Investigational Treatment
  Covered on a case by case basis in accordance with the provisions of
Section 4910
of the New York State P.H.L.  

 
     

 
       
Detoxification Services
  Covered when medically necessary on either an inpatient or outpatient basis.
Such
services are referred to as “Medically Managed Detoxification Services” when
provided in facilities licensed under Title 14 NYCRR Part 816.6 or Article 28 of
the Public’ Health Law; and “Medically Supervised Inpatient and Outpatient
Withdrawal Services” when provided in facilities licensed under Title 14 NYCRR
Part 816.7.  

 
     

APPENDIX K
October 1, 2004
K-14

124

  1.   PREPAID BENEFIT PACKAGE DEFINITIONS OF COVERED SERVICES  

A. Medical Services

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). 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.

la. Inpatient Stay Pending Alternate Level of Medical Care

Inpatient stay pending alternate level of medical care, or continued care in a
hospital pending placement in an alternate lower medical level of care,
consistent with the provisions of 18 NYCRR 505.20 and 10 NYCRR, Part 85.

2. Professional Ambulatory Services

Outpatient hospital services are provided through ambulatory care facilities.
Ambulatory care facilities include hospital outpatient departments (OPD),
diagnostic and treatment centers (free standing clinics) and emergency rooms:
These facilities may provide those necessary medical, surgical, and
rehabilitative services and items authorized by their, operating certificates.
Outpatient services (clinic) also include preventive; primary medical,
specialty, mental health, C/THP and family planning services provided by
ambulatory care facilities.

Hospital OPDs and D&T centers may perform ordered ambulatory services. The
purpose of ordered ambulatory services is to make available to the Participating
Provider those services needed to complement the provision of ambulatory care in
his/her office. Examples are: diagnostic testing and radiology.

3. Physician Services

“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:

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

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.

The following are also included without limitations:

  •   pharmaceuticals and medical supplies routinely furnished or administered
as part of a clinic or office visit;  

  •   physical examinations, including those which are necessary for employment,
school, and camp;  

  •   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;  

  •   health and mental health assessments for the purpose of making
recommendations regarding a Enrollee’s disability status for Federal SS1
applications;:  

  •   health assessments for the Infant /Child Assessment Program (1CHAP);  

  •   annual preventive health visits for adolescents;  

  •   new admission exams for school children if required by the LDSS;  

  •   health screening, assessment and treatment of refugees, including
completing SDOH/LDSS required forms; .  

  •   Child/Teen Health Program (C/THP) services which are comprehensive primary
health care services provided to children under twenty-one (21) years of age
(see Section 10 of this Agreement).  

APPENDIX K
October 1, 2004
K-15

125

4. Home Health Services
18 NYCRR 505.23(a)(3)

Home health care services are provided to Enrollees in their homes by a home
health agency certified under Article 36 of the New York State P.H.L. (Certified
Home Health Agency — CHHA). Home health services mean the following services
when prescribed by a Provider and provided to a Medicaid managed care Enrollee
in his or her home:

  •   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;  

  •   physical therapy, occupational therapy, or speech pathology and audiology
services; and  

  •   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.  

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.

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.

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.

5. Private Duty Nursing Services

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 can be provided through an approved certified home health agency, a
licensed home care agency, or a private Practitioner. The location of nursing
services may be in the Enrollee’s home or in the hospital.

Private duty nursing services are covered only when determined by the attending
physician to be medically necessary. Nursing services may be intermittent,
part-time or continuous and provided in accordance with the ordering physicians,
or certified nurse practitioner’s written treatment plan.

6. Emergency Room Services

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.

7. Services of Other Practitioners
a) Nurse Practitioner Services
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.

APPENDIX K
October 1, 2004
K- 16

126

The following services are also included in the certified nurse practitioner’s
scope of services, without limitation:

  •   Child/Teen Health Program(C/THP) services which are comprehensive primary
health care services provided to children under twenty-one (21) (see page 20 of
this Appendix and Section 10.5 of this Agreement);  

• Physical examinations including those which are necessary for employment,
school and camp.

b. Rehabilitation Services

18 NYCRR 505.11

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. Rehabilitation services are covered as medically necessary,
when ordered by the Contractor’s Participating’ Provider.

c. 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.

d. Clinical Psychological Services

18 NYCRR 505.18(a)

Clinical psychological services include psychological evaluation, testing and
therapeutic treatment for personality or behavior disorders.

e. Foot Care Services

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.

Services provided by a podiatrist for persons under twenty-one (21) must be
covered upon referral of a physician, registered physician’s assistant,
certified nurse practitioner or certified midwife.

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.

8. Eye Care and Low Vision Services 18 NYCRR §505.6(b)(1-3)

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. Eyecare coverage includes the replacement of lost or
destroyed eyeglasses. The replacement of the complete pair of eyeglasses should
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 should duplicate the
original prescription and frames. Repairs to, and replacements of, frames and/or
lenses must be rendered as needed.

APPENDIX K

October 1, 2004

K-17

MCOs that allow upgrades of eyeglass frames or additional features, cannot apply
the eyeglass benefit towards the cost and bill the difference to the Enrollee.
However, if the Contractor does not include upgraded eyeglasses or additional
features such as scratchcoating, progressive lenses, or photogray lenses, the
Enrollee may choose to purchase the upgraded frame or feature by paying the
entire cost as a private customer.

Examinations for diagnosis and treatment for visual defects and/or eye disease
is provided only as necessary and as required by the Enrollee’s particular
condition. Examinations which include refraction are limited to every two
(2) years unless otherwise justified as medically necessary.

Eyeglasses do not require changing more frequently than every two (2) years
unless medically indicated, such as a change in correction greater than ‘/2
diopter, or unless the glasses are lost, damaged, or destroyed.

An ophthalmic dispenser fills the prescription of an optometrist or
opthalmologist and supplies eyeglasses or other vision aids upon the order of a
qualified practitioner.

Enrollees may self-refer to any Participating Provider of vision services
(optometrist or opthalmologist) for refractive vision services.

9. Laboratory Services

18 NYCRR §505.7(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, with the exception of HIV phenotypic, HIV virtual
phenotypic and HIV genotypic drug resistance tests, which arc not included in
the Benefit Package and are covered by Medicaid fee-for-service.

All laboratory testing sites providing services under this Contract 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 MMIS Provider Manual.

  10.   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.

  11.   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
that include outreach, education, appointment scheduling, administrative case
management and transportation assistance.

APPENDIX K

October 1, 2004

K-18

12. Durable Medical Equipment (DME)

18 NYCRR §505.5(a)(1) and Section 4.4 of the MMIS DME, Medical and Surgical
Supplies and Prosthetic and Orthotic Appliances Provider Manual

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 fined, designed or fashioned for a particular
individual’s use. Where equipment is intended for use by only one (l) person, it
may be either custom made or customized.  

DME must be ordered by a qualified practitioner and procured from a
Participating Provider.

13. Audiology, Hearing Aid Services and Products

18 NYCRR 005.31 (a)(l)(2) and Section 4.7 of the MMIS 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 (hearing aid batteries are excluded from the Benefit
Package, but are covered by Medicaid fee-for-service as part of the prescription
benefit).

14. Preventive Care

Preventive care means care and services to. avert disease/illness and/or its
consequences. There are three (3) levels of preventive care: 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.

The following preventive services are also included in the managed care Benefit
Package. These preventive services are essential for promoting wellness and
preventing illness. MCOs must offer the following :

  •   General health education classes.  

  •   Pneumonia and influenza immunizations for at risk populations.  

  •   Smoking cessation classes, with targeted outreach for adolescents and
pregnant women.  

  •   Childbirth education classes.  

  •   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.  

  •   Nutrition counseling, with targeted outreach for diabetics and pregnant
women.  

  •   Extended care coordination, as needed, for pregnant women.  

HIV counseling and testing.

15. Prosthetic/Orthotic Orthopedic Footwear

Section 4.5, 4.6 and 4.7 of the MMIS DME, Medical and Surgical Supplies and
Prosthetic and Orthotic Appliances Provider Manual

APPENDIX K

October 1, 2004

K-20

a. Prosthetics are those appliances or devices ordered for an Enrollee by a
Participating Provider 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, ordered for an Enrollee by a
qualified practitioner 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. 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.

16. Renal Dialysis

Renal dialysis is covered when medically necessary as ordered by a qualified
medical professional. 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.

17. Experimental or Investigational Treatment

Experimental and investigational treatment is covered on a case by case basis.

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 New York State P.H.L. under the
following conditions:

  (1)   The Enrollee has had coverage of a health care service denied on the
basis that such service is experimental and investigational, and  

  (2)   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 health care plan, or

(c) for which there exists a clinical trial, and

  (3)   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:

  (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

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

APPENDIX K
October 1, 2004
K-21

B. Behavioral Health Services

These services include Chemical Dependence and Mental Health Services.

Chemical Dependence Services:
For all: Enrollees not categorized as SSI or SSI related, Chemical Dependence
Services in the Benefit Package include inpatient treatment services including
inpatient rehabilitation and treatment services programs, Detoxification
Services (Medically Managed Inpatient Detoxification and Medically Supervised
Inpatient and Outpatient Withdrawal Services) and self referral for assessment
as described below.

For all Enrollees categorized as SSI or SSI related, the Benefit Package
includes Detoxification Services (Medically Managed Inpatient Detoxification and
Medically Supervised Inpatient and Outpatient Withdrawal Services). All other
Chemical Dependence Services, including Chemical Dependence Inpatient
Rehabilitation and Treatment, are covered on a Medicaid fee-for-service basis
for the SSI population.

Mental Health Services:
The Mental Health Services listed below are in the Benefit Package for all
Enrollees not categorized as SSI or SSI related. For Enrollees who are
categorized as SSI or SSI related, all Mental Health Services are covered on a
Medicaid fee-for-service basis.

1. Chemical Dependence Services a. Detoxification Services

i) Medically Managed Inpatient Detoxification

These programs provide medically directed twenty-four 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 Part 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.

ii) Medically Supervised Withdrawal

(a) 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 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 Part 816.7.

(b) Medically Supervised Outpatient Withdrawal

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 by Title 14 NYCRR Part 816.7.

APPENDIX K
October 1, 2004
K-22

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 stop-loss provisions specified in Section 3.11 of this Agreement.

b. Chemical Dependence Inpatient Rehabilitation and Treatment Services

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 arc 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 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.

MCOs will be reimbursed for qualifying inpatient days of chemical dependence
inpatient treatment beyond thirty (30) days according to stop-loss provisions
contained in Section 3.12 of this Agreement.

c. Chemical Dependence Assessment Self-Referral

Enrollees must be allowed to self refer for one (1) assessment from a
Contractor’s participating provider in a twelve (12) month period.

2. Mental Health Services

Mental Health Services are subject to the stop-loss provisions specified in
Section 3.12 of this Agreement.

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 New York State P.H.L.

b. Outpatient Services

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 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. For further information regarding service
coverage consult the following MMIS Provider Manuals: Clinic, Ambulatory
Services for Mental Illness (Clinic Treatment Program), Clinical Psychology, and
Physician (Psychiatric Services).

Enrollees. must be allowed to self-refer for one (1) mental health assessment
from a Contractor’s Participating Provider in a twelve (12) month period. In the
case of children, such self-referrals may originate at the request of a school
guidance counselor or similar source.

Services provided through OMH designated clinics for Enrollees with a clinical
diagnosis of SED are covered by Medicaid fee-for-service.

APPENDIX K
October 1, 2004
K-23

C. Other Covered Services

1. Federally Qualified Health Center (FQHC) Services

FQHC services include physician services, services and supplies covered under
SSA §1861(s)(2) (A). Services include primary health, referral for supplemental
health services, health education, patient case management, including outreach,
counseling, referral and follow-up services (sec 42 USC §254c(a) & (b)).

Prepaid Benefit Package

II. Optional Covered Services (at Discretion of LDSS and/or Contractor)

A. Family Planning and Reproductive Health Care

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. These include: diagnosis and all medically necessary
treatment, sterilization, screening and treatment for sexually transmissible
diseases and screening for disease and pregnancy.

Also included is HIV counseling and testing when provided as part of a family
planning visit. Additionally, reproductive health care includes coverage of all
medically necessary abortions. Elective induced abortions must be covered for
New York City recipients. Fertility services are not covered.

If the Contractor excludes family planning from its Benefit Package, the
Contractor is still required to provide the following services:

i) screening, related diagnosis, ambulatory treatment, and referral to
Participating Provider as

     
ii)
  needed for dysmenorrhea, cervical cancer or other pelvic
abnormality/pathology;
screening, related diagnosis, and referral to Participating Provider for anemia,
cervical cancer,

glycosuria, proteinuria, hypertension, breast disease and pregnancy.

B. Dental Services

Dental care includes preventive, prophylactic and other routine dental care,
services, supplies and dental prosthetics required to alleviate a serious health
condition, including one which affects employability.

Dental surgery performed in an ambulatory or inpatient setting is the
responsibility of the Contractor whether dental services are a covered plan
benefit, or not. Inpatient claims and referred ambulatory claims for dental
services provided in an inpatient or outpatient hospital setting for surgery,
anesthesiology, X-rays, etc. are the responsibility of the Contractor. In these
situations, the professional services of the dentist are covered by Medicaid
fee-for-service. The Contractor should set up procedures to prior approve dental
services provided in inpatient and ambulatory settings.

As described in Sections 10.16 and 10.28 of this Agreement, Enrollees may
self-refer to Article 28 clinics operated by academic dental centers to obtain
covered dental services.

If Contractor’s Benefit Package excludes dental services:,

  i)   Enrollees may obtain routine exams, orthodontic services and appliances,
dental office surgery, fillings, prophylaxis, and other Medicaid covered dental
services from any qualified Medicaid provider who shall claim reimbursement from
MMIS; and  

APPENDIX K
October 1, 2004
K-25

127

  ii)   Inpatient and referred ambulatory claims for medical services provided
in an inpatient or outpatient hospital setting in conjunction with a dental
procedure (e.g. anesthesiology, X-rays), are the responsibility of the
Contractor. In these situations, the professional services of the dentist are
covered Medicaid fee-for-service.  

C. Transportation Services

18 NYCRR §505.10

a. Non-Emergency Transportation

Transportation expenses are covered when transportation is essential in order
for an Enrollee to obtain necessary medical care and services which are covered
under the Medicaid program (either as part of the Contractor’s Benefit Package
or by fee-for-service Medicaid). Non-emergent transportation guidelines may be
developed in conjunction with the LDSS, based on the LDSS’ approved
transportation plan.

Transportation services means transportation by ambulance, ambulette fixed wing
or airplane transport, invalid coach, taxicab, livery, public transportation, or
other means appropriate to the Enrollee’s medical condition; and a
transportation attendant to accompany the Enrollee, if necessary. Such services
may include the transportation attendant’s transportation, meals, lodging and
salary; however, no salary will be paid to. a transportation attendant who, is a
member of the Enrollee’s family.

When the Contractor is capitated for non-emergency transportation, the
Contractor is also responsible for providing transportation to Medicaid covered
services that are not part of the Contractor’s Benefit Package.

For Contractors that cover non-emergency transportation in the Benefit Package,
transportation costs to MMTP services may be reimbursed by Medicaid
fee-for-service in accordance with the LDSS transportation polices in local
districts where there is a systematic method to discretely identify and
reimburse such transportation costs.

For Enrollees with disabilities, the method of transportation must reasonably
accommodate their needs, taking into account the severity and nature of the
disability.

b. Emergency Transportation

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 medical services while the
Enrollee is being transported.

Emergency medical services means the provision of initial urgent medical care
including, but not limited to, the treatment of trauma, burns, respiratory,
circulatory and obstetrical emergencies.

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

APPENDIX K

October 1, 2004

K-26
Prepaid Benefit Package
III. 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:

A. MEDICAL NON-COVERED SERVICES

1. Personal Care Agency Services

Personal care services (PCS) are the provision of some or total assistance with
personal hygiene, dressing and feeding; and nutritional and environmental
support (meal preparation and housekeeping). Such services must be essential to
the maintenance of the Enrollee’s health and safety in his or her own home. The
service has to be ordered by a physician, and there has to be a medical need for
the service. Licensed home care services agencies, as opposed to certified home
health agencies, are the primary providers of PCS. 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).

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 a plan of care.

2. Residential Health Care. Facilities (RHCF)

Permanent residency in a Residential Health Care Facility (RHCF) is not covered
(see 18 NYCRR §360-1.4 (k)). Rehabilitation services in such a setting are
covered as medically necessary when ordered by the Contractor’s Participating
Provider. -

3. Hospice Program

Hospice is a coordinated program of home and inpatient care that provides
non-curative medical and support services for persons certified by a physician
to be terminally ill with a life expectancy of six (6) months or less. Hospice
programs provide patients and families with palliative and supportive care to
meet the special needs arising out of physical, psychological, spiritual, social
and economic stresses which are experienced during the final stages of illness
and during dying and bereavement.

Hospices are organizations which must be certified under Article 40 of the NYS
P.H.L. All services must be provided by qualified employees and volunteers of
the hospice or by qualified staff through contractual arrangements to the extent
permitted by federal and state requirements. All services must be provided
according to a written plan of care which reflects the changing needs of the
patient/family.

If an Enrollee in the Contractor’s plan becomes terminally ill and receives
Hospice Program services he or she may remain enrolled and continue to access
the Contractor’s Benefit Package while Hospice costs are paid for by Medicaid
fee-for-service.

4. 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
D1N/1E 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.

APPENDIX K

October 1, 2004

K-27

B. Non-Covered Behavioral Health Services 1. Chemical Dependence Services

a. Outpatient Rehabilitation and Treatment Services

i). 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 the Office of Alcohol and Substance Abuse Services
(OASAS) under Title 14 NYCRR, Part 828.

ii). 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.

iii). 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 Part 822.9.

iv). 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.

b. Chemical Dependence Services Ordered by the LDSS

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:

  •   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  

• have been determined to be able to work with limitations (work limited) and
are simultaneously mandated by the district into Chemical Dependence Inpatient
Rehabilitation and Treatment Services (including alcohol and substance abuse
treatment services )pursuant to work activity requirements.

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).

The Contractor is responsible for the provision and payment of Medically Managed
Detoxification Services in this Agreement.

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, 2004

K-28

2. Mental Health Services

a. Intensive Psychiatric Rehabilitation Treatment Programs (IPRT)

A time limited active psychiatric rehabilitation designed to assist a patient in
forming and achieving mutually agreed upon goals in living, learning, working
and social environments, to intervene with psychiatric rehabilitative
technologies to overcome functional disabilities. IPRT services are ‘certified
by OMH under 14 NYCRR, Part 587.

b. Day Treatment

A combination of diagnostic, treatment, and rehabilitative procedures which,
through supervised and planned activities and extensive client-staff
interaction, provides the services of the clinic treatment program, as well as
social training, task and skill training and socialization activities. Services
are expected to be, of six (6) months duration. These services are certified by
OMH under 14 NYCRR, Part 587.

c. Continuing Day Treatment

Provides treatment designed to maintain or enhance current levels of functioning
and skills, maintain community living, and develop self-awareness and
self-esteem. Includes: assessment and treatment planning; discharge planning;
medication therapy; medication education; case management; health screening and
referral; rehabilitative readiness development; psychiatric rehabilitative
readiness determination and referral; and symptom management. These services are
certified by OMH under 14 NYCRR, Part 587.

d. 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.

e. 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.

f. 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 OTHER NON-COVERED SERVICES.

g. 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.

APPENDIX K

October 1, 2004

K-29

  h.   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.

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.

J. Personalized Recovery Oriented Services (PROS)

PROS, licensed and reimbursed pursuant to 14 NYCCR Part 512, are designed to
assist individuals in recovery from the disabling effects of mental illness
through the coordinated delivery of a customized array of rehabilitation,
treatment, and support services in traditional settings and in off-site
locations. Specific components of PROS include Community Rehabilitation and
Support, Intensive Rehabilitation, Ongoing Rehabilitation and Support and
Clinical Treatment.

3. Rehabilitation Services Provided to Residents of OI\IH Licensed Community
Residences (CRs) and Family Based Treatment Programs, as follows:

a. OMH Licensed CRs*

Rehabilitative services in community residences are interventions, therapies and
activities which are medically therapeutic and remedial in nature, and are
medically necessary for the maximum reduction of functional and adaptive
behavior defects associated with the person’s mental illness.

b. Family-Based Treatment*

Rehabilitative services in family-based treatment programs are intended to
provide treatment to seriously emotionally disturbed children and youth to
promote their successful functioning and _integration into the natural family,
community, school or independent living situations. Such services are provided
in consideration of a child’s developmental stage. Those children determined
eligible for admission are placed in surrogate family homes for care and
treatment.

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

4. Office of Mental Retardation and Developmental Disabilities (OMRDD) Services

  a.   Long Term Therapy Services Provided by Article 16-Clinic Treatment
Facilities or Article 28 Facilities  

These services are provided to persons with developmental disabilities including
medical or remedial services recommended by a physician or other licensed
practitioner of the healing arts for a maximum reduction of the effects of
physical or mental disability and restoration of the .person to his or her best
possible functional level. It also includes the fitting, training, and
modification of assistive devices by licensed practitioners or trained others
under their direct supervision. Such services are designed to ameliorate or
limit the disabling condition and to allow the person to remain in or move to,
the least restrictive residential and/or day setting. These services are
certified by OMRDD under 14 NYCRR, Part 679 for 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, 2004

K-30

b. Day Treatment

A planned combination of diagnostic, treatment and, rehabilitation services
provided to developmentally disabled individuals in need of a broad range of
services, but who do not need intensive twenty-four (24) hour care and medical
supervision. The services provided as identified in the comprehensive assessment
may include nutrition, recreation, self-care, independent living, therapies,
nursing, and transportation services. These services are generally provided in
1CF or a comparable setting. These services are certified by OMRDD under 14
NYCRR, Part 690.

c. Medicaid Service Coordination (MSC)

Medicaid Service Coordination (MSC) is a Medicaid State Plan service provided by
OMRDD which assists persons with developmental disabilities and mental
retardation to gain access to necessary services and supports appropriate to the
needs of the needs of the individual. MSC is provided by qualified service
coordinators and uses a person centered planning process in developing,
implementing and maintaining an Individualized Service Plan (ISP) with and for a
person with developmental disabilities and mental retardation. MSC promotes the
concepts of a choice, individualized services and consumer satisfaction.

MSC is provided by authorized vendors who have a contract with OMRDD, and who
are paid monthly pursuant to such contract. Persons who receive MSC must not
permanently reside in an ICF for. persons with developmental disabilities, a
developmental center, a skilled nursing facility or any other hospital or
Medical Assistance institutional setting that provides service coordination.
They must also not concurrently be enrolled in any other comprehensive Medicaid
long term service coordination program/service including the Care at Home
Waiver.

Please note: See generic definition of Comprehensive Medicaid. Case Management
(CMCM) under OTHER NON-COVERED SERVICES.

d. Home And Community Based Services Waivers (HCBS)

The Home and Community-Based Services Waiver serves persons with developmental
disabilities who would otherwise be admitted to an ICF/ MR if waiver services
were not provided. HCBS waivers services include residential habilitation, day
habilitation, prevocational, supported work, respite, adaptive devices,
consolidated supports and services, environmental modifications, family
education and training, live-in caregiver, and plan of care support services.
These services are authorized pursuant to a SSA Section 1915(c) waiver from
DHHS.

e. Services Provided Through the Care At Home Program (OMRDD)

The OMRDD Care at Home 11I, Care at Home IV, and Care at Home VI waivers, serve
children who would otherwise not be eligible for Medicaid because of their
parents’ income and resources, and who would otherwise be eligible for an ICF/MR
level of care. Care at Home waiver services include service coordination,
respite and assistive technologies. Care at Home waiver services are authorized
pursuant to a SSA section 1915(c) waiver from DHHS.

C. Other Non-Covered Services

1. The Early Intervention Program (EIP) — Children Birth to Two (2) Years of Age

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, Mental
Retardation and Alcoholism Services; Erie County — The Department of Youth
Services; Jefferson County — the Office of Community Services; and Ulster County
— the Department of Social Services).

APPENDIX K

October 1, 2004

K-30

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 MMIS 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 will be expected to refer any enrolled child
suspected of having
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..

Additionally, the locally designated early intervention agencies will be
instructed on how to identify a managed care Enrollee and the need to contact
the Contractor to coordinate service provision.

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

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.

PSHSP services rendered to children three (3) through four (4) years of age in
conjunction with an approved IEP are categorized as Non-Covered.

The PSHSP services will be identified on MMIS 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.

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

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 ([EP) for
each child evaluated in need of special education and medically related
services.

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.

The SSHSP services are identified on MMIS 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.

4. 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
should work collaboratively with the CMCM case manager to coordinate the
provision of services covered by the Contractor. CMCM programs will be
instructed on how to identify a managed care Enrollee on EMEVS and informed on
the need to contact the Contractor to coordinate service provision.

APPENDIX K

October 1, 2004

K-31

5. Directly Observed Therapy for Tuberculosis Disease

Tuberculosis directly observed therapy (TB/DOT) is the direct observation of
oral ingestion of TB medications to assure patient compliance with the
physician’s prescribed medication regimen. While the clinical management of
tuberculosis is covered in the Benefit Package, TB/DOT where applicable, can be
billed directly to MMIS by any SDOH approved fee-for-service Medicaid TB/DOT
Provider. The Contractor remains responsible for communicating, cooperating and
coordinating clinical management of TB with the TB/DOT Provider.

6. 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.

7. 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.

8. Fertility Services
Fertility services are not covered by the Benefit Package nor by Medicaid
fee-for-service.
9. Adult Day Health Care

Adult Day Health Care means care and services provided to a registrant in a
residential health care facility or approved extension site under the medical
direction of a physician and which is provided by personnel of the adult day
health care program in accordance with a comprehensive assessment of care needs
and individualized health care plan, ongoing implementation and coordination of
the health care plan, and transportation.

Registrant means a person who is a nonresident of the residential health care
facility who is functionally impaired and not homebound and who requires certain
preventive, diagnostic, therapeutic, rehabilitative or palliative items or
services provided by a general hospital, or residential health care facility;
and whose assessed social and health care needs, in the professional judgment of
the physician of record, nursing staff, Social Services and other professional
personnel of the adult day health care program can be met in while or in part
satisfactorily by delivery of appropriate services in such program.

10. Personal Emergency Response Services (PERS)

Personal Emergency Response Services (PERS) are not covered by the Benefit
Package. PERS are covered on a fee-for-service basis through contracts between
the LDSS and PERS vendors.

11. 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

APPENDIX K
October 1, 2004
K-32

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.

IV. Schedule A of Appendix K

Prepaid Benefit Package

Coverage Status of Optional Covered Services

County: New York City Department of Health and Mental Hygiene MCO: CarePlus,
L.L.C.

          Service   Coverage   Status     Covered by   Not Covered by    
Contractor   Contractor
Family Planning
  v  

 
     

 
       
Dental Services
  v  

 
     

 
       
Emergency Transportation
  v  

 
     

 
       
Non-Emergency Transportation
  v  

 
     

APPENDIX K
October 1, 2004
K-32

128

APPENDIX L

129

Approved Capitation Payment Rates
APPENDIX L
October 1, 2004
L-1
CAREPLUS, LLC Medicaid Managed Care Rates

MMIS ID#: 01617894 Approved by DOB: Yes DOH HMO #: 04-008 Reinsurance: Private

Effective Date: 04/01/04 Region: NYC
County: NYC Status: Mandatory

S.CONTPremium Grout)
TANF/SN <6mo M/F TANF/SN 6mo-14 F TANF/SN 15-20 F TANF/SN 6mo-20 M TANF 21+ M/F
SN 21-29 M/F
SN 30+ M/F
SSI 6mo-20 M/F SSI 21-64 M/F
SSI 65+ M/F
Maternity Kick Payment Newborn Kick Payment

Optional Benefits Offered:

x Emergency Transportation

x Non-Emergent Transportation

Rate Amount.

$262.80
$91.60
$114.00
$101.84
$184.92
$180.95
$237.13
$187.68
$491.54
$385.04

$4,563.75
$2,714.20

xDental

xFamily Planning

©Box will be checked if the optional benefit is covered by the plan

Benefit Limitations:

Outpatient Mental Health Cap of 20 visits

Inpatient Mental Health\Substance Abuse Cap of 30 Days

130

APPENDIX M

Service Area

131

APPENDIX M
October 1, 2004
M-1
CarePlus, L.L.C.

The Contractor’s Medicaid managed care service area is comprised of Kings, New
York, Queens, and Richmond Counties in their entirety.

132

APPENDIX M
October 1, 2004
M-2
APPENDIX N

GUIDELINES FOR INTERACTIONS BETWEEN

NEW YORK CITY DEPARTMENT OF HEALTH AND MENTAL HYGIENE

AND

133

MANAGED CARE ORGANIZATIONS
Appendix N
NYC DOHMH
October 1, 2004
1Appendix N

Guidelines for Interactions between
New York City Department of Health and Mental Hygiene and
Managed Care Organizations

This Appendix is intended to supplement other Contractor requirements set forth
in the Agreement, which pertain to public health issues, including the
requirement to deliver all medically necessary services as set forth in
Section 10 and Appendix K of this Agreement, and to adopt practice guidelines
consistent with current standards of care, including standards pertaining to
public health issues.

1. Coordination with DOHMH

The Contractor shall provide the New York City Department of Health and Mental
Hygiene (DOHMH) with available information requested by DOHMH in the course of
conducting epidemiological investigations.

2. Provider Reporting Obligations

  a)   The Contractor shall make reasonable efforts to assure timely and
accurate compliance by participating providers with public health reporting
requirements relating to communicable disease and conditions mandated in the New
York City Health Code pursuant to 24 RCNY §§ 1103-1107 -and Title 21, Article 3
of the NYS Public Health Law.

  b)   The Contractor shall make reasonable efforts to assure timely and
accurate compliance by participating providers with other mandated reporting
requirements, including the following:

  •   Infants and toddlers suspected of having a developmental delay or
disability

  •   Suspected instances of child abuse

  •   Immunization (reporting to immunization registry)

  •   Additional reporting requirements adopted by the New York City Health Code

c) “Reasonable efforts” shall include:

  (i)   for mandated reporting requirements described in both (2) (a) and (2)
(b) above: educating participating providers on treatment guidelines and
instructions for reporting included in the NYC DOHMH Compendium of Public Health
Requirements and Recommendations  

  •   including reporting requirements in the Contractor’s provider manual or
other written instructions or guidelines  

(ii) for mandated reporting requirements described in (2) (a) above:

  •   letters from the Contractor to providers who generated claims that suggest
that a member may have a reportable disease or condition, encouraging such
providers  

to report and providing information on how to report. Other methods for follow
up with providers, subject to DOHMH approval, may be employed.

3. Member Outreach/Education

The Contractor shall provide health education to members on an on-going basis
such as member newsletters, outreach activities, health education classes or
individual counseling on preventive health and public health topics. Examples of
such topics could include:

  •   HIV/AIDS  

  •   encourage enrollee counseling and testing  

  •   inform members as to availability of sterile needles and syringes  

Appendix N
NYC DOHMH
October 1, 2004
2

• STDs

  •   Inform members that confidential STD services are available at DOHMH
facilities for non-enrolled sexual and needle-sharing partners at no charge

  •   Lead poisoning prevention

  •   Maternal and child health, including importance of developmental screening
for children

  •   Injury prevention, including age appropriate anticipatory guidance

  •   Domestic violence

  •   Smoking cessation Asthma

  •   Immunization

  •   Mental health services

  •   Diabetes

  •   Family planning

  •   Screening for Cancer

  •   Chemical Dependence

  •   Physical fitness and nutrition

  •   Cardiovascular disease and hypertension

4. Provider Education

  •   DOHMH shall prepare a public health compendium (“Compendium”) with public
health guidelines, protocols, and recommendations which it shall make available
directly to providers and to the Contractor.  

  •   The Contractor shall adapt public health guidance from the Compendium for
its internal protocols, practice manuals and guidelines.  

  •   The Contractor will assist DOHMH in its efforts to disseminate written or
electronic materials to its providers by providing electronic addresses if known
by Contractor (fax and/or e-mail) for its participating providers, updated
semi-annually.  

  •   The Contractor shall promote the use of rapid HIV testing among its
providers.  

5. MCO Staff Responsibilities and Training

a) Early Intervention Services.

The Contractor shall ensure that appropriate MCO staff, such as member services
staff and case managers are knowledgeable about early intervention services and
provide technical assistance and consultation to families concerning early
intervention services (including eligibility, referral process and coordination
of services).

b) Domestic Violence.

i) The Contractor shall designate a DV coordinator who can:

  •   Provide technical assistance to participating providers in documenting
cases of domestic violence;  

  •   Provide referrals to members or their providers, to obtain protective,
legal and or supportive social services;

  •   Provide consultative assistance to other staff within the Contractor’s
organization.  

  ii)   The Contractor shall distribute a directory of resources for victims of
domestic violence to appropriate staff, such as member services staff or case
managers.  

Appendix N
NYC DOHMH
October 1, 2004
3

6. Medical Directors

  a)   The Contractor’s Medical Director shall participate in Medical Directors’
Meetings with the medical directors of the other Medicaid managed care plans in
New York City and representatives of the New York City Department of Health and
Mental Hygiene. The purpose of the Medical Directors’ Meetings shall be to share
public health information and data, recommend that certain public information be
disseminated by the managed care organizations to their participating providers,
discuss public health strategies and outreach efforts and potential
collaborative projects, encourage the development of plan policies that support
public health strategies and provide a vehicle for communication between the
Medicaid health plans and the various bureaus and divisions of the NYC
Department of Health and Mental Hygiene.  

  b)   The Contractor’s Medical Director shall attend all periodic meetings,
which shall not exceed one every two months. In the event that the Medical
Director is unable to attend a particular meeting, the Contractor will designate
an appropriate substitute to attend the meeting.

  c)   DOHMH, following consultation with the Medical Directors, may create
workgroups on particular public health topics. The Contractor‘s Medical Director
may participate in any or all of the workgroups, but shall participate on at
least one of the designated workgroups.

7. Payment to DOHMH for Benefit Package Service Delivery

The Contractor shall reimburse DOHMH at the rates contained in Attachment N-I
for the following documented services provided to the Contractor’s enrollees:

a) Immunization services;
b) New Admission exams;

c) Each visit by an enrollee of the Contractor to a DOHMH TB clinic, for
services which may include physician visits, patient clinical management, lab,
or radiology services.

Appendix N
NYC DOHMH
October 1, 2004
4

APPENDIX N SCHEDULE N-1

NEW YORK CITY DEPARTMENT OF HEALTH AND MENTAL HYGIENE

FEE SCHEDULE

          SERVICE   FEE
TB CLINIC
  $ 125  
IMMUNIZATION
  $ 50  
NEW ADMISSION EXAM
  $ 95  

Appendix N
NYC DOHMH
October 1, 2004
6

134