Medicaid Family Health Plus Contract for NYC


    

      Exhibit
        10.1

      


      


      MEDICAID
        MANAGED CARE

       

      AND
        FAMILY HEALTH PLUS

       

      MODEL
        CONTRACT

       

      October
        1,2005

       

       

       

       

       

       

       


      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      


       

      AGREEMENT
        BETWEEN

       

      The
        City
        of New York 

       

      And
        

       

      Wellcare
        of New York, Inc.

       

      This
        Agreement is made by and between

       

      


       

      The
        City
        of New York Acting through,

       

      Department
        of Health and Mental Hygiene ["DOHMH"] 

       

      Located
        at

       

      161
        William Street, 5th
        floor


       

      New
        York,
        NY 10038

       

      And

       

      Wellcare
        of New York, Inc. 

       

      Located
        at

       

      11
        West
        19th
        Street,
        Second floor 

       

      New
        York,
        NY 10011

       

      


       

       

      RECITALS

      October
        1,2005

      Page
        1
        of 2

       

      


      
        
           

        

        
           

          
            

          

        

        
           

        

      


      STATE
        OF NEW YORK 

      MEDICAID
        AND FAMILY HEALTH PLUS

      PARTICIPATING
        MANAGED CARE PLAN AGREEMENT

       

      This
        AGREEMENT is hereby made by and between the New York City Department of Health
        and Mental Hygiene (DOHMH) and Wellcare of New York, Inc. located at 11 West
        19th
        Street,
        Second Floor, New York, NY 10011.

       

      RECITALS

       

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

       

      WHEREAS,
        pursuant to Title 11 of Article 5 of the SSL, the Commissioner of Health
        has
        established a managed care program under the medical assistance program,
        known
        as the Medicaid Managed Care (MMC) Program; and

       

      WHEREAS,
        pursuant to Title 11 -D of Article 5 of the SSL, a health insurance program
        known as Family Health Plus (FHPlus) has been created for Eligible Persons
        who
        do not qualify for Medicaid; and

       

      WHEREAS,
        organizations certified under Article 44 of the New York State Public Health
        Law
        (PHL) are eligible to provide comprehensive health services through
        comprehensive health services plans to Eligible Persons as defined in Titles
        11
        and 11-D of the SSL, MMC and FHPlus Programs, respectively; and

       

      WHEREAS,
        the Contractor is organized under the laws of New York State and is certified
        under Article 44 of the PHL and has offered to provide covered health services
        to Eligible Persons residing in the geographic area specified in Appendix
        M of
        this Agreement (Service Area, Benefit Package Options, and Enrollment
        Elections); and

       

      WHEREAS,
        the SDOH and DOHMH have determined that the Contractor meets the qualifications
        established for participation in the MMC Program or the FHPlus Program or
        both
        to provide the applicable health care coverage to Eligible Persons in the
        geographic area specified in Appendix M of this Agreement; and

       

      WHEREAS,
        Chapter 364-j(5)(d) of the SSL authorizes the local department of social
        services in a city with a population of over two million to contract with
        managed care providers who meet the qualifications for participation in the
        MMC
        Program and since in the City of New York such authority has been delegated
        to
        the DOHMH;

       

      NOW
        THEREFORE,
        the
        parties agree as follows:


       

      


      RECITALS

      October
        1, 2005 

      Page
        2 of
        2

      
        
          
          

        

        
          
          

          
          

        

        
          
          

        

      

       

      Table
        of Contents for 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.
        DOHMH
        Initiated Termination

      b.
        Contractor and DOHMH Initiated Termination

      c.
        Contractor Initiated Termination

      d.
        Termination Due to Loss of Funding

      2.8
        Close-Out Procedures

      2.9
        Rights and Remedies

      2.10
        Notices

      2.11
        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
        Payment for Newborns

      3.9
        Supplemental Maternity Capitation Payment

      3.10
        Contractor Financial Liability

      3.11
        Inpatient Hospital Stop-Loss Insurance for Medicaid Managed Care (MMC)
        Enrollees

      3.12
        Mental Health and Chemical Dependence Stop-Loss for MMC Enrollees

      3.13
        Residential Health Care Facility Stop-Loss for MMC Enrollees

      3.14
        Stop-Loss Documentation and Procedures for the MMC Program

      3.15
        Family Health Plus (FHPlus) Reinsurance

      3.16
        Tracking Visits Provided by Indian Health Clinics - Applies to MMC Program
        Only

      


      


      


      Section
        4
        Service Area 

      Section
        5
        Reserved

      


       

      TABLE
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      Table
        of Contents for Model Contract

       

      Section
        6
        Enrollment

      6.1
        Populations Eligible for
        Enrollment

      6.2
        Enrollment Requirements

      6.3
        Equality of Access to Enrollment

      6.4
        Enrollment Decisions

      6.5
        Auto
        Assignment - For MMC Program Only

      6.6
        Prohibition Against Conditions on Enrollment

      6.7
        Newborn Enrollment

      6.8
        Effective Date of Enrollment

      6.9
        Roster

      6.10
        Automatic Re-Enrollment

       

      Section
        7
        Lock-In Provisions

          7.1
        Lock-In Provisions in MMC Mandatory Local Social Services Districts and for
        Family Health Plus

      7.2
        Disenrollment During a Lock-In Period

      7.3
        Notification Regarding Lock-In and End of Lock-In Period

      7.4
        Lock-In and Change in Eligibility Status

       

      Section
        8
        Disenrollment

      8.1
        Disenrollment Requirements

      8.2
        Disenrollment Prohibitions

      8.3
        Disenrollment Requests

      a.
        Routine Disenrollment Requests 

      b.
        Non-Routine Disenrollment Requests

      8.4
        Contractor Notification of Disenrollments

      8.5
        Contractor's Liability

      8.6
        Enrollee Initiated Disenrollment

      8.7
        Contractor Initiated Disenrollment

      8.8
        LDSS
        Initiated Disenrollment

       

      Section
        9
        Guaranteed Eligibility

      9.1
        General Requirements

      9.2
        Right
        to Guaranteed Eligibility

      9.3
        Covered Services During Guaranteed Eligibility

      9.4
        Disenrollment During Guaranteed Eligibility

       

      Section
        10 Benefit Package Requirements

      10.1
        Contractor Responsibilities

      10.2
        Compliance with State Medicaid Plan and Applicable Laws

      10.3
        Definitions

      10.4
        Child Teen Health Program/Adolescent Preventive Services

      10.5
        Foster Care Children - Applies to MMC Program Only

      10.6
        Child Protective Services

      10.7
        Welfare Reform - Applies to MMC Program Only

      10.8
        Adult Protective Services

      10.9
        Court-Ordered Services

      


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      Table
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      10.10
        Family Planning and Reproductive Health Services

      10.11
        Prenatal Care

      10.12
        Direct Access

      10.13
        Emergency Services

      10.14
        Medicaid Utilization Thresholds (MUTS)

      10.15
        Services for Which Enrollees Can Self-Refer

      a.
        Mental
        Health and Chemical Dependence Services

      b.
        Vision
        Services

      c.
        Diagnosis and Treatment of Tuberculosis

      d.
        Family
        Planning and Reproductive Health Services

      e.
        Article 28 Clinics Operated by Academic Dental Centers

      10.16
        Second Opinions for Medical or Surgical Care

      10.17
        Coordination with Local Public Health Agencies

      10.18
        Public Health Services

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

      b.
        Immunizations

      c.
        Prevention and Treatment of Sexually Transmitted Diseases 

      d.
        Lead
        Poisoning - Applies to MMC Program Only

      10.19
        Adults with Chronic Illnesses and Physical or Developmental
        Disabilities

      10.20
        Children with Special Health Care Needs

      10.21
        Persons Requiring Ongoing Mental Health Services

      10.22
        Member Needs Relating to HIV

      10.23
        Persons Requiring Chemical Dependence Services

      10.24
        Native Americans

      10.25
        Women, Infants, and Children (WIC)

      10.26
        Urgently Needed Services

      10.27
        Dental Services Provided by Article 28 Clinics Operated by Academic Dental
        Centers Not Participating in Contractor's Network- Applies to MMC Program
        Only

      10.28
        Hospice Services

         
        10.29 Prospective Benefit Package Change for Retroactive SSI Determinations
        -Applies to MMC Program Only

      10.30
        Coordination of Services

       

      Section
        11 Marketing

      11.1
        Information Requirements

      11.2
        Marketing Plan

      11.3
        Marketing Activities

      11.4
        Prior Approval of Marketing Materials and Procedures

      11.5
        Corrective and Remedial Actions

       

      Section
        12 Member Services

      12.1
        General Functions

      12.2
        Translation and Oral Interpretation

      12.3
        Communicating with the Visually, Hearing and Cognitively Impaired

       

      


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      Table
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      Section
        13 Enrollee Rights and Notification

      13.1
        Information Requirements

      13.2
        Provider Directories/Office Hours for Participating Providers

      13.3
        Member ID Cards

      13.4
        Member Handbooks

      13.5
        Notification of Effective Date of Enrollment

      13.6
        Notification of Enrollee Rights

      13.7
        Enrollee's Rights

      13.8
        Approval of Written Notices

      13.9
        Contractor's Duty to Report Lack of Contact

      13.10
        LDS
        S Notification of Enrollee's Change in Address

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

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

       

      Section
        14 Action and Grievance System

      14.1
        General Requirements

      14.2
        Actions

      14.3
        Grievance System

      14.4
        Notification of Action and Grievance System Procedures

      14.5
        Complaint, Complaint Appeal and Action Appeal Investigation
        Determinations

       

      Section
        15 Access Requirements

      15.1
        General Requirement

      15.2
        Appointment Availability Standards

      15.3
        Twenty-Four (24) Hour Access

      15.4
        Appointment Waiting Times

      15.5
        Travel Time Standards

      15.6
        Service Continuation 

      a.
        New
        Enrollees 

      b.
        Enrollees Whose Health Care Provider Leaves Network

      15.7
        Standing Referrals

      15.8
        Specialist as a Coordinator of Primary Care

      15.9
        Specialty Care Centers 

      15.10
        Cultural Competence

       

      Section
        16 Quality Management

      16.1
        Internal Quality Management Program

      16.2
        Standards of Care

       

      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

      17.4
        Cooperation During Review of Services by External Review Agency

       

       

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      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
        Liquidated Damages

      18.5
        Notification of Changes in Report Due Dates, Requirements or
        Formats

      18.6
        Reporting Requirements

      18.7
        Ownership and Related Information Disclosure

      18.8
        Public Access to Reports

      18.9
        Professional Discipline

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

      18.11
        Conflict of Interest Disclosure

      18.12
        Physician Incentive Plan Reporting

       

      Section
        19 Records 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 Prospective Enrollees

      20.2
        Medical Records of Foster Children

      20.3
        Confidentiality of Medical Records

      20.4
        Length of Confidentiality Requirements

       

      Section
        21 Provider Network

      21.1
        Network Requirements

      21.2
        Absence of Appropriate Network Provider

      21.3
        Suspension of Enrollee Assignments to Providers

      21.4
        Credentialing

      21.5
        SDOH
        Exclusion or Termination of Providers

      21.6
        Application Procedure

      21.7
        Evaluation Information

      21.8
        Choice/Assignment of Primary Care Providers (PCPs)

      21.9
        Enrollee PCP Changes

      21.10
        Provider Status Changes

      21.11
        PCP
        Responsibilities

      21.12
        Member to Provider Ratios

      21.13
        Minimum PCP Office Hours 

      a.
        General Requirements 

      b.
        Waiver
        of Minimum Hours

      21.14
        Primary Care Practitioners

      a.
        General Limitations

      


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      b.
        Specialists and Sub-specialists as PCPs

      c.
        OB/GYN
        Providers as PCPs

      d.
        Certified Nurse Practitioners as PCPs

      21.15
        PCP
        Teams

      a.
        General Requirements

      b.
        Registered Physician Assistants as Physician Extenders

      c.
        Medical Residents and Fellows

      21.16
        Hospitals

      a.
        Tertiary Services 

      b.
        Emergency Services

      21.17
        Dental Networks

      21.18
        Presumptive Eligibility Providers

      21.19
        Mental Health and Chemical Dependence Services Providers

      21.20
        Laboratory Procedures

      21.21
        Federally Qualified Health Centers (FQHCs)

      21.22
        Provider Services Function

      21.23
        Pharmacies - Applies to FHPlus Program Only

       

      Section
        22 Subcontracts and Provider Agreements

      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
        Restrictions on Disclosure

      22.8
        Transfer of Liability

      22.9
        Termination of Health Care Professional Agreements

      22.10
        Health Care Professional Hearings

      22.11
        Non-Renewal of Provider Agreements

      22.12
        Notice of Participating Provider Termination

      22.13
        Physician Incentive Plan

       

      Section
        23 Fraud and Abuse

      23.1
        General Requirements

      23.2
        Prevention Plans and Special Investigation Units

       

      Section
        24 Americans with Disabilities Act (ADA) Compliance Plan

       

      Section
        25 Fair Hearings

      25.1
        Enrollee Access to Fair Hearing Process

      25.2
        Enrollee Rights to a Fair Hearing

      25.3
        Contractor Notice to Enrollees

      25.4
        Aid
        Continuing

      25.5
        Responsibilities of SDOH

      25.6
        Contractor's Obligations

       

      


      


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      Table
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      Section
        26 External Appeal 

      26.1
        Basis for External Appeal

      26.2
        Eligibility For External Appeal

      26.3
        External Appeal Determination

      26.4
        Compliance With External Appeal Laws and Regulations

      26.5
        Member Handbook

       

      Section
        27 Intermediate Sanctions

      27.1
        General

      27.2
        Unacceptable Practices

      27.3
        Intermediate Sanctions

      27.4
        Enrollment Limitations

      27.5
        Due
        Process

      


      


      Section
        28 Environmental Compliance 

      Section
        29 Energy Conservation 

      Section
        30 Independent Capacity of Contractor 

      Section
        31 No Third Party Beneficiaries

      Section
        32 Indemnification

      32.1
        Indemnification by Contractor

      32.2
        Indemnification by DOHMH

       

      Section
        33 Prohibition on Use of Federal Funds for Lobbying

      33.1
        Prohibition of Use of Federal Funds for Lobbying

      33.2
        Disclosure Form to Report Lobbying

      33.3
        Requirements of Subcontractors

       

      Section
        34 Non-Discrimination

      34.1
        Equal Access to Benefit Package

      34.2
        Non-Discrimination

      34.3
        Equal Employment Opportunity

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

       

      Section
        35 Compliance with Applicable Laws

      35.1
        Contractor and DOHMH Compliance With Applicable Laws

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

      35.3
        Certificate of Authority Requirements

      35.4
        Notification of Changes In Certificate of Incorporation

      35.5
        Contractor's Financial Solvency Requirements

      35.6
        Compliance With Care For Maternity Patients

      35.7
        Informed Consent Procedures for Hysterectomy and Sterilization

      
         

        


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      35.8
        Non-Liability of Enrollees For Contractor's Debts 

      35.9
        DOHMH Compliance With Conflict of Interest Laws 

      35.10
        Compliance With New York State Public Health Law (PHL) Regarding External
        Appeals

      


      


      Section
        36 New York State Standard Contract Clauses and Local Standard Clauses


      


      Signature
        Page

       

      


       

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
 

    

    
      Table
        of Contents for Model Contract 

      APPENDICES




    


    A.
      New
      York State Standard Clauses

    B.
      Certification Regarding Lobbying

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


    D.
      New
      York State Department of Health Marketing Guidelines 

    E.
      New
      York State Department of Health Member Handbook Guidelines

    F.
      New
      York State Department of Health Action and Grievance System Requirements for
      the
      MMC and FHPlus Programs

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

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

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

    J.
      New
      York State Department of Health Guidelines for Contractor Compliance with the
      Federal ADA

    K.
      Prepaid Benefit Package Definitions of Covered and Non-Covered
      Services

    L.
      Approved Capitation Payment Rates

    M.
      Service Area, Benefit Options and Enrollment Elections

    N.
      New
      York City Specific Contracting Requirements

    0.
      Requirements for Proof of Workers' Compensation and Disability Benefits
      Coverage

    P.
      RESERVED

    Q.
      RESERVED

    R.
      New
      York City Standard Local Clauses

    


    


    


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      1.
        DEFINITIONS

       

      "Auto-assignment"
        means a
        process by which an MMC Eligible Person, as this term is defined in this
        Agreement, who is mandated to enroll in the MMC Program, but who has not
        selected and enrolled in an MCO within sixty (60) days of receipt of the
        mandatory notice sent by the LDSS, is assigned to an MCO offering an MMC
        product
        in the MMC Eligible Person's county of fiscal responsibility in accordance
        with
        the auto-assignment algorithm determined by the SDOH.

       

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

       

      "Benefit
        Package"
        means
        the covered services for the MMC and/or FHPlus Programs, described in Appendix
        K
        of this Agreement, to be provided to the Enrollee, as Enrollee is defined
        in
        this Agreement, by or through the Contractor, including optional Benefit
        Package
        services, if any, as specified in Appendix M of this Agreement.

       

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

       

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

       

      "Child/Teen
        Health Program" or "C/THP"
        means
        the program of early and periodic

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

       

      "Comprehensive
        HIV Special Needs Plan" or "HIV SNP"
        means an
        MCO certified pursuant to Section forty-four hundred three-c (4403-c) of
        Article
        44 of the PHL which, in addition to providing or arranging for the provision
        of
        comprehensive health services on a capitated basis, including those for which
        Medical Assistance payment is authorized pursuant to Section three hundred
        sixty-five-a (365-a) of the SSL, also provides or arranges for the provision
        of
        specialized HIV care to HIV positive persons eligible to receive benefits
        under
        Title XIX of the federal Social Security Act or other public
        programs.

       

       

      SECTION
        1

      (DEFINITIONS)

      October
        1, 2005

      1-1

      



      "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 Benefit Package
        and reimbursable under Title XIX of the Federal Social Security Act (SSA),
        SSL §
364-j(4)(r).

       

      "Days"
        means
        calendar days except as otherwise stated.

      


      "Designated
        Third Party Contractor"
        means an
        MCO with which the SDOH has contracted to provide Family Planning and
        Reproductive Health Services for FHPlus Enrollees of a MCO that does not
        include
        such services in its Benefit Package.

      


      "Detoxification
        Services"
        means
        Medically Managed Detoxification Services and Medically Supervised Inpatient
        and
        Outpatient Withdrawal Services as defined in Appendix K of this
        Agreement.

      


      "Disenrollment"
        means
        the process by which an Enrollee's membership in the Contractor's MMC or
        FHPlus
        product terminates.

      


      "Effective
        Date of Disenrollment"
        means
        the date on which an Enrollee may no longer receive services from the
        Contractor, pursuant to Section 8.5 and Appendix H of this
        Agreement.

       

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

      


      "Eligible
        Person"
        means
        either an MMC Eligible Person or a FHPlus Eligible Person as these terms
        are
        defined in 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 pregnant woman, the health of the woman or
        her
        unborn child 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
        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.

       

       

       

      SECTION
        1

      (DEFINITIONS)

      October
        1, 2005

      1-2

      



       

      "Enrollee"
        means
        either an MMC Enrollee or FHPlus Enrollee as these terms are defined in this
        Agreement.

      


      "Enrollment"
        means
        the process by which an Enrollee's membership in the Contractor's MMC or
        FHPlus
        product begins.

       

      "Enrollment
        Broker"
        means
        the state and/or county-contracted entity that provides Enrollment, education,
        and outreach services to Eligible Persons; effectuates Enrollments and
        Disenrollments in MMC and FHPlus; and provides other contracted services
        on
        behalf of the SDOH and the LDSS.

      


      "Enrollment
        Facilitator"
        means an
        entity under contract with SDOH, and its agents, that assists children and
        adults to complete the Medicaid, Family Health Plus, Child Health Plus, Special
        Supplemental Food Program for WIC, and Prenatal Care Assistance Program (PCAP)
        application and the enrollment and recertification processes, to the extent
        permitted by federal and state law and regulation. This includes assisting
        individuals in completing the required application form, conducting the
        face-to-face interview, assisting in the collection of required documentation,
        assisting in the MCO selection process, and referring individuals to WIC
        or
        other appropriate sites.

       

      "Experienced
        HIV Provider"
        means an
        entity grant-funded by the SDOH AIDS

      Institute
        to provide clinical and/or supportive services or an entity licensed or
        certified by the SDOH to provide HIV/AIDS services.

      


      "Facilitated
        Enrollment"
        means
        the enrollment infrastructure established by SDOH to assist children and
        adults
        in applying for Medicaid, Family Health Plus, Child Health Plus, WIC, or
        PCAP
        using a joint application, and recertifying for these programs, as allowed
        by
        federal and state law and regulation.

       

      "Family
        Health Plus" or "FHPlus"
        means
        the health insurance program established under Title 11-D of Article 5 of
        the
        SSL.

      


      "FHPlus
        Eligible Person"
        means a
        person whom the LDSS, state or federal government determines to have met
        the
        qualifications established in state or federal law necessary to receive FHPlus
        benefits under Title 11-D of the SSL and who meets all the other conditions
        for
        enrollment in the FHPlus Program.

      


      "FHPlus
        Enrollee"
        means a
        FHPlus Eligible Person who either personally or through an authorized
        representative, has enrolled in the Contractor's FHPlus product.

      


      "FiscalAgent"
        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.

      


       

       

      SECTION 1

      (DEFINITIONS)

      October
        1, 2005

      1-3

       

      



      "Guaranteed
        Eligibility"
        means
        the period beginning on the Enrollee’s Effective Date of Enrollment with the
        Contractor and ending six (6) months thereafter, during which the Enrollee
        may
        be entitled to continued Enrollment in the Contractor's MMC or FHPlus product,
        as applicable, despite the loss of eligibility as set forth in Section 9
        of this
        Agreement.

       

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

      


      "HIV
        Specialist PCP"
        means a
        Primary Care Provider that meets the qualifications for HIV Specialist as
        defined by the Medical Care Criteria Committee of the SDOH
        AIDS
        Institute.

       

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

      


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

       

      "Local
        Public Health Agency" or "LPHA"
        means
        the city or county government agency responsible for monitoring the population's
        health, promoting the health and safety of the public, delivering public
        health
        services and intervening when necessary to protect the health and safety
        of the
        public.

      


      "Local
        Department of Social Services" or "LDSS"
        means a
        city or county social services district as constituted by Section 61 of the
        SSL.

      


      "Lock-In
        Period"
        means
        the period of time during which an Enrollee may not change MCOs, unless the
        Enrollee can demonstrate Good Cause as established in state law and specified
        in
        Appendix H of this Agreement.

      


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

       

      


      


       

      SECTION
        1

      (DEFINITIONS)

      October
        1,2005

      1-4

       

      



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

      


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

      


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

      


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

      


      "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 an MMC Enrollee or an FHPlus
        Enrollee.

       

      "MMCEligible
        Person" means a person whom the LDSS, state or federal government
        determines to have met the qualifications established in state and federal
        law
        necessary to receive medical assistance under Title 11 of the SSL and who
        meets
        all the other conditions for enrollment in the MMC Program.

       

      "MMCEnrollee"
        means an MMC Eligible Person who either personally or through an authorized
        representative, has enrolled in, or has been auto-assigned to, the Contractor's
        MMC product.

       

      "Native
        American"
        means,
        for purposes of this Agreement, a person identified in the Medicaid eligibility
        system as a Native American.

      


      "Nonconsensual
        Enrollment"
        means
        Enrollment of an Eligible Person, other than through Auto-assignment, newborn
        Enrollment or case addition, in an MCO's MMC or FHPlus 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, as this term is defined in this Agreement.

      


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

      


      


       

      SECTION
        1

      (DEFINITIONS)

      October
        1,2005

      1-5

      



      "Permanent
        Placement Status"
        means
        the status of an individual in a Residential Health Care Facility (RHCF)
        when
        the LDSS determines that the individual is not expected to return home based
        on
        medical evidence affirming the individual's need for permanent RHCF
        placement.

      


      "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
        MMC Eligible Person who is not yet enrolled in a MCO that is participating
        in
        the MMC Program.

      


      "Prepaid
        Capitation PlanRoster"
        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 for the coming month, subject to any revisions communicated
        in
        writing or electronically by SDOH, LDSS, or the Enrollment Broker.

       

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

       

      "Preventive
        Care"
        means
        the care or services rendered to avert disease/illness and/or its consequences.
        There are three levels of preventive care: primary, such as immunizations,
        aimed
        at preventing disease; secondary, such as disease screening programs aimed
        at
        early detection of disease; and tertiary, such as physical therapy, aimed
        at
        restoring function after the disease has occurred. Commonly, the term
        "preventive care" is used to designate prevention and early detection programs
        rather than treatment programs.

       

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

      


      "Prospective
        Enrollee"
        means
        any individual residing in the Contractor's Service Area that has not yet
        enrolled in a MCO's MMC or FHPlus product.

      


      


       

      


      SECTION
        1


      (DEFINITIONS)

       October
        1,2005 

      1-6

       

      



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

      


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

       

      "Seriously
        Emotionally Disturbed" or "SED"
        means an
        individual through seventeen

      (17)
        years of age who meets the criteria established by the Commissioner of Mental
        Health, including children and adolescents who have a designated diagnosis
        of
        mental illness under the most recent edition of the diagnostic and statistical
        manual of mental disorders, and (1) whose severity and duration of mental
        illness results in substantial functional disability or (2) who require mental
        health services on more than an incidental basis.

       

      "Seriously
        and Persistently Mentally Ill" or "SPMI"
        means an
        individual eighteen

      (18)
        years or older who meets the criteria established by the Commissioner of
        Mental
        Health, including persons who have a designated diagnosis of mental illness
        under the most recent edition of the diagnostic and statistical manual of
        mental
        disorders, and (1) whose severity and duration of mental illness results
        in
        substantial functional disability or (2) who require mental health services
        on
        more than an incidental basis.

       

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

      


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

      


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

       

      "UrgentlyNeeded
        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 MMC or FHPlus Participating
        Provider.

       

       

      SECTION
        1

      (DEFINITIONS)

      October
        1, 2005

      1-7

       

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

       

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

      
         

        2.1
          Term

         

        a)
          This
          Agreement is effective October 1, 2005 and shall remain in effect until
          September 30, 2007; or until the execution of an extension, renewal or
          successor
          Agreement between the Contractor and the DOHMH approved by  the SDOH,, 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 an additional
          three (3) year term, subject to the approval of SDOH, DHHS, and any other
          entities as required by law or regulation.

        c)
          The
          maximum duration of this Agreement is five (5) years; provided however
          an
          extension to this Agreement beyond the five 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, or in relevant part, should federal financial participation
          for
          the MMC and/or FHPlus Program expire.

         

        2.2
          Amendments

         

        a)
          This
          Agreement may be modified only in writing. Unless otherwise specified in
          this
          Agreement, modifications must be signed by the parties and approved by
          the SDOH,
          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.

         

        


        b)
          DOHMH
          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 DOHMH and SDOH
          being
          out of compliance with state or federal law.

        


         

         

        SECTION 
          2

        (AGREEMENT
          TERM, AMENDMENTS. EXTENSIONS, 

        AND
          GENERAL CONTRACT ADMINISTRATION PROVISIONS) 

        October
          1, 2005

        2-1

        



        c)
          The
          Contractor will return the signed amendment or notify the DOHMH 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 SDOH, the DHHS, and any other
          entity as required in law or regulation. SDOH will provide a notice of
          such
          approval to the Contractor and the DOHMH upon such approval.

         

        2.4
          Entire Agreement

        a)
          This
          Agreement, including those attachments, schedules, appendices, exhibits,
          and
          addenda that have been specifically incorporated herein and written plans
          submitted by the Contractor and maintained on file by SDOH and/or DOHMH
          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:

         

        i)
          Appendix A, Standard Clauses for all New York State Contracts;

        ii)
          Appendix R, Local Standard Clauses for all New York City Contracts;

        iii)
          Appendix N, New York City Specific Requirements;

        iv)
          The
          body of this Agreement;

           
          v) The appendices attached to the body of this Agreement, other than Appendix
          A,
          R and N;

        vi)
          The
          Contractor's approved:

        A)
          Marketing Plan on file with SDOH and DOHMH

        B)
          Action
          and Grievance System Procedures on file with SDOH

        C)
          Quality Management Plan on file with SDOH

        D)
          ADA
          Compliance Plan on file with SDOH and DOHMH 

        E)
          Fraud
          and Abuse Prevention Plan on file with SDOH.

         

         

        SECTION  2

        (AGREEMENT
          TERM, AMENDMENTS, EXTENSIONS. 

        AND
          GENERAL CONTRACT ADMINISTRATION PROVISIONS)

        October
          1,2005 

        2-2

        



        2.5
          Renegotiation

         

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

         

        2.6
          Assignment and Subcontracting

         

        


        a)
          The
          Contractor shall not, without DOHMH and SDOH's prior written consent, assign,
          transfer, convey, sublet, or otherwise dispose of this Agreement; of the
          Contractor's right, title, interest, obligations, or duties under the Agreement;
          of the Contractor's power to execute the Agreement; or, by power of attorney
          or
          otherwise, of any of the Contractor's rights to receive monies due or to
          become
          due under this Agreement. DOHMH and SDOH agree that they 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 DOHMH and SDOH's consent shall be
          void.

         

        b)
          Contractor may not enter into any subcontracts related to the delivery
          of
          services to Enrollees, except by a 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 as defined
          in
          10 NYCRR Part 98, it must be approved by SDOH prior to its becoming effective.
          Any subcontract entered into by Contractor shall fulfill the requirements
          of 42
          CFR Parts 434 and 438 to the extent 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 DOHMH and to SDOH for
          carrying out all activities under this Agreement and that no subcontract
          shall
          limit or terminate Contractor's responsibility.

         

         

        SECTION
          2

        (AGREEMENT
          TERM, AMENDMENTS, EXTENSIONS, 

        AND
          GENERAL CONTRACT ADMINISTRATION PROVISIONS) 

        October
          1,2005

        2-3

        



        2.7 Termination

         

        a)
          DOHMH
          Initiated Termination

         

        i)
          DOHMH
          shall have the right to terminate this Agreement, in whole or in part;
          for
          either the Contractor's MMC or FHPlus product if applicable or for either
          or
          both products in specified counties of Contractor's service area as identified
          in Appendix M , 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 MMC or FHPlus Program 'or engaged in an unacceptable
          practice pursuant to Section 27.2 of this Agreement;

        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 such longer
          period as the parties may agree, of SDOH or DOHMH'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);

        or

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

         

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

         

          
          iii) If SDOH suspends, limits or revokes Contractor's Certificate of Authority
          under PHL § 4404, 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

         

        SECTION 
          2

        (AGREEMENT
          TERM, AMENDMENTS. EXTENSIONS, 

        AND
          GENERAL CONTRACT ADMINISTRATION PROVISIONS) 

        October
          1-2005

        2-4

        



        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 MMC
          and/or FHPlus products under this Agreement in any designated geographic
          areas
          not affected by such action, and shall terminate its MMC and/or FHPlus
          products
          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 DOHMH shall notify Enrollees
          of the
          termination, or delegate responsibility for such notification to the Contractor,
          and such notice shall include a statement that Enrollees may disenroll
          immediately without cause.

         

        b)
          Contractor and DOHMH Initiated Termination

        The
          Contractor and the DOHMH each shall have the right to terminate this '
          Agreement
          in its entirety, for either the Contractor's MMC or FHPlus product if
          applicable, or for either or both products in specified counties of the
          Contractor's service area as identified in Appendix M, in the event that
          SDOH
          and the Contractor fail to reach agreement on the monthly Capitation Rates.
          In
          such event, the party exercising its right shall give the other party and
          SDOH
          written notice specifying the reason for and the effective date of termination,
          which shall not be less time than will permit an orderly transition of
          Enrollees, but no more than ninety (90) days.

         

        c)
          Contractor Initiated Termination

        


        i)
          The
          Contractor shall have the right to terminate this Agreement in its entirety,
          for
          either the Contractor's MMC or FHPlus product if applicable, or for either
          or
          both products in specified counties of the Contractor's service area as
          identified in Appendix M, in the event that DOHMH 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 within such longer period as the
          parties may agree, of the Contractor's written request for compliance.
          The
          Contractor shall give DOHMH written notice specifying the reason for and
          the
          effective date of the termination, which shall not be less time than will
          permit
          an orderly transition of Enrollees, but no more than ninety (90)
          days.

        


         

        SECTION 
          2

        (AGREEMENT
          TERM, AMENDMENTS. EXTENSIONS,

        AND
          GENERAL CONTRACT ADMINISTRATION PROVISIONS)

        October
          1,2005

        2-5

         

        



        ii)
          The
          Contractor shall have the right to terminate this Agreement, in its entirety,
          for either the Contractor's MMC or FHPlus product if applicable, or for
          either
          or both products in specified counties of the Contractor's service area
          as
          specified in Appendix M, in the event that its obligations are materially
          changed by modifications to this Agreement and its Appendices by SDOH or
          DOHMH.
          In such event, Contractor shall give DOHMH and SDOH written notice within
          thirty
          (30) days of notification of changes to the Agreement or Appendices specifying
          the reason and the effective date of termination, which shall not be less
          time
          than will permit an orderly transition of Enrollees, but no more than ninety
          (90) days.

        


        


        iii)
          The
          Contractor shall have the right to terminate this Agreement in' its entirety,
          for either the Contractor's MMC or FHPlus product if applicable, or for
          either
          or both products in specified counties of the Contractor's service area
          as
          identified in Appendix M, if the Contractor is unable to provide services
          pursuant to this Agreement because of a natural disaster and/or an act
          of God to
          such a degree that Enrollees cannot obtain reasonable access to services
          within
          the Contractor's organization, and, after diligent efforts, the Contractor
          cannot make other provisions for the delivery of such services. The Contractor
          shall give SDOH and DOHMH written notice of any such termination that
          specifies:

        


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

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

        C)
          the
          effective date of the termination, which shall not be less time than will
          permit
          an orderly transition of Enrollees, but no more than ninety
          (90)days.

        


         

        d)
          Termination Due To Loss of Funding

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

        


         

        SECTION 
          2

        (AGREEMENT
          TERM, AMENDMENTS. EXTENSIONS. 

        AND
          GENERAL CONTRACT ADMINISTRATION PROVISIONS) 

        October
          1, 2005

        2-6

        


        

          2.8
            Close-Out Procedures :

           

          a)
            Upon
            termination or expiration of this Agreement in its entirety, for either
            the
            Contractor's MMC or FHPlus product is applicable, or for either or both
            products
            in specified counties of the Contractor's service area as identified
            in Appendix
            M, 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 DOHMH and that the DOHMH, and the SDOH have 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 DOHMH, 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)
            If
            this Agreement is terminated in its entirety, the Contractor shall submit
            to
            DOHMH, SDOH, and authorized federal, state or local agencies, within
            ninety (90)
            days of termination, a final financial statement, made by a certified
            public
            accountant, unless the Contractor requests of DOHMH and receives written
            approval from SDOH, DOHMH and all other governmental agencies from which
            approval is required, for an extension of time for this submission;

          


          iv)
            The
            Contractor shall establish an appropriate plan acceptable to and prior
            approved
            by the DOHMH and SDOH for the orderly transition of Enrollees. This plan
            shall
            include the provision of pertinent information to. identified Enrollees
            who are:
            pregnant; currently receiving treatment for a chronic or life threatening
            condition; prior approved for services or surgery; or whose care is being
            monitored by a case manager to assist them in making decisions which
            will
            promote continuity of care; and

           

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

           

          


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

           

           

          SECTION 
            2

          (AGREEMENT
            TERM, AMENDMENTS. EXTENSIONS.

          AND
            GENERAL CONTRACT ADMINISTRATION PROVISIONS)

          October
            1.2005

          2
            -
            7

          



          2.9
            Rights and Remedies

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

           

          2.10
            Notices

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

           

          For
            DOHMH:

          New
            York
            City Department of Health and Mental Hygiene

          125
            Worth
            Street, CN # 29C

          New
            York,
            NY 10013

          ATTN:
            Assistant Commissioner

          Division
            of Health Care Access and Improvement

           

          For
            SDOH:

          New
            York
            State Department of Health Empire State Plaza Coming Tower, Room 2074
            Albany, NY
            1223 7-0065

           

          For
            the
            Contractor:

          WellCare
            of New York, Inc. 11 West 19th
            Street,
            Second floor New York, NY 10011 ATTN: Vice President

           

           

          SECTION 
            2

          (AGREEMENT
            TERM, AMENDMENTS. EXTENSIONS, 

          AND
            GENERAL CONTRACT ADMINISTRATION PROVISIONS)

          October
            1, 2005

          2-8

          



          2.11
            Severability

           

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

           

          


          


          SECTION 
            2

          (AGREEMENT
            TERM. AMENDMENTS,
            EXTENSIONS. 

          AND
            GENERAL CONTRACT ADMINISTRATION PROVISIONS)

          October
            1,
2005

          2-9

           

          
            
               

            

            
               

              
                

              

            

            
               

            

          

          

            3.
              COMPENSATION

             

            3.1
              Capitation Payments

            


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

            


            b)
              The
              monthly Capitation Rates are attached hereto as Appendix L, which is
              hereby made
              a part of this Agreement as if set forth fully herein.

            


            c)
              The
              monthly capitation payments, and the Supplemental Newborn Capitation
              Payment
              andthe
              Supplemental Maternity Capitation Payment, when applicable, to the
              Contractor
              shall constitute full and complete payments to the Contractor for all
              services
              that the Contractor provides, except for payments due the Contractor
              as set
              forth in Sections 3.11, 3.12, and 3.13 of this Agreement for MMC
              Enrollees.

            


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

             

            3.2
              Modification of Rates During Contract Period

            


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

            


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

            


            c)
              In the
              event that the SDOH and the Contractor fail to reach agreement on the
              modifications to the monthly Capitation Rates, the SDOH will provide
              formal
              written notice to the Contractor and the DOHMH of the amount and effective
              date
              of the modified Capitation Rates approved by the State Division of
              the Budget.
              The Contractor shall have the option of terminating this Agreement
              if such
              approved modified Capitation Rates are not acceptable. In such cases,
              the
              Contractor shall give written notice to the SDOH and the DOHMH within
              thirty
              (30) days of the date of the formal written notice of the modified
              Capitation
              Rates from SDOH specifying the reasons for and effective date of termination.
              The effective date of termination shall be ninety (90) days from the
              date of the
              Contractor's written notice, unless the SDOH determines that an orderly
              disenrollment can be accomplished in fewer days.

             

            SECTION
              3

            (COMPENSATION)
              

            October
              1,2005


            3-1

            



            During
              the period commencing with the effective date of the SDOH modified
              Capitation
              Rates, through the effective date of termination of the Agreement,
              the
              Contractor shall have the option of continuing to receive capitation
              payments at
              the expired Capitation Rates or at the modified Capitation Rates approved
              by the
              SDOH and the Division of the Budget for the rate period.

            


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

             

            3.3
              Rate
              Setting Methodology

            


            a)
              Capitation rates shall be determined prospectively and shall not be
              retroactively adjusted to reflect actual Medicaid fee-for-service data
              or
              Contractor experience for the time period covered by the rates. Capitated
              rates
              in effect as of April 1, 2006 and thereafter, shall be certified to
              be -
              actuarially sound in accordance with 42 CFR § 438.6(c).

            


            b)
              Notwithstanding the provisions set forth in Section 3.3(a) above, the
              DOHMH
              reserves the right to terminate this Agreement, in its entirety for
              either the
              Contractor's MMC or FHPlus product if applicable, or for either or
              both products
              in specified counties of the Contractor's service area as set forth
              in Appendix
              M, pursuant to Section 2.7 of this Agreement, upon determination by
              SDOH that
              the aggregate monthly Capitation Rates are not cost effective.

             

            3.4
              Payment of Capitation

             

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

             

            SECTION
              3

            (COMPENSATION)
              

            October
              1,2005 

            3-2

            



            The
              Fiscal Agent will also use its best efforts to resolve any billing
              problem
              relating to the Contractor's claims as soon as possible. In accordance
              with
              Section 41 of the New York State Finance Law (State Finance Law), the
              State and
              New York City 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 US
              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,
              the
              Enrollment Broker, or an Enrollee, Prospective 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

             

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

             

            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 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

             

            SECTION
              3

            (COMPENSATION)

            October
              1, 2005

            3-3

            



            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 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
              Payment For Newborns

             

            a)
              The
              Contractor shall be responsible for all costs and services included
              in the
              Benefit Package associated with an Enrollee's newborn, unless the child
              is
              Excluded from Medicaid Managed Care pursuant to Appendix H of this
              Agreement, or
              the Contractor does not offer a MMC product in the mother's local social
              services district.

            


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

            


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

             

            d)
              The
              Contractor cannot bill for a Supplemental Newborn Capitation Payment
              unless the
              newborn hospital or birthing center payment has been paid by the Contractor.
              The
              Contractor must maintain on file evidence of payment to the hospital
              or birthing
              center of the claim for the newborn stay. Failure to have supporting
              records
              may, upon an audit, result in recoupment of the Supplemental Newborn
              Capitation
              Payment by SDOH.

             

            3.9
              Supplemental Maternity Capitation Payment

             

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

            


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

             

            


            SECTION
              3

            (COMPENSATION)
              

            October
              1,2005 

            3-4

             

            



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

            


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

            


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

            


            f)
              The
              Contractor may not bill a Supplemental Maternity Capitation Payment
              until the
              hospital inpatient or birthing center delivery is paid by the Contractor,
              and
              the Contractor must maintain on file evidence of payment of the delivery,
              plus
              any other inpatient and outpatient services for the maternity care
              of the
              Enrollee to be eligible to receive a Supplemental Maternity Capitation
              Payment.
              Failure to have supporting records may, upon audit, result in recoupment
              of the
              Supplemental Maternity Capitation Payment by the SDOH.

             

            3.10
              Contractor Financial Liability

             

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

             

            3.11
              Inpatient Hospital Stop-Loss Insurance for MMC Enrollees

            


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

            


            b)
              Under
              NYS stop-loss coverage, if the hospital inpatient expenses incurred
              by the
              Contractor for an individual MMC Enrollee during any calendar year
              reaches
              $50,000, the Contractor shall be compensated for eighty percent (80%)
              of the
              cost of hospital inpatient services in excess of this amount up to
              a maximum of
              $250,000. Above that amount, the Contractor will be compensated for
              one hundred
              percent (100%) of cost. All compensation shall be based on the lower
              of the
              Contractor's negotiated hospital rate or Medicaid rates of payment

             

             

            SECTION
              3

            (COMPENSATION)
              

            October
              1, 2005

            3-5

            



            ⁯
The
              Contractor has elected to have NYS provide stop-loss reinsurance for
              MMC
              Enrollees.

             

            OR

             

            X
              The
              Contractor has not elected to have NYS provide stop-loss reinsurance
              for MMC
              Enrollees.

             

            


             

            3.12
              Mental Health and Chemical Dependence Stop-Loss for MMC Enrollees

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

             

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

            


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

             

            3.13
              Residential Health Care Facility Stop-Loss for MMC Enrollees

             

            The
              Contractor will be compensated for medically necessary and clinically
              appropriate Medicaid reimbursable inpatient Residential Health Care
              Facility
              services, as defined in Appendix K of this Agreement, provided to MMC
              Enrollees
              in excess of sixty (60) days during a calendar year at the lower of
              the
              Contractor's negotiated rates or Medicaid rate of payment.

            


             

            SECTION
              3


            (COMPENSATION)
              

            October
              1, 2005

            3-6

             


            3.14  
              Stop-Loss Documentation and Procedures for the MMC Program

            


            The
              Contractor must follow procedures and documentation requirements in
              accordance
              with the New York State Department of Health stop-loss policy and procedure
              manual. The State has the right to recover from the Contractor any
              stop-loss
              payments that are later found not to conform to these SDOH
              requirements.

             

            3.15
              FHPlus Reinsurance

            The
              Contractor shall purchase reinsurance coverage unless it can demonstrate
              to
              SDOH's satisfaction the ability to self insure.

            


            3.16
              Tracking Visits Provided by Indian Health Clinics - Applies to MMC
              Program
              Only

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

            


             

            SECTION
              3

            (COMPENSATION)

            October
              1,2005

            3-7

            


            
              
                 

              

              
                 

                
                  

                

              

              
                 

              

            

          

        

      

    

     


    4.
      SERVICE AREA

     

    The
      Contractor's service area for Medicaid Managed Care and/or FHPlus shall consist
      of the county(ies) described in Appendix M of this Agreement, which is hereby
      made a part of this Agreement as if set forth fully herein. Such service area
      is
      the specific geographic area within which Eligible Persons must reside to enroll
      in either the Contractor's Medicaid Managed Care and/or FHPlus
      product.

    


     

    SECTION
      4

    (SERVICE
      AREA)

    October
      1,2005

    4-1

     

    



     

    5. RESERVED

     

    
       

      SECTION
        5

      October
        1,2005

      5-1

    

     

     

    


    
      
         

      

      
         

        
          

        

      

      
         

      

    


    6.
      ENROLLMENT

     

    6.1
      Populations Eligible for Enrollment

     

    a)
      Medicaid Managed Care Populations

    All
      Eligible Persons who meet the criteria in Section 364-j of the SSL and/or New
      York State's Operational Protocol for the Partnership Plan and who reside in
      the
      Contractor's service area, as specified in Appendix M of this Agreement, shall
      be eligible for Enrollment in the Contractor's Medicaid Managed Care
      product.

     

    b)
      Family
      Health Plus Populations

    All
      Eligible Persons who meet the criteria listed in Section 369-ee of the SSL
      and/or New York State's Operational Protocol for the Partnership Plan and who
      reside in the Contractor's service area, as specified in Appendix M of this
      Agreement, shall be eligible for Enrollment in the Contractor's Family Health
      Plus product.

     

    6.2
      Enrollment Requirements

     

    The
      Contractor agrees 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.

     

    6.3
      Equality of Access to Enrollment

     

    The
      Contractor shall accept Enrollments of Eligible Persons in the order in which
      the Enrollment applications 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.

     

    6.4
      Enrollment Decisions

    An
      Eligible Person's decision to enroll in the Contractor's MMC or FHPlus product
      shall be voluntary except as otherwise provided in Section 6.5 of this
      Agreement.

     

    SECTION
      6

    (ENROLLMENT)
      

    October
      1,2005

    6-1

    



    6.5
      Auto
      Assignment - For MMC Program Only

    


    An
      MMC
      Eligible Person whose Enrollment is mandatory under the Medicaid Managed Care
      Program and who fails to select and enroll in an MCO within sixty (60) days
      of
      receipt of notice of mandatory Enrollment may be assigned by the SDOH or the
      LDSS to the Contractor's MMC product pursuant to SSL §364-j and in accordance
      with Appendix H of this Agreement.

     

    6.6
      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 into the Contractor's MMC
      or
      FHPlus product upon the performance of any act. Neither the Contractor nor
      the
      LDSS shall suggest in any way that failure to enroll in the Contractor's MMC
      or
      FHPlus product may result in a loss of benefits, except in the case of the
      FHPlus Program when the Contractor is the sole MCO offering a FHPlus product
      in
      the Enrollee's county of fiscal responsibility.

     

    6.7
      Newborn Enrollment

     

    a)
      All
      newborn children not Excluded from Enrollment in the MMC Program pursuant to
      Appendix H of this Agreement, shall be enrolled in the M[CO in which the
      newborn's mother is an Enrollee, effective from the first day of the child's
      month of birth, unless the MCO in which the mother is enrolled does not offer
      a
      MMC product in the mother's county of fiscal responsibility.

     

    b)
      In
      addition to the responsibilities set forth in Appendix H of this Agreement,
      the
      Contractor is responsible for coordinating with the LDSS the efforts to ensure
      that all newborns are enrolled in the Contractor's MMC product, if
      applicable.

     

    c)
      The
      SDOH and LDSS shall be responsible for ensuring that timely Medicaid eligibility
      determination and Enrollment of the newborns is effected consistent with state
      laws, regulations, and policy and with the newborn Enrollment requirements
      set
      forth in Appendix H of this Agreement.

     

    6.8
      Effective Date of Enrollment

    a)
      For
      MMC Enrollees, the Contractor and the LDSS are responsible for notifying the
      MMC
      Enrollee of the expected Effective Date of Enrollment.

     

    b)
      For
      FHPlus Enrollees, the Contractor must notify the FHPlus Enrollee of the
      Effective Date of Enrollment.

     

     

    SECTION 
      6

    (ENROLLMENT)

     October
      1,2005 

    6-2

    



    c)
      Notification may be accomplished through a "Welcome Letter." To the extent
      practicable, such notification must precede the Effective Date of
      Enrollment.

    


    d)
      In the
      event that the actual Effective Date of Enrollment changes, the Contractor,
      and
      for MMC Enrollees, the LDSS, must notify the Enrollee of the
      change.

    


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

    


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

    


    ii)
      Contractor shall not be liable for any part of the cost of a hospital stay
      for a
      MMC Enrollee who is admitted to the hospital prior to the Effective Date of
      Enrollment in the Contractor's MMC product and who remains hospitalized on
      the
      Effective Date of Enrollment; except when the MMC Enrollee, on or after the
      Effective Date of Enrollment, 1) is transferred from one hospital to another;
      or
      2) is discharged from one unit in the hospital to another unit in the same
      facility and under Medicaid fee-for-service payment rules, the method of payment
      changes from: a) Diagnostic Related Group (DRG) case-based rate of payment
      per
      discharge to a per diem rate of payment exempt from DRG case-based payment
      rates, or b) from a per diem payment rate exempt from DRG case-based payment
      rates either to another per diem rate, or a DRG case-based payment rate. In
      such
      instances, the Contractor shall be liable for the cost of the consecutive
      stay.

    


    iii)
      Contractor shall not be liable for any part of the cost of a hospital stay
      for
      an FHPlus Enrollee who is admitted to the hospital prior to the Effective Date
      of Enrollment in the Contractor's FHPlus product and who has not been discharged
      as of the Effective Date of Enrollment, up to the date the FHPlus Enrollee
      is
      discharged.

    


    iv)
      Except for newborns, an Enrollee's Effective Date of Enrollment shall be the
      first day of the month on which the Enrollee's name appears on the Roster for
      that month.

     

     

    SECTION
      6

    (ENROLLMENT)
      

    October
      1, 2005

    6-3

    


    6.9
      Roster:

    
 

    a)
      The
      first and second monthly Rosters generated by SDOH in combination shall serve
      as
      the official Contractor Enrollment list for purposes of 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 or the Enrollment Broker. If the LDSS or Enrollment
      Broker 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 Rosters electronically.


     

     

    6.10
      Automatic Re-Enrollment:

     

    a)
      An
      Enrollee who loses Medicaid or FHPlus eligibility and who regains eligibility
      for either Medicaid or FHPlus within a three (3) month period, will be
      automatically prospectively re-enrolled in the Contractor's MMC or FHPlus
      product unless:

    


    i)
      the
      Contractor does not offer such product in the Enrollee's county of fiscal
      responsibility; or

    


    ii)
      the
      Enrollee indicates in writing that he/she wishes to enroll in another MCO or,
      if
      permitted, receive coverage under Medicaid fee-for-service.

     

     

    SECTION 
      6

    (ENROLLMENT)
      

    October
      1, 2005

    6-4

    


    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    


    7.
      LOCK-IN PROVISIONS 

    


    7.1
      Lock-In Provisions in MMC Mandatory Local Social Services Districts and
      for
      Family Health Plus

    All
      MMC
      Enrollees residing in local social service districts where Enrollment in the
      MMC
      Program is mandatory and all FHPlus Enrollees are subject to a twelve (12)
      month
      Lock-In Period following the Effective Date of Enrollment, with an initial
      ninety (90) day grace period in which to disenroll without cause and enroll
      in
      another MCO's MMC or FHPlus product, if available.

     

    7.2
      Disenrollment During a Lock-In Period

    An
      Enrollee subject to Lock-In may disenroll from the Contractor's MMC or FHPlus
      product during the Lock-In Period for Good Cause as defined in Appendix H of
      this Agreement.

     

    7.3
      Notification Regarding Lock-In and End of Lock-In Period

    The
      LDSS,
      either directly or through the Enrollment Broker, is responsible for notifying
      Enrollees of their right to change MCOs in the Enrollment confirmation notice
      sent to individuals after they have selected an MCO or been auto-assigned (the
      latter being applicable to areas where the mandatory MMC Program is in effect).
      The SDOH or its designee will be responsible for providing a notice of end
      of
      Lock-In and the right to change MCOs at least sixty (60) days prior to the
      first
      Enrollment anniversary date as outlined in Appendix H of this
      Agreement.

     

    7.4
      Lock-In and Change in Eligibility Status

    Enrollees
      who lose Medicaid or FHPlus eligibility and regain eligibility for either
      Medicaid or FHPlus within a three (3) month period, will not be subject to
      a new
      Lock-in Period unless they opt to change MCOs pursuant to Section 6.10 of this
      Agreement.

    


     

    SECTION
      7


    (LOCK-IN
      PROVISIONS)

    October
      1.2005

     7-1

    


    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    


    8.
      DISENROLLMENT

     

    8.1
      Disenrollment 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 making the final determination concerning Disenrollment
      requests.

     

    8.2
      Disenrollment Prohibitions

    Enrollees
      shall not be disenrolled from the Contractor's MMC or FHPlus product based
      on
      any of the factors listed in Section 34 (Non-Discrimination) of this Agreement.
      :

     

    8.3
      Disenrollment Requests

     

    a)
      -Routine Disenrollment Requests

    The
      LDSS
      is responsible for processing Routine Disenrollment requests to take effect
      as
      specified in Appendix H of this Agreement. 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.

     

    b)
      Non-Routine Disenrollment Requests

     

    


    i)
      Enrollees with an urgent medical need to disenroll from the Contractor's MMC
      or
      FHPlus product may request an expedited Disenrollment by the LDSS. An MMC
      Enrollee who requests a return to Medicaid fee-for-service based on his/her
      HIV,
      End State Renal disease (ESRJD) or SPMI/SED status is categorically eligible
      for
      an expedited Disenrollment on the basis of urgent medical need.

    


    ii)
      Enrollees with a complaint of Nonconsensual Enrollment may request an expedited
      Disenrollment by the LDSS.

    


    iii)
      In
      districts where homeless individuals are Exempt, as described in Appendices
      H
      and M of this Agreement, homeless MMC Enrollees residing in the shelter system
      may request an expedited Disenrollment by the LDSS.

     

    


    SECTION
      8


    (DISENROLLMENT)

     October
      1,2005 

    8-1

     

    



    iv)
      Retroactive Disenrollments may be warranted in rare instances and may be
      requested of the LDSS as described in Appendix H of this Agreement.

    


    v)
      Substantiation of non-routine Disenrollment requests by the LDSS will result
      in
      Disenrollment in accordance with the timeframes as set forth in Appendix H
      of
      this Agreement.

     

    8.4
      Contractor Notification of Disenrollments

     

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

    b)
      In the
      event that the LDSS intends to retroactively disenroll an Enrollee. on a date
      prior to the first day of the month of the Disenrollment request, the LDSS
      is
      responsible for consulting with the Contractor prior to Disenrollment. Such
      consultation shall not be required for the retroactive Disenrollment of
      Supplemental Security Income (SSI) infants where it is clear that the'
      Contractor was not a risk for the provision of Benefit Package services for
      any
      portion of the retroactive period.

     

    c)
      In all
      cases of retroactive Disenrollment, including Disenrollments effective the
      first
      day of the current month, the LDSS is responsible for noticing 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 Benefit
      Package services during the month.

     

    8.5
      Contractor's Liability

    


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

    


    i)
      The
      Contractor shall be liable for any part of the cost of a hospital stay for
      a MMC
      Enrollee who is admitted to the hospital prior to the Effective Date of
      Disenrollment from the Contractor's MMC product and who remains hospitalized
      on
      the Effective Date of Disenrollment; except when the MMC Enrollee. on or after
      the Effective Date of Disenrollment, 1) is transferred from one hospital to
      another; or 2) is discharged from one unit in the hospital to another unit
      in
      the same facility and under Medicaid fee-for-service payment rules, the method
      of payment changes from: a) DRG case-based rate of payment per discharge to
      a
      per diem rate of payment exempt from DRG case-based payment rates,
      or

    


    


    SECTION
      8


    (DISENROLLMENT)
      

    October
      1, 2005

    8-2

     

    



    b)
      from a
      per diem payment rate exempt from DRG case-based payment rates to either another
      per diem rate, or a DRG case-based payment rate. In such instances, the
      Contractor shall not be liable for the cost of the consecutive stay. For the
      purposes of this paragraph, "hospital stay" does not include a stay in a
      hospital that is a) certified by Medicare as a long-term care hospital and
      b)
      has an average length of stay for all patients greater than ninety-five (95)
      days as reported in the Statewide Planning and Research Cooperative System
      (SPARCS) Annual Report 2002; in such instances, Contractor liability will cease
      on the Effective Date of Disenrollment.

    


    ii)
      The
      Contractor shall be liable for any part of the cost of a hospital stay for
      a
      FHPlus Enrollee who is admitted to the hospital prior to the Effective Date
      of
      Disenrollment from the Contractor's FHPlus product and who has not been
      discharged as of the Effective Date of Disenrollment, upto
      the date
      the FHPlus Enrollee is discharged.

    


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

     

    8.6
      Enrollee Initiated Disenrollment

     

    a)
      An
      Enrollee subject to Lock-In as described in Section 7 of this Agreement may
      initiate Disenrollment from the Contractor's MMC or FHPlus product for Good
      Cause as defined in Appendix H of this Agreement at any time during the Lock-In
      period by filing an oral or written request with the LDSS.

    


    b)
      Once
      the Lock-In Period has expired, the Enrollee may disenroll from the Contractor's
      MMC or FHPlus product at any time, for any reason.

     

    8.7
      Contractor Initiated Disenrollment

    


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

     

    b)
      Consistent with 42 CFR § 438.56 (b), the Contractor may not request
      Disenrollment because of an adverse change in the Enrollee's health status,
      or
      because of the Enrollee's utilization of medical services, diminished mental
      capacity, or uncooperative or disruptive behavior resulting from the Enrollee's
      special needs (except where continued Enrollment in the Contractor's
      MMC

     

     

    SECTION 
      8

    (DISENROLLMENT)

    October
      1,2005 

    8-3

    



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

     

    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, he/she will not
      be
      re-enrolled with the Contractor's MMC or FHPlus product unless the Contractor
      first agrees to such re-enrollment.

     

    8.8
      LDSS
      Initiated Disenrollment

     

    a)
      The
      LDSS is responsible for promptly initiating Disenrollment when:

     

    i)
      an
      Enrollee is no longer eligible for MMC or FHPlus; or

    


    ii)
      the
      Guaranteed Eligibility period ends and an Enrollee is no longer eligible for
      MMC
      or FHPlus benefits; or

     

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

    


    iv)
      an
      Enrollee becomes ineligible for Enrollment pursuant to Section 6.1 of this
      Agreement; or

    


    v)
      an
      Enrollee has moved outside the service area covered by this Agreement, unless
      Contractor can demonstrate that:

    


    A)
      the
      Enrollee has made an informed choice to continue Enrollment -with the Contractor
      and that Enrollee will have sufficient access to the Contractor's provider
      network; and

     

    B)
      fiscal
      responsibility for Medicaid or FHPlus coverage remains in the county of
      origin.

    


    


    SECTION
      8

     (DISENROLLMENT)
      

    October
      1.2005

    8-4

     

    


    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    


    9.
      GUARANTEED ELIGIBILITY 

     

    9.1
      General Requirements ;

    SDOH,
      the
      LDSS and the Contractor will follow the policies in this section subject to
      state and federal law and regulation.

     

    9.2
      Right
      to Guaranteed Eligibility

    


    a)
      New
      Enrollees, other than those identified in Section 9.2(b) below, who would
      otherwise lose Medicaid or FHPlus eligibility during the first six (6) months
      of
      Enrollment will retain the right to remain enrolled in the Contractor's MMC
      or
      FHPlus product, as applicable, under this Agreement for a period of six (6)
      months from their Effective Date of Enrollment.

     

    b)
      Guaranteed Eligibility is not available to the following Enrollees:

    


    i)
      Enrollees who lose eligibility due to death, moving out of State, or
      incarceration;

     

    ii)
      Female MMC Enrollees with a net available income in excess of medically
      necessary income but at or below two hundred percent (200%) of the federal
      poverty level who are only eligible for Medicaid while they are pregnant and
      then through the end of the month in which the sixtieth (60 ) day following
      the
      end of the pregnancy occurs.

    


    c)
      If,
      during the first six (6) months of Enrollment in the Contractor's MMC product,
      an MMC Enrollee becomes eligible for Medicaid only as a spend-down, the MMC
      Enrollee will be eligible to remain enrolled in the Contractor's MMC product
      for
      the remainder of the six (6) month Guaranteed Eligibility period. During the
      six
      (6) month Guaranteed Eligibility period, an MMC Enrollee eligible for spend-down
      and in need of wrap-around services has the option of spending down to gain
      full
      Medicaid eligibility for the wrap-around services. In this situation, the LDSS
      is responsible for monitoring the MMC Enrollee's need for wrap-around services
      and manually setting coverage codes as appropriate.

    


    d)
      FHPlus
      Enrollees who become eligible for Medicaid benefits without an income or
      resource spend-down will not be entitled to a Guaranteed Eligibility
      period.

    


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

     

    


    SECTION
      9


    (GUARANTEED
      ELIGIBILITY)

    October
      1, 2005

    9-1

    



    9.3
      Covered
      Services During Guaranteed Eligibility

     

    The
      services covered during the Guaranteed Eligibility period shall be those
      contained in the Benefit Package, as specified in Appendix K of this Agreement.
      MMC enrollees shall also be eligible to receive Free Access to family planning
      and reproductive health services as set forth in Section 10.10 of this Agreement
      and pharmacy services on a Medicaid fee-for-service basis during the Guaranteed
      Eligibility period.

     

    9.4
      Disenrollment During Guaranteed Eligibility

    


    a)
      An
      Enrollee-initiated Disenrollment from the Contractor's MMC or FHPlus product
      terminates the Guaranteed Eligibility period.

     

    b)
      During
      the Guarantee Eligibility period, an Enrollee may not change MCOs.

     

     

    SECTION
      9


    (GUARANTEED
      ELIGIBILITY)

    October
      1, 2005

    9-2

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    

      10.
        BENEFIT PACKAGE REQUIREMENTS 

       

      10.1
        Contractor Responsibilities 

       

      Contractor
        must provide or arrange for the provision of all services set forth in the
        Benefit Package for MMC Enrollees and FHPlus Enrollees subject to any exclusions
        or limitations imposed by federal or state Law during the period of this
        Agreement. SDOH and LDSS shall assure that Medicaid services covered under
        the
        Medicaid fee-for-service program but not covered in the Benefit Package are
        available to and accessible by MMC Enrollees.

       

      10.2
        Compliance with State Medicaid Plan and Applicable Laws

      


      a)
        All
        services provided under the Benefit Package to MMC Enrollees must comply
        with
        all the standards of the State Medicaid Plan established pursuant to Section
        363-a of the SSL and shall satisfy all other applicable requirements of the
        SSL
        and PHL.

      


      b)
        Benefit Package Services provided by the Contractor through its FHPlus product
        shall comply with all applicable requirements of the PHL and SSL.

       

      10.3
        Definitions

      The
        Contractor agrees to the definitions of "Benefit Package" and "Non-Covered
        Services" contained in Appendix K, which is incorporated by reference
        as if
        set
        forth fully herein.

       

      10.4
        Child Teen Health Program/Adolescent Preventive Services

      


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

      


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

      


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

       

       

      SECTION
        10

      (BENEFIT
        PACKAGE REQUIRJEMENTS) 

      October
        1,2005

      10-1

      



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

      


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

      


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

      


      i)
        Educate Enrollees who are pregnant women or who are parents of Enrollees
        under
        age 21 about the program and its importance to a child's or adolescent's
        health.

       

      ii)
        Educate Participating Providers about the program and their responsibilities
        under it.

      


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

      


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

      


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

      


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

      


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

       

       

      SECTION
        10

      (BENEFIT
        PACKAGE REQUIREMENTS) 

      October
        1.2005

      10-2

      



      10.5
        Foster Care Children - Applies to MMC Program Only

       

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

       

      10.6
        Child Protective Services

      The
        Contractor shall comply with the requirements specified for child protective
        examinations, provision of medical information to the child protective services
        investigation and court ordered services as specified in 18 NYCRR Part 432,
        and
        any subsequent amendments thereto. Medically necessary services must be covered,
        whether provided by the Contractor's Participating Providers or not.
        Non-Participating Providers will be reimbursed at the Medicaid fee schedule
        by
        the Contractor.

       

      10.7
        Welfare Reform - Applies to MMC Program only

      


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

       

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

      


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

       

      SECTION
        10

      (BENEFIT
        PACKAGE REQUIREMENTS)

      October
        1,2005

      10-3

      



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

      


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

      


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

      


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

      


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

      


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

       

      h)
        The
        Contractor is responsible for the provision of services in Sections 10.9,
        10.15
        (a) and 10.23 of this Agreement for MMC Enrollees requiring LDSS mandated
        Chemical Dependence Services.

       

      10.8
        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, including referrals for mental health and/or
        chemical dependency evaluations, and all Court Ordered Services for
        adults

       

       

      SECTION
        10

      (BENEFIT
        PACKAGE REQUIREMENTS)

      October
        1,2005

      10-4

       


      Court-ordered
        services that are included in the Benefit Package must be covered, whether
        provided by the Contractor's Participating Provider or not. Non-Participating
        Providers will be reimbursed at the Medicaid fee schedule by the
        Contractor.

       

      10.9
        Court-Ordered Services

      


      a)
        The
        Contractor shall provide any Benefit Package services to Enrollees as ordered
        by
        a court of competent jurisdiction, regardless of whether the court order
        requires such services to be 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
        covered by the Benefit Package and reimbursable by Medicaid or Family Health
        Plus, as applicable.

      


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

       

      10.10
        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.

      


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

      


      ii)
        FHPlus Enrollees may receive such services from any Participating Provider
        if
        the Contractor includes Family Planning and Reproductive Health services
        in its
        Benefit Package, or directly from a provider affiliated with the Designated
        Third Party Contractor if such services are not included in the Contractor's
        Benefit Package, as specified in Appendix M of this Agreement, without referral
        from the FHP Enrollee's PCP and without approval from the
        Contractor.

       

       

      SECTION
        10

      (BENEFIT
        PACKAGE REQUIREMENTS) 

      October
        1.2005

      10-5

       

      b)
        The
        Contractor shall permit Enrollees to exercise their right to obtain Family
        Planning and Reproductive Health services.

       

      i)
        If the
        Contractor includes Family Planning and Reproductive Health services in its
        Benefit Package, 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.

       

      ii)
        If
        the Contractor does not include Family Planning and Reproductive Health services
        in its Benefit Package, the Contractor shall comply with the requirements
        of
        Part C.3 of Appendix C of this Agreement, including assuring that Enrollees
        are
        folly informed of their rights.

       

      10.11
        Prenatal Care

      


      The
        Contractor is responsible for arranging for the provision of comprehensive
        Prenatal Care Services to all pregnant Enrollees including all services
        enumerated in Subdivision 1, Section 2522 of the PHL in accordance with 10
        NYCRR
§ 85.40 (Prenatal Care Assistance Program).

       

      10.12
        Direct Access

      


      The
        Contractor shall offer female Enrollees direct access to primary and preventive
        obstetrics and gynecology services, follow-up care as a result of a primary
        and
        preventive visit, and any care related to pregnancy from Participating Providers
        of her choice, without referral from the PCP as set forth in PHL
§4406-b(l).

       

      10.13
        Emergency Services

       

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

      


      b)
        The
        Contractor agrees that it will not require prior authorization for services
        in a
        medical or behavioral health emergency. The Contractor agrees to inform its
        Enrollees that access to
        Emergency Services is not restricted and 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 

       

       

      SECTION 10

      (BENEFIT
        PACKAGE REQUIREMENTS)

      October
        1,2005

      10-6

      



      Participating
        Provider or
        a
        Non-Participating Provider, and may not deny payments for failure of the
        Emergency Services provider or Enrollee to give notice.

      


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

      


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

       

      10.14
        Medicaid Utilization Thresholds (MUTS)

      


      MMC
        Enrollees may be subject to MUTS for outpatient pharmacy services which are
        billed to Medicaid fee-for-service and for dental services provided without
        referral at Article 28'clinics operated by academic dental centers as described
        in Section 10.27 of this Agreement. MMC Enrollees are not otherwise subject
        to
        MUTS for services included in the Benefit Package.

       

      10.15
        Services for Which Enrollees Can Self-Refer

       

      a)
        Mental
        Health and Chemical Dependence Services

      


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

      


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

       

       

      SECTION
        10

      (BENEFIT
        PACKAGE REQUIREMENTS)

      October
        1, 2005

      10-7

      



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

       

      iv)
        The
        Contractor will implement policies and procedures to ensure that Enrollees
        receive follow-up Benefit Package services from appropriate providers based
        on
        the findings of their mental health and/or Chemical Dependence assessment(s),
        consistent with Section 15.2(a)(x) and (xi) of this Agreement.

      


      v)
        The
        Contractor will implement policies and procedures to ensure that Enrollees
        are
        referred to appropriate Chemical Dependence providers based on the findings
        of
        the Chemical Dependence assessment by the Contractor's Participating Provider,
        consistent with Section 15.2(a)(x) and (xi) of this Agreement.

       

      b)
        Vision
        Services

      The
        Contractor will allow its Enrollees to self-refer to any Participating Provider
        of vision services (optometrist or ophthalmologist) for refractive vision
        services as described in Appendix K of this Agreement.

       

      c)
        Diagnosis and Treatment of Tuberculosis

      Enrollees
        may self-refer to public health agency facilities for the diagnosis and/or
        treatment of TB as described in Section 10.18(a) of this Agreement.

       

      d)
        Family
        Planning and Reproductive Health Services

       

      Enrollees
        may self-refer to family planning and reproductive health services as described
        in Section 10.10 and Appendix C of this Agreement.

       

      e)
        Article 28 Clinics Operated by Academic Dental Centers

      MMC
        Enrollees may self-refer to Article 28 clinics operated by academic dental
        centers to obtain covered dental services as described in Section 10.27 of
        this
        Agreement.

       

       

      SECTION
        10

      (BENEFIT
        PACKAGE REQUIREMENTS)

      October
        1, 2005 

      10-8

      



      10.16
        Second Opinions for Medical or Surgical Care:

      The
        Contractor will allow Enrollees to obtain second opinions for diagnosis of
        a
        condition, treatment or surgical procedure by a qualified physician or
        appropriate specialist, including one affiliated with a specialty care center.
        In the event that the Contractor determines that it does not have a
        Participating Provider in its network with appropriate training and experience
        qualifying the Participating Provider to provide a second opinion, the
        Contractor shall make a referral to an appropriate Non-Participating Provider.
        The Contractor shall pay for the cost of the services associated with obtaining
        a second opinion regarding medical or surgical care, including diagnostic
        and
        evaluation services, provided by the Non-Participating Provider.

       

      10.17
        Coordination with Local Public Health Agencies:

      The
        Contractor will coordinate its public health-related activities with the
        Local
        Public Health Agency (LPHA) consistent with the SDOH MCO and Public Health
        Guidelines. Coordination mechanisms and operational protocols for addressing
        public health issues will be negotiated with the LPHA and be customized to
        reflect local public health priorities. Negotiations must result in agreements
        regarding required Contractor activities related to public health as set
        forth
        in Appendix N of this Agreement as if set forth fully herein.

       

      10.18
        Public Health Services

      


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

      


      i)
        Tuberculosis Screening, Diagnosis and Treatment services are included in
        the
        Benefit Package as set forth in Appendix K.3 (3) (e) of this
        Agreement.

      


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

      


      B)
        The
        SDOH will coordinate with the 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. State and local departments of health will also
        be
        available to offer technical assistance to the Contractor in establishing
        TB
        policies and procedures.

      


      C)
        The
        Contractor is responsible for screening, diagnosis and treatment of TB, except
        for TB/DOT services.

       

       

      SECTION
        10

      (BENEFIT
        PACKAGE REQUIREMENTS) 

      October,
        2005

      10-9

      



      D)
        The
        Contractor shall inform all Participating Providers of their responsibility
        to
        report TB cases to the LPHA.

      


      ii)
        Enrollees may self-refer to Local Public Health Agency facilities for the
        diagnosis and/or treatment of TB.

      


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

       

      B)
        The
        Contractor will make best effort 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.

      


      C)
        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 Section 10.17 of this Agreement, unless these services
        are ordered by a court of competent jurisdiction; 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.

       

      D)
        Prior
        authorization for hospital admission 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;

      


      E)
        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.

       

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

      


      iii)
        Directly Observed Therapy (TB/DOT) is not included in the Benefit Package
        as set
        forth in Appendix K.3 (3) (e) and K.4 of this Agreement.

      


      A)
        The
        Contractor will not be capitated or financially liable for these
        costs.

      


      B)
        The
        Contractor agrees to make all reasonable efforts to ensure communication,
        cooperation and coordination with TB/DOT providers regarding clinical care
        and
        services.

       

       

      SECTION
        10

      (BENEFIT
        PACKAGE REQUIREMENTS) 

      October
        1.2005

      10-10

       

      C)
        MMC
        Enrollees may use any Medicaid fee-for-service TB/DOT provider.

      


      iv)
        HIV
        counseling and testing provided to a MMC Enrollee during a TB 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.

       

      b)
        Immunizations

      


      i)
        Immunizations are included in the Benefit Package as provided in Appendix
        K of
        this Agreement.

      


      A)
        The
        Contractor is responsible for all costs associated with vaccine purchase
        and
        administration associated with adult immunizations.

      


      B)
        The
        Contractor is responsible for all costs associated with vaccine administration
        associated with childhood immunizations. The Contractor is not responsible
        for
        vaccine purchase costs associated with childhood immunizations and will inform
        all Participating Providers that the vaccines may be obtained free of charge
        from the Vaccine for Children Program.

       

      ii)
        Enrollees may self refer to the LPHA facilities for their
        immunizations.

      


      A)
        The
        Contractor agrees to reimburse the LPHA when an Enrollee has self referred
        for
        immunizations.

       

      B)
        The
        Contractor will make best effort 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.

       

      C)
        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, 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, the LPHA is responsible for
        delivering the service as appropriate.

       

      c)
        Prevention and Treatment of Sexually Transmitted Diseases

      The
        Contractor will be responsible for ensuring that its Participating Providers
        educate their Enrollees about the risk and prevention of sexually transmitted
        disease (STD). The Contractor also will be responsible for ensuring that
        its

       

       

      SECTION
        10

      (BENEFIT
        PACKAGE REQUIREMENTS)

      October
        1.2005

      10-11

      



      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
        MMC
        Enrollee during an 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.

       

      d)
        Lead
        Poisoning - Applies to MMC Program Only

      


      The
        Contractor will be responsible for carrying out and ensuring that its
        Participating Providers comply with lead poisoning screening and follow-up
        as
        specified in 10 NYCRR Sub-part 67-1. The Contractor shall require its
        Participating Providers to coordinate with the LPHA to assure appropriate
        follow-up in terms of environmental investigation, risk management and reporting
        requirements.

       

      10.19
        Adults with Chronic Illnesses and Physical or Developmental
        Disabilities

      


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

       

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

      


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

      


      A)
        develop protocols describing the Contractor's case management services and
        minimum qualification requirements for case management staff;

      B)
        develop and implement protocols for monitoring effectiveness of case management
        based on patient outcomes;

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

      D)
        provide regular information to Participating Providers on the case management
        services available to Enrollees and the criteria for referring Enrollees
        for
        case management services.

       

       

      SECTION
        10

      (BENEFIT
        PACKAGE REQUIREMENTS)

      October
        1,2005

      10-12

      



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

       

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

      


      v)
        Satisfactory systems for coordinating service delivery with Non-Participating
        Providers, including behavioral health providers for all Enrollees.

       

      vi)
        Policies: and procedures to allow for the continuation of existing relationships
        with Non-Participating Providers, consistent with PHL § 4403(6)(e) and Section
        15.6 of this Agreement.

       

      10.20
        Children with Special Health Care Needs

      


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

      


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

      


      ii)
        An
        adequate network of pediatric providers and sub-specialists, and contractual
        relationships with tertiary institutions, to meet such children's medical
        needs.

      


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

      


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

      


      


      SECTION
        10

      (BENEFIT
        PACKAGE REQUIREMENTS)

      October
        1.2005

      10-13

      



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

       

      10.21
        Persons Requiring Ongoing Mental Health Services

      


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

      


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

       

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

       

      iii)
        Satisfactory case management systems or satisfactory case
        management.

      


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

       

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

       

      10.22
        Member Needs Relating to HIV

       

      a)
        The
        Contractor must inform MMC Enrollees newly diagnosed with HIV. infection
        or
        AIDS, who are known to the Contractor, of their enrollment options including
        the
        ability to return to the Medicaid fee-for-service program or to disenroll
        from
        the Contractor's MMC product and to enroll into HIV SNPs, if such plan is
        available.

       

      b)
        The
        Contractor will inform Enrollees about HIV counseling and testing

      services
        available through the Contractor's Participating Provider network; HIV
        counseling and testing services available when performed as part of a Family
        Planning and Reproductive Health encounter; and anonymous counseling and
        testing
        services available from SDOH, LPHA clinics and other New York City programs.
        Counseling and testing rendered outside of a Family Planning and Reproductive
        Health encounter, as well as services provided as the
        result of an HIV+ diagnosis, will be furnished by the Contractor in accordance
        with standards of care.

       

       

      SECTION
        10

      (BENEFIT
        PACKAGE REQUIREMENTS)

      October
        1,2005

      10-14

      



      c)
        The
        Contractor agrees that anonymous testing may toe furnished to the Enrollee
        without prior approval by the Contractor and may be conducted at anonymous
        testing sites. Services provided for HIV treatment may only be obtained from
        the
        Contractor during the period the Enrollee is enrolled in the Contractor's
        MMC or
        FHPlus product.

      


      d)
        To
        adequately address the HIV prevention needs of uninfected Enrollees, as well
        as
        the special needs of Enrollees with HIV infection, the Contractor shall have
        in
        place all of the following:

      


      


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

              


      

      


      ii)
        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, New York City and the LPHA.

      


       

      SECTION
        10

      (BENEFIT
        PACKAGE REQUIREMENTS)

      October
        1,2005

      10-15

      


      



      iii)
        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 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.

       

      iv)
        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 Participating
        Providers about how to obtain information about the availability of Experienced
        HIV Providers and HIV Specialist PCPs.

       

      v)
        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 Contractor provided case management,
        and/or, with appropriate consent of the Enrollee, HIV community-based
        psychosocial case management services and/or COBRA Comprehensive Medicaid
        Case
        Management (CMCM) services for MMC Enrollees.

       

      vi)
        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. In New York City, these shall be reported to the
        New
        York City Commissioner of Health. Access to partner notification services
        must
        be consistent with 10 NYCRR Part 63.

       

      


      vii)
        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.

      


      


      SECTION
        10

      (BENEFIT
        PACKAGE REQUIREMENTS)

      October
        1.2005

      10-16

      



      10.23
        Persons Requiring Chemical Dependence Services

      


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

      


      
        	i)  	
                A
                  Participating Provider network which includes of all the required
                  provider
                  types listed in Section 21 of this
                  Agreement.

              


      

      


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

      


      iii)
        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.

       

      iv)
        Satisfactory case management systems.

       

      v)
        Satisfactory systems for coordinating service delivery between physical health,
        chemical dependence, and mental health providers, and coordinating services
        received from Participating Providers with other services, including Social
        Services.

      


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

       

      10.24
        Native Americans

       

      If
        an
        Enrollee is a Native American and the Enrollee chooses to access primary
        care
        services through his/her tribal health center, the PCP authorized by the
        Contractor to refer the Enrollee for services included in the Benefit Package
        must develop a relationship with the Enrollee's PCP at the tribal health
        center
        to coordinate services for said Native American Enrollee.

       

      10.25
        Women, Infants, and Children (W1C)

      The
        Contractor shall develop linkage agreements or other mechanisms to refer
        Enrollees who are pregnant and Enrollees with children younger than five
        (5)
        years of age to WIC local agencies for nutritional assessments and
        supplements.

       

       

      SECTION
        10 

      (BENEFIT
        PACKAGE REQUIREMENTS)

      October
        1.2005

      10-17

      



      10.26
        Urgently Needed Services 

      


      The
        Contractor is financially responsible for Urgently Needed Services. Urgently
        Needed Services are covered only in the United States, the Commonwealth of
        Puerto Rico, the U.S. Virgin Islands, Guam, American Samoa, the Northern
        Mariana
        Islands and Canada. The Contractor may require the Enrollee or the Enrollee's
        designee to coordinate with the Contractor or the Enrollee's PCP prior to
        receiving care.

      


      10.27
        Dental Services Provided by Article 28 Clinics Operated by Academic Dental
        Centers Not Participating in Contractor's Network - Applies to MMC Program
        Only

       

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

      


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

       

      10.28
        Hospice Services

       

      a)
        For
        FHPlus only: the Contractor shall provide a coordinated hospice program of
        home
        and inpatient services which provides non-curative medical and support services
        for FHPlus Enrollees certified by a physician to be terminally ill with a
        life
        expectancy of six months or less. Hospices must be certified under Article
        40 of
        the New York State Public Health Law.

      


      b)
        MMC
        Enrollees receive coverage for hospice services through the Medicaid
        fee-for-service program.

       

      10.29
        Prospective Benefit Package Change for Retroactive SSI Determinations -Applies
        to MMC Program Only

      


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

       

      SECTION 10

      (BENEFIT
        PACKAGE REQUIREMENTS)

      October
        1,2005

      10-18

      



      10.30
        Coordination of Services

       

      a)
        The
        Contractor shall coordinate care for Enrollees, as applicable,
        with:

       

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

      


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

      


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

       

      iv)
        WIC,
        Head Start, Early Intervention;

       

      v)
        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;

      


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

       

      x)
        School-based health centers.

      


      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
        MCO
        Enrollees.

      


      


      SECTION
        10 

      (BENEFIT
        PACKAGE REQUIREMENTS)

      October
        1,2005 

      10-19

       

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

         

      

    

    11.
      MARKETING

     

    11.1
      Information Requirements

    


    a)
      The
      Contractor shall provide Prospective Enrollees, upon request, with
      pre-enrollment and post-enrollment information pursuant to PHL § 4408 and SSL §
364-j.

     

    b)
      The
      Contractor shall provide Prospective Enrollees, upon request, with the most
      current and complete listing of Participating Providers, as described in Section
      13.2(a) of this Agreement, in hardcopy, along with any updates to that
      listing.

     

    c)
      The
      Contractor shall provide Potential Enrollees with pre-enrollment and
      post-enrollment information pursuant to 42 CFR § 438.10(e).

    


    d)
      The
      Contractor must inform Potential Enrollees that oral interpretation service
      is
      available for any language and that information is available in alternate
      formats and how to access these formats.

     

    11.2
      Marketing Plan

     

    a)
      The
      Contractor shall have a Marketing plan that has been prior-approved by the
      SDOH
      and the DOHMH that describes the Marketing activities the Contractor will
      undertake within the service area, as specified in Appendix M of this Agreement,
      during the term of this Agreement.

    


    b)
      The
      Marketing plan and all Marketing activities must comply with the Marketing
      Guidelines which are set forth in Appendix D and any New York City Specific
      marketing requirements as set forth in Appendix N, which are hereby made a
      part
      of this Agreement as if set forth fully herein.

    


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

     

    11.3
      Marketing Activities

    


    Marketing
      activities by the Contractor shall conform to the approved Marketing
      Plan.

     

    SECTION
      11 

    (MARKETING)
      

    October
      1, 2005

    11-1


    11.4
      Prior Approval of Marketing Materials and Procedures

     

    The
      Contractor shall submit all procedures and materials related to Marketing to
      Prospective Enrollees to the SDOH for prior written approval, as described
      in
      Appendix D of this Agreement. The Contractor shall not use any procedures or
      materials that the SDOH has not approved. Marketing materials shall be made
      available by the Contractor throughout its entire service area. Marketing
      materials may be customized for specific counties and populations within the
      Contractor's service area. All Marketing activities should provide for equitable
      distribution of materials without bias toward or against any group.

     

    11.5
      Corrective and Remedial Actions

    


    a)
      If the
      Contractor's Marketing activities do not comply with the Marketing Guidelines
      set forth in Appendix D of this Agreement or the Contractor's approved Marketing
      plan, the SDOH and/or the DOHMH, may take the actions described in (i), (ii)
      and
      (iii) below to protect the interests of Enrollees and the integrity of the
      MMC
      and FHPlus Programs. The Contractor shall take the corrective and remedial
      actions directed by the SDOH and/or DOHMH within the specified
      timeframes.

    


    i)
      If the
      Contractor or its representative commits a first time infraction of the
      Marketing Guidelines and/or the Contractor's approved Marketing plan, and the
      SDOH and/or the DOHMH deem the infraction to be minor or unintentional in
      nature, the SDOH and/or the DOHMH may issue a warning letter to the
      Contractor.

    


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

    


    iii)
      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, or DOHMH,
      in consultation with the SDOH, may in addition to any other legal remedy
      available to SDOH and/or DOHMH in law or equity:

     

     

    SECTION
      11 

    (MARKETING)
      

    October
      1, 2005

    11-2

     

    



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

     

    B)
      suspend new Enrollments, other than newborns, for a period upto
      the
      remainder of the Agreement period;or

    


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

     

    SECTION
      11

    (MARKETING)

    October
      1, 2005

    11-3

    


    
      
         

      

      
         

        
          

        

      

      
         

      

    


    12.
      MEMBER SERVICES

     

    12.1
      General
      Functions

    


    a)
      The
      Contractor shall operate a Member Services Department 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)
      At a
      minimum, the Member Services Department must be staffed at a ratio of at least
      one (1) full time equivalent Member Service Representative for every four
      thousand (4,000) or fewer Enrollees.

     

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

    


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

     

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

    


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

     

    iv)
      Clarifying information in the member handbook for Enrollees.

     

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

    


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

     

    12.2
      Translation and Oral Interpretation

    


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

            


    

    


     

    SECTION
      12

    (MEMBER
      SERVICES)

    October
      1,2005

    12-1

     

     

     

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

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

     

    12.3
      Communicating with the Visually, Hearing and Cognitively Impaired

    


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

    


    


    


    SECTION
      12 

    (MEMBER
      SERVICES) 

    October
      1, 2005

    12-2

     

    


    
      
         

      

      
         

        
          

        

      

      
         

      

    


    13.
      ENROLLEE RIGHTS AND NOTIFICATION

     

    13.1
      Information Requirements

    


    a)
      The
      Contractor shall provide new Enrollees with the information identified in PHL
§
4408, SSL § 364-j, SSL § 369-ee and 42 CFR § 438.10 (f) and (g).

    


    b)
      The
      Contractor shall provide such information to the Enrollee within fourteen (14)
      days of the Effective Date of Enrollment. The Contractor may provide such
      information to the Enrollee through the Member Handbook referenced in Section
      13.4 of this Agreement.

    


    c)
      The
      Contractor must provide Enrollees with an annual notice that this information
      is
      available to them upon request.

    


    d)
      The
      Contractor must inform Enrollees that oral interpretation service is available
      for any language and that information is available in alternative formats and
      how to access these formats.

     

    13.2
      Provider Directories/Office Hours for Participating Providers

     

    a)
      The
      Contractor shall maintain and update, on a quarterly basis, a listing by
      specialty of the names, addresses and telephone numbers of all Participating
      Providers, including facilities. Such a list/directory shall include names,
      office addresses, telephone numbers, board certification for physicians,
      information on language capabilities and wheelchair accessibility of
      Participating Providers. The list should also identify providers that are not
      accepting new patients.

    


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

    


    c)
      Enrollees must be notified of updates in writing at least annually in one of
      the
      following methods: (1) provide updates in hardcopy; (2) provide a new complete
      listing/directory in hardcopy; or (3) provide written notification that a new
      complete listing/directory is available and will be provided upon request either
      in hardcopy, or electronically if the Contractor has the capability of providing
      such data in an electronic format and the data is requested in that format
      by an
      Enrollee.

    


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

     

     

    SECTION
      13

    (ENROLLEE
      RIGHTS AND NOTIFICATION) 

    October
      1,2005 

    13-1

    



    13.3
      Member ID Cards

    


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

    


    i)
      the
      name of the Enrollee's clinic (if applicable);

    


    ii)
      the
      name of the Enrollee's PCP and the PCP's telephone number (if an Enrollee is
      being served by a PCP team, the name of the individual shown on the card should
      be the lead provider);

    


    iii)
      the
      member services toll free telephone number;

    


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


    


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

    


    b)
      PCP
      information may be embossed on the card or affixed to the card by. a
      sticker.

    


    c)
      The
      Contractor shall issue an identification card within fourteen (14) days of
      an
      Enrollee's Effective Date of Enrollment. If unforeseen circumstances, such
      as
      the lack of identification of a PCP, prevent the Contractor from forwarding
      the
      official identification card to new Enrollees within the fourteen (14) day
      period, alternative measures by which Enrollees may identify themselves such
      as
      use of a Welcome Letter or a temporary identification card shall be deemed
      acceptable until such time as a PCP is either chosen by the Enrollee or auto
      assigned by the Contractor. The Contractor agrees to implement an alternative
      method by which individuals may identify himself/herself as Enrollees prior
      to
      receiving the card (e.g., using a "welcome letter" from the Contractor) and
      to
      update PCP information on the identification card. Newborns of Enrollees need
      not present ID cards in order to receive Benefit Package services from the
      Contractor and its Participating Providers. The Contractor is not responsible
      for providing Benefit Package services to newborns Excluded from the MMC Program
      pursuant to Appendix H of this Agreement, or when the Contractor does not offer
      an MMC product in the mother's county of fiscal responsibility.

     

    13.4
      Member Handbooks

    


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

     

     

    SECTION
      13

    (ENROLLEE
      RIGHTS AND NOTIFICATION) 

    October
      1, 2005

    13-2

    



    13.5
      Notification of Effective Date of Enrollment

     

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

     

    13.6
      Notification of Enrollee Rights

    


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

    


    i)
      Inform
      the Enrollee about the Contractor's policies with respect to obtaining medical
      services, including services for which the Enrollee may self-refer pursuant
      to
      Section 10.15 of this Agreement, and what to do in an emergency.

    


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

    


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

    


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

     

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

     

     

    SECTION
      13

    (ENROLLEE
      RIGHTS AND NOTIFICATION) 

    October
      1.2005

    13-3

    



    vi)
      Advise Enrollee about opportunities available to learn about the Contractor's
      policies and benefits in greater detail (e.g., welcome meeting, Enrollee
      orientation and education sessions).

    


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

     

    13.7
      Enrollee's Rights

     

    a)
      The
      Contractor shall, in compliance with the requirements of 42 CFR § 438.6(i)(l)
      and 42 CFR Part 489 Subpart I, 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 § 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 have policies and procedures that protect the Enrollee's right
      to:

     

    i)
      receive information about the Contractor and managed care;

    


    ii)
      be
      treated with respect and due consideration for his or her dignity and
      privacy;

     

    iii)
      receive information on available treatment options and alternatives, presented
      in a manner appropriate to the Enrollee's condition and ability to
      understand;

     

    iv)
      participate in decisions regarding his or her health care, including the right
      to refuse treatment;

     

    v)
      be
      free from any form of restraint or seclusion used as a means of coercion,
      discipline, convenience or retaliation, as specified in Federal regulations
      on
      the use of restraints and seclusion; and

    


    vi)
      If
      the privacy rule, as set forth in 45 CFR Parts 160 and 164 Subparts A and E,
      applies, 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
      l64.526.

     

     

    SECTION
      13

    (ENROLLEE
      RIGHTS AND NOTIFICATION) 

    October
      1,2005 

    13-4

    



    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 13.7(0) above. 

     

    13.8
      Approval of Written Notices

    


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

     

    13.9
      Contractor's Duty to Report Lack of Contact

    


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

     

    13.10
      LDSS Notification of Enrollee's Change in Address

    


    The
      LDSS
      is responsible for notifying the Contractor of any known change in address
      of
      Enrollees.

    


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

     

    The
      Contractor must provide written notification of the effective date of any
      Contractor-initiated, SDOH and DOHMH approved Benefit Package change to
      Enrollees. Notification to Enrollees must be provided at least thirty (30)
      days
      in advance of the effective date of such change.

     

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

    


    a)
      With
      prior notice to and approval of the SDOH and DOHMH, the Contractor shall inform
      each Enrollee in writing of any withdrawal by the Contractor from the MMC or
      FHPlus Program pursuant to Section 2.7 of this Agreement, withdrawal from the
      service area encompassing the Enrollee's zip code, and/or significant changes
      to
      the Contractor's Participating Provider network pursuant to Section 21.1(d)
      of
      this Agreement, except that the Contractor need not notify Enrollees who will
      not be affected by such changes.

     

    b)
      The
      Contractor shall provide the notifications within the timeframes specified
      by
      SDOH, and shall obtain the prior approval of the notification from SDOH in
      consultation with DOHMH.

     

     

    SECTION
      13

    (ENROLLEE
      RIGHTS AND NOTIFICATION) 

    October
      1,2005 

    13-5

    


    
      
         

      

      
         

        
          

        

      

      
         

      

    


    14.
      ACTION AND GRIEVANCE SYSTEM

     

     

    14.1
      General Requirements

     

    a)
      The
      Contractor shall establish and maintain written Action procedures and a
      comprehensive Grievance System that complies with the Managed Care Action and
      Grievance System Requirements for MMC and FHPlus Programs described in Appendix
      F, which is hereby made a part of this Agreement as if set forth fully herein.
      Nothing herein shall release the Contractor from its responsibilities under
      PHL
§ 440 8-a or PHL Article 49 and 10 NYCRR Part 98 that is not otherwise expressly
      established in Appendix F.

    


    b)
      The
      Contractor's Action procedure and Grievance System shall be approved by the
      SDOH
      and kept on file with the Contractor and SDOH.

    


    c)
      The
      Contractor shall not modify its Action procedure or Grievance System without
      the
      prior written approval of SDOH, and shall provide SDOH with a copy of the
      approved modification within fifteen (15) days of its approval.

     

    14.2
      Actions

    


    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 Determination 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, or Enrollee's condition. 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.

     

     

    SECTION
      14

    (ACTION
      AND GRIEVANCE SYSTEM) 

    October
      1, 2005

    14-1

    



    14.3
      Grievance System

     

    a)
      The
      Contractor shall ensure that its 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.

    


    b)
      The
      Contractor shall ensure that persons with authority to require corrective action
      participate in the Grievance System.

     

    14.4
      Notification of Action and Grievance System Procedures

    


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

     

    b)
      The
      Contractor will provide written notice of the following Complaint, Complaint
      Appeal, Action Appeal and fair hearing procedures 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:

     

    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 file Complaints, Complaint Appeals and Action Appeals and
      the process and timeframes for filing;

     

    iii)
      the
      Enrollee's right to designate a representative to file Complaints,

    Complaint
      Appeals and Action Appeals on his/her behalf;

    


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

    


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

    


    vi)
      the
      Enrollee's right to request continuation of benefits while an Action Appeal
      or
      state fair hearing 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;

     

     

    SECTION
      14

    (ACTION
      AND GRIEVANCE SYSTEM)

    October
      1,2005

    14-2

    



    vii)
      the
      right of the provider to reconsideration of an Adverse Determination pursuant
      to
      Section 4903(6) of the PHL; and |

     

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

     

    14.5
      Complaint, Complaint Appeal and Action Appeal Investigation
      Determinations

    The
      Contractor must adhere to determinations resulting from Complaint, Complaint
      Appeal and Action Appeal investigations conducted by SDOH.

     

     

    SECTION
      14

    (ACTION
      AND GRIEVANCE SYSTEM) 

    October
      1,2005 

    14-3

     

    
      
         

      

      
         

        
          

        

      

      
         

      

    


    15.
      ACCESS REQUIREMENTS

     

    
       

      15.1
        General Requirement

       

      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.

       

      15.2
        Appointment Availability Standards

      


      a)
        The
        Contractor shall comply with the following minimum appointment availability
        standards, as applicable. 1

       

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

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

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

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

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

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

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

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

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

      x)
        Pursuant to an emergency or hospital discharge, mental health or chemical
        dependence follow-up visits with a Participating Provider (as included in
        the
        Benefit Package): within five (5) days of request, or
        as
        clinically indicated. 

      xi)
        Non-urgent mental health or chemical dependence visits with a Participating
        Provider (as included in the Benefit Package): within two (2) weeks of
        request.

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

       

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

    

     

     

    SECTION
      15 

    (ACCESS
      REQUIREMENTS) 

    October
      1,2005

    15-1

     

    



    xiii)
      Provider visits to make health, mental health and chemical dependence
      assessments for the purpose of making recommendations regarding a recipient's
      ability to perform work when requested by a LDSS; within ten (10) days of
      request by an MMC Enrollee, in accordance with Section 10.7 of this
      Agreement.

     

    15.3
      Twenty-Four (24) Hour Access

     

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

     

    b)
      The
      Contractor may satisfy the requirement in Section 15.3(a) by requiring their
      PCPs and OB/GYNs to have primary responsibility for serving as an after hours
      "on-call" telephone resource to members with medical problems. Under no
      circumstances may the Contractor routinely refer calls to an emergency
      room.

     

    15.4
      Appointment Waiting Times

    


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

     

    15.5
      Travel Time Standards

     

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

     

    b)
      Primary Care

    


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

    


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

     

    


    SECTION
      15

    (ACCESS
      REQUIREMENTS)

    October
      1,2005

    15-2

    c)
      Other
      Providers

     

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

     

    15.6
      Service Continuation 

     

    a)
      New
      Enrollees

     

    i)
      If a
      new Enrollee has an existing relationship with a health care provider who is
      not
      a member of the Contractor's provider network, the Contractor shall permit
      the
      Enrollee to continue an ongoing course of treatment by the Non-Participating
      Provider during a transitional period of up to sixty (60) days from the
      Effective Date of Enrollment, if, (1) the Enrollee has a life-threatening
      disease or condition or a degenerative and disabling disease or condition,
      or
      (2) the -Enrollee has entered the second trimester of pregnancy at the Effective
      Date of Enrollment, in which case the transitional period shall include the
      provision of post-partum care directly related to the delivery up until sixty
      (60) days post partum. If the new Enrollee elects to continue to receive care
      from such Non-Participating Provider, such care shall be authorized by the
      Contractor for the transitional period only if the Non-Participating Provider
      agrees to:

    


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

    


    B)
      adhere
      to the Contractor's quality assurance requirements and agrees to provide to
      the
      Contractor necessary medical information related to such care; and

    


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

    


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

     

    


    SECTION
      15

    (ACCESS
      REQUIREMENTS) 

    October
      1,2005

    15-3

     

    



    b)
      Enrollees Whose Health Care Provider Leaves Network

     

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

    


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

    


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

    


    B)
      adhere
      to the Contractor's quality assurance requirements and agrees to provide to
      the
      Contractor necessary medical information related to such care; and

     

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

    


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

     

    15.7
      Standing Referrals

     

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

     

     

    SECTION
      15 

    (ACCESS
      REQUIREMENTS) 

    October
      1,2005

    15-4

    



    15.8
      Specialist as a Coordinator of Primary Care

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

     

    15.9
      Specialty Care Centers

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

     

    15.10
      Cultural Competence

    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.

     

    SECTION
      15

    (ACCESS
      REQUIREMENTS)

    October
      1,2005

    15-5

    


    
      
         

      

      
         

        
          

        

      

      
         

      

    

    16.
      QUALITY
      MANAGEMENT

     

    16.1
      Internal Quality Management Program

     

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

    


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

     

    16.2
      Standards of Care

     

    a)
      The
      Contractor must adopt practice guidelines consistent with current standards
      of
      care, complying with recommendations of professional specialty groups or the
      guidelines of programs such as the American Academy of Pediatrics, the American
      Academy of Family Physicians, the US Task Force on Preventive Care, the New
      York
      State Child/Teen Health Program (C/THP) standards for provision of care to
      individuals under age twenty-one (21), the American Medical Association's
      Guidelines for Adolescent and Preventive Services, the US Department of Health
      and Human Services Center for Substance Abuse Treatment, the American College
      of
      Obstetricians and Gynecologists, the American Diabetes Association, and the
      AIDS
      Institute clinical standards for adult, adolescent, and pediatric
      care.

     

    b)
      The
      Contractor must ensure that its decisions for utilization management, enrollee
      education, coverage of services, and other areas to which the practice
      guidelines apply are consistent with the guidelines.

    


     

    SECTION
      16

    (QUALITY
      ASSURANCE) 

    October
      1, 2005

    16-1

     

    



    c)
      The
      Contractor must have mechanisms in place to disseminate any changes in practice
      guidelines to its Participating Providers at least annually, or more frequently,
      as appropriate.

    


    d)
      The
      Contractor shall develop and implement protocols for identifying Participating
      Providers who do not adhere to practice guidelines and for making reasonable
      efforts to improve the performance of these providers.

     

    e)
      Annually, the Contractor shall select a minimum of two practice guidelines
      and
      monitor the performance of appropriate Participating Providers (or a sample
      of
      providers) against such guidelines.

     

    


     

    SECTION
      16

    (QUALITY
      ASSURANCE)

    October
      1,2005

    16-2

     

    


    
      
         

      

      
         

        
          

        

      

      
         

      

    


    17.
      MONITORING AND EVALUATION

     

    17.1
      Right to Monitor Contractor Performance

     

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

     

    17.4
      Cooperation During Review of Services by External Review Agency

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

     

     

    SECTION
      17

    (MONITORING
      AND EVALUATION) 

    October
      1,2005 

    17-1

     

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    



    18.
      CONTRACTOR REPORTING REQUIREMENTS 

     

    18.1
      General Requirements 

     

    a)
      The
      Contractor must maintain a health information system that collects, analyzes,
      integrates, and reports data. The system must provide information on areas,
      including but not limited to, utilization. Complaints and Appeals, and
      Disenrollments for other than loss of Medicaid or FHPlus eligibility. The system
      must be sufficient to provide the data necessary to comply with the requirements
      of this Agreement.

    


    b)
      The
      Contractor must take the following steps to ensure that data received from
      Participating Providers is accurate and complete: verify the accuracy and
      timeliness of reported data; screen the data for completeness, logic and
      consistency; and collect utilization data in standardized formats as requested
      by SDOH.

     

    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 Agreement in an agreed media format within sixty
      (60) days of the close of the applicable semi-annual or annual reporting period,
      and within fifteen (15) business days of the close of the applicable quarterly
      reporting period.

     

    18.3
      SDOH
      Instructions for Report Submissions

     

    SDOH,
      with notice to the DOHMH, will provide Contractor with instructions for
submitting
      the reports required by SDOH in Section 18-6 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
      Liquidated Damages

    


    The
      Contractor shall pay liquidated damages of $2,500 to SDOH if any report required
      pursuant to this Section is materially incomplete, contains material
      misstatements or inaccurate information, or is not submitted in the requested
      format. The Contractor shall pay liquidated damages of $2,500 to the SDOH if
      its
      monthly encounter data submission is not received by the Fiscal Agent by the
      due
      date specified in Section 18.6 (a) (iv) of this Agreement. The Contractor shall
      pay liquidated damages of $500 to SDOH for each day other reports required
      by
      this Section are late. The SDOH shall not impose liquidated damages for a first
      time infraction by the Contractor unless the SDOH deems the infraction to be
      a
      material misrepresentation of fact or the Contractor fails to cure the first
      infraction within a reasonable period of time upon notice from the SDOH.
      Liquidated

     

    SECTION
      18

    (CONTRACTOR
      REPORTING REQUIREMENTS)

     October
      1, 2005

    18-1

    



    damages
      may be waived at the sole discretion of SDOH. Nothing in this Section shall
      limit other remedies or rights available to SDOH and DOHMH relating to
the
      timeliness, completeness and/or accuracy of Contractor's reporting
      submission.

     

    18.5
      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 SDOH.
      .

     

    18.6
      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.

     

    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 applicable SIL §§ 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 DOHMH.

    
 

    SECTION
      18

    (CONTRACTOR
      REPORTING REQUIREMENTS) 

    October
      1, 2005

    18-2

    



    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 all contracted
      services rendered to the Enrollee in the current or any preceding months.
      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 in the Quality
      Assurance Reporting Requirements (QARR). The Contractor must arrange for an
      NCQA-certified entity to audit the QARR data prior to its submission to the
      SDOH
      unless this requirement is specifically waived by the SDOH. The SDOH will select
      the measures which will be audited.

     

    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 received during the preceding quarter via
      the Summary Complaint Form on the HPN. The Summary Complaint Form has been
      developed by the SDOH to categorize the type of Complaints and Action Appeals
      subject to PHL § 4408-a received by the Contractor.

    


    B)
      The
      Contractor agrees to provide on a quarterly basis, via Summary Complaint Form
      on
      the HPN, the total number of Complaints and Action Appeals subject to PHL §
4408-a 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. These
      records shall be readily available for review by the SDOH and DOHMH upon
      request.

    


    C)
      Nothing in this Section is intended to limit the right of the DOHMH, 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.

     

     

    SECTION
      18

    (CONTRACTOR
      REPORTING REQUIREMENTS) 

    October
      1, 2005

    18-3

    



    vii)
      Fraud and Abuse Reporting Requirements:

     

    A)
      The
      Contractor must submit quarterly, via the HPN Complaint reporting format, the
      number of Complaints of fraud or abuse made to the Contractor that warrant
      preliminary investigation by the Contractor.

    


    B)
      The
      Contractor also must submit to the SDOH the following information on an ongoing
      basis for each confirmed case of fraud and abuse it identifies through
      Complaints, organizational monitoring, contractors, subcontractors, providers,
      beneficiaries, Enrollees, or any other source:

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

    II)
      The
      source that identified the fraud or abuse;

    III)
      The
      type of provider, entityor
      organization that committed the fraud or abuse;

    IV)
      A
      description of the fraud or abuse;

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

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

    VII)
      Other data/information as prescribed by SDOH.

    


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

     

    viii)
      Participating Provider Network Reports:

    


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

     

     

    SECTION
      18

    (CONTRACTOR
      REPORTING REQUIREMENTS) 

    October
      1,2005

    18-4

    



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

    


    The
      Contractor will conduct a county specific (or service area if appropriate)
      review of appointment availability and twenty-four (24) hour access and
      availability surveys annually. Results of such surveys must be kept on file
      and
      be readily available for review by the SDOH or DOHMH, upon request.

     

    x)
      Clinical
      Studies:

    


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

    


    B)
      The
      Contractor is required to conduct at least one (1) internal performance
      improvement project each year in a priority topic area of its choosing with
      the
      mutual agreement of the SDOH and SDOH's - external quality review organization.
      The Contractor may conduct its performance improvement project in conjunction
      with one or more MCOs. The purpose of these projects will be to promote quality
      improvement within the Contractor's MMC and/or FHPlus product. SDOH will provide
      guidelines which address study structure and reporting format. Written reports
      of these projects will be provided to the SDOH and validated by the external
      quality review organization.

     

    xi)
      Independent Audits:

    


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

     

    xii)
      New
      Enrollee Health Screening Completion Report:

    


    The
      Contractor shall submit a quarterly report within thirty (30) days of the close
      of the quarter showing the percentage of new Enrollees for which the Contractor
      was able to complete a health screening consistent with Section 13.6(a)(ii)
      of
      this Agreement.

     

    xiii)
      Additional Reports:

     

    Upon
      request by the SDOH, or as specified by DOHMH in Appendix N, 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

    


    


    SECTION
      18

    (CONTRACTOR
      REPORTING REQUIREMENTS)

    October
      1.2005

    18-5

     

     

    18.7
      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) (Sections 1124 and 1903(m)(4) of the SSA).

     

    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 Agreement 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 MMC and/or
      FHPlus Program for which the data and information is collected, reported,
      prepared and submitted.

     

    18.9
      Professional Discipline

     

    a)
      Pursuant to PHL § 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 of any of the following:

    


    i)
      the
      termination of a health care Provider Agreement pursuant to Section 4406-d
      of
      the PHL 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 Participating Provider Agreement 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 New York State Education
      Law (Education Law).

     

    


    SECTION
      18

    (CONTRACTOR
      REPORTING REQUIREMENTS) 

    October
      1,2005 

    18-6

    



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

     

    a)
      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 or state
      government, or otherwise excluded from participating in procurement
      activities:

    


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

    


    ii)
      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 MMC Program and/or the FHPlus Program,
      consistent with requirements of SSA § 1932 (d)(l).

     

    18.11
      Conflict of Interest Disclosure

    


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

     

    18.12
      Physician Incentive Plan Reporting

    


    The
      Contractor shall submit to SDOH annual reports containing the information on
      all
      of its Physician Incentive Plan arrangements in accordance with 42 CFR §
438.6(h) or, if no such arrangements are in place, attest to that fact. 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.

     

    
       

    

    SECTION
      18

    (CONTRACTOR
      REPORTING REQUIREMENTS) 

    October
      1, 2005

    18-7

    


    
      
         

      

      
         

        
          

        

      

      
         

      

    


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

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

    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)
      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 principles.

     

    19.3
      Access to Contractor Records

     

    The
      Contractor shall provide DOHMH, 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.

     

     

     

    SECTION
      19

    (RECORDS
      MAINTENANCE AND
      AUDIT
      RIGHTS)

     October
      1,2005 

    19-1

     

    



    19.4
      Retention Periods

    


    


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

    


     

    


    SECTION
      19 

    (RECORDS
      MAINTENANCE AND AUDIT RIGHTS)

    October
      1, 2005 

    19-2

    


    
      
         

      

      
         

        
          

        

      

      
         

      

    


    20.
      CONFIDENTIALITY

    


    20.1
      Confidentiality of Identifying Information about Enrollees, Potential Enrollees
      and Prospective Enrollees

    All
      information relating to services to Enrollees, Potential Enrollees and
Prospective
      Enrollees which is obtained by the Contractor shall be confidential pursuant
      to
      the PHL including PHL Article 27-F, the provisions of Section 369(4) of the
      SSL,
      42 U.S.C. § 1396a(a)(7) (Section 1902(a)(7) of the SSA), Section 33.13 of the
      Mental Hygiene Law, and regulations promulgated under such laws, including
      42
      CFR Part 2 pertaining to Alcohol and Substance Abuse Services. Such information,
      including information relating to services provided to Enrollees, Potential
      Enrollees and Prospective Enrollees 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 MMC and/or FHPlus information, as applicable.

     

    20.2
      Medical Records of Foster Children

     

    Medical
      records of Enrollees enrolled in foster care programs shall be disclosed to
      local social service officials in accordance with Sections 358-a, 384-a and
      392
      of the SSL and 18 NYCRR § 507.1.

     

    20.3
      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.

     

    20.4
      Length of Confidentiality Requirements

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

    


     

    SECTION
      20 

    (CONFIDENTIALITY)
      

    October
      1,2005 

    20-1

     

    


    
      
         

      

      
         

        
          

        

      

      
         

      

    


    21.
      PROVIDER NETWORK

     

    21.1
      Network Requirements

    


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

     

    i)
      In
      establishing the network, the Contractor must consider the
      following:

    anticipated
      Enrollment, expected utilization of services by the population to be enrolled,
      the number and types of providers necessary to furnish the services in the
      Benefit Package, the number of providers who are not accepting new patients,
      and
      the geographic location of the providers and Enrollees.

    


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

     

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

     

    b)
      The
      Contractor shall not include in its network any provider

    


    i)
      who
      has been sanctioned or prohibited from participation in Federal health care
      programs under either Section 1128 or Section 1128Aofthe SSA; or

     

    ii)
      who
      has had his/her licensed suspended by the New York State Education Department
      or
      the SDOH Office of Professional Medical Conduct.

    


    c)
      The
      Contractor must require that Participating Providers offer hours of operation
      that are no less than the hours of operation offered to commercial members
      or,
      if the provider serves only MMC Enrollees and/or FHPlus Enrollees, comparable
      to
      hours offered for Medicaid fee-for-service patients.

    


    d)
      The
      Contractor shall submit its network for SDOH to assess for adequacy through
      the
      HPN prior to execution of this Agreement, quarterly thereafter throughout the
      term of this Agreement, and upon request by SDOH when SDOH determines there
      has
      been a significant change that could affect adequate capacity and quarterly
      thereafter.

    


     

    SECTION
      21 

    (PROVIDER
      NETWORK) 

    October
      1,2005 

    21-1

     

    



    e)
      Contractor must limit participation to providers who agree that payment received
      from the Contractor for services included in the Benefit Package is payment
      in
      full for services provided to Enrollees, except for the collection of applicable
      co-payments from Enrollees as provided by law.

     

    21.2
      Absence of Appropriate Network Provider

    


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

     

    21.3
      Suspension of Enrollee Assignments To Providers

     

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

     

    21.4
      Credentialing

     

    a)
      Credentialing/Recredentialing Process

    The
      Contractor shall have in place a formal process, consistent with SDOH
      Recommended Guidelines for Credentialing Criteria, for credentialing
      Participating Providers on a periodic basis (not less than once every three
      (3)
      years) and for monitoring Participating Providers performance.

     

    b)
      Licensure

     

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

    


    SECTION
      21 

    (PROVIDER
      NETWORK) 

    October
      1,2005 

    21-2

     

     

    c)
      Minimum Standards

    


    i)
      The
      Contractor agrees that all network physicians will meet at least one (1) of
      the
      following standards, except as specified in Section 21.15 (c) and Appendix
      I of
      this Agreement:

    


    A)
      Be
      board-certified or board-eligible in their area of specialty;

    B)
      Have
      completed an accredited residency program; or

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

     

    21.5
      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 MMC and/or FHPlus 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.

     

    21.6
      Application Procedure

     

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

    


    b)
      The
      selection process may not discriminate against particular providers that serve
      high-risk populations or specialize in conditions that require costly
      treatment.

    


    c)
      The
      Contractor may not discriminate with regard to the participation, reimbursement,
      or indemnification of any provider who is acting within the

    


    SECTION
      21

    (PROVIDER
      NETWORK) 

    October
      1,2005

    21-3

    



    scope
      of
      his or her license or certification under applicable State law solely on the
      basis of that license or certification. This does not preclude the Contractor
      from including providers only to the extent necessary to meet its needs; or
      from
      establishing different payment rates for different counties or different
      specialists; or from establishing measures designed to maintain the quality
      of
      services and control costs consistent with its responsibilities.

    


    d)
      If the
      Contractor does not approve an individual or group of providers as Participating
      Providers, it must give the affected providers written notice of the reason
      for
      its decision.

     

    21.7
      Evaluation Information

    


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

     

    21.8
      Choice/Assignment of Primary Care Providers (PCPs)

    


    a)
      The
      Contractor shall offer each Enrollee the choice of no fewer than three (3)
      Primary Care Providers within distance/travel time standards as set forth in
      Section 15.5 of this Agreement.

     

    b)
      Contractor must assign a PCP to Enrollees who fail to select a PCP. The
      assignment of a PCP by the Contractor may occur after written notification
      to
      the Contractor of the Enrollment (through Roster or other method) and after
      written notification of the Enrollee by the Contractor but in no event later
      than thirty (30) days after notification of Enrollment, and only after the
      Contractor has made reasonable efforts as set forth in Section 13.6 of this
      Agreement to contact the Enrollee and inform him/her of his/her right to choose
      a PCP.

     

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

    


    i)
      Enrollee's geographic location;

     

    SECTION
      21

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      NETWORK) 

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      1,2005 

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    ii)
      any
      special health care needs, if known by the Contractor; and iii) any special
      language needs, if known by the Contractor.

     

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

     

    21.9
      Enrollee PCP Changes

    


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

    


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

     

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

    


    d)
      In the
      event that an assignment of a new PCP is necessary due to the unavailability
      of
      the Enrollee's former PCP, such assignment shall be made in accordance with
      the
      requirements of Section 21.8 of this Agreement.

     

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

    


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

    


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

    


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

    


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

    


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

    


     

    SECTION
      21 

    (PROVIDER
      NETWORK) 

    October
      1,2005 

    21-5

     

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

     

    21.10
      Provider Status Changes

     

    a)
      PCP
      Changes

     

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

     

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

    


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

    


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

     

    b)
      Other
      Provider Changes

     

    In
      the
      event that an Enrollee is in an ongoing course of treatment with another
      Participating Provider who becomes unavailable to continue to provide services
      to such Enrollee, the Contractor shall provide written notice to the Enrollee
      within fifteen (15) days from the date on which the Contractor becomes aware
      of
      the Participating Provider's unavailability to the Enrollee. In such cases,
      the
      notice shall describe the procedures for continuing care consistent with PHL
§
4403(6)(e) and for choosing an alternative Participating Provider.

     

    21.11
      PCP
      Responsibilities

    


    In
      conformance with the Benefit Package, the PCP shall provide health counseling
      and advice; conduct baseline and periodic health examinations; diagnose and
      treat conditions not requiring the services of a specialist; arrange inpatient
      care, consultations with specialists, and laboratory and radiological services
      when medically necessary; coordinate the findings of consultants and
      laboratories; and interpret such findings to the Enrollee and the Enrollee's
      family, subject
      to the confidentiality provisions of Section 20 of this 

    


    SECTION
      21 

    (PROVIDER
      NETWORK) 

    October
      1,2005

    21-6

    



    Agreement,
      and maintain a current medical record for the Enrollee. The PCP shall also
      be
      responsible for determining the urgency of a consultation with a specialist
      and
      shall arrange for all consultation appointments within appropriate time
      frames.

     

    21.12
      Member to Provider Ratios

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

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

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

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

     

    21.13
      Minimum PCP Office Hours

     

    a)
      General Requirements

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

     

    b)
      Waiver
      of Minimum Hours

     

    The
      minimum office hours requirement may be waived under certain circumstances.
      A
      request for a waiver must be submitted by the Contractor to the Medical Director
      of the Office of Managed Care for review and approval;

    and
      the
      physician must be available at least eight hours/week; the physician must be
      practicing in a Health Provider Shortage Area (HPSA) or other similarly
      determined shortage area; the physician must be able to fulfill the other
      responsibilities of a PCP (as described in this Section); and the waiver request
      must demonstrate there are systems in place to guarantee continuity of care
      and
      to meet all access and availability standards (24-hour/7 days per week coverage,
      appointment availability, etc.).

    


    21.14
      Primary Care Practitioners 

     

    a)
      General Limitations

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

    


    SECTION
      21 

    (PROVIDER
      NETWORK) 

    October
      1,2005 

    21-7

     

    b)
      Specialist and Sub-specialist as PCPs

    


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

     

    c)
      OB/GYN
      Providers as PCPs

    


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

     

    d)
      Certified Nurse Practitioners as PCPs

    


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

     

    21.15
      PCP
      Teams

     

    a)
      General Requirements

    


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

     

    b)
      Registered Physician Assistants as Physician Extenders

    


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

     

    c)
      Medical Residents and Fellows

    


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

     

     

    SECTION
      21 

    (PROVIDER
      NETWORK)

    October
      1, 2005

    21-8

     

    21.16
      Hospitals

     

    a)
      Tertiary Services

    


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

     

    b)
      Emergency Services

    


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

     

    21.17
      Dental Networks

     

    a)
      If the
      Contractor includes dental services in its Benefit Package, the Contractor's
      dental network shall include geographically accessible general dentists
      sufficient to offer each Enrollee a choice of two (2) primary care dentists
      in
      their Service Area and to achieve a ratio of at least one (1) primary care
      dentist for each 2,000 Enrollees. Networks must also include at least one (1)
      pediatric dentist and one (1) oral surgeon. Orthognathic surgery, temporal
      mandibular disorders (TMD) and oral/maxillofacial prosthodontics must be
      provided through any qualified dentist, either in-network or by referral.
      Periodontists and endodontists must also be available by referral. The network
      should include dentists with expertise in serving special needs populations
      (e.g., HIV+ and developmentally disabled patients).

    


    b)
      Dental
      surgery performed in an
      ambulatory or inpatient setting is the responsibility of the Contractor whether
      dental services are a covered benefit or not, as set forth in Appendix K.2
      (25),
      Dental Services, of this Agreement.

     

    21.18
      Presumptive Eligibility Providers

     

    The
      Contractor must offer Presumptive Eligibility Providers the opportunity to
      be
      Participating Providers in its MMC product. The terms of the contract must
      be
      at

    


    


    SECTION
      21

    (PROVIDER
      NETWORK) 

    October
      1,2005 

    21-9

    



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

     

    21.19
      Mental Health and Chemical Dependence Services Providers

    


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

    


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

     

    21.20
      Laboratory Procedures

     

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

     

    21.21
      Federally Qualified Health Centers (FQHCs)

    


    a)
      In a
      county where Enrollment in the Contractor's MMC product is voluntary, the
      Contractor is not required to contract with FQHCs. However, when an FQHC is
      a
      Participating Provider of the Contractor network, the Provider Agreement must
      include a provision whereby the Contractor agrees to compensate the FQHC for
      services provided to Enrollees at a payment rate that is not less than the
      level
      and amount that the Contractor would pay another Participating Provider that
      is
      not an FQHC for a similar set of services.

    


    b)
      In a
      county where Enrollment in the Contractor's MMC product is mandatory and/or
      the
      Contractor offers a FHPlus product, the Contractor shall contract with FQHCs
      operating in that county. However, the Contractor has the option to make a
      written request to the SDOH for an exemption from the FQHC contracting
      requirement if the Contractor can demonstrate, with supporting documentation,
      that it has adequate capacity and will provide a comparable level of clinical
      and enabling services (e.g., outreach, referral services, social

    


    


    SECTION
      21 

    (PROVIDER
      NETWORK) 

    October
      1,2005 

    21-10

    



    support
      services, culturally sensitive services such as training for medical and
      administrative staff, medical and non-medical and case management services)
      to
      vulnerable populations in lieu of contracting with an FQHC in the county.
      Written requests for exemption from this requirement are subject to approval
      by
      CMS.

    


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

     

    21.22
      Provider Services Function

    


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

     

    i)
      Assisting providers with prior authorization and referral
      protocols.

    ii)
      Assisting providers with claims payment procedures. 

    iii)
      Fielding and responding to provider questions and complaints.

     

    21.23
      Pharmacies - Applies to FHPlus Program Only

    


    a)
      For
      those counties in which the Contractor offers a FHPlus product as specified
      in
      Appendix M of this Agreement, the Contractor shall include pharmacies as
      Participating Providers in its FHPlus product in sufficient numbers to meet
      the
      following distance/travel time standards:

    


    i)
      Non-Metropolitan areas - thirty (30 )miles/ thirty (30) minutes from the FHPlus
      Enrollee's residence.

     

    ii)
      Metropolitan areas - thirty (30) minutes from the FHPlus Enrollee's residence
      by
      public transportation from the FHPlus Enrollee's residence.

    


    b)
      Transport time and distance in rural areas may be greater than thirty (30)
      minutes or thirty (30) miles from the FHPlus Enrollee's residence only if based
      on the community standard for accessing care or if by FHPlus Enrollee choice.
      Where the transport time and/or distances are greater, the exceptions must
      be
      justified and documented by SDOH on the basis of community
      standards.

    


    c)
      The
      Contractor also must contract with twenty-four (24) hour pharmacies and must
      ensure that all FHPlus Enrollees have access to at least one such pharmacy
      within thirty (30) minutes travel time (by car or public transportation) from
      the FHPlus Enrollee's residence, unless none are located within such a distance.
      If none are located within thirty (30) minutes travel

    


     

    SECTION
      21 

    (PROVIDER
      NETWORK) 

    October
      1, 2005

    21-11

    



    time
      from
      the FHPlus Enrollee's residence, the Contractor must include the closest site
      in
      its network.

     

    d)
      For
      certain conditions, such as hemophilia, PKU, and cystic fibrosis, the Contractor
      is encouraged to make pharmacy arrangements with specialty centers treating
      these conditions, when such centers are able to demonstrate quality and cost
      effectiveness.

    


    e)
      The
      Contractor may make use of mail order prescription deliveries, where clinically
      appropriate and desired by the FHPlus Enrollee.

    


    f)
      The
      Contractor may utilize formularies and may employ the services of a pharmacy
      benefit manager or utilization review agent, provided that such manager or
      agent
      covers a prescription drug benefit equivalent to the requirements for
      prescription drug coverage described in Appendix K of this Agreement and
      maintains an internal and external review process for medical
      exceptions.

     

     

    SECTION
      21 

    (PROVIDER
      NETWORK)

    October
      1,2005 

    21-12

     

    


    
      
         

      

      
         

        
          

        

      

      
         

      

    


    22.
      SUBCONTRACTS AND PROVIDER AGREEMENTS

     

    22.1
      Written Subcontracts

     

    a)
      The
      Contractor may not enter into any subcontracts related to the delivery of
      services to Enrollees, 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 the subcontract shall impair the rights
      of the DOHMH or the State under this Agreement. No contractual relationship
      shall be deemed to exist between the subcontractor and the DOHMH or the
      State.

    


    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.

     

    22.2
      Permissible Subcontracts

    


    Contractor
      may subcontract for provider services as set forth in Sections 2.6 and 21 of
      this Agreement and management services including, but not limited to, marketing,
      quality assurance and utilization review activities and such other services
      as
      are acceptable to the SDOH. 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
      seldom used subspecialty and Emergency Services, Family Planning Services,
      and
      services for which Enrollees can self refer, pursuant to Section 10.15 of this
      Agreement, shall be provided through Provider Agreements with Participating
      Providers.

     

    22.4
      Approvals

    


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

    


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

     

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

     

     

    SECTION
      22

    (SUBCONTRACTS
      AND PROVIDER AGREEMENTS) 

    October
      1, 2005

    22-1

    



    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 report 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 work performed by the subcontractor must be in accordance with the terms
      of
      this Agreement; and

    


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

    


    b)
      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 DOHMH, LDSS, SDOH, or DHHS.

     

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

    


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

     

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

    


    f)
      The
      Contractor shall also require 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, DOHMH, the Enrollees, or persons
      acting on an Enrollee's behalf.

    


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

    


    h)
      The
      Contractor shall ensure that all Provider Agreements entered into with Providers
      require acceptance of a woman's Enrollment in the Contractor's MMC or FHPlus
      product as sufficient to provide services to her newborn, unless the newborn
      is
      excluded from Enrollment in the MMC Program pursuant to Section 6.1 of this
      Agreement, or the Contractor does not offer a MMC product in the mother's county
      of fiscal responsibility

     

    SECTION
      22 

    (SUBCONTRACTS
      AND PROVIDER AGREEMENTS)

    October
      1.2005

     22-2

     

    i)
      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 Participating Providers and to Non-Participating
      Providers, as applicable, for items and services covered under this Agreement
      on
      a timely basis, consistent with the claims payment procedures described in
      SIL §
3224-a.

     

    22.7
      Restrictions on Disclosure

    


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

    


    i)
      Disclosing to any subscriber, Enrollee, patient, designated representative
      or,
      where appropriate, Prospective Enrollee any information that such provider
      deems
      appropriate regarding:

    


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

    


    B)
      the
      provisions, terms, or requirements of the Contractor's MMC or FHPlus products
      as
      they relate to the Enrollee, where applicable.

     

    ii)
      Filing a complaint, making a report or comment to an appropriate governmental
      body regarding the policies or practices of the Contractor when he or she
      believes that the policies or practices negatively impact upon the quality
      of,
      or access to, patient care.

     

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

     

    22.8
      Transfer of Liability

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

     

     

    SECTION
      22

    (SUBCONTRACTS
      AND PROVIDER AGREEMENTS) 

    October
      1, 2005

    22-3

     

    22.9
      Termination of Health Care Professional Agreements

     

    a)
      General Requirements

    


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

    


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

     

    b)
      Notice
      of Health Care Professional Termination

     

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

     

    A)
      The
      reasons for the proposed action;

    


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

     

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

    


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

    


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

     

     

    SECTION 22

    (SUBCONTRACTS
      AND PROVIDER AGREEMENTS) 

    October
      1,2005 

    22-4

     


    22.10
      Health Care Professional Hearings 

     

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

    


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

     

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

     

    iii)
      A
      decision by the hearing panel to terminate a health care professional shall
      be
      effective not less than thirty (30) days after the receipt by the health care
      professional of the hearing panel's decision. Notwithstanding the termination
      of
      a health care professional for cause or pursuantto
      a
      hearing, the Contractor shall permit an Enrollee to continue an on-going course
      of treatment for a transition period of up to ninety (90) days, and post-partum
      care, subject to the provider's agreement, pursuant to PHL §
4403(6)(e).

     

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

     

    22.11
      Non-Renewal of Provider Agreements

    


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

     

     

    SECTION
      22

    (SUBCONTRACTS
      AND PROVIDER AGREEMENTS) 

    October
      1, 2005

    22-5

    



    22.12
      Notice of Participating Provider Termination

    


    a)
      The
      Contractor shall notify DOHMH and SDOH of any notice of termination or
      non-renewal of an IPA or institutional network Provider Agreement, or medical
      group Provider Agreement that serves five percent (5%) or more of the enrolled
      population in a LDSS and/or when the termination or non-renewal of the medical
      group provider will leave fewer than two (2) Participating Providers of that
      type within the LDSS, unless immediate termination of the Provider Agreement
      is
      justified. The notice shall include an impact analysis of the termination or
      non-renewal with regard to Enrollee access to care.

    


    b)
      The
      Contractor shall provide the notification required in (a) above to the DOHMH
      and
      the SDOH ninety (90) days prior to the effective date of the termination of
      the
      Provider Agreement or immediately upon notice from such Participating Provider
      if less than ninety (90) days.

    


    c)
      The
      Contractor shall provide the notification required in (a) above to the DOHMH
      and
      the SDOH if the Contractor and the Participating Providers have failed to
      execute a renewal Provider Agreement forty-five (45) days prior to the
      expiration of the current Provider Agreement.

     

    d)
      In
      addition to the notification required in (a) above, the Contractor shall submit
      a contingency plan to DOHMH and SDOH, at least forty-five (45) days prior to
      the
      termination or expiration of the Provider Agreement, identifying the number
      of
      Enrollees affected by the potential withdrawal of the provider from the
      Contractor's network and specifying how services previously furnished by the
      Participating Providers will be provided in the event of its withdrawal from
      the
      Contractor's network. If the Participating Provider is a hospital, the
      Contractor shall identify the number of doctors that would not have admitting
      privileges in the absence of such Participating hospital.

     

    e)
      In
      addition to the notification required in (a) above, the Contractor shall develop
      a transition plan for Enrollees who are patients of the Participating Provider
      withdrawing from the Contractor's network subject to approval by DOHMH and
      SDOH.
      DOHMH and SDOH may direct the Contractor to provide notice to the Enrollees
      who
      are patients of PCPs or specialists including available options for the
      patients, and availability of continuing care, consistent with Section 13.8
      of
      this Agreement, not less than thirty (30) days prior to the termination or
      expiration of the Provider Agreement. In the event that Provider Agreements
      are
      terminated or are not renewed with less than the notice period required by
      this
      Section, the Contractor shall immediately notify DOHMH and SDOH, and develop
      a
      transition plan on an expedited basis and provide notice to affected Enrollees
      upon DOHMH and SDOH consent to the transition plan and Enrollee
      notice.

    


     

    SECTION
      22

    (SUBCONTRACTS
      AND PROVIDER AGREEMENTS) 

    October
      1,2005

    22-6

    



    f)
      Upon
      Contractor notice of failure to renew, or termination of, a Provider Agreement,
      the DOHMH and the SDOH, in their sole discretion, may waive the requirement
      of
      submission of a contingency plan upon a determination by the DOHMH and SDOH
      that:

     

    i)
      the
      impact upon Enrollees is not significant, and/or

    


    ii)
      the
      Contractor and Participating Provider are continuing to negotiate in good faith
      and consent to extend the Provider Agreement for a period of time necessary
      to
      provide not less than thirty (30) days notice to Enrollees.

    


    g)
      DOHMH
      and SDOH reserve the right to take any other action permitted by this Agreement
      and under regulatory or statutory authority, including but not limited to
      terminating this Agreement.

     

    22.13
      Physician Incentive Plan

    


    a)
      If
      Contractor elects to operate a Physician Incentive Plan, the Contractor agrees
      that no specific payment will be made directly or indirectlyto
      a
      Participating Provider that is 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 Provider Agreements for 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.

    


    c)
      In the
      event that the incentive arrangements place the Participating 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
      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 Provider Agreement

     

     

    SECTION
      22

    (SUBCONTRACTS
      AND PROVIDER AGREEMENTS) 

    October
      1,2005 

    22-7

    


    
      
         

      

      
         

        
          

        

      

      
         

      

    


    23.
      FRAUD AND ABUSE

     

    23.1
      General Requirements

    The
      Contractor shall comply with the Federal fraud and abuse requirements of 42
      CFR
§ 438.608.

     

    23.2
      Prevention Plans and Special Investigation Units

    If
      the
      Contractor has over 10,000 Enrollees in the aggregate in any given year, the
      Contractor must file a Fraud and Abuse Prevention Plan with the Commissioner
      of
      Health and develop a special investigation unit for the detection, investigation
      and prevention of fraudulent activities to the extent required by PHL § 4414 and
      SDOH regulations.

     

    24.
      AMERICANS WITH DISABILITIES ACT COMPLIANCE PLAN

     

    Contractor
      must comply with Title II of the ADA and Section 504 of the Rehabilitation
      Act
      of 1973 for program accessibility, and must develop an ADA Compliance Plan
      consistent with the SDOH Guidelines for 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, in collaboration with the DOHMH,
      and be filed with the SDOH and the DOHMH, and be kept on file by the
      Contractor.

     

    25.
      FAIR HEARINGS

     

    25.1
      Enrollee Access to Fair Hearing Process

     

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

     

    25.2
      Enrollee Rights to a Fair Hearing

    


    Enrollees
      may request a fair hearing regarding adverse LDSS determinations concerning
      enrollment, disenrollment and eligibility, and regarding the denial,
      termination, suspension or reduction of a clinical treatment or other Benefit
      Package services by the Contractor. For issues related to disputed services,
      Enrollees must have received an adverse determination from the Contractor or
      its
      approved utilization review agent either overriding a recommendation to provide
      services by a Participating Provider or confirming the decision of a
      Participating Provider to deny those services. An Enrollee may also seek a
      fair
      hearing for a failure by the Contractor to act with reasonable promptness with
      respect to such services. Reasonable promptness shall mean compliance with
      the
      timeframes established for review of grievances and utilization review in
      Sections 44 and 49 of the Public Health Law, the grievance system requirements
      j
      of 42 CFR Part 438 and Appendix F of this Agreement.

    


    SECTION
      23 - SECTION
      36

     October
      1.2005

    -1-

     

     

    25.3
      Contractor Notice to Enrollees

    


    a)
      Contractor must issue a written notice of Action and right to fair hearing
      within applicable timeframes to any Enrollee when taking an adverse Action
      and
      when making an Appeal determination as provided in Appendix F of this
      Agreement.

    


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

     

    25.4
      Aid
      Continuing

     

    a)
      Contractor shall be required to continue the provision of the Benefit Package
      services that are the subject of the fair hearing to an Enrollee (hereafter
      referred to as "aid continuing") if so ordered by the NYS Office of
      Administrative Hearings (OAH) under the following circumstances:

    


    i)
      Contractor has or is seeking to reduce, suspend or terminate a treatment or
      Benefit Package service currently being provided;

     

    ii)
      Enrollee has filed a timely request for a fair hearing with OAH;
      and

    


    iii)
      There is a valid order for the treatment or service from a Participating
      Provider.

     

    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 in writing; or the treatment or service 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 timely requests a fair hearing, Contractor shall, at the
      direction of either SDOH or LDSS, restore the disputed services and/or benefits
      consistent with the provisions of Section 25.4 (b) of this
      Agreement.

     

    25.5
      Responsibilities of SDOH

    


    SDOH
      will
      make every reasonable effort to ensure that the Contractor receives timely
      notice in writing by fax, or e-mail, of all requests, schedules and directives
      regarding fair hearings.

     

     

    SECTION
      23 - SECTION 36

    October
      1,2005 

    -2-

    



    25.6
      Contractor's Obligations

    


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

    


    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 as required under state and federal laws and
      by
      Section 14 and Appendix F of this Agreement. Enrollees may seek redress of
      Adverse Determinations simultaneously through Contractor's internal process
      and
      the State fair hearing process. If Contractor has reversed its initial
      determination and provided the service to the Enrollee, Contractor may request
      a
      waiver from appearing at the hearing and, in submitted papers, explain that
      it
      has withdrawn its initial determination and is providing the service or
      treatment formerly in dispute.

    


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

    


    d)
      If
      SDOH investigates a Complaint that has as its basis the same dispute that is
      the
      subject of a pending fair hearing and. as a result of its investigation,
      concludes that the disputed services and/or benefits should be provided to
      the
      Enrollee, Contractor shall comply with SDOH's directive to provide those
      services and/or benefits and provide notice to OAH and Enrollee as required
      by
      Section 25.6(b) of this Agreement.

    


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

     

     

    SECTION
      23 - SECTION 36

    October
      1, 2005

    -3-

    



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

    


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

    


    h)
      The
      information describing fair hearing rights, aid continuing. Action, Service
      Authorization, utilization review. Complaint and Appeal procedures shall be
      included in all MMC and FHPlus member handbooks and shall comply with Section
      14
      and Appendices E and F of this Agreement.

     

    i)
      Contractor shall bear the burden of proof at hearings regarding the reduction,
      suspension or termination of ongoing services. In the event that Contractor's
      initial adverse determination is upheld as a result of a fair hearing, any
      aid
      continuing provided pursuant to that hearing request, may be recouped by
      Contractor.

     

     

    26.
      EXTERNAL APPEAL

     

    26.1
      Basis for External Appeal

     

    Enrollees
      are eligible to request an External Appeal when one or more covered health
      care
      services have been denied by the Contractor on the basis that the service(s)
      is
      not medically necessary or is experimental or investigational.

     

    26.2
      Eligibility for External Appeal

    


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

    


     

    SECTION
      23 - SECTION 36 

    October
      1,2005 

    -4-

     

    



    26.3
      External Appeal Determination

    


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

     

    26.4
      Compliance with External Appeal Laws and Regulations

    


    The
      Contractor must comply with the provisions of Sections 4910-4914 of the PHL
      and
      10 NYCRR Part 98 regarding the External Appeal program.

     

    26.5
      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 Member Handbook. The Member Handbook shall comply with Section
      13
      and the Member Handbook Guidelines, Appendix E, of this Agreement.

     

    27.
      INTERMEDIATE SANCTIONS

     

    27.1
      General

     

    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 pursuant to 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.

     

    27.2
      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 MMC Program or FHPlus Program.

    


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

     

     

    SECTION
      23 - SECTION 36

    October
      1.2005

    -5-

    



    iv)
      Misrepresenting or falsifying information that it furnishes to an Enrollee,
      Potential Enrollee, health care provider, 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 the State or that contain false or
      materially misleading information.

    


    vii)
      Violating any other applicable requirements of SSA §§ 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.

     

    27.3
      Intermediate Sanctions

     

    a)
      Intermediate Sanctions may include but are not limited to:

     

    i)
      Civil
      monetary penalties.

    


    ii)
      Suspension of all new enrollment, including auto assignments, after the
      effective date of the sanction.

     

    iii)
      Termination of the Agreement, pursuant to Section 2.7 of this
      Agreement.

     

    27.4
      Enrollment Limitations

     

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

    


    b)
      The
      SDOH shall have the right, upon notice to the DOHMH, to limit, suspend or
      terminate Enrollment activities by the Contractor and/or Enrollment into the
      Contractor's MMC and/or FHPlus 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 

    


     

    SECTION
      23 - SECTION 36 

    October
      1, 2005

    -6-

     

    



    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 MMC
      and/or FHPlus product is unnecessary. Nothing in this paragraph limits other
      remedies available to the SDOH or the DOHMH under this Agreement.

     

    27.5
      Due
      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).

     

    28.
      ENVIRONMENTAL COMPLIANCE

     

    The
      Contractor shall comply with all applicable standards, orders, or requirements
      issued under Section 306 of the Clean Air Act (42 U.S.C. § 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 Part 15) that prohibit the use of the facilities included
      on
      the EPA List of Violating Facilities. The Contractor shall report violations
      to
      SDOH and to the Assistant Administrator for Enforcement of the EPA.

     

    29.
      ENERGY CONSERVATION

     

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

     

    30.
      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, DOHMH, SDOH or the DHHS.

     

    31.
      NO THIRD PARTY BENEFICIARIES

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

     

    32.
      INDEMNIFICATION

     

    32.1
      Indemnification by Contractor

     

     

    SECTION
      23 - SECTION 36

    October
      1,2005

     -7-

    



    a)
      The
      Contractor shall indemnify, defend, and hold harmless the SDOH, DOHMH and the
      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;

    


    iii)
      any
      liability, including costs and expenses, for violation of proprietary rights,
      copyrights, or rights of privacy by the Contractor, its officers, agents,
      employees or subcontractors, 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
      DOHMH will provide the Contractor with prompt written notice of any claim made
      against the DOHMH, and the Contractor, at its sole option, shall defend or
      settle said claim. The DOHMH shall cooperate with the Contractor to the extent
      necessary for the Contractor to discharge its obligation under Section 32.1
      (a).

     

    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 DOHMH, its employees, or agents.

     

    32.2
      Indemnification by DOHMH

    


    The
      DOHMH
      shall indemnify and hold harmless the Contractor and its officers, agents,
      and
      employees from any loss or damage resulting from actions by the DOHMH pursuant
      to the terms of Appendix R, Section 6.3 herein.

     

    33.
      PROHIBITION ON USE OF FEDERAL FUNDS FOR LOBBYING

     

    33.1
      Prohibition of Use of Federal Funds for Lobbying

    


    The
      Contractor agrees, pursuant to 31 U.S.C. § 1352 and 45 CFR Part 93, that no
      Federally appropriated funds have been paid or will be paid to any person by
      or
      on behalf of the Contractor for the purpose of influencing or attempting to
      influence an officer or employee of any agency, a Member of Congress, an officer
      or employee of Congress, or an employee of a Member of Congress in
      connection

    


    


    SECTION
      23 - SECTION 36

     October
      1, 2005

    -8-

     

     

    with
      the
      award of any Federal contract, the making of any federal grant, the making
      of
      any Federal loan, the entering into of any cooperative agreement, or the
      extension, continuation, renewal, amendment, or modification of any Federal
      contract, grant, loan, or cooperative agreement. The Contractor agrees to
      complete and submit the "Certification Regarding Lobbying," Appendix B attached
      hereto and incorporated herein, if this Agreement exceeds $100,000.

     

    33.2
      Disclosure Form to Report Lobbying

    


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

     

    33.3
      Requirements of Subcontractors

    


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

     

    34.
      NON-DISCRIMINATION

     

    34.1
      Equal Access to Benefit Package

    


    Except
      as
      otherwise provided in applicable sections of this Agreement the Contractor
      shall
      provide the Medicaid Managed Care and/or Family Health Plus Benefit Package(s)
      to MMC and/or FHPlus Enrollees, respectively, in the same manner, in accordance
      with the same standards, and with the same priority as members of the Contractor
      enrolled under any other contracts.

     

    34.2
      Non-Discrimination

    


    The
      Contractor shall not discriminate against Eligible Persons or Enrollees for
      Medicaid Managed Care and/or Family Health Plus 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.

     

     

    SECTION
      23 - SECTION 36 

    October
      1, 2005

    -9-

     

    



    34.3
      Equal Employment Opportunity

    


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

     

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

     

    The
      Contractor shall not prohibit, restrict or discourage enrolled Native Americans
      from receiving care from or accessing: a) Medicaid reimbursed health services
      from or through a tribal health or urban Indian health facility or center and/or
      b) Family Health Plus covered benefits from or through a tribal health or urban
      Indian health facility or center which is included in the Contractor's
      network.

     

    35.
      COMPLIANCE WITH APPLICABLE LAWS

     

    35.1
      Contractor and DOHMH Compliance With Applicable Laws

    


    Notwithstanding
      any inconsistent provisions in this Agreement, the Contractor and DOHMH shall
      comply with all applicable requirements of the State Public Health Law; the
      State Social Services Law; Title XIX of the Social Security Act;

    Title
      VI
      of the Civil Rights Act of 1964 and 45 CFR Part 80, as amended; Title IX of
      the
      Education Amendments of 1972; Section 504 of the Rehabilitation Act of 1973
      and
      45 CFR Part 84, as amended; the Age Discrimination Act of 1975 and 45 CFR Part
      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 thereunder; 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.

     

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

    


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

     

    35.3
      Certificate of Authority Requirements

    


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

    


     

    SECTION
      23 - SECTION 36 

    October
      1, 2005

    -
      10-

     

    



    35.4
      Notification of Changes in Certificate of Incorporation

     

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

     

    35.5
      Contractor's Financial Solvency Requirements

    


    The
      Contractor, for the duration of this Agreement, shall remain in compliance
      with
      all applicable state requirements for financial solvency for MCOs offering
      Medicaid Managed Care and/or Family Health Plus products, as applicable. 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, LDSSs and the
      Enrollees in the event of Contractor 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.

     

    35.6
      Compliance With Care for Maternity Patients

    


    Contractor
      must comply with § 2803-n of the PHL and § 3216 (i) (10) (a) of the State
      Insurance Law related to hospital care for maternity patients.

     

    35.7
      Informed Consent Procedures for Hysterectomy and Sterilization

    


    The
      Contractor is required and shall require Participating Providers to comply
      with
      the informed consent procedures for Hysterectomy and Sterilization specified
      in
      42 CFR Part 441, sub-part F, and 18 NYCRR § 505.13.

     

    35.8
      Non-Liability of Enrollees for Contractor's Debts

    


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

     

    SECTION
      23 - SECTION 36 

    October
      1,2005

    -11-

     

    



    35.9
      SDOH
      Compliance With Conflict of Interest Laws

    


    DOHMH
      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.

     

    35.10
      Compliance With PHL Regarding External Appeals

    


    Contractor
      must comply with Article 49 Title II of the PHL regarding external appeal of
      adverse determinations.

    


    


    36.
      NEW YORK STATE STANDARD CONTRACT CLAUSES AND LOCAL STANDARD
      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 and R, respectively, attached to and incorporated into this
      Agreement as if set forth fully herein, and any amendment thereto.

    


     

    SECTION
      23 - SECTION 36 

    October
      1, 2005

    -
      12-

     

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    

      This
        Agreement is effective October 1, 2005 and shall remain in effect until
        September 30, 2007 or until the execution of an extension, renewal or successor
        agreement as provided for in the Agreement.

       

      In
        Witness Whereof, the parties have duly executed this Agreement on the dates
        appearing below their respective signatures.

       

      

        
          	
                  By:

                	
                  /s/
                    Todd S. Farha

                	
                  By:

                	
                  /s/
                    Illegible

                
	 	
                  

                	 	
                  

                
	 	
                  WellCare
                    of New York, Inc.

                	 	 
	
                   

                  Date:
                    

                	
                  10/11/05

                	
                  Date:

                	
                  10/17/05

                
	 	
                  

                	 	
                  

                
	 	 	 	 


        


         

        Approval
          as to form and certification as to legal authority was granted by the
          Corporation Counsel on: September
          16, 2005.

         

         

         

         

        SIGNATURE
          PAGE

        OCTOBER
          1

        
 

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

        
 

        STATE
          OF
          FLORIDA

        SS:

        COUNTY
          OF
          HILLSBOROUGH

        


         

        On
          this
11th
          day
          of October,
          2005,
          Todd
          S. Farha came
          before me, to me known to be the President
          & CEO of
          WellCare
          of New York, Inc
          , who
          is
          duly authorized to execute the foregoing instrument on behalf of said
          corporation and s/he acknowledged to me that s/he executed the same for
          the
          purpose therein mentioned

        


        


        
          	
                  KATHLEEN
                    R. CASEY

                  Notary
                    Public-State of Florida

                  My
                    Commission Expires Apr 22,2008 Commission # DD305227

                  Bonded
                    By National Notary Assn.

                	 	
                  /S/
                    Kathleen R. Casey

                
	 	 	
                  

                  Notary
                    Public

                
	 	 	 	
                   

                


        

        


         

        STATE
          OF
          NEW YORK

        SS:

        COUNTY
          OF
          NEW YORK

        


         

        On
          this
          27th day
          of
October,
          2005,
          Thomas
          Frieden came
          before me, to me known and known to be the Commissioner
          , in the
          New York City Department of Health and Mental Hygiene, who is duly authorized
          execute the foregoing instrument on behalf of the city and s/he acknowledged
          to
          me that s/he executed the same for the purpose therein mentioned.

        


        


        
          	
                  FRANK
                    LANE

                  Notary
                    Public, State of New York

                  No.
                    01LA50114224

                  Qualified
                    in Queens County

                  Commission
                    Expires Nov 3, 2005

                	 	
                  /S/
                    Frank Lane

                
	 	 	
                  

                  Notary
                    Public

                
	 	 	 	
                   

                


        

         

         

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

         

         

         

         

        APPENDIX
          A

         

         

         

        New
          York State Standard Clauses

         

         

         

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

         

         

         

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

         

      

    


    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 Worker;;' 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

     

     

    Page
      1

    


    


    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 (2NYCKR 105.4).

    


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

    


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

    


    May,
      2003

    



    



    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 S100,000.00 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 Slate assisted
      housing project is committed to expend or does expend funds for the acquisition,
      construction, demolition, replacement, major repair or renovation of real
      property and improvements thereon for such project, then:

    


    (a)
      The
      Contractor will not discriminate against employees or applicants for employment
      because of race, creed, color, national origin, sex, age, disability or marital
      status, and will undertake or continue existing programs of affirmative action
      to ensure that minority group members and women are afforded equal employment
      opportunities without discrimination. Affirmative action shall mean
      recruitment,

     

     

    Page
      2

    


     

    employment,
      job assignment, promotion, upgrading?, 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 title 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 I)-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 [he United States Postal Service as refused
      or
      undeliverable. Contractor must promptly notify the State, in writing, of each
      and every change of address to which service of process can be made. Service
      by
      the State to the last known address shall be sufficient. Contractor will have
      thirty (30) calendar days after service hereunder is complete in which to
      respond.

     

     

    May,2003

     

    



    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
      - 7th
      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 Slate;

    


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

    


     

    


    Page
      3


    


     

    (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.

     

    


     

     

    May
      20003


     

    


    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    


     

    APPENDIX
      B

     

    Certification
      Regarding Lobbying

     

     

     

     

     

     

     

     

     

     

    APPENDIX
      B 

    October
      1,2005

    B-l

     

    


    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    


    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:               
      10/11/05


    SIGNATURE:  
      /s/ Todd S. Farha

     

    TITLE:
President
      and CEO

     

    ORGANIZATION:
WellCare
      of New York,
      Inc

     

    APPENDIX
      B 

    October
      1,2005 

    B-2

     

    


    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    


     

    Appendix
      C

     

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

     

    


     

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

     

    C.2
      Requirements for MCOs that Include Family Planning and Reproductive Health
      Services in Their Benefit Package

     

    C.3
      Requirements for MCOs That Do Not Include Family Planning Services and
      Reproductive Health Services in Their Benefit Package

    


    


    
      APPENDIX
        C 

      October
        1,2005 

      C-l


    

    


    


    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    


     


    C.I

     

    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 famished
      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 insertion/removal of an intrauterine device (IUD),
      insertion/removalof
      contraceptive implants, and injection procedures involving Pharmaceuticals
      such
      as Depo-Provera;

     

    B)
      sterilization;

     

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

     

    D)
      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)
      For
      MMC Enrollees - The Contractor is responsible for pharmaceuticals and medical
      supplies such as IUDS and Depo-Provera that must be famished 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. Other pharmacy prescriptions, medical supplies, and 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

     

    


    APPENDIX
      C 

    October
      1,2005

    C-2

     

    



    reimbursable
      drugs by the Enrollee from any appropriate eMedNY-enrolled health care provider
      of the Enrollee's choice.

     

    B)
      For
      FHPlus Enrollees - The Contractor, if it includes such services in its Benefit
      Package, or the Designated Third Party Contractor that provides such services
      to
      FHPlus Enrollees when the Contractor does not provide Family Planning and
      Reproductive Health services, is responsible for prescription contraceptives
      provided by a Participating pharmacy, consistent with the pharmacy benefit
      package described in Appendix K. The Contractor or the Designated Third Party
      Contractor must cover at least one of every type of the following methods of
      contraception:

     

    I)
      Oral

    II)
      Oral,
      emergency

    III)
      Injectable

    IV)
      Transdermal

    V)
      Intravaginal

    VI)
      Intravaginal, systemic

    VII)
      Implantable

     

    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
      MMC
      Enrollees

     

    a)
      Free
      Access means MMC Enrollees 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 includes such services in its 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

    


    


    APPENDIX
      C

     October
      1,2005

    C-3

     

    



    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. 

     

    3.
      Access to Services for FHPlus Enrollees

     

    a)
      FHPlus
      Enrollees 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 Services encounter, from either the
      Contractor or through the Designated Third Party Contractor, as applicable.
      No
      referral from the PCP or approval by the Contractor is required to access such
      services.

     

    b)
      The
      Contractor is responsible for routine obstetric and/or gynecologic care,
      including hysterectomies, pre-natal, delivery and post-partum care, regardless
      of whether Family Planning and Reproductive Health services are included in
      the
      Contractor's Benefit Package.

     

     

    Appendix
      C

    October
      1,2005

    C-4

    


     

    
 

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

     

    C.2

     

    Requirements
      for MCOs that Include Family Planning and Reproductive Health Services in Their
      Benefit Package

     

    1.
      Notification to Enrollees

     

    a)
      If the
      Contractor includes Family Planning and Reproductive Health services in its
      Benefit Package (as indicated in Appendix M of this Agreement) the Contractor
      must notify all Enrollees of reproductive age, including minors who may be
      sexually active, at the time of Enrollment about their right to obtain Family
      Planning and
      Reproductive
      Health services and supplies 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 HIV 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)
      MMC
      Enrollees "must receive
      notification that they also have the right to obtain Family Planning and
      Reproductive Health services in accordance with MMC's Free Access policy as
      defined in C.I 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 MMC 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
      care will be fully covered, including when a MMC Enrollee obtains such services
      in accordance with MMC's 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)
      The
      Contractor will be charged for Family Planning and Reproductive Health services
      furnished to MMC Enrollees by eMedNY-enrolled Non-Participating Providers at
      the
      applicable Medicaid rate or fee. In such instances, Non-Participating Providers
      will bill Medicaid fee-for-service and the SDOH will issue a
      confidential

     

     

     

    APPENDIX
      C 

    October
      1,2005 

    C-5

     

    



    charge
      back to the Contractor. Such charge back mechanism will comply with all
      applicable patient confidentiality requirements.

     

     

    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 that
      Participating Providers comply with all of the requirements set forth in
      Sections 17 and 18 of the PHL -and 10 NYCRR §751.9 and Part 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
      the disclosure.

     

    4.
      Informing and Standards

     

    a)
      The
      Contractor will inform its Participating Providers and administrative personnel
      about policies concerning MMC Free Access as defined in C.I 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.

     

     

    APPENDIX
      C 

    October
      1,2005 

    C-6

     

    


    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    


     

    C.3

     

    Requirements
      for MCOs That Do Not

    Include
      Family Planning Services and Reproductive Health Services in Their Benefit
      Package

     

    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 1223
      7.

     

    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 Prospective 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 either through fee-for-service Medicaid providers
      for
      MMC Enrollees; and/or through the Designated Third Party Contractor for FHPlus
      Enrollees;

     

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

    


     

    APPENDIX
      C

    October
      1,2005 

    C-7

    



    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 MMC Enrollees and
      through the Designated Third Party Contractor to FHPlus Enrollees; and that
      anonymous counseling and testing services are available from SDOH, Local Public
      Health Agency clinics and other New York City 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 MMC Enrollees to secure
      such
      services through fee-for-service Medicaid from any provider/clinic which offers
      these services and accepts Medicaid, and the right of all FHPlus Enrollees
      to
      secure such services through the Designated Third Party Contractor.

     

    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 web site of the Contractor which includes information
      concerning its MMC or FHPlus product(s). Such information shall be prominently
      displayed and easily navigated.

     

    C)
      A
      description of the mechanisms to provide all new MMC 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 Prospective Enrollee requests information
      about
      these non-covered services, the Contractor's Marketing or Enrollment
      representative or member services department will advise the Enrollee or
      Prospective 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.

     

     

    APPENDIX
      C

    October
      1,2005

    C-8

    



    II)
      MMC
      Enrollees can use their Medicaid card to receive these non-covered services
      from
      any doctor or clinic that provides these services and accepts Medicaid. FHPlus
      Enrollees can receive these ^non-covered services through the Designated Third
      Party Contractor under contract with SDOH in the Enrollee's geographic
      area.

     

    III)
      Each
      MMC Enrollee and Prospective MMC 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)
      The
      Contractor will provide the name and phone number of the Designated Third Party
      Contractor under SDOH contract to provide such services to FHPlus Enrollees
      and
      Prospective FHPlus Enrollees. It is the responsibility of the Designated Third
      Party Contractor to mail to each FHPlus Enrollee or Prospective FHPlus Enrollee
      who calls, a copy of the SDOH approved letter explaining the Enrollee's right
      to
      receive such services, and an SDOH approved list of Family Planning Providers
      and Pharmacies in the Designated Third Party Contractor's network. The
      Designated Third Party Contractor is responsible for mailing these materials
      within fourteen (14) days of notice by the Contractor of a new Enrollee in
      the
      Contractor's FHPlus product.

     

    V)
      Enrollees can call the Contractor's member services number for further
      information about how to obtain these non-covered services. MMC 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. FHPlus
      Enrollees can also call the Designated Third Party Contractor for a list of
      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 or LDSS 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 MMC Free Access, as defined in C.I of this Appendix, and/or the FHPlus
      Designated Third Party Contractor for FHPlus Enrollees, H1V counseling and
      testing; reimbursement for Family Planning and Reproductive

    


    


    APPENDIX
      C 

    October
      1,2005 

    C-9

     

    



    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 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.

     

    C)
      The
      procedure(s) for informing the Contractor's Participating primary care
      providers, 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
      MMC's Free Access policy, as defined in C.I of this Appendix, and/or through
      the
      SDOH-contracted Designated Third Party for FHPlus Enrollees.

     

    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 MMC Enrollees,
      they do so as a fee-for-service Medicaid practitioner, independent of the
      Contractor.

     

    II)
      if
      they also participate in the FHPlus Designated Third Party Contractor's network
      and they render non-covered Family Planning and Reproductive Health Services
      to
      FHPlus Enrollees, they do so as a participating provider with that MCO,
      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:

    


    


    APPENDIX
      C

    October
      1,2005 

    C-10

     

    



    I)
      offer
      those services to MMC Enrollees on a fee-for-service basis as an eMedNY-enrolled
      provider, or to FHPlus Enrollees as a Participating Provider of the Designated
      Third Party Contractor; or

     

    II)
      provide MMC Enrollees with a copy of the SDOH approved list of Medicaid Family
      Planning Providers, and/or provide FHPlus Enrollees with the name and number
      of
      the Designated Third Party Contractor, or

     

    III)
      give
      Enrollees the Contractor's member services number to call to obtain either
      the
      list of Medicaid Family Planning Providers or the name and number of the
      Designated Third Party Contractor, as applicable.

     

    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 or under the Designated Third Party
      contract with SDOH.

     

    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.

     

    C)
      A
      statement that the Contractor will prepare a monthly list of MMC Enrollees
      who
      have been sent a copy of the SDOH approved letter and the SDOH approved list
      of
      Family Planning providers, and a list of FHPlus Enrollees who have been provided
      with the name and telephone number of the Designated Third Party Contractor
      in
      their geographic area. 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.

     

    


    APPENDIX
      C

    October
      1
      ,2005 

    C-ll

    



    E)
      A
      description of the mechanisms to provide the Designated Third Party Contractor
      with a monthly listing of all FHPlus Enrollees within seven (7) days of receipt
      of the Contractor's monthly Enrollment Roster and any subsequent updates or
      adjustments. A copy of each file will also be provided simultaneously to the
      SDOH.

    


     

    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 Participating
      Providers comply with all of the requirements set forth in Sections 17 and
      18 of
      the PHL and 10 NYCRR § 751.9 and Part 753 relating to informed consent and
      confidentiality.

     

    b)
      Participating Providers and/or the Designated Third Party Contractor '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.

     

     

    APPENDIX
      C 

    October
      1, 2005 

    C-12

     

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

     

     

    Appendix
      D

    
       

      


      New
        York
        State Department of Health 

      Marketing
        Guidelines

    

     

    



    
    

    D.I Marketing
      Plans

    D.2 Marketing
      Materials

    D.3
       Marketing
      Activities

     

     

     

     

    APPENDIX
      D

    October
      1,2005 

    D-l

    



     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

     

    MARKETING
      GUIDELINES

     

    1. General

     

    a)
      The
      purpose of these guidelines is to provide an operational framework for
      localities and managed care organizations (MCOs) offering MMC or FHPlus products
      in the development of MCO Marketing plans, materials, and activities and to
      describe SDOH's Marketing rules, MCO Marketing requirements, and prohibited
      practices.

     

    b)
      If the
      Contractor's Marketing activities do not comply with the Marketing Guidelines
      set forth in this Appendix or the Contractor's approved Marketing plan, the
      SDOH
      and the DOHMH may take actions pursuant to Section 11.5 of this Agreement in
      their sole discretion deemed necessary to protect the interests of Prospective
      Enrollees, Potential Enrollees and Enrollees and the integrity of the MMC and
      FHPlus Programs.

     

    c)
      This
      Appendix contains the following sections:

     

    i)
      D.I,
      Marketing Plans;

    ii)
      D.2,
      Marketing Materials; and 

    iii)
      D.3,
      Marketing Activities.

     

    APPENDIX
      D

    October
      1,2005 

    D-2

     

     

     

     

     

    D.1

    Marketing
      Plans

     

     

    1.
      The
      Contractor shall develop a Marketing plan that meets SDOH guidelines and any
      New
      York City specific marketing requirements as set forth in Appendix N
      .

     

    2.
      The
      SDOH, in consultation with DOHMH, is responsible for the review and approval
      of
      the Contractor's Marketing plan.

     

    3.
      Approved Marketing plans set forth the allowable terms and conditions and the
      proposed activities that the Contractor intends to undertake during the contract
      period.

     

    4.
      The
      Contractor must have on file with the SDOH and the DOHMH, an SDOH and
      DOHMH-approved Marketing plan prior to the contract award date or before
      Marketing and enrollment begin, whichever is sooner. Subsequent changes to
      the
      Marketing plan must be submitted to SDOH for approval, in consultation with
      DOHMH, at least sixty (60) days before implementation.

     

    5.
      The
      Marketing plan shall include: a stated Marketing goal and strategies; Marketing
      activities; a description of the information provided by marketers, including
      an
      overview of managed care; and staff training, development and responsibilities.
      The following must be included in the Contractor's description of materials
      to
      be used: distribution methods; primary Marketing locations, and a listing of
      the
      kinds of community service events the Contractor anticipates sponsoring and/or
      participating in for the purposes of providing information and/or distributing
      Marketing materials.

     

    6.
      The
      Contractor must describe how it is able to meet the informational needs, related
      to Marketing, for the physical and cultural diversity of Prospective Enrollees.
      This may include, but not be limited to: a description of the Contractor's
      provisions for Non-English speaking Prospective Enrollees, interpreter services,
      alternate communication mechanisms, including sign language, Braille, audio
      tapes, and/or use of Telecommunications Device for the Deaf (TDD)/TTY services
      and how the Contractor will make oral interpretation services available to
      Potential Enrollees and Enrollees free of charge.

     

    7.
      The
      Contractor shall describe measures for monitoring and enforcing compliance
      with
      these Guidelines by its Marketing Representatives and its Participating
      Providers including: the prohibition of door-to-door solicitation and cold-call
      telephoning; a description of the development of mailing lists of Prospective
      Enrollees that maintains client confidentiality and that honors the client's
      express request for direct contact by the Contractor; a description and planned
      means of distribution of pre-enrollment gifts and incentives to Prospective
      Enrollees; and a description of the training, compensation and supervision
      of
      its Marketing Representatives.

     

     

    APPENDIX
      D

    October
      1,2005 

    D-3

     

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

     

    D.2

    Marketing
      Materials

     

    1. Definition

     

    a)
      Marketing materials generally include the concepts of advertising, public
      service announcements, printed publications, and other broadcast or electronic
      messages designed to increase awareness and interest in the Medicaid Managed
      Care Program or the FHPlus Program and/or the Contractor's MMC or FHPlus
      product. The target audience for MMC Marketing materials is MMC Eligible Persons
      who are not enrolled in a MCO offering a MMC product and who are living in
      the
      Contractor's service area, if the Contractor offers a MMC product. The target
      audience for FHPlus Marketing materials is low-income uninsured people who
      do
      not qualify for Medicaid who are living in the Contractor's service area, if
      the
      Contractor offers a FHPlus product.

     

    b)
      Marketing materials include any information that references the MMC or FHPlus
      Program, is intended for general distribution, and is produced in a variety
      of
      print, broadcast, and direct Marketing mediums. These generally include: radio,
      television, billboards, newspapers, leaflets, informational brochures, videos,
      telephone book yellow page ads, letters, and posters. Additional materials
      requiring Marketing approval include a listing of items to be provided as
      nominal gifts or incentives.

     

    2.
      Marketing Material Requirements

     

    a)
      Marketing materials must be written in prose that is understood at a fourth-to
      sixth-grade reading level and must be printed in at least ten (10) point
      type.

     

    b)
      Marketing materials must be made available throughout the Contractor's entire
      service area. Materials may be customized for specific counties and populations
      within the Contractor's service area. All Marketing activities should provide
      for equitable distribution of materials without bias toward or against any
      group.

     

    c)
      The
      Contractor must make available written Marketing and other informational
      materials (e.g., member handbooks) in a language other than English whenever
      at
      least five percent (5%) of the Prospective Enrollees of the Contractor in any
      county of the service area speak that particular language and do not speak
      English as a first language. SDOH will inform the DOHMH and the DOHMH will
      inform the Contractor when the five percent (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 that
      are
      included within the Contractor's Marketing plan. SDOH will determine the need
      for other-than-English translations based on county-specific census data or
      other available measures.

     

    d)
      Alternate forms of communications must be provided for persons with visual,
      hearing, speech, physical, or developmental disabilities. These alternate
      forms

     

     

    APPENDIX
      D

    October
      1, 2005

    D-4

     

    
 


    include
      Braille or audiotapes for the visually impaired, TTY access for those with
      certified speech or hearing disabilities, and use of American Sign Language
      and/or integrative technologies.

     

    e)
      The
      Contractor's name, mailing address (and location, if different), and toll-free
      phone number must be prominently displayed on the cover of all multi-paged
      Marketing materials.

     

    f)
      Marketing materials must not contain false, misleading, or ambiguous
      information-such as "You have been pre-approved for the XYZ Health Plan," or
      "If
      you do not choose a plan you will lose your Medicaid coverage," or "You get
      free, unlimited visits." Materials must not use broad, sweeping statements.
      

     

    g)
      The
      material must accurately reflect general information, which is applicable to
      the
      average consumer of the MMC Program or FHPlus Program.

     

    h)
      The
      Contractor may not use logos or wording used by government agencies if such
      use
      could imply or cause confusion about a connection between a governmental agency
      and the Contractor.

     

    i)
      Marketing materials may not make reference to incentives that may be available
      to Enrollees after they enroll in the Contractor's MMC or FHPlus product, such
      as "If you join the XYZ Plan, you will receive a free baby carriage after you
      complete eight prenatal visits."

     

    j)
      Marketing materials that are prepared for distribution or presentation by the
      LDSS, Enrollment Broker, or SDOH-approved Enrollment Facilitators, must be
      provided in a manner that is easily understood and appropriate to the target
      audience. The material covered must include sufficient information to assist
      the
      individual in making an informed choice of MCO.

     

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

     

    1)
      Marketing materials shall not mention other MCOs offering MMC or FHPlus products
      by name except for materials approved by SDOH and developed to present available
      MCO choices in an unbiased manner, or as part of a transition of Enrollees
      from
      an MCO that withdraws from the MMC or FHPlus Program.

     

    3.
      Prior Approvals

     

    a)
      The
      SDOH, in consultation with DOHMH, will review and approve the Contractor's
      Marketing plan and all Marketing materials and advertising.

     

     

    APPENDIX
      D

    October
      1,2005 

    D-5


    


    i)
      The
      SDOH will coordinate its review and approval of materials that are specific
      to
      New York City with the DOHMH. :

     

    b)
      The
      SDOH will adhere to a sixty (60) day "file and use" policy, whereby materials
      submitted by the Contractor must be reviewed and commented on within sixty
      (60)
      days of submission or the Contractor may assume the materials have been approved
      if the reviewer has not submitted any written comment.

     

    


     

    4.
      Dissemination of Outreach Materials

     

    


    a)
      Upon
      request, the Contractor shall provide to the LDSS, Enrollment Broker and/or
      SDOH-approved Enrollment Facilitators, sufficient quantities of approved
      Marketing materials or alternative informational materials that describe
      coverage in the LDSS jurisdiction.

    


    b)
      The
      Contractor shall, upon request, submit to the DOHMH, LDSS, Enrollment Broker
      or
      SDOH-approved Enrollment Facilitators, current provider directories, as
      described in Section 13.2 of this Agreement, together with information that
      describes how to determine whether a provider is presently
      available.

    


    


    APPENDIX
      D

     October
      1 2005 

    D-6

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    



    D.3

    Marketing
      Activities

     

    1.
      Description and Requirements

     

    


    a)
      Marketing includes any occasion during which Marketing information and material
      regarding MMC and FHPlus Programs and information about the Contractor's MMC
      or
      FHPlus products are presented to Prospective Enrollees. Marketing activities
      include verbal presentations or distribution of written materials, which may
      or
      may not be accompanied by the giving away of nominal gifts.

    


    b)
      With
      prior DOHMH/LDSS approval, the Contractor may engage in Marketing activities
      that include community-sponsored social gatherings, provider-hosted
      informational sessions, or Contractor-sponsored events. Events may include
      such
      activities as health fairs workshops on health promotion, holiday parties,
      after
      school programs, raffles, etc. These events must not be restricted to Potential
      Enrollees.

    


    c)
      The
      Contractor may conduct media campaigns (i.e., distribution of
      information/materials regarding the MMC and/or FHPlus Programs and/or its
      specific MMC and/or FHPlus products to encourage Prospective Enrollees to enroll
      in its MMC or FHPlus product.) All media materials, including television, radio,
      billboards, subway and bus posters, and electronic messages, must be
      pre-approved by the SDOH at least thirty (30) days prior to the
      campaign.

     

    d)
      The
      Contractor will be forthright in its presentations to allow Prospective
      Enrollees to exercise an informed choice.

     

    e)
      If
      Contractor does not include Family Planning and Reproductive Health services
      in
      its Benefit Package, as specified in Appendix M of this Agreement, the Marketing
      Representative must tell Prospective 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)
      whenever needed, Family Planning and Reproductive Health services may be
      obtained by MMC Enrollees through fee-for-service Medicaid from any provider
      who
      accepts Medicaid, and by FHPlus Enrollees from the Designated Third-Party
      Contractor (including the name and phone number of the Designated Third Party
      Contractor for the Prospective Enrollee's geographic area);

     

    iii)
      no
      referral is needed for Family Planning and Reproductive Health services;
      and

     

    iv)
      there
      will be no cost to the Enrollee for Family Planning and Reproductive Health
      services.

    


    


    APPENDIX
      D 

    October
      1, 2005

    D-7

     

    



    2.
      Marketing Sites

     

    a)
      With
      prior DOHMH/LDSS approval, the Contractor may distribute approved Marketing
      material in such places as: an income support maintenance center, community
      centers, markets, pharmacies, hospitals and other provider sites, schools,
      health fairs, a resource center established by the LDSS or the Enrollment
      Broker, and other areas where Prospective Enrollees are likely to gather. The
      DOHMH/LDSS may require the Contractor to provide a minimum of two weeks notice
      to the DOHMH/LDSS regarding marketing at approved locations so that the
      DOHMH/LDSS may fulfill its role in monitoring Contractor marketing
      activities.

    


    b)
      The
      Contractor shall comply with the applicable restrictions on Marketing
      established in SSL § 364-j(4)(e), SSL § 369-ee and the SDOH Marketing
      Guidelines. The Contractor shall not engage in practices prohibited by law
      and
      regulation, including cold call Marketing or door-to-door solicitation. Cold
      Call Marketing means any unsolicited personal contact by the Contractor with
      a
      Prospective Enrollee for the purpose of Marketing. The Contractor shall not
      market to Prospective Enrollees at their homes without the permission of the
      Prospective Enrollee.

    


    c)
      The
      Contractor shall comply with LDSS written requirements regarding scheduling',
      staffing, and on-site procedures when marketing at LDSS sites.

    


    d)
      The
      Contractor shall neither conduct Marketing nor distribute Marketing materials
      in
      hospital emergency rooms, including emergency room waiting areas, patient rooms
      or treatment areas (except for waiting areas) or other sites as are prohibited
      by the Commissioner of Health pursuant to SSL § 364-j(4)(e) or SSL § 369-ee for
      FHPlus.

    


    e)
      The
      Contractor may not require its Participating Providers to distribute
      Contractor-prepared communications to their patients.

     

    f)
      The
      Contractor shall instruct its Participating Providers regarding the following
      requirements applicable to communications with their patients about the MMC
      and
      FHPlus products offered by the Contractor and other MCOs with which the
      Participating Providers may have contracts:

    


    i)
      Participating Providers who wish to let their patients know of their
      affiliations with one or more MCOs must list each MCO with whom they have
      contracts.

    


    ii)
      Participating Providers may display the Contractor's Marketing materials,
      provided that appropriate notice is conspicuously posted for all other MCOs
      with
      whom the Provider has a contract.

    


    iii)
      Upon
      termination of a Provider Agreement with the Contractor, a provider that has
      contracts with other MCOs that offer MMC or FHPlus products may notify his/her
      patients of the change in status and the impact of such change on the
      patient.

     

    APPENDIX
      D

    October
      1,2005 

    D-8

    



     

    3.
      Marketing Representatives

    


    a)
      The
      Contractor shall require its Marketing Representatives, including employees
      assigned to market its MMC and FHPlus products, and employees of Marketing
      subcontractors, to successfully complete a training program about the basic
      concepts of managed care and the Enrollee's rights and responsibilities relating
      to Enrollment in an MCO's MMC or FHPlus product. The Contractor shall submit
      a
      copy of the training curriculum for its Marketing Representatives to SDOH as
      part of the Marketing plan. The Contractor shall be responsible for the
      activities of its Marketing Representatives and the Marketing activities of
      any
      subcontractor or management entity.

    


    b)
      The
      Contractor shall ensure that its Marketing Representatives engage in
      professional and courteous behavior in their interactions with LDSS staff,
      staff
      from other health plans. Eligible Persons and Prospective Enrollees. The
      Contractor shall neither participate nor encourage nor accept inappropriate
      behavior by its Marketing Representatives, including but not limited to
      interference with other MCO presentations, talking negatively about another
      MCO,
      or participating in a Medicaid or FHPlus client's verification interview with
      LDSS staff.

    


    c)
      The
      Contractor shall not offer compensation to Marketing Representatives, including
      salary increases or bonuses, based solely on the number of individuals they
      enroll. However, the Contractor may base compensation of Marketing
      Representatives on periodic performance evaluations which consider Enrollment
      productivity as one of several performance factors during a performance period,
      subject to the following requirements:

    


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

     

    ii)
      The
      Contractor may not pay a "commission" or fixed amount per
      enrollment;

     

    


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

    


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

     

     

    APPENDIX
      D 

    October
      1,2005

    D-9

     

    



    4.
      Restricted Marketing Activities

     

    a)
      The
      Contractor shall not engage in the following practices:

    


    i)
      misrepresenting the Medicaid fee-for-service, MMC Program or FHPlus Program
      or
      the program or policy requirements of the LDSS or the SDOH, in Marketing
      encounters or materials;

    


    ii)
      purchasing or otherwise acquiring or using mailing lists of Eligible Persons
      from third party vendors, including providers and LDSS offices;

    


    iii)
      using raffle tickets or event attendance or sign-in sheets to develop mailing
      lists of Prospective Enrollees;

    


    iv)
      offering incentives (i.e., any type of inducement whose receipt is contingent
      upon the individual's Enrollment) of any kind to Prospective Enrollees to enroll
      in the Contractor's MMC or FHPlus product.

    


    b)
      The
      Contractor may 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 the Capitation Rate the Contractor will receive
      for
      such Eligible Person. Health assessments may not be performed by the Contractor
      prior to Enrollment. The Contractor may inquire about existing primary care
      relationships of the applicant and explain whether and how such relationships
      may be maintained. Upon request, each Prospective Enrollee shall be provided
      with a listing of all the Contractor's Participating Providers, including PCPs,
      specialists and facilities in the Contractor's network. The Contractor may
      respond to a Prospective Enrollee's question about whether a particular PCP,
      specialist or facility is a Participating Provider of the Contractor in the
      network. However, the Contractor shall not inquire about the types of
      specialists utilized by the Prospective Enrollee.

     

    c)
      The
      Contractor may offer nominal gifts of not more than five dollars ($5.00) in
      fair-market value as part of a health fair or other Marketing activity to
      stimulate interest in the MMC or FHPlus Program and/or the Contractor. Such
      gifts must be pre-approved by the SDOH, and offered without regard to
      Enrollment. The Contractor must submit a listing and description of intended
      items to be distributed at Marketing activities as nominal gifts, including
      a
      listing of item donors or co-sponsors for approval. The submission of actual
      samples or photographs of intended nominal gifts will not be routinely required,
      but must be made available upon request by the SDOH reviewer.

    


    d)
      The
      Contractor may offer its Enrollees rewards for completing a health goal, such
      as
      finishing all prenatal visits, participating in a smoking cessation session,
      attending initial orientation sessions upon enrollment, and timely completion
      of
      immunizations or other health related programs. Such rewards may not exceed
      fifty dollars ($50.00)

    


     

    APPENDIX
      D 

    October
      1,2005

    D-10

     

    



    in
      fair-market value per Enrollee over a twelve (12) month period, and must be
      related to a health goal. The Contractor may not make reference to these rewards
      in its pre-enrollment Marketing materials or discussions and all such rewards
      must be approved by the SDOH.

     

    APPENDIX
      D

    October
      1,2005

    D-ll

     

     

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

     

     

    Appendix
      E

     

     

     

    New
      York
      State Department of Health Member Handbook Guidelines

     

     

     

     

     

     

    APPENDIX 
      E 

    October
      1,2005 

    E-l

     

     

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    



    Member
      Handbook Guidelines

     

    1.
      Purpose

    


    a)
      This
      document contains Member Handbook guidelines for use
      by the
      Contractor to develop handbooks for MMC and FHPlus Enrollees covered under
      this
      Agreement.

    


    b)
      These
      guidelines reflect the review criteria used by the SDOH Office of Managed Care
      in its review of all MMC and FHPlus Member Handbooks. Member Handbooks and
      addenda must be approved by SDOH prior to printing and distribution by the
      Contractor.

     

    2.
      SDOH Model Member Handbook

     

    a)
      The
      SDOH Model Member Handbook includes all required information specified in this
      Appendix, written at an acceptable reading level. The Contractor may adapt
      the
      SDOH Model Member Handbook to reflect its specific policies and procedures
      for
      its MMC or FHPlus product.

    


    b)
      SDOH
      strongly recommends the Contractor use the SDOH Model Member Handbook language
      for the following required disclosure areas in the Contractor's Member
      Handbook:

     

    i)
      access
      to Family Planning and Reproductive Health services;

     

    ii)
      self
      referral policies;

     

    iii)
      obtaining OB/GYN services;

     

    iv)
      the
      definitions of medical necessity and Emergency Services;

    


    v)
      protocols for Action, utilization review, Complaints, Complaint Appeals, Action
      Appeals, External Appeals, and fair hearings;

     

    vi)
      protocol for newborn Enrollment; and

    


    vii)
      listing of Enrollee entitlements, including benefits, rights and
      responsibilities, and information available upon request.

    


    c)
      A copy
      of the SDOH Model Member Handbook is available from the SDOH Office of Managed
      Care, Bureau of Intergovernmental Affairs.

     

    


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    3.
      General Format

    


    a)
      It is
      expected that most MCOs will develop separate handbooks for their MMC and FHPlus
      Enrollees. The Contractor must include the required contents as per Section
      4 of
      this Appendix for both the MMC and FHPlus Programs, as applicable, and list
      the
      information available upon request in accordance with Section 5 of this Appendix
      in their Member Handbooks.

    


    b)
      The
      Contractor must write Member Handbooks in a style and reading level that will
      accommodate the reading skills of many MMC and FHPlus Enrollees. In general
      the
      writing should be at no higher than a sixth-grade level, taking into
      consideration the need to incorporate and explain certain technical or
      unfamiliar terms to assure accuracy. The text must be printed in at least
      ten-point font, preferably twelve-point font. The SDOH reserves the right to
      require evidence that a handbook has been tested against the sixth-grade
      reading-level standard. 

    


    c)
      The
      Contractor must make Member handbooks available in a language other than English
      whenever at least five percent (5%) of the Prospective Enrollees of the
      Contractor in any county in the Contractor's service area speak that particular
      language and do not speak English as a first language. Member handbooks must
      be'
      made accessible to non-English speaking and visually and hearing impaired
      Enrollees.

     

    4.
      Requirements for Handbook Contents

     

    a)
      General Overview (how the MMC or FHPlus product works)

    


    i)
      Explanation of the Contractor's MMC or FHPlus product, including what happens
      when an Eligible Person enrolls.

     

    ii)
      Explanation of the Contractor-issued Enrollee ID card, obtaining routine medical
      care, help by telephone, and general information pertaining to the Contractor's
      MMC or FHPlus product, i.e., location of the Contractor, providers,
      etc.

    


    iii)
      Invitation to attend scheduled orientation sessions and other educational and
      outreach activities.

     

    b)
      Provider Listings

    


    i)
      The
      Contractor may include the following information in the handbook, or as an
      insert to the handbook or produce this information as a separate document and
      reference such document in the handbook. 

    


    A)
      A
      current listing of providers, including facilities and site
      locations.

     

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      E 

    October
      1,2005 

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    B)
      Separate listings of Participating Providers that are Primary Care Providers
      and
      specialty providers; including location, phone number, and board certification
      status.

    


    C)
      Listing also must include a notice of how to determine if a Participating
      Provider is accepting new patients.

    


    c)
      Voluntary or Mandatory Enrollment - For MMC Program Only 

    i)
      Must
      indicate whether Enrollment is voluntary or mandatory.

    ii)
      If
      the Contractor offers a MMC product in both mandatory and voluntary counties,
      an
      explanation of the difference, i.e., Disenrollment rules, etc.

     

    d)
      Choice
      of Primary Care Provider

    


    i)
      Explanation of the role of PCP as a coordinator of care, giving some examples,
      and how to choose one for self and family.

    


    ii)
      How
      to make an appointment with the PCP, importance of base line physical,
      immunizations and
      well-child care.

     

    iii)
      Explanation of different types of PCPs, i.e., family practitioner, pediatrician,
      internist, etc.

    


    iv)
      Notification that the Contractor will assign the Enrollee to a PCP if one is
      not
      chosen in thirty (30) days.

     

    v)
      OB/GYN
      choice rules for women.

     

    e)
      Changing Primary Care Provider

    


    i)
      Explanation of the Contractor's policy, timeframes, and process related to
      an
      Enrollee changing his or her PCP. (Enrollees may change PCPs thirty (30) days
      after the initial appointment with their PCP, and the Contractor may elect
      to
      limit the Enrollee to changing PCPs without cause to once every six
      months.)

    


    ii)
      Explanation of process for changing OB/GYN when applicable. 

    iii)
      Explanation of requirements for choosing a specialist as PCP.

     

    f)
      Referrals to Specialists (Participating or Non-Participating)

    


    
      	i)  	
              Explanation
                of specialist care and how referrals are accomplished.
                

            


    

    
      	ii)  	
              Explanation
                of the process for changing
                specialists.

            


    

     

     

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      E

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      1,2005 

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    iii)
      Explanation of self-referral services, i.e., OB/GYN services, HIV counseling
      and
      testing, eye exams, etc. . ;

    


    iv)
      Notice that an Enrollee may obtain a referral to a Non-Participating Provider
      when the Contractor does not have a Participating Provider with appropriate
      training or experience to meet the needs of the Enrollee and the procedure
      for
      obtaining such referrals.

    


    v)
      Notice
      that an Enrollee with a condition that requires ongoing care from a specialist
      may request a standing referral to such a specialist and the procedure for
      obtaining such referrals.

    


    vi)
      Notice that an Enrollee with a life-threatening condition or disease or a
      degenerative and disabling condition or disease, either of which requires
      specialized medical care over a prolonged period of time, may request access
      to
      a specialist possessing the credentials to be responsible for providing or
      coordinating the Enrollee's medical care; and the procedure for obtaining such
      a
      specialist.

    


    vii)Notice
      that an Enrollee with a life-threatening condition or disease, or a'
      degenerative and disabling condition or disease, either of which requires
      specialized medical care over a prolonged period of time, may request access
      to
      a specialty care center; and the procedure for obtaining such
      access.

     

    g)
      Covered and Non-Covered Services

    


    i)
      Benefits and services covered by the Contractor's MMC or FHPlus product,
      including benefit maximums and limits.

    


    ii)
      Definition of medical necessity, as defined in this Agreement, and its use
      to
      determine whether benefits will be covered.

    


    iii)
      Medicaid covered services that are not covered by the Contractor's MMC product
      or are excluded from the MMC Program, and how to access these services. (MMC
      Program Member Handbooks only.)

    


    iv)
      A
      description of services not covered by MMC, Medicaid fee-for-service or the
      FHPlus Programs.

    


    v)
      Prior
      Authorization and other requirements for obtaining treatments and
      services.

    


    vi)
      Access to Family Planning and Reproductive Health services, and for MMC Program
      Member Handbooks, the Free Access policy for MMC Enrollees, pursuant to Appendix
      C of this Agreement.

     

     

    APPENDIX
      E

    October
      1,2005 

    E-5

     

     


    vii)
      HIV
      counseling and testing free access policy. (MMC Program Member Handbooks
      only.)

    


    viii)
      Direct access policy for dental services provided at Article 28 clinics operated
      by academic dental centers when dental is in the Benefit Package. (MMC Program
      Member Handbooks only.)

    


    ix)
      The
      Contractor's policy relating to emergent and non-emergent transportation,
      including who to call and what to do if the Contractor's MMC product does not
      cover emergent or non-emergent transportation. (MMC Program Member Handbooks
      only.)

    


    x)
      For
      FHPlus Program Member Handbooks, coverage of emergent transportation and what
      to
      do if needed.

    


    xi)
      Contractor's toll-free number for Enrollees to call for more information.


    xii)
      Any
      cost-sharing (e.g., copays for Contractor covered services). 

    h)
      Out of
      Area Coverage "

    Explanation
      of what to do and who to call if medical care is required when Enrollee is
      out
      of his or her county of fiscal responsibility or the Contractor's service
      area.

     

    i)
      Emergency and Post Stabilization Care Access

    


    i)
      Definition of Emergency Services, as defined in law and regulation, including
      examples of situations that constitute an emergency and situations that do
      not.

     

    ii)
      What
      to do in an emergency, including notice that services in a true emergency.
      are
      not subject to prior approval.

    


    iii)
      A
      phone number to call if the PCP is not available. iv) Explanation of what to
      do
      in non-emergency situations (PCP, urgent care, etc.).

    


    v)
      Locations where the Contractor provides Emergency Services and
      Post-stabilization Care Services.

    


    vi)
      Notice to Enrollees that in a true emergency they may access services at any
      provider of Emergency Services.

     

    vii)
      Definition of Post-Stabilization care services and how to access
      them.

     

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      E 

    October
      1,2005 

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    j)
      Actions and Utilization Review 

     

     

    i)
      Circumstances under which Actions and utilization review will be undertaken
      (in
      accordance with Appendix F of this Agreement).

     

    ii)
      Toll-free telephone number of the utilization review department or
      subcontractor.

    


    iii)
      Time
      frames in which Actions and UR determinations must be made for prospective,
      retrospective, and concurrent reviews.

     

    iv)
      Right
      to reconsideration.

     

    v)
      Right
      to file an Action Appeal, orally or in writing, including expedited and standard
      Action Appeals processes and the timeframes for Action Appeals.

     

    vi)
      Right
      to designate a representative.

    


    vii)A
      notice that all Adverse Determinations will be made by qualified clinical
      personnel and that all notices will include information about the basis of
      the
      determination, and further Action Appeal rights (if any). -

     

    k)
      Enrollment and Disenrollment Procedures

    


    i)
      Where
      appropriate, explanation of Lock-In requirements and when an Enrollee may change
      to another MCO, or for MMC Enrollees if permitted, return to Medicaid
      fee-for-service, for Good Cause, as defined in Appendix H of this
      Agreement.

     

    ii)
      Procedures for Disenrollment.

    


    iii)
      LDSS
      or Enrollment Broker as appropriate phone number for information on Enrollment
      and Disenrollment.

     

    1)
      Rights
      and Responsibilities of Enrollees

    


    i)
      Explanation of what an Enrollee has the right to expect from the Contractor
      in
      the way of medical care and treatment of the Enrollee as specified in Section
      13.7 of this Agreement.

     

    ii)
      General responsibilities of the Enrollee.

    


    iii)
      Enrollee's potential financial responsibility for payment when services are
      furnished by a Non-Participating Provider or are furnished by any provider
      without required authorization or when a procedure, treatment, or service is
      not
      a covered benefit. Also note exceptions such as family planning and HIV
      counseling/testing.

     

     

    APPENDIX
      E

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      1, 2005

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    iv)
      Enrollee's rights under State law to formulate advance directives.

    


    v)
      The
      manner in which Enrollees may participate in the development of Contractor
      policies.

     

    m)
      Language

     

    Description
      of how the Contractor addresses the needs of non-English speaking
      Enrollees.

     

    n)
      Grievance Procedures (Complaints)

    


    i)
      Right
      to file a Complaint regarding any dispute between the Contractor and an Enrollee
      (in accordance with Appendix F of the Agreement).

     

    ii)
      Right
      to file a Complaint orally.

     

    iii)
      The
      Contractor's toll-free number for filing oral Complaints.

     

    iv)
      Time
      frames and circumstances for expedited and standard Complaints.

    


    v)
      Right
      to appeal a Complaint determination and the procedures for filing a Complaint
      Appeal.

    


    vi)
      Time
      frames and circumstances for expedited and standard Complaint Appeals. vii)
      Right to designate a representative.

    


    viii)A
      notice that all determinations involving clinical disputes will be made by
      qualified clinical personnel and that all notices will include information
      about
      the basis of the determination, and further appeal rights (if any).

     

    ix)
      SDOH's toll-free number for medically related Complaints.

     

    x)
      New
      York State Insurance Department number for certain complaints relating to
      billing.

     

    o)
      Fair
      Hearing

    


    i)
      An
      explanation that the Enrollee has a right to a State fair hearing and aid to
      continue in some situations and that the Enrollee may be required to repay
      the
      Contractor for services received if the fair hearing decision is adverse to
      the
      Enrollee.

    


    ii)
      A
      description of situations when the Enrollee may ask for a fair hearing as
      described in Section 25 of this Agreement, including: a SDOH or LDSS decision
      about the Enrollee staying in or leaving the Contractor's MMC or FHPlus product;
      a Contractor determination that stops or limits Medicaid benefits; and a
      Contractor's Complaint determination that upholds a provider's decision not
      to
      order Enrollee-requested services.

     

     

    APPENDIX
      E

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    i)
      An
      explanation of how to request a fair hearing (assistance through member
      services, LDSS, State fair hearing contact).

     

    p)
      External Appeals

    


    i)
      A
      description of circumstances under which an Enrollee may request an External
      Appeal.

     

    ii)
      Timeframes for applying for External Appeal and for
      decision-making.

     

    iii)
      How
      and where to apply for an expedited appeal.

     

    iv)
      A
      description of the expedited External Appeal timeframe.

    


    v)
      The
      process for Contractor and Enrollee to agree on waiving the Contractor's
      internal UR Appeals process.

     

    q)
      Payment Methodologies

    


    Description
      prepared annually of the types of methodologies the Contractor uses to reimburse
      providers, specifying the type of methodology used to reimburse particular
      types
      of providers or for the provision of particular types of services.

     

    r)
      Physician Incentive Plan Arrangements

    


    The
      Member Handbook must contain a statement indicating the Enrollees and
      Prospective Enrollees are entitled to ask if the Contractor has special
      financial arrangements with physicians that can affect the use of referrals
      and
      other services that they might need and how to obtain this
      information.

     

    s)
      How
      and Where to Get More Information

     

    i)
      How to
      access a member services representative through a toll-free number.

    


    ii)
      How
      and when to contact LDSS for assistance. 

    


    5.
      Other Information Available Upon Enrollee's Request

    a)
      Information on the structure and operation of the Contractor's organization.
      List of the names, business addresses, and official positions of the membership
      of the board of directors, officers, controlling persons, owners or partners
      of
      the Contractor.

     

    APPENDIX
      E

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    b)
      Copy
      of the most recent annual certified financial statement of the Contractor,
      including a balance sheet and summary of receipts and disbursements prepared
      by
      a CPA.

     

    c)
      Copy
      of the most recent individual, direct pay subscriber contracts.

    


    d)
      Information relating to consumer complaints compiled pursuant to Section 210
      of
      the SIL.

    


    e)
      Procedures for protecting the confidentiality of medical records and other
      Enrollee information.

    


    f)
      Written description of the organizational arrangements and ongoing procedures
      of
      the Contractor's quality assurance program.

    


    g)
      Description of the procedures followed by the Contractor in making
      determinations about the experimental or investigational nature of medical
      devices, or treatments in clinical trials.

     

    h)
      Individual health practitioner affiliations with Participating
      hospitals.

    


    i)
      Specific written clinical review criteria relating to a particular condition
      or
      disease and, where appropriate, other clinical information which the Contractor
      might consider in its Service Authorization or utilization review
      process.

    


    j)
      Written application procedures and minimum qualification requirements for health
      care providers to be considered by the Contractor.

    


    k)
      Upon
      request, the Contractor is required to provide the following information on
      the
      incentive arrangements affecting Participating Providers to Enrollees, previous
      Enrollees and Prospective Enrollees:

    


    
      	i)  	
              Whether
                the Contractor's Provider Agreements or subcontracts include Physician
                Incentive Plans (PIP) that affect the use of referral
                services.

            


    

    ii)
      Information on the type of incentive arrangements used. 

    iii)
      Whether stop-loss protection is provided for physicians and physicians
      groups.

    iv)
      If
      the Contractor  is
      at substantial financial risk, as defined in the PIP regulations, a summary
      of
      the required customer satisfaction survey results.

     

     

    APPENDIX
      E

    October
      1, 2005

    E-10

     

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    APPENDIX
      F

     

     

     

    New
      York
      State Department of Health Action and Grievance System Requirements for MMC
      and
      FHPlus Programs

     

     

     

    F.I
      Action
      Requirements

    F.2
      Grievance System Requirements

     

     

    



     

     

    
      APPENDIX
        F

      October
        1,2005 

      F-1

       

       

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    F.I

     

    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,
      including a request for a referral or for 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 more of 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.

    


    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
      or
      an approval of a Service Authorization Request is in an amount, duration, or
      scope that is less than requested.

     

    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.

     

     

    APPENDIX
      F

    October
      1,2005 

    F-2

     

    



    2.
      General Requirements

    


    a)
      The
      Contractor's policies and procedures for Service Authorization Determinations
      and utilization review determinations shall comply with 42 CFR Part 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 may request 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 handle the request
      under standard review 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.

    


    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.

     

    3.
      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.

    


    b)
      For
      Concurrent Review 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:

     

    APPENDIX
      F

    October
      1, 2005

    F-3

     

     


    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 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.

    


    d)
      If the
      Contractor extended its- review as provided in paragraph 3(c) above, the
      Contractor must make a Service Authorization Determination arid notice 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.

    


    4.
      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

    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;

    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;

     

     

    APPENDIX
      F

    October
      1,2005 

    F-4

    



    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. 1 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 include 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
      right of the Enrollee to file a Complaint (as defined in Appendix F.2 of this
      Agreement)regarding the extension;

    E)
      the
      process for filing a Complaint with the Contractor and the timeframes within
      which a Complaint determination must be made;

    F)
      the
      right of an Enrollee to designate a representative to file a
      Complainton
      behalf
      of
      the Enrollee; and 

    G)
      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.2 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.

     

    


    APPENDIX
      F 

    October
      1, 2005

    F-5

     

    



    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 benefitsor
      for
      termination or reduction in benefits, as applicable, containing the Enrollee's
      fair hearing and aid continuing rights. 

    


    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/investigational;"

    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 an External Appeal.

     

    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;

    


    iii)
      the
      Contractor denies a claim for services provided by a Non-Participating Provider
      or 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 MMC or FHPlus coverage on the date of service;

     

     

    APPENDIX
      F

    October
      1, 2005

    F-6

     

    
 


    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;

    


    iii)
      if a
      duplicate claim is submitted by the Enrollee or a Participating Provider, 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 MMC Benefit Package and
      is
      provided to a MMC 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.

     

     

    APPENDIX
      F

    October
      1, 2005

    F-7

     

    


    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    


    F.2

     

    Grievance
      System Requirements

     

    


    1.
      Definitions

    


    a)
      A
      Grievance System means the Contractor's 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 Section 13.4 and 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.

     

     

    APPENDIX
      F

    October
      1,2005 

    F-8

    



    e)
      The
      Contractor's procedures for accepting Complaints, Complaint Appeals and Action
      Appeals shall include: 

     

    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;

     

    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 sixty (60) business
      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 25.4 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, signed, 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, modify if needed,
      sign 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

     

     

    APPENDIX
      F

    October
      1, 2005

    F-9

    



    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.

    


    iii)
      The
      Contractor must send a written acknowledgement of 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. 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
      determination.

     

    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.

     

    4.
      Timeframes for Resolution of Action Appeals

    


    a)
      The
      Contractor's Action Appeals process shall indicate the following specific
      timeframes regarding Action Appeal resolution:

     

     

    APPENDIX
      F

    October
      1,2005 

    F-10

    



    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 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.

    


    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.

    


    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
      right of the Enrollee to file a Complaint regarding the extension;

     

     

    APPENDIX
      F

    October
      1,2005

    F-ll

    



    E)
      the
      process for filing a Complaint with the Contractor and the timeframes within
      which a Complaint determination must be made;

    F)
      the
      right of an Enrollee to designate a representative to file a Complaint on behalf
      of the Enrollee; and 

    G)
      the
      right of the Enrollee to contact the New York State Department of Health
      regarding his or her their 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;

    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)
      aclear
      statement- that the notice constitutes the final adverse determination and
      specifically use the terms "medical necessity" or
      "experimental/investigational;"

    II)
      the
      Enrollee's coverage type;

    III)
      the
      procedure 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;

    VII)
      the
      contact person, telephone number, company name and full address of the
      utilization review agent, if the determination was made by the
      agent;

    and

    VIII)
      if
      the Contractor has a second level internal review process, the notice shall
      contain instructions on how to file a second level Action Appeal and a statement
      in bold text that the timeframe for requesting an External Appeal begins upon
      receipt of the final adverse determination of the first level Action Appeal,
      regardless of whether or not a second level of Action Appeal is requested,
      and
      that by choosing to request a second level Action Appeal, the time may expire
      for the Enrollee to request an External appeal.

     

    APPENDIX
      F

    October
      1,2005

     F-12

    



    6.
      Complaint Process

    


    a)
      The
      Contractor' Complaint process shall include the following regarding the handling
      of Enrollee Complaints:

    


    i)
      The
      Enrollee, or his or her designee, may file a Complaint regarding any dispute
      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 included in the Contractor's quarterly HPN Complaint report
      submitted 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.

    


    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.

     

     

    APPENDIX
      F

    October
      1, 2005

    F-13



    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 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.

    


    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

     

    a)
      The
      Contractor's procedures regarding Enrollee Complaint Appeals shall include
      the
      following:

     

    i)
      The
      Enrollee or designee has no less than sixty (60) business days after receipt
      of
      the notice of the Complaint determination to file a written Complaint Appeal.
      Complaint Appeals may be submitted by letter or by a form provided by the
      Contractor.

     

    ii)
      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.

    


    iii)
      Complaint Appeals of clinical matters must be decided by personnel qualified
      to
      review the Appeal, including licensed, certified or registered health
      care

     

     

    APPENDIX
      F

    October
      1, 2005

    F-14

    



    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).

     

    iv)
      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.

     

    v)
      Complaint Appeals shall be decided and notification provided to the Enrollee
      no
      more than:

    


    A)
      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

    B)
      thirty
      (30) business days after the receipt of all necessary information in all other
      instances.

     

    vi)
      The
      notice of the Contractor's Complaint Appeal determination shall
      include:

    


    A)
      the
      detailed reasons for the determination;

    B)
      the
      clinical rationale for the determination in cases where the determination has
      a
      clinical basis;

    C)
      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;

    D)
      instructions for any further Appeal, if applicable.

     

    10. Records

     

    a)
      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:

     

    i)
      date
      the Complaint was filed;

     

    ii)
      copy
      of the Complaint, if written;

     

    iii)
      date
      of receipt of and copy of the Enrollee's written confirmation, if
      any;

    


    iv)
      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;

     

    v)
      date
      and copy of the Enrollee's Action Appeal or Complaint Appeal;

     

    vi)
      Enrollee or provider requests for expedited Action Appeals and
      Complaint

    Appeals
      and the Contractor's determination;

     

    vii)
      necessary documentation to support any extensions;


     

    APPENDIX
      F

    October
      1, 2005

    F-15

    



    viii)
      determination and date of determination of the Action Appeals and Complaint
      Appeals;

    


    ix)
      the
      titles and credentials of clinical staff who reviewed the Action Appeals and
      Complaint Appeals; and

     

    x)
      Complaints unresolved for greater than forty-five (45) days.

     

     

    APPENDIX
      F

    October
      1,2005

    F-16

     

     

    
      
        
        

      

      
        
        

      

      
        
          

        

      

       

       

       

      APPENDIX
        G

       

       

      SDOH
        Requirements For The Provision Of Emergency Care and Services

       

       

       

       

       

       

       

       

       

      APPENDIX
        G

      October
        1, 2005

      G-l

    

     

     

    
 

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    


    SDOH
      Requirements for the Provision of Emergency Care and
      Services

     

    1. Definitions

     

    a)
      "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 pregnant woman, the health of the woman or her
      unborn child 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.

     

    


     

    b)
      "Emergency Services"
      means
      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.

    


    c)
      "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, under the circumstances described in Section 3 below, to improve or resolve
      the Enrollee's condition.

     

    2.
      Coverage and Payment of Emergency Services

    


    a)
      The
      Contractor must cover and pay for Emergency Services regardless of whether
      the
      provider that furnishes the services has a contract with the
      Contractor.

    


    b)
      The
      Contractor must advise Enrollees that they may access Emergency Services at
      any
      Emergency Services provider.

    


    c)
      Prior
      authorization for treatment of an Emergency Medical Condition is never
      required.

    


    APPENDIX
      G 

    October
      1.2005

    G-2

     

    



    d)
      The
      Contractor may not deny payment for treatment obtained in either of the
      following circumstances:

    


    i)
      An
      Enrollee had an Emergency Medical Condition, including cases in which the
      absence of immediate medical attention would not have had the outcomes specified
      in the definition of Emergency Medical Condition above.

    


    ii)
      A
      representative of the Contractor instructs the Enrollee to seek Emergency
      Services.

     

    e)
      A
      Contractor may not:

    


    i)
      limit
      what constitutes an Emergency Medical Condition based on lists of diagnoses
      or
      symptoms; or

    


    ii)
      refuse to cover emergency room services based on the failure of the provider,
      or
      the Enrollee to give the Contractor notice of the emergency room
      visit.

    


    f)
      An
      Enrollee who has an Emergency Medical Condition may not be held liable for
      payment of subsequent screening and treatment needed to diagnose the specific
      condition or stabilize the patient.

     

    g)
      The
      attending emergency physician, or the provider actually treating the Enrollee,
      is responsible for determining when the Enrollee is sufficiently stabilized
      for
      transfer or discharge, and that determination is binding on the Contractor
      for
      payment.

     

    3.
      Coverage and Payment of Post-stabilization Care
      Services

     

    a)
      The
      Contractor is financially responsible for Post-stabilization Care Services
      furnished by a provider within or outside the Contractor's network
      when:

     

    i)
      they
      are pre-approved by a Participating Provider, as authorized by the Contractor,
      or other authorized Contractor representative;

    


    ii)
      they
      are not pre-approved by a Participating Provider, as authorized by the
      Contractor, or other authorized Contractor representative, but administered
      to
      maintain the Enrollee's stabilized condition within one
      [1} hour
      of a request to the Contractor for pre-approval of further Post-stabilization
      Care Services;

    


    iii)
      they
      are not pre-approved by a Participating Provider, as authorized by the
      Contractor, or other authorized Contractor representative, but administered
      to
      maintain, improve or resolve the Enrollee's stabilized condition
      if:

    


    A)
      The
      Contractor does not respond to a request for pre-approval within one
      (1)
      hour;

    B)
      The
      Contractor cannot be contacted; or

     

    APPENDIX
      G 

    October
      1, 2005

    G-3

    



    C)
      The
      Contractor's representative and the treating physician cannot reach an agreement
      concerning the Enrollee's care and a plan physician is not available for
      consultation. In this situation, the Contractor must give the treating physician
      the opportunity to consult with a plan physician and the treating physician
      may
      continue with care of the patient until a plan physician is reached or one
      of
      the criteria in 3(b) is met.

    


    iv)
      The
      Contractor must limit charges to Enrollees for Post-stabilization Care Services
      to an amount no greater than what the organization would charge the Enrollee
      if
      he or she had obtained the services through the Contractor.

    


    b)
      The
      Contractor's financial responsibility to the treating emergency provider for
      Post-stabilization Care Services it has not pre-approved ends when:

    


    i)
      A plan
      physician with privileges at the treating hospital assumes responsibility for
      the Enrollee's care;

     

    ii)
      A
      plan physician assumes responsibility for the Enrollee's care through
      transfer;

    


    iii)
      A
      Contractor representative" and the treating physician reach an agreement
      concerning the Enrollee's careor

     

    iv)
      The
      Enrollee is discharged.

     

    4.
      Protocol for Acceptable Transfer Between Facilities

     

    a)
      All
      relevant COBRA requirements must be met.

     

    b)
      The
      Contractor must provide for an appropriate (as determined by the emergency
      department physician) transfer method/level with personnel as
      needed.

    c)
      The
      Contractor must contact/arrange for an available, accepting physician and
      patient bed at the receiving institution.

    d)
      If a
      patient is not transferred within eight (8) hours to an appropriate inpatient
      setting after the decision to admit has been made, then admission at the
      original facility is deemed authorized.

     

    5.
      Triage Fees

    


    For
      emergency room services that do not meet the definition of Emergency Medical
      Condition, the Contractor shall pay the hospital a triage fee of $40.00 in
      the
      absence of a negotiated rate.

     

     

    APPENDIX,
      G

    October
      1.2005

    G-4

     

    



    6.
      Emergency Transportation

    


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

     

    APPENDIX
      G 

    October
      1,2005 

    G-5

     

    


     

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    



    APPENDIX
      H

     

     

     

     

    New
      York
      State Department of Health Requirements 

    for
      the
      Processing of Enrollments and DisenroIIments 

    in
      the
      MMC and FHPlus Programs

     

     

     

     

     

     

     

     

     

     

    APPENDIX
      H 

    October
      1, 2005

     

     

     

     

    
 

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    
 

    SDOH
      Requirements 

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

     

    1. General

     

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

     

    2. Enrollment

     

    a)
      SDOH
      Responsibilities:

    


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

    


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

     

    b)
      LDSS
      Responsibilities:

     

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

    


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

    


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

     

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

    


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

     

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

     

    


    APPENDIX
      H 

    October
      1. 2005 

    H-2

     

    



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

    


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

    


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

    


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

    


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

    


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

    


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

    


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

     

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

    


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

     

     

    APPENDIX
      H

    October
      1
      - 2005

    H-3

    



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

     

    A)
      LDSS
      directly enters data into PCP Subsystem; or

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

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

    


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

     

    A)
      For
      mandatory MMC program only - Initial Notification Letter: This letter informs
      Eligible Persons about the mandatory MMC program and the timeframes for choosing
      a MCO offering a MMC product. Included with the letter are managed care
      brochures, an Enrollment form, and information on their rights and
      responsibilities under this program, including the option for HIV/AIDS infected
      individuals who are categorically exempt from the mainstream MMC program to
      enroll in an HIV SNP on a voluntary basis in LDSS jurisdictions where HIV SNPs
      exist.

     

    B)
      For
      mandatory MMC program only - Reminder Letter: A letter to all Eligible Persons
      in a mandatory category who have not responded by submitting a completed
      Enrollment form within thirty (30) days of being sent or given an Enrollment
      packet.

     

    C)
      For
      MMC program - Enrollment Confirmation Notice for MMC Enrollees: This notice
      indicates the Effective Date of Enrollment, the name of the MCO and all
      individuals who are being enrolled. This notice should also be used for case
      additions and re-enrollments into the same MCO. There is no requirement that
      an
      Enrollment Confirmation Notice be sent to FHPlus Enrollees.

    


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

     

    E)
      For
      MMC program only - Exemption Request Forms: Exemption forms are provided to
      MMC
      Eligible Persons upon request if they wish to apply for an Exemption.
      Individuals pre-coded on the system as meeting Exemption or Exclusion criteria
      do not need to complete an Exemption request form. This notice is required
      for
      mandatory MMC Eligible Persons.

    


     

    APPENDIX
      H 

    October
      1. 2005

    H-4

     

    



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

     

    c)
      Contractor Responsibilities:

     

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

     

    ii)
      The
      Contractor must notify new MMC and FHPlus Enrollees of their Effective Date
      of
      Enrollment. In the event that the actual Effective Date of Enrollment is
      different from that previously, given to the Enrollee, the Contractor must
      notify the Enrollee of the actual date of Enrollment. This may be accomplished
      through a Welcome Letter. To the extent practicable, such notification must
      precede the Effective Date of Enrollment.

     

    iii)
      The
      Contractor must report any changes in status for its enrolled members to the
      LDSS within five (5) business days of such information becoming known to the
      Contractor. This includes, but is not limited to, factors that may impact
      Medicaid or FHPlus eligibility such as address changes, verification of
      pregnancy, incarceration, third party insurance, etc.

     

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

     

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

     

    3.
      Newborn Enrollments

    


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

     

     

    APPENDIX
      H 

    October
      1. 2005

    H-5

     

    



    b)
      SDOH
      Responsibilities:

    


    i)
      The
      SDOH will update WMS with information on the newborn received from hospitals,
      consistent with the requirements of Section 366-g of the SSL as amended by
      Chapter 412 of the Laws 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 and enroll the newborn
      in
      the mother's MCO if the newborn is not already enrolled, the mother's MCO offers
      a MMC product, and the newborn is not identified as SSI or SSI-related and
      therefore Excluded from the MMC Program pursuant to Section 2(b)(xi) of this
      Appendix. The newborn will be retroactively enrolled back to the first
      (1st)
      day of
      the month of birth. Based on the transaction date of the Enrollment of the
      newborn on the PCP subsystem, the newborn will appear on either the next month's
      Roster or the subsequent month's Roster. On Rosters for upstate and NYC, the
      "PCP Effective From Date" will indicate the first day of the month of birth,
      as
      described in 01 OMM/ADM 5 "Automatic Medicaid Enrollment for Newborns." If
      the
      newborn's Enrollment is not completed by this process, the LDSS is responsible
      for Enrollment (see (c)(iv) below).

     

    c)
      LDSS
      Responsibilities:

     

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

    


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

    


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

    


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

     

    d)
      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

     

    
      APPENDIX
        H 

    

    October
      1. 2005

    H-6

     

    
 


    pregnant
      woman's name, Client ID Number (CIN), and the expected date of confinement
      (EDC). 

     

    


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

    


    iii)
      In
      districts that use an Enrollment Broker, the Contractor shall not submit
      electronic Enrollments of newborns to the Enrollment Broker, as this will
      interfere with the retroactive Enrollment of the newborn back to the first
      (1st)
      day of
      the month of birth. For newborns whose mothers are not enrolled in the
      Contractor's MMC or FHPlus product and who were not pre-enrolled into the
      Contractor's MMC product as unborns, the Contractor may submit electronic
      Enrollment of the newborns to the Enrollment Broker. In such cases, the
      Effective Date of Enrollment will be prospective.

    


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

     

    v)
      The
      Contractor is responsible for provision of services to a newborn and payment
      of
      the hospital or birthing center bill if the mother is an Enrollee at the time
      of
      the newborn's birth, even if the newborn is not yet on the Roster, unless the
      Contractor does not offer a MMC product in the mother's county of fiscal
      responsibility or the newborn is Excluded from the MMC Program pursuant to
      Section 2(b)(xi) of this Appendix.

     

    vi)
      Within fourteen (14) days of the date on which the Contractor becomes aware
      of
      the birth, the Contractor will issue a letter, informing parent(s) about the
      newborn's Enrollment and how to access care, or a member identification
      card.

    


    vii)In
      those cases in which the Contractor is aware of the pregnancy, the Contractor
      will ensure that enrolled pregnant women select a PCP for their infants prior
      to
      birth.

    


    viii)The
      Contractor will ensure that the newborn is linked with a PCP prior to discharge
      from the hospital or birthing center, in those instances in which the Contractor
      has received appropriate notification of birth prior to discharge.

     

    APPENDIX
      H 

    October
      1. 2005

    H-7

     

    



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

    


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

     

    b)
      SDOH
      Responsibilities:

     

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

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

     

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

     

    c)
      LDSS
      Responsibilities:

     

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

    


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

     

    d)
      Contractor Responsibilities:

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

     

    5.
      Roster Reconciliation:

     

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

     

    b)
      SDOH
      Responsibilities:

    


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

     

    
       

      APPENDIX
        H 
October
      1. 2005

    H-8

    



    A)
      SDOH
      shall send the Contractor and LDSS monthly (according to a schedule established
      by SDOH), a complete list of all Enrollees for which the Contractor is expected
      to assume medical risk beginning on the 1st
      of the
      following month (First Monthly Roster). Notification to the Contractor and
      LDSS
      will be accomplished via paper transmission, magnetic media, or the
      HPN.

     

    B)
      SDOH
      shall send the Contractor and LDSS monthly, at the time of the first monthly
      roster production, a Disenrollment Report listing those Enrollees from the
      previous month's roster who were disenrolled, transferred to another MCO, or
      whose Enrollments were deleted from the file. Notification to the Contractor
      and
      LDSS will be accomplished via paper transmission, magnetic media, or the
      HPN.

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

     

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

     

    c)
      LDSS
      Responsibilities:

     

    i)
      The
      LDSS is responsible for notifying the Contractor electronically or in writing
      of
      changes in the Roster and error report, no later than the end of the month.
      (Note: To the extent practicable the date specified must allow for timely notice
      to Enrollees regarding their Enrollment status. The Contractor and the LDSS
      may
      develop protocols for the purpose of resolving Roster discrepancies that remain
      unresolved beyond the end of the month.)

     

    


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

     

    d)
      Contractor Responsibilities:

     

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

     

    


    ii)
      The
      Contractor must submit claims to the State's Fiscal Agent for all Eligible
      Persons that are on the 1st
      and
      2nd
      Rosters,
      adjusted to add Eligible Persons enrolled by the LDSS after Roster production
      and to remove individuals

     

    
      APPENDIX   H

    

    October
      1. 2005 

    H-9

    



    disenrolled
      by LDSS after Roster production (as notified td the Contractor). In the cases
      of
      retroactive Disenrollments, the Contractor is responsible for submitting an
      adjustment to void any previously paid premiums for the period of retroactive
      Disenrollment, where the Contractor was not at risk for the provision of Benefit
      Package services. Payment of subcapitation does not constitute "provision of
      Benefit Package services."

     

    6.
      Disenrollment:

     

    a)
      LDSS
      Responsibilities:

    


    i)
      The
      LDSS is responsible for accepting requests for Disenrollment directly from
      Enrollees and may not require Enrollees to approach the Contractor for a
      Disenrollment form. Where an LDSS is authorized to mandate Enrollment, all
      requests for Disenrollment must be directed to the LDSS or the Enrollment
      Broker. The LDSS and the Enrollment Broker must utilize the State-approved
      Disenrollment forms.

     

    ii)
      Enrollees may initiate a request for an expedited Disenrollment to the LDSS.
      The
      LDSS will expedite the Disenrollment process in those cases where an Enrollee's
      request for Disenrollment involves an urgent medical need, a complaint of
      non-consensual Enrollment or, in local districts where homeless individuals
      are
      exempt, homeless individuals in the shelter system. If approved, the LDSS will
      manually process the Disenrollment through the PCP Subsystem. MMC Enrollees
      who
      request to be disenrolled from managed care based on their documented HIV,
      ESRD,
      or SPMI/SED status are categorically eligible for an expedited Disenrollment
      on
      the basis of urgent medical need.

    


    iii)
      The
      LDSS is responsible for processing routine Disenrollment requests to take effect
      on the first (1st)
      day of
      the following month if the request is madebefore
      the
      fifteenth (15th)
      day of
      the month. In no event shall the Effective Date of Disenrollment be later than
      the first (1st)
      day of
      the second month after the month in which an Enrollee requests a
      Disenrollment.

    


    iv)
      The
      LDSS is responsible for disenrolling Enrollees automatically upon death or
      loss
      of Medicaid or FHPlus eligibility. All such Disenrollments will be effective
      at
      the end of the month in which the death or loss of eligibility occurs or at
      the
      end of the last month of Guaranteed Eligibility, where applicable.

    


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

     

     

    APPENDIX
      H 

    October
      1. 2005

    H-10

     

    


    A)
      The
      Contractor has failed to furnish accessible and appropriate medical care
      services or supplies to which the Enrollee is entitled under the terms of the
      contract under which the Contractor has agreed to provide services. This
      includes, but is not limited to the failure to:

    


    I)
      provide primary care services;

    II)
      arrange for in-patient care, consultation with specialists, or laboratory and
      radiological services when reasonably necessary;

    III)
      arrange for consultation appointments;

    IV)
      coordinate and interpret any consultation findings with emphasis on continuity
      of medical care;

    V)
      arrange for services with qualified licensed or certified
      providers;

    VI)
      coordinate the Enrollee's overall medical care such as periodic immunizations
      and diagnosis and treatment of any illness or injury; or

    


    B)
      The
      Contractor cannot make a Primary Care Provider available to the Enrollee within
      the time and distance standards prescribed by SDOH; or

    


    C)
      The
      Contractor fails to adhere to the standards prescribed by SDOH and such failure
      negatively and specifically impacts the Enrollee; or

    


    D)
      The
      Enrollee moves his/her residence out of the Contractor's service area or to
      a
      county where the Contractor does not offer the product the Enrollee is eligible
      for; or

    E)
      The
      Enrollee meets the criteria for an Exemption or Exclusion as set forth in
      2(b)(xi) of this Appendix; or

     

    F)
      It is
      determined by the LDSS, the SDOH, or its agent that the Enrollment was not
      consensual;or

     

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

     

    H)
      The
      Contractor is a primary care partial capitation provider that does not have
      a
      utilization review process in accordance with Title I of Article 49 of the
      PHL
      and the Enrollee requests Enrollment in an MCO that has such a utilization
      review process; or

    


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

    


     

    


    APPENDIX
      H 

    October
      1. 2005 

    H-ll

    



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

     

    K)
      An
      FHPlus Enrollee is pregnant.

    


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

    


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

    


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

    


    ix)
      The
      LDSS is responsible for ensuring that retroactive Disenrollments are used only
      when absolutely necessary. Circumstances warranting a retroactive Disenrollment
      are rare and include when an Enrollee is determined to have been
      non-consensually enrolled in a MCO; he or she enters or resides in a residential
      institution under circumstances which render the individual Excluded from the
      MMC program; is incarcerated; is an SSI infant less than six (6) months of
      age;
      is simultaneously in receipt of comprehensive health care coverage from a MCO
      and is Enrolled in either the MMC or FHPlus product of the same MCO; it is
      determined that an Enrollee with more than one Client Identification Number
      (CIN) is enrolled in a MCO's MMC or FHPlus product under more than one of the
      CINs; or he or she died - as long as the Contractor was not at risk for
      provision of Benefit Package services for any portion of the retroactive period.
      Payment of subcapitation does not constitute "provision of Benefit Package
      services." The LDSS is responsible for notifying the Contractor of the
      retroactive Disenrollment prior to the action. The LDSS is responsible for
      finding out if the Contractor has made payments to providers on behalf of the
      Enrollee prior to Disenrollment. After this information is obtained, the LDSS
      and Contractor will agree on a retroactive Disenrollment or prospective
      Disenrollment date. In all cases of retroactive Disenrollment, including
      Disenrollments effective the first day of the current month, the LDSS is
      responsible for sending notice to the Contractor at the time of Disenrollment,
      of the Contractor's responsibility to submit to the SDOH's Fiscal Agent voided
      premium claims 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.

    


     

    APPENDIX
      H 

    October
      1. 2005

    H-12

    


     

    


     

    x)
      Generally the effective dates of Disenrollment are prospective. Effective dates
      for other than routine Disenrollments are described below: 

     

    
      
        	
                Reason
                  for Disenrollment

              	
                Effective
                  Date of Disenrollment

              
	
                A)
                  Infants weighing less than 1200 grams at birth and other infants
                  under six
                  (6) months of age who meet the criteria for the SSI or SSI related
                  category

              	
                First
                  Day of the month of birth or the month of onset of disability,
                  whichever
                  is later

              
	
                B)
                  Death of Enrollee

              	
                First
                  day of the month after death

              
	
                C)
                  Incarceration

              	
                First
                  day of the month of incarceration (note-Contractor is at risk for
                  covered
                  services only to the date of incarceration and is entitled to the
                  capitation payment for the month of incarceration)

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

              	
                First
                  day of the month of entry or first day of the month of classification
                  of
                  the stay as permanent subsequent to entry (note-Contractor is at
                  risk for
                  covered services only to the date of entry or classification of
                  the stay
                  as permanent subsequent to entry, and is entitled to the capitation
                  payment for the month of entry or classification of the stay as
                  permanent
                  subsequent to entry) 

              
	
                E)
                  Individual's effective date of Enrollment or autoassignment into
                  a MMC
                  product occurred while meeting institutional criteria in (D)
                  above

              	
                Effective
                  Date of Enrollment in the Contractor's Plan

              
	
                F)
                  Non-consensual Enrollment

              	
                Retroactive
                  to the first day of the month of Enrollment

              
	
                G)
                  Enrollee moved outside of the District/County of Fiscal
                  Responsibility

              	
                First
                  day of the month after the update of the

                system
                  with the new address '

              
	
                H)
                  Urgent medical need

              	
                First
                  day of the next month after determination except where medical
                  need
                  requires an earlier Disenrollment

              
	
                I)
                  Homeless Enrollees in Medicaid Managed Care residing in the shelter
                  system
                  in NYC or in other districts where homeless individuals are
                  exempt

              	
                Retroactive
                  to the first day of the month of the request

              
	
                J)
                  Individual is simultaneously in receipt of comprehensive health
                  care
                  coverage from an MCO and is Enrolled in either the MMC or FHPlus
                  product
                  of the same MCO

              	
                First
                  day of the month after simultaneous coverage began

              
	
                K)
                  An Enrollee with more than one Client Identification Number (CIN)
                  is
                  enrolled in an MCO's MMC or FHPlus product under more than one
                  of the
                  CINs

              	
                First
                  day of the month the duplicate Enrollment
                  began

              


      

    

     

     

     

    '
      In
      counties outside of New York City, LDSSs should work together to ensure
      continuity of care through the Contractor if the Contractor's service area
      includes the county to which the Enrollee has moved and the Enrollee, with
      continuous eligibility, wishes to stay enrolled in the Contractor's MMC or
      FHPlus product. In New York City, Enrollees, not in guaranteed status, who
      move
      out of the Contractor's Service Area but not outside of the City of New York
      (e.g., move from one borough to another), will not be involuntarily disenrolled,
      but must request a Disenrollment or transfer. These Disenrollments will be
      performed on a routine basis unless there is an urgent medical need to expedite
      the Disenrollment.

     

    


     

    APPENDIX
      H

    October
      1. 2005 

    H-14

     

     


    xi)
      The
      LDSS is responsible for rendering a determination and responding within thirty
      (30) days of the receipt of a fully documented request for Disenrollment, except
      for Contractor-initiated Disenrollments where the LDSS decision must be made
      within fifteen (15) days. The LDSS, to the extent possible, is responsible
      for
      processing an expedited Disenrollment within two (2) business days of its
      determination that an expedited Disenrollment is warranted.

     

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

    


    xiii)
      The
      LDSS is responsible for sending the following notices to Enrollees regarding
      their Disenrollment status. Where practicable, the process will allow for timely
      notification to Enrollees unless there is Good Cause to disenroll more
      expeditiously.

    


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

    


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

    


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

    


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

    


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

     

     

    APPENDIX
      H

    October
      1, 2005 

    H-15

    



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

     

    xvi)
      The
      LDSS is responsible for reviewing each Contractor-requested Disenrollment in
      accordance with the provisions of Section 8.7 of this Agreement and this
      Appendix. Where applicable, the LDSS may consult with local mental health and
      substance abuse authorities in the district when making the determination to
      approve or disapprove the request.

    


    xvii)
      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.

    


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

     

    b)
      Contractor Responsibilities:

     

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

     

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

    


    iii)
      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
      Enrollees that may impact eligibility for Enrollment such as address changes,
      incarceration, death, Exclusion from the MMC program, etc.

     

    iv)
      Pursuant to Section 8.7 of this Agreement, the Contractor may initiate an
      involuntary Disenrollment if the Enrollee engages in conduct or behavior that
      seriously impairs the Contractor's ability to furnish services to either the
      Enrollee or other Enrollees, provided that the Contractor has made and
      documented reasonable efforts to resolve the problems presented by the
      Enrollee

     

     

    APPENDIX
      H

    October
      1, 2005 

    H-16

    



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

    


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

    


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

    


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

     

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

     

     

    APPENDIX
      H

    October
      1, 2005 

    H-17

     

     

     

    
 

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

     

     

     APPENDIX
      I

     

     

     

     

    New
      York
      State Department of Health Guidelines for 

    Use
      of
      Medical Residents and Fellows

     

     

     

     

     

     

     

     

     

     

    APPENDIX
      I 

    October
      1, 2005

    1-1

     

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    Medical
      Residents and Fellows 

     

     

     

    1. Medical Residents and Fellows for Primary Care

     

    a)
      The
      Contractor may utilize medical residents and fellows as participants (but not
      designated as 'primary care providers') in the care of Enrollees as long as
      all
      of the following conditions are met:

    


    i)
      Residents/fellows are a part of patient care teams headed by fully licensed
      and
      Contractor credentialed attending physicians serving patients in one or more
      training sites in an "up weighted" or "designated priority" residency program.
      Residents/fellows in a training program which was disapproved as a designated
      priority program solely due to the outcome measurement requirement for graduates
      may be eligible to participate in such patient care teams.

    


    ii)
      Only
      the attending physicians and certified nurse practitioners on the training
      team,
      not residents/fellows, may be credentialed to the Contractor and may be
      empanelled with Enrollees. Enrollees must be assigned an attending physician
      or
      certified nurse practitioner to act as their PCP, though residents/fellows
      on
      the team may provide care during all or many of the visits to the Enrollee
      as
      long as the majority of these visits are under the direct supervision of the
      Enrollee's designated PCP. Enrollees have the right to request and receive
      care
      by their PCP in addition or instead of being seen by a resident or
      fellow.

     

    iii)
      Residents/fellows may work with attending physicians and certified nurse
      practitioners to provide continuity of care to patients under the supervision
      of
      the patient's PCP. Patients must be made aware of the resident/fellow and
      attending PCP relationship and be informed of their rights to be cared for
      directly by their PCP.

     

    iv)
      Residents/fellows eligible to be involved in a continuity relationship with
      patients must be available at least twenty percent (20%) of the total training
      time in the continuity of care setting and no less than ten percent (10%) of
      training time in any training year must be in the continuity of care setting
      and
      no fewer than nine (9) months a year must be spent in the continuity of care
      setting.

    


    v)
      Residents/fellows meeting these criteria provide increased capacity for
      Enrollment to their team according to the formula below. Only hours spent
      routinely scheduled for patient care in the continuity of care training site
      may
      count as providing capacity and are basedon
      1.0
      FTE=40
      hours.

    


    PGY-1
        300perFTE
      

    PGY-2
        750
      per
      FTE

    PGY-3
        1125
      per
      FTE 

    PGY-4
      and
      above  1500
      per
      FTE

    


     

    APPENDIX
      1 

    October
      1, 2005

    I-2

     

    



    vi)
      In
      order for a resident/fellow to provide continuity of care to an Enrollee, both
      the resident/fellow and the attending PCP must have regular hours in the
      continuity site and must be scheduled to be in the site together the majority
      of
      the time.

    


    vii)A
      preceptor/attending is required to be present a minimum of sixteen (16) hours
      of
      combined precepting and direct patient care in the primary care setting to
      be
      counted as a team supervising PCP and accept an increased number of Enrollees
      based upon the residents/fellows working on his/her team. Time spent in patient
      care activities at other clinical sites or in other activities off-site is
      not
      counted towards this requirement.

    


    viii)A
      sixteen (16) hour per week attending may have no more than four (4)
      residents/fellows on their team. Attendings spending twenty-four (24) hours
      per
      week in patient care/supervisory activity at the continuity site may have six
      (6) residents/fellows per team. Attendings spending thirty-two (32) hours per
      week may have eight (8) residents/fellows on their team. Two (2) or more
      attendings may join together to form a larger team as long as the ratio of
      attending to residents/fellows does not exceed 1:4 and all attendings comply
      with the sixteen (16) hour minimum.

     

    ix)
      Responsibility for the care of the Enrollee remains with the attending
      physician. All attending and resident/fellow teams must provide adequate
      continuity of care, twenty-four (24) hour a day, seven (7) day a week coverage,
      and appointment and availability access. Enrollees must be given the name of
      the
      responsible primary care physician (attending) in writing and be told how he
      or
      she may contact the attending physician or covering physician, if
      needed.

    


    x)
      Residents/fellows who do not qualify to act as continuity providers as part
      of
      an attending and resident/fellow team may still participate in the episodic
      care
      of Enrollees as long as that care is under the supervision of an attending
      physician credentialed to the Contractor. Such residents/fellows do not add
      to
      the capacity of that attending to empanel Enrollees.

     

    xi)
      Certified nurse practitioners and registered physician's assistants may not
      act
      as attending preceptors for resident physicians or fellows.

     

    2.
      Medical Residents and Fellows as Specialty Care Providers

    


    a)
      Residents/fellows may participate in the specialty care of Enrollees in all
      settings supervised by fully licensed and Contractor credentialed specialty
      attending physicians.

    


    b)
      Only
      the attending physicians, not residents or fellows, may be credentialed by
      the
      Contractor. Each attending must be credentialed by each MCO with which he or
      she
      will participate. Residents/fellows may perform all or many of the clinical
      services for the Enrollee


     

    APPENDIX
      1 

    October
      1, 2005

    I-3

     

    



    as
      long
      as these clinical services are under the supervision of an appropriately
      credentialed specialty physician. Even when residents/fellows are credentialed
      by their program in particular procedures, certifying their competence to
      perform and teach those procedures, the overall care of each Enrollee remains
      the responsibility of the supervising Contractor credentialed
      attending.

     

    c)
      The
      Contractor agrees that although many Enrollees will identify a resident or
      fellow as their specialty provider, the responsibility for all clinical
      decision-making remains ultimately with the attending physician of
      record.

    


    d)
      Enrollees must be given the name of the responsible attending physician in
      writing and be told how they may contact their attending physician or covering
      physician, if needed. This allows Enrollees to assist in the communication
      between their primary care provider and specialty attending and enables them
      to
      reach the specialty attending if an emergency arises in the course of their
      care. Enrollees must be made aware of the resident/fellow and attending
      relationship and must have a right to be cared for directly by the responsible
      attending physician, if requested.

    


    e)
      Enrollees requiring ongoing specialty care must be cared for in a continuity
      of
      care setting. This requires the ability to make follow-up appointments with
      a
      particular resident/fellow and attending physician team, or if that provider
      team is not available, with a member of the provider's coverage group in order
      to insure ongoing responsibility for the patient by his/her Contractor
      credentialed specialist. The responsible specialist and his/her specialty
      coverage group must be identifiable to the patient as well as to the referring
      primary care provider.

    


    f)
      Attending specialists must be available for emergency consultation and care
      during non-clinic hours. Emergency coverage may be provided by residents/fellows
      under adequate supervision. The attending or a member of the attending's
      coverage group must be available for telephone and/or in-person consultation
      when necessary.

     

    g)
      All
      training programs participating in the MMC or FHPlus Program must be accredited
      by the appropriate academic accrediting agency.

    


    h)
      All
      sites in which residents/fellows train must produce legible (preferably
      typewritten) consultation reports. Reports must be transmitted such that they
      are received in a time frame consistent with the clinical condition of the
      patient, the urgency of the problem and the need for follow-up by the primary
      care physician. At a minimum, reports should be transmitted so that they are
      received no later than two (2) weeks from the date of the specialty
      visit.

    


    i)
      Written reports are required at the time of initial consultation and again
      with
      the receipt of all major significant diagnostic information or changes in
      therapy. In addition, specialists must promptly report to the referring primary
      care physician any significant findings or urgent changes in therapy which
      result from the specialty consultation.

     

    


    APPENDIX
      I

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      1, 2005

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    3.
      Training Sites 

    


    All
      training sites must deliver the same standard of care to all patients
      irrespective of payor. Training sites must integrate the care of Medicaid,
      FHPlus, uninsured and private patients in the same settings.

    


    


    APPENDIX
      I

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      1, 2005 

    I-5

     

    


    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    


     

    APPENDIX
      J

     

     

     

    New
      York
      State Department of Health Guidelines for Contractor 

    Compliance
      with the Federal Americans with Disabilities Act

    


    


    


     

    


    


    


    


    APPENDIX
      J 

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      1, 2005

    J-l

     

    


    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    


    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 MMC and FHPlus are government programs, health services
      provided through MMC and FHPlus Programs must be accessible to all that qualify
      for them.

    


    Contractor
      responsibilities for compliance with the ADA are imposed under Title II and
      Section 504 when, as a Contractor in a MMC or FHPlus Program, a Contractor
      is
      providing a government service. If an individual provider under contract with
      the Contractor is not accessible, it is the responsibility of the Contractor
      to
      make arrangements to assure that alternative services are provided. The
      Contractor 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 Participating Providers. 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 Enrollee.

    


    Contractor
      responsibilities for compliance with the ADA are also imposed under Title III
      when the Contractor 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
      Contractors 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 MCO Qualification Standards to qualify MCOs for participation in the MMC
      and FHPlus Programs. Pursuant to the State's responsibility to assure program
      access to all Enrollees, 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.

     

     

    APPENDIX
      J 

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    The
      objectives of these guidelines are threefold:

     

    •
To
      ensure that Contractors take appropriate steps to measure access and assure
      program accessibility for persons with disabilities;

    •
To
      provide a framework for Contractors as they develop a plan to assure compliance
      with the Americans with Disabilities Act (ADA); and

     

    •
To
      provide standards for the review of the Contractor 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, Braille materials, large print materials, or other
      effective methods of making visually delivered materials available to
      individuals with visual impairments.

    


    B.
      "Disability" means a mental or physical impairment that substantially limits
      one
      or more of the major life activities of an individual; a record of such
      impairment; or being regarded as having such an impairment.

     

    III.
      SCOPE OF CONTRACTOR COMPLIANCE PLAN

    


    The
      Contractor Compliance Plan must address accessibility to services at
      Contractor's program sites, including both Participating Provider sites and
      Contractor facilities intended for use by Enrollees.

    


    


    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


    


     

    APPENDIX
      J 

    October
      1, 2005

    J-3

     

    



    effective
      as communications with others. The Contractor Compliance Plan must include
      a
      detailed description of how Contractor 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 Contractor Compliance Plan will describe the steps or actions
      the Contractor will take to assure accessibility to services equivalent to
      those
      offered at the inaccessible facilities.

    


    A.
      PRE-ENROLLMENT MARKETING AND EDUCATION 

    STANDARD
      FOR COMPLIANCE

    Marketing
      staff, activities and materials will be made available to persons with
      disabilities. Marketing materials will be made available in alternative formats
      (such as Braille, large print, and audiotapes) 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 Contractor 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

    


    


    COMPLIANCE
      PLAN SUBMISSION

    


    


    1.
      A
      description of methods to ensure that the Contractor's Marketing presentations
      (materials and communications) are accessible to persons with auditory, visual
      and cognitive impairments

    2.
      A
      description of the Contractor'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

    


     

    APPENDIX
      J 

    October
      1, 2005

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    B.
      MEMBER SERVICES DEPARTMENT

    


    Member
      services functions include the provision to Enrollees of information necessary
      to make informed choices about treatment options, to effectively utilize the
      health care resources, to assist Enrollees in making appointments, and to field
      questions and Complaints, to assist Enrollees with the Complaint
      process.

     

    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 Contractor'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 >
Vi"
      ramped,
      doorways with minimum 32" opening

    4.
      Interior halls and passageways providing a clear and unobstructed path or travel
      at least 36" wide to bathrooms and other rooms commonly used by
      Enrollees

    5.
      Waiting rooms, restrooms, and other rooms used by Enrollees are accessible
      to
      people with disabilities

    6.
      Sign
      language interpreters and other auxiliary aids and services provided in
      appropriate circumstances

    7.
      Materials available in alternative formats, such as Braille, large print, audio
      tapes

    8.
      Staff
      training which includes sensitivity training related to disability issues
      (Resources and technical assistance are available through the NYS Office of
      Advocate for Persons with Disabilities - V/TTY (800) 522-4369; and the NYC
      Mayor's Office for People with Disabilities - (212) 788-2830 or TTY
      (212)788-2838)

    9.
      Availability of activities and educational materials tailored to specific
      conditions/illnesses and secondary conditions that affect these populations
      (e.g. secondary infection prevention, decubitus prevention, special exercise
      programs, etc.)

    10.
      Contractor 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

    


    


    APPENDIX
      J 

    October
      1, 2005

    J-5

     

     

    COMPLIANCE
      PLAN SUBMISSION

     

    1.
      A
      description of accessibility to the Contractor's -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 Contractor's 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 the Contractor's 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

    


    B2.
      IDENTIFICATION OF ENROLLEES WITH DISABILITIES STANDARD FOR
      COMPLIANCE

    The
      Contractor 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. The Contractor may not
      discriminate against a Prospective Enrollee based on his/her current health
      status or anticipated need for future health care. The Contractor may not
      discriminate on the basis of disability, or perceived disability of an Enrollee
      or their family member. Health assessment forms may not be used by the
      Contractor prior to Enrollment. Once a MCO has been chosen, a health assessment
      form may be used to assess the person's health care needs.

    


    


    


    SUGGESTED
      METHODS FOR COMPLIANCE

    


    1.
      Appropriate post Enrollment health screening for each Enrollee, using an
      appropriate health screening tool

    2.
      Patient profiles by condition/disease for comparative analysis to national
      norms, with appropriate outreach and education

    3.
      Process for follow-up of needs identified by initial screening; e.g. referrals,
      assignment of case manager, assistance with scheduling/keeping
      appointments

    4.
      Enrolled population disability assessment survey

    5.
      Process for Enrollees who acquire a disability subsequent to Enrollment to
      access appropriate services

     

     

    APPENDIX
      J 

    October
      1, 2005

    J-6

     

     

    COMPLIANCE
      PLAN SUBMISSION

    


    A
      description of how the .Contractor 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

    


    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 Contractor. 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)788-283
      8)

    4.
      Activities and fairs that include sign language interpreters or the distribution
      of a written summary of the Marketing script used by Contractor 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

    


     

    APPENDIX
      J 

    October
      1, 2005

    J-7

     

    COMPLIANCE
      PLAN SUBMISSION

     

    1.
      A
      description of how the Contractor will advise Enrollees with disabilities,
      during the new Enrollee orientation on how to access care

    2.
      A
      description of how the Contractor 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 Contractor 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 Contractor will assure that reasonable
      alternative site and services are available

    3.
      A
      description of how the Contractor 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 Contractor will identify if an Enrollee with a disability
      requires on-going mental health services and how the Contractor will encourage
      early entry into treatment

    5.
      A
      description of how the Contractor will notify Enrollees with disabilities as
      to
      how to access transportation, where applicable

     

     

    B4.
      COMPLAINTS, COMPLAINT APPEALS AND ACTION APPEALS STANDARD FOR
      COMPLIANCE

     

    The
      Contractor will establish and maintain a procedure to protect the rights and
      interests of both Enrollees and the Contractor by receiving, processing, and
      resolving Complaints, Complaint Appeals and Action Appeals in an expeditious
      manner, with the goal of ensuring resolution of Complaints, Complaint Appeals,
      and Action Appeals and access to appropriate services as rapidly as
      possible.

    All
      Enrollees must be informed about the Grievance System within their Contractor
      and the procedure for filing Complaints, Complaint Appeals and Action Appeals.
      This information will be made available through the Member Handbook, SDOH
      toll-free Complaint line (1-(800) 206-8125) and the Contractor's Complaint
      process annually, as well as when the Contractor denies a benefit or referral.
      The Contractor will inform Enrollees of the Contractor's Grievance System;
      Enrollees' right to contact the LDSS or SDOH with a Complaint, and to file
      a
      Complaint Appeal, 

     

     

    APPENDIX
      J

    October
      1, 2005 

    J-8

     

     

    Action
      Appeal or request a fair hearing; the right to appoint a designee to handle
      a
      Complaint, Complaint Appeal or Action Appeal; and the toll free Complaint line.
      The Contractor will maintain designated staff to take and process Complaints,
      Complaint Appeals and Action Appeals, and be responsible for assisting Enrollees
      in Complaint, Complaint Appeal or Action Appeal resolution.

     

    The
      Contractor 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 Complaint Appeals and Action Appeals.

     

    SUGGESTED
      METHODS FOR COMPLIANCE

     

    1.
      Toll-free 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

    


    COMPLIANCE
      PLAN SUBMISSION

     

    1.
      A
      description of how the Contractor's Complaint, Complaint Appeals and Action
      appeal procedures shall be accessible for persons with disabilities,
      including:

    •
      procedures for Complaints, Complaint Appeals and Action 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, Complaint Appeals or Action Appeals, 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 the Contractor monitors Complaints, Complaint Appeals and
      Action Appeals related to people with disabilities. Also, as part of the
      Compliance Plan, the Contractor must submit a summary report based on the
      Contractor's most recent year's Complaints, Complaint Appeals and Action Appeals
      data.

     

    C.
      CASE MANAGEMENT

     

    STANDARD
      FOR COMPLIANCE

    


    The
      Contractor must have in place adequate case management systems to identify
      the
      service needs of all Enrollees, including Enrollees with chronic illness and
      Enrollees with disabilities, and ensure that medically necessary covered
      benefits are delivered on a timely basis. These systems must include procedures
      for standing referrals, specialists as PCPs, and referrals to specialty centers
      for Enrollees who require specialized medical 

     

    
       

      APPENDIX
        J

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        1, 2005

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    care
      over
      a prolonged period of time (as determined by a treatment plan approved by the
      Contractor in consultation with the primary care provider, the designated
      specialist and the Enrollee or his/her designee), out-of-network referrals
      and
      continuation of existing treatment relationships with out-of-network 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-network 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 Contractor staff to function as case managers for special
      needs populations, or sub-contract arrangements for case management


    5.
      Procedures for informing Enrollees about the availability of case management
      services

     

    COMPLIANCE
      PLAN SUBMISSION

    


    1.
      A
      description of the Contractor 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 Contractor'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 Contractor's protocol for assignment of specialists as PCP,
      and for standing referrals to specialists and specialty centers, out-of-network
      referrals and continuing treatment relationships

    4.
      A
      description of the Contractor's notice procedures to Enrollees regarding the
      availability of case management services, specialists as PCPs, standing
      referrals to specialists and specialty centers, out-of-network referrals and
      continuing treatment relationships

    


    D.
      PARTICIPATING PROVIDERS STANDARD FOR COMPLIANCE

     

    The
      Contractor's network 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.

     

     

    APPENDIX
      J

    October
      1, 2005

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    SUGGESTED
      METHODS FOR COMPLIANCE

     

    1.
      Process for the Contractor to evaluate provider network to ascertain the degree
      of provider accessibility to persons with disabilities, to identify barriers
      to
      access and required modifications to policies/procedures

    2.
      Model
      protocol to assist Participating Providers, at their point of service, to
      identify Enrollees who require case manager, audio, visual, mobility aids,
      or
      other accommodations

    3.
      Model
      protocol for determining needs of Enrollees with mental
      disabilities

    4.
      Use of
      Wheelchair Accessibility Certification Form (see attached)

    5.
      Submission of map of physically accessible sites

    6.
      Training for providers re: compliance with Title III of ADA, e.g. site access
      requirements for door widths, wheelchair ramps, accessible diagnostic/treatment
      rooms and equipment; communication issues; attitudinal barriers related to
      disability, etc. (Resources and technical assistance are available through
      the
      NYS Office of Advocate for Persons with Disabilities -V/TTY (800) 522-4369;
      and
      the NYC Mayor's Office for People with Disabilities - (212) 788-2830 or TTY
      (212) 788-2838).

    7.
      Use of
      NYS Office of Persons with Disabilities (OAPD) ADA Accessibility 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 the Contractor 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
      Contractor 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, a description
      of
      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, a description of reasonable alternative methods to ensure that services
      will be made accessible

    2.
      A
      description of how the Contractor's specialty network is sufficient to meet
      the
      needs of Enrollees with disabilities

     

     

    APPENDIX
      J 

    October
      1, 2005 

    J-ll

     

    


    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

    •
The
      Contractor 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 the ADA Compliance Summary Report or Contractor statement that
      data submitted to SDOH on the Health Provider Network (HPN) files is an accurate
      reflection of each network's physical accessibility.

    


    E.
      POPULATIONS WITH SPECIAL HEALTH CARE NEEDS STANDARD FOR
      COMPLIANCE

    The
      Contractor 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. The Contractor 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-network referrals,
      and
      continuation "of existing relationships with out-of-network providers for course
      of treatment

    2.
      Linkages with behavioral health agencies, disability and advocacy organizations,
      etc.

    3.
      Adequate network of providers and sub-specialists (including pediatric providers
      and sub-specialists) and contractual relationships with tertiary
      institutions

    4.
      Procedures for assuring that these populations receive appropriate diagnostic
      work-ups on a timely basis

    5.
      Procedures for assuring that these populations receive appropriate access to
      durable medical equipment on a timely basis

    6.
      Procedures for assuring that these populations receive appropriate allied health
      professionals (Physical, Occupational and Speech Therapists, Audiologists)
      on a
      timely basis

    7.
      State
      designation as a Well Qualified Plan to serve the OMRDD population and
      look-alikes

     

    COMPLIANCE
      PLAN SUBMISSION

    


    1.
      A
      description of arrangements to ensure access to specialty care providers and
      centers in and out of New York State, standing referrals, specialist physicians
      to function as PCP, out-of-network referrals, and continuation of existing
      relationships (out-of-network) for diagnosis and treatment of rare
      disorders

     

    APPENDIX
      J 

    October
      1, 2005 

    J-l2

    


    


     

    2.
      A
      description of appropriate service delivery for children with disabilities.
      This
      may include a description of methods for interacting with school districts,
      child protective service agencies, early intervention officials, behavioral
      health, and disability and advocacy organizations. 

    3.
      A
      description of the sub-specialist network, including contractual relationships
      with tertiary institutions to meet the health care needs of people with
      disabilities

     

    F.
      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.


     

    APPENDIX
      J

    October
      1, 2005 

    J-13

    


     

    


    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.

     

     

    APPENDIX
      J

    October
      1,2005 

    J-14

     

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    



    APPENDIX
      K

     

     

    PREPAID
      BENEFIT PACKAGE DEFINITIONS OF COVERED 

    AND
      NON-COVERED SERVICES

    

       

       

      K.1
          Chart of Prepaid Benefit Package

      -
        Medicaid Managed Care Non-SSI (MMC Non-SSI)

      -
        Medicaid Managed Care SSI (MMC SSI)

      -
        Medicaid Fee-for-Service (MFFS)

      -
        Family
        Health Plus (FHPlus)

       

      K.2
         Prepaid
        Benefit Package Definitions of Covered Services

       

      K.3
         Medicaid
        Managed Care Definitions of Non-Covered Services

       

      K.4
          Family
        Health Plus Non-Covered Services

      


      


       

       

      
 

      


      
        APPENDIX
          K

        October
          1, 2005 

        K-l



      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


     

     


    APPENDIX
      K PREPAID BENEFIT PACKAGE DEFINITIONS OF COVERED AND NON-COVERED
      SERVICES

     

    1. General

     

    a)
      The
      categories of services in the Medicaid Managed Care and Family Health Plus
      Benefit Packages, including optional-covered services shall be provided by
      the
      Contractor to MMC Enrollees and FHPlus Enrollees, respectively, when medically
      necessary under the terms of this Agreement. The definitions of covered and
      non-covered services herein are in summary form; the full description and scope
      of each covered service as established by the New York Medical Assistance
      Program are set forth in the applicable NYS Medicaid Provider Manual, except
      for
      the Eye Care and Vision benefit for FHPlus Enrollees which is described in
      Section 19 of Appendix K.2.

     

    b)
      All
      care provided by the Contractor, pursuant to this Agreement, must be provided,
      arranged, or authorized by the Contractor or its Participating Providers with
      the exception of most behavioral health services to SSI or SSI related
      beneficiaries, and emergency services, emergency transportation, Family Planning
      and Reproductive Health services, mental health and chemical dependence
      assessments (one (1) of each per year), court ordered services, and services
      provided by Local Public Health Agencies as described in Section 10 of this
      Agreement.

     

    c)
      This
      Appendix contains the following sections:

     

    i)
      K.I -
      "Chart of Prepaid Benefit Package" lists the services provided by
      the

    Contractor
      to all Medicaid Managed Care Non-SSI Enrollees, Medicaid Managed Care SSI
      Enrollees, Medicaid fee-for-service coverage for carved out and wraparound
      benefits, and Family Health Plus Enrollees.

     

    ii)
      K.2 -
      "Prepaid Benefit Package Definitions Of Covered Services" describes the covered
      services, as numbered in K.I. Each service description applies to both MMC
      and
      FHPlus Benefit Package unless otherwise noted.

    


    iii)
      K.3
      - "Medicaid Managed Care Definitions of Non-Covered Services" describes services
      that are not covered by the MMC Benefit Package. These services are covered
      by
      the Medicaid fee-for-service program unless otherwise noted.

     

    iv)
      K.4 -
      "Family Health Plus Non-Covered Services" lists the services that are not
      covered by the FHPlus Benefit Package. There is no Medicaid fee-for-service
      coverage available for any service outside of the FHPlus Benefit
      Package.

     

     

    APPENDIX
      K

    October
      1, 2005

    K-2

    


    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    


    K.1

    


    PREPAID
      BENEFIT PACKAGE

    


    
      	
              *

            	
              Covered
                Services

            	
              MMC
                Non-SSI

            	
              MMC
                SSI

            	
              MFFS

            	 	
              FHPlus
                **

            
	
              1.  

            	
              Inpatient
                Hospital Services

            	
              Covered,
                unless admit date precedes Effective Date of Enrollment [see § 6.8 of this
                Agreement] 

            	
              Covered,
                unless admit date precedes Effective Date of Enrollment [see § 6.8 of this
                Agreement]

            	
              Stay
                covered only when admit precedes Effective Date of Enrollment [see
§ 6.8
                of this Agreement] 

            	 	
              Covered,
                unless admit date precedes Effective Date of Enrollment [see § 6.8 of this
                Agreement]

            
	
              2.  

            	
              Inpatient
                Stay Pending Alternate Level of Medical Care

            	
              Covered

            	
              Covered

            	 	 	
              Covered

            
	
              3.  

            	
              Physician
                Services

            	
              Covered

            	
              Covered

            	 	 	
              Covered

            
	
              4.  

            	
              Nurse
                Practitioner Services

            	
              Covered

            	
              Covered

            	 	 	
              Covered

            
	
              5.  

            	
              Midwifery
                Services

            	
              Covered

            	
              Covered

            	 	 	
              Covered

            
	
              6.  

            	
              Preventive
                Health Services

            	
              Covered

            	
              Covered

            	 	 	
              Covered

            
	
              7.  

            	
              Second
                Medical/Surgical Opinion

            	
              Covered

            	
              Covered

            	 	 	
              Covered

            
	
              8.  

            	
              Laboratory
                Services

            	
              Covered

            	
              Covered

            	
              HIV
                phenotypic virtual phenotypic and genotypic drug resistant
                tests

            	 	
              Covered

            
	
              9.  

            	
              Radiology
                Services

            	
              Covered

            	
              Covered

            	 	 	
              Covered

            
	
              10.  

            	
              Prescription
                and Non-Prescription (OTC) Drugs, Medical Supplies, and Enteral
                Formula

            	
              Pharmaceuticals
                and medical supplies routinely furnished or administered as part
                of a
                clinic or office visit

            	
              Pharmaceuticals
                and medical supplies routinely furnished or administered as part
                of a
                clinic or office visit

            	
              Covered
                outpatient drugs from the list of Medicaid reimbursable prescription
                drugs, subject to any applicable co-payments

            	 	
              Covered,
                may be limited to generic. Vitamins (except to treat an illness or
                condition), OTCs, and medical supplies are not covered

            
	
              11.  

            	
              Smoking
                Cessation Products

            	 	 	
              Covered

            	 	
              Covered

            
	
              12.  

            	
              Rehabilitation
                Services

            	
              Covered

            	
              Covered

            	 	 	
              Covered
                for short term inpatient, and limited to 20 visits per calendar year
                for
                outpatient PT and OT

            
	
              13.  

            	
              EPSDT
                Services/Child Teen Health Program (C/THP)

            	
              Covered

            	
              Covered

            	
              Covered

            	 	
              Covered

            


    

    


     

    APPENDIX
      K

    October
      1, 2005

    K-3

     

     

    
      


      *See
        K.2
        for Scope of Benefits 

      **No
        Medicaid fee-for service-wrap around is
        available. Subject to applicable co-pays.

      Note:
        If
        cell is blank, there is no coverage.


    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    


    


     

    


    
      	
              *

            	
              Covered
                Services

            	
              MMC
                Non-SSI

            	
              MMC
                SSI

            	
              MFFS

            	 	
              FHPlus
                **

            
	
              14.  

            	
              Home
                Health Services

            	
              Covered

            	
              Covered

            	 	 	
              Covered
                for 40 visits in lieu of a skilled nursing facility stay or
                hospitalization, plus 2 post partum home visits for high risk
                women

            
	
              15.  

            	
              Private
                Duty Nursing Services

            	
              Covered

            	
              Covered

            	 	 	
              Not
                covered

            
	
              16.  

            	
              Hospice

            	 	 	
              Covered

            	 	
              Covered

            
	
              17.  

            	
              Emergency
                Services

              Post-Stabilization
                Care Services (see also Appendix G of this Agreement)

            	
              Covered

              Covered

            	
              Covered

              Covered

            	 	 	
              Covered

              Covered

            
	
              18.  

            	
              Foot
                Care Services

            	
              Covered

            	
              Covered

            	 	 	
              Covered

            
	
              19.  

            	
              Eye
                Care and Low vision Services

            	
              Covered

            	
              Covered

            	 	 	
              Covered

            
	
              20.  

            	
              Durable
                Medical Equipment (DME)

            	
              Covered

            	
              Covered

            	 	 	
              Covered

            
	
              21.  

            	
              Audiology,
                Hearing Aids Services and Products

            	
              Covered
                except for hearing aid batteries

            	
              Covered
                except for hearing aid batteries

            	
              Hearing
                aid batteries

            	 	
              Covered
                including hearing aid batteries

            
	
              22.  

            	
              Family
                Planning and Reproductive Health Services

            	
              Covered
                if included in Contractor’s Benefit Package as per Appendix M of this
                Agreement

            	
              Covered
                if included in Contractor’s Benefit Package as per Appendix M of this
                Agreement

            	
              Covered
                pursuant to Appendix C of Agreement

            	 	
              Covered
                if included in Contractor’s Benefit Package as per Appendix M of this
                Agreement or through the DTP Contractor

            
	
              23.  

            	
              Non-Emergency
                Transportation

            	
              Covered
                if included in Contractor’s Benefit Package as per Appendix M of this
                Agreement

            	
              Covered
                if included in Contractor’s Benefit Package as per Appendix M of this
                Agreement

            	
              Covered
                if not included in contractor’s benefit package

            	 	
              Not
                covered, except for transportation to C/THP services for 19 and 20
                year
                olds

            
	
              24.  

            	
              Emergency
                Transportation

            	
              Covered
                if included in Contractor’s Benefit Package as per Appendix M of this
                Agreement

            	
              Covered
                if included in Contractor’s Benefit Package as per Appendix M of this
                Agreement

            	
              Covered
                if not included in Contractor’s Benefit Package

            	 	
              Covered

            


    

    


     

    APPENDIX
      K

    October
      1, 2005

    K-4

     

    *See
      K.2
      for Scope of Benefits 

    **No
      Medicaid fee-for service-wrap around is
      available. Subject to applicable co-pays.

    Note:
      If
      cell is blank, there is no coverage.

     

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    



    
      	
              *

            	
              Covered
                Services

            	
              MMC
                Non-SSI

            	
              MMC
                SSI

            	
              MFFS

            	 	
              FHPlus
                **

            
	
              25.  

            	
              Dental
                Services

            	
              Covered
                if included in Contractor’s Benefit Package as per Appendix M of this
                Agreement, except orthodontia

            	
              Covered
                if included in Contractor’s Benefit Package as per Appendix M of this
                Agreement, except orthodontia

            	
              Covered
                if not included in Contractor’s Benefit Package, Orthodontia in all
                instances

            	 	
              Covered,
                if included in Contractor’s Benefit Package as per Appendix M of this
                Agreement, excluding orthodontia

            
	
              26.  

            	
              Court-Ordered
                Services

            	
              Covered,
                pursuant to court order (see also § 10.9 of this
                Agreement)

            	
              Covered,
                pursuant to court order (see also § 10.9 of this
                Agreement)

            	 	 	
              Covered,
                pursuant to court order (see also § 10.9 of this
                Agreement)

            
	
              27.  

            	
              Prosthetic/Orthotic
                Services/Orthopedic Footwear

            	
              Covered

            	
              Covered

            	 	 	
              Covered,
                except orthopedic shoes

            
	
              28.  

            	
              Mental
                Health Services

            	
              Covered

            	 	
              Covered
                for SSI Enrollees

            	 	
              Covered
                subject to calendar year benefit limit of 30 days inpatient, 60 visits
                outpatient, combined with chemical dependency services

            
	
              29.  

            	
              Detoxification
                Services

            	
              Covered

            	
              Covered

            	 	 	
              Covered

            
	
              30.  

            	
              Chemical
                Dependency Inpatient Rehabilitation and Treatment Services

            	
              Covered
                subject to stop loss

            	 	
              Covered
                for SSI recipients

            	 	
              Covered
                subject to calendar year benefit limit 30 days combined with mental
                health
                services

            
	
              31.  

            	
              Chemical
                Dependence Outpatient

            	 	 	
              Covered

            	 	
              Covered
                subject to calendar year benefit limits of 60 visits combined with
                mental
                health services

            
	
              32.  

            	
              Experimental
                and/or Investigational Treatment

            	
              Covered
                on a case by case basis

            	
              Covered
                on a case by case basis

            	 	 	
              Covered
                on a case by case basis

            
	
              33.  

            	
              Renal
                Dialysis

            	
              Covered

            	
              Covered

            	 	 	
              Covered

            
	
              34.  

            	
              Residential
                Health Care Facility Services (RHCF)

            	
              Covered,
                except for individuals in permanent placement

            	
              Covered,
                except for individuals in permanent placement

            	 	 	 


    

     

     

    APPENDIX
      K

    October
      1, 2005

    K-5

    
      *See
        K.2
        for Scope of Benefits 

      **No
        Medicaid fee-for service-wrap around is
        available. Subject to applicable co-pays.

      Note:
        If
        cell is blank, there is no coverage.

    

     

    


    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    


     


    



    K.2

    PREPAID
      BENEFIT PACKAGE

    DEFINITIONS
      OF COVERED SERVICES

     

    


    Service
      definitions in this Section pertain to both MMC and FHPlus unless otherwise
      indicated.

    


    1. 
      Inpatient Hospital Services

    


    Inpatient
      hospital services, as medically necessary, shall include, except as
      otherwise

    specified,
      the care, treatment, maintenance and nursing services as may be required,
      on

    an
      inpatient hospital basis, up to 365 days per year (366 days in leap year).
      The
      Contractor will not be responsible for hospital stays that commence prior to
      the
      Effective Date of Enrollment (see Section 6.8 of this Agreement), but will
      be
      responsible for stays that commence prior to the Effective Date of Disenrollment
      (see Section 8.5 of this

    Agreement).
      Among other services, inpatient hospital services encompass a full range of
      

    necessary
      diagnostic and therapeutic care including medical, surgical,
      nursing,

    radiological,
      and rehabilitative services. Services are provided under the direction of
      a

    physician,
      certified nurse practitioner, or dentist.

    


    2. Inpatient
      Stay Pending Alternate Level of Medical Care

    


    Inpatient
      stay pending alternate level of medical care, or continued care in a
      hospital

    pending
      placement in an alternate lower medical level of care, consistent with the
      

    provisions
      of 18 NYCRR § 505.20 and 10 NYCRR Part 85.

    


    3. Physician
      Services

    


    a)
      "Physicians' services," whether furnished in the office, the Enrollee's home,
      a
      hospital, a skilled nursing facility, or elsewhere, means services furnished
      by
      a physician:

    


    i)
       within
      the scope of practice of medicine as defined in law by the New York State
      Education Department; and

    


    ii) by
      or
      under the personal supervision of an individual licensed and currently
      registered by the New York State Education Department to practice
      medicine.

    


    
      	 	
              b)

            	
              Physician
                services include the fall range of preventive care services, primary
                care
                medical services and physician specialty services that fall within
                a
                physician's scope of practice under New York State
                law.

            


    

     

    
      	 	
              c)

            	
              The
                following are also included without
                limitations:

            


    

    


    i) pharmaceuticals
      and medical supplies routinely furnished or administered as part of a clinic
      or
      office visit

     

    


    APPENDIX
      K

    October
      1, 2005

    K-6

    



    ii) physical
      examinations, including those which are necessary for employment, school, and
      camp;

    


    
      	 	
              iii)

            	
              physical
                and/or mental health, or chemical dependence examinations of children
                and
                their parents as requested by the LDSS to fulfill its statutory
                responsibilities for the protection of children and adults and for
                children in foster care;

            


    

    


    iv) health
      and mental health assessments for the purpose of making recommendations
      regarding a Enrollee's disability status for Federal SSI
      applications;

    


    v) health
      assessments for the Infant /Child Assessment Program (ICHAP);

    


    
      	 	
              vi)

            	
              annual
                preventive health visits for adolescents; vii) new admission exams
                for
                school children if required by the LDSS; viii) health screening,
                assessment and treatment of refugees, including completing SDOH/LDSS
                required forms; 

            


    

    


    ix) Child/Teen
      Health Program (C/THP) services which are comprehensive primary health care
      services provided to persons under twenty-one (21) years of age (see Section
      10
      of this Agreement).

    


    4. Certified
      Nurse Practitioner Services

    


    
      	 	
              a)

            	
              Certified
                nurse practitioner services include preventive services, the diagnosis
                of
                illness and physical conditions, and the performance of therapeutic
                and
                corrective measures, within the scope of the certified nurse
                practitioner's licensure and collaborative practice agreement with
                a
                licensed physician in accordance with the requirements of the NYS
                Education Department. 

            


    

    


    b)
      The
      following services are also included in the certified nurse practitioner's
      scope
      of services, without limitation:

    


    i)
      Child/Teen Health Program(C/THP) services which are comprehensive primary health
      care services provided to persons under twenty-one (21) (see Item 13 of this
      Appendix and Section 10.4 of this Agreement);

    


    ii)
      Physical examinations, including those which are necessary for employment,
      school and camp.

    
 

    APPENDIX
      K

    October
      1, 2005

    K-7

     

    


    5. Midwifery
      Services

    SSA
§1905
      (a)(17). Education Law §6951(i).

    


    Midwifery
      services include the management of normal pregnancy, childbirth and postpartum
      care as well as primary preventive reproductive health care to essentially
      healthy women as specified in a written practice agreement and shall include
      newborn evaluation, resuscitation and referral for infants. The care may be
      provided on an inpatient or outpatient basis including in a birthing center
      or
      in the Enrollee's home as appropriate. The midwife must be licensed by the
      NYS
      Education Department.

    


    6. Preventive
      Health Services

    


    
      	 	
              a)

            	
              Preventive
                health services means care and services to avert disease/illness
                and/or
                its consequences. There are three (3) levels of preventive health
                services: 1) primary, such as immunizations, aimed at preventing
                disease;
                2) secondary, such as disease screening programs aimed at early detection
                of disease; and 3) tertiary, such as physical therapy, aimed at restoring
                function after the disease has occurred. Commonly, the term "preventive
                care" is used to designate prevention and early detection programs
                rather
                than restorative programs.

            


    

    


    
      	 	
              b)

            	
              The
                Contractor must offer the following preventive health services essential
                for promoting and preventing
                illness:

            


    

    


    i) General
      health education classes.

    ii) Pneumonia
      and influenza immunizations for at risk populations.

    iii) Smoking
      cessation classes, with targeted outreach for adolescents and pregnant
      women.

    iv) Childbirth
      education classes.

    v) Parenting
      classes covering topics such as bathing, feeding, injury prevention, sleeping,
      illness prevention, steps to follow in an emergency, growth and development,
      discipline, signs of illness, etc.

    vi)
      Nutrition counseling, with targeted outreach for diabetics and pregnant
      women.

    vii) Extended
      care coordination, as needed, for pregnant women. 

    viii)HIV
      counseling and testing.

    


    7. Second
      Medical/Surgical Opinions

    


    The
      Contractor will allow Enrollees to obtain second opinions for diagnosis of
      a
      condition, treatment or surgical procedure by a qualified physician or
      appropriate specialist, including one affiliated with a specialty care center.
      In the event that the Contractor determines that it does not have a
      Participating Provider in its network with appropriate training and experience
      qualifying the Participating Provider to provide a second opinion, the
      Contractor shall make a referral to an appropriate Non-Participating Provider.
      The Contractor shall pay for the cost of the services associated with obtaining
      a second opinion regarding medical or surgical care, including diagnostic and
      evaluation services, provided by the Non-Participating Provider.

    


    


    APPENDIX
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    8. Laboratory
      Services

    18
      NYCRR§505.7(a)

    


    
      	 	
              a)

            	
              Laboratory
                services include medically necessary tests and procedures ordered
                by a
                qualified medical professional and listed in the Medicaid fee schedule
                for
                laboratory services.

            


    

    


    
      	 	
              b)

            	
              All
                laboratory testing sites providing services under this Agreement
                must have
                a permit issued by the New York State Department of Health and a
                Clinical
                Laboratory Improvement Act (CLIA) certificate of waiver, a physician
                performed microscopy procedures (PPMP) certificate, or a certificate
                of
                registration along with a CLIA identification number. Those laboratories
                with certificates of waiver or a PPMP certificate may perform only
                those
                specific tests permitted under the terms of their waiver. Laboratories
                with certificates of registration may perform a full range of laboratory
                tests for which they have been certified. Physicians providing laboratory
                testing may perform only those specific limited laboratory procedures
                identified in the Physician's NYS Medicaid Provider
                Manual.

            


    

    


    
      	 	
              c)

            	
              For
                MMC only: coverage for HIV phenotypic, HIV virtual phenotypic and
                HIV
                genotypic drug resistance tests are covered by Medicaid
                fee-for-service.

            


    

    


    
      	
              9.

            	
              Radiology
                Services

            


    

    
      	 	
              18
                NYCRR § 505.17(c)(7)(d)

            


    

    


    Radiology
      services include medically necessary services provided by qualified
      practitioners in the provision of diagnostic radiology, diagnostic ultrasound,
      nuclear medicine, radiation oncology, and magnetic resonance imaging (MRI).
      These services may only be performed upon the order of a qualified
      practitioner.

    


    10. Prescription
      and Non-Prescription (OTC) Drugs, Medical Supplies and Enteral
 Formulas

    


    
      	 	
              a)

            	
              For
                Medicaid fee-for-service only: Medically necessary prescription and
                non-prescription OTC) drugs, medical supplies and enteral formula
                are
                covered when ordered by a qualified
                provider.

            


    

    


    
      	 	
              b)

            	
              MMC
                Enrollees are covered for prescription drugs through the Medicaid
                fee-for-service program. Pharmaceuticals and medical supplies routinely
                furnished or administered as part of a clinic or office visit are
                covered
                by the MMC Program. Self-administered injectable drugs (including
                those
                administered by a family member) and injectable drugs administered
                during
                a home care visit are covered by Medicaid fee-for-service if the
                drug is
                on the list of Medicaid reimbursable prescription drugs or covered
                by the
                Contractor, subject to medical necessity, if the drug is not on the
                list
                of Medicaid reimbursable prescription
                drugs.

            


    

    


     

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              c)

            	
              For
                Family Health Plus only:

            


    

    


    i) Prescription
      drugs are covered, but may be limited to generic medications where medically
      acceptable. All medications used for preventive and therapeutic purposes are
      covered, as well as family planning or contraceptive medications or
      devices.

    


    ii) Coverage
      includes enteral formulas for home use for which a physician or other provider
      authorized to prescribe has issued a written order. Enteral formulas for the
      treatment of specific diseases shall be distinguished from nutritional
      supplements taken electively. Coverage for certain inherited diseases of amino
      acid and organic acid metabolism shall include modified solid food products
      that
      are low-protein or which contain modified protein. Vitamins are not covered
      except when necessary to treat a diagnosed illness or condition.

    


    iii) Experimental
      and/or investigational drugs are generally excluded, except where approved
      in
      the course of experimental/investigational treatment.

    


    iv) Drugs
      prescribed for cosmetic purposes are excluded.

    


    v) Over-the-counter
      items are excluded with the exception of diabetic supplies, including insulin
      and smoking cessation agents. Non-prescription (OTC) drugs and medical supplies
      are not covered.

    


    11. Smoking
      Cessation Products

    


    
      	 	
              a)

            	
              MMC
                Enrollees are covered for smoking cessation products through the
                Medicaid
                fee-for-service program.

            


    

    


    
      	 	
              b)

            	
              For
                Family Health Plus only: At least two courses of smoking cessation
                therapy
                per person per year, as medically necessary are covered. A course
                of
                therapy is defined as no more than a ninety (90)-day supply, (an
                original
                prescription and two (2) refills, even if less than a thirty (30)-day
                supply is dispensed in any fill). Duplicative use of one agent is
                not
                allowed (i.e., same drug/same dosage form/same strength). Both
                prescription and over-the-counter therapies/agents are covered; this
                includes nicotine patches, inhalers, nasal sprays, gum, and Zyban
                (bupropion).

            


    

    


    12. Rehabilitation
      Services

    18
      NYCRR505.11

    


    
      	 	
              a)

            	
              Rehabilitation
                services are provided for the maximum reduction of physical or mental
                disability and restoration of the Enrollee to his or her best functional
                level. Rehabilitation services include care and services rendered
                by
                physical therapists, speech-language pathologists and occupational
                therapists. Rehabilitation services may be provided in an Article
                28
                inpatient or outpatient facility, an Enrollee's home, in an approved
                home
                health agency, in the office of a qualified private practicing therapist
                or speech pathologist, or for a child in a school, pre-school or
                community

            


    

    


    


    APPENDIX
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    setting,
      or in a Residential Health Care Facility (RHCF) as long as the Enrollee's stay
      is classified as a rehabilitative stay and meets the requirements for covered
      RHCF services as defined herein. For the MMC Program, rehabilitation services
      provided in Residential Health Care Facilities are subject to the stop-loss
      provisions specified in Section 3.13 of this Agreement. Rehabilitation services
      are covered as medically necessary, when ordered by the Contractor's
      Participating Provider.

    


    
      	 	
              b)

            	
              For
                Family Health Plus only: Outpatient visits for physical and occupational
                therapy is limited to twenty (20) visits per calendar year. Coverage
                for
                speech therapy services is limited to those required for a condition
                amenable to significant clinical improvement within a two month
                period.

            


    

    


    
      	
              13.

            	
              Early
                and Periodic Screening Diagnostic and Treatment (EPSDT) Services
                Through
                the Child Teen Health Program (C/THP) and Adolescent Preventive
                Services

            


    

    18
      NYCRR§508.8

    


    Child/Teen
      Health Program (C/THP) is a package of early and periodic screening, including
      inter-periodic screens and, diagnostic and treatment services that New York
      State offers all Medicaid eligible children under twenty-one (21) years of
      age.
      Care and services shall be provided in accordance with the periodicity schedule
      and guidelines developed by the New York State Department of Health. The care
      includes necessary health care, diagnostic services, treatment and other
      measures (described in §1905(a) of the Social Security Act) to correct or
      ameliorate defects, and physical and mental illnesses and conditions discovered
      by the screening services (regardless of whether the service is otherwise
      included in the New York State Medicaid Plan). The package of services includes
      administrative services designed to assist families obtain services for children
      including outreach, education, appointment scheduling, administrative case
      management and transportation assistance.

    


    14. Home
      Health Services

    18
      NYCRR505.23(a)(3)

    


    
      	 	
              a)

            	
              Home
                health care services are provided to Enrollees in their homes by
                a home
                health agency certified under Article 36 of the PHL (Certified Home
                Health
                Agency -CHHA)Home health services mean the following services when
                prescribed by a Provider and provided to a Enrollee in his or her
                home:

            


    

    


    i) nursing
      services provided on a part-time or intermittent basis by a CHHA or, if there
      is
      no CHHA that services the county/district, by a registered professional nurse
      or
      a licensed practical nurse acting under the direction of the Enrollee's
      PCP;

    


    ii) physical
      therapy, occupational therapy, or speech pathology and audiology services;
      and

    


    iii) home
      health services provided by a person who meets the training requirements of
      the
      SDOH, is assigned by a registered professional nurse to provide home health
      aid
      services in accordance with the Enrollee's plan of care, and is supervised
      by
      a

    


    


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    registered
      professional nurse from a CHHA or if the Contractor has no CHHA available,
      a
      registered nurse, or therapist.

    


    
      	 	
              b)

            	
              Personal
                care tasks performed by a home health aide incidental to a certified
                home
                health care agency visit, and pursuant to an established care plan,
                are
                covered.

            


    

    


    
      	 	
              c)

            	
              Services
                include care rendered directly to me Enrollee and instructions to
                his/her
                family or caretaker such as teacher or day care provider in the procedures
                necessary for the Enrollee's treatment or
                maintenance.

            


    

    


    
      	 	
              d)

            	
              The
                Contractor must provide up to two (2) post partum home visits for
                high
                risk infants and/or high risk mothers, as well as to women with less
                than
                a forty-eight (48) hour hospital stay after a vaginal delivery or
                less
                than a ninety-six (96) hour stay after a cesarean delivery. Visits
                must be
                made by a qualified health professional (minimum qualifications being
                an
                RN with maternal/child health background), the first visit to occur
                within
                forty-eight (48) hours of
                discharge.

            


    

    


    
      	 	
              e)

            	
              For
                Family Health Plus only: coverage is limited to forty (40) home health
                care visits per calendar year in lieu of a skilled nursing facility
                stay
                or hospitalization. Post partum home visits apply only to high risk
                mothers. For the purposes of this Section, visit is defined as the
                delivery of a discreet service (e.g. nursing, OT, PT, ST, audiology
                or
                home health aide). Four (4) hours of home health aide services equals
                one
                visit.

            


    

    


    15. Private
      Duty Nursing Services - For MMC Program Only

    


    a) Private
      duty nursing services shall be provided by a person possessing a license and
      current registration from the NYS Education Department to practice as a
      registered professional nurse or licensed practical nurse. Private duty nursing
      services can be provided through an approved certified home health agency,
      a
      licensed home care agency, or a private Practitioner. The location of nursing
      services may be in the MMC Enrollee's home or in the hospital.

    


    b) Private
      duty nursing services are covered only when determined by the attending
      physician to be medically necessary. Nursing services may be intermittent,
      part-time or continuous and provided in accordance with the ordering physicians,
      or certified nurse practitioner's written treatment plan.

    


    16. Hospice
      Services

    


    a) Hospice
      Services means a coordinated hospice program of home and inpatient services
      which provide non-curative medical and support services for Enrollees certified
      by a physician to be terminally ill with a life expectancy of six (6) months
      or
      less.

    


     

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    b) Hospice
      services include palliative and supportive care provided to an Enrollee to
      meet
      the special needs arising out of physical, psychological, spiritual, social
      and
      economic stress which are experienced during the final stages of illness and
      during

    dying
      and
      bereavement. Hospices must be certified under Article 40 of the New York State
      Public Health Law. 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 Enrollee and the Enrollee's family. Family members are eligible for
      up to
      five visits for bereavement counseling.

    


    c) Medicaid
      Managed Care Enrollees receive coverage for hospice services through the
      Medicaid fee-for-service program.

    


    17. Emergency
      Services

    


    a) Emergency
      conditions, medical or behavioral, the onset of which is sudden, manifesting
      itself by symptoms of sufficient severity, including severe pain, that a prudent
      layperson, possessing an average knowledge of medicine and health, could
      reasonably expect the absence of medical attention to result in (a) placing
      the
      health of the person afflicted with such condition in serious jeopardy, or
      in
      the case of a behavioral condition placing the health of such person or others
      in serious jeopardy;(b) serious impairment of such person's bodily functions;
      (c) serious dysfunction of any bodily organ or part of such person; or (d)
      serious disfigurement of such person are covered. Emergency services include
      health care procedures, treatments or services, needed to evaluate or stabilize
      an Emergency Medical Condition including psychiatric stabilization and medical
      detoxification from drugs or alcohol. A medical assessment (triage) is covered
      for non-emergent conditions. See also Appendix G of this Agreement.

    


    b) Post
      Stabilization Care Services means 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.
      These services are covered pursuant to Appendix G of this
      Agreement.

    


    18. Foot
      Care Services

    


    a) Covered
      services must include routine foot care when the physical conditions of any
      Enrollee's (regardless of age) poses a hazard due to the presence of localized
      illness, injury or symptoms involving the foot, or when performed as a necessary
      and integral part of otherwise covered services such as the diagnosis and
      treatment of diabetes, ulcers, and infections.

    


    b) Services
      provided by a podiatrist for persons under twenty-one (21) must be covered
      upon
      referral of a physician, registered physician assistant, certified nurse
      practitioner or licensed midwife.

    


     

    APPENDIX
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    c) Routine
      hygienic care of the feet, the treatment of corns and calluses, the trimming
      of
      nails, and other hygienic care such as cleaning or soaking feet, is not covered
      in the absence of a pathological condition.

    


    


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    19. Eye
      Care and Low Vision Services

    18
      NYCRR§505.6(b)(l-3)

    SSL
      §369-ee (l)(e)(xii)

    


    a) For
      Medicaid Managed Care only:

    


    i) Emergency,
      preventive and routine eye care services are covered. Eye care includes the
      services of ophthalmologists, optometrists and ophthalmic dispensers, and
      includes eyeglasses, medically necessary contact lenses and polycarbonate
      lenses, artificial eyes (stock or custom-made), low vision aids and low vision
      services. Eye care coverage includes the replacement of lost or destroyed
      eyeglasses. The replacement of a complete pair of eyeglasses must duplicate
      the
      original prescription and frames. Coverage also includes the repair or
      replacement of parts in situations where the damage is the result of causes
      other than defective workmanship. Replacement parts must duplicate the original
      prescription and frames. Repairs to, and replacements of, frames and/or lenses
      must be rendered as needed.

    


    ii) If
      the
      Contractor does not provide upgraded eyeglass frames or additional features
      (such as scratch coating, progressive lenses or photo-gray lenses) as part
      of
      its covered vision benefit, the Contractor cannot apply the cost of its covered
      eyeglass benefit to the total cost of the eyeglasses the Enrollee wants and
      bill
      only the difference to the Enrollee. The Enrollee can choose to purchase the
      upgraded frames and/or additional features by paying the entire cost of the
      eyeglasses as a private customer. For example, if the Contractor covers standard
      bifocal eyeglasses and the Enrollee wants no-line bifocal eyeglasses, the
      Enrollee must choose between taking the standard bifocal eyeglasses or paying
      the full price of the no-line bifocal eyeglasses (not just the difference
      between the cost of bifocal lenses and the no-line lenses). The Enrollee must
      be
      informed of this fact by the vision care provider at the time that the glasses
      are ordered.

    


    iii) Examinations
      for diagnosis and treatment for visual defects and/or eye disease are provided
      only as necessary and as required by the Enrollee's particular condition.
      Examinations which include refraction are limited to once every twenty four
      (24)
      months unless otherwise justified as medically necessary.

    


    iv) Eyeglasses
      do not require changing more frequently than once every twenty four (24) months
      unless medically indicated, such as a change in correction greater than 1/2
      diopter, or unless the glasses are lost, damaged, or destroyed.

    


    v) An
      ophthalmic dispenser fills the prescription of an optometrist or ophthalmologist
      and supplies eyeglasses or other vision aids upon the order of a qualified
      practitioner.

    


    vi) MMC
      Enrollees may self-refer to any Participating Provider of vision services
      (optometrist or ophthalmologist) for refractive vision services not more
      frequently than once every twenty four (24) months, or if otherwise justified
      as

    


    


    APPENDIX
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    medically
      necessary or if eyeglasses are lost, damaged or destroyed as described
      above.

    


    
      	 	
              b)

            	
              For
                Family Health Plus only:

            


    

    


    i) Covered
      Services include emergency vision care, and the following preventive and routine
      vision care provided once in any twenty four (24) month period:

    


    A) one
      eye
      examination;

    B) either:
      one pair of prescription eyeglass lenses and a frame, or prescription contact
      lenses where medically necessary; and

    C) one
      pair
      of medically necessary occupational eyeglasses.

    


    ii) An
      ophthalmic dispenser fills the prescription of an optometrist or ophthalmologist
      and supplies eyeglasses or other vision aids upon the order of a qualified
      practitioner.

    


    iii) FHPlus
      Enrollees may self-refer to any Participating Provider of vision services
      (optometrist or ophthalmologist) for refractive vision services not more
      frequently than once every twenty-four (24) months.

    


    iv) If
      the
      Contractor does not provide upgraded frames or additional features that the
      Enrollee wants (such as scratch coating, progressive lenses or photo-gray
      lenses) as part of its covered vision benefit, the Contractor cannot apply
      the
      cost of its covered eyeglass benefit to the total cost of the eyeglasses the
      Enrollee wants and bill only the difference to the Enrollee. The Enrollee can
      choose to purchase the upgraded frames and/or additional features by paying
      the
      entire cost of the eyeglasses as a private customer. For example, if the
      Contractor covers standard bifocal eyeglasses and the Enrollee wants no-line
      bifocal eyeglasses, the Enrollee must choose between taking the standard bifocal
      glasses or paying the full price for the no-line bifocal eyeglasses (not just
      the difference between the cost of bifocal lenses and no-line lenses). The
      Enrollee must be informed of this fact by me vision care provider at the time
      that the glasses are ordered.

    


    v) Contact
      lenses are covered only when medically necessary. Contact lenses shall not
      be
      covered solely because the FHPlus Enrollee selects contact lenses in lieu of
      receiving eyeglasses.

    


    vi) Coverage
      does not include the replacement of lost, damaged or destroyed
      eyeglasses.

    


    vii) The
      occupational vision benefit for FHPlus Enrollees covers the cost of job related
      eyeglasses if that need is determined by a Participating Provider through
      special testing done in conjunction with a regular vision examination. Such
      examination shall determine whether a special pair of eyeglasses would improve
      the performance of job-related activities. Occupational eyeglasses can be
      provided in addition to regular glasses but are available only in conjunction
      

    


    


    APPENDIX
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    with
      a
      regular vision benefit once in any twenty-four (24) month period. FHPlus
      Enrollees may purchase an upgraded frame or lenses for occupational eyeglasses
      by paying the entire cost as a private customer. Sun-sensitive and polarized
      lens options are not available for occupational eyeglasses.

    


    20. Durable
      Medical Equipment (DME)

    18
      NYCRR
§505.5(a)(l) and Section 4.4 of the NYS Medicaid DME, Medical and  Surgical
      Supplies and Prosthetic and Orthotic Appliances Provider Manual

    


    a) Durable
      Medical Equipment (DME) are devices and equipment, other than medical/surgical
      supplies, enteral formula, and prosthetic or orthotic appliances, and have
      the
      following characteristics:

    


    i) can
      withstand repeated use for a protracted period of time;

    ii) are
      primarily and customarily used for medical purposes;

    iii) are
      generally not useful to a person in the absence of illness or injury;
      and

    iv) are
      usually not fitted, designed or fashioned for a particular individual's use.
      Where equipment is intended for use by only one (1) person, it may be either
      custom made or customized.

    


    b) Coverage
      includes equipment servicing but excludes disposable medical
      supplies.

    


    21. Audiology,
      Hearing Aid Services and Products

    18
      NYCRR
§505.31 (a)(l)(2) and Section 4.7 of the NYS Medicaid Hearing Aid

    Provider
      Manual

    


    a) Hearing
      aid services and products are provided in compliance with Article 37-A of the
      General Business Law when medically necessary to alleviate disability caused
      by
      the loss or impairment of hearing. Hearing aid services include: selecting,
      fitting and dispensing of hearing aids, hearing aid checks following dispensing
      of hearing aids, conformity evaluation, and hearing aid repairs.

    


    b) Audiology
      services include audiometric examinations and testing, hearing aid evaluations
      and hearing aid prescriptions or recommendations, as medically
      indicated.

    


    c) Hearing
      aid products include hearing aids, earmolds, special fittings, and replacement
      parts.

    


    d) Hearing
      aid batteries:

    


    
      	 	
              i)

            	
              For
                Family Health Plus only: Hearing aid batteries are covered as part
                of the
                prescription drug benefit.

            


    

    


    
      	 	
              ii)

            	
              For
                Medicaid Managed Care only: Hearing aid batteries are covered through
                the
                Medicaid fee-for-service program.

            


    

    


     

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    22. Family
      Planning and Reproductive Health Care

    


    a) Family
      Planning and Reproductive Health Care services means the offering, arranging
      and
      furnishing of those health services which enable Enrollees, including minors
      who
      may be sexually active, to prevent or reduce the incidence of unwanted
      pregnancy, as specified in Appendix C of this Agreement.

    


    b) HIV
      counseling and testing is included in coverage when provided as part of a Family
      Planning and Reproductive Health visit.

    


    c) All
      medically necessary abortions are covered, as specified in Appendix C of this
      Agreement.

    


    d) Fertility
      services are not covered.

    


    e) If
      the
      Contractor excludes Family Planning and Reproductive Health services from its
      Benefit Package, as specified in Appendix M of this Agreement, the Contractor
      is
      required to comply with the requirements of Appendix C.3 of this Agreement
      and
      still provide the following services:

    


    i) screening,
      related diagnosis, ambulatory treatment, and referral to Participating Provider
      as needed for dysmenorrhea, cervical cancer or other pelvic
      abnormality/pathology;

    


    ii) screening,
      related diagnosis, and referral to Participating Provider for anemia, cervical
      cancer, glycosuria, proteinuria, hypertension, breast disease and
      pregnancy.

    


    23. Non-Emergency
      Transportation

    


    a) Transportation
      expenses are covered for MMC Enrollees when transportation is essential in
      order
      for a MMC 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 Medicaid fee-for-service). Non-emergent transportation guidelines
      may be developed in conjunction with the LDSS, based on the LDSS' approved
      transportation plan.

    


    b) Transportation
      services means transportation by ambulance, ambulette fixed wing or airplane
      transport, invalid coach, taxicab, livery, public transportation, or other
      means
      appropriate to the MMC Enrollee's medical condition; and a transportation
      attendant to accompany the MMC Enrollee, if necessary. Such services may include
      the transportation attendant's transportation, meals, lodging and salary;
      however, no salary will be paid to a transportation attendant who is a member
      of
      the MMC Enrollee's family.

    


    c) When
      the
      Contractor is capitated for non-emergency transportation, the Contractor is
      also
      responsible for providing transportation to Medicaid covered services that
      are
      not part of the Contractor's Benefit Package.

    


    


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    d) Non-emergency
      transportation is covered for FHPlus Enrollees that are nineteen (19) or twenty
      (20) years old and are receiving C/THP services.

    


    e) For
      MMC
      Enrollees with disabilities, the method of transportation must reasonably
      accommodate their needs, taking into account the severity and nature of the
      disability.

    


    d) Non-emergency
      transportation is covered for FHPlus Enrollees that are nineteen
      (19)

    or
      twenty
      (20) years old and are receiving C/THP services.

    


    24. Emergency
      Transportation

    


    a) Emergency
      transportation can only be provided by an ambulance service including air
      ambulance service. Emergency ambulance transportation means the provision of
      ambulance transportation for the purpose of obtaining hospital services for
      an
      Enrollee who suffers from severe, life-threatening or potentially disabling
      conditions which require the provision of Emergency Services while the Enrollee
      is being transported.

    


    b) Emergency
      Services means the health care procedures, treatments or services needed to
      evaluate or stabilize an Emergency Medical Condition including, but not limited
      to, the treatment of trauma, bums, respiratory, circulatory and obstetrical
      emergencies.

    


    c) Emergency
      ambulance transportation is transportation to a hospital emergency room
      generated by a "Dial 911" emergency system call or some other request for an
      immediate response to a medical emergency. Because of the urgency of the
      transportation request, insurance coverage or other billing provisions are
      not
      addressed until after the trip is completed. When the Contractor is capitated
      for this benefit, emergency transportation via 911 or any other emergency call
      system is a covered benefit and the Contractor is responsible for payment.
      Contractor shall reimburse the transportation provider for all emergency
      ambulance services without regard for final diagnosis or prudent layperson
      standard.

    


    25. Dental
      Services

    


    a) Dental
      care includes preventive, prophylactic and other routine dental care, services,
      supplies and dental prosthetics required to alleviate a serious health
      condition, including one which affects employability. Orthodontic services
      are
      not covered.

    


    b) Dental
      surgery performed in an ambulatory or inpatient setting is the responsibility
      of
      the Contractor whether dental services are included in the Benefit Package
      or
      not. Inpatient claims and referred ambulatory claims for dental services
      provided in an inpatient or outpatient hospital setting for surgery,
      anesthesiology. X-rays, etc. are the responsibility of the Contractor. The
      Contractor shall set up procedures to prior approve dental services provided
      in
      inpatient and ambulatory settings.

    


    


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    c) For
      Medicaid Managed Care only:

    


    
      	 	
              i)

            	
              As
                described in Sections 10.15 and 10.27 of this Agreement, Enrollees
                may
                self-refer to Article 28 clinics operated by academic dental centers
                to
                obtain covered dental services if dental services are included in
                the
                Benefit Package.

            


    

    
      	 	
              ii)

            	
              Professional
                services of a dentist for dental surgery performed in an ambulatory
                or
                inpatient setting are billed Medicaid fee-for-service if the Contractor
                does not include dental services in the benefit
                package.

            


    

    


    d) For
      Family Health Plus only: professional services of a dentist for dental surgery
      performed in an ambulatory or inpatient setting are not covered.

    


    26. Court
      Ordered Services

    


    Court
      ordered services are those services ordered by a court of competent jurisdiction
      which are performed by or under the supervision of a physician, dentist, or
      other provider qualified under State law to furnish medical, dental, behavioral
      health (including treatment for mental health and/or chemical dependence),
      or
      other covered services. The Contractor is responsible for payment of those
      services included in the benefit package.

    


    27. Prosthetic/Orthotic
      Orthopedic Footwear

    Section
      4.5, 4.6 and 4.7 of the NYS Medicaid DME, Medical and Surgical Supplies
      and

    Prosthetic
      and Orthotic Appliances Provider Manual

    


    a) Prosthetics
      are those appliances or devices which replace or perform the function of any
      missing part of the body. Artificial eyes are covered as part of the eye care
      benefit.

    


    b) Orthotics
      are those appliances or devices which are used for the purpose of supporting
      a
      weak or deformed body part or to restrict or eliminate motion in a diseased
      or
      injured part of the body.

    


    c) Medicaid
      Managed Care: Orthopedic Footwear means shoes, shoe modifications, or shoe
      additions which are used to correct, accommodate or prevent a physical deformity
      or range of motion malfunction in a diseased or injured part of the ankle or
      foot; to support a weak or deformed structure of the ankle or foot, or to form
      an integral part of a brace.

    


    28. Mental
      Health Services

    


    a) Inpatient
      Services

    


    All
      inpatient mental health services, including voluntary or involuntary admissions
      for mental health services. The Contractor may provide the covered benefit
      for
      medically necessary mental health inpatient services through hospitals licensed
      pursuant to Article 28 of the PHL.

    


    


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    b) Outpatient
      Services

    


    Outpatient
      services including but not limited to: assessment, stabilization, treatment
      planning, discharge planning, verbal therapies, education, symptom management,
      case management services, crisis intervention and outreach services, chlozapine
      monitoring and collateral services as certified by the New York State Office
      of
      Mental Health (OMH). Services may be provided in-home, in an office or in the
      community. Services may be provided by licensed OMH providers or by other
      providers of mental health services including clinical psychologists and
      physicians.

    


    c) Family
      Health Plus Enrollees have a combined mental health/chemical dependency benefit
      limit of thirty (30) days inpatient and sixty (60) outpatient visits per
      calendar year.

    


    d) MMC
      SSI
      Enrollees obtain all mental health services through the Medicaid fee-for-service
      program.

    


    29. Detoxification
      Services

    


    a) Medically
      Managed Inpatient Detoxification

    


    These
      programs provide medically directed twenty-four (24) hour care on an inpatient
      basis to individuals who are at risk of severe alcohol or substance abuse
      withdrawal, incapacitated, a risk to self or others, or diagnosed with an acute
      physical or mental co-morbidity. Specific services include, but are not limited
      to: medical management, bio-psychosocial assessments, stabilization of medical
      psychiatric / psychological problems, individual and group counseling, level
      of
      care determinations and referral and linkages to other services as necessary.
      Medically Managed Detoxification Services are provided by facilities licensed
      by
      OASAS under Title 14 NYCRR§ 816.6 and the Department of Health as a general
      hospital pursuant to Article 28 of the Public Health Law or by the Department
      of
      Health as a general hospital pursuant to Article 28 of the Public Health
      Law.

    


    b) Medically
      Supervised Withdrawal

    


    
      	 	
              i)

            	
              Medically
                Supervised Inpatient Withdrawal

            


    

    


    
      	 	 	
              These
                programs offer treatment for moderate withdrawal on an inpatient
                basis.
                Services must include medical supervision and direction under the
                care of
                a physician in the treatment for moderate withdrawal. Specific services
                must include, but are not limited to: medical assessment within
                twenty-four (24) hours of admission; medical supervision of intoxication
                and withdrawal conditions; bio-psychosocial assessments; individual
                and
                group counseling and linkages to other services as necessary. Maintenance
                on methadone while a patient is being treated for withdrawal from
                other
                substances may be provided where the provider is appropriately authorized.
                Medically Supervised Inpatient Withdrawal services are provided by
                facilities licensed under Title 14 NYCRR §
                816.7.

            


    

    


     

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    ii) Medically
      Supervised Outpatient Withdrawal

    


    These
      programs offer treatment for moderate withdrawal on an outpatient basis.
      Required services include, but are not limited to: medical supervision of
      intoxication and withdrawal conditions; bio-psychosocial assessments; individual
      and group counseling; level of care determinations; discharge planning; and
      referrals to appropriate services. Maintenance on methadone while a patient
      is
      being treated for withdrawal from other substances may be provided where the
      provider is appropriately authorized. Medically Supervised Outpatient Withdrawal
      services are provided by facilities licensed under Title 14 NYCRR
§816.7.

    


    c) For
      Medicaid Managed Care only: all detoxification and withdrawal services are
      a
      covered benefit for all Enrollees, including those categorized as SSI or
      SSI-related. Detoxification Services in Article 28 inpatient hospital facilities
      are subject to the inpatient hospital stop-loss provisions specified in Section
      3.11 of this Agreement

    


     

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    30. Chemical
      Dependence Inpatient Rehabilitation and Treatment Services

    


    a) Services
      provided include intensive management of chemical dependence symptoms and
      medical management of physical or mental complications from chemical dependence
      to clients who cannot be effectively served on an outpatient basis and who
      are
      not in need of medical detoxification or acute care. These services can be
      provided in a hospital or free-standing facility. Specific services can include,
      but are not limited to: comprehensive admission evaluation and treatment
      planning; individual group, and family counseling; awareness and relapse
      prevention; education about self-help groups; assessment and referral services;
      vocational and educational assessment; medical and psychiatric consultation;
      food and housing; and HIV and AIDS education. These services may be provided
      by
      facilities licensed by the New York State Office of Alcoholism and Substance
      Abuse Services (OASAS) to provide Chemical Dependence Inpatient Rehabilitation
      and Treatment Services under Title 14 NYCRR Part 818. Maintenance on methadone
      while a patient is being treated for withdrawal from other substances may be
      provided where the provider is appropriately authorized.

    


    b) Family
      Health Plus Enrollees have a combined mental health/chemical dependency benefit
      limit of thirty (30) days inpatient and sixty (60) outpatient visits per
      calendar year.

    


    31. Outpatient
      Chemical Dependency Services

    


    a) Medically
      Supervised Ambulatory Chemical Dependence Outpatient Clinic
      Programs

    


    Medically
      Supervised Ambulatory Chemical Dependence Outpatient Clinic Programs are
      licensed under Title 14 NYCRR Part 822 and provide chemical dependence
      outpatient treatment to individuals who suffer from chemical abuse or dependence
      and their family members or significant others.

    


    b) Medically
      Supervised Chemical Dependence Outpatient Rehabilitation Programs

    


    Medically
      Supervised Chemical Dependence Outpatient Rehabilitation Programs provide full
      or half-day services to meet the needs of a specific target population of
      chronic alcoholic persons who need a range of services which are different
      from
      those typically provided in an alcoholism outpatient clinic. Programs are
      licensed by as Chemical Dependence Outpatient Rehabilitation Programs under
      Title 14 NYCRR § 822.9.

    


    c) Outpatient
      Chemical Dependence for Youth Programs

    


    Outpatient
      Chemical Dependence for Youth Programs (OCDY) licensed under Title 14 NYCRR
      OCDY
      part 823 programs offer discrete, ambulatory clinic services to
      chemically-dependent youth in a treatment setting that supports abstinence
      from
      chemical dependence (including alcohol and substance abuse)
      services.

     

    


    APPENDIX
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    d) Medicaid
      Managed Care Enrollees access outpatient chemical dependency services through
      the Medicaid fee-for-service program.

    


    32. Experimental
      and/or Investigational Treatment

    


    a) Experimental
      and investigational treatment is covered on a case by case basis.

    


    b) Experimental
      and/or investigational treatment for life-threatening and/or disabling illnesses
      may also be considered for coverage under the external appeal process pursuant
      to the requirements of Section 4910 of the PHL under the following
      conditions:

    


    i) The
      Enrollee has had coverage of a health care service denied on the basis that
      such
      service is experimental and investigational, and

    


    ii) The
      Enrollee's attending physician has certified that the Enrollee has a
      life-threatening or disabling condition or disease:

    


    A) for
      which
      standard health services or procedures have been ineffective or would be
      medically inappropriate, or

    


    B) for
      which
      there does not exist a more beneficial standard health service or procedure
      covered by the Contractor, or

    


    C) for
      which
      there exists a clinical trial, and

    


    iii) The
      Enrollee's provider, who must be a licensed, board-certified or board-eligible
      physician, qualified to practice in the area of practice appropriate to treat
      the Enrollee's life-threatening or disabling condition or disease, must have
      recommended either:

    


    A) a
      health
      service or procedure that, based on two (2) documents from the available medical
      and scientific evidence, is likely to be more beneficial to the Enrollee than
      any covered standard health service or procedure; or

    


    B) a
      clinical trial for which the Enrollee is eligible; and

    


    iv) The
      specific health service or procedure recommended by the attending physician
      would otherwise be covered except for the Contractor's determination that the
      health service or procedure is experimental or investigational.

    


    33. Renal
      Dialysis

    


    Renal
      dialysis may be provided in an inpatient hospital setting, in an ambulatory
      care
      facility, or in the home on recommendation from a renal dialysis
      center.

     

    


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    34. Residential
      Health Care Facility (RHCF) Services - For MMC Program
      Only

    


    a) Residential
      Health Care Facility (RHCF) Services means inpatient nursing home services
      provided by facilities licensed under Article 28 of the New York State Public
      Health Law, including AIDS nursing facilities. Covered services includes the
      following health care services: medical supervision, twenty-four (24) hour
      per
      day nursing care, assistance with the activities of daily living, physical
      therapy, occupational therapy, and speech/language pathology services and other
      services as specified in the New York State Health Law and Regulations for
      residential health care facilities and AIDS nursing facilities. These services
      should be provided to an MMC Enrollee:

    


    i) Who
      is
      diagnosed by a physician as having one or more clinically determined illnesses
      or conditions that cause the MMC Enrollee to be so incapacitated, sick, invalid,
      infirm, disabled, or convalescent as to require at least medical and nursing
      care; and

    


    ii) Whose
      assessed health care needs, in the professional judgment of the MMC Enrollee's
      physician or a medical team:

    


    A) do
      not
      require care or active treatment of the MMC Enrollee in a general or special
      hospital;

    


    B) cannot
      be
      met satisfactorily in the MMC Enrollee's own home or home substitute through
      provision of such home health services, including medical and other health
      and
      health-related services as are available in or near his or her community;
      and

    


    C) cannot
      be
      met satisfactorily in the physician's office, a hospital clinic, or other
      ambulatory care setting because of the unavailability of medical or other health
      and health-related services for the MMC Enrollee in such setting in or near
      his
      or her community.

    


    b) The
      Contractor is also responsible for respite days and bed hold days authorized
      by
      the Contractor.

    


    c) The
      Contractor is responsible for all medically necessary and clinically appropriate
      inpatient Residential Health Care Facility services authorized by the Contractor
      up to a sixty (60) day calendar year stop-loss for MMC Enrollees who are not
      in
      Permanent Placement Status as determined by LDSS.

    


     

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    K.3

    


    Medicaid
      Managed Care Prepaid Benefit Package

    Definitions
      of Non-Covered Services

    


    The
      following services are excluded from the Contractor's Benefit Package, but
      are
      covered, in most instances, by Medicaid fee-for-service:

    


    1. Medical
      Non-Covered Services

    


    a) Personal
      Care Agency Services

    


    i) Personal
      care services (PCS) are the provision of some or total assistance with personal
      hygiene, dressing and feeding; and nutritional and environmental support (meal
      preparation and housekeeping). Such services must be essential to the
      maintenance of the Enrollee's health and safety in his or her own home. The
      service has to be ordered by a physician, and there has to be a medical need
      for
      the service. Licensed home care services agencies, as opposed to certified
      home
      health agencies, are the primary providers of PCS. Enrollee's receiving PCS
      have
      to have a stable medical condition and are generally expected to be in receipt
      of such services for an extended period of time (years).

    


    ii) Services
      rendered by a personal care agency which are approved by the LDSS are not
      covered under the Benefit Package. Should it be medically necessary for the
      PCP
      to order personal care agency services, the PCP (or the Contractor on the
      physician's behalf) must first contact the Enrollee's LDSS contact person for
      personal care. The district will determine the Enrollee's need for personal
      care
      agency services and coordinate with the personal care agency to develop a plan
      of care.

    


    b) Residential
      Health Care Facilities (RHCF) 

    Services
      provided in a Residential Health Care Facility (RHCF) to an individual who
      is
      determined by the LDSS to be in Permanent Status are not covered.

    


    c) Hospice
      Program

    


    i) 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.

    


    ii) Hospices
      are organizations which must be certified under Article 40 of the PHL. All
      services must be provided by qualified employees and volunteers of
      the

    


    APPENDIX
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    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.

    


    iii) If
      an
      Enrollee becomes terminally ill and receives Hospice Program services he or
      she
      may remain enrolled and continue to access the Contractor's Benefit Package
      while Hospice costs are paid for by Medicaid fee-for-service.

    


    d) Prescription
      and Non-Prescription (OTC) Drugs, Medical Supplies, and Enteral
      Formula

    


    Coverage
      for drugs dispensed by community pharmacies, over the counter drugs,
      medical/surgical supplies and enteral formula are not included in the Benefit
      Package and will be paid for by Medicaid fee-for-service. Medical/surgical
      supplies are items other than drugs, prosthetic or orthotic appliances, or
      DME
      which have been ordered by a qualified practitioner in the treatment of a
      specific medical condition and which are: consumable, non-reusable, disposable,
      or for a specific rather than incidental purpose, and generally have no
      salvageable value (e.g. gauze pads, bandages and diapers). Pharmaceuticals
      and
      medical supplies routinely furnished or administered as part of a clinic or
      office visit are covered.

    


    2. Non-Covered
      Behavioral Health Services

    


    a) Chemical
      Dependence Services

    


    i) Outpatient
      Rehabilitation and Treatment Services

    


    A) 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 OASAS under 14 NYCRR Part 828.

    


    B) Medically
      Supervised Ambulatory Chemical Dependence Outpatient Clinic
      Programs

    


    Medically
      Supervised Ambulatory Chemical Dependence Outpatient Clinic Programs are
      licensed under Title 14 NYCRR Part 822 and provide chemical dependence
      outpatient treatment to individuals who suffer from chemical abuse or dependence
      and their family members or significant others.

    


    


    APPENDIX
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    C) Medically
      Supervised Chemical Dependence Outpatient Rehabilitation Programs

    


    Medically
      Supervised Chemical Dependence Outpatient Rehabilitation Programs provide full
      or half-day services to meet the needs of a specific target population of
      chronic alcoholic persons who need a range of services which are different
      from
      those typically provided in an alcoholism outpatient clinic. Programs are
      licensed by as Chemical Dependence Outpatient Rehabilitation Programs under
      Title 14 NYCRR § 822.9.

    


    D) Outpatient
      Chemical Dependence for Youth Programs

    


    Outpatient
      Chemical Dependence for Youth Programs (OCDY) licensed under Title 14 NYCRR
      Part
      823, establish programs and service regulations for OCDY programs. OCDY programs
      offer discrete, ambulatory clinic services to chemically-dependent youth in
      a
      treatment setting that supports abstinence from chemical dependence (including
      alcohol and substance abuse) services.

    


    ii) Chemical
      Dependence Services Ordered by the LDSS

    


    A) The
      Contractor is not responsible for the provision and payment of Chemical
      Dependence Inpatient Rehabilitation and Treatment Services ordered by the LDSS
      and provided to Enrollees who have:

    


    I) been
      assessed as unable to work by the LDSS and are mandated to receive Chemical
      Dependence Inpatient Rehabilitation and Treatment Services as a condition of
      eligibility for Public Assistance or Medicaid, or

    


    II) have
      been
      determined to be able to work with limitations (work limited) and are
      simultaneously mandated by the LDSS into Chemical Dependence Inpatient
      Rehabilitation and Treatment Services (including alcohol and substance abuse
      treatment services) pursuant to work activity requirements.

    


    B) The
      Contractor is not responsible for the provision and payment of Medically
      Supervised Inpatient and Outpatient Withdrawal Services ordered by the LDSS
      under Welfare Reform (as indicated by Code 83).

    


    C) The
      Contractor is responsible for the provision and payment of Medically Managed
      Detoxification Services in this Agreement.

    


    D) If
      the
      Contractor is already providing an Enrollee with Chemical Dependence Inpatient
      Rehabilitation and Treatment Services and Detoxification Services and the LDSS
      is satisfied with the level of care and services, then the Contractor will
      continue to be responsible for the provision and payment of these
      services.

    


    APPENDIX
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    b) Mental
      Health Services

    


    i) Intensive
      Psychiatric Rehabilitation Treatment Programs (IPRT)

    


    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.

    


    ii) 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.

    


    iii) 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.

    


    iv) Day
      Treatment Programs Serving Children

    


    Day
      treatment programs are characterized by a blend of mental health and special
      education services provided in a fully integrated program. Typically these
      programs include: special education in small classes with an emphasis on
      individualized instruction, individual and group counseling, family services
      such as family counseling, support and education, crisis intervention,
      interpersonal skill development, behavior modification, art and music
      therapy.

    


    v) Home
      and
      Community Based Services Waiver for Seriously Emotionally Disturbed
      Children

    


    This
      waiver is in select counties for children and adolescents who would otherwise
      be
      admitted to an institutional setting if waiver services were not provided.
      The
      services include individualized care coordination, respite, family support,
      intensive in-home skill building, and crisis response.

    


     

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    vi) Case
      Management

    


    The
      target population consists of individuals who are seriously and persistently
      mentally ill (SPMI), require intensive, personal and proactive intervention
      to
      help them obtain those services which will permit functioning in the community
      and either have symptomology which is difficult to treat in the existing mental
      health care system or are unwilling or unable to adapt to the existing mental
      health care system. Three case management models are currently operated pursuant
      to an agreement with OMH or a local governmental unit, and receive Medicaid
      reimbursement pursuant to 14 NYCRR Part 506. Please note: See generic definition
      of Comprehensive Medicaid Case Management (CMCM) under Item 3 - "Other
      Non-Covered Services".

    


    vii) Partial
      Hospitalization

    


    Provides
      active treatment designed to stabilize and ameliorate acute systems, serves
      as
      an alternative to inpatient hospitalization, or reduces the length of a hospital
      stay within a medically supervised program by providing the
      following:

    assessment
      and treatment planning; health screening and referral; symptom management;
      medication therapy; medication education; verbal therapy; case management;
      psychiatric rehabilitative readiness determination and referral and crisis
      intervention. These services are certified by OMH under NYCRR Part
      587.

    


    viii) Services
      Provided Through OMH Designated Clinics for Children With A Diagnosis of Serious
      Emotional Disturbance (SED)

    


    These
      are
      services provided by designated OMH clinics to children and adolescents with
      a
      clinical diagnosis of SED.

    


    ix) 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.

    


    x) Personalized
      Recovery Oriented Services (PROS)

    


    PROS,
      licensed and reimbursed pursuant to 14 NYCRR 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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              c)

            	
              Rehabilitation
                Services Provided to Residents of OMH Licensed Community Residences
                (CRs)
                and Family Based Treatment Programs, as
                follows:

            


    

    


    i) 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.

    


    ii) 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 § 586.3, Part 594 and Part
      595.

    


    


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

    


    i) 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.

    


    ii) 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

    


     

    APPENDIX
      K 

    October
      1, 2005 

    K-31

    



    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.

    


    iii) Medicaid
      Service Coordination (MSC)

    


    Medicaid
      Service Coordination (MSC) is a Medicaid State Plan service provided by OMRDD
      which assists persons with developmental disabilities and mental retardation
      to
      gain access to necessary services and supports appropriate to the needs of
      the
      needs of the individual. MSC is provided by qualified service coordinators
      and
      uses a person centered planning process in developing, implementing and
      maintaining an Individualized Service Plan (ISP) with and for a person with
      developmental disabilities and mental retardation. MSC promotes the concepts
      of
      a choice, individualized services and consumer satisfaction. MSC is provided
      by
      authorized vendors who have a contract with OMRDD, and who are paid monthly
      pursuant to such contract. Persons who receive MSC must not permanently reside
      in an ICF for persons with developmental disabilities, a developmental center,
      a
      skilled nursing facility or any other hospital or Medical Assistance
      institutional setting that provides service coordination. They must also not
      concurrently be enrolled in any other comprehensive Medicaid long term service
      coordination program/service including the Care at Home Waiver. Please note:
      See
      generic definition of Comprehensive Medicaid Case Management (CMCM) under Item
      3
      "Other Non-Covered Services."

    


    iv) Home
      And
      Community Based Services Waivers (HCBS)

    


    The
      Home
      and Community-Based Services Waiver serves persons with developmental
      disabilities who would otherwise be admitted to an ICF/MR if waiver services
      were not provided. HCBS waivers services include residential habilitation,
      day
      habilitation, prevocational, supported work, respite, adaptive devices,
      consolidated supports and services, environmental modifications, family
      education and training, live-in caregiver, and plan of care support services.
      These services are authorized pursuant to a SSA § 1915(c) waiver from
      DHHS.

    


    v) Services
      Provided Through the Care At Home Program (OMRDD)

    


    The
      OMRDD
      Care at Home III, Care at Home IV, and Care at Home VI waivers, serve children
      who would otherwise not be eligible for Medicaid because of their parents'
      income and resources, and who would otherwise be eligible for an ICF/MR level
      of
      care. Care at Home waiver services include service coordination, respite and
      assistive technologies. Care at Home waiver services are authorized pursuant
      to
      a SSA § 1915(c) waiver from DHHS.

     

    


    APPENDIX
      K 

    October
      1, 2005 

    K-32

    



    3. Other
      Non-Covered Services

    


    a) The
      Early
      Intervention Program (EIP) - Children Birth to Two (2) Years of Age

    


    i) This
      program provides early intervention services to certain children, from birth
      through two (2) years of age, who have a developmental delay or a diagnosed
      physical or mental condition that has a high probability of resulting in
      developmental delay. All managed care providers must refer infants and toddlers
      suspected of having a delay to the local designated Early Intervention agency
      in
      their area. (In most municipalities, the County Health Department is the
      designated agency, except: New York City - the Department of Health and Mental
      Hygiene; Erie County - The Department of Youth Services; Jefferson County -the
      Office of Community Services; and Ulster County - the Department of Social
      Services).

    


    ii) Early
      intervention services provided to this eligible population are categorized
      as
      Non-Covered. These services, which are designed to meet the developmental needs
      of the child and the needs of the family related to enhancing the child's
      development, will be identified on eMedNY by unique rate codes by which only
      the
      designated early intervention agency can claim reimbursement. Contractor covered
      and authorized services will continue to be provided by the Contractor.
      Consequently, the Contractor, through its Participating Providers, will be
      expected to refer any enrolled child suspected of having a developmental delay
      to the locally designated early intervention agency in their area and
      participate in the development of the Child's Individualized Family Services
      Plan (IFSP). Contractor's participation in the development of the IFSP is
      necessary in order to coordinate the provision of early intervention services
      and services covered by the Contractor.

    


    iii) SDOH
      will
      instruct the locally designated early intervention agencies on how to identify
      an Enrollee and the need to contact the Contractor or the Participating Provider
      to coordinate service provision.

    


    b) Preschool
      Supportive Health Services-Children Three (3) Through Four (4) Years of
      Age

    


    i) The
      Preschool Supportive Health Services Program (PSHSP) enables counties and New
      York City to obtain Medicaid reimbursement for certain educationally related
      medical services provided by approved preschool special education programs
      for
      young children with disabilities. The Committee on Preschool Special Education
      in each school district is responsible for the development of an Individualized
      Education Program (IEP) for each child evaluated in need of special education
      and medically related health services.

    


    ii) PSHSP
      services rendered to children three (3) through four (4) years of age in
      conjunction with an approved IEP are categorized as Non-Covered.

    


    


    APPENDIX
      K 

    October
      1, 2005 

    K-33

    



    iii) The
      PSHSP
      services will be identified on eMedNY by unique rate codes through which only
      counties and New York City can claim reimbursement. In addition, a limited
      number of Article 28 clinics associated with approved pre-school programs are
      allowed to directly bill Medicaid fee-for-service for these services. Contractor
      covered and authorized services will continue to be provided by the
      Contractor.

    


    
      	 	
              c)

            	
              School
                Supportive Health Services-Children Five (5) Through Twenty-One (21)
                Years
                of Age

            


    

    


    i) The
      School Supportive Health Services Program (SSHSP) enables school districts
      to
      obtain Medicaid reimbursement for certain educationally related medical services
      provided by approved special education programs for children with disabilities.
      The Committee on Special Education in each school district is responsible for
      the development of an Individualized Education Program (IEP) for each child
      evaluated in need of special education and medically related
      services.

    


    ii) SSHSP
      services rendered to children five (5) through twenty-one (21) years of age
      in
      conjunction with an approved IEP are categorized as Non-Covered.

    


    iii) The
      SSHSP
      services are identified on eMedNY by unique rate codes through which only school
      districts can claim Medicaid reimbursement. Contractor covered and authorized
      services will continue to be provided by the Contractor.

    


    d) Comprehensive
      Medicaid Case Management (CMCM)

    


    A
      program
      which provides "social work" case management referral services to a targeted
      population (e.g.: pregnant teens, mentally ill). A CMCM case manager will assist
      a client in accessing necessary services in accordance with goals contained
      in a
      written case management plan. CMCM programs do not provide services directly,
      but refer to a wide range of service Providers. Some of these services are:
      medical, social, psycho-social, education, employment, financial, and mental
      health. CMCM referral to community service agencies and/or medical providers
      requires the case manager to work out a mutually agreeable case coordination
      approach with the agency/medical providers. Consequently, if an Enrollee of
      the
      Contractor is participating in a CMCM program, the Contractor must 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 and informed on the need to contact the
      Contractor to coordinate service provision.

    


    e) 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 included
      in
      the Benefit Package, TB/DOT where applicable, can be billed directly to eMedNY
      by any SDOH approved Medicaid fee-for-service TB/DOT Provider. The

    


    APPENDIX
      K 

    October
      1, 2005 

    K-34

    



    Contractor
      remains responsible for communicating, cooperating and coordinating clinical
      management of TB with the TB/DOT Provider.

    


    f) AIDS
      Adult Day Health Care

    


    Adult
      Day
      Health Care Programs (ADHCP) are programs designed to assist individuals with
      HIV disease to live more independently in the community or eliminate the need
      for residential health care services. Registrants in ADHCP require a greater
      range of comprehensive health care services than can be provided in any single
      setting, but do not require the level of services provided in a residential
      health care setting. Regulations require that a person enrolled in an ADHCP
      must
      require at least three (3) hours of health care delivered on the basis of at
      least one (1) visit per week- While health care services are broadly defined
      in
      this setting to include general medical care, nursing care, medication
      management, nutritional services, rehabilitative services, and substance abuse
      and mental health services, the latter two (2) cannot be the sole reason for
      admission to the program. Admission criteria must include, at a minimum, the
      need for general medical care and nursing services.

    


    g) HIV
      COBRA
      Case Management

    


    The
      HIV
      COBRA (Community Follow-up Program) Case Management Program is a program that
      provides intensive, family-centered case management and community follow-up
      activities by case managers, case management technicians, and community
      follow-up workers. Reimbursement is through an hourly rate billable to Medicaid.
      Reimbursable activities include intake, assessment, reassessment, service plan
      development and implementation, monitoring, advocacy, crisis intervention,
      exit
      planning, and case specific supervisory case-review conferencing.

    


    h) Adult
      Day
      Health Care

    


    
      	 	
              i)

            	
              Adult
                Day Health Care means care and services provided to a registrant
                in a
                residential health care facility or approved extension site under
                the
                medical direction of a physician and which is provided by personnel
                of the
                adult day health care program in accordance with a comprehensive
                assessment of care needs and individualized health care plan, ongoing
                implementation and coordination of the health care plan, and
                transportation.

            


    

    


    
      	 	
              ii)

            	
              Registrant
                means a person who is a nonresident of the residential health care
                facility who is functionally impaired and not homebound and who requires
                certain preventive, diagnostic, therapeutic, rehabilitative or palliative
                items or services provided by a general hospital, or residential
                health
                care facility; and whose assessed social and health care needs, in
                the
                professional judgment of the physician of record, nursing staff.
                Social
                Services and other professional personnel of the adult day health
                care
                program can be met in whole or in part satisfactorily by delivery
                of
                appropriate services in such
                program.

            


    

    


     

    APPENDIX
      K 

    October
      1, 2005 

    K-35

    



    i) Personal
      Emergency Response Services (PERS)

    


    Personal
      Emergency Response Services (PERS) are not included in the Benefit Package.
      PERS
      are covered on a fee-for-service basis through contracts between the LDSS and
      PERS vendors.

    


    j) School-Based
      Health Centers

    


    A
      School-Based Health Center (SBHC) is an Article 28 extension clinic that is
      located in a school and provides students with primary and preventive physical
      and mental health care services, acute or first contact care, chronic care,
      and
      referral as needed. SBHC services include comprehensive physical and mental
      health histories and assessments, diagnosis and treatment of acute and chronic
      illnesses, screenings (e.g., vision, hearing, dental, nutrition, TB), routine
      management of chronic diseases (e.g., asthma, diabetes), health education,
      mental health counseling and/or referral, immunizations and physicals for
      working papers and sports.

     

    APPENDIX
      K 

    October
      1, 2005 

    K-36

     

     

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    



    K.4

    Family
      Health Plus

    Non-Covered
      Services

    


    


    


    1. Non-Emergent
      Transportation Services (except for 19 and 20 year olds receiving C/THP
Services)

    2. Personal
      Care Agency Services

    3. Private
      Duty Nursing Services

    4. Long
      Term
      Care - Residential Health Care Facility Services

    5. Non-Prescription
      (OTC) Drugs and Medical Supplies

    6. Alcohol
      and Substance Abuse (ASA) Services Ordered by the LDSS

    7. Office
      of
      Mental Health/ Office of Mental Retardation and Developmental Disabilities
      Services

    8. School
      Supportive Health Services

    9. Comprehensive
      Medicaid Case Management (CMCM)

    10. Directly
      Observed Therapy for Tuberculosis Disease

    11. AIDS
      Adult Day Health Care

    12. HIV
      COBRA
      Case Management

    13. Home
      and
      Community Based Services Waiver

    14. Methadone
      Maintenance Treatment Program

    15. Day
      Treatment

    16. IPRT

    17. Infertility
      Services

    18. Adult
      Day
      Health Care

    19. School
      Based Health Care Services

    20. Personal
      Emergency Response Systems

     

    


    APPENDIX
      K 

    October
      1, 2005 

    K-37

    


    


    


    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    


     

    APPENDIX
      L

     

    Approved
      Capitation Payment Rates

     

     

     

     

     

     

     

     

     

     

     

     

    

      


      APPENDIX
        L

      October
        1,2005

      L-1

    

     

     

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

     

    

      
        	
                WELLCARE
                  OF NEW YORK, INC.

                Medicaid
                  Managed Care Rates

              
	
                MMIS
                  ID#: 01182503 

                Approved
                  by DOB: Yes 

                DOH
                  HMO #: 05-045 

                Reinsurance:
                  No

              	
                Effective
                  Date: 01/01/06 

                Region:
                  NYC

                County:
                  NEW YORK CITY 

                Status:
                  Mandatory

              
	
                Premium
                  Group

              	
                Rate
                  Amount

              
	
                TANF/SN
                  <6mo M/F

              	
                $183.05

              
	
                TANF/SN
                  6mo-14 F

              	
                $86.10

              
	
                TANF/SN
                  15-20 F

              	
                $93.49

              
	
                TANF/SN
                  6mo-20 M

              	
                $94.92

              
	
                TANF
                  21+ M/F

              	
                $170.77

              
	
                SN 21-29
                  M/F

              	
                $134.54

              
	
                SN
                  30+ M/F

              	
                $220.67

              
	
                SSI
                  6mo-20 M/F

              	
                $217.87

              
	
                SSI
                  21-64 M/F

              	
                $443.71

              
	
                SSI
                  65+ M/F

              	
                $368.51

              
	
                Maternity
                  Kick Payment

              	
                $4,834.20

              
	
                Newborn
                  Kick Payment

              	
                $3,064.90

              


      

      


      


      


      


      
        	
                Optional
                  Benefits Offered

              	 
	
                R
                  Emergency Transportation

              	
                £
                  Dental

              
	
                R
                  Non-Emergent Transportation

              	
                R
                  Family Planning

              


      

      


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

       

       

      
        


        APPENDIX
          L

        October
          1,2005

        L-2

         

      


      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      


      



      
        	
                WELLCARE
                  OF NEW YORK, INC.

                Medicaid
                  Managed Care Rates

              
	
                MMIS
                  ID#: 01182503 

                Approved
                  by DOB: Yes 

                DOH
                  HMO #:
                  05-023 

                Reinsurance:
                  No

              	
                Effective
                  Date: 04/01/05 

                Region:
                  NYC

                County:
                  NEW YORK CITY

                Status:
                  Mandatory

              
	
                Premium
                  Group

              	
                Rate
                  Amount

              
	
                TANF/SN
                  <6mo M/F

              	
                $183.05

              
	
                TANF/SN
                  6mo-14 F

              	
                $86.10

              
	
                TANF/SN
                  15-20 F

              	
                $93.49

              
	
                TANF/SN
                  6mo-20 M

              	
                $94.92

              
	
                TANF
                  21+ M/F

              	
                $170.77

              
	
                SN
                  21-29 M/F

              	
                $134.54

              
	
                SN
                  30+ M/F

              	
                $220.67

              
	
                SSI
                  6mo-20 M/F

              	
                $208.09

              
	
                SSI
                  21-64 M/F

              	
                $423.79

              
	
                SSI
                  65+ M/F

              	
                $351.96

              
	
                Maternity
                  Kick Payment

              	
                $4,834.20

              
	
                Newborn
                  Kick Payment

              	
                $3,064.90

              


      

      


      


      


      
        	
                Optional
                  Benefits Offered

              	 
	
                R
                  Emergency Transportation

              	
                £
                  Dental

              
	
                R
                  Non-Emergent Transportation

              	
                R
                  Family Planning

              


      

      


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

       

       

      
        


        APPENDIX
          L

        October
          1,2005

        L-3

      


      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      


      


    

    
       

    

    


    


     

    APPENDIX
      M

     

    Service
      Area, Benefit Options, and Enrollment Elections

    


    


    


    


    


    


    


    


    


    


    


    APPENDIX
      M

    October
      1,2005

    M-l

     

     

    
 

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

     

     

    Schedule
      1 of Appendix M

    Service
      Area, Program Participation and Prepaid Benefit Package Optional Covered
      Services

     

    1.
      Service Area

    The
      Contractor's service area is comprised of the counties listed in Column A of
      this schedule in their entirety.

     

    2.
      Program Participation and Optional Benefit Package Covered
      Services

    a)
      For
      each county listed in Column A below, an entry of "yes" in the subsections
      of
      Columns B and C means the Contractor offers the MMC and/or FHPlus product and/or
      includes the optional service indicated in its Benefit Package.

    


    b)
      For
      each county listed in Column A below, an entry of "no" in the subsections of
      Columns B and C means the Contractor does not offer the MMC and/or FHPlus
      product and/or does not include the optional service indicated in its Benefit
      Package.

    


    c)
      In the
      schedule below, an entry of "N/A" means not applicable for the purposes of
      this
      Agreement.

     

    3.
      Effective Date

     

    The
      effective date of this Schedule is October 1, 2005.

     

    
      	
              Contractor:
                WellCare of New York, Inc.

            
	
               

              Column
                A 

              County

            	
              Column
                B 

              Medicaid
                Managed Care

            	
              Column
                C 

              FHPlus

            
	
              Contractor
                Participates

            	
              Dental

            	
              Family
                Planning

            	
              Non-Emergency
                Transportation

            	
              Emergency
                Transportation

            	
              Contractor
                Participates

            	
              Dental

            	
              Family
                Planning

            
	
              Bronx

            	
              Yes

            	
              No

            	
              Yes

            	
              Yes

            	
              Yes

            	
              N/A

            	
              N/A

            	
              N/A

            
	
              Kings

            	
              Yes

            	
              No

            	
              Yes

            	
              Yes

            	
              Yes

            	
              N/A

            	
              N/A

            	
              N/A

            
	
              New
                York

            	
              Yes

            	
              No

            	
              Yes

            	
              Yes

            	
              Yes

            	
              N/A

            	
              N/A

            	
              N/A

            
	
              Queens

            	
              Yes

            	
              No

            	
              Yes

            	
              Yes

            	
              Yes

            	
              N/A

            	
              N/A

            	
              N/A

            


    

     

    


     

    


    


    APPENDIX
      M 

    October
      1, 2005

    M-3

     

    



    Schedule
      2 of Appendix M

    LDSS
      Election of Enrollment in Medicaid Managed Care For Foster Care Children and
      Homeless Persons

     

    1.
      Effective October 1, 2005, in the Contractor's service area, Medicaid Eligible
      Persons in the following categories will be eligible for Enrollment in the
      Contractor's Medicaid Managed Care product at the LDSS's option as described
      in
      (a) and (b) as follows, and indicated by an "X" in the chart below:

     

    a)
      Options for foster care children in the direct care of LDSS:

     

    i)
      Children in LDSS direct care are mandatorily enrolled in MMC
      (mandatory

    counties
      only);

    ii)
      Children in LDSS direct care are enrolled in on a case by case basis in MMC
      (mandatory or voluntary counties);

    iii)
      All
      foster care children are Excluded from Enrollment in MMC (mandatory or voluntary
      counties).

     

    b)
      Options for homeless persons living in shelters outside of New York
      City:

     

    i)
      Homeless persons are mandatorily enrolled in MMC (mandatory counties
      only);

    ii)
      Homeless persons are enrolled in on a case by case basis in MMC (mandatory
      or

    voluntary
      counties);

    iii)
      All
      homeless persons are Excluded from Enrollment in MMC (mandatory or voluntary
      counties). 

    


    c)
      In the
      schedule below, an entry of "N/A" means not applicable for the purposes of
      this
      Agreement.

     

    
      	
              Contractor:
                WellCare of New York, Inc.

            
	
               

              County

            	
               

              Foster
                Care Children

            	
               

              Homeless
                Persons

            
	
              Mandatorily
                Enrolled

            	
              Enrolled
                on Case by Case Basis

            	
              Excluded
                from Enrollment

            	
              Mandalorily
                Enrolled

            	
              Enrolled
                on Case by Case Basis

            	
              Excluded
                from Enrollment

            
	
              Bronx

            	 	 	
              X

            	
              N/A

            	
              N/A

            	
              N/A

            
	
              Kings

            	
               

            	
               

            	
              X

            	
              N/A

            	
              N/A

            	
              N/A

            
	
              New
                York

            	
               

            	
               

            	
              X

            	
              N/A

            	
              N/A

            	
              N/A

            
	
              Queens

            	
               

            	
               

            	
              X

            	
              N/A

            	
              N/A

            	
              N/A

            


    

     

    


     

    APPENDIX
      M 

    October
      1. 2005 

    M-3

     

    


    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    


     

    Appendix
      N

     

    New
      York
      City Specific Contracting Requirement

     

    


     

    


     

    


    


    


    


    


    


    


    APPENDIX
      N 

    October
      1, 2005

    N-l

     

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    


    Appendix
      N 

    New
      York City Specific Contracting Requirements

     

    1. General

     

    a)
      In New
      York City, the Contractor will comply with all provisions of the main body
      and
      other Appendices of this Agreement, except as otherwise expressly established
      in
      this Appendix.

    


    b)
      This
      Appendix sets forth New York City Specific Contracting Requirements and contains
      the following sections:

     

    N.
      1
      Compensation for Public Health Services

    N.2
      Coordination with DOHMH on Public Health Initiatives

    N.3
      Benefits

    N.4
      Additional Reporting Requirements

    N.5
      Quality Management

    N.6
      New
      York City Additional Marketing Guidelines

    N.7
      Guidelines for Processing Enrollments and Disenrollments in New York City


    N.8
      New
      York City Transportation Policy Guidelines

     

    Schedule
      1 DOHMH Public Health Services Fee Schedule

    


    


    


    


    APPENDIX
      N October 1,2005 

    N-2

    


    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    


    N.I

     

    Compensation
      for Public Health Services

     

    1.
      The
      Contractor shall reimburse DOHMH at the rates contained in Schedule 1 of this
      Appendix for Enrollees who receive the following services from DOHMH facilities,
      except in those instances where DOHMH may bill Medicaid
      fee-for-service.

     

    a)
      Diagnosis and/or treatment of TB

    b)
      HIV
      counseling and testing that is not part of an STD or TB visit

    c)
      Adult
      and child immunizations

    d)
      Lead
      poison screening

    e)
      Dental
      services

     

    2.
      Notwithstanding Sections 10.18 (a) (ii) (C) and (b) (ii)(C) of this Agreement,
      the

    following
      requirements concerning Contractor notification and documentation of services
      shall apply in New York City:

    


    a)
      DOHMH
      shall confirm the Enrollee's membership in the Contractor's MMC product on
      the
      date of service through EMEDNY prior to billing for these services.

    


    b)
      DOHMH
      must submit claims for services provided to Enrollees no later than one year
      from the date of service.

    


    c)
      The
      Contractor shall not require pre-authorization, notification to the Contractor
      or contacts with the PCP for the above mentioned services.

    


    d)
      DOHMH
      shall make reasonable efforts to notify the Contractor that it has provided
      the
      above mentioned services to an Enrollee.

    


    


     

    


    


    APPENDIX
      N October 1,2005

    N-3

     

    


    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    


    N.2

     

    Coordination
      with DOHMH on Public Health Initiatives

     

    1.
      Coordination with DOHMH

    


    a)
      The
      Contractor shall provide the DOHMH with existing information requested by DOHMH
      to conduct epidemiological investigations.

     

    2.
      Provider Reporting Obligations

     

    a)
      The
      Contractor shall make reasonable efforts to assure timely and
      accurate

    compliance
      by Participating Providers with public health reporting requirements relating
      to
      communicable disease and conditions mandated in the New York City Health Code
      pursuant to 24 RCNY §§ 1103-1107 and Title 21, Article 3 of the NYS Public
      Health Law.

     

    b)
      The
      Contractor shall make reasonable efforts to assure timely and
      accurate

    compliance
      by Participating Providers with other mandated reporting requirements, including
      the following:

     

    i)
      Infants and toddlers suspected of having a developmental delay or
      disability;

    ii)
      Suspected instances of child abuse;

    iii)
      Immunization (reporting to immunization registry); and 

    iv)
      Additional reporting requirements adopted by the New York City Health
      Code

     

    c)
      "Reasonable efforts" shall include:

    


    i)
      For
      mandated reporting requirements described in paragraphs (2)(a) and (2)(b)
      above:

    


    A)
      Educating Participating Providers on treatment guidelines and instructions
      for
      reporting included in the NYC DOHMH Compendium
      of Public Health Requirements and Recommendations.

    B)
      Including reporting requirements in the Contractor's provider manual or other
      written instructions or guidelines

     

    ii)
      For
      mandated reporting requirements described in paragraph (2)(a)
      above:

    


    A)
      Letters from the Contractor to Participating Providers who generated claims
      that
      suggest that an Enrollee may have a reportable disease or condition, encouraging
      such providers to report and providing information on how to
      report.

    B)
      Other
      methods for follow up with Participating Providers, subject to DOHMH approval,
      may be employed.

     

    


    


    


    APPENDIX
      N 

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      1, 2005

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    3.
      Matching to Registries

    


    a)
      The
      Contactor shall participate in matches of its Enrollees to the DOHMH
      immunization and lead registries through submission of files in formats
      specified by DOHMH Immunization and Lead Poisoning Prevention
      Programs.

     

    i)
      Matches to the Citywide Immunization Registry shall occur, at a minimum, twice
      a
      year, in March and October, but may occur more frequently at the Contractor's
      discretion. The file matches which occur in March and October will include
      all
      children aged 18 through 30 months who are enrolled in the Contractor's MMC
      Product at the time of the match, regardless of the children's length of
      Enrollment in the Contractor's MMC Product. Additional file matches, done at
      the
      discretion of the Contractor, may include any group of children currently
      enrolled in the Contractor's MMC Product at the time of the match and may be
      done at any time of year.

    


    ii)
      Matches to the City Lead Registry shall occur at least twice a year, but may
      occur more frequently as agreed by both the Contractor and the DOHMH Lead
      Poisoning Prevention Program. Files for these matches shall be submitted in
      March and October, and will include all children up to 36 months of age who
      are
      enrolled in the Contractor's MMC Product at the time of the match, regardless
      of
      the children's length of Enrollment in the Contractor's MMC
      Product.

     

    b)
      Formats for reports from the DOHMH to the Contractor based on these matches
      will
      be developed through discussion between the Contractor and DOHMH
      programs.

     

    c)
      The
      Contractor will follow up with Participating Providers of Enrollees who have
      not
      been appropriately immunized or screened for lead poisoning to facilitate
      provision of appropriate services.

     

    d)
      The
      following provisions regarding confidentiality shall apply:

    


    i)
      Consistent with the New York City Health Code §11.07 (c) and (d), the Contractor
      and DOHMH shall keep confidential all identifying information provided by the
      DOHMH and not further disclose to any other person or entity such identifying
      information unless compelled by law to disclose such identifying information,
      except as provided in provided in paragraph 3(c) above.

    


    ii)
      The
      Contractor shall notify the DOHMH Office of General Counsel for Health in
      writing, of the receipt of any document seeking disclosure of identifying
      information that is not accompanied by a written consent from the parent or
      guardian of an Enrollee authorizing the disclosure of such identifying
      information as follows:

    


    A)
      Such
      notice shall be given not later than five days prior to the date on which a
      disclosure is required by a subpoena, court order or other document, and shall
      attach a copy of the document requesting identifying information.

    


     

    APPENDIX
      N 

    October
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    B)
      If a
      subpoena, court order or other document requests disclosure to be made within
      five days or less after its receipt by the Contractor, the Contractor shall
      provide DOHMH with such notice as far in advance of the disclosure date as
      possible, but in no circumstance shall the Contractor make such disclosure
      without prior notice to the DOHMH.

    


    C)
      The
      Contractor acknowledges that DOHMH may elect to seek a court order prohibiting
      the disclosure of identifying information when it deems it appropriate to do
      so,
      and consents to DOHMH's intervention in any proceeding, including, but not
      limited to any judicial proceeding, that seeks the disclosure of identifying
      information.

     

    4.
      Enrollee Outreach/Education

     

    a)
      The
      Contractor shall provide health education to Enrollees on an on-going basis
      through methods such as distribution of Enrollee newsletters, health education
      classes or individual counseling on preventive health and public health topics.
      Each topic below shall be covered at least once every two years.

     

    i)
      HIV/AIDS

    A)
      Encourage Enrollee counseling and testing

    B)
      Inform" Enrollees as to availability of sterile needles and syringes


    


    ii)
      STDs

    A)
      Inform
      Enrollees that confidential STD services are available at DOHMH Facilities
      for
      non-enrolled sexual and needle-sharing partners at no charge

    


    iii)
      Lead
      poisoning prevention 

    iv)
      Maternal and child health, including importance of developmental screening
      for
      children

    v)
      Injury
      prevention, including age appropriate anticipatory guidance vi) Domestic
      violence 

    vii)
      Smoking cessation 

    viii)
      Asthma 

    ix)
      Immunization 

    x)
      Mental
      health services xi) Diabetes 

    xii)
      Family planning 

    xiii)
      Screening for Cancer 

    xiv)
      Chemical Dependence 

    xv)
      Physical fitness and nutrition 

    xvi)
      Cardiovascular disease and hypertension

     

    5.
      Provider Education

    


    a)
      DOHMH
      shall prepare a public health compendium ("Compendium") with public health
      guidelines, protocols, and recommendations which it shall make available
      directly to Participating Providers and to the Contractor.

    


     

    APPENDIX
      N 

    October
      1,2005 

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    b)
      The
      Contractor shall adapt public health guidance from the Compendium for its
      internal protocols, practice manuals and guidelines.

    


    c)
      The
      Contractor will assist DOHMH in its efforts to disseminate electronic materials
      to its Participating Providers by providing electronic addresses if known by
      Contractor (fax and/or e-mail) for its Participating Providers, updated semi-
      annually.

     

    d)
      The
      Contractor shall promote the use of rapid HIV testing among its Participating
      Providers.

     

    6.
      MCO Staff
      Responsibilities and Training

     

    a)
      Early
      Intervention Services

    


    i)
      The
      Contractor shall ensure that appropriate MCO staff, such as member services
      staff and case managers are knowledgeable about early intervention services
      and
      provide technical assistance and consultation to Enrollees concerning early
      intervention services (including eligibility, referral process and coordination
      of services).

     

    b)
      Domestic Violence .

     

    i)
      The
      Contractor shall designate a domestic violence coordinator who can:

    


    A)
      Provide technical assistance to Participating Providers in documenting cases
      of
      domestic violence;

    B)
      Provide referrals to Enrollees or their Participating Providers, to obtain
      protective, legal and or supportive social services; and

    C)
      Provide consultative assistance to other staff within the Contractor's
      organization.

     

    ii)
      The
      Contractor shall distribute a directory of resources for victims of domestic
      violence to appropriate staff, such as member services staffer case
      managers.

     

    7.
      Medical Directors

     

    a)
      The
      Contractor's Medical Director shall participate in Medical Directors' Meetings
      with the medical directors of the other MCOs participating in the MMC
      Programin
      New
      York
      City and representatives of the New York City Department of Health and Mental
      Hygiene. The purpose of the Medical Directors' Meetings shall be to share public
      health information and data; recommend that certain public health information
      be
      disseminated by the MCOs to their Participating Providers; discuss public health
      strategies and outreach efforts and potential collaborative projects; encourage
      the development of MCO policies that support public health strategies; and
      provide a vehicle for communication between the MCOs participating in the MMC
      Program and the various bureaus and divisions of the NYC Department of Health
      and Mental Hygiene.

     

     

    APPENDIX
      N

    October
      1.2005

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    b)
      The
      Contractor's Medical Director shall attend all periodic meetings, which shall
      not exceed one every two months. In the event that the Medical Director is
      unable to attend a particular meeting, the Contractor will designate an
      appropriate substitute to attend the meeting. 

     

    c)
      DOHMH,
      following consultation with the Medical Directors, may create workgroups on
      particular public health topics. The Contractor's Medical Director may
      participate in any or all of the workgroups, but shall participate in at least
      one of the designated workgroups.

     

    8.
      Take Care New York

     

    a)
      The
      Contractor shall:

    


    i)
      Educate Enrollees regarding prevention and treatment of diseases and conditions
      included in the Take Care New York initiative (TCNY);

    


    ii)
      Disseminate TCNY health passports or materials containing similar content
      approved by DOHMH to Enrollees;

    


    iii)
      Disseminate reminders to obtain recommended health screenings at age appropriate
      intervals to Enrollees; and

     

    iv)
      Educate Participating Providers on recommended clinical guidelines regarding
      prevention and treatment/management of diseases and conditions described in
      the
      TCNY initiative.

    


    b)
      The
      Contractor shall select one condition annually from the TCNY initiative and
      perform the following:

     

    i)
      Identify Enrollees with the condition using information from multiple sources
      (e.g., utilization data, including hospitalizations and ER visits; provider
      referrals;

    new
      Enrollee screenings; self-referrals by Enrollees) and maintain such information
      in a patient registry; and

     

    ii)
      Develop and submit to DOHMH for approval a proposal to evaluate the
      effectiveness of Contractor interventions for this condition by tracking service
      utilization and assessing health outcomes.

    


    c)
      The
      Contractor shall, upon request by DOHMH, participate in one or more TCNY
      workgroups or other activities sponsored by the DOHMH.

    


     

    APPENDIX
      N 

    October
      1,2005

    N-8

     

    


    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    


    N.3
      

     

    Benefits

    


    


    1.
      Transitional Home Health Services Pending Placement in Personal Care Agency
      Services

    


    a)
      Transitional home health services are home health services as defined in
      Appendix K of this Agreement provided by the Contractor to an MMC Enrollee
      while
      the Human Resources Administration's determination regarding a request for
      the
      provision of personal care agency services to the Enrollee is pending.
      Transitional home health services are available to MMC Enrollees in addition
      to
      the home health care services otherwise covered under the Benefit Package as
      medically necessary.

     

    b)
      The
      Contractor shall be responsible for providing transitional home health services
      to MMC Enrollees for up to a thirty (30) day period as follows:

    


    i)
      For
      MMC enrollees discharged from a hospital or RHCF and for whom personal care
      agency services have been requested by the hospital/RHCF discharge planner,
      the
      thirty (30) day period shall commence with the day following the MMC Enrollee's
      discharge from the hospital or RHCF. Transitional home health services shall
      not
      be available if the MMC Enrollee: was hospitalized less than thirty (30) days,
      was in receipt of personal care agency services prior to his/her admission
      to
      the hospital or RHCF, and requires the same level and hours of personal care
      agency services upon discharge.

    


    ii)
      For
      MMC Enrollees who have been receiving home health care services in the community
      and for whom personal care agency services have been ordered by the Enrollee's
      physician, the thirty (30) day period shall commence with the day following
      the
      last day that the Contractor approved home health care services to be medically
      necessary.

     

    c)
      The
      Contractor shall provide reasonable assistance as requested regarding the
      completion of forms required by the Human Resources Administration to initiate
      the review of a request for personal care agency services. Such form, commonly
      referred to as the Ml 1Q, requires physician orders, signed by the licensed
      physician, to be received by HRA within thirty (30) calendar days of the
      physician's examination.

    


    


    APPENDIX
      N 

    October
      1, 2005

    N-9

     

     

    
 

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    


    N.4

     

    Additional
      Reporting Requirements

     

    1.
      DOHMH,
      will provide Contractor with instructions for submitting the reports required
      by
      paragraphs 4(c), (d) and (e) below. These instructions shall include time
      frames, and requisite formats. The instructions, time frames and formats may
      be
      modified by DOHMH upon sixty (60) days written notice to the
      Contractor.

    


    2.
      The
      Contractor shall submit reports that are required to be submitted to DOHMH
      by
      this Agreement electronically.

    


    3.
      The
      Contractor shall pay liquidated damages of $500 to DOHMH for any report required
      by paragraphs 4(c), (d) and (e) below which is materially incomplete, contains
      material misstatements or inaccurate information or is not submitted on time
      in
      the requested format. The DOHMH shall not impose liquidated damages for a first
      time infraction by the Contractor unless DOHMH deems the infraction to be a
      material misrepresentation of fact or the Contractor fails to cure the first
      infraction within a reasonable period of time upon notice from the DOHMH.
      Liquidated damages may be waived at the sole discretion of DOHMH.

     

    4.
      The
      Contractor shall submit the following reports to DOHMH:

    


    a)
      The
      Contractor shall provide DOHMH with all reports submitted to SDOH pursuant
      to
      Sections 18.6(a)(i), (ii), (vi), (vii), and (xii) of this
      Agreement.

     

    b)
      Upon
      request by DOHMH, the Contractor shall submit to DOHMH reports submitted to
      SDOH
      pursuant to Section 18.6(a)(iii); and Section 18.6(xi) and/or SECTION 23.2
      of
      this Agreement.

     

    c)
      To
      meet the appointment availability review requirements of Section 18.6(a)(ix),
      the Contractor shall conduct a service area specific review of appointment
      availability for two specialist types, to be determined by DOHMH, semi-annually.
      Reports on the results of such surveys must be kept on file by the Contractor
      and be readily available for review by SDOH and DOHMH, and submitted to the
      DOHMH.

    


    d)
      The
      Contractor shall conduct annual Enrollee satisfaction surveys of its Medicaid
      Enrollees in New York City and report to DOHMH on the results of these surveys.
      The Contractor shall not be required to conduct a separate survey during those
      calendar years during which an Enrollee satisfaction survey is conducted by
      SDOH
      or its designee. DOHMH, in its sole discretion, may waive this requirement
      in a
      particular year and/or limit the survey to a targeted
      sub-population.

     

     

    APPENDIX
      N

    October
      1,2005 

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    i)
      The
      surveys shall follow guidelines established by DOHMH and the methodology must
      be
      approved by DOHMH. Surveys should exclude data from non-NYC counties, but sample
      all boroughs within the Contractor's service area.

     

    


     

    e)
      Upon
      request by the DOHMH, 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 DOHMH reserves the right to
      give
      thirty (30) days notice in circumstances where time is of the
      essence.

    


     

    APPENDIX
      N 

    October
      1,2005

    N-ll


    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    


    


    N.5

     

    Quality
      Management

     

    1.
      The
      Contractor's quality management program, as approved by SDOH, must be kept
      on
      file with the DOHMH. The Contractor shall notify the DOHMH when it modifies
      its
      quality management program.

    


    


     

    


    


    


    


    APPENDIX
      N 

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      1, 2005

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    N.6

     

    New
      York City Additional Marketing Guidelines

     

    1.
      Prior Approvals

     

    a)
      In
      addition to the Marketing submission and approval requirements of Section 11
      and
      Appendix D of this Agreement, the Contractor shall submit to DOHMH for review
      and prior approval, in consultation with SDOH, the following:

     

    i)
      The
      Contractor's Marketing plan;

    A)
      The
      Contractor must have on file with DOHMH an approved Marketing plan prior to
      the
      contract award date or before Marketing and Enrollment begin whichever is
      sooner. Subsequent changes to the Marketing plan must be submitted to the SDOH
      and DOHMH for approval at least 60 days before implementation.

     

    B)
      The
      Marketing plan shall include a copy of the training curriculum for the
      Contractor's Marketing Representatives and a description of the minimum
      qualifications for the Contractor's Marketing staff.

     

    ii)
      A
      copy of all Contractor written policies and procedures related to Marketing
      to
      Prospective Enrollees in New York City.

     

    iii)
      A
      copy of all Marketing material and scripts for Marketing presentations in New
      York City;

    


    A)
      Marketing materials sent by Participating Providers to their patients must
      be
      pre-approved by DOHMH.

     

    iv)
      Advertising that is targeted solely to New York City including videos, broadcast
      material (radio, television, or electronic), billboards, mass transit and print
      advertising material.

     

    2.
      Marketing Schedules

     

    a)
      Contractor shall submit to the DOHMH, a bi-weekly schedule of all Marketing
      activities in accordance with instructions for submitting the schedule and
      requisite formats provided by DOHMH. The instructions, time frames and formats
      may be modified by DOHMH with thirty days prior notice to the
      Contractor.

     

    b)
      Contractor shall submit electronically a schedule of all intended marketing
      activities within HRA sites to both HRA and DOHMH.

     

    c)
      DOHMH
      may, in its sole discretion, waive the reporting of certain
      activities.

    


    APPENDIX
      N 

    October
      1,2005 

    N-13

     

    



    3.
      Marketing Materials

    


    a)
      The
      Contractor shall ensure that Marketing brochures or similar materials that
      describe Contractor services, benefits and enrollment shall contain the
      following information:

     

    i)
      Contractor's name and toll free telephone number and TTY

    ii)
      A
      contact telephone number for New York Medicaid CHOICE

    iii)
      The
      Potential Enrollee has a choice among several alternative MCOs in his or her
      neighborhood

    iv)
      The
      Potential Enrollee will have a choice among at least three Primary Care
      Providers 

    v)
      Upon
      Enrollment in an MCO's MMC Product, the Enrollee will be required to use his
      or
      her Primary Care Provider and other MCO Participating Providers exclusively
      for
      medical care, except in certain limited circumstances 

    vi)
      Upon
      Enrollment in an MCO's MMC Product, the Enrollee will have 90 days to disenroll
      without cause, and thereafter will not be allowed to disenroll or ' transfer
      without good cause for the next nine months 

    vii)
      Newborns will automatically be enrolled in the mother's MCO's MMC Product viii)
      Language advising Prospective Enrollees to verify with the provider of their
      choice that the provider participates in the Contractor's network and is
      available to serve the Enrollee 

    ix)
      If
      the Contractor does not include Family Planning and Reproductive Health services
      in its Benefit Package, the Marketing brochure must tell Prospective Enrollees
      that:

    


    A)
      Certain Family Planning and Reproductive Health services (such as

    abortion,
      sterilization and birth control) are not covered by the Contractor;

    B)
      Such
      services may be obtained through fee-for-service Medicaid from any provider
      who
      accepts Medicaid; and

    C)
      No
      referral is needed for such services and that there will be no cost to the
      Enrollee for such services.

     

    b)
      Foreign language translations of Marketing materials need not be independently
      reviewed by DOHMH if the Contractor submits a letter by the translation service
      attesting that it has used its best efforts to accurately translate the
      Marketing material into the specified languages. At a minimum, the translation
      service must perform a reverse translation, (translate the foreign language
      version back into English and compare to original document). Translated
      materials must meet the readability standards described in Section 13.8 of
      this
      Agreement.

     

    4.
      Marketing Encounters

     

    a)
      Marketing encounters must clearly inform Potential Enrollees of the Partnership
      Plan policies described in paragraphs (3)(a)(iii) through (ix) above, in
      addition to meeting any other information requirements of Section 11.1 and
      Appendix D of this Agreement.

     

    


    APPENDIX
      N 

    October
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    N-14

     

    



    b)
      Marketing Representatives shall ask Prospective Enrollees whether they are
      currently enrolled in another MCO's MMC Product, and shall not market |to
      persons who are enrolled in another MCO's MMC Product.

     

    c)
      Marketing Representatives must give a copy of the document, "What Managed Care
      Plans are Available in My Neighborhood" to Prospective Enrollees at each
      Marketing encounter.

     

    d)
      Marketing Representatives shall ask Prospective Enrollees whether they currently
      have a provider whom they would like to continue to see, and shall assist him
      or
      her in making sure that this provider participates in the Contractor's
      network.

     

    e)
      Marketing Representatives shall give a business card, identifying the name
      of
      the representative, the name of the Contractor, and a telephone contact number
      (which may be the Contractor's member services number) to each Prospective
      Enrollee so that he or she may ask follow-up questions. In the alternative,
      the
      Marketing Representative may have this information printed or stamped on the
      Contractor's Marketing flyers or brochures that are distributed to each
      Prospective Enrollee.

     

    f)
      Marketing Representatives shall inform Prospective Enrollees that upon
      Enrollment they shall receive either a phone call or a welcome package from
      the
      Contractor to assess their health care needs and explain how to access
      Contractor services.

     

    5.
      Marketing In HRA Facilities

     

    a)
      Contractor may conduct Marketing activities within HRA facilities with the
      prior
      approval of NYC HRA and must adhere to HRA procedures. HRA shall give Contractor
      an allotted number of allowable Marketing Representatives at each HRA facility,
      and Contractor shall not exceed this allotment. No other Marketing
      Representatives for Contractor may market within a two block perimeter of an
      HRA
      facility. Additionally, when a Medicaid community office is located in a
      hospital facility. Contractor may not market within 60 feet of the Medicaid
      community office. The Contractor is required to adhere to all HRA Marketing
      guidelines when marketing in HRA facilities. HRA has the right to suspend
      Marketing privileges within their facilities for failure to adhere to these
      guidelines.

     

    6.
      Marketing Sites

     

    a)
      The
      Contractor may not market at sites that were not reported on its Marketing
      schedule to DOHMH.

     

    b)
      The
      Contractor shall not market in homeless shelters.

     

    c)
      The
      Contractor shall not market in low income housing projects unless permission
      is
      requested by the Contractor for a special event in the public areas of the
      project, and

     

     

    APPENDIX
      N 

    October 
      I 2005 

    N-15


     

    
 

    approval
      is received in writing from the facility, and a copy sent to DOHMH with the
      Marketing schedule.

     

    d)
      The
      Contractor shall not market within a two block perimeter of an HRA facility
      (except as authorized by paragraph 5(a) of these guidelines).

     

    e)
      The
      Contractor may not market in the same room or immediate proximity of New York
      Medicaid CHOICE presentations.

     

    7.
      Marketing Conduct

     

    a)
      All
      Marketing activities shall be conducted in an orderly, non-disruptive manner
      and
      shall not interfere with the privacy of Prospective Enrollees or the general
      community.

     

    8.
      Marketing Representatives

     

    a)
      The
      Contractor's Marketing Representatives must attend Marketing training sessions
      provided by DOHMH, upon request from DOHMH.

     

    b)
      Marketing Representatives must wear visible badges with the name of the
      Contractor and
      the
      Marketing Representative's name during all Marketing activities.

     

    c)
      Marketing Representatives may not wear any additional identification badge
      from
      a Participating Provider or facility that is likely to confuse Enrollees or
      lead
      them to believe that the Marketing Representative is an employee of such
      organization. The Contractor shall obtain prior approval from DOHMH to wear
      identification badges bearing the name of any other organization.

     

    d)
      Marketing Representatives employed by a subcontractor of the Contractor
      or

    affiliated
      with a community based organization which performs outreach, education and
      Enrollment on behalf of the Contractor, shall attend a training session
      conducted by the Contractor consistent with the training curriculum approved
      by
      DOHMH.

     

    9.
      Marketing Infractions

     

    a)
      In
      addition to the corrective and remedial actions specified in Section 11.5 of
      this Agreement, if the Contractor or its representative commits a repeat
      violation or an infraction which is not minor or unintentional, DOHMH may,
      following consultation with SDOH, impose liquidated damages of $2000.00 for
      each
      such infraction. Imposition of liquidated damages shall be taken at the sole
      discretion of the DOHMH except that DOHMH shall not impose liquidated damages
      for any infraction of the Contractor where SDOH has imposed a monetary
      sanction.

    


     

    


    


    APPENDIX
      N 

    October
      1,2005 

    N-16

     

    


    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    


    N.7

     

    


    Guidelines
      For the Processing Of Enrollments and Disenrollments in New York
      City

     

    1.
      Notwithstanding any contrary provisions in Appendix H, in New York City,
      Enrollment error reports are generated by the Enrollment Broker to the
      Contractor generally within 24-48 hours of Contractor Enrollment submissions
      and
      the Contractor is able to resubmit corrections via the Enrollment Broker before
      Roster pulldown. Changes in Enrollee eligibility or Enrollment status that
      occur
      prior to production of the monthly Roster are reported by the State to the
      Contractor with their rosters. Changes in Enrollee eligibility status that
      occur
      subsequent to production of the monthly Roster shall be reported by the
      Enrollment Broker by means of the electronic bulletin board. Reports of
      Disenrollments processed by the Enrollment Broker shall be reported to the
      Contractor as they occur by means of the electronic bulletin board. Reports
      of
      Disenrollments processed by HRA shall be reported to the Contractor manually
      as
      they occur or through the HPN. In the event that the electronic bulletin board
      notification process is not available for any reason, the Contractor shall
      use
      EMEDNY to verify loss of eligibility.

     

    2.
      Paragraph 6(a)(iv) of Appendix H of this Agreement (LDSS responsibilities)
      is
      not applicable in New York City. In the event that an Enrollee loses Medicaid
      eligibility, the PCP Enrollment is left on the system and removed thereafter
      by
      SDOH if no eligibility reinstatement occurs.

     

    3.
      Paragraph 3(d)(ii) of Appendix H of this Agreement is not applicable in New
      York
      City. The Contractor shall not send verification of the infant's demographic
      data to the HRA unless thirty days has expired since the date of birth and
      the
      Contractor has not received confirmation via the HPN of a successful Enrollment
      through the automated Enrollment system. When the thirty days has expired the
      Contractor shall, within 10 days, send verification of the infant's demographic
      data to the HRA including: the mother's name and CIN; and the newborn's name,
      CIN, sex and date of birth. Upon receipt of the data, if the Enrollment does
      not
      appear on the system, HRA will process the retroactive Enrollment.

    


    4.
      In New
      York City, Enrollees may initiate a request for an expedited Disenrollment
      to
      the HRA. The HRA will expedite the Disenrollment process in those cases where:
      an Enrollee's request for Disenrollment involves an urgent medical need; the
      Enrollee is a homeless individual residing in the shelter system in New York
      City; the Enrollee has HIV, ESRD, or a SPMI/SED condition; the request involves
      a complaint of non-consenusal Enrollment; or the Enrollee is certified blind
      or
      disabled and meets an exemption criteria. If approved, the HRA will manually
      process the Disenrollment.

     

    5.
      Notwithstanding paragraph (6)(a)(ix) of Appendix H of this Agreement, in New
      York City, further notification by HRA is not required prior to retroactive
      Disenrollment in the following instances:

    


     

    


    


    APPENDIX
      N 

    October
      1.2005

    N-17

     

    



    (a)
      death
      or incarceration of an Enrollee;

    (b)
      an
      Enrollee has duplicate CINs and is enrolled in an MCOFs MMC or FHPlus product
      under more than one of the CINS; or 

    (c)
      where
      there has been communication between the Contractor and HRA or the Enrollment
      Broker regarding the date of disenrollment.

     

    Consistent
      with paragraph 6 (a) (ix) of Appendix H of this Agreement, the LDSS remains
      responsible for sending a 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. Such
      notice shall be completed by the LDSS to include:

    the
      Disenrollment Effective Date, the reason for the retroactive Disenrollment,
      and
      the months for which premiums must be repayed. The Contractor has 10 days to
      notify the LDSS should it refute the Disenrollment Effective Date, based on
      a
      belief that the Contractor was at risk for the • provision of Benefit Package
      Services for any month for which recoupment of premium has been requested.
      However failure by the LDSS to so notify the Contractor does not affect the
      right of SDOH to recover premium payment as authorized by Section 3.6 of this
      Agreement.

     

     

     

    APPENDIX
      N 

    October
      1,2005 

    N-18

     

    


     

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    
 

    N.8

     

    New
      York City Transportation Policy Guidelines

     

    1.
      The
      Medicaid Managed Care Program contractual Benefit Package in New York City
      includes transportation to all medical care and services that are covered under
      the Medicaid program, regardless of whether the specific medical service is
      included in the . Benefit Package or paid for on a fee-for-service basis, except
      for transportation costs to Methadone Maintenance Treatment Programs. The
      transportation obligation includes the cost of meals and lodging incurred when
      going to and returning from a provider of medical care and services when
      distance and travel time require these costs.

     

    2.
      Generally, the Contractor may provide transportation by giving or reimbursing
      the Enrollee subway/bus tokens for the round trip for their medical care and
      services, if public transportation is available for such care and services.
      The
      Contractor is not required to provide transportation if the distance to the
      medical appointment is so short that the Enrollee would customarily walk to
      perform other routine errands. The Contractor may adopt policies requiring
      a
      minimum distance between an Enrollee's residence and the medical appointment,
      which may not be greater than ten blocks; however,
      the policy must provide transportation for Enrollees living a lesser distance
      upon a showing of special circumstances such as a physical disability on a
      case-by-case basis.

     

    3.
      If the
      Enrollee has disabilities or medical conditions which prevent him or her
      from

    utilizing
      public transportation, the MCO must provide accessible transportation which
      is
      appropriate to the disability or condition such as livery, ambulette, or taxi.
      The MCO may require pre-authorization of non-public transportation except for
      emergency transportation.

     

    a)
      The
      MCO shall provide livery transportation under the following circumstances,
      unless the Enrollee requires transportation by ambulette or
      ambulance:

     

    i)
      The
      Enrollee is able to travel independently but due to a debilitating physical
      or
      mental condition, cannot use the mass transit system. 

    ii)
      The
      Enrollee is traveling to and from a location that is inaccessible by mass
      transit. 

    iii)
      The
      Enrollee cannot access the mass transit system due to temporary severe weather,
      which prohibits use of the normal mode of transportation.

     

    b)
      The
      MCO shall provide ambulette transportation under the following circumstances,
      unless the Enrollee requires transportation by ambulance:

     

    i)
      The
      Enrollee requires personal assistance from the driver in entering/exiting the
      Enrollee's residence, the ambulette and the medical facility.

    


    


     

    APPENDIX
      N 

    October
      1, 2005

    N-19

     

    



    ii)
      The
      Enrollee is wheelchair-bound (non-collapsible or requires a specially configured
      vehicle). 

    iii)
      The
      Enrollee has a mental impairment and requires the personal assistance of the
      ambulette driver, 

    iv)
      The
      Enrollee has a severe, debilitating weakness or is mentally disoriented as
      a
      result of medical treatment and requires the personal assistance of the
      ambulette driver. 

    v)
      The
      Enrollee has a disabling physical condition that requires the use of a walker,
      cane, crutch or brace and is unable to use livery service or mass
      transportation.

     

    c)
      The
      MCO shall provide non-emergency ambulance transportation when the Enrollee
      must
      be transported on a stretcher and/or requires the administration of life support
      equipment by trained medical personnel. The use of non-emergency ambulance
      is
      indicated when the Enrollee's condition would prohibit any other form of
      transport.'

     

    4.
      Emergency transportation may only be provided by accessing 911 emergency
      ambulances. Urgent care transportation may be provided by any mode of
      transportation so long as such mode is appropriate for the medical condition
      or
      disability experienced by the Enrollee.

     

    5. If
      an attendant is Medically Necessary to accompany the Enrollee to the medical
      appointment, the Contractor is responsible for the transportation of the
      attendant. A medically required attendant (authorized by the attending
      physician) may include a family member, friend, legal guardian or home health
      worker. When a child travels to medical care and services, and an attendant
      is
      required, the parent or guardian of the child may act as an attendant. In these
      situations, the costs of the transportation, lodging and meals of the parent
      or
      guardian may be reimbursable, and authorization of the attending physician
      is
      not required.

    


     

    APPENDIX
      N 

    October
      1,2005 

    N-20

     

    


    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    


    Schedule
      1 of Appendix N

    DOHMH
      Public Health Services Fee Schedule

     

    
      
        	
                SERVICE

              	
                FEE

              
	
                TB
                  CLINIC

              	
                $125.00

              
	
                IMMUNIZATION
                  

              	
                $
                  50.00 

              
	
                LEAD
                  POISONING SCREENING 

              	
                $
                  15.00 

              
	
                HIV
                  COUNSELING AND TESTING VISIT 

              	
                $
                  96.47 

              
	
                HIV
                  COUNSELING AND NO TESTING 

              	
                $90.12

              
	
                HIV
                  POST TEST COUNSELING

              	 
	
                -
                  Visit Negative Result

              	
                $72.54

              
	
                -
                  Visit Positive Result

              	
                $
                  90.12

              
	
                LAB
                  TESTS

              	 
	
                HIV
                  1 (ELISA Test)

              	
                $12.27

              
	
                HIV
                  Antibody, Confirmatory (Western Blot)

              	
                $26.75

              
	
                DENTAL
                  SERVICES

              	
                $108.00

              


      

    

     

    
 

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

     

    Appendix
      O

     

     

     

    Requirements
      for Proof of Workers' Compensation and Disability Benefits Coverage

    


     

     

     

     

     

     

    
 

    Appendix O
      

    October
      1,2005

    O-1

    


    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    


    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 0:

     

    a)
      Certificate of Workers' Compensation Insurance, on the Workers' Compensation
      Board form C-105.2 (naming the NYS Department of Health, Coming 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, Coming
      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 0:

     

    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.

    


    


     

    Appendix
      0 

    October
      1.2005

    0-2

     

     

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

     

    APPENDIX
      P

    


    


    


    Reserved

     

     

     

     

     

     

    APPENDIX
      P

    October
      1,2005

    P-l

     

     

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

     

     

    
      APPENDIX
        Q

      


      


      


      Reserved

       

       

       

       

       

       

      APPENDIX
        Q

      October
        1,2005

      Q-l



    


    


    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    


    APPENDIX
      R

     

     

    New
      York City Standard Local Clauses

     

     

     

    R.I
      General
      Provisions Governing Contracts for Consultants, Professional and Technical
      Services (Not-For-Profit Entities)

     

    R.2
      General
      Provisions Governing Contracts for Consultants, Professional and Technical
      Services (For-Profit Entities)

    


     

    


    


    APPENDIX
      R October 1, 2005

    R-l

    


     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

     

    

      APPENDIX
        R 1

       

      GENERAL
        PROVISIONS GOVERNING CONTRACTS FOR CONSULTANTS, PROFESSIONAL AND TECHNICAL
        SERVICES (Not-For-Profit
        entities)

    

    

      
        	
                CONTENTS

              	
                Page

              	
                 

              	
                 

              	
                 

              	
                
                  Page

                

              
	
                ARTICLE
                  1.

              	
                DEFINITIONS

              	
                2

              	
                 

              	
                6.5

              	
                Waiver

              	
                12

              
	
                 

              	
                 

              	
                 

              	
                 

              	
                6.6

              	
                Notice

              	
                12

              
	
                ARTICLE
                  2.

              	
                REPRESENTATIONS
                  AND WARRANTIES

              	
                 

                2

              	
                 

              	
                6.7

              	
                All
                  Legal Provisions Deemed Included

              	
                12

              
	
                2.1

              	
                Procurement
                  of Agreement 

              	
                2

              	
                 

              	
                6.8

              	
                Severability

              	
                12

              
	
                2.2

              	
                Conflict
                  of interest

              	
                2

              	
                 

              	
                6.9

              	
                Political
                  Activity

              	
                12

              
	
                2.3

              	
                Fair
                  Practices

              	
                2

              	
                 

              	
                6.10

              	
                Modification

              	
                12

              
	
                 

              	
                 

              	
                 

              	
                 

              	
                6.11

              	
                Paragraph
                  Headings

              	
                13

              
	
                ARTICLE
                  3.

              	
                AUDIT
                  BY DEPARTMENT 

                AND
                  CITY

              	
                 

                3

              	
                 

              	
                6.12

              	
                No
                  removal of records from premises

              	
                13

              
	
                 

              	
                 

              	
                 

              	
                 

              	
                6.13

              	
                Inspection
                  at site

              	
                13

              
	
                ARTICLE
                  4.

              	
                CONVENANTS
                  OF THE CONTRACTOR 

              	
                 

                3

              	
                 

              	
                6.14

              	
                Pricing

              	
                13

              
	
                4.1

              	
                Employees

              	
                3

              	
                 

              	
                ARTICLE
                  7.

              	
                MERGER

              	
                13

              
	
                4.2

              	
                Independent
                  Contractor Status

              	
                4

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                4.3

              	
                Insurance

              	
                4

              	
                 

              	
                ARTICLE
                  8. 

              	
                CONDITIONS
                  PRECEDENT

              	
                13

              
	
                4.4

              	
                Protection
                  of City Property.

              	
                6

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                4.5

              	
                Confidentiality

              	
                6

              	
                 

              	
                ARTICLE
                  9.

              	
                PPB
                  RULES

              	
                14

              
	
                4.6

              	
                Books
                  and Records

              	
                6

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                4.7

              	
                Retention
                  of Records

              	
                6

              	
                 

              	
                ARTICLE
                  10.

              	
                STATE
                  LABOR LAW AND CITY ADMINISTRTIVE CODE

              	
                 

                14

              
	
                4.8

              	
                Compliance
                  with Law

              	
                6

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                4.9

              	
                Investigation
                  Clause

              	
                6

              	
                 

              	
                ARTICLE
                  11.

              	
                FORUM
                  PROVISION

              	
                15

              
	
                4.10

              	
                Assignment

              	
                8

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                4.11

              	
                Subcontracting

              	
                8

              	
                 

              	
                ARTICLE
                  12.

              	
                EQUAL
                  EMPLOYMENT OPPORTUNITY

              	
                 

                15

              
	
                4.12

              	
                Publicity

              	
                9

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                4.13

              	
                Participation
                  in an International Boycott

              	
                9

              	
                 

              	
                ARTICLE
                  13.

              	
                NO
                  DAMAGE FOR DELAY

              	
                16

              
	
                4.14

              	
                Inventions,
                  Patents, and Copyrights

              	
                9

              	
                 

              	
                ARTICLE
                  14.

              	
                CONSULTANT
                  REPORT INFORMATION

              	
                 

                16

              
	
                4,15

              	
                Infringements

              	
                9

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                4.16

              	
                Anti-Trust

              	
                10

              	
                 

              	
                ARTICLE
                  15.

              	
                RESOLUTION
                  OF DISPUTES

              	
                17

              
	
                 

              	
                 

              	
                 

              	
                 

              	
                15.4

              	
                Presentation
                  of Dispute to Agency head

              	
                17

              
	
                ARTICLE
                  5.

              	
                TERMINATION

              	
                10

              	
                 

              	
                15.5

              	
                Presentation
                  of dispute to the controller

              	
                18

              
	
                5.1

              	
                Termination
                  of Agreement

              	
                10

              	
                 

              	
                15.6

              	
                Contract
                  Dispute Resolution Board

              	
                19

              
	
                 

              	
                 

              	
                 

              	
                 

              	
                15.7

              	
                Petition
                  to Contract Dispute Resolution Board

              	
                19

              
	
                ARTICLE
                  6.

              	
                MISCELLANEOUS

              	
                11

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                6.1

              	
                Conflict
                  of Laws

              	
                11

              	
                 

              	
                ARTICLE
                  16.

              	
                PROMPT
                  PAYMENT

              	
                20

              
	
                6.2

              	
                General
                  Release

              	
                11

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                6.3

              	
                Claims
                  and Actions Thereon

              	
                11

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                6.4

              	
                No
                  Claims Against Officers, Agents, or Employees

              	
                 

                11

              	
                 

              	 	 	 


      

    

     

     

     

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    


    ARTICLE
      1. DEFINITIONS

    As
      used
      throughout this Agreement, the following terms shall have the meaning set forth
      below:

    a.
      "City"
      shall
      mean the City of New York, its departments and political
      subdivisions.

     

    b.
      "Comptroller"
      shall
      mean the Comptroller of the City of New York.

     

    c.
      "Department"
      or
      "Agency"
      shall
      mean the DEPARTMENT OF HEALTH. AND MENTAL HYGIENE

     

    d.
      "Commissioner"
      or
      "Administrator"
      shall
      mean the COMMISSIONER OF HEALTH AND MENTAL

     

    HYGIENE
      or his
      duly authorized representative. The term "duly authorized representative" shall
      include any

     

    person
      or
      persons acting within the limits of his or her authority.

     

    e.
      "Law"
      or
      "Laws" shall include but not be limited to the New York City Charter, the New
      York City AdministrativeCode, a local law of the City of New York, and any
      ordinance, rule or regulation having the Force of law.
      

    f.
      "Contractor"or"ConsuItant" shall
      mean
      VENDOR

     

    ARTICLE
      2. REPRESENTATIONS AND WARRANTIES

    2.1
      PROCUREMENT
      OF AGREEMENT

    A.
      The
      Contractor represents and warrants that no person or selling agency has been
      employed or retained to solicit or secure this Agreement upon an agreement
      or
      understanding for a commission, percentage, brokerage fee, contingent fee or
      any
      other compensation. The Contractor further represents and warrants that no
      payment, gift or thing of value has been made, given or promised to obtain
      this
      or any other agreement between the parties. The Contractor makes such
      representations and warranties to induce the City to enter into this Agreement
      and the City relies upon such representations and warranties in the execution
      hereof.

    B.
      For a
      breach or violation of such representations or warranties, the Administrator
      shall have the right to annul this Agreement without liability, entitling the
      City to recover all monies paid hereunder and the Contractor shall not make
      claim for, or be entitled to recover, any sum or sums due under this Agreement.
      This remedy, if effected, shall not constitute the sole remedy afforded the
      City
      for the falsity or breach, nor shall it constitute a waiver of the City's right
      to claim damages or refuse payment or to take any other action provided for
      by
      law or pursuant to this Agreement.

     

    2.2
      CONFLICT
      OF INTEREST

    The
      Contractor represents and warrants that neither it nor any of its directors,
      officers, members, partners or employees, has any interest nor shall they
      acquire any interest, directly or indirectly, which would or may conflict in
      any
      manner or degree with the performance or rendering of the services herein
      provided. The Contractor further represents and warrants that in the performance
      of this Agreement no person having such interest or possible interest shall
      be
      employed by it. No elected official or other officer or employee of the City
      or
      Department, nor any person whose salary is payable, in whole or in part, from
      the City Treasury, shall participate in any decision relating to this Agreement
      which affects his or her personal interest or the interest of any corporation,
      partnership or association in which he or she is, directly or indirectly,
      interested; nor shall any such person have any interest, direct or indirect,
      in
      this Agreement or in the proceeds thereof.

     

    2.3
      FAIR
      PRACTICES

    The
      Contractor and each person signing on behalf of any contractor represents and
      warrants and certifies, under penalty of perjury, that to the best of its
      knowledge and belief:

      
A.
      The
      prices in this contract have been arrived at independently without collusion,
      consultation, communication, or

    agreement,
      for the purpose of restricting competition, as to any matter relating to such
      prices with any other bidder or with any competitor;

    B.
      Unless
      otherwise required by law, the prices which have been quoted in this contract
      and on the proposal submitted by the Contractor have not been knowingly
      disclosed by the Contractor prior to the proposal opening, directly or
      indirectly, to any other bidder or to any competitor; and

    C.
      No
      attempt has been made or will be made by the Contractor to induce any other
      person, partnership or corporation to submit or not to submit a proposal for
      the
      purpose of restricting competition. The fact that the Contractor (a) has
      published price lists, rates, ortariffs covering items being procured, (b)
      has
      informed prospective customers of proposed

    


    NFP.W/P.L.

    -2-

    


    


    or
      pending publication of new or revised price lists for such items, or © has sold
      the same items to other customers at the same prices being bid, does not
      constitute, without more, a disclosure within the meaning of the
      above.

     

    ARTICLE
      3. AUDIT BY THE DEPARTMENT AND CITY

    3.1
      All
      vouchers or invoices presented for payment to be made hereunder, and the books,
      records and accounts upon which said vouchers or invoices are based are subject
      to audit by the Department and by the Comptroller of the City of New York
      pursuant to the powers and responsibilities as conferred upon said Department
      and said Comptroller by the New York City Charter and Administrative Code of
      the
      City of New York, as well as all orders and regulations promulgated pursuant
      thereto.

     

    3.2
      The
      Contractor shall submit any and all documentation and justification in support
      of expenditures or fees under this Agreement as may be required by said
      Department and said Comptroller so that they may evaluate the reasonableness
      ofthe charges and shall make its records available to the Department and to
      the
      Comptroller as they consider necessary.

     

    3.3
      All
      books, vouchers, records, reports, canceled checks and any and all similar
      material may be subject to periodic inspection, review and audit by the State
      of
      New York, Federal Government and other persons duly authorized by the City.
      Such
      audit may include examination and review ofthe source and application of all
      funds whether from the City, any State, the Federal Government, private sources
      or otherwise.

     

    3.4
      The
      contractor shall not be entitled to final payment under the Agreement until
      all
      requirements have been satisfactorily met.

     

    ARTICLE
      4. COVENANTS OF THE CONTRACTOR

    4.1
      EMPLOYEES

    A.
      All
      experts or consultants or employees ofthe Contractor who are employed by the
      Contractor to perform work under this contract are neither employees ofthe
      City
      nor under contract to the City and the Contractor alone is responsible for
      their
      work, direction, compensation and personal conduct while engaged under this
      Agreement. Nothing in this contract shall impose any liability or duty on the
      City for the acts, omissions, liabilities or obligations ofthe Contractor any
      person, firm company, agency, association, expert, consultant, independent
      contractor, specialist, trainee, employee, servant, or agent, or for taxes
      of
      any nature including but not limited to unemployment insurance, workmen's
      compensation, disability benefits and social security, or, except as
      specifically stated in this contract, to any person, firm or
      corporation.

    


    B.
      The
      Contractor shall be solely responsible for all physical injuries or death to
      its
      agents, servants, or employees or to any other person or damage to any property
      sustained during its operations and work on the project under this agreement
      resulting from any act of omission or commission or error in judgment of any
      of
      its officers, trustees, employees, agents, servants, or independent contractors,
      and shall hold harmless and indemnify the City from liability upon any and
      all
      claims for damages on account of such injuries or death to any such person
      or
      damages to property on account of any neglect, fault or default ofthe
      Contractor, its officers, trustees, employees, agents, servants, or independent
      contractors. The Contractor shall be solely responsible for the safety and
      protection of all of its employees whether due to the negligence, fault or
      default ofthe Contractor or not.

     

    C.
      Workmen's
      Compensation and Disability Benefits

    If
      this
      Agreement be of such a character that the employees engaged thereon are required
      to be insured by the provision of Chapter 615 ofthe Laws of 1922, known as
      the
      "Workmen's Compensation Law" and acts amendatory thereto, the Agreement shall
      be
      void and of no effect unless the Contractor shall secure compensation for the
      benefit of, and keep insured during the life of this Agreement such employees
      in
      compliance with the provisions of said law, inclusive of Disability Benefits,;
      and, shall furnish the Department with two (2) certificates of these insurance
      coverages.

     

    D.
      Unemployment
      Insurance

    Unemployment
      Insurance coverage shall be obtained and provided by the Contractor for its
      employees.

    


    NFP.W/P.L.
      

    -3-

     

    


    


    E.
      Minimum
      Wage 

    Except
      for those employees whose minimum wage is required to be fixed pursuant to
      Section 220 of the Labor Law of the State of New York, all persons employed
      by
      the Contractor in the performance of this Agreement shall be paid, without
      subsequent deduction or rebate, unless expressly authorized by law, not less
      than the minimum wage as prescribed by law. Any breach or violation of the
      foregoing shall be deemed a breach or violation of a material provision of
      this
      Agreement.

     

    4.2
      INDEPENDENT
      CONTRACTOR STATUS

    The
      Contractor and the Department agree that the Contractor is an independent
      contractor, and not an employee of the Department or the City of New York,
      and
      that in accordance with such status as independent contractor, the Contractor
      covenants and agrees that neither it nor its employees or agents will hold
      themselves out as, nor claim to be, officers or employees of the City ofNew
      York, or of any department, agency or unit thereof, by reason hereof, and that
      they will not, by reason hereof, make any claim, demand or application to or
      for
      any right or privilege applicable to an officer or employee of the City ofNew
      York, including, but not limited to, Workmen's Compensation coverage.
      Unemployment Insurance Benefits, Social Security coverage or employee retirement
      membership or credit.

     

    4.3
      INSURANCE

    A.
      INSURANCE
      REQUIREMENTS FOR CONTRACTORS

    Contractors
      shall procure and maintain for the duration of the contract insurance against
      claims for injuries to persons or damages to property which may arise from
      or in
      connection with the performance of the work hereunder by the Contractor, his
      agents, representatives, employees or subcontractors. All required insurance
      policies shall be maintained with companies that may lawfully issue the required
      policy and have an A.M. Best rating of at least A-7 or a Standard and Poor's
      rating of at least AA, unless prior written approval is obtained from the
      Mayor's Office of Operations. The cost of such insurance shall be included
      in
      the Contractor's bid.

     

    a.
      Minimum
      Scope of Insurance

    Coverage
      shall be at least as broad as:

    1.
      Insurance Services Office form number GL 0002 (1/73) covering Comprehensive
      General Liability and Insurance Services Office form number GL 0404 covering
      Broad Form Comprehensive General Liability; or Insurance Services Office
      Commercial General Liability coverage ("occurrence" form CG 0001).(ED
      11/85).

    2.Insurance
      Services Office form number CA 0001 (Ed. 1/78) covering Automobile Liability,
      code 1 "any auto" and endorsements CA 2232 and CA 0112.

    3.
      Workers' Compensation insurance as required by Labor Code of the State ofNew
      York and Employers Liability insurance.

     

    b.
      Minimum
      Limits of Insurance

    Contractor
      shall maintain limits no less than:

    1.
      Comprehensive General Liability: $1,000,000.00 combined single limit per
      accident for bodily injury and property damage.

    2-Professional
      liability: 1 Million Dollars per occurrence; Three Million Dollars
      Aggregate.

    3.
      Workers' Compensation and Employers Liability: Workers' Compensation limits
      as
      required by the Labor Code of the State of New York Employers Liability limits
      of $1,000,000.00 per accident. Pursuant to Section 57 of the NYS Workers'
      Compensation Law, the vendor has submitted proof of workers' compensation and
      disability benefits coverage to the agency.

    


     

    


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    -4-

     

    


    


    c.
      Deductibles
      and Self-Insured Retentions

    Any
      deductibles and self-insured retentions must be declared to and approved by
      the
      Agency. At the option of the Agency, either: the insurer shall reduce or
      eliminate such deductibles or self-insured retentions as respects and Agency,
      its officers, officials and employees; or the Contractor shall procure a bond
      guaranteeing payment of losses and related investigations, claim administration
      and defense expenses.

     

    1.
      General Liability and Automobile Liability Coverages

     

    a.
      The
      City, its officers, officials and employees are to be covered as insured as
      respects: liability arising out of activities performed by or on behalf of
      the
      Contractor; products and completed operations of the Contractor; premises owned,
      leases or used by the Contractor; or automobiles owned, leased, hired or
      borrowed by the Contractor. The coverage shall contain no special limitations
      on
      the scope of protection afforded to the City, its officers, officials and
      employees.

    b.
      The
      Contractor's insurance coverage shall be primary insurance as respect the City,
      its officers, officials, and employees. Any other insurance or self-insurance
      maintained by the Agency, its officers, officials and employees shall be excess
      of and not contribute with the Contractor's insurance.

    c.
      Any
      failure to comply with reporting provisions of the policies shall not affect
      coverage provided to the Agency, its officers, officials, and
      employees.

    d.
      The
      Contractor's insurance shall apply separately to each insured against whom
      claim
      is made or suit is brought, except with respect to the limits of the insurers
      liability.

     

    2.
      Workers' Compensation and Employers Liability Coverage

    The
      insurer shall agree to waive all rights of subrogation against the Agency,
      its
      officers, officials, and employees for losses arising from work performed by
      the
      Contractor for Agency. -

     

    3.
      All
      Coverages

     

    Each
      insurance policy required by this clause shall be endorsed to state that
      coverage shall not be suspended, voided, cancelled by either party, reduced
      in
      coverage or in limits except after sixty (60) days prior written notice by
      certified mail, return receipt requested, has been given to the
      City.

     

    d.
      Acceptability
      of Insurers

    Insurance
      is to be placed with insurers with an A.M. Best rating of at least A-7 or a
      Standard and Poor's rating of at least AA, unless prior written approval is
      obtained from the Mayor's Office of Operations.

     

    e.
      Verification
      of Coverage

    Contractor
      shall furnish the City with Certificates of Insurance effecting coverage
      required by this clause.' The Certificates for each insurance policy are to
      be
      signed by a person authorized by that insurer to bind coverage on its behalf.
      The Certificates are to be on forms provided by the Agency and are to be
      received and approved by the Agency before work commences. The Agency reserves
      the right to obtain complete, certified copies of all required insurance
      policies, at any time.

     

    f.
      Subcontractors

    Contractor
      shall include all subcontractors as insured under its policies or shall furnish
      separate Certificates for each subcontractor. All coverages for subcontractors
      shall be subject to all of the requirements stated herein.

     

    B.
      In the
      event that any claim is made or any action is brought against the City arising
      out of negligent or careless acts of an employee of the Contractor, either
      within or without the scope of his employment, or arising out of Contractor's
      negligent performance of this Agreement, then the City shall have the right
      to
      withhold further payments hereunder for the purpose of set-off in sufficient
      sums to cover the said claim or action. The rights and remedies of the City
      provided for in this clause shall not be exclusive and are in addition to any
      other rights and remedies provided by law or this Agreement, 

    


     

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    4.4
      PROTECTION
      OF CITY PROPERTY

     

    A.
      The
      Contractor assumes the risk of, and shall be responsible for, any loss or damage
      to City property, including property and equipment leased by the City, used
      in
      the performance of this Agreement; and caused, either directly or indirectly
      by
      the acts, conduct, omissions or lack of good faith of the Contractor, its
      officers, managerial personnel and employees, or any person, firm, company,
      agent or others engaged by the Contractor as expert, consultant, specialist
      or
      subcontractor hereunder.

     

    B.
      In the
      event that any such City property is lost or damaged, except for normal wear
      and
      tear, then the City shall have the right to withhold further payments hereunder
      for the purpose of set-off, in sufficient sums to cover such loss or
      damage.

     

    C.
      The
      Contractor agrees to indemnify the City and hold it harmless from any and all
      liability or claim for damages due to any such loss or damage to any such City
      property described in subsection A above.

    


    D.
      The
      rights and remedies of the City provided herein shall not be exclusive and
      are
      in addition to any other rights and remedies provided by law or by this
      Agreement.

     

    4.5
      CONFIDENTIALITY

    All
      of
      the reports, information or data, furnished to or prepared, assembled or used
      by
      the Contractor under this Agreement are to be held confidential, and prior
      to
      publication, the Contractor agrees that the same shall not be made available
      to
      any individual or organization without the prior written approval of the
      Department.

     

    4.6
      BOOKS
      AND RECORDS

    The
      Contractor agrees to maintain separate and accurate books, records, documents
      and other evidence and accounting procedures and practices which sufficiently
      and properly reflect all direct and indirect costs of any nature expended in
      the
      performance of this Agreement.

     

    4.7
      RETENTION
      OF RECORDS

    The
      Contractor agrees to retain all books, records, and other documents relevant
      to
      this Agreement for six years after the final payment or termination of this
      Agreement, whichever is later. City, State and Federal auditors and any other
      persons duly authorized by the Department shall have full access to and the
      right to examine any of said materials during said period.

     

    4.8
      COMPLIANCE
      WITH LAW

    Contractor
      shall render all services under this Agreement in accordance with the applicable
      provisions of federal, state and local laws, rules and regulations as are in
      effect at the time such services are rendered.

     

    4.9
      INVESTIGATION
      CLAUSE

    1.
      The
      parties to this agreement agree to cooperate fully and faithfully with any
      investigation, audit or inquiry conducted by a State of New York (State) or
      City
      of New York (City) governmental agency or authority that is empowered directly
      or by designation to compel the attendance of witnesses and to examine witnesses
      under oath, or conducted by the Inspector General of a governmental agency
      that
      is a party in interest to the transaction, submitted bid, submitted proposal,
      contract, lease, permit, or license that is the subject of the investigation,
      audit or inquiry.

    2(a)
      If
      any person who has been advised that his or her statement, and any information
      from such statement, will not be used against him or her in any subsequent
      criminal proceeding refuses to testify before a grand jury or other governmental
      agency or authority empowered directly or by designation to compel the
      attendance of witnesses and to examine witnesses under oath concerning the
      award
      of or performance under any transaction,

    


    


    NFP.W/P.L.
      

    -6-

     

    


    


    agreement,
      lease, permit, contract, or license entered into with the City, the State,
      or
      any political subdivision or public authority thereof, or the Port Authority
      of
      New York and New Jersey, or any local development corporation within the City,
      or any public benefit corporation organized under the laws of the State of
      New
      York, or;

     

    (b)
      If
      any person refuses to testify for a reason other than the assertion of his
      or
      her privilege against self-incrimination in an investigation, audit or inquiry
      conducted by a City or State governmental agency or authority empowered directly
      or by designation to compel the attendance of witnesses and to take testimony
      under oath, or by the Inspector General of the governmental agency that is
      a
      party in interest in, and is seeking testimony concerning the award of, or
      performance under, any transaction, agreement, lease, permit, contract . or
      license entered into with the City, the State, or any political subdivision
      thereof or any local development corporation within the City, then;

    


    3(a)
      The
      commissioner or agency head whose agency is a party in interest to the
      transaction, submitted bid, submitted proposal, contract, lease, permit, or
      license shall convene a hearing, upon not less than five (5) days written notice
      to the parties involved, to determine if any penalties should attach for the
      failure of a person to testify.

    


    3(b)
      If
      any non-governmental party to the hearing requests an adjournment, the
      commissioner or agency head who convened the hearing may, upon granting the
      adjournment, suspend any contract, lease, permit, or license pending the final
      determination pursuant to paragraph 5 below without the City incurring any
      penalty or damages for delay or otherwise.

    


    4.
      The
      penalties which may attach after a final determination by the commissioner
      or
      agency head may include but shall not exceed:

    


    (a)
      The
      disqualification for a period not to exceed five (5) years from the date of
      an
      adverse determination for any person, or any entity of which such person was
      a
      member at the time the testimony was sought, from submitting bids for, or
      transacting business with, or entering into or obtaining any contract, lease,
      permit or license with or from the City; and/or

    


    (b)
      The
      cancellation or termination of any and all such existing City contracts, leases,
      permits or licenses that the refusal to testify concerns and that have not
      been
      assigned as permitted under this agreement, nor the proceeds of which pledged,
      to an unaffiliated and unrelated institutional lender for fair value prior
      to
      the issuance of the . notice scheduling the hearing, without the City incurring
      any penalty or damages on account of such cancellation or termination; monies
      lawfully due for goods delivered, work done, rentals, or fees accrued prior
      to
      the cancellation or termination shall be paid by the City.

    


    5.
      The
      commissioner or agency head shall consider and address in reaching his or her
      determination and in assessing an appropriate penalty the factors in paragraphs
      (a) and (b) below. He or she may also consider, if relevant and appropriate,
      the
      criteria established in paragraphs (c) and (d) below in addition to any other
      information which may be relevant and appropriate:

    


    (a)
      The
      party's good faith endeavors or lack thereof to cooperate fully and faithfully
      with any governmental investigation or audit, including but not limited to
      the
      discipline, discharge, or disassociation of any person failing to testify,
      the
      production of accurate and complete books and records, and the forthcoming
      testimony of all other members, agents, assignees or fiduciaries whose testimony
      is sought.

     

    (b)
      The
      relationship of the person who refused to testify to any entity that is a party
      to the hearing, including, but not limited to, whether the person whose
      testimony is sought has an ownership interest in the entity and/or the degree
      of
      authority and responsibility the person has within the entity.

     

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    (c)
      The
      nexus of the testimony sought to the subject entity and its contracts, leases,
      permits or licenses with the City.

    


    (d)
      The
      effect a penalty may have on an unaffiliated and unrelated party or entity
      that
      has a significant interest in an entity subject to penalties under 4 above,
      provided that the party or entity has given actual notice to the commissioner
      or
      agency head upon the acquisition of the interest, or at the hearing called
      for
      in 3(a) above gives notice and proves that such interest was previously
      acquired. Under either circumstance the party or entity must present evidence
      at
      the hearing demonstrating the potential adverse impact a penalty will have
      on
      such person or entity.

    


    6.
      The
      term "license" or "permit" as used herein shall be defined as a license, permit,
      franchise or concession not granted as a matter of right.

     

    (a)
      The
      term "person" as used herein shall be defined as any natural person doing
      business alone or associated with another person or entity as a partner,
      director, officer, principal or employee.

    


    b)
      The
      term "entity" as used herein shall be defined as any firm, partnership,
      corporation, association, or person that receives monies, benefits, licenses,
      leases, or permits from or through the City or otherwise transacts business
      with
      the City.

    


    (c)
      The
      term "member" as used herein shall be defined as any person associated with
      another person or entity as a partner, director, officer, principal or
      employee.

    


    7.
      . In
      addition to and notwithstanding any other provision of this agreement the
      Commissioner or agency head may in his or her sole discretion terminate this
      agreement upon not less than three (3) days written notice in the event
      contractor fails to promptly report in writing to the Commissioner of
      Investigation of the City of New York any solicitation of money, goods, requests
      for future employment or other benefit or thing of value, by or on behalf of
      any
      employee of the City or other person, firm, corporation or entity for any
      purpose which may be related to the procurement or obtaining of this agreement
      by the contractor, or affecting the performance of this contract.

     

    4.10 ASSIGNMENT

    A.
      The
      Contractor shall not assign, transfer, convey or otherwise dispose of this
      Agreement or of Contractor's rights, obligations, duties, in whole or in part,
      or of its right to execute it, or its right, title or interest in it or any
      part
      thereof, or assign, by power of attorney or otherwise, any of the notices due
      or
      to become due under this contract, unless the prior written consent of the
      Administrator shall be obtained. Any such assignment, transfer, conveyance
      or
      other disposition without such consent shall be void.

    


    B.
      Failure of the Contractor to obtain any required consent to any assignment,
      shall be cause for termination for cause, at the option of the Administrator;
      and if so terminated, the City shall thereupon be relieved and discharged from
      any further liability and obligation to the Contractor, its assignees or
      transferees, and all monies that may become due under the contract shall be
      forfeited to the City except so much thereof as may be necessary to pay the
      Contractor's employees.

    


    C.
      The
      provisions of this clause shall not hinder, prevent, or affect an assignment
      by
      the Contractor for the benefit of its creditors made pursuant to the laws of
      the
      State of New York.

    


    D.
      This
      Agreement may be assigned by the City to any corporation, agency or
      instrumentality having authority to accept such assignment.

     

    4.11
      SUBCONTRACTING

    A.
      The
      Contractor agrees not to enter into any subcontracts for the performance of
      its
      obligations, in whole or in part, under this Agreement without the prior written
      approval of the Department. Two copies of each such proposed
      subcontract

     

    NFP.W/P.L.

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    shall
      be
      submitted to the Department with the Contractor's written request for approval.
      All such subcontracts shall contain provisions specifying:

    1.
      that
      the work performed by the subcontractor must be in accordance with the terms
      of
      the Agreement between the Department and the Contractor,

    2.
      that
      nothing contained in such agreement shall impair the rights of the
      Department,

    3.
      that
      nothing contained herein, or under the Agreement between the Department and
      the
      Contractor, shall create any contractual relation between the subcontractor
      and
      the Department, and

    4.
      that
      the subcontractor specifically agrees to be bound by the confidentiality
      provision set forthin
      this
      Agreement between the Department and the Contractor.

    B.
      The
      Contractor agrees that it is fully responsible to the Department for the acts
      and omissions of the subcontractors and of persons either directly or indirectly
      employed by them as it is for the acts and omissions of persons directly
      employed by it.

    


    C.
      The
      aforesaid approval is required in all cases other than individual
      employer-employee contracts. 

    


    D.
      The
      Contractor shall not in any way be relieved of any responsibility under this
      Contract by any subcontract.

     

    4.12
      PUBLICITY

    A.
      The
      prior written approval of the Department is required before the Contractor
      or
      any of its employees, servants, agents, or independent contractors may, at
      any
      time, either during or after completion or termination of this Agreement, make
      any statement to the press or issue any material for publication through any
      media of communication bearing on the work performed or data collected under
      this Agreement.

    


    B.
      If the
      Contractor publishes a work dealing with any aspect of performance under this
      Agreement, or of the results and accomplishments attained in such performance,
      the Department shall have a royalty free, non-exclusive and irrevocable license
      to reproduce, publish or otherwise use and to authorize others to use the
      publication.

     

    4.13
      PARTICIPATION
      IN AN INTERNATIONAL BOYCOTT

    A.
      The
      Contractor agrees that neither the Contractor nor any substantially-owned
      affiliated company is participating or shall participate in an international
      boycott in violation of the provisions of the Export Administration Act of
      1979,
      as amended, or the regulations of the United States Department of Commerce
      promulgated thereunder.

    


    B.
      Upon
      the final determination by the Commerce Department or any other agency of the
      United States as to, or conviction of the Contractor or a substantially-owned
      affiliated company thereof, participation in an international boycott in
      violation of the provisions of the Export Administration Act of 1979, as
      amended, or the regulations promulgated thereunder, the Comptroller may, at
      his
      option, render forfeit and void this contract.

     

    C.
      The
      Contractor shall comply in all respects, with the provisions of Section 6-114
      of
      the Administrative Code of the City of New York and the rules and regulations
      issued by the Comptroller thereunder.

     

    4.14
      INVENTIONS.
      PATENTS AND COPYRIGHTS

    A.
      Any
      discovery or invention arising out of or developed in the course of performance
      of this Agreement shall be promptly and fully reported to the Department, and
      if
      this work is supported by a federal grant of funds, shall be promptly and fully
      reported to the Federal Government for determination as to whether patent
      protection on such invention shall be sought and how the rights in the invention
      or discovery, including rights under any patent issued thereon, shall be
      disposed of and administered in order to protect the public
      interest.

    


    B.
      No
      report, document or other data produced in whole or in part with contract funds
      shall be copyrighted by the Contractor nor shall any notice of copyright be
      registered by the Contractor in connection with any report, document or other
      data developed for the contract.

    


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    -9-

     

    


    


    C.
      In no
      case shall subsections A and B of this section apply to, or prevent the
      Contractor from asserting or protecting its rights in any report, document
      or
      other data, or any invention which existed prior to or was developed or
      discovered independently from the activities directly related to this
      Agreement.

     

    4.15
      INFRINGEMENTS

    The
      Contractor shall be liable to the Department and hereby agrees to indemnify
      and
      hold the Department harmless for any damage or loss or expense sustained by
      the
      Department from any infringement by the Contractor of any copyright, trademark
      or patent rights of design, systems, drawings, graphs, charts, specifications
      orprinted matter furnished orused by the Contractor in the performance of this
      Agreement.

    


    4.16
      ANTI-TRUST

    The
      Contractor hereby assigns, sells, and transfers to the City all right, title
      and
      interest in and to any claims and causes of action arising under the anti-trust
      laws of the State of New York or of the United States relating to the particular
      goods or services purchased or procured by the City under this
      Agreement.

     

    ARTICLES.
      TERMINATION

    5.1
      TERMINATION
      OF AGREEMENT

     

    A.
      The
      Department and/or City shall have the right to terminate this Agreement,
      inwhole
      or
      in part:

    1.
      Under
      any right to terminate as specified in any section of this
      Agreement.

    2.
      Upon
      the failure of the Contractor to comply with any of the terms and conditions
      of
      this Agreement.

    3.
      Upon
      the Contractor's becoming insolvent.

    4.
      Upon
      the commencement under the Bankruptcy Act of any proceeding by or against the
      Contractor, either voluntarily or involuntarily. -

    5.
      Upon
      the Commissioner's determination, termination is in the best interest of the
      City.

    


    B.
      The
      Department or City shall give the Contractor written notice of any termination
      of this Agreement specifying therein the applicable provisions of subsection
      A
      of this section and the effective date thereof which shall not be less than
      ten
      (10) days from the date the notice is received.

    


    C.
      The
      Contractor shall be entitled to apply to the Department to have this Agreement
      terminated by said Department by reason of any failure in the performance of
      this Agreement (including any failure by the Contractor to make progress in
      the
      prosecution of work hereunder which endangers such performance), if such failure
      arises out of causes beyond the control and without the fault or negligence
      of
      the Contractor. Such causes may include, but are not restricted to: acts of
      God
      or of the public enemy; acts of the Government in either its sovereign or
      contractual capacity; fires; floods; epidemics; quarantine restrictions;
      strikes; freight embargoes; or any other cause beyond the reasonable control
      of
      the Contractor. The determination that such failure arises out of causes beyond
      the control and without the fault or negligence of the Contractor shall be
      made
      by the Department which agrees to exercise reasonable judgment therein. If
      such
      a determination is made and the Agreement terminated by the Department pursuant
      to such application by the Contractor, such termination shall be deemed to
      be
      without cause.

    


    D
      Upon
      termination of this Agreement the Contractor shall comply with the Department
      or
      City close-out procedures, including but not limited to:

    


    1.
      Accounting for and refund to the Department or City, within thirty (30) days,
      any unexpended funds which have been paid to the Contractor pursuant to this
      agreement.

    2.
      Furnishing within thirty (30) days an inventory to the Department or City of
      all
      equipment, appurtenances and property purchased through or provided under this
      Agreement carrying out any Department or City directive concerning the
      disposition thereof.

    3.
      Not
      incurring or paying any further obligation pursuant to this Agreement beyond
      the
      termination date. Any obligation necessarily incurred by the Contractor on
      account of this Agreement prior to receipt of notice of termination and falling
      due after such date shall be paid by the Department or City in accordance with
      the terms of this Agreement. In no event shall the word "obligation as used
      herein,,"

     

    NFP.W/P.L.

     -10-

     

    


    


    be
      construed as including any lease agreement, oral or written, entered into
      between the Contractor and its landlord.

    4.
      Turn
      over to the Department or City or its designees all books, records, documents
      and material specifically relating to this Agreement.

    5.
      Submit, within ninety (90) days, a final statement and report relating to this
      Agreement. The report shall be made by a certified public accountant or a
      licensed public accountant.

     

    E.
      In the
      event the Department or City shall terminate this Agreement, in whole or in
      part, as provided in paragraphs 1,2, 3, or 4 of subsection A of this section,
      the Department or City may procure, upon such terms and in such manner as deemed
      appropriate, services similar to those so terminated, and the Contractor shall
      continue the performance of this Agreement to the extent not terminated
      hereby.

     

    F.
      Not
      withstanding any other provisions of this contract, the Contractor shall not
      be
      relieved of liability to the City for damages sustained by the City by virtue
      of
      Contractor's breach of the contract, and the City may withhold payments to
      the
      Contractor for the purpose of set-off until such time as the exact amount of
      damages due to the City from the Contractor is determined.

     

    G.
      The
      provisions of the Agreement regarding confidentiality of information shall
      remain in full force and effect following any termination.

     

    H.
      The
      rights and remedies of the City provided in this section shall not be exclusive
      and are in addition to all other rights and remedies provided by law or under
      this Agreement.

     

    ARTICLE
      6. MISCELLANEOUS

     

    6.1
      CONFLICT
      OF LAWS

    All
      disputes arising out of this Agreement shall be interpreted and decided in
      accordance with the laws of the State of New York.

     

    6.2
      GENERAL
      RELEASE

    The
      acceptance by the Contractor or its assignees of the final payment under this
      contract, whether by voucher, judgment of any court of competent jurisdiction
      or
      any other administrative means, shall constitute and operate as a general
      release to the City from any and all claims of and liability to the Contractor
      arising out of the performance of this contract.

     

    6.3
      CLAIMS
      AND ACTIONS THEREON

    A.
      No
      action at law or proceeding in equity against the City or Department shall
      lie
      or be maintained upon any claim based upon this Agreement or arising out of
      this
      Agreement or in any way connected with this Agreement unless the Contractor
      shall have strictly complied with all requirements relating to the giving of
      notice and of information with respect to such claims, all as herein
      provided.

    B.
      No
      action shall lie or be maintained against the City by Contractor upon any claims
      based upon this Agreement unless such action shall be commenced within six
      (6)
      months after the date of filing in the Office of the Comptroller of the City
      of
      the certificate for the final payment hereunder, or within six (6) months of
      the
      termination or conclusion of this Agreement, or within six (6) months after
      the
      accrual of the Cause of Action, whichever first occurs.

    C.
      In the
      event any claim is made or any action brought in any way relating to the
      Agreement herein, the Contractor shall diligently render to the Department
      and/or the City of New York without additional compensation any and all
      assistance which the Department and/or the City of New York may require of
      the
      Contractor.

     

    D.
      The
      Contractor shall report to the Department in writing within three (3) working
      days of the initiation by or against the Contractor of any legal action or
      proceeding in connection with or relating to this Agreement.

     

    NFP.W/P.L.
      -11-

     

    


    


    6.4
      NO
      CLAIM AGAINST OFFICERS. AGENTS OR EMPLOYEES

    No
      claim
      whatsoever shall be made by the Contractor against any officer, agent or
      employee of the City for, or on account of, anything done or omitted in
      connection with this contract.

     

    6.5
      WAIVER

    Waiver
      by
      the Department of a breach of any provision of this Agreement shall not be
      deemed to be a waiver of any other or subsequent breach and shall not be
      construed to be a modification of the terms of the Agreement unless and until
      the same shall be agreed to in writing by the Department or City as required
      and
      attached to the original Agreement.

     

    6.6
      NOTICE

    The
      Contractor and the Department hereby designate the business addresses
      hereinabove specified as the places where all notices, directions or
      communications from one such party to the other party shall be delivered, or
      to
      which they shall be mailed. Actual delivery of any such notice, direction or
      communication to a party at the aforesaid place, or delivery by certified mail
      shall be conclusive and deemed to be sufficient service thereof upon such party
      as of the date such notice, direction or communication is received by the party.
      Such address may be changed at any time by an instrument in writing executed
      and
      acknowledged by the party making such change and delivered to the other party
      in
      the manner as specified above. Nothing in this section shall be deemed to serve
      as a waiver of any requirements for the service of notice or process in the
      institution of an action or proceeding as provided by law, including the Civil
      Practice Law and Rules.

     

    6.7
      ALL
      LEGAL PROVISIONS DEEMED INCLUDED

    It
      is the
      intent and understanding of the parties to this Agreement that each and every
      provision of law required to be inserted in this Agreement shall be and is
      inserted herein. Furthermore, it is hereby stipulated that every such provision
      is to be deemed to be inserted herein, and if, through mistake or otherwise,
      any
      such provision is not inserted, or is not inserted in correct form, then this
      Agreement shall forthwith upon the application of either party be amended by
      such insertion so as to comply strictly with the law and without prejudice
      to
      the rights of either party hereunder.

     

    6.8
      SEVERABILITY

    If
      this
      Agreement contains any unlawful provision not an essential part of the Agreement
      and which shall not appear to have been a controlling or material inducement
      to
      the making thereof, the same shall be deemed of no effect and shall upon notice
      by either party, be deemed stricken from the Agreement without affecting the
      binding force of the remainder.

     

    6.9
      POLITICAL
      ACTIVITY

    There
      shall be no partisan political activity or any activity to further the election
      or defeat of any candidate for public, political or party office as part of
      or
      in connection with this Agreement, nor shall any of the funds provided under
      this Agreement be used for such purposes.

     

    6.10
      MODIFICATION

    This
      Agreement may be modified by the parties in writing in a manner not materially
      affecting the substance hereof. It may not be altered or modified
      orally.

     

    A.
      CONTRACT
      CHANGES

    Changes
      may be made to this contract only as duly authorized by the Agency Chief
      Contracting Officer of his or her designee. Vendors deviating from the
      requirements of an original purchase order or contract without a duly authorized
      change order document, or written contract modification or amendment, do so
      at
      their own risk. All such duly authorized changes, modifications and amendments
      will be reflected in a written change order and become a part of the original
      contract. Contract changes will be made only for work necessary to complete
      the
      work included in the original scope of the contract, and for non-material
      changes to the scope of the contract. Changes are not permitted for any material
      alteration in the scope of the work. Changes may include any one or more of
      the
      following:

    - Specification
      changes to account for design errors or omissions;

     

    NFP.W/P.L.
      -12-

     

    


    


    
      	 	
              -

            	
              changes
                in contract amount due to authorized additional or omitted work.
                Any such
                changes require appropriate price and cost analysis to determine
                reasonableness. In addition, except for non-construction requirements
                contracts, all changes that cumulatively exceed the greater often
                percent
                of the original contract amount or $100,000 shall be approved by
                the City
                Chief Procurement Officer;

            


    

    
      	 	
              -

            	
              Extensions
                of a contract term for good and sufficient cause for a cumulative
                period
                not to exceed one year from the date of expiration of this current
                contract. Requirements contracts shall be subject to this
                limitation;

            


    

    
      	 	
              -

            	
              Changes
                in delivery location;

            


    

    - Changes
      in shipment method; and 

    - Any
      other
      change not inconsistent with §4-02 of the P.P.B. Rules (ed. 9/00), or any
      successor Rule.

    


    The
      Contractor may be entitled to a price adjustment for extra work performed
      pursuant to a written change order. If any part of the contract work is
      necessarily delayed by a change order, the Contractor may be entitled to an
      extension of time for performance. Adjustments to price shall be validated
      for
      reasonableness by using appropriate price and cost analysis.

     

    6.11
      PARAGRAPH
      HEADINGS

    Paragraph
      headings are inserted only as a matter of convenience and for reference and
      in
      no way define, limit or describe the scope or intent of this contract and in
      no
      way affect this contract.

     

    6.12
      NO
      REMOVAL OF RECORDS FROM PREMISES

    Where
      performance of this Agreement involves use by the Contractor of Departmental
      papers, files, data or records at Departmental facilities or offices, the
      Contractor shall not remove any such papers, files, data or records, therefrom
      without the prior approval of the Department's designated official.

     

    6.13
      INSPECTION
      AT SITE

    The
      Department shall have the right to have representatives of the Department or
      of
      the City or of the State or Federal governments present at the site of the
      engagement to observe the work being performed.

     

    6.14
      PRICING

    A.
      The
      Contractor shall when ever required during the contract, including but not
      limited to the time of bidding, submit cost or pricing data and formally certify
      that, to the best of its knowledge and belief, the cost or pricing date
      submitted was accurate, complete, and current as of a specified date. The
      Contractor shall be required to keep its submission of cost and pricing date
      current until the contract has been completed.

    B.
      The
      price of any change order or contract modification subject to the conditions
      of
      paragraph A, shall be adjusted to exclude any significant sums by which the
      City
      finds that such price was based on cost or price data furnished by the supplier
      which was inaccurate, incomplete, or not current as of the date agreed upon
      between the parties.

    C.
      Time
      for Certification.
      The
      Contractor must certify that the cost or pricing data submitted are accurate,
      complete and current as of a mutually determined date.

    D.
      Refusal
      to Submit Data.
      When any
      contractor refuses to submit the required data to support a price, the
      Contracting Officer shall not allow the price.

    E.
      Certificate
      of Current Cost or Pricing Data. Form of Certificate.
      In those
      cases when cost or pricing data is required, certification shall be made using
      a
      certificate substantially similar to the one contained in Chapter 4 of the
      PPB
      rules and such certification shall be retained in the agency contract
      file.

     

    ARTICLE
      7. MERGER

    This
      written Agreement contains all the terms and conditions agreed upon by the
      parties hereto, and no other agreement, oral or otherwise, regarding the subject
      matter of this Agreement shall be deemed to exist or to bind any of the parties
      hereto, or to vary any of the terms contained herein.

     

    NFP.W/P.L.
      -13-

     

    


    


    ARTICLE
      8. CONDITIONS PRECEDENT

    This
      contract shall neither be binding nor effective unless:

    A.
      Approved by the Mayor pursuant to the provisions of Executive Order No. 42,
      dated October 9, 1975, in the event the

    Executive
      Order requires such approval; and 

    B.
      Certified by the Mayor (Mayor's Fiscal Committee created pursuant to Executive
      Order No. 43, dated October 14,1975) that performance thereof will be in
      accordance with the City's financial plan; and 

    C.
      Approved by the New York State Financial Control Board (Board) pursuant to
      the
      New York State Financial Emergency Act for the City of New York, as amended,
      (the "Act"), in the event regulations of the Board pursuant to the Act require
      such approval.

     

    D.
      It has
      been authorized by the Mayor and the Comptroller shall have endorsed his
      certificate that there remains unexpended and unapplied a balance of the
      appropriation of funds applicable thereto sufficient to pay the estimated
      expense of carrying out this Agreement. The requirements of this section of
      the
      contract shall be in addition to, and not in lieu of, any approval or
      authorization otherwise required for this contract to be effective and for
      the
      expenditure of City funds.

     

    ARTICLE
      9. PPB RULES

    This
      contract is subject to the Rules of the Procurement Policy Board of the City
      of
      New York effective August 1, 1990, as amended. In the event of a conflict
      between said Rules and a provision of this contract, the Rules shall take
      precedence.

     

    ARTICLE
      10. STATE LABOR LAW AND CITY ADMINISTRATIVE CODE

    1.
      As
      required by New York State Labor Law Section 220-e:

    a.
      That
      in the hiring of employees for the performance of work under this contract
      or
      any subcontract hereunder, neither the Contractor, Subcontractor, nor any person
      acting on behalf of such Contractor or Subcontractor, shall by reason of race,
      creed, color, sex or national origin discriminate against any citizen of the
      State of New York who is qualified and available to perform the work to which
      the employment relates;

    b.
      That
      neither the Contractor, subcontractor, nor any person on his behalf shall,
      in
      any manner, discriminate against or intimidate any employee hired for the
      performance of work under this contract on account of race, creed, color, sex
      or
      national origin;

    c.
      That
      there may be deducted from the amount payable to the Contractor by the City
      under this contract a penalty of five dollars for each person for each calendar
      day during which such person was discriminated against or intimidated in
      violation of the provisions of this contract; and 

    d.
      That
      this contract may be canceled or terminated by the City and all monies due
      or to
      become due hereunder may be forfeited, for a second or any subsequent violation
      of the terms or conditions of this section of the contract.

    e.
      The
      aforesaid provisions of this section covering every contract for or on behalf
      of
      the State or a municipality for the manufacture, sale or distribution of
      materials, equipment or supplies shall be limited to operations performed within
      the territorial limits of the State of New York.

     

    2.
      As
      required by New York City Administrative Code Section 6-108:

    a.
      It
      shall be unlawful for any person engaged in the construction, alteration or
      repair of buildings or engaged in the construction or repair of streets or
      highways pursuant to a contract with the City or engaged in the manufacture,
      sale or distribution of materials, equipment or supplies pursuant to a contract
      with the City to refuse to employ or to refuse to continue in any employment
      any
      person on account of the race, color or creed of such person.

    b.
      It
      shall be unlawful for any person or any servant, agent or employee of any
      person, described in subdivision (a) above, to ask, indicate or transmit, orally
      or in writing, directly or indirectly, the race, color, creed or religious
      affiliation of any person employed or seeking employment from such person,
      firm
      or corporation.

    c.
      Disobedience of the foregoing provisions shall be deemed a violation of a
      material provision of this contract.

    d.
      Any
      person, or the employee, manager or owner of or officer of such firm or
      corporation who shall violate any of the provisions of this section shall,
      upon
      conviction thereof, be punished by a fine of not more than one hundred dollars
      or by imprisonment for not more than thirty days, or both.

    


    NFP.W/P.L.

    -14-

    


    


    ARTICLE
      11. FORUM PROVISION CHOICE OF LAW. CONSENT TO JURISDICTION AND
      VENUE

    This
      Contract shall be deemed to be executed in the City of New York, State of New
      York. regardless of the domicile of the Contractor, and shall be governed by
      and
      construed in accordance with the laws of the State of New York. The parties
      agree that any and all claims asserted by or against the City arising under
      this
      Contract or related thereto shall be heard and determined either in the courts
      of the United States located in New York City ("Federal Courts") or in the
      courts of the State of New York ("New York State Courts") located in the City
      and County of New York. To effect this Agreement and intent, the Contractor
      agrees:

    a.
      If the
      City initiates any action against the Contractor in Federal Court or in New
      York
      State Court, service of process may be made on the Contractor either in person,
      wherever such Contractor may be found, or by registered mail addressed to the
      Contractor at its address as set forth in this Contract, or to such other
      address .as the Contractor may provide to the City in writing; and

    b.
      With
      respect to any action between the City and the Contractor in New York State
      Court, the Contractor hereby expressly waives and relinquishes any rights it
      might otherwise have (I) to move to dismiss on grounds of forum non
      conveniens;
      (ii) to
      remove to Federal Court; and (iii) to move for a change of venue to a New York
      State Court outside New York County.

    c.
      With
      respect to any action between the City and the Contractor in Federal Court
      located in New York City, the Contractor expressly waives and relinquishes
      any
      right it might otherwise have to move to transfer the action to a United States
      Court outside the City of New York.

    d.
      If the
      Contractor commences any action against the City in a court located other than
      in the City and State
      of New
      York,
      upon request of the City, the Contractor shall either consent to a transfer
      of
      the action to a court of competent jurisdiction located in the City and State
      ofNew York or, if the court where the action is initially brought will not
      or
      cannot transfer the action, the Contractor shall consent to dismiss such action
      without prejudice and may thereafter reinstitute the action in a court of
      competent jurisdiction in New York City. If any provision(s) of this Article
      is
      held unenforceable for any reason, each and all other provision(s) shall
      nevertheless remain in full force and effect.

     

    ARTICLE
      12. EQUAL EMPLOYMENT OPPORTUNITY

    This
      contract is subject to the requirements of Executive Order No. 50 (1980) as
      revised ("E.O. 50") and the Rules and Regulations promulgated thereunder. No
      contract will be awarded unless and until these requirements have been complied
      with in their entirety. By signing this contract, the contractor agrees that
      it:

    1.
      will
      not engage in any unlawful discrimination against any employee or applicant
      for
      employment because of race, creed, color, national origin, sex age, disability,
      marital status or sexual orientation with respect to all employment decisions
      including, but not limited to, recruitment, hiring, upgrading, demotion,
      downgrading, transfer, training, rates of pay or other forms of compensation,
      layoff, termination, and all other terms and conditions of
      employment;

    2.
      the
      contractor agrees that when it subcontracts it will not engage in any unlawful
      discrimination in the selection of subcontractors on the basis of the owner's
      race, color, creed, national origin, sex, age, disability, marital status or
      sexual orientation;

    3.
      will
      state in all solicitations or advertisements for employees placed by or on
      behalf of the contractor that all qualified applicants will receive
      consideration for employment without unlawful discrimination based on race,
      creed, color, national origin, sex, age, disability, marital status or sexual
      orientation, or that it is an equal employment opportunity
      employer;

    4.
      will
      send to each labor organization or representative of workers with which it
      has a
      collective bargaining agreement or other contract or memorandum of
      understanding, written notification of its equal employment opportunity
      commitments under E. 0. 50 and the rules and regulations promulgated thereunder;
      and

    5.
      will
      furnish all information and reports including an Employment Report before the
      award of the contract which are required by E. 0. 50, the rules and regulations
      promulgated thereunder, and orders of the Director of the Bureau of Labor
      Services ("Bureau"), and will permit access to its books, records and accounts
      by the Bureau for the purposes of investigation to ascertain compliance with
      such rules, regulations, and orders. The contractor understands that in the
      event of its noncompliance with nondiscrimination clauses of this contract
      or
      with any of such rules, regulations, or orders, such noncompliance shall
      constitute a material breach of the contract and noncompliance with the E.
      0. 50
      and the rules and regulations promulgated thereunder. After a hearing held
      pursuant to the rules of the Bureau, the Director may direct the imposition
      by
      the contracting agency held of any or all of the following
      sanctions:

    (i)
      disapproval of the contractor;

     

    NFP.W/P.L.
      -15-

     

    


    


    (ii)
      suspension or termination of the contract;

    (iii)
      declaring the contractor in default; or '

    (iv)
      in
      lieu of any of the foregoing sanctions, the Director may impose an employment
      program. The Director of the Bureau may recommend to the contracting agency
      head
      that a Board of Responsibility be convened for purposes of declaring a
      contractor who has repeatedly failed to comply with E.O. 50 and the rule and
      regulations promulgated thereunder to be nonresponsible. The contractor agrees
      to include the provisions of the foregoing paragraphs in every subcontract
      or
      purchase order in excess of $50,000 to which it becomes a party unless exempted
      by E.O. 50 and the rules and regulations promulgated thereunder, so that such
      provisions will be binding upon each subcontractor or vendor. The contractor
      will take such action with respect to any subcontract or purchase order as
      may
      be directed by the Director of the Bureau of Labor Services as a means of
      enforcing such provisions, including sanctions for noncompliance. The contractor
      further agrees that it will refrain from entering into any contract or contract
      modification subject to E.O. 50 and the rules and regulations promulgated
      thereunder with a subcontractor who is not in compliance with the requirements
      of E.O. 50 and the rules and regulations promulgated thereunder.

     

    ARTICLE
      13. NO DAMAGE FOR DELAY

    The
      Contractor agrees to make no claim for damages for delay in the performance
      of
      this Contract occasioned by any act or omission to act of the City or any of
      its
      representatives, and agrees that any such claim shall be fully compensated
      for
      by an extension of time to complete performance of the work as provided
      herein.

     

    ARTICLE
      14. CONSULTANT REPORT INFORMATION

    A
      copy of
      each consultant report submitted by a consultant to any City official or to
      any
      officer, employee, agent or representative of a City department, agency,
      commission or body or to any corporation, association or entity whose expenses
      are paid in whole or in part from the City treasury shall be furnished to the
      Commissioner of the department to which such report was submitted or, if not
      a
      City department, then to the chief controlling officer or officers of such
      other
      office or entity. A copy of such report shall also be furnished to the Director
      of the Mayor's Office of Construction for matters related to construction or
      to
      the Director of the Mayor's Office of Operations for all other
      matters.

     

    ARTICLE
      15. RESOLUTION OF DISPUTES

    15.1
      All
      disputes between the City and the Contractor of the kind delineated in this
      section that arise under, or by virtue of this Contract shall be finally
      resolved in accordance with the provisions of this section and Section 4-09
      of
      the Rules of the Procurement Policy Board ("PPB Rules"), and any successor
      Rule.
      The procedure for resolving all disputes of the kind delineated herein shall
      be
      the exclusive means of resolving any such disputes.

    


    a.
      This
      section shall not apply to disputes concerning matters dealt with in other
      sections of the PPB Rules or to disputes involving patents, copyrights,
      trademarks, or trade secrets (as interpreted by the courts of New York State)
      relating to proprietary rights in computer software.

    


    b.
      For
      construction and construction-related services this section shall apply only
      to
      disputes about the scope of work delineated by the Contract, the interpretation
      of Contract Documents, the amount to be paid for extra work or disputed work
      performed in connection with the Contract, the conformity of the Contractor's
      work to the Contract, and the acceptability and quality of the Contractor's
      work; such disputes arise when the Engineer makes a determination with which
      the
      Contractor disagrees.

    


    15.2
      All
      determinations required by this section shall be made in writing, clearly
      stated, with a reasoned explanation for the determination based on the
      information and evidence presented to the party making the determination.
      Failure to make such determination within the time period required by this
      section shall be deemed a non-determination without prejudice that will allow
      appeal to the next level.

     

    15.3
      During such time as any dispute is being presented, heard, and considered
      pursuant to this section, the contract terms shall remain in full force and
      effect and the Contractor shall continue to perform work in accordance with
      the
      Contract and as directed by the Agency Chief Contracting Officer or Engineer.
      Failure of the Contractor to continue the work as directed shall constitute
      a
      waiver by the Contractor of any and all claims being presented pursuant to
      this
      section and a material breach of Contract.

    


    NFP.W/P.L.
      

    -16-

     

    


    


    15.4
      Presentation
      of Dispute to Agency Head.

     

    (A)
      Notice of Dispute and Agency Response. The Contractor shall present its dispute
      in writing ("Notice of Dispute") to the Agency Head within the time specified
      herein or, if no time is specified, within thirty (30) days of receiving notice
      of the determination or action that is the subject of the dispute. This notice
      requirement shall not be read to replace any other notice requirements contained
      in the Contract. The Notice of Dispute shall include all the facts, evidence,
      documents, or other basis upon which the Contractor relies in support of its
      position, as well as a detailed computation demonstrating how any amount of
      money claimed by the Contractor in the dispute was arrived at. Within thirty
      (30) days after receipt of the detailed written submission, the Agency Chief
      Contracting Officer or, in the case of construction or construction-related
      services, the Engineer shall submit to the Agency Head all materials he or
      she
      deems pertinent to the dispute. Following initial submissions to the Agency
      Head, either party may demand of the other the production of any document or
      other material the demanding party believes may be relevant to the dispute.
      The
      requested party shall produce all relevant materials that are not otherwise
      protected by a legal privilege recognized by the courts of New York State.
      Any
      question of relevancy shall be determined by the Agency Head whose decision
      shall be final. Wilful failure of the Contractor to produce any requested
      material whose relevancy the Contractor has not disputed, or whose relevancy
      has
      been affirmatively determined, shall constitute a waiver by the Contractor
      of
      its claim.

    


    (B)
      Agency Head Inquiry. The Agency Head shall examine the material and may, in
      his
      or her discretion, convene an informal conference with the Contractor and the
      Agency Chief Contracting Officer and, in the case of construction or
      construction-related services, the Engineer to resolve the issue by mutual
      consent prior to reaching a determination. The Agency Head may seek such
      technical or other expertise as he or she shall deem appropriate, including
      the
      use of neutral mediators, and require any such additional material from either
      or both parties as he or she deems fit. The Agency Head's ability to render,
      and
      the effect of, a decision hereunder shall not be impaired by any negotiations
      in
      connection with the dispute presented, whether or not the Agency Head
      participated therein. The Agency Head may or, at the request of any party to
      the
      dispute, shall compel the participation of any other contractor with a contract
      related to the work of this Contract, and that contractor shall be bound by
      the
      decision of the Agency Head. Any contractor thus brought into the dispute
      resolution proceeding shall have the same rights to make presentations and
      to
      seek review as the Contractor initiating the dispute.

    


    (C)
      Agency Head Determination. Within thirty (30) days after the receipt of all
      materials and information, or such longer time as may be agreed to by the
      parties, the Agency Head shall make his or her determination and shall deliver
      or send a copy of such determination to the Contractor and Agency Chief
      Contracting Officer and, in the case of construction or construction-related
      services, the Engineer, together with a statement concerning how the decision
      may be appealed.

    


    (D)
      Finality of Agency Head Decision. The Agency Head's decision shall be final
      and
      binding on all parties, unless presented to the Contract Dispute Resolution
      Board pursuant to this section. The City may not take a petition to the Contract
      Dispute Resolution Board. However, should the Contractor take such a petition,
      the City may seek, and the Board may render, a determination less favorable
      to
      the Contractor and more favorable to the City than the decision of the Agency
      Head.

    


    15.5
      Presentation
      of Dispute to the Comptroller.
      Before
      any dispute may be brought by the Contractor to the Contract Dispute Resolution
      Board, the Contractor must first present its claim to the comptroller for his
      or
      her review, investigation, and possible adjustment.

    


    (A)
      Time,
      Form, and Content of Notice. Within thirty (30) days of its receipt of a
      decision by the Agency Head, the Contractor shall submit to the Comptroller
      and
      to the Agency Head a Notice of Claim regarding its dispute with the Agency.
      The
      Notice of Claim shall consist of(i) a brief written statement of the substance
      of the dispute, the amount of money, if any, claimed and the reason(s) the
      Contractor contends the dispute was wrongly decided by the Agency Head; (ii)
      a
      copy of the written decision of the Agency Head, and (iii) a copy of all
      materials submitted by the Contractor to the Agency, including the Notice of
      Dispute. The Contractor may not present to the Comptroller any material not
      presented to the Agency Head, except at-the request of the
      Comptroller.

    (B)
      Agency Response. Within thirty (30) days of receipt of the Notice of Claim,
      the
      Agency shall make available to the Comptroller a copy of all material submitted
      by the Agency to the Agency Head in connection with the dispute. The Agency
      may
      not present to the Comptroller any material not presented to the Agency Head
      except at the request of the Comptroller.

    


    NFP.W/P.L.
      

    -17-

     

    


    


    (C)
      Comptroller Investigation. The Comptroller may investigate the claim in dispute
      and, in the course of such investigation, may exercise all powers provided
      in
      sections 7-201 and 7-203 of the New York City Administrative Code. In addition,
      the Comptroller may demand of either party, and such party shall provide,
      whatever additional material the Comptroller deems pertinent to the claim,
      including original business records of the Contractor. Wilful failure of the
      Contractor to produce within fifteen (15) days any material requested by the
      Comptroller shall constitute a waiver by the Contractor of its claim. The
      Comptroller may also schedule an informal conference to be attended by the
      Contractor, Agency representatives, and any other personnel desired by the
      Comptroller.

     

    (D)
      Opportunity of Comptroller to Compromise or Adjust Claim. The Comptroller shall
      have forty-five (45) days from his or her receipt of all materials referred
      to
      in 5. (C) to investigate the disputed claim. The period for investigation and
      compromise may be further extended by agreement between the Contractor and.
      the
      Comptroller, to a maximum of ninety (90) days from the Comptroller's receipt
      of
      all the materials. The Contractor may not present its petition to the Contract
      Dispute Resolution Board until the period for investigation and compromise
      delineated in this paragraph has expired. In compromising or adjusting any
      claim
      hereunder, the Comptroller may not revise or disregard the terms of the Contract
      between the parties.

     

    15.6
      Contract
      Dispute Resolution Board.
      There
      shall be a Contract Dispute Resolution Board composed of:

    A.
      the
      chief administrative law judge of the Office of Administrative Trials and
      Hearings ("OATH") or his/her designated OATH administrative law judge, who
      shall
      act as chairperson, and may adopt operational procedures and issue such orders
      consistent with this section as may be necessary in the execution of the
      Contract Dispute Resolution Board's functions, including, but not limited to,
      granting extensions of time to present or respond to submissions;

    


    B.
      the
      City Chief Procurement Officer or a designee; or in the case of disputes
      involving construction, the Director of the Office of Construction or his/her
      designee; any designee shall have the requisite background to consider and
      resolve the merits of the dispute and shall not have participated personally
      and
      substantially in the particular matter that is the subject of the dispute or
      report to anyone who so participated, and

     

    C.
      a
      neutral person with appropriate expertise. This person shall be selected by
      the
      presiding administrative lawjudge from a prequalified panel of individuals,
      established and administered by OATH, with appropriate background to act as
      decision-makers in a dispute. Such individuals may not have a contract or
      dispute with the City or be an officer or employee of any company or
      organization that does, or regularly represents persons, companies, or
      organizations having disputes with the City.

     

    15.7
      Petition
      to Contract Dispute Resolution Board.
      In the
      event the claim has not been settled or adjusted by the Comptroller within
      the
      period provided in this section, the Contractor, within thirty (30) days
      thereafter, may petition the Contract Dispute Resolution Board to review the
      Agency Head determination.

    


    (A)
      Form
      and Content of Petition by Contractor. The Contractor shall present its dispute
      to the Contract Dispute Resolution Board in the form of a Petition, which shall
      include (i) a brief written statement of the substance of the dispute, the
      amount of money, if any, claimed and the reason(s) the Contractor contends
      that
      the dispute was wrongly decided by the Agency Head; (ii) a copy of the written
      decision of the Agency Head; (iii) copies of all materials submitted by the
      Contractor to the Agency; (iv) a copy of the written decision of the
      Comptroller, if any, and (v) copies of all correspondence with, or written
      material submitted by the Contractor to, the Comptroller's Office. The
      Contractor shall concurrently submit four complete sets of the Petition: one
      to
      the Corporation Counsel (Attn: Commercial and Real Estate Litigation Division),
      and three to the Contract Dispute Resolution Board at oath's
      offices
      with proof of service on the Corporation Counsel. In addition, the supplier
      shall submit a copy of the statement of the substance of the dispute, cited
      in
      (i) above to both the Agency Head and the Comptroller.

     

    (B)
      Agency Response. Within thirty (30) days of its receipt of the Petition by
      the
      Corporation Counsel, the Agency shall respond to the brief written statement
      of
      the Contractor and make available to the Board at oath's
      offices
      and one to the Contractor, all material it submitted to the Agency Head and
      Comptroller. Extensions of time for submittal of the agency response shall
      be
      given as necessary upon a showing of good cause or, upon the consent of the
      parties, for an initial period of up to thirty (30) days.

     

    (C)
      Further Proceedings. The Board shall permit the Contractor to present its case
      by

     

    NFP.W/P.L.

     -18-

     

    


    


    the
      submission of memoranda, briefs, and oral argument. The Board shall also permit
      the Agency to present its case in response to the Contractor by the submission
      of memoranda, briefs, and oral argument. If requested by the Corporation
      Counsel, the Comptroller shall provide reasonable assistance in the preparation
      of the Agency's case. Neither the Contractor nor the Agency may support its
      case
      with any documentation or other material that was not considered by the
      Comptroller, unless requested by the Board. The Board, at its discretion, may
      seek such technical or other expertise as it shall deem appropriate and may
      seek, on its own or upon application of a party, any such additional material
      from any party as it deems fit. The Board, in its discretion, may combine more
      than one dispute between the parties of concurrent resolution.

     

    (D)
      Contract Dispute Resolution Board Determination. Within forty-five (45) days
      of
      the conclusion of all written submissions and oral arguments, the Board shall
      render a written decision resolving the dispute. In an unusually complex case,
      the Board may render its decision in a longer period of time, not to exceed
      ninety (90) days, and shall so advise the parties at the commencement of this
      period. The Board's decision must be consistent with the terms of the Contract.
      In reaching its decision, the Board shall accord no precedential significance
      to
      prior decisions of the Board involving other non-related contracts.

    


    (E)
      Notification of Contract Dispute Resolution Board Decision. The Board shall
      send
      a copy of its decision to the Contractor, the Agency Chief Contracting Officer,
      the Corporation Counsel, the Comptroller, and in the case of construction or
      construction-related services, the Engineer. A decision in favor of the
      Contractor shall be subject to the prompt payment provisions of the PPB Rules.
      The Required Payment Day shall be thirty (30) days after the date the parties
      are formally notified of the Board's decision.

    


    (F)
      Finality of Contract Dispute Resolution Board Decision. The Board's decision
      shall be final and binding on all parties. Any party may seek review of the
      Board's decision solely in the form of a challenge, made within four (4) months
      of the date of the Board's decision, in a court of competent jurisdiction of
      the
      State ofNew York, County of New York, pursuant to Article 78 of the Civil
      Practice Law and Rules. Such review by the court shall be limited to the
      question of whether or not the Board's decision was made in violation of lawful
      procedure, was affected by an error of law, or was arbitrary and capricious
      or
      an abuse of discretion. No evidence or information shall be introduced or relied
      upon in such proceeding that was not presented to the Board in accordance with
      Section 4-09 of the PPB Rules.

    


    15.8
      Any
      termination, cancellation, or alleged breach of the Contract prior to or during
      the pendency of any proceedings pursuant to this section shall not affect or
      impair the ability of the Agency Head or Contract Dispute Resolution Board
      to
      make a binding and final decision pursuant to this section.

     

    ARTICLE
      16. PROMPT PAYMENT

    The
      Prompt Payment provisions set forth in Chapter 4, Section 4-06 of the
      Procurement Policy Board Rules in effect at the time for this solicitation
      will
      be applicable to payments made under this contract. The provisions require
      the
      payment to the contractors of interest on payments made after the required
      payment date except as set forth in Section 4-06 of the Rules;

    


    The
      contractor must submit a proper invoice to receive payment, except where the
      contract provides that the contractor will be paid at predetermined intervals
      without having to submit an invoice for each scheduled payment.

    


    Determinations
      of interest due will be made in accordance with the provisions of the
      Procurement Policy Board Rules and General Municipal Law Section
      3-a.

     

    NFP.W/P.L.
      

    -19-

    


    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    

      APPENDIX
        R2

       

      GENERAL
        PROVISIONS GOVERNING CONTRACTS FOR CONSULTANTS, PROFESSIONAL AND TECHNICAL
        SERVICES (For-Profit Entities)

       

      



       

       

      
        
          	 CONTENTS	 PAGE
	
                  ARTICLE
                    1.

                	
                  DEFINITIONS

                	
                  1

                
	
                  ARTICLE
                    2.

                	
                  REPRESENTATIONS
                    AND WARRANTIES 

                	
                  1

                
	
                  ARTICLE
                    3. 

                	
                  AUDIT
                    BY THE DEPARTMENT AND CITY 

                	
                  2

                
	
                  ARTICLE
                    4. 

                	
                  COVENANTS OF
                    THE CONTRACTOR 

                	
                  3

                
	
                  ARTICLE
                    5.

                	
                  TERMINATION
                    

                	
                  10

                
	
                  ARTICLE
                    6

                	
                  MISCELLANEOUS
                    

                	
                  12

                
	
                  ARTICLE
                    7. 

                	
                  MERGER
                    

                	
                  15

                
	
                  ARTICLE
                    8.

                	
                  CONDITIONS
                    PRECEDENT 

                	
                  15

                
	
                  ARTICLE
                    9.

                	
                  PPB
                    RULES 

                	
                  15

                
	
                  ARTICLE
                    10.

                	
                  STATE
                    LABOR LAW AND CITY ADMINISTRATIVE CODE

                	
                  15

                
	
                  ARTICLE
                    11.

                	
                  FORUM
                    PROVISION

                	
                  16

                
	
                  ARTICLE
                    12

                	
                  EQUAL
                    EMPLOYMENT OPPORTUNITY

                	
                  17

                
	
                  ARTICLE
                    13

                	
                  NO
                    DAMAGE FOR DELAY

                	
                  18

                
	
                  ARTICLE
                    14

                	
                  CONSULTANT
                    REPORT INFORMATION

                	
                  18

                
	
                  ARTICLE
                    15. 

                	
                  RESOLUTION
                    OF DISPUTES

                	
                  18

                
	
                  ARTICLE
                    16.

                	
                  PROMPT
                    PAYMENT

                	
                  22

                
	
                  ARTICLE
                    17.

                	
                  MACBRIDE
                    PRINCIPLES ADMINISTRATIVE CODE

                	
                  22

                


        

      

       

       

      ARTICLE
        1. DEFINITIONS

      As
        used
        throughout this Agreement, the following a-ms shall have the meaning set
        forth
        below:

      a.
        "City"
        shall
        mean the City of New York, its

      departments
        and political subdivisions.

      b.
        "Comptroller"
        shall
        mean the Comptroller

      of
        the
        City of New York. 

      c. 
        "Department"
        or
        "Agency" shall mean the DEPARTMENT
        OF HEALTH AND MENTAL HYGIENE

      d.
        "Commissioner"
        or
        "Administrator
        shall
        mean the COMMISSIONER OF HEALTH AND MENTAL HYGIENE or his duly authorized
        representative. The term "duly authorized representative" shall include any
        person or persons acting within the limits of his or her authority.


      e.
        "Law"
        or
        "Laws"
        shall
        include but not be limited to the New York City Charter, the New York City
        Administrative Code, a local law of the City of New York, and any ordinance,
        rule or regulation having the force of law.

      f.
        "Contractor"or"ConsuItant"
        shall
        mean WellCare of New York, Inc.

       

      ARTICLE
        2. REPRESENTATIONS AND WARRANTIES

      


      2.1
        PROCUREMENT
        OF AGREEMENT  

      A.
        The
        Contractor represents and warrants that no person or selling agency has been
        employed or retained to solicit or secure this Agreement upon an agreement
        or
        understanding for a commission, percentage, brokerage fee, contingent fee
        or any
        other compensation. The Contractor further represents and warrants that no
        payment, gift or thing of value has been made, given or promised to obtain
        this
        or any other agreement between the parties. The Contractor makes such
        representations and warranties to induce the City to enter into
        this
        Agreement and the City relies upon such representations and warranties in
        the
        execution hereof.

      


      B.
        For a
        breach or violation of such representations or warranties, the Administrator
        shall have the right to annul this Agreement without liability, entitling
        the
        City to recover all monies paid hereunder and the Contractor shall not make
        claim for, or be entitled to recover, any sum or sums due under this Agreement.
        This remedy, if effected, shall not constitute the sole remedy afforded the
        City
        for the falsity or breach, nor shall it constitute a waiver of the City's
        right
        to claim damages or refuse payment or to take any other action provided for
        by
        law or pursuant to this Agreement.

       

      2.2
        CONFLICT OF INTEREST

      The
        Contractor represents and warrants that neither it nor any of its directors,
        officers, members, partners or employees, has any interest nor shall they
        acquire any interest, directly or indirectly, which would or may conflict
        in any
        manner or degree with the performance or rendering of the services herein
        provided. The Contractor further represents and warrants that in the performance
        of this Agreement no person having such interest or possible interest shall
        be
        employed by it. No elected official or other officer or employee of the City
        or
        Department, nor any person whose salary is payable, in whole or in part,
        from
        the City Treasury, shall participate in any decision relating to this Agreement
        which affects his or her personal interest or the interest of any corporation,
        partnership or association in which he or she is, directly or indirectly,
        interested; nor shall any such person have any interest, direct or indirect,
        in
        this Agreement or in the proceeds thereof.

      


      2.3
        FAIR PRACTICES

      The
        Contractor and each person signing on behalf of any contractor represents
        and
        warrants and certifies, under penalty of perjury, that to the best of its
        knowledge and belief:

      


      A.
        The
        prices in this contract have been arrived at independently without collusion,
        consultation, communication, or agreement, for the purpose of restricting
        competition, as to any matter relating to such prices with any other bidder
        or
        with any competitor;

      B.
        Unless
        otherwise required by law, the prices which have been quoted in this contract
        and on the proposal submitted by the Contractor have not been knowingly
        disclosed by the Contractor prior to the proposal opening, directly or
        indirectly, to any other bidder or to any competitor; and 

      C.
        No
        attempt has been made or will be made by the Contractor to induce any other
        person, partnership or corporation to submit or not to submit a proposal
        for the
        purpose of restricting competition. 

      


      The
        fact
        that the Contractor (a) has published price lists, rates, or tariffs covering
        items being procured, (b) has informed prospective customers of proposed
        or
        pending publication of new or revised price lists for such items, or (c)
        has
        sold the same items to other customers at the same prices being bid, does
        not
        constitute, without more, a disclosure within the meaning of the
        above.

       

      ARTICLE
        3. AUDIT BY THE DEPARTMENT AND CITY

       

      


      3.1
        All
        vouchers or invoices presented for payment to be made hereunder, and the
        books,
        records and accounts upon which said vouchers or invoices are based are subject
        to audit by the Department and by the Comptroller of the City of New York
        pursuant to the powers and responsibilities as conferred upon said Department
        and said Comptroller by the New York City Charter and Administrative Code
        of the
        City of New York, as well as all orders and regulations promulgated pursuant
        thereto.

      3.2
        The
        Contractor shall submit any and all documentation and justification in support
        of expenditures or fees under this Agreement as may be required by said
        Department and said Comptroller so that they may evaluate the reasonableness
        of
        the charges and shall make its records available to the Department and to
        the
        Comptroller as they consider necessary.

      



       

      Profit.w/P.L.

       

      -2-

       

      
 


      3.3
        All
        books, vouchers, records, reports, canceled checks and any and all similar
        material may be subject to periodic inspection, review and audit by the State
        of
        New York, Federal Government and other persons duly authorized by the City.
        Such
        audit may include examination and review of the source and application of
        all
        funds whether from the City, any State, the Federal Government, private sources
        or otherwise.

      3.4
        The
        contractor shall not be entitled to final payment under the Agreement until
        all
        requirements have been satisfactorily met.

       

      ARTICLE
        4. COVENANTS OF THE CONTRACTOR

      


      4.1
        EMPLOYEES

      


      A.
        All
        experts or consultants or employees of the Contractor who are employed by
        the
        Contractor to perform work under this contract are neither employees of the
        City
        nor under contract to the City and the Contractor alone is responsible for
        their
        work, direction, compensation and personal conduct while engaged under this
        Agreement. Nothing in this contract shall impose any liability or duty on
        the
        City for the acts, omissions, liabilities or obligations of the Contractor
        any
        person, firm company, agency, association, expert, consultant, independent
        contractor, specialist, trainee, employee, servant, or agent, or for taxes
        of
        any nature including but not limited to unemployment insurance, workmen's
        compensation, disability benefits and social security, or, except as
        specifically stated in this contract, to any person, firm or
        corporation.

      


      B.
        The
        Contractor shall be solely responsible for all physical injuries or death
        to its
        agents, servants, or employees or to any other person or damage to any property
        sustained during its operations and work on the project under this agreement
        resulting from any act of omission or commissioner error in judgment of any
        of
        its officers, trustees, Employees, agents, servants, or independent contractors
        and shall hold harmless, and indemnify the city from liability upon any and
        all
        claims for damages on account of such injuries or death to any such person
        or
        damages to property on account for any neglect, fault or default of the
        contractor, its officers trustees, employees, agents, servants, or independent
        contractors. The Contractor shall be solely responsible for the safety and
        protection of all of its employees whether due to the negligence, fault or
        default of the contractor or not.

      


      C. Workmen’s
        Compensation and Disability Benefits: 

      If
        this
        agreement be of such a character that the employees engages thereon are required
        to be insured by the provision of Chapter 615 of the Laws of 1992, known
        as the
“Workmen’s Compensation Law” and acts amendatory thereto, the agreement shall be
        void and of no effect unless the Contractor shall secure compensation for
        the
        benefit of, and keep such insured during the life of this agreement such
        employees compliance with the provisions of said law, inclusive of Disabilities
        Benefits; and shall furnish the Department with two (2) certificates of these
        insurance coverages.

      


      
        	D.  	
                Unemployment
                  Insurance: 

              


      

      Unemployment
        Insurance coverage shall be obtained and provided by the contractor for its
        employees

      


      E. Minimum
        Wage

      Except
        for those employees whose minimum wage is required to be fixed pursuant to
        Section 220 of the Labor Law of the State of New York, all persons employees
        by
        the contractor in the performance of this agreement shall be paid, without
        subsequent deduction or rebate, unless expressly authorized by the law, not
        less
        than the minimum wage as prescribed by law. Any breach or violation of the
        foregoing shall be deemed a breach or violation of a material provision of
        this
        Agreement.

       

      


       

      


      Profit.w/P.L

      -3-

       

      4.2
        INDEPENDENT CONTRACTOR STATUS The
        Contractor and the Department agree that the Contractor is an independent
        contractor, and not an employee of the Department or the City of New York,
        and
        that in accordance with such status as independent contractor, the Contractor
        covenants and agrees that neither it nor its employees or agents will hold
        themselves out as, nor claim to be, officers or employees of the City of
        New
        York, or of any department, agency or unit thereof, by reason hereof, and
        that
        they will not, by reason hereof, make any claim, demand or application to
        or for
        any right or privilege applicable to an officer or employee of the City of
        New
        York, including, but not limited to, Workmen's Compensation coverage.
        Unemployment Insurance Benefits, Social Security coverage or employee retirement
        membership or credit. 

       

      4.3
        INSURANCE

      A.
        Insurance
        Requirements for Contractors 

      Contractors
        shall procure and maintain for the duration of the contract insurance against
        claims for injuries to persons or damages to property which may arise from
        or in
        connection with the performance of the work hereunder by the Contractor,
        his
        agents, representatives, employees or subcontractors. All required insurance
        policies shall be maintained with companies that may lawfully issue the required
        policy and have an A.M. Best rating of at least A-7 or a Standard and Poor's
        rating of at least AA, unless prior written approval is obtained from the
        Mayor's Office of Operations. The cost of such insurance shall be included
        in
        the Contractor's bid.

      


      a.
        Minimum
        Scope of Insurance

      Coverage
        shall be at least as broad as:

      


      
        	1.  	
                Insurance
                  Services Office form number GL 0002 (1/73) covering Comprehensive
                  General
                  Liability and Insurance Services Office form number GL 0404 covering
                  Broad
                  Form Commercial General Liability; Insurance General Liability;
                  or
                  Insurance Services Office Commercial General Liability coverage
                  ("occurrence" form CG 0001).(ED
                  11/85).

              


      

      
        	2.  	
                Insurance
                  Services Office form number CA 0001 (Ed. 1/78) covering Automobile
                  Liability, code 1 "any auto" and endorsements CA 2232 and CA 0112.
                  

              


      

      
        	3.  	
                Workers'
                  Compensation insurance as required by Labor Code of the State of
                  New York
                  and Employers Liability insurance. 

              


      

      
        	b.  	
                Minimum
                  Limits of Insurance Contractor
                  shall maintain limits no less than:

              


      

      1. Comprehensive
        General Liability:

      $1,000,000.00
        combined single limit per accident for bodily injury and property
        damage.

      2. 
        Professional liability: 1 Million Dollars per occurrence; Three Million Dollars
        Aggregate.

      3. Workers'
        Compensation and Employers Liability: Workers' Compensation limits as required
        by the Labor Code of the State of New York Employers Liability limits of
        $1,000,000.00 per accident. Pursuant to Section 57 of the NYS Workers'
        Compensation Law, the vendor has submitted proof of workers' compensation
        and
        disability benefits coverage to the agency.

      c. Deductibles
        and Self-Insured Retentions. Any
        deductibles and self-insured retentions must be declared to and approved
        by the
        Agency. At the option of the Agency, either: the insurer shall reduce or
        eliminate such deductibles or self-insured retentions as respects the Agency,
        its officers, officials and employees; or the Contractor shall procure a
        bond
        guaranteeing payment of losses and related investigations, claim administration
        and defense expenses.

      1. General
        Liability and Automobile Liability Coverages

       

       

      Profit.w/P.L.
        

      -4-

       

      


      



      a.
         The
        City,
        its officers, officials and employees are to be covered as insured as respects:
        liability arising out of activities performed by or on behalf of the Contractor;
        products and completed operations of the Contractor; premises owned, leases
        or
        used by the Contractor; or automobiles owned, leased, hired or borrowed by
        the
        Contractor. The coverage shall contain no special limitations on the scope
        of
        protection afforded to the City, its officers, officials and employees.


      


      b. The
        Contractor's insurance coverage shall be primary insurance as respect the
        City,
        its officers, officials, and employees. Any other insurance or self-insurance
        maintained by the Agency, its officers, officials and employees shall be
        excess
        of and not contribute with the Contractor's insurance. 

      


      
        	c.  	
                Any
                  failure to comply with reporting provisions of the policies shall
                  not
                  affect coverage provided to the Agency, .its officers, officials,
                  and
                  employees. 

              


      

      


      
        	d.  	
                The
                  Contractor's insurance shall apply separately to each insured against
                  whom
                  claim is made or suit is brought, except with respect to the limits
                  of the
                  insurers liability. 

              


      

      


      
        	2.  	
                Workers
                  Compensation and Employers Liability
                  Coverage

              


      

      The
        insurer shall agree to waive all rights of subrogation against the Agency,
        its
        officers, officials, and employees for losses /rising from work performed
        by the
        Contractor for Agency. 

      


      3.
        All
        Coverages

      Each
        insurance policy required by this clause shall be endorsed to state that
        coverage shall not be suspended, voided, canceled by either party, reduced
        in
        coverage or in limits except after sixty (60) days prior written notice by
        certified mail, return receipt requested, has been given to the City.


      


      
        	d.  	
                Acceptability
                  of Insurers 

              


      

      Insurance
        is to be placed with insurers with a Best's rating of no less than an A.M.
        Best
        rating of at least A-7 or a Standard and Poor's rating of at least AA, unless
        prior written approval is obtained from the Mayor's Office of
        Operations.

      


      
        	e.  	
                Verification
                  of Coverage Contractor
                  shall furnish the City with Certificates of Insurance effecting
                  coverage
                  required by this clause. The Certificates for each insurance policy
                  are to
                  be signed by a person authorized by that insurer to bind coverage
                  on its
                  behalf. The Certificates are to be on forms provided by the Agency
                  and are
                  to be received and approved by the Agency before work commences.
                  The
                  Agency reserves the right to obtain complete, certified copies
                  of all
                  required insurance policies, at any time.


              


      

      


      
        	f.  	
                Subcontractors

              


      

      Contractor
        shall include all subcontractors as insured under its policies or shall furnish
        separate Certificates for each subcontractor. All coverages for subcontractors
        shall be subject to all of the requirements stated herein.

      


      
 

      


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      B.
        In the
        event that any claim is made or any action is brought against the City arising
        out of negligent or careless acts of an employee of the Contractor, either
        within or without the scope of his employment, or arising out of Contractor's
        negligent performance of this Agreement, then the City shall have the right
        to
        withhold further payments hereunder for the purpose of set-off in sufficient
        sums to cover the said claim or action. The rights and remedies of the City
        provided for in this clause shall not be exclusive and are in addition to
        any
        other rights and remedies provided by law or this Agreement.

      


      4.4
        PROTECTION OF CITY PROPERTY

      


      A.
        The
        Contractor assumes the risk of, and shall be responsible for, any loss or
        damage
        to City property, including property and equipment leased by the City, used
        in
        the performance of this Agreement; and caused, either directly or indirectly
        by
        the acts, conduct, omissions or lack of good faith of the Contractor, its
        officers, managerial personnel and employees, or any person, firm, company,
        agent or others engaged by the Contractor as expert, consultant, specialist
        or
        subcontractor hereunder.

      B.
        In the
        event that any such City property is lost or damaged, except for normal wear
        and
        tear, then the City shall have the right to withhold further payments hereunder
        for the purpose of set-off, in sufficient sums to cover such loss or
        damage.

      C.
        The
        Contractor agrees to indemnify the City and hold it harmless from any and
        all
        liability or claim for damages due to any such loss or damage to any such
        City
        property described in subsection A above.

      D.
        The
        rights and remedies of the City provided herein shall not be exclusive and
        are
        in addition to any other rights and remedies provided by law or by this
        Agreement.

      


       

      4.5
        CONFIDENTIALITY

      All
        of
        the reports, information or data, furnished to or prepared, assembled or
        used by
        the Contractor under this Agreement are to be held confidential, and prior
        to
        publication, the Contractor agrees that the same shall not be made available
        to
        any individual or organization without the prior written approval of the
        Department.

       

      4.6
        BOOKS
        AND RECORDS

      The
        Contractor agrees to maintain separate and accurate books, records, documents
        and other evidence and accounting procedures and practices which sufficiently
        and properly reflect all direct and indirect costs of any nature expended
        in the
        performance of this Agreement.

      


      4.7
        RETENTION
        OF RECORDS

      The
        Contractor agrees to retain all books, records, and other documents relevant
        to
        this Agreement for six years after the final payment or termination of this
        Agreement, whichever is later. City, State and Federal auditors and any other
        persons duly authorized by the Department shall have full access to and the
        right to examine any of said materials during said period.

      


      4.8
        COMPLIANCE
        WITH LAW

      Contractor
        shall render all services under this Agreement in accordance with the applicable
        provisions of federal, state and local laws, rules and regulations as are
        in
        effect at the time such services are rendered.

      


      4.9
        INVESTIGATION CLAUSE

       

      


       

      1. The
        parties to this agreement agree to cooperate fully and faithfully with any
        investigation, audit or ' inquiry conducted by a State of New York (State)
        or
        City of New York (City) governmental agency or authority that is empowered
        directly or by designation to compel the attendance of witnesses and to examine
        witnesses under oath, or conducted by the Inspector General of a governmental
        agency that is a party in interest to the transaction, submitted bid, submitted
        proposal, contract, lease, permit, or license that is the subject of the
        investigation, audit or inquiry.

       

      2.

       

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      (a)
        If
        any person who has been advised that his or her statement, and any information
        from such statement, will not be used against him or her in any subsequent
        criminal proceeding refuses to testify before a grand jury or other governmental
        agency or authority empowered directly or by designation to compel the
        attendance of witnesses and to examine witnesses under oath concerning the
        award
        of or performance under any transaction, agreement, lease, permit, contract,
        or
        license entered into with the City, the State, or any political subdivision
        or
        public authority thereof, or the Port Authority of New York and New Jersey,
        or
        any local development corporation within the City, or any public benefit
        corporation organized under the laws of the State of New York, or;

       

      


      2.

      (b)
        If
        any person refuses to testify for-a reason other than the assertion of his
        or
        her privilege against self-incrimination in an investigation, audit or inquiry
        conducted by a City or State governmental agency or authority empowered directly
        or by designation to compel the attendance of witnesses and to take testimony
        under oath, or by the Inspector General of the governmental agency that is
        a
        party in interest in, and is seeking testimony concerning the award of, or
        performance under, any transaction, agreement, lease, permit, contract, or
        license entered into with the City, the State, or any political subdivision
        thereof or any local development corporation within the City, then;

       

      3.

      (a)
        The
        commissioner or agency head whose agency is a party in interest to the
        transaction, submitted bid, submitted proposal, contract, lease, permit,
        or
        license shall convene a hearing, upon not less than five (5) days written
        notice
        to the parties involved, to determine if any penalties should attach for
        the
        failure of a person to testify.

      


      3. 

      (b)
        If
        any non-governmental party to the hearing requests an adjournment, the
        commissioner or agency head who convened the hearing may, upon granting the
        adjournment, suspend any contract, lease, permit, or license pending the
        final
        determination pursuant to paragraph 5 below without the City incurring any
        penalty or damages for delay or otherwise.

      


      4.
        The
        penalties which may attach after a final determination by the commissioner
        or
        agency head may include but shall not exceed:

      


      (a)
        The
        disqualification for a period not to exceed five (5) years from the date
        of an
        adverse determination for any person, or any entity of which such person
        was a
        member at the time the testimony was sought, from submitting bids for, or
        transacting business with, or entering into or obtaining any contract, lease,
        permit or license with or from the City; and/or

      (b)
        The
        cancellation or termination of any and all such existing City contracts,
        leases,
        permits or licenses that the refusal to testify concerns and that have not
        been
        assigned as permitted under this agreement, nor the proceeds of which pledged,
        to an unaffiliated and unrelated institutional lender for fair value prior
        to
        the issuance of the notice scheduling the hearing, without the City incurring
        any penalty or damages on account of such cancellation or termination; monies
        lawfully due for goods delivered, work done, rentals, ' or fees accrued prior
        to
        the cancellation or termination shall be paid by the City.

      


      5.
        The
        commissioner or agency head shall consider and address in reaching his or
        her
        determination and in assessing an appropriate penalty the factors in paragraphs
        (a) and (b) below. He or she may also consider, if relevant and appropriate,
        the
        criteria established in paragraphs (c) and (d) below in addition to any other
        information which may be relevant and appropriate:

      


       

      Profit.w/P.L.

       

      -7-

      


      (a)
        The
        party's good faith endeavors or lack thereof to cooperate fully and faithfully
        with any governmental investigation or audit, including but not limited to
        the
        discipline, discharge, or disassociation of any person failing to testify,
        the
        production of accurate and complete books and records, and the forthcoming
        testimony of all other members, agents, assignees or fiduciaries whose testimony
        is sought.

      (b)
        The
        relationship of the person who refused to testify to any entity that is a
        party
        to the hearing, including, but not limited to, whether the person whose
        testimony is sought has an ownership interest in the entity and/or the degree
        of
        authority and responsibility the person has within the entity.

      (c)
        The
        nexus of the testimony sought to the subject entity and its contracts, leases,
        permits or licenses with the City.

      (d)
        The
        effect a penalty may have on an unaffiliated and unrelated party or entity
        that
        has a significant interest in an entity subject to penalties under 4 above,
        provided that the party or entity has given actual notice to the commissioner
        or
        agency head upon the acquisition of the interest, or at the hearing called
        for
        in 3 (a) above gives notice and proves that such interest was previously
        acquired. Under either circumstance the party or entity must present evidence
        at
        the hearing demonstrating the potential adverse impact a penalty will have
        on
        such person or entity.

       

      6.

      (a)
        The
        term "license" or "permit" as used herein shall be defined as a license,
        permit,
        franchise or concession not granted as a matter of right.

      (b)
        The
        term "person" as used herein shall be defined as any natural person doing
        business alone or associated with another person or entity as a partner,
        director, officer, principal or employee.

      (c)
        The
        term "entity" as used herein shall be defined as any firm, partnership,
        corporation, association, or person that receives monies, benefits, licenses,
        leases, or permits from or through the City or otherwise transacts business
        with
        the City.

      (d)
        The
        term "member" as used herein shall be defined as any person associated with
        another person or entity as a partner, director, officer, principal or
        employee,

      


      7.
        In
        addition to and notwithstanding any other provision of this agreement the
        Commissioner or agency head may in his or her sole discretion terminate this
        agreement upon not less than three (3) days written notice in the event
        contractor fails to promptly report in writing to the Commissioner of
        Investigation of the City of New York any solicitation of money, goods, requests
        for future employment or other benefit or thing of value, by or on behalf
        of any
        employee of the City or other person, firm, corporation or entity for any
        purpose which may be related to the procurement or obtaining of this agreement
        by the contractor, or affecting the performance of this contract. 

      


      4.10
        ASSIGNMENT

      A.
        The
        Contractor shall not assign, transfer, convey or otherwise dispose of this
        Agreement or of Contractor's rights, obligations, duties, in whole or in
        part,
        or of its right to execute it, or its right, title or interest in it or any
        part
        thereof, or assign, by power of attorney or otherwise, any of the notices
        due or
        to become due under this contract, unless the prior written consent of the
        Administrator shall be obtained. Any such assignment, transfer, conveyance
        or
        other disposition ' without such consent shall be void. 

      B.
        Failure of the Contractor to obtain any required consent to any assignment,
        shall be cause for termination for cause, at the option of the Administrator;
        and if so terminated, the City shall thereupon be relieved and discharged
        from
        any further liability and obligation to the Contractor, its assignees or
        transferees, and all monies that may become due under the contract shall
        be
        forfeited to the City

      


      


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      except
        so
        much thereof as may be necessary to pay the Contractor's employees.

      C.
        The
        provisions of this clause shall not hinder, prevent, or affect an assignment
        by
        the Contractor for the benefit of its creditors made pursuant to the laws
        of the
        State of New York. 

      D.
        This
        Agreement may be assigned by the City to any corporation, agency or
        instrumentality having authority to accept such assignment.

      


      4.11
        SUBCONTRACTING

      A.
        The
        Contractor agrees not to enter into any subcontracts for the performance
        of its
        obligations, in whole or in part, under this Agreement without the prior
        written
        approval of the Department. Two copies of each such proposed subcontract
        shall
        be submitted to the Department with the Contractor's written request for
        approval. All such subcontracts shall contain provisions
        specifying:

      1.
        that
        the work performed by the subcontractor must be in accordance with the terms
        of
        the Agreement between the Department and the Contractor,

      2.
        that
        nothing contained in such agreement shall impair the rights of the
        Department,

      3.
        that
        nothing contained herein, or under the Agreement between the Department and
        the
        Contractor, shall create any contractual relation between the subcontractor
        and
        the Department, and

      4.
        that
        the subcontractor specifically agrees to be bound by the confidentiality
        provision set forth in this Agreement between the Department and the
        Contractor.

      B.
        The
        Contractor agrees that it is fully responsible to the Department for the
        acts
        and omissions of the subcontractors and of persons either directly or indirectly
        employed by them as it is for the acts and omissions of persons directly
        employed by it.

      C.
         The
        aforesaid approval is required in all cases other than individual
        employer-employee contracts. 

      D.
         The
        Contractor shall not in any way be relieved of any responsibility under this
        Contract by any subcontract. 

      


      4.12 PUBLICITY

      A.
         The
        prior
        written approval of the Department is required before the Contractor or any
        of
        its employees, servants, agents, or independent contractors may, at any time,
        either during or after completion or termination of this Agreement, make
        any
        statement to the press or issue any material for publication through any
        media
        of communication bearing on the work performed or data collected under this
        Agreement.

      B.
         If
        the
        Contractor publishes a work dealing with any aspect of performance under
        this
        Agreement, or of the results and accomplishments attained in such performance,
        the Department shall have a royalty free, non-exclusive and irrevocable license
        to reproduce, publish or otherwise use and to authorize others to use the
        publication

      


      4.13.
        PARTICIPATION
        IN AN INTERNATIONAL BOYCOTT 

      A.
         The
        Contractor agrees that neither the Contractor nor any substantially-owned
        affiliated company is participating or shall participate in an international
        boycott in violation of the provisions of the Export Administration Act of
        1979,
        as amended, or the regulations of the United States Department of Commerce
        promulgated thereunder. 

      B.
        Upon
        the final determination by the Commerce Department or any other agency of
        the
        United States as to, or conviction of the Contractor or a

      


       

      Profit.w/P.L,

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      substantially-owned
        affiliated company thereof, participation in an international boycott in
        violation of the provisions of the Export Administration Act of 1979, as
        amended, or the regulations promulgated thereunder, the Comptroller may,
        at his
        option, render forfeit and void this contract.

      C.
        The
        Contractor shall comply in all respects, with the provisions of Section 6-114
        of
        the Administrative Code of the City of New York and the rules and regulations
        issued by the Comptroller thereunder.

      


      4.14
        INVENTIONS.
        PATENTS AND COPYRIGHTS

      A.
        Any
        discovery or invention arising out of or developed in the course of performance
        of this Agreement shall be promptly and fully reported to the Department,
        and if
        this work is supported by a federal grant of funds, shall be promptly and
        fully
        reported to the Federal Government for determination as to whether patent
        protection on such invention shall be sought and how the rights in the invention
        or discovery, including rights under any patent issued thereon, shall be
        disposed of and administered in order to protect the public
        interest.

      B.
        No
        report, document or other data produced in whole or in part with contract
        funds
        shall be copyrighted by the Contractor nor shall any notice of copyright
        be
        registered by the Contractor in connection with any report, document or other
        data developed for the contract.

      C.
        In no
        case shall subsections A and B of this section apply to, or prevent the
        Contractor from asserting or protecting its rights in any report, document
        or
        other data, or any invention which existed prior to or was developed or
        discovered independently from the activities directly related to this
        Agreement.

      


      4.15
        INFRIGEMENTS

      The
        Contractor shall be liable to the Department and hereby agrees to indemnify
        and
        hold the Department harmless for any damage or loss or expense sustained
        by the
        Department from any infringement by the Contractor of any copyright, trademark
        or patent rights of design, systems, drawings, graphs, charts, specifications
        or
        printed matter furnished or used by the Contractor in the performance of
        this
        Agreement. 

      


      4.16
        ANTI-TRUST

       

      The
        Contractor hereby assigns, sells, and transfers to the City all right, title
        and
        interest in and to any claims and causes of action arising under the anti-trust
        laws of the State of New York or of the United States relating to the particular
        goods or services purchased or procured by the City under this
        Agreement.

       

      ARTICLE
        5. TERMINATION

       

      


      5.1
        TERMINATION
        OF AGREEMENT 

      A.
        The
        Department and/or City shall have the right to terminate this Agreement,
        in
        whole or in part:

      1.
        Under
        any right to terminate as specified in any section of this
        Agreement.

      2.
        Upon
        the failure of the Contractor to comply with any of the terms and conditions
        of
        this Agreement.

      3.
        Upon
        the Contractor's becoming insolvent.

      4.
        Upon
        the commencement under the Bankruptcy Act of any proceeding by or against
        the
        Contractor, either voluntarily or involuntarily.

      5.
        Upon
        the Commissioner's determination, termination is in the best interest of
        the
        City.

      B.
        The
        Department or City shall give the Contractor written notice of any termination
        of this Agreement specifying therein the applicable provisions of subsection
        A
        of this section and the effective date thereof which shall not be

      


       

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      less
        than
        ten (10) days from the date the notice is

       

      received.

      C.
        The
        Contractor shall be entitled to apply to the Department to have this Agreement
        terminated by said Department by reason of any failure in the performance
        of
        this Agreement (including any failure by the Contractor to make progress
        in the
        prosecution of work hereunder which endangers such performance), if such
        failure
        arises out of causes beyond the control and without the fault or negligence
        of
        the Contractor. Such causes may include, but are not restricted to: acts
        of God
        or of the public enemy; acts of the Government in either its sovereign or
        contractual capacity; fires; floods; epidemics; quarantine restrictions;
        strikes; freight embargoes; or any other cause beyond the reasonable control
        of
        the Contractor. The determination that such failure arises out-of causes
        beyond
        the control and without the fault or negligence of the Contractor shall be
        made
        by the Department which agrees to exercise reasonable judgment therein. If
        such
        a determination is made and the Agreement terminated by the Department pursuant
        to such application by the Contractor, such termination shall be deemed to
        be
        without cause.

      D.
         Upon
        termination of this Agreement the Contractor shall comply with the Department
        or
        City close-out procedures, including but not limited to:

      1.
        Accounting for and refund to the Department or City, within thirty (30) days,
        any unexpended funds which have been paid to the Contractor pursuant to this
        agreement.

      2.
        Furnishing within thirty (30) days an inventory to the Department or City
        of all
        equipment, appurtenances and property purchased through or provided under
        this
        Agreement carrying out any Department or City directive concerning the
        disposition thereof. 

      
        	3.  	
                Not
                  incurring or paying any further obligation pursuant to this Agreement
                  beyond the termination date. Any obligation necessarily incurred
                  by the .
                  Contractor on account of this Agreement prior to receipt of notice
                  of
                  termination and falling due after such date shall be paid by the
                  Department or City in accordance with the terms of this Agreement.
                  In no
                  event shall the word "obligation," as used herein, be construed
                  as
                  including any lease agreement, oral or written, entered into between
                  the
                  Contractor and its landlord. 

              


      

      
        	4.  	
                Turn
                  over to the Department or City or its designees all books, records,
                  documents and material specifically relating to this
                  Agreement.

              


      

      5.
        Submit, within ninety (90) days, a final statement and report relating to
        this
        Agreement. The report shall be made by a certified public accountant or a
        licensed public accountant.

      E.
        In the
        event the Department or City shall terminate this Agreement, in whole or
        in
        part, as provided in paragraphs 1, 2, 3, or 4 of subsection A of this section,
        the Department or City may procure, upon such terms and in such manner as
        deemed
        appropriate, services similar to those so terminated, and the Contractor
        shall
        continue the performance of this Agreement to the extent not terminated
        hereby.

      F.
        Not
        withstanding any other provisions of this contract, the Contractor shall
        not be
        relieved of liability to the City for damages sustained by the City by virtue
        of
        Contractor's breach of the contract, and the City may withhold payments to
        the
        Contractor for the purpose of set-off until

      


       

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      such
        time
        as the exact amount of damages due to the City from the Contractor is
        determined.

      G.
        The
        provisions of the Agreement regarding confidentiality of information shall
        remain in full force and effect following any termination.

      H.
        The
        rights and remedies of the City provided in this section shall not be exclusive
        and are in addition to all other rights and remedies provided by law or under
        this Agreement.

       

      ARTICLE
        6. MISCELLANEOUS

      


      6.1
        CONFLICT OF LAWS

      All
        disputes arising out of this Agreement shall be interpreted and decided in
        accordance with the laws of the State of New York.

      


      6.2
        GENERAL RELEASE

      The
        acceptance by the Contractor or its assignees of the final payment under
        this
        contract, whether by voucher, judgment of any court of competent jurisdiction
        or
        any other administrative means, shall constitute and operate as a general
        release to the City from any and all claims of and liability to the Contractor
        arising out of the performance of this contract.

      


      6.3
        CLAIMS
        AND ACTIONS THEREON

      A.
        No
        action at law or proceeding in equity against the City or Department shall
        lie
        or be maintained upon any claim based upon this Agreement or arising out
        of this
        Agreement or in any way connected with this Agreement unless the Contractor
        shall have strictly complied with all requirements relating to the giving
        of
        notice and of information with respect to such claims, all as herein
        provided.

      B.
        No
        action shall lie or be maintained against the City by Contractor upon any
        claims
        based upon this Agreement unless such action shall be commenced within six
        (6)
        months after the date of filing in the Office of the Comptroller of the City
        of
        the certificate for the final payment hereunder, or within six (6) months
        of the
        termination or conclusion of this Agreement, or within six (6) months after
        the
        accrual of the Cause of Action, whichever first occurs.

       

      C.
        In the
        event any claim is made or any action brought in any way relating to the
        Agreement herein, the Contractor shall diligently render to the Department
        and/or the City of New York without additional compensation any and all
        assistance which the Department and/or the City of New York may require of
        the
        Contractor.

      D.
        The
        Contractor shall report to the Department in writing within three (3) working
        days of the initiation by or against the Contractor of any legal action or
        proceeding in connection with or relating to this Agreement.

      


      6.4
        NO
        CLAIM AGAINST OFFICERS. AGENTS OR EMPLOYEES 

      No
        claim
        whatsoever shall be made by the Contractor against any officer, agent or
        employee of the City for, or on account of, anything done or omitted in
        connection with this contract.

      


      6.5
        WAIVER

      Waiver
        by
        the Department of a breach of any provision of this Agreement shall not be
        deemed to be a waiver of any other or subsequent breach and shall not be
        construed to be a modification of the terms of the Agreement unless and until
        the same shall be agreed to in writing by the Department or City as required
        and
        attached to the original Agreement.

      


      6.6
        NOTICE

      The
        Contractor and the Department hereby designate the business addresses
        hereinabove specified as the places where all notices, directions or
        communications from one such party to the other party shall be delivered,
        or to
        which they shall be mailed. Actual delivery of any such notice, direction
        or
        communication to a party at the

      


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      aforesaid
        place, or delivery by certified mail shall be conclusive and deemed to be
        sufficient service thereof upon such party as of the date such notice, direction
        or communication is received by the party. Such address may be changed at
        any
        time by an instrument in writing executed and acknowledged by the party making
        such change and delivered to the other party in the manner as specified above.
        Nothing in this section shall be deemed to serve as a waiver of any requirements
        for the service of notice or process in the institution of an action or
        proceeding as provided by law, including the Civil Practice Law and
        Rules.

      


      6.7
        ALL LEGAL PROVISIONS DEEMED INCLUDED

      It
        is the
        intent and understanding of the parties to this Agreement that each and every
        provision of law required to be inserted in this Agreement shall be and is
        inserted herein. Furthermore, it is hereby stipulated that every such provision
        is to be deemed to be inserted herein, and if, through mistake or otherwise,
        any
        such provision is not inserted, or is not inserted in correct form, then
        this
        Agreement shall forthwith upon the application of either party be amended
        by
        such insertion so as to comply strictly with the law and without prejudice
        to
        the rights of either party hereunder.

      


      6.8
        SEVERABILITY

      If
        this
        Agreement contains any unlawful provision not an essential part of the Agreement
        and which shall not appear to have been a controlling or material inducement
        to
        the making thereof, the same shall be deemed of no effect and shall upon
        notice
        by either party, be deemed stricken from the Agreement without affecting
        the
        binding force of the remainder.

      


      6.9
        POLITICAL ACTIVITY

      There
        shall be no partisan political activity or any activity to further the election
        or defeat of any candidate for public, political or party office as part
        of or
        in connection with this Agreement, nor shall any of the funds provided under
        this Agreement be used for such purposes.

      


      6.10
        MODIFICATION

      This
        Agreement may be modified by the parties in writing in a manner not materially
        affecting the substance hereof. It may not be altered or modified
        orally.

       

      A.
        CONTRACT
        CHANGES
        Changes
        may be made to this contract only as duly authorized by the Agency Chief
        Contracting Officer of his or her designee. Vendors deviating from the
        requirements of an original purchase order or contract without a duly authorized
        change order document, or written contract modification or amendment, do
        so at
        their own risk. All such duly authorized changes, modifications and amendments
        will be reflected in a written change order and become a part of the original
        contract. Contract changes will be made only for work necessary to complete
        the
        work included in the original scope of the contract, and for non-material
        changes to the scope of the contract. Changes are not permitted for any material
        alteration in the scope of the work. Changes may include any one or more
        of the
        following:

      -
        Specification changes to account for design errors or omissions;

      -
        changes
        in contract amount due to authorized additional or omitted work. Any such
        changes require appropriate price and cost analysis to determine reasonableness.
        In addition, except for non-construction requirements contracts, all changes
        that cumulatively exceed the greater often percent of the original contract
        amount or $100,000 shall be approved by the City Chief Procurement
        Officer;

      -
        Extensions of a contract term for good and sufficient cause for a cumulative
        period not to exceed one year from the date of expiration of this current
        contract. Requirements contracts shall be subject to this
        limitation;

      -
        Changes
        in delivery location;

       

      -
        Changes
        in shipment method; and

      -
        Any
        other change not inconsistent with

      



      Profit.w/P.L.
        

      -13-

       

      



      §
5-02
        of
        the P.P.B. Rules (ed. 9/99), or any successor Rule.

      


      The
        Contractor may be entitled to a price adjustment for extra work performed
        pursuant to
        a
        written change order. If any part of the contract work is necessarily delayed
        by
        a change order, the Contractor may be entitled to an extension of time for
        performance. Adjustments to price shall be validated for reasonableness by
        using
        appropriate price and cost analysis.

      


      6.11
        PARAGRAPH
        HEADINGS

      Paragraph
        headings are inserted only as a matter of convenience and for reference and
        in
        no way define, limit or describe the scope or intent of this contract and
        in no
        way affect this contract.

      


      6.12
        NO
        REMOVAL OF RECORDS FROM PREMISES

      Where
        performance of this Agreement involves use by the Contractor of Departmental
        papers, files, data or records at Departmental facilities or offices, the
        Contractor shall not remove any such papers, files, data or records, therefrom
        without the prior approval of the Department's designated official.


      


      


      6.13
        INSPECTION
        AT SITE

      The
        Department shall have the right to have representatives of the Department
        or of
        the City or of
        the
        State or Federal governments present at the site of the engagement to observe
        the work being performed.

      


      6.14
        PRICING

      A.
         The
        Contractor shall when ever required during the contract, including but not
        limited to the time of bidding, submit cost or pricing data and formally
        certify
        that, to the best of its knowledge and belief, the cost or pricing date
        submitted was accurate, complete, and current as of a specified date. The
        Contractor shall be required to keep its submission of cost and pricing date
        current until the contract has been completed.

      B.
        The
        price of any change order or contract modification subject to the conditions
        of
        paragraph A, shall be adjusted to exclude any significant sums by which the
        City
        finds that such price was based on cost or price data furnished by the supplier
        which was inaccurate, incomplete, or not current as of the date agreed upon
        between the parties. 

      


      
        	C.  	
                Time
                  for Certification.
                  The Contractor must certify that the cost or pricing data submitted
                  are
                  accurate, complete and current as of a mutually determined
                  date

              


      

      D. Refusal
        to Submit Data.
        When any
        contractor refuses to submit the required data to support a price, the
        Contracting Officer shall not allow the price. 

      E. Certificate
        of Current Cost or Pricing Data.

      Form
        of Certificate.
        In those
        cases when cost or pricing data is required, certification shall be made
        using a
        certificate substantially similar to the one contained in Chapter 4 of the
        PPB
        rules and such certification shall be retained in the agency contract
        file.

      


      ARTICLE
        7. MERGER

      


      This
        written Agreement contains all the terms and conditions agreed upon by the
        parties hereto, and no other agreement, oral or otherwise, regarding the
        subject
        matter of tills Agreement shall be deemed to exist or to bind any of the
        parties
        hereto, or to vary any of the terms contained herein.

      


      ARTICLE
        8. CONDITIONS PRECEDENT

      This
        contract shall neither be binding nor effective unless:

      A.
         Approved
        by the Mayor pursuant to the provisions of Executive Order No. 42, dated
        October
        9, 1975, in the event the Executive Order requires such approval;
        and

      


      Profit.w/P.L.
        

      -14-

      


       

      


      
        	
                B.
                  

              	
                Certified
                  by the Mayor (Mayor's Fiscal Committee created pursuant to Executive
                  Order
                  No. 43, dated October 14, 1975) that performance thereof will be
                  in
                  accordance with the City's financial plan; and


              


      

      C.
         Approved
        by the New York State Financial Control Board (Board) pursuant to the New
        York
        State Financial Emergency Act for the City of New York, as amended, (the
        "Act"),
        in the event regulations of the Board pursuant to the Act require such approval.
        

      D.
         It
        has
        been authorized by the Mayor and the Comptroller shall have endorsed his
        certificate that there remains unexpended and unapplied a balance of the
        appropriation of funds applicable thereto sufficient to pay the estimated
        expense of carrying out this Agreement.

      


      The
        requirements of this section of the contract shall be in addition to, and
        not in
        lieu of, any approval or authorization otherwise required for this contract
        to
        be effective and for the expenditure of City funds.

       

      ARTICLE
        9. PPB RULES

      This
        contract is subject to the Rules of the Procurement Policy Board of the City
        of
        New York effective August 1, 1990, as amended. In the event of a conflict
        between said Rules and a provision of this contract, the Rules shall take
        precedence.

       

      ARTICLE
        10. STATE LABOR LAW AND CITY ADMINISTRATIVE CODE

      1.
        As
        required by New York State Labor Law Section 220-e:

      a.
        That
        in the hiring of employees for the performance of work under this contract
        or
        any subcontract hereunder, neither the Contractor, Subcontractor, nor any
        person
        acting on behalf of such Contractor or Subcontractor, shall by reason of
        race,
        creed, color, sex or national origin discriminate against any citizen of
        the
        State of New York who is qualified and available to perform the work to which
        the employment relates;

      b.
         That
        neither the Contractor, subcontractor, nor any person on his behalf shall,
        in
        any manner, discriminate against or intimidate any employee hired for the
        performance of work under this contract on account of race, creed, color,
        sex or
        national origin;

      c.
        That
        there may be deducted from the amount payable to the Contractor by the City
        under this contract a penalty of five dollars for each person for each calendar
        day during which such person was discriminated against or intimidated in
        violation of the provisions of this contract; and

      d.
        That
        this contract may be canceled or terminated by the City and all monies due
        or to
        become due hereunder may be forfeited, for a second or any subsequent violation
        of the terms or conditions of this section of the contract.

      e.
        The
        aforesaid provisions of this section covering every contract for or on behalf
        of
        the State or a municipality for the manufacture, sale or distribution of
        materials, equipment or supplies shall be limited to operations performed
        within
        the territorial limits of the State of New York.

      2.
        As
        required by New York City Administrative Code Section 6-108:

      a.
        It
        shall be unlawful for any person engaged in the construction, alteration
        or
        repair of buildings or engaged in the construction or repair of streets or
        highways pursuant to a contract with the City or. engaged in the manufacture,
        sale or distribution of' materials, equipment or supplies pursuant to a contract
        with the City to refuse to employ or to refuse to continue in any employment
        any
        person on account of the race, color or creed of such person.

      b.
        It
        shall be unlawful for any person or any servant, agent or employee of any
        person, described in subdivision (a) above, to ask, indicate or transmit,
        orally
        or in writing, directly or indirectly, the race, color, creed or religious
        affiliation of any person employed or seeking employment from such person,
        firm
        or corporation.

      


       

      Profit.w/P.L.
        15-

       

      


      c.
        Disobedience of the foregoing provisions shall be deemed a violation of a
        material provision of this contract.

      d.
        Any
        person, or the employee, manager or owner of or officer of such firm or
        corporation who shall violate any of the provisions of this section shall,
        upon
        conviction thereof, be punished by a fine of not more than one hundred dollars
        or by imprisonment for not more than thirty days, or both.

       

      ARTICLE
        11. FORUM PROVISION

      Choice
        of Law, Consent to Jurisdiction and Venue This
        Contract shall be deemed to be executed in the City of New York, State of
        New
        York, regardless of the domicile of the Contractor, and shall be governed
        by and
        construed in accordance with the laws of the State of New York.

      The
        parties agree that any and all claims asserted by or against the City arising
        under this Contract or related thereto shall be heard and determined either
        in
        the courts of the United States located in New York City ("Federal Courts")
        or
        in the courts of the State of New York ("New York State Courts") located
        in the
        City and County of New York. To effect this Agreement and intent, the Contractor
        agrees:

      a.
        If the
        City initiates any action against the

      Contractor
        in Federal Court or in New York State Court, service of process may be made
        on
        the Contractor either in person, wherever such Contractor may be found, or
        by
        registered mail addressed to the Contractor at its address as set forth in
        this
        Contract, or to such other address as the Contractor may provide to the City
        in
        writing; and

      b.
        With
        respect to any action between the City and the Contractor in New York State
        Court, the Contractor hereby expressly waives and relinquishes any rights
        it
        might otherwise have (I) to move to dismiss on grounds of forum non
        conveniens;
        (ii) to
        remove to Federal Court; and (iii) to move for a change of venue to a New
        York
        State Court outside New York County.

      c.
        With
        respect to any action between the City and the Contractor in Federal Court
        located in New York City, the Contractor expressly waives and relinquishes
        any
        right it might otherwise have to move to transfer the action to a United
        States
        Court outside the City of New York.

      d.
        If the
        Contractor commences any action against the City in a court located other
        than
        in the City and State of New York, upon request of the City, the Contractor
        shall either consent to a transfer of the action to a court of competent
        jurisdiction located in the City and State of New York or, if the court where
        the action is initially brought will not or cannot transfer the action, the
        Contractor shall consent to dismiss such action without prejudice and may
        thereafter reinstitute the action in a court of competent jurisdiction in
        New
        York City. If any provision(s) of this Article is held unenforceable for
        any
        reason, each and all other provision(s) shall nevertheless remain in full
        force
        and effect.

       

      ARTICLE
        12. EQUAL EMPLOYMENT OPPORTUNITY

      This
        contract is subject to the requirements of Executive Order No. 50 (1980)
        as
        revised ("E.O. 50") and the Rules and Regulations promulgated thereunder.
        No
        contract will be awarded unless and until these requirements have been complied
        with in their entirety. By signing this contract, the contractor agrees that
        it:

      1.
        will
        not engage in any unlawful discrimination against any employee or applicant
        for
        employment because of race, creed, color, national origin, sex age, disability,
        marital status or sexual orientation with respect to all employment decisions
        including, but not limited to, recruitment, hiring, upgrading, demotion,
        downgrading, transfer, training, rates of pay or other forms of compensation,
        layoff, termination, and all other terms and conditions of
        employmEnt;

      2.
        the
        contractor agrees that when it subcontracts it will not engage in any unlawful
        discrimination in

       

      


      Profit.w/P.L.

      16-

       

      the
        selection of subcontractors on the basis of the owner's race, color, creed,
        national origin, sex, age. disability, marital status or sexual
        orientation;

      3.
        will
        state in all solicitations or advertisements for employees placed by or on
        behalf of the contractor that all qualified applicants will receive
        consideration for employment without unlawful discrimination based on race,
        creed, color, national origin, sex, age, disability, marital status or sexual
        orientation, or that it is an equal employment opportunity
        employer;

      4.
        will
        send to each labor organization or representative of workers with which it
        has a
        collective bargaining agreement or other contract or memorandum of
        understanding, written notification of its equal employment opportunity
        commitments under E. 0. 50 and the rules and regulations promulgated thereunder;
        and

      5.
        will
        furnish all information and reports including an Employment Report before
        the
        award of the contract which are required by E-. 0. 50, the rules and regulations
        promulgated thereunder, and orders of the Director of the Bureau of Labor
        Services ("Bureau"), and will permit access to its books, records and accounts
        by the Bureau for the purposes of investigation to ascertain compliance with
        such rules, regulations, and orders. The contractor understands that in the
        even
        of its noncompliance with nondiscrimination clauses of this contract or with
        any
        of such rules, regulations, or orders, such noncompliance shall constitute
        a
        material breach of the contract and noncompliance with the E. 0. 50 and the
        rules and regulations promulgated thereunder. After a hearing held pursuant
        to
        the rules of the Bureau, the Director may direct the imposition by the
        contracting agency held of any or all of the following sanctions:

      (I)
        disapproval of the contractor;

      (ii)
        suspension or termination of the contract;

      (iii)
        declaring the contractor in default; or (iv) in lieu of any of the foregoing
        sanctions, the Director may impose an employment program.

      The
        Director of the Bureau may recommend to the contracting agency head that
        a Board
        of Responsibility be convened for purposes of declaring a contractor who
        has
        repeatedly failed to comply with E.O. 50 and the rule and regulations
        promulgated thereunder to be nonresponsible. The contractor agrees to include
        the provisions of the foregoing paragraphs in every subcontract or purchase
        order in excess of $50,000 to which it becomes a party unless exempted by
        E.O.
        50 and the rules and regulations promulgated thereunder, so that such provisions
        will be binding upon each subcontractor or vendor. The contractor will take
        such
        action with respect to any subcontract or purchase order as may be directed
        by
        the Director of the Bureau of Labor Services as a means of enforcing such
        provisions, including sanctions for noncompliance.

      The
        contractor further agrees that it will refrain from entering into any contract
        or contract modification subject to E.O. 50 and the rules and regulations
        promulgated thereunder with a subcontractor who is not in compliance with
        the
        requirements of E.O. 50 and the rules and regulations promulgated
        thereunder.

       

      ARTICLE
        13. NO DAMAGE FOR DELAY

      The
        Contractor agrees to make no claim for damages for delay in the performance
        of
        this Contract occasioned by any act or omission to act of the City or any
        of its
        representatives, and agrees that any such claim shall be fully compensated
        for
        by an extension of time to complete performance of the work as provided
        herein.

       

      ARTICLE
        14. CONSULTANT REPORT INFORMATION

       

      A
        copy of
        each consultant report submitted by a consultant to any City official or
        to any
        officer, employee, agent or representative of a City department, agency,
        commission or body or to any

       

      


       

      Profit.w/P.L.

      -17-

      


      corporation,
        association or entity whose expenses are paid in whole or in part from the
        City
        treasury shall be furnished to the Commissioner of the department to which
        such
        report was submitted or, if not a City department, then to the chief controlling
        officer or officers of such other office or entity. A copy of such report
        shall
        also be furnished to the Director of the Mayor's Office of Construction for
        matters related to construction or to the Director of the Mayor's Office
        of
        Operations for all other matters.

       

      ARTICLE
        15. RESOLUTION OF DISPUTES

       

      15.1 All
        disputes between the City and the Contractor of the kind delineated in this
        section that arise under, or by virtue of, this Contract shall be finally
        resolved in accordance with the provisions of this section and Section 5-11
        of
        the Rules of the Procurement Policy Board ("PPB Rules"). The procedure for
        resolving all disputes of the kind delineated herein shall be the exclusive
        means of resolving any such disputes.

       

      a.
        This
        section shall not apply to disputes concerning matters dealt with in other
        sections of the PPB Rules or to disputes involving patents, copyrights,
        trademarks, or trade secrets (as interpreted by the courts of New York State)
        relating to proprietary rights in computer software.

       

      b.
        For
        construction and construction-related services this section shall apply only
        to

      disputes
        about the scope of work delineated by the Contract, the interpretation of
        Contract Documents, the amount to be paid for extra work or disputed work
        performed in connection with the Contract, the conformity of the Contractor's
        work to the Contract, and he acceptability and quality of the Contractor's
        work;
        such disputes arise when the Engineer makes a determination with which the
        Contractor disagrees.

      5.2
        All
        determinations required by this section shall be made in writing, clearly
        stated, with a reasoned explanation for the determination based on the
        information and evidence presented to the party making the determination.
        Failure to make such determination within the time period required by this
        section shall be deemed a non-determination without prejudice that will allow
        appeal to the next level.

       

      15.3
        During such time as any dispute is being presented, heard, and considered
        pursuant to this section, the contract terms shall remain in full force and
        effect and the Contractor shall continue to perform work in accordance with
        the
        Contract and as directed by the Agency Chief Contracting Officer or Engineer.
        Failure of the Contractor to continue the work as directed shall constitute
        a
        waiver by the Contractor of any and all claims being presented pursuant to
        this
        section and a material breach of Contract.

       

      15.4 Presentation
        of Dispute to Agency Head.

       

      (A)
        Notice of Dispute and Agency Response. The Contractor shall present its dispute
        in writing ("Notice of Dispute") to the Agency Head within the time specified
        herein or, if no time is specified, within thirty (30) days of receiving
        notice
        of the determination or action that is the subject of the dispute. This notice
        requirement shall not be read to replace any other notice requirements contained
        in the Contract. The Notice of Dispute shall include all the facts, evidence,
        documents, or other basis upon which the Contractor relies in support of
        its
        position, as well as a detailed computation demonstrating' how any amount
        of
        money claimed by the Contractor in the dispute was arrived at. Within thirty
        (30) days after receipt of the detailed written submission, the Agency Chief
        Contracting Officer or, in the case of construction or construction-related
        services, the Engineer shall submit to the Agency Head all materials he or
        she
        deems pertinent to the dispute. Following initial submissions to the Agency
        Head, either party may demand of the other the production of any document
        or
        other material the demanding party believes may be relevant to the dispute.
        The
        requested party shall produce all relevant materials

       

       

      Profit.w/P.L.

      -18-

       

      


      that
        are
        not otherwise protected by a legal privilege recognized by the courts of
        New
        York State. Any question of relevancy shall be determined by the Agency Head
        whose decision shall be final. Wilful failure of the Contractor to produce
        any
        requested material whose relevancy the Contractor has not disputed, or whose
        relevancy has been affirmatively determined, shall constitute a waiver by
        the
        Contractor of its claim.

       

      (B)
        Agency Head Inquiry. The Agency Head shall examine the material and may,
        in his
        or her discretion, convene an informal conference with the Contractor and
        the
        Agency Chief Contracting Officer and, in the case of construction or
        construction-related services, the Engineer to resolve the issue by mutual
        consent prior to reaching a determination. The Agency Head may seek such
        technical or other expertise as he or she shall deem appropriate, including
        the
        use of neutral mediators, and require any such additional material from either
        or both parties as he or she deems fit. The Agency Head's ability to render,
        and
        the effect of, a decision hereunder shall not be impaired by any negotiations
        in
        connection with the dispute presented, whether or not the Agency Head
        participated therein. The Agency Head may or, at the request of any party
        to the
        dispute, shall compel the participation of any other contractor with a contract
        related to the work of this Contract, and that contractor shall be bound
        by the
        decision of the Agency Head. Any contractor thus brought into the dispute
        resolution proceeding shall have the same rights to make presentations and
        to
        seek review as the Contractor initiating the dispute.

       

      (C)
        Agency Head Determination. Within thirty (30) days after the receipt of all
        materials and information, or such longer time as may be agreed to by the
        parties, the Agency Head shall make his or her determination and shall deliver
        or send a copy of such determination to the Contractor and Agency Chief
        Contracting Officer and, in the case of construction or construction-related
        services, the Engineer, together with a statement concerning how the decision
        may be appealed.

      


      (D)
        Finality of Agency Head Decision. The Agency Head's decision shall be final
        and
        binding on all parties, unless presented to the Contract Dispute Resolution
        Board pursuant to this section. The City may not take a petition to the Contract
        Dispute Resolution Board. However, should the Contractor take such a petition,
        the City may seek, and the Board may render, a determination less favorable
        to
        the Contractor and more favorable to the City than the decision of the Agency
        Head.

       

      15.5
        Presentation of Dispute to the Comptroller. Before any dispute may be brought
        by
        the Contractor to the Contract Dispute Resolution Board, the Contractor must
        first present its claim to the comptroller for his or her review, investigation,
        and possible adjustment.

       

      (A)
        Time,
        Form, and Content of Notice. Within thirty

      (3
        0)
        days of its receipt of a decision by the Agency Head, the Contractor shall
        submit to the Comptroller and to the Agency Head a Notice of Claim regarding
        its
        dispute with the Agency. The Notice of Claim shall consist of (i) a brief
        written statement of the substance of the dispute, the amount of money, if
        any,
        claimed and the reason(s) the Contractor contends the dispute was wrongly
        decided by the Agency Head; (ii) a copy of the written decision of the Agency
        Head, and (iii) a copy of all materials submitted by the Contractor to the
        Agency, including the Notice of Dispute. The Contractor may not present to
        the
        Comptroller any material not presented to the Agency Head, except at-the
        request
        of the Comptroller.

       

      (B)
        Agency Response. Within thirty (30) days of receipt of the Notice of Claim,
        the
        Agency shall make available to the Comptroller a copy of all material submitted
        by the Agency to the Agency Head in connection with the dispute. The Agency
        may
        not present to the Comptroller any material not presented to the Agency Head
        except at the request of the Comptroller.

       

      (C)
        Comptroller Investigation. The Comptroller may investigate the claim in dispute
        and, in the course of such

       

       

      


      Profit.w/P.L.
        

      -19-

      



      investigation,
        may exercise all powers provided in sections 7-201 and 7-203 of the New York
        City Administrative Code. In addition, the Comptroller may demand of either
        party, and such party shall provide, whatever additional material the
        Comptroller deems pertinent to the claim, including original business records
        of
        the Contractor. Wilful failure of the Contractor to produce within fifteen
        (15)
        days any material requested by the Comptroller shall constitute a waiver
        by the
        Contractor of its claim. The Comptroller may also schedule an informal
        conference to be attended by the Contractor, Agency representatives, and
        any
        other personnel desired by the Comptroller.

       

      (D)
        Opportunity of Comptroller to Compromise or Adjust Claim. The Comptroller
        shall
        have forty-five (45) days from his or her receipt of all materials referred
        to
        in 5. (C) to investigate the disputed claim. The period for investigation
        and
        compromise may be further extended by agreement between the Contractor and
        the
        Comptroller, to a maximum of ninety (90) days from the Comptroller's receipt
        of
        all the materials. The Contractor may not present its petition to the Contract
        Dispute Resolution Board until the period for investigation and compromise
        delineated in this paragraph has expired. In compromising or adjusting any
        claim
        hereunder, the Comptroller may not revise or disregard the terms of the Contract
        between the parties.

       

      15.6
        Contract Dispute Resolution Board. There shall be a Contract Dispute Resolution
        Board composed of:

       

      (a)
        the
        chief administrative law judge of the Office of Administrative Trials and
        Hearings ("OATH") or his/her designated OATH administrative law judge, who
        shall
        act as chairperson, and may adopt operational procedures and issue such orders
        consistent with this section as may be necessary in the execution of the
        Contract Dispute Resolution Board's functions, including, but not limited
        to,
        granting extensions of time to present or respond to submissions;

      


      (b)
        the
        City Chief Procurement Officer or a designee; or in the case of disputes
        involving construction, the Director of the Office of Construction or his/her
        designee; any designee shall have the requisite background to consider and
        resolve the merits of the dispute and shall not have participated personally
        and
        substantially in the particular matter that is the subject of the dispute
        or
        report to anyone who so participated, and

       

      (c)
        a
        neutral person with appropriate expertise. This person shall be selected
        by the
        presiding administrative law judge from a prequalified panel of individuals,
        established and administered by OATH, with appropriate background to act
        as
        decision-makers in a dispute. Such individuals may not have a contract or
        dispute with the City or be an officer or employee of any company or
        organization that does, or regularly represents persons. companies, or
        organizations having disputes with the City.

       

      15.7
        Petition to Contract Dispute Resolution Board. In the event the claim has
        not
        been settled or adjusted by the Comptroller within the period provided in
        this
        section, the Contractor, within thirty (30) days thereafter, may petition
        the
        Contract Dispute Resolution Board to review the Agency Head
        determination.

       

      (A)
        Form
        and Content of Petition by Contractor. The Contractor shall present its dispute
        to the Contract Dispute Resolution Board in the form of a Petition, which
        shall
        include (i) a brief written statement of the substance of the dispute, the
        amount of money, if any, claimed and the reason(s) the Contractor contends
        that
        the dispute was wrongly decided by the Agency Head; (ii) a copy of the written
        decision of the Agency Head; (iii) copies of all materials submitted by the
        Contractor to the Agency; (iv) a copy of the written decision of the
        Comptroller, if any, and (v) copies of all correspondence with, or written
        material submitted by the Contractor to, the Comptroller's Office. The
        Contractor shall concurrently submit four complete sets of the Petition:
        one to
        the Corporation Counsel (Attn: Commercial and

      


       

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      Real
        Estate Litigation Division), and three to the Contract Dispute Resolution
        Board
        at oath's
        offices
        with proof of service on the Corporation Counsel. In addition, the supplier
        shall submit a copy of the statement of the substance of the dispute, cited
        in
        (i) above to both the Agency Head and the Comptroller.

       

      (B)
        Agency Response. Within thirty (30) days of its receipt of the Petition by
        the
        Corporation Counsel, the Agency shall respond to the brief written statement
        of
        the Contractor and make available to the Board at oath's
        offices
        and one to the Contractor, all material it submitted to the Agency Head and
        Comptroller. Extensions of time for submittal of the agency response shall
        be
        given as necessary upon a showing of good cause or, upon the consent of the
        parties, for an initial period of up to thirty (30) days.

       

      (C)
        Further Proceedings. The Board shall permit the Contractor to present its
        case
        by

      the
        submission of memoranda, briefs, and oral argument. The Board shall also
        permit
        the Agency to present its case in response to the Contractor by the submission
        of memoranda, briefs, and oral argument. If requested by the Corporation
        Counsel, the Comptroller shall provide reasonable assistance in the preparation
        of the Agency's case. Neither the Contractor nor the Agency may support its
        case
        with any documentation or other material that was not considered by the
        Comptroller, unless requested by the Board. The Board, at its discretion,
        may
        seek such technical or other expertise as it shall deem appropriate and may
        seek, on its own or upon application of a party, any such additional material
        from any party as it deems fit. The Board, in its discretion, may combine
        more
        than one dispute between the parties of concurrent resolution.

      


      (D)
        Contract Dispute Resolution Board Determination. Within forty-five (45) days
        of
        the conclusion of all written submissions and oral arguments, the Board shall
        render a written decision resolving the dispute. In an unusually complex
        case,
        the Board may render its decision in a longer period of time, not to exceed
        ninety (90) days, and shall so advise the parties at the commencement of
        this
        period. The Board's decision must be consistent with the terms of the Contract.
        In reaching its decision, the Board shall accord no precedential significance
        to
        prior decisions of the Board involving other non-related contracts.

       

      (E)
        Notification of Contract Dispute Resolution Board Decision. The Board shall
        send
        a copy of its decision to the Contractor, the Agency Chief Contracting Officer,
        the Corporation Counsel, the Comptroller, and in the case of construction
        or
        construction-related services, the Engineer. A decision in favor of the
        Contractor shall be subject to the prompt payment provisions of the PPB Rules.
        The Required Payment Day shall be thirty (30) days after the date the parties
        are formally notified of the Board's decision.

       

      (F)
        Finality of Contract Dispute Resolution Board Decision. The Board's decision
        shall be final and binding on all parties. Any party may seek review of the
        Board's decision solely in the form of a challenge, made within four (4)
        months
        of the date of the Board's decision, in a court of competent jurisdiction
        of the
        State of New York, County of New York, pursuant to Article 78 of the Civil
        Practice Law and Rules. Such review by the court shall be limited to the
        question of whether or not the Board's decision was made in violation of
        lawful
        procedure, was affected by an error of law, or was arbitrary and capricious
        or
        an abuse of discretion. No evidence or information shall be introduced or
        relied
        upon in such proceeding that was not presented to the Board in' accordance
        with
        Section 5-11 of the PPB Rules.

       

      15.8
        Any
        termination, cancellation, or alleged breach of the Contract prior to or
        during
        the pendency of any proceedings pursuant to this section shall not affect
        or
        impair the ability of the Agency Head or Contract Dispute Resolution Board
        to
        make a binding and final decision pursuant to this section.

       

      ARTICLE
        16. PROMPT PAYMENT

       

      The
        Prompt Payment provisions set forth in Chapter 5,

       

      


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      Section
        5-07 of the Procurement Policy Board Rules in effect at the time for this
        solicitation will be applicable to payments made under this contract. The
        provisions require the payment to the contractors of interest on payments
        made
        after the required payment date except as set forth in subdivisions c(3)
        and
        d(2), (3), (4) and (5) of Section 5-07 of the Rules.

       

      The
        contractor must submit a proper invoice to receive payment, except where
        the
        contract provides that the contractor will be paid at predetermined intervals
        without having to submit an invoice for each scheduled payment.

       

      Determinations
        of interest due will be made in accordance with the provisions of the
        Procurement Policy Board Rules and General Municipal Law Section
        3-a.

       

      ARTICLE
        17.

      MACBRIDE
        PRINCIPLES PROVISIONS FOR NEW YORK CITY CONTRACTORS

       

      ARTICLE
        I. MACBRIDE PRINCIPLES NOTICE TO ALL PROSPECTIVE
        CONTRACTORS

      Local
        Law
        No. 34 of 1991 became effective on September 10, 1991 and added section 6-115.1
        to the Administrative Code of the City of New York. The local law provides
        for
        certain restrictions on City contracts to express the opposition of the people
        of the City of New York to employment discrimination practices in Northern
        Ireland and to encourage companies doing business in Northern Ireland to
        promote
        freedom of workplace opportunity.

      Pursuant
        to Section 6-115. ^prospective contractors for contracts to provide goods
        or
        services involving an expenditure of an amount greater than ten thousand
        dollars, or for construction involving an amount greater than fifteen thousand
        dollars, are asked to sign a rider in which they covenant and represent,
        as a
        material condition of their contract, that any business in Northern Ireland
        operations conducted by the contractor and any individual or legal entity
        in
        which the contractor holds a ten percent or greater ownership interest and
        any
        individual or legal entity that holds a ten percent or greater ownership
        interest in the contractor will be conducted in accordance with the MacBride
        Principles of nondiscrimination in employment.

      Prospective
        contractors are not required to agree to these conditions. However, in the
        case
        of contracts let by competitive sealed bidding, whenever the lowest responsible
        bidder has not agreed to stipulate to the conditions set forth in this notice
        and another bidder who has agreed to stipulate to such conditions has submitted
        a bid within five percent of the lowest responsible bid for a contract to
        supply
        goods, services or construction of comparable quality, the contracting entity
        shall refer such bids to the Mayor, the Speaker or other officials, as
        appropriate, who may determine, in accordance with applicable law and rules,
        that it is in the best interest of the city that the contract be awarded
        to
        other than the lowest responsible bidder pursuant to Section 313 (b)(2) of
        the
        City Charter.

      In
        the
        case of contracts let by other than competitive sealed bidding, if a prospective
        contractor does not agree to these conditions, no agency, elected official
        or
        the Council shall award the contract to that bidder unless the entity seeking
        to
        use the goods, services or construction certifies in writing that the contract
        is necessary for the entity to perform its functions and there is no other
        responsible contractor who will supply goods, services or construction of
        comparable quality at a comparable price.

       

      PART
        A

      In
        accordance with section 6-115.1 of the Administrative Code of the City of
        New
        York, the contractor stipulates that such contractor and any individual or
        legal
        entity in which the contractor holds a ten percent or greater ownership interest
        and any individual or legal entity that holds a ten percent or greater ownership
        interest in the contractor either (a) have no business operations in Northern
        Ireland, or (b) shall take lawful steps in good faith to conduct any business
        operations they have in Northern Ireland in accordance with the MacBride
        Principles, and shall permit independent monitoring of their compliance with
        such principles.

       

       

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      PART
        B

       

      For
        purposes of this section, the following terms shall have the following
        meanings:

      1.
        "MacBride Principles" shall mean those principles relating to nondiscrimination
        in employment and freedom of workplace opportunity which require employers
        doing
        business in Northern Ireland to:

      (1)
        increase the representation of individuals from under represented religious
        groups in the work force, including managerial, supervisory, administrative,
        clerical and technical jobs;

      (2)
        take
        steps to promote adequate security for the protection of employees from under
        represented religious groups both at the workplace and while traveling to
        and
        from work;

      (3)
        ban
        provocative religious or-political emblems from the workplace;

      (4)
        publicly advertise all job openings and make special recruitment efforts
        to
        attract applicants from under represented religious groups;

      (5)
        establish layoff, recall and termination procedures which do not in practice
        favor a particular religious group;

      (6)
        abolish all job reservations, apprenticeship restrictions and different
        employment criteria which discriminate on the basis of religion;

      (7)
        develop training programs that will prepare substantial numbers of current
        employees from under represented religious groups for skilled jobs, including
        the expansion of existing programs and the creation of new programs to train,
        upgrade and improve the skills of workers from under represented religious
        groups;

      (8)
        establish procedures to assess, identify and actively recruit employees from
        under represented religious groups with potential for further advancement;
        and


      (9)
        appoint a senior management staff member to oversee affirmative action efforts
        and develop a timetable to ensure their full implementation.

      


      ARTICLE
        II. ENFORCEMENT OF ARTICLE I.

      The
        contractor agrees that the covenants and representation in Article I above
        are
        material conditions to this contract. In the event the contracting entity
        receives information that the contractor who made the stipulation required
        by
        this section is in violation thereof, the contracting entity shall review
        such
        information and give the contractor an opportunity to respond. If the
        contracting entity finds that a violation has occurred, the entity shall
        have
        the right to declare the contractor in default and/or terminate this contract
        for cause and procure the supplies, services or work from another source
        in any
        manner the entity deems proper. In the event of such termination, the contractor
        shall pay to the entity, or the entity in its sole discretion may withhold
        from
        any amounts otherwise payable to the contractor, the difference between the
        contract price for the uncompleted portion of this contract and the cost
        to the
        contracting entity of completing performance of this contract either itself
        or
        by engaging another contractor or contractors. In the case of a requirements
        contract, the contractor shall be liable for such difference in price for
        the
        entire amount of supplies required by the contracting entity for the uncompleted
        term of its contract. In the case of a construction contract, the contracting
        entity shall also have the right to hold the contractor in partial or total
        default in accordance with the default provisions of this contract, and/or
        may
        seek debarment or suspension of the contractor. The rights and remedies of
        the
        entity hereunder shall be in addition to, and not in lieu of, any rights
        and
        remedies the entity has pursuant to this contract or by operation of
        law.

       

       

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