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Back to Form 8-K
 
Exhibit 10.2
 
MEDICAID ADVANTAGE PLUS (MAP) MODEL CONTRACT MISCELLANEOUS/CONSULTANT SERVICES

(Non-Competitive Award)

STATE AGENCY (Name and Address):
 
NYS Comptroller's Number: C021887
New York State Department of Health Office of Managed Care
Empire State Plaza
Corning Tower, Room 2074
Albany, NY 12237
 
Originating Agency Code: 12000
CONTRACTOR (Name and Address):
 
TYPE OF PROGRAM:
WellCare of New York, Inc.
11 West 19th Street
New York, New York 10011
 
Medicaid Advantage Plus
CHARITIES REGISTRATION NUMBER:
 
CONTRACT TERM:
N/A
 
FROM: July 1,2007
FEDERAL TAX IDENTIFICATION NUMBER:
 
TO: December 31, 2009
141676443
 
 
MUNICIPALITY NUMBER (if applicable):
FUNDING AMOUNT FOR CONTRACT TERM: Based on approved capitation rates
N/A
 
 
STATUS:
 
THIS CONTRACT IS RENEWABLE FOR TWO ADDITIONAL ONE YEAR PERIODS SUBJECT TO THE
APPROVAL OF THE NYS DEPARTMENT OF HEALTH, THE DEPARTMENT OF HEALTH AND HUMAN
SERVICES AND THE OFFICE OF THE STATE COMPTROLLER.
CONTRACTOR IS [ ] IS NOT [X] A SECTARIAN ENTITY
 
CONTRACTOR IS [ ]   IS NOT [X] A NOT-FOR-PROFIT ORGANIZATION
 
CONTRACTOR IS [X]   IS NOT [ ] ANY STATE BUSINESS ENTERPRISE
   

Medicaid Advantage Plus Contract
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IN WITNESS THEREOF, the parties hereto have executed or approved this AGREEMENT
as of the dates appearing under their signatures.

CONTRACTOR SIGNATURE
STATE AGENCY SIGNATURE
By:    /s/  Todd S. Farha   
   /s/   Kathleen Shure
Title: President & CEO
Title: Director, Division of Managed Care and Program Evaluation, Office of
Health Insurance Programs
Date: 5/31/2007
Date: 6/27/07
 
State Agency Certification:
In addition to the acceptance of this contract, I also certify that original
copies of this signature page will be attached to all other exact copies of this
contract.

STATE OF FLORIDA

County of Hillsborough
 
On the 31 Day of May, 2007, before me personally appeared Todd S. Fahra to me
known, who being by me duly sworn, did depose and say that he/she resides at
Tampa, Florida that he is the President & CEO of WellCare of New York, Inc. the
corporation described herein which executed the foregoing instrument; and that
he/she signed his/her name thereto by order of the board of directors of said
corporations.

Notary

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2007

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Table of Contents for Medicaid Advantage Plus Model Contract

Recitals

Section 1  Definitions
Section 2. Agreement Term, Amendments, Extensions, and General Contract
Administration Provisions 
2.1 Term
2.2 Amendments

2.3 Approvals
2.4 Entire Agreement
2.5 Renegotiation
2.6 Assignment and Subcontracting
2.7 Termination
a.SDOH Initiated Termination
b.Contractor and SDOH Initiated Termination
c.Contractor Initiated Termination

d.Termination Due to Loss of Funding
2.8 Enrollee Transition Plan

2.9 Agreement Close-Out Procedures
2.10 Rights and Remedies
2.11 Notices
2.12 Severability

Section 3. Compensation
3.1 Capitation Payments
3.2 Modification of Rates During Contract Period
3.3 Rate Setting Methodology
3.4 Payment of Capitation
3.5 Denial of Capitation Payments

3.6 SDOH Right to Recover Premiums
3.7 Third Party Health Insurance Determination
3.8 Contractor Financial Liability
3.9  Spenddown and Net Available Monthly Income (NAMI)

Section 4. Service Area

Section 5. Eligibility For Enrollment in Medicaid Advantage Plus
5.1  Eligibility to Enroll in Medicaid Advantage Plus
5.2  Not Eligible to Enroll in the Medicaid Advantage Plus Program
5.3  Change in Eligibility Status

Section 6. Enrollment
6.1 Enrollment Requirements
6.2  Equality of Access to Enrollment

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6.3 Enrollment Decisions
6.4 Prohibition Against Conditions on Enrollment
6.5 Effective Date of Enrollment
6.6 Contractor Liability
6.7 Roster
6.8 Automatic Re-Enrollment

6.9 Failure to Enroll in Contractor's Medicare Advantage Product
6.10 Spenddown and Net Available Monthly Income (NAMI)
6.11 Enrollment Limits

Section 7. RESERVED

Section 8. Disenrollment
8.1 Disenrollment Requirements
8.2  Disenrollment Prohibitions
8.3  Disenrollment Requests
8.4  Disenrollment Notifications
8.5 Contractor's Liability
8.6 Contractor Referrals to Alternative Services

8.7 Enrollee Initiated Disenrollment
8.8 Contractor Initiated Disenrollment
8.9 LDSS Initiated Disenrollment

Section 9. RESERVED

Section 10. Benefit Package, Covered and Non-Covered Services
10.1 Contractor Responsibilities
10.2 SDOH Responsibilities

10.3 Benefit Package and Non-Covered Services Descriptions
10.4 Adult Protective Services
10.5 Court-Ordered Services
10.6 Family Planning and Reproductive Health Services
10.7 Emergency and Post Stabilization Care Services
10.8 Medicaid Utilization Thresholds (MUTS)
10.9 Services for Which Enrollees Can Self-Refer
10.10 Prevention and Treatment of Sexually Transmitted Diseases
10.11 Enrollee Needs Relating to HIV

10.12 Persons Requiring Chemical Dependence Services
10.13 Care Management
10.14 Urgently Needed Services

10.15 Coordination of Services

Section 11. Marketing
11.1 Marketing Requirements

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Section 12. Member Services
12.1 General Functions
12.2 Translation and Oral Interpretation

12.3 Communicating with the Visually, Hearing and Cognitively Impaired

Section 13. Enrollee Notification
13.1 General Requirements
13.2 Enrollment Agreement/Attestation
13.3 Member ID Cards
13.4 Enrollee Rights

Section 14. Organization Determinations, Actions, and Grievance System
14.1 General Requirements
14.2  Filing and Modification of Medicaid Advantage Plus Action Appeals and/or
Grievance Procedures
14.3 Medicaid Advantage Plus Action and Grievance System Additional Provisions 
14.4 Complaint Investigation Determinations

Section 15. Access Requirements

Section 16. Quality Management and Performance Improvement
16.1 Quality Management and Performance Improvement Program
16.2 Chronic Care Improvement Programs
16.3 Reporting
16.4 Quality Indicators and Standards
16.5 External Quality Review

Section 17. Monitoring and Evaluation
17.1 Right to Monitor Contractor Performance
17.2  Cooperation During Monitoring and Evaluation
17.3 Cooperation During On-Site Reviews

Section 18. Contractor Reporting Requirements
18.1 General Requirements

18.2 Time Frames for Report Submissions
18.3  SDOH Instructions for Report Submissions

18.4  Notification of Changes in Report Due Dates, Requirements or Formats
18.5 Reporting Requirements
18.6 Ownership and Related Information Disclosure
18.7  Data Certification
18.8 Public Access to Reports
18.9 Certification Regarding Individuals Who Have Been Debarred or Suspended by
Federal, State or Local Government
18.10 Conflict of Interest Disclosure
18.11 Physician Incentive Plan Reporting

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Section 19Records Maintenance and Audit Rights
19.1 Maintenance of Contractor Performance Records
19.2 Maintenance of Financial Records and Statistical Data
19.3  Access to Contractor Records
19.4  Retention Periods

Section 20.   Confidentiality
20.1  Confidentiality of Identifying Information about Enrollees, Potential
Enrollees and Applicants
20.2  Confidentiality of Medical Records
20.3   Length of Confidentiality Requirements

Section 21. Participating Providers

21.1 General Requirements
21.2  Medicaid Advantage Plus Network Requirements
21.3 Professional Discipline
21.4 SDOH Exclusion or Termination of Providers
21.5  Payment in Full
21.6  Dental Networks
 
Section 22. Subcontracts and Provider Agreements for Medicaid Advantage Plus
Covered Services
22.1 Written Subcontracts
22.2 Permissible Subcontracts
22.3 Provision of Services through Provider Agreements
22.4 Approvals
22.5 Required Components
22.6 Timely Payment

22.7  Recovery of Overpayments to Providers
22.8  Physician Incentive Plan
22.9  Provider Termination Notices

Section 23. Americans With Disabilities Act Compliance Plan

Section 24. Fair Hearings
24.1 Enrollee Access to Fair Hearing Process
24.2 Enrollee Rights to a Fair Hearing
24.3 Contractor Notice to Enrollees
24.4  Aid Continuing

24.5  Contractor's Obligations

Section 25 External Appeal
25.1 Basis for External Appeal
25.2  Eligibility for External Appeal

25.3  External Appeal Determination
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25.4  Compliance with External Appeal Laws and Regulations
25.5 Member Handbook

 
Section 26.  Intermediate Sanctions
26.1  General
26.2  Unacceptable Practices
26.3  Intermediate Sanctions
26.4 Enrollment Limitations
26.5 Due Process

Section 27. Environmental Compliance
 
Section 28. Energy Conservation

Section 29. Independent Capacity of Contractor
 
Section 30. No Third Party Beneficiaries
 
Section 31. Indemnification
31.1 Indemnification by Contractor
31.2 Indemnification by SDOH

Section 32. Prohibition on Use of Federal Funds for Lobbying
32.1 Prohibition of Use of Federal Funds for Lobbying
32.2  Disclosure Form to Report Lobbying
32.3 Requirements of Subcontractors

Section 33. Non-Discrimination
33.1 Equal Access to Benefit Package
33.2 Non-Discrimination
33.3 Equal Employment Opportunity
33.4  Native Americans Access to Services From Tribal or Urban Indian Health
Facility
 
Section 34.  Compliance with Applicable Laws and Regulations

34.1  Contractor and SDOH Compliance with Applicable Laws
34.2  Nullification of Illegal, Unenforceable, Ineffective or Void Contract
Provisions
34.3  Certificate of Authority Requirements
34.4 Notification of Changes in Certificate of Incorporation
34.5 Contractor's Financial Solvency Requirements
34.6 Non-Liability of Enrollees for Contractor's Debts
34.7 SDOH Compliance with Conflict of Interest Laws
34.8 Compliance Plan

Section 35New York State Standard Contract Claus

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APPENDICES
A. New York State Standard Contract Clauses
B. Certification Regarding Lobbying
B-1. Certification Regarding MacBride Fair Employment Principles

C. New York State Department of Health Requirements for Provision of Free Access
to Family Planning and Reproductive Health Services

D. New York State Department of Health Medicaid Advantage Plus Marketing
Guidelines

E. New York State Department of Health Medicaid Advantage Plus Member Handbook
Guidelines

F. New York State Department of Health Medicaid Advantage Plus Action and
Grievance System Requirements

G. RESERVED

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

I. RESERVED

J. New York State Department of Health Guidelines for Contractor Compliance with
the Federal Americans with Disabilities Act

K. Medicare and Medicaid Advantage Plus Products and Non-Covered Services

L. Approved Capitation Payment Rates

M. Service Area
N. RESERVED
O. Requirements for Proof of Workers' Compensation and Disability Benefits
Coverage

P. RESERVED

Q. RESERVED

R. Additional Specifications for the Medicaid Advantage Plus Agreement
X. Modification Agreement Form
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This AGREEMENT is hereby made by and between the New York State Department of
Health (SDOH) and WellCare of New York. Inc. (Contractor) located at: 11 West
19th Street. New York. New York 10011.

RECITALS

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

WHEREAS, pursuant to Article 44 of the Public Health Law (PHL), the New York
State Department of Health (SDOH) is authorized to issue Certificates of
Authority to establish Health Maintenance Organizations (HMOs), PHL §4400 et
seq., and Managed Long Term Care Plans (MLTCPs), PHL §4403-f; and

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

WHEREAS, the Contractor is a corporation organized under the laws of New York
State and is certified under Article 44 of the State Public Health Law and

WHEREAS, the Contractor has applied to participate in the Managed Long Term Care
Program and the SDOH has determined that the Contractor meets the qualification
criteria established for participation; and

WHEREAS, the Contractor is an entity which has been determined to be an eligible
Medicare Advantage Organization by the Administrator of the Centers for Medicare
and Medicaid Services (CMS) under 42 CFR 422.503; and has entered into a
contract with CMS pursuant to §§1851 through 1859 of the Social Security Act to
operate a coordinated care plan, as described in its final Plan Benefit Package
(PBP) bid submission proposal approved by CMS, in compliance with 42 CFR 422 and
other applicable Federal statutes, regulations and policies; and

WHEREAS, the Contractor is an entity that has amended its contract with CMS to
include an agreement to offer qualified Medicare Part D coverage pursuant to
§§1860D-1 through 1860D-42 of the Social Security Act and K of 42 CFR 422 or is
a Specialized Medicare Advantage Plan for Special Needs Individuals which
includes qualified Medicare Part D prescription drug coverage; and

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WHEREAS, the Contractor offers a comprehensive health services plan and
represents that it is able to make provision for furnishing the Medicare Plan
Benefit Package (Medicare Part C benefit), the Medicare Voluntary Prescription
Drug Benefit (Medicare Part D) and the Medicaid Advantage Plus Product as
defined in this Agreement and has proposed to provide coverage of these Medicaid
Advantage Plus products to Eligible Persons as defined in this Agreement
residing in the geographic area specified in Appendix M.

NOW THEREFORE, the parties agree as follows:

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2007
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1. DEFINITIONS

"Applicant" is an individual who has expressed a desire to pursue enrollment in
a managed long-term care plan

"Capitation Rate" means the fixed monthly amount that the Contractor receives
from the State for an Enrollee to provide that Enrollee with the Medicaid
Advantage Plus Benefit Package.

"Care Management" is a process that assists Enrollees to access necessary
covered services as identified in the care plan. It also provides referral and
coordination of other services in support of the care plan. Care management
services will assist Enrollees to obtain needed medical, social, educational,
psychosocial, financial and other services in support of the care plan
irrespective of whether the needed services are covered under the capitation
payment of this Agreement.

"Care Plan (or plan of care)" is a written description in the cafe management
record of member-specific health care goals to be achieved and the amount,
duration and scope of the covered services to be provided to an Enrollee in
order to achieve such goals. The care plan is based on assessment of the
member's health care needs and developed in consultation with the member and
his/her informal supports. Effectiveness of the care plan is monitored through
reassessment and a determination as to whether the health care goals are being
met. Non-covered services which interrelate with the covered services identified
on the care plan and services of informal supports necessary to support the
health care goals and effectiveness of the covered services should be clearly
identified on the care plan or elsewhere in the care management record.

CMS means the U.S. Centers for Medicare and Medicaid Services, formerly known as
HCFA.

"Court-Ordered Services" means those services that the Contractor is required to
provide to Enrollees pursuant to orders of courts of competent jurisdiction,
provided however, that such ordered services are within the Contractor's
Medicare and Medicaid Advantage Plus Benefit Packages.

"Days" means calendar days except as otherwise stated.

"DHHS" means the U.S. Department of Health and Human Services.

"Disenrollment" means the process by which an Enrollee's membership in the
Contractor's Medicaid Advantage Plus Product terminates.

"Dually Eligible" means eligible for both Medicare and Medicaid.

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DEFINITIONS
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"Effective Date of Disenrollment" means the date on which an Enrollee is no
longer a member of the Contractor's Medicaid Advantage Plus Product.

"Effective Date of Enrollment" means the date on which an Enrollee is a member
of the Contractor's Medicaid Advantage Plus Product.

"Eligible Person" means a person whom the LDSS, state or federal government
determines to be eligible for Medicaid and who meets all the other conditions
for enrollment in the Medicaid Advantage Plus Program as set forth in Section
5.1 of this Agreement.

"eMedNY" means the electronic Medicaid system of New York State for eligibility
verification and Medicaid provider claim submission and payments.

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

"Emergency Services" means covered services that are needed to treat an
Emergency Medical Condition. Emergency services include health care procedures,
treatments or services needed to evaluate or stabilize an Emergency Medical
Condition including psychiatric stabilization and medical detoxification from
drugs or alcohol.

"Enrollee" means an Eligible Person who, either personally or through an
authorized representative, has enrolled in the Contractor's Medicaid Advantage
Plus Product pursuant to Section 6 of this Agreement.

"Enrollment" means the process by which an Enrollee's membership in a
Contractor's Medicaid Advantage Plus Product begins.

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

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

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2007 DEFINITIONS
SECTION 1
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"Local Department of Social Services" or "LDSS" means a city or county social
services district as constituted by §61 of the SSL.

"Managed Care Organization" or "MCO" means a health maintenance organization
("HMO") or managed long-term care plan ("MLTCP") certified under Article 44 of
the New York State PHL.

"Marketing" means activity of the Contractor, subcontractor or individuals or
entities affiliated with the Contractor, as described in Appendix D, by which
information about the Contractor is made known to Eligible Persons for the
purpose of persuading such persons to enroll in the Contractor's Medicaid
Advantage Plus Product.

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

"Medicaid Advantage Plus Benefit Package" means the services and benefits
described in Appendix K-2 of this Agreement, plus the CMS approved Medicare
supplemental premium for the Medicare Part C benefits described in Appendix K-1
of this Agreement, if any, included in the Capitation Rate paid to the MCO by
the State.

" Medicaid Advantage Plus Program" means the program that the State has
developed to enroll persons who are nursing home certifiable and who are Dually
Eligible in managed long-term care pursuant §4403-f of the Public Health Law.

"Medicaid Advantage Plus Product" means the product offered by a qualified MCO
to Eligible Persons under this Agreement as described in Appendix K-2 of this
Agreement.

"Medicaid Advantage Plus Covered Services" means those services included in the
Medicaid Advantage Plus Benefit Package that are covered solely by Medicaid and
which are not included in the Contractor's plan Benefit Package Bid submission
proposal as approved by CMS.

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

"Medically Necessary" as applicable to services that the Contractor determines
are a Medicaid only benefit and to services that the Contractor determines are a
benefit under both Medicare and Medicaid, means health care and services that
are necessary to prevent, diagnose, manage or treat conditions in the person
that cause acute suffering, endanger life, result in illness or infirmity,
interfere with such person's capacity for normal activity, or threaten some
significant handicap.

Medicaid Advantage Plus Contract
2007 DEFINITIONS
SECTION 1
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"Medicare Advantage Benefit Package" means all the health care services and
supplies that are covered by the Contractor's Medicare Advantage Product
including Medicare Part C and qualified Part D Benefits, on file with CMS, as
described in Appendix K-1 of this Agreement.

"Medicare Advantage Organization" means a public or private organization
licensed by the State as a risk-bearing entity that is under contract with CMS
to provide the Medicare Advantage Benefit Package as defined in this Agreement.

"Medicare Advantage Product" means the product offered by a qualified MCO to
Eligible Persons under this Agreement as described in Appendix K-1 of this
Agreement.

"Member Handbook" means the publication prepared by the Contractor and issued to
Enrollees to inform them of their benefits and services, how to access health
care services and to explain their rights and responsibilities as a Medicaid
Advantage Plus Enrollee.

"Nonconsensual Enrollment" means Enrollment of an Eligible Person, in a Medicaid
Advantage Plus Product, without the consent of the Eligible Person or consent of
a person with the legal authority to act on behalf of the Eligible Person at the
time of Enrollment.

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

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

"Physician Incentive Plan" or "PIP" means any compensation arrangement between
the Contractor or one of its contracting entities and a physician or physician
group that may directly or indirectly have the effect of reducing or limiting
services furnished to the Contractor's Enrollees.

"Post-stabilization Care Services" means covered services, related to an
Emergency Medical Condition, that are provided after an Enrollee is stabilized
in order to maintain the stabilized condition, or to improve or resolve the
Enrollee's condition.

"Potential Enrollee" means an Eligible Person as defined in this Agreement who
has not yet enrolled in the Contractor's Medicaid Advantage Plus Product.

"Prepaid Capitation Plan Roster" or "Roster" means the enrollment list generated
on a monthly basis by SDOH by which LDSS and Contractor are informed of
specifically which Eligible Persons the Contractor will be serving in the
Medicaid Advantage Plus Program for the coming month, subject to any revisions
communicated in writing or electronically by SDOH or LDSS.

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2007 DEFINITIONS
SECTION 1
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"Provider Agreement" means any written contract between the Contractor and a
Participating Provider to provide medical care and/or services to the
Contractor's Enrollees.

Surplus Amounts: shall mean the amount of medical expenses the LDSS determines a
"medically needy" individual must incur in any period in order to be eligible
for medical assistance. Surplus amounts may be referred to as spenddown amounts
or the amount of net available monthly income (NAMI) determined by the LDSS that
a nursing home resident must pay monthly to the nursing home in accordance with
the requirements of the medical assistance program.

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

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2007
DEFINITIONS
SECTION 1
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2.1 AGREEMENT TERM, AMENDMENTS, EXTENSIONS, AND GENERAL CONTRACT ADMINISTRATION
PROVISIONS 
 
2.1 Term
 

a)
This Agreement is effective July 1, 2007 and shall remain in effect until
December 31, 2009 or until the execution of an extension, renewal or successor
Agreement approved by the SDOH, the Office of the New York State Attorney
General (OAG), the New York State Office of the State Comptroller (OSC), and the
US Department of Health and Human Services (DHHS), and any other entities as
required by law or regulation, whichever occurs first.

b)
This Agreement shall not be automatically renewed at its expiration. The parties
to the Agreement shall have the option to renew this Agreement for two (2)
additional one (1) year terms, subject to the approval of the SDOH, OAG, OSC,
DHHS, and any other entities as required by law or regulation.

c)
The maximum duration of this Agreement is five (5) years; provided, however,
that an extension to this Agreement beyond the five (5) year maximum may be
granted for reasons including, but not limited to, the following:

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

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

d)
Notwithstanding the foregoing, this Agreement will automatically terminate in
its entirety should federal financial participation for the Medicaid Advantage
Plus program expire.

 
2.2 Amendments

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

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2007
AGREEMENT TERM, AMENDMENTS, EXTENSIONS

AND GENERAL CONTRACT ADMINISTRATION PROVISIONS
SECTION 2
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b) SDOH will make reasonable efforts to provide the Contractor with notice and
opportunity to comment with regard to proposed amendment of this Agreement
except when provision of advance notice would result in the SDOH being out of
compliance with state or federal law.

 
c) The Contractor will return the signed amendment or notify the SDOH that it
does not agree with the terms of the amendment within ten (10) business days of
the date of the Contractor's receipt of the proposed amendment.

2.3 Approvals

This Agreement and any amendments to this Agreement shall not be effective or
binding unless and until approved, in writing, by the OAG, OSC, DHHS and any
other entity as required in law or regulation.

2.4 Entire Agreement

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

1)  Appendix A, Standard Clauses for all New York State Contracts;
2)  The body of this Agreement
3)  The appendices attached to the body of this Agreement, other than Appendix
A;
4)   The Contractor's approved:
i) Medicaid Advantage Plus Marketing Plan, if applicable, on file with SDOH
ii)Action and Grievance System Procedures on file with SDOH
iii) ADA Compliance Plan on file with SDOH
 
2.5  Renegotiation

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

 
Medicaid Advantage Plus Contract
2007
AGREEMENT TERM, AMENDMENTS, EXTENSIONS
AND GENERAL CONTRACT ADMINISTRATION PROVISIONS
SECTION 2

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2.6  Assignment and Subcontracting

a)
The Contractor shall not, without SDOH's prior written consent, assign,
transfer, convey, sublet, or otherwise dispose of this Agreement; of the
Contractor's right, title, interest, obligations, or duties under the Agreement;
of the Contractor's power to execute the Agreement; or, by power of attorney or
otherwise, of any of the Contractor's rights to receive monies due or to become
due under this Agreement. SDOH agrees that it will not unreasonably withhold
consent of the Contractor's assignment of this Agreement, in whole or in part,
to a parent, affiliate or subsidiary corporation, or to a transferee of all or
substantially all of its assets. Any assignment, transfer, conveyance, sublease,
or other disposition without SDOH's consent shall be void.

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

2.7  Termination

a) SDOH Initiated Termination

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

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

B)
has engaged in an unacceptable practice under 18 NYCRR, Part 515, that affects
the fiscal integrity of the Medicaid program or engaged in an unacceptable
practice pursuant to Section 26.2 of this Agreement;

Medicaid Advantage Plus Contract
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AGREEMENT TERM, AMENDMENTS, EXTENSIONS
AND GENERAL CONTRACT ADMINISTRATION PROVISIONS
SECTION 2

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

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

E)
becomes insolvent;

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

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

H)
 terminates or fails to renew its contract with CMS pursuant to § 1851 through
1859 of the Social Security Act to offer the Medicare Advantage Product,
including Medicare Part C benefits as defined in this Agreement and qualified
Medicare Part D benefits, to Eligible Persons residing in the service area
specified in Appendix M. In such instances, the Contractor shall notify the SDOH
of the termination or failure to renew the contract with CMS immediately upon
knowledge of the impending termination or failure to renew.

 
 

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

 iii)   If SDOH suspends, limits or revokes Contractor's Certificate of
Authority under PHL Article 44, and:

 
 A. If such action results in the Contractor ceasing to have authority to serve
the entire contracted service area, as defined by Appendix M of this Agreement,
this Agreement shall terminate on the date the Contractor ceases to have such
authority; or

Medicaid Advantage Plus Contract
2007
AGREEMENT TERM, AMENDMENTS, EXTENSIONS
AND GENERAL CONTRACT ADMINISTRATION PROVISIONS
SECTION 2

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B. If such action results in the Contractor retaining authority to serve some
portion of the contracted service area, the Contractor shall continue to offer
its Medicaid Advantage Plus Product under this Agreement in any designated
geographic area not affected by such action, and shall terminate its Medicaid
Advantage Plus Product in the geographic areas where the Contractor ceases to
have authority to serve.

 
iv) No hearing will be required if this Agreement terminates due to SDOH
suspension, limitation or revocation of the Contractor's Certificate of
Authority.

 
v) Prior to the effective date of the termination the SDOH shall notify
Enrollees of the termination, or delegate responsibility for such notification
to the Contractor, and such notice shall include a statement that Enrollees may
disenroll immediately from the Contractor's Medicaid Advantage Plus Product.

 
vi) SDOH reserves the right to terminate this Agreement in the event it is found
that the certification filed by the Contractor in accordance with New York State
Finance Law 139-k was intentionally false or intentionally incomplete. Upon such
finding, the State may exercise its termination right by providing written
notification to the Contractor is accordance with the written notification terms
of this Agreement.

b) Contractor and SDOH Initiated Termination

 
i)The Contractor and the SDOH each shall have the right to terminate this
Agreement in the event that SDOH and the Contractor fail to reach agreement on
the monthly Capitation Rates.

 
ii)The Contractor and the SDOH shall each have the right to terminate this
Agreement in the event the Contractor terminates or fails to renew its contract
with CMS to offer the Medicare Advantage Product, as defined in this Agreement,
to Eligible Persons in the service area as specified in Appendix M.

 
iii) In such events, the party exercising its right shall give the other party
written notice specifying the reason for and the effective date of termination,
which shall not be less time than will permit an orderly disenrollment of
Enrollees from the Contractor's Medicaid Advantage Plus Product. However, in the
event that this Agreement is terminated due to the Contractor's failure to renew
its contract with CMS to offer the Medicare Advantage Product, or that the
Contractor's Medicare Advantage contract with CMS otherwise expires or
terminates, this Agreement shall terminate on the effective date of the
termination of the Contractor's contract with CMS.

 

Medicaid Advantage Plus Contract

2007
AGREEMENT TERM, AMENDMENTS, EXTENSIONS
AND GENERAL CONTRACT ADMINISTRATION PROVISIONS
SECTION 2

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c) Contractor Initiated Termination

 
i) The Contractor shall have the right to terminate this Agreement in the event
that SDOH materially breaches the Agreement or fails to comply with any term or
condition of this Agreement that is not cured within twenty (20) days, or to
such longer period as the parties may agree, of the Contractor's written request
for compliance. The Contractor shall give SDOH written notice specifying the
reason for and the effective date of the termination, which shall not be less
time than will permit an orderly disenrollment of Enrollees from the
Contractor's Medicaid Advantage Plus Product.

 
ii) The Contractor shall have the right to terminate this Agreement in the event
that its obligations are materially changed by modifications to this Agreement
and its Appendices by SDOH. In such event, Contractor shall give SDOH written
notice within thirty (30) days of notification of changes to the Agreement or
Appendices specifying the reason and the effective date of termination, which
shall not be less time than will permit an orderly disenrollment of Enrollees
from the Contractor's Medicaid Advantage Plus Product.

 
iii) The Contractor shall have the right to terminate this Agreement in its
entirety or in specified counties of the Contractor's service area if the
Contractor is unable to provide the Medicaid Advantage Plus Benefit Package
pursuant to this Agreement because of a natural disaster and/or an act of God to
such a degree that Enrollees cannot obtain reasonable access to Medicaid
Advantage Plus services within the Contractor's organization, and, after
diligent efforts, the Contractor cannot make other provisions for the delivery
of such services. The Contractor shall give SDOH written notice of any such
termination that specifies:

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

B)
the Contractor's attempts to make other provision for the delivery of Medicaid
Advantage Plus Services; and

C)
the effective date of the termination, which shall not be less time than will
permit an orderly disenrollment of Enrollees from the Contractor's Medicaid
Advantage Plus Product.

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2007
AGREEMENT TERM, AMENDMENTS, EXTENSIONS
AND GENERAL CONTRACT ADMINISTRATION PROVISIONS
SECTION 2
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d) Termination Due To Loss of Funding

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

2.8 Enrollee Transition Plan

a)
Upon expiration and non-renewal, or termination of this Contract, and the
establishment of a termination date, the Contractor shall comply with the
phase-out plan that the Contractor has developed and that SDOH has approved.

 
i) The Contractor shall contact other community resources to determine the
availability of other programs to accept the Enrollees into their programs;

 
ii) The Contractor shall assist Enrollees by referring them, and by making their
care management record and other Enrollees service records available as
appropriate to health care providers and/or programs;

 
iii) The Contractor shall establish a list of Enrollees that is prioritized
according to those Enrollees requiring the most skilled care; and

 
iv) Based upon the Enrollee's established priority and a determination of the
availability of alternative resources, individual care plans shall be developed
by the Contractor for each Enrollee in collaboration with the Enrollee, the
Enrollee's family and appropriate community resources.

b)
In conjunction with such termination and disenrollment, the Contractor shall
provide such other reasonable assistance as the SDOH may request affecting that
transaction.

c)
Upon completion of individual care plans and reinstatement of the Enrollee's
Medicaid benefits through the fee-for-service system or enrollment in another
managed care plan, an Enrollee shall be disenrolled from the Contractor's
Medicaid Advantage Plus Product.

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2007
AGREEMENT TERM, AMENDMENTS, EXTENSIONS
AND GENERAL CONTRACT ADMINISTRATION PROVISIONS
SECTION 2
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2.9 Agreement Close-Out Procedures

a)
Upon termination or expiration of this Agreement, in its entirety or in specific
counties in the Contractor's service area, and in the event that it is not
scheduled for renewal, the Contractor shall comply with close-out procedures
that the Contractor develops in conjunction with LDSS, and the SDOH has
approved.

 
 
The close-out procedures shall include the following:

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

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

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

iv)    SDOH shall promptly pay all claims and amounts owed to the Contractor.

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

 
2.10 Rights and Remedies

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

Medicaid Advantage Plus Contract
2007
AGREEMENT TERM, AMENDMENTS, EXTENSIONS
AND GENERAL CONTRACT ADMINISTRATION PROVISIONS
SECTION 2
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2.11 Notices

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

For SDOH:
 
New York State Department of Health
Empire State Plaza
Corning Tower, Rm. 2084
Albany, NY 12237-0065

For the Contractor:
Chief Executive Officer
WellCare of New York, Inc.
11 West 19th Street New York, NY 10011

2.12 Severability

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

Medicaid Advantage Plus Contract
2007
AGREEMENT TERM, AMENDMENTS, EXTENSIONS
AND GENERAL CONTRACT ADMINISTRATION PROVISIONS
SECTION 2
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3.COMPENSATION

3.1  Capitation Payments

a)
Compensation to the Contractor shall consist of a monthly capitation payment for
each Enrollee as described in this Section.

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

c)
The monthly capitation payments to the Contractor shall constitute full and
complete payments to the Contractor by SDOH for all services that the Contractor
provides pursuant to Appendix K-2 this Agreement.

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

3.2  Modification of Rates During Contract Period

Modification to Capitation Rates during the term of this Agreement shall be
subject to approval by the New York State Division of the Budget (DOB) and shall
be incorporated into this Agreement by written amendment mutually agreed upon by
the SDOH and the Contractor, as specified in Section 2.2 of this Agreement.

3.3   Rate Setting Methodology

a)
Capitation Rates shall be determined prospectively and shall not be
retroactively adjusted to reflect actual fee-for-service data or plan experience
for the time period covered by the rates.

b)
Capitated rates shall be certified to be actuarially sound in accordance with 42
CFR 438.6(c).

c)
Notwithstanding the provisions set forth in Section 3.3 (a) and (b) above, the
SDOH reserves the right to terminate this Agreement in its entirety, or for
specified counties of the Contractor's service area, pursuant to Section 2.7 of
this Agreement, upon determination by SDOH that the aggregate monthly Capitation
Rates are not cost effective.

Medicaid Advantage Plus Contract
2007
COMPENSATION
SECTION 3
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3.4 Payment of Capitation

a)
The monthly capitation payments for each Enrollee are due to the Contractor from
the Effective Date of Enrollment until the Effective Date of Disenrollment of
the Enrollee or termination of this Agreement, whichever occurs first. The
Contractor shall receive a full month's capitation payment for the month in
which Disenrollment occurs. The Roster generated by SDOH with any modification
communicated electronically or in writing by the LDSS prior to the end of the
month in which the Roster is generated, shall be the Enrollment list for
purposes of eMedNY premium billing and payment, as discussed in Section 6.7 and
Appendix H of this Agreement.

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

3.5 Denial of Capitation Payments

If the Centers for Medicare and Medicaid Services (CMS) denies payment for new
Enrollees, as authorized by SSA § 1903(m)(5) and 42 CFR 438.730 (e), or such
other applicable federal statutes or regulations, based upon a determination
that Contractor failed substantially to provide medically necessary items and
services, imposed premium amounts or charges in excess of permitted payments,
engaged in discriminatory practices as described in SSA § 1932(e)(l)(A)(iii),
misrepresented or falsified information submitted to CMS, SDOH, LDSS, or an
Enrollee, Potential Enrollee, or health care provider, or failed to comply with
federal requirements (i.e., 42 CFR 422.208 and 42 CFR 438.6 (h)) relating to the
Physician Incentive Plans, SDOH and LDSS will deny capitation payments to the
Contractor for the same Enrollees for the period of time for which CMS denies
such payment.

3.6 SDOH Right to Recover Premiums

 
a) 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 Medicaid Advantage Plus Product; to have been
incarcerated; to have moved out of the Contractor's service area; or to have
died. In any event, the State may only recover premiums paid for Medicaid
Enrollees listed on a Roster if it is determined by the SDOH that the Contractor
was not at risk for provision of Medicaid Advantage Plus Benefit Package
services for any portion of the payment period.

 
Medicaid Advantage Plus Contract

 
2007 COMPENSATION

 
SECTION 3

 
-2-

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b.) The parties acknowledge and accept that the SDOH has the right to recover
premiums paid to the Contractor for Enrollees listed on the monthly roster where
the Contractor has failed to initiate involuntary disenrollment in accordance
with the timeframes and requirements contained in Section 8 of this Agreement.
The Department may recover the premiums effective on the first day of the month
following the month in which the Contractor was required to initiate the
involuntary disenrollment.

3.7  Third Party Health Insurance Determination

The Contractor will make diligent efforts to determine whether Enrollees have
third party health insurance (TPHI). The LDSS is also responsible for making
diligent efforts to determine if Enrollees have TPHI and to maintain third party
information on the Welfare Management System (WMS)/eMedNY Third Party Resource
System. The Contractor shall make good faith efforts to coordinate benefits with
and collect TPHI recoveries from other insurers, and must inform the LDSS of any
known changes in status of TPHI insurance eligibility within thirty (30) days of
learning of a change in TPHI. The Contractor may use the Roster as one method to
determine TPHI information. The Contractor will be permitted to retain one
hundred percent (100%) of any reimbursement for Medicaid Advantage Plus Benefit
Package services obtained from TPHI. Capitation Rates are net of TPHI
recoveries. In no instances may an Enrollee be held responsible for disputes
over these recoveries.

3.8 Contractor Financial Liability

Contractor shall not be financially liable for any services rendered to an
Enrollee prior to his or her Effective Date of Enrollment in the Contractor's
Medicaid Advantage Plus Product.

3.9 Spenddown and Net Available Monthy Income (NAMI)

Capitation rates will exclude all required spenddown and NAMI regardless of
whether the Contractor collects the amounts. The Contractor shall report the
spenddown and NAMI for each Enrollee in accordance with the time frames and in
the format prescribed by the Department.

Medicaid Advantage Plus Contract
2007
COMPENSATION
SECTION 3
-3-

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4.   SERVICE AREA

The Service Area described in Appendix M of this Agreement, which is hereby made
a part of this Agreement as if set forth fully herein, is the specific
geographic area within which Eligible Persons must reside in order to be
eligible to enroll in the Contractor's Medicaid Advantage Plus Product.

Medicaid Advantage Plus Contract
2007
SERVICE AREA
SECTION 4
-1-
 
 

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5. ELIGIBILITY FOR ENROLLMENT IN MEDICAID ADVANTAGE PLUS

5.1 Eligibility to Enroll in the Medicaid Advantage Plus Program

a)
Except as specified in Section 5.2, persons meeting the following criteria shall
be eligible to enroll in the Contractor's Medicaid Advantage Plus Product:

 
i) Must have full Medicaid coverage or full Medicaid coverage with Qualified
Medicare Beneficiary (QMB) eligibility;

 
ii) Must have evidence of Medicare Part A & B coverage; or be enrolled in
Medicare Part C coverage;

 
iii) Must reside in the service area as defined in Appendix M of this Agreement;

 
iv) Must be 18 years of age or older;

 
v) Must enroll in the Contractor's Medicare Advantage Product as defined in
Section 1 and Appendix K-l of this Agreement;

 
vi) Must be eligible for nursing home level of care (as of the time of
enrollment);

 
vii) Must be capable, at the time of enrollment of returning to or remaining in
his/her home and community without jeopardy to his/her health and safety, based
upon criteria provided by SDOH; and

 
viii) Must require care management and be expected to need at least one of the
following services covered by Medicaid Advantage Plus Product for at least 120
days from the effective date of enrollment;

 

(a)   nursing services in the home;

(b)   therapies in the home;

(c)     home health aide services;

(d)    personal care services in the home

(e) adult day health care; or

(f)
social day care if used as a substitute for in-home personal care services.

Medicaid Advantage Plus Contract
2007
ELIGIBILITY
SECTION 5
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b)  Participation in the Medicaid Advantage Plus Program and enrollment in the
Contractor's Medicaid Advantage Plus Product is voluntary for all Eligible
Persons.

5.2  Not Eligible to Enroll in the Medicaid Advantage Plus Program

Persons meeting the following criteria are not eligible to enroll in the
Contractor's Medicaid Advantage Plus Product:

a)
Individuals who are medically determined to have End Stage Renal Disease (ESRD)
at the time of enrollment, unless such individuals meet the exceptions to
Medicare Advantage eligibility rules for persons who have ESRD as found in
Section 20.2.2 of the Medicare Managed Care Manual.

b)
Individuals who are only eligible for the Qualified Medicare Beneficiary (QMB),
Specified Low Income Medicare Beneficiary (SLIMB) or the Qualified Individual-1
(QI-1) and are not otherwise eligible for Medical Assistance.

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

d)
Individuals who are residents of residential health care facilities ("RHCF") at
the time of Enrollment, if discharge back to the community is not expected
within the first month following effective date of enrollment.

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

f)  Individuals enrolled in the Restricted Recipient Program.

g) Individuals with a "County of Fiscal Responsibility" code of 99.

h) Individuals admitted to a Hospice program prior to time of enrollment (if an
Enrollee enters a Hospice program while enrolled in the Contractor's plan,
he/she may remain enrolled in the Contractor's plan to maintain continuity of
care with his/her PCP).

i) Individuals with a "County of Fiscal Responsibility" code of 97 (OMH in
eMedNY).

j)  Individuals with a "County of Fiscal Responsibility" code of 98 (OMRDD in
eMedNY) will be excluded until program features are approved by the State and
operational at the local district level to permit these individuals to
voluntarily enroll in Medicaid Advantage Plus.

k) Individuals who are residents of a facility operated under the auspices of
the State Office of Mental Health (OMH), the Office of Alcoholism and Substance
Abuse Services (OASAS) or the State Office of Mental Retardation and
Developmental Disabilities (OMRDD) or is enrolled in another managed care plan
capitated by Medicaid, a Home and Community-Based Services waiver program, a
Comprehensive Medicaid Case Management Program (CMCM) or OMRDD Day Treatment
Program.

 
Medicaid Advantage Plus Contract
2007
ELIGIBILITY
SECTION 5
-2-

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5.3 Change in Eligibility Status

a)
The Contractor must report to the LDSS any change in status of its Enrollees,
which may impact the Enrollee's eligibility for Medicaid or Medicaid Advantage
Plus, within five (5) business days of such information becoming known to the
Contractor. This information includes, but is not limited to: change of address;
incarceration; permanent placement in a residential institution or program other
than a nursing home, rendering the individual ineligible for enrollment in
Medicaid Advantage Plus; death; and disenrollment from the Contractor's Medicare
Advantage Product as defined in this Agreement.

b)
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 Plus plan eligibility and
enrollment.

Medicaid Advantage Plus Contract
2007
ELIGIBILITY
SECTION 5

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6.  ENROLLMENT

6.1 Enrollment Requirements

The LDSS and the Contractor agree to conduct enrollment of Eligible Persons in
accordance with the policies and procedures set forth in Appendix H of this
Agreement, which is hereby made a part of this Agreement as if set forth fully
herein.

6.2 Equality of Access to Enrollment

The Contractor shall accept Enrollments of Eligible Persons in the order in
which they are received without restriction and without regard to the Eligible
Person's age, sex, race, creed, physical or mental handicap/developmental
disability, national origin, sexual orientation, type of illness or condition,
need for health services or to the Capitation Rate that the Contractor will
receive for such Eligible Person.

6.3 Enrollment Decisions

An Eligible Person's decision to enroll in the Contractor's Medicaid Advantage
Plus Product shall be voluntary. However, as a condition of eligibility for
Medicaid Advantage Plus, individuals may only enroll in the Contractor's
Medicaid Advantage Plus Product if they also enroll in the Contractor's Medicare
Advantage Product as defined in this Agreement.

6.4  Prohibition Against Conditions on Enrollment

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

6.5 Effective Date of Enrollment

a)
At the time of Enrollment, the Contractor must notify the Enrollee of the
expected Effective Date of Enrollment.

b)
To the extent practicable, such notification must precede the Effective Date of
Enrollment.

c)
In the event that the actual Effective Date of Enrollment changes, the
Contractor must notify the Enrollee of the change.

d) An Enrollee's Effective Date of Enrollment shall be the first day of the
month in which the Enrollee's name appears on the Prepaid Capitation Plan Roster
and is enrolled in the Contractor's Medicare Advantage Product for that month.

Medicaid Advantage Plus Contract
2007
ENROLLMENT
SECTION 6
-1-

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6.6  Contractor Liability

As of the Effective Date of Enrollment, and until the Effective Date of
Disenrollment from the Contractor's Medicaid Advantage Plus Product, the
Contractor shall be responsible for the provision and cost of the Medicaid
Advantage Plus Benefit Package as described in Appendix K-2 of this Agreement
for Enrollees whose names appear on the Prepaid Capitation Plan Roster.

6.7 Roster

a)
The first and second monthly Rosters generated by SDOH in combination shall
serve as the official Contractor enrollment list for purposes of eMedNY premium
billing and payment, subject to ongoing eligibility of the Enrollees as of the
first (1st) day of the Enrollment month. Modifications to the Roster may be made
electronically or in writing by the LDSS. If the LDSS notifies the Contractor in
writing or electronically of changes in the Roster and provides supporting
information as necessary prior to the effective date of the Roster, the
Contractor will accept that notification in the same manner as the Roster.

b)
The LDSS is responsible for making data on eligibility determinations available
to the Contractor and SDOH to resolve discrepancies that may arise between the
Roster and the Contractor's enrollment files in accordance with the provisions
in Appendix H of this Agreement.

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

6.8  Automatic Re-Enrollment

An Enrollee who is disenrolled from the Contractor's Medicaid Advantage Plus
Product due to loss of Medicaid eligibility and who regains eligibility within a
three (3) month period will be automatically re-enrolled in the Contractor's
Medicaid Advantage Plus Product, provided that the individual remains enrolled
in the Contractor's Medicare Advantage Product as defined in this Agreement
unless:
a)
 the Contractor does not offer a Medicaid Advantage Plus Product in the
Enrollee's county of fiscal responsibility; or

 b) the Enrollee indicates in writing that he/she wishes to enroll in another
MLTC plan, another MLTC plan's Medicaid Advantage Plus and Medicare Advantage
Products, or receive Medicaid coverage through Medicaid fee-for-service.

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6.9  Failure to Enroll in the Contractor's Medicare Advantage Product

If an Enrollee's enrollment in the Contractor's Medicare Advantage Product is
rejected by CMS, the Contractor must notify the local social services district
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 Plus Product retroactive to the Effective Date
of Enrollment.

6.10  Spenddown/Net Available Monthly Income (NAMI)

a) The LDSS shall determine an Enrollee's spenddown or NAMI amount.

b)
The Contractor agrees to notify the LDSS in writing when an Enrollee with a
monthly spenddown is admitted to an inpatient facility so the spenddown can be
recalculated and a determination made regarding the amount, if any, of the
spenddown owed to the inpatient facility. The notification will include the
Enrollee's name, Medicaid number, hospital name and other information as
directed by the Department.

c)
The Contractor agrees to notify the LDSS in writing prior to admission of an
Enrollee to a nursing facility, to allow Medicaid eligibility to be redetermined
using institutional eligibility rules. The notification will include the
Enrollee's name, Medicaid number, nursing facility name and other information as
directed by the Department. If such an Enrollee is determined by the LDSS to be
financially ineligible for Medicaid nursing facility services, the LDSS shall
notify the Contractor of such determination.

6.11  Enrollment Limits

a)
The Contractor will request written permission from the Department to suspend
enrollment when the Contractor determines that it lacks access to sufficient or
adequate resources to provide or arrange for the safe and effective delivery of
Covered Services to additional Enrollees. Resumption of enrollment will occur
only with Department approval, not to be unreasonably delayed, after written
notice from the Contractor that adequately describes how the situation
precipitating the suspension was corrected.

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b)
 The Department may establish enrollment limits based either on a determination
of readiness or on limits established pursuant to § 4403-f of Public Health Law.

c)
  The Department shall send copies of all notices regarding suspension and
resumption of enrollment to the LDSS.

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2007
ENROLLMENT
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7.        RESERVED

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2007
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SECTION 7
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8. DISENROLLMENT

8.1Disenrollment Requirements
a) The Contractor agrees to conduct Disenrollment of an Enrollee in accordance
with the policies and procedures for Disenrollment set forth in Appendix H of
this Agreement.
b) LDSSs are responsible for processing Disenrollment requests.

8.2 Disenrollment Prohibitions

Enrollees shall not be disenroUed from the Contractor's Medicaid Advantage Plus
Product based on any of the following reasons:

a)
high utilization of covered medical services, an existing condition or a change
in the Enrollee's health, diminished mental capacity or uncooperative or
disruptive behavior resulting from his or her special needs unless the behavior
results in the Enrollee becoming ineligible for Medicaid Advantage Plus
continued enrollment as described in Section 8.8 (b)(i) of this Agreement;

b)
any of the factors listed in Section 33 (Non-Discrimination) of this Agreement;
or
 

c)  the Capitation Rate payable to the Contractor.

8.3  Disenrollment Requests

The LDSS is responsible for processing Enrollee requests for disenrollment to
take effect on the first (1st) day of the next month, to the extent possible. In
no event shall the Effective Date of Disenrollment be later than the first (1st)
day of the second (2nd) month after the month in which an Enrollee requests a
Disenrollment.

8.4  Disenrollment Notification

a)
Notwithstanding anything herein to the contrary, the Roster, along with any
changes sent by the LDSS to the Contractor in writing or electronically, shall
serve as official notice to the Contractor of Disenrollment of an Enrollee.

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

c)
In all cases of retroactive Disenrollment, including Disenrollments effective
the first day of the current month, the LDSS is responsible for notifying the
Contractor at the time of Disenrollment, of the Contractor's responsibility to
submit to the SDOH's Fiscal Agent voided premium claims for any months of
retroactive Disenrollment where the Contractor was not at risk for the provision
of the Medicaid Advantage Plus Benefit Package during the month.

8.5  Contractor's Liability

The Contractor shall continue to provide and arrange for the provision of
covered services until the effective date of disenrollment. The Department will
continue to pay capitation fees for an Enrollee until the effective date of
disenrollment. The Contractor is not responsible for providing the Medicaid
Advantage Plus Benefit Package under this Agreement after the Effective Date of
Disenrollment.

8.6  Contractor Referrals to Alternative Services

The Contractor, in consultation with the Enrollee, prior to the Enrollee's
effective date of disenrollment, shall make all necessary referrals to
alternative services, for which the plan is not financially responsible, to be
provided subsequent to disenrollment, when necessary, and advise the Enrollee in
writing of the proposed disenrollment date.

8.7  Enrollee Initiated Disenrollment

a)
An Enrollee may initiate voluntary disenrollment at any time from the
Contractor's Medicaid Advantage Plus Product for any reason upon oral or written
notification to the Contractor. The Contractor must provide written confirmation
to the Enrollee of receipt of an oral request and maintain a copy in the
Enrollee's record. The Contractor shall attempt to obtain the Enrollee's
signature on the Contractor's voluntary disenrollment form, but may not delay
the disenrollment while it attempts to secure the Enrollee's signature on the
disenrollment form. The effective date of disenrollment must be no later than
the first day of the second month in which the disenrollment was requested.

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DISENROLLMENT
SECTION 8

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b)
An Enrollee who elects to join and/or receive services from another managed care
plan capitated by Medicaid, a Home and Community Based Services waiver program,
OMRDD Day Treatment or a CMCM is considered to have initiated disenrollment from
Contractor's Medicaid Advantage Plus Product.

8.8 Contractor Initiated Disenrollment

a)
The Contractor must notify the LDSS and initiate an Enrollee's Disenrollment
from the Contractor's Medicaid Advantage Plus Product in the following cases:

 
 
i) A change in residence makes the Enrollee ineligible to be a member of the
plan;

 
ii) The Enrollee is no longer a member of the Contractor's Medicare Advantage
Product as defined in this Agreement;

  iii) The Enrollee dies;

 
iv) The Enrollee's status changes such that he/she is no longer eligible to
participate in Medicaid Advantage Plus Product as described in Section 5 of this
Agreement;

 
v) The Enrollee has been absent from the service area for more than 90
consecutive days. Prior to the effective date of the disenrollment the
Contractor must arrange and provide all necessary Covered Services; or

 
vi) The Enrollee is no longer eligible for nursing home level of care as
determined at the last comprehensive assessment of the calendar year using the
assessment tool prescribed by the SDOH, unless the Contractor, and the LDSS
agree that termination of the services provided by the Contractor could
reasonably be expected to result in the Enrollee being eligible for nursing home
level of care (as determined with the assessment tool prescribed by the SDOH)
within the succeeding six-month period. The Contractor shall provide the LDSS
the results of its assessment and recommendations regarding continued enrollment
or disenrollment within five (5) business days of the comprehensive assessment.

b)
The Contractor may initiate an Enrollee's disenrollment from the Contractor's
Medicaid Advantage Plus Product in the following cases:

 
 
i) The Enrollee or the Enrollee's family member or informal caregiver engages in
conduct or behavior that seriously impairs the Contractor's ability to furnish
services to either that particular Enrollee or other Enrollees; provided,
however, the Contractor must have made and documented reasonable efforts to
resolve the problems presented by the individual.

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ii) The Enrollee provides fraudulent information on an enrollment form or the
Enrollee permits abuse of an enrollment card in the Medicaid Advantage Plus
Program.

 
iii) The Enrollee fails to pay or make arrangements satisfactory to Contractor
to pay the amount, as determined by the LDSS, owed to the Contractor as
spenddown/surplus or Net Available Monthly Income (NAMI) within thirty (30) days
after such amount first becomes due, provided that during that thirty (30) day
period Contractor first makes a reasonable effort to collect such amount,
including making a written demand for payment, and advising the Enrollee in
writing of his/her prospective disenrollment.

 
iv) The Enrollee knowingly fails to complete and submit any necessary consent or
release.

c)
Contractor-initiated Disenrollments must be carried out in accordance with the
requirements and timeframes described in Appendix H of this Agreement.

d)
Once an Enrollee has been disenrolled at the Contractor's request, the
Contractor may reject the individual's re-enrollment with the Contractor.
However, if an Enrollee was previously disenrolled under Section 8.8 (b) (i)
above, the Contractor may not reject the individual's enrollment without first
substantiating and maintaining written documentation that the circumstances
which resulted in the disenrollment have not been remedied.

LDSS Initiated Disenrollment

The LDSS is responsible for promptly initiating Disenrollment from the
Contractor's Medicaid Advantage Plus Product when:

a)
an Enrollee fails to enroll or stay enrolled in the Contractor's Medicare
Advantage Product as specified in Sections 6.9 and 8.8 (a)(ii) and (iv) of this
Agreement; or

b)
an Enrollee is no longer eligible for Medicaid or Medicaid Advantage Plus
benefits; or

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

d) an Enrollee becomes ineligible for Enrollment pursuant to Section 5.2 of this
Agreement, as appropriate.

          
 
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2007
DISENROLLMENT
SECTION 8
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9. RESERVED

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2007
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BENEFIT PACKAGE, COVERED AND NON-COVERED SERVICES

10.1Contractor Responsibilities

a)
The Contractor agrees to provide the Medicare Advantage Benefit Package, as
described in Appendix K-l of this Agreement, to Enrollees of the Contractor's
Medicaid Advantage Plus Product subject to any exclusions or limitations imposed
by Federal or State law during the period of this Agreement. Such services and
supplies shall be provided in compliance with the requirements of the
Contractor's Medicare Advantage Coordinated Care Plan contract with CMS and all
applicable federal statutes, regulations and policies.

b)
The Contractor agrees to provide the Medicaid Advantage Plus Benefit Package, as
described in Appendix K-2 of this Agreement, to Enrollees of the Contractor's
Medicaid Advantage Plus Product subject to any exclusions or limitations imposed
by Federal or State law during the period of this Agreement. Such services and
supplies, shall be provided in compliance with the requirements of this
Agreement, the State Medicaid Plan established pursuant to § 363-a of the State
Social Services Law, and all other applicable federal and state statutes,
regulations and policies.

10.2  SDOH Responsibilities

SDOH shall assure that Medicaid services covered under the Medicaid
fee-for-service program as described in Appendix K-3 of this Agreement which are
not covered in the Medicare or Medicaid Advantage Plus Benefit Packages are
available to, and accessible by, Medicaid Advantage Plus Enrollees.

10.3  Benefit Package and Non-Covered Services Descriptions

The Medicare and Medicaid Advantage Plus Benefit Packages and Non-Covered
Services agreed to by the Contractor and the SDOH are contained in Appendix K,
which is hereby made a part of this Agreement as if set forth fully herein.

10.4  Adult Protective Services

The Contractor shall cooperate with LDSS in the implementation of 18 NYCRR Part
457 and any subsequent amendments thereto with regard to medically necessary
health and mental health services and all Court Ordered Services for adults to
the extent such services are included in the Contractor's Medicare and Medicaid
Advantage Plus Benefit Packages as described in Appendix K of this Agreement.
The Contractor is responsible for payment of those services as covered by the
Medicare and Medicaid Advantage Plus  Benefit Packages, even when provided by
Non-Participating Providers. Non-Participating Providers will be reimbursed at
the Medicaid fee schedule by the Contractor.

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10.5 Court-Ordered Services

a)
The Contractor shall provide any Medicare and Medicaid Advantage Plus Benefit
Package services to Enrollees as ordered by a court of competent jurisdiction,
regardless of whether such services are provided by a Participating Provider or
by a Non-Participating Provider. Non-Participating Providers shall be reimbursed
by the Contractor at the Medicaid fee schedule. The Contractor is responsible
for court-ordered services to the extent that such court-ordered services are
included in the Contractor's Medicare Advantage and Medicaid Advantage Plus
Benefit Packages as described in Appendix K of this Agreement.

b)
Court Ordered Services are those services ordered by the court performed by, or
under the supervision of a physician, dentist, or other provider qualified under
State law to furnish medical, dental, behavioral health (including mental health
and/or chemical dependence services), or other Medicare and Medicaid Advantage
Plus covered services. The Contractor is responsible for payment of those
services as covered by the Contractor's Medicare and Medicaid Advantage Plus
Benefit Packages, even when provided by Non-Participating Providers.

10.6 Family Planning and Reproductive Health Services

a)
Nothing in this Agreement shall restrict the right of Enrollees to receive
Family Planning and Reproductive Health Services, as defined in Appendix C of
this Agreement, which is hereby made a part of this Agreement as if set forth
fully herein.

b)
Enrollees may receive such services from any qualified Medicaid provider,
regardless of whether the provider is a Participating Provider or a
Non-Participating Provider in the Contractor's Medicare Advantage Product,
without referral from the Enrollee's PCP and without approval from the
Contractor.

c)
The Contractor shall permit Enrollees to exercise their right to obtain Family
Planning and Reproductive Health Services from either the Contractor, if Family
Planning and Reproductive Health Services are provided by the Contractor, or
from any appropriate Medicaid enrolled Non-Participating family planning
Provider, without a referral from the Enrollee's PCP and without approval by the
Contractor.

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d)
If Contractor provides Family Planning and Reproductive Health Services to its
Enrollees, the Contractor shall comply with the requirements in Part C-2 of
Appendix C of this Agreement, including assuring that Enrollees are fully
informed of their rights.

e)
If Contractor does not provide Family Planning and Reproductive Health Services
to its Enrollees, the Contractor shall comply with Part C.3 of Appendix C of
this Agreement, including assuring that Enrollees are fully informed of their
rights.

10.7    Emergency and Post Stabilization Care Services

a)
The Contractor shall provide Emergency and Post Stabilization Care Services in
accordance with applicable federal and state requirements, including 42 CFR
422.113.

b)
The Contractor shall ensure that Enrollees are able to access Emergency Services
twenty four (24) hours per day, seven (7) days per week.

c)
The Contractor agrees that it will not require prior authorization for services
in a medical or behavioral health emergency. The Contractor agrees to inform its
Enrollees that access to Emergency Services is not restricted and that Emergency
Services may be obtained from a Non-Participating Provider without penalty.
Nothing herein precludes the Contractor from entering into contracts with
providers or facilities that require providers or facilities to provide
notification to the Contractor after Enrollees present for Emergency Services
and are subsequently stabilized. The Contractor must pay for services for
Emergency Medical Conditions whether provided by a Participating Provider or a
Non-Participating Provider, and may not deny payments for failure of the
Emergency Services provider or Enrollee to give notice.

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

e.)
 Coverage and payment for Emergency Services that meet the prudent layperson
definition shall be covered and paid in accordance with the requirements of the
federal Medicare program.

f.)
 In addition, the Contractor shall cover and reimburse for general hospital
emergency department services and physician services provided to an Enrollee
while the Enrollee is receiving general hospital  emergency department services,
in accordance with the following requirements when such services do not meet the
prudent layperson standard:

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i)
Participating Providers

A)
Payment by the Contractor for general hospital emergency department services
provided to an Enrollee by a Participating Provider shall be at the rate of
payment specified in the contract between the Contractor and the general
hospital for emergency services.

B)
Payment by the Contractor for physician services provided to an Enrollee by a
Participating Provider while receiving general hospital emergency department
services shall be at the rate of payment specified in the contract between the
Contractor and the physician.

ii) Non-Participating Providers

A)
Payment by the Contractor for general hospital emergency department services
provided to an Enrollee by a Non-Participating Provider shall be at the Medicaid
fee-for-service rate, inclusive of the capital component, in effect on the date
that the service was rendered.

B)
Payment by the Contractor for physician services provided to an Enrollee by a
Non-Participating Provider while receiving general hospital emergency department
services shall be at the Medicaid fee-for-service rate in effect on the date
that the service was rendered.

10.8  Medicaid Utilization Thresholds (MUTS)

Enrollees may be subject to MUTS for services which are billed to Medicaid
fee-for-service. Enrollees are not otherwise subject to MUTS for services
included in the Medicaid Advantage Plus Benefit Package.

10.9  Services for Which Enrollees Can Self-Refer

In addition to those covered services for which Medicare Advantage and Medicaid
Advantage Plus Enrollees can self-refer, Medicare Advantage and Medicaid
Advantage Plus Enrollees may self-refer to:

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a) 
Public health agency facilities for Tuberculosis Screening, Diagnosis and
Treatment; including Tuberculosis Screening, Diagnosis and Treatment; Directly
Observed Therapy (TB/DOT) as described below.

i. 
 It is the State's preference that Enrollees receive TB diagnosis and treatment
through the Contractor's Medicare Advantage Product, to the extent that
Participating Providers experienced in this type of care are available.

ii. 
The SDOH will coordinate with the Local Public Health Agency (LPHA) to evaluate
the Contractor's protocols against State and local guidelines and to review the
tuberculosis treatment protocols and networks of Participating Providers to
verify their readiness to treat tuberculosis patients. SDOH and LPHAs will also
be available to offer technical assistance to the Contractor in establishing TB
policies and procedures.

iii.
The Contractor shall inform participating providers of their responsibility to
report TB cases to the LPHA.

iv
The Contractor agrees to reimburse public health clinics when physician visit
and patient management or laboratory and radiology services are rendered to
their Enrollees, within the context of TB diagnosis and treatment.

v 
The Contractor will make best efforts to negotiate fees for these services with
the LPHA. If no agreement has been reached, the Contractor agrees to reimburse
the public health clinics for these services at rates determined by SDOH.

vi  
The LPHA is responsible for: 1) giving notification to the Contractor before
delivering TB-related services, if so required in the public health agreement
established pursuant to this Section, unless these services are ordered by a
court of competent jurisdiction; and 2) making reasonable efforts to verify with
the Enrollee's PCP that he/she has not already provided TB care and treatment;
and 3) providing documentation of services rendered along with the claim.
vii)  Prior authorization for inpatient hospital admissions may not be required
by the Contractor for an admission pursuant to a court order or an order of
detention issued by the local commissioner or director of public health.

viii 
The Contractor shall provide the LPHA with access to health care practitioners
on a twenty-four (24) hour a day seven (7) day a week basis who can authorize
inpatient hospital admissions. The Contractor shall respond to the LPHA's
request for authorization within the same day.

ix
The Contractor will not be financially liable for treatments rendered to
Enrollees who have been institutionalized as a result of a local commissioner's
order due to non-compliance with TB care regimens.

x  
The Contractor will not be financially liable for Directly Observed Therapy
(DOT) costs. While all other clinical management of tuberculosis is covered by
the Contractor, TB/DOT, where applicable, may be billed to any SDOH approved
fee-for-service Medicaid provider.

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The Contractor agrees to make all reasonable efforts to ensure coordination with
DOT providers regarding clinical care and services. Enrollees may use any
Medicaid fee-for-service TB/DOT provider. xi)  HIV counseling and testing
provided to a Medicaid Advantage Plus Enrollee during a TB related visit at a
public health clinic, directly operated by a LPHA will be covered by Medicaid
fee-for-service (FFS) at rates established by the SDOH.

b)
Family Planning and Reproductive Health services as described in Appendix C of
this Agreement.

 
c) Immunizations
i)  
The Contractor agrees to reimburse the LPHA when Enrollees self-refer to LPHAs
for immunizations covered by Contractor's Medicare Advantage Plan.

ii)
The LPHA is responsible for making reasonable efforts to (1) determine the
Enrollee's managed care membership status; and (2) ascertain the Enrollee's
immunization status. Reasonable efforts shall consist of client interviews,
review of medical records, and, when available, access to the Immunization
Registry. When an Enrollee presents a membership card with a PCP's name, the
LPHA is responsible for calling the PCP. If the LPHA is unable to verify the
immunization status from the PCP or learns that immunization is needed, the LPHA
is responsible for delivering the service as appropriate, and the Contractor
will reimburse the LPHA at the negotiated rate or in the absence of an
agreement, at rates determined by SDOH.

10.10 Prevention and Treatment of Sexually Transmitted Diseases

The Contractor will be responsible for ensuring that its Participating Providers
educate their Enrollees about the risk and prevention of sexually transmitted
disease (STD). The Contractor also will be responsible for ensuring that its
Participating Providers screen and treat Enrollees for STDs and report cases of
STD to the LPHA and cooperate in contact investigation, in accordance with
existing state and local laws and regulations. HIV counseling and testing
provided to an Enrollee during a STD related visit at a public health clinic,
directly operated by a LPHA, will be covered by Medicaid fee-for-service at
rates established by SDOH.

10.11 Enrollee Needs Relating to HIV

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

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i) 
  Anonymous testing may be furnished to the Enrollee without prior approval by
the Contractor and may be conducted at anonymous testing sites available to
clients. Services provided for HIV treatment may only be obtained from the
Contractor during the period the Enrollee is enrolled in the Contractor's plan.

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

iii)
Policies and procedures promoting the early identification of HIV infection in
Enrollees. Such policies and procedures shall include at a minimum: assessment
methods for recognizing the early signs and symptoms of HIV disease; initial and
routine screening for HIV risk factors through administration of sexual behavior
and drug and alcohol use assessments; and the provision of information to all
Enrollees regarding the availability of HIV CTRPN services from Participating
Providers, or as part of a Family Planning and Reproductive Health services
visit pursuant to Appendix C of this Agreement, and the availability of
anonymous CTRPN services from New York State and the LPHA.

iv)
 Policies and procedures that require Participating Providers to provide HIV
counseling and recommend HIV testing to pregnant women in their care. The HIV
counseling and testing provided shall be done in accordance with Article 27-F of
the PHL. Such policies and procedures shall also direct Participating Providers
to refer any HIV positive women in their care to clinically appropriate services
for both the women and their newborns.

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

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

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

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

10.12  Persons Requiring Chemical Dependence Services

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

 
i) Satisfactory methods for identifying persons requiring such services and
encouraging self-referral and early entry into treatment and methods for
referring Enrollees to the New York Office of Alcohol and Substance Abused
Services (OASAS) for appropriate services beyond the Contractor's Benefit
Package (e.g., halfway houses).
 

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

 
iii) Satisfactory case management systems.
 

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

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

10.13    Care Management

a)
Care management entails the establishment and implementation of a written care
plan and assisting enrollees to access services authorized under the care plan.
Care management includes referral to and coordination of other necessary
medical, and social, educational, psychosocial, financial and other services of
the care plan irrespective of whether such services are covered by the plan

b)
The Contractor shall comply with policies and procedures consistent with 42 CFR
438.210 and Appendix K of this Agreement that have received prior written
approval from the Department. The Contractor agrees to submit any proposed
material revisions to the approved coverage and authorization of services
policies and procedures for Department approval prior to implementation of the
revised procedures.

c)
The Contractor shall have and comply with written policies and procedures for
care management consistent with the coordination and continuity requirements of
42 CFR 438.208.

d)
The Contractor's care management system shall ensure that care provided is
adequate to meet the needs of individual Enrollees and is appropriately
coordinated, and shall consist of both automated information systems and
operational policies and procedures.

e)
A comprehensive reassessment of the Enrollee and a plan of care update shall be
performed as warranted by the Enrollee's condition but in any event at least
once every six (6) months.

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2007
BENEFIT PACKAGE AND NON-COVERED
SERVICES DESCRIPTIONS
SECTION 10
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f) 
  The Contractor shall develop a care management system consistent with the
following provisions:

i)  
The Contractor shall arrange for health care professionals, as appropriate (such
as physicians, nurses, social workers, therapists) to provide care management
services to all Enrollees. An interdisciplinary team may provide care
management.

ii) Care management services include, but are not limited to:

     

A) initial assessments of Enrollees;

B) reassessments of Enrollees;

C)
management of covered services and coordination of covered services with
non-covered services and services provided by other community resources and
informal supports;

D)
development of individual care plans, in consultation with the Enrollee and
her/his informal supports, specifying health care goals, the types and frequency
of authorized covered services and non-covered services and supports necessary
to maintain the care plan;

E)
monitoring the progress of each Enrollee to evaluate whether the covered
services provided are appropriate and in accord with the care plan; and

F)
evaluating whether the care plan continues to meet the Enrollee's needs.

 
 

iii) The care management system includes processes for:
 

A) generating and receiving referrals among providers;

B) sharing clinical and treatment plan information;

C) obtaining consent to share confidential medical and treatment plan
information among providers consistent with all applicable state and federal law
and regulation;

D)  providing Enrollees with written notification of authorized services;

E)
enlisting the involvement of community organizations that are not providing
covered services, but are otherwise important to the health and well-being of
Enrollees; and

F)
assuring that the organization of and documentation included in the care
management record meet all applicable professional standards.

 
 

iv)
The care management system requires care managers to have access to
participating medical and social services professionals and para-professionals
who on a routine basis provide direct care and services as required by the
Enrollee's status.

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2007
BENEFIT PACKAGE AND NON-COVERED
SERVICES DESCRIPTIONS
SECTION 10
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10.14 Urgently Needed Services
 
The Contractor is financially responsible for Urgently Needed Services.
 
10.15  Coordination of Services
 
a)The Contractor shall coordinate care for Enrollees with:
 
i)  the court system (for court ordered evaluations and treatment);

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

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

  v) programs funded through the Ryan White CARE Act;

 
vi)other pertinent entities that provide services out of network;

  vii) Prenatal Care Assistance Program (PCAP) Providers; viii) local
governmental units responsible for public health, mental health,  mental
retardation or Chemical Dependence Services; and ix)    specialized providers of
long term care for people with developmental disabilities.

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

 
Medicaid Advantage Plus Contract
2007
BENEFIT PACKAGE AND NON-COVERED
SERVICES DESCRIPTIONS
SECTION 10

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MARKETING

11.1    Marketing Requirements

a)
The Contractor agrees to follow the Medicare Advantage Marketing Guidelines as
set forth in Chapter 3 of CMS's Medicare Managed Care Manual, as well as all
applicable statutes and regulations including and without limitation § 1851 (h)
of the Social Security Act and 42 CFR 422.80, 422.111, and 423.50 when marketing
to individuals entitled to enroll in Medicare Advantage.

b)
The Contractor shall conduct marketing activities for Potential Enrollees
consistent with 42 CFR 438.104, applicable State Law and its implementing
regulations and shall comply with the Medicaid Advantage Plus Marketing
Guidelines as defined in Appendix D of this document as if set forth fully
herein.

Medicaid Advantage Plus Contract
2007
MARKETING
SECTION 11

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MEMBER SERVICES

12.1     General Functions

a)
The Contractor shall operate a Member Services function during regular business
hours, which must be accessible to Enrollees via a toll-free telephone line.
Personnel must also be available via a toll-free telephone line (which can be
the member services toll-free line or separate toll-free lines) not less than
during regular business hours to address complaints and utilization review
inquiries. In addition, the Contractor must have a telephone system capable of
accepting, recording or providing instruction in response to incoming calls
regarding complaints and utilization review during other than normal business
hours and measures in place to ensure a response to those calls the next
business day after the call was received.

b)  Member Services staff must be responsible for the following:

 
 
i)   Explaining the benefits and covered services offered under the Medicare and
Medicaid Advantage Plus Products, including applicable conditions and
limitations, and any conditions associated with the receipt or use of benefits,
and assisting Enrollees in making appointments;

 
ii) Explaining the Contractor's rules for obtaining Medicare and Medicaid
Advantage Plus Benefit Package services and additional services available to the
Enrollee through use of his/her Medicaid benefit card;

 
iii) Providing information on: the providers from whom Enrollees may obtain
Medicare and Medicaid Advantage Plus Benefit Package Services, any out-of-area
coverage provided by the plan, and coverage of emergency services and urgently
needed care;

 
iv) Fielding and responding to Enrollee questions and complaints regarding the
Contractor's Medicare and Medicaid Advantage Plus Products and benefits, and
advising Enrollees of the prerogative to complain at any time to the CMS
regarding the Medicare Advantage Product, and to the SDOH and LDSS, regarding
the Medicaid Advantage Plus Product;

 
v) Accommodating Applicants and Enrollees who require language translation and
communications assistance;

 
vi) Clarifying information in the member handbooks for Enrollees regarding the
Contractor's Medicare and Medicaid Advantage Plus Products and benefits;

Medicaid Advantage Plus Contract
2007
MEMBER SERVICES
SECTION 12
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vii) Advising Enrollees of the Contractor's applicable complaint and appeals
programs, utilization review processes, and the Enrollee's rights to a fair
hearing or external review;

 
viii) Clarifying an Enrollee's Disenrollment rights and responsibilities under
the Contractor's Medicare and Medicaid Advantage Plus Products;

 
ix) Conducting post enrollment orientation activities, including orientation of
Enrollees, Enrollees' families or representatives and
 

  x) Conducting health promotion and wellness activities.

 
C.
The Contractor shall develop and implement written procedures and protocols to
assure that member and provider services are provided in a manner that is
responsive to cultural considerations and specific needs of its Enrollees.

12.2    Translation and Oral Interpretation

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

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

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

 
d)
The Contractor must inform Enrollees, Applicants and Potential Enrollees that
oral interpretation is available for any language and written information is
available in prevalent languages and how to access those services, including
notices about this available in the member handbook.

e)
The Contractor must provide Potential Enrollees, Applicants and Enrollees with
information about the availability of non-English speaking participating
providers and how to access the services of a specific non-English speaking
participating provider.

f)
Medicare Advantage Plan and Medicaid Advantage Plus Plan provider directories
must identify the languages spoken by participating providers.

Medicaid Advantage Plus Contract
2007
MEMBER SERVICES
SECTION 12
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12.3  Communicating with the Visually, Hearing and Cognitively Impaired

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

 
Medicaid Advantage Plus Contract
2007
MEMBER SERVICES
SECTION 12
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ENROLLEE NOTIFICATION

13.1     General Requirements

a)
The Contractor shall disclose required information to Potential Enrollees and
Enrollees as prescribed by applicable federal and state law and regulations
found at 42 CFR 422.111, New York PHL §4408, and 42 CFR 438.10 and any specific
guidance issued by CMS and SDOH. The Contractor must provide Enrollees with an
annual notice that this information is available upon request.

b)
The Contractor must submit to the Department for prior approval a description of
how the Contractor will provide information and annual notification to its
Enrollees as required by this Section, including.

 
• 
evidence that the material is written in 12 point type at a minimum and prose
written in clear, simple, understandable language at the 4th to 6th grade
reading level;

• 
the methods the Contractor will use to provide information to Applicants and
Enrollees who speak other than English as a primary language;

• 
the methods of making alternate formats available to persons who are visually
and hearing impaired; and

• 
the method and timetable for updating and disseminating the list of
Participating Providers.

 
c)
The Contractor shall provide the materials developed by SDOH to all Potential
Enrollees, a member handbook which is approved by SDOH and consistent with the
Medicaid Advantage Plus Model Handbook Guidelines in Appendix E, which is hereby
made a part of this Agreement as if set forth fully herein, and the provider
network to all Applicants prior to enrollment and to Enrollees.

d)
The Contractor shall give Enrollees prior written notice of significant changes
to the information identified in subsection 13.1 (c) of this Section. Such
notice shall be at least thirty (30) days prior to the effective date of the
change pursuant to 42 CFR 438.10(f)(4).

e)
The Contractor shall annually notify Enrollees in writing of their disenrollment
rights and their right to request the information specified in 42 CFR 438.10
(f)(6) and (g).

Medicaid Advantage Plus Contract
2007
ENROLLEE NOTIFICATION
SECTION 13
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f)
Medicaid Advantage Plus enrollment notices and materials shall include, but not
be limited to the following:

Provider Directories

Member ID Cards
Member Handbooks

Notice of the Effective Date of Enrollment
Notice of Termination, Service Area Changes and Network Changes at
least 30 days before the effective date of the change.
Summary of Benefits

g)
Integrated post enrollment materials including member handbooks, member notices,
and summary of benefits targeted to Enrollees of the Contractor's Medicare and
Medicaid Advantage Plus Products must be prior approved by the CMS Regional
Office, in collaboration with SDOH.

13.2    Enrollment Agreement/Attestation

Using a form developed by SDOH, the Contractor shall obtain a signed enrollment
agreement/attestation from each Applicant/Enrollee that the Applicant/Enrollee
has:

a)
received a member handbook which includes the rules and responsibilities of plan
membership and which expressly delineates covered and non-covered services;

b)
agreed to the terms and conditions for Medicaid Advantage Plus enrollment stated
in the member handbook;

c)
understood that enrollment in the Contractor's Medicaid Advantage Plus is
voluntary;

d)
received a copy of the Contractor's current provider network listing and agreed
to use network providers for covered services; and
 

e) has been advised of the projected date of enrollment.

      

13.3   Member ID Cards

The Contractor must issue an identification card to the Enrollee that complies
with CMS and SDOH specifications.

Medicaid Advantage Plus Contract
2007
ENROLLEE NOTIFICATION
SECTION 13
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13.4 Enrollee Rights

a)
The Contractor shall, in compliance with the requirements of 42 CFR 422.128,42
CFR 489.100 and 102, maintain written policies and procedures regarding advance
directives and inform each Enrollee in writing at the time of enrollment of an
individual's rights under State law to formulate advance directives and of the
Contractor's policies regarding the implementation of such rights. The
Contractor shall include in such written notice to the Enrollee materials
relating to advance directives and health care proxies as specified in 10 NYCRR
Part 98 and Part 700.5. The written information.must reflect changes in State
law as soon as possible, but no later than ninety (90) days after the effective
date of the change.

b)
The Contractor shall develop and implement written policies and procedures
regarding Enrollee rights which fulfill the requirements of 42 CFR 438.100 and
applicable State law and regulation, including the following rights to:

 

 i)  receive medically necessary care;

ii) timely access to care and services;

iii) privacy about medical records and treatment;

iv)
get information on available treatment options and alternatives presented in an
understandable manner and language;

v) 
get information in a language the Enrollee understands and oral translation
services free of charge;

vi)
get information necessary to give informed consent before the start of
treatment;

vii) be treated with respect and dignity;

viii)
request and receive a copy of his or her medical records and request that they
be amended or corrected, as specified in 45 CFR 164.524 and 164.526., if the
privacy rule, as set forth in 45 CFR 160 and 164, A and E, applies;

ix)
take part in decisions about Enrollee health care, including the right to refuse
treatment;

x)
be free from any form of restraint or seclusion used as a means of coercion,
discipline, convenience or retaliation;

Medicaid Advantage Plus Contract
2007
ENROLLEE NOTIFICATION
SECTION 13
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xi)
get care without regard to sex, race, health status, color, age, national
origin, sexual orientation, marital status or religion;

xii)
be told where, when and how to get the services the Enrollee needs from Medicaid
Advantage Plus, including how to get covered benefits from out-of-network
providers if they are not available in the Medicaid Advantage Plus network;

xiii)
complain to the New York State Department of Health or the Local Department of
Social Services; and, the Right to use the New York State Fair Hearing System
and/or a New York State External Appeal, where appropriate, and

xiv)
appoint someone to speak for the Enrollee about the care the Enrollee needs.

c)
The Contractor's policies and procedures must require that neither the
Contractor nor its Participating Providers adversely regard an Enrollee who
exercises his/her rights in 13.4(b) above.

Medicaid Advantage Plus Contract
2007
ENROLLEE NOTIFICATION
SECTION 13
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14.   ORGANIZATION DETERMINATIONS, ACTIONS AND GRIEVANCE SYSTEM

14.1  General Requirements

a)
The Contractor agrees to comply with, and shall establish and maintain written
Organization Determination and Action procedures and a comprehensive Grievance
System, as described in Appendix F, which is hereby made a part of this
Agreement as if set forth fully herein, that complies with:

 

 i) all procedures and requirements of 42 CFR 422 Subpart M and Chapter 13 of
CMS's Medicare Managed Care Manual for services that the Contractor determines
are a Medicare only benefit.

ii)
all procedures and requirements of 42 CFR 422 Subpart 422 and Chapter 13 of
CMS's Medicare Managed Care Manual for services the Contractor determines to be
a benefit covered under both Medicare and Medicaid, except that:

A)
The Contractor will determine whether services are Medically Necessary as that
term is defined in this Agreement; and

B)
When the Contractor intends to reduce, suspend, or terminate a previously
authorized service within an authorization period, the notification provisions
of paragraph F.2 (4) (a) of Appendix F of this Agreement shall apply.

iii)
all procedures and requirements of the Grievance System described in Appendix F
of this Agreement and 42 CFR 438.400 et seq., for services that the Contractor
determines are a Medicaid only benefit. With respect to Medicaid-only services,
nothing herein shall release the Contractor from its responsibilities under PHL
§ 4408-a or PHL Article 49 and 10 NYCRR Part 98 that are not otherwise expressly
established in Appendix F of this Agreement.

b)
For services that the Contractor determines are a benefit under Medicare and
Medicaid, the Contractor agrees to offer Enrollees the right to pursue the
Medicare appeal procedures or the Medicaid Advantage Plus Action Appeals
and/or Grievance System in the manner described and provided for in Appendix F
of this Agreement.

 
14.2
   Filing and Modification of Medicaid Advantage Plus Action Appeals and/or
Grievance Procedures

 
a)
The Contractor's Action and Grievance System Procedures governing services
determined by the Contractor to be a Medicaid only benefit and services
determined by the Contractor to be a benefit under both Medicare and Medicaid
shall be approved by the SDOH and kept on file with the Contractor and SDOH.

Medicaid Advantage Plus Contract
2007
ORGANIZATION DETERMINTION ACTIONS
AND GRIEVANCE SYSTEM
SECTION 14
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b)
The Contractor shall not modify its Action and Grievance System Procedures
without the prior written approval of SDOH.

14.3  Medicaid Advantage Plus Action and Grievance System Additional Provisions

a)
The Contractor must have in place effective mechanisms to ensure consistent
application of review criteria for Service Authorization Determinations and
consult with the requesting provider when appropriate.

b)
If the Contractor subcontracts for Service Authorization Determinations and
utilization review, the Contractor must ensure that its subcontractors have in
place and follow written policies and procedures for delegated activities
regarding processing requests for initial and continuing authorization of
services consistent with Article 49 of the PHL, 10 NYCRR Part 98,42 CFR Part
438, Appendix F of this Agreement, and the Contractor's policies and procedures.

c)
The Contractor must ensure that compensation to individuals or entities that
perform Service Authorization and utilization management activities is not
structured to include incentives that would result in the denial, limiting, or
discontinuance of Medically Necessary services to Enrollees.

d)
The Contractor or its subcontractors may not arbitrarily deny or reduce the
amount, duration, or scope of a covered service solely because of the diagnosis,
type of illness, Enrollee's condition, or cost of services. The Contractor may
place appropriate limits on a service on the basis of criteria such as Medical
Necessity or utilization control, provided that the services furnished can
reasonably be expected to achieve their purpose.

e)
The Contractor shall ensure that its Medicaid Advantage Plus Grievance System
includes methods for prompt internal adjudication of Enrollee Complaints,
Complaint Appeals and Action Appeals and provides for the maintenance of a
written record of all Complaints, Complaint Appeals and Action Appeals received
and reviewed and their disposition, as specified in Appendix F of this
Agreement.

f)
The Contractor shall ensure that persons with authority to require corrective
action participate in the Medicaid Advantage Plus Grievance System.

g)
The Contractor's Grievance System Procedures for services determined by the
Contractor to be a Medicaid only benefit and services determined by the
Contractor to be a benefit under both Medicare and Medicaid shall be described
in the Contractor's Medicaid Advantage Plus member handbook and shall be made
available to all Medicaid Advantage Plus Enrollees.

Medicaid Advantage Plus Contract
2007
ORGANIZATION DETERMINTION ACTIONS
AND GRIEVANCE SYSTEM
SECTION 14
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When the Contractor makes a final adverse determination about an Action it has
taken, the Contractor will advise Enrollees of their right to a fair hearing as
appropriate and comply with the procedures established by SDOH for the
Contractor to participate in the fair hearing process, as set forth in Section
24 of this Agreement. Such procedures shall include the provision of a Medicaid
notice in accordance with 42 CFR 438.210 and 438.404.

When the Contractor makes a final adverse determination about an Action it has
taken, the Contractor will also advise Enrollees of their right to an External
Appeal, related to services determined by the Contractor to be a Medicaid only
benefit or services determined by the Contractor to be a benefit under both
Medicare and Medicaid, in accordance with Section 25 of this Agreement.

 
The Contractor will provide written notice to all Participating Providers, and
subcontractors to whom the Contractor has delegated utilization review and
Service Authorization Determination procedures, at the time they enter into an
agreement with the Contractor, of the following Medicaid Advantage Plus
Complaint, Complaint Appeal, Action Appeal and fair hearing procedures and when
such procedures may be applicable:

 

 i)
 the Enrollee's right to a fair hearing, how to obtain a fair hearing, and
representation rules at a hearing;
 

ii)
 the Enrollee's right to an External Appeal and how to request an External
appeal;

iii)
the Enrollee's right to file Complaints, Complaint Appeals and Action Appeals
and the process and timeframes for filing;

iv)
the Enrollee's right to designate a representative to file Complaints, Complaint
Appeals and Action Appeals on his/her behalf;

v)
the availability of assistance from the Contractor for filing Complaints,
Complaint Appeals and Action Appeals;

vi)
the toll-free numbers to file oral Complaints, Complaint Appeals and Action
Appeals;

vii)
the Enrollee's right to request continuation of benefits while an Action Appeal
or state fair hearing of the Contractor's decision to terminate, reduce or
suspend a service is pending, and that if the Contractor's Action is upheld in a
hearing, the Enrollee may be liable for the cost of any continued benefits;

Medicaid Advantage Plus Contract
2007
ORGANIZATION DETERMINTION ACTIONS
AND GRIEVANCE SYSTEM
SECTION 14
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viii)
the right of the provider to reconsideration of an Adverse Determination
pursuant to § 4903(6) of the PHL; and

ix)
the right of the provider to appeal a retrospective Adverse Determination
pursuant to § 4904(1) of the PHL.

14.4  Complaint Investigation Determinations

The Contractor must adhere to determinations resulting from investigations
regarding complaints filed with the SDOH.

Medicaid Advantage Plus Contract
2007
ORGANIZATION DETERMINTION ACTIONS
AND GRIEVANCE SYSTEM
SECTION 14

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15.  ACCESS REQUIREMENTS

a)
The Contractor agrees to provide Enrollees access to Medicare Advantage Benefit
Package and Medicaid Advantage Plus Benefit Package Services as described in
Appendix K-1 and K-2 of this Agreement in a manner consistent with
professionally recognized standards of health care and access standards required
by applicable federal and state law.

b)
The Contractor will establish and implement mechanisms to ensure that
Participating Providers comply with timely access requirements, monitor
regularly to determine compliance and take corrective action if there is a
failure to comply.

c)
The Contractor will participate in the State's efforts to promote the delivery
of services in a culturally competent manner to all Enrollees, including those
with limited English proficiency and diverse cultural and ethnic backgrounds.

Medicaid Advantage Plus Contract
2007
ACCESS REQUIREMENTS
SECTION 15
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16.  QUALITY MANAGEMENT AND PERFORMANCE IMPROVEMENT

16.1  Quality Management and Performance Improvement Program

The Contractor agrees to operate an ongoing quality management and performance
improvement program in accordance with § 1852 (e) of the Social Security Act
("SSA") 42 CFR 422.152 and 42 CFR 438.240, and all applicable New York State law
and regulations.

16.2  Chronic Care Improvement Program

The Contractor agrees to conduct a Chronic Care Improvement Program (CCIP)
relevant to its membership as directed by CMS and to submit the annual report on
the Contractor's CCIP to CMS and SDOH.

16.3  Reporting

The Contractor agrees to conduct performance improvement projects and to measure
performance using standard measures required by CMS, and to report results to
CMS and SDOH, if required by CMS. Standard measures may include:

•        Health Plan and Employer Data Information Set (HEDIS);

•        Consumer Assessment of Health Plan Survey (CAHPS); and
•        Health Outcomes Survey (HOS).

16.4 Quality Indicators and Standards

The Contractor agrees to participate with SDOH in the development and
implementation of quality indicators and standards specific to the long term
care services furnished to Enrollees, pursuant to the terms of this Agreement.

16.5 External Quality Review

The Contractor agrees to cooperate with any external quality review conducted by
or at the direction of the Department or DHHS.

Medicaid Advantage Plus Contract
2007
QUALITY MANAGEMENT AND
PERFORMANCE IMPROVEMENT
SECTION 16
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17. MONITORING AND EVALUATION

17.1 Right to Monitor Contractor Performance

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

17.2  Cooperation During Monitoring and Evaluation

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

17.3  Cooperation During On- Site Reviews

The Contractor shall cooperate with SDOH and/or its designee and DHHS in any
on-site review of the Contractor's operations.

Medicaid Advantage Plus Contract
2007
MONITORING AND EVALUATION
SECTION 17
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18. CONTRACTOR REPORTING REQUIREMENTS

18.1  General Requirements

a)
TheContractor must maintain a health information system that collects, analyzes,
integrates and reports data. The system must be sufficient to provide the data
necessary to comply with the requirements of this Agreement.

b)
The Contractor must take steps to ensure that data entered into the system,
particularly that received from Participating Providers, is accurate and
complete.

c)
The Contractor must make collected information available to CMS and SDOH, as
requested under this Agreement.

18.2  Time Frames for Report Submissions

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

18.3  SDOH Instructions for Report Submissions

SDOH will provide Contractor with instructions for submitting the reports
required by Section 18.6 (a)(i) through (x) of this Agreement, including time
frames, and requisite formats. The instructions, time frames and formats may be
modified by SDOH upon sixty (60) days written notice to the Contractor.

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

SDOH may extend due dates, or modify report requirements or formats upon a
written request by the Contractor to the SDOH, where the Contractor has
demonstrated a good and compelling reason for the extension or modification. The
determination to grant a modification or extension of time shall be made by the
SDOH.

18.5  Reporting Requirements

 
a)  The Contractor shall submit the following reports to SDOH (unless otherwise
specified). The Contractor will certify the data submitted pursuant to this
section as required by SDOH. The certification shall be in the manner and format
established by SDOH and must attest, based on best knowledge, information, and
belief to the accuracy, completeness and truthfulness of the data being
submitted.

Medicaid Advantage Plus Contract

2007

CONTRACTOR REPORTING REQUIREMENTS
SECTION 18
-1-

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i)   Annual Financial Statements:

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

ii) Quarterly Financial Statements:

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

iii) Other Financial Reports:

Contractor shall submit financial reports, including certified annual financial
statements, and make available documents relevant to its financial condition to
SDOH and the State Insurance Department (SID) in a timely manner as required by
State laws and regulations including, but not limited to, PHL § 4403-a § 4404
and § 4409, Title 10 NYCRR Part 98 and when applicable, State Insurance Law §§
304, 305, 306, and 310. The SDOH may require the Contractor to submit such
relevant financial reports and documents related to its financial condition to
the LDSS.

iv) Encounter Data:

The Contractor shall prepare and submit encounter data on a monthly basis to
SDOH through SDOH's designated Fiscal Agent. Each provider is required to have a
unique identifier. Submissions shall be comprised of encounter records, or
adjustments to previously submitted records, which the Contractor has received
and processed from provider encounter or claim records of any contracted
services rendered to the Enrollee in the current or any preceding months,
including both Medicare and Medicaid covered services. Monthly submissions must
be received by the Fiscal Agent in accordance with the time frames specified in
the MEDS II data dictionary on the HPN to assure the submission is included in
the Fiscal Agent's monthly production processing.

v) Quality of Care Performance Measures:

The Contractor shall prepare and submit reports to SDOH, as specified by CMS for
the Medicare Advantage Program. Reports should be duplicative of reports
submitted to CMS, and separate reports for the dual eligible population are not
required.

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vi)   Complaint and Action Appeal Reports:

A)
The Contractor must provide the SDOH on a quarterly basis, and within fifteen
(15) business days of the close of the quarter, a summary of all Complaints and
Action Appeals subject to PHL §4408-a and 42 CFR 438 Subpart F received during
the preceding quarter related to Medicaid Only Covered Services and services
determined by the Contractor to be a benefit under both Medicare and Medicaid in
a manner directed by SDOH.

B)
The Contractor also agrees to provide on a quarterly basis, or in a manner
directed by SDOH, the total number of Complaints and Action Appeals subject to
PHL §4408-a and 42 CFR 438 Subpart F and related to Medicaid Only Covered
Services and services determined by the Contractor to be a benefit under both
Medicare and Medicaid that have been unresolved for more than forty-five (45)
days. The Contractor shall maintain records on these and other Complaints,
Complaint Appeals and Action Appeals pursuant to Appendix F of this Agreement.

C)
Nothing in this Section is intended to limit the right of the SDOH or its
designee to obtain information immediately from a Contractor pursuant to
investigating a particular Enrollee or provider Complaint, Complaint Appeal or
Action Appeal.

vii)  Fraud and Abuse Reporting Requirements:

A)
The Contractor must submit quarterly, in a format acceptable to SDOH, the number
of Complaints of fraud or abuse made to the Contractor related to Medicaid Only
Covered Services identified in Appendix K-2 and services covered jointly by
Medicare and Medicaid that warrant preliminary investigation by the Contractor.

B)
The Contractor must also submit to the SDOH the following on an ongoing basis
for each confirmed case of fraud or abuse it identifies through Complaints,
organizational monitoring, contractors, subcontractors, providers,
beneficiaries, Enrollees, etc related to Medicaid Only Covered Services
identified in Appendix K-2:

1)
The name of the individual or entity that committed the fraud or abuse;

2)   The source that identified the fraud or abuse;

                

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3)
The type of provider, entity or organization that committed the fraud or abuse;

4)  A description of the fraud or abuse;

5) The approximate dollar amount of the fraud or abuse;

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

7) Other data/information as prescribed by SDOH.

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

viii)  Participating Provider Network Reports:

The Contractor shall submit electronically to the HPN or any other manner
acceptable to SDOH, an updated provider network report on a quarterly basis for
providers of services described in Appendix K-2. The Contractor shall submit an
annual notarized attestation that the providers listed in each submission have
executed an agreement with the Contractor to serve Contractor's Medicaid
Enrollees. Networks must be reported separately for each county in which the
Contractor operates.

ix) Quality Assessment and Performance Improvement Projects:

a)
The Contractor will submit reports to SDOH on all quality assessment and
performance improvement projects directed by CMS for the Medicare Advantage
Program, including the annual report on the Contractor's Chronic Care
Improvement Program. Reports should be duplicative of reports submitted to CMS,
and separate reports for the dual eligible population are not required.

b) Performance Improvement Projects

 
The Contractor will be required to conduct performance improvement projects that
focus on clinical and non-clinical areas consistent with the requirements of 42
CFR 438.240. The purpose of these studies will be to promote quality improvement
within the managed long-term care plan. At least one (1) performance improvement
project each year will be selected as a priority and approved by the Department.
Results of each of these annual studies will be provided to the Department in a
required format. Results of other performance improvement projects will be
included in the minutes of the quality committee and reported to the Department
upon request.

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x)  Enrollee Health and Functional Status:

The Contractor shall submit Enrollee health and functional status data for each
of their Enrollees in the format and according to the timeframes specified by
the SDOH. The data shall consist of Semi-Annual Assessment of Members (SAAM) or
any other such instrument the SDOH may request. The data shall be submitted at
least semi-annually or on a more frequent basis if requested by the SDOH.

xi)  Disenrollment Report:

This report is to be completed twice a year. The first report will cover the
operation of the demonstration for the period January 1 through June 30. The
second report will cover the period from July 1 through December 31. The
completed report is to be provided to the SDOH within sixty (60) days after the
period in a format to be specified by the SDOH.

xii)  Additional Reports:

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

18.6  Ownership and Related Information Disclosure

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

18.7  Data Certification

The Contractor shall comply with the data certification requirements in 42 CFR
438.604 and 438.606.

a)
The types of data subject to certification include, but are not limited to,
enrollment information, encounter data, the premium proposal, contracts and all
other financial data. The certification shall be in a format prescribed by the
Department and must be sent at the time the report or data are submitted.

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b)
 The certification shall be signed by the Plan's Chief Executive Officer, the
Chief Financial Officer or an individual with designated authority; and, the
certification shall attest to the accuracy, completeness and truthfulness of the
data.

18.8  Public Access to Reports

Any data, information, or reports collected and prepared by the Contractor and
submitted to NYS authorities in the course of performing their duties and
obligation under this program will be deemed to be a record of the SDOH subject
to and consistent with the requirements of Freedom of Information Law. This
provision is made in consideration of the Contractor's participation in the
Medicaid Advantage Plus Program for which the data and information is collected,
reported, prepared and submitted.
 
18.9  Certification Regarding Individuals Who Have Been Debarred Or Suspended By
Federal, State, or Local Government
 
Contractor will certify to the SDOH initially and immediately upon changed
circumstances from the last such certification that it does not knowingly have
an individual who has been debarred or suspended by the federal, state or local
government, or otherwise excluded from participating in procurement activities:

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

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

18.10   Conflict of Interest Disclosure

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

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18.11   Physician Incentive Plan Reporting

The Contractor shall submit to SDOH annual reports containing the information on
all of its Physician Incentive Plan arrangements in accordance with 42 CFR 438.6
(h) or, if no such arrangements are in place, attest to that. The contents and
time frame of such reports shall comply with the requirements of 42 CFR 422.208
and 422.210 and be in a format provided by SDOH.

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19.  RECORDS MAINTENANCE AND AUDIT RIGHTS

19.1  Maintenance of Contractor Performance Records

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

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 and expenses incurred
under this Agreement, and

iii) 
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)
Credentials for subcontractors and providers used by subcontractors shall be
maintained in a manner accessible to the Contractor and furnished to the
Department, upon request.

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

19.2  Maintenance of Financial Records and Statistical Data

The Contractor shall maintain all financial records and statistical data
according to generally accepted accounting and/or statutory accounting
principles where applicable.

19.3Access 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) of such records. The Contractor shall
give access to such records on two (2) business days prior written notice,
during normal business hours, unless otherwise provided or permitted by
applicable laws, rules, or regulations.

 
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19.4    Retention Periods

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

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20.CONFIDENTIALITY
 
20.1  Confidentiality of Identifying Information about Enrollees, Potential
Enrollees and Applicants

All information relating to services to Enrollees, Eligible Persons and
Potential Enrollees which is obtained by the Contractor shall be confidential
pursuant to the PHL including PHL Article 27-F, the provisions of § 369(4) of
the SSL,  42 U.S.C. § 1396a (a)(7) (§ 1902(a)(7) of SSA), § 33.13 of the Mental
Hygiene Law, and regulations promulgated under such laws including 42 CFR
422.118 and 42 CFR Part 2 pertaining to Alcohol and Substance Abuse Services.
Such information including information relating to services provided to
Enrollees, Potential Enrollees and Applicants under this Agreement shall be used
or disclosed by the Contractor only for a purpose directly connected with
performance of the Contractor's obligations. It shall be the responsibility of
the Contractor to inform its employees and contractors of the confidential
nature of Medicaid information.

20.2  Confidentiality of Medical Records

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

20.3  Length of Confidentiality Requirements

The provisions of this Section shall survive the termination of this Agreement
and shall bind the Contractor so long as the Contractor maintains any
individually identifiable information relating to Enrollees, Potential Enrollees
and Applicants.

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21.  PARTICIPATING PROVIDERS

21.1  General Requirements

a)
The Contractor agrees to comply with all applicable requirements and standards
set forth at 42 CFR 422.112, Subpart C; 422, Subpart E; 422.504(a)(6) and
422.504(i), Subpart K; 423, Subpart C and other applicable federal laws and
regulations related to MCO relationships with providers and with related
entities, contractors and subcontractors for services in the Contractor's
Medicare Advantage Product.

b)
The Contractor agrees to comply with all applicable requirements and standards
set forth at PHL Article 44,10 NYCRR Part 98, and other applicable federal and
state laws and regulations related to MCO relationships with providers and with
related entities, contractors and subcontractors for services in the
Contractor's Medicaid Advantage Plus Product.

21.2  Medicaid Advantage Plus Network Requirements

a)
The Contractor agrees to allow each Enrollee the choice of Participating
Provider of covered service to the extent possible and appropriate.

b)
The Contractor agrees to maintain and demonstrate to the Department's
satisfaction, a sufficient and adequate network for the delivery of all covered
services either directly or through subcontracts. The Contractor shall meet
applicable federal and state standards regarding adequacy of provider network
capacity. If the network is unable to provide necessary services under this
Contract for a particular Enrollee, the Contractor agrees to adequately and
timely furnish these services outside of the Contractor's network for as long as
the Contractor is unable to provide them within the network.

c)
In establishing the network, the Contractor must consider the following:
anticipated Enrollment, expected utilization of Medicaid Advantage Plus services
by the population to be enrolled, the number and types of providers necessary to
furnish the services in the Medicaid Advantage Plus Benefit Package, the number
of providers who are not accepting new patients, and the geographic location of
the providers and Enrollees.

d)
The Contractor's Medicaid Advantage Plus Plan network must contain all of the
provider types necessary to furnish the services identified in Appendix K-2.

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

 
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f) 
The Contractor shall not include in its network any provider who has been
sanctioned or prohibited from participation in Federal health care programs
under either § 1128 or § 1128 A of the SSA, or who has had his/her license
suspended by the New York State Education Department or the SDOH Office of
Professional Medical Conduct.

21.3  Professional Discipline

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

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

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

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

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

21.4   SDOH Exclusion or Termination of Providers

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

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21.5  Payment in Full

Contractor must limit participation to providers who agree that payment received
from the Contractor for services included in the Medicare and Medicaid Advantage
Plus Benefit Packages is payment in full for services provided to Enrollees,
except for the collection of applicable co-payments from Enrollees as provided
by law.

21.6    Dental Networks

The Contractor's dental network shall include geographically accessible general
dentists sufficient to offer each Enrollee a choice of two (2) primary care
dentists in their Service Area and to achieve a ratio of at least one (1)
primary care dentist for each 2,000 Enrollees. Networks must also include at
least one (1) oral surgeon. Orthognathic surgery, temporal mandibular disorders
(TMD) and oral/maxillofacial prosthodontics must be provided through any
qualified dentist, either in-network or by referral. Periodontists and
endodontists must also be available by referral.

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22. SUBCONTRACTS AND PROVIDER AGREEMENTS FOR MEDICAID ADVANTAGE PLUS COVERED
SERVICES

22.1  Written Subcontracts

a)
Contractor may not enter into any subcontracts related to the delivery of the
services identified in Appendix K-2 except by a written agreement.

b)
If the Contractor enters into subcontracts for the performance of work pursuant
to this Agreement, the Contractor shall retain full responsibility for
performance of the subcontracted services. Nothing in this subcontract shall
impair the rights of the State under this Agreement. No sub-contractual
relationship shall be deemed to exist between the subcontractor and the SDOH or
the State. The Contractor shall oversee and is accountable to the Department for
all functions and responsibilities that are described in this Contract.

c)
The delegation by the Contractor of its responsibilities assumed by this
Agreement to any subcontractors will be limited to those specified in the
subcontracts. The Contractor may only delegate activities or functions to a
subcontractor in a manner consistent with requirements set forth in this
Contract, 42 CFR 434 and 438 and applicable State law and regulations.

22.2  Permissible Subcontracts

Contractor may subcontract for provider services as set forth in Section 2.6 and
21 of this Agreement, for management services and for other services as are
acceptable to the SDOH. The Contractor must evaluate the prospective
subcontractor's ability to perform the activities to be delegated.

22.3  Provision of Services through Provider Agreements

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

22.4  Approvals

a)
Provider Agreements related to Medicaid Only Covered Services shall require the
approval of SDOH as set forth in PHL § 4402 and 10 NYCRR Part 98.

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b)
The Contractor may only delegate management responsibilities as defined by State
regulation by means of a Department approved management services agreement. Both
the proposed management services agreement and the proposed management entity
must be approved by the Department pursuant to the provisions of 10 NYCRR Part
98-1.11 before any such agreement may be become effective.

c)
The Contractor shall notify SDOH of any material amendments to any such Provider
Agreement as set forth in 10 NYCRR Part 98.

22.5    Required Components

a)    All subcontracts, including Provider Agreements entered into by the
Contractor to provide program services under this Agreement shall contain
provisions specifying:
i) 
 the activities and reporting responsibilities delegated to the subcontractor,
and provide for revoking the delegation, in whole or in part, and imposing other
sanctions if the subcontractor's performance does not satisfy standards set
forth in this Agreement, and an obligation for the provider to take corrective
action;

ii)
that the Contractor will provide, no less than thirty (30) days prior to
implementation, any new rules or policies and procedures regarding quality
improvement, service authorizations, member appeals and grievances and provider
credentialing, or any changes thereto, to a the subcontractor;

iii) 
that the credentials of affiliated professionals or other health care providers
will be reviewed directly by the Contractor; or the credentialing process of the
subcontractor will be reviewed and approved by the Contractor and the Contractor
must audit the credentialing process on an ongoing basis;

iv) 
how the subcontractor shall participate in the Contractor's quality assurance,
service authorization and grievance and appeals processes;, and the monitoring
and evaluation of the Contractor's plan;

v)
how the subcontractor will insure that pertinent contracts, books, documents,
papers and records of their operations are available to the Department, HHS,
Comptroller of the State of New York, Comptroller General of the United States
and/or their respective designated representatives, for inspection, evaluation
and audit, through six years from the final date of the subcontract or from the
date of completion of any audit, whichever is later; vi)  that the work
performed by the subcontractor must be in accordance with the terms of this
Agreement, and

vii) 
that the subcontractor specifically agrees to be bound by the confidentiality
provisions set forth in this Agreement.

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b)
Any services or other activities performed by a subcontractor in accordance with
a contract between the subcontractor and the Contractor will be consistent and
comply with the Contractor's obligations under this Contract and applicable
state and federal laws and regulations.

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

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

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

f)
Nothing contained in this Agreement shall create any contractual relationship
between any subcontractor of the Contractor, including its Participating
Providers, and the SDOH.

g)
Any subcontract entered into by the Contractor shall fulfill the requirements of
42 CFR 434 and 438 that are appropriate to the service or activity delegated
under such subcontract.

h)
The Contractor shall also ensure that, in the event the Contractor fails to pay
any subcontractor, including any Participating Provider in accordance with the
subcontract or Provider Agreement, the subcontractor or Participating Provider
will not seek payment from the SDOH, LDSS, the Enrollees, or persons acting on
an Enrollee's behalf.

i)
The Contractor shall include in every Provider Agreement a procedure for the
resolution of disputes between the Contractor and its Participating Providers.
Any and all such disputes shall be resolved using the Department's
interpretation of the terms and provisions of this Contract, and portions of
subcontracts executed hereunder that relate to services pursuant to this
Contract. If a subcontract provides for arbitration or mediation, it shall
expressly acknowledge that the Commissioner of the Department of Health is not
bound by arbitration or mediation decisions. Arbitration or mediation must occur
within New York State, and the subcontract shall provide that the Commissioner
will be given notice of all issues going to arbitration or mediation, and copies
of all decisions.

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j)
The Contractor must monitor the subcontractor's performance on an ongoing basis
and subject it to formal review according to time frames established by the
State, consistent with State laws and regulations, and the terms of this
Agreement. When deficiencies or areas for improvement are identified, the
Contractor and subcontractor must take corrective action.

22.6  Timely Payment

Contractor shall make payments to health care providers for items and services
included in the Contractor's Medicaid Advantage Plus Product on a timely basis,
consistent with the claims payment procedures described in SIL § 3224-a.

22.7  Recovery of Overpayments to Providers

Consistent with the exception language in Section 3324-b of the Insurance Law,
the Contractor shall 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.

22.8  Physician Incentive Plan

a)
If Contractor elects to operate a Physician Incentive Plan, Contractor agrees
that no specific payment will be made directly or indirectly under the plan to a
physician or physician group as an inducement to reduce or limit medically
necessary services furnished to an Enrollee. Contractor agrees to submit to SDOH
annual reports containing the information on its physician incentive plan in
accordance with 42 CFR 438.6 (h). The contents of such reports shall comply with
the requirements of 42 CFR 422.208 and 422.210 and be in a format to be provided
by SDOH.

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

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

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

22.9  Provider Termination Notice

The Contractor shall provide the Department at least sixty (60) days notice
prior to the termination of any subcontract, the termination of which would
preclude an Enrollee's access to a covered service by provider type under this
Agreement, and specify how services previously furnished by the subcontractor
will be provided. In the event a subcontract is terminated on less than sixty
(60) days notice, the Contractor shall notify the Department immediately but in
no event more than seventy-two (72) hours after notice of termination is either
issued or received by the Contractor.

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23.  AMERICANS WITH DISABILITIES ACT COMPLIANCE PLAN

Contractor must comply with Title II of the ADA and § 504 of the Rehabilitation
Act of 1973 for program accessibility, and must develop an ADA Compliance Plan
consistent with the applicable SDOH Guidelines for Medicaid MCO Compliance with
the ADA set forth in Appendix J, which is hereby made a part of this Agreement
as if set forth fully herein. Said plan must be approved by the SDOH, be filed
with the SDOH and be kept on file by the Contractor.
24.  FAIR HEARINGS

24.1  Enrollee Access to Fair Hearing Process

Enrollees in the Contractor's Medicaid Advantage Plus Product may access the
fair hearing process related to services determined by the Contractor to be a
Medicaid only benefit or services determined by the Contractor to be a benefit
under both Medicare and Medicaid in accordance with applicable federal and state
laws and regulations, if the member elects to use the Medicaid appeal process.
The Contractor must abide by and participate in New York State's Fair Hearing
Process and comply with determinations made by a fair hearing officer.

24.2  Enrollee Rights to a Fair Hearing

Enrollees in the Contractor's Medicaid Advantage Plus Product may request a fair
hearing regarding adverse LDSS determinations concerning enrollment,
disenrollment and eligibility, and regarding the denial, termination, suspension
or reduction of a service determined by the Contractor to be a Medicaid only
benefit or a benefit under both Medicare and Medicaid, if the member elects to
use the Medicaid appeal process.. For issues related to disputed services,
Enrollees must have received a final adverse determination on Appeal from the
Contractor or its approved utilization review agent confirming an initial
adverse determination to deny services or terminate, suspend or reduce services
the Enrollee is currently receiving during his or her service authorization
period. An Enrollee may also seek a fair hearing for a failure by the Contractor
to act with reasonable promptness with respect to such services. Reasonable
promptness shall mean compliance with the time frames established for review of
grievances and utilization review in Articles 44 and 49 of the Public Health
Law, the grievance system requirements of 42 CFR 438 and Appendix F of this
Agreement.

24.3  Contractor Notice to Enrollees

a)
Pursuant to Appendix F of this Agreement, the Contractor must issue a written
Notice of Action to any Enrollee when taking an adverse Action and when making
an Action Appeal determination, issue a notice of the right to request a fair
hearing within applicable timeframes when the service is determined by the
Contractor to be a Medicaid only benefit or a benefit under both Medicare and
Medicaid. If the service is a benefit under both Medicare and Medicaid, the
Enrollee is advised of his or her right to elect either the Medicare or Medicaid
appeals process.

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b)
Contractor agrees to serve notice on affected Enrollees by mail and must
maintain documentation of such.

24.4  Aid Continuing

a)
Contractor shall be required to continue the provision of services determined by
the Contractor to be a Medicaid only benefit or a benefit under both Medicare
and Medicaid that are the subject of the fair hearing to an Enrollee
(hereafter referred to as "aid continuing") if so ordered by the O AH under the
following circumstances:

 
 
i) Contractor has or is seeking to reduce, suspend or terminate such service or
treatment currently authorized;
ii) Enrollee has filed a timely request for a fair hearing with OAH; and
iii) There is a valid order for the service or treatment from a Participating
Provider when the requirement for such an order is identified in the
Contractor's service authorization criteria approved by SDOH.

 
b)
Contractor shall provide aid continuing until the matter has been resolved to
the Enrollee's satisfaction or until the administrative process is completed and
there is a determination from OAH that Enrollee is not entitled to receive the
service, the Enrollee withdraws the request for aid continuing and/or the fair
hearing or the service or treatment originally ordered by the provider has been
completed, whichever occurs first.

c)
If the services and/or benefits in dispute have been terminated, suspended or
reduced and the Enrollee requests a fair hearing in a timely manner, Contractor
shall, at the direction of the LDSS, restore the disputed services and/or
benefits consistent with the provisions of Section 24.4(a) of this Agreement.

24.5 Contractor's Obligations

a) 
Contractor shall appear at all scheduled fair hearings concerning its clinical
determinations and/or Contractor-initiated Disenrollments and/or Contactor
recommended denials of enrollment to present evidence as justification for its
determination or submit written evidence as justification for its determination
regarding the disputed benefits and/or services. If Contractor will not be
making a personal appearance at the fair hearing, the written material must be
submitted to OAH and Enrollee or Enrollee's representative at least three (3)
business days prior to the scheduled hearing. If the hearing is scheduled fewer
than three (3) business days after the request, Contractor must deliver the
evidence to the hearing site no later than one (1) business day prior to the
hearing, otherwise Contractor must appear in person. Notwithstanding the above
provisions, Contractor may be required to make a personal appearance at the
discretion of the hearing officer and/or SDOH.

 

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b)
Despite an Enrollee's request for a State fair hearing in any given dispute,
Contractor is required to maintain and operate in good faith its own internal
Complaint and Appeal processes for services determined by the Contractor to be a
Medicaid only benefit or a benefit under both Medicare and Medicaid as required
under state and federal laws and by Section 14 and Appendix F of this Agreement.
Enrollees may only request a State fair hearing and/or External Appeal as a
result of the Contractor's Final Adverse Determinations.

c)
Contractor shall comply with all determinations rendered by OAH at fair
hearings. Failure by Contractor to maintain such compliance shall constitute
breach of this Agreement. Nothing in this Section shall limit the remedies
available to SDOH, LDSS or the federal government relating to any non­compliance
by Contractor with a fair hearing determination or Contractor's refusal to
provide disputed services.

d)
If SDOH, through its Complaint investigation process, or OAH, by a determination
after a fair hearing, directs Contractor to provide a service that was denied by
Contractor, Contractor may either directly provide the service, arrange for the
provision of that service or pay for the provision of that service by a
Non-Participating Provider. If the services were not furnished during the period
in which the fair hearing was pending, the Contractor must authorize and furnish
the disputed services promptly and as expeditiously as the Enrollee's health
condition requires.

e)
Contractor agrees to abide by changes made to this Section of the Agreement with
respect to the fair hearing, Service Authorization, Action, Action Appeal,
Complaint and Complaint Appeal processes by SDOH in order to comply with any
amendments to applicable state or federal statutes or regulations.

f)
Contractor agrees to identify a contact person within its organization who will
serve as a liaison to OAH for the purpose of receiving fair hearing requests,
scheduled fair hearing dates and adjourned fair hearing dates and compliance
with State directives. Such individual shall be accessible to the State by
e-mail; shall monitor e-mail for correspondence from the State at least once
every business day; and shall agree, on behalf of Contractor, to accept notices
to the Contractor transmitted via e-mail as legally valid.

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g)
 The information describing fair hearing rights, aid continuing, Service
Authorization, Action Appeal, Complaint and Complaint Appeal procedures shall be
included in all Medicaid Advantage Plus member handbooks and shall comply with
Section 14, and Appendix F of this Agreement.

h)
 Contractor shall bear the burden of proof at hearings regarding the reduction,
suspension or termination of ongoing services determined by the Contractor to be
a Medicaid only benefit or a benefit under both Medicare and Medicaid. In the
event that Contractor's final adverse determination is upheld as a result of a
fair hearing, any aid continuing provided pursuant to that hearing request, may
be recouped by Contractor.

25. EXTERNAL APPEAL

25.1  Basis for External Appeal

Enrollees in the Contractor's Medicaid Advantage Plus Product are eligible to
request an External Appeal when one or more health care services determined by
the Contractor to be a Medicaid only benefit or a benefit under both Medicare
and Medicaid has been denied by the Contractor on the basis that the service(s)
is not medically necessary or is experimental or investigational.

25.2  Eligibility for External Appeal

An Enrollee is eligible for an External Appeal when the Enrollee has received a
final adverse determination from the Contractor, or both the Enrollee and the
Contractor have agreed to waive internal Action Appeal procedures in accordance
with PHL § 4914 (2) 2 (a). A provider is also eligible for an External Appeal of
retrospective denials.

25.3  External Appeal Determination

The External Appeal determination is binding on the Contractor; however, a fair
hearing determination supersedes an external appeal determination for Medicaid
Advantage Plus Enrollees.

25.4  Compliance with External Appeal Laws and Regulations

The Contractor must comply with the provisions of §§ 4910-4914 of the PHL and 10
NYCRR Part 98 regarding the External Appeal program with respect to services
determined by the Contractor to be a Medicaid only benefit or a benefit under
both the Medicare and Medicaid programs.

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25.5 Member Handbook

The Contractor shall describe its action and utilization review policies and
procedures, including a notice of the right to an External Appeal together with
a description of the External Appeal process and the timeframes for External
Appeal in the Medicaid Advantage Plus Handbook.

26. INTERMEDIATE SANCTIONS

26.1  General

Contractor is subject to imposition of sanctions as authorized by 42 CFR 422,
Subpart O. In addition, for the Medicaid Advantage Plus Program, the Contractor
is subject to the imposition of sanctions as authorized by State and Federal law
and regulation, including the SDOH's right to impose sanctions for unacceptable
practices as set forth in 18 NYCRR Part 515 and civil and monetary penalties as
set forth in 18 NYCRR Part 516 and 42 CFR 438.700, and such other sanctions and
penalties as are authorized by local laws and ordinances and resultant
administrative codes, rules and regulations related to the Medical Assistance
Program or to the delivery of the contracted for services.

26.2  Unacceptable Practices

 
a)  Unacceptable practices for which the Contractor may be sanctioned include,
but are not limited to:

 
i)  Failing to provide medically necessary services that the Contractor is
required to provide under its contract with the State.

 
ii)  Imposing premiums or charges on Enrollees that are in excess of the
premiums or charges permitted under the Medicaid Advantage Plus Program.

 
iii) Discriminating among Enrollees on the basis of their health status or need
for health care services.

 
iv) Misrepresenting or falsifying information that the Contractor furnishes to
an Enrollee, Eligible Persons, Potential Enrollees, health care providers, the
State or to CMS.

 
v) Failing to comply with the requirements for Physician Incentive Plans, as set
forth in 42 CFR 422.208 and 422.210.

 
vi) Distributing directly or through any agent or independent contractor,
marketing materials that have not been approved by CMS and the State or that
contain false or materially misleading information.

 
vii) Violating any other applicable requirements of SS A § § 1903 m) or 1932 and
any implementing regulations.

 
viii) Violating any other applicable requirements of 18 NYCRR or 10 NYCRR Part
98.

 
ix) Failing to comply with the terms of this Agreement.

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26.3  Intermediate Sanctions

Intermediate Sanctions may include, but are not limited to:

a)Civil and monetary penalties.
b) Suspension of all new Enrollment, after the effective date of the sanction.

c) Termination of the Agreement, pursuant to Section 2.7 of this Agreement.
 
26.4  Enrollment Limitations

The SDOH shall have the right, upon notice to the LDSS, to limit, suspend, or
terminate Enrollment activities by the Contractor and/or enrollment into the
Contractor's Medicaid Advantage Plus Product upon ten (10) days written notice
to the Contractor. The written notice shall specify the action(s) contemplated
and the reason(s) for such action(s) and shall provide the Contractor with an
opportunity to submit additional information that would support the conclusion
that limitation, suspension or termination of Enrollment activities or
Enrollment in the Contractor's plan is unnecessary. The Department reserves the
right to suspend enrollment immediately in situations involving imminent danger
to the health and safety of Enrollees. Nothing in this paragraph limits other
remedies available to the SDOH under this Agreement.

26.5Due Process

The Contractor will be afforded due process pursuant to federal and state law
and regulations (42 CFR 438.710,18 NYCRR Part 516, and Article 44 of the PHL).

ENVIRONMENTAL COMPLIANCE

The Contractor shall comply with all applicable standards, orders, or
requirements issued under Section 306 of the Clean Air Act (42 U.S.C. §
1857(h)), Section 508 of the Federal Water Pollution Control Act as
amended   (33 U.S.C. § 1368), Executive Order 11738, and the Environmental
Protection Agency ("EPA") regulations (40 CFR 15) that prohibit the use of the
facilities included on the EPA List of Violating Facilities. The Contractor
shall report violations to SDOH and to the Assistant Administrator for
Enforcement of the EPA.

ENERGY CONSERVATION

The Contractor shall comply with any applicable mandatory standards and policies
relating to energy efficiency that are contained in the State Energy
Conservation regulation issued in compliance with the Energy Policy and
Conservation Act of 1975 (Pub. L. 94-165) and any amendment to the Act.

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29.  INDEPENDENT CAPACITY OF CONTRACTOR

The parties agree that the Contractor is an independent Contractor, and that the
Contractor, its agents, officers, and employees act in an independent capacity
and not as officers or employees of LDSS, DHHS or the SDOH.

30.  NO THIRD PARTY BENEFICIARIES

Only the parties to this Agreement and their successors in interest and assigns
have any rights or remedies under or by reason of this Agreement.

31.  INDEMNIFICATION

31.1     Indemnification by Contractor

a)
The Contractor shall indemnify, defend, and hold harmless the SDOH and LDSS, and
their officers, agents, and employees and the Enrollees and their eligible
dependents from:

 

 i)   any and all claims and losses accruing or resulting to any and all
Contractors, subcontractors, materialmen, laborers, and any other person, firm,
or corporation furnishing or supplying work, services, materials, or supplies in
connection with the performance of this Agreement;

ii)
any and all claims and losses accruing or resulting to any person, firm, or
corporation that may be injured or damaged by the Contractor, its officers,
agents, employees, or subcontractors, including Participating Providers, in
connection with the performance of this Agreement, and

iii)
any liability, including costs and expenses, for violation of proprietary
rights, copyrights, or rights of privacy, arising out of the publication,
translation, reproduction, delivery, performance, use, or disposition of any
data furnished under this Agreement, or based on any libelous or otherwise
unlawful matter contained in such data.

b)
The SDOH will provide the Contractor with prompt written notice of any claim
made against the SDOH, and the Contractor, at its sole option, shall defend or
settle said claim. The SDOH shall cooperate with the Contractor to the extent
necessary for the Contractor to discharge its obligation under Section 31.1.

c)
The Contractor shall have no obligation under this section with respect to any
claim or cause of action for damages to persons or property solely caused by the
negligence of SDOH its employees, or agents.

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31.2  Indemnification by SDOH

Subject to the availability of lawful appropriations as required by State
Finance Law § 41, the SDOH agrees to indemnify and hold the Contractor harmless
from any liability, loss or damages, claim, suit or judgment, and all allowable
costs and expenses of any kind or nature, as determined by the New York State
Court of Claims and arising out of the actions or the omissions of the SDOH, its
officers, agents or employees in connection with this Agreement. 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.

32.  PROHIBITION ON USE OF FEDERAL FUNDS FOR LOBBYING

32.1  Prohibition of Use of Federal Funds for Lobbying

The Contractor agrees, pursuant to 31 U.S.C. § 1352 and 45 CFR 93, that no
Federally appropriated funds have been paid or will be paid to any person by or
on behalf of the Contractor for the purpose of influencing or attempting to
influence an officer or employee of any agency, a Member of Congress, an officer
or employee of Congress, or an employee of a Member of Congress in connection
with the award of any Federal contract, the making of any federal grant, the
making of any Federal loan, the entering into of any cooperative agreement, or
the extension, continuation, renewal, amendment, or modification of any Federal
contract, grant, loan, or cooperative agreement. The Contractor agrees to
complete and submit the "Certification Regarding Lobbying", Appendix B attached
hereto and incorporated herein, if this Agreement exceeds $100,000.

32.2  Disclosure Form to Report Lobbying

If any funds other than Federally appropriated funds have been paid or will be
paid to any person for the purpose of influencing or attempting to influence an
officer or employee of any agency, a Member of Congress, an officer or employee
of Congress, or an employee of a Member of Congress in connection with the award
of any Federal contract, the making of any Federal grant, the making of any
Federal loan, the entering into of any cooperative agreement, or the extension,
continuation, renewal, amendment, or modification of any Federal contract,
grant, loan, or cooperative agreement, and the Agreement exceeds $100,000, the
Contractor shall complete and submit Standard Form-LLL "Disclosure Form to
Report Lobbying," in accordance with its instructions.

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32.3     Requirements of Subcontractors

The Contractor shall include the provisions of this section in its subcontracts,
including its Provider Agreements. For all subcontracts, including Provider
Agreements, that exceed $100,000, the Contractor shall require the
subcontractor, including any Participating Provider to certify and disclose
accordingly to the Contractor.

33.  NON-DISCRIMINATION

33.1 Equal Access to Benefit Package

Except as otherwise provided in applicable sections of this Agreement the
Contractor shall provide the Medicaid Advantage Plus Benefit Package to all
Enrollees in the same manner, in accordance with the same standards, and with
the same priority as Enrollees of the Contractor enrolled under any other
contracts.

33.2 Non-Discrimination

The Contractor shall not discriminate against Eligible Persons or Enrollees on
the basis of age, sex, race, creed, physical or mental handicap/developmental
disability, national origin, sexual orientation, type of illness or condition,
need for health services, or Capitation Rate that the Contractor will receive
for such Eligible Persons or Enrollees.

33.3 Equal Employment Opportunity

Contractor must comply with Executive Order 11246, entitled "Equal Employment
Opportunity" as amended by Executive Order 11375, and as supplemented in
Department of Labor regulations.

33.4 Native Americans Access to Services from Tribal or Urban Indian Health
Facility

The Contractor shall not prohibit, restrict or discourage enrolled Native
Americans from receiving care from or accessing Medicaid reimbursed health
services from or through a tribal health or urban Indian health facility or
center.

34.  COMPLIANCE WITH APPLICABLE LAWS AND REGULATIONS

34.1     Contractor and SDOH Compliance with Applicable Laws

Notwithstanding any inconsistent provisions in this Agreement, the Contractor
and SDOH shall comply with all applicable requirements of the State Public
Health Law; the State Insurance Law; the State Social Services Law; and state

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regulations related to the aforementioned state statutes. Such state laws and
regulations shall not be deemed to be applicable to the extent that they are
pre­empted by federal laws. The Contractor also shall comply with Titles XVIII
and XIX of the Social Security Act and regulations promulgated thereunder,
including but not limited to 42 CFR 422,423 and 438; Title VI of the Civil
Rights Act of 1964 and 45 CFR. 80, as amended; § 504 of the Rehabilitation Act
of 1973 and 45 CFR. 84, as amended; Age Discrimination Act of 1975 and 45 CFR.
91, as amended; the ADA; Title XIII of the Federal Public Health Services Act,
42 U.S.C. § 300e et seq., and the regulations promulgated there under; the
Health Insurance Portability and Accountability Act of 1996 (P.L. 104-191) and
related regulations; and all other applicable legal and regulatory requirements
in effect at the time that this Agreement is signed and as adopted or amended
during the term of this Agreement. The parties agree that this Agreement shall
be interpreted according to the laws of the State of New York.

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

Should any provision of this Agreement be declared or found to be illegal or
unenforceable, ineffective or void, then each party shall be relieved of any
obligation arising from such provision; the balance of this Agreement, if
capable of performance, shall remain in full force and effect.

34.3  Certificate of Authority Requirements

The Contractor must satisfy conditions for issuance of a certificate of
authority, including proof of financial solvency, as specified in 10 NYCRR Part
98.

34.4  Notification of Changes in Certificate of Incorporation

The Contractor shall notify SDOH of any amendment to its Certificate of
Incorporation or Articles of Organization pursuant to 10 NYCRR Part 98.

34.5  Contractor's Financial Solvency Requirements

The Contractor, for the duration of this Agreement, shall remain in compliance
with all applicable state requirements for financial solvency for MCOs
participating in the Medicaid Program. The Contractor shall continue to be
financially responsible as defined in PHL §4403 (l)(c) and shall comply with the
contingent reserve fund and escrow deposit requirements of 10 NYCRR Part 98 and
must meet minimum net worth requirements established by SDOH and the State
Insurance Department. The Contractor shall make provision, satisfactory to SDOH,
for protections for SDOH, LDSS and the Enrollees in the event of HMO or
subcontractor insolvency, including but not limited to, hold harmless and
continuation of treatment provisions in all provider agreements which protect
SDOH, LDSSs and Enrollees from costs of treatment and assures continued access
to care for Enrollees.

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34.6 Non-Liability of Enrollees for Contractor's Debts

Contractor agrees that in no event shall the Enrollee become liable for the
Contractor's debts as set forth in SSA § 1932(b)(6).

34.7  SDOH Compliance with Conflict of Interest Laws

SDOH and its employees shall comply with Article 18 of the General Municipal Law
and all other appropriate provisions of New York State law, local laws and
ordinances and all resultant codes, rules and regulations pertaining to
conflicts of interest.

34.8  Compliance Plan

The Contractor agrees to implement a compliance plan in accordance with the
requirements of 42 CFR 422.503(b)(4)(vi) and 42 CFR 438.608.

35.  NEW YORK STATE STANDARD CONTRACT CLAUSES

The parties agree to be bound by the standard clauses for all New York State
contracts and standard clauses, if any, for local government contracts contained
in Appendix A, attached to and incorporated into this Agreement as if set forth
fully herein, and any amendment thereto.

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APPENDIX A
New York State Standard Contract Clauses
 
 

 
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STANDARD CLAUSES FOR NYS CONTRACTS

APPENDIX A

STANDARD CLAUSES FOR NYS CONTRACTS
 
The parties to the attached contract, license, lease, amendment or other
agreement of any kind (hereinafter, "the contract" or "this contract") agree to
be bound by the following clauses which are hereby made a part of the contract
(the word "Contractor" herein refers to any party other than the State, whether
a contractor, licenser, licensee, lessor, lessee or any other party):

1.EXECUTORY CLAUSE. In accordance with Section 41 of the State Finance Law, the
State shall have no liability under this contract to the Contractor or to anyone
else beyond funds appropriated and available for this contract.

2. NON-ASSIGNMENT CLAUSE. In accordance with Section 138 of the State Finance
Law, this contract may not be assigned by the Contractor or its right, title or
interest therein assigned, transferred, conveyed, sublet or otherwise disposed
of without the previous consent, in writing, of the State and any attempts to
assign the contract without the State's written consent are null and void. The
Contractor may, however, assign its right to receive payment without the State's
prior written consent unless this contract concerns Certificates of
Participation pursuant to Article 5-A of the State Finance Law.

3. COMPTROLLER'S APPROVAL. In accordance with Section 112 of the State Finance
Law (or, if this contract is with the State University or City University of New
York, Section 355 or Section 6218 of the Education Law), if this contract
exceeds $15,000 (or the minimum thresholds agreed to by the Office of the State
Comptroller for certain S.U.N.Y. and C.U.N. Y. contracts), or if this is an
amendment for any amount to a contract which, as so amended, exceeds said
statutory amount, or if, by this contract, the State agrees to give something
other than money when the value or reasonably estimated value of such
consideration exceeds $10,000, it shall not be valid, effective or binding upon
the State until it has been approved by the State Comptroller and filed in his
office. Comptroller's approval of contracts let by the Office of General
Services is required when such contracts exceed $30,000 (State Finance Law
Section 163.6.a).

4.WORKERS' COMPENSATION BENEFITS. In accordance with Section 142 of the State
Finance Law, this contract shall be void and of no force and effect unless the
Contractor shall provide and maintain coverage during the life of this contract
for the benefit of such employees as are required to be covered by the
provisions of the Workers' Compensation Law.

5.NON-DISCRIMINATION REQUIREMENTS. To the extent required by Article 15 of the
Executive Law (also known as the Human Rights Law) and all other State and
Federal statutory and constitutional non-discrimination provisions, the
Contractor will not discriminate against any employee or applicant for
employment because of race, creed, color, sex, national origin, sexual
orientation, age, disability, genetic predisposition or carrier status, or
marital status. Furthermore, in accordance with Section 220-e of the Labor Law,
if this is a contract for the construction, alteration or repair of any public
building or public work or for the manufacture, sale or distribution of
materials, equipment or supplies, and to the extent that this contract shall be
performed within the State of New York, Contractor agrees that neither it not
its subcontractors shall, by reason of race, creed, color, disability, sex,
or national origin: (a) discriminate in hiring against any New York
State citizen who is qualified and available to perform the work; or
(b) discriminate against or intimidate any employee hired for the performance of
work under this contract. If this is a building service contract as defined in
Section 230 of the Labor Law, then, in accordance with Section 239 thereof,
Contractor agrees that neither it nor its subcontractors shall by reason of
race, creed, color, national origin, age, sex or disability: (a) discriminate in
hiring against any New York State citizen who is qualified and available to
perform the work; or
(b) discriminate   against   or  intimidate   any   employee   hired   for  the
performance of work under this contract. Contractor is subject to fines of
$50.00 per person per day for any violation of Section 220-e or Section 239 as
well as possible termination of this contract and forfeiture of all moneys due
hereunder for a second or subsequent violation.

6.WAGE AND HOURS PROVISIONS. If this is a public work contract covered by
Article 8 of the Labor Law or a building service contract covered by Article 9
thereof, neither Contractor's employees nor the employees of its subcontractors
may be required or permitted to work more than the number of hours or days
stated in said statutes, except as otherwise provided in the Labor Law and as
set forth in prevailing wage and supplement schedules issued by the State
Labor Department. Furthermore, Contractor and its subcontractors must pay
at least the prevailing wage rate and pay or provide the prevailing supplements,
including the premium rates for overtime pay, as determined by the State Labor
Department in accordance with the Labor Law.

7. NON-COLLUSIVE BIDDING CERTIFICATION. In accordance with Section 139-d of the
State Finance Law, if this contract was awarded based upon the submission of
bids, Contractor warrants, under penalty of perjury, that its bid was arrived at
independently and without collusion aimed at restricting competition. Contractor
further warrants that, at the time Contractor submitted its bid, an authorized
and responsible person executed and delivered to the State a non-collusive
bidding certification on Contractor's behalf.

8. INTERNATIONAL BOYCOTT PROHIBITION. In accordance with Section 220-f of the
Labor Law and Section 139-h of the State Finance Law, if this contract exceeds
$5,000, the Contractor agrees, as a material condition of the contract, that
neither the Contractor nor any substantially owned or affiliated person, firm,
partnership or corporation has participated, is participating, or shall
participate in an international boycott in violation of the federal Export
Administration Act of 1979 (50 USC App. Sections 2401 et seq.) or regulations
thereunder. If such Contractor, or any of the aforesaid affiliates of
Contractor, is convicted or is otherwise found to have violated said laws or
regulations upon the final determination of the United States Commerce
Department or any other appropriate agency of the United States subsequent to
the contract's execution, such contract, amendment or modification thereto shall
be rendered forfeit and void. The Contractor shall so notify the State
Comptroller within five (5) business days of such conviction, determination or
disposition of appeal (2NYCRR 105.4).

9. SET-OFF RIGHTS. The State shall have all of its common law, equitable and
statutory rights of set-off. These rights shall include, but not be limited to,
the State's option to withhold for the purposes of set­off any moneys due to the
Contractor under this contract up to any amounts due and owing to the State with
regard to this contract, any other contract with any State department or agency,
including any contract for a term commencing prior to the term of this contract,
plus any amounts due and owing to the State for any other reason including,
without limitation, tax delinquencies, fee delinquencies or monetary penalties
relative thereto. The State shall exercise its set-off rights in accordance with
normal State practices including, in cases of set-off pursuant to an audit, the
finalization of such audit by the State agency, its representatives, or the
State Comptroller.

10.RECORDS. The Contractor shall establish and maintain complete and accurate
books, records, documents, accounts and other evidence directly pertinent to
performance under this contract (hereinafter, collectively, "the Records"). The
Records must be kept for the balance of the calendar year in which they were
made and for six (6) additional years thereafter. The State Comptroller, the
Attorney General and any other person or entity authorized to conduct an
examination, as well as the agency or agencies involved in this contract, shall
have access to the Records during normal business hours at an office of the
Contractor

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STANDARD CLAUSES FOR NYS CONTRACTS

APPENDIX A
 
within the State of New York or, if no such office is available, at a mutually
agreeable and reasonable venue within the State, for the term specified above
for the purposes of inspection, auditing and copying. The State shall take
reasonable steps to protect from public disclosure any of the Records which are
exempt from disclosure under Section 87 of the Public Officers Law (the
"Statute") provided that: (i) the Contractor shall timely inform an appropriate
State official, in writing, that said records should not be disclosed; and (ii)
said records shall be sufficiently identified; and (iii) designation of said
records as exempt under the Statute is reasonable. Nothing contained herein
shall diminish, or in any way adversely affect, the State's right to discovery
in any pending or future litigation.

11. IDENTIFYING INFORMATION AND PRIVACY NOTIFICATION, (a) FEDERAL EMPLOYER
IDENTIFICATION NUMBER and/or FEDERAL SOCIAL SECURITY NUMBER. All invoices or New
York State standard vouchers submitted for payment for the sale of goods or
services or the lease of real or personal property to a New York State agency
must include the payee's identification number, i.e., the seller's or lessor's
identification number. The number is either the payee's Federal employer
identification number or Federal social security number, or both such numbers
when the payee has both such numbers. Failure to include this number or numbers
may delay payment. Where the payee does not have such number or numbers,
the payee, on its invoice or New York State standard voucher, must give
the reason or reasons why the payee does not have such number or numbers.

(b) PRIVACY NOTIFICATION. (1) The authority to request the above personal
information from a seller of goods or services or a lessor of real or personal
property, and the authority to maintain such information, is found in Section 5
of the State Tax Law. Disclosure of this information by the seller or lessor to
the State is mandatory. The principal purpose for which the information is
collected is to enable the State to identify individuals, businesses and others
who have been delinquent in filing tax returns or may have understated their tax
liabilities and to generally identify persons affected by the taxes administered
by the Commissioner of Taxation and Finance. The information will be used for
tax administration purposes and for any other purpose authorized by law.

(2) The personal information is requested by the purchasing unit of the agency
contracting to purchase the goods or services or lease the real or personal
property covered by this contract or lease. The information is maintained in New
York State's Central Accounting System by the Director of Accounting Operations,
Office of the State Comptroller, AESOB, Albany, New York 12236.

12. EQUAL EMPLOYMENT OPPORTUNITIES FOR MINORITIES AND WOMEN. In accordance with
Section 312 of the Executive Law, if this contract is: (i) a written agreement
or purchase order instrument, providing for a total expenditure in excess
of $25,000.00, whereby a contracting agency is committed to expend or does
expend funds in return for labor, services, supplies, equipment, materials or
any combination of the foregoing, to be performed for, or rendered or furnished
to the contracting agency; or (ii) a written agreement in excess of $100,000.00
whereby a contracting agency is committed to expend or does expend funds for the
acquisition, construction, demolition, replacement, major repair or renovation
of real property and improvements thereon; or (iii) a written agreement
in excess of $100,000.00 whereby the owner of a State assisted housing project
is committed to expend or does expend funds for the acquisition, construction,
demolition, replacement, major repair or renovation of real property and
improvements thereon for such project, then:

(a) The Contractor will not discriminate against employees or applicants for
employment because of race, creed, color, national origin, sex, age, disability
or marital status, and will undertake or continue existing programs of
affirmative action to ensure that minority group members and women are afforded
equal employment opportunities without discrimination.    Affirmative action
shall mean recruitment, employment, job assignment, promotion, upgradings,
demotion, transfer, layoff, or termination and rates of pay or other forms of
compensation;

(b) at the request of the contracting agency, the Contractor shall request each
employment agency, labor union, or authorized representative of workers with
which it has a collective bargaining or other agreement or understanding, to
furnish a written statement that such employment agency, labor union or
representative will not discriminate on the basis of race, creed, color,
national origin, sex, age, disability or marital status and that such union or
representative will affirmatively cooperate in the implementation of the
contractor's obligations herein; and

(c) the Contractor shall state, in all solicitations or advertisements for
employees, that, in the performance of the State contract, all qualified
applicants will be afforded equal employment opportunities without
discrimination because of race, creed, color, national origin, sex, age,
disability or marital status.

Contractor will include the provisions of "a", "b", and "c" above, in every
subcontract over $25,000.00 for the construction, demolition, replacement, major
repair, renovation, planning or design of real property and improvements thereon
(the "Work") except where the Work is for the beneficial use of the Contractor.
Section 312 does not apply to: (i) work, goods or services unrelated to this
contract; or (ii) employment outside New York State; or (iii) banking services,
insurance policies or the sale of securities. The State shall consider
compliance by a contractor or subcontractor with the requirements of any federal
law concerning equal employment opportunity which effectuates the purpose of
this section. The contracting agency shall determine whether the imposition of
the requirements of the provisions hereof duplicate or conflict with any such
federal law and if such duplication or conflict exists, the contracting agency
shall waive the applicability of Section 312 to the extent of such duplication
or conflict. Contractor will comply with all duly promulgated and lawful rules
and regulations of the Governor's Office of Minority and Women's Business
Development pertaining hereto.

13.  CONFLICTING TERMS. In the event of a conflict between the terms of the
contract (including any and all attachments thereto and amendments thereof) and
the terms of this Appendix A, the terms of this Appendix A shall control.

14. GOVERNING LAW. This contract shall be governed by the laws of the State of
New York except where the Federal supremacy clause requires otherwise.

15.  LATE PAYMENT. Timeliness of payment and any interest to be paid to
Contractor for late payment shall be governed by Article 11-A of the State
Finance Law to the extent required by law.

16.  NO ARBITRATION. Disputes involving this contract, including the breach or
alleged breach thereof, may not be submitted to binding arbitration (except
where statutorily authorized), but must, instead, be heard in a court of
competent jurisdiction of the State of New York.

17.  SERVICE OF PROCESS. In addition to the methods of service allowed by the
State Civil Practice Law & Rules ("CPLR"), Contractor hereby consents to service
of process upon it by registered or certified mail, return receipt requested.
Service hereunder shall be complete upon Contractor's actual receipt of process
or upon the State's receipt of the return thereof by the United States Postal
Service as refused or undeliverable. Contractor must promptly notify the State,
in writing, of each and every change of address to which service of process can
be made. Service by the State to the last known address shall be sufficient.
Contractor will have thirty (30) calendar days after service hereunder is
complete in which to respond.

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STANDARD CLAUSES FOR NYS CONTRACTS

APPENDIX A
 
18. PROHIBITION ON PURCHASE OF TROPICAL HARDWOODS. The Contractor certifies and
warrants that all wood products to be used under this contract award will be in
accordance with, but not limited to, the specifications and provisions of State
Finance Law §165. (Use of Tropical Hardwoods) which prohibits purchase and use
of tropical hardwoods, unless specifically exempted, by the State or any
governmental agency or political subdivision or public benefit corporation.
Qualification for an exemption under this law will be the responsibility of the
contractor to establish to meet with the approval of the State.

In addition, when any portion of this contract involving the use of woods,
whether supply or installation, is to be performed by any subcontractor, the
prime Contractor will indicate and certify in the submitted bid proposal that
the subcontractor has been informed and is in compliance with specifications and
provisions regarding use of tropical hardwoods as detailed in §165 State Finance
Law. Any such use must meet with the approval of the State; otherwise, the bid
may not be considered responsive. Under bidder certifications, proof of
qualification for exemption will be the responsibility of the Contractor to meet
with the approval of the State.

19.  MACBRIDE   FAIR   EMPLOYMENT   PRINCIPLES.      In accordance with the
MacBride Fair Employment Principles (Chapter 807 of the Laws of 1992), the
Contractor hereby stipulates that the Contractor either (a) has no business
operations in Northern Ireland, or (b) shall take lawful steps in good faith to
conduct any business operations in Northern Ireland in accordance with the
MacBride Fair Employment Principles (as described in Section 165 of the New York
State Finance Law), and shall permit independent monitoring of compliance with
such principles.

20.  OMNIBUS PROCUREMENT ACT OF 1992. It is the policy of New York State to
maximize opportunities for the participation of New York State business
enterprises, including minority and women-owned business enterprises as bidders,
subcontractors and suppliers on its procurement contracts.

Information on the availability of New York State subcontractors and suppliers
is available from:

NYS Department of Economic Development Division for Small Business 30 South
Pearl St--7lh Floor Albany, New York 12245 Telephone: 518-292-5220

A directory of certified minority and women-owned business enterprises is
available from:

NYS Department of Economic Development
Division of Minority and Women's Business Development
30 South Pearl St - 2nd Floor
Albany, New York 12245
http://www.empire.state.ny.us

The Omnibus Procurement Act of 1992 requires that by signing this bid proposal
or contract, as applicable, Contractors certify that whenever the total bid
amount is greater than $1 million:

(a)The Contractor has made reasonable efforts to encourage the participation of
New York State Business Enterprises as suppliers and subcontractors, including
certified minority and women-owned business enterprises, on this project, and
has retained the documentation of these efforts to be provided upon request to
the State;

(b)The Contractor has complied with the Federal Equal Opportunity Act of 1972
(P.L. 92-261), as amended;

(c)The Contractor agrees to make reasonable efforts to provide notification to
New York State residents of employment opportunities on this project through
listing any such positions with the Job Service Division of the New York State
Department of Labor, or providing such notification in such manner as is
consistent with existing collective bargaining contracts or agreements. The
Contractor agrees to document these efforts and to provide said documentation to
the State upon request; and

(d)The Contractor acknowledges notice that the State may seek to obtain offset
credits from foreign countries as a result of this contract and agrees to
cooperate with the State in these efforts.

21.  RECIPROCITY AND SANCTIONS PROVISIONS. Bidders are hereby notified that if
their principal place of business is located in a country, nation, province,
state or political subdivision that penalizes New York State vendors, and if the
goods or services they offer will be substantially produced or performed outside
New York State, the Omnibus Procurement Act 1994 and 2000 amendments (Chapter
684 and Chapter 383, respectively) require that they be denied contracts which
they would otherwise obtain. NOTE: As of May 15, 2002, the list of
discriminatory jurisdictions subject to this provision includes the states of
South Carolina, Alaska, West Virginia, Wyoming, Louisiana and Hawaii. Contact
NYS Department of Economic Development for a current list of jurisdictions
subject to this provision.

22.  PURCHASES OF APPAREL. In accordance with State Finance Law 162 (4-a), the
State shall not purchase any apparel from any vendor unable or unwilling to
certify that: (i) such apparel was manufactured in compliance with all
applicable labor and occupational safety laws, including, but not limited to,
child labor laws, wage and hours laws and workplace safety laws, and (ii) vendor
will supply, with its bid (or, if not a bid situation, prior to or at the time
of signing a contract with the State), if known, the names and addresses of each
subcontractor and a list of all manufacturing plants to be utilized by the
bidder.

 
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APPENDIX B
Certification Regarding Lobbying

 
 
Medicaid Advantage Plus Contract
APPENDIX B
CERTIFICATION REGARDING LOBBYING
2007
1

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APPENDIX B
Certification Regarding Lobbying

The undersigned certifies, to the best of his or her knowledge, that:

1.
No Federal appropriated funds have been paid or will be paid to any person by or
on behalf of the Contractor for the purpose of influencing or attempting to
influence an officer or employee of any agency, a Member of Congress, an officer
or employee of a Member of Congress in connection with the award of any Federal
loan, the entering into of any cooperative agreement, or the extension,
continuation, renewal, amendment, or modification of any Federal contract,
grant, loan, or cooperative agreement.

2.
If any funds other than Federal appropriated funds have been paid or will be
paid to any person for the purpose of influencing or attempting to influence an
officer or employee of any agency, a Member of Congress in connection with the
award of any Federal contract, the making of any Federal grant, the making of
any Federal loan, the entering into of any cooperative agreement, or the
extension, continuation, renewal, amendment, or modification of any Federal
contract, grant, loan, or cooperative agreement, and the Agreement exceeds
$100,000, the Contractor shall complete and submit Standard Form -LLL
"Disclosure Form to Report Lobbying", in accordance with its instructions.

3.
The Contractor shall include the provisions of this section in all provider
Agreements under this Agreement and require all Participating providers whose
Provider Agreements exceed $100,000 to certify and disclose accordingly to the
Contractor.

This certification is a material representation of fact upon which reliance was
place when this transaction was made or entered into. Submission of this
certification is a prerequisite for making or entering into this transaction
pursuant to U.S.C. Section 1352. The failure to file the required certification
shall subject the violator to a civil penalty of not less than $10,000 and not
more than $100,000 for each such failure.

Date
5/31/2007
Signature:
  /s/ Todd Farha       
Title:
President & CEO
Organization:
WellCare of New York, Inc.

 

Medicaid Advantage Plus Contract
APPENDIX B
CERTIFICATION REGARDING LOBBYING
2007
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APPENDIX B-l

Certification Regarding MacBride Fair Employment Principles

Medicaid Advantage Plus Contract
APPENDIX B
CERTIFICATION REGARDING LOBBYPNG
2007
3

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APPENDIX B-l

 
NONDISCRIMINATION IN EMPLOYMENT IN NORTHERN IRELAND: MacBRIDE FAIR EMPLOYMENT
PRINCIPLES

Note:   Failure to stipulate to these principles may result in the contract
being awarded to another bidder. Governmental and non-profit organizations are
exempted from this stipulation requirement.

In accordance with Chapter 807 of the Laws of 1992 (State Finance Law Section
174-b), the Contractor, by signing this Agreement, certifies that it or any
individual or legal entity in which the Contractor holds a 10% or greater
ownership interest, or any individual or legal entity that holds a 10% or
greater ownership interest in the Contractor, either:

·
has business operations in Northern Ireland:       Y    N  X
   

·
if yes to above, shall take lawful steps in good faith to conduct any business
operations they have in Northern Ireland in accordance with the MacBride Fair
Employment Principles relating to non-discrimination in employment and freedom
of workplace opportunity regarding such operations in Northern Ireland, and
shall permit independent monitoring of their compliance with such
Principles:       Y  N

Medicaid Advantage Plus Contract
APPENDIX B
CERTIFICATION REGARDING LOBBYPNG
2007

4

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APPENDIX C

New York State Department of Health
Requirements for the Provision of Free Access to
Family Planning and Reproductive Health Services

 
C.l    Definitions and General Requirements for the Provision of Family Planning
and Reproductive Health Services

 
C.2    Requirements for MCOs that Provide Family Planning and Reproductive
Health Services

 
C.3    Requirements for MCOs That Do Not Provide Family Planning and
Reproductive Health Services

Medicaid Advantage Pius Contract
APPENDIX C
REQUIREMENTS FOR PROVISION OF FREE ACCESS
2007
1

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C.l
 
 
Definitions and General Requirements for the Provision of Family Planning and
Reproductive Health Services

1.        Family Planning and Reproductive Health Services

a) 
Family Planning and Reproductive Health Services mean the offering, arranging
and furnishing of those health services which enable Enrollees, including minors
who may be sexually active, to prevent or reduce the incidence of unwanted
pregnancies.

 
i)   Family Planning and Reproductive Health Services include the following
medically-necessary services, related drugs and supplies which are furnished or
administered under the supervision of a physician, licensed midwife or certified
nurse practitioner during the course of a Family Planning and Reproductive
Health visit for the purpose of:

A)
contraception, including all FDA-approved birth control methods, devices such as
insertion/removal of an intrauterine device (IUD) or insertion/removal of
contraceptive implants, and injection procedures involving Pharmaceuticals such
as Depo-Provera;
 

B) 
sterilization;
 

C)    emergency contraception and follow up;

 
D)
screening, related diagnosis, and referral to a Participating Provider for
pregnancy;

E)
medically-necessary induced abortions, which are procedures, either medical or
surgical, that result in the termination of pregnancy. The determination
of medical necessity shall include positive evidence of pregnancy, with
an estimate of its duration.

 
ii) Family Planning and Reproductive Health Services include those education and
counseling services necessary to render the services effective.

 
iii) Family Planning and Reproductive Health Services include
medically-necessary ordered contraceptives and pharmaceuticals:

 
A) The Contractor is responsible for pharmaceuticals and medical supplies such
as IUDS and Depo-Provera that must be furnished or administered under the
supervision of a physician, licensed midwife, or certified nurse practitioner
during the course of a Family Planning and Reproductive Health visit and for
prescription drugs included in the Contractor's Medicare Part D Prescription
Drug Benefit. Over-the-counter drugs are not the responsibility of the
Contractor and are to be obtained when covered on the New York State list of
Medicaid reimbursable drugs by the Enrollee from any appropriate eMedNY-enrolled
health care provider of the Enrollee's choice.

Medicaid Advantage Plus Contract
APPENDIX C
REQUIREMENTS FOR PROVISION OF FREE ACCESS
2007

2

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b)
When clinically indicated, the following services may be provided as a part of a
Family Planning and Reproductive Health visit:

 
i)   Screening, related diagnosis, ambulatory treatment and referral as needed
for dysmenorrhea, cervical cancer, or other pelvic abnormality/pathology.

 
ii)  Screening, related diagnosis and referral for anemia, cervical cancer,
glycosuria, proteinuria, hypertension and breast disease.

  iii)  Screening and treatment for sexually transmissible disease.

   iv) HIV blood testing and pre- and post-test counseling.

 
2.        Free Access to Services for EnroIIees

a)
Free Access means EnroIIees may obtain Family Planning and Reproductive Health
Services, and HIV blood testing and pre-and post-test counseling when performed
as part of a Family Planning and Reproductive Health encounter, from either the
Contractor, if it provides such services in its Medicare Advantage Benefit
Package, or from any appropriate eMedNY-enrolled health care provider of the
Enrollee's choice. No referral from the PCP or approval by the Contractor is
required to access such services.

b)
The Family Planning and Reproductive Health Services listed above are the only
services which are covered under the Free Access policy. Routine obstetric
and/or gynecologic care, including hysterectomies, pre-natal, delivery and
post-partum care are not covered under the Free Access policy, and are the
responsibility of the Contractor.

Medicaid Advantage Plus Contract
APPENDIX C
REQUIREMENTS FOR PROVISION OF FREE ACCESS
2007

3

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C.2

Requirements for MCOs that Provide Family Planning and Reproductive

Health Services

1. Notification to Enrollees

a)
If the Contractor provides Family Planning and Reproductive Health Services, the
Contractor must notify all Enrollees of reproductive age at the time of
Enrollment about their right to obtain Family Planning and Reproductive Health
Services and supplies without referral or approval. The notification must
contain the following:

 
i)   Information about the Enrollee's right to obtain the full range of Family
Planning and Reproductive Health Services, including HTV counseling and testing
when performed as part of a Family Planning and Reproductive Health encounter,
from the Contractor's Participating Provider without referral, approval or
notification.

 
ii) Enrollees must receive notification that they also have the right to obtain
Family Planning and Reproductive Health Services in accordance with the Medicaid
Free Access policy as defined in C.l of this Appendix.

 
iii) A current list of qualified Participating Family Planning Providers who
provide the full range of Family Planning and Reproductive Health Services
within the Enrollee's geographic area, including addresses and telephone
numbers. The Contractor may also provide Enrollees with a list of qualified
Non-Participating providers who accept Medicaid and who provide the full range
of these services.

 
iv) Information that the cost of the Enrollee's Family Planning and Reproductive
Health care will be fully covered, including when an Enrollee obtains such
services in accordance with the Medicaid Free Access policy.

2.  Billing Policy

a)
The Contractor must notify its Participating Providers that all claims for
Family Planning and Reproductive Health Services must be billed to the
Contractor and not the Medicaid fee-for-service program.

b) Non-Participating Providers will bill Medicaid fee-for-service.

3.  Consent and Confidentiality

a) 
The Contractor will comply with federal, state, and local laws, regulations and
policies regarding informed consent and confidentiality and ensure Participating
Providers comply with all of the requirements set forth in §§ 17 and 18 of the
PHL and 10 NYCRR Parts 751.9 and 753 relating to informed consent and
confidentiality.

Medicaid Advantage Plus Contract
APPENDIX C
REQUIREMENTS FOR PROVISION OF FREE ACCESS
2007

4

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b)
Participating Providers may share patient information with appropriate
Contractor personnel for the purposes of claims payment, utilization review and
quality assurance, unless the provider agreement with the Contractor provides
otherwise. The Contractor must ensure that an Enrollee's use of Family Planning
and Reproductive Health services remains confidential and is not disclosed to
family members or other unauthorized parties, without the Enrollee's consent to
the disclosure.

4.        Informing and Standards

a)
The Contractor will inform its Participating Providers and administrative
personnel about policies concerning Free Access as defined in C.l of this
Appendix, where applicable; HIV counseling and testing; reimbursement for Family
Planning and Reproductive Health encounters; Enrollee Family Planning and
Reproductive Health education and confidentiality.

b)
The Contractor will inform its Participating Providers that they must comply
with professional medical standards of practice, the Contractor's practice
guidelines, and all applicable federal, state, and local laws. These include but
are not limited to, standards established by the American College of
Obstetricians and Gynecologists, the American Academy of Family Physicians, the
U.S. Task Force on Preventive Services and the New York State Child/Teen Health
Program. These standards and laws recognize that Family Planning counseling is
an integral part of primary and preventive care.

Medicaid Advantage Plus Contract
APPENDIX C
REQUIREMENTS FOR PROVISION OF FREE ACCESS
2007
5

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C.3

Requirements for MCOs That Do Not
Provide Family Planning and Reproductive Health Services

1.  Requirements

a)
The Contractor agrees to comply with the policies and procedures stated in the
SDOH-approved statement described in Section 2 below.

b)
Within ninety (90) days of signing this Agreement, the Contractor shall submit
to the SDOH a policy and procedure statement that the Contractor will use to
ensure that its Enrollees are fully informed of their rights to access a full
range of Family Planning and Reproductive Health Services, using the following
guidelines. The statement must be sent to the Director, Office of Managed Care,
NYS Department of Health, Coming Tower, Room 2001, Albany, NY 12237.

c)
SDOH may waive the requirement in (b) above if such approved statement is
already on file with SDOH and remains unchanged.

2.  Policy and Procedure Statement

a)
The policy and procedure statement regarding Family Planning and Reproductive
Health Services must contain the following:

i)   Enrollee Notification

A)
A statement that the Contractor will inform Potential Enrollees, new Enrollees
and current Enrollees that:

I)
Certain Family Planning and Reproductive Health Services (such as abortion,
sterilization and birth control) are not covered by the Contractor, but that
routine obstetric and/or gynecologic care, including hysterectomies, pre-natal,
delivery and post-partum care are covered by the Contractor;

II)
Such Family Planning and Reproductive Health Services that are not covered by
the Contractor may be obtained through fee-for-service Medicaid providers for
Medicaid Advantage Plus Enrollees;

III)
No referral is needed for such services, and there will be no cost to the
Enrollee for such services;

Medicaid Advantage Plus Contract
APPENDIX C
REQUIREMENTS FOR PROVISION OF FREE ACCESS
2007
6

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IV)
HIV counseling and testing services are available through the Contractor and are
also available as part of a Family Planning and Reproductive Health encounter
when furnished by a fee-for-service Medicaid provider to Medicaid Advantage Plus
Enrollees; and that anonymous counseling and testing services are available from
SDOH, Local Public Health Agency clinics and other New York City or county
programs.

B)
A statement that this information will be provided in the following manner:

I)
Through the Contractor's written Marketing materials, including the Member
Handbook. The Member Handbook and Marketing materials will indicate that the
Contractor has elected not to cover certain Family Planning and Reproductive
Health Services, and will explain the right of all Medicaid Advantage Plus
Enrollees to secure such services through fee-for-service Medicaid from any
provider/clinic which offers these services and who accepts Medicaid.

II)
Orally at the time of Enrollment and any time an inquiry is made regarding
Family Planning and Reproductive Health Services.

III)
By inclusion on any website of the Contractor which includes information
concerning its Medicaid Advantage Plus product. Such information shall be
prominently displayed and easily navigated.

C)
A description of the mechanisms to provide all new Medicaid Advantage Plus
Enrollees with an SDOH approved letter explaining how to access Family Planning
and Reproductive Health Services and the SDOH approved list of Family Planning
providers. This material will be furnished by SDOH and mailed to the Enrollee no
later than fourteen (14) days after the Effective Date of Enrollment.

D)
A statement that if an Enrollee or Potential Enrollee requests information about
these non-covered services, the Contractor's Marketing or Enrollment
representative or member services department will advise the Enrollee or
Potential Enrollee as follows:

I)
Family Planning and Reproductive Health Services such as abortion, sterilization
and birth control are not covered by the Contractor and that only routine
obstetric and/or gynecologic care, including hysterectomies, pre-natal, delivery
and post-partum care are the responsibility of the Contractor.

II)
Medicaid Advantage Plus Enrollees can use their Medicaid card to receive these
non-covered services from any doctor or clinic that provides these services and
accepts Medicaid.

Medicaid Advantage Plus Contract
APPENDIX C
REQUIREMENTS FOR PROVISION OF FREE ACCESS
2007
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III)
Each Medicaid Advantage Plus Enrollee and Prospective Enrollee who calls will be
mailed a copy of the SDOH approved letter explaining the Enrollee's right to
receive these non-covered services, and an SDOH approved list of Family Planning
Providers who participate in Medicaid in the Enrollee's community. These
materials will be mailed within two (2) business days of the contact.

IV)
Enrollees can call the Contractor's member services number for further
information about how to obtain these non-covered services. Medicaid Advantage
Plus Enrollees can also call the New York State Growing-Up-Healthy Hotline
(1-800-522-5006) to request a copy of the list of Medicaid Family Planning
Providers.

E) The procedure for maintaining a manual log of all requests for such
information, including the date of the call, the Enrollee's client
identification number (CIN), and the date the SDOH approved letter and SDOH
approved list were mailed, where applicable. The Contractor will review this log
monthly and upon request, submit a copy to SDOH.

ii) Participating Provider and Employee Notification

A)
A statement that the Contractor will inform its Participating Providers and
administrative personnel about Family Planning and Reproductive Health policies
under Medicaid Advantage Plus Free Access, as defined in C.l of this Appendix,
HIV counseling and testing; reimbursement for Family Planning and Reproductive
Health encounters; Enrollee Family Planning and Reproductive Health education
and confidentiality.

B)
A statement that the Contractor will inform its Participating Providers that
they must comply with professional medical standards of practice, the
Contractor's practice guidelines, and all applicable federal, state, and local
laws. These include but are not limited to, standards established by the
American College of Obstetricians and Gynecologists, the American Academy of
Family Physicians, the U.S. Task Force on Preventive Services. These standards
and laws recognize that Family Planning counseling is an integral part of
primary and preventive care.

C)
The procedure(s) for informing the Contractor's Participating primary care
providers, family practice physicians, obstetricians, and gynecologists that the
Contractor has elected not to cover certain Family Planning and Reproductive
Health Services, but that routine obstetric and/or gynecologic care, including
hysterectomies, pre-natal, delivery and post-partum care are covered; and that
Participating Providers may provide, make referrals, or arrange for non-covered
services in accordance with Medicaid Advantage Free Access policy, as defined in
C.l of this Appendix.

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D)
A description of the mechanisms to inform the Contractor's
Participating Providers that:

I)
 if they also participate in the fee-for-service Medicaid program and they
render non-covered Family Planning and Reproductive Health Services to Medicaid
Advantage Plus Enrollees, they do so as a fee-for-service Medicaid practitioner,
independent of the Contractor.

E)
A description of the mechanisms to inform Participating Providers that,
if requested by the Enrollee, or, if in the provider's best professional
judgment, certain Family Planning and Reproductive Health Services not
offered through the Contractor are medically indicated in accordance with
generally accepted standards of professional practice, an appropriately
trained professional should so advise the Enrollee and either:

I)
offer those services to Medicaid Advantage Plus Enrollees on a fee-for-service
basis as an eMedNY-enrolled provider, or

II)
provide Medicaid Advantage Plus Enrollees with a copy of the SDOH approved list
of Medicaid Family Planning Providers, or

III)
give Enrollees the Contractor's member services number to call to obtain the
list of Medicaid Family Planning Providers.

F)
A statement that the Contractor acknowledges that the exchange of
medical information, when indicated in accordance with generally accepted
standards of professional practice, is necessary for the overall coordination of
Enrollees' care and assist Primary Care Providers in providing the highest
quality care to the Contractor's Enrollees, The Contractor must also acknowledge
that medical record information maintained by Participating Providers may
include information relating to Family Planning and Reproductive Health
Services provided under the fee-for-service Medicaid program.

iii) Quality Assurance Initiatives

A)
A statement that the Contractor will submit any materials to be furnished to
Enrollees and providers relating to access to non-covered Family Planning and
Reproductive Health Services to SDOH, Office of Managed Care for its review and
approval before issuance. Such materials include, but are not limited to, Member
Handbooks, provider manuals, and Marketing materials.

B)
A description of monitoring mechanisms the Contractor will use to assess the
quality of the information provided to Enrollees.

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C)
A statement that the Contractor will prepare a monthly list of Medicaid
Advantage Plus Enroll ees who have been sent a copy of the SDOH approved letter
and the SDOH approved list of Family Planning providers. This information will
be available to SDOH upon request.

D)
A statement that the Contractor will provide all new employees with a copy of
these policies. A statement that the Contractor's orientation programs will
include a thorough discussion of all aspects of these policies and procedures
and that annual retraining programs for all employees will be conducted to
ensure continuing compliance with these policies.

3. Consent and Confidentiality

a)
The Contractor must comply with federal, state, and local laws, regulations and
policies regarding informed consent and confidentiality and ensure that
Participating Providers comply with all of the requirements set forth in §§ 17
and 18 of the PHL and 10 NYCRR Parts 751.9 and 753 relating to informed consent
and confidentiality.

b)
Participating Providers may share patient information with appropriate
Contractor personnel for the purposes of claims payment, utilization review and
quality assurance, unless the provider agreement with the Contractor provides
otherwise. The Contractor must ensure that an Enrollee's use of Family Planning
and Reproductive Health Services remains confidential and is not disclosed to
family members or other unauthorized parties, without the Enrollee's consent to
disclosure.

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APPENDIX D

New York State Department of Health Medicaid Advantage Plus Marketing Guidelines

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APPENDIX D
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APPENDIX D
MEDICAID ADVANTAGE PLUS MARKETING GUIDELINES

I.       Purpose

The purpose of these guidelines is to provide an operational framework for the
development of marketing materials and the conduct of marketing activities for
the Medicaid Advantage Plus Program. The marketing guidelines set forth in this
Appendix do not replace the CMS marketing requirements for Medicare Advantage
Plans; they supplement them.

Marketing Materials

A.      Definitions

1.
Marketing materials means materials that are produced in any medium by or
on behalf of the Contractor's Medicaid Advantage Plus Product and can reasonably
be interpreted as intended to market to Potential Enrollees. Marketing materials
may not be used for a Medicaid Advantage Plus Product without the prior written
consent of the Commissioner, the Superintendent of Insurance and the Director of
the State Office for the Aging. Marketing materials requiring consent include:

a)
advertising, public service announcements, printed publications, and other
broadcast or electronic messages designed to increase awareness of and interest
in, or otherwise persuade an eligible person to enroll in a Medicaid Advantage
Plus Product and

b)
any information that references the Medicaid Advantage Plus is intended for
general distribution and is produced in a variety of print, broadcast, and
direct marketing media, including, but not limited to, scripts, radio,
television, billboards, newspapers, leaflets, brochures, videos, telephone
books, advertising, letters, posters and the member handbook.

2.
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 Plus 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

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

3.
The Contractor shall advise Potential Enrollees, in written materials related to
enrollment, to verify with the medical services providers they prefer, or with
whom they have an existing relationship with, are included in Contractor's
provider network, and are available to serve the participant.

C. Prior Approvals

1.
The CMS and SDOH will jointly review and approve Medicaid Advantage Plus Program
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. SDOH
will coordinate consultation with the State Insurance Department and the State
Office for the Aging.

2.
CMS and SDOH will jointly review and approve the following Medicaid Advantage
Plus Program 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 Plus 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 coordinating consultation
with the State Insurance Department and the State Office for the Aging.

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

5.
Approved marketing materials shall be kept on file in the offices of the
Contractor, the LDSS, the SDOH, and CMS.

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 Plus). Marketing activities intended to sell a
Medicaid managed care product shall be defined as activities which are conducted
pursuant to a Medicaid Advantage Plus 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 Plus 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 Advantage Plus
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 Plus Product explain Medicare products offered by the
Contractor as well as the Contractor's Medicaid Advantage Plus product.

B.    Marketing at LDSS Offices

With prior LDSS approval, MCOs may distribute CMS/SDOH approved Medicaid
Advantage Plus 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 Plus. The Contractor shall be
responsible for the activities of its marketing representatives and the
activities of any subcontractor or management entity.

D.    Medicaid Advantage Plus -Specific Marketing Requirements

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The requirements in Section D apply only if marketing activities for the
Medicaid Advantage Plus Program are conducted pursuant to a Medicaid Advantage
Plus 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 Plus Product.

1.   Approved Marketing Plan

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

b.
Approved Marketing plans will set forth the terms and conditions and proposed
activities of the Medicaid Advantage Plus dedicated staff during the contract
period.   The following must be included: description of materials and formats
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 Plus marketing materials.

c.
An approved marketing plan must be on file with the SDOH for its
contracted service area prior to the Contractor engaging in the Medicaid
Advantage Plus specific marketing activities.

d.
The plan shall include :

i)   stated marketing goals and strategies;
ii) a description of marketing activities, and the training, development and
responsibilities of dedicated marketing staff;
iii) a staffing plan including personnel qualifications, training content and
compensation methodology and levels; iv) a description of the Contractor's
monitoring activities to ensure compliance with this section; and
v)  identification of the primary marketing locations at which marketing will be
conducted.

e.
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.

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f.
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 Plus dedicated Marketing representatives.

2.      Compensation for Dedicated Medicaid Advantage Plus Marketing Staff

The Contractor shall not offer compensation to Medicaid Advantage Plus dedicated
Marketing Representatives, including salary increases or bonuses, based solely
on the number of individuals they enroll in Medicaid Advantage 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 his/her total
annual compensation;

d.
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 ortheLDSS.

3.      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.

4.
Marketing in Emergency Rooms, Other Patient Care Areas or Other Service Delivery
Sites
 
Contractors may not distribute materials or assist Potential Enrollees in
completing Medicaid Advantage Plus application forms in hospital emergency
rooms, in provider offices, or other areas where health care is delivered unless
requested by the individual.

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5.   Enrollment Incentives

Contractors may not offer incentives of any kind to Medicaid recipients to join
Medicaid Advantage Plus. Incentives are defined as any type of inducement whose
receipt is contingent upon the recipients joining the Contractor's product.

E. General Marketing Restrictions

The following restrictions apply anytime the Contractor markets its Medicaid
Advantage Plus product:

1.
Contractors are prohibited from misrepresenting the Medicaid program, the
Medicaid Advantage Plus, 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 or need
for services of any Enrollee or their family member. 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 Medicaid Advantage Plus network. The Contractor may respond to
a Potential Enrollee's question about whether a particular specialist is in the
network and may inquire about the types of specialists utilized by the Potential
Enrollee.

4.
Contractors may not require participating providers to distribute Contractor
prepared communications to their patients, including communications which
compare the benefits of different Medicaid Advantage Plus plans, unless the
materials have the concurrence of all Medicaid Advantage Plus plans involved,
and have received prior approval by SDOH, and by CMS, if Medicare Advantage is
referenced.

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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 Medicaid Advantage Plus plans and Medicaid clients.
Examples of inappropriate behavior include interfering with other Medicaid
Advantage Plus plan presentations or talking negatively about another Medicaid
Advantage Plus plan.

Marketing Infractions

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 Plus Marketing Guidelines or the Contractor's approved Medicaid
Advantage Plus 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.

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 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 Plus Marketing
activities for a period up to the end of the Agreement period;

b)
suspend new Medicaid Advantage Plus 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.

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APPENDIX E

New York State Department of Health
Medicaid Advantage Plus
Member Handbook Guidelines

 
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Introduction

Managed care organizations (MCOs) under contract to provide a Medicaid Advantage
Plus Product to Dually-Eligible beneficiaries must provide Enrollees with a
Medicaid Advantage Plus member handbook which is consistent with the current
model Medicaid Advantage Plus member handbook provided by SDOH and approved by
the CMS Regional Office and the SDOH. This model handbook is to be issued by the
Contractor to Enrollees in addition to the handbook or Explanation of Coverage
(EOC) required by CMS for Medicare Advantage. The model member handbook may be
revised based on changes in the law and the changing needs of the program.
Handbooks must be approved by the CMS Regional Office and the SDOH prior to
printing and distribution by the Contractor.

General Format

Member handbooks must be written in a style and reading level that will
accommodate the reading skills of Medicaid recipients. In general the writing
should not exceed a fourth to sixth-grade reading level, taking into
consideration the need to incorporate and explain certain technical or
unfamiliar terms to assure accuracy. The text must be printed in at least twelve
(12) point font. The SDOH reserves the right to require evidence that a handbook
has been tested against the sixth-grade reading-level standard. Member handbooks
must be available in languages other than English whenever at least five percent
(5%) of the Prospective Enrollees in any county in the Contractor's service area
speak that particular language and do not speak English as a first language. The
information contained in the handbook must be available from the Contractor in
alternative formats to meet the needs of individuals who are visually impaired,
etc

Model Medicaid Advantage Plus Handbook

It will be the responsibility of the SDOH to provide a copy of the current model
Medicaid Advantage Plus member handbook to the Contractor.

Medicaid Advantage Plus Contract

APPENDIX E
MEMBER HANDBOOK GUIDELINES
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APPENDIX F

New York State Department of Health
Medicaid Advantage Plus
Action and Grievance System Requirements

F.l     General Requirements
F.2     Action Requirements
F.3     Grievance System Requirements

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F.l

General Requirements
 
1.  Organization Determinations

a)
Organization Determinations means any decision by or on behalf of a MCO
regarding payment or services to which an Enrollee believes he or she is
entitled. For the purposes of this Agreement, Organization Determinations are
synonymous with Action, as defined by this Appendix.

b)
Organization Determinations regarding services determined by the Contractor to
be benefits covered solely by Medicare shall be conducted in accordance with the
procedures and requirements of 42 CFR 422 Subpart M and the Medicare Managed
Care Manual.

c)
Organization Determinations regarding services determined by the Contractor to
be benefits covered by both Medicare and Medicaid shall be conducted in
accordance with the procedures and requirements of 42 CFR 422 Subpart M and the
Medicare Managed Care Manual, except that:
 

   
i)  the Contractor will determine whether services are Medically Necessary as
that term is defined in this Agreement; and
ii) when the Contractor intends to reduce, suspend, or terminate a
previously authorized service within an authorization period, the notification
provisions of paragraph F.2(4)(a) of this Appendix shall apply.

 
d)
Organization Determinations regarding services determined by the Contractor to
be solely covered by Medicaid shall be conducted in accordance with Appendix F.l
of this Agreement, 42 CFR 438, Articles 44 and 49 of the PHL, and 10 NYCRR Part
98, not otherwise expressly established herein.

2.  Notices, Actions, Action Appeals, Complaints and Complaint Appeals

a)
Services determined by the Contractor to be benefits solely covered by Medicare
are subject to the Medicare Advantage Complaint and Appeals Process. In these
cases, the Contractor will follow such procedures to notify Enrollees, and
providers as applicable, regarding Organization Determinations and offer the
Enrollee Medicare appeal rights.

b)
Services determined by the Contractor to be solely covered by Medicaid are
subject to the Medicaid Advantage Plus Grievance System. In these cases, the
Contractor will follow such procedures to notify Enrollees and providers
regarding Organization

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Determinations and offer Action Appeal, Complaint, and Complaint Appeals rights
in accordance with Appendices F.2 and F.3 of this Agreement and the requirements
of 42 CFR 438, Articles 44 and 49 of the PHL, and 10 NYCRR Part 98, not
otherwise expressly established herein.

c)
 For Organization Determinations regarding services determined by the Contractor
to be a benefit under both Medicare and Medicaid, the Contractor must offer
Enrollees the right to pursue either the Medicare appeal procedures or the
Medicaid Advantage Plus Action, Action Appeals, Complaint, and Complaint Appeals
procedures.

 
i)   As part of, or attached to, the appropriate Organization Determination
notice of Action, the Contractor must provide Enrollees with a notice that
informs the Enrollee of his or her appeal rights under both the Medicare and
Medicaid Advantage Plus programs, and of their right to select either the
Medicare or Medicaid Advantage Plus appeals process, and instructions to make
such selection. Such notice shall inform the Enrollee that:

A) 
if he or she chooses to pursue the Medicare appeal procedures to challenge a
service denial, suspension, reduction, or termination, the Enrollee may not
pursue a Medicaid Advantage Plus appeal and may not file a Fair Hearing request
with the state; and

B) 
if he or she chooses to pursue the Medicaid Advantage Plus Medicaid appeal
procedures to challenge a service denial, suspension, reduction, or termination,
the Enrollee has up to 60 days from the date of the Contractor's Notice of
Action to pursue a Medicare appeal, regardless of the status of the Medicaid
Advantage Plus appeal.

 
ii)     The Contractor will enclose with the notice described in (i) above the
notice of Action and other attachments as may be required by Appendix F.2
(5)(a)(iii). However, the notice of Action need not duplicate information
provided in the Organization Determination notice it is attached to.

 
iii)     If the Enrollee files an appeal, but fails to select either the
Medicare or Medicaid Advantage Plus procedure, the default procedure will be the
Medicaid Advantage Plus procedure.

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F.2
Action Requirements
 
1.        Definitions

a)
Service Authorization Request means a request by an Enrollee or a provider on
the Enrollee's behalf, to the Contractor for the provision of a service or for a
referral to a non-covered service.

 
i)   Prior Authorization Request is a Service Authorization Request by the
Enrollee, or a provider on the Enrollee's behalf, for coverage of a new service,
whether for a new authorization period or within an existing authorization
period, before such service is provided to the Enrollee.

 
ii) Concurrent Review Request is a Service Authorization Request by an Enrollee,
or a provider on Enrollee's behalf, for continued, extended or an increase in an
authorized service than what is currently authorized by the Contractor.

b)
Service Authorization Determination means the Contractor's approval or denial of
a Service Authorization Request or an approval of a Service Authorization
Request is in an amount, duration, or scope that is less than requested of a
Service Authorization Request.

c)
Adverse Determination means a denial of a Service Authorization Request by the
Contractor on the basis that the requested service is not Medically Necessary,
an approval of a Service Authorization Request in an amount, duration, or scope
that is less than requested or a reduction, suspension, or termination of a
previously authorized service
 

d) An Action means an activity of a Contractor or its subcontractor that results
in:

   
i) 
the denial or limited authorization of a Service Authorization Request,
including the type or level of service;

ii) the reduction, suspension, or termination of a previously authorized
service;

iii) the denial, in whole or in part, of payment for a service;

iv) failure to provide services in a timely manner as defined by applicable
State law and regulation and Section 15 of this Agreement; or

v)  failure of the Contractor to act within the timeframes for resolution and
notification of determinations regarding Complaints, Action Appeals and
Complaint Appeals provided in this Appendix.

 
 
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APPENDIX F
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2007
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v) 
failure of the Contractor to act within the timeframes for resolution and
notification of determinations regarding Complaints, Action Appeals and
Complaint Appeals provided in this Appendix.
 
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General Requirements

a)
The Contractor's policies and procedures for Service Authorization
Determinations and utilization review determinations shall comply with 42 CFR
438 and Article 49 of the PHL, including but not limited to the following:

 
i)   Expedited review of a Service Authorization Request must be conducted when
the Contractor determines or the provider indicates that a delay would seriously
jeopardize the Enrollee's life or health or ability to attain, maintain, or
regain maximum function. The Enrollee also may request an expedited review of a
Prior Authorization Request or Concurrent Review Request. If the Contractor
denies the Enrollee's request for expedited review, the Contractor must notify
the Enrollee in writing that the request for the expedited review has been
denied, and that the Contractor will handle the request under standard review
timeframes, detailing the specifics of those timeframes.

 
ii) Any determination to deny a Service Authorization Request or to authorize a
service in an amount, duration, or scope that is less than requested, must be
made by a licensed, certified, or registered health care professional. If such
Adverse Determination was based on medical necessity, the determination must be
made by a clinical peer reviewer as defined by PHL §4900(2)(a).

 
iii) The Contractor is required to provide notice by phone and in writing to the
Enrollee and to the provider of Service Authorization Determinations, whether
adverse or not, within the timeframe specified in Section 3 below. Notice to the
provider must contain the same information as the Notice of Action for the
Enrollee which is identified in Section F.2 (5) of this Appendix.

 
iv) The Contractor is required to provide the Enrollee written notice of any
Action other than a Service Authorization Determinations within the timeframe
specified in Section 4 below.

Timeframes for Service Authorization Determinations

a) 
 For Prior Authorization Requests, the Contractor must make a Service
Authorization Determination and notice the Enrollee of the determination by
phone and in writing as fast as the Enrollee's condition requires and no more
than:

 
i)   In the case of an expedited review, three (3) business days after receipt
of the Service Authorization Request; or

 
ii) In all other cases, within three (3) business days of receipt of necessary
information, but no more than fourteen (14) days after receipt of the Service
Authorization request.

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b)
For Concurrent Review Requests, the Contractor must make a Service
Authorization Determination and notify the Enrollee of the determination by
phone and in writing as fast as the Enrollee's condition requires and no more
than:

 
i)   In the case of an expedited review, one (1) business day after receipt of
necessary information but no more than three (3) business days after receipt of
the Service Authorization Request; or

 
ii) In all other cases, within one (1) business day of receipt of necessary
information, but no more than fourteen (14) days after receipt of the Service
Authorization Request.

c)
Timeframes for Service Authorization Determinations may be extended for up
to fourteen (14) days from the date the extension notice is sent by the
Contractor, if:

 
i)   the Enrollee, the Enrollee's designee, or the Enrollee's provider requests
an extension orally or in writing; or

 
ii) The Contractor can demonstrate or substantiate that there is a need for
additional information and how the extension is in the Enrollee's best interest.
The Contractor must send notice of the extension to the Enrollee. The Contractor
must maintain sufficient documentation of extension determinations to
demonstrate, upon SDOH's request, that the extension was justified, and must
explain in the written notice to the Enrollee how the extension is in the best
interest of the Enrollee.

d)
If the Contractor extended its review as provided in paragraph 3(c) above,
the Contractor must make a Service Authorization Determination and notify the
Enrollee by phone and in writing as fast as the Enrollee's condition requires
and within three (3) business days after receipt of necessary information for
Prior Authorization Requests or within one (1) business day after receipt of
necessary information for Concurrent Review Requests, but in no event later than
the date the extension expires.

Timeframes for Notices of Actions Other Than Service Authorizations
Determinations

a) 
When the Contractor intends to reduce, suspend, or terminate a previously
authorized service within an authorization period, it must provide the Enrollee
with a written notice at least ten (10) days prior to the intended Action,
except:

 i)   the period of advance notice is shortened to five (5) days in cases of
confirmed

ii)
Enrollee fraud; or ii) the Contractor may mail notice not later than date of the
Action for the following:
A) the death of the Enrollee;

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B)
a signed written statement from the Enrollee requesting service termination or
giving information requiring termination or reduction of services (where the
Enrollee understands that this must be the result of supplying the information);

C)
the Enrollee's admission to an institution where the Enrollee is ineligible for
further services;

D)
the Enrollee's address is unknown and mail directed to the Enrollee is returned
stating that there is no forwarding address;

E)
the Enrollee has been accepted for Medicaid services by another jurisdiction; or

        F) the Enrollee's physician prescribes a change in the level of medical
care.

 
b)
The Contractor must mail written notice to the Enrollee on the date of the
Action when the Action is denial of payment, in whole or in part, except as
provided in paragraph F.2 6(b) below.

c)
When the Contractor does not reach a determination within the Service
Authorization Determination timeframes described above, it is considered an
Adverse Determination, and the Contractor must send notice of Action to the
Enrollee on the date the timeframes expire.

5.        Format and Content of Notices

a)  The Contractor shall ensure that all notices are in writing, in easily
understood language and are accessible to non-English speaking and visually
impaired Enrollees. Notices shall include that oral interpretation and alternate
formats of written material for Enrollees with special needs are available and
how to access the alternate formats.

i) 
Notice to the Enrollee that the Enrollee's request for an expedited review has
been denied shall state that the request will be reviewed under standard
timeframes, including a description of the timeframes.

ii)  Notice to the Enrollee regarding a Contractor-initiated extension shall
include:

  A) the reason for the extension;

  B) an explanation of how the delay is in the best interest of the Enrollee;

  C) any additional information the Contractor requires from any source to make
its determination;

  D) the revised date by which the MCO will make its determination;

  E) the right of the Enrollee to file a Complaint (as defined in Appendix F.3
of this Agreement) regarding the extension;

  F) the process for filing a Complaint with the Contractor and the
timeframes within which a Complaint determination must be made;

 
G) the right of an Enrollee to designate a representative to file a Complaint
on behalf of the Enrollee; and

    
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H) the right of the Enrollee to contact the New York State Department of Health
regarding his or her Complaint, including the SDOH's toll-free number for
Complaints.

 
iii) Notice to the Enrollee of an Action shall include:

A)  the description of the Action the Contractor has taken or intends to take;
B)   the reasons for the Action, including the clinical rationale, if any;
C)  the Enrollee's right to file an Action Appeal (as defined in Appendix F.3 of
this Agreement), including:
I)
The fact that the Contractor will not retaliate or take any discriminatory
action against the Enrollee because he/she filed an Action Appeal.

II)
The right of the Enrollee to designate a representative to file Action Appeals
on his/her behalf;

D)
the process and timeframe for filing an Action Appeal with the
Contractor, including an explanation that an expedited review of the Action
Appeal can be requested if a delay would significantly increase the risk to an
Enrollee's health, a toll-free number for filing an oral Action Appeal and a
form, if used by the Contractor, for filing a written Action Appeal;

E)
a description of what additional information, if any, must be obtained by
the Contractor from any source in order for the Contractor to make an
Appeal determination;

F) the timeframes within which the Action Appeal determination must be made;

G) the right of the Enrollee to contact the New York State Department of Health
with his or her Complaint, including the SDOH's toll-free number for Complaints;
and

  
H)
 the notice entitled "Managed Care Action Taken" for denial of benefits or for
termination or reduction in benefits, as applicable. I)   For Actions based on
issues of Medical Necessity or an experimental or investigational treatment, the
notice of Action shall also include:

I)
a clear statement that the notice constitutes the initial adverse determination
and specific use of the terms "medical necessity" or "experimental/in
vestigational";

II)
a statement that the specific clinical review criteria relied upon in making the
determination is available upon request; and

III)
a statement that the Enrollee may be eligible for, and the timeframes for filing
an External Appeal, including that if so eligible, the Enrollee may request an
External Appeal after first filing an expedited Action Appeal with the
Contractor and receiving notice that the Contractor upholds its adverse
determination, or after filing a standard Action Appeal with the Contractor and
receiving the Contractor's final adverse determination, or after the Contractor
and the Enrollee agree to waive the internal Action Appeal process.

 
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6.        Contractor Obligation to Notice

a)
The Contractor must provide written Notice of Action to Enrollees and providers
in accordance with the requirements of this Appendix, including, but not limited
to, the following circumstances (except as provided for in paragraph 6(b)
below):

 
i)   the Contractor makes a coverage determination or denies a request for a
referral, regardless of whether the Enrollee has received the benefit;

 
ii) the Contractor determines that a service does not have appropriate
authorization and the Contractor will not pay the claim;

 
iii) the Contractor denies a claim for services provided by a Non-Participating
Provider for any reason;
 

  iv) the Contractor denies a claim or service due to medical necessity;

   
v) the Contractor rejects a claim or denies payment due to a late claim
submission;

 
 
vi) the Contractor denies a claim because it has determined that the Enrollee
was not eligible for Medicaid Advantage Plus coverage on the date of service;

 
vii) the Contractor denies a claim for service rendered by a Participating
Provider due to lack of a referral;

 
viii) the Contractor denies a claim because it has determined it is not the
appropriate payor; or

 
ix) the Contractor denies a claim due to a Participating Provider billing for
Benefit Package services not included in the Provider Agreement between the
Contractor and the Participating Provider.

b)
The Contractor is not required to provide written Notice of Action to Enrollees
in the following circumstances:

 
i)   When there is a prepaid capitation arrangement with a Participating
Provider and the Participating Provider submits a fee-for-service claim to the
Contractor for a service that falls within the capitation payment;

 
ii) if a Participating Provider of the Contractor itemizes or "unbundles" a
claim for services encompassed by a previously negotiated global fee
arrangement;

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iii) if a duplicate claim is submitted by the Enrollee or a Participating
Provider for which the Contractor will not make payment, no notice is required,
provided an initial notice has been issued;

 
iv) if the claim is for a service that is carved-out of the Benefit Package and
is provided to an Enrollee through Medicaid fee-for-service, however, the
Contractor should notify the provider to submit the claim to Medicaid;

 
v) if the Contractor makes a coding adjustment to a claim (up-coding or
down-coding) and its Provider Agreement with the Participating Provider includes
a provision allowing the Contractor to make such adjustments;

   
vi) if the Contractor has paid the negotiated amount reflected in the Provider
Agreement with a Participating Provider for the services provided to the
Enrollee and denies the Participating Provider's request for additional payment;
or

 
 
vii) if the Contractor has not yet adjudicated the claim. If the Contractor has
pended the claim while requesting additional information, a notice is not
required until the coverage determination has been made.

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F3
Medicaid Advantage Plus Grievance System Requirements

1.  Definitions

a)
A Grievance System means the Contractor's Medicaid Advantage Plus Complaint and
Appeal process, and includes a Complaint and Complaint Appeal process, a process
to appeal Actions, and access to the State's fair hearing system.

b)
For the purposes of this Agreement, a Complaint means an Enrollee's expression
of dissatisfaction with any aspect of his or her care other than an Action. A
"Complaint" means the same as a "grievance" as defined by 42 CFR 438.400 (b).
 

 c)  
An Action Appeal means a request for a review of an Action.
 

 d)  A Complaint Appeal means a request for a review of a Complaint
determination.

 
e)
An Inquiry means a written or verbal question or request for information posed
to the Contractor with regard to such issues as benefits, contracts, and
organization rules. Neither Enrollee Complaints nor disagreements with
Contractor determinations are Inquiries.

2.  Grievance System - General Requirements

a)
The Contractor shall describe its Grievance System in the Member Handbook, and
it must be accessible to non-English speaking, visually, and hearing impaired
Enrollees. The handbook shall comply with The Member Handbook Guidelines
(Appendix E) of this Agreement.

b)
The Contractor will provide Enrollees with any reasonable assistance in
completing forms and other procedural steps for filing a Complaint, Complaint
Appeal or Action Appeal, including, but not limited to, providing interpreter
services and toll-free numbers with TTY/TDD and interpreter capability.

c)
The Enrollee may designate a representative to file Complaints, Complaint
Appeals and Action Appeals on his/her behalf.

d)
The Contractor will not retaliate or take any discriminatory action against the
Enrollee because he/she filed a Complaint, Complaint Appeal or Action Appeal.

e)
The Contractor's procedures for accepting Complaints, Complaint Appeals and
Action Appeals shall include:

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i)   toll-free telephone number;
ii) designated staff to receive calls;
iii) "live" phone coverage at least 40 hours a week during normal business
hours, and

iv) a mechanism to receive after hours calls, including either:
A)
a telephone system available to take calls and a plan to respond to all such
calls no later than on the next business day after the calls were recorded; or

B)
a mechanism to have available on a twenty-four (24) hour, seven (7) day a week
basis designated staff to accept telephone Complaints, whenever a delay would
significantly increase the risk to an Enrollee's health.

f)   The Contractor must ensure that personnel making determinations regarding
Complaints, Complaint Appeals and Action Appeals were not involved in previous
levels of review or decision-making. If any of the following applies,
determinations must be made by qualified clinical personnel as specified in this
Appendix:
 
i)   A denial of an Action Appeal based on lack of medical necessity.
ii) A Complaint regarding denial of expedited resolution of an Action Appeal.
iii) A Complaint, Complaint Appeal, or Action Appeal that involves clinical
issues.
 
3.  Action Appeals Process

a)
The Contractor's Action Appeals process shall indicate the following regarding
resolution of Appeals of an Action:

 
i)   The Enrollee, or his or her designee, will have no less than forty-five
(45) days from the date of the notice of Action to file an Action Appeal. An
Enrollee filing an Action Appeal within ten (10) days of the notice of Action or
by the intended date of an Action, whichever is later, that involves the
reduction, suspension, or termination of previously approved services may
request "aid continuing" in accordance with Section 24.4 of this Agreement.

 
ii) The Enrollee may file a written Action Appeal or an oral Action Appeal. Oral
Action Appeals must be followed by a written Action Appeal. The Contractor may
provide a written summary of an oral Action Appeal to the Enrollee (with the
acknowledgement or separately) for the Enrollee to review and, modify if needed,
and return to the Contractor. If the Enrollee or provider requests expedited
resolution of the Action Appeal, the oral Action Appeal does not need to be
-confirmed in writing. The date of the oral filing of the Action Appeal will be
the date of the Action Appeal for the purposes of the timeframes for resolution
of Action Appeals. Action Appeals resulting from a Concurrent Review must be
handled as an expedited Action Appeal.

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iii) The Contractor must send a written acknowledgement of the Action Appeal,
including the name, address and telephone number of the individual or department
handling the Action Appeal, within fifteen (15) days of receipt. If a
determination is reached before the written acknowledgement is sent, the
Contractor may include the written acknowledgement with the notice of Action
Appeal determination (one notice).

 
iv) The Contractor must provide the Enrollee reasonable opportunity to present
evidence, and allegations of fact or law, in person as well as in writing. The
Contractor must inform the Enrollee of the limited time to present such evidence
in the case of an expedited Action Appeal. The Contractor must allow the
Enrollee or his or her designee, both before and during the Action Appeals
process, to examine the Enrollee's case file, including medical records and any
other documents and records considered during the Action Appeals process. The
Contractor will consider the Enrollee, his or her designee, or legal estate
representative of a deceased Enrollee a party to the Action Appeal.

 
v) The Contractor must have a process for handling expedited Action Appeals.
Expedited resolution of the Action Appeal must be conducted when the Contractor
determines or the provider indicates that a delay would seriously jeopardize the
Enrollee's life or health or ability to attain, maintain, or regain maximum
function. The Enrollee may request an expedited review of an Action Appeal. The
Contract must agree to expedite the Appeal if the Appeal was the result of a
denial of concurrent Service Authorization request. If the Contractor denies the
Enrollee's request for an expedited review, the Contractor must handle the
request under standard Action Appeal resolution timeframes, make reasonable
efforts to provide prompt oral notice of the denial to the Enrollee and send
written notice of the denial within two (2) days of the denial of the request
for the expedited review determination and indicate in the notice that the
Contractor will be handling the request under standard action appeal timeframes.

 
vi) The Contractor must ensure that punitive action is not taken against a
provider who either requests an expedited resolution or supports an Enrollee's
Appeal.

 
vii) Action Appeals of clinical matters must be decided by personnel qualified
to review the Action Appeal, including licensed, certified or registered health
care professionals who did not make the initial determination, at least one of
whom must be a clinical peer reviewer, as defined by PHL §4900(2)(a). Action
Appeals of non-clinical matters shall be determined by qualified personnel at a
higher level than the personnel who made the original determination.

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4. Timeframes for Resolution of Action Appeals

 
a)  The Contractor's Action Appeals process shall indicate the following
specific timeframes regarding Action Appeal resolution:

 
i)   The Contractor will resolve Action Appeals as fast as the Enrollee's
condition requires, and no later than thirty (30) days from the date of the
receipt of the Action Appeal.

 
ii)  The Contractor will resolve expedited Action Appeals as fast as the
Enrollee's condition requires, within two (2) business days of receipt of
necessary information and no later than three (3) business days of the date of
the receipt of the Action Appeal.

 
iii) Timeframes for Action Appeal resolution, in either (i) or (ii) above, may
be extended for up to fourteen (14) days if:

A)
the Enrollee, his or her designee, or the provider requests an extension orally
or in writing; or

B)
the Contractor can demonstrate or substantiate that there is a need for
additional information and the extension is in the Enrollee's interest. The
Contractor must send notice of the extension to the Enrollee. The Contractor
must maintain sufficient documentation of extension determinations to
demonstrate, upon SDOH's request, that the extension was justified.

C)
The Contractor must inform the Enrollee in writing if it will be taking an
extension and how the extension is in the best interest of the Enrollee.

 
iv) The Contractor will make a reasonable effort to provide oral notice to the
Enrollee, his or her designee, and the provider where appropriate, for expedited
Action Appeals at the time the Action Appeal determination is made.

 
v)  The Contractor must send written notice to the Enrollee, his or her
designee, and the provider where appropriate, within two (2) business days of
the Action Appeal determination.

5. Action Appeal Notices

 
a) The Contractor shall ensure that all notices are in writing and in easily
understood language and are accessible to non-English speaking and visually
impaired Enrollees. Notices shall include that oral interpretation and alternate
formats of written material for Enrollees with special needs are available and
how to access the alternate formats.

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i)  
Notice to the Enrollee that the Enrollee's request for an expedited Action
Appeal has been denied shall include that the request will be reviewed under
standard Action Appeal timeframes, including a description of the timeframes.
This notice may be combined with the acknowledgement.

ii) Notice to the Enrollee regarding an Contractor-initiated extension shall
include:

A)  the reason for the extension;
B) an explanation of how the delay is in the best interest of the Enrollee;
C) any additional information the Contractor requires from any source to make
its determination;
D) the revised date by which the MCO will make its determination;
E) the right of the Enrollee to file a Complaint regarding the extension;
F) the process for filing a Complaint with the Contractor and the
timeframes within which a Complaint determination must be made;
H) the right of the Enrollee to contact the New York State Department of Health
regarding his or her Complaint, including the SDOH's toll-free number for
Complaints.
 
iii) Notice to the Enrollee of Action Appeal Determination shall include:
A) Date the Action Appeal was filed and a summary of the Action Appeal;
B) Date the Action Appeal process was completed;
C) the results and the reasons for the determination, including the clinical
rationale, if any;
D) If the determination was not in favor of the Enrollee, a description of
Enrollee's fair hearing rights, if applicable; including the appropriate Fair
Hearing notice;
E) the right of the Enrollee to contact the New York State Department of
Health regarding his or her Complaint, including the SDOH's toll-free number
for Complaints; and
F)
For Action Appeals involving Medical Necessity or an experimental
or investigational treatment, the notice must also include:

I) a clear statement that the notice constitutes the final adverse determination
and specifically use the terms "medical necessity" or
"experimental/investigational";
II) the Enrollee's insurance coverage type;
III)  the procedure/service in question, and if available and applicable the
name of the provider and developer/manufacturer of the health care service;
IV)  statement that the Enrollee is eligible to file an External Appeal and the
timeframe for filing;
V)  a copy of the "Standard Description and Instructions for Health Care
Consumers to Request an External Appeal" and the External Appeal application
form;
VI) the Contractor's contact person and telephone number; and

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VII)
 the contact person, telephone number, company name and full address of the
utilization review agent, if the determination was made by the agent.

6.  Complaint Process

a) 
 The Contractor' Complaint process shall include the following regarding the
handling of Enrollee Complaints:

a.   The Enrollee, or his or her designee, may file a Complaint expressing
dissatisfaction with any aspect of his or her care other than an Action with the
Contractor orally or in writing. The Contractor may have requirements for
accepting written Complaints either by letter or Contractor supplied form. The
Contractor cannot require an Enrollee to file a Complaint in writing.

ii)
The Contractor must provide written acknowledgment of any Complaint not
immediately resolved, including the name, address and telephone number of the
individual or department handling the Complaint, within fifteen (15) business
days of receipt of the Complaint. The acknowledgement must identify any
additional information required by the Contractor from any source to make a
determination. If a Complaint determination is made before the written
acknowledgement is sent, the Contractor may include the acknowledgement with the
notice of the determination (one notice).

iii) Complaints shall be reviewed by one or more qualified personnel.

iv) Complaints pertaining to clinical matters shall be reviewed by one or more
licensed, certified or registered health care professionals in addition to
whichever non-clinical personnel the Contractor designates.

7.  Timeframes for Complaint Resolution by the Contractor

a) 
The Contractor's Complaint process shall indicate the following specific
timeframes regarding Complaint resolution:

 
i)   If the Contractor immediately resolves an oral Complaint to the Enrollee's
satisfaction, that Complaint may be considered resolved without any additional
written notification to the Enrollee. Such Complaints must be logged by the
Contractor and report on a quarterly basis to SDOH in accordance with Section 18
of this Agreement.

 
ii) Whenever a delay would significantly increase the risk to an Enrollee's
health, Complaints shall be resolved within forty-eight (48) hours after receipt
of all necessary information and no more than seven (7) days from the receipt of
the Complaint.

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iii) All other Complaints shall be resolved within forty-five (45) days after
the receipt of all necessary information and no more than sixty (60) days from
receipt of the Complaint. The Contractor shall maintain reports of Complaints
unresolved after forty-five (45) days in accordance with Section 18 of this
Agreement.

b)
Timeframes for Complaint resolution may be extended for up to fourteen (14) days
from the date the extension notice is sent by the Contractor, if:

 
i)   the Enrollee, the Enrollee's designee, or the Enrollee's provider requests
an extension orally or in writing; or

 
ii) The Contractor can demonstrate or substantiate that there is a need for
additional information and how the extension is in the Enrollee's interest. The
Contractor must send notice of the extension to the Enrollee. The Contractor
must maintain sufficient documentation of extension determinations to
demonstrate, upon SDOH's request, that the extension was justified, and must
explain in the written notice to the Enrollee how the extension is in the best
interest of the Enrollee.

 
iii) )If the Contractor extended its review as provided in paragraph 7(b) above,
the Contractor must resolve the Complaint and notice the Enrollee by phone and
in writing as fast as the Enrollee's condition requires and within three (3)
business days of its decision, but in no event later than the date the extension
expires.

8.  Complaint Determination Notices

a)
The Contractor's procedures regarding the resolution of Enrollee Complaints
shall include the following:

 
i)   Complaint Determinations by the Contractor shall be made in writing to the
Enrollee or his/her designee (except as identified in subsection (7)(a) (i)
above) and include:

           

A)   the detailed reasons for the determination;

B)
in cases where the determination has a clinical basis, the clinical rationale
for the determination;

C)
the procedures for the filing of an appeal of the determination, including a
form, if used by the Contractor, for the filing of such a Complaint Appeal; and
notice of the right of the Enrollee to contact the State Department of Health
regarding his or her Complaint, including SDOH's toll-free number for
Complaints.

ii) If the Contractor was unable to make a Complaint determination because
insufficient information was presented or available to reach a determination,
the Contractor will send a written statement that a determination could not be
made to the Enrollee on the date the allowable time to resolve the Complaint has
expired.

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iii)
In cases where delay would significantly increase the risk to an Enrollee's
health, the Contractor shall provide notice of a determination by telephone
directly to the Enrollee or to the Enrollee's designee, or when no phone is
available, some other method of communication, with written notice to follow
within three (3) business days.

9.  Complaint Appeals

The Contractor's procedures regarding Enrollee Complaint Appeals shall include
the following:

a)
The Enrollee or designee has sixty (60) business days after receipt of the
notice of the Complaint determination to file a written Complaint Appeal.
Complaint Appeals may be submitted by letter or by a form provided by the
Contractor.

b)
Within fifteen (15) business days of receipt of the Complaint Appeal, the
Contractor shall provide written acknowledgment of the Complaint Appeal,
including the name, address and telephone number of the individual designated to
respond to the Appeal. The Contractor shall indicate what additional
information, if any, must be provided for the Contractor to render a
determination.

c)
Complaint Appeals of clinical matters must be decided by personnel qualified to
review the Appeal, including licensed, certified or registered health care
professionals who did not make the initial determination, at least one of whom
must be a clinical peer reviewer, as defined by PHL §4900(2)(a).

d)
Complaint Appeals of non-clinical matters shall be determined by qualified
personnel at a higher level than the personnel who made the original Complaint
determination.

e)
Complaint Appeals shall be decided and notification provided to the Enrollee no
more than:

 
i) two (2) business days after the receipt of all necessary information when a
delay would significantly increase the risk to an Enrollee's health; or

 
ii) thirty (30) business days after the receipt of all necessary information in
all other instances.

f)
The notice of the Contractor's Complaint Appeal determination shall include:

 

  i) the detailed for the determinations;

 
ii) the clinical rationale for the determination in cases where the
determination has a clinical basis;

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iii) the notice shall also inform the Enrollee of his/her option to also contact
the State Department of Health with his/her Complaint, including the SDOH's
toll-free number for Complaints;

  iv) instructions for any further Appeal, if applicable.

 
10.  Records

The Contractor shall maintain a file on each Complaint, Action Appeal and
Complaint Appeal. These records shall be readily available for review by the
SDOH, upon request. The file shall include:

a)  date the Complaint was filed;
b)  copy of the Complaint, if written;
c)  date of receipt of and copy of the Enrollee's written confirmation, if any;

d)  log of Complaint determination including the date of the determination and
the titles of the personnel and credentials of clinical personnel who reviewed
the Complaint;

e)   date and copy of the Enrollee's Action Appeal or Complaint Appeal;

f)    Enrollee or provider requests for expedited Action Appeals and Complaint
Appeals and the Contractor's determination;

g)   necessary documentation to support any extensions;
h)  determination and date of determination of the Action Appeals and Complaint
Appeals;
i)  the titles and credentials of clinical staff who reviewed the Action Appeals
and Complaint Appeals; and
j)   Complaints unresolved for greater than forty-five (45) days.

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GRIEVANCE SYSTEM REQUIREMENTS
2007
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APPENDIX G

RESERVED

Medicaid Advantage Plus Contract
APPENDIX G
Reserved

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APPENDIX H

New York State Department of Health Guidelines for the
Processing of Medicaid Advantage Plus Enrollments and Disenrollments

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SDOH Guidelines
For the Processing of Medicaid Advantage Plus Enrollments and Disenrollments

General

The Contractor's Enrollment and Disenrollment procedures for the Medicaid
Advantage Plus Product shall be consistent with these requirements, except to
allow LDSS and the Contractor flexibility in developing processes that will meet
the needs of both parties, the SDOH may allow material modifications to
timeframes and some procedures, subject to SDOH prior written approval before
their implementation. Where an Enrollment Broker exists, the Enrollment Broker
may be responsible for some or all of the LDSS responsibilities.

Enrollment Policy

A.
Enrollments will only be processed using the following timeframes if
the Medicaid eligibility of a potential enrollee has been established and
when Medicaid recertification is not required within 30 days of the effective
date of enrollment.

B.
If the enrollment application lacks information related to Medicaid
eligibility, and that lack of information would preclude appropriate processing
of the enrollment in the Welfare Management System (WMS) or eMedNY,
the effective date of enrollment is not required to meet the new processing
review timeframes. The LDSS may require additional information or clarification
from the Contractor in this circumstance.

C.
Plans are encouraged to submit completed enrollment applications on a
weekly basis rather than "holding" applications until the 20th day of the month.

D.
The Contractor is required to submit the following enrollment
application information to the LDSS:

 
i.   Enrollee agreement and attestation;

 
ii.   theDMS-1 or successor instrument;

 
iii.   the Semi-Annual Assessment of Members (SAAM);

 
iv.   the plan of care developed by the Contractor, and

 
v.   transmittal sheet(s) with any information required by the LDSS to effect
the enrollment.

The LDSS may require that the plan also submit evidence of Medicaid eligibility
in a form to be approved by the SDOH.

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E.
In most circumstances the LDSS prior enrollment review will be limited to
assuring the completeness of the assessment and other documentation described
above in D. However, in certain instances, the LDSS, if it chooses, will review
a number of cases prior to enrollment to assure that the eligibility criteria
are met.

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

G.
 If the LDSS determines that the enrollment application is incomplete, it may
delay the enrollment to secure a complete enrollment application from the
Contractor.

H.
 Post enrollment audits will be conducted on every enrollment application or a
sample of applications as agreed upon by the LDSS and Department.

I.
The LDSS audit must be limited to a review of the documentation identified in
subsection D above to determine if the following enrollment criteria are met,
and that the Applicant:

i.   meets the age requirements approved for the Contractor;
ii.  is a resident of the Contactor's service area;
iii. is eligible for nursing home level of care;
iv. is capable, at the time of enrollment, of returning to or remaining in his
or her home and community without jeopardy to health and safety; and
v.   is expected to require the long term care services of the Contractor for at
least 120 days from the effective date of enrollment.

J. 
If, based upon the review/audit, the LDSS determines that that the enrollee was
inappropriately enrolled because she/he did not meet the contractual eligibility
criteria at the time of enrollment, the LDSS must notify the Contractor in
writing.

K.
Any disagreement between the Contractor and the LDSS about the individual's
eligibility will be resolved using the LDSS/Contractor Dispute Resolution
process approved by SDOH.

L. 
 If, based on the outcome of the dispute resolution, the enrollee is not found
to meet the eligibility criteria for enrollment, the LDSS must notify the
Contractor in writing that it will proceed with the member's disenrollment.

M.
The LDSS will notify the enrollee of the district's intent to disenroll the
member, based on the member's failure to meet the enrollment eligibility
criteria. The notice will include the enrollee's right to request a Fair Hearing
with aid continuing.

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N.
 The Contractor must continue to provide and arrange covered services until the
effective date of disenrollment. The Department will continue to pay capitation
fees for an enrollee until the effective date of disenrollment.

O.
Prior to the enrollee's disenrollment, the Contractor will assist the enrollee
by referring the enrollee, and by making their care management record and other
enrollee service records available as appropriate to health care providers
and/or programs.

3.      SDOH Responsibilities

A.
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.

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

4.      LDSSResponsibilities:

A.
The LDSS has the primary responsibility for processing Medicaid Advantage
Plus enrollments.

B.
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 Plus Product eligibility.

C.
The LDSS is responsible for processing Enrollments in Medicaid Advantage
Plus 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.

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

E.
Only the LDSS may determine Enrollee spenddown and/or Net Available
Monthly Income (NAMI) surplus amounts and will notify the plan of the amount.
The Contractor's inability to collect funds from Enrollees will not change the
plan's spenddown or NAMI adjustment.

F.
The LDSS is responsible for notifying the Contractor about the status of
enrollment applications that are accepted, denied or pended.

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G. 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:

 
i.   LDSS directly enters data into PCP Subsystem; or
 

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

 
iii. LDSS electronically transfers data via a dedicated line, from eMedNY to the
PCP Subsystem.

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

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

J.   The LDSS is responsible for sending the following notices to the Applicant:

 
i.     Enrollment Confirmation Notice: This notice indicates the Effective Date
of Enrollment, the name of the Medicaid Advantage Plus 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 Plus 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 Plus
Benefit rendered during the retroactive period if the benefit was provided by a
non-Medicaid participating provider.

 
ii.   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 Plus Product. This notice must include fair hearing rights.

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2007
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5.   Contractor Responsibilities:

A.
The Contractor, using the patient assessment instrument specified by SDOH,
will evaluate all Applicants to assess:

i.      their eligibility for nursing home level of care at the time of
enrollment; ii. that they are capable at the time of enrollment, of returning to
or remaining in their home and/or community without jeopardy to their health
and/or safety,
based upon criteria provided by SDOH; and iii. that they are expected to require
at least one of the following services and care management for at least 120 days
from the effective date of enrollment:

•      nursing services in the home;

•      therapies in the home;
•      home health aide services;
•      personal care services in the home;

•      adult day health care; or
•      social day care if used as a substitute for in-home personal care
services.

B.
The potential that an Applicant may require acute hospital inpatient services or
nursing home placement during such 120 day period shall not be taken into
consideration by the Contractor when assessing an Applicant's eligibility for
enrollment.

C.
If the Contractor operates in an approved service area which encompasses more
than one local department of social services (LDSS), and the Contractor has
knowledge that an Enrollee proposes to change residence from one local social
services district to another within the Contractor's approved service area, the
Contractor must notify the original LDSS of the pending move and must, upon the
request of the receiving LDSS, provide a new assessment of the Enrollee to the
receiving LDSS. Continued enrollment is dependent upon the approval of the
receiving LDSS.

D.
Applicant may withdraw an application or enrollment agreement prior to the
effective date of enrollment by indicating his or her wishes orally or in
writing. All withdrawals must be acknowledged by the Contractor to the Applicant
in writing.

E.
If the Contractor meets face-to-face with an Applicant to discuss enrollment,
and the Applicant chooses not to enroll, the Contractor must send a written
notice to the Applicant confirming non-enrollment.

F.
The Contractor may find that the Applicant does not meet the enrollment
criteria identified in Section 5.1 of this Agreement and may advise the
Applicant of such. If the Applicant wants to pursue enrollment, despite being
notified of the Contractor's finding, the Contractor must transmit the
application to the LDSS, and notify the Applicant that the Contractor will
recommend denial of enrollment if the Applicant does not choose to withdraw his
or her application. Only the LDSS may deny enrollment.

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G.
 The Contractor will notify enrollment referral sources, as appropriate, if the
Applicant doesn't enroll.

H.
The Contractor shall comply with enrollment procedures developed by the
Contractor and the LDSS and approved by the Department. Such written procedures
shall address all aspects of application processing and shall contain the
enrollment forms to be used by the Contractor. The Contractor agrees to submit
any proposed material revisions to the approved enrollment procedures in writing
for SDOH approval prior to the revised procedures becoming effective.

I.  
 The Contractor is responsible for obtaining documentation of Medicare A and B
coverage prior to sending the Enrollment transaction to the LDSS for processing;
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.

J. 
  The Contractor must report any changes in status for 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, factors that may impact
Medicaid or Medicaid Advantage Plus eligibility such as address changes,
incarceration, third party insurance other than Medicare, Disenrollment from the
Contractor's Medicare Advantage Product, etc.

K.
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 Plus Plan.

L. 
 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.

M.
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.

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6.   Newborn Medicaid Eligibility

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)

 
iii) In the event that the LDSS learns of an Enrollee's pregnancy prior to the
Contractor, the LDSS is responsible for establishing Medicaid eligibility and
enrolling the unborn 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).

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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), gender and the date of birth.

7.   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 lsl day 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
LDSS will be accomplished via paper transmission, magnetic media, or the HPN.

 
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 Plus 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 Enrollment status. The Contractor and the LDSS may develop
protocols for the purpose of resolving Roster discrepancies that remain
unresolved beyond the end of the month).

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

D. Contractor Responsibilities:

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

 
ii.   The Contractor must submit claims to the State's Fiscal Agent for all
Eligible Persons that are on the 1st and 2n Rosters, adjusted to add Eligible
Persons enrolled by the LDSS after Roster production and to remove individuals
disenrolled by LDSS after Roster production (as notified to the Contractor). In
the cases of retroactive Disenrollments, the Contractor is responsible for
submitting an adjustment to void any previously paid premiums for the period of
retroactive Disenrollment, where the Contractor was not at risk for the
provision of Benefit Package services. Payment of sub-capitation does not
constitute "provision of Benefit Package services."

8.  Disenrollment:

A. LDSS Responsibilities:

 
i.   Enrollees may request to disenroll from the Contractor's Medicaid Advantage
Plus Product at any time for any reason, orally or in writing. A Disenrollment
request may be made by the Enrollee to the LDSS or the Contractor.

 
ii.    Medicaid Advantage Plus plans and the LDSS must use State-approved
Disenrollment forms.

 
iii. 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.

 
iv. The LDSS is responsible for disenrolling Enrollees automatically upon death,
Disenrollment from the Contractor's Medicare Advantage Product, or loss of
Medicaid eligibility. AH 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.

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v.  The LDSS is responsible for promptly disenrolling an Enrollee whose Medicaid
eligibility or status changes such that he/she is deemed by the LDSS to no
longer be eligible for Medicaid Advantage Plus enrollment. The LDSS is
responsible for providing Enrollees with a notice of their right to request a
fair hearing.

 
vi. 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 Plus Product,
is enrolled when ineligible for Enrollment, or when an Enrollee enters or
resides in an entity or program identified in Section 5.1 of this Agreement
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." 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.

 
vii. 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 for any full months of retroactive Disenrollment where the Contractor was
not at risk for the provision of Benefit Package services during the month.
However, failure by the LDSS to so notify the Contractor does not affect the
right of the SDOH to recover the premium payment as authorized by Section 3.6 of
this Agreement.

 
viii. Generally the effective dates of Disenrollment are prospective. Effective
dates for other than routine Disenrollments are described below:

 
a.
Death of Enrollee - Effective Date of Disenrollment is the first day of the
month after death.

 
b.
Incarceration - Effective date of disenrollment is the first day of the month
of incarceration (Note: the Contactor is at risk for covered services only to
the date of incarceration and is entitled to capitation payments for the entire
month in which the incarceration occurs.

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c.
Non-consensual Enrollment - Effective date of disenrollment is the first day
of the month of Enrollment.

d.
Enrollee moved outside of the District/County of Fiscal Responsibility -
Effective date of disenrollment is the first day of the month after the update
of the system with the new address  In counties outside of New York City, the
LDSS 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 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.

e.
An Enrollee with more than one Client Identification Number (CIN) is enrolled
in the Contractor's Medicaid Advantage Plus Product under more than one of
the CINs - Effective date of disnrollment is the first day of the month the
duplicate Enrollment began.

 
ix. The LDSS is responsible for sending a notice of Disenrollment to Enrollees
regarding their disenrollment. These notices will advise the Enrollee of the
LDSS's determination regarding an Enrol lee-initiated, LDSS-initiated or
Contractor-initiated Disenrollment and will include the Effective Date of
Disenrollment. In cases where the Enrollee is being involuntarily disenrolled,
the notice must contain fair hearing rights.

 
x.   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 Plus Product until the
disposition of the fair hearing, if Aid to Continue is ordered by the New York
State Office of Administrative Hearings.

 
xi. The LDSS is responsible for reviewing each Contractor-requested
Disenrollment in accordance with the provisions of Section 8(B) 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.

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

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xiii. After the LDSS receives 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.   The Contractor is responsible for informing Enrollees of their right to
disenroll at any time for any reason.

 
ii.  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 of receipt of the request for
disenrollment from the Enrollee. During pull-down week, these forms may be faxed
to the LDSS with the hard copy to follow.

 
iii. 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.

 
iv. Following LDSS procedures, the Contractor will refer cases which are
appropriate for an LDSS-initiated Disenrollment and will submit supporting
documentation to the LDSS. This includes, but is not limited to, changes in
status for its enrolled members that may impact eligibility for Enrollment such
as address changes, incarceration, death, ineligibility for Medicaid Advantage
Plus Enrollment, change in Medicare status, etc.

 
v.   The Contractor may initiate an involuntary disenrollment for any of the
reasons identified in Section 8.8 of this Agreement.

a.
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.

b.
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.

c.
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.

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d.  
The Contractor will not consider an Enrollee disenrolled without confirmation
from the LDSS or the Roster,

Medicaid Advantage Plus Contract
APPENDIX H

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2007

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APPENDIX I

RESERVED

Medicaid Advantage Plus Contract
APPENDIX I
(RESERVED)
2007

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APPENDIX J
 
New York State Department of Health Guidelines for Contractor Compliance with
the Federal Americans with Disabilities Act

 

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GUIDELINES FOR MEDICAID MCO COMPLIANCE WITH THE AMERICANS WITH DISABILITIES ACT
(ADA)

I.          Objectives                                                                                                                                                                                              
Title II of the Americans With Disabilities Act (ADA) and Section 504 of the
Rehabilitation Act of 1973 (Section 504) provides that no qualified individual
with a disability shall, by reason of such disability, be excluded from
participation in or denied access to the benefits of services, programs or
activities of a public entity, or be subject to discrimination by such an
entity. Public entities include State and local government and ADA and Section
504 requirements extend to all programs and services provided by State and local
government. Since Medicaid is a government program, health services provided
through Medicaid Managed Care, including Medicaid Advantage Plus , must be
accessible to all who qualify for the program.

MCO responsibilities for compliance with the ADA are imposed under Title II and
Section 504 when, as a contractor in a Medicaid program, a plan is providing a
government service. If an individual provider under contract with the MCO is not
accessible, it is the responsibility of the MCO to make arrangements to assure
that alternative services are provided. The MCO may determine it is expedient to
make arrangements with other providers, or to describe reasonable alternative
means and methods to make these services accessible through its existing
contractors. The goals of compliance with ADA Title II requirements are to offer
a level of services that allows people with disabilities access to the program
in its entirety, and the ability to achieve the same health care results as any
program participant.

MCO responsibilities for compliance with the ADA are also imposed under Title
III when the MCO functions as a public accommodation providing services to
individuals (e.g. program areas and sites such as marketing, education, member
services, orientation, complaints and appeals). The goals of compliance with ADA
Title III requirements are to offer a level of services that allows people with
disabilities full and equal enjoyment of the goods, services, facilities or
accommodations that the entity provides for its customers or clients. New and
altered areas and facilities must be as accessible as possible. Whenever MCOs
engage in new construction or renovation, compliance is also required with
accessible design and construction standards promulgated pursuant to the ADA as
well as State and local laws. Title III also requires that public accommodations
undertake "readily achievable barrier removal" in existing facilities where
architectural and communications barriers can be removed easily and without much
difficulty or expense.

The state uses Plan Qualification Standards to qualify MCOs for participation in
the Medicaid Advantage Plus Program pursuant to the state's responsibility to
assure program access to all recipients, the Plan Qualification Standards
require each MCO to submit an ADA

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Compliance Plan that describes in detail how the MCO will make services,
programs and activities readily accessible and useable by individuals with
disabilities. In the event that certain program sites are not readily
accessible, the MCO must describe reasonable alternative methods for making the
services or activities accessible and usable.
Title II of the Americans With Disabilities Act (ADA) and Section 504 of the
Rehabilitation Act of 1973 (Section 504) provides that no qualified individual
with a disability shall, by reason of such disability, be excluded from
participation in or denied access to the benefits of services, programs or
activities of a public entity, or be subject to discrimination by such an
entity. Public entities include State and local government and ADA and Section
504 requirements extend to all programs and services provided by State and local
government. Since Medicaid is a government program, health services provided
through Medicaid Managed Care, including Medicaid Advantage Plus , must be
accessible to all who qualify for the program.

MCO responsibilities for compliance with the ADA are imposed under Title II and
Section 504 when, as a contractor in a Medicaid program, a plan is providing a
government service. If an individual provider under contract with the MCO is not
accessible, it is the responsibility of the MCO to make arrangements to assure
that alternative services are provided. The MCO may determine it is expedient to
make arrangements with other providers, or to describe reasonable alternative
means and methods to make these services accessible through its existing
contractors. The goals of compliance with ADA Title II requirements are to offer
a level of services that allows people with disabilities access to the program
in its entirety, and the ability to achieve the same health care results as any
program participant.

MCO responsibilities for compliance with the ADA are also imposed under Title
III when the MCO functions as a public accommodation providing services to
individuals (e.g. program areas and sites such as marketing, education, member
services, orientation, complaints and appeals). The goals of compliance with ADA
Title III requirements are to offer a level of services that allows people with
disabilities full and equal enjoyment of the goods, services, facilities or
accommodations that the entity provides for its customers or clients. New and
altered areas and facilities must be as accessible as possible. Whenever MCOs
engage in new construction or renovation, compliance is also required with
accessible design and construction standards promulgated pursuant to the ADA as
well as State and local laws. Title III also requires that public accommodations
undertake "readily achievable barrier removal" in existing facilities where
architectural and communications barriers can be removed easily and without much
difficulty or expense.

The state uses Plan Qualification Standards to qualify MCOs for participation in
the Medicaid Advantage Plus Program. Pursuant to the state's responsibility to
assure program access to all recipients, the Plan Qualification Standards
require each MCO to submit an ADA Compliance Plan that describes in detail how
the MCO will make services, programs and activities readily accessible and
useable by individuals with disabilities. In the event that certain program
sites are not readily accessible, the MCO must describe reasonable alternative
methods for making the services or activities accessible and usable.

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The objectives of these guidelines are threefold:
• to ensure that MCOs take appropriate steps to measure access and assure
program accessibility for persons with disabilities; 
• to provide a framework for managed care organizations (MCos) as they develop a
plan to assire compliance with the Americans with Disabilities Act (ADA); and
• to provide standards for the review of MCO Compliance Plans.

These guidelines include a general standard followed by a discussion of specific
considerations and suggestions of methods for assuring compliance. Please be
advised that, although these guidelines and any subsequent reviews by State and
local governments can give the contractor guidance, it is ultimately the
contractor's obligation to ensure that it complies with its contractual
obligations, as well as with the requirements of the ADA, Section 504, and other
federal, state and local laws. Other federal, state and local statutes and
regulations also prohibit discrimination on the basis of disability and may
impose requirements in addition to those established under ADA. For example,
while the ADA covers those impairments that "substantially" limit one or more of
the major life activities of an individual, New York City Human Rights Law
deletes the modifier "substantially".

II.        Definitions

A.
"Auxiliary aids and services" may include qualified interpreters, note takers,
computer-aided transcription services, written materials, telephone handset
amplifiers, assistive listening systems, telephones compatible with hearing
aids, closed caption decoders, open and closed captioning, telecommunications
devices for enrollees who are deaf or hard of hearing (TTY/TDD), video test
displays, and other effective methods of making aurally delivered materials
available to individuals with hearing impairments; qualified readers, taped
texts, audio recordings, Brailled materials, large print materials, or other
effective methods of making visually delivered materials available to
individuals with visual impairments.

B.
"Disability" means a mental or physical impairment that substantially limits one
or more of the major life activities of an individual; a record of such
impairment; or being regarded as having such an impairment.

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III.      Scope of MCO Compliance Plan
The MCO Compliance Plan must address accessibility to services at the MCO's
program sites, including both participating provider sites and MCO facilities
intended for use by enrollee.

IV.      Program Accessibility
Public programs and services, when viewed in their entirety, must be readily
accessible to and useable by individuals with disabilities. This standard
includes physical access, non-discrimination in policies and procedures and
communication. Communications with individuals with disabilities are required to
be as effective as communications with others. The MCO Compliance Plan must
include a detailed description of how MCO services, programs and activities are
readily accessible and usable by individuals with disabilities. In the event
that full physical accessibility is not readily available for people with
disabilities, the MCO Compliance Plan will describe the steps or actions the MCO
will take to assure accessibility to services equivalent to those offered at the
inaccessible facilities.

IV.       Program Accessibility

A.        Pre-cnrollmcnt Marketing and Education

Standard for Compliance:
Marketing staff, activities and materials will be made available to persons with
disabilities. Marketing materials will be made available in alternative formats
(such as Braille, large print, audio tapes) so that they are readily usable by
people with disabilities.

Suggested Methods for Compliance

1.
Activities held in physically accessible location, or staff at activities
available to meet with person in an accessible location as necessary

2.
Materials available in alternative formats, such as Braille, large print, audio
tapes

3.
Staff training which includes training and information regarding attitudinal
barriers related to disability

4.
Activities and fairs that include sign language interpreters or the distribution
of a written summary of the marketing script used by plan marketing
representatives

5.
Enrollee health promotion material/activities targeted specifically to persons
with disabilities (e.g. secondary infection prevention, decubitus prevention,
special exercise programs, etc.)

6.
Policy statement that marketing representatives will offer to read or summarize
to blind or vision impaired individuals any written material that is typically
distributed to all enrollees

7.
Staff/resources available to assist individuals with cognitive impairments in
understanding materials

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Compliance Plan
Submission                                                                                                                                                                                                        
1.
A description of methods to ensure that the MCO's marketing presentations
(materials and communications) are accessible to persons with auditory, visual
and cognitive impairments

2.
A description of the MCO's policies and procedures, including marketing
training, to ensure that marketing representatives neither screen health status
nor ask questions about health status or prior health care services

IV.      Program
Accessibility                                                                                                                                                                                                       
 
B.        Member Services
Department                                                                                                                                                                               .                  .        
Member services functions include the provision to enroUees of information
necessary to make informed choices about treatment options, to effectively
utilize the health care resources, to assist enroUees in making appointments,
and to field questions and complaints, to assist enrollees with the complaint
process.

Bl.      Accessibility

Standard for
Compliance:                                                                                                                              
Member Services sites and functions will be made accessible to, and usable by,
people with disabilities.

Suggested Methods for Compliance (include, but are not limited to those
identified below)              
                                                                                                                                                                                      
1.
Exterior routes of travel, at least 36" wide, from parking areas or public
transportation stops into the MCO's facility

2.
If parking is provided, spaces reserved for people with disabilities, pedestrian
ramps at sidewalks, and drop-offs

3.
Routes of travel into the facility are stable, slip-resistant, with all steps>
V? ramped, doorways with minimum 32" opening

4.
Interior halls and passageways providing a clear and unobstructed path or travel
at least 36" wide to bathrooms and other rooms commonly used by enrol lees

5.
Waiting rooms, restrooms, and other rooms used by enroUees are accessible to
people with disabilities

6.
Sign language interpreters and other auxiliary aids and services provided in
appropriate circumstances

7.
Materials available in alternative formats, such as Braille, large print, audio
tapes

8.
Staff training which includes sensitivity training related to disability issues
[Resources and technical assistance are available through the NYS Office of
Advocate for Persons with Disabilities - V/TTY (800) 522-4369; and the NYC
Mayor's Office for People with Disabilities - (212) 788-2830 or TTY
(212)788-2838]

9. Availability of activities and educational materials tailored to specific
conditions/illnesses and secondary conditions that affect these populations
(e.g. secondary infection prevention, decubitus prevention, special exercise
programs, etc.)

           

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10.
MCO staff trained in the use of telecommunication devices for enrollees who are
deaf or hard of hearing (TTY/TDD) as well as in the use of NY Relay for phone
communication

11.           New enrollee orientation available in audio or by interpreter
services
12.
Policy that when member services staff receive calls through the NY Relay, they
will offer to return the call utilizing a direct TTY/TDD connection

Compliance Plan Submission
1.
A description of accessibility to the member services department or reasonable
alternative means to access member services for enrollees using wheelchairs (or
other mobility aids)

2.
A description of the methods the member services department will use to
communicate with enrollees who have visual or hearing impairments, including any
necessary auxiliary aid/services for enrollees who are deaf or hard of hearing,
and TTY/TDD technology or NY Relay Service available through a toll-free
telephone number

 3.   A description of the training provided to member services staff to assure
that staff adequately understands how to implement the requirements of the
program, and of these guidelines, and are sensitive to the needs of persons with
disabilities

  
IV.       Program
Accessibility                                                                                                                                                                                                       
B2.      Identification of Enrollees with
Disabilities                                                                                                                                                                                               

Standard for
Compliance:                                                                                                                                                                                                       
MCOs must have in place satisfactory methods/guidelines for identifying persons
at risk of, or having, chronic diseases and disabilities and determining their
specific needs in terms of specialist physician referrals, durable medical
equipment, medical supplies, home health services etc. MCOs may not discriminate
against a potential enrollee based on his/her current health status or
anticipated need for future health care. MCOs may not discriminate on the basis
of disability, or perceived disability of an enrollee or their family member.

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Suggested Methods for
Compliance                                                                                                                                                                                          
1.
Appropriate post enrollment health screening for each enrollee, using an
appropriate health screening tool

2.
Patient profiles by condition/disease for comparative analysis to national
norms, with appropriate outreach and education

3.
Process for follow-up of needs identified by initial screening; e.g. referrals,
assignment of case manager, assistance with scheduling/keeping appointments

4.
Enrolled population disability assessment survey

5.
Process for enrollees who acquire a disability subsequent to enrollment to
access appropriate services

Compliance Plan
Submission                                                                                                                                                                                              .         
1.           A description of how the MCO will identify special health care,
physical access or communication needs of enrollees on a timely basis, including
but not limited to the health care needs of enrollees who:
are blind or have visual impairments, including the type of auxiliary aids and
services required by the enrollee are deaf or hard of hearing, including the
type of auxiliary aids and services required by the enrollee have mobility
impairments, including the extent, if any, to which they can ambulate have other
physical or mental impairments or disabilities, including cognitive
impairments •have conditions which may require more intensive case management

IV.      Program Accessibility
 
B3.      New Enrollee Orientation

Standard for
Compliance:                                                                                                                                                                                        
Enrollees will be given information sufficient to ensure that they understand
how to access medical care through the plan. This information will be made
accessible to, and usable by, people with disabilities.

Suggested Methods for
Compliance                                                                                                                                                                                                 

1.
Activities held in physically accessible location, or staff at activities
available to meet with person in an accessible location as necessary

2.   Materials available in alternative formats, such as Braille, large print,
audio tapes

3.  Staff training which includes sensitivity training related to disability
issues [Resources and technical assistance are available through the NYS Office
of Advocate for Persons with Disabilities - V/TTY (800) 522-4369; and the NYC
Mayor's Office for People with Disabilities - (212) 788-2830 or TTY
(212)788-2838]

                     
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4.
Activities and fairs that include sign language interpreters or the distribution
of a written summary of the marketing script used by plan marketing
representatives

5.
Include in written/audio materials available to all enrollees information
regarding how and where people with disabilities can access help in getting
services, for example help with making appointments or for arranging special
transportation, an interpreter or assistive communication devices

6.  Staff/resources available to assist individuals with cognitive impairments
in understanding materials

          

Compliance Plan Submission
1.            A description of how the MCO will advise enrollees with
disabilities, during the new enrollee orientation on how to access care
2.
A description of how the MCO will assist new enrollees with disabilities (as
well as current enrollees who acquire a disability) in selecting or arranging an
appointment with a Primary Care Practitioner (PCP)

•
This should include a description of how the MCO will assure and provide notice
to enrollees who are deaf or hard of hearing, blind or who have visual
impairments, of their right to obtain necessary auxiliary aids and services
during appointments and in scheduling appointments and follow-up treatment with
participating providers 

•
In the event that certain provider sites are not physically accessible to
enrollees with mobility impairments, the MCO will assure that reasonable
alternative site and services are available

3.
A description of how the MCO will determine the specific needs of an enrollee
with or at risk of having a disability/chronic disease, in terms of specialist
physician referrals, durable medical equipment (including assistive technology
and adaptive equipment), medical supplies and home health services and will
assure that such contractual services are provided

4.
A description of how the MCO will identify if an enrollee with a disability
requires on-going mental health services and how MCO will encourage early entry
into treatment

5.   A description of how the MCO will notify enrollees with disabilities as to
how to access transportation, where applicable

          

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IV.      Program Accessibility

B4.      Complaints and Appeals

Standard for Compliance:
The MCO will establish and maintain a procedure to protect the rights and
interests of both enrollees and managed care plans by receiving, processing, and
resolving complaints and appeals in an expeditious manner, with the goal of
ensuring resolution of complaints/appeals and access to appropriate services as
rapidly as possible.

All enrollees must be informed about the overall grievance system within their
plan and the procedure for filing complaints and/or appeals. This information
will be made available through the member handbook, the SDOH toll-free complaint
line [l-(800) 206-8125] and the plan's complaint process annually, as well as
when the MCO denies a benefit or referral. The MCO will inform enrollees of: the
MCO's procedures; enrollees' right to contact the local district or SDOH with a
complaint, and to file an appeal or request a fair hearing; the right to appoint
a designee to handle a complaint or appeal; the toll free complaint line. The
MCO will maintain designated staff to take and process complaints, and be
responsible for assisting enrollees in complaint resolution.

The MCO will make all information regarding the grievance system available to
and usable by people with disabilities, and will assure that people with
disabilities have access to sites where enrollees typically file complaints and
requests for appeals.

Suggested Methods for
Compliance                                                                                                                                                                                                         
1.  800 complaint phone line with TDD/TTY capability
2.  Staff trained in complaint process, and able to provide interpretive or
assistive support to enrollee during the complaint process
3.  Notification materials and complaint forms in alternative formats for
enrollees with visual or hearing impairments
4.  Availability of physically accessible sites, e.g. member services department
sites
5.  Assistance for individuals with cognitive
impairments                                                                                                                                                                                               

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Compliance Plan
Submission                                                                                                                                                            __                           .         
1. A description of how MCO's complaint and appeal procedures shall be
accessible for persons with disabilities, including:
procedures for complaints and appeals to be made in person at sites accessible
to persons with mobility impairments procedures accessible to persons with
sensory or other impairments who wish to make verbal complaints, and to
communicate with such persons on an ongoing basis as to the status or their
complaints and rights to further appeals description of methods to ensure
notification material is available in alternative formats for enrollees with
vision and hearing impairments
2. A description of how MCOs monitor appeals and grievances related to people
with disabilities.

IV.       Program Accessibility
 
C.        Case Management

Standard for
Compliance:                                                                                                                                                                                                     
MCOs must have in place an adequate case management systems to identify the
service needs of all enrollees, including enrollees with chronic illness and
enrollees with disabilities, and ensure that medically necessary covered
benefits are delivered on a timely basis. In addition to the care management
requirements identified in Section 10 of this Agreement, these systems must
include procedures for standing referrals, specialists as PCPs, and referrals to
specialty centers for enrollees who require specialized medical care over
a prolonged period of time (as determined by a treatment plan approved by the
MCO in consultation with the primary care provider, the designated specialist
and the enrollee or his/her designee), out of plan referrals and continuation of
existing treatment relationships with out-of-plan providers (during transitional
period).

Suggested Methods for
Compliance                                                                                                                                                                                                        
1.
Procedures for requesting specialist physicians to function as PCP

2.
Procedures for requesting standing referrals to specialists and/or specialty
centers, out of plan referrals, and continuation of existing treatment
relationships

3.
Procedures to meet enrollee needs for, durable medical equipment, medical
supplies, home visits as appropriate

4.
Appropriately trained MCO staff to function as case managers for special needs
populations, or sub-contract arrangements for case management

5.
Procedures for informing enrollees about the availability of case management
services                                                                                                                                                                                              .

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Compliance Plan
Submission                                                                                                                                                                                            
1.
A description of the MCO case management program for people with disabilities,
including case management functions, procedures for qualifying for and being
assigned a case manager , and description of case management staff
qualifications

2.
A description of the MCO's model protocol to enable participating providers, at
their point of service, to identify enrollees who require a case manager

3.
A description of the MCO's protocol for assignment of specialists as PCP, and
for standing referrals to specialists and specialty centers, out-of-plan
referrals and continuing treatment relationships

4.  A description of the MCO's notice procedures to enrollees regarding the
availability of case management services, specialists as PCPs, standing
referrals to specialists and specialty centers, out-of-plan referrals and
continuing treatment relationships

 
IV.       Program Accessibility 
 
D. Participating Providers
 
Standard for Compliance:
MCOs networks will include all the provider types necessary to furnish the
benefit package, to assure appropriate and timely health care to all enrollees,
including those with chronic illness and/or disabilities. Physical accessibility
is not limited to entry to a provider site, but also includes access to services
within the site, e.g. exam tables and medical equipment.

Suggested Methods for Compliance
 
1.
Process for MCO to evaluate provider network to ascertain the degree of provider
accessibility to persons with disabilities, to identify barriers to access and
required modifications to policies/procedures

2.
Model protocol to assist participating providers, at their point of service, to
identify enrollees who require case manager, audio, visual, mobility aids, or
other accommodations

3. Model protocol for determining needs of enrollees with mental disabilities

4.  Use of Wheelchair Accessibility Certification Form (see attached)

5.  Submission of map of physically accessible sites

6.
Training for providers re: compliance with Title III of ADA, e.g. site access
requirements for door widths, wheelchair ramps, accessible diagnostic/treatment
rooms and equipment; communication issues; attitudinal barriers related to
disability, etc. [Resources and technical assistance are available through the
NYS Office of Advocate for Persons with Disabilities -V/TTY (800) 522-4369; and
the NYC Mayor's Office for People with Disabilities - (212) 788-2830 or TTY
(212)788-2838]

     
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7.
Use of ADA Checklist for Existing Facilities and NYC Addendum to OAPD ADA
Accessibility Checklist as guides for evaluating existing facilities and for new
construction and/or alteration.

Compliance Plan Submission
1.
A description of how MCO will ensure that its participating provider network is
accessible to persons with disabilities. This includes the following:

• 
Policies and procedures to prevent discrimination on the basis of disability or
type of illness or condition Identification of participating provider sites
which are accessible by people with mobility impairments, including people using
mobility devices. If certain provider sites are not physically accessible to
persons with disabilities, the MCO shall describe reasonable, alternative means
that result in making the provider services readily accessible.

• 
Identification of participating provider sites which do not have access to sign
language interpreters or reasonable alternative means to communicate with
enrollees who are deaf or hard of hearing; and for those sites describe
reasonable alternative methods to ensure that services will be made accessible

• 
Identification of participating providers which do not have adequate
communication systems for enrollees who are blind or have vision impairments
(e.g. raised symbol and lettering or visual signal appliances), and for those
sites describe reasonable alternative methods to ensure that services will be
made accessible

 2.  A description of how the MCO's specialty network is sufficient to meet the
needs of enrollees with disabilities

 3.    A description of methods to ensure the coordination of out-of-network
providers to meet the needs of the enrollees with disabilities

• 
This may include the implementation of a referral system to ensure that the
health care needs of enrollees with disabilities are met appropriately

• 
MCO shall describe policies and procedures to allow for the continuation of
existing relationships with out-of-network providers, when in the best interest
of the enrollee with a disability

4.
Submission of ADA Compliance Summary Report (see attached - county
specific/borough specific for NYC) or MCO statement that data submitted to SDOH
on the Health Provider Network (HPN) files is an accurate reflection of each
network's physical accessibility 

 
 
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IV.      Program Accessibility

E.        Populations Special Health Care Needs

Standard for Compliance:
MCOs will have satisfactory methods for identifying persons at risk of, or
having, chronic disabilities and determining their specific needs in terms of
specialist physician referrals, durable medical equipment, medical supplies,
home health services, etc. MCOs will have satisfactory systems for coordinating
service delivery and, if necessary, procedures to allow continuation of existing
relationships with out-of-network provider for course of treatment.
 
Suggested Methods for Compliance
1.
Procedures for requesting standing referrals to specialists and/or specialty
centers, specialist physicians to function as PCP, out of plan referrals, and
continuation of existing relationships with out-of-network providers for course
of treatment

2.
Contracts with school-based health centers

3.
Linkages with preschool services, child protective agencies, early intervention
officials, behavioral health agencies, disability and advocacy organizations,
etc.

4.
Adequate network of providers and subspecialists (including pediatric providers
and sub-specialists) and contractual relationships with tertiary institutions

5.     for assuring that these populations receive appropriate diagnostic
workups on a timely basis

6.   Procedures for assuring that these populations receive appropriate access
to durable medical equipment on a timely basis

7.
Procedures for assuring that these populations receive appropriate allied health
professionals (Physical, Occupational and Speech Therapists, Audiologists) on a
timely basis

8. State designation as a Well Qualified Plan to serve OMRDP population and
look-alikes

           
Compliance Plan Submission

A description of arrangements to ensure access to specialty care providers and
centers in and out of New York State, standing referrals, specialist physicians
to function as PCP, out of plan referrals, and continuation of existing
relationships (out-of-plan) for diagnosis and treatment of rare disorders.
 
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V.        ADDITIONAL ADA RESPONSIBILITIES FOR PUBLIC ACCOMMODATIONS     
                                                                                                                                                                                                    
Please note that Title III of the ADA applies to all non-governmental providers
of health care. Title III of the Americans With Disabilities Act prohibits
discrimination on the basis of disability in the full and equal enjoyment of
goods, services, facilities, privileges, advantages or accommodations of any
place of public accommodation. A public accommodation is a private entity that
owns, leases or leases to, or operates a place of public accommodation. Places
of public accommodation identified by the ADA include, but are not limited to,
stores (including pharmacies) offices (including doctors' offices), hospitals,
health care providers, and social service centers.

New and altered areas and facilities must be as accessible as possible. Barriers
must be removed from existing facilities when it is readily achievable, defined
by the ADA as easily accomplishable without much difficulty or expense. Factors
to be considered when determining if barrier removal is readily achievable
include the cost of the action, the financial resources of the site involved,
and, if applicable, the overall financial resources of any parent corporation or
entity. If barrier removal is not readily achievable, the ADA requires alternate
methods of making goods and services available. New facilities must be
accessible unless structurally impracticable.

Title III also requires places of public accommodation to provide any auxiliary
aids and services that are needed to ensure equal access to the services it
offers, unless a fundamental alteration in the nature of services or an undue
burden would result. Auxiliary aids include but are not limited to qualified
sign interpreters, assistive listening systems, readers, large print materials,
etc. Undue burden is defined as "significant difficulty or expense". The factors
to be considered in determining "undue burden" include, but are not limited to,
the nature and cost of the action required and the overall financial resources
of the provider. "Undue burden" is a higher standard than "readily achievable"
in that it requires a greater level of effort on the part of the public
accommodation.

Please note also that the ADA is not the only law applicable for people with
disabilities. In some cases, State or local laws require more than the ADA. For
example, New York City's Human Rights Law, which also prohibits discrimination
against people with disabilities, includes people whose impairments are not as
"substantial" as the narrower ADA and uses the higher "undue burden"
("reasonable") standard where the ADA requires only that which is "readily
achievable". New York City's Building Code does not permit access waivers for
newly constructed facilities and requires incorporation of access features as
existing facilities are renovated. Finally, the State Hospital code sets a
higher standard than the ADA for provision of communication (such as sign
language interpreters) for services provided at most hospitals, even on an
outpatient basis.

Medicaid Advantage Plus Contract
APPENDIX J
GUIDELINES FOR CONTRACTOR COMPLIANCE
2007
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APPENDIX K

Medicare Advantage and Medicaid Advantage Plus Products
And Non-Covered Services

 
 
 
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APPENDIX K
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APPENDIX K

Appendix K is organized into three parts:

I.           Appendix K-l

Medicare Advantage Product

II.           Appendix K-2

Medicaid Advantage Plus Product
Description of Medicaid Advantage Plus Covered Services
 
III.    Appendix K-3 
Non-Covered Services

 

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APPENDIX Kl

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.

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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 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 bars). 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, management training and supplies including coverage
for glucose monitors, test strips, and lancets. No 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.
Outpatient Drugs
Medicare Part B covered prescription drugs and other drugs obtained  by a
provider and  administered  in  a physician office or clinic setting covered by
Medicaid.

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APPENDIX K
COVERED AND NON-COVERED SERVICES
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Medicare Advantage Benefit Package for Dual Eligibles
Category of Service
Included in Medicare Capitation
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 also includes 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 co-payment.
Routine Physical Exam 1 /year
Up to one routine physical per year. No co-payment.
Health/Wellness Education
Coverage for health and wellness education, including but not limited to general
health education classes, smoking cessation classes, etc., 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 Plus Contract
APPENDIX K

COVERED AND NON-COVERED SERVICES

2007

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APPENDIX K2

MEDICAID ADVANTAGE PLUS PRODUCT

Medicaid Advantage Plus 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.
Skilled Nursing Facility
Care provided in SNF in excess of the Medicare 100 day limit per benefit period.
Home Health
Non-Medicare covered home health services, including home health aide services
and nursing supervision to medically unstable individuals.
Personal Care Services
Medically necessary assistance with activities such as personal hygiene,
dressing and feeding; and nutritional and environmental support function tasks.
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
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 (when not
covered by Medicare) dental services
Transportation - Non-Emergency
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.
Medicaid/SurgicaJ Supplies, Enteral/Parenteral Formula and Supplements, and
Hearing Aid Batteries
Medically necessary supplies and formula and supplements and hearing aid
batteries

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APPENDIX K
COVERED AND NON-COVERED SERVICES
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Medicaid Advantage Plus Benefit Package for Dual Eligibles
Category of Service
Included in Medicaid Capitation
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.
Nutrition
Assessment of nutritional status/needs, development and evaluation of treatment
plans, nutrition education and counseling, in-service education. Includes
cultural considerations.
Medical Social Services
Assessment, arranging and providing aid for social problems related to
maintaining individual at home.
Social and Environmental Supports
Services and items to support member's medical need. May include home
maintenance tasks, homemaker/chore services, housing improvement, and respite
care.
Home Delivered and Congregate Meals
Meals provided at home or in congregate settings, e.g., senior centers to
individuals unable to prepare meals or have them prepared.
Adult Day Health Care
Includes medical, nursing, food and nutrition, social services, rehabilitation
therapy, leisure activities, dental, pharmaceutical, and other ancillary
services. Services furnished in approved SNF or extension site.
Social Day Care
Structured comprehensive program providing socialization; supervision,
monitoring; personal care, nutrition in a protective setting.
Personal Emergency Response Services (PERS)
Electronic device that enables individuals to secure help in a physical,
emotional or environmental emergency.
Assisted Living Program
Service may be a substitute for other services in the plan of care and paid
through the capitation.

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APPENDIX K
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DESCRIPTION OF MEDICAID ONLY SERVICES IN MEDICAID ADVANTAGE PLUS 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 Care in Skilled Nursing Facility

Skilled nursing facility days for Medicaid Advantage Plus Program.Enrollees
provided by a licensed facility as specified in Chapter V, 10 NYCRR, in excess
of the first 100 days in the Medicare Advantage benefit period.

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.

Personal Care Services

Personal care services (PCS) are the provision of some or total assistance with
such activities as personal hygiene, dressing and feeding; and nutritional and
environmental support function tasks (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. Personal care must be medically necessary,
ordered by the Enrollee's physician and provided by a qualified person as
defined in Part 700.2(b)(14) 10 NYCRR, in accordance with a plan of care.

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. The location of nursing
services may be in the Enrollee's home.

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 provided in accordance with the ordering physician,
registered physician assistant or certified nurse practitioner's written
treatment plan.

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2007

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Dental Services

Dental services include, but shall not be limited to. preventive, prophylactic
and other dental care, services, supplies, routine exams, prophylaxis, oral
surgery (when not covered by Medicare), and   dental prosthetic and orthotic
appliances required to alleviate a serious health condition, including one which
affects employability.

Non-Emergency Transportation

Transportation expenses are covered when transportation is essential in order
for an Enrollee to obtain necessary medical care and services which are covered
under the Medicaid program (either as part of the Contractor's Benefit Package
or by fee-for-service Medicaid). Non-emergent transportation guidelines may be
developed in conjunction with the LDSS, based on the LDSS' approved
transportation plan.

Transportation services means transportation by ambulance, ambulette, fixed wing
or airplane transport, invalid coach, taxicab, livery, public transportation, or
other means appropriate to the Enrollee's medical condition; and a
transportation attendant to accompany the Enrollee, if necessary. Such services
may include the transportation attendant's transportation, meals, lodging and
salary; however, no salary will be paid to a transportation attendant who is
amember of the Enrollee's family.

For EnroUees with disabilities, the method of transportation must reasonably
accommodate their needs, taking into account the severity and nature of the
disability.

Medical and Surgical Supplies, Enteral and Parenteral Formula and Hearing Aid
Batteries

These items are generally considered to be one-time only use, consumable items
routinely paid for under the Durable Medical Equipment category of
fee-for-service Medicaid.

Nutrition

Nutrition services includes the assessment of nutritional needs and food
patterns, or the planning for the provision of foods and drink appropriate for
the individual's physical and medical needs and environmental conditions, or the
provision of nutrition education and counseling to meet normal and therapeutic
needs. In addition, these services may include the assessment of nutritional
status and food preferences, planning for provision of appropriate dietary
intake within the patient's home environment and cultural considerations,
nutritional education regarding therapeutic diets as part of the treatment
milieu, development of a nutritional treatment plan, regular evaluation and
revision of nutritional plans, provision of in-service education to health
agency staff as well as consultation on specific dietary problems of patients
and nutrition teaching to patients and families. These services must be provided
by a qualified nutritionist as defined in Part 700.2(b)(5), 10 NYCRR.

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APPENDIX K
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Medical Social Services

Medical social services include assessing the need for, arranging for and
providing aid for social problems related to the maintenance of a patient in the
home where such services are performed by a qualified social worker and provided
within a plan of care. These services must be provided by a qualified social
worker as defined in Section 700.2(b)(24) 10 NYCRR.

Social and Environmental Supports

Social and environmental supports are services and items that support the
medical needs of the Enrollees and are included in an Enrollee's plan of care.
These services and items include but are not limited to the following: home
maintenance tasks, homemaker/chore services, housing improvement, and respite
care.

Home Delivered and Congregate Meals

Home delivered and congregate meals are meals provided at home or in congregate
settings, e.g. senior centers to individuals unable to prepare meals or have
them prepared.

Adult Day Health Care

Adult day health care is care and services provided in aresidential health care
facility or approved extension site under the medical direction of a physician
to a person who is functionally impaired, not homebound, and who requires
certain preventive, diagnostic, therapeutic, rehabilitative or palliative items
or services. Adult day health care includes the following services: medical,
nursing, food and nutrition, social services, rehabilitation therapy, leisure
time activities which are a planned program of diverse meaningful activities,
dental, pharmaceutical, and other ancillary services.

Social Day Care

Social day care is a structured, comprehensive program which provides
functionally impaired individuals with socialization; supervision and
monitoring; personal care; and nutrition in aprotective setting during any part
of the day, but for less than a 24 hour period. Additional services may include
and are not limited to maintenance and enhancement of daily living skills,
transportation, care giver assistance and case coordination and assistance.

Personal Emergency Response Services (PERS)

Personal Emergency Response System (PERS) is an electronic device which enables
certain high-risk patients to secure help in the event of a physical, emotional
or environmental emergency. A variety of electronic alert systems now exist
which employ different signaling devices. Such systems are usually connected to
a patient's phone and signal a response center once a "help" button is activate.
In the event of an emergency, the signal is received and appropriately acted
upon by a response center.

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Assisted Living Program

Assisted Living Program provides personal care, housekeeping, supervision, home
health aides. Personal emergency response services, nursing, physical therapy,
occupational therapy, speech therapy, medical supplies and equipment, adult day
health care, a range of home health services and the case management services of
a registered professional nurse. Services are provided in an adult home or
enriched housing setting. The room and board component of the Assisted Living
Program may not be covered by the plan.

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APPENDIX K
COVERED AND NON-COVERED SERVICES
2007
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APPENDIX K3

NON COVERED SERVICES

The following services will not be the responsibility of the Contractor under
the Medicare/Medicaid program:

Services Covered by Direct Reimbursement from Original Medicare

•   Hospice services provided to Medicare Advantage members

Services Covered byMedicaid-Fee-for-Service

•   Out of network Family Planning services under the direct access provisions,
•  Medicaid Pharmacy Benefits as 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)
•    Methadone Maintenance Treatment Programs
•   Certain Mental Health Services, including
o   Intensive Psychiatric Rehabilitation Treatment Programs,

o   Day Treatment,
o   Continuing Day Treatment,
o   Case Management for Seriously and Persistently Mentally 111 (sponsored by
state or local mental health units),
o   Partial Hospitalizations,
o   Assertive Community Treatment (ACT),
o   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,
•      Home and Community Based Waiver Program Services,
•      Directly Observed Therapy for Tuberculosis Disease, and
•      AIDS Adult Day Health Care

Medicaid Advantage Pius Contract
APPENDIX K
COVERED AND NON-COVERED SERVICES
2007
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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 Medicare Advantage Enrollees

Hospice services provided to Medicare Advantage Enrollees by a 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
PHL. 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.           Pharmacy Benefits as Permitted by State Law

NYS Medicaid continues to provide coverage for certain drugs excluded from the
Medicare Part D benefit such as barbiturates, benzodiazepines, and some
prescription vitamins, and some non­prescription 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 their 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:
atypical antipsychotics, antidepressants, anti-retroviral used in the treatment
of HIV/AIDS, and anti-rejection drugs used in the treatment of tissue and organ
transplants only when these drugs are not covered by the specific plan, the
patient does not meet the plan's utilization management requirements or there
are quantity limits inconsistent with the prescribed amount.

4.           Out of Network Family Planning Services

As described in Section 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

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APPENDIX K

COVERED AND NON-COVERED SERVICES
2007
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by Medicaid fee-for-service at the Medicaid fee schedule. Family Planning and
Reproductive Health Care 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 is HIV counseling and testing when provided as part of a family
planning visit. Additionally, reproductive health care includes coverage of all
medically necessary abortions. Elective induced abortions must be covered for
New York City recipients. Fertility services are not covered.

5.           Methadone Maintenance Treatment Program (MMTP)

Consists of drug detoxification, drug dependence counseling, and rehabilitation
services which include chemical management of the patient with methadone.
Facilities that provide methadone maintenance treatment do so as their principal
mission and are certified by the Office of Alcohol and Substance Abuse Services
(OASAS) under Title 14 NYCRR, Part 828.

6.       Certain Mental Health Services

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)

A time limited active psychiatric rehabilitation designed to assist a patient in
forming and achieving mutually agreed upon goals in living, learning, working
and social environments, to intervene with psychiatric rehabilitative
technologies to overcome functional disabilities. IPRT services are certified by
OMH under 14 NYCRR, Part 587.

b.             Day Treatment

A combination of diagnostic, treatment, and rehabilitative procedures which,
through supervised and planned activities and extensive client-staff
interaction, provides the services of the clinic treatment program, as well as
social training, task and skill training and socialization activities. Services
are expected to be of six (6) months duration. These services are certified by
OMH under 14 NYCRR, Part 587.

c.             Continuing Day Treatment

Provides treatment designed to maintain or enhance current levels of functioning
and skills, maintain community living, and develop self-awareness and
self-esteem. Includes: assessment and treatment planning; discharge planning;
medication therapy; medication education; case management; health screening and
referral; rehabilitative readiness development; psychiatric rehabilitative
readiness determination and referral; and symptom management. These services are
certified by OMH under 14 NYCRR, Part 587.

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2007
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This waiver is in select counties for children and adolescents who would
otherwise be admitted to an institutional setting if waiver services were not
provided. The services include individualized care coordination, respite, family
support, intensive in-home skill building, and crisis response.

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 14 NYCRR Part 506.

Please note: See generic definition of Comprehensive Medicaid Case Management
(CMCM) in this section.

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 NYCRR Part
587.

Assertive Community Treatment (ACT)

ACT is a mobile team-based approach to delivering comprehensive and flexible
treatment, rehabilitation, case management and support services to individuals
in their natural living setting. ACT programs deliver integrated services to
recipients and adjust services over time to meet the recipient's goals and
changing needs; are operated pursuant to approval or certification by OMH; and
receive Medicaid reimbursement pursuant to 14 NYCRR Part 508.

Personalized Recovery Oriented Services (PROS)

PROS, licensed and reimbursed pursuant to 14 NYCCR Part 512, are designed to
assist individuals in recovery from the disabling effects of mental illness
through the coordinated delivery of a customized array of rehabilitation,
treatment, and support services in traditional settings and in off-site
locations. Specific components of PROS include Community Rehabilitation and
Support, Intensive Rehabilitation, Ongoing Rehabilitation and Support and
Clinical Treatment.

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7.  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 the person's mental illness.

b.  Family-Based Treatment*

Rehabilitative services in family-based treatment programs are intended to
provide treatment to seriously emotionally disturbed children and youth to
promote their successful functioning and integration into the natural family,
community, school or independent living situations. Such services are provided
in consideration of a child's developmental stage. Those children determined
eligible for admission are placed in surrogate family homes for care and
treatment. These services are certified by OMH under 14 NYCRR Parts 586.3, 594
and 595.

8. Office of Mental Retardation and Developmental Disabilities (OMRDD) Services

a.
Long Term Therapy Services Provided by Article 16-Clinic Treatment Facilities
or Article 28 Facilities

These services are provided to persons with developmental disabilities including
medical or remedial services recommended by a physician or other licensed
practitioner of the healing arts for a maximum reduction of the effects of
physical or mental disability and restoration of the person to his or her best
possible functional level. It also includes the fitting, training, and
modification of assistive devices by licensed practitioners or trained others
under their direct supervision. Such services are designed to ameliorate or
limit the disabling condition and to allow the person to remain in or move to,
the least restrictive residential and/or day setting. These services are
certified by OMRDD under 14 NYCRR, Part 679 (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
ICF or a comparable setting. These services are certified by OMRDD under 14
NYCRR, Part 690.

Medicaid Advantage Plus Contract
APPENDIX K
COVERED AND NON-COVERED SERVICES
2007
16

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c.     Medicaid Service Coordination (MSC)

Medicaid Service Coordination (MSC) is a Medicaid State Plan service provided by
OMRDD which assists persons with developmental disabilities and mental
retardation to gain access to necessary services and supports appropriate to the
needs of the needs of the individual. MSC is provided by qualified service
coordinators and uses a person centered planning process in developing,
implementing and maintaining an Individualized Service Plan (ISP) with and for a
person with developmental disabilities and mental retardation. MSC promotes the
concepts of a choice, individualized services and consumer satisfaction.

MSC is provided by authorized vendors who have a contract with OMRDD, and who
are paid monthly pursuant to such contract. Persons who receive MSC must not
permanently reside in an ICF for persons with developmental disabilities, a
developmental center, a skilled nursing facility or any other hospital or
Medical Assistance institutional setting that provides service coordination.
They must also not concurrently be enrolled in any other comprehensive Medicaid
long term service coordination program/service.including the Care at Home
Waiver.

Please note: See generic definition of Comprehensive Medicaid Case Management
(CMCM) in this section.

9.   Home and Community Based Services (HCBS) Waiver Program Services

There are a number of Home and Community-Based Waiver Programs that provides
services authorized pursuant to SSA Section 1915(c) waivers from DHHS. The
programs include the Long Term Home Health Care Program, the Traumatic Brain
Injury (TBI) Program, the ICF/MR Waiver, as well as Medicaid Care at Home HCBS
Programs and OMRDD Care at Home Programs.

10.  Comprehensive Medicaid CaseManagement (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. Some of these services are:
medical, social, psycho-social, education, employment, financial, and mental
health. CMCM referral to community service agencies and/or medical providers
requires the case manager to work out a mutually agreeable case coordination
approach with the agency/medical providers. Consequently, if an Enrollee of the
Contractor is participating in a CMCM program, the Contractor should work
collaboratively with the CMCM case manager to coordinate the provision of
services covered by the Contractor. CMCM programs will be instructed on how to
identify a managed care Enrollee on eMedNY and informed on the need to contact
the Contractor to coordinate service provision.

Medicaid Advantage Plus Contract
APPENDIX K
COVERED AND NON-COVERED SERVICES
2007
17

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11. Directly Observed Therapy for Tuberculosis Disease

Tuberculosis directly observed therapy (TB/DOT) is the direct observation of
oral ingestion of TB medications to assure patient compliance with the
physician's prescribed medication regimen. While the clinical management of
tuberculosis is covered in the Benefit Package, TB/DOT where applicable, can be
billed directly to MMIS by any SDOH approved fee-for-service Medicaid TB/DOT
Provider. The Contractor remains responsible for communicating, cooperating and
coordinating clinical management of TB with the TB/DOT Provider.

12.   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 genera] medical care and nursing services.

13. HIV COBRA CaseManagement

The HIV COBRA (Community Follow-up Program) Case Management Program is a program
that provides intensive, family-centered case management and community follow-up
activities by case managers, case management technicians, and community
follow-up workers. Reimbursement is through an hourly rate billable to Medicaid.
Reimbursable activities include intake, assessment, reassessment, service plan
development and implementation, monitoring, advocacy, crisis intervention, exit
planning, and case specific supervisory case-review conferencing.

Medicaid Advantage Plus Contract
APPENDIX K
COVERED AND NON-COVERED SERVICES
2007

18

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Appendix L
 
Approved Capitation Payment Rates

WellCare of New York, Inc. Medicaid Advantage Plus

Effective Date: 2007

Age Group
Monthly Capitation Amount (PMPM)
18-64
$3,522.46
65+
$3,522.46

Medicaid Advantage Plus Contract

APPENDIX L
APPROVED CAPITATION PAYMENT RATES
2007

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APPENDIX M

Service Area

The Contractor's Medicaid Advantage Plus service area is comprised of the
following Counties in their entirety:

Bronx
Kings
New York
Queens

Medicaid Advantage Plus Contract
APPENDIX M
SERVICE AREA
2007

1

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APPENDIX N
Reserved

Medicaid Advantage Plus Contract
APPENDIX N
(RESERVED)
2007
1

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APPENDIX O
 
Requirements for Proof of Workers' Compensation and Disability Benefits Coverage

 

Medicaid Advantage Plus Contract
APPENDIX O
PROOF OF COVERAGE
2007
1

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Requirements for Proof of Coverage

Unless the Contractor is a political sub-division of New York State, the
Contractor shall provide proof, completed by the Contractor's insurance carrier
and/or the Workers' Compensation Board, of coverage for:

1.
Workers' Compensation, for which one of the following is incorporated into
this Agreement herein as an attachment to Appendix O:

a)
Certificate of Workers' Compensation Insurance, on the Workers' Compensation
Board form C-105.2 (naming the NYS Department of Health, Corning Tower, Rm.
1325, Albany, 12237-0016), or Certificate of Workers' Compensation Insurance, on
the State Insurance Fund form U-26.3 (naming the NYS Department of Health,
Corning Tower, Rm. 1325, Albany, 12237-0016); or

b)
Certificate of Workers Compensation Self-Insurance, form SI-12, or Certificate
of Group Workers' Compensation Self-Insurance, form GSI-105.2; or

c)
Affidavit for New York Entities And Any Out Of State Entities With No Employees,
That New York State Workers' Compensation And/Or Disability Benefits Coverage Is
Not Required, form WC/DB-100, completed for Workers' Compensation; or Affidavit
That An OUT-OF-STATE OR FOREIGN EMPLOYER Working In New York State Does Not
Require Specific New York State Workers' Compensation And/Or Disability Benefits
Insurance Coverage, form WC/DB-101, completed for Workers' Compensation;
[Affidavits must be notarized and stamped as received by the NYS Workers'
Compensation Board]; and

2.
Disability Benefits Coverage, for which one of the following is incorporated
into this Agreement herein as an attachment to Appendix O:

a)
Certificate of Disability Benefits Insurance, form DB-120.1; or
Certificate/Cancellation of Insurance, form DB-820/829; or

b)           Certificate of Disability Benefits Self-Insurance, form DB-155; or

c)
Affidavit for New York Entities And Any Out Of State Entities With No Employees,
That New York State Workers' Compensation And/Or Disability Benefits Coverage Is
Not Required, form WC/DB-100, completed for Disability Benefits; or Affidavit
That An OUT-OF-STATE OR FOREIGN EMPLOYER Working In New York State Does Not
Require Specific New York State Workers' Compensation And/Or Disability Benefits
Insurance Coverage, form WC/DB-101, completed for Disability Benefits;
[Affidavits must be notarized and stamped as received by the NYS Workers'
Compensation Board].

NOTE: ACORD forms are NOT acceptable proof of coverage

Medicaid Advantage Plus Contract
APPENDIX O
PROOF OF COVERAGE
2007
2

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APPENDIX P
Reserved

 
 
Medicaid Advantage Plus Contract
APPENDIX P
(RESERVED)
2007

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APPENDIX Q
Reserved

Medicaid Advantage Plus Contract
APPENDIX Q
(RESERVED)
2007

 

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APPENDIX R

Additional Specifications for the Medicaid Advantage Plus Agreement

Medicaid Advantage Plus Contract
APPENDIX R
ADDITIONAL SPECIFICATIONS
2007

1

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APPENDIX R
Additional Specifications for the Medicaid Advantage Plus Agreement

1. Contractor will give continuous attention to performance of its obligations
herein for the duration of this Agreement and with the intent that the
contracted services shall be provided and reports submitted in a timely manner
as SDOH may prescribe.

2. Contractor will possess, at no cost to the State, all qualifications,
licenses and permits to engage in the required business as may be required
within the jurisdiction where the work specified is to be performed. Workers to
be employed in the performance of this Agreement will possess the
qualifications, training, licenses and permits as may be required within such
jurisdiction.

3. Work for Hire Contract

If pursuant to this Agreement the Contractor will provide the SDOH with software
or other copyrightable materials, this Agreement shall be considered a "Work for
Hire Contract." The SDOH will be the sole owner of all source code and any
software which is developed or included in the application software provided to
the SDOH as a part of this Agreement.

4. Technology Purchases Notification - The following provisions apply if this
Agreement procures only "Technology"

a)
For the purposes of this policy, "technology" applies to all services and
commodities, voice/data/video and/or any related requirement, major software
acquisitions, systems modifications or upgrades, etc., that result in a
technical method of achieving a practical purpose or in improvements of
productivity. The purchase can be as simple as an order for new or replacement
personal computers, or for a consultant to design a new system, or as complex as
a major systems improvement or innovation that changes how an agency conducts
its business practices.

b)
If this Agreement is for procurement of software over $20,000, or other
technology over $50,000, or where the SDOH determines that the potential exists
for coordinating purchases among State agencies and/or the purchase may be of
interest to one or more other State agencies, PRIOR TO APPROVAL by OSC, this
Agreement is subject to review by the Governor's Task Force on Information
Resource Management.

c)
The terms and conditions of this Agreement may be extended to any other State
agency in New York.

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APPENDIX R
ADDITIONAL SPECIFICATIONS
2007
2

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5. Subcontracting

The Contractor agrees not to enter into any agreements with third party
organizations for the performance of its obligations, in whole or in part, under
this Agreement without the State's prior written approval of such third parties
and the scope of the work to be performed by them. The State's approval of the
scope of work and the subcontractor does not relieve the Contractor of its
obligation to perform fully under this Agreement.

6. Sufficiency of Personnel and Equipment

If SDOH is of the opinion that the services required by the specifications
cannot satisfactorily be performed because of insufficiency of personnel, SDOH
shall have the authority to require the Contractor to use such additional
personnel to take such steps necessary to perform the services satisfactorily at
no additional cost to the State.

7. Provisions Upon Default

a)
The services to be performed by the Contractor shall be at all times subject to
the direction and control of the SDOH as to all matters arising in connection
with or relating to this Agreement.

b)
In the event that the Contractor, through any cause, fails to perform any of the
terms, covenants or promises of this Agreement, the SDOH acting for and on
behalf of the State, shall thereupon have the right to terminate this Agreement
by giving notice in writing of the fact and date of such termination to the
Contractor, pursuant to Section 2 of this Agreement.

 
c)    If, in the judgment of the SDOH, the Contractor acts in such a way which
is likely to or does impair or prejudice the interests of the State, the SDOH
acting for and on behalf of the State, shall thereupon have the right to
terminate this Agreement by giving notice in writing of the fact and date of
such termination to the Contractor, pursuant to Section 2 of this Agreement.

8. Minority And Women Owned Business Policy Statement

The SDOH recognizes the need to take affirmative action to ensure that Minority
and Women Owned Business Enterprises are given the opportunity to participate in
the performance of the SDOH's contracting program. This opportunity for full
participation in our free enterprise system by traditionally socially and
economically disadvantaged persons is essentia] to obtain social and economic
equality and improve the functioning of the State economy.

Medicaid Advantage Plus Contract
APPENDIX R
ADDITIONAL SPECIFICATIONS
2007
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It is the intention of the SDOH to provide Minority and Women Owned Business
Enterprises with equal opportunity to bid on contracts awarded by this agency in
accordance with the State Finance Law.

9. Insurance Requirements

 
a)     The Contractor must without expense to the State procure and maintain,
until final acceptance by the SDOH of the work covered by this Agreement,
insurance of the kinds and in the amounts hereinafter provided, by insurance
companies authorized to do such business in the State of New York covering all
operations under this Agreement, whether performed by it or by subcontractors.
Before commencing the work, the Contractor shall furnish to the SDOH a
certificate or certificates, in a form satisfactory to SDOH, showing that it has
complied with the requirements of this section, which certificate or
certificates shall state that the policies shall not be changed or cancelled
until thirty days written notice has been given to SDOH. The kinds and amounts
of required insurance are:

i) A policy covering the obligations of the Contractor in accordance with the
provisions of Chapter 41, Laws of 1914, as amended, known as the Workers'
Compensation Law, and the Agreement shall be void and of no effect unless the
Contractor procures such policy and maintains it until acceptance of the work.

ii) Policies of Bodily Injury Liability and Property Damage Liability Insurance
of the types hereinafter specified, each within limits of not less than $500,000
for all damages arising out of bodily injury, including death at any time
resulting therefrom sustained by one person in any one occurrence, and subject
to that limit for that person, not less than $1,000,000 for all damages arising
out of bodily injury, including death at any time resulting therefrom sustained
by two or more persons in any one occurrence, and not less than $500,000 for
damages arising out of damage to or destruction of property during any single
occurrence and not less than $1,000,000 aggregate for damages arising out of
damage to or destruction of property during the policy period.

A)           Contractor's Liability Insurance issued to and covering the
liability of the Contractor with respect to all work performed by it under this
Agreement.

B)           Automobile Liability Insurance issued to and covering the liability
of the People of the State of New York with respect to all operations under this
Agreement, by the Contractor or by its subcontractors, including omissions and
supervisory acts of the State.

Certification Regarding Debarment and Suspension

a)        Regulations of the U.S. Department of Health and Human Services,
located at Part 76 of Title 45 of the Code of Federal Regulations (CFR),
implement Executive Orders 12549 and 12689 concerning debarment and suspension
of participants in Federal

Medicaid Advantage Plus Contract
APPENDIX R
ADDITIONAL SPECIFICATIONS
2007
4

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program and activities. Executive Order 12549 provides that, to the extent
permitted by law, Executive departments and agencies shall participate in a
government wide system for non-procurement debarment and suspension. Executive
Order 12689 extends the debarment and suspension policy to procurement
activities of the Federal Government. A person who is debarred or suspended by a
Federal agency is excluded from Federal financial and non-financial assistance
and benefits under Federal programs and activities, both directly (primary
covered transaction) and indirectly (lower tier covered transactions). Debarment
or suspension by one Federal agency has government wide effect.

b) Pursuant to the above cited regulations, the SDOH (as a participant in a
primary covered transaction) may not knowingly do business with a person who is
debarred, suspended, proposed for debarment, or subject to other government wide
exclusion (including an exclusion from Medicare and State health care program
participation on or after August 25, 1995), and the SDOH must require its
contractors, as lower tier participants, to provide the certification as set
forth below;

i)   CERTIFICATION REGARDING DEBARMENT, SUSPENSION, INELIGIBILITY AND VOLUNTARY
EXCLUSION-LOWER TIER COVERED TRANSACTIONS

Instructions for Certification

A)
By signing this Agreement, the Contractor, as a lower tier participant, is
providing the certification set out below.

B)
The certification in this clause is a material representation of fact upon which
reliance was placed when this transaction was entered into. If it is later
determined that the lower tier participant knowingly rendered an erroneous
certification, in addition to other remedies available to the Federal
Government, the department or agency with which this transaction originated may
pursue available remedies, including suspension and/or debarment.

C)
The lower tier participant shall provide immediate written notice to the SDOH if
at any time the lower tier participant learns that its certification was
erroneous when submitted or had become erroneous by reason of changed
circumstances.

D)
The terms covered transaction, debarred, suspended, ineligible, lower tier
covered transaction, participant, person, primary covered transaction,
principal, proposal, and voluntarily excluded, as used in this clause, have the
meaning set out in the Definitions and Coverage sections of rules implementing
Executive Order 12549. The Contractor may contact the SDOH for assistance in
obtaining a copy of those regulations.

Medicaid Advantage Pius Contract
APPENDIX R
ADDITIONAL SPECIFICATIONS
2007
5

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E)
The lower tier participant agrees that it shall not knowingly enter into any
lower tier covered transaction with a person who is proposed for debarment under
48 CFR Subpart 9.4, debarred, suspended, declared ineligible, or
voluntarily excluded from participation in this covered transaction, unless
authorized by the department or agency with which this transaction originated.

F)
The lower tier participant further agrees that it will include this clause
titled "Certification Regarding Debarment, Suspension, Ineligibility and
Voluntary Exclusion-Lower Tier Covered Transactions," without modification, in
all lower tier covered transactions.

G)
A participant in a covered transaction may rely upon a certification of
a participant in a lower tier covered transaction that it is not proposed for
debarment under 48 CFR 9.4, debarred, suspended, ineligible, or voluntarily
excluded from covered transactions, unless it knows that the certification is
erroneous. A participant may decide the method and frequency by which it
determines the eligibility of its principals. Each participant may, but is not
required to, check the Excluded Parties List System.

H)
Nothing contained in the foregoing shall be construed to require establishment
of a system of records in order to render in good faith the certification
required by this clause. The knowledge and information of a participant is not
required to exceed that which is normally possessed by a prudent person in the
ordinary course of business dealings.

I)
Except for transactions authorized under paragraph E of these instructions, if a
participant in a covered transaction knowingly enters into a lower tier covered
transaction with a person who is proposed for debarment under 48 CFR Subpart
9.4, suspended, debarred, ineligible, or voluntarily excluded from participation
in this transaction, in addition to other remedies available to the Federal
Government, the department or agency with which this transaction originated may
pursue available remedies, including suspension and/or debarment.

 
ii)     Certification Regarding Debarment, Suspension, Ineligibility and
Voluntary Exclusion - Lower Tier Covered Transactions

 
(A)      The lower tier participant certifies, by signing this Agreement, that
neither it nor its principals is presently debarred, suspended, proposed for
debarment, declared ineligible, or voluntarily excluded from participation in
this transaction by any Federal department agency.

Medicaid Advantage Plus Contract
APPENDIX R
ADDITIONAL SPECIFICATIONS
2007
6

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(B)      Where the lower tier participant is unable to certify to any of the
statements in this certification, such participant shall attach an explanation
to this Agreement.

Reports and Publications

a)
Any materials, articles, papers, etc., developed by the Contractor pertaining to
the MMC Program or FHPlus Program must be reviewed and approved by the SDOH for
conformity with the policies and guidelines of the SDOH prior to dissemination
and/or publication. It is agreed that such review will be conducted in an
expeditious manner. Should the review result in any unresolved disagreements
regarding content, the Contractor shall be free to publish in scholarly journals
along with a disclaimer that the views within the Article or the policies
reflected are not necessarily those of the New York State Department of Health.

b)
Any publishable or otherwise reproducible material developed under or in the
course of performing this Agreement, dealing with any aspect of performance
under this Agreement, or of the results and accomplishments attained in such
performance, shall be the sole and exclusive property of the State, and shall
not be published or otherwise disseminated by the Contractor to any other party
unless prior written approval is secured from the SDOH or under circumstances as
indicated in paragraph (a) above. Any and all net proceeds obtained by the
Contractor resulting from any such publication shall belong to and be paid over
to the State. The State shall have a perpetual royalty-free, non-exclusive and
irrevocable right to reproduce, publish or otherwise use, and to authorize
others to use, any such material for governmental purposes.

c)
No report, document or other data produced in whole or in part with the funds
provided under this Agreement may be copyrighted by the Contractor or any of its
employees, nor shall any notice of copyright be registered by the Contractor or
any of its employees in connection with any report, document or other data
developed pursuant to this Agreement.

d)
All reports, data sheets, documents, etc. generated under this Agreement shall
be the sole and exclusive property of the SDOH. Upon completion or termination
of this Agreement the Contractor shall deliver to the SDOH upon its demand all
copies of materials relating to or pertaining to this Agreement. The Contractor
shall have no right to disclose or use any of such material and documentation
for any purpose whatsoever, without the prior written approval of the SDOH or
its authorized agents.

Medicaid Advantage Plus Contract
APPENDIX R
ADDITIONAL SPECIFICATIONS
2007
7

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e)
The Contractor, its officers, agents and employees and subcontractors shall
treat all information, which is obtained by it through its performance under
this Agreement, as confidential information to the extent required by the laws
and regulations of the United States and laws and regulations of the State of
New York.

Provisions Related to New York State Procurement Lobbying Law

The state reserves the right to terminate this agreement in the event it is
found that the certification filed by the contractor in accordance with New York
State Finance Law 139-k was intentionally false or intentionally incomplete.
Upon such finding, the State may exercise its termination right by providing
written notification to the contractor is accordance with the written
notification terms of this agreement.

Provisions Related to New York State Information Security Breach and
Notification Act

Contractor shall comply with the provisions of the New York State Information
Security Breach and Notification Act (General Business Law Section 899-aa; State
Technology Law Section 208). Contractor shall be liable for the costs associated
with such breach if caused by the Contractor's negligent or willful acts or
omissions, or the negligent or willful acts or omissions of Contractor's agents,
officers, employees or subcontractors.

Medicaid Advantage Plus Contract

APPENDIX R
ADDITIONAL SPECIFICATIONS

2007

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APPENDIX X
Modification Agreement Form

Medicaid Advantage Plus Contract
APPENDIX X
2007

 

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APPENDIX X

Agency Code
Contract No.
Period
Funding Amount for Period

This is an AGREEMENT between THE STATE OF NEW YORK, acting by and through ,
having its principal office at (hereinafter referred to as the STATE), and
hereinafter referred to as the CONTRACTOR), for modification of Contract Number
as amended in attached Appendix(ices).

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

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

CONTRACTOR SIGNATURE
By:
STATE AGENCY SIGNATURE
By:
 
Printed Name
Title:
Printed Name
Title:
Date:
Date:
 
 
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 NEW YORK
County of ___________________
 
 
On the ______________  day of __________ , before me personally appeared
_____________________________, to me known, who being by me duly sworn, did
depose and say that he/she resides at ______________, that he/she is the
___________________ of ______________, the corporation described herein which
executed the foregoing instrument; and that he/she signed his/her name thereto
by order of the board of directors of said corporation.
(Notary)

STATE COMPTROLLER'S SIGNATURE

Title:

Date:

APPENDIX X
2007
2