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

Back to Form 8-K [form8k.htm]
 
Exhibit 10.1
 
APPENDIX X
[Amendment Number 5]

Agency Code 12000
Contract No. C020454
Period 4/1/07-9/30/08
Funding Amount for Period Based on approved capitation rates

This is an AGREEMENT between THE STATE OF NEW YORK, acting by and through The
New York State Department of Health, having its principal office at Corning
Tower, Room 2001, Empire State Plaza, Albany NY 12237, (hereinafter referred to
as the STATE), and WellCare of New York, Inc., (hereinafter referred to as the
CONTRACTOR), to modify Contract Number C020454 as set forth below. The effective
date of these modifications is April 1, 2007, unless otherwise noted below.

1. Amend Section 19.1 of the "Table of Contents for Model Contract," to read,
"Section 19.1 Maintenance of Contractor Performance Records, Records Evidencing
Enrollment Fraud and Documentation Concerning Duplicate CINs."

2. Amend Section 3.6, "SDOH Right to Recover Premiums." to read as follows:

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 MMC 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 MMC Enrollee's Guaranteed
Eligibility period; or to have died. SDOH has a right to recover premiums for
FHPlus Enrollees listed on the Roster who are determined to have been
incarcerated; to have moved out of the Contractor's service area; or to have
died. In any event, the State may only recover premiums paid for MMC and/or
FHPlus 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. Notwithstanding the foregoing, the SDOH always
has the right to recover duplicate MMC or FHPlus premiums paid for persons
enrolled under more than one Client Identification Number (CIN) in the
Contractor's MMC or FHPlus product whether or not the Contractor has made
payments to providers.

3. Amend Section 19.1, "Maintenance of Contractor Performance Records," to read
as follows:

19.1   Maintenance of Contractor Performance Records, Records Evidencing
Enrollment Fraud and Documentation Concerning Duplicate CINs

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

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

ii) all financial records and statistical data that 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, any reserves related
thereto and expenses incurred under this Agreement;

Appendix X
MMC/FHPlus Contract Amendment
April 1, 2007
Page 1

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

iii) all documents concerning enrollment fraud or the fraudulent use of any CIN;

iv) all documents concerning duplicate CINs;

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

b)  The Contractor shall maintain all Access NY Health Care (DOH-4220), Medicaid
Choice, and SDOH enrollment applications (DOH-4097) and recertification forms
completed by the Contractor or its subcontractors in fulfilling its
responsibilities related to Facilitated Enrollment as set forth in Appendix P of
this Agreement.

c) The record maintenance requirements of this Section shall survive the
termination, in whole or in part, of this Agreement.

4.  Amend Section 19.3, "Access to Contractor Records," to read as follows:

19.3   Access to Contractor Records

The Contractor shall provide 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). 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. Notwithstanding the foregoing, when records are sought in
connection with a "fraud" or "abuse" investigation, as defined respectively in
10 NYCRR §98.1.21 (a) (1) and (a) (2), all costs associated with production and
reproduction shall be the responsibility of the Contractor.

5. Amend C.L 1. a) iii) B) of Appendix C, "New York State Department of Health
Requirements for the Provision of Family Planning and Reproductive Health," to
read as follows:

B) For FHPlus Enrollees - The Contractor, if it includes such services in its
Benefit Package is responsible for covering contraceptives, including emergency
contraceptives, provided by a Participating pharmacy or a participating provider
or clinic. The Contractor is responsible for prescription contraceptives
consistent with the pharmacy benefit package as described in Appendix K, as well
as for contraceptives obtained and administered by a provider in an office or
clinic setting. When the Contractor does not provide Family Planning and
Reproductive Health Services, the Designated Third Party Contractor that covers
such services for FHPlus Enrollees is responsible for contraceptives, including
emergency contraceptives, provided by a Participating pharmacy or a
participating provider or clinic. The Designated Third Party Contractor is
responsible for prescription contraceptives consistent with the pharmacy benefit
package as described in Appendix K, as well as for contraceptives obtained and
administered by a provider in an office or clinic setting. The Contractor or the
Designated Third Party Contractor must cover at least one of every type of the
following methods of contraception:

I)  Oral
II) Oral, emergency
III) Injectable
Appendix X

MMC/FHPIus Contract Amendment
April 1, 2007
Page 2

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

IV) Transdermal
V)  Intravaginal
VI) Intravaginal, systemic
VII) Implantable

6.   The attached Appendix H, "New York State Department of Health Requirements
for the Processing of Enrollments and Disenrollments in the MMC and FHPlus
Programs," is substituted for the period beginning April 1, 2007.

7.   The attached Appendix L, "Approved Capitation Payment Rates," is
substituted for the period beginning April 1, 2007.
 
All other provisions of said AGREEMENT shall remain in full force and effect.

Appendix X
MMC/FHPlus Contract Amendment
April 1, 2007
Page 3

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

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

CONTRACTOR SIGNATURE
STATE AGENCY SIGNATURE
By:   /s/   Todd S. Farha
By:   /s/   Vallencia Lloyd
Todd S. Farha

Vallencia Lloyd
Title: President and CEO
Title: Deputy Director, DMC & PE
Date: 10/5/07
Date: 11/2/07

 
State Agency Certification:
In addition to the acceptance of this contract, I also certify that original
copies of this signature page will be attached to all other exact copies of this
contract.

 

STATE OF FLORIDA
County of Hillsborough

On this 5th day of October, 2007, before me personally appeared Todd S. Farha,
to me known, who being by me duly sworn, did depose and say that he/she resides
at Tampa, Florida, that he/she is the President & CEO of WellCare of New York,
Inc., the corporation described herein which executed the foregoing instrument;
and that he/she signed his/her name hereto by order of the board of directors of
said corporation.

  /s/  Sara L. Gallo
(Notary)
 
Approved:
Approved
 

ATTORNEY GENERAL
 
 
(STAMP)
APPROVED AS TO FORM NYS ATTORNEY GENERAL
NOV 23 2007
LORRAINE I. REMO
ASSOCIATE ATTORNEY
 
Thomas P. DiNapoli
STATE COMPTROLLER
 
(STAMP)
APPROVED
DEPT. OF AUDIT & CONTROL
DEC 13 2007
Illegible
FOR THE STATE COMPTROLLER
 
Title:
Title:
Date:
Date:
   

Appendix X
MMC/FHPlus Contract Amendment
April 1, 2007
Page 4

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

 
APPENDIX H
 
New York State Department of Health Requirements
for the Processing of Enrollments and Disenrollments
in the MMC and FHPlus Programs

 
APPENDIX H
April 1, 2007
H-l
 
 

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

SDOH Requirements
for the Processing of Enrollments and Disenrollments
in the MMC and FHPlus Programs

1.  General

The Contractor's Enrollment and Disenrollment procedures shall be consistent
with these requirements, except that to allow LDSS and the Contractor
flexibility in developing processes that will meet the needs of both parties,
SDOH, upon receipt of a written request from either the LDSS or the Contractor,
may allow modifications to timeframes and some procedures. Where an Enrollment
Broker exists, the Enrollment Broker will be responsible for some or all of the
LDSS responsibilities as set forth in the Enrollment Broker Contract.

2. Enrollment

a) SDOH Responsibilities:

i) The SDOH is responsible for monitoring LDSS program activities and providing
technical assistance to the LDSS and the Contractor to ensure compliance with
the State's policies and procedures.

ii) SDOH reviews and approves proposed Enrollment materials prior to the
Contractor publishing and disseminating or otherwise using the materials.

b) LDSS Responsibilities:

i)  The LDSS has the primary responsibility for the Enrollment process.

ii) Each LDSS determines Medicaid and FHPlus eligibility. To the extent
practicable, the LDSS will follow up with Enrollees when the Contractor provides
documentation of any change in status which may affect the Enrollee's Medicaid,
FHPlus, or MMC eligibility.

iii) The LDSS is responsible for coordinating the Medicaid and FHPlus
application and Enrollment processes.

iv) The LDSS is responsible for providing pre-enrollment information to Eligible
Persons, consistent with Sections 364-j(4)(e)(iv) and 369-ee of the SSL, and the
training of persons providing Enrollment counseling to Eligible Persons.

v) The LDSS is responsible for informing Eligible Persons of the availability of
MCOs and HIV SNPs offering MMC and/or FHPlus products and the scope of services
covered by each.

APPENDIX H
April 1, 2007
H-2

 
vi) The LDSS is responsible for informing Eligible Persons of the right to
confidential face-to-face Enrollment counseling and will make confidential
face-to-face sessions available upon request.

vii)   The LDSS is responsible for instructing Eligible Persons to verify with
the medical services providers they prefer, or have an existing relationship
with, that such medical services providers are Participating Providers of the
selected MCO and are available to serve the Enrollee. The LDSS includes such
instructions to Eligible Persons in its written materials related to Enrollment.

viii) For Enrollments made during face-to-face counseling, if the Prospective
Enrollee has a preference for particular medical services providers, Enrollment
counselors shall verify with the medical services providers that such medical
services providers whom the Prospective Enrollee prefers are Participating
Providers of the selected MCO and are available to serve the Prospective
Enrollee.

ix) The LDSS is responsible for the timely processing of managed care Enrollment
applications, Exemptions, and Exclusions.

x) The LDSS is responsible for determining the status of Enrollment
applications. Applications will be enrolled, pended or denied. The LDSS will
notify the Contractor of the denial of any Enrollment applications that the
Contractor assisted in completing and submitting to the LDSS under the
circumstances described in 2(c)(i) of this Appendix.

xi) The LDSS is responsible for determining the Exemption and Exclusion status
of individuals determined to be eligible for Medicaid under Title 11 of the SSL.

A) Exempt means an individual eligible for Medicaid under Title 11 of the SSL
determined by the LDSS or the SDOH to be in a category of persons, as specified
in Section 364-j of the SSL and/or New York State's Operational Protocol for the
Partnership Plan, that are not required to participate in the MMC Program;
however, individuals designated as Exempt may elect to voluntarily enroll.

B) Excluded means an individual eligible for Medicaid under Title 11 of the SSL
determined by the LDSS or the SDOH to be in a category of persons, as specified
in Section 364-j of the SSL and/or New York State's Operational Protocol for the
Partnership Plan, that are precluded from participating in the MMC Program.

xii) Individuals eligible for Medicaid under Title 11 of the SSL in the
following categories will be eligible for Enrollment in the Contractor's MMC
product at the LDSS's option, as indicated in Schedule 2 of Appendix M.

A) Foster care children in the direct care of LDSS;

APPENDIX H
April 1, 2007
H-3

 
B) Homeless persons living in shelters outside of New York City.

xiii) The LDSS is responsible for entering individual Enrollment form data and
transmitting that data to the State's Prepaid Capitation Plan (PCP) Subsystem.
The transfer of Enrollment information may be accomplished by any of the
following:

A)  LDSS directly enters data into PCP Subsystem; or

B) LDSS or Contractor submits a tape to the State, to be edited and entered into
PCP Subsystem; or

C) LDSS electronically transfers data, via a dedicated line or Medicaid
Eligibility Verification System (MEVS) to the PCP Subsystem.

xiv) The LDSS is responsible for sending the following required notices to
Eligible Persons:

A) For mandatory MMC program only - Initial Notification Letter: This letter
informs Eligible Persons about the mandatory MMC program and the timeframes for
choosing a MCO offering a MMC product. 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 MMC program to
enroll in an HIV SNP on a voluntary basis in LDSS jurisdictions where HIV SNPs
exist.

B) For mandatory MMC program only - 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.

C) For MMC program - Enrollment Confirmation Notice for MMC Enrollees: 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 MCO. There is no requirement that an
Enrollment Confirmation Notice be sent to FHPlus Enrollees.

D) Notice of Denial of Enrollment: This notice is used when an individual has
been determined by LDSS to be ineligible for Enrollment into the MMC or FHPlus
program. This notice must include fair hearing rights. This notice is not
required when Medicaid or FHPlus eligibility is being denied (or closed).

E) For MMC program only - Exemption Request Forms: Exemption forms areprovided
to MMC Eligible Persons upon request if they wish to apply for an

APPENDIX H
April 1, 2007
H-4
 

Exemption.  Individuals precoded on the system as meeting Exemption or Exclusion
criteria do not need to complete an Exemption request form. This notice is
required for mandatory MMC Eligible Persons.

F) For MMC program only - Exemption and Exclusion Request Approval or Denial:
This notice is designed to inform a recipient who applied for an exemption or
who failed to provide documentation of exclusion criteria when requested by the
LDSS of the LDSS’s disposition of the request,  including the right to a fair
hearing if the request for exemption or exclusion is denied. This notice is
required for voluntary and mandatory MMC Eligible Persons.

c)   Contractor Responsibilities:

i) To the extent permitted by law and regulation, the Contractor may accept
Enrollment forms from Potential Enrollees for the MMC program, provided that the
appropriate education has been provided to the Potential Enrollee by the LDSS
pursuant to Section 2(b) of this Appendix. In those instances, the Contractor
will submit resulting Enrollments to the LDSS, within a maximum of five (5)
business days from the day the Enrollment is received by the Contractor (unless
otherwise agreed to by SDOH and LDSS).

ii) The Contractor must notify new MMC and FHPlus Enrollees of their Effective
Date of Enrollment. In the event that the actual Effective Date of Enrollment is
different from that previously 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.

iii) The Contractor must notify the LDSS within five (5) business days of such
information becoming blown to the Contractor of any Medicaid or FHPlus Enrollees
whose eligibility for those programs was established based on false information
contained in applications completed by the Contractor or its subcontractors in
fulfilling its responsibilities related to Facilitated Enrollment as set forth
in Appendix P of this Agreement. Such information may include, but is not
limited to, household income and/or resources (as defined in Subpart 360-4 of 18
NYCRR), household size, or address. The foregoing responsibility supplements
those set forth in Sections 23.1 and 23.2 of this Agreement.

iv) The Contractor must report any changes that affect or may affect the
eligibility status of 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, address changes, verification of pregnancy, incarceration, third
party insurance, etc.

APPENDIX H
April 1, 2007
H-5

v) The Contractor, within five (5) business days of identifying cases where a
person may be enrolled in the Contractor's MMC or FHPlus product under more than
one CIN, must convey that information in writing to the LDSS.

vi) The Contractor shall advise Prospective Enrollees, in written materials
related to Enrollment, to verify with the medical services providers they
prefer, or have an existing relationship with, that such medical services
providers are Participating Providers of the selected MCO and are available to
serve the Prospective Enrollee.

vii)The Contractor shall accept all Enrollments as ordered by the Office of
Temporary and Disability Assistance's Office of Administrative Hearings due to
fair hearing requests or decisions.

3. Newborn Enrollments

a) The Contractor agrees to enroll and provide coverage for eligible newborn
children effective from the time of birth.

b) SDOH Responsibilities:

i) The SDOH will update WMS with information on the newborn received from
hospitals, consistent with the requirements of Section 366-g of the SSL as
amended by Chapter 412 of the Laws of1999.

ii) 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 the newborn is not already enrolled, the mother's MCO
offers a MMC product, and the newborn is not identified as SSI or SSI-related
and therefore Excluded from the MMC Program pursuant to Section 2(b)(xi) of this
Appendix. 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 Rosters for upstate and NYC, the
"PCP Effective From Date" will indicate the first day of the month of birth, as
described in 01 OMM/ADM 5 "Automatic Medicaid Enrollment for Newborns." If the
newborn's Enrollment is not completed by this process, the LDSS is responsible
for Enrollment (see (c)(iv) below).

c) LDSS Responsibilities:

i) Grant Medicaid eligibility for newborns for one (1) year if born to a woman
eligible for and receiving Medicaid or FHPlus on the date of the newborn's
birth.

ii) The LDSS is responsible for adding eligible unborns to all WMS cases that
include a pregnant woman as soon as the pregnancy is medically verified.

APPENDIX H
April 1, 2007
H-6

iii) In the event that the LDSS learns of an Enrollee's pregnancy prior to the
Contractor, the LDSS is responsible for establishing Medicaid eligibility and
enrolling the unborn in the Contractor's MMC product. If the Contractor does not
offer a MMC product, the pregnant woman will be asked to select a MCO offering a
MMC product for the unborn. If a MCO offering a MMC product is unavailable, or
if Enrollment is voluntary in the LDSS jurisdiction and an MCO is not chosen by
the mother, the newborn will be eligible for Medicaid fee-for-service coverage,
and such information will be entered on the WMS.

iv) The LDSS is responsible for newborn Enrollment if enrollment is not
successfully completed under the "SDOH Responsibilities" process as outlined in
2(b)(ii) above.

Contractor Responsibilities:

i) The Contractor must notify the LDSS in writing of any Enrollee that is
pregnant within thirty (30) days of knowledge of the pregnancy. Notifications
should be transmitted to the LDSS at least monthly. The notifications should
contain the pregnant woman's name, Client ID Number (CIN), and the expected date
of confinement (EDC).

ii) 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.

iii) In districts that use an Enrollment Broker, the Contractor shall not submit
electronic Enrollments of newborns to the Enrollment Broker, because 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 MMC or FHPlus product and who were not pre-enrolled into the
Contractor's MMC product as unborns, the Contractor may submit electronic
Enrollment of the newborns to the Enrollment Broker. In such cases, the
Effective Date of Enrollment will be prospective.

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

v) The Contractor is responsible for provision of services to a 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,
unless the Contractor does not offer a MMC product in the mother's county of
fiscal

APPENDIX H
April 1, 2007
H-7

responsibility or the newborn is Excluded from the MMC Program pursuant to
Section 2(b)(xi) of this Appendix.

vi) 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.

vii) 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.

viii)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.

4. Auto-Assignment Process (Applies to Mandatory MMC Program Only):

a) This section only applies to a LDSS where CMS has given approval and the LDSS
has begun mandatory Enrollment into the Medicaid Managed Care Program. The
details of the auto-assignment process are contained in Section 12 of New York
State's Operational Protocol for the Partnership Plan.

b) SDOH Responsibilities:

i) The SDOH, LDSS or Enrollment Broker will assign MMC Eligible Persons not
pre-coded in WMS as Exempt or Excluded, who have not chosen a MCO offering a MMC
product in the required time period, to a MCO offering a MMC product using an
algorithm as specified in §364-j(4)(d) of the SSL.

ii) SDOH will ensure the auto-assignment process automatically updates the PCP
Subsystem, and will notify MCOs offering MMC products of auto-assigned
individuals electronically.

iii) SDOH will notify the LDSS electronically on a daily basis of those
individuals for whom SDOH has selected a MCO offering a MMC product through the
Automated PCP Update Report. Note: This does not apply in Local Districts that
utilize an Enrollment Broker.

c) LDSS Responsibilities:

i) The LDSS is responsible for tracking an individual's choice period.

ii) As with Eligible Persons who voluntarily choose a MCO's MMC product, the
LDSS is responsible for providing notification to assigned individuals regarding
their Enrollment status as specified in Section 2 of this Appendix.

d) Contractor Responsibilities:

APPENDIX H
April 1, 2007
H-8

i)   The Contractor is responsible for providing notification to assigned
individualsregarding their Enrollment status as specified in Section 2 of this
Appendix.

5. Roster Reconciliation:

a)   All Enrollments are effective the first of the month.

b) SDOH Responsibilities:

i) The SDOH maintains both the PCP subsystem Enrollment files and the WMS
eligibility files, using data entered by the LDSS. SDOH uses data contained in
both these files to generate the Roster.

A) SDOH shall send the Contractor 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 1st of the following month
(First Monthly Roster). Notification to the Contractor and LDSS will be
accomplished via paper transmission, magnetic media, or the HPN.

B) SDOH shall send the Contractor 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 Contractor and
LDSS will be accomplished via paper transmission, magnetic media, or the HPN.

C) The SDOH shall also forward an error report as necessary to the Contractor
and LDSS.

D) On the first (1st) weekend after the first (1st) day of the month following
the generation of the first (1st) Roster, SDOH shall send the Contractor and
LDSS a second Roster which contains any additional Enrollees that the LDSS has
added for Enrollment for the current month. The SDOH will also include any
additions to the error report that have occurred since the initial error report
was generated.

c) LDSS Responsibilities:

i) The LDSS is responsible for notifying the Contractor electronically or in
writing of changes in the 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. The Contractor and the
LDSS may develop protocols for the purpose of resolving Roster discrepancies
that remain unresolved beyond the end of the month.)

APPENDIX H
April 1, 2007
H-9

ii) Enrollment and eligibility issues are reconciled by the LDSS to the extent
possible, through manual adjustments to the PCP subsystem Enrollment and WMS
eligibility files, if appropriate.

d)  Contractor Responsibilities:

i)   The Contractor is at risk for providing Benefit Package services for those
Enrollees listed on the 1st and 2nd Rosters for the month in which the 2nd
Roster is generated.    Contractor is not at risk for providing services to
Enrollees who appear on the monthly Disenrollment report.

ii) The Contractor must submit claims to the State's Fiscal Agent for all
Eligible Persons that are on the 1st and 2nd Rosters, 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 does not
constitute "provision of Benefit Package services."

6. Disenrollment:

a)   LDSS Responsibilities:

i) The LDSS is responsible for accepting requests for Disenrollment directly
from Enrollees and may not require Enrollees to approach the Contractor 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. The LDSS and the Enrollment Broker must utilize the State-approved
Disenrollment forms.

ii) 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 non­consensual Enrollment or, in 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. MMC
Enrollees 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.

iii) The LDSS is responsible for processing routine Disenrollment requests to
take effect on the first (lst) 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.

APPENDIX H
April 1, 2007
H-10

iv) The LDSS is responsible for disenrolling Enrollees automatically upon death
or loss of Medicaid or FHPlus 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.

v)  The LDSS  is responsible for informing Enrollees of their right to change
Contractors if there is more than one available including any applicable Lock-In
restrictions. Enrollees subject to Lock-In may disenroll after the grace period
for Good Cause as defined below. The LDSS is responsible for determining if the
Enrollee has Good Cause and processing the Disenrollment request in accordance
with the procedures outlined in this Appendix. The LDSS is responsible for
providing Enrollees with notice of their right to request a fair hearing if
their Disenrollment request is denied. Such notice must include the reason(s)
for the denial. An Enrollee has Good Cause to disenroll if:

A) The Contractor has failed to furnish accessible and appropriate medical care
services or supplies to which the Enrollee is entitled under the terms, of the
contract under which the Contractor has agreed to provide services. This
includes, but is not limited to the failure to:
I) provide primary care services;
II) arrange for in-patient care, consultation with specialists, or laboratory
and radiological services when reasonably necessary;
III) arrange for consultation appointments;
IV) coordinate and interpret any consultation findings with emphasis on
continuity of medical care;
V) arrange for services with qualified licensed or certified providers;
VI) coordinate the Enrollee's overall medical care such as periodic
immunizations and diagnosis and treatment of any illness or injury; or

B) The Contractor cannot make a Primary Care Provider available to the Enrollee
within the time and distance standards prescribed by SDOH; or
C) The Contractor fails to adhere to the standards prescribed by SDOH and such
failure negatively and specifically impacts the Enrollee; or
D) The Enrollee moves his/her residence out of the Contractor's service area or
to a county where the Contractor does not offer the product the Enrollee is
eligible for; or
E) The Enrollee meets the criteria for an Exemption or Exclusion as set forth
in2(b)(xi) of this Appendix; or
F) It is determined by the LDSS, the SDOH. or its agent that the Enrollment was
not consensual; or

APPENDIX H
April 1, 2007
H-ll

G) The Enrollee, the Contractor and the LDSS agree that a change of MCOs would
be in the best interest of the Enrollee; or

H) The Contractor is a primary care partial capitation provider that does not
have a utilization review process in accordance with Title I of Article 4.9 of
the PHL and the Enrollee requests Enrollment in an MCO that has such a
utilization review process; or

I) The Contractor has elected not to cover the Benefit Package service that an
Enrollee seeks and the service is offered by one or more other MCOs in the
Enrollee's county of fiscal responsibility; or

J)   The Enrollee's medical condition requires related services to be performed
at the same time but all such related services cannot be arranged by the
Contractor because the Contractor has elected not to cover one of the services
the Enrollee seeks, and the Enrollee's Primary Care Provider or another provider
determines that receiving the services separately would subject the Enrollee to
unnecessary risk; or

K) An FHPlus Enrollee is pregnant.

vi) An Enrollee subject to Lock-In may initiate Disenrollment for Good Cause by
filing an oral or written request with the LDSS.

vii) The LDSS is responsible for promptly disenrolling an MMC Enrollee whose MMC
eligibility or health status changes such that he/she is deemed by the LDSS to
meet the Exclusion criteria. The LDSS will provide the MMC Enrollee with a
notice of his or her right to request a fair hearing.

viii) In instances where an MMC Enrollee requests Disenrollment due to MMC
Exclusion, the LDSS must notify the MMC Enrollee of the approval or denial of
exclusion/Disenrollment status, including fair hearing rights if Disenrollment
is denied.

ix) The LDSS is responsible for ensuring that retroactive Disenrollments are
used only when absolutely necessary. Circumstances warranting a retroactive
Disenrollment are rare and include when an Enrollee is determined to have been
non-consensually enrolled in a MCO; he or she enters or resides in a residential
institution under circumstances which render the individual Excluded from the
MMC program; is incarcerated; is an SSI infant less than six (6) months of age;
is simultaneously in receipt of comprehensive health care coverage from an MCO
and is enrolled in either the MMC or FHPlus product of the same MCO; or he or
she has died - 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."
Notwithstanding the foregoing, the SDOH always has the right to recover
duplicate MMC or FHPlus premiums paid for persons enrolled under more than

APPENDIX H
April 1, 2007
H-12

one Client Identification Number (CIN) in the Contractor's MMC or FHPlus product
whether or not the Contractor has made payments to providers.

x) The SDOH may recover premiums paid for Medicaid or FHPlus Enrollees whose
eligibility for those programs was based on false information, when such false
information was provided as a result of intentional actions or failures to act
on the part of an employee of the Contractor; and the Contractor shall have no
right of recourse against the Enrollee or a providers of service for the cost of
services provided to the Enrollee for the period covered by such premiums.

xi) The LDSS is responsible for notifying the Contractor of the retroactive
Disenrollment prior to the action. The LDSS is responsible for finding out if
the Contractor has made payments to providers on behalf of the Enrollee prior to
Disenrollment. After this information is obtained, the LDSS and Contractor will
agree on a retroactive Disenrollment or prospective Disenrollment date. In all
cases of retroactive Disenrollment, including Disenrollments effective the first
day of the current month, the LDSS is responsible for sending notice to the
Contractor at the time of Disenrollment, of the Contractor's responsibility to
submit to the SDOH's Fiscal Agent voided premium claims within thirty (30)
business days of notification from the LDSS for any full months of retroactive
Disenrollment where the Contractor was not at risk for the provision of Benefit
Package services during the month. Notwithstanding the foregoing, the SDOH
always has the right to recover duplicate MMC or FHPlus premiums paid for
persons enrolled under more than one Client Identification Number (CIN) in the
Contractor's MMC or FHPlus product whether or not the Contractor has made
payments to providers. Failure by the LDSS to 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 or for the State Attorney General to bring legal
action to recover any overpayment.

APPENDIX H
April 1, 2007
H-13

xii) 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
A) 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 re1ated category
 
 
First Day of the month of birth of the month of onset of disability, whichever
is later.
B) Death of Enrollee
 
 
First day of the month after death
C) Incarceration

 
First day of the month of incarceration (note- Contractor is at risk for covered
services only to the date of incarceration and is entitled to the capitation
payment for the month of incarceration)
 
D) Medicaid Managed Care Enrollee entered or stayed in a residential institution
under circumstances which rendered the individual excluded from managed care, or
is in receipt of waivered services through the Long Term Home Health Care
Program (LTHHCP), including when an Enrollee is admitted to a hospital that 1)
is certified by Medicare as a long-term care hospital and 2) has an average
length of stay for all patients greater than ninety-five (95) days as reported
in the Statewide Planning and Research Cooperative System (SPARCS) Annual Report
2002.
 
 
First day of the month of entry or first day of the month of classification of
the stay as permanent subsequent to entry (note-Contractor is at risk for
covered services only to the date of entry or classification of the stay as
permanent subsequent to entry, and is entitled to the capitation payment for the
month of entry or classification of the stay as permanent subsequent to entry)

E) Individual's effective date of Enrollment orautoassignment into a MMC product
occurred whilemeeting institutional criteria in (D) above
 
 
Effective Date of Enrollment in the Contractor's Plan

F) Non-consensual Enrollment
 
 
Retroactive to the first day of the month of the request
G) Enrollee moved outside of the District/County of Fiscal Responsibility
 
 
First day of the month after the update of the system with the new address1
H) Urgent medical need
 
 
First day of the next month after determination except where medical need
requires an earlier Disenrollment
I)  Homeless Enrollees in Medicaid Managed Care 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
J) Individual is simultaneously in receipt of comprehensive health care coverage
from an MCO and is Enrolled in either the MMC or FHPIus product of the same MCO
 
 
First day of the month after simultaneous coverage began

K) An Enrollee with more than one Client Identification Number (CIN) is enrolled
in an MCO's MMC or FHPIus product under more than one of the CINs
 
First day of the month the duplicate Enrollment began

1 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 MMC or
FHPIus product. In 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.

APPENDIX H
April 1, 2007
H-14

 
xiii) The LDSS is responsible for rendering a determination and responding
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. The LDSS, to the extent
possible, is responsible for processing an expedited Disenrollment within two
(2) business days of its determination that an expedited Disenrollment is
warranted.

xiv) The Contractor must respond timely to LDSS inquiries regarding Good
Cause  Disenrollment requests to enable the LDSS to make a determination within
thirty (30) days of the receipt of the request from the Enrollee.

xv) 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: This notice will advise the Enrollee of the LDSS's
determination regarding an Enrollee-initiated, LDSS-initiated or
Contractor-initiated Disenrollment and will include the Effective Date of
Disenrollment. In cases where the Enrollee is being involuntarily disenrolled,
the notice must contain fair hearing rights.

B) When the LDSS denies any Enrollee's request for Disenrollment pursuant to
Section 8 of this Agreement, the LDSS is responsible for informing the Enrollee
in writing, explaining the reason for the denial, stating the facts upon which
the denial is based, citing the statutory and regulatory authority and advising
the Enrollee of his/her right to a fair hearing pursuant to 18NYCRR Part 358.

C) End of Lock-In Notice: Where Lock-In provisions are applicable, Enrollees
must be notified sixty (60) days before the end of their Lock-In Period. The
SDOH or its designee is responsible for notifying Enrollees of this provision in
applicable LDSS jurisdictions.

D) Notice of Change to Guarantee Coverage: This notice will advise the Enrollee
that his or her Medicaid or FHPlus eligibility is ending and how this affects
his or her Enrollment in a MCO's MMC or FHPlus product. This notice contains
pertinent information regarding Guaranteed Eligibility benefits and dates of
coverage. If an Enrollee is not eligible for Guarantee, this notice is not
necessary.

xvi) The LDSS may require that a MMC Enrollee that has been disenrolled at the
request of the Contractor be returned to the Medicaid fee-for-service program.
In the FHPlus program, a FHPlus Enrollee disenrolled at the request of the
Contractor, may choose another MCO offering a FHPlus product. If the FHPlus
Enrollee does not choose, or there is not another MCO offering FHPlus in the
LDSS jurisdiction, the case will be closed.

APPENDIX H
April 1, 2007
H-15

xvii) In those instances where the LDSS approves the Contractor's request to
disenroll an Enrollee, and the Enrollee requests a fair hearing, the Enrollee
will remain enrolled in the Contractor's MMC or FHPlus product until the
disposition of the fair hearing if Aid to Continue is ordered by the New York
State Office of Administrative Hearings.

xviii) The LDSS is responsible for reviewing each Contractor-requested
Disenrollment in accordance with the provisions of Section 8.7 of this Agreement
and this Appendix. 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.

xix) The LDSS is responsible for establishing procedures whereby the Contractor
refers cases which are appropriate for an LDSS-initiated Disenrollment and
submits supporting documentation to the LDSS.

xx) After the LDSS receives and, if appropriate, approves the request for
Disenrollment either from the Enrollee or the Contractor, the LDSS is
responsible for updating the PCP subsystem file with an end date. The Enrollee
is removed from the Contractor's Roster.

b)  Contractor Responsibilities:

i) In those instances where the Contractor directly receives Disenrollment
forms, the Contractor will forward these Disenrollments to the LDSS for
processing within five (5) business days (or according to Section 6 of this
Appendix). During pulldown week, these forms may be faxed to the LDSS with the
hard copy to follow.

ii) The Contractor must accept and transmit all requests for voluntary
Disenrollments from its Enrollees to the LDSS, and shall not impose any barriers
to Disenrollment requests. The Contractor may require that a Disenrollment
request be in writing, contain the signature of the Enrollee, and state the
Enrollee's correct Contractor or Medicaid identification number.

iii) The Contractor will make a good faith effort to identify cases which may be
appropriate for an LDSS-initiated Disenrollment. Within five (5) business days
of identifying such cases and following LDSS procedures, the Contractor will, in
writing, 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 Enrollees that may impact eligibility for
Enrollment such as address changes, incarceration, death, exclusion from the MMC
program, the apparent enrollment of a member in the Contractor's MMC or FHPlus
product under more than one CTN, etc.

APPENDIX H
April 1, 2007
H-16
 

iv) Pursuant to Section 8.7 of this Agreement, 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.

v) 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 MMC or FHPlus product seriously impairs the
Contractor's ability to furnish services to either the Enrollee or other
Enrollees).

vi) 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.

vii) 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.

viii) 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.

ix) The Contractor will not consider an Enrollee disenrolled without
confirmation from the LDSS or the Roster (as described in Section 5 of this
Appendix).

APPENDIX H
April 1, 2007
H-17

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

APPENDIX L
Approved Capitation Payment Rates

APPENDIX L
April 1, 2007
L-l

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

WELLCARE OF  NEW YORK,   INC.
Medicaid Managed Care Rates

MMIS  ID#:  01182503
Effective Date:   04/01/07
Approved by DOB: Yes
Region: Northeast
Reinsurance:   No
County:   ALBANY

Premium Group
Rate Amount
TANF/SN  <6mo M/F
$266.66
TANF/SN  6mo-14  F
$90.84
TANF/SN  15-20   F
$132.88
TANF/SN  6mo-20  M
$88.65
TANF 21-64 M/F
$215.57
SN  21-29  M/F
$204.54
SN  30-64  M/F
$370.80
SSI 6mo-20  M/F
$179.30
SSI 21-64 M/F
$500.80
SSI 65+ M/F
$445.49
Maternity  Kick  Payment
$5,224.57
Newborn  Kick  Payment
$1,804.39

Optional   Benefits  Offered:
 
R Emergency    Transportation
£ Dental
R Non-Emergent    Transportation
R Family  Planning

 
Box will be checked if the optional benefit is covered by the plan

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

WELLCARE OF  NEW YORK,   INC.
Medicaid Managed Care Rates

MMIS  ID#:  01182503
Effective Date:   04/01/07
Approved by DOB: Yes
Region:  Central
Reinsurance:   No
County:   COLUMBIA

Premium Group
Rate Amount
TANF/SN  <6mo M/F
$259.46
TANF/SN  6mo-14  F
$85.50
TANF/SN  15-20   F
$143.93
TANF/SN  6mo-20  M
$85.89
TANF 21-64 M/F
$234.78
SN  21-29  M/F
$220.56
SN  30-64  M/F
$376.32
SSI 6mo-20  M/F
$183.98
SSI 21-64 M/F
$483.54
SSI 65+ M/F
$400.37
Maternity  Kick  Payment
$5,603.31
Newborn  Kick  Payment
$2,059.21

Optional   Benefits  Offered:
 
R Emergency    Transportation
£ Dental
R Non-Emergent    Transportation
R Family  Planning

 
Box will be checked if the optional benefit is covered by the plan

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

WELLCARE OF  NEW YORK,   INC.
Medicaid Managed Care Rates

MMIS  ID#:  01182503
Effective Date:   04/01/07
Approved by DOB: Yes
Region: Mid-Hudson
Reinsurance:   No
County:   DUTCHESS

Premium Group
Rate Amount
TANF/SN  <6mo M/F
$272.19
TANF/SN  6mo-14  F
$96.26
TANF/SN  15-20   F
$139.03
TANF/SN  6mo-20  M
$105.93
TANF 21-64 M/F
$234.51
SN  21-29  M/F
$215.62
SN  30-64  M/F
$436.83
SSI 6mo-20  M/F
$181.04
SSI 21-64 M/F
$496.83
SSI 65+ M/F
$433.14
Maternity  Kick  Payment
$5,792.84
Newborn  Kick  Payment
$2,367.65

Optional   Benefits  Offered:
 
R Emergency    Transportation
£ Dental
£ Non-Emergent    Transportation
R Family  Planning

 
Box will be checked if the optional benefit is covered by the plan

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

 

WELLCARE OF  NEW YORK,   INC.
Medicaid Managed Care Rates

MMIS  ID#:  01182503
Effective Date:   04/01/07
Approved by DOB: Yes
Region:  Central
Reinsurance:   No
County:  GREENE

Premium Group
Rate Amount
TANF/SN  <6mo M/F
$257.23
TANF/SN  6mo-14  F
$83.67
TANF/SN  15-20   F
$141.62
TANF/SN  6mo-20  M
$84.02
TANF 21-64 M/F
$231.91
SN  21-29  M/F
$217.76
SN  30-64  M/F
$373.21
SSI 6mo-20  M/F
$180.88
SSI 21-64 M/F
$479.49
SSI 65+ M/F
$398.65
Maternity  Kick  Payment
$5,603.31
Newborn  Kick  Payment
$2,059.21

Optional   Benefits  Offered:
 
R Emergency    Transportation
£ Dental
£ Non-Emergent    Transportation
R Family  Planning

 
Box will be checked if the optional benefit is covered by the plan

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

 
WELLCARE OF  NEW YORK,   INC.
Medicaid Managed Care Rates

MMIS  ID#:  01182503
Effective Date:   04/01/07
Approved by DOB: Yes
Region: Mid-Hudson
Reinsurance:   No
County:   ORANGE

Premium Group
Rate Amount
TANF/SN  <6mo M/F
$268.99
TANF/SN  6mo-14  F
$95.49
TANF/SN  15-20   F
$135.91
TANF/SN  6mo-20  M
$104.90
TANF 21-64 M/F
$231.09
SN  21-29  M/F
$211.14
SN  30-64  M/F
$430.70
SSI 6mo-20  M/F
$177.21
SSI 21-64 M/F
$488.48
SSI 65+ M/F
$428.29
Maternity  Kick  Payment
$5,792.84
Newborn  Kick  Payment
$2,367.65

Optional   Benefits  Offered:
 
£ Emergency    Transportation
£ Dental
£ Non-Emergent    Transportation
R Family  Planning

 
Box will be checked if the optional benefit is covered by the plan
 

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

 
WELLCARE OF  NEW YORK,   INC.
Medicaid Managed Care Rates

MMIS  ID#:  01182503
Effective Date:   04/01/07
Approved by DOB: Yes
Region: Northeast
Reinsurance:   No
County:   RENSSELAER

Premium Group
Rate Amount
TANF/SN  <6mo M/F
$264.44
TANF/SN  6mo-14  F
$89.01
TANF/SN  15-20   F
$130.59
TANF/SN  6mo-20  M
$86.79
TANF 21-64 M/F
$212.69
SN  21-29  M/F
$201.74
SN  30-64  M/F
$367.69
SSI 6mo-20  M/F
$176.21
SSI 21-64 M/F
$496.76
SSI 65+ M/F
$443.78
Maternity  Kick  Payment
$5,224.57
Newborn  Kick  Payment
$1,804.39

Optional   Benefits  Offered:
 
R Emergency    Transportation
£ Dental
£ Non-Emergent    Transportation
R Family  Planning

 
Box will be checked if the optional benefit is covered by the plan

 

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

WELLCARE OF  NEW YORK,   INC.
Medicaid Managed Care Rates

MMIS  ID#:  01182503
Effective Date:   04/01/07
Approved by DOB: Yes
Region: Northeast Metro
Reinsurance:   No
County:   ROCKLAND

Premium Group
Rate Amount
TANF/SN  <6mo M/F
$251.68
TANF/SN  6mo-14  F
$89.59
TANF/SN  15-20   F
$113.90
TANF/SN  6mo-20  M
$100.10
TANF 21-64 M/F
$193.73
SN  21-29  M/F
$267.15
SN  30-64  M/F
$420.16
SSI 6mo-20  M/F
$179.66
SSI 21-64 M/F
$557.33
SSI 65+ M/F
$420.16
Maternity  Kick  Payment
$4,860.78
Newborn  Kick  Payment
$1,569.65

Optional   Benefits  Offered:
 
R Emergency    Transportation
£ Dental
£ Non-Emergent    Transportation
R Family  Planning

 
Box will be checked if the optional benefit is covered by the plan

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

 
WELLCARE OF  NEW YORK,   INC.
Medicaid Managed Care Rates

MMIS  ID#:  01182503
Effective Date:   04/01/07
Approved by DOB: Yes
Region: Mid-Hudson
Reinsurance:   No
County:   ULSTER

Premium Group
Rate Amount
TANF/SN  <6mo M/F
$268.99
TANF/SN  6mo-14  F
$95.49
TANF/SN  15-20   F
$135.91
TANF/SN  6mo-20  M
$104.90
TANF 21-64 M/F
$231.09
SN  21-29  M/F
$211.14
SN  30-64  M/F
$430.70
SSI 6mo-20  M/F
$177.21
SSI 21-64 M/F
$488.48
SSI 65+ M/F
$428.29
Maternity  Kick  Payment
$5,792.84
Newborn  Kick  Payment
$2,367.65

Optional   Benefits  Offered:
 
£ Emergency    Transportation
£ Dental
£ Non-Emergent    Transportation
R Family  Planning

 
Box will be checked if the optional benefit is covered by the plan

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

WELLCARE OF NEW YORK, INC.

Family Health Plus Rates Effective April 1, 2007

         
Optional benefits covered 
County
Adults with Children 19 - 64
Adults without Children 19 - 29
Adults without Children 30 - 64
Maternity Kick
Family Planning
Dental
ALBANY
$253.35
$250.47
$510.54
$5,224.57
Yes
Yes
COLUMBIA
$271.75
$259.93
$499.25
$5,603.31
Yes
Yes
DUTCHESS
$261.25
$292.21
$529.01
$5,792.84
Yes
Yes
GREENE
$271.75
$259.93
$499.25
$5,603.31
Yes
Yes
ORANGE
$261.25
$292.21
$529.01
$5,792.84
Yes
Yes
RENSSELAER
$253.35
$250.47
$510.54
$5,224.57
Yes
Yes
ROCKLAND
$257.02
$209.67
$472.63
$4,860.78
Yes
Yes
ULSTER
$261.25
$292.21
$529.01
$5,792.84
Yes
Yes
NEW YORK CITY
$196.94
$151.51
$245.72
$5,523.56
Yes
Yes

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