nysamendment3.htm


     

    Back to Form
8-K

    Exhibit
10.1


    APPENDIX
X

    [Amendment
Number 3]

    


    
      	
              Agency
      Code 12000

            	
              Contract
      Number CO21236

            
	
              Period
      1/1/08 —
      12/31/09

            	
              Funding
      Amount for Period Based on approved
      capitation rates

            


    

    


     

    This is
an AGREEMENT between THE STATE OF NEW YORK, acting by and through The New York State
Department of Health, having its principal office at Corning Tower, Room
2001, Empire State
Plaza, Albany NY 12237, (hereinafter referred to as the STATE), and WellCare of New York, Inc.,
(hereinafter referred to as the CONTRACTOR), to modify Contract Number CO21236
as set forth below as set forth below and to extend the contract period
through December 31, 2009. The effective date of these modifications is January
1, 2008.

     

    
      	
               
      

            	
              1.

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

            


    

     

    
      	
               
      

            	
              2.

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

            


    

     

    3.6          
SDOH Right to Recover Premiums

     

    The
parties acknowledge and accept that the SDOH has a right to recover premiums
paid to the Contractor for Enrollees listed on the monthly Roster who are later
determined for the entire applicable payment month to have been disenrolled from
the Contractor's Medicare Advantage Product; to have been in an institution; to
have been incarcerated; to have moved out of the Contractor's service area
subject to any time remaining in the Enrollee's Guaranteed Eligibility period;
or to have died. In any event, the State may only recover premiums paid for
Medicaid Enrollees listed on a Roster if it is determined by the SDOH that the
Contractor was not at risk for provision of Benefit Package services for any
portion of the payment period. Notwithstanding the foregoing, the SDOH always
has the right to recover duplicate Medicaid Advantage premiums paid for persons
enrolled under more than one Client Identification Number (ON) in the
Contractor's Medicaid Advantage product whether or not the Contractor has made
payments to providers.

     

    
      	
            	
              3.

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

            


    

     

    
      	
            	
              19.1

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

            


       

       

      
        	
              	
                a)

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

              


      

       

    

    
      	
               
      

            	
              i)
      

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


    

     

    
      
        
          Appendix
X 

          Medicaid
Advantage Contract Amendment

           January 1,
2008

           Page
1

        

      

      
         


        
          

        

      

      
         


      

    


    
      	
               
      

            	
              ii)

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

            


    

     

    
      	
               
      

            	
              iii)

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

            


    

     

    
      	
               
      

            	
              iv)

            	
              all
      documents concerning duplicate
CINs;

            


    

     

    
      	
               
      

            	
              v)

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

            


    

     

    
       

      
        	
              	
                b)

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

              


      

    

     

    
      	
            	
              4.

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

            


    

     

    
    

    
      
        	
              	
                19.3

              	
                 Access to
      Contractor Records

              
	 	 	The
      Contractor shall provide SDOH, the Comptroller of the State of New York,
      DHHS, the Comptroller General of the United States, and their authorized
      representatives with access to all records relating to Contractor
      performance under this Agreement for the purposes of examination, audit,
      and copying (at reasonable cost to the requesting party). The Contractor
      shall give access to such records on two (2) business days prior written
      notice, during normal business hours, unless otherwise provided or
      permitted by applicable laws, rules, or regulations. Notwithstanding the
      foregoing, when records are sought in connection with a "fraud" or "abuse"
      investigation, as defined respectively in 10 NYCRR §98.1.21 (a) (1) and
      (a) (2), all costs associated with production and reproduction shall be
      the responsibility of the Contractor.


      

       

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


      

       

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


      

    

    


    
      
        
          
            
              	
                      Appendix
      X 

                      Medicaid
      Advantage Contract Amendment

                       January
      1, 2008

                       Page
      2

                    


            

             

          

        

        
          
            

          

        

        
           


        

      

    

    
       

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


      

    

     

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




    
      	
               
      

            	
              7.

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

            


    

     

    
      	 	
              8.

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

            


    

     

    
      	
               
      

            	
              9.

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

            


    

     

    
      	 	
              10.

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

            


    

     

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


    
      
        
          Appendix
X 

          Medicaid
Advantage Contract Amendment

           January 1,
2008

           Page
3

        

      

      
         


        
          

        

      

      
         


      

    


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

     

    
      	
              CONTRACTOR
      SIGNATURE

               

            	
              STATE
      AGENCY SIGNATURE

            
	
              By:  /s/ Heath
      Schiesser                              
      

            	
              By:
      /s/ Vallencia
      Lloyd                                  

            
	
                    
      

                      Heath
      Schiesser                                    

                                       
      (Print name)

            	
                   Vallencia
      Lloyd___                                 
      

                                   
      (Print name)

            
	
               

              Title:  President and
      CEO                            
      

            	
              Title:
      Deputy Director,
      DMC                        
      

            
	
               

              Date:
      5/12/08                                                 
      

            	
              Date:
      6/3/08                                                     
      

            
	 
      	
              State
      Agency Certification:

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

            


    

    


    


    STATE OF
FLORIDA

    


    County of
Hillsborough

    


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

    


    /s/ Sara
Gallo                                                  

    (Notary)

     

    
 

    
      	
              Approved:

               

              /s/ Lorraine
      Remo

               

              ATTORNEY
      GENERAL

            	
              Approved:

               

              /s/ name
      illegible

               

              Thomas
      P. DiNapoli

              STATE
      COMPTROLLER

            
	
              Title:
      Associate Attorney

            	
              Title:
      

            
	
              Date:
      June 10, 2009

            	
              Date:
      June 17, 2008

            


    

    

      
        
          
            Appendix
X

            Medicaid
Advantage Contract Amendment

            January 1,
2008

            Page
4  

          

        

        
           


          
            

          

        

        
           


        

      

Appendix
D

     

    New York
State Department of Health

    Medicaid
Advantage Marketing Guidelines


    
      
        
          Medicaid
Advantage Contract Amendment

          Appendix D

          State January 1,
2008

           D-1 


        

      

      
         


        
          

        

      

      
         


      

    


    MEDICAID
ADVANTAGE MARKETING GUIDELINES

     

    I.             
Purpose

     

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

     

    II.            Marketing
Materials

     

     A.  
Definitions

     

    
      	
               
      

            	
              1.

            	
              Marketing
      materials generally include the concepts of advertising, public service
      announcements, printed publications, and other broadcast or electronic
      messages designed to increase awareness and interest in a Contractor's
      Medicaid Advantage product. The target audience for these marketing
      materials is Eligible Persons as defined in Section 5.1 of this Agreement
      living in the defined service area.

            


    

     

    
      	
               
      

            	
              2.

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

            


    

     

     B.   
Marketing Material Requirements

     

     In
addition to meeting CMS' Medicare Advantage marketing requirements and guidance
on marketing to individuals entitled to Medicare and Medicaid:

     

    
      	
            	
              1.

            	
               Medicaid
      Advantage marketing materials must be written in prose that is understood
      at a fourth-to sixth-grade reading level except when the Contractor is
      using language required by CMS, and must be printed in at least twelve
      (12) point font.

            


    

     

    
      	
            	
              2.

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

            


    

     

    
      
        
          
            Medicaid
Advantage Contract Amendment

            Appendix D

            State January 1,
2008

             D-2

          

        

         


      

      
        
          

        

      

      
         


      

    

     

    
      	
            	
              3.

            	
              The
      Contractor shall advise potential Enrollees, in written materials related
      to enrollment, to verify with the medical services providers they prefer,
      or have an existing relationship with, that such medical services
      providers participate in the selected managed care provider's network and
      are available to serve the
participant.

            


    

     

                  
  C.    Prior Approvals

     

    
      	
               
      

            	
              1.

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

            


    

     

    
      	
               
      

            	
              2.

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

            


    

     

    
      	
               
      

            	
              a.

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

            


    

     

    
      	
               
      

            	
              b.

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

            


    

     

    
      	
               
      

            	
              c.

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

            


    

     

    
    

    
      	
               
      

            	
              3.

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

            


    

     

    
      	
               
      

            	
              4.

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

            


    


    
      
        
          Medicaid
Advantage Contract Amendment

          Appendix D

          State January 1,
2008

           D-3 


        

      

      
         


        
          

        

      

      
         


      

    

     

    
      	
            	
              5.

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

            


    

     

                  
  D.   Dissemination of Outreach Materials to LDSS

     

    
      	
               
      

            	
              1.

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

            


    

     

    
      	
               
      

            	
              2.

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

            


    

     

    III.           Marketing
Activities

     

                  
  A.    General Requirements

     

    
      	
               
      

            	
              1.

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

            


    

     

    
      	
                            
      

            	
              2.

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

            


    

      

                 
   B.    Marketing at LDSS Offices

     

                 
   With prior LDSS approval, MCOs may distribute CMS/SDOH approved
Medicaid Advantage marketing materials in the local social services district
offices and facilities.

     

                
    C.    Responsibility for Marketing
Representatives

     

                    
Individuals employed by the Contractor as marketing representatives and
employees of marketing subcontractors must have successfully completed the
Contractor's training

                   
 program including training related to an Enrollee's rights and
responsibilities in Medicaid Advantage. The Contractor shall be responsible for
the activities of its marketing 

                    
representatives and the activities of any subcontractor or management
entity.


    
      
        
          Medicaid
Advantage Contract Amendment

          Appendix D

          State January 1,
2008

           D-4 


        

      

      
         


        
          

        

      

      
         


      

    


                    
D.   Medicaid Advantage Specific Marketing
Requirements

     

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

                   
 which a dedicated staff of marketing representatives employed by the
Contractor or by an entity with which the Contractor has a subcontract are
engaged in marketing    

                    
activities with the sole purpose of enrolling recipients in the Contractor's
Medicaid Advantage product.

     

    
      	
            	
              1.

            	
              Approved
      Marketing Plan

            


    

     

    
      	
               
      

            	
              a.

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

            


    

     

    
      	
               
      

            	
              b.

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

            


    

     

    
      	
               
      

            	
              c.

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

            


    

     

    
      	
               
      

            	
              d.

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

            


    

     

    
      	
               
      

            	
              e.

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

            


    

     

    
      	
               
      

            	
              f.

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

            


    


    
      
        
          Medicaid
Advantage Contract Amendment

          Appendix D

          State January 1,
2008

           D-5 


        

      

      
         


        
          

        

      

      
         


      

    

     

    
      	
               
      

            	
              g.

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

            


    

     

    
      	
            	
              2.

            	
              Prohibition
      of Cold Call Marketing Activities 

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


    

     

                    
E.    General Marketing Restrictions

     

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

     

    
      	 	1.	  Contractors
      are prohibited from misrepresenting the Medicaid program, the Medicaid
      Advantage Program or the policy requirements of the LDSS or
  SDOH.
	 	 	 
	 	2. 	 Contractors
      are prohibited from purchasing or otherwise acquiring or using mailing
      lists that specifically identify Medicaid recipients from third party
      vendors, including providers and LDSS offices, unless otherwise permitted
      by CMS. The Contractor may produce materials and cover their costs of
      mailing to Medicaid recipients if the mailing is carried out by the State
      or LDSS, without sharing specific Medicaid information with the
      Contractor.
	 	 	 
	
               
      

            	
              3.

            	
              Contractors
      may not discriminate against a potential Enrollee based on his/her current
      health status or anticipated need for future health care. The Contractor
      may not discriminate on the basis of disability or perceived disability of
      any Enrollee or their family member. Health assessments may not be
      performed by the Contractor prior to enrollment. The Contractor may
      inquire about existing primary care relationships of the applicant and
      explain whether and how such relationships may be maintained. Upon
      request, each potential Enrollee shall be provided with a listing of all
      participating providers and facilities in the MCO's network. The
      Contractor may respond to a potential Enrollee's question about whether a
      particular specialist is in the network. However, the Contractor is
      prohibited from inquiring about the types of specialists utilized by the
      potential Enrollee.

            


    


    
      
        
          
            Medicaid
Advantage Contract Amendment

            Appendix D

            State January 1,
2008

             D-6

          

        

         


      

      
        
          

        

      

      
         


      

    

     

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


    

     

    
      	
               
      

            	
              a.

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

            


    

     

    
      	
               
      

            	
              b.

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

            


    

     

    
      	
            	
              c.

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

            


    

    

      
        
          
            Medicaid
Advantage Contract Amendment

            Appendix D

            State January 1,
2008

             D-7 


          

        

        
           


          
            

          

        

        
           


        

      

    

     

    
      	
               
      

            	
              d.

            	
              Sign
      on bonuses for Marketing Representatives are
  prohibited;

            


    

     

    
      	
               
      

            	
              e.

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

            


    

     

    
      	
               
      

            	
              f.

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

            


    

     

    
      	
               
      

            	
              g.

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

            


    

     

    
      	
               
      

            	
              h.

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

            


    

     

    
      	
               
      

            	
              i.

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

            


    

     

    
      	
            	
              j.

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

            


    

     

    IV.        
  Marketing Infractions

     

    
                     
A.    Infractions of Medicaid marketing guidelines, as found in
Appendix D, Sections III D and E, may result in the following actions being
taken by the SDOH, in consultation

                           
  with the LDSS, to protect the interests of the program and its
clients. These actions shall be taken by the SDOH in collaboration with the LDSS
and the CMS Regional 

                             
Office.

    

    
    

     

    
      	
               
      

            	
              1.

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

            


    

     

    
      	
               
      

            	
              2.

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

            


    


    
      
        
          Medicaid
Advantage Contract Amendment

          Appendix D

          State January 1,
2008

           D-8

        

         


      

      
        
          

        

      

      
         


      

    

       

    
      	
            	
              3.

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

            


    

     

    
      	
               
      

            	
              a)

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

            


    

     

    
      	
               
      

            	
              b)

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

            


    

     

    
      	
            	
              c)

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

            


      

        
          
            
              Medicaid
Advantage Contract Amendment

              Appendix D

              State January 1,
2008

               D-9 


            

          

          
             


            
              

            

          

          
             


          

        

APPENDIX
H

    

     

    New
York State Department of Health Guidelines for the

    Processing
of Medicaid Advantage Enrollments and Disenrollments


    
      
        
          
            Medicaid
Advantage Contract

            APPENDIX
H
State
January 1, 2008
H-1

          

        

         


      

      
        
          

        

      

      
         


      

    

     

    Appendix
H

     

    SDOH
Guidelines

    For
the Processing of Medicaid Advantage Enrollments and

    Disenroliments

     

    1.    General

     

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

     

    2.    Enrollment

     

    a)
SDOH Responsibilities:

     

    
      	
               
      

            	
              i)

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

            


    

     

    
      	
               
      

            	
              ii)

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

            


    

     

    b)
LDSS Responsibilities:

     

    
      	
               
      

            	
              i)

            	
              The
      LDSS has the primary responsibility for processing Medicaid Advantage
      enrollments.

            


    

     

    
      	
               
      

            	
              ii)

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

            


    

     

    
      	
            	
              iii)

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

            


    

     

    
      
        
          
            Medicaid
Advantage Contract

            APPENDIX
H
State
January 1, 2008
H-2 


          

        

      

      
         


        
          

        

      

      
         


      

    

     

    
      	
            	
              iv)

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

              

            


    

     

    
      	
            	
              v)

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

              

            


    

     

    
    

    
      	
            	
              vi)

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

                

              

            


    

    
    

     

    
    

    
      	
            	
              vii)

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

                  

                

              

            


    

    
    

     

    
      	
            	
              viii)

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

                  

                

              

            


    

     

    
      	
            	
              ix)

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

                    

                  

                

              

            


    

     

    
      	
            	
              x)

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

                      

                    

                  

                

              

            


    

     

    
      	
            	
              xi)

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

                        

                      

                    

                  

                

              

            


    

     

    
      	
            	
              xii)

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

                          

                        

                      

                    

                  

                

              

            


    

    
    

     

    
      	
            	
              xiii)

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

                          

                        

                      

                    

                  

                

              

            


    

    
    

     

    
      
        
          
            	
                    
                      
                        Medicaid
      Advantage Contract

                        APPENDIX
      H
State
      January 1, 2008
H-3

                      

                    

                  


          

           

        

      

      
        
          

        

      

      
         


      

    

     

    
      	
               
      

            	
              A)

            	
              LDSS
      directly enters data into PCP Subsystem;
or

            


    

     

    
      	
               
      

            	
              B)

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

            


    

     

    
      	
            	
              C)

            	
              LDSS
      electronically transfers data via a dedicated line, from eMedNY to the PCP
      Subsystem.

            


    

     

    
      	
            	
              xiv)

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

                            

                          

                        

                      

                    

                  

                

              

            


    

     

    
      	
            	
              xv)

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

                            

                          

                        

                      

                    

                  

                

              

            


    

     

    
      	
            	
              xvi)

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

                            

                          

                        

                      

                    

                  

                

              

            


    

     

    
      	
            	
              xvii)

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

                          

                        

                      

                    

                  

                

              

            


    

     

    
      	
               
      

            	
              A)

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

            


    

     

    
      	
               
      

            	
              B)

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

            


    


    
      
        
          
            Medicaid
Advantage Contract

            APPENDIX
H
State
January 1, 2008
H-4 


          

        

      

      
         


        
          

        

      

      
         


      

    

     

               
c) Contractor Responsibilities:

     

    
      	
               
      

            	
              i)

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

            


    

     

    
      	
               
      

            	
              ii)

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

            


    

     

    
      	
               
      

            	
              iii)

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

            


    

     

    
      	
               
      

            	
              iv)

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

            


    

     

    
      	
            	
              v)

            	
              The
      Contractor must report any changes that affect or may affect the Medicaid
      or Medicaid Advantage eligibility status of its Enrollees to the LDSS
      within five (5) business days of such information becoming known to the
      Contractor. This includes, but is not limited to, address changes,
      incarceration, third party insurance other than Medicare, Disenrollment
      from the Contractor's Medicare Advantage Product,
  etc.

            


    

     

    
      
        
          Medicaid
Advantage Contract

          
            
              APPENDIX
H
State
January 1, 2008
H-5

            

          

        

         


      

      
        
          

        

      

      
         


      

    


    
      	
               
      

            	
              vi)

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

            


    

     

    
      	
               
      

            	
              vii)

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

            


    

     

    
      	
               
      

            	
              viii)

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

            


    

     

    
      	
               
      

            	
              ix)

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

            


    

     

    3.  
 Newborn Enrollments:

     

               
a) SDOH Responsibilities:

     

    
      	
               
      

            	
              i)

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

            


    

     

    
      	
               
      

            	
              ii)

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

            


    

     

               
b) LDSS Responsibilities:

     

    
      	
               
      

            	
              i)

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

            


    

     

    
      	
               
      

            	
              ii)

            	
              The
      LDSS is responsible for adding eligible unborns to all WMS cases that
      include a pregnant woman as soon as the pregnancy is medically verified.
      (NYS DSS Administrative
      Directive 85 ADM-33)

            


    


    
      
        
          Medicaid
Advantage Contract

          
            
              APPENDIX
H
State
January 1, 2008
H-6

            

          

        

         


      

      
        
          

        

      

      
         


      

    

     

    
      	
               
      

            	
              iii)

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

            


    

     

    
      	
               
      

            	
              iv)

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

            


    

     

    
      	
               
      

            	
              v)

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

            


    

     

               
c) Contractor Responsibilities:

     

    
      	
               
      

            	
              i)

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

            


    

     

    
      	
               
      

            	
              ii)

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

            


    

     

    4.   
Roster Reconciliation:

     

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

     

            b)
SDOH Responsibilities:

     

    
      	
               
      

            	
              i)

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

            


    

     

    
      	
               
      

            	
              ii)

            	
              SDOH
      shall send monthly to the Contractor and LDSS (according to a schedule
      established by SDOH) a complete list of all Enrollees for which the
      Contractor is expected to assume medical risk beginning on the 1st
      of the following month (First Monthly Roster). Notification to the
      Contractor and LDSS will be 

                accomplished
      via paper transmission, magnetic media, or the
  HPN.

              

            


    

     

    
      	
            	
              iii)

            	
              
                SDOH
      shall send the Contractor and LDSS monthly, at the time of the first
      monthly roster production, a Disenrollment Report listing those Enrollees
      from the previous month's roster who were disenrolled, transferred to
      another MCO, or whose Enrollments were deleted from the file. Notification
      to the Contractor and LDSSs will be accomplished via paper transmission,
      magnetic media, or the HPN.

              

            


    

     

    
      
        
          
            Medicaid
Advantage Contract

            APPENDIX
H
State
January 1, 2008
H-7 


          

        

      

      
         


        
          

        

      

      
         


      

    

     

    
    

    
    

    
      	
               
      

            	
              iv)

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

            


    

    


    
      	
               
      

            	
              v)

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

            


    

     

               
c) LDSS Responsibilities:

     

    
      	
               
      

            	
              i)

            	
              The
      LDSS is responsible for notifying the Contractor electronically or in
      writing of changes in the First Roster and error report, no later than the
      end of the month. This includes, but is not limited to, new Enrollees
      whose Enrollments in Medicaid Advantage were processed subsequent to the
      pull-down date but prior to the Effective Date of Enrollment. (Note: To
      the extent practicable the date specified must allow for timely notice to
      Enrollees regarding their Enrolhnent status. The Contractor and the LDSS
      may develop protocols for the purpose of resolving Roster discrepancies
      that remain unresolved beyond the end of the
  month).

            


    

     

    
      	
               
      

            	
              ii)

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

            


    

     

                d)
Contractor Responsibilities:

     

    
      	
               
      

            	
              i)

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

            


    

     

    
      	
               
      

            	
              ii)

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

            


    


    
      
        
          Medicaid
Advantage Contract

          APPENDIX
H
State
January 1, 2008
H-8 


        

      

      
         


        
          

        

      

      
         


      

    

     

    5.   
Disenrollment:

     

                a)
LDSS Responsibilities:

     

    
      	
               
      

            	
              i)

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

            


    

     

    
      	
               
      

            	
              ii)

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

            


    

     

    
      	
               
      

            	
              iii)

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

            


    

     

    
      	
               
      

            	
              iv)

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

            


    

     

    
      	
               
      

            	
              v)

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

            


    

     

    
      	
               
      

            	
              vi)

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

            


    

     

    
      	
            	
              vii)

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

            


    

     

    
      
         
Medicaid
Advantage Contract

          APPENDIX
H
State
January 1, 2008
H-9 


        

      

      
         


        
          

        

      

      
         


      

    

     

    
      	
            	
              viii)

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

            


    

     

    
      	
               
      

            	
              ix)

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

            


    

     

    
      	
               
      

            	
              x)

            	
              The
      LDSS is responsible for notifying the Contractor of the retroactive
      disenrollment prior to the action: The LDSS is responsible
      for finding out if the Contractor has made payments to providers on behalf
      of the Enrollee prior to Disenrollment. After this information is
      obtained, the LDSS and Contractor will agree on a retroactive
      Disenrollment or prospective Disenrollment
  date.

            


    

     

    
      	
            	
               

            	
              In
      all cases of retroactive Disenrollment, including Disenrollments effective
      the first day of the current month, the LDSS is responsible for sending
      notice to the Contractor at the time of Disenrollment, of the Contractor's
      responsibility to submit to the SDOH's Fiscal Agent voided premium claims
      within thirty (30) business days of notification from the LDSS for any
      full months of retroactive Disenrollment where the Contractor was not at
      risk for the provision of Benefit Package services during the month. 
      Notwithstanding the foregoing, the SDOH always has the right to recover
      duplicate Medicaid Advantage premiums paid for persons enrolled under more
      than one Client Identification Number (CIN) in the Contractor's Medicaid
      Advantage product whether or not the Contractor has made payments to
      providers. Failure by the LDSS to notify the Contractor does not affect
      the right of the SDOH to recover the premium payment as authorized by
      Section 3.6 of this Agreement or for the State Attorney General to bring
      legal action to recover any
overpayment.

            


    

     

    
      
        
          Medicaid
Advantage Contract

          APPENDIX
H
State
January 1, 2008
H-10

        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    
      	
            	
              xi)

            	
              
                Generally
      the effective dates of Disenrollment are prospective. Effective dates for
      other than routine Disenrollments are described
    below:

              

            


    

     

    
      	
              Reason
      for Disenrollment

            	
              Effective
      Date of Disenrollment

            
	
              ·Death of
      Enrollee

            	
              ·First day of
      the month after death

            
	
              ·Incarceration

            	
              ·First day of
      the month of incarceration (note-Contractor is at risk for covered
      services

               only
      to the date of incarceration and is entitled to the capitation payment for
      the month

               of
      incarceration).

            
	
              ·Enrollee
      entered or stayed in a residential institution under circumstances
      which

               rendered
      the individual ineligible for enrollment in Medicaid Advantage or is in
      receipt of 

              waivered
      services through the Long Term Home Health Care Program (LTHHCP),
      

              including
      when an Enrollee is admitted to a hospital that 1) is certified by
      Medicare as a 

              long-term
      care hospital and 2) has an average length of stay for all patients
      greater than 

              ninety-five
      (95) days as reported in the Statewide Planning and Research
      Cooperative

              System
      (SPARCS) Annual Report 2002.

            	
              ·First day of
      the month of entry or first day of the month of classification of the stay
      as

               permanent,
      subsequent to entry (note-Contractor is at risk for covered services only
      to

               the
      date of entry or classification of the stay as permanent subsequent to
      entry, and is

               entitled
      to the capitation payment for the month of entry or classification of the
      stay as  

              permanent
      subsequent to entry).

            
	
              ·Individual
      enrolled while ineligible for enrollment

            	
              ·Effective Date
      of Enrollment in the Contractor's Plan.

            
	
              ·Non-consensual
      Enrollment

            	
              ·Retroactive to
      the first day of the month of Enrollment

            
	
              ·Enrollee moved
      outside of the District/County of Fiscal Responsibility

            	
              ·First day of
      the month after the update of the system with the new
    address*

            
	
              ·Urgent medical
      need

            	
              ·First day of
      the next month after determination except where medical need requires
      an 

               earlier
      Disenrollment

            
	
              ·Homeless
      Enrollees in Medicaid Advantage residing in the shelter system in
      NYC

            	
              ·Retroactive to
      the first day of the month of the request

            
	
              ·An Enrollee
      with more than one Client Identification Number (CIN) is enrolled in
      the

               Contractor's
      Medicaid Advantage Product under more than one of the
CINs.

            	
              ·First day of
      the month the duplicate Enrollment
began.

            


    

     

    
      	
              *
      In counties outside of New York City, LDSSs should work together to ensure
      continuity of care through the Contractor if the Contractor's service area
      includes the county to which the Enrollee has moved and the Enrollee, with
      continuous eligibility, wishes to stay enrolled in the Contractor's plan.
      In New York City, Enrollees, not in guaranteed status, who move out of the
      Contractor's Service Area but not outside, of the City of New York (e.g.,
      move from one borough to another), will not be involuntarily disenrolled,
      but must request a Disenrollment or transfer. These Disenrollments will be
      performed on a routine basis unless there is an urgent medical need to
      expedite
      the Disenrollment.

            


    


    
      
        
          Medicaid
Advantage Contract

          APPENDIX
H
State
January 1, 2008
H-11 


        

      

      
         


        
          

        

      

      
         


      

    

     

    
      	
            	
              xii)

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

                

              

            


    

     

    
      	
            	
              xiii)

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

                

              

            


    

     

    
    

    
      	
            	
              xiv)

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

                  

                

              

            


    

    
    

     

    
    

    
    

    
      	
            	
              xv)

            	
              
                
                  
                     The
      LDSS is responsible for sending the following notices to Enrollees
      regarding their Disenrollment status. Where practicable, the process will
      allow for timely notification to Enrollees unless there is "good cause" to
      disenroll more
  expeditiously.

                  

                

              

            


    

     

    
      	
               

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

            


    

     

    
      	
               

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

              

            


    

     

    
      	
               

            	 C)	
              
                Notice
      of Change to "Guarantee Coverage": This notice will advise the Enrollee
      that his or her Medicaid coverage is ending and how this affects his or
      her enrollment in the Medicaid AdvantageProduct. This notice contains
      pertinent information regarding "Guaranteed Eligibility" benefits and
      dates of coverage. If an Enrollee is not eligible for guarantee, this
      notice is not necessary.

              

            


    

    
    

     

    
      
        
          Medicaid
Advantage Contract

          APPENDIX
H
State
January 1, 2008
H-12

        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    
    

    
      	
            	
              xvi)

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

                  

                

              

            


    

     

     

    
      	
            	
              xvii)

            	
              
                
                  
                    
                      The
      LDSS is responsible for reviewing each Contractor requested Disenrollment
      in accordance with the provisions of Section 8.7 of this Agreement.
      Where applicable, the LDSS may consult with local mental health and
      substance abuse authorities in the district when making the determination
      to approve or disapprove the
      request.

                    

                  

                

              

            
	 	 	 
	 	 xviii)	 The
      LDSS is responsible for establishing procedures whereby the Contractor
      refers cases which are appropriate for an LDS S-initiated Disenrollment
      and submits supporting documentation to the LDSS.
	 	 	 
	 	 xix)	After
      the LDSS receives and, if appropriate, approves the request for
      Disenrollment either from the Enrollee or the Contractor, the LDSS is
      responsible for updating the PCP subsystem file with an end date. The
      Enrollee is removed from the Contractor's
Roster.


    

    
    

     

          
b) Contractor Responsibilities:

     

    
      	
               
      

            	
              i)

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

            


    

     

    
      	
               
      

            	
              ii)

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

            


    

     

    
      	
            	
              iii)

            	
              The
      Contractor will make a good faith effort to identify cases which may be
      appropriate for an LDSS-initiated Disenrollment. Within five (5) business
      days of identifying such cases and following LDSS procedures, the
      Contractor will, in writing, refer cases which are appropriate for an
      LDSS-initiated Disenrollment and will submit supporting documentation to
      the LDSS. This includes, but is not limited to, changes in status for its
      enrolled members that may impact eligibility for Enrollment in an MCO such
      as address changes, incarceration, death, ineligibility for Medicaid
      Advantage Enrollment, change in Medicare status, the apparent enrollment
      of a member in the Contractor's Medicaid Advantage
      product under more than one CIN,
etc.

            


       

      
        
          
            Medicaid
Advantage Contract

            APPENDIX
H
State
January 1, 2008
H-13

          

        

        
          
          

          
            

          

        

        
          
          

        

      

       

    

    
      	
            	
              iv)

            	
              With
      respect to Contractor-initiated
Disenrollments:

            


    

     

    
      	
               

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

              

            


    

     

    
    

    
      	
               
      

            	
              i)

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

            


    


    
    

    
      	
               
      

            	
              ii)

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

            


    

     

    
      	
            	
              B)

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

            


    

     

    
      	
               
      

            	
              C)

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

            


    

     

    
      	
               
      

            	
              D)

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

            


    

     

    
      	
            	
              E)

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

            


    

     

    
      	
            	
              v)

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

            


    

     

    
      
        
          Medicaid
Advantage Contract

          APPENDIX
H
State
January 1, 2008
H-14 


        

      

      
         


        
          

        

      

      
         


      

    

     

    APPENDIX
K

     

    Medicare
and Medicaid Advantage Products

    And
Non-Covered Services


    
      
        
          Medicaid
Advantage Contract

          APPENDIX
K
State
January 1, 2008
K-1 


        

      

      
         


        
          

        

      

      
         


        
           

        

      

    

     

    APPENDIX
K

     

    Appendix
K is organized into three parts:

     

    I.          Appendix
K-I

     

                Medicare
Advantage Product

     

    II.         Appendix
K-2

     

               
Medicaid Advantage Product

     

                Contractor/County
Election of Coverage for Optional Services Description of Medicaid Only Covered
Services

     

    III.       Appendix
K-3

     

               
Non-Covered Services


    
      
        
          
            Medicaid
Advantage Contract

            APPENDIX
K
State
January 1, 2008
K-2

          

        

         


      

      
        
          

        

      

      
         


        
           

        

      

    


    
      APPENDIX
K1



    MEDICARE
ADVANTAGE PRODUCT

     

    
      	
              Medicare
      Advantage Benefit Package for Dual Eligibles

            
	
              Category
      of Service

            	
              Included
      in Medicare Capitation

            
	
              Inpatient
      Hospital Care Including Substance Abuse and Rehabilitation
      Services

            	
              Up
      to 365 days per year (366 days for leap year) with no deductible or
      co-payment

            
	
              Inpatient
      Mental Health

            	
              Medically
      necessary care with no deductible or co-payment. 190-day lifetime limit in
      a psychiatric hospital.

            
	
              Skilled
      Nursing Facility

            	
              Care
      provided in a skilled nursing facility. Covered for 100 days each benefit
      period. No prior hospital stay required. No co-payment.

            
	
              Home
      Health

            	
              Medically
      necessary intermittent skilled nursing care, home health aide services and
      rehabilitation services. No co-payment.

            
	
              PCP
      Office Visits

            	
              Primary
      care doctor office visits. No co-payment.

            
	
              Specialist
      Office Visits

            	
              Specialist
      office visits.  Subject to $10 co-payment for each specialist
      office visit.

            
	
              Chiropractic

            	
              Manual
      manipulation of the spine to correct subluxation provided by chiropractors
      or other qualified providers. Subject to $10
co-payment.

            
	
              Podiatry

            	
              Medically
      necessary foot care, including care for medical conditions affecting lower
      limbs, subject to $10 co-payment. Visits for routine foot care up to 4
      visits per year, not subject to co-payment.

            
	
              Outpatient
      Mental Health

            	
              Individual
      and group therapy visits, subject to co-payment of $20 per individual or
      group visit. Enrollee must be able to self-refer for one assessment from a
      network provider in a twelve (12) month period.

            
	
              Outpatient
      Substance Abuse

            	
              Individual
      and group visits subject to $20 co-payment per group or individual visit.
      Enrollee must be able to self-refer for one assessment from a network
      provider in a twelve (12) month period.

            
	
              Outpatient
      Surgery

            	
              Medically
      necessary visits to an ambulatory surgery center or outpatient hospital
      facility. No co-payment.

            
	
              Ambulance

            	
              Transportation
      provided by an ambulance service, including air ambulance. Emergency
      transportation if for the purpose of obtaining hospital services for an
      enrollee who suffers from severe, life-threatening or potentially
      disabling conditions which require the provision of emergency services
      while the enrollee is being transported.  Includes
      transportation to a hospital emergency room generated by a "Dial 911". No
      co-payment.

            


    


    
      
        
          
            Medicaid
Advantage Contract

            APPENDIX
K
State
January 1, 2008
K-3

          

        

      

      
         


        
          

        

      

      
         


      

    


    
      	
              Medicare
      Advantage Benefit Package for Dual Eligibles

            
	
              Category
      of Service

            	
              Included
      in Medicare Capitation

            
	
              Emergency
      Room

            	
              Care
      provided in an emergency room subject to prudent layperson standard. $50
      co-payment per visit. Co-payment waived if admitted to the hospital within
      24 hours for the same condition.

            
	
              Urgent
      Care

            	
              Urgently
      needed care in most cases outside the plan's service area. Subject to $10
      co-payment.

            
	
              Outpatient
      Rehabilitation (OT, PT, Speech)

            	
              Occupational
      therapy, physical therapy and speech and language therapy subject to $10
      co-payment.

            
	
              Durable
      Medical Equipment (DME)

            	
              Medicare
      and Medicaid covered durable medical equipment, including devices and
      equipment other than medical/surgical supplies, enteral formula, and
      prosthetic or orthotic appliances having the following characteristics:
      can withstand repeated use for a protracted period of time; are primarily
      and customarily used for medical purposes; are generally not useful to a
      person in the absence of illness or injury and are usually not fitted,
      designed or fashioned for a particular individual's use. Must be ordered
      by a qualified practitioner. No homebound prerequisite and including
      non-Medicare DME covered by Medicaid (e.g., tub stool; grab bar). No
      co-payment or coinsurance.

            
	
              Prosthetics

            	
              Medicare
      and Medicaid covered prosthetics, orthotics and orthopedic footwear. No
      diabetic prerequisite for orthotics. Not subject to co-payment or
      coinsurance.

            
	
              Diabetes
      Monitoring

            	
              Diabetes
      self-monitoring and management training and supplies including coverage
      for glucose monitors, test strips, and lancets. None of which are subject
      to co-payments. OTC diabetic supplies such as 2x2 gauze pads, alcohol
      swabs/pads, insulin syringes and needles are covered by Part
      D.

            
	
              Diagnostic
      Testing

            	
              Diagnostic
      tests, x-rays, lab services and radiation therapy. No
      co-payments.

            
	
              Bone
      Mass Measurement

            	
              Bone
      Mass Measurement for people at risk. No co-payment

            
	
              Colorectal
      Screening

            	
              Colorectal
      screening for people, age 50 and older. No co payment.

            
	
              Immunizations

            	
              Flu,
      hepatitis B vaccine for people who are at risk, Pneumonia vaccine. No
      co-payment.

            
	
              Mammograms

            	
              Annual
      screening for women age 40 and older. No referral necessary. No
      co-payment.

            
	
              Pap
      Smear and Pelvic Exams

            	
              Pap
      smears and Pelvic Exams for women. No co-payment.

            
	
              Prostate
      Cancer Screening

            	
              Prostrate
      Cancer Screening exams for men age 50 and older. No
      co-payment.

            


    


    
      
        
          
            Medicaid
Advantage Contract

            APPENDIX
K
State
January 1, 2008
K-4 


          

        

      

      
         


        
          

        

      

      
         


      

    


    
      	
              Medicare
      Advantage Benefit Package for Dual Eligibles

            
	
              Category
      of Service

            	
              Included
      in Medicare Capitation

            
	
              Outpatient
      Drugs

            	
              Medicare
      Part B covered prescription drugs and other drugs obtained by a provider
      and administered in a physician office or clinic setting that are covered
      by Medicaid. (No Part D).

            
	
              Hearing
      Services

            	
              Medicare
      and Medicaid hearing services and products when medically necessary to
      alleviate disability caused by the loss or impairment of hearing. Services
      include hearing aid selecting, fitting, and dispensing; hearing aid checks
      following dispensing, conformity evaluations and hearing aid repairs;
      audiology services including examinations and testing, hearing aid
      evaluations and hearing aid prescriptions; and hearing aid products
      including hearing aids, earmolds, special fittings and replacement parts.
      No co-payment or limitations.

            
	
              Vision
      Care Services

            	
              Services
      of optometrists, ophthalmologists and ophthalmic dispensers including
      eyeglasses, medically necessary contact lenses and poly-carbonate lenses,
      artificial eyes (stock or custom-made), low vision aids and low vision
      services. Coverage includes the replacement of lost or destroyed glasses
      and the repair or replacement of parts. Coverage also includes
      examinations for diagnosis and treatment for visual defects and/or eye
      disease. Examinations for refraction are limited to every two (2) years
      unless otherwise justified as medically necessary. Eyeglasses do not
      require changing more frequently than every two (2) years unless medically
      necessary or unless the glasses are lost, damaged or destroyed. No
      prerequisite of cataract services. No co-payment.

            
	
              Routine
      Physical Exam 1/year

            	
              Up
      to one routine physical per year. No co-payment.

            
	
              Health/Wellness
      Education

            	
              Coverage
      for the following: general health education classes, parenting classes,
      smoking cessation classes, childbirth, education and nutrition counseling,
      plus additional benefits at plan option including but not limited to items
      such as newsletters, nutritional training, congestive heart program,
      health club membership/fitness classes,  nursing hotline,
      disease management, other wellness services. No
    co-payments.

            
	
              Additional
      Part C Benefits, if any

            	 
      
	
              Medicare
      Part D Prescription Drug Benefit as Approved by CMS

            	 
      


    


    
      
        
          
            Medicaid
Advantage Contract

            APPENDIX
K
State
January 1, 2008
K-5 

          

        

      

      
         


        
          

        

      

      
         


      

    

     

    APPENDIX
K2

     

    MEDICAID
ADVANTAGE PRODUCT

     

    
      	
              Medicaid
      Advantage Benefit Package for Dual Eligibles

            
	
              Category
      of Service

            	
              Included
      in Medicaid Capitation

            
	
              Inpatient
      Mental Health

            	
              Days
      in excess of the Medicare 190-day lifetime maximum.

            
	
              Home
      Health

            	
              Non-Medicare
      covered home health services (e.g. home health aide services with nursing
      supervision to medically unstable individuals).

            
	
              Specialist
      Office Visits

            	
              Elimination
      of $10 co-payment.

            
	
              Podiatry

            	
              Elimination
      of $10 co-payment for medically necessary footcare.

            
	
              Outpatient
      Mental Health

            	
              Elimination
      of $20 co-payment.

            
	
              Outpatient
      Substance Abuse

            	
              Elimination
      of $20 co-payment.

            
	
              Emergency
      Room

            	
              Elimination
      of $50 co-payment

            
	
              Urgent
      Care

            	
              Elimination
      of $10 co-payment.

            
	
              Outpatient
      Rehabilitation (OT, PT, Speech)

            	
              Elimination
      of $10 co-payment.

            
	
              Dental

              (Optional benefit outside
      of NYC)

            	
              Medicaid
      covered dental services including necessary preventive, prophylactic and
      other routine dental care, services and supplies and dental prosthetics to
      alleviate a serious health condition. Ambulatory or inpatient surgical
      dental services subject to prior authorization.

            
	
              Transportation
      — Routine (Optional
      benefit outside of NYC)

            	
              Transportation
      essential for an enrollee to obtain necessary medical care and services
      under the plan's benefits or Medicaid fee-for-service. Includes ambulette,
      invalid coach, taxicab, livery, public transportation, or other means
      appropriate to the enrollee's medical condition and a transportation
      attendant to accompany the enrollee, if necessary.

            
	
              Private
      Duty Nursing

            	
              Medically
      necessary private duty nursing services in accordance with the ordering
      physician, registered physician assistant or certified nurse
      practitioner's written treatment
plan.

            


    


    
      
        
          
            Medicaid
Advantage Contract

            APPENDIX
K
State
January 1, 2008
K-6 


          

        

      

      
         


        
          

        

      

      
         


      

    


    MCO
COVERAGE

    OF
OPTIONAL SERVICES

    MEDICAID
ADVANTAGE BENEFIT PACKAGE

    


    


    


    MCO:
WellCare of New York,
Inc.

    


    


    
      	
               

              Service
      Area

            	
              Medicaid
      Advantage Coverage Status

            
	
              Dental
      Services

            	
              Non-Emergency
      Transportation

            
	
              Albany

            	
              Not
      Covered

            	
              Not
      Covered

            


    


    
      
        
          Medicaid
Advantage Contract

          
            
              APPENDIX
K
State
January 1, 2008
K-7

            

          

        

         


      

      
        
          

        

      

      
         


      

    


    DESCRIPTION
OF MEDICAID ONLY SERVICES IN

    MEDICAID
ADVANTAGE BENEFIT PACKAGE:

     

    Inpatient
Mental Health Over 190-Day Lifetime Limit

     

    All
inpatient mental health services, including voluntary or involuntary admissions
for mental health services over the Medicare 190-Day Lifetime Limit. The
Contractor may provide the covered benefit for medically necessary mental health
impatient services through hospitals licensed pursuant to Article 28 of the New
York State P.H.L.

     

    Non-Medicare
Covered Home Health Services

     

    Medicaid
covered home health services include the provision of skilled services not
covered by Medicare (e.g. physical therapist to supervise maintenance program
for patients who have reached their maximum restorative potential or nurse to
pre-fill syringes for disabled individuals with diabetes) and /or home health
aide services as required by an approved plan of care developed by a certified
home health agency.

     

    Private
Duty Nursing Services

     

    Private
duty nursing services provided by a person possessing a license and current
registration from the NYS Education Department to practice as a registered
professional nurse or licensed practical nurse. Private duty nursing services
can be provided through an approved certified home health agency, a licensed
home care agency, or a private Practitioner.

     

    Private
duty nursing services are covered when determined by the attending physician to
be medically necessary. Nursing services may be intermittent, part-time or
continuous and must be provided in an Enrollee's home in accordance with the
ordering physician, registered physician assistant or certified nurse
practitioner's written treatment plan.

     

    Dental
Services (optional benefit outside of NYC)

     

    Dental
services include, but shall not be limited to, preventive, prophylactic and
other routine dental care, services, supplies and dental prosthetics required to
alleviate a serious health condition, including one which affects
employability.

     

    Dental
surgery performed in an ambulatory or inpatient setting is the responsibility of
the Contractor whether dental services are a covered plan benefit, or not.
Inpatient claims and referred ambulatory claims for dental services ancillary to
dental surgery provided in an inpatient or outpatient hospital setting are the
responsibility of the Contractor. In these situations, the professional services
of the dentist are covered by Medicaid fee-for-service. The Contractor should
set up procedures to prior approve dental services provided in inpatient and
ambulatory settings.


    
      
        
          
            Medicaid
Advantage Contract

            APPENDIX
K
State
January 1, 2008
K-8 


          

        

      

      
         


        
          

        

      

      
         


      

    


    As
described in Sections 10.9 and 10.18 of this Agreement, Enrollees may self-refer
to Article 28 clinics operated by academic dental centers to obtain covered
dental services.

     

    If
Contractor's Benefit Package excludes dental services:

     

    
      	
              i)

            	
              Enrollees
      may obtain routine exams, orthodontic services and appliances, dental
      office surgery, fillings, prophylaxis, and other Medicaid covered dental
      services from any qualified Medicaid provider who shall claim
      reimbursement from eMedNY; and

            


    

    
      	
              ii)

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

            


    

     

    Non-Emergency
Transportation (optional benefit outside of NYC)

     

    Transportation
expenses are covered when transportation is essential in order for an Enrollee
to obtain necessary medical care and services which are covered under the
Medicaid program (either as part of the Contractor's Benefit Package or by
fee-for-service Medicaid). Non-emergent transportation guidelines may be
developed in conjunction with the LDSS, based on the LDSS' approved
transportation plan.

     

    Transportation
services means transportation by ambulance, ambulette, fixed wing or airplane
transport, invalid coach, taxicab, livery, public transportation, or other means
appropriate to the Enrollee's medical condition; and a transportation attendant
to accompany the Enrollee, if necessary. Such services may include the
transportation attendant's transportation, meals, lodging and salary; however,
no salary will be paid to a transportation attendant who is a member of the
Enrollee's family.

     

    When the
Contractor is capitated for non-emergency transportation, the Contractor is also
responsible for providing transportation for an Enrollee to obtain Medicaid
covered services that are not part of the Contractor's Benefit
Package.

     

    For
Contractors that cover non-emergency transportation in the Medicaid Advantage
Benefit Package, transportation costs to MMTP services may be reimbursed by
Medicaid FFS in accordance with the LDSS transportation policies in local
districts in which there is a systematic method to discretely identify and
reimburse such transportation costs.

     

    For
Enrollees with disabilities, the method of transportation must reasonably
accommodate their needs, taking into account the severity and nature of the
disability.


    
      
        
          
            
              Medicaid
Advantage Contract

              APPENDIX
K
State
January 1, 2008
K-9

            

          

        

         


      

      
        
          

        

      

      
         


      

    

     

    APPENDIX K3

     

    NON
COVERED SERVICES

     

    The
following services will not be the responsibility of the MCO under the
Medicare/Medicaid program:

     

    Services
Covered by Direct Reimbursement from Original Medicare

    
      	
               
      

            	
              ·

            	
              Hospice
      services provided to Medicare Advantage
members

            


    

    
      	
               
      

            	
              ·

            	
              Other
      services deemed to be covered by Original Medicare by
  CMS

            


    

     

    
      	
               
      

            	
              Services
      Covered by Medicaid Fee for Service

            


    

    
      	
               
      

            	
              ·

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

            


    

    
      	
               
      

            	
              ·

            	
              Skilled
      Nursing Facility (SNF) days not covered by
  Medicare

            


    

    
      	
               
      

            	
              ·

            	
              Personal
      Care Services

            


    

    
      	
               
      

            	
              ·

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

            


    

    
      	
               
      

            	
              ·

            	
              Methadone
      Maintenance Treatment Programs

            


    

    
      	
               
      

            	
              ·

            	
              Certain
      Mental Health Services, including:

            


    

    
      	
               
      

            	
              ·

            	
              Intensive
      Psychiatric Rehabilitation Treatment
Programs

            


    

    
      	
               
      

            	
              ·

            	
              Day
      Treatment

            


    

    
      	
               
      

            	
              ·

            	
              Continuing
      Day Treatment

            


    

    
      	
               
      

            	
              ·

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

            


    

    
      	
               
      

            	
              ·

            	
              Partial
      Hospitalizations

            


    

    
      	
               
      

            	
              ·

            	
              Assertive
      Community Treatment (ACT)

            


    

    
      	
               
      

            	
              ·

            	
              Personalized
      Recovery Oriented Services (PROS)

            


    

    
      	
               
      

            	
              ·

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

            


    

    
      	
               
      

            	
              ·

            	
              Office
      of Mental Retardation and Developmental Disabilities (OMRDD)
      Services

            


    

    
      	
               
      

            	
              ·

            	
              Comprehensive
      Medicaid Case Management

            


    

    
      	
               
      

            	
              ·

            	
              Directly
      Observed Therapy for Tuberculosis
Disease

            


    

    
      	
               
      

            	
              ·

            	
              AIDS
      Adult Day Health Care

            


    

    
      	
               
      

            	
              ·

            	
              HIV
      COBRA Case Management

            


    

    
      	
               
      

            	
              ·

            	
              Adult
      Day Health Care

            


    

    
      	
               
      

            	
              ·

            	
              Personal
      Emergency Response Services
(PERS)

            


    


    
      
        
          
            Medicaid
Advantage Contract

            APPENDIX
K
State
January 1, 2008
K-10 


          

        

      

      
         


        
          

        

      

      
         


      

    


    Medicaid
Advantage Program Optional Benefits

     

    
      	
               
      

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


            


    

    ▪ Non-Emergency
Transportation Services

    ▪ Dental
Service

     

    Both of
these services, however, are mandatory in NYC.


    
      
        
          
            
              Medicaid
Advantage Contract

              APPENDIX
K
State
January 1, 2008
K-11

            

          

        

         


      

      
        
          

        

      

      
         


      

    

     

    DESCRIPTION
OF NON-COVERED SERVICES

     

    The
following services are excluded from the Contractor's Medicare and Medicaid
Benefit Packages, and are covered, in most instances, by Medicare or Medicaid
fee-for-service:

     

    1.         
  Hospice Services Provided to Medicaid Advantage
Enrollees

     

    Hospice
services provided to Medicare Advantage Enrollees by Medicare approved hospice
providers are directly reimbursed by Medicare. Hospice is a coordinated program
of home and inpatient care that provides non-curative medical and support
services for persons certified by a physician to be terminally ill with a life
expectancy of six (6) months or less. Hospice programs provide patients and
families with palliative and supportive care to meet the special needs arising
out of physical, psychological, spiritual, social and economic stresses which
are experienced during the final stages of illness and during dying and
bereavement.

     

    Hospices
are organizations which must be certified under Article 40 of the NYS P.H.L. and
approved by Medicare. All services must be provided by qualified employees and
volunteers of the hospice or by qualified staff through contractual arrangements
to the extent permitted by federal and state requirements. All services must be
provided according to a written plan of care which reflects the changing needs
of the patient/family.

     

    If an
Enrollee in the Contractor's plan becomes terminally ill and receives Hospice
Program services, he or she may remain enrolled and continue to access the
Contractor's Benefit Package while Hospice costs are paid for by Medicare
fee-for-service.

     

    2.      
     Other Services Deemed to be Covered by Original
Medicare by CMS 

     

    3.            Personal
Care Agency Services

     

    Personal
care services (PCS) involve the provision of some or total assistance with
personal hygiene, dressing and feeding and nutritional and environmental support
(meal preparation and housekeeping). Such services must be essential to the
maintenance of the Enrollee's health and safety in his or her own home. The
services must be ordered by a physician, and there has to be a medical need for
the services. Licensed home care services agencies, as opposed to certified home
health agencies, are the primary providers of PCS. Enrollees receiving PCS must
have a stable medical condition and are generally expected to be in receipt of
such services for an extended period of time (years).

     

    Services
rendered by a personal care agency which are approved by the LDSS are not
covered under the Medicare or Medicaid Benefit Packages. Should it be medically
necessary for the PCP to order personal care agency services, the PCP (or the
Contractor on the physician's behalf) must first contact the Enrollee's LDSS
contact person for personal care. The district will determine the Enrollee's
need for personal care agency services and coordinate a plan of care with the
personal care agency.


    
      
        
          
            Medicaid
Advantage Contract

            APPENDIX
K
State
January 1, 2008
K-12 


          

        

      

      
         


        
          

        

      

      
         


      

    

     

    
      	
              4.

            	
              Skilled
      Nursing Facility Days Not Covered by
Medicare

            


    

     

    Skilled
nursing facility days for Medicaid Advantage Enrollees in excess of the first
one hundred (100) days in the benefit period are covered by Medicaid on a fee
for service basis.

     

    
      	
              5.

            	
              Prescription
      Drugs Permitted by State Law, Certain Medical Supplies and Enteral
      Formulas Not Covered by Medicare

            


    

     

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

     

    
      	
              6.

            	
              Out
      of Network Family Planning Services

            


    

     

    As
described in Sections 10.6 and 10.9 of this Agreement, out of network family
planning services provided by qualified Medicaid providers to plan enrollees
will be directly reimbursed by Medicaid fee-for-service at the Medicaid fee
schedule. "Family Planning and Reproductive Health Services" means those health
services which enable Enrollees, including minors who may be sexually active, to
prevent or reduce the incidence of unwanted pregnancy. These include: diagnosis
and all medically necessary treatment, sterilization, screening and treatment
for sexually transmissible diseases and screening for disease and
pregnancy.

     

    Also
included are HIV counseling and testing when provided as part of a family
planning visit. Additionally, reproductive health care includes coverage of all
medically necessary abortions. Elective induced abortions must be covered for
New York City recipients. Fertility services are not covered.

     

    
      	
              7.

            	
              Dental
      (when not in benefit package)

            


    

     

    (See
description in Appendix K-2)

     

    8.           
Non-Emergency Transportation (when not in benefit package)


    
      
        
          Medicaid
Advantage Contract

          
            
              APPENDIX
K
State
January 1, 2008
K-13

            

          

        

         


      

      
        
          

        

      

      
         


      

    


    (See
description in Appendix K-2)

     

    9.       
    Methadone Maintenance Treatment Program
(MMTP)

     

    MMTP
consists of drug detoxification, drug dependence counseling, and rehabilitation
services which include chemical management of the patient with methadone.
Facilities authorized to provide methadone maintenance treatment certified by
the Office of Alcohol and Substance Abuse Services (OASAS) under Part 828 of 14
NYCRR.

     

    10.          Certain
Mental Health Services

     

    The
Contractor is not responsible for the provision and payment of the following
services, which are reimbursed through Medicaid fee-for-service.

     

    
      	
              a.

            	
              Intensive
      Psychiatric Rehabilitation Treatment Programs
  (IPRT)

            


    

     

    IPRT is a
time-limited active psychiatric rehabilitation designed to assist a patient in
forming and achieving mutually agreed upon goals in living, learning, working
and social environments and to intervene with psychiatric rehabilitative
technologies to overcome functional disabilities. IPRT services are certified by
OMH under Part 587 of 14 NYCRR.

     

    b.           Day
Treatment

     

    Day
Treatment is a combination of diagnostic, treatment, and rehabilitative
procedures which, through supervised and planned activities and extensive
client-staff interaction, provides the services of the clinic treatment program,
as well as social training, task and skill training and socialization
activities. These services are certified by OMH under Part 587 of 14
NYCRR.

     

    c.           Continuing
Day Treatment

     

    Continuing
Day Treatment is designed to maintain or enhance current levels of functioning
and skills, maintain community living, and develop self-awareness and
self-esteem. It includes: assessment and treatment planning, discharge planning,
medication therapy, medication education, case management, health screening and
referral, rehabilitative readiness development, psychiatric rehabilitative
readiness determination and referral, and symptom management. These services are
certified by OMH under Part 587 of 14 NYCRR.

     

    
      	
              d.

            	
              Case
      Management for Seriously and Persistently Mentally Ill Sponsored by State
      or Local Mental Health Units

            


    

     

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


    
      
        
          
            Medicaid
Advantage Contract

            APPENDIX
K
State
January 1, 2008
K-14 


          

        

      

      
         


        
          

        

      

      
         


      

    


    Please
note: See generic definition of Comprehensive Medicaid Case Management (CMCM) in
this section.

     

    e.           Partial
Hospitalization Not Covered by Medicare

     

    Provides
active treatment designed to stabilize and ameliorate acute systems, serves as
an alternative to inpatient hospitalization, or reduces the length of a hospital
stay within a medically supervised program by providing the following:
assessment and treatment planning; health screening and referral; symptom
management; medication therapy; medication education; verbal therapy; case
management; psychiatric rehabilitative readiness determination and referral and
crisis intervention. These services are certified by OMH under Part 587 of 14
NYCRR.

     

    f.           
Assertive Community Treatment (ACT)

     

    ACT is a
mobile team-based approach to delivering comprehensive and flexible treatment,
rehabilitation, case management and support services to individuals in their
natural living setting. ACT programs deliver integrated services to recipients
and adjust services over time to meet the recipient's goals and changing needs.
They are operated pursuant to approval or certification by OMH; and receive
Medicaid reimbursement pursuant to Part 508 of 14 NYCRR.

     

    g.           Personalized
Recovery Oriented Services (PROS)

     

    PROS,
licensed and reimbursed pursuant to Part 512 of 14 NYCRR, are designed to assist
individuals in recovery from the disabling effects of mental illness through the
coordinated delivery of a customized array of rehabilitation, treatment, and
support services in traditional settings and in off-site locations. Specific
components of PROS include Community Rehabilitation and Support, Intensive
Rehabilitation, Ongoing Rehabilitation and Support and Clinical
Treatment.

     

    
      	
              11.       
       Rehabilitation Services Provided to Residents of OMH Licensed
      Community Residences (CRs) and Family Based Treatment Programs, as
      follows:

            


    

     

    a.           OMH
Licensed CRs*

     

    Rehabilitative
services in community residences are interventions, therapies and activities
which are medically therapeutic and remedial in nature, and are medically
necessary for the maximum reduction of functional and adaptive behavior defects
associated with a person's mental illness.

     

    b.           Family-Based
Treatment*

     

    Rehabilitative
services in family-based treatment programs are intended to provide treatment to
seriously emotionally disturbed children and youth to promote their successful
functioning and integration into the family, community, school or independent
living situations. Such services are provided in consideration of a child's
developmental stage. Children determined eligible for admission are placed in
surrogate family homes for care and treatment. These services are certified by
OMH under Section 586.3, and Parts 594 and 595 of 14 NYCRR .


    
      
        
          
            
              Medicaid
Advantage Contract

              APPENDIX
K
State
January 1, 2008
K-15

            

          

        

         


      

      
        
          

        

      

      
         


      

    


    12.        
Office of Mental Retardation and Developmental Disabilities (OM D)
Services

     

    
      	
              a.

            	
              Long
      Term Therapy Services Provided by Article 16-Clinic Treatment Facilities
      or Article 28 Facilities

            


    

     

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

     

    
      	
              b.

            	
              Day
      Treatment

            


    

     

    A planned
combination of diagnostic, treatment and rehabilitation services provided to
developmentally disabled individuals in need of a broad range of services, but
who do not need intensive twenty-four (24) hour care and medical supervision.
The services provided as identified in the comprehensive assessment may include
nutrition, recreation, self-care, independent living, therapies, nursing, and
transportation services. These services are generally provided in an
Intermediate Care Facility (ICF) or a comparable setting. These services are
certified by OMRDD under Part 690 of 14 NYCRR.

     

    c.          
Medicaid Service Coordination (MSC)

     

    Medicaid
Service Coordination (MSC) is a Medicaid State Plan service provided by OMRDD
which assists persons with developmental disabilities and mental retardation to
gain access to necessary services and supports appropriate to the needs of the
needs of the individual. MSC is provided by qualified service coordinators and
uses a person centered planning process in developing, implementing and
maintaining an Individualized Service Plan (ISP) with and for a person with
developmental disabilities and mental retardation. MSC promotes the concepts of
a choice, individualized services and consumer satisfaction.

     

    MSC is
provided by authorized vendors who have a contract with OMRDD, and who are paid
monthly pursuant to such contract. Persons who receive MSC must
not permanently reside in an ICF for persons with developmental
disabilities, a developmental center, a skilled nursing facility or any other
hospital or Medical Assistance institutional setting that provides service
coordination. They must also not concurrently be enrolled in any other
comprehensive Medicaid long term service coordination program/service, including
the Care at Home Waiver.


    
      
        
          
            Medicaid
Advantage Contract

            APPENDIX
K
State
January 1, 2008
K-16 


          

        

      

      
         


        
          

        

      

      
         


      

    


    Please
note: See generic definition of Comprehensive Medicaid Case Management (CMCM) in
this section.

     

    d.           Home
And Community Based Services Waivers (HCBS)

     

    The Home
and Community-Based Services Waiver serves persons with developmental
disabilities who would otherwise be admitted to an ICF/MR if waiver services
were not provided. HCBS waivers services include residential habilitation, day
habilitation, prevocational, supported work, respite, adaptive devices,
consolidated supports and services, environmental modifications, family
education and training, live-in caregiver, and plan of care support services.
These services are authorized pursuant to a waiver under Section 1915(c) of the
Social Security Act (SSA).

     

    e.           Services
Provided Through the Care At Home Program (OMRDD)

     

    The OMRDD
Care at Home III, Care at Home IV, and Care at Home VI waivers, serve children
who would otherwise not be eligible for Medicaid because of their parents'
income and resources, and who would otherwise be eligible for an ICF/MR level of
care. Care at Home waiver services include service coordination, respite and
assistive technologies. Care at Home waiver services are authorized pursuant to
a waiver under Section 1915(c) of the (SSA).

     

    13.         Comprehensive
Medicaid Case Management (CMCM)

     

    A program
which provides "social work" case management referral services to a targeted
population (e.g.: teens, mentally ill). A CMCM case manager will assist a client
in accessing necessary services in accordance with goals contained in a written
case management plan. CMCM programs do not provide services directly, but refer
to a wide range of service providers. The nature of these services include:
medical, social, psycho-social, education, employment, financial, and mental
health. CMCM referral to community service agencies and/or medical providers
requires the case manager to work out a mutually agreeable case coordination
approach with the agency/medical providers. Consequently, if an Enrollee of the
Contractor is participating in a CMCM program, the Contractor should work
collaboratively with the CMCM case manager to coordinate the provision of
services covered by the Contractor. CMCM programs will be instructed on how to
identify a managed care Enrollee on eMedNY so that the program can contact the
Contractor or to coordinate service provision.

     

    14.         Directly
Observed Therapy for Tuberculosis Disease

     

    Tuberculosis
directly observed therapy (TB/DOT) is the direct observation of oral ingestion
of TB medications to assure patient compliance with the physician's prescribed
medication regimen. While the clinical management of tuberculosis is covered in
the Benefit Package, TB/DOT where applicable, can be billed directly to MMIS by
any SDOH approved fee-for­service Medicaid TB/DOT Provider. The Contractor
remains responsible for communicating, cooperating and coordinating clinical
management of TB with the TB/DOT Provider.


    
      
        
          
            
              Medicaid
Advantage Contract

              APPENDIX
K
State
January 1, 2008
K-17

            

          

        

         


      

      
        
          

        

      

      
         


      

    

     

    15.         AIDS
Adult Day Health Care

     

    Adult Day
Health Care Programs (ADHCP) are programs designed to assist individuals with
HIV disease to live more independently in the community or eliminate the need
for residential health care services. Registrants in ADHCP require a greater
range of comprehensive health care services than can be provided in any single
setting, but do not require the level of services provided in a residential
health care setting. Regulations require that a person enrolled in an ADHCP must
require at least three (3) hours of health care delivered on the basis of at
least one (1) visit per week. While health care services are broadly defined in
this setting to include general medical care, nursing care, medication
management, nutritional services, rehabilitative services, and substance abuse
and mental health services, the latter two (2) cannot be the sole reason for
admission to the program. Admission criteria must include, at a minimum, the
need for general medical care and nursing services.

     

    16.         HIV
COB Case Management

     

    The HIV
COBRA (Community Follow-up Program) Case Management Prograrn is a program that
provides intensive, family-centered case management and community follow-up
activities by case managers, case management technicians, and community
follow-up workers. Reimbursement is through an hourly rate billable to Medicaid.
Reimbursable activities include intake, assessment, reassessment, service plan
development and implementation, monitoring, advocacy, crisis intervention, exit
planning, and case specific supervisory case-review conferencing.

     

    17.         Adult
Day Health Care

     

    Adult Day Health Care means
care and services provided to a registrant in a residential health care facility
or approved extension site under the medical direction of a physician and which
is provided by personnel of the adult day health care program in accordance with
a comprehensive assessment of care needs and an individualized health care plan,
and providing ongoing implementation and coordination of the health care plan,
and transportation.

     

    Registrant means a person who
is a nonresident of the residential health care facility, who is functionally
impaired and not homebound, and who requires certain preventive, diagnostic,
therapeutic, rehabilitative or palliative items or services provided by a
general hospital, or residential health care facility; and whose assessed social
and health care needs, in the professional judgment of the physician of record,
nursing staff, Social Services and other professional personnel of the adult day
health care program can be met satisfactorily in whole or in part by delivery of
appropriate services in such program.

     

    18.         Personal
Emergency Response Services (PERS)

     

    Personal
Emergency Response Services (PERS) are not covered by the Benefit Package. PERS
are covered on a fee-for-service basis through contracts between the LDSS and
PERS vendors.


    
      
        
          
            Medicaid
Advantage Contract

            APPENDIX
K
State
January 1, 2008
K-18 


          

        

      

      
         


        
          

        

      

      
         


      

    


    APPENDIX
L

     

    Approved
Capitation Payment Rates


    
      
        
          
            
              Medicaid
Advantage Contract

              APPENDIX
L
State
January 1, 2008
L1

            

          

        

         


      

      
        
          

        

      

      
         


      

    


    WELLCARE
OF NEW YORK, INC.

    Dual
Eligible Medicaid Managed Care Rates

    


    


    
      	
              MMIS
      ID#:

            	
              02645710

            	
              Effective
      Date: 01/01/08

            
	
              Region:

            	
              Upstate

            	 
      
	
              County:

            	
              Albany

            	 
      


    

     

     

    
      	
              Rate
      Code

            	
              Premium Group

            	
              Rate Amount

            
	
              2370

            	
              DUALLY
      ELIGIBLE SSI 21-64 MALE/FEMALE

            	
              $35.37

            
	
              2371

            	
              DUALLY
      ELIGIBLE SSI 65+ MALE/FEMALE

            	
              $33.54

            


    

     

    Optional Benefits
Offered:-

    
      	
              o

            	
              Dental

            


    

    
      	
              o

            	
              Non-Emergent
      Transportation

            


    

     

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