EX-10.48.1






MEDICAID MANAGED CARE MODEL CONTRACT




Amendment of Agreement




Between

The City of New York

And

CarePlus, LLC




This Amendment, effective January 1, 2005, amends the Medicaid Managed Care Model Contract
(hereinafter referred to as the “Agreement”) made by and between the City of New York acting
through the New York City Department of Health and Mental Hygiene (hereinafter referred to as
"DOHMH” or “LDSS”) and  CarePlus, LLC  (hereinafter referred to as “MCO”
or “Contractor”).



WHEREAS, the parties entered into an Agreement effective October 1, 2004 for the purpose of
providing prepaid case managed health services to Medical Assistance recipients residing in New
York City; and



WHEREAS, the parties desire to amend said Agreement to modify certain provisions to reflect
current circumstances and intentions;



NOW THEREFORE, effective January 1, 2005, it is mutually agreed by the parties to amend this
Agreement as follows:



The attached “Table of Contents for Model Contract” is substituted for the period
beginning January 1, 2005.



Add to Section 1, Definitions, a definition for “Permanent Placement Status,” to read as

follows:




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



Amend Section 3.1 (c), “Capitation Payments,” to read as follows:




	 	c)	 	The monthly capitation payments and the Supplemental Newborn Capitation Payment and the
Supplemental Maternity Capitation Payment to the Contractor shall constitute full and
complete payments to the Contractor for all services that the Contractor provides pursuant to
this Agreement subject to stop-loss provisions set forth in Section 3.11, 3.12, and 3.13 of
this Agreement.





January 1, 2005 Amendment




1




1




Add a new Section 3.13, “Residential Health Care Facility Stop-Loss,” to
read as follows: 3.13 Residential Health Care Facility Stop-Loss



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



Add a new Section 3.14, “Stop-Loss Procedures and Documentation,” to read as
follows: 3.14 Stop-Loss Procedures and Documentation



The Contractor must follow procedures and documentation requirements in accordance
with the New York State Department of Health stop-loss policy and procedure manual.
Payments made for stop-loss claims that do not conform to SDOH requirements are
subject to recoupment.



Renumber Sections 3.13, “Enrollment Limitations,” and 3.14, “Tracking Visits Provided
by Indian Health Clinics,” as Sections 3.15, and 3.16 respectively.



Amend Section 18.2, “SDOH Instructions for Report Submissions” to read as follows:




SDOH, with prior notice to the LDSS, will provide Contractor with instructions for submitting the
reports required by Section 18.5 (a) through (m), including time frames, and requisite formats.
The instructions, time frames and formats may be modified by SDOH with prior notice to the LDSS,
and thereafter upon sixty (60) days written notice to the Contractor. The LDSS, with prior notice
to SDOH, shall provide the Contractor with instructions for submitting the reports required by
Section 18.5(n), including time frames and requisite formats.



Amend Section 18.4, “Notification of Changes in Report Due Dates, Requirements or
Formats" to read as follows:




SDOH or LDSS may extend due dates, or modify report requirements or formats upon a written
request by the Contractor to the SDOH or LDSS with a copy of the request to the other agency,
where the Contractor has demonstrated a good and compelling reason for the extension or
modification. The determination to grant a modification or extension of time shall be made by
SDOH with regard to annual and quarterly statements, complaint reports, audits, encounter data,
change of ownership, clinical studies, QARR, and provider network reports. The determination to
grant a modification or extension of time shall be made by the LDSS with respect to reports
required by Sections 18.5 (m) and (n) of the Agreement.



Amend “Reporting Requirements,” Section 18.5 (c), “Other Financial Reports” to read
as follows:



c) Other Financial Reports:




Contractor shall submit financial reports, including certified annual financial statements,
and make available documents relevant to its financial condition to SDOH and the State
Insurance Department (SID) in a timely manner as required by State laws and regulations
including but not limited to PHL §§ 4403-a, 4404 and 4409, Title 10 NYCRR §§ 98.11, 98.16 and
98.17 and applicable Insurance Law §§ 304, 305, 306, and 310. The LDSS reserves the right to
require Contractor to submit such relevant financial reports and documents related to the
financial condition of the MCO to the LDSS, as set forth in Section 18.5(n) of this
Agreement.



Amend “Reporting Requirements,” Section 18.5 (f), “Complaint Reports” to read as
follows: f) Complaint Reports:




The Contractor must provide the SDOH on a quarterly basis, and within fifteen (15) business
days of the close of the quarter, a summary of all complaints received during the,, preceding
quarter on the Health Provider Network (“HPN”).



January 1, 2005 Amendment

2




2





The Contractor also agrees to provide on a quarterly basis, via the HPN, the
total number of complaints that have been unresolved for more than forty-five (45) days. The
Contractor shall maintain records on these and other complaints which shall include all
correspondence related to the complaint, and an explanation of disposition. These records
shall be readily available for review by the SDOH or LDSS upon request.




Nothing in this Section is intended to limit the right of the SDOH and the LDSS to obtain
information immediately from a Contractor pursuant to investigating a particular Enrollee or
provider complaint. ,




The LDSS reserves the right to require the Contractor to submit a hardcopy of complaint
reports in Section 18.5(n) of this Agreement.




Amend Section 32.2, “Indemnification by LDSS,” to read as follows:




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



The attached Appendix K, “Prepaid Benefit Package Definitions of Covered and
Non-Covered Services,” is substituted for the period beginning January 1, 2005.




Schedule A of Appendix K, “Prepaid Benefit Package Coverage Status of Optional Covered
Services,” as included in the executed Agreement effective October 1, 2004, remains
unchanged.



January 1, 2005 Amendment




3




This Amendment is effective January 1, 2005, and the Agreement, including the modifications
made by this Amendment, shall remain in effect until September 30, 2005 or until the execution of
an extension, renewal or successor agreement as provided for in the Agreement.



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



	 	 	 	 	 
	For the Contractor:	 	For the LDSS:
	By /s/ K Ajmani	 	By
	Karin Ajmani
	(Printed Name)	 	(Printed Name)
	Title President & CEO	 	Title
	Date	 	Date













January 1, 2005 Amendment

4




3




I:IDATAIINTERGOVICONTRACT\05AMDRHCIAMENDMNT\AM 105nyc.DOC Last revised 11/26/04



January 1, 2005 Amendment

5




4





Table of Contents for Model Contract



Recitals



	 	 	 	 	 
	Section 1

	 	Definitions
	 	

	 
	 	 	 	 
	Section 2	 	Agreement Term, Amendments, Extensions, and General Contract

	 
	 	 	 	 
	
 
	 	Administration Provisions

2.1

2.2

2.3

2.4

2.5

2.6

2.7
	 	

Term

Amendments and Extensions

Approvals

Entire Agreement

Renegotiation

Assignment and Subcontracting

Termination








a. LDSS Initiated Termination of Contract


b. Contractor and LDSS Initiated Termination


c. Contractor Initiated Termination


d. Termination Due to Loss of Funding



	 	 	 	 	 
	
 
	 	2.8

2.9

2.10

2.11
	 	Close-Out Procedures

Rights and Remedies

Notices

Severability
	 
	 	 	 	 
	Section 3

	 	Compensation

3.1

3.2

3.3

3.4

3.5

3.6

3.7

3.8

3.9

3.10

3.11

3.12
	 	

Capitation Payments

Modification of Rates During Contract Period

Rate Setting Methodology

Payment of Capitation

Denial of Capitation Payments

SDOH Right to Recover Premiums

Third Party Health Insurance Determination

Payment for Newborns

Supplemental Maternity Capitation Payment

Contractor Financial Liability

Inpatient Hospital Stop-Loss Insurance

Mental Health and Chemical Dependence Stop-Loss







	 	 	 	 	 
	 	 	3.13 Residential Health Care Facility Stop-Loss

	 
	 	 	 	 
	
 
	 	3.14

3.15

3.16
	 	Stop-Loss Procedures and Documentation

Enrollment Limitations

Tracking Visits Provided by Indian Health Clinics
	 
	 	 	 	 
	Section 4

	 	Service Area
	 	

	 
	 	 	 	 
	Section 5	 	Eligible, Exempt and Excluded Populations

	 
	 	 	 	 
	
 
	 	5.1

5.2

5.3

5.4

5.5
	 	Eligible Populations

Exempt Populations

Excluded Populations

Family Health Plus

Family Enrollment







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5





Table of Contents for Model Contract



	 	 	 	 	 
	Section 6

	 	Enrollment

6.1

6.2

6.3

6.4

6.5

6.6

6.7

6.8

6.9

6.10
	 	

Enrollment Guidelines

Equality of Access to Enrollment

Enrollment Decisions

Auto Assignment

Prohibition Against Conditions on Enrollment

Family Enrollment

Newborn Enrollment

Effective Date of Enrollment

Roster

Automatic Re-Enrollment
	 
	 	 	 	 
	Section 7

	 	Lock-In Provisions

7.1

7.2

7.3

7.4
	 	

Lock-In Provisions in Voluntary Counties

Lock-In Provisions in Mandatory Counties and New York City

Disenrollment During Lock-In Period

Notification Regarding Lock-In and End of Lock-In Period
	 
	 	 	 	 
	Section 8

	 	Disenrollment

8.1

8.2

8.3

8.4
	 	

Disenrollment Guidelines

Disenrollment Prohibitions

Reasons for Voluntary Disenrollment

Processing of Disenrollment Requests








a. Routine Disenrollment


b. Expedited Disenrollment


c. Retroactive Disenrollment



	 	 	 
	8.5

8.6

8.7

	 	Contractor Notification of Disenrollments

Contractor’s Liability

Enrollee Initiated Disenrollment








a. Disenrollment for Good Cause



	 	 	 	 	 
	
 
	 	8.8

8.9
	 	Contractor Initiated Disenrollment

LDSS Initiated Disenrollment
	 
	 	 	 	 
	Section 9

	 	Guaranteed Eligibility
	 	

	 
	 	 	 	 
	Section 10	 	Benefit Package, Covered and Non-Covered Services

	 
	 	 	 	 
	
 
	 	10.1

10.2

10.3
	 	Contractor Responsibilities

Compliance with State Medicaid Plan and Applicable Laws

Definitions







	 	 	 
	10.4 Provision of Services Through Participating and Non-Participating Providers

	 
	 	 
	10.5

10.6

10.7

10.8

10.9

10.10

10.11

10.12

10.13

10.14

10.15

	 	Child Teen Health Program / Adolescent Preventive Services

Foster Care Children

Child Protective Services

Welfare Reform

Adult Protective Services

Court-Ordered Services

Family Planning and Reproductive Health Services

Prenatal Care

Direct Access

Emergency Services

Medicaid Utilization Thresholds (MUTS)







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2

Table of Contents for Model Contract




10.16 Services for Which Enrollees Can Self-Refer




a. Mental Health and Chemical Dependence Services


b. Vision Services


c. Diagnosis and Treatment of Tuberculosis


d. Family Planning and Reproductive Health Services


e. Article 28 Clinics Operated by Academic Dental Centers



	 	 	 
	10.17

10.18

10.19

	 	Second Opinions for Medical or Surgical Care

Coordination with Local Public Health Agencies

Public Health Services








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






b. Immunizations


c. Prevention and Treatment of Sexually Transmitted Diseases


d. Lead Poisoning



	 	 	 
	10.20

10.21

10.22

10.23

10.24

10.25

10.26

10.27

	 	Adults with Chronic Illnesses and Physical or Developmental Disabilities

Children with Special Health Care Needs

Persons Requiring Ongoing Mental Health Services

Member Needs Relating to HIV

Persons Requiring Chemical Dependence Services

Native Americans

Women, Infants, and Children (WIC)

Urgently Needed Services








	 	10.28	 	Dental Services Provided by Article 28 Clinics Operated by
Academic Dental Centers Not Participating in Contractor’s Network	 






10.29 Coordination of Services


10.30 Prospective Benefit Package Change for Retroactive SSI Determinations



	 	 	 	 	 
	Section 11

	 	Marketing

11.1

11.2

11.3

11.4

11.5
	 	

Marketing Plan

Marketing Activities

Prior Approval of Marketing Materials, Procedures, Subcontracts

Marketing Infractions

LDSS Option to Adopt Additional Marketing Guidelines
	 
	 	 	 	 
	Section 12

	 	Member Services

12.1

12.2

12.3
	 	

General Functions

Translation and Oral Interpretation

Communicating with the Visually, Hearing and Cognitively Impaired
	 
	 	 	 	 
	Section 13

	 	Enrollee Notification

13.1

13.2

13.3

13.4

13.5

13.6

13.7

13.8

13.9
	 	

Provider Directories/Office Hours for Participating Providers

Member ID Cards

Member Handbooks

Notification of Effective Date of Enrollment

Notification of Enrollee Rights

Enrollee’s Rights to Advance Directives

Approval of Written Notices

Contractor’s Duty to Report Lack of Contact

Contractor Responsibility to Notify Enrollee of Expected Effective Date








of Enrollment



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Table of Contents for Model Contract





13.10 LDSS Notification of Enrollee’s Change in Address




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






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





	 	 	 	 	 
	Section 14	 	Complaint and Appeal Procedure

	 
	 	 	 	 
	
 
	 	14.1

14.2

14.3

14.4
	 	Contractor’s Program to Address Complaints

Notification of Complaint and Appeal Program

Guidelines for Complaint and Appeal Program

Complaint Investigation Determinations
	 
	 	 	 	 
	Section 15

	 	Access Requirements

15.1

15.2

15.3

15.4
	 	

Appointment Availability Standards

Twenty-Four (24) Hour Access

Appointment Waiting Times

Travel Time Standards








a. Primary Care


b. Other Providers




15.5 Service Continuation




a. New Enrollees


b. Enrollees Whose Health Care Provider Leaves Network



	 	 	 	 	 	 	 
	
 
	 	15.6

15.7

15.8
	 	Standing Referrals

Specialist as a Coordinator of Primary Care

Specialty Care Centers
	 
	 	 	 	 	 	 
	Section 16

	 	Quality Assurance

16.1

16.2
	 	

Internal Quality Assurance Program

Standards of Care
	 
	 	 	 	 	 	 
	Section 17

	 	Monitoring and Evaluation

17.1

17.2

17.3

17.4
	 	

Right To Monitor Contractor Performance

Cooperation During Monitoring And Evaluation

Cooperation During On-Site Reviews

Cooperation During Review of Services by External Review Agency
	 
	 	 	 	 	 	 
	Section 18	 	Contractor Reporting Requirements
	 
	 	 	 	 	 	 
	
 
	 	 	18.1	 	 	Time Frames for Report Submissions







18.2 SDOH Instructions for Report Submissions 18.3
Liquidated Damages


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




a. Annual Financial Statements


b. Quarterly Financial Statements


c. Other Financial Reports


d. Encounter Data


e. Quality of Care Performance Measures


f. Complaint Reports


g. Fraud and Abuse Reporting Requirements


h. Participating Provider Network Reports


i. Appointment Availability/Twenty-Four Hour (24) Access and




Availability Surveys




j. Clinical Studies


k. Independent Audits



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4

Table of Contents for Model Contract





1. New Enrollee Health Screening Completion Report


m. Additional Reports


n. LDSS Specific Reports



	 	 	 
	18.6

18.7

18.8

18.9

	 	Ownership and Related Information Disclosure

Revision of Certificate of Authority

Public Access to Reports

Professional Discipline







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



	 	 	 
	
 
	 	18.11 Conflict of Interest Disclosure

18.12 Physician Incentive Plan Reporting
	 
	 	 
	Section 19

	 	Records Maintenance and Audit Rights

19.1 Maintenance of Contractor Performance Records

19.2 Maintenance of Financial Records and Statistical Data

19.3 Access to Contractor Records

19.4 Retention Periods
	 
	 	 
	Section 20

	 	Confidentiality








20.1 Confidentiality of Identifying Information about Medicaid Recipients and
Applicants



	 	 	 	 	 
	Section 21

	 	20.2

20.3

20.4

Participating Providers

21.1
	 	Medical Records of Foster Children

Confidentiality of Medical Records

Length of Confidentiality Requirements



Network Requirements








a. Sufficient Number


b. Absence of Appropriate Network Provider


c. Suspension of Enrollee Assignments to Providers


d. Notice of Provider Termination




21.2 Credentialing




a. Licensure


b. Minimum Standards


c. Credentialing/Recredentialing Process


d. Application Procedure



	 	 	 
	21.3

21.4

21.5

21.6

21.7

21.8

21.9

21.10

21.11

	 	SDOH Exclusion or Termination of Providers

Evaluation Information

Payment In Full

Choice/Assignment of PCPs

PCP Changes

Provider Status Changes

PCP Responsibilities

Member to Provider Ratios

Minimum Office Hours








a. General Requirements


b. Medical Residents



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	 	 	Table of Contents for Model Contract
	21.12

	 	Primary Care Practitioners








a. General Limitations


b. Specialists and Sub-specialists as PCPs


c. OB/GYN Providers as PCPs


d. Certified Nurse Practitioners as PCPs




e. Registered Physician’s Assistants as Physician Extenders




21.13 PCP Teams




a. General Requirements


b. Medical Residents




21.14 Hospitals




a. Tertiary Services


b. Emergency Services



	 	 	 	 	 
	
 
	 	21.15

21.16

21.17

21.18

21.19

21.20
	 	Dental Networks

Presumptive Eligibility Providers

Mental Health and Chemical Dependence Services Providers

Laboratory Procedures

Federally Qualified Health Centers (FQHCs)

Provider Services Function
	 
	 	 	 	 
	Section 22	 	Subcontracts and Provider Agreements

	 
	 	 	 	 
	
 
	 	22.1

22.2

22.3

22.4

22.5

22.6

22.7

22.8

22.9

22.10

22.11

22.12
	 	Written Subcontracts

Permissible Subcontracts

Provision of Services Through Provider Agreements

Approvals

Required Components

Timely Payment

Restrictions on Disclosure

Transfer of Liability

Termination of Health Care Professional Agreements

Health Care Professional Hearings

Non-Renewal of Provider Agreements

Physician Incentive Plan
	 
	 	 	 	 
	Section 23

	 	Fraud and Abuse Prevention Plan
	 	

	 
	 	 	 	 
	Section 24	 	Americans With Disabilities Act Compliance Plan

	 
	 	 	 	 
	Section 25

	 	Fair Hearings

25.1

25.2

25.3

25.4

25.5

25.6
	 	

Enrollee Access to Fair Hearing Process

Enrollee Rights to a Fair Hearing

Contractor Notice to Enrollees

Aid Continuing

Responsibilities of SDOH

Contractor’s Obligations
	 
	 	 	 	 
	Section 26

	 	External Appeal

26.1

26.2

26.3

26.4
	 	

Basis for External Appeal

Eligibility For External Appeal

External Appeal Determination

Compliance With External Appeal Laws and Regulations







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Table of Contents for Model Contract



	 	 	 	 	 
	Section 27

	 	Intermediate Sanctions
	 	

	 
	 	 	 	 
	Section 28

	 	Environmental Compliance
	 	

	 
	 	 	 	 
	Section 29

	 	Energy Conservation
	 	

	 
	 	 	 	 
	Section 30

	 	Independent Capacity of Contractor
	 	

	 
	 	 	 	 
	Section 31

	 	No Third Party Beneficiaries
	 	

	 
	 	 	 	 
	Section 32

	 	Indemnification

32.1

32.2
	 	

Indemnification by Contractor

Indemnification by LDSS
	 
	 	 	 	 
	Section 33	 	Prohibition on Use of Federal Funds for Lobbying

	 
	 	 	 	 
	
 
	 	33.1

33.2

33.3
	 	Prohibition of Use of Federal Funds for Lobbying

Disclosure Form to Report Lobbying

Requirements of Subcontractors
	 
	 	 	 	 
	Section 34

	 	Non-Discrimination

34.1

34.2

34.3
	 	

Equal Access to Benefit Package

Non-Discrimination

Equal Employment Opportunity








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



	 	 	 	 	 	 	 
	Section 35	 	Compliance with Applicable Laws
	 
	 	 	 	 	 	 
	
 
	 	 	35.1	 	 	Contractor and LDSS Compliance With Applicable Laws








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



	 	 	 
	
 
	 	35.3 Certificate of Authority Requirements

35.4 Notification of Changes In Certificate of Incorporation

35.5 Contractor’s Financial Solvency Requirements

35.6 Compliance With Care For Maternity Patients

35.7 Informed Consent Procedures for Hysterectomy and Sterilization

35.8 Non-Liability of Enrollees For Contractor’s Debts

35.9 LDSS Compliance With Conflict of Interest Laws

35.10 Compliance With PHL Regarding External Appeals
	 
	 	 
	Section 36

	 	New York State Standard Contract Clauses







Section 37 Insurance
Requirements Signature Page



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	 	 	 	Table of Contents for Model Contract
APPENDICES	 





A. New York State Standard Clauses and Local Standard Clauses, if applicable


B. Certification Regarding Lobbying




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





D. New York State Department of Health Marketing Guidelines


E. New York State Department of Health Member Handbook Guidelines




	 	F.	 	New York State Department of Health Medicaid Managed Care Complaint and Appeals
Requirements	 






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






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





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



J. New York State Department of Health Guidelines of Federal Americans with Disabilities Act


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


L. Approved Capitation Payment Rates


M. Service Area



N. Contractor-County Specific Agreements



A.




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January 1, 2005

8

APPENDIX K




PREPAID BENEFIT PACKAGE




DEFINITIONS OF COVERED AND




12




NON-COVERED SERVICES

APPENDIX K

January 1, 2005

K- I

APPENDIX K

PREPAID BENEFIT PACKAGE

DEFINITIONS OF COVERED AND NON-COVERED SERVICES




The categories of services in the Medicaid Managed Care Benefit Package, when listed as
covered services shall be provided by the Contractor to Enrollees when medically necessary under
the terms of this Agreement. The definitions of covered and non-covered services therein are in
summary form; the full description and scope of each Medicaid covered service as established by the
New York Medical Assistance Program are set forth in the applicable MMIS Provider Manual.



All care provided by the Contractor, pursuant to this Agreement, must be provided, arranged, or
authorized by the Contractor or its Participating Providers with the exception of most behavioral
health services to SSI or SSI related beneficiaries (see Benefit Package K-2), and emergency
services, emergency transportation, family planning, mental health and chemical dependence
assessments (one (1) of each per year), court ordered services, and services provided by Local
Public Health Agencies as described in Section 10 of this Agreement.



This Appendix contains the following two (2) charts:



K-1 A summary of services provided by the Contractor to all Non-SSI Enrollees.


K-2 A summary of services provided by the Contractor to all SSI Enrollees.



Also included:




	 	 	 	Prepaid Benefit Package Definitions of Covered Services A)
Medical Services	 





1. Inpatient Hospital Services


1 a. Inpatient Stay Pending Alternate Level of Medical Care


2. Professional Ambulatory Services


3. Physician Services


4. Home Health Services


5. Private Duty Nursing Services


6. Emergency Room Services


7. Services of Other Practitioners‘


8. Eye Care and Low Vision Services


9. Laboratory Services


10. Radiology Services


11. Early Periodic Screening Diagnosis and Treatment (EPSDT)




Services Through the Child Teen Health Program (C/THP) and


Adolescent Preventive Services




12. Durable Medical Equipment (DME)


13. Audiology, Hearing Aid Services and Products


14. Preventive Care


15. Prosthetic/Orthotic Orthopedic Footwear


16. Renal Dialysis




17. Experimental or Investigational Treatment


18. Residential Health Care Facility (RHCF) Services




B) Behavioral Health Services




1 Chemical Dependence Services




a) Detoxification Services




i) Medically Managed Inpatient Detoxification


ii) Medically Supervised Withdrawal




	 	b)	 	Chemical Dependence Inpatient
Rehabilitation and Treatment Services	 






c) Chemical Dependence Assessment Self-Referral



APPENDIX K

January 1, 2005

K-2




13





2. Mental Health Services




a) Inpatient Services


b) Outpatient Services




C) Other Covered Services




1. Federally Qualified Health Center (FQHC) Services




	 	II.	 	Optional Covered Services (at discretion of LDSS and/or Contractor) [See Schedule A of
Appendix K for Coverage Status]	 






A) Family Planning and Reproductive Health Care


B) Dental Services


C) Transportation Services




1. Non-Emergency Transportation


2. Emergency Transportation



III. Definitions of Non-Covered Services




A) Medical Non-Covered Services




1. Personal Care Agency Services


2. Residential Health Care Facilities (RHCF)


3. Hospice Program




	 	4.	 	Prescription and Non-Prescription (OTC)
Drugs, Medical Supplies, and Enteral Formula	 






B) Non-Covered Behavioral Health Services




1. Chemical Dependence Services




a) Outpatient Rehabilitation and Treatment Services




i) Methadone Maintenance Treatment Program (MMTP)




	 	ii)	 	Medically
Supervised Ambulatory Chemical Dependence
Outpatient Clinic Programs	 






	 	iii)	 	Medically
Supervised Chemical Dependence Outpatient
Rehabilitation Programs	 






iv) Outpatient Chemical Dependence for Youth Programs




b) Chemical Dependence Services Ordered by the LDSS




2. Mental Health Services




	 	a)	 	Intensive Psychiatric
Rehabilitation Treatment Programs (IPRT)	 






b) Day Treatment


c) Continuing Day Treatment




	 	d)	 	Day Treatment Programs
Serving Children






	 	e)	 	Home and Community
Based Services Waiver for Seriously Emotionally Disturbed
Children	 






f) Case Management


g) Partial Hospitalization




	 	h)	 	Services Provided
through OMH Designated Clinics for Children With a
Diagnosis of Serious Emotional Disturbance (SED)	 






	 	i)	 	Assertive Community
Treatment (ACT)






	 	j)	 	Personalized Recovery
Oriented Services (PROS)






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






a) OMH Licensed CRs


b) Family-Based Treatment



APPENDIX K




January 1, 2005




K- 3









14




	 	4.	 	Office of Mental Retardation and Developmental
Disabilities (OMRDD) Services	 






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






b) Day Treatment


c) Medicaid Service Coordination (MSC)


d) Home and Community Based Services Waivers (HCBS)




	 	e)	 	Services Provided Through
the Care at Home Program (OMRDD)	 






C) Other Non-Covered Services




	 	1.	 	The Early Intervention Program (EIP) -
Children Birth to Two (2) Years of Age






2. Preschool Supportive Health Services — Children Three (3)




Through Four (4) Years of Age




3. School Supportive Health Services — Children Five (5) Through




Twenty-One (21) Years of Age




4. Comprehensive Medicaid Case Management (CMCM)


5. Directly Observed Therapy for Tuberculosis Disease


6. AIDS Adult Day Health Care


7. HIV COBRA Case Management


8. Fertility Services


9. Adult Day Health. Care


10. Personal Emergency Response Systems (PERS)


11. School-Based Health Centers




	 	IV.	 	Schedule A of Appendix K, Prepaid Benefit Package, Coverage Status of Optional Covered
Services





APPENDIX K




January I, 2005




15




K- 4

APPENDIX K-1




MANAGED CARE PLAN PREPAID BENEFIT PACKAGE




	 	 	 	 	 	 	 	 	 
	Covered Services
	 	Managed Care Plan Scope of Benefit                                                                   	 	Covered by Medicaid Fee-For-Service
	 	 	 	 	 
	 
	 	Up to 365 medically necessary days per year (366 for leap year) in accordance
	 	 	 	 
	 
	 	with the stop-loss provisions of Section 3.10 of this Agreement. Includes inpatient
	 	 	 	 
	 
	 	detoxification services provided in Article 28 hospitals for all Enrollees. Inpatient
	 	 	 	 
	Inpatient Hospital Services
	 	dental services are covered. (See dental definition)
	 	 	 	 
	 	 	 	 	 	 	 
	 
	 	Continued care in a hospital pending placement in an alternate lower medical level
	 	 	 	 
	Inpatient Stay Pending Alternate
	 	of care, consistent with the provisions of 18 NYCRR.505.20 and 10 NYCRR, Part
	 	 	 	 
	Level of Medical Care
	 		85.		 	 	 	 
	 
	 	 	 	 	 	 	 	 
	 
	 	Provided through ambulatory care facilities including hospital outpatient
	 	 	 	 
	 
	 	departments, D&T centers, and emergency rooms. Services include medical,
	 	 	 	 
	 
	 	surgical, preventive, primary, rehabilitative, specialty care, mental health, family
	 	 	 	 
	 
	 	planning, C/THPservices and ambulatory dental surgery. Covered as needed
	 	 	 	 
	Professional Ambulatory Services
	 	based on medical necessity.
	 	 	 	 
	 	 	 	 	 	 	 
	 
	 	Care or service to avert disease/illness and/or its consequences. Preventive care
	 	 	 	 
	 
	 	includes primary care, secondary care and tertiary care. Coverage includes general
	 	 	 	 
	 
	 	health education classes, smoking cessation classes, childbirth education classes,
	 	 	 	 
	 
	 	parenting classes and nutrition counseling (with targeted outreach to persons with
	 	 	 	 
	 
	 	diabetes and pregnant women). HIV counseling and testing is a covered service for
	 	 	 	 
	Preventive Health Services
	 	all Enrollees.
	 	 	 	 
	 	 	 	 	 	 	 
	 
	 	Covered when medically necessary as ordered by a qualified medical professional,                     
	 	HIV phenotypic, HIV virtual phenotypic and HIV

	 
	 	and when listed in the Medicaid fee schedule. Coverage excludes HIV                                  
	 	genotypic drug resistance tests with a Provider's

	Laboratory Services
	 	phenotypic, HIV virtual phenotypic and HIV genotypic drug resistance tests.                          
	 	order.

	 	 	 	 	 
	_
	 	Covered when medically necessary as ordered by a qualified medical professional,
	 	 	 	 
	Radiology Services
	 	and when ordered and provided by a qualified medical professional/practitioner.
	 	 	 	 
	 	 	 	 	 	 	 
	 
	 	EPSDT is a package of early and periodic screening, including inter-periodic
	 	 	 	 
	 
	 	screens and, diagnostic and treatment services that are offered to all Medicaid                      
	 	Services not included in the managed care Benefit

	EPSDT Services/Child Teen
	 	eligible children under twenty-one (21) years of age known in New York State as                      
	 	Package ordered by the child's physician based on

	Health Program (C/THP)
	 	the Child Teen Health Program (C/THP).                                                               
	 	the results of a screening.

	 	 	 	 	 







APPENDIX K




January 1, 2005




K-5




	 	 	 	 	 
	Covered Services	 	Managed Care Plan Scope of Benefit	 	Covered by Medicaid Fee-For-Service
	Home Health Services	 	Home health care services include medically necessary nursing, home health aide	 	Services rendered by a personal
	 	 	services, equipment and appliances, physical therapy, speech/language pathology,	 	care agency which are approved by
	 	 	occupational therapy, social work services or nutritional services provided by a	 	the Local Social Services District
	 	 	home health care agency pursuant to an established care plan. Personal care	 	when ordered by the Enrollee's
	 	 	tasks performed by a home health aide in connection with a home health care	 	Primary Care Provider (PCP). The
	 	 	agency visit, and pursuant to an established care plan, are covered.	 	district will determine the
	 	 	 	 	applicant's need for personal care
	 	 	 	 	agency services and coordinate a
	 	 	 	 	plan of care with the personal care
	 	 	 	 	agency.
	Private Duty Nursing Services	 	Covered service when medically necessary in accordance with the ordering	 	 
	 	 	physician, registered physician assistant or certified nurse practitioner's	 	 
	 	 	written	 	 
	 	 	treatment plan.	 	 
	Emergency Room Services

	 	Covered for emergency conditions, medical or behavioral, the onset of which is

sudden, manifesting itself by symptoms of sufficient severity, including severe

pain, that a prudent layperson, possessing an average knowledge of medicine and

health, could reasonably expect the absence of medical attention to result in

(a) placing the health of the person afflicted with such condition in serious

jeopardy, or in the case of a behavioral condition placing the health of such

person or others in serious jeopardy; (b) serious impairment of such person’s

bodily functions; (c) serious dysfunction of any bodily organ or part of such

person; or (d) serious disfigurement of such person. Emergency services include

health care procedures, treatments or services, including psychiatric

stabilization and medical detoxification from drugs or alcohol that are provided

for an emergency medical condition. A medical assessment (triage) is covered for

non-emergent conditions.
	 	

























	 
	 	 	 	 
	Foot Care Services

	 	Foot care when the Enrollee’s (any age) physical condition poses a hazard due to

the presence of localized illness, injury or symptoms involving the foot, or

when performed as a necessary and integral part of otherwise covered services

such as

the diagnosis and treatment of diabetes, ulcers, and infections.
	 	









	 
	 	 	 	 
	Eye Care and Low Vision Services

	 	Eye care includes the services of an ophthalmologist; optometrist and an

ophthalmic dispenser and coverage for contact lenses, polycarbonate lenses,

artificial eyes and replacement of lost or destroyed glasses (including repairs)

when medically necessary.

Artificial eyes are covered as ordered by a Contractor’s Participating Provider.
	 	
















APPENDIX K




January 1, 2005




K-6




	 	 	 	 	 
	Covered Services Managed Care Plan Scope of Benefit	Covered by Medicaid Fee-For-Service
	 	 	DME are devices and equipment other than medical/surgical supplies, enteral	 	 
	 	 	formula, and prosthetic or orthotic appliances. Covered when medically necessary	 	 
	 	 	as ordered by a Contractor's Participating Provider and procured from a	 	Excluded services, such as disposable
	Durable Medical Equipment	 	Participating Provider. Coverage excludes disposable medical/surgical supplies	 	medical/surgical supplies and enteral formula with a
	(DME)	 	and enteral formula.	 	Provider's order.
	 	 	Provided when medically necessary to alleviate disability caused by the loss or	 	 
	 	 	impairment of hearing. Hearing aid products include hearing aids, earmolds,	 	Excluded services, such as hearing aid batteries
	Hearing Aids Services	 	special fittings, and replacement parts. Coverage excludes hearing aid batteries.	 	with a Provider's order.
	Family Planning and

Reproductive Health Services

See Schedule A of Appendix K

for Coverage Status

	 	Family planning means the offering, arranging, and furnishing of those health

services which enable individuals, including minors, who may be sexually active,

to prevent or reduce the incidence of unintended pregnancies and includes the

screening, diagnosis and treatment, as medically necessary, for sexually

transmissible diseases, sterilization services and screening for pregnancy.

Reproductive health services also includes all medically necessary abortions.
	 	



Enrollees may always obtain family planning and

HIV testing and counseling services, when part of a

family planning visit, outside of the plan’s network

from any Provider that accepts Medicaid.







APPENDIX K




January 1, 2005




K-7




	 	 	 	 	 
	Covered Services	 	Managed Care Plan Scope of Benefit	 	Covered by Medicaid Fee-For-Service
	
 
	 	Non-Emergency Transportation:
	 	

	Transportation Services

Non-Emergency Transportation

See Schedule A of Appendix

K for Coverage Status

Emergency Transportation

See Schedule A of Appendix

K for Coverage Status

	 	Transportation expenses are covered when transportation is essential in order for an

Enrollee to obtain necessary medical care and services which are covered under this

Benefit Package (or by fee-for-service Medicaid for carved-out services).

Non-emergent transportation guidelines may be developed in conjunction with the

LDSS, based on the LDSS’ approved transportation plan.

Transportation services means transportation by ambulance, ambulette or invalid

coach, taxicab, livery, public transportation, or other means appropriate to the

Enrollee’s medical condition; and a transportation attendant to accompany the

Enrollee, if necessary. Such services may include the transportation attendant’s

transportation, meals, lodging and salary; however, no salary will be paid to a

transportation attendant who is a member of the Enrollee’s family.

For Enrollees with disabilities, the method of transportation must reasonably

accommodate their needs, taking into account the severity and nature of the

disability.

Emergency Transportation

Emergency transportation can only be provided by an ambulance service. Emergency

transportation is covered for Enrollees suffering from severe, life-threatening or

potentially disabling conditions which require the provision of emergency medical

services while the Enrollee is being transported.
	 	



For Contractors that do not cover

transportation services, these

services are paid for

fee-for-service. Non-emergent

transportation requests should be

referred to the LDSS.

For Contractors that cover

non-emergency transportation in the

Benefit Package, transportation

costs to MMTP services may be

reimbursed by Medicaid

fee-for-service in accordance with

the LDSS transportation polices in

local districts where there is a

systematic method to discretely

identify and reimburse such

transportation costs.
	 
	 	 	 	 
	
 
	 	Optional Benefit Package dental services include:
	 	

	Dental Services

See Schedule A of Appendix K

for Coverage Status

	 	• Medically necessary preventive, prophylactic and other routine dental care,

services and supplies and dental prosthetics required to alleviate a serious health

condition, including one which affects employability.

As described in Sections 10.16 and 10.28 of this Agreement, Enrollees may self-refer

to Article 28 clinics operated by academic dental centers to obtain covered dental

services.

All Contractors must cover the following, even if dental services is not a plan

covered benefit:

• Ambulatory or inpatient surgical services (subject to prior authorization by the

Contractor).

Coverage excludes the professional services of the dentist if dental services are not

covered by the Contractor’s Benefit Package.
	 	









Routine exams, orthodontic services

and appliances, dental office

surgery, fillings, prophylaxis,

provided to Enrollees of plans not

electing to cover dental services.

Orthodontic services are always

covered by fee-forservice.







APPENDIX K




January 1, 2005




K-8




	 	 	 	 	 
	 Covered Services Managed Care Plan Scope of Benefit	Covered by Medicaid Fee-For-Service
	Court-Ordered Services

	 	Coverage includes such services ordered by a court of competent jurisdiction if the

services are in the Contractor’s Benefit Package.
	 	



	 

	 	 
	 	

	 
	 	 	 	 
	Prosthetic/Orthotic

Services/Orthopedic Footwear

	 	Covered when medically necessary as ordered by the Contractor’s Participating

Provider.
	 	



	 

	 	 
	 	

	 
	 	 	 	 
	Mental Health Services

	 	Covered when medically necessary, in accordance with the stop-loss provisions as

described in Section 3.12 of this Agreement. Enrollees must be allowed to self-

refer for one (1) mental health assessment from a Contractor’s Participating

Provider in a twelve (12) month period. In the case of children, such self-referrals

may originate at the request of a school guidance counselor or similar source.
	 	All services in excess of twenty (20) outpatient

visits and thirty (30) inpatient days in accordance

with the stop-loss provisions in Section 3.12 of this

Agreement. Contractor continues to reimburse

mental health service providers and coordinate care.

The Contractor is reimbursed for payment through

the stop-loss provisions.
	 

	 	 
	 	 
	 
	 	 	 	 
	Detoxification Services

	 	Covered when medically necessary on either an inpatient or outpatient basis. Such

services are referred to as “Medically Managed Detoxification Services” when

provided in facilities licensed under Title 14 NYCRR Part 816.6 or Article 28 of

the Public Health Law; and “Medically Supervised Inpatient and Outpatient

Withdrawal Services” when provided in facilities licensed under Title 14 NYCRR

Part 816.7.
	 	





Medically Supervised Inpatient and Outpatient

Withdrawal Services, when ordered by the LDSS

under Welfare Reform (as indicated by “code 83”).
	 

	 	 
	 	 
	 
	 	 	 	 
	Chemical Dependence Inpatient

Rehabilitation and Treatment

Services

	 	Covered when medically necessary in accordance with the stop-loss provisions

described in Section 3.12 of this Agreement.
	 	Chemical Dependence Inpatient Rehabilitation and

Treatment Services when ordered by the LDSS

under Welfare Reform (as indicated by “code 83”)
	 

	 	 
	 	 
	 
	 	 	 	 
	Chemical Dependence

Assessment Self-Referral

	 	Enrollees must be allowed to self refer for one (1) assessment from a Contractor’s

participating provider in a twelve (12) month period.
	 	



	 

	 	 
	 	

	 
	 	 	 	 
	Experimental and/or

Investigational Treatment

	 	Covered on a case by case basis in accordance with the provisions of Section 4910

of the New York State P.H.L.
	 	



	 

	 	 
	 	

	 
	 	 	 	 
	Renal Dialysis

	 	Renal dialysis is covered when medically necessary as ordered by a qualified

medical professional. Renal dialysis may be provided in an inpatient hospital

setting, in an ambulatory care facility, or in the home on recommendation from a

renal dialysis center.
	 	







	 

	 	 
	 	

	 
	 	 	 	 
	Residential Health Care Facility

(RHCF) Services

	 	Residential Health Care Facility Services means inpatient nursing home services

provided by facilities licensed under New York State Public Health Law, including

AIDS nursing facilities. Covered services include the following health care

services: medical supervision, 24-hour per day nursing care, assistance with the

activities of daily living, physical therapy, occupational therapy, and

speech/language pathology services and other services as specified in the New

York State Public Health Law and Regulations for residential health care facilities

and AIDS nursing facilities. RHCF Services are subject to the stop-loss provisions

specified in Section 3.13 of this Agreement.
	 	

















	 

	 	 
	 	








APPENDIX K




January 1, 2005




16




K-9

K-2

MANAGED CARE PLAN PREPAID HEALTH ONLY BENEFIT PACKAGE

For SSI and SSI Related Recipients




	 	 	 	 	 
	Covered Services	 	Managed Care Plan Scope of Benefit	 	Covered by Medicaid Fee-For-Service
	Inpatient Hospital Services

	 	Up to 365 medically necessary days per year (366 for leap year) in accordance

with the stop-loss provisions of Section 3.10 of this Agreement. Includes inpatient

detoxification services provided in Article 28 hospitals for all Enrollees. Inpatient

dental services are covered.
	 	







	 

	 	 
	 	

	 
	 	 	 	 
	Inpatient Stay Pending Alternate

Level of Medical Care

Professional Ambulatory Services

	 	Continued care in a hospital pending placement in an alternate lower

medical level

of care, consistent with the provisions of 18 NYCRR 505.20 and 10 NYCRR, Part

85.

Provided through ambulatory care facilities including hospital outpatient

departments, D&T centers, and emergency rooms. Services include medical,

surgical, preventive, primary, rehabilitative, specialty care, family planning,

C/THP services and ambulatory dental surgery. Covered as needed based on

medical necessity.
	 	















Mental Health and Chemical Dependence services.
	 

	 	 
	 	 
	 
	 	 	 	 
	EPSDT Services/ Child Teen

Health Program (C/THP)

	 	EPSDT is a package of early and periodic screening, including inter-periodic

screens and diagnostic and treatment services that are offered to all Medicaid

eligible children under twenty-one (21) years of age, known in New York State as

the Child Teen Health Plan (C/THP).
	 	

Services not included in the managed care Benefit

Package ordered by the child’s physician based on

the results of a screening.
	 

	 	 
	 	 
	 
	 	 	 	 
	Preventive Health Services

	 	Care and services to avert disease/illness and/or its consequences. Preventive care

includes primary care, secondary care and tertiary care. Coverage includes general

health education classes, smoking cessation classes, childbirth education classes,

parenting classes and nutrition counseling (with targeted outreach to persons with

diabetes and pregnant women). HIV counseling and testing is a covered

service for

all Enrollees.
	 	













	 

	 	 
	 	

	 
	 	 	 	 
	Home Health Services

	 	Home health care services include medically necessary nursing, home health aide

services, equipment and appliances, physical therapy, speech/language pathology,

occupational therapy, social work services or nutritional services provided by a

home health care agency pursuant to an established care plan. Personal care tasks

performed by a home health aide in connection with a home health care agency

visit, and pursuant to an established care plan, are covered.
	 	Services rendered by a personal care agency which

are approved by the Local Social Services District

when ordered by the Enrollee’s Primary Care

Provider (PCP). The district will determine the

applicant’s need for personal care agency services

and coordinate with the personal care agency a plan

of care.
	 

	 	 
	 	 







APPENDIX K




. January 1, 2005




K-10




	 	 	 	 	 
	Covered Services Managed Care Plan Scope of Benefit	Covered by Medicaid Fee-For-Service
	Private Duty Nursing Services

	 	Covered service when medically necessary in accordance with the ordering

physician, registered physician assistant or certified nurse practitioner’s written

treatment plan.
	 	





	 

	 	 
	 	

	 
	 	 	 	 
	Emergency Room Services

	 	Covered for emergency conditions, medical or behavioral, the onset of which is

sudden, manifesting itself by symptoms of sufficient severity, including severe

pain, that a prudent layperson, possessing an average knowledge of medicine and

health, could reasonably expect the absence of medical attention to result in (a)

placing the health of the person afflicted with such condition in serious jeopardy,

or in the case of a behavioral condition placing the health of such person or others

in serious jeopardy; (b) serious impairment of such person’s bodily functions; (c)

serious dysfunction of any bodily organ or part of such person; or (d) serious

disfigurement of such person, Emergency services include health care procedures,

treatments or services, including psychiatric stabilization and medical

detoxification from drugs or alcohol that are provided for an emergency medical

condition. A medical assessment (triage) is covered for non-emergent conditions.
	 	























	 

	 	 
	 	

	 
	 	 	 	 
	Foot Care Services

	 	Foot care when the Enrollee’s (of any age) physical condition poses a hazard due

to the presence of localized illness, injury or symptoms involving the foot, or when

performed as a necessary and integral part of otherwise covered services such as

the diagnosis and treatment of diabetes, ulcers, and infections.
	 	







	 

	 	 
	 	

	 
	 	 	 	 
	Eye Care and Low Vision

Services

	 	Eye care includes the services of an ophthalmologist, optometrist and an

ophthalmic dispenser and coverage for contact lenses, polycarbonate lenses,

artificial eyes and replacement of lost or destroyed glasses (including repairs)

when medically necessary.

Artificial eyes are covered as ordered by the Contractor’s Participating Provider.
	 	









	 

	 	 
	 	








APPENDIX K

January 1, 2005

K-11




	 	 	 	 	 
	Covered Services Managed Care Plan Scope of Benefit	Covered by Medicaid Fee-For-Service
	
 
	 	Optional Benefit Package dental services include:
	 	

	Dental Services

See Schedule A of Appendix K

for Coverage Status

	 	• Medically necessary preventive, prophylactic and other routine dental care,

services and supplies and dental prosthetics required to alleviate a serious

health condition, including one which affects employability.

As described in Sections 10.16 and 10.28 of this Agreement, Enrollees may self-

refer to Article 28 clinics operated by academic dental centers to obtain covered

dental services.

All Contractors must cover the following, even if dental services is not a plan

covered benefit:

• Ambulatory or inpatient surgical services (subject to prior authorization by the

Contractor).
	 	











Routine exams, orthodontic services and appliances,

dental office surgery, fillings, prophylaxis, provided

to Enrollees of MCOs not electing to cover dental

services.
	 
	 	 	 	 
	
 
	 	Coverage excludes the professional services of the dentist if dental services are not

covered by the Contractor’s Benefit Package.
	 	



	
 
	 	 
	 	

	 
	 	 	 	 
	Family Planning and

	 	Family planning means the offering, arranging, and furnishing of those health
	 	Enrollees may always obtain family planning and
	 
	 	 	 	 
	Reproductive Health Services

	 	services which enable individuals, including minors, who may be sexually active,
	 	HIV testing and counseling services, when part of a
	 
	 	 	 	 
	See Schedule A of Appendix K

	 	to prevent or reduce the incidence of unintended pregnancies and includes the

screening, diagnosis and treatment, as medically necessary, for sexually
	 	family planning visit, outside of the Contractor’s

network from any Provider that accepts Medicaid.
	 
	 	 	 	 
	for Coverage Status

	 	transmissible diseases, sterilization services and screening for pregnancy.

Reproductive health services also includes all medically necessary abortions.
	 	



	 

	 	 
	 	








APPENDIX K

January 1, 2005

K-12




	 	 	 	 	 
	Covered Services	 	Managed Care Plan Scope of Benefit	 	Covered by Medicaid Fee-For-Service
	 	 	Non-Emergency Transportation:	 	 
	Transportation

Services Non-Emergency

Transportation:

See Schedule A of Appendix

K for Coverage Status

Emergency Transportation:

See Schedule A of Appendix K

for Coverage Status

	 	Transportation expenses are covered when transportation is essential in

order for an Enrollee to obtain necessary medical care and services which

are covered under this Benefit Package (or by fee-for-service Medicaid for

carved-out services). Non-emergent transportation guidelines may be

developed in conjunction with the LDSS, based on the LDSS’ approved

transportation plan.

Transportation services means transportation by ambulance, ambulette or

invalid coach, taxicab, livery, public transportation, or other means

appropriate to the Enrollee’s medical condition; and a transportation

attendant to accompany the Enrollee, if necessary, Such services may

include the transportation attendant’s transportation, meals, lodging and

salary; however, no salary will be paid to a transportation attendant who

is a member of the Enrollee’s family.

For Enrollees with disabilities, the method of transportation must

reasonably accommodate their needs, taking into account the severity and

nature of the disability.

Emergency Transportation

Emergency transportation can only be provided by an ambulance service.

Emergency transportation is covered for Enrollees suffering from severe,

life-threatening or potentially disabling conditions which require the

provision of emergency medical services while the Enrollee is being

transported.
	 	









For Contractors that do not cover

transportation services, these

services are paid for

fee-for-service. Non-emergent

transportation requests should be

referred to the LDSS.

For Contractors that cover

non-emergency transportation in the

Benefit Package, transportation

costs to MMTP services may be

reimbursed by Medicaid

fee-for-service in accordance with

the LDSS transportation polices in

local districts where there is a

systematic method to discretely

identify and reimburse such

transportation costs.
	 
	 	 	 	 
	Laboratory Services

	 	Covered when medically necessary as ordered by a medical professional, and

when listed in the Medicaid fee schedule. Coverage excludes HIV

phenotypic,

HIV virtual phenotypic and HIV genotypic drug resistance tests.
	 	HIV phenotypic, HIV virtual

phenotypic and HIV genotypic drug

resistance tests with a Provider’s

order.
	
 
	 	 	 	 
	 
	 	 	 	 
	Radiology Services

	 	Covered when medically necessary as ordered by a medical professional, and

when ordered and provided by a qualified medical professional/practitioner.
	 	



	 
	 	 	 	 
	Durable Medical Equipment (DME)

	 	DME are devices and equipment other than medical/surgical supplies enteral

formula, and prosthetic or orthotic appliances. Covered when medically

necessary as ordered by the Contractor’s Participating Provider and

procured from a Participating Provider. Coverage excludes disposable

medical/surgical supplies and enteral formula.
	 	Excluded services, such as

disposable medical/surgical supplies

and enteral formula with a

Provider’s order.










PPENDIX K




January 1, 2005




K-13




	 	 	 	 	 
	Covered Services Managed

	 	Care Plan Scope of Benefit Covered
	 	by Medicaid Fee-For-Service
	 

	 	 
	 	 
	 
	 	 	 	 
	Hearing Aid Services

	 	Provided when medically necessary to alleviate disability caused by the loss or

impairment of hearing. Hearing aid products include hearing aids, earmolds,

special fittings, and replacement parts. Coverage excludes hearing aid batteries.
	 	

Excluded services, such as hearing aid batteries

with a Provider’s order.
	 

	 	 
	 	 
	 
	 	 	 	 
	Court-Ordered Services

	 	Coverage includes such services ordered by a court of competent jurisdiction if the

services are in the Contractor’s Benefit Package.
	 	



	 

	 	 
	 	

	 
	 	 	 	 
	Prosthetic/Orthotic Services/Orthotic

Footwear

	 	Covered when medically necessary as ordered by a managed care plan qualified

medical professional.
	 	



	 

	 	 
	 	

	 
	 	 	 	 
	Renal Dialysis

	 	Renal dialysis is covered when medically necessary as ordered by a qualified

medical professional. Renal dialysis may be provided in an inpatient hospital

setting, in an ambulatory care facility, or in the home on recommendation from a

renal dialysis center.
	 	







	 

	 	 
	 	

	 
	 	 	 	 
	Experimental and/or

Investigational Treatment

	 	Covered on a case by case basis in accordance with the provisions of Section 4910

of the New York State P.H.L.
	 	



	 

	 	 
	 	

	 
	 	 	 	 
	Detoxification Services

	 	Covered when medically necessary on either an inpatient or outpatient basis. Such

services are referred to as “Medically Managed Detoxification Services” when

provided in facilities licensed under Title 14 NYCRR Part 816.6 or Article 28 of

the Public Health Law; and “Medically Supervised Inpatient and Outpatient

Withdrawal Services” when provided in facilities licensed under Title 14 NYCRR

Part 816.7.
	 	











	 

	 	 
	 	

	 
	 	 	 	 
	Residential Health Care Facility

(RHCF) Services

	 	Residential Health Care Facility Services means inpatient nursing home services

provided by facilities licensed under New York State Public Health Law, including

AIDS nursing facilities. Covered services include the following health care

services: medical supervision, 24-hour per day nursing care, assistance with the

activities of daily living, physical therapy, occupational therapy, and

speech/language pathology services and other services as specified in the New

York State Public Health Law and Regulations for residential health care facilities

and AIDS nursing facilities. RHCF Services are subject to the stop-loss provisions

specified in Section 3.13 of this Agreement.
	 	

















	 

	 	 
	 	








APPENDIX K




January 1, 2005




K-14









17




	 	I.	 	PREPAID BENEFIT PACKAGE DEFINITIONS OF COVERED SERVICES	 





A. Medical Services



1. Inpatient Hospital Services



Inpatient hospital services, as medically necessary, shall include, except as otherwise
specified, the care, treatment, maintenance and nursing services as may be required, on an
inpatient hospital basis, up to 365 days per year (366 days in leap year). Among other services,
inpatient hospital services encompass a full range of necessary diagnostic and therapeutic care
including medical, surgical, nursing, radiological, and rehabilitative services. Services are
provided under the direction of a physician, certified nurse practitioner, or dentist.



la. Inpatient Stay Pending Alternate Level of Medical Care



Inpatient stay pending alternate level of medical care, or continued care in a hospital pending
placement in an alternate lower medical level of care, consistent with the provisions of 18 NYCRR
505.20 and 10 NYCRR, Part 85.



2. Professional Ambulatory Services



Outpatient hospital services are provided through ambulatory care facilities. Ambulatory care
facilities include hospital outpatient departments (OPD), diagnostic and treatment centers (free
standing clinics) and emergency rooms. These facilities may provide those necessary medical,
surgical, and rehabilitative services and items authorized by their operating certificates.
Outpatient services (clinic) also include preventive, primary medical, specialty, mental health,
C/THP and family planning services provided by ambulatory care facilities.



Hospital OPDs and D&T centers may perform ordered ambulatory services. The purpose of ordered
ambulatory services is to make available to the Participating Provider those services needed to
complement the provision of ambulatory care in his/her office. Examples are: diagnostic testing
and radiology.



3. Physician Services




“Physicians’ services,” whether furnished in the office, the Enrollee’s home, a hospital, a
skilled nursing facility, or elsewhere, means services furnished by a physician:




	 	(1)	 	within the scope of practice of medicine or osteopathy as defined in law by
the New York State Education Department; and






	 	(2)	 	by or under the personal supervision of an individual licensed and currently
registered by the New York State Education Department to practice medicine or
osteopathy.





Physician services include the full range of preventive care services, primary care medical
services and physician specialty services that fall within a physician’s scope of practice under
New York State law.



The following are also included without limitations:




	 	•	 	pharmaceuticals and medical supplies routinely furnished or administered as part of a clinic or office visit;






	 	•	 	physical examinations, including those which are necessary for employment, school, and camp;






	 	•	 	physical and/or mental health, or chemical dependence examinations of children and
their parents as requested by the LDSS to fulfill its statutory responsibilities for the
protection of children and adults and for children in foster care;	 






	 	•	 	health and mental health assessments for the purpose of making recommendations
regarding a Enrollee’s disability status for Federal SSI applications;	 






	 	•	 	health assessments for the Infant /Child Assessment Program (ICHAP);	 






	 	•	 	annual preventive health visits for adolescents;	 






	 	•	 	new admission exams for school children if required by the LDSS;	 





APPENDIX K




January 1, 2005




K-15





	 	•	 	health screening, assessment and treatment of refugees, including completing
SDOH/LDSS required forms;	 






	 	•	 	Child/Teen Health Program (C/THP) services which are comprehensive primary health care
services provided to children under twenty-one (21) years of age (see Section 10 of this
Agreement).





4. Home Health Services




	 	18	 	NYCRR
505.23(a)(3)	 






Home health care services are provided to Enrollees in their homes by a home health agency
certified under Article 36 of the New York State P.H.L. (Certified Home Health Agency — CHHA).
Home health services mean the following services when prescribed by a Provider and provided to a
Medicaid managed care Enrollee in his or her home:




	 	•	 	nursing services provided on a part-time or intermittent basis by a CHHA
or, if there is no CHHA that services the county/district, by a registered
professional nurse or a licensed practical nurse acting under the direction
of the Enrollee’s PCP;






	 	•	 	physical therapy, occupational therapy, or speech pathology and audiology
services; and






home health services provided by a person who meets the training requirements
of the SDOH, is assigned by a registered professional nurse to provide home
health aid services in accordance with the Enrollee’s plan of care, and is
supervised by a registered professional nurse from a CHHA or if the Contractor
has no CHHA available, a registered nurse, or therapist.



Personal care tasks performed by a home health aide incidental to a certified home health care
agency visit, and pursuant to an established care plan, are covered.



Services include care rendered directly to the Enrollee and instructions to his/her family or
caretaker such as teacher or day care provider in the procedures necessary for the Enrollee’s
treatment or maintenance.



The Contractor must provide up to two (2) post partum home visits for high risk infants and/or
high risk mothers, as well as to women with less than a forty-eight (48) hour hospital stay after
a vaginal delivery or less than a ninety-six (96) hour stay after a cesarean delivery. Visits
must be made by a qualified health professional (minimum qualifications being an RN with
maternal/child health background), the first visit to occur within forty-eight (48) hours of
discharge.



5. Private Duty Nursing Services



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



Private duty nursing services are covered only when determined by the attending physician to be
medically necessary. Nursing services may be intermittent, part-time or continuous and provided in
accordance with the ordering physicians, or certified nurse practitioner’s written treatment plan.



6. Emergency Room Services



Emergency conditions, medical or behavioral, the onset of which is sudden, manifesting itself by
symptoms of sufficient severity, including severe pain, that a prudent layperson, possessing an
average knowledge of medicine and health, could reasonably expect the absence of medical attention
to result in (a) placing the health of the person afflicted with such condition in serious
jeopardy, or in the case of a behavioral condition placing the health of such person or others in
serious jeopardy; (b) serious impairment of such person’s bodily functions; (c) serious
dysfunction of any bodily organ or part of such person; or (d) serious disfigurement of such
person are covered. Emergency services include health care procedures, treatments or services,
needed to evaluate or stabilize an Emergency Medical Condition including psychiatric stabilization
and medical detoxification from drugs or alcohol. A medical assessment (triage) is covered for
non-emergent conditions.



APPENDIX K




January 1, 2005




K-16




7. Services of Other
Practitioners a) Nurse Practitioner
Services




Nurse practitioner services include preventive services, the diagnosis of illness and physical
conditions, and the performance of therapeutic and corrective measures, within the scope of the
certified nurse practitioner’s licensure and collaborative practice agreement with a licensed
physician in accordance with the requirements of the NYS Education Department.



The following services are also included in the certified nurse practitioner’s scope of
services, without limitation:




	 	•	 	Child/Teen Health Program(C/THP) services which are comprehensive primary health care
services provided to children under twenty-one (21) (see page 20 of this Appendix and
Section 10.5 of this Agreement);	 





• Physical examinations including those which are necessary for employment, school and camp.




	 	b.	 	Rehabilitation
Services	 





18 NYCRR 505.11



Rehabilitation services are provided for the maximum reduction: of physical or mental
disability and restoration of the Enrollee to his or her best functional level. Rehabilitation
services include care and services rendered by physical therapists, speech-language pathologists
and occupational therapists. Rehabilitation services may be provided in an Article 28 inpatient
or outpatient facility, an Enrollee’s home, in an approved home health agency, in the office of a
qualified private practicing therapist or speech pathologist, or for a child in a school,
pre-school or community setting, or in a Residential Health Care Facility (RHCF) as long as the
Enrollee’s stay is classified as a rehabilitative stay and meets the requirements for covered
RHCF services as defined herein. Rehabilitation services provided in Residential Health Care
Facilities are subject to the stop-loss provisions specified in Section 3.13 of this Agreement.
Rehabilitation services are covered as medically necessary, when ordered by the Contractor’s
Participating Provider.



c. Midwifery Services


SSA §1905 (a)(17), Education Law §6951(i).



Midwifery services include the management of normal pregnancy, childbirth and postpartum care as
well as primary preventive reproductive health care to essentially healthy women as specified in a
written practice agreement and shall include newborn evaluation, resuscitation and referral for
infants. The care may be provided on an inpatient or outpatient basis including in a birthing
center or in the Enrollee’s home as appropriate. The midwife must be licensed by the NYS Education
Department.




	 	d.	 	Clinical Psychological
Services	 





18 NYCRR 505.18(a)




Clinical psychological services include psychological evaluation, testing and therapeutic
treatment for personality or behavior disorders.



e. Foot Care Services




Covered services must include routine foot care when any Enrollee’s (regardless of age) physical
condition poses a hazard due to the presence of localized illness, injury or symptoms involving
the foot, or when performed as a necessary and integral part of otherwise covered services such
as the diagnosis and treatment of diabetes, ulcers, and infections.




Services provided by a podiatrist for persons under twenty-one (21) must be covered upon referral
of a physician, registered physician’s assistant, certified nurse practitioner or certified
midwife.



Routine hygienic care of the feet, the treatment of corns and calluses, the trimming of nails,
and other hygienic care such as cleaning or soaking feet, is not covered in the absence of a
pathological condition.



APPENDIX K




January I, 2005




K-17









18




	 	8.	 	Eye Care and Low Vision
Services	 





18 NYCRR §505.6(b)(1-3)



Eye care includes the services of ophthalmologists, optometrists and ophthalmic dispensers, and
includes eyeglasses, medically necessary contact lenses and polycarbonate lenses, artificial eyes
(stock or custom-made), low vision aids and low vision services. Eyecare coverage includes the
replacement of lost or destroyed eyeglasses. The replacement of the complete pair of eyeglasses
should duplicate the original prescription and frames. Coverage also includes the repair or
replacement of parts in situations where the damage is the result of causes other than defective
workmanship. Replacement parts should duplicate the original prescription and frames. Repairs to,
and replacements of, frames and/or lenses must be rendered as needed.



MCOs that allow upgrades of eyeglass frames or additional features, cannot apply the eyeglass
benefit towards the cost and bill the difference to the Enrollee. However, if the Contractor does
not include upgraded eyeglasses or additional features such as scratchcoating, progressive
lenses, or photogray lenses, the Enrollee may choose to purchase the upgraded frame or feature by
paying the entire cost as a private customer.



Examinations for diagnosis and treatment for visual defects and/or eye disease is provided only as
necessary and as required by the Enrollee’s particular condition. Examinations which include
refraction are limited to every two (2) years unless otherwise justified as medically necessary.



Eyeglasses do not require changing more frequently than every two (2) years unless medically
indicated, such as a change in correction greater than 1/2 diopter, or unless the glasses are lost,
damaged, or destroyed.




An ophthalmic dispenser fills the prescription of an optometrist or opthalmologist and supplies
eyeglasses or other vision aids upon the order of a qualified practitioner.




Enrollees may self-refer to any Participating Provider of vision services (optometrist or
opthalmologist) for refractive vision services.




	 	9.	 	Laboratory Services
18 NYCRR §505.7(a)	 






Laboratory services include medically necessary tests and procedures ordered by a qualified
medical professional and listed in the Medicaid fee schedule for laboratory services, with the
exception of HIV phenotypic, HIV virtual phenotypic and HIV genotypic drug resistance tests, which
are not included in the Benefit Package and are covered by Medicaid fee-for-service.




All laboratory testing sites providing services under this Contract must have a permit issued by
the New York State Department of Health and a Clinical Laboratory Improvement Act (CLIA)
certificate of waiver, a physician performed microscopy procedures (PPMP) certificate, or a
certificate of registration along with a CLIA identification number. Those laboratories with
certificates of waiver or a PPMP certificate may perform only those specific tests permitted under
the terms of their waiver. Laboratories with certificates of registration may perform a full range
of laboratory tests for which they have been certified. Physicians providing laboratory testing
may perform only those specific limited laboratory procedures identified in the Physician’s MMIS
Provider Manual.



10. Radiology Services


18 NYCRR§505 .1 7(c)(7)(d)



Radiology services include medically necessary services provided by qualified practitioners in the
provision of diagnostic radiology, diagnostic ultrasound, nuclear medicine, radiation oncology,
and magnetic resonance imaging (MRI). These services may only be performed upon the order of a
qualified practitioner.



APPENDIX K

January 1, 2005

K-18





	 	11.	 	Early Periodic Screening Diagnosis and Treatment (EPSDT) Services Through the Child Teen
Health Program (C/THP) and Adolescent Preventive Services 18 NYCRR §508.8





Child/Teen Health Program (C/THP) is a package of early and periodic screening, including
inter-periodic screens and, diagnostic and treatment services that New York State offers all
Medicaid eligible children under twenty-one (21) years of age. Care and services shall be provided
in accordance with the periodicity schedule and guidelines developed by the New York State
Department of Health. The care includes necessary health care, diagnostic services, treatment and
other measures (described in § 1905(a) of the Social Security Act) to correct or ameliorate
defects, and physical and mental illnesses and conditions discovered by the screening services
(regardless of whether the service is otherwise included in the New York State Medicaid Plan). The
package of services includes administrative services designed to assist families obtain services
for children that include outreach, education, appointment scheduling, administrative case
management and transportation assistance.




12. Durable Medical Equipment (DME)




18 NYCRR §505.5(a)(1) and Section 4.4 of the MMIS DME, Medical and Surgical Supplies and
Prosthetic and Orthotic Appliances Provider Manual




Durable Medical Equipment (DME) are devices and equipment, other than medical/surgical supplies,
enteral formula, and prosthetic or orthotic appliances, and have the following characteristics:




(i) can withstand repeated use for a protracted period of time;


(ii) are primarily and customarily used for medical purposes;


(iii) are generally not useful to a person in the absence of illness or injury; and




	 	(iv)	 	are usually not fitted, designed or fashioned for a particular
individual’s use. Where equipment is intended for use by only one (1) person, it
may be either custom made or customized.	 





DME must be ordered by a qualified practitioner and procured from a Participating Provider.



13. Audiology, Hearing Aid Services and Products




18 NYCRR §505.31 (a)(1)(2) and Section 4.7 of the MMIS Hearing Aid Provider Manual




	 	a)	 	Hearing aid services and products are provided in compliance with Article 37-A of the
General Business Law when medically necessary to alleviate disability caused by the loss or
impairment of hearing. Hearing aid services include: selecting, fitting and dispensing of
hearing aids, hearing aid checks following dispensing of hearing aids, conformity evaluation,
and hearing aid repairs.






	 	b)	 	Audiology services include audiometric examinations and testing, hearing aid evaluations and
hearing aid prescriptions or recommendations, as medically indicated.






	 	c)	 	Hearing aid products include hearing aids, earmolds, special fittings, and replacement parts
(hearing aid batteries are excluded from the Benefit Package, but are covered by Medicaid
fee-for-service as part of the prescription benefit).





14. Preventive Care



Preventive care means care and services to avert disease/illness and/or its consequences. There
are three (3) levels of preventive care: 1) primary, such as immunizations, aimed at preventing
disease; 2) secondary, such as disease screening programs aimed at early detection of disease; and
3) tertiary, such as physical therapy, aimed at restoring function after the disease has occurred.
Commonly, the term “preventive care” is used to designate prevention and early detection programs
rather than restorative programs.



The following preventive services are also included in the managed care Benefit Package. These
preventive services are essential for promoting wellness and preventing illness. MCOs must offer
the following :




	 	•	 	General health education classes.






	 	•	 	Pneumonia and influenza immunizations for at risk populations.






	 	•	 	Smoking cessation classes, with targeted outreach for adolescents and pregnant women.






	 	•	 	Childbirth education classes.





APPENDIX K




January 1, 2005




K-I9





	 	•	 	Parenting classes covering topics such as bathing, feeding, injury prevention,
sleeping, illness prevention, steps to follow in an emergency, growth and development,
discipline, signs of illness, etc.






	 	•	 	Nutrition counseling, with targeted outreach for diabetics and pregnant women.






	 	•	 	Extended care coordination, as needed, for pregnant women.






	 	•	 	HIV counseling and testing.





15. Prosthetic/Orthotic Orthopedic Footwear



Section 4.5, 4.6 and 4.7 of the MMIS DME, Medical and Surgical Supplies and Prosthetic and
Orthotic Appliances Provider Manual



a. Prosthetics are those appliances or devices ordered for an Enrollee by a Participating
Provider which replace or perform the function of any missing part of the body. Artificial eyes
are covered as part of the eye care benefit.



b. Orthotics are those appliances or devices, ordered for an Enrollee by a qualified practitioner
which are used for the purpose of supporting a weak or deformed body part or to restrict or
eliminate motion in a diseased or injured part of the body.



c. Orthopedic Footwear means shoes, shoe modifications, or shoe additions which are used to
correct, accommodate or prevent a physical deformity or range of motion malfunction in a diseased
or injured part of the ankle or foot; to support a weak or deformed structure of the ankle or
foot, or to form an integral part of a brace.



16. Renal Dialysis



Renal dialysis is covered when medically necessary as ordered by a qualified medical
professional. Renal dialysis may be provided in an inpatient hospital setting, in an ambulatory
care facility, or in the home on recommendation from a renal dialysis center.



17. Experimental or Investigational Treatment



Experimental and investigational treatment is covered on a case by case basis.



Experimental or investigational treatment for life-threatening and/or disabling illnesses may also
be considered for coverage under the external appeal process pursuant to the requirements of
Section 4910 of New York State P.H.L. under the following conditions:




	 	(1)	 	The Enrollee has had coverage of a health care service denied on the basis that such service
is experimental and investigational, and






	 	(2)	 	The Enrollee’s attending physician has certified that the Enrollee has a life-threatening or
disabling condition or disease:






(a) for which standard health services or procedures have been ineffective or would be
medically inappropriate, or




(b) for which there does not exist a more beneficial standard health service or procedure
covered by the health care plan, or




(c) for which there exists a clinical trial, and




	 	(3)	 	The Enrollee’s provider, who must be a licensed, board-certified or board-eligible
physician, qualified to practice in the area of practice appropriate to treat the
Enrollee’s life-threatening or disabling condition or disease, must have recommended
either:	 





APPENDIX K




January 1, 2005




K-20





	 	(a)	 	a health service or procedure that, based on two (2) documents from the
available medical and scientific evidence, is likely to be more beneficial to the
Enrollee than any covered standard health service or procedure; or	 






(b) a clinical trial for which the Enrollee is eligible; and




	 	(4)	 	The specific health service or procedure recommended by the attending physician would
otherwise be covered except for the MCO’s determination that the health service or procedure
is experimental or investigational.	 





18. Residential Health Care Facility (RHCF) Services



Residential Health Care Facility (RHCF) Services means inpatient nursing home services provided
by facilities licensed under Article 28 of the New York State Public Health Law, including AIDS
nursing facilities. Covered services includes the following health care services: medical
supervision, 24-hour per day nursing care, assistance with the activities of daily living,
physical therapy, occupational therapy, and speech/language pathology services and other services
as specified in the New York State Health Law and Regulations for residential health care
facilities and AIDS nursing facilities. These services should be provided to an Enrollee:




	 	(a)	 	Who is diagnosed by a physician as having one or more clinically determined
illnesses or conditions that cause the Enrollee to be so incapacitated, sick,
invalid, infirm, disabled, or convalescent as to require at least medical and
nursing care; and	 






	 	(b)	 	Whose assessed health care needs, in the professional judgment of the
Enrollee’s physician or a medical team:	 






	 	i)	 	do not require care or active treatment of the Enrollee in a
general or special hospital;






ii) cannot be met satisfactorily in the Enrollee’s own home or home substitute




through provision of such home health services, including medical and other


health and health-related services as are available in or near his or her


community; and




	 	iii)	 	cannot be met satisfactorily in the physician’s office, a
hospital clinic, or other ambulatory care setting because of the
unavailability of medical or other health and health-related services for the
Enrollee in such setting in or near his or her community.






The Contractor is also responsible for respite days and bed hold days authorized by the
Contractor.



The Contractor is responsible for all medically necessary and clinically appropriate inpatient
Residential Health Care,, Facility services authorized by the Contractor up to a sixty
(60) day calendar year stop-loss for Enrollees who are not in Permanent Placement Status as
determined by LDSS.



B. Behavioral Health Services



These services include Chemical Dependence and Mental Health Services.



• Chemical Dependence Services:




For all Enrollees not categorized as SSI or SSI related, Chemical Dependence Services in the
Benefit Package include inpatient treatment services including inpatient rehabilitation and
treatment services programs, Detoxification Services (Medically Managed Inpatient
Detoxification and Medically Supervised Inpatient and Outpatient Withdrawal Services) and
self-referral for assessment as described below.




For all Enrollees categorized as SSI or SSI related, the Benefit Package includes
Detoxification Services (Medically Managed Inpatient Detoxification and Medically Supervised
Inpatient and Outpatient Withdrawal Services). All other Chemical Dependence Services,
including Chemical Dependence Inpatient Rehabilitation and Treatment, are covered on a
Medicaid fee-for-service basis for the SSI population.



APPENDIX K




January 1, 2005




K-21




• Mental Health Services:




The Mental Health Services listed below are in the Benefit Package for all Enrollees not
categorized as SSI or SSI related. For Enrollees who are categorized as SSI or SSI related, all
Mental Health Services are covered on a Medicaid fee-for-service basis.



1. Chemical Dependence Services a.
Detoxification Services



i) Medically Managed Inpatient Detoxification




These programs provide medically directed twenty-four hour care on an inpatient basis to
individuals who are at risk of severe alcohol or substance abuse withdrawal, incapacitated, a
risk to self or others, or diagnosed with an acute physical or mental co-morbidity. Specific
services include, but are not limited to: medical management, bio-psychosocial assessments,
stabilization of medical psychiatric / psychological problems, individual and group
counseling, level of care determinations and referral and linkages to other services as
necessary. Medically Managed Detoxification Services are provided by facilities licensed by
OASAS under Title 14 NYCRR Part 816.6 and the Department of Health as a general hospital
pursuant to Article 28 of the Public Health Law or by the Department of Health as a general
hospital pursuant to Article 28 of the Public Health Law.




	 	ii)	 	Medically Supervised Withdrawal (a) Medically
Supervised Inpatient Withdrawal	 





These programs offer treatment for moderate withdrawal on an inpatient basis. Services must
include medical supervision and direction under the care of a physician in the treatment for
moderate withdrawal. Specific services must include, but are not limited to: medical
assessment within twenty four hours of admission; medical supervision of intoxication and
withdrawal conditions; bio-psychosocial assessments; individual and group counseling and
linkages to other services as necessary. Maintenance on methadone while a patient is being
treated for withdrawal from other substances may be provided where the provider is
appropriately authorized. Medically Supervised Inpatient Withdrawal services are provided by
facilities licensed under Title 14 NYCRR Part 816.7.




(b) Medically Supervised Outpatient Withdrawal



These programs offer treatment for moderate withdrawal on an outpatient basis. Required
services include, but are not limited to: medical supervision of intoxication and withdrawal
conditions; bio-psychosocial assessments; individual and group counseling; level of care
determinations; discharge planning; and referrals to appropriate services. Maintenance on
methadone while a patient is being treated for withdrawal from other substances may be
provided where the provider is appropriately authorized. Medically Supervised Outpatient
Withdrawal services are provided by facilities licensed by Title 14 NYCRR Part 816.7.



All detoxification and withdrawal services are a covered benefit for all Enrollees, including
those categorized as SSI or SSI related.



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



b. Chemical Dependence Inpatient Rehabilitation and Treatment Services




Services provided include intensive management of chemical dependence symptoms and medical
management of physical or mental complications from chemical dependence to clients who cannot be
effectively served on an outpatient basis and who are not in need of medical detoxification or
acute care. These services can be provided in a hospital or free-standing facility. Specific
services can include, but are not limited to: comprehensive admission evaluation and treatment
planning; individual group, and family counseling; awareness and relapse prevention; education
about self-help groups; assessment and referral services; vocational and educational assessment;
medical and psychiatric consultation; food and housing; and HIV and AIDS education. These
services may be provided by facilities licensed by OASAS to provide: Chemical Dependence
Inpatient Rehabilitation and Treatment Services under Title 14 NYCRR Part 818. Maintenance on
methadone while a patient is being treated for withdrawal from other substances may be provided
where the provider is appropriately authorized.



APPENDIX K




January 1, 2005




K-22





MCOs will be reimbursed for qualifying inpatient days of chemical dependence inpatient
treatment beyond thirty (30) days according to stop-loss provisions contained in Section 3.12
of this Agreement.



c. Chemical Dependence Assessment Self-Referral



Enrollees must be allowed to self refer for one (1) assessment from a Contractor’s
participating provider in a twelve (12) month period.



2. Mental Health Services



Mental Health Services are subject to the stop-loss provisions specified in Section 3.12 of this
Agreement.



a. Inpatient Services



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



b. Outpatient Services



Outpatient services including but not limited to: assessment, stabilization, treatment planning,
discharge planning, verbal therapies, education, symptom management, case management services,
crisis intervention and outreach services, chlozapine monitoring and collateral services as
certified by OMH. Services may be provided in-home, office or the community. Services may be
provided by licensed OMH providers or by other providers of mental health services including
clinical psychologists and physicians. For further information regarding service coverage consult
the following MMIS Provider Manuals: Clinic, Ambulatory Services for Mental Illness (Clinic
Treatment Program), Clinical Psychology, and Physician (Psychiatric Services).



Enrollees must be allowed to self-refer for one (1) mental health assessment from a Contractor’s
Participating Provider in a twelve (12) month period. In the case of children, such self-referrals
may originate at the request of a school guidance counselor or similar source.




Services provided through OMH designated clinics for Enrollees with a clinical diagnosis of SED
are covered by Medicaid fee-for-service.



C. Other Covered Services



1. Federally Qualified Health Center (FQHC) Services



FQHC services include physician services, services and supplies covered under SSA §1861(s)(2) (A).
Services include primary health, referral for supplemental health services, health education,
patient case management, including outreach, counseling, referral and follow-up services (see 42
USC §254c(a) & (b)).



APPENDIX K




January 1,2005




19




K-23

Prepaid Benefit Package




II. Optional Covered Services (at Discretion of LDSS and/or Contractor)



A. Family Planning and Reproductive Health Care



Family Planning and Reproductive Health Care services means the offering, arranging and
furnishing of those health services which enable Enrollees, including minors, who may be
sexually active to prevent or reduce the incidence of unwanted pregnancy. These include:
diagnosis and all medically necessary treatment, sterilization, screening and treatment for
sexually transmissible diseases and screening for disease and pregnancy.



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



If the Contractor excludes family planning from its Benefit Package, the Contractor is still
required to provide the following services:




i) screening, related diagnosis, ambulatory treatment, and referral to Participating Provider as



	 	 	 
	ii)

	 	needed for dysmenorrhea, cervical cancer or other pelvic abnormality/pathology;

screening, related diagnosis, and referral to Participating Provider for anemia, cervical cancer,








glycosuria, proteinuria, hypertension, breast disease and pregnancy.




B. Dental Services




Dental care includes preventive, prophylactic and other routine dental care, services,
supplies and dental prosthetics required to alleviate a serious health condition, including
one which affects employability.




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



As described in Sections 10.16 and 10.28 of this Agreement, Enrollees may self-refer to
Article 28 clinics operated by academic dental centers to obtain covered dental services.




If Contractor’s Benefit Package excludes dental services:




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






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






	 	C.	 	Transportation
Services	 





18 NYCRR §505.10




a. Non-Emergency Transportation




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



APPENDIX K

January 1, 2005

K-24





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




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




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




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




b. Emergency Transportation




Emergency transportation can only be provided by an ambulance service including air ambulance
service. Emergency ambulance transportation means the provision of ambulance transportation for
the purpose of obtaining hospital services for an Enrollee who suffers from severe,
life-threatening or potentially disabling conditions which require the provision of emergency
medical services while the Enrollee is being transported.




Emergency medical services means the provision of initial urgent medical care including, but not
limited to, the treatment of trauma, bums, respiratory, circulatory and obstetrical emergencies.



Emergency ambulance transportation is transportation to a hospital emergency room generated by a
“Dial 911” emergency system call or some other request for an immediate response to a medical
emergency. Because of the urgency of the transportation request, insurance coverage or other
billing provisions are not addressed until after the trip is completed. When the Contractor is
capitated for this benefit, emergency transportation via 911 or any other emergency call system is
a covered benefit and the Contractor is responsible for payment.



APPENDIX K




January 1, 2005




K-25




Prepaid Benefit Package




III. Definitions of Non-Covered Services




The following services are excluded from the Contractor’s Benefit Package, but are covered, in
most instances, by Medicaid fee-for-service:



A. MEDICAL NON-COVERED SERVICES



1. Personal Care Agency Services



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



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



2. Residential Health Care Facilities (RHCF)



Services provided in a Residential Health Care Facility (RHCF) to an individual who is determined
by the LDSS to be in Permanent Placement Status in the RHCF are not covered.



3. Hospice Program



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



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



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



4. Prescription and Non-Prescription (OTC) Drugs, Medical Supplies, and Enteral Formula



Coverage for drugs dispensed by community pharmacies, over the counter drugs, medical/surgical
supplies and enteral formula are not included in the Benefit Package and will be paid for by
Medicaid fee-for-service. Medical/surgical supplies are items other than drugs, prosthetic or
orthotic appliances, or DME which have been ordered by a qualified practitioner in the treatment
of a specific medical condition and which are: consumable, non-reusable, disposable, or for a
specific rather than incidental purpose, and generally have no salvageable value (e.g. gauze pads,
bandages and diapers). Pharmaceuticals and medical supplies routinely furnished or administered as
part of a clinic or office visit are covered.



APPENDIX K

January 1, 2005

K-26




20




B. Non-Covered Behavioral Health Services


1. Chemical Dependence Services



a. Outpatient Rehabilitation and Treatment Services



i). Methadone Maintenance Treatment Program (MMTP)



Consists of drug detoxification, drug dependence counseling, and rehabilitation services which
include chemical management of the patient with methadone. Facilities that provide methadone
maintenance treatment do so as their principal mission and are certified by the Office of Alcohol
and Substance Abuse Services (OASAS) under Title 14 NYCRR, Part 828.



ii). Medically Supervised Ambulatory Chemical Dependence Outpatient Clinic Programs



Medically Supervised Ambulatory Chemical Dependence Outpatient Clinic Programs are licensed under
Title 14 NYCRR Part 822 and provide chemical dependence outpatient treatment to individuals who
suffer from chemical abuse or dependence and their family members or significant others.



iii): Medically Supervised Chemical Dependence Outpatient Rehabilitation Programs



Medically Supervised Chemical Dependence Outpatient Rehabilitation Programs provide full or
half-day services to meet the needs of a specific target population of chronic alcoholic persons
who need a range of services which are different from those typically provided in an alcoholism
outpatient clinic. Programs are licensed by as Chemical Dependence Outpatient Rehabilitation
Programs under Title 14 NYCRR Part 822.9.




iv). Outpatient Chemical Dependence for Youth Programs




Outpatient Chemical Dependence for Youth Programs (OCDY) licensed under Title 14 NYCRR Part 823,
establishes programs and service regulations for OCDY programs. OCDY programs offer discrete,
ambulatory clinic services to chemically-dependent youth in a treatment setting that supports
abstinence from chemical dependence (including alcohol and substance abuse) services.




b. Chemical Dependence Services Ordered by the LDSS




The Contractor is not responsible for the provision and payment of Chemical Dependence Inpatient
Rehabilitation and Treatment Services ordered by the LDSS and provided to Enrollees who have:




	 	•	 	been assessed as unable to work by the LDSS and are mandated to receive
Chemical Dependence Inpatient Rehabilitation and Treatment Services as a condition
of eligibility for Public Assistance or Medicaid, or






	 	•	 	have been determined to be able to work with limitations (work
limited) and are simultaneously mandated by the district into Chemical Dependence
Inpatient Rehabilitation and Treatment Services (including alcohol and substance
abuse treatment services )pursuant to work activity requirements.	 





The Contractor is not responsible for the provision and payment of Medically Supervised
Inpatient and Outpatient Withdrawal Services ordered by the LDSS under Welfare Reform (as
indicated by Code 83).



The Contractor is responsible for the provision and payment of Medically Managed Detoxification
Services in this Agreement.



If the Contractor is already providing an Enrollee with Chemical Dependence Inpatient
Rehabilitation and Treatment Services and Detoxification Services and the LDSS is satisfied
with the level of care and services, then the Contractor will continue to be responsible for
the provision and payment of these services.



APPENDIX K

January 1,2005

K-27




2. Mental Health Services




a. Intensive Psychiatric Rehabilitation Treatment Programs (IPRT)




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




b. Day Treatment




A combination of diagnostic, treatment, and rehabilitative procedures which, through supervised
and planned activities and extensive client-staff interaction, provides the services of the
clinic treatment program, as well as social training, task and skill training and socialization
activities. Services are expected to be of six (6) months duration. These services are
certified by OMH under 14 NYCRR, Part 587.




c. Continuing Day Treatment




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




d. Day Treatment Programs Serving Children



Day treatment programs are characterized by a blend of mental health and special education
services provided in a fully integrated program. Typically these programs include: special
education in small classes with an emphasis on individualized instruction, individual and group
counseling, family services such as family counseling, support and education, crisis
intervention, interpersonal skill development, behavior modification, art and music therapy.



e. Home and Community Based Services Waiver for Seriously Emotionally Disturbed Children



This waiver is in select counties for children and adolescents who would otherwise be admitted to
an institutional setting if waiver services were not provided. The services include
individualized care coordination, respite, family support, intensive in-home skill building, and
crisis response.



f. Case Management



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



Please note: See generic definition of Comprehensive Medicaid Case Management (CMCM) under OTHER
NON-COVERED SERVICES.



g. Partial Hospitalization



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




	 	h.	 	Services Provided Through OMH Designated Clinics for Children With A Diagnosis of Serious
Emotional Disturbance (SED)





APPENDIX K




January 1, 2005




K-28





These are services provided by designated OMH clinics to children and adolescents with a
clinical diagnosis of SED.



i. Assertive Community Treatment (ACT)




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



j. Personalized Recovery Oriented Services (PROS)



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



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




a. OMH Licensed CRs*




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




b. Family-Based Treatment*




Rehabilitative services in family-based treatment programs are intended to provide treatment to
seriously emotionally disturbed children and youth to promote their successful functioning and
integration into the natural family, community, school or independent living situations. Such
services are provided in consideration of a child’s developmental stage. Those children determined
eligible for admission are placed in surrogate family homes for care and treatment.




*These services are certified by OMH under 14 NYCRR Part 586.3, 594 and 595.



4. Office of Mental Retardation and Developmental Disabilities (OMRDD) Services




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






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



b. Day Treatment



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



APPENDIX K




January 1, 2005




K-29




c. Medicaid Service Coordination (MSC)



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



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



Please note: See generic definition of Comprehensive Medicaid Case Management (CMCM) under OTHER
NON-COVERED SERVICES.




d. Home And Community Based Services Waivers (HCBS)




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




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




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



C. Other Non-Covered Services



1. The Early Intervention Program (EIP) — Children Birth to Two (2) Years of Age


This program provides early intervention services to certain children, from birth through two (2)
years of age, who have a developmental delay or a diagnosed physical or mental condition that has
a high probability of resulting in developmental delay. All managed care providers must refer
infants and toddlers suspected of having a delay to the local designated Early Intervention
agency in their area. (In most municipalities, the County Health Department is the designated
agency, except: New York City — the Department of Health, Mental Retardation and Alcoholism
Services; Erie County — The Department of Youth Services; Jefferson County — the Office of
Community Services; and Ulster County — the Department of Social Services).



Early intervention services provided to this eligible population are categorized as Non-Covered.
These services, which are designed to meet the developmental needs of the child and the needs of
the family related to enhancing the child’s development, will be identified on MMIS by unique rate
codes by which only the designated early intervention agency can claim reimbursement. Contractor
covered and authorized services will continue to be provided by the Contractor. Consequently, the
Contractor will be expected to refer any enrolled child suspected of having a developmental delay
to the locally designated early intervention agency in their area and participate in the
development of the Child’s Individualized Family Services Plan (IFSP). Contractor’s participation
in the development of the IFSP is necessary in order to coordinate the provision of early
intervention services and services covered by the Contractor.



Additionally, the locally designated early intervention agencies will be instructed on how to
identify a managed care Enrollee and the need to contact the Contractor to coordinate service
provision.



APPENDIX K

January 1, 2005

K-30




2. Preschool Supportive Health Services-Children Three (3) Through Four (4) Years of Age




The Preschool Supportive Health Services Program (PSHSP) enables counties and New York City to
obtain Medicaid reimbursement for certain educationally related medical services provided by
approved preschool special education programs for young children with disabilities. The Committee
on Preschool Special Education in each school district is responsible for the development of an
Individualized Education Program (IEP) for each child evaluated in need of special education and
medically related health services.




PSHSP services rendered to children three (3) through four (4) years of age in conjunction with an
approved IEP are categorized as Non-Covered.




The PSHSP services will be identified on MMIS by unique rate codes through which only counties and
New York City can claim reimbursement. In addition, a limited number of Article 28 clinics
associated with approved pre-school programs are allowed to directly bill Medicaid fee-for-
service for these services. Contractor covered and authorized services will continue to be
provided by the Contractor.



3. School Supportive Health Services-Children Five (5) Through Twenty-One (21) Years of Age



The School Supportive Health Services Program (SSHSP) enables school districts to obtain Medicaid
reimbursement for certain educationally related medical services provided by approved special
education programs for children with disabilities. The Committee on Special Education in each
school district is responsible for the development of an Individualized Education Program (IEP)
for each child evaluated in need of special education and medically related services.



SSHSP services rendered to children five (5) through twenty-one (21) years of age in conjunction
with an approved IEP are categorized as Non-Covered.



The SSHSP services are identified on MMIS by unique rate codes through which only school districts
can claim Medicaid reimbursement. Contractor covered and authorized services will continue to be
provided by the Contractor.



4. Comprehensive Medicaid Case Management (CMCM)



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



5. Directly Observed Therapy for Tuberculosis Disease




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



6. AIDS Adult Day Health Care



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



APPENDIX K

January 1, 2005

K-31




7. HIV COBRA Case Management



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



8. Fertility Services Fertility services are not covered by the Benefit Package nor by Medicaid
fee-for-service.


9. Adult Day Health Care



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




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



10. Personal Emergency Response Services (PERS)




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



provided in a residential health care setting. Regulations require that a person enrolled in an
ADHCP must require at least three (3) hours of health care delivered on the basis of at least one
(1) visit per week. While health care services are broadly defined in this setting to include
general medical care, nursing care, medication management, nutritional services, rehabilitative
services, and substance abuse and mental health services, the latter two (2) cannot be the sole
reason for admission to the program. Admission criteria must include, at a minimum, the need for
general medical care and nursing services.



11. School-Based Health Centers



A School-Based Health Center (SBHC) is an Article 28 extension clinic that is located in a school
and provides students with primary and preventive physical and mental health care services, acute
or first contact care, chronic care, and referral as needed. SBHC services include comprehensive
physical and mental health histories and assessments, diagnosis and treatment of acute and chronic
illnesses, screenings (e.g., vision, hearing, dental, nutrition, TB), routine management of chronic
diseases (e.g., asthma, diabetes), health education, mental health counseling and/or referral,
immunizations and physicals for working papers and sports.



21




APPENDIX K

January 1, 2005

K-32




Amendment to Medicaid Managed Care Model Contract — Effective 1/1/05




Residential Health Care Clarifications & Miscellaneous Revisions




	 	 	 	 	 	 	 	 	 	 	 	 	 
	Contract	 	 	 	 	 	 
	Section	 	Topic / Reason for Change	 	Contract Language Change	 	Status
	Sect. 1
	 	Definitions                                  	 	"Permanent Placement Status" means the status of an individual	 	 	 	 
	 
	 	"Permanent Placement Status"	 	in a
	 	 	 	 
	 
	 	Newly added definition                       
	 	 	—	 	 	 	 	 
	 
	 	 	 	 	 	Residential Health Care Facility (RHCF when the LDSS determines
	 	 	 	 
	 
	 	 	 	 	 	that
	 	 	 	 
	 
	 	 	 	 	 	the individual is not expected to return home based on medical
	 	 	 	 
	 
	 	 	 	 	 	evidence affirming the individual’s need for permanent RHCF
	 	 	 	 
	 
	 	 	 	 	 	placement.
	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	c) The monthly capitation payments and the Supplemental Newborn	 	 	 	 
	 
	 	 	 	 	 	Capitation Payment and the Supplemental Maternity Capitation
	 	 	 	 
	 
	 	Capitation Payments                          
	 	Payment to the Contractor shall constitute full and complete
	 	 	 	 
	 
	 	Conforming reference change                  
	 	payments to the Contractor for all services that the Contractor
	 	 	 	 
	 
	 	associated with addition of new              
	 	provides pursuant to this Agreement subject to stop-loss
	 	 	 	 
	 
	 	Section 3.13, Residential Health             
	 	provisions set forth in Section 3.11, and 3.12, and 3.13 of
	 	 	 	 
	Sect. 3.1 (c)
	 	Care Facility Stop-Loss                      
	 	this Agreement.
	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	3.13 Residential Health Care Facility Stop-Loss	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	The Contractor will be compensated for medically
	 	 	 	 
	 
	 	 	 	 	 	necessary and clinically appropriate Medicaid
	 	 	 	 
	 
	 	 	 	 	 	reimbursable inpatient Residential Health Care
	 	 	 	 
	 
	 	 	 	 	 	Facility services as defined in Appendix K in
	 	 	 	 
	 
	 	 	 	 	 	excess of sixty (60) days during a calendar year at
	 	 	 	 
	 
	 	 	 	 	 	the lower of the Contractor's negotiated rates or
	 	 	 	 
	Sect. 3.13
	 	Residential Health Care Facility             
	 	 	—	 	 	 	 	 
	(New item)
	 	Stop-Loss                                    
	 	Medicaid rate of payment.
	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 







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Residential Health Care Clarifications & Miscellaneous Revisions




	 	 	 	 	 	 	 	 	 	 	 	 	 
	Contract	 	 	 	 	 	 
	Section	 	Topic / Reason for Change	 	Contract Language Change	 	Status
	 
	 	 	 	 	 	3.14 Stop-Loss Procedures and Documentation	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	The Contractor must follow procedures and
	 	 	 	 
	 
	 	 	 	 	 	documentation requirements in accordance with the
	 	 	 	 
	 
	 	 	 	 	 	New York State Department of Health stop-loss
	 	 	 	 
	 
	 	 	 	 	 	policy and procedure manual. Payments made for
	 	 	 	 
	 
	 	 	 	 	 	stop-loss claims that do not conform to SDOH
	 	 	 	 
	Sect. 3.14
	 	Stop-Loss Procedures and                    
	 	 	—	 	 	 	 	 
	(New Item)
	 	Documentation                               
	 	requirements are subject to recoupment.
	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 
	Sections 3.13
and 3.14
Renumber
Sections 3.13,
“Enrollment
Limitations,”
	 	Enrollment Limitations
	 	 	 	 	 	 	 	 
	and 3.14,
	 	Tracking Visits Provided by
	 	 	 	 	 	 	 	 
	“Tracking Visits
	 	Indian Health Clinics
	 	 	 	 	 	 	 	 
	Provided by
	 	Conforming numbering change
	 	 	 	 	 	 	 	 
	Indian Health
	 	associated with addition of new
	 	 	 	 	 	 	 	 
	Clinics,” as
	 	Section 3.13, Residential Health
	 	 	 	 	 	 	 	 
	Sections 3.15,
	 	Care Facility Stop-Loss and new
	 	 	 	 	 	 	 	 
	and 3.16
	 	Section 3.14 Stop-Loss
	 	 	 	 	 	 	 	 
	respectively.
	 	Procedures and Documentation                
	 	Renumber original Sections 3.13 and 3.14 as indicated.
	 	 	 	 
	 	 	 	 	 	 	 	 	 







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23




Amendment to Medicaid Managed Care Model Contract — Effective 1/1/05




Residential Health Care Clarifications & Miscellaneous Revisions




	 	 	 	 	 	 	 
	Contract	 	 	 	 	 	 
	Section	 	Topic / Reason for Change	 	Contract Language Change	 	Status
	 	 	 	 	SDOH, with prior notice	 	 
	 	 	 	 	to the LDSS, will provide	 	 
	 	 	 	 	Contractor with	 	 
	 	 	 	 	instructions for	 	 
	 	 	 	 	submitting the reports	 	 
	 	 	 	 	required by Section 18.5	 	 
	 	 	 	 	(a) through (nmm),	 	 
	 	 	 	 	including time frames,	 	 
	 	 	 	 	and requisite formats.	 	 
	 	 	 	 	The instructions, time	 	 
	 	 	 	 	frames and formats may be	 	 
	 	 	 	 	modified by SDOH with	 	 
	 	 	 	 	prior notice to the LDSS,	 	 
	 	 	 	 	and thereafter upon sixty	 	 
	 	 	 	 	(60) days written notice	 	 
	 	 	 	 	to the Contractor. The	 	 
	 	 	 	 	LDSS, with prior notice	 	 
	 	 	 	 	to SDOH, shall provide	 	 
	 	 	 	 	the Contractor with	 	 
	 	 	 	 	instructions for	 	 
	 	 	 	 	submitting the reports;	 	 
	 	 	 	 	required by Section	 	 
	 	 	SDOH Instructions for Report	 	18.5(en)S	 	 
	 	 	Submissions	 	including time frames and	 	 
	Section 18.2	 	Technical correction	 	requisite formats.	 	 
	Section 18.4

	 	Notification of Changes in Report

Due Dates, Requirements or

Formats

Technical correction
	 	SDOH or LDSS may extend

due dates, or modify

report requirements or

formats upon a written

request by the Contractor

to the SDOH or LDSS with

a copy of the request to

the other agency, where

the Contractor has

demonstrated a good and

compelling reason for the

extension or

modification. The

determination to grant a

modification or;

extension of time shall

be made by SDOH with

regard to annual and

quarterly statements,

complaint reports,

audits, encounter data,

change of

ownership, clinical

studies, QARR, and

provider network reports.

The determination to

grant a modification or

extension of time shall

be made by the LDSS with

respect to No Contact,

PCP auto assignment, and

reports required by

Sections 18.5 (am) and

(en) of the Agreement.
	 	










































































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	Contract	 	 	 	 	 	 
	Section	 	Topic / Reason for Change	 	Contract Language Change	 	Status
	
 
	 	 	 	c) Other Financial Reports:
	 	

	Section 18.5 (c)

	 	Reporting Requirements — Other

Financial Reports:

Technical correction
	 	Contractor shall submit financial reports, including certified

annual financial statements, and make available documents relevant to

its financial condition to SDOH and the State

Insurance Department (SID) in a timely manner as required

by State laws and regulations including but not limited to

PHL§§ 4403-a, 4404 and 4409, Title 10 NYCRR §§ 98.11,

98.16 and 98.17 and applicable Insurance Law §§ 304, 305,

306 and 310. The LDSS reserves the right to require Contractor

to submit such relevant financial reports and documents related

to the financial condition of the MCO to the LDSS, as set forth in

Section 18.5(en) of this Agreement.
	 	





















	 

	 	 
	 	 
	 	








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	Contract	 	 	 	 	 	 
	Section	 	Topic / Reason for Change	 	Contract Language Change	 	Status
	
 
	 	 	 	f) Complaint Reports:
	 	

	Section 18.5 (f)

	 	Reporting Requirements -

Complaint Reports

Technical correction
	 	The Contractor must provide the SDOH on a quarterly

basis, and within fifteen (15) business days of the

close of the quarter, a summary of all complaints

received during the preceding quarter on the Health

Provider Network (“HPN”).

The Contractor also agrees to provide on a quarterly

basis, via the HPN, the total number of complaints that

have been unresolved for more than forty-five (45)

days. The Contractor shall maintain records on these

and other complaints which shall include all correspondence

related to the complaint, and an explanation of disposition.

These records shall be readily available for review by the

SDOH or LDSS upon request.

Nothing in this Section is intended to limit the right of the SDOH

and the LDSS to obtain information immediately from a Contractor

pursuant to investigating a particular Enrollee or provider

complaint.

The LDSS reserves the right to require the Contractor to submit a

hardcopy of complaint reports in Section 18.5(en) of this

Agreement.
	 	







































	 

	 	 
	 	 
	 	








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	Contract	 	 	 	 	 	 
	Section	 	Topic / Reason for Change	 	Contract Language Change	 	Status
	Section 32.2
	 	Indemnification by LDSS                      
	 	32.2 Indemnification by LDSS	 	Change in NYC model
	 
	 	Note: This change will only be               	 	The LDSS shall indemnify and hold harmless the Contractor                             
	 	only.
	 
	 	in the contracts between NYC                 	 	and its officers, agents, and employees from any and all claims
	 	 	 	 
	 
	 	and its participating MCOs.                  	 	for damages any lose or  damages resulting from actions by the
	 	 	 	 
	 
	 	Change requested by NYC                      	 	 	—	 	 	 	 	 
	 
	 	Department of Law.                           	 	LDSS or  their Contractors in their connection with under this
	 	 	 	 
	 
	 	 	 	 	 	Agreement, for performance except such the Contractor, its
	 	 	 	 
	 
	 	 	 	 	 	negligence or culpable act of officers, agents, employees, or
	 	 	 	 
	 
	 	 	 	 	 	subcontractors, including Participating Providers pursuant to
	 	 	 	 
	 
	 	 	 	 	 	the terms of Appendix A Part IL Section 6.3 herein.
	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 
	App. K
Table of
Contents
	 	Residential Health Care Facility
	 	 	 	 	 	 	 	 
	(Add New Item)
	 	(RHCF) Services                              
	 	18. Residential Health Care Facility (RHCF) Services	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 







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	Contract	 	 	 	 	 	 
	Section	 	Topic / Reason for Change	 	Contract Language Change	 	Status
	
 
	 	 	 	Managed Care Plan Scope of Benefit

Residential Health Care Facility

Services means inpatient nursing

home services provided by

facilities licensed under New York

State Public Health Law, including

AIDS nursing facilities. Covered

services include the following

health care services: medical

supervision, 24-hour per day
	 	



















	
 
	 	 	 	 
	 	

	App. K

Appendix K-1

and K-2 charts

(Add New Item

to end of each

chart, under

“Managed Care

Plan Scope of

Benefit”

column)

	 	Residential Health Care Facility

(RHCF) Services

Clarify the range of covered

services and Contractor

responsibility
	 	nursing care, assistance with the

activities of daily living,

physical therapy, occupational

therapy, and speech/language

pathology services and other

services as specified in the New

York State Public Health Law and

Regulations for residential health

care facilities and AIDS nursing

facilities. RHCF Services are

subject to the stop-loss

provisions specified in Section

3.13 of this Agreement.
	 	

























	
 
	 	 	 	 
	 	








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	Contract	 	 	 	 	 	 
	Section	 	Topic / Reason for Change	 	Contract Language Change	 	Status
	 
	 	 	 	 	 	b. Rehabilitation Services
	 	 	 	 
	 
	 	 	 	 	 	18 NYCRR 505.11	 	 	 	 
	 
	 	 	 	 	 	Rehabilitation services are provided for the maximum reduction of
	 	 	 	 
	 
	 	 	 	 	 	physical or mental disability and restoration of the Enrollee to his or
	 	 	 	 
	 
	 	 	 	 	 	her best functional level. Rehabilitation services include
	 	 	 	 
	 
	 	 	 	 	 	care and services rendered by physical therapists, speech-language
	 	 	 	 
	 
	 	 	 	 	 	pathologists and occupational therapists. Rehabilitation services may be
	 	 	 	 
	App. K, I.
	 	 	 	 	 	provided in an Article 28 inpatient or outpatient facility, an
	 	 	 	 
	Prepaid Benefit
	 	 	 	 	 	Enrollee's home, in an approved home health agency, in the office of a
	 	 	 	 
	Package
	 	 	 	 	 	qualified
	 	 	 	 
	Definitions of
	 	 	 	 	 	private practicing therapist or speech pathologist, or for a
	 	 	 	 
	Covered
	 	 	 	 	 	child in a school, pre-school or community setting, or in a Residential
	 	 	 	 
	Services, A.
	 	 	 	 	 	Health Care Facility (RHCF) as long as  the Enrollee's stay is
	 	 	 	 
	Medical
	 	 	 	 	 	classified as a rehabilitative stay and meets the requirements for
	 	 	 	 
	Services,
	 	 	 	 	 	covered RHCF services as defined herein.
	 	 	 	 
	#7. Services of
	 	 	 	 	 	 	—	 	 	 	 	 
	Other
	 	 	 	 	 	Rehabilitation services provided in Residential Health Care Facilities
	 	 	 	 
	Practitioners,
	 	 	 	 	 	are subject to the stop-loss provisions specified in Section 3.13 of
	 	 	 	 
	b.)
	 	 	 	 	 	this Agreement. Rehabilitation services are covered as medically
	 	 	 	 
	Rehabilitation
	 	 	 	 	 	necessary, when ordered by the
	 	 	 	 
	Services
	 	Rehabilitation Services               
	 	 	—	 	 	 	 	 
	 
	 	 	 	 	 	Contractor's Participating Provider.
	 	 	 	 







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	Contract	 	 	 	 	 	 
	Section	 	Topic / Reason for Change	 	Contract Language Change	 	Status
	 
	 	 	 	 	 	18. Residential Health Care Facility (RHCF) Services	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	Residential Health Care Facility (RHCF) Services means inpatient nursing
	 	 	 	 
	 
	 	 	 	 	 	home services provided by facilities licensed wider Article 28 of the New
	 	 	 	 
	 
	 	 	 	 	 	York State Public Health Law, including AIDS nursing facilities. Covered
	 	 	 	 
	 
	 	 	 	 	 	services includes the following health care services: medical supervision,
	 	 	 	 
	 
	 	 	 	 	 	24-hour per day nursing care, assistance with the activities of daily	 	 	 	 
	 
	 	 	 	 	 	living, physical therapy, occupational therapy, and speech/language
	 	 	 	 
	 
	 	 	 	 	 	pathology services and other services as specified in the New York State
	 	 	 	 
	 
	 	 	 	 	 	Public Health Law and Regulations for residential health care facilities
	 	 	 	 
	 
	 	 	 	 	 	and AIDS nursing facilities. These services should be provided to an
	 	 	 	 
	 
	 	 	 	 	 	Enrollee:
	 	 	 	 
	 
	 	 	 	 	 	a. Who is diagnosed by a physician as having one or more clinically
	 	 	 	 
	 
	 	 	 	 	 	determined illnesses or conditions that cause the Enrollee to be so
	 	 	 	 
	 
	 	 	 	 	 	incapacitated, sick, invalid, infirm, disabled, or convalescent as to
	 	 	 	 
	 
	 	 	 	 	 	require at least medical and nursing care; and
	 	 	 	 
	 
	 	 	 	 	 	b. Whose assessed health care needs, in the professional
	 	 	 	 
	 
	 	 	 	 	 	judgment of the Enrollee's physician or a medical team:
	 	 	 	 
	 
	 	 	 	 	 	i. do not require care or active treatment of the Enrollee in a
	 	 	 	 
	 
	 	 	 	 	 	general or special hospital;
	 	 	 	 
	 
	 	 	 	 	 	ii. cannot be met satisfactorily in the Enrollee's own home or home
	 	 	 	 
	 
	 	 	 	 	 	substitute through provision of such home health services, including
	 	 	 	 
	 
	 	 	 	 	 	medical and other health and health-related services as are available in or
	 	 	 	 
	 
	 	 	 	 	 	near his or her community; and
	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	iii. cannot be met satisfactorily in the physician's office, a hospital
	 	 	 	 
	 
	 	 	 	 	 	clinic, or other ambulatory care setting because of the unavailability of
	 	 	 	 
	 
	 	 	 	 	 	medical or other health and health-related services for the Enrollee in
	 	 	 	 
	 
	 	 	 	 	 	such, setting in or near his or her community.
	 	 	 	 
	 
	 	 	 	 	 	The Contractor is also responsible for respite days and bed hold days
	 	 	 	 
	 
	 	 	 	 	 	authorized by the Contractor.
	 	 	 	 
	App. K, I. Prepaid
	 	Residential Health Care               
	 	 	—	 	 	 	 	 
	Benefit Package
	 	Facility (RHCF) Services              
	 	The Contractor is responsible for all medically necessary and clinically
	 	 	 	 
	Definitions of
	 	Clarify the range of                  
	 	appropriate inpatient Residential Health Care Facility services authorized
	 	 	 	 
	Covered Services,
	 	covered services and                  
	 	by the Contractor up to a sixty (60) day calendar year stop-loss for
	 	 	 	 
	A. Medical Services
	 	Contractor responsibility             
	 	Enrollees who are not in Permanent Placement Status as determined by LDSS.
	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 







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	Contract	 	 	 	 	 	 
	Section	 	Topic / Reason for Change	 	Contract Language Change	 	Status
	App. K

Section III,

Non-Covered

Services; 2.

Other Non-

Covered

Services

	 	Residential Health Care Facilities

(RHCF)

Clarify that permanent residency

in a RHCF is not a covered

service in the Medicaid managed

care benefit package.
	 	2. Residential Health Care Facilities (RHCF)

Residency Services provided in a Residential

Health Care Facility (RHCF) to an individual

who is determined by the LDSS to be in

Permanent Placement Status in the RHCF is

are not covered (see 1.8 NYCRR 1.4

Rehabilitation in §360 (k)) services such a

setting by are covered as medically

necessary when ordered the Contractor’s

Participating Provider.
	 	



















	
 
	 	 	 	 
	 	








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