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    Exhibit
      10.1
 

    
      
        
          APPENDIX
            X

        

        
          [Amendment
            Number 5]

        

        
          


        

        
          	
                  Agency
                    Code 12000

                	
                  Contract
                    No. C020454

                
	
                  Period
                    4/1/07-9/30/08

                	
                  Funding
                    Amount for Period Based
                    on approved
                    capitation rates

                


        

        
          


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

        

        
          


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

        

        
          


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

        

        
          


          3.6   SDOH
            Right to Recover Premiums

        

        
          


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

        

        
          


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

        

        
          


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

        

        
          


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

        

        
          


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

        

        
          


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

        

        
          


          Appendix
            X

        

        
          MMC/FHPlus
            Contract Amendment

        

        
          April
            1,
            2007

        

        
          Page
            1

        


        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        


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

        

        
          


          iv)
            all
            documents concerning duplicate CINs;

        

        
          


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

        

        
          


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

        

        
          


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

        

        
          


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

        

        
          


          19.3   Access
            to Contractor Records

        

        
          


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

        

        
          


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

        

        
          


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

        

        
          


          I)  Oral

        

        
          II) Oral,
            emergency

        

        
          III)
            Injectable

        

        
          Appendix
            X


        

        
          MMC/FHPIus
            Contract Amendment

        

        
          April
            1,
            2007

        

        
          Page
            2

        


        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        


        
          IV)
            Transdermal

        

        
          V) 
            Intravaginal

        

        
          VI)
            Intravaginal, systemic

        

        
          VII)
            Implantable

        

        
          


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

        

        
          


          7.   The
            attached Appendix L,
            "Approved Capitation Payment Rates," is substituted for the period beginning
            April 1,
            2007.

           

        

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

        

        
          


        

        
          


        

        
          


        

        
          


        

        
          Appendix
            X

        

        
          MMC/FHPlus
            Contract Amendment

        

        
          April
            1,
            2007

        

        
          Page
            3

        

        
          


          


        

        
          


          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

          


        

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

        
          


        

        
          


        

        
          	
                  CONTRACTOR
                    SIGNATURE

                	
                  STATE
                    AGENCY SIGNATURE

                
	
                  By:
                      /s/   Todd
                    S. Farha

                	
                  By:   /s/   Vallencia
                    Lloyd

                
	
                  Todd
                    S. Farha

                  
                  

                	
                  Vallencia
                    Lloyd

                
	
                  Title:
                    President and CEO

                	
                  Title:
                    Deputy Director, DMC & PE

                
	
                  Date:
                    10/5/07

                	
                  Date:
                    11/2/07

                  
                  

                
	 	
                  State
                    Agency Certification:

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

                


        

        
           

        

        
          


        

        
          STATE
            OF
            FLORIDA

        

        
          County
            of
            Hillsborough

        

        
          


        

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

        

        
          


        

        
          


        

        
            /s/  Sara
            L. Gallo

        

        
          (Notary)

        

        
           

        

        
          	
                  Approved:

                	
                  Approved

                   

                
	
                  
                  

                  ATTORNEY
                    GENERAL 
                     

                     

                    (STAMP)

                    APPROVED
                      AS TO FORM NYS ATTORNEY
                      GENERAL

                    NOV
                      23 2007

                    LORRAINE
                      I. REMO

                    ASSOCIATE
                      ATTORNEY

                     

                  

                	
                  Thomas
                    P. DiNapoli

                  STATE
                    COMPTROLLER

                   

                  (STAMP)

                  APPROVED

                  DEPT.
                    OF AUDIT &
                    CONTROL

                  DEC
                    13 2007

                  Illegible

                  FOR
                    THE STATE
                    COMPTROLLER

                   

                
	
                  Title:

                	
                  Title:

                
	
                  Date:

                	
                  Date:

                
	 	 


        

        
          


        

        
          


        

        
          
            
              Appendix
                X

            

            
              MMC/FHPlus
                Contract Amendment

            

            
              April
                1,
                2007

            

            
              Page
                4

            



          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        
          


        

        
           

        

        
          APPENDIX
            H

        

        
           

          New
            York
            State Department of Health Requirements

        

        
          for
            the
            Processing of Enrollments and Disenrollments

        

        
          in
            the
            MMC and FHPlus Programs

        

        
          


           

          APPENDIX
            H

        

        
          April
            1,
            2007

        

        
          H-l

           

           

        


        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        


        
          SDOH
            Requirements

        

        
          for
            the Processing of Enrollments and Disenrollments

        

        
          in
            the MMC and FHPlus Programs

        

        
          


          1.  General

        

        
          


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

        

        
          


          2.
            Enrollment

        

        
          


          a)
            SDOH
            Responsibilities:

        

        
          


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

        

        
          


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

        

        
          


          b)
            LDSS
            Responsibilities:

        

        
          


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

        

        
          


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

        

        
          


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

        

        
          


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

        

        
          


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

        

        
          


          APPENDIX
            H

        

        
          April
            1,
            2007

        

        
          H-2

        


        
           

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

        

        
          


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

        

        
          


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

        

        
          


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

        

        
          


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

        

        
          


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

        

        
          


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

        

        
          


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

        

        
          


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

        

        
          


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

        

        
          


          APPENDIX
            H

        

        
          April
            1,
            2007

        

        
          H-3


        

        
           

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

        

        
          


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

        

        
          


          A)  LDSS
            directly enters data into PCP Subsystem; or

        

        
          


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

        

        
          


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

        

        
          


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

        

        
          


          A)
            For
            mandatory MMC program only - Initial Notification Letter: This letter
            informs
            Eligible Persons about the mandatory MMC program and the timeframes for
            choosing
            a MCO offering a MMC product. Included with the letter are managed care
            brochures, an Enrollment form, and information on their rights and
            responsibilities under this program, including the option for HIV/AIDS
            infected
            individuals who are categorically exempt from the mainstream MMC program
            to
            enroll in an HIV SNP on a voluntary basis in LDSS jurisdictions where
            HIV SNPs
            exist.

        

        
          


          B)
            For
            mandatory MMC program only - Reminder Letter: A letter to all Eligible
            Persons
            in a mandatory category who have not responded by submitting a completed
            Enrollment form within thirty (30) days of being sent or given an Enrollment
            packet.

        

        
          


          C)
            For
            MMC program - Enrollment Confirmation Notice for MMC Enrollees: This
            notice
            indicates the Effective Date of Enrollment, the name of the MCO and all
            individuals who are being enrolled. This notice should also be used for
            case
            additions and re-enrollments into the same MCO. There is no requirement
            that an
            Enrollment Confirmation Notice be sent to FHPlus Enrollees.

        

        
          


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

        

        
          


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


        

        


        
          


          APPENDIX
            H

        

        
          April
            1,
            2007

        

        
          H-4

           

        


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

        

        
          


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

        

        
          


          c)   Contractor
            Responsibilities:

        

        
          


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

        

        
          


          ii)
            The
            Contractor must notify new MMC and FHPlus Enrollees of their Effective
            Date of
            Enrollment. In the event that the actual Effective Date of Enrollment
            is
            different from that previously given to the Enrollee, the Contractor
            must notify
            the Enrollee of the actual date of Enrollment. This may be accomplished
            through
            a Welcome Letter. To the extent practicable, such notification must precede
            the
            Effective Date of Enrollment.

        

        
          


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

        

        
          


          iv)
            The
            Contractor must report any changes that affect or may affect the eligibility
            status of its enrolled members to the LDSS within five (5) business days
            of such
            information becoming known to the Contractor. This includes, but is not
            limited
            to, address changes, verification of pregnancy, incarceration, third
            party
            insurance, etc.

        

        
          


          APPENDIX
            H

        

        
          April
            1,
            2007

        

        
          H-5

        


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

        

        
          


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

        

        
          


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

        

        
          


          3. Newborn
            Enrollments

        

        
          


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

        

        
          


          b)
            SDOH
            Responsibilities:

        

        
          


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

        

        
          


          ii)
            Upon
            notification of the birth by the hospital or birthing center, the SDOH
            will
            update WMS with the demographic data for the newborn and enroll the newborn
            in
            the mother's MCO if the newborn is not already enrolled, the mother's
            MCO offers
            a MMC product, and the newborn is not identified as SSI or SSI-related
            and
            therefore Excluded from the MMC Program pursuant to Section 2(b)(xi)
            of this
            Appendix. The newborn will be retroactively enrolled back to the first
            (1st)
            day of
            the month of birth. Based on the transaction date of the Enrollment of
            the
            newborn on the PCP subsystem, the newborn will appear on either the next
            month's
            Roster or the subsequent month's Roster. On Rosters for upstate and NYC,
            the
            "PCP Effective From Date" will indicate the first day of the month of
            birth, as
            described in 01 OMM/ADM 5 "Automatic Medicaid Enrollment for Newborns."
            If the
            newborn's Enrollment is not completed by this process, the LDSS is responsible
            for Enrollment (see (c)(iv) below).

        

        
          


          c)
            LDSS
            Responsibilities:

        

        
          


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

        

        
          


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

        

        
          


          APPENDIX
            H

        

        
          April
            1,
            2007

        

        
          H-6

        


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

        

        
          


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

        

        
          


          Contractor
            Responsibilities:

        

        
          


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

        

        
          


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

        

        
          


          iii)
            In
            districts that use an Enrollment Broker, the Contractor shall not submit
            electronic Enrollments of newborns to the Enrollment Broker, because
            this will
            interfere with the retroactive Enrollment of the newborn back to the
            first
            (1st)
            day of
            the month of birth. For newborns whose mothers are not enrolled in the
            Contractor's MMC or FHPlus product and who were not pre-enrolled into
            the
            Contractor's MMC product as unborns, the Contractor may submit electronic
            Enrollment of the newborns to the Enrollment Broker. In such cases, the
            Effective Date of Enrollment will be prospective.

        

        
          


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

        

        
          


          v)
            The
            Contractor is responsible for provision of services to a newborn and
            payment of
            the hospital or birthing center bill if the mother is an Enrollee at
            the time of
            the newborn's birth, even if the newborn is not yet on the Roster, unless
            the
            Contractor does not offer a MMC product in the mother's county of
            fiscal

        

        
          


          APPENDIX
            H

        

        
          April
            1,
            2007

        

        
          H-7

        


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

        

        
          


          vi)
            Within fourteen (14) days of the date on which the Contractor becomes
            aware of
            the birth, the Contractor will issue a letter, informing parent(s) about
            the
            newborn's Enrollment and how to access care, or a member identification
            card.

        

        
          


        

        
          vii)
            In
            those cases in which the Contractor is aware of the pregnancy, the Contractor
            will ensure that enrolled pregnant women select a PCP for their infants
            prior to
            birth.

        

        
          


          viii)The
            Contractor will ensure that the newborn is linked with a PCP prior to
            discharge
            from the hospital or birthing center, in those instances in which the
            Contractor
            has received appropriate notification of birth prior to
            discharge.

        

        
          


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

        

        
          


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

        

        
          


          b)
            SDOH
            Responsibilities:

        

        
          


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

        

        
          


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

        

        
          


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

        

        
          


          c)
            LDSS
            Responsibilities:

        

        
          


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

        

        
          


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

        

        
          


          d)
            Contractor Responsibilities:

        

        
          


          APPENDIX
            H

        

        
          April
            1,
            2007

        

        
          H-8

        


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

        

        
          


          5.
            Roster Reconciliation:

        

        
          


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

        

        
          


          b)
            SDOH
            Responsibilities:

        

        
          


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

        

        
          


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

        

        
          


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

        

        
          


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

        

        
          


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

        

        
          


          c)
            LDSS
            Responsibilities:

        

        
          


          i)
            The
            LDSS is responsible for notifying the Contractor electronically or in
            writing of
            changes in the Roster and error report, no later than the end of the
            month.
            (Note: To the extent practicable the date specified must allow for timely
            notice
            to Enrollees regarding their Enrollment status. The Contractor and the
            LDSS may
            develop protocols for the purpose of resolving Roster discrepancies that
            remain
            unresolved beyond the end of the month.)

        

        
          


          APPENDIX
            H

        

        
          April
            1,
            2007

        

        
          H-9

        


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

        

        
          


          d)  Contractor
            Responsibilities:

        

        
          


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

        

        
          


          ii)
            The
            Contractor must submit claims to the State's Fiscal Agent for all Eligible
            Persons that are on the 1st
            and
            2nd
            Rosters, adjusted to add Eligible Persons enrolled by the LDSS after
            Roster
            production and to remove individuals disenrolled by LDSS after Roster
            production
            (as notified to the Contractor). In the cases of retroactive Disenrollments,
            the
            Contractor is responsible for submitting an adjustment to void any previously
            paid premiums for the period of retroactive Disenrollment, where the
            Contractor
            was not at risk for the provision of Benefit Package services. Payment
            of
            subcapitation does not constitute "provision of Benefit Package
            services."

        

        
          


          6. Disenrollment:

        

        
          


          a)   LDSS
            Responsibilities:

        

        
          


          i)
            The
            LDSS is responsible for accepting requests for Disenrollment directly
            from
            Enrollees and may not require Enrollees to approach the Contractor for
            a
            Disenrollment form. Where an LDSS is authorized to mandate Enrollment,
            all
            requests for Disenrollment must be directed to the LDSS or the Enrollment
            Broker. The LDSS and the Enrollment Broker must utilize the State-approved
            Disenrollment forms.

        

        
          


          ii)
            Enrollees may initiate a request for an expedited Disenrollment to the
            LDSS. The
            LDSS will expedite the Disenrollment process in those cases where an
            Enrollee's
            request for Disenrollment involves an urgent medical need, a complaint
            of
            non­consensual Enrollment or, in local districts where homeless individuals
            are exempt, homeless individuals in the shelter system. If approved,
            the LDSS
            will manually process the Disenrollment through the PCP Subsystem. MMC
            Enrollees
            who request to be disenrolled from managed care based on their documented
            HIV,
            ESRD, or SPMI/SED status are categorically eligible for an expedited
            Disenrollment on the basis of urgent medical need.

        

        
          


          iii)
            The
            LDSS is responsible for processing routine Disenrollment requests to
            take effect
            on the first (lst)
            day of
            the following month if the request is made before the fifteenth (15th)
            day of
            the month. In no event shall the Effective Date of Disenrollment be later
            than
            the first (1st)
            day of
            the second month after the month in which an Enrollee requests a
            Disenrollment.

        

        
          


          APPENDIX
            H 

          April
            1,
            2007

        

        
          H-10

        


        
          iv)
            The
            LDSS is responsible for disenrolling Enrollees automatically upon death
            or loss
            of Medicaid or FHPlus eligibility. All such Disenrollments will be effective
            at
            the end of the month in which the death or loss of eligibility occurs
            or at the
            end of the last month of Guaranteed Eligibility, where
            applicable.


        

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

        

        
          


          A)
            The
            Contractor has failed to furnish accessible and appropriate medical care
            services
            or supplies to which the Enrollee is entitled under the terms, of the
            contract
            under which the Contractor has agreed to provide services.
            This

        

        
          includes,
            but is not limited to the failure to:

        

        
          I)
            provide primary care services;

        

        
          II)
            arrange for in-patient care, consultation with specialists, or laboratory
            and
            radiological services when reasonably necessary;

        

        
          III)
            arrange for consultation appointments;

        

        
          IV)
            coordinate and interpret any consultation findings with emphasis on continuity
            of medical care;

        

        
          V)
            arrange for services with qualified licensed or certified
            providers;

        

        
          VI)
            coordinate the Enrollee's overall medical care such as periodic immunizations
            and diagnosis and treatment of any illness or injury; or

        

        
          


          B)
            The
            Contractor cannot make a Primary Care Provider available to the Enrollee
            within
            the time and distance standards prescribed by SDOH; or

        

        
          C)
            The
            Contractor fails to adhere to the standards prescribed by SDOH and such
            failure
            negatively and specifically impacts the Enrollee; or

        

        
          D)
            The
            Enrollee moves his/her residence out of the Contractor's service area
            or to a
            county where the Contractor does not offer the product the Enrollee is
            eligible
            for; or

        

        
          E)
            The
            Enrollee meets the criteria for an Exemption or Exclusion as set forth
            in2(b)(xi)
            of this Appendix; or

        

        
          F)
            It is
            determined by the LDSS, the SDOH. or its agent that the Enrollment was
            not
            consensual; or

        

        
          


          APPENDIX
            H

        

        
          April
            1,
            2007

        

        
          H-ll

        


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

        

        
          


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

        

        
          


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

        

        
          


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

        

        
          


          K)
            An
            FHPlus Enrollee is pregnant.

        

        
          


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

        

        
          


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

        

        
          


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

        

        
          


          ix)
            The
            LDSS is responsible for ensuring that retroactive Disenrollments are
            used only
            when absolutely necessary. Circumstances warranting a retroactive Disenrollment
            are rare and include when an Enrollee is determined to have been
            non-consensually enrolled in a MCO; he or she enters or resides in a
            residential
            institution under circumstances which render the individual Excluded
            from the
            MMC program; is incarcerated; is an SSI infant less than six (6) months
            of age;
            is simultaneously in receipt of comprehensive health care coverage from
            an MCO
            and is enrolled in either the MMC or FHPlus product of the same MCO;
            or he or
            she has died - as long as the Contractor was not at risk for provision
            of
            Benefit Package services for any portion of the retroactive period. Payment
            of
            subcapitation does not constitute "provision of Benefit Package services."
            Notwithstanding the foregoing, the SDOH always has the right to recover
            duplicate MMC or FHPlus premiums paid for persons enrolled under more
            than

        

        
          


          APPENDIX
            H

        

        
          April
            1,
            2007

        

        
          H-12

        


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

        

        
          


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

        

        
          


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

        

        
          


          APPENDIX
            H

        

        
          April
            1,
            2007

        

        
          H-13

        

        
          


        

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

        

        


        
          	
                  Reason
                    for Disenrollment

                	 	
                  Effective
                    Date of Disenrollment

                
	
                  
                    A)
                      Infants weighing less than 1200 grams at birth and other infants
                      under six
                      (6) months of age who meet the criteria for the SSI or SSI
                      re1ated
                      category

                     

                  

                	 	
                  First
                    Day of the month of birth of the month of onset of disability,
                    whichever
                    is later.

                
	
                  
                    B)
                      Death of Enrollee

                     

                  

                	 	
                  
                    First
                      day of the month after death

                  

                
	
                  
                    C)
                      Incarceration

                  

                  
                  

                	 	
                  First
                    day of the month of incarceration (note- Contractor is at risk
                    for covered
                    services only to the date of incarceration and is entitled to
                    the
                    capitation payment for the month of incarceration)

                   

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

                     

                  

                	 	
                  
                    First
                      day of the month of entry or first day of the month of classification
                      of
                      the stay as permanent subsequent to entry (note-Contractor
                      is at risk for
                      covered services only to the date of entry or classification
                      of the stay
                      as permanent subsequent to entry, and is entitled to the capitation
                      payment for the month of entry or classification of the stay
                      as permanent
                      subsequent to entry)

                  

                
	
                  
                  

                  
                    
                    

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

                     

                  

                	 	
                  
                    Effective
                      Date of Enrollment in the Contractor's Plan

                  

                
	
                  
                  

                  
                    
                    

                    F)
                      Non-consensual Enrollment

                     

                  

                	 	
                  
                    Retroactive
                      to the first day of the month of the request

                  

                
	
                  G)
                    Enrollee moved outside of the District/County of Fiscal
                    Responsibility

                   

                	 	
                  
                    First
                      day of the month after the update of the system with the new
                      address1

                  

                
	
                  
                    H)
                      Urgent medical need

                     

                  

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

                  

                
	
                  
                    I)  Homeless
                      Enrollees in Medicaid Managed Care residing in the shelter
                      system in NYC
                      or in other districts where homeless individuals are exempt

                     

                  

                	 	
                  
                    Retroactive
                      to the first day of the month of the request

                  

                
	
                  
                    J)
                      Individual is simultaneously in receipt of comprehensive health
                      care
                      coverage from an MCO and is Enrolled in either the MMC or FHPIus
                      product
                      of the same MCO

                     

                  

                	 	
                  
                    First
                      day of the month after simultaneous coverage
                      began

                  

                
	
                  
                  

                  
                    
                    

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

                  

                	 	
                  
                    First
                      day of the month the duplicate Enrollment
                      began

                  

                


        

        
          


          1
            In
            counties outside of New York City, LDSSs should work together to ensure
            continuity of care through the Contractor if the Contractor's service
            area
            includes the county to which the Enrollee has moved and the Enrollee,
            with
            continuous eligibility, wishes to stay enrolled in the Contractor's MMC
            or
            FHPIus product. In New York City, Enrollees, not in guaranteed status,
            who move
            out of the Contractor's Service Area but not outside of the City of New
            York
            (e.g., move from one borough to another), will not be involuntarily disenrolled,
            but must request a Disenrollment or transfer. These Disenrollments will
            be
            performed on a routine basis unless there is an urgent medical need to
            expedite
            the Disenrollment.

        

        
          


          APPENDIX
            H

        

        
          April
            1,
            2007

        

        
          H-14

        


        
           

          xiii)
            The
            LDSS is responsible for rendering a determination and responding within
            thirty
            (30) days of the receipt of a fully documented request for Disenrollment,
            except
            for Contractor-initiated Disenrollments where the LDSS decision must
            be made
            within fifteen (15) days. The LDSS, to the extent possible, is responsible
            for
            processing an expedited Disenrollment within two (2) business days of
            its
            determination that an expedited Disenrollment is warranted.

        

        
          


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

        

        
          


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

        

        
          


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

        

        
          


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

        

        
          


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

        

        
          


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

        

        
          


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

        

        
          


          APPENDIX
            H

        

        
          April
            1,
            2007

        

        
          H-15

        


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

        

        
          


        

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

        

        
          


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

        

        
          


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

        

        
          


          b)  Contractor
            Responsibilities:

        

        
          


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

        

        
          


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

        

        
          


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

        

        
          


          APPENDIX
            H

        

        
          April
            1,
            2007

        

        
          H-16

           

        


        
          iv)
            Pursuant to Section 8.7 of this Agreement, the Contractor may initiate
            an
            involuntary Disenrollment if the Enrollee engages in conduct or behavior
            that
            seriously impairs the Contractor's ability to furnish services to either
            the
            Enrollee or other Enrollees, provided that the Contractor has made and
            documented reasonable efforts to resolve the problems presented by the
            Enrollee.

        

        
          


        

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

        

        
          


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

        

        
          


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

        

        
          


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

        

        
          


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

        

        
          


          APPENDIX
            H

        

        
          April
            1,
            2007

        

        
          H-17

        


        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        


        
          APPENDIX
            L

        

        
          Approved
            Capitation Payment Rates

        

        
          


          APPENDIX
            L

        

        
          April
            1,
            2007

        

        
          L-l

        


        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        


        
          WELLCARE
            OF  NEW YORK,   INC.

        

        
          Medicaid
            Managed Care Rates

        

        
          


        

        
          	
                  MMIS  ID#:  01182503

                	
                  Effective
                    Date:   04/01/07

                
	
                  Approved
                    by DOB: Yes

                	
                  Region:
                    Northeast

                
	
                  Reinsurance:   No

                	
                  County:   ALBANY

                


        

        
          


        

        
          


        

        
          	
                  Premium
                    Group

                	
                  Rate
                    Amount

                
	
                  TANF/SN  <6mo
                    M/F

                	
                  $266.66

                
	
                  TANF/SN  6mo-14  F

                	
                  $90.84

                
	
                  TANF/SN  15-20   F

                	
                  $132.88

                
	
                  TANF/SN  6mo-20  M

                	
                  $88.65

                
	
                  TANF
                    21-64 M/F

                	
                  $215.57

                
	
                  SN  21-29  M/F

                	
                  $204.54

                
	
                  SN  30-64  M/F

                	
                  $370.80

                
	
                  SSI
                    6mo-20  M/F

                	
                  $179.30

                
	
                  SSI
                    21-64 M/F

                	
                  $500.80

                
	
                  SSI
                    65+ M/F

                	
                  $445.49

                
	
                  Maternity  Kick  Payment

                	
                  $5,224.57

                
	
                  Newborn  Kick  Payment

                	
                  $1,804.39

                


        

        
          


        

        
          


        

        
          	
                  Optional   Benefits  Offered:

                	 
	
                  R
                    Emergency    Transportation

                	
                  £
                    Dental

                
	
                  R
                    Non-Emergent    Transportation

                	
                  R
                    Family  Planning

                


        

        
           

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

        


        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        


        
          WELLCARE
            OF  NEW YORK,   INC.

        

        
          Medicaid
            Managed Care Rates

        

        
          


        

        
          	
                  MMIS  ID#:  01182503

                	
                  Effective
                    Date:   04/01/07

                
	
                  Approved
                    by DOB: Yes

                	
                  Region:  Central

                
	
                  Reinsurance:   No

                	
                  County:   COLUMBIA

                


        

        
          


        

        
          


        

        
          	
                  Premium
                    Group

                	
                  Rate
                    Amount

                
	
                  TANF/SN  <6mo
                    M/F

                	
                  $259.46

                
	
                  TANF/SN  6mo-14  F

                	
                  $85.50

                
	
                  TANF/SN  15-20   F

                	
                  $143.93

                
	
                  TANF/SN  6mo-20  M

                	
                  $85.89

                
	
                  TANF
                    21-64 M/F

                	
                  $234.78

                
	
                  SN  21-29  M/F

                	
                  $220.56

                
	
                  SN  30-64  M/F

                	
                  $376.32

                
	
                  SSI
                    6mo-20  M/F

                	
                  $183.98

                
	
                  SSI
                    21-64 M/F

                	
                  $483.54

                
	
                  SSI
                    65+ M/F

                	
                  $400.37

                
	
                  Maternity  Kick  Payment

                	
                  $5,603.31

                
	
                  Newborn  Kick  Payment

                	
                  $2,059.21

                


        

        
          


        

        
          


        

        
          	
                  Optional   Benefits  Offered:

                	 
	
                  R
                    Emergency    Transportation

                	
                  £
                    Dental

                
	
                  R
                    Non-Emergent    Transportation

                	
                  R
                    Family  Planning

                


        

        
           

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

        


        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        


        
          


        

        
          


        

        
          WELLCARE
            OF  NEW YORK,   INC.

        

        
          Medicaid
            Managed Care Rates

        

        
          


        

        
          	
                  MMIS  ID#:  01182503

                	
                  Effective
                    Date:   04/01/07

                
	
                  Approved
                    by DOB: Yes

                	
                  Region:
                    Mid-Hudson

                
	
                  Reinsurance:   No

                	
                  County:   DUTCHESS

                


        

        
          


        

        
          


        

        
          	
                  Premium
                    Group

                	
                  Rate
                    Amount

                
	
                  TANF/SN  <6mo
                    M/F

                	
                  $272.19

                
	
                  TANF/SN  6mo-14  F

                	
                  $96.26

                
	
                  TANF/SN  15-20   F

                	
                  $139.03

                
	
                  TANF/SN  6mo-20  M

                	
                  $105.93

                
	
                  TANF
                    21-64 M/F

                	
                  $234.51

                
	
                  SN  21-29  M/F

                	
                  $215.62

                
	
                  SN  30-64  M/F

                	
                  $436.83

                
	
                  SSI
                    6mo-20  M/F

                	
                  $181.04

                
	
                  SSI
                    21-64 M/F

                	
                  $496.83

                
	
                  SSI
                    65+ M/F

                	
                  $433.14

                
	
                  Maternity  Kick  Payment

                	
                  $5,792.84

                
	
                  Newborn  Kick  Payment

                	
                  $2,367.65

                


        

        
          


        

        
          


        

        
          	
                  Optional   Benefits  Offered:

                	 
	
                  R
                    Emergency    Transportation

                	
                  £
                    Dental

                
	
                  £
                    Non-Emergent    Transportation

                	
                  R
                    Family  Planning

                


        

        
           

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

        

        
          


        

        
          


        

        
          


          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        
           

        

        
          


        

        
          WELLCARE
            OF  NEW YORK,   INC.

        

        
          Medicaid
            Managed Care Rates

        

        
          


        

        
          	
                  MMIS  ID#:  01182503

                	
                  Effective
                    Date:   04/01/07

                
	
                  Approved
                    by DOB: Yes

                	
                  Region:  Central

                
	
                  Reinsurance:   No

                	
                  County:  GREENE

                


        

        
          


        

        
          


        

        
          	
                  Premium
                    Group

                	
                  Rate
                    Amount

                
	
                  TANF/SN  <6mo
                    M/F

                	
                  $257.23

                
	
                  TANF/SN  6mo-14  F

                	
                  $83.67

                
	
                  TANF/SN  15-20   F

                	
                  $141.62

                
	
                  TANF/SN  6mo-20  M

                	
                  $84.02

                
	
                  TANF
                    21-64 M/F

                	
                  $231.91

                
	
                  SN  21-29  M/F

                	
                  $217.76

                
	
                  SN  30-64  M/F

                	
                  $373.21

                
	
                  SSI
                    6mo-20  M/F

                	
                  $180.88

                
	
                  SSI
                    21-64 M/F

                	
                  $479.49

                
	
                  SSI
                    65+ M/F

                	
                  $398.65

                
	
                  Maternity  Kick  Payment

                	
                  $5,603.31

                
	
                  Newborn  Kick  Payment

                	
                  $2,059.21

                


        

        
          


        

        
          


        

        
          	
                  Optional   Benefits  Offered:

                	 
	
                  R
                    Emergency    Transportation

                	
                  £
                    Dental

                
	
                  £
                    Non-Emergent    Transportation

                	
                  R
                    Family  Planning

                


        

        
           

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

        

        
          


        

        
          


          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        
           

          WELLCARE
            OF  NEW YORK,   INC.

        

        
          Medicaid
            Managed Care Rates

        

        
          


        

        
          	
                  MMIS  ID#:  01182503

                	
                  Effective
                    Date:   04/01/07

                
	
                  Approved
                    by DOB: Yes

                	
                  Region:
                    Mid-Hudson

                
	
                  Reinsurance:   No

                	
                  County:   ORANGE

                


        

        
          


        

        
          


        

        
          	
                  Premium
                    Group

                	
                  Rate
                    Amount

                
	
                  TANF/SN  <6mo
                    M/F

                	
                  $268.99

                
	
                  TANF/SN  6mo-14  F

                	
                  $95.49

                
	
                  TANF/SN  15-20   F

                	
                  $135.91

                
	
                  TANF/SN  6mo-20  M

                	
                  $104.90

                
	
                  TANF
                    21-64 M/F

                	
                  $231.09

                
	
                  SN  21-29  M/F

                	
                  $211.14

                
	
                  SN  30-64  M/F

                	
                  $430.70

                
	
                  SSI
                    6mo-20  M/F

                	
                  $177.21

                
	
                  SSI
                    21-64 M/F

                	
                  $488.48

                
	
                  SSI
                    65+ M/F

                	
                  $428.29

                
	
                  Maternity  Kick  Payment

                	
                  $5,792.84

                
	
                  Newborn  Kick  Payment

                	
                  $2,367.65

                


        

        
          


        

        
          


        

        
          	
                  Optional   Benefits  Offered:

                	 
	
                  £
                    Emergency    Transportation

                	
                  £
                    Dental

                
	
                  £
                    Non-Emergent    Transportation

                	
                  R
                    Family  Planning

                


        

        
           

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

           

        

        
          


          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        
          


        

        
           

        

        
          WELLCARE
            OF  NEW YORK,   INC.

        

        
          Medicaid
            Managed Care Rates

        

        
          


        

        
          	
                  MMIS  ID#:  01182503

                	
                  Effective
                    Date:   04/01/07

                
	
                  Approved
                    by DOB: Yes

                	
                  Region:
                    Northeast

                
	
                  Reinsurance:   No

                	
                  County:   RENSSELAER

                


        

        
          


        

        
          


        

        
          	
                  Premium
                    Group

                	
                  Rate
                    Amount

                
	
                  TANF/SN  <6mo
                    M/F

                	
                  $264.44

                
	
                  TANF/SN  6mo-14  F

                	
                  $89.01

                
	
                  TANF/SN  15-20   F

                	
                  $130.59

                
	
                  TANF/SN  6mo-20  M

                	
                  $86.79

                
	
                  TANF
                    21-64 M/F

                	
                  $212.69

                
	
                  SN  21-29  M/F

                	
                  $201.74

                
	
                  SN  30-64  M/F

                	
                  $367.69

                
	
                  SSI
                    6mo-20  M/F

                	
                  $176.21

                
	
                  SSI
                    21-64 M/F

                	
                  $496.76

                
	
                  SSI
                    65+ M/F

                	
                  $443.78

                
	
                  Maternity  Kick  Payment

                	
                  $5,224.57

                
	
                  Newborn  Kick  Payment

                	
                  $1,804.39

                


        

        
          


        

        
          


        

        
          	
                  Optional   Benefits  Offered:

                	 
	
                  R
                    Emergency    Transportation

                	
                  £
                    Dental

                
	
                  £
                    Non-Emergent    Transportation

                	
                  R
                    Family  Planning

                


        

        
           

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

        

        
          


        

        
          


        

        
           

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        
          


        

        
          


        

        
          WELLCARE
            OF  NEW YORK,   INC.

        

        
          Medicaid
            Managed Care Rates

        

        
          


        

        
          	
                  MMIS  ID#:  01182503

                	
                  Effective
                    Date:   04/01/07

                
	
                  Approved
                    by DOB: Yes

                	
                  Region:
                    Northeast Metro

                
	
                  Reinsurance:   No

                	
                  County:   ROCKLAND

                


        

        
          


        

        
          


        

        
          	
                  Premium
                    Group

                	
                  Rate
                    Amount

                
	
                  TANF/SN  <6mo
                    M/F

                	
                  $251.68

                
	
                  TANF/SN  6mo-14  F

                	
                  $89.59

                
	
                  TANF/SN  15-20   F

                	
                  $113.90

                
	
                  TANF/SN  6mo-20  M

                	
                  $100.10

                
	
                  TANF
                    21-64 M/F

                	
                  $193.73

                
	
                  SN  21-29  M/F

                	
                  $267.15

                
	
                  SN  30-64  M/F

                	
                  $420.16

                
	
                  SSI
                    6mo-20  M/F

                	
                  $179.66

                
	
                  SSI
                    21-64 M/F

                	
                  $557.33

                
	
                  SSI
                    65+ M/F

                	
                  $420.16

                
	
                  Maternity  Kick  Payment

                	
                  $4,860.78

                
	
                  Newborn  Kick  Payment

                	
                  $1,569.65

                


        

        
          


        

        
          


        

        
          	
                  Optional   Benefits  Offered:

                	 
	
                  R
                    Emergency    Transportation

                	
                  £
                    Dental

                
	
                  £
                    Non-Emergent    Transportation

                	
                  R
                    Family  Planning

                


        

        
           

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

        

        


        
          


        

        
          


          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        
          


        

        
           

        

        
          WELLCARE
            OF  NEW YORK,   INC.

        

        
          Medicaid
            Managed Care Rates

        

        
          


        

        
          	
                  MMIS  ID#:  01182503

                	
                  Effective
                    Date:   04/01/07

                
	
                  Approved
                    by DOB: Yes

                	
                  Region:
                    Mid-Hudson

                
	
                  Reinsurance:   No

                	
                  County:   ULSTER

                


        

        
          


        

        
          


        

        
          	
                  Premium
                    Group

                	
                  Rate
                    Amount

                
	
                  TANF/SN  <6mo
                    M/F

                	
                  $268.99

                
	
                  TANF/SN  6mo-14  F

                	
                  $95.49

                
	
                  TANF/SN  15-20   F

                	
                  $135.91

                
	
                  TANF/SN  6mo-20  M

                	
                  $104.90

                
	
                  TANF
                    21-64 M/F

                	
                  $231.09

                
	
                  SN  21-29  M/F

                	
                  $211.14

                
	
                  SN  30-64  M/F

                	
                  $430.70

                
	
                  SSI
                    6mo-20  M/F

                	
                  $177.21

                
	
                  SSI
                    21-64 M/F

                	
                  $488.48

                
	
                  SSI
                    65+ M/F

                	
                  $428.29

                
	
                  Maternity  Kick  Payment

                	
                  $5,792.84

                
	
                  Newborn  Kick  Payment

                	
                  $2,367.65

                


        

        
          


        

        
          


        

        
          	
                  Optional   Benefits  Offered:

                	 
	
                  £
                    Emergency    Transportation

                	
                  £
                    Dental

                
	
                  £
                    Non-Emergent    Transportation

                	
                  R
                    Family  Planning

                


        

        
           

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

        

        
          


          


        

        
          


          


        


        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        


        


        
          


          WELLCARE
            OF NEW YORK, INC.

        

        
          


          Family
            Health Plus Rates Effective
            April 1, 2007

        

        


        
          	 	 	 	 	 	
                  
                    Optional
                      benefits covered 

                  

                
	
                  
                    County

                  

                	
                  
                    Adults
                      with Children 19
                      - 64

                  

                	
                  
                    Adults
                      without Children 19 - 29

                  

                	
                  
                    Adults
                      without Children 30 - 64

                  

                	
                  
                    Maternity
                      Kick

                  

                	
                  
                    Family
                      Planning

                  

                	
                  
                    Dental

                  

                
	
                  
                    ALBANY

                  

                	
                  
                    $253.35

                  

                	
                  
                    $250.47

                  

                	
                  
                    $510.54

                  

                	
                  
                    $5,224.57

                  

                	
                  
                    Yes

                  

                	
                  
                    Yes

                  

                
	
                  
                    COLUMBIA

                  

                	
                  
                    $271.75

                  

                	
                  
                    $259.93

                  

                	
                  
                    $499.25

                  

                	
                  
                    $5,603.31

                  

                	
                  
                    Yes

                  

                	
                  
                    Yes

                  

                
	
                  
                    DUTCHESS

                  

                	
                  
                    $261.25

                  

                	
                  
                    $292.21

                  

                	
                  
                    $529.01

                  

                	
                  
                    $5,792.84

                  

                	
                  
                    Yes

                  

                	
                  
                    Yes

                  

                
	
                  
                    GREENE

                  

                	
                  
                    $271.75

                  

                	
                  
                    $259.93

                  

                	
                  
                    $499.25

                  

                	
                  
                    $5,603.31

                  

                	
                  
                    Yes

                  

                	
                  
                    Yes

                  

                
	
                  
                    ORANGE

                  

                	
                  
                    $261.25

                  

                	
                  
                    $292.21

                  

                	
                  
                    $529.01

                  

                	
                  
                    $5,792.84

                  

                	
                  
                    Yes

                  

                	
                  
                    Yes

                  

                
	
                  
                    RENSSELAER

                  

                	
                  
                    $253.35

                  

                	
                  
                    $250.47

                  

                	
                  
                    $510.54

                  

                	
                  
                    $5,224.57

                  

                	
                  
                    Yes

                  

                	
                  
                    Yes

                  

                
	
                  
                    ROCKLAND

                  

                	
                  
                    $257.02

                  

                	
                  
                    $209.67

                  

                	
                  
                    $472.63

                  

                	
                  
                    $4,860.78

                  

                	
                  
                    Yes

                  

                	
                  
                    Yes

                  

                
	
                  
                    ULSTER

                  

                	
                  
                    $261.25

                  

                	
                  
                    $292.21

                  

                	
                  
                    $529.01

                  

                	
                  
                    $5,792.84

                  

                	
                  
                    Yes

                  

                	
                  
                    Yes

                  

                
	
                  
                    NEW
                      YORK CITY

                  

                	
                  
                    $196.94

                  

                	
                  
                    $151.51

                  

                	
                  
                    $245.72

                  

                	
                  
                    $5,523.56

                  

                	
                  
                    Yes

                  

                	
                  
                    Yes