exv10w6w6



 





Exhibit 10.6.6




STATE OF NEW JERSEY




DEPARTMENT OF HUMAN SERVICES




DIVISION OF MEDICAL ASSISTANCE AND HEALTH SERVICES




AND




AMERIGROUP NEW JERSEY, INC.




AGREEMENT TO PROVIDE HMO SERVICES




In accordance with Article 7, section 7.11.2A and 7.11.2B of the contract
between AMERIGROUP New Jersey, Inc. and the State of New Jersey, Department of
Human Services, Division of Medical Assistance and Health Services (DMAHS),
effective date October 1, 2000, all parties agree that certain sections of the
contract shall be amended to be effective September 1, 2004, as follows:




 









 








Exhibit 10.6.6





	1.	 	Article 1, “Definitions” section for the following definitions:






	•	 	Comprehensive Orthodontic Treatment (new);






	•	 	Grievance






	 	 	shall be amended as reflected in the relevant pages of Article 1 attached
hereto and incorporated herein.






	2.	 	Article 4, “Provision of Health Care Services,” Sections 4.1.2(A)27;
4.1.2(B); 4.1.4(A)3(a) (new); 4.1.6(A)14; 4.1.7(C)15; 4.4; 4.5.2(B);
4.5.4(B); 4.5.6(A); 4.6.2(P) and 4.8.1(F) shall be amended as reflected
in Article 4, Sections 4.1.2(A)27; 4.1.2(B); 4.1.4(A)3(a)(new);
4.1.6(A)14; 4.1.7(C)15; 4.4; 4.5.2(B); 4.5.4(B); 4.5.6(A); 4.6.2(P) and
4.8.1(F) attached hereto and incorporated herein.






	3.	 	Article 5, “Enrollee Services,” Sections 5.8.2(NN) and 5.15.1(B) shall
be amended as reflected in Article 5, Section 5.8.2(NN) and 5.15.1(B)
attached hereto and incorporated herein.






	4.	 	Article 8, “Financial Provisions,” Section 8.5.2.8 shall be amended as
reflected in Article 8, Section 8.5.2.8 attached hereto and incorporated
herein.






	5.	 	Appendix, Section C, “Capitation Rates,” shall be revised as reflected
in SFY 2005 Capitation Rates attached hereto and incorporated herein.




 









 











Exhibit 10.6.6




All other terms and conditions of the October 1, 2000 contract and
subsequent amendments remain unchanged except as noted above.




The contracting parties indicate their agreement by their signatures.




	 	 	 	 	 	 	 
	AMERIGROUP
	 	State of New Jersey

	New Jersey, Inc.
	 	Department of Human Services

	 	 	 	 	 
	BY:

	 	/S/ Norine Yukon
	 	BY:	 	 
	

	 	
 
	 	 	 	
 
	 	 	 	 	 
	

	 	 	 	 	 	Ann Clemency Kohler
	 	 	 	 	 
	TITLE:President and CEO	 	TITLE: Director, DMAHS
	
	 	 	 	 
	 	 	 	 	 
	 DATE: July 14, 2004	 	DATE:	 	 
	
	 	 	 	
 







APPROVED AS TO FORM ONLY




Attorney General




State of New Jersey





		
	BY: 	

 
  Deputy Attorney General






		
	DATE: 	









 









 








Exhibit 10.6.6




with the contractor. Marketing by an employee of the contractor is considered
direct; marketing by an agent is considered indirect.




Commissioner—the Commissioner of the New Jersey Department of Human Services
or a duly authorized representative:




Complaint—a protest by an enrollee as to the conduct by the contractor or any
agent of the contractor, or an act or failure to act by the contractor or any
agent of the contractor, or any other matter in which an enrollee feels
aggrieved by the contractor, that is communicated to the contractor and that
could be resolved by the contractor within five (5) business days, except for
urgent situations, and as required by the exigencies of the situation.




Complaint Resolution—completed actions taken to fully settle a complaint to the
DMAHS’ satisfaction.




Comprehensive Orthodontic Treatment—the utilization of fixed orthodontic
appliances (bands/brackets and arch wires) to improve the craniofacial
dysfunction and/or dentofacial deformity of the patient.




Comprehensive Risk Contract—a risk contract that covers comprehensive
services, that is, inpatient hospital services and any of the following
services, or any three or more of the following services:





	1.	 	Outpatient hospital services.
	 
	2.	 	Rural health clinic services.
	 
	3.	 	FQHC services.
	 
	4.	 	Other laboratory and X-ray services.
	 
	5.	 	Nursing facility (NF) services.
	 
	6.	 	Early and periodic screening, diagnosis and treatment (EPSDT) services.
	 
	7.	 	Family planning services.
	 
	8.	 	Physician services.
	 
	9.	 	Home health services.





Condition—a disease, illness, injury, disorder, or biological or psychological
condition or status for which treatment is indicated.




Contested Claim—a claim that is denied because the claim is an ineligible
claim, the claim submission is incomplete, the coding or other required
information to be submitted is incorrect, the amount claimed is in dispute, or
the claim requires special treatment.




Continuity of Care—the plan of care for a particular enrollee that should
assure progress without unreasonable interruption.




Contract—the written agreement between the State and the contractor, and
comprises the contract, any addenda, appendices, attachments, or amendments
thereto.




			
	 	 	 
	Amended as of September 1, 2004
	 	I-5







 









 






Exhibit 10.6.6




Governing Body—a managed care organization’s Board of Directors or, where the
Board’s participation with quality improvement issues is not direct, a
designated committee of the senior management of the managed care
organization.




Grievance—means an expression of dissatisfaction about any matter or a
complaint that is submitted in writing, or that is orally communicated and
could not be resolved within five (5) business days of receipt.




Grievance System-means the overall system that includes grievances and appeals
at the contractor level and access to the State fair hearing process. -




Group Model—a type of HMO operation similar to a group practice except that
the group model must meet the following criteria: (a) the group is a separate
legal entity, (i.e. administrative entity) apart from the HMO; (b) the group
is usually a corporation or — partnership; (c) members of the group must pool
their. income; (d) members of the group must share medical equipment, as well
as technical and administrative staff; (e)-members of the group must devote at
least 50 percent of their time to the group; and (f) members of the group must
have “substantial responsibility” for delivery of health services to HMO
members, within four years of qualification. After that period, the group may
request additional time or a waiver in accordance with federal regulations at
42 C.F.R. Section 110.104(2), Subpart A.




HCFA—the Health Care Financing Administration, the former name of CMS
(Centers for Medicare and Medicaid Services), within the U.S. Department of
Health and Human Services.




Health Benefits Coordinator (HBC)—the external organization under contract
with the Department whose primary responsibility is to assist Medicaid
eligible individuals in contractor selection and enrollment.




Health Care Professional—a physician or other health care professional if
coverage for the professional’s services is provided under the contractor’s
contract for the services. It includes podiatrists, optometrists,
chiropractors, psychologists, dentists, physician assistants, physical or
occupational therapists and therapist assistants, speech-language
pathologists, audiologists, registered or licensed practical nurses (including
nurse practitioners, clinical nurse specialists, certified registered nurse
anesthetists, and certified nurse midwives), licensed certified social
workers, registered respiratory therapists, and certified respiratory therapy
technicians.




Health Care Services—are all preventive and therapeutic medical, dental,
surgical, ancillary (medical and non-medical) and supplemental benefits
provided to enrollees to diagnose, treat, and maintain the optimal well-being
of enrollees provided by physicians, other health care professionals,
institutional, and ancillary service providers.




Health Insurance—private insurance available through an individual or group
plan that covers health services. It is also referred to as Third Party
Liability.




			
	 	 	 
	Amended as of September 1, 2004
	 	I-12







 









 






Exhibit 10.6.6





	21.	 	Medical Supplies
	 
	22.	 	Prosthetics and Orthotics including certified shoe provider.
	 
	23.	 	Dental Services
	 
	24.	 	Organ Transplants — includes donor and recipient costs.
Exception: The contractor will not be responsible for
transplant-related donor and recipient inpatient hospital costs
for-an individual placed on a transplant list while in the
Medicaid FFS program prior to initial enrollment into the
contractor’s plan.
	 
	25.	 	Transportation Services for any contractor-covered service
or non-contractor covered service including ambulance, mobile
intensive care units (MICUs) and invalid coach (including lift
equipped vehicles)
	 
	26.	 	Post-acute Care
	 
	27.	 	Mental Health/Substance Abuse Services for enrollees who are clients
of
the Division of Developmental Disabilities. Exception — partial
care services are not covered by the contractor.






	B.	 	Conditions Altering Mental Status. Those diagnoses which are
categorized as altering the mental status of an individual but are of
organic origin shall be part of the contractor’s medical, financial and
care management responsibilities for all categories of enrollees. These
include the diagnoses in the following ICD-9-CM
Series:





	 	 	 	 	 	 	 
	1.

	 	 	290.0	 	 	Senile dementia, simple type
	 
	 	 	 	 	 	 
	2.

	 	 	290.1	 	 	Presenile dementia
	 
	 	 	 	 	 	 
	3.

	 	 	290.10	 	 	Presenile dementia, uncomplicated
	 
	 	 	 	 	 	 
	4.

	 	 	290.11	 	 	Presenile dementia with delerium
	 
	 	 	 	 	 	 
	5.

	 	 	290.12	 	 	Presenile dementia with delusional features
	 
	 	 	 	 	 	 
	6.

	 	 	290.13	 	 	Presenile dementia with depressive features
	 
	 	 	 	 	 	 
	7.

	 	 	290.2	 	 	Senile dementia with delusional or depressive features
	 
	 	 	 	 	 	 
	8.

	 	 	290.20	 	 	Senile dementia with delusional features
	 
	 	 	 	 	 	 
	9.

	 	 	290.21	 	 	Senile dementia with depressive features
	 
	 	 	 	 	 	 
	10.

	 	 	290.3	 	 	Senile dementia with delerium
	 
	 	 	 	 	 	 
	11.

	 	 	290.4	 	 	Arteriosclerotic dementia
	 
	 	 	 	 	 	 
	12.

	 	 	290.40	 	 	Arteriosclerotic dementia, uncomplicated
	 
	 	 	 	 	 	 
	13.

	 	 	290.41	 	 	Arteriosclerotic dementia with delirium
	 
	 	 	 	 	 	 
	14.

	 	 	290.42	 	 	Arteriosclerotic dementia with delusional features
	 
	 	 	 	 	 	 
	15.

	 	 	290.43	 	 	Arteriosclerotic dementia with depressive features
	 
	 	 	 	 	 	 
	16.

	 	 	290.8	 	 	Other specific senile psychotic conditions
	 
	 	 	 	 	 	 
	17.

	 	 	290.9	 	 	Unspecified senile psychotic condition







			
	 	 	 
	Amended as of July September 1, 2004
	 	IV-6







 









 





Exhibit 10.6.6


	 	 	 	 	 	 	 
	18.

	 	 	291.1	 	 	Alcohol amnestic syndrome
	 
	 	 	 	 	 	 
	19.

	 	 	291.2	 	 	Other alcoholic dementia
	 
	 	 	 	 	 	 
	20.

	 	 	292.82	 	 	Drug induced dementia
	 
	 	 	 	 	 	 
	21.

	 	 	292.83	 	 	Drug-induced amnestic syndrome
	 
	 	 	 	 	 	 
	22.

	 	 	292.9	 	 	Unspecified drug induced mental disorders
	 
	 	 	 	 	 	 
	23.

	 	 	293.0	 	 	Acute delirium
	 
	 	 	 	 	 	 
	24.

	 	 	293.1	 	 	Subacute delirium
	 
	 	 	 	 	 	 
	25.

	 	 	293.8	 	 	Other specific transient organic mental disorders
	 
	 	 	 	 	 	 
	26.

	 	 	293.81	 	 	Organic delusional syndrome
	 
	 	 	 	 	 	 
	27.

	 	 	293.82	 	 	Organic hallucinosis syndrome
	 
	 	 	 	 	 	 
	28.

	 	 	293.83	 	 	Organic affective syndrome
	 
	 	 	 	 	 	 
	29.

	 	 	293.84	 	 	Organic anxiety syndrome.
	 
	 	 	 	 	 	 
	30.

	 	 	294.0	 	 	Amnestic syndrome
	 
	 	 	 	 	 	 
	31.

	 	 	294.1	 	 	Dementia in conditions classified elsewhere
	 
	 	 	 	 	 	 
	32.

	 	 	294.8	 	 	Other specified organic brain syndromes (chronic)
	 
	 	 	 	 	 	 
	33.

	 	 	294.9	 	 	Unspecified organic brain syndrome (chronic)
	 
	 	 	 	 	 	 
	34.

	 	 	305.1	 	 	Non-dependent abuse of drugs — tobacco
	 
	 	 	 	 	 	 
	35.

	 	 	310.0	 	 	Frontal lobe syndrome
	 
	 	 	 	 	 	 
	36.

	 	 	310.2	 	 	Postconcussion syndrome
	 
	 	 	 	 	 	 
	37.

	 	 	310.8	 	 	Other specified nonpsychotic mental disorder following

organic brain damage
	 
	 	 	 	 	 	 
	38.

	 	 	310.9	 	 	Unspecified nonpsychotic mental disorder following

organic brain damage








	 	 	In addition, the contractor shall retain responsibility for
delivering all covered Medicaid mental health/substance abuse
services (except partial care services) to enrollees who are
clients of the Division of Developmental Disabilities (referred to
as “clients of DDD”). Articles Four and Five contain further
information regarding clients of DDD.






	4.1.3	 	SERVICES REMAINING IN FEE-FOR-SERVICE PROGRAM AND MAY NECESSITATE
CONTRACTOR ASSISTANCE TO THE ENROLLEE TO ACCESS THE SERVICES





A. The following services provided by the New Jersey Medicaid
program under its State plan shall remain in the fee-for-service
program but may require medical orders by the contractor’s
PCPs/providers. These services shall not be included in the
contractor’s capitation.




	1.	 	Personal Care Assistant Services (not covered for
NJ FamilyCare Plans B and C)
	 
	2.	 	Medical Day Care (not covered for NJ FamilyCare Plans B and C)





			
	 	 	 
	Amended as of September 1, 2004
	 	IV-7







 









 





Exhibit 10.6.6


	 	 	
1. Procedure Codes to be paid by Medicaid FFS
up to 60 days after first time
New Jersey Care 2000+ enrollment:





	 	 	 	 	 	 	 	 	 	 	 	 	 
	02710
	 	 	 	 	 	 	02792	 	 	 	03430	 
	02720
	 	 	 	 	 	 	02950	 	 	 	05110	 
	02721
	 	 	 	 	 	 	02952	 	 	 	05120	 
	02722
	 	 	 	 	 	 	02954	 	 	 	05211	 
	02750
	 	 	 	 	 	 	03310	 	 	 	05211-52	 
	02751
	 	 	 	 	 	 	03320	 	 	 	05212	 
	02752
	 	 	 	 	 	 	03330	 	 	 	05212-52	 
	02790
	 	 	 	 	 	 	03410-22	 	 	 	05213	 
	02791
	 	 	 	 	 	 	03411	 	 	 	05214	 








	 	 	Procedure Codes to be paid by Medicaid FFS up to 120 days
from date of last preliminary extractions after patient
enrolls in New Jersey Care 2000+ (applies to tooth codes 5 -
12 and 21 - 28 only):
	 
	 	 	 05130

05130-22
 05140

05140-22

	 
	3.	 	Extraction Procedure Codes to be paid by Medicaid
FFS up to 120 days from last date of preliminary extractions
after first time New Jersey Care 2000+ enrollment in
conjunction with the following codas (05130, 05130-22, 05140,
05140-22):
	 
	 	 	07110
 07130
 07210





4.1.4 ‘MEDICAID COVERED SERVICES NOT PROVIDED BY CONTRACTOR





	A.	 	Mental Health/Substance Abuse. The following mental
health/substance abuse services (except for the conditions listed
in 4.1.2.B) will be managed by the State or its agent for non-DDD
enrollees, including all NJ FamilyCare enrollees. (The contractor
will retain responsibility for furnishing mental health/substance
abuse services, excluding partial care services and the cost of the
drugs listed below, to Medicaid enrollees who are clients of the
Division of Developmental Disabilities).






	~1.	 	 Substance Abuse Services-diagnosis,
treatment, and detoxification
	 
	- 2.	 	 Costs for Methadone maintenance and its
administration
	 
	- 3.	 	 Mental Health Services






	a.	 	Partial care services are covered by the Medicaid program.





			
	 	 	 
	Amended as of September 1, 2004
	 	IV-9







 









 



Exhibit 10.6.6


	4.	 	Home Health Care Services — Limited to skilled nursing for a home
bound beneficiary which is provided or supervised by a registered
nurse, and home health aide when the purpose of the treatment is
skilled care; and medical social services which are necessary for the
treatment of the beneficiary’s medical condition
	 
	5.	 	Hospice Services
	 
	6.	 	Inpatient Hospital Services, including general hospitals, special
hospitals, and rehabilitation hospitals. — The contractor shall not be
responsible when the primary admitting diagnosis is mental health or
substance abuse related.
	 
	7.	 	Outpatient Hospital Services, including outpatient surgery
	 
	8.	 	Laboratory Services — All laboratory testing sites providing
services under this contract must have either a Clinical Laboratory
Improvement Act (CLIA) certificate of waiver or a certificate of
registration along with a CLIA identification number. Those providers
with certificates of waiver shall provide only the types of tests
permitted under the terms of their waiver. Laboratories with
certificates of registration may perform a full range of laboratory
services.
	 
	9.	 	Radiology Services — Diagnostic and therapeutic
	 
	10.	 	Optometrist Services, including one routine eye examination per year
	 
	11.	 	Optical appliances — Limited to one pair of glasses (or contact
lenses) per 24 month period or as medically necessary
	 
	12.	 	Organ transplant services which are — non-experimental
or —
non-investigational
	 
	13.	 	Prescription drugs, excluding over-the-counter drugs Exception:
See Article 8 regarding Protease Inhibitors and other antiretrovirals.
	 
	14.	 	Dental Services — Limited to preventive dental services for
children under the age of 12 years, including oral examinations, oral
prophylaxis, and topical application of fluorides. Exception —
comprehensive orthodontia treatment services shall be provided,
through completion of required services, for any enrollee under the
age of 19 years whose orthodontia services were initiated while
enrolled with the contractor as a Medicaid, NJ FamilyCare Plan A, B,
or C enrollee. The contractor shall not be responsible for orthodontia
services to a Plan D enrollee under the age of 19 years old that were





			
	 	 	 
	Amended as of September 1, 2004
	 	IV-12







 









 






Exhibit 10.6.6





	 	 	initiated while that individual was enrolled with another
contractor. The enrollee must continue enrollment in the HMO
where services were initiated until those services were
completed or until the member loses Medicaid/NJ FamilyCare
eligibility. Active treatment begins with the placement of the
orthodontic appliances (banding). Cases that were authorized but
not banded do not qualify for continuation of care.
	 
	15.	 	Podiatrist Services — Excludes routine hygienic care of
the feet; including the treatment of corns and calluses, the
trimming of nails, and other hygienic care such as cleaning or
soaking feet, in the absence of a pathological condition
	 
	16.	 	Prosthetic appliances — Limited to the initial provision
of a prosthetic device that temporarily or permanently replaces
all or part of an external body part lost or impaired as a result
of disease, injury, or congenital defect. Repair and replacement
services are covered when due to congenital growth.
	 
	17.	 	Private duty nursing — Only when authorized by the contractor
	 
	18.	 	Transportation Services — Limited to ambulance for medical
emergency only
	 
	19.	 	Well child care including immunizations, lead screening and
treatments
	 
	20.	 	Maternity and related newborn care
	 
	21.	 	Diabetic supplies and equipment






	B.	 	Services Available To NJ FamilyCare Plan D Under Fee-For-Service.
The following services are available to NJ FamilyCare Plan D
enrollees under fee-for-service:






	1.	 	Abortion services
	 
	2.	 	Outpatient Rehabilitation Services — Physical therapy,
Occupational therapy, and Speech therapy for non-chronic
conditions and acute illnesses and injuries. Limited to treatment
for a 60-day (that is, 60 business days) consecutive period per
incident of illness or injury beginning with the first day of
treatment per contract year. Speech therapy services rendered for
treatment of delays in speech development, unless resulting from
disease, injury or congenital defects are not covered





			
	 	 	 
	Amended as of September 1, 2004
	 	IV-13







 









 






Exhibit 10.6.6





	12.	 	Durable Medical Equipment — excludes any equipment
not listed in Appendix, Section B.4.1, and not covered
if not part of inpatient hospital discharge plan
	 
	13.	 	Early and Periodic Screening, Diagnosis and
Treatment (EPSDT) services
	 
	14.	 	Transportation Services, including
non-emergency ambulance, invalid coach, and lower mode
transportation
	 
	15.	 	Hearing Aid Services and Audiology
	 
	16.	 	Blood and Blood Plasma, except
administration of blood, processing of blood, processing
fees and fees related to autologous blood donations are
covered.
	 
	17.	 	Cosmetic Services
	 
	18.	 	Custodial Care
	 
	19.	 	Special Remedial and Educational Services
	 
	20.	 	Experimental and Investigational Services
	 
	21.	 	Medical Supplies (except diabetic supplies)
	 
	22.	 	Infertility Services
	 
	23.	 	Rehabilitative Services for Substance Abuse
	 
	24.	 	Weight reduction programs or dietary
supplements, except operations, procedures or treatment
of obesity when approved by the contractor
	 
	25.	 	Acupuncture and acupuncture therapy, except
when performed as a form of anesthesia in connection with
covered surgery
	 
	26.	 	Temporomandibular joint disorder treatment,
including treatment performed by prosthesis placed
directly in the teeth
	 
	27.	 	Recreational therapy
	 
	28.	 	Sleep therapy
	 
	29.	 	Court-ordered services
	 
	30.	 	Thermograms and thermography
	 
	31.	 	Biofeedback
	 
	32.	 	Radial keratotomy
	 
	33.	 	Respite Care
	 
	34.	 	Inpatient hospital services for mental health
	 
	35.	 	Inpatient and outpatient services for substance abuse
	 
	36.	 	Partial hospitalization





			
	 	 	 
	Amended as of September 1, 2004
	 	IV-18







 









 




Exhibit 10.6.6


	F.	 	Developmental disabilities clinics




4.4 COORDINATION WITH MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES




	 	 	The State shall retain a separate Mental Health/Substance Abuse system
for the coordination and monitoring of most mental health/substance
abuse conditions. The contractor shall furnish MH/SA services except
partial care services to clients of DDD. However, as described below,
the contractor shall retain responsibility for MI-USA screening;
referrals, prescription drugs; higher-mode transportation, and for
treatment of the conditions identified in Article 4.1.2B.






	A.	 	Screening Procedures. Mental health and substance abuse
problems shall be systematically identified and addressed by the
enrollee’s PCP at the earliest possible time following initial
participation of the enrollee in the contractor’s plan or after
the onset of a condition requiring mental health and/or substance
-abuse treatment. PCPs and other providers shall utilize mental
health/substance abuse screening tools as set forth in Section
B.4.9 of the Appendices as well as other mechanisms to facilitate
early identification of mental health and substance abuse needs
for treatment. The contractor may request permission to use
alternative screening tools. The use of alternative screening
tools shall be pre-approved by DMAHS. The lack of motivation of
an enrollee to participate in treatment shall = not be considered
a factor in determining medical necessity and shall not be used
as a rationale for withholding or limiting treatment of an
enrollee.
	 
	 	 	The contractor shall present its policies and procedures
regarding how its providers will identify enrollees with MH/SA
service needs, how they will encourage these enrollees to begin
treatment, and the screening tools to be used to identify
enrollees requiring MH/SA services. The contractor should refer
to the DSM-IV Primary Care Version in development of its
procedures.
	 
	B.	 	Referrals. The contractor shall be responsible for
referring or coordinating referrals of enrollees as indicated to
Mental Health/Substance Abuse providers. In order to facilitate
this, the contractor may contact DMHS or its agent (e.g., if the
State contracts with a third party administrator (TPA) for a list
of MH/SA providers. Enrollees may be referred to a MH/SA provider
by the PCP, family members, other providers, State agencies, the
contractor’s staff, or may self-refer.






	1.	 	The contractor shall be responsible for
referrals from MI-I/SA providers for medical diagnostic
work-up to formulate a diagnosis or to effect the treatment
of a MH/SA disorder and ongoing medical care for any
enrollee with a M-I/SA diagnosis and shall coordinate the
care with the MH/SA provider. This includes the
responsibility for physical examinations (with the exception
of physical examinations performed in direct connection with
the administration of Methadone, which will remain FFS),
neurological evaluations, laboratory testing and radiologic
examinations,




 



			
	Amended as of September 1, 2004
	 	IV-45







 









 






Exhibit 10.6.6





	 	 	that physical and communication barriers do not prohibit enrollees
with disabilities from obtaining services from the contractor.
	 
	6.	 	Services for enrollees with special needs must be provided
in a manner responsive to the nature of a person’s
disability/specific health care need and include adequate time for
the provision of the service.






	B.	 	The contractor shall ensure that any new enrollee identified (either by the
information on the Medical. Information form at the time
of enrollment or by contractor providers after enrollment) as having
complex/chronic conditions receives immediate transition planning. The
planning shall be completed within a timeframe appropriate to the
enrollee’s condition, but in no case later than ten (10) business days
from the effective date of enrollment when the Medical
Information form has an indication of special health care needs or
within thirty (30) days after special conditions are identified by a
provider. This transition planning shall not constitute the IHCP
described in Sections 4.5.4 and 4.6.5. Transition planning shall provide
for a brief, interim plan to ensure uninterrupted services until a more
detailed plan of care is developed. The transition planning process
includes, but is not limited to:






	1.	 	Review of existing care plans.
	 
	2.	 	Preparation of a transition plan that ensures continuous
care during the transfer into the contractor’s network.
	 
	3.	 	If durable medical equipment had been ordered prior to
enrollment but not received by the time of enrollment, the
contractor must coordinate and follow-through to ensure that the
enrollee receives necessary equipment.






	C.	 	Outreach and Enrollment Staff The contractor shall have outreach and
enrollment staff who are trained to work with enrollees with special
needs, are knowledgeable about their care needs and concerns, and are
able to converse in the different languages common among the enrolled
population, including TDD/TT and American Sign Language if necessary.
	 
	D.	 	Specialty Care. The contractor shall have a procedure by which a new
enrollee upon enrollment, or an enrollee upon diagnosis, who requires
very complex, highly specialized health care services over a prolonged
period of time, or with (i) a life-threatening condition or disease or
(ii) a degenerative and/or disabling condition or disease, either of
which requires specialized medical care over a prolonged period of time,
may receive a referral to a specialist or a specialty care center with
expertise in treating the life-threatening disease or specialized
condition, who shall be responsible for and capable of providing and
coordinating the enrollee’s primary and specialty care.





			
	 	 	 
	Amended as of September 1, 2004
	 	IV-49







 









 





Exhibit 10.6.6


	 	 	
endocrinology, infectious disease, orthopedics, neurology,
neurosurgery, ophthalmology, physiatry, pulmonology, surgery,
and urology, as well as providers who have knowledge and
experience in behavioral-developmental pediatrics, adolescent
health, geriatrics, and chronic illness management.
	 
	5.	 	The network shall include an appropriate and
accessible number of institutional facilities, professional
allied personnel, home care and community based services to
perform the contractor-covered services included in this
contract.






	B.	 	SCHSNA. The contractor shall include in its provider network
Special Child Health Services Network Agencies (SCHSNA) for children
with special health care needs. These agencies are designated and
approved by the Department of Health and Senior Services and include
Pediatric Ambulatory Tertiary Centers (pediatric tertiary centers
may also be used when a pediatric subspecialty is not sufficiently
accessible in a county to meet the needs of the-child), Regional
Cleft Lip/Palate Centers, Pediatric AIDS/HIV Network, Comprehensive
Regional Sickle Ce1UHemoglobinopathies Treatment Centers, PKU
Treatment Centers, Genetic Testing and Counseling Centers, and
Hemophilia Treatment Centers, and others as designated from time to
time by the Department of Health and Senior Services. A list of such
providers is found in Section B.4.10 of the Appendices.
	 
	C.	 	Credentialing. The contractor shall collect and maintain, as
part of its credentialing process or through special survey process,
information from: licensed practitioners including pediatricians and
pediatric subspecialists about the nature and extent of their
experience in serving children with special health care needs
including developmental disabilities.





4.5.4 CARE MANAGEMENT AND COORDINATION OF CARE FOR PERSONS WITH SPECIAL
NEEDS




	A.	 	The contractor shall provide coordination of care to actively
link the enrollee to providers, medical services, residential,
social and other support services as needed. For persons with
special needs, care management shall be provided, but, for those
with higher needs, as determined through the Complex Needs
Assessment (the CNA is described in Article 4.6.5), the contractor
shall provide care management at a higher level of intensity. (See
Section B.4.12 of the Appendices for a flowchart of the three levels
of care management.) Specific requirements for this highest level of
care management are described below.
	 
	B.	 	Complex Needs Assessment. For enrollees with special needs,
the contractor shall perform a Complex Needs Assessment no later
than forty-five (45) days (or earlier, if urgent) from initial
enrollment if special needs are indicated on the
Medical Information Form or from the point of identification of
special needs. See 4.6.5 for a description of the CNA. Additional
time will be permitted





			
	 	 	 
	Amended as of September 1, 2004
	 	IV-54







 









 




Exhibit 10.6.6


	 	 	
Case Management Units (See Appendix B.4.11) in accordance with the
Department of Health and Senior Services procedures for referrals,
and sharing information with early intervention providers.




4.5.6 CLIENTS OF THE DIVISION OF DEVELOPMENTAL DISABILITIES


	A.	 	The contractor shall provide all physical health services
required by this contract as well as the MH/SA services (except
partial care services) included in the Medicaid State Plan to
enrollees who are clients of DDD. The contractor shall include in
its provider network a specialized network of providers who will
deliver both physical as well as MH/SA services, except providers
of partial care
services, (in accordance with Medicaid program standards) to
clients of DDD, and ensure continuity of care within that network.
	 
	B.	 	The contractor’s specialized network shall provide disease
management services
for clients of DDD, which shall include participation in:






	1.	 	Care Management, including Complex Needs
Assessment, development and implementation of IHCP, referral,
coordination of care, continuity of care, monitoring, and
follow-up and documentation.
	 
	2.	 	Coordination of care across multi-disciplinary
treatment teams to assist PCPs in identifying the providers
within the network who will meet the specific needs and health
care requirements of clients of DDD with both physical health
and MH/SA needs and provide continuity of care with an
identified provider who has an established relationship with
the patient.
	 
	3.	 	Apply quality improvement techniques/protocols to
effect improved quality of life outcomes.
	 
	4.	 	Design and implement clinical pathways and
practice guidelines that will produce overall quality outcomes
for specific diseases/conditions identified in clients of DDD.
	 
	5.	 	Medical treatment.






	C.	 	The specialized provider network shall consist of
credentialed providers for physical health and MH/SA services, who
have experience and expertise in treating clients of DDD who have
both physical health and MH/SA needs, and who can provide internal
management of the complex care needs of these enrollees. The
contractor shall ensure that the specialized provider network will
be able to deliver identified physical health and MH/SA outcomes.
	 
	D.	 	Clients of DDD may, at their option, receive their physical
health and/or MH/SA services from any qualified provider in the
contractor’s network. They are not required to receive their
services through the contractor’s specialized network.
	 
	 	 	 





			
	Amended as of September 1, 2004
	 	IV-58







 









 





Exhibit 10.6.6


	 	 	its aggregate, enrolled commercial and Medicare population in the
State or region (if these data are collected and reported to DHSS,
a copy of the report should be submitted also to DMAHS) the
following clinical indicator measures:





	 	 	 
	HEDIS	 	Report Period
	Reporting Set Measures
	 	by Contract Year

	Childhood Immunization Status

	 	annually
	Adolescent Immunization Status

	 	annually
	Well-Child Visits in first 15 months of life

	 	annually
	Well-Child
Visits in the 3rd, 4th, 5th and 6th year of life

	 	annually
	Adolescent Well-Care Visits

	 	annually
	Prenatal and Postpartum Care

	 	annually
	Breast Cancer Screening

	 	annually
	Cervical Cancer Screening

	 	annually
	Use of Appropriate
Medications for People with Asthma

	 	annually








	 	 	Childhood & Adolescent Immunization HEDIS data for NJ FamilyCare
enrollees up to the age of 19 years must be reported separately.
	 
	Q.	 	Quality Improvement Projects (QIPs). The contractor shall participate
in QIPs defined annually by the State with input from the contractor. The State
will, with input from the contractor and possibly other MCEs, define
measurable improvement goals and QIP-specific measures which shall serve as
the focus for each QIP. The contractor shall be responsible for designing and
implementing strategies for achieving each QIP’s objectives. At the beginning
of each contract year the contractor shall present a plan for designing and
implementing such strategies, which shall receive approval from the State prior
to implementation. The contractor shall then submit semiannual progress reports
summarizing performance relative to each of the objectives of each contract
year.
	 
	 	 	The QIPs shall be completed annually and shall include the areas
identified below. The external review organization (ERO) under contract with
DHS shall prepare a final report for year one that will contain data, using
State-approved sampling and measurement methodologies, for each of the
measures below. Changes in required QIPs shall be defined by the DHS and
incorporated into the contract by amendment.
	 
	 	 	For each measure the DHS will identify a baseline and a compliance
standard. Baseline data, target standards, and compliance
standards shall be established or updated by the State.
	 
	 	 	If DHS determines that the contractor is not in compliance with
the requirements of the annual QIP objectives, either based on the
contractor’s progress report or





			
	 	 	 
	Amended as of September 1, 2004
	 	IV-65







 









 






Exhibit 10.6.6





	D.	 	The contractor shall include in its network at least one (1)
hospital located in the inner city urban area and at least 1
non-urban-based hospital in every county except where indicated in
Article 4.8.8.M. For those counties with only one (1) hospital, the
contractor shall include that hospital in its network subject to
good faith negotiations.
	 
	E.	 	The contractor shall offer a choice of two specialists in each
county where
available. If only one or no providers of a particular specialty is
available, the contractor shall provide documentation of the lack
of availability and propose alternative specialty providers in
neighboring counties.
	 
	F.	 	The contractor shall include in its network mental
health/substance abuse providers for Medicaid covered MI4/SA
services with expertise to serve enrollees who are clients of the
Division of Developmental Disabilities. Exception — partial care
services are not covered by the contractor.
	 
	G.	 	Changes in large provider groups, IPAs or subnetworks such as
pharmacy benefits manager, vision network, or dental network shall be
submitted to DMAHS for review and prior approval at least ninety (90)
days before the anticipated change. The submission shall include
contracts, provider network files, enrollee/provider notices and any
other pertinent information.
	 
	H.	 	Requirement to contract with FQHC. The contractor shall
contract for primary care services with at least one Federally
Qualified Health Center (FQHC) located in each enrollment area
based off the availability and capacity of the FQHCs in that area. FQHC
providers shall meet the contractor’s credentialing andprogram
requirements.
	 
	 	 	Requirement to contract with Children’s Hospital of New Jersey at
Newark Beth Israel Medical Center for school-based health services.
The contractor shall contract with the Children’s Hospital of New
Jersey at Newark Beth Israel Medical Center for the provision of
primary health care services, including but not limited to, EPSDT
services, and dental care services, to be provided at designated
schools in the city of Newark. Providers at the school-based
clinics shall meet the contractor’s credentialing and program
requirements of this contract.





4.8.2 PRIMARY CARE PROVIDER REQUIREMENTS





	A.	 	The contractor shall offer each enrollee a choice of two (2)
or more primary care physicians within the enrollee’s county of
residence. Where applicable, this offer can be made to an authorized
person. An enrollee with special needs shall be given the choice of
a primary care provider which must include a pediatrician,
general/family practitioner, and internist, and may include
physician specialists and nurse practitioners. The PCP shall
supervise the care of the enrollee with special needs who requires a
team approach. Subject to any limitations in the





			
	 	 	 
	Amended as of September 1, 2004
	 	IV-96







 









 




Exhibit 10.6.6


KK. An
explanation of the appropriate uses of the Medicaid/NJ FamilyCare
identification card and the contractor identification card;


LL. A notification,
whenever applicable, that some primary care physicians
may employ other health care practitioners, such as nurse practitioners
or physician assistants, who may participate in the patient’s care;


MM. The
enrollee’s or, where applicable, an authorized person’s signed
authorization on the enrollment application allows release of medical
records;


NN. Notification
that the enrollee’s health status- survey
will be sent to the contractor by the enrollee;


OO. A notice
that enrollment and disenrollment is subject to verification
and approval by DMAH-S;


PP. An explanation
of procedures to follow if enrollees receive bills from providers of
services, in or out of network;


QQ. An
explanation of the enrollee’s financial responsibility for payment
when services are provided by a health care provider who is not part of
the contractor’s organization or when a procedure, treatment or service
is not a covered health care benefit by the contractor and/or by
Medicaid;



RR. A written explanation at the time of enrollment of the enrollee’s right
to terminate enrollment, and any other restrictions on the exercise of
those rights, to conform to 42 U.S.C. § 1396b(m)(2)(F)(ii). The initial
enrollment information and the contractor’s member handbook shall be
adequate to convey this notice and shall have DMAHS approval prior to
distribution;



SS. An explanation that the contractor will contact or facilitate contact
with, and require its PCPs to use their best efforts to contact, each new
enrollee or, where applicable, an authorized person, to schedule an
appointment for a complete, age/sex specific baseline physical, and for
enrollees with special needs who have been identified through a Complex
Needs Assessment as having complex needs, the development of an
Individual Health Care Plan at a time mutually agreeable to the
contractor and the enrollee, but not later than ninety (90) days after
the effective date of enrollment for children under twenty-one (21) years
of age, and not later than one hundred eighty (180) days after initial
enrollment for adults; for adult clients of DDD, no later than ninety
(90) days after the effective date of enrollment; and encourage enrollees
to contact the contractor and/or their PCP to schedule an appointment;



			
	 	 	 
	Amended as of September 1, 2004
	 	V-17







 









 



Exhibit 10.6.6


	 	 	The contractor’s system and procedure shall be available to both
Medicaid beneficiaries and NJ FamilyCare beneficiaries. All
enrollees have available the complaint and grievance/appeal
process under the contractor’s plan, the Department of Health and
Senior Services and, for Medicaid and certain NJ FamilyCare
beneficiaries (i.e., Plan A enrollees and beneficiaries with a
PSG of 380 under Plan D), the Medicaid Fair Hearing process.
Individuals eligible solely through NJ FamilyCare Plans B, C, D,
and H (except for Plan D and H individuals with a program status
code of 380), do not have the right to a Medicaid Fair Hearing.
	 
	B.	 	Complaints. The contractor shall have procedures for
receiving, responding to, and documenting resolution of enrollee
complaints that are received orally and are of a less serious or
formal nature. Complaints that are resolved to the
enrollee’s satisfaction within five (5) business days of
receipt do not require a formal written response or notification.
The contractor shall call back an enrollee within twenty-four hours
of the initial contact if the contractor is unavailable for any
reason or the matter cannot be readily resolved during the initial
contact. Any complaint that is not resolved within three business
days shall be treated as a grievance/appeal, in accordance with
requirements defined in Article 5.15.3.
	 
	C.	 	HBC Coordination. The contractor shall coordinate its efforts
with the health benefits coordinator including referring the
enrollee to the HBC for assistance as needed in the management of
the complaint/grievance/appeal procedures.
	 
	 	 	DMAFIS Intervention. DMAHS shall have the right to intercede on an
enrollee’s behalf at any time during the contractor’s
complaint/grievance/appeal process: whenever there is an indication
from the enrollee, or, where applicable, authorized person, or the
BBC that a serious quality of care issue is not being addressed
timely or appropriately. Additionally, the enrollee may be
accompanied by a representative of the enrollee’s choice to any
proceedings and grievances/appeals.
	 
	E.	 	Legal Rights. Nothing in this Article shall be construed as
removing any legal rights of enrollees under State or federal law,
including the right to file judicial actions to enforce rights.




5.15.2 NOTIFICATION TO ENROLLEES OF GRIEVANCE/APPEAL PROCEDURE



	A.	 	The contractor shall provide all enrollees or, where
applicable, an authorized person, upon enrollment in the
contractor’s plan, and annually thereafter, pursuant to this
contract, with a concise statement of the contractor’s
grievance/appeal procedure and the enrollees’ rights to a hearing
by the Independent Utilization Review Organization (IURO) per NJAC
8:38-8.7 as well as their right to pursue the Medicaid Fair Hearing
process described in N.J.A.C. 10:49-10.1 et seq. The information
shall be provided through an annual mailing, a member handbook, or
any other method approved by DMAHS. The contractor shall prepare
the 





			
	 	 	 
	Amended as of September 1, 2004
	 	V-36





 









 






Exhibit 10.6.6




8.5.2.4 NJ FAMILYCARE PLAN D PARENTS/CARETAKERS





	 	 	This grouping includes capitation rates for NJ FamilyCare Plan D
parents/caretakers, excluding individuals with AIDS, and include only
enrollees 19 years of age or older.





8.5.2.5 DYFS AND AGING OUT FOSTER CHILDREN





	 	 	This grouping includes capitation rates for Division of Youth and Family
Services, excluding individuals with-AIDS and clients of DDD.





. 8.5.2.6 ABD WITHOUT. MEDICARE





	 	 	Compensation to the contractor for the ABD individuals without Medicare
will be risk-adjusted using the Health Based Payments System (HBPS),
which is described in Article 8.6. HBPS adjusts for the diagnosis of
AIDS; therefore, separate AIDS rates are not necessary for this
population. Finally, the HBPS adjusts for age and sex so separate rates
for age and sex within this population are not necessary.





8.5.2.7 ABD WITH MEDICARE





	 	 	This grouping includes capitation rates for the ABD with Medicare
population, excluding individuals with AIDS and clients of DDD.





8.5.2.8 CLIENTS OF DDD





	 	 	This grouping includes all enrollees except ABD individuals without
Medicare. The contractor shall be paid separate, statewide rates for
subgroups of the DDD population, excluding individuals with AIDS. These
rates include covered MH/SA services.





8.5.2.9 ENROLLEES WITH AIDS





	 	 	This grouping includes all enrollees except ABD individuals without
Medicare.






	A.	 	The contractor shall be paid special statewide capitation
rates for enrollees with AIDS.
	 
	B.	 	The contractor will be reimbursed double the AIDS rate, once in a
member
lifetime, in the first month of payment for a recorded diagnosis of
AIDS,
prospective and newly diagnosed. This is a one-time-only-per-member
payment,
regardless of MCE.





8.5.2.10 RESERVED




			
	 	 	 
	Amended as of September 1, 2004
	 	VIII-7







 









 




Exhibit 10.6.6



 
State of New Jersey


DEPARTMENT OF HUMAN SERVICES

DIVISION OF MEDICAL ASSISTANCE AND HEALTH SERVICES

PO Box 712



	 	 	 	 	 
	JAMES E. MCGREEVEY
	 	TRENTON, NJ 08625-0712
	 	JAMES M. DAVY
	Governor
	 	TELEPHONE 1-800-356-1561
	 	Commissioner
	 
	 	 	 	ANN CLEMENCY KOHLER
	
	 	 	 	Director







July 2, 2004




Norine Yukon

President & CEO

AMERIGROUP New Jersey, Inc.

399 Thornall Street

9th Floor

Edison NJ 08837



Dear Ms. Yukon:




Enclosed is an amendment to the managed care contract. This amendment
will carve out partial care services for clients of DDD enrolled in an
HMO, and adds some clarifying language regarding orthodontia services
for certain eligible beneficiaries.




The amendment does not include Section C, Capitation Rates. This will
be sent under separate cover.




Please return the signature page (5 original copies) to the Office of
Managed Health Care by July 23, 2004.




Sincerely,







Jill
Simone, MD

Executive Director

Office of Managed Health Care



JS

Enclosure

c:       Rita Hemingway

          John Koehn



                    r




NJ Depa




 









 








Exhibit 10.6.6




New Jersey Is An Equal Opportunity Employer