Back to Form 8-K [form8-k.htm]
Exhibit 10.1

APPENDIX X
[Amendment Number 3]

Agency Code 12000
Contract Number CO21236
Period 1/1/08 — 12/31/09
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 CO21236 as set forth below as set forth
below and to extend the contract period through December 31, 2009. The effective
date of these modifications is January 1, 2008.
 
 
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 Enrollees listed on the monthly Roster who are later
determined for the entire applicable payment month to have been disenrolled from
the Contractor's Medicare Advantage Product; to have been in an institution; to
have been incarcerated; to have moved out of the Contractor's service area
subject to any time remaining in the Enrollee's Guaranteed Eligibility period;
or to have died. In any event, the State may only recover premiums paid for
Medicaid Enrollees listed on a Roster if it is determined by the SDOH that the
Contractor was not at risk for provision of Benefit Package services for any
portion of the payment period. Notwithstanding the foregoing, the SDOH always
has the right to recover duplicate Medicaid Advantage premiums paid for persons
enrolled under more than one Client Identification Number (ON) in the
Contractor's Medicaid Advantage 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 ClNs

 
 
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;

 
Appendix X
Medicaid Advantage Contract Amendment
 January 1, 2008
 Page 1
 

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ii)
all financial records and statistical data that SDOH and DHHS 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;

 
 
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 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 Section 22.7 "Recovery of Overpayments to Providers" to read as
follows:

 

  22.7   Recovery of Overpayments to Providers           Consistent with the
exception language in Section 3224-b of the Insurance Law, the Contractor shall
have and retain the right to audit participating providers' claims for a six
year period from the date the care, services or supplies were provided or
billed, whichever is later, and to recoup any overpayments discovered as a
result of the audit. This six year limitation does not apply to situations in
which fraud may be involved or in which the provider or an agent of the provider
prevents or obstructs the Contractor's auditing.

Appendix X
Medicaid Advantage Contract Amendment
 January 1, 2008
 Page 2

 

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  6.  Amend Section 31.2 "Indemnification by SDOH" to read as follows:

 

31.2   Indemnification by SDOH           Subject to the availability of lawful
appropriations as required by State Finance Law § 41 and consistent with § 8 of
the State Court of Claims Act, SDOH shall hold the Contractor harmless from and
indemnify it for any final judgment of a court of competent jurisdiction to the
extent attributable to the negligence of SDOH or its officers or employees when
acting within the course and scope of their employment. Provisions concerning
the SDOH's responsibility for any claims for liability as may arise during the
term of this Agreement are set forth in the New York State Court of Claims Act,
and any damages arising for such liability shall issue from the New York State
Court of Claims Fund or any applicable, annual appropriation of the Legislature
for the State of New York.

 
7.
The attached Appendix D, "New York State Department of Health Medicaid
Advantage. Marketing Guidelines," is substituted for the period beginning
January 1, 2008.

 

 
8.
The attached Appendix H, "New York State Department of Health Guidelines for the
Processing of Medicaid Advantage Enrollments and Disenrollments" is substituted
for the .period beginning January 1, 2008.

 
 
9.
The attached Appendix K, "Medicare and Medicaid Advantage Products and
Non-Covered Services," is substituted for the period beginning January 1, 2008.

 

 
10.
The attached Appendix L, "Approved Capitation Payment Rates," is substituted for
the period beginning January 1, 2008.

 
All other provisions of said AGREEMENT shall remain in full force and effect.

Appendix X
Medicaid Advantage Contract Amendment
 January 1, 2008
 Page 3
 

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IN WITNESS WHEREOF, the parties hereto have executed or approved this AGREEMENT
as of the dates appearing under their signatures.
 
CONTRACTOR SIGNATURE
 
STATE AGENCY SIGNATURE
By:  /s/ Heath Schiesser                              
By: /s/ Vallencia Lloyd                                  
      
        Heath Schiesser                                    
                          (Print name)
     Vallencia Lloyd___                                 
                      (Print name)
 
Title:  President and CEO                            
Title: Deputy Director, DMC                        
 
Date: 5/12/08                                                 
Date: 6/3/08                                                     
 
State Agency Certification:
In addition to the acceptance of this contract, I also certify that original
copies of this signature page will be attached to all other exact copies of this
contract.

STATE OF FLORIDA

County of Hillsborough

On the 12th day of May 20008, before me personally appeared Heath Schiesser, to
me known, who being by me duly sworn, did depose and say that he resides at
Tampa, Florida, that he is the President & CEO o WellCare of New York, Inc., the
corporation described herein which executed the foregoing instrument; and that
he/she signed his/her name thereto by order of the board of the directors of
said corporation.

/s/ Sara Gallo                                                  
(Notary)
 

 
Approved:
 
/s/ Lorraine Remo
 
ATTORNEY GENERAL
Approved:
 
/s/ name illegible
 
Thomas P. DiNapoli
STATE COMPTROLLER
Title: Associate Attorney
Title:
Date: June 10, 2009
Date: June 17, 2008

Appendix X
Medicaid Advantage Contract Amendment
January 1, 2008
Page 4 
 

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Appendix D
 
New York State Department of Health
Medicaid Advantage Marketing Guidelines

Medicaid Advantage Contract Amendment
Appendix D
State January 1, 2008
 D-1 
 

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MEDICAID ADVANTAGE MARKETING GUIDELINES
 
I.              Purpose
 
The purpose of these guidelines is to provide an operational framework for the
Medicaid managed care organizations (MCOs) in the development of marketing
materials and the conduct of marketing activities for the Medicaid Advantage
Program. The marketing guidelines set forth in this Appendix do not replace the
CMS marketing requirements for Medicare Advantage Plans; they supplement them.
 
II.            Marketing Materials
 
 A.   Definitions
 
 
1.
Marketing materials generally include the concepts of advertising, public
service announcements, printed publications, and other broadcast or electronic
messages designed to increase awareness and interest in a Contractor's Medicaid
Advantage product. The target audience for these marketing materials is Eligible
Persons as defined in Section 5.1 of this Agreement living in the defined
service area.

 
 
2.
For purposes of this Agreement, marketing materials include any information that
references the Contractor's Medicaid Advantage Product and which is intended for
distribution to Dual Eligibles, and is produced in a variety of print,
broadcast, and direct marketing mediums. These generally include: radio,
television, billboards, newspapers, leaflets, informational brochures, videos,
telephone book yellow page ads, letters, and posters. Additional materials
requiring marketing approval include a listing of items to be provided as
nominal gifts or incentives.

 
 B.    Marketing Material Requirements
 
 In addition to meeting CMS' Medicare Advantage marketing requirements and
guidance on marketing to individuals entitled to Medicare and Medicaid:
 
1.
 Medicaid Advantage marketing materials must be written in prose that is
understood at a fourth-to sixth-grade reading level except when the Contractor
is using language required by CMS, and must be printed in at least twelve (12)
point font.

 
2.
The Contractor must make available written marketing and other informational
materials (e.g., member handbooks) in a language other than English whenever at
least five percent (5%) of the Prospective Enrollees of the Contractor in any
county of the service area speak that particular language and do not speak
English as a first language. SDOFI will inform the LDSS and LDSS will inform the
Contractor when the 5% threshold has been reached. Marketing materials to be
translated include those key materials, such as informational brochures, that
are produced for routine distribution, and which are included within the MCO's
marketing plan. SDOH will determine the need for other than English translations
based on county specific census data or other available measures.

 
Medicaid Advantage Contract Amendment
Appendix D
State January 1, 2008
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3.
The Contractor shall advise potential Enrollees, in written materials related to
enrollment, to verify with the medical services providers they prefer, or have
an existing relationship with, that such medical services providers participate
in the selected managed care provider's network and are available to serve the
participant.

 
                 C.    Prior Approvals
 
 
1.
The CMS and SDOH will jointly review and approve Medicaid Advantage marketing
videos, materials for broadcast (radio, television, or electronic), billboards,
mass transit (bus, subway or other livery) and statewide/regional print
advertising materials in accordance with CMS timeframes for review of marketing
materials. These materials must be submitted to the CMS Regional Office for
review. CMS will coordinate SDOH input in the review process just as SDOH will
coordinate LDSS input in the review process.

 
 
2.
CMS and SDOH will jointly review and approve the following Medicaid Advantage
marketing materials:

 
 
a.
Scripts or outlines of presentations and materials used at health fairs and
other approved types of events and locations;

 
 
b.
All pre-enrollment written marketing materials – written marketing materials
include brochures and leaflets, and presentation materials used by marketing
representatives;

 
 
c.
All direct mailing from the Contractor specifically targeted to the Medicaid
market.

 

 
3.
The Contractor shall electronically submit all materials related to marketing
Medicaid Advantage to Dually Eligible persons to the CMS Regional Office for
prior written approval. The CMS Medicare Regional Office Plan Manager will be
responsible for obtaining SDOH input in the review and approval process in
accordance with CMS timeframes for the review of marketing materials. Similarly,
SDOH will be responsible for obtaining LDSS input in the review and approval
process.

 
 
4.
The Contractor shall not distribute or use any Medicaid Advantage marketing
materials that the CMS Regional Office and the SDOH have not jointly approved,
prior to the expiration of the required review period.

Medicaid Advantage Contract Amendment
Appendix D
State January 1, 2008
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5.
 Approved marketing materials shall be kept on file in the offices of the
Contractor, the LDSS, the SDOH, and CMS.

 
                 D.   Dissemination of Outreach Materials to LDSS
 
 
1.
Upon request, the Contractor shall provide to the LDSS and/or Enrollment Broker,
sufficient quantities of approved Marketing materials or alternative
informational materials that describe coverage in the LDSS jurisdiction.

 
 
2.
The Contractor shall, upon request, submit to the LDSS or Enrollment Broker, a
current provider directory, together with information that describes how
to determine whether a provider is presently available.

 
III.           Marketing Activities
 
                 A.    General Requirements
 
 
1.
The Contractor must follow the State's Medicaid marketing rules and the
requirements of 42 CFR 438.104 to the extent applicable when conducting
marketing activities that are primarily intended to sell a Medicaid managed care
product (i.e., Medicaid Advantage). Marketing activities intended to sell a
Medicaid managed care product shall be defined as activities which are conducted
pursuant to a Medicaid Advantage marketing program in which a dedicated staff of
marketing representatives employed by the Contractor, or by an entity with which
the Contractor has subcontracted, are engaged in marketing activities with the
primary purpose of enrolling recipients in the Contractor's Medicaid Advantage
product.

 
              
2.
Marketing activities that do not meet the above criteria shall not be construed
as having a primary purpose of intending to sell a Medicaid managed care product
and shall be conducted in accordance with Medicare Advantage marketing
requirements. Such activities include but are not limited to plan sponsored
events in which marketing representatives not dedicated to the marketing of the
Medicaid Advantage product explain Medicare products offered by the Contractor
as well as the Contractor's Medicaid Advantage product.

  
                 B.    Marketing at LDSS Offices
 
                 With prior LDSS approval, MCOs may distribute CMS/SDOH approved
Medicaid Advantage marketing materials in the local social services district
offices and facilities.
 
                 C.    Responsibility for Marketing Representatives
 
                 Individuals employed by the Contractor as marketing
representatives and employees of marketing subcontractors must have successfully
completed the Contractor's training
                 program including training related to an Enrollee's rights and
responsibilities in Medicaid Advantage. The Contractor shall be responsible for
the activities of its marketing
                 representatives and the activities of any subcontractor or
management entity.

Medicaid Advantage Contract Amendment
Appendix D
State January 1, 2008
 D-4 
 

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                 D.   Medicaid Advantage Specific Marketing Requirements
 
                 The requirements in Section D apply only if marketing
activities for the Medicaid Advantage Program are conducted pursuant to a
Medicaid Advantage marketing program in
                 which a dedicated staff of marketing representatives employed
by the Contractor or by an entity with which the Contractor has a subcontract
are engaged in marketing    
                 activities with the sole purpose of enrolling recipients in the
Contractor's Medicaid Advantage product.
 
1.
Approved Marketing Plan

 
 
a.
The Contractor must submit a plan of Medicaid Advantage Marketing activities
that meet the SDOH requirements to the SDOH.

 
 
b.
The SDOH is responsible for the review and approval of Medicaid Advantage
Marketing plans, using a SDOH and CMS approved checklist.

 
 
c.
Approved Marketing plans will set forth the terms and conditions and proposed
activities of the Medicaid Advantage dedicated staff during the contract period.
The following must be included: description of materials to be used,
distribution methods; primary types of marketing locations and a listing of the
kinds of community service events the Contractor anticipates sponsoring and/or
participating in during which it will provide information and/or distribute
Medicaid Advantage marketing materials.

 
 
d.
An approved marketing plan must be on file with the SDOH and each LDSS in its
contracted service area prior to the Contractor engaging in the Medicaid
Advantage specific marketing activities.

 
 
e.
The plan shall include stated marketing goal and strategies, marketing
activities, and the training, development and responsibilities of dedicated
marketing staff.

 
 
f.
The Contractor must describe how it is able to meet the informational needs
related to marketing for the physical and cultural diversity of its potential
membership. This may include, but not be limited to, a description of the
Contractor's other than English language provisions, interpreter services,
alternate communication mechanisms including sign language, Braille, audio
tapes, and/or use of Telecommunications Devices for the Deaf (TTY) services.

Medicaid Advantage Contract Amendment
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State January 1, 2008
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g.
The Contractor shall describe measures for monitoring and enforcing compliance
with these guidelines by its Marketing representatives including the prohibition
of door to door solicitation and cold-call telephoning; a description of the
development of pre-enrollee mailing lists that maintains client confidentiality
and honors the client's express request for direct contact by the Contractor;
the selection and distribution of pre-enrollment gifts and incentives to
prospective enrollees ; and a description of the training, compensation and
supervision of its Medicaid Advantage dedicated Marketing representatives.

 
2.
Prohibition of Cold Call Marketing Activities 
    Contractors are prohibited from directly or indirectly, engaging in door to
door, telephone, or other cold-call marketing activities.         3.  Marketing
in Emergency Rooms or Other Patient Care Areas     Contractors may not
distribute materials or assist prospective Enrollees in completing Medicaid
Advantage application forms in hospital emergency rooms, in provider offices, or
other areas where health care is delivered unless requested by the individual.  
       4.  Enrollment Incentives     Contractors may not offer incentives of any
kind to Medicaid recipients to join Medicaid Advantage. Incentives are defined
as any type of inducement whose receipt is contingent upon the recipients
joining the Contractor's Medicaid Advantage product.

 
                 E.    General Marketing Restrictions
 
                 The following restrictions apply anytime the Contractor markets
its Medicaid Advantage product:
 

  1.   Contractors are prohibited from misrepresenting the Medicaid program, the
Medicaid Advantage Program or the policy requirements of the LDSS or SDOH.      
  2.   Contractors are prohibited from purchasing or otherwise acquiring or
using mailing lists that specifically identify Medicaid recipients from third
party vendors, including providers and LDSS offices, unless otherwise permitted
by CMS. The Contractor may produce materials and cover their costs of mailing to
Medicaid recipients if the mailing is carried out by the State or LDSS, without
sharing specific Medicaid information with the Contractor.      
 
3.
Contractors may not discriminate against a potential Enrollee based on his/her
current health status or anticipated need for future health care. The Contractor
may not discriminate on the basis of disability or perceived disability of any
Enrollee or their family member. Health assessments may not be performed by the
Contractor prior to enrollment. The Contractor may inquire about existing
primary care relationships of the applicant and explain whether and how such
relationships may be maintained. Upon request, each potential Enrollee shall be
provided with a listing of all participating providers and facilities in the
MCO's network. The Contractor may respond to a potential Enrollee's question
about whether a particular specialist is in the network. However, the Contractor
is prohibited from inquiring about the types of specialists utilized by the
potential Enrollee.

Medicaid Advantage Contract Amendment
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State January 1, 2008
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  4. Contractors may not require participating providers to distribute plan
prepared communications to their patients, including communications which
compare the benefits of different health plans, unless the materials have the
concurrence of all MCOs involved, and have received prior approval by SDOH, and
by CMS, if Medicare Advantage is referenced.         5.  Contractors are
responsible for ensuring that their Marketing representatives engage in
professional and courteous behavior in their interactions with LDSS staff, staff
from other health plans and Medicaid clients. Examples of inappropriate behavior
include interfering with other health plan presentations or talking negatively
about another health plan.         6. The Contractor shall not market to
enrollees of other health plans. If the Contractor becomes aware during a
marketing encounter that an individual is enrolled in another health plan, the
marketing encounter must be promptly terminated, unless the individual
voluntarily suggests dissatisfaction with the health plan in which he or she is
enrolled.         7.  The Contractor shall not offer compensation including
salary increases or bonuses, based solely on the number of individuals enrolled
by Marketing Representatives who are licensed to offer Medicare products only,
including Medicaid Advantage, and who also market Medicaid, Family Health Plus
and Child Health Plus. However, the Contractor may base compensation of these
Marketing Representatives on periodic performance evaluations which consider
enrollment productivity as one of several performance factors during a
performance period, subject to the following requirements:

 
 
a.
"Compensation" shall mean any remuneration required to be reported as income or
compensation for federal tax purposes;

 
 
b.
The Contractor may not pay a "commission" or fixed amount per enrollment;

 
c.
The Contractor may not award bonuses more frequently than quarterly, or for an
annual amount that exceeds ten percent (10%) of a Marketing Representative's
total annual compensation;

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d.
Sign on bonuses for Marketing Representatives are prohibited;

 
 
e.
Where productivity is a factor in the bonus determination, bonuses must be
structured in such a way that productivity carries a weight of no more than 30%
of the total bonus and that application quality/accuracy must carry a weight
equal to or greater than the productivity component;

 
 
f.
The Contractor must limit salary adjustments for Marketing Representatives to
annual adjustments except where the adjustment occurs during the first year of
employment after a traditional trainee/probationary period or in the event of a
company wide adjustment;

 
 
g.
The Contractor is prohibited from reducing base salaries for Marketing
Representatives for failure to meet productivity targets;

 
 
h.
The Contractor is prohibited from offering non-monetary compensation such as
gifts and trips to Marketing Representatives;

 
 
i.
The Contractor shall have human resource policies and procedures for the earning
and payment of overtime and must be able to produce documentation (such as time
sheets) to support overtime compensation; and

 
j.
The Contractor shall keep written documentation, including performance
evaluations or other tools it uses as a basis for awarding bonuses or increasing
the salary of Marketing Representatives and employees involved in Marketing and
make such documentation available for inspection by SDOH or the LDSS.

 
IV.           Marketing Infractions
 
                A.    Infractions of Medicaid marketing guidelines, as found in
Appendix D, Sections III D and E, may result in the following actions being
taken by the SDOH, in consultation
                        with the LDSS, to protect the interests of the program
and its clients. These actions shall be taken by the SDOH in collaboration with
the LDSS and the CMS Regional
                        Office.

 
 
1.
If the Contractor or its representative commits a first time infraction of
marketing guidelines and the SDOH, in consultation with the LDSS, deems the
infraction to be minor or unintentional in nature, the SDOH and/or the LDSS may
issue a warning letter to the Contractor.

 
 
2.
If the Contractor engages in Marketing activities that the SDOH determines, in
its sole discretion, to be an intentional or serious breach of the Medicaid
Advantage Marketing Guidelines or the Contractor's approved Medicaid Advantage
Marketing Plan, or a pattern of minor breaches, SDOH, in consultation with the
LDSS, may require the Contractor to, and the Contractor shall prepare and
implement a corrective action plan acceptable to the SDOH within a specified
timeframe. In addition, or alternatively, SDOH may impose sanctions, including
monetary penalties, as permitted by law.

Medicaid Advantage Contract Amendment
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State January 1, 2008
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3.
If the Contractor commits further infractions, fails to pay monetary penalties
within the specified timeframe, fails to implement a corrective action plan in a
timely manner or commits an egregious first time infraction, the SDOH, in
consultation with the LDSS, may in addition to any other legal remedy available
to the SDOH in law or equity:

 
 
a)
direct the Contractor to suspend its Medicaid Advantage. Marketing activities
for a period up to the end of the Agreement period;

 
 
b)
suspend new Medicaid Advantage Enrollments, for a period up to the remainder of
the Agreement period; or

 
c)
 terminate this Agreement pursuant to termination procedures described in
Section 2.7 of this Agreement.

Medicaid Advantage Contract Amendment
Appendix D
State January 1, 2008
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APPENDIX H
 
New York State Department of Health Guidelines for the
Processing of Medicaid Advantage Enrollments and Disenrollments

Medicaid Advantage Contract
APPENDIX H
State January 1, 2008
H-1
 

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Appendix H
 
SDOH Guidelines
For the Processing of Medicaid Advantage Enrollments and
Disenroliments
 
1.    General
 
The Contractor's Enrollment and Disenrollment procedures for Medicaid Advantage
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, the 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 Local District 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 processing Medicaid Advantage
enrollments.

 
 
ii)
Each LDSS determines Medicaid 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 and/or Medicaid
Advantage eligibility.

 
iii)
LDSS is responsible for providing pre-enrollment information on Medicaid
Advantage to Dually Eligible beneficiaries, consistent with Social Services Law,
Section 364-j (4)(e)(iv) and train persons providing enrollment counseling to
Eligible Persons.

 
Medicaid Advantage Contract
APPENDIX H
State January 1, 2008
H-2 
 

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iv)
The LDSS is responsible for informing Eligible Persons of the availability of
Medicaid Advantage Products, the scope of services covered by each, and that
enrollment is voluntary.

 
v)
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.

 

vi)
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 written
instructions to Eligible Persons in its written materials related to Enrollment.

 

vii)
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.

 
viii)
The LDSS is responsible for the timely processing of Medicaid Advantage
Enrollment applications received from participating health plans.

 
ix)
The LDSS is responsible for processing Enrollments in Medicaid Advantage without
edits for Medicare coverage in the Welfare Management System (WMS); however the
LDSS is responsible for ensuring that WMS is updated with Medicare A and B
coverage status for new Enrollees upon review of documentation provided by the
Contractor or the Enrollee.

 
x)
The LDSS is responsible for determining the eligibility status of Medicaid
Advantage enrollment applications. Applications will be enrolled, pended or
denied.

 
xi)
The LDSS is responsible for processing Medicaid Advantage enrollment
applications until the last day of the month preceding the Effective Date of
Enrollment, to the extent possible.

 
xii)
The LDSS is responsible for notifying the Contractor of plan-assisted enrollment
applications that are accepted, pended or denied.

 
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:

 
Medicaid Advantage Contract
APPENDIX H
State January 1, 2008
H-3

 

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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, from eMedNY to the PCP
Subsystem.

 
xiv)
Extensive use of the secondary roster will be utilized to coordinate the
Effective Dates of Enrollment for Medicaid and Medicare Advantage.

 
xv)
The LDSS is responsible for prospectively re-enrolling an Enrollee who is
disenrolled from the Contractor's Medicaid Advantage Product due to loss of
Medicaid eligibility, who regains eligibility within three months, in the
Contractor's Medicaid Advantage Product, provided that the individual remains
enrolled in the Contractor's Medicare Advantage Product.

 
xvi)
The LDSS is responsible for processing new Enrollment applications to transfer a
member of the Contractor's Medicaid managed care product to the Contractor's
Medicaid Advantage Product if the Enrollee, upon gaining Medicare eligibility,
wishes to enroll in the Contractor's Medicaid Advantage Product. To the extent
possible, such Enrollments shall be made effective the first day of the month
that the Enrollee's Medicare Advantage Coverage is effective.

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

 
 
A)
Enrollment Confirmation Notice: This notice indicates the Effective Date of
Enrollment, the name of the Medicaid Advantage Product and the individual who is
being enrolled. This notice must also include a statement advising the
individual that if his/her Medicare Advantage enrollment is denied by CMS, the
individual's Medicaid Advantage Enrollment will be voided retroactively back to
the Effective Date of Enrollment. In such instances, the individual may be
responsible for the cost of any Medicaid Advantage Benefit rendered during the
retroactive period if the benefit was provided by a non-Medicaid participating
provider.

 
 
B)
Notice of Denial of Enrollment: This notice is used when an individual has been
determined by LDSS to be ineligible for enrollment into a Medicaid Advantage
Product. This notice must include fair hearing rights.

Medicaid Advantage Contract
APPENDIX H
State January 1, 2008
H-4 
 

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

 
 
            c) Contractor Responsibilities:
 
 
i)
To the extent permitted by law and regulation, the Contractor is responsible for
assisting Dually Eligible persons eligible for enrollment in Medicaid Advantage
to complete the Enrollment application. The Contractor will submit plan
Enrollments to the LDSS, within a maximum of five (5) business days from the day
the Enrollment is received by the Contractor (unless otherwise agreed to by SDOH
and LDS S).

 
 
ii)
The Contractor is responsible for obtaining documentation of Medicare A and B
coverage prior to sending the Enrollment transaction to the LDSS for processing.
In all areas where Enrollments are not processed by the Enrollment Broker, the
documentation must accompany the Enrollment form to the LDSS. Acceptable
documentation includes: a current Medicare card or other documentation
acceptable to CMS or received by the Contractor from interaction with CMS' data
systems.

 
 
iii)
In areas where Enrollments are submitted electronically to the Enrollment
Broker, the Contractor is responsible for forwarding the documentation of
current Medicare A and B coverage to the Enrollment Broker within five (5)
business days of learning from the Enrollment Broker that evidence of Medicare A
and B coverage is not reflected in the WMS system.

 
 
iv)
The Contractor must notify new Enrollees of their Effective Date of Enrollment.
To the extent practicable, such notification must precede the Effective Date of
Enrollment. This notice must also include a statement advising the individual
that if his/her Medicare Advantage enrollment is denied by CMS, the individual's
Medicaid Advantage Enrollment will be voided retroactively back to the Effective
Date of Enrollment. In such instances, the individual may be responsible for the
cost of any Medicaid Advantage Benefit rendered during the retroactive period if
the benefit was provided by a non-Medicaid participating provider.

 
v)
The Contractor must report any changes that affect or may affect the Medicaid or
Medicaid Advantage eligibility status of its Enrollees 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, incarceration, third party
insurance other than Medicare, Disenrollment from the Contractor's Medicare
Advantage Product, etc.

 
Medicaid Advantage Contract
APPENDIX H
State January 1, 2008
H-5
 

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

 

 
vi)
If an Enrollee's Enrollment in the Contractor's Medicare Advantage Product is
rejected by CMS, the Contractor must notify the LDSS within five (5) business
days of learning of CMS' rejection of the Enrollment. In such instances, the
LDSS shall delete the Enrollee's Enrollment in the Contractor's Medicaid
Advantage Plan.

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

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

 
 
ix)
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) SDOH Responsibilities:
 
 
i)
The SDOH will update WMS with information on the newborn received from hospitals
or birthing centers, consistent with the requirements of Section 366-g of the
Social Services Law as amended by Chapter 412 of the Laws of 1999.

 
 
ii)
Upon notification of the birth by the hospital or birthing center, the SDOH will
update WMS with the demographic data for the newborn generating appropriate
Medicaid coverage.

 
            b) LDSS Responsibilities:
 
 
i)
The LDSS is responsible for granting Medicaid eligibility for newborns for one
(1) year if born to a woman eligible for and receiving MA assistance on the date
of birth. (Social Services Law Section 366 (4) (1))

 
 
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. (NYS
DSS Administrative Directive 85 ADM-33)

Medicaid Advantage Contract
APPENDIX H
State January 1, 2008
H-6
 

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

 
 
 
iii)
In the event that the LDSS learns of an Enrollee's pregnancy prior to the
Contractor, the LDSS is to establish MA eligibility and pre-enroll the unborn
into Medicaid managed care in cases where an enrollment form is received.

 
 
iv)
When a newborn is enrolled in managed care, the LDSS is responsible for sending
an Enrollment Confirmation Notice to inform the mother of the Effective Date of
Enrollment, which is the first (1st) day of the month of birth, and the plan in
which the newborn is enrolled.

 
 
v)
The LDSS may develop a transmittal form to be used for unborn/newborn
notification between the Contractor and the LDSS.

 
            c) 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)
Upon the newborn's birth, the Contractor must send verifications of infant's
demographic data to the LDSS, within five (5) days after knowledge of the birth.
The demographic data must include: the mother's name and CIN, the newborn's name
and CIN (if newborn has a CIN), sex and the date of birth.

 
4.    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 input by the LDSS. SDOH uses data contained in
both these files to generate the Roster.

 
 
ii)
SDOH shall send monthly to the Contractor and LDSS (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.

 
iii)
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
LDSSs will be accomplished via paper transmission, magnetic media, or the HPN.

 
Medicaid Advantage Contract
APPENDIX H
State January 1, 2008
H-7 
 

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

 
 

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

 
v)
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 First Roster and error report, no later than the end
of the month. This includes, but is not limited to, new Enrollees whose
Enrollments in Medicaid Advantage were processed subsequent to the pull-down
date but prior to the Effective Date of Enrollment. (Note: To the extent
practicable the date specified must allow for timely notice to Enrollees
regarding their Enrolhnent 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).

 
 
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 2" 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 lst and 2" Rosters (see Appendix H, page 7), adjusted to
add Eligible Persons enrolled by the LDSS after Roster production and to remove
individuals disenrolled by LDSS after Roster production (as notified to the
Contractor). In the cases of retroactive Disenrollments, the Contractor is
responsible for submitting an adjustment to void any previously paid premiums
for the period of retroactive Disenrollment, where the Contractor was not at
risk for the provision of Benefit Package services. Payment of sub-capitation
does not constitute "provision of Benefit Package services."

Medicaid Advantage Contract
APPENDIX H
State January 1, 2008
H-8 
 

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

 
 
5.    Disenrollment:
 
            a) LDSS Responsibilities:
 
 
i)
Enrollees may request to disenroll from the Contractor's Medicaid Advantage
Product at any time for any reason. Disenrollment requests may be made by
Enrollees to the LDSS, the Enrollment Broker, or the Contractor.

 
 
ii)
Medicaid Advantage Plans, LDSSs, and the Enrollment Broker must utilize
State-approved Disenrollment forms.

 
 
iii)
The LDSS will accept requests for Disenrollment directly from the Enrollee or
from the Contractor.

 
 
iv)
Enrollees may initiate a request for an expedited Disenrollment to the LDSS. The
LDSS is responsible for expediting the Disenrollment process in those cases
where an Enrollee's request for Disenrollment involves concurrent Disenrollment
from the Contractor's Medicare Advantage Product, an urgent medical need, a
complaint of non­consensual enrollment or, in New York City, homeless
individuals in the shelter system. If approved, the LDSS will manually process
the Disenrollment through the PCP Subsystem. Enrollees who request to be
disenrolled from Medicaid Advantage based on their documented HIV, ESRD, or
SPMI/SED status are categorically eligible for an expedited Disenrollment on the
basis of urgent medical need.

 
 
v)
The LDSS is responsible for processing routine Disenrollment requests to take
effect on the first (1st) day of the following month to the extent possible. 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.

 
 
vi)
The LDSS is responsible for disenrolling Enrollees automatically upon death,
Disenrollment from the Contractor's Medicare Advantage Product, or loss of
Medicaid eligibility. All such Disenrollments will be effective at the end of
the month in which the death, Effective Date of Disenrollment from the
Contractor's Medicare Advantage Product, or loss of eligibility occurs, or at
the end of the last month of Guaranteed Eligibility, where applicable.

 
vii)
The LDSS is responsible for promptly disenrolling an Enrollee whose managed care
eligibility or status changes such that he/she is deemed by the LDSS to no
longer be eligbile for Medicaid Advantage Enrollment.  The LDSS is responsibile
for providing Enrollees with a notice of their right to request a fair hearing.

 
  Medicaid Advantage Contract
APPENDIX H
State January 1, 2008
H-9 
 

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

 
 
viii)
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 individual is deemed to have been
non-consensually enrolled in the Contractor's Medicaid Advantage Product, is
enrolled when ineligible for Enrollment, or when an Enrollee enters or resides
in a residential institution under circumstances which render the individual
ineligible; is incarcerated; is retroactively disenrolled from the Contractor's
Medicare Advantage Product, or dies - as long as the Contractor was not at risk
for provision of Benefit Package services for any portion of the retroactive
period. Payment of subcapitation does not constitute "provision of Benefit
Package services." Notwithstanding the foregoing, the SDOH always has the right
to recover duplicate Medicaid Advantage premiums paid for persons enrolled under
more than one Client Identification Number (CIN) in the Contractor's Medicaid
Advantage product whether or not the Contractor has made payments to providers.

 
 
ix)
The SDOH may recover premiums paid for Medicaid Advantage Enrollees whose
eligibility for this program 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 provider of services for the cost of
services provided to the Enrollee for the period covered by such premiums.

 
 
x)
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 Medicaid Advantage premiums
paid for persons enrolled under more than one Client Identification Number (CIN)
in the Contractor's Medicaid Advantage 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.

 
Medicaid Advantage Contract
APPENDIX H
State January 1, 2008
H-10

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

 
xi)
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
·Death of Enrollee
·First day of the month after death
·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).
·Enrollee entered or stayed in a residential institution under circumstances
which
 rendered the individual ineligible for enrollment in Medicaid Advantage 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).
·Individual enrolled while ineligible for enrollment
·Effective Date of Enrollment in the Contractor's Plan.
·Non-consensual Enrollment
·Retroactive to the first day of the month of Enrollment
·Enrollee moved outside of the District/County of Fiscal Responsibility
·First day of the month after the update of the system with the new address*
·Urgent medical need
·First day of the next month after determination except where medical need
requires an 
 earlier Disenrollment
·Homeless Enrollees in Medicaid Advantage residing in the shelter system in NYC
·Retroactive to the first day of the month of the request
·An Enrollee with more than one Client Identification Number (CIN) is enrolled
in the
 Contractor's Medicaid Advantage Product under more than one of the CINs.
·First day of the month the duplicate Enrollment began.

 
* In counties outside of New York City, LDSSs should work together to ensure
continuity of care through the Contractor if the Contractor's service area
includes the county to which the Enrollee has moved and the Enrollee, with
continuous eligibility, wishes to stay enrolled in the Contractor's plan. 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.

Medicaid Advantage Contract
APPENDIX H
State January 1, 2008
H-11 
 

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

 
 
xii)
The LDSS is responsible for informing Enrollees of their right to disenroll at
any time for any reason.

 
xiii)
The LDSS will render a decision within five (5) days of the receipt of a fully
documented request for Disenrollment.

 

xiv)
To the extent possible, the LDSS is responsible for processing an expedited
disenrollment within two (2) business days of its determination that an
expedited Disenrollment is warranted.

 

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: These notices will advise the Enrollee of the LDSS's
determination regarding an Enrollee-initiated, LDSS­initiated 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 18 NYCRR Part 358.

 
 
 C)
Notice of Change to "Guarantee Coverage": This notice will advise the Enrollee
that his or her Medicaid coverage is ending and how this affects his or her
enrollment in the Medicaid AdvantageProduct. 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.

 
Medicaid Advantage Contract
APPENDIX H
State January 1, 2008
H-12

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

 

xvi)
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
in the Contractor's Medicaid Advantage Product until the disposition of the fair
hearing, if Aid to Continue is ordered by the New York State Office of
Administrative Hearings.

 
 
xvii)
The LDSS is responsible for reviewing each Contractor requested Disenrollment in
accordance with the provisions of Section 8.7 of this Agreement. Where
applicable, the LDSS may consult with local mental health and substance abuse
authorities in the district when making the determination to approve or
disapprove the request.
         xviii)  The LDSS is responsible for establishing procedures whereby the
Contractor refers cases which are appropriate for an LDS S-initiated
Disenrollment and submits supporting documentation to the LDSS.          xix)
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 5 of this Appendix).
During pull-down 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 enrolled members that may impact
eligibility for Enrollment in an MCO such as address changes, incarceration,
death, ineligibility for Medicaid Advantage Enrollment, change in Medicare
status, the apparent enrollment of a member in the Contractor's Medicaid
Advantage product under more than one CIN, etc.

 
Medicaid Advantage Contract
APPENDIX H
State January 1, 2008
H-13

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

 
iv)
With respect to Contractor-initiated Disenrollments:

 
 
A)
The Contractor may initiate an involuntary Disenrollment if the Enrollee:

 

 
i)
engages in conduct or behavior that seriously impairs the Contractor's ability
to furnish services to either the Enrollee or other Enrollee's, provided that
the Contractor has made and documented reasonable efforts to resolve the
problems presented by the Enrollee; or

 
ii)
provides fraudulent information on an enrollment form or permits abuse of an
enrollment card except when the Enrollee is no longer eligible for Medicaid and
is in his/her Guaranteed Eligibility period.

 
B)
The Contractor may not request Disenrollment because of an adverse change in the
Enrollee's health status, or because of the Enrollee's utilization of medical
services, diminished mental capacity, or uncooperative or disruptive behavior
resulting from the Enrollee's special needs (except where continued enrollment
in the Contractor's plan seriously impairs the Contractor's ability to furnish
services to either the Enrollee or other Enrollees).

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

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

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

 
v)
The Contractor will not consider an Enrollee disenrolled without confirmation
from the LDSS or the Roster (as described in Section 4 of this Appendix).

 
Medicaid Advantage Contract
APPENDIX H
State January 1, 2008
H-14 
 

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

 
 
APPENDIX K
 
Medicare and Medicaid Advantage Products
And Non-Covered Services

Medicaid Advantage Contract
APPENDIX K
State January 1, 2008
K-1 
 

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

 
 
 
APPENDIX K
 
Appendix K is organized into three parts:
 
I.          Appendix K-I
 
            Medicare Advantage Product
 
II.         Appendix K-2
 
            Medicaid Advantage Product
 
            Contractor/County Election of Coverage for Optional Services
Description of Medicaid Only Covered Services
 
III.       Appendix K-3
 
            Non-Covered Services

Medicaid Advantage Contract
APPENDIX K
State January 1, 2008
K-2
 

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

 
 

APPENDIX K1

MEDICARE ADVANTAGE PRODUCT
 
Medicare Advantage Benefit Package for Dual Eligibles
Category of Service
Included in Medicare Capitation
Inpatient Hospital Care Including Substance Abuse and Rehabilitation Services
Up to 365 days per year (366 days for leap year) with no deductible or
co-payment
Inpatient Mental Health
Medically necessary care with no deductible or co-payment. 190-day lifetime
limit in a psychiatric hospital.
Skilled Nursing Facility
Care provided in a skilled nursing facility. Covered for 100 days each benefit
period. No prior hospital stay required. No co-payment.
Home Health
Medically necessary intermittent skilled nursing care, home health aide services
and rehabilitation services. No co-payment.
PCP Office Visits
Primary care doctor office visits. No co-payment.
Specialist Office Visits
Specialist office visits.  Subject to $10 co-payment for each specialist office
visit.
Chiropractic
Manual manipulation of the spine to correct subluxation provided by
chiropractors or other qualified providers. Subject to $10 co-payment.
Podiatry
Medically necessary foot care, including care for medical conditions affecting
lower limbs, subject to $10 co-payment. Visits for routine foot care up to 4
visits per year, not subject to co-payment.
Outpatient Mental Health
Individual and group therapy visits, subject to co-payment of $20 per individual
or group visit. Enrollee must be able to self-refer for one assessment from a
network provider in a twelve (12) month period.
Outpatient Substance Abuse
Individual and group visits subject to $20 co-payment per group or individual
visit. Enrollee must be able to self-refer for one assessment from a network
provider in a twelve (12) month period.
Outpatient Surgery
Medically necessary visits to an ambulatory surgery center or outpatient
hospital facility. No co-payment.
Ambulance
Transportation provided by an ambulance service, including air ambulance.
Emergency transportation if for the purpose of obtaining hospital services for
an enrollee who suffers from severe, life-threatening or potentially disabling
conditions which require the provision of emergency services while the enrollee
is being transported.  Includes transportation to a hospital emergency room
generated by a "Dial 911". No co-payment.

Medicaid Advantage Contract
APPENDIX K
State January 1, 2008
K-3
 

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

 

Medicare Advantage Benefit Package for Dual Eligibles
Category of Service
Included in Medicare Capitation
Emergency Room
Care provided in an emergency room subject to prudent layperson standard. $50
co-payment per visit. Co-payment waived if admitted to the hospital within 24
hours for the same condition.
Urgent Care
Urgently needed care in most cases outside the plan's service area. Subject to
$10 co-payment.
Outpatient Rehabilitation (OT, PT, Speech)
Occupational therapy, physical therapy and speech and language therapy subject
to $10 co-payment.
Durable Medical Equipment (DME)
Medicare and Medicaid covered durable medical equipment, including devices and
equipment other than medical/surgical supplies, enteral formula, and prosthetic
or orthotic appliances having the following characteristics: can withstand
repeated use for a protracted period of time; are primarily and customarily used
for medical purposes; are generally not useful to a person in the absence of
illness or injury and are usually not fitted, designed or fashioned for a
particular individual's use. Must be ordered by a qualified practitioner. No
homebound prerequisite and including non-Medicare DME covered by Medicaid (e.g.,
tub stool; grab bar). No co-payment or coinsurance.
Prosthetics
Medicare and Medicaid covered prosthetics, orthotics and orthopedic footwear. No
diabetic prerequisite for orthotics. Not subject to co-payment or coinsurance.
Diabetes Monitoring
Diabetes self-monitoring and management training and supplies including coverage
for glucose monitors, test strips, and lancets. None of which are subject to
co-payments. OTC diabetic supplies such as 2x2 gauze pads, alcohol swabs/pads,
insulin syringes and needles are covered by Part D.
Diagnostic Testing
Diagnostic tests, x-rays, lab services and radiation therapy. No co-payments.
Bone Mass Measurement
Bone Mass Measurement for people at risk. No co-payment
Colorectal Screening
Colorectal screening for people, age 50 and older. No co payment.
Immunizations
Flu, hepatitis B vaccine for people who are at risk, Pneumonia vaccine. No
co-payment.
Mammograms
Annual screening for women age 40 and older. No referral necessary. No
co-payment.
Pap Smear and Pelvic Exams
Pap smears and Pelvic Exams for women. No co-payment.
Prostate Cancer Screening
Prostrate Cancer Screening exams for men age 50 and older. No co-payment.

Medicaid Advantage Contract
APPENDIX K
State January 1, 2008
K-4 
 

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

 

Medicare Advantage Benefit Package for Dual Eligibles
Category of Service
Included in Medicare Capitation
Outpatient Drugs
Medicare Part B covered prescription drugs and other drugs obtained by a
provider and administered in a physician office or clinic setting that are
covered by Medicaid. (No Part D).
Hearing Services
Medicare and Medicaid hearing services and products when medically necessary to
alleviate disability caused by the loss or impairment of hearing. Services
include hearing aid selecting, fitting, and dispensing; hearing aid checks
following dispensing, conformity evaluations and hearing aid repairs; audiology
services including examinations and testing, hearing aid evaluations and hearing
aid prescriptions; and hearing aid products including hearing aids, earmolds,
special fittings and replacement parts. No co-payment or limitations.
Vision Care Services
Services of optometrists, ophthalmologists and ophthalmic dispensers including
eyeglasses, medically necessary contact lenses and poly-carbonate lenses,
artificial eyes (stock or custom-made), low vision aids and low vision services.
Coverage includes the replacement of lost or destroyed glasses and the repair or
replacement of parts. Coverage also includes examinations for diagnosis and
treatment for visual defects and/or eye disease. Examinations for refraction are
limited to every two (2) years unless otherwise justified as medically
necessary. Eyeglasses do not require changing more frequently than every two (2)
years unless medically necessary or unless the glasses are lost, damaged or
destroyed. No prerequisite of cataract services. No co-payment.
Routine Physical Exam 1/year
Up to one routine physical per year. No co-payment.
Health/Wellness Education
Coverage for the following: general health education classes, parenting classes,
smoking cessation classes, childbirth, education and nutrition counseling, plus
additional benefits at plan option including but not limited to items such as
newsletters, nutritional training, congestive heart program, health club
membership/fitness classes,  nursing hotline, disease management, other wellness
services. No co-payments.
Additional Part C Benefits, if any
 
Medicare Part D Prescription Drug Benefit as Approved by CMS
 

Medicaid Advantage Contract
APPENDIX K
State January 1, 2008
K-5 
 

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

 
 
APPENDIX K2
 
MEDICAID ADVANTAGE PRODUCT
 
Medicaid Advantage Benefit Package for Dual Eligibles
Category of Service
Included in Medicaid Capitation
Inpatient Mental Health
Days in excess of the Medicare 190-day lifetime maximum.
Home Health
Non-Medicare covered home health services (e.g. home health aide services with
nursing supervision to medically unstable individuals).
Specialist Office Visits
Elimination of $10 co-payment.
Podiatry
Elimination of $10 co-payment for medically necessary footcare.
Outpatient Mental Health
Elimination of $20 co-payment.
Outpatient Substance Abuse
Elimination of $20 co-payment.
Emergency Room
Elimination of $50 co-payment
Urgent Care
Elimination of $10 co-payment.
Outpatient Rehabilitation (OT, PT, Speech)
Elimination of $10 co-payment.
Dental
(Optional benefit outside of NYC)
Medicaid covered dental services including necessary preventive, prophylactic
and other routine dental care, services and supplies and dental prosthetics to
alleviate a serious health condition. Ambulatory or inpatient surgical dental
services subject to prior authorization.
Transportation — Routine (Optional benefit outside of NYC)
Transportation essential for an enrollee to obtain necessary medical care and
services under the plan's benefits or Medicaid fee-for-service. Includes
ambulette, invalid coach, taxicab, livery, public transportation, or other means
appropriate to the enrollee's medical condition and a transportation attendant
to accompany the enrollee, if necessary.
Private Duty Nursing
Medically necessary private duty nursing services in accordance with the
ordering physician, registered physician assistant or certified nurse
practitioner's written treatment plan.

Medicaid Advantage Contract
APPENDIX K
State January 1, 2008
K-6 
 

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

 

MCO COVERAGE
OF OPTIONAL SERVICES
MEDICAID ADVANTAGE BENEFIT PACKAGE

MCO: WellCare of New York, Inc.

 
Service Area
Medicaid Advantage Coverage Status
Dental Services
Non-Emergency Transportation
Albany
Not Covered
Not Covered

Medicaid Advantage Contract
APPENDIX K
State January 1, 2008
K-7
 

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

 

DESCRIPTION OF MEDICAID ONLY SERVICES IN
MEDICAID ADVANTAGE BENEFIT PACKAGE:
 
Inpatient Mental Health Over 190-Day Lifetime Limit
 
All inpatient mental health services, including voluntary or involuntary
admissions for mental health services over the Medicare 190-Day Lifetime Limit.
The Contractor may provide the covered benefit for medically necessary mental
health impatient services through hospitals licensed pursuant to Article 28 of
the New York State P.H.L.
 
Non-Medicare Covered Home Health Services
 
Medicaid covered home health services include the provision of skilled services
not covered by Medicare (e.g. physical therapist to supervise maintenance
program for patients who have reached their maximum restorative potential or
nurse to pre-fill syringes for disabled individuals with diabetes) and /or home
health aide services as required by an approved plan of care developed by a
certified home health agency.
 
Private Duty Nursing Services
 
Private duty nursing services provided by a person possessing a license and
current registration from the NYS Education Department to practice as a
registered professional nurse or licensed practical nurse. Private duty nursing
services can be provided through an approved certified home health agency, a
licensed home care agency, or a private Practitioner.
 
Private duty nursing services are covered when determined by the attending
physician to be medically necessary. Nursing services may be intermittent,
part-time or continuous and must be provided in an Enrollee's home in accordance
with the ordering physician, registered physician assistant or certified nurse
practitioner's written treatment plan.
 
Dental Services (optional benefit outside of NYC)
 
Dental services include, but shall not be limited to, preventive, prophylactic
and other routine dental care, services, supplies and dental prosthetics
required to alleviate a serious health condition, including one which affects
employability.
 
Dental surgery performed in an ambulatory or inpatient setting is the
responsibility of the Contractor whether dental services are a covered plan
benefit, or not. Inpatient claims and referred ambulatory claims for dental
services ancillary to dental surgery provided in an inpatient or outpatient
hospital setting are the responsibility of the Contractor. In these situations,
the professional services of the dentist are covered by Medicaid
fee-for-service. The Contractor should set up procedures to prior approve dental
services provided in inpatient and ambulatory settings.

Medicaid Advantage Contract
APPENDIX K
State January 1, 2008
K-8 
 

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

 

As described in Sections 10.9 and 10.18 of this Agreement, Enrollees may
self-refer to Article 28 clinics operated by academic dental centers to obtain
covered dental services.
 
If Contractor's Benefit Package excludes dental services:
 
i)
Enrollees may obtain routine exams, orthodontic services and appliances, dental
office surgery, fillings, prophylaxis, and other Medicaid covered dental
services from any qualified Medicaid provider who shall claim reimbursement from
eMedNY; and

ii)
Inpatient and referred ambulatory claims for medical services provided in an
inpatient or outpatient hospital setting in conjunction with a dental procedure
(e.g. anesthesiology, x-rays), are the responsibility of the Contractor. In
these situations, the professional services of the dentist are covered Medicaid
fee-for-service.

 
Non-Emergency Transportation (optional benefit outside of NYC)
 
Transportation expenses are covered when transportation is essential in order
for an Enrollee to obtain necessary medical care and services which are covered
under the Medicaid program (either as part of the Contractor's Benefit Package
or by fee-for-service Medicaid). Non-emergent transportation guidelines may be
developed in conjunction with the LDSS, based on the LDSS' approved
transportation plan.
 
Transportation services means transportation by ambulance, ambulette, fixed wing
or airplane transport, invalid coach, taxicab, livery, public transportation, or
other means appropriate to the Enrollee's medical condition; and a
transportation attendant to accompany the Enrollee, if necessary. Such services
may include the transportation attendant's transportation, meals, lodging and
salary; however, no salary will be paid to a transportation attendant who is a
member of the Enrollee's family.
 
When the Contractor is capitated for non-emergency transportation, the
Contractor is also responsible for providing transportation for an Enrollee to
obtain Medicaid covered services that are not part of the Contractor's Benefit
Package.
 
For Contractors that cover non-emergency transportation in the Medicaid
Advantage Benefit Package, transportation costs to MMTP services may be
reimbursed by Medicaid FFS in accordance with the LDSS transportation policies
in local districts in which there is a systematic method to discretely identify
and reimburse such transportation costs.
 
For Enrollees with disabilities, the method of transportation must reasonably
accommodate their needs, taking into account the severity and nature of the
disability.

Medicaid Advantage Contract
APPENDIX K
State January 1, 2008
K-9
 

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

 
 
APPENDIX K3
 
NON COVERED SERVICES
 
The following services will not be the responsibility of the MCO under the
Medicare/Medicaid program:
 
Services Covered by Direct Reimbursement from Original Medicare
 
·
Hospice services provided to Medicare Advantage members

 
·
Other services deemed to be covered by Original Medicare by CMS

 
 
Services Covered by Medicaid Fee for Service

 
·
Out of network Family Planning services provided under the direct access
provisions of the waiver

 
·
Skilled Nursing Facility (SNF) days not covered by Medicare

 
·
Personal Care Services

 
·
Medicaid Pharmacy Benefits allowed by State Law (select drug categories excluded
from the Medicare Part D benefit and certain medications included in the Part D
benefit when the Enrollee is unable to receive them from his/her Medicare
Advantage Plan), also certain Medical Supplies and Enteral Formula when not
covered by Medicare.

 
·
Methadone Maintenance Treatment Programs

 
·
Certain Mental Health Services, including:

 
·
Intensive Psychiatric Rehabilitation Treatment Programs

 
·
Day Treatment

 
·
Continuing Day Treatment

 
·
Case Management for Seriously and Persistently Mentally Ill (sponsored by state
or local mental health units)

 
·
Partial Hospitalizations

 
·
Assertive Community Treatment (ACT)

 
·
Personalized Recovery Oriented Services (PROS)

 
·
Rehabilitation Services Provided to Residents of OMH Licensed Community
Residences (CRs) and Family Based Treatment Programs

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

 
·
Comprehensive Medicaid Case Management

 
·
Directly Observed Therapy for Tuberculosis Disease

 
·
AIDS Adult Day Health Care

 
·
HIV COBRA Case Management

 
·
Adult Day Health Care

 
·
Personal Emergency Response Services (PERS)

Medicaid Advantage Contract
APPENDIX K
State January 1, 2008
K-10 
 

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

 

Medicaid Advantage Program Optional Benefits
 
 
Optional benefits will be covered Medicaid fee for service if the MCO elects not
to cover these services in their Medicaid Advantage Product. Currently the only
two (2) optional benefits are:

▪ Non-Emergency Transportation Services
▪ Dental Service
 
Both of these services, however, are mandatory in NYC.

Medicaid Advantage Contract
APPENDIX K
State January 1, 2008
K-11
 

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

 
 
DESCRIPTION OF NON-COVERED SERVICES
 
The following services are excluded from the Contractor's Medicare and Medicaid
Benefit Packages, and are covered, in most instances, by Medicare or Medicaid
fee-for-service:
 
1.            Hospice Services Provided to Medicaid Advantage Enrollees
 
Hospice services provided to Medicare Advantage Enrollees by Medicare approved
hospice providers are directly reimbursed by Medicare. Hospice is a coordinated
program of home and inpatient care that provides non-curative medical and
support services for persons certified by a physician to be terminally ill with
a life expectancy of six (6) months or less. Hospice programs provide patients
and families with palliative and supportive care to meet the special needs
arising out of physical, psychological, spiritual, social and economic stresses
which are experienced during the final stages of illness and during dying and
bereavement.
 
Hospices are organizations which must be certified under Article 40 of the NYS
P.H.L. and approved by Medicare. All services must be provided by qualified
employees and volunteers of the hospice or by qualified staff through
contractual arrangements to the extent permitted by federal and state
requirements. All services must be provided according to a written plan of care
which reflects the changing needs of the patient/family.
 
If an Enrollee in the Contractor's plan becomes terminally ill and receives
Hospice Program services, he or she may remain enrolled and continue to access
the Contractor's Benefit Package while Hospice costs are paid for by Medicare
fee-for-service.
 
2.            Other Services Deemed to be Covered by Original Medicare by CMS
 
3.            Personal Care Agency Services
 
Personal care services (PCS) involve the provision of some or total assistance
with personal hygiene, dressing and feeding and nutritional and environmental
support (meal preparation and housekeeping). Such services must be essential to
the maintenance of the Enrollee's health and safety in his or her own home. The
services must be ordered by a physician, and there has to be a medical need for
the services. Licensed home care services agencies, as opposed to certified home
health agencies, are the primary providers of PCS. Enrollees receiving PCS must
have a stable medical condition and are generally expected to be in receipt of
such services for an extended period of time (years).
 
Services rendered by a personal care agency which are approved by the LDSS are
not covered under the Medicare or Medicaid Benefit Packages. Should it be
medically necessary for the PCP to order personal care agency services, the PCP
(or the Contractor on the physician's behalf) must first contact the Enrollee's
LDSS contact person for personal care. The district will determine the
Enrollee's need for personal care agency services and coordinate a plan of care
with the personal care agency.

Medicaid Advantage Contract
APPENDIX K
State January 1, 2008
K-12 
 

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

 
 
4.
Skilled Nursing Facility Days Not Covered by Medicare

 
Skilled nursing facility days for Medicaid Advantage Enrollees in excess of the
first one hundred (100) days in the benefit period are covered by Medicaid on a
fee for service basis.
 
5.
Prescription Drugs Permitted by State Law, Certain Medical Supplies and Enteral
Formulas Not Covered by Medicare

 
NYS Medicaid continues to provide coverage for categories of drugs excluded from
the Medicare Part D benefit such as barbiturates, benzodiazepines, and some
prescription vitamins, and some non-prescription drugs. NYS also provides a wrap
around program which covers medications that are included in the Part D benefit
when the recipient is unable to receive them from his or her Part D plan.
Effective January 1, 2007, drugs which are covered through this Medicaid
wrap-around benefit will be limited to the following four categories of drugs:
1) atypical antipsychotics, 2) antidepressants, 3) antiretrovirals used in the
treatment of HIV/AIDS, and 4) anti-rejection drugs used in the treatment of
tissue and organ transplants, but only when 1) these drugs are not covered by
the specific plan, 2) the patient does not meet the plan's utilization
management requirements, or 3) there are quantity limits inconsistent with the
prescribed amount. Certain medical/surgical supplies and enteral formula covered
by Medicaid and not included in the Contractor's Medicare Advantage Benefit
Package also will be paid for by Medicaid fee-for-service. Medical/surgical
supplies are items other than drugs, prosthetic or orthotic appliances, or DME,
which have been ordered by a qualified practitioner in the treatment of a
specific medical condition and which are: consumable, non-reusable, disposable,
or for a specific rather than incidental purpose, and generally have no
salvageable value (e.g. gauze pads, bandages and diapers). Pharmaceuticals and
medical supplies routinely furnished or administered as part of a clinic or
office visit are covered by the Contractor.
 
6.
Out of Network Family Planning Services

 
As described in Sections 10.6 and 10.9 of this Agreement, out of network family
planning services provided by qualified Medicaid providers to plan enrollees
will be directly reimbursed by Medicaid fee-for-service at the Medicaid fee
schedule. "Family Planning and Reproductive Health Services" means those health
services which enable Enrollees, including minors who may be sexually active, to
prevent or reduce the incidence of unwanted pregnancy. These include: diagnosis
and all medically necessary treatment, sterilization, screening and treatment
for sexually transmissible diseases and screening for disease and pregnancy.
 
Also included are HIV counseling and testing when provided as part of a family
planning visit. Additionally, reproductive health care includes coverage of all
medically necessary abortions. Elective induced abortions must be covered for
New York City recipients. Fertility services are not covered.
 
7.
Dental (when not in benefit package)

 
(See description in Appendix K-2)
 
8.            Non-Emergency Transportation (when not in benefit package)

Medicaid Advantage Contract
APPENDIX K
State January 1, 2008
K-13
 

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

 

(See description in Appendix K-2)
 
9.            Methadone Maintenance Treatment Program (MMTP)
 
MMTP consists of drug detoxification, drug dependence counseling, and
rehabilitation services which include chemical management of the patient with
methadone. Facilities authorized to provide methadone maintenance treatment
certified by the Office of Alcohol and Substance Abuse Services (OASAS) under
Part 828 of 14 NYCRR.
 
10.          Certain Mental Health Services
 
The Contractor is not responsible for the provision and payment of the following
services, which are reimbursed through Medicaid fee-for-service.
 
a.
Intensive Psychiatric Rehabilitation Treatment Programs (IPRT)

 
IPRT is a time-limited active psychiatric rehabilitation designed to assist a
patient in forming and achieving mutually agreed upon goals in living, learning,
working and social environments and to intervene with psychiatric rehabilitative
technologies to overcome functional disabilities. IPRT services are certified by
OMH under Part 587 of 14 NYCRR.
 
b.           Day Treatment
 
Day Treatment is a combination of diagnostic, treatment, and rehabilitative
procedures which, through supervised and planned activities and extensive
client-staff interaction, provides the services of the clinic treatment program,
as well as social training, task and skill training and socialization
activities. These services are certified by OMH under Part 587 of 14 NYCRR.
 
c.           Continuing Day Treatment
 
Continuing Day Treatment is designed to maintain or enhance current levels of
functioning and skills, maintain community living, and develop self-awareness
and self-esteem. It includes: assessment and treatment planning, discharge
planning, medication therapy, medication education, case management, health
screening and referral, rehabilitative readiness development, psychiatric
rehabilitative readiness determination and referral, and symptom management.
These services are certified by OMH under Part 587 of 14 NYCRR.
 
d.
Case Management for Seriously and Persistently Mentally Ill Sponsored by State
or Local Mental Health Units

 
The target population consists of individuals who are seriously and persistently
mentally ill (SPMI), require intensive, personal and proactive intervention to
help them obtain those services which will permit functioning in the community
and either have symptomology which is difficult to treat in the existing mental
health care system or are unwilling or unable to adapt to the existing mental
health care system. Three case management models are currently operated pursuant
to an agreement with OMH or a local governmental unit, and receive Medicaid
reimbursement pursuant to Part 506 of 14 NYCRR.

Medicaid Advantage Contract
APPENDIX K
State January 1, 2008
K-14 
 

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

 

Please note: See generic definition of Comprehensive Medicaid Case Management
(CMCM) in this section.
 
e.           Partial Hospitalization Not Covered by Medicare
 
Provides active treatment designed to stabilize and ameliorate acute systems,
serves as an alternative to inpatient hospitalization, or reduces the length of
a hospital stay within a medically supervised program by providing the
following: assessment and treatment planning; health screening and referral;
symptom management; medication therapy; medication education; verbal therapy;
case management; psychiatric rehabilitative readiness determination and referral
and crisis intervention. These services are certified by OMH under Part 587 of
14 NYCRR.
 
f.            Assertive Community Treatment (ACT)
 
ACT is a mobile team-based approach to delivering comprehensive and flexible
treatment, rehabilitation, case management and support services to individuals
in their natural living setting. ACT programs deliver integrated services to
recipients and adjust services over time to meet the recipient's goals and
changing needs. They are operated pursuant to approval or certification by OMH;
and receive Medicaid reimbursement pursuant to Part 508 of 14 NYCRR.
 
g.           Personalized Recovery Oriented Services (PROS)
 
PROS, licensed and reimbursed pursuant to Part 512 of 14 NYCRR, are designed to
assist individuals in recovery from the disabling effects of mental illness
through the coordinated delivery of a customized array of rehabilitation,
treatment, and support services in traditional settings and in off-site
locations. Specific components of PROS include Community Rehabilitation and
Support, Intensive Rehabilitation, Ongoing Rehabilitation and Support and
Clinical Treatment.
 
11.         Rehabilitation Services Provided to Residents of OMH Licensed
Community Residences (CRs) and Family Based Treatment Programs, as follows:

 
a.           OMH Licensed CRs*
 
Rehabilitative services in community residences are interventions, therapies and
activities which are medically therapeutic and remedial in nature, and are
medically necessary for the maximum reduction of functional and adaptive
behavior defects associated with a person's mental illness.
 
b.           Family-Based Treatment*
 
Rehabilitative services in family-based treatment programs are intended to
provide treatment to seriously emotionally disturbed children and youth to
promote their successful functioning and integration into the family, community,
school or independent living situations. Such services are provided in
consideration of a child's developmental stage. Children determined eligible for
admission are placed in surrogate family homes for care and treatment. These
services are certified by OMH under Section 586.3, and Parts 594 and 595 of 14
NYCRR .

Medicaid Advantage Contract
APPENDIX K
State January 1, 2008
K-15
 

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

 

12.         Office of Mental Retardation and Developmental Disabilities (OM D)
Services
 
a.
Long Term Therapy Services Provided by Article 16-Clinic Treatment Facilities or
Article 28 Facilities

 
These services are provided to persons with developmental disabilities including
medical or remedial services recommended by a physician or other licensed
practitioner of the healing arts for a maximum reduction of the effects of
physical or mental disability and restoration of the person to his or her best
possible functional level. It also includes the fitting, training, and
modification of assistive devices by licensed practitioners or trained others
under their direct supervision. Such services are designed to ameliorate or
limit the disabling condition and to allow the person to remain in or move to,
the least restrictive residential and/or day setting. These services are
certified by OMRDD under Part 679 of 14 NYCRR (or they are provided by Article
28 Diagnostic and Treatment Centers that are explicitly designated by the SDOH
as serving primarily persons with developmental disabilities). If care of this
nature is provided in facilities other than Article 28 or Article 16 centers, it
is a covered service.
 
b.
Day Treatment

 
A planned combination of diagnostic, treatment and rehabilitation services
provided to developmentally disabled individuals in need of a broad range of
services, but who do not need intensive twenty-four (24) hour care and medical
supervision. The services provided as identified in the comprehensive assessment
may include nutrition, recreation, self-care, independent living, therapies,
nursing, and transportation services. These services are generally provided in
an Intermediate Care Facility (ICF) or a comparable setting. These services are
certified by OMRDD under Part 690 of 14 NYCRR.
 
c.           Medicaid Service Coordination (MSC)
 
Medicaid Service Coordination (MSC) is a Medicaid State Plan service provided by
OMRDD which assists persons with developmental disabilities and mental
retardation to gain access to necessary services and supports appropriate to the
needs of the needs of the individual. MSC is provided by qualified service
coordinators and uses a person centered planning process in developing,
implementing and maintaining an Individualized Service Plan (ISP) with and for a
person with developmental disabilities and mental retardation. MSC promotes the
concepts of a choice, individualized services and consumer satisfaction.
 
MSC is provided by authorized vendors who have a contract with OMRDD, and who
are paid monthly pursuant to such contract. Persons who receive MSC must
not permanently reside in an ICF for persons with developmental disabilities, a
developmental center, a skilled nursing facility or any other hospital or
Medical Assistance institutional setting that provides service coordination.
They must also not concurrently be enrolled in any other comprehensive Medicaid
long term service coordination program/service, including the Care at Home
Waiver.

Medicaid Advantage Contract
APPENDIX K
State January 1, 2008
K-16 
 

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

 

Please note: See generic definition of Comprehensive Medicaid Case Management
(CMCM) in this section.
 
d.           Home And Community Based Services Waivers (HCBS)
 
The Home and Community-Based Services Waiver serves persons with developmental
disabilities who would otherwise be admitted to an ICF/MR if waiver services
were not provided. HCBS waivers services include residential habilitation, day
habilitation, prevocational, supported work, respite, adaptive devices,
consolidated supports and services, environmental modifications, family
education and training, live-in caregiver, and plan of care support services.
These services are authorized pursuant to a waiver under Section 1915(c) of the
Social Security Act (SSA).
 
e.           Services Provided Through the Care At Home Program (OMRDD)
 
The OMRDD Care at Home III, Care at Home IV, and Care at Home VI waivers, serve
children who would otherwise not be eligible for Medicaid because of their
parents' income and resources, and who would otherwise be eligible for an ICF/MR
level of care. Care at Home waiver services include service coordination,
respite and assistive technologies. Care at Home waiver services are authorized
pursuant to a waiver under Section 1915(c) of the (SSA).
 
13.         Comprehensive Medicaid Case Management (CMCM)
 
A program which provides "social work" case management referral services to a
targeted population (e.g.: teens, mentally ill). A CMCM case manager will assist
a client in accessing necessary services in accordance with goals contained in a
written case management plan. CMCM programs do not provide services directly,
but refer to a wide range of service providers. The nature of these services
include: medical, social, psycho-social, education, employment, financial, and
mental health. CMCM referral to community service agencies and/or medical
providers requires the case manager to work out a mutually agreeable case
coordination approach with the agency/medical providers. Consequently, if an
Enrollee of the Contractor is participating in a CMCM program, the Contractor
should work collaboratively with the CMCM case manager to coordinate the
provision of services covered by the Contractor. CMCM programs will be
instructed on how to identify a managed care Enrollee on eMedNY so that the
program can contact the Contractor or to coordinate service provision.
 
14.         Directly Observed Therapy for Tuberculosis Disease
 
Tuberculosis directly observed therapy (TB/DOT) is the direct observation of
oral ingestion of TB medications to assure patient compliance with the
physician's prescribed medication regimen. While the clinical management of
tuberculosis is covered in the Benefit Package, TB/DOT where applicable, can be
billed directly to MMIS by any SDOH approved fee-for­service Medicaid TB/DOT
Provider. The Contractor remains responsible for communicating, cooperating and
coordinating clinical management of TB with the TB/DOT Provider.

Medicaid Advantage Contract
APPENDIX K
State January 1, 2008
K-17
 

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

 
 
15.         AIDS Adult Day Health Care
 
Adult Day Health Care Programs (ADHCP) are programs designed to assist
individuals with HIV disease to live more independently in the community or
eliminate the need for residential health care services. Registrants in ADHCP
require a greater range of comprehensive health care services than can be
provided in any single setting, but do not require the level of services
provided in a residential health care setting. Regulations require that a person
enrolled in an ADHCP must require at least three (3) hours of health care
delivered on the basis of at least one (1) visit per week. While health care
services are broadly defined in this setting to include general medical care,
nursing care, medication management, nutritional services, rehabilitative
services, and substance abuse and mental health services, the latter two (2)
cannot be the sole reason for admission to the program. Admission criteria must
include, at a minimum, the need for general medical care and nursing services.
 
16.         HIV COB Case Management
 
The HIV COBRA (Community Follow-up Program) Case Management Prograrn is a
program that provides intensive, family-centered case management and community
follow-up activities by case managers, case management technicians, and
community follow-up workers. Reimbursement is through an hourly rate billable to
Medicaid. Reimbursable activities include intake, assessment, reassessment,
service plan development and implementation, monitoring, advocacy, crisis
intervention, exit planning, and case specific supervisory case-review
conferencing.
 
17.         Adult Day Health Care
 
Adult Day Health Care means care and services provided to a registrant in a
residential health care facility or approved extension site under the medical
direction of a physician and which is provided by personnel of the adult day
health care program in accordance with a comprehensive assessment of care needs
and an individualized health care plan, and providing ongoing implementation and
coordination of the health care plan, and transportation.
 
Registrant means a person who is a nonresident of the residential health care
facility, who is functionally impaired and not homebound, and who requires
certain preventive, diagnostic, therapeutic, rehabilitative or palliative items
or services provided by a general hospital, or residential health care facility;
and whose assessed social and health care needs, in the professional judgment of
the physician of record, nursing staff, Social Services and other professional
personnel of the adult day health care program can be met satisfactorily in
whole or in part by delivery of appropriate services in such program.
 
18.         Personal Emergency Response Services (PERS)
 
Personal Emergency Response Services (PERS) are not covered by the Benefit
Package. PERS are covered on a fee-for-service basis through contracts between
the LDSS and PERS vendors.

Medicaid Advantage Contract
APPENDIX K
State January 1, 2008
K-18 
 

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APPENDIX L
 
Approved Capitation Payment Rates

Medicaid Advantage Contract
APPENDIX L
State January 1, 2008
L1
 

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WELLCARE OF NEW YORK, INC.
Dual Eligible Medicaid Managed Care Rates

MMIS ID#:
02645710
Effective Date: 01/01/08
Region:
Upstate
 
County:
Albany
 

 
 
Rate Code
Premium Group
Rate Amount
2370
DUALLY ELIGIBLE SSI 21-64 MALE/FEMALE
$35.37
2371
DUALLY ELIGIBLE SSI 65+ MALE/FEMALE
$33.54

 
Optional Benefits Offered:-
o
Dental

o
Non-Emergent Transportation

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