Exhibit 10.6.6

STATE OF NEW JERSEY

DEPARTMENT OF HUMAN SERVICES

DIVISION OF MEDICAL ASSISTANCE AND HEALTH SERVICES

AND

AMERIGROUP NEW JERSEY, INC.

AGREEMENT TO PROVIDE HMO SERVICES

In accordance with Article 7, section 7.11.2A and 7.11.2B of the contract
between AMERIGROUP New Jersey, Inc. and the State of New Jersey, Department of
Human Services, Division of Medical Assistance and Health Services (DMAHS),
effective date October 1, 2000, all parties agree that certain sections of the
contract shall be amended to be effective September 1, 2004, as follows:

 

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Exhibit 10.6.6

1.   Article 1, “Definitions” section for the following definitions:

•   Comprehensive Orthodontic Treatment (new);

•   Grievance

    shall be amended as reflected in the relevant pages of Article 1 attached
hereto and incorporated herein.

2.   Article 4, “Provision of Health Care Services,” Sections 4.1.2(A)27;
4.1.2(B); 4.1.4(A)3(a) (new); 4.1.6(A)14; 4.1.7(C)15; 4.4; 4.5.2(B); 4.5.4(B);
4.5.6(A); 4.6.2(P) and 4.8.1(F) shall be amended as reflected in Article 4,
Sections 4.1.2(A)27; 4.1.2(B); 4.1.4(A)3(a)(new); 4.1.6(A)14; 4.1.7(C)15; 4.4;
4.5.2(B); 4.5.4(B); 4.5.6(A); 4.6.2(P) and 4.8.1(F) attached hereto and
incorporated herein.

3.   Article 5, “Enrollee Services,” Sections 5.8.2(NN) and 5.15.1(B) shall be
amended as reflected in Article 5, Section 5.8.2(NN) and 5.15.1(B) attached
hereto and incorporated herein.

4.   Article 8, “Financial Provisions,” Section 8.5.2.8 shall be amended as
reflected in Article 8, Section 8.5.2.8 attached hereto and incorporated herein.

5.   Appendix, Section C, “Capitation Rates,” shall be revised as reflected in
SFY 2005 Capitation Rates attached hereto and incorporated herein.

 

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Exhibit 10.6.6

All other terms and conditions of the October 1, 2000 contract and subsequent
amendments remain unchanged except as noted above.

The contracting parties indicate their agreement by their signatures.

              AMERIGROUP
  State of New Jersey
New Jersey, Inc.
  Department of Human Services
         
BY:
  /S/ Norine Yukon   BY:    

 

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          Ann Clemency Kohler           TITLE:President and CEO   TITLE:
Director, DMAHS

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                   DATE: July 14, 2004   DATE:    

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APPROVED AS TO FORM ONLY

Attorney General

State of New Jersey

BY: 

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  Deputy Attorney General

DATE: 

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Exhibit 10.6.6

with the contractor. Marketing by an employee of the contractor is considered
direct; marketing by an agent is considered indirect.

Commissioner—the Commissioner of the New Jersey Department of Human Services or
a duly authorized representative:

Complaint—a protest by an enrollee as to the conduct by the contractor or any
agent of the contractor, or an act or failure to act by the contractor or any
agent of the contractor, or any other matter in which an enrollee feels
aggrieved by the contractor, that is communicated to the contractor and that
could be resolved by the contractor within five (5) business days, except for
urgent situations, and as required by the exigencies of the situation.

Complaint Resolution—completed actions taken to fully settle a complaint to the
DMAHS’ satisfaction.

Comprehensive Orthodontic Treatment—the utilization of fixed orthodontic
appliances (bands/brackets and arch wires) to improve the craniofacial
dysfunction and/or dentofacial deformity of the patient.

Comprehensive Risk Contract—a risk contract that covers comprehensive services,
that is, inpatient hospital services and any of the following services, or any
three or more of the following services:

1.   Outpatient hospital services.   2.   Rural health clinic services.   3.  
FQHC services.   4.   Other laboratory and X-ray services.   5.   Nursing
facility (NF) services.   6.   Early and periodic screening, diagnosis and
treatment (EPSDT) services.   7.   Family planning services.   8.   Physician
services.   9.   Home health services.

Condition—a disease, illness, injury, disorder, or biological or psychological
condition or status for which treatment is indicated.

Contested Claim—a claim that is denied because the claim is an ineligible claim,
the claim submission is incomplete, the coding or other required information to
be submitted is incorrect, the amount claimed is in dispute, or the claim
requires special treatment.

Continuity of Care—the plan of care for a particular enrollee that should assure
progress without unreasonable interruption.

Contract—the written agreement between the State and the contractor, and
comprises the contract, any addenda, appendices, attachments, or amendments
thereto.

      Amended as of September 1, 2004   I-5

 

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Exhibit 10.6.6

Governing Body—a managed care organization’s Board of Directors or, where the
Board’s participation with quality improvement issues is not direct, a
designated committee of the senior management of the managed care organization.

Grievance—means an expression of dissatisfaction about any matter or a complaint
that is submitted in writing, or that is orally communicated and could not be
resolved within five (5) business days of receipt.

Grievance System-means the overall system that includes grievances and appeals
at the contractor level and access to the State fair hearing process. -

Group Model—a type of HMO operation similar to a group practice except that the
group model must meet the following criteria: (a) the group is a separate legal
entity, (i.e. administrative entity) apart from the HMO; (b) the group is
usually a corporation or — partnership; (c) members of the group must pool
their. income; (d) members of the group must share medical equipment, as well as
technical and administrative staff; (e)-members of the group must devote at
least 50 percent of their time to the group; and (f) members of the group must
have “substantial responsibility” for delivery of health services to HMO
members, within four years of qualification. After that period, the group may
request additional time or a waiver in accordance with federal regulations at 42
C.F.R. Section 110.104(2), Subpart A.

HCFA—the Health Care Financing Administration, the former name of CMS (Centers
for Medicare and Medicaid Services), within the U.S. Department of Health and
Human Services.

Health Benefits Coordinator (HBC)—the external organization under contract with
the Department whose primary responsibility is to assist Medicaid eligible
individuals in contractor selection and enrollment.

Health Care Professional—a physician or other health care professional if
coverage for the professional’s services is provided under the contractor’s
contract for the services. It includes podiatrists, optometrists, chiropractors,
psychologists, dentists, physician assistants, physical or occupational
therapists and therapist assistants, speech-language pathologists, audiologists,
registered or licensed practical nurses (including nurse practitioners, clinical
nurse specialists, certified registered nurse anesthetists, and certified nurse
midwives), licensed certified social workers, registered respiratory therapists,
and certified respiratory therapy technicians.

Health Care Services—are all preventive and therapeutic medical, dental,
surgical, ancillary (medical and non-medical) and supplemental benefits provided
to enrollees to diagnose, treat, and maintain the optimal well-being of
enrollees provided by physicians, other health care professionals,
institutional, and ancillary service providers.

Health Insurance—private insurance available through an individual or group plan
that covers health services. It is also referred to as Third Party Liability.

      Amended as of September 1, 2004   I-12

 

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Exhibit 10.6.6

21.   Medical Supplies   22.   Prosthetics and Orthotics including certified
shoe provider.   23.   Dental Services   24.   Organ Transplants — includes
donor and recipient costs. Exception: The contractor will not be responsible for
transplant-related donor and recipient inpatient hospital costs for-an
individual placed on a transplant list while in the Medicaid FFS program prior
to initial enrollment into the contractor’s plan.   25.   Transportation
Services for any contractor-covered service or non-contractor covered service
including ambulance, mobile intensive care units (MICUs) and invalid coach
(including lift equipped vehicles)   26.   Post-acute Care   27.   Mental
Health/Substance Abuse Services for enrollees who are clients of the Division of
Developmental Disabilities. Exception — partial care services are not covered by
the contractor.

B.   Conditions Altering Mental Status. Those diagnoses which are categorized as
altering the mental status of an individual but are of organic origin shall be
part of the contractor’s medical, financial and care management responsibilities
for all categories of enrollees. These include the diagnoses in the following
ICD-9-CM Series:

             
1.
    290.0     Senile dementia, simple type
 
           
2.
    290.1     Presenile dementia
 
           
3.
    290.10     Presenile dementia, uncomplicated
 
           
4.
    290.11     Presenile dementia with delerium
 
           
5.
    290.12     Presenile dementia with delusional features
 
           
6.
    290.13     Presenile dementia with depressive features
 
           
7.
    290.2     Senile dementia with delusional or depressive features
 
           
8.
    290.20     Senile dementia with delusional features
 
           
9.
    290.21     Senile dementia with depressive features
 
           
10.
    290.3     Senile dementia with delerium
 
           
11.
    290.4     Arteriosclerotic dementia
 
           
12.
    290.40     Arteriosclerotic dementia, uncomplicated
 
           
13.
    290.41     Arteriosclerotic dementia with delirium
 
           
14.
    290.42     Arteriosclerotic dementia with delusional features
 
           
15.
    290.43     Arteriosclerotic dementia with depressive features
 
           
16.
    290.8     Other specific senile psychotic conditions
 
           
17.
    290.9     Unspecified senile psychotic condition

      Amended as of July September 1, 2004   IV-6

 

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Exhibit 10.6.6

             
18.
    291.1     Alcohol amnestic syndrome
 
           
19.
    291.2     Other alcoholic dementia
 
           
20.
    292.82     Drug induced dementia
 
           
21.
    292.83     Drug-induced amnestic syndrome
 
           
22.
    292.9     Unspecified drug induced mental disorders
 
           
23.
    293.0     Acute delirium
 
           
24.
    293.1     Subacute delirium
 
           
25.
    293.8     Other specific transient organic mental disorders
 
           
26.
    293.81     Organic delusional syndrome
 
           
27.
    293.82     Organic hallucinosis syndrome
 
           
28.
    293.83     Organic affective syndrome
 
           
29.
    293.84     Organic anxiety syndrome.
 
           
30.
    294.0     Amnestic syndrome
 
           
31.
    294.1     Dementia in conditions classified elsewhere
 
           
32.
    294.8     Other specified organic brain syndromes (chronic)
 
           
33.
    294.9     Unspecified organic brain syndrome (chronic)
 
           
34.
    305.1     Non-dependent abuse of drugs — tobacco
 
           
35.
    310.0     Frontal lobe syndrome
 
           
36.
    310.2     Postconcussion syndrome
 
           
37.
    310.8     Other specified nonpsychotic mental disorder following
organic brain damage
 
           
38.
    310.9     Unspecified nonpsychotic mental disorder following
organic brain damage

    In addition, the contractor shall retain responsibility for delivering all
covered Medicaid mental health/substance abuse services (except partial care
services) to enrollees who are clients of the Division of Developmental
Disabilities (referred to as “clients of DDD”). Articles Four and Five contain
further information regarding clients of DDD.

4.1.3   SERVICES REMAINING IN FEE-FOR-SERVICE PROGRAM AND MAY NECESSITATE
CONTRACTOR ASSISTANCE TO THE ENROLLEE TO ACCESS THE SERVICES

A. The following services provided by the New Jersey Medicaid program under its
State plan shall remain in the fee-for-service program but may require medical
orders by the contractor’s PCPs/providers. These services shall not be included
in the contractor’s capitation.

1.   Personal Care Assistant Services (not covered for NJ FamilyCare Plans B and
C)   2.   Medical Day Care (not covered for NJ FamilyCare Plans B and C)

      Amended as of September 1, 2004   IV-7

 

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Exhibit 10.6.6

    1. Procedure Codes to be paid by Medicaid FFS up to 60 days after first time
New Jersey Care 2000+ enrollment:

                         
02710
            02792       03430  
02720
            02950       05110  
02721
            02952       05120  
02722
            02954       05211  
02750
            03310       05211-52  
02751
            03320       05212  
02752
            03330       05212-52  
02790
            03410-22       05213  
02791
            03411       05214  

    Procedure Codes to be paid by Medicaid FFS up to 120 days from date of last
preliminary extractions after patient enrolls in New Jersey Care 2000+ (applies
to tooth codes 5 - 12 and 21 - 28 only):        05130
05130-22
05140
05140-22
  3.   Extraction Procedure Codes to be paid by Medicaid FFS up to 120 days from
last date of preliminary extractions after first time New Jersey Care 2000+
enrollment in conjunction with the following codas (05130, 05130-22, 05140,
05140-22):       07110
07130
07210

4.1.4 ‘MEDICAID COVERED SERVICES NOT PROVIDED BY CONTRACTOR

A.   Mental Health/Substance Abuse. The following mental health/substance abuse
services (except for the conditions listed in 4.1.2.B) will be managed by the
State or its agent for non-DDD enrollees, including all NJ FamilyCare enrollees.
(The contractor will retain responsibility for furnishing mental
health/substance abuse services, excluding partial care services and the cost of
the drugs listed below, to Medicaid enrollees who are clients of the Division of
Developmental Disabilities).

~1.   Substance Abuse Services-diagnosis, treatment, and detoxification   - 2.  
Costs for Methadone maintenance and its administration   - 3.   Mental Health
Services

a.   Partial care services are covered by the Medicaid program.

      Amended as of September 1, 2004   IV-9

 

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Exhibit 10.6.6

4.   Home Health Care Services — Limited to skilled nursing for a home bound
beneficiary which is provided or supervised by a registered nurse, and home
health aide when the purpose of the treatment is skilled care; and medical
social services which are necessary for the treatment of the beneficiary’s
medical condition   5.   Hospice Services   6.   Inpatient Hospital Services,
including general hospitals, special hospitals, and rehabilitation hospitals. —
The contractor shall not be responsible when the primary admitting diagnosis is
mental health or substance abuse related.   7.   Outpatient Hospital Services,
including outpatient surgery   8.   Laboratory Services — All laboratory testing
sites providing services under this contract must have either a Clinical
Laboratory Improvement Act (CLIA) certificate of waiver or a certificate of
registration along with a CLIA identification number. Those providers with
certificates of waiver shall provide only the types of tests permitted under the
terms of their waiver. Laboratories with certificates of registration may
perform a full range of laboratory services.   9.   Radiology Services —
Diagnostic and therapeutic   10.   Optometrist Services, including one routine
eye examination per year   11.   Optical appliances — Limited to one pair of
glasses (or contact lenses) per 24 month period or as medically necessary   12.
  Organ transplant services which are — non-experimental or —
non-investigational   13.   Prescription drugs, excluding over-the-counter drugs
Exception: See Article 8 regarding Protease Inhibitors and other
antiretrovirals.   14.   Dental Services — Limited to preventive dental services
for children under the age of 12 years, including oral examinations, oral
prophylaxis, and topical application of fluorides. Exception — comprehensive
orthodontia treatment services shall be provided, through completion of required
services, for any enrollee under the age of 19 years whose orthodontia services
were initiated while enrolled with the contractor as a Medicaid, NJ FamilyCare
Plan A, B, or C enrollee. The contractor shall not be responsible for
orthodontia services to a Plan D enrollee under the age of 19 years old that
were

      Amended as of September 1, 2004   IV-12

 

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Exhibit 10.6.6

    initiated while that individual was enrolled with another contractor. The
enrollee must continue enrollment in the HMO where services were initiated until
those services were completed or until the member loses Medicaid/NJ FamilyCare
eligibility. Active treatment begins with the placement of the orthodontic
appliances (banding). Cases that were authorized but not banded do not qualify
for continuation of care.   15.   Podiatrist Services — Excludes routine
hygienic care of the feet; including the treatment of corns and calluses, the
trimming of nails, and other hygienic care such as cleaning or soaking feet, in
the absence of a pathological condition   16.   Prosthetic appliances — Limited
to the initial provision of a prosthetic device that temporarily or permanently
replaces all or part of an external body part lost or impaired as a result of
disease, injury, or congenital defect. Repair and replacement services are
covered when due to congenital growth.   17.   Private duty nursing — Only when
authorized by the contractor   18.   Transportation Services — Limited to
ambulance for medical emergency only   19.   Well child care including
immunizations, lead screening and treatments   20.   Maternity and related
newborn care   21.   Diabetic supplies and equipment

B.   Services Available To NJ FamilyCare Plan D Under Fee-For-Service. The
following services are available to NJ FamilyCare Plan D enrollees under
fee-for-service:

1.   Abortion services   2.   Outpatient Rehabilitation Services — Physical
therapy, Occupational therapy, and Speech therapy for non-chronic conditions and
acute illnesses and injuries. Limited to treatment for a 60-day (that is, 60
business days) consecutive period per incident of illness or injury beginning
with the first day of treatment per contract year. Speech therapy services
rendered for treatment of delays in speech development, unless resulting from
disease, injury or congenital defects are not covered

      Amended as of September 1, 2004   IV-13

 

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Exhibit 10.6.6

12.   Durable Medical Equipment — excludes any equipment not listed in Appendix,
Section B.4.1, and not covered if not part of inpatient hospital discharge plan
  13.   Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services  
14.   Transportation Services, including non-emergency ambulance, invalid coach,
and lower mode transportation   15.   Hearing Aid Services and Audiology   16.  
Blood and Blood Plasma, except administration of blood, processing of blood,
processing fees and fees related to autologous blood donations are covered.  
17.   Cosmetic Services   18.   Custodial Care   19.   Special Remedial and
Educational Services   20.   Experimental and Investigational Services   21.  
Medical Supplies (except diabetic supplies)   22.   Infertility Services   23.  
Rehabilitative Services for Substance Abuse   24.   Weight reduction programs or
dietary supplements, except operations, procedures or treatment of obesity when
approved by the contractor   25.   Acupuncture and acupuncture therapy, except
when performed as a form of anesthesia in connection with covered surgery   26.
  Temporomandibular joint disorder treatment, including treatment performed by
prosthesis placed directly in the teeth   27.   Recreational therapy   28.  
Sleep therapy   29.   Court-ordered services   30.   Thermograms and
thermography   31.   Biofeedback   32.   Radial keratotomy   33.   Respite Care
  34.   Inpatient hospital services for mental health   35.   Inpatient and
outpatient services for substance abuse   36.   Partial hospitalization

      Amended as of September 1, 2004   IV-18

 

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Exhibit 10.6.6

F.   Developmental disabilities clinics

4.4 COORDINATION WITH MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES

    The State shall retain a separate Mental Health/Substance Abuse system for
the coordination and monitoring of most mental health/substance abuse
conditions. The contractor shall furnish MH/SA services except partial care
services to clients of DDD. However, as described below, the contractor shall
retain responsibility for MI-USA screening; referrals, prescription drugs;
higher-mode transportation, and for treatment of the conditions identified in
Article 4.1.2B.

A.   Screening Procedures. Mental health and substance abuse problems shall be
systematically identified and addressed by the enrollee’s PCP at the earliest
possible time following initial participation of the enrollee in the
contractor’s plan or after the onset of a condition requiring mental health
and/or substance -abuse treatment. PCPs and other providers shall utilize mental
health/substance abuse screening tools as set forth in Section B.4.9 of the
Appendices as well as other mechanisms to facilitate early identification of
mental health and substance abuse needs for treatment. The contractor may
request permission to use alternative screening tools. The use of alternative
screening tools shall be pre-approved by DMAHS. The lack of motivation of an
enrollee to participate in treatment shall = not be considered a factor in
determining medical necessity and shall not be used as a rationale for
withholding or limiting treatment of an enrollee.       The contractor shall
present its policies and procedures regarding how its providers will identify
enrollees with MH/SA service needs, how they will encourage these enrollees to
begin treatment, and the screening tools to be used to identify enrollees
requiring MH/SA services. The contractor should refer to the DSM-IV Primary Care
Version in development of its procedures.   B.   Referrals. The contractor shall
be responsible for referring or coordinating referrals of enrollees as indicated
to Mental Health/Substance Abuse providers. In order to facilitate this, the
contractor may contact DMHS or its agent (e.g., if the State contracts with a
third party administrator (TPA) for a list of MH/SA providers. Enrollees may be
referred to a MH/SA provider by the PCP, family members, other providers, State
agencies, the contractor’s staff, or may self-refer.

1.   The contractor shall be responsible for referrals from MI-I/SA providers
for medical diagnostic work-up to formulate a diagnosis or to effect the
treatment of a MH/SA disorder and ongoing medical care for any enrollee with a
M-I/SA diagnosis and shall coordinate the care with the MH/SA provider. This
includes the responsibility for physical examinations (with the exception of
physical examinations performed in direct connection with the administration of
Methadone, which will remain FFS), neurological evaluations, laboratory testing
and radiologic examinations,

 

Amended as of September 1, 2004   IV-45

 

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Exhibit 10.6.6

    that physical and communication barriers do not prohibit enrollees with
disabilities from obtaining services from the contractor.   6.   Services for
enrollees with special needs must be provided in a manner responsive to the
nature of a person’s disability/specific health care need and include adequate
time for the provision of the service.

B.   The contractor shall ensure that any new enrollee identified (either by the
information on the Medical. Information form at the time of enrollment or by
contractor providers after enrollment) as having complex/chronic conditions
receives immediate transition planning. The planning shall be completed within a
timeframe appropriate to the enrollee’s condition, but in no case later than ten
(10) business days from the effective date of enrollment when the Medical
Information form has an indication of special health care needs or within thirty
(30) days after special conditions are identified by a provider. This transition
planning shall not constitute the IHCP described in Sections 4.5.4 and 4.6.5.
Transition planning shall provide for a brief, interim plan to ensure
uninterrupted services until a more detailed plan of care is developed. The
transition planning process includes, but is not limited to:

1.   Review of existing care plans.   2.   Preparation of a transition plan that
ensures continuous care during the transfer into the contractor’s network.   3.
  If durable medical equipment had been ordered prior to enrollment but not
received by the time of enrollment, the contractor must coordinate and
follow-through to ensure that the enrollee receives necessary equipment.

C.   Outreach and Enrollment Staff The contractor shall have outreach and
enrollment staff who are trained to work with enrollees with special needs, are
knowledgeable about their care needs and concerns, and are able to converse in
the different languages common among the enrolled population, including TDD/TT
and American Sign Language if necessary.   D.   Specialty Care. The contractor
shall have a procedure by which a new enrollee upon enrollment, or an enrollee
upon diagnosis, who requires very complex, highly specialized health care
services over a prolonged period of time, or with (i) a life-threatening
condition or disease or (ii) a degenerative and/or disabling condition or
disease, either of which requires specialized medical care over a prolonged
period of time, may receive a referral to a specialist or a specialty care
center with expertise in treating the life-threatening disease or specialized
condition, who shall be responsible for and capable of providing and
coordinating the enrollee’s primary and specialty care.

      Amended as of September 1, 2004   IV-49

 

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Exhibit 10.6.6

    endocrinology, infectious disease, orthopedics, neurology, neurosurgery,
ophthalmology, physiatry, pulmonology, surgery, and urology, as well as
providers who have knowledge and experience in behavioral-developmental
pediatrics, adolescent health, geriatrics, and chronic illness management.   5.
  The network shall include an appropriate and accessible number of
institutional facilities, professional allied personnel, home care and community
based services to perform the contractor-covered services included in this
contract.

B.   SCHSNA. The contractor shall include in its provider network Special Child
Health Services Network Agencies (SCHSNA) for children with special health care
needs. These agencies are designated and approved by the Department of Health
and Senior Services and include Pediatric Ambulatory Tertiary Centers (pediatric
tertiary centers may also be used when a pediatric subspecialty is not
sufficiently accessible in a county to meet the needs of the-child), Regional
Cleft Lip/Palate Centers, Pediatric AIDS/HIV Network, Comprehensive Regional
Sickle Ce1UHemoglobinopathies Treatment Centers, PKU Treatment Centers, Genetic
Testing and Counseling Centers, and Hemophilia Treatment Centers, and others as
designated from time to time by the Department of Health and Senior Services. A
list of such providers is found in Section B.4.10 of the Appendices.   C.  
Credentialing. The contractor shall collect and maintain, as part of its
credentialing process or through special survey process, information from:
licensed practitioners including pediatricians and pediatric subspecialists
about the nature and extent of their experience in serving children with special
health care needs including developmental disabilities.

4.5.4 CARE MANAGEMENT AND COORDINATION OF CARE FOR PERSONS WITH SPECIAL NEEDS

A.   The contractor shall provide coordination of care to actively link the
enrollee to providers, medical services, residential, social and other support
services as needed. For persons with special needs, care management shall be
provided, but, for those with higher needs, as determined through the Complex
Needs Assessment (the CNA is described in Article 4.6.5), the contractor shall
provide care management at a higher level of intensity. (See Section B.4.12 of
the Appendices for a flowchart of the three levels of care management.) Specific
requirements for this highest level of care management are described below.   B.
  Complex Needs Assessment. For enrollees with special needs, the contractor
shall perform a Complex Needs Assessment no later than forty-five (45) days (or
earlier, if urgent) from initial enrollment if special needs are indicated on
the Medical Information Form or from the point of identification of special
needs. See 4.6.5 for a description of the CNA. Additional time will be permitted

      Amended as of September 1, 2004   IV-54

 

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Exhibit 10.6.6

    Case Management Units (See Appendix B.4.11) in accordance with the
Department of Health and Senior Services procedures for referrals, and sharing
information with early intervention providers.

4.5.6 CLIENTS OF THE DIVISION OF DEVELOPMENTAL DISABILITIES

A.   The contractor shall provide all physical health services required by this
contract as well as the MH/SA services (except partial care services) included
in the Medicaid State Plan to enrollees who are clients of DDD. The contractor
shall include in its provider network a specialized network of providers who
will deliver both physical as well as MH/SA services, except providers of
partial care services, (in accordance with Medicaid program standards) to
clients of DDD, and ensure continuity of care within that network.   B.   The
contractor’s specialized network shall provide disease management services for
clients of DDD, which shall include participation in:

1.   Care Management, including Complex Needs Assessment, development and
implementation of IHCP, referral, coordination of care, continuity of care,
monitoring, and follow-up and documentation.   2.   Coordination of care across
multi-disciplinary treatment teams to assist PCPs in identifying the providers
within the network who will meet the specific needs and health care requirements
of clients of DDD with both physical health and MH/SA needs and provide
continuity of care with an identified provider who has an established
relationship with the patient.   3.   Apply quality improvement
techniques/protocols to effect improved quality of life outcomes.   4.   Design
and implement clinical pathways and practice guidelines that will produce
overall quality outcomes for specific diseases/conditions identified in clients
of DDD.   5.   Medical treatment.

C.   The specialized provider network shall consist of credentialed providers
for physical health and MH/SA services, who have experience and expertise in
treating clients of DDD who have both physical health and MH/SA needs, and who
can provide internal management of the complex care needs of these enrollees.
The contractor shall ensure that the specialized provider network will be able
to deliver identified physical health and MH/SA outcomes.   D.   Clients of DDD
may, at their option, receive their physical health and/or MH/SA services from
any qualified provider in the contractor’s network. They are not required to
receive their services through the contractor’s specialized network.        

Amended as of September 1, 2004   IV-58

 

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Exhibit 10.6.6

    its aggregate, enrolled commercial and Medicare population in the State or
region (if these data are collected and reported to DHSS, a copy of the report
should be submitted also to DMAHS) the following clinical indicator measures:

      HEDIS   Report Period Reporting Set Measures

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

  by Contract Year

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Childhood Immunization Status
  annually
Adolescent Immunization Status
  annually
Well-Child Visits in first 15 months of life
  annually
Well-Child Visits in the 3rd, 4th, 5th and 6th year of life
  annually
Adolescent Well-Care Visits
  annually
Prenatal and Postpartum Care
  annually
Breast Cancer Screening
  annually
Cervical Cancer Screening
  annually
Use of Appropriate Medications for People with Asthma
  annually

    Childhood & Adolescent Immunization HEDIS data for NJ FamilyCare enrollees
up to the age of 19 years must be reported separately.   Q.   Quality
Improvement Projects (QIPs). The contractor shall participate in QIPs defined
annually by the State with input from the contractor. The State will, with input
from the contractor and possibly other MCEs, define measurable improvement goals
and QIP-specific measures which shall serve as the focus for each QIP. The
contractor shall be responsible for designing and implementing strategies for
achieving each QIP’s objectives. At the beginning of each contract year the
contractor shall present a plan for designing and implementing such strategies,
which shall receive approval from the State prior to implementation. The
contractor shall then submit semiannual progress reports summarizing performance
relative to each of the objectives of each contract year.       The QIPs shall
be completed annually and shall include the areas identified below. The external
review organization (ERO) under contract with DHS shall prepare a final report
for year one that will contain data, using State-approved sampling and
measurement methodologies, for each of the measures below. Changes in required
QIPs shall be defined by the DHS and incorporated into the contract by
amendment.       For each measure the DHS will identify a baseline and a
compliance standard. Baseline data, target standards, and compliance standards
shall be established or updated by the State.       If DHS determines that the
contractor is not in compliance with the requirements of the annual QIP
objectives, either based on the contractor’s progress report or

      Amended as of September 1, 2004   IV-65

 

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Exhibit 10.6.6

D.   The contractor shall include in its network at least one (1) hospital
located in the inner city urban area and at least 1 non-urban-based hospital in
every county except where indicated in Article 4.8.8.M. For those counties with
only one (1) hospital, the contractor shall include that hospital in its network
subject to good faith negotiations.   E.   The contractor shall offer a choice
of two specialists in each county where available. If only one or no providers
of a particular specialty is available, the contractor shall provide
documentation of the lack of availability and propose alternative specialty
providers in neighboring counties.   F.   The contractor shall include in its
network mental health/substance abuse providers for Medicaid covered MI4/SA
services with expertise to serve enrollees who are clients of the Division of
Developmental Disabilities. Exception — partial care services are not covered by
the contractor.   G.   Changes in large provider groups, IPAs or subnetworks
such as pharmacy benefits manager, vision network, or dental network shall be
submitted to DMAHS for review and prior approval at least ninety (90) days
before the anticipated change. The submission shall include contracts, provider
network files, enrollee/provider notices and any other pertinent information.  
H.   Requirement to contract with FQHC. The contractor shall contract for
primary care services with at least one Federally Qualified Health Center
(FQHC) located in each enrollment area based off the availability and capacity
of the FQHCs in that area. FQHC providers shall meet the contractor’s
credentialing andprogram requirements.       Requirement to contract with
Children’s Hospital of New Jersey at Newark Beth Israel Medical Center for
school-based health services. The contractor shall contract with the Children’s
Hospital of New Jersey at Newark Beth Israel Medical Center for the provision of
primary health care services, including but not limited to, EPSDT services, and
dental care services, to be provided at designated schools in the city of
Newark. Providers at the school-based clinics shall meet the contractor’s
credentialing and program requirements of this contract.

4.8.2 PRIMARY CARE PROVIDER REQUIREMENTS

A.   The contractor shall offer each enrollee a choice of two (2) or more
primary care physicians within the enrollee’s county of residence. Where
applicable, this offer can be made to an authorized person. An enrollee with
special needs shall be given the choice of a primary care provider which must
include a pediatrician, general/family practitioner, and internist, and may
include physician specialists and nurse practitioners. The PCP shall supervise
the care of the enrollee with special needs who requires a team approach.
Subject to any limitations in the

      Amended as of September 1, 2004   IV-96

 

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Exhibit 10.6.6

KK. An explanation of the appropriate uses of the Medicaid/NJ FamilyCare
identification card and the contractor identification card;

LL. A notification, whenever applicable, that some primary care physicians may
employ other health care practitioners, such as nurse practitioners or physician
assistants, who may participate in the patient’s care;

MM. The enrollee’s or, where applicable, an authorized person’s signed
authorization on the enrollment application allows release of medical records;

NN. Notification that the enrollee’s health status- survey will be sent to the
contractor by the enrollee;

OO. A notice that enrollment and disenrollment is subject to verification and
approval by DMAH-S;

PP. An explanation of procedures to follow if enrollees receive bills from
providers of services, in or out of network;

QQ. An explanation of the enrollee’s financial responsibility for payment when
services are provided by a health care provider who is not part of the
contractor’s organization or when a procedure, treatment or service is not a
covered health care benefit by the contractor and/or by Medicaid;

RR. A written explanation at the time of enrollment of the enrollee’s right to
terminate enrollment, and any other restrictions on the exercise of those
rights, to conform to 42 U.S.C. § 1396b(m)(2)(F)(ii). The initial enrollment
information and the contractor’s member handbook shall be adequate to convey
this notice and shall have DMAHS approval prior to distribution;

SS. An explanation that the contractor will contact or facilitate contact with,
and require its PCPs to use their best efforts to contact, each new enrollee or,
where applicable, an authorized person, to schedule an appointment for a
complete, age/sex specific baseline physical, and for enrollees with special
needs who have been identified through a Complex Needs Assessment as having
complex needs, the development of an Individual Health Care Plan at a time
mutually agreeable to the contractor and the enrollee, but not later than ninety
(90) days after the effective date of enrollment for children under twenty-one
(21) years of age, and not later than one hundred eighty (180) days after
initial enrollment for adults; for adult clients of DDD, no later than ninety
(90) days after the effective date of enrollment; and encourage enrollees to
contact the contractor and/or their PCP to schedule an appointment;

      Amended as of September 1, 2004   V-17

 

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Exhibit 10.6.6

    The contractor’s system and procedure shall be available to both Medicaid
beneficiaries and NJ FamilyCare beneficiaries. All enrollees have available the
complaint and grievance/appeal process under the contractor’s plan, the
Department of Health and Senior Services and, for Medicaid and certain NJ
FamilyCare beneficiaries (i.e., Plan A enrollees and beneficiaries with a PSG of
380 under Plan D), the Medicaid Fair Hearing process. Individuals eligible
solely through NJ FamilyCare Plans B, C, D, and H (except for Plan D and H
individuals with a program status code of 380), do not have the right to a
Medicaid Fair Hearing.   B.   Complaints. The contractor shall have procedures
for receiving, responding to, and documenting resolution of enrollee complaints
that are received orally and are of a less serious or formal nature. Complaints
that are resolved to the enrollee’s satisfaction within five (5) business days
of receipt do not require a formal written response or notification. The
contractor shall call back an enrollee within twenty-four hours of the initial
contact if the contractor is unavailable for any reason or the matter cannot be
readily resolved during the initial contact. Any complaint that is not resolved
within three business days shall be treated as a grievance/appeal, in accordance
with requirements defined in Article 5.15.3.   C.   HBC Coordination. The
contractor shall coordinate its efforts with the health benefits coordinator
including referring the enrollee to the HBC for assistance as needed in the
management of the complaint/grievance/appeal procedures.       DMAFIS
Intervention. DMAHS shall have the right to intercede on an enrollee’s behalf at
any time during the contractor’s complaint/grievance/appeal process: whenever
there is an indication from the enrollee, or, where applicable, authorized
person, or the BBC that a serious quality of care issue is not being addressed
timely or appropriately. Additionally, the enrollee may be accompanied by a
representative of the enrollee’s choice to any proceedings and
grievances/appeals.   E.   Legal Rights. Nothing in this Article shall be
construed as removing any legal rights of enrollees under State or federal law,
including the right to file judicial actions to enforce rights.

5.15.2 NOTIFICATION TO ENROLLEES OF GRIEVANCE/APPEAL PROCEDURE

A.   The contractor shall provide all enrollees or, where applicable, an
authorized person, upon enrollment in the contractor’s plan, and annually
thereafter, pursuant to this contract, with a concise statement of the
contractor’s grievance/appeal procedure and the enrollees’ rights to a hearing
by the Independent Utilization Review Organization (IURO) per NJAC 8:38-8.7 as
well as their right to pursue the Medicaid Fair Hearing process described in
N.J.A.C. 10:49-10.1 et seq. The information shall be provided through an annual
mailing, a member handbook, or any other method approved by DMAHS. The
contractor shall prepare the

      Amended as of September 1, 2004   V-36

 

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Exhibit 10.6.6

8.5.2.4 NJ FAMILYCARE PLAN D PARENTS/CARETAKERS

    This grouping includes capitation rates for NJ FamilyCare Plan D
parents/caretakers, excluding individuals with AIDS, and include only enrollees
19 years of age or older.

8.5.2.5 DYFS AND AGING OUT FOSTER CHILDREN

    This grouping includes capitation rates for Division of Youth and Family
Services, excluding individuals with-AIDS and clients of DDD.

. 8.5.2.6 ABD WITHOUT. MEDICARE

    Compensation to the contractor for the ABD individuals without Medicare will
be risk-adjusted using the Health Based Payments System (HBPS), which is
described in Article 8.6. HBPS adjusts for the diagnosis of AIDS; therefore,
separate AIDS rates are not necessary for this population. Finally, the HBPS
adjusts for age and sex so separate rates for age and sex within this population
are not necessary.

8.5.2.7 ABD WITH MEDICARE

    This grouping includes capitation rates for the ABD with Medicare
population, excluding individuals with AIDS and clients of DDD.

8.5.2.8 CLIENTS OF DDD

    This grouping includes all enrollees except ABD individuals without
Medicare. The contractor shall be paid separate, statewide rates for subgroups
of the DDD population, excluding individuals with AIDS. These rates include
covered MH/SA services.

8.5.2.9 ENROLLEES WITH AIDS

    This grouping includes all enrollees except ABD individuals without
Medicare.

A.   The contractor shall be paid special statewide capitation rates for
enrollees with AIDS.   B.   The contractor will be reimbursed double the AIDS
rate, once in a member lifetime, in the first month of payment for a recorded
diagnosis of AIDS, prospective and newly diagnosed. This is a
one-time-only-per-member payment, regardless of MCE.

8.5.2.10 RESERVED

      Amended as of September 1, 2004   VIII-7

 

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Exhibit 10.6.6

(SEAL) [w68052w6805201.gif]
 
State of New Jersey

DEPARTMENT OF HUMAN SERVICES
DIVISION OF MEDICAL ASSISTANCE AND HEALTH SERVICES
PO Box 712

          JAMES E. MCGREEVEY   TRENTON, NJ 08625-0712   JAMES M. DAVY Governor  
TELEPHONE 1-800-356-1561   Commissioner         ANN CLEMENCY KOHLER      
Director

July 2, 2004

Norine Yukon
President & CEO
AMERIGROUP New Jersey, Inc.
399 Thornall Street
9th Floor
Edison NJ 08837

Dear Ms. Yukon:

Enclosed is an amendment to the managed care contract. This amendment will carve
out partial care services for clients of DDD enrolled in an HMO, and adds some
clarifying language regarding orthodontia services for certain eligible
beneficiaries.

The amendment does not include Section C, Capitation Rates. This will be sent
under separate cover.

Please return the signature page (5 original copies) to the Office of Managed
Health Care by July 23, 2004.

Sincerely,

(-s- Jill Simone) [w68052w6805202.gif]

Jill Simone, MD
Executive Director
Office of Managed Health Care

JS
Enclosure
c:       Rita Hemingway
          John Koehn

                    r

NJ Depa

 

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Exhibit 10.6.6

New Jersey Is An Equal Opportunity Employer