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APPENDIX X
[Amendment Number
 Agency Code 12000
    
    Contract No. C020429Period
4/1/06 - 9/30/08
    
    Funding Amount for Period Based on approved capitation rates
 The New York State Department of Health, Coming Tower, Room 2001., Empire State Plaza, Albany NY 12237, CarePlus, LLC, Contract Number C020429
 1.
    
    Amend Section 1, Definitions, the definition for Designated
Third Party Contractor, to read as follows:
 Designated Third Party Contractor
 2.
    
    The attached Appendix C, New York State Department of
Health Requirements for the Provision of Family Planning and
Reproductive Health, is substituted for the period beginning April 1,
2006.3.
    
    Effective January 1, 2006, Item Number 10 in Section K.1,
Prepaid Benefit Package, of Appendix K, Prepaid Benefit Package
Definitions of Covered and Non-Covered Services. is amended to read
as follows:
 *
    
    CoveredServices
    
    MC SSI
    
    MC SI
    
    MIFFS
    
    
    
    FHPlus**10.
    
    Prescription and Non-
Prescription (OTC) Drugs,
Medical Supplies, and Enteral
Formula
    
    Pharmaceuticals and
medical supplies
routinely furnished or
administered as part
of a clinic or office
visit, except
Risperdal Consta [see
Appendix K.3, 2. b)
xi) of this
Agreement]
    
    Pharmaceuticals and
medical supplies
routinely furnished or
administered as part of
a clinic or office visit,
except Risperdal
Consta [see Appendix
K.3, 2. b) xi) of this
Agreement]
    
    Covered
outpatient drugs
from the list of
Medicaid
reimbursable
prescription
drugs, subject to
any applicable
co-payments
    
    
    
    Covered, may
be limited to
generic.
Vitamins
(except to treat
an illness or
condition),
OTCs, and
medical supplies
are not covered
 4.
    
    Effective January 1, 2006, Subsection xi) is added to Subsection 2.,
Non-Covered Behavioral Health Services, b)
Mental Health Services, of Section K.3, Medicaid Managed Care
Prepaid Benefit Package Definitions of Non-Covered Services, in Appendix
K, Prepaid Benefit Package Definitions of Covered and Non-Covered
Services, and reads as follows:
  5.
    
    The attached Appendix L, Approved Capitation Payment
Rates, is substituted for the period beginning April 1,
2006.




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CONTRACTOR SIGNATURE
    
    STATE AGENCY SIGNATUREBy:
    
    By:PrintedPrinted NameTitle:Name Title:Date:Date:State Agency Certification:In addition to the acceptance of this
contract, I also certify that original
copies of this signature page will be
attached to all other exact copies
of this contract.
 STATE OF NEW YORK))
    
    SS.:County of                                               )On the                 day of
    
    
    20, before me personally appeared, to me known, who being by me duly sworn, did depose and say that he/she residesat
that he/she is the of , the corporation described herein which executed the foregoing
instrument; and that he/she signed his/her name thereto by order of the board of directors of
said corporation.
 (Notary)Date:STATE COMPTROLLERS SIGNATURE
    
    Title:




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Appendix C
New York State Department of Health
Requirements for the Provision of
Family Planning and Reproductive Health Services
 C.1 Definitions and General Requirements for the Provision of
Family Planning and Reproductive Health Services
 C.2 Requirements for MCOs that Include Family Planning and
Reproductive Health Services in Their Benefit Package
 C.3 Requirements for MCOs That Do Not Include Family Planning Services and
Reproductive Health Services in Their Benefit Package




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C.1
 Definitions and General Requirements for the Provision of Family Planning and Reproductive
Health Services
 1.
    
    Family Planning and Reproductive Health Services
 a)
    
    Family Planning and Reproductive Health services mean the offering,
arranging and furnishing of those health services which enable Enrollees, including
minors who may be sexually active, to prevent or reduce the incidence of unwanted
pregnancies.
 i)
    
    Family Planning and Reproductive Health services include the
following medically-necessary services, related drugs and supplies which are
furnished or administered under the supervision of a physician, licensed midwife
or certified nurse practitioner during the course of a Family Planning and
Reproductive Health visit for the purpose of:
 A)
    
    contraception, including all FDA-approved birth control
methods, devices such as insertion/removal of an intrauterine device (IUD)
or insertion/removal of contraceptive implants, and injection procedures
involving Pharmaceuticals such as Depo-Provera;B)
    
    emergency contraception and follow up;C)
    
    sterilization;D)
    
    screening, related diagnosis, and referral to a
Participating Provider for pregnancy;E)
    
    medically-necessary induced abortions, which are
procedures, either medical or surgical, that result in the termination of
pregnancy. The determination of medical necessity shall include positive
evidence of pregnancy, with an estimate of its duration.
 ii)
    
    Family Planning and Reproductive Health services include those
education and counseling services necessary to render the services effective.iii)
    
    Family Planning and Reproductive Health services include
medically-necessary ordered contraceptives and pharmaceuticals:
 A)
    
    For MMC Enrollees  The contractor is responsible for
pharmaceuticals and medical supplies such as IUDS and Depo-Provera that
must be furnished or administered under the supervision of a physician,
licensed midwife, or certified nurse practitioner during the course of a
Family Planning and Reproductive Health visit. Other pharmacy prescriptions
including




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B)
    
    For FHPIus Enrollees  The Contractor, if it includes such
services in its Benefit Package is responsible for covering prescription
contraceptives, including emergency contraceptives, provided by a Participating
pharmacy, consistent with the pharmacy benefit package as described in Appendix
K. When the Contractor does not provide Family Planning and Reproductive Health
Services, the Designated Third Party Contractor that covers such services for
FHPIus Enrollees is responsible for prescription contraceptives, including
emergency contraceptives, provided by a Participating pharmacy, consistent with
the pharmacy benefit package as described in Appendix K. The Contractor or the
Designated Third Party Contractor must cover at least one of every type of the
following methods of contraception:
 I)
    
    OralII)
    
    Oral, emergencyIII)
    
    InjectableIV)
    
    TransdermalV)
    
    IntravaginalVI)
    
    Intravaginal, systemicVII)
    
    Implantable
 b)
    
    When clinically indicated, the following services may be provided as a part of
a Family Planning and Reproductive Health visit:
 i)
    
    Screening, related diagnosis, ambulatory treatment and referral as
needed for dysmenorrhea, cervical cancer, or other pelvic abnormality/pathology.ii)
    
    Screening, related diagnosis and referral for anemia, cervical cancer,
glycosuria, proteinuria, hypertension and breast disease.iii)
    
    Screening and treatment for sexually transmissible disease.iv)
    
    HIV testing and pre- and post-test counseling.
 2.
    
    Free Access to Services for MMC Enrollees
 a)
    
    Free Access means MMC Enrollees may obtain Family Planning and Reproductive
Health services, and HIV testing and pre-and post-test counseling when performed as
part of a Family Planning and Reproductive Health encounter, from either the
Contractor, if it includes such services in its Benefit Package, or from any
appropriate




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b)
    
    The Family Planning and Reproductive Health services listed above are the only
services which are covered under. the Free Access policy. Routine obstetric and/or
gynecologic care, including hysterectomies, pre-natal, delivery and post-partum care
are not covered under the Free Access policy, and are the responsibility of the
Contractor.
 3.
    
    Access to Services for FHPIus Enrollees
 a)
    
    FHPIus Enrollees may obtain Family Planning and Reproductive Health services,
and HIV testing and pre-and post-test counseling when performed as part of a Family
Planning and Reproductive Services encounter, from either the Contractor or through the
Designated Third Party Contractor, as applicable. No referral from the PCP or approval
by the Contractor is required to access such services.b)
    
    The Contractor is responsible for routine obstetric and/or gynecologic care,
including hysterectomies, pre-natal, delivery and post-partum care, regardless of
whether Family Planning and Reproductive Health services are included in the
Contractors .Benefit Package.




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C.2
 Requirements for MCOs that Include Family Planning and Reproductive Health Services in Their Benefit Package
 1.
    
    Notification to Enrollees
 a)
    
    If the Contractor includes Family Planning and Reproductive Health services in
its Benefit Package (as per Appendix M of this Agreement) the Contractor must notify
all Enrollees of reproductive age, including minors who may be sexually active, at the
time of Enrollment about their right to obtain Family Planning and Reproductive Health
services and supplies without referral or approval. The notification must contain the
following:
 i)
    
    Information about the Enrollees right to obtain the full range of
Family Planning and Reproductive Health services, including HIV counseling and
testing when performed as part of a Family Planning and Reproductive Health
encounter, from the Contractors Participating Provider without referral, approval
or notification.ii)
    
    MMC Enrollees must receive notification that they also have the right to
obtain Family Planning and Reproductive Health services in accordance with MMCs
Free Access policy as defined in C.1 of this Appendix.iii)
    
    A current list of qualified Participating Family Planning Providers who
provide the full range of Family Planning and Reproductive Health services within
the Enrollees geographic area, including addresses and telephone numbers. The
Contractor may also provide MMC Enrollees with a list of qualified
Non-Participating providers who accept Medicaid and who provide the fullrange of
these services.iv)
    
    Information that the cost of the Enrollees Family Planning and
Reproductive care will be fully covered, including when a MMC Enrollee obtains such
services in accordance with MMCs Free Access policy.
 2.
    
    Billing Policy
 a)
    
    The Contractor must notify its Participating Providers that all claims for
Family Planning and Reproductive services must be billed to the Contractor and not the
Medicaid fee-for-service program.b)
    
    The Contractor will be charged for Family Planning and Reproductive Health
services furnished to MMC Enrollees by eMedNY-enrolled Non-Participating Providers at
the applicable Medicaid rate or fee. In such instances, Non-Participating Providers
will bill Medicaid fee-for-service and the SDOH will issue a confidential




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3.
    
    Consent and Confidentiality
 a)
    
    The Contractor will comply with federal, state, and local laws, regulations and
policies regarding informed consent and confidentiality and ensure Participating
Providers comply with all of the requirements set forth in Sections 17 and 18 of the
PHL and 10 NYCRR Section 751.9 and Part 753 relating to informed consent and
confidentiality.b)
    
    Participating Providers may share patient information with appropriate
Contractor personnel for the purposes of claims payment, utilization review and quality
assurance, unless the provider agreement with the Contractor provides otherwise. The
Contractor must ensure that any Enrollees use including a minors use of Family
Planning and Reproductive Health services remains confidential and is not disclosed to
family members or other unauthorized parties, without the Enrollees consent to the
disclosure.
 4.
    
    Informing and Standards
 a)
    
    The Contractor will inform its Participating Providers and administrative
personnel about policies concerning MMC Free Access as defined in C.1 of this Appendix,
where applicable; HIV counseling and testing; reimbursement for Family Planning and
Reproductive Health encounters; Enrollee Family Planning and Reproductive Health
education and confidentiality.b)
    
    The Contractor will inform its Participating Providers that they must comply
with professional medical standards of practice, the Contractors practice guidelines,
and all applicable federal, state, and local laws. These include but are not limited
to, standards established by the American College of Obstetricians and Gynecologists,
the American Academy of Family Physicians, the U.S. Task Force on Preventive Services
and the New York State Child/Teen Health Program. These standards and laws recognize
that Family Planning counseling is an integral part of primary and preventive care.




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C.3
 Requirements for MCOs That Do Not
Include Family Planning Services and Reproductive Health Services in Their
Benefit Package
 1.
    
    Requirements
 a)
    
    The Contractor agrees to comply with the policies and procedures stated in the
SDOH-approved statement described in Section 2 below.b)
    
    Within ninety (90) days of signing this Agreement, the Contractor shall submit
to the SDOH a policy and procedure statement that the Contractor will use to ensure
that its Enrollees are fully informed of their rights to access a full range of Family
Planning and Reproductive Health services, using the following guidelines. The
statement must be sent to the Director, Office ofManaged Care, NYS
Department ofHealth, Corning Tower, Room 2001, Albany, NY 12237.c)
    
    SDOH may waive the requirement in (b) above if such approved statement is
already on file with SDOH and remains unchanged.
 2.
    
    Policy and Procedure Statement
 a)
    
    The policy and procedure statement regarding Family Planning and Reproductive
Health services must contain the following:
 i)
    
    Enrollee Notification
 A)
    
    A statement that the Contractor will inform Prospective
Enrollees, new Enrollees and current Enrollees that:
 I)
    
    Certain Family Planning and Reproductive Health services
(such as abortion, sterilization and birth control) are not covered by the
Contractor, but that routine obstetric and/or gynecologic care, including
hysterectomies, pre-natal, delivery and post-partum care are covered by the
Contractor;II)
    
    Such Family Planning and Reproductive Health Services
that are not covered by the Contractor may be obtained through
fee-for-service Medicaid providers for MMC Enrollees and through the
Designated Third Party Contractor for FHPIus Enrollees;III)
    
    No referral is needed for such services, and there will
be no cost to the Enrollee for such services.




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IV)
    
    HIV counseling and testing services are available through the Contractor and
are also available as part of a Family Planning and Reproductive Health encounter when
furnished by a fee-for-service Medicaid provider to MMC Enrollees and through the
Designated Third Party Contractor to FHPIus Enrollees; and that anonymous counseling and
testing services are available from SDOH, Local Public Health Agency clinics and other
county programs.
 B)
    
    A statement that this information will be provided in the following manner:
 I)
    
    Through the Contractors written Marketing materials, including the Member Handbook.
The Member Handbook and Marketing materials will indicate that the Contractor has elected
not to cover certain Family Planning and Reproductive Health services, and will explain
the right of all MMC Enrollees to secure such services through fee-for-service Medicaid
from any provider/clinic which offers these services and who accepts Medicaid, and the
right of all FHPIus Enrollees to secure such services through the Designated Third Party
Contractor.II)
    
    Orally at the time of Enrollment and any time an inquiry is made regarding Family
Planning and Reproductive Health services.III)
    
    By inclusion on any web site of the Contractor which includes information concerning
its MMC or FHPIus product(s). Such information shall be prominently displayed and easily
navigated.
 C)
    
    A description of the mechanisms to provide all new MMC Enrollees and FHPIus Enrollees with
an SDOH approved letter explaining how to access Family Planning and Reproductive Health
services and the SDOH approved list of Family Planning providers. This material will be
furnished by SDOH and mailed to the Enrollee no later than fourteen (14) days after the
Effective Date of Enrollment.D)
    
    A statement that if an Enrollee or Prospective Enrollee requests information about these
non-covered services, the Contractors Marketing or Enrollment representative or member
services department will advise the Enrollee or Prospective Enrollee as follows:
 I)
    
    Family Planning and Reproductive Health services such as abortion, sterilization and
birth control are not covered by the Contractor and that only routine obstetric and/or
gynecologic care, including hysterectomies, pre-natal, delivery and post-partum care are
the responsibility of the Contractor.




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II)
    
    MMC Enrollees can use their Medicaid card to receive these non-covered services
from any doctor or clinic that provides these services and accepts Medicaid. FHPIus
Enrollees can receive these non-covered services through the Designated Third Party
Contractor using either the Designated Third Party Contractors identification card or the
Contractors card which shall include the Enrollees Client Identification Number.III)
    
    Each MMC Enrollee and Prospective MMC Enrollee who calls will be mailed a copy of the
SDOH approved letter explaining the Enrollees right to receive these non-covered services,
and an SDOH approved list of Family Planning Providers who participate in Medicaid in the
Enrollees community. These materials will be mailed within two (2) business days of the
contact.IV)
    
    The Contractor will provide the name and phone number of the Designated Third Party
Contractor or such other organization designated by the SDOH to provide such services to
FHPIus Enrollees and Prospective FHPIus Enrollees. It is the responsibility of the
Designated Third Party Contractor or such other organization designated by the SDOH to
mail to each FHPIus Enrollee or Prospective FHPlus Enrollee who calls, a copy of the SDOH
approved letter explaining the Enrollees right to receive such services, and an SDOH
approved list of Family Planning Providers from which the Enrollee may access family
planning services. The Designated Third Party Contractor or such other organization
designated by the SDOH is responsible for mailing these materials within fourteen (14)
days of notice by the Contractor of a new Enrollee in the Contractors FHPlus product.V)
    
    Enrollees can call the Contractors member services number for further information
about how to obtain these non-covered services. MMC Enrollees can also call the New York
State Growing-Up-Healthy Hotline (1-800-522-5006) to request a copy of the list of
Medicaid Family Planning Providers. FHPIus Enrollees can also call the Designated Third
Party Contractor or such other organization designated by the SDOH for a list of Family
Planning providers.
 E)
    
    The procedure for maintaining a manual log of all requests for such information, including
the date of the call, the Enrollees client identification number (CIN), and the date the SDOH
approved letter and SDOH or LDSS approved list were mailed, where applicable. The Contractor
will review this log monthly and upon request, submit a copy to SDOH.




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ii)
    
    Participating Provider and Employee Notification
 A)
    
    A statement that the Contractor will inform its Participating Providers and
administrative personnel about Family Planning and Reproductive Health policies under MMC
Free Access, as defined in C.1 of this Appendix, and/or the FHPlus Designated Third Party
Contractor for FHPIus Enrollees, HIV counseling and testing; reimbursement for Family
Planning and Reproductive Health encounters; Enrollee Family Planning and Reproductive
Health education and confidentiality.B)
    
    A statement that the Contractor will inform its Participating Providers that they
must comply with professional medical standards of practice, the Contractors practice
guidelines, and all applicable federal, state, and local laws. These include but are not
limited to, standards established by the American College of Obstetricians and
Gynecologists, the American Academy of Family Physicians, the U.S. Task Force on
Preventive Services and the New York State Child/Teen Health Program. These standards and
laws recognize that Family Planning counseling is an integral part of primary and
preventive care.C)
    
    The procedure(s) for informing the Contractors Participating, primary care
providers, family practice physicians, obstetricians, gynecologists and pediatricians
that the Contractor has elected not to cover certain Family Planning and Reproductive
Health services, but that routine obstetric and/or gynecologic care, including
hysterectomies, pre-natal, delivery and postpartum care are covered; and that
Participating Providers may provide, make referrals, or arrange for non-covered services
in accordance with MMCs Free Access policy, as defined in C.1 of this Appendix, and/or
through the SDOH-contracted Designated Third Party for FHPlus Enrollees.D)
    
    A description of the mechanisms to inform the Contractors Participating Providers
that:
 I)
    
    if they also participate in the fee-for-service Medicaid program and they
render non-covered Family Planning and Reproductive Health services to MMC Enrollees,
they do so as a fee-for-service Medicaid practitioner, independent of the Contractor.II)
    
    if they also participate with the FHPIus Designated Third Party Contractor
and they render non-covered Family Planning and Reproductive Health Services to
FHPIus Enrollees, they do so as a participating provider with the Designated Third
Party Contractor, independent of the Contractor.
 E)
    
    A description of the mechanisms to inform Participating Providers that, if
requested by the Enrollee, or, if in the providers best professional judgment,




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I)
    
    offer those services to MMC Enrollees on a fee-for-service basis as an
eMedNY-enrolled provider, or to FHPIus Enrollees as a Participating Provider of the
Designated Third Party Contractor; orII)
    
    provide MMC Enrollees with a copy of the SDOH approved list of Medicaid
Family Planning Providers, and/or provide FHPlus Enrollees with the name and number of
the Designated Third Party Contractor, orIII)
    
    give Enrollees the Contractors member services number to call to obtain
either the list of Medicaid Family Planning Providers or the name and number of the
Designated Third Party Contractor, as applicable.
 F)
    
    A statement that the Contractor acknowledges that the exchange of medical
information, when indicated in accordance with generally accepted standards of
professional practice, is necessary for the overall coordination of Enrollees care and
assist Primary Care Providers in providing the highest quality care to the Contractors
Enrollees. The Contractor must also acknowledge that medical record information maintained
by Participating Providers may include information relating to Family Planning and
Reproductive Health services provided under the fee-for-service Medicaid program or under
the Designated Third Party contract with SDOH.
 iii)
    
    Quality Assurance Initiatives
 A)
    
    A statement that the Contractor will submit any materials to be furnished to
Enrollees and providers relating to access to non-covered Family Planning and Reproductive
Health services to SDOH, Office of Managed Care for its review and approval before
issuance. Such materials include, but are not limited to, Member Handbooks, provider
manuals, and Marketing materials.B)
    
    A description of monitoring mechanisms the Contractor will use to assess the quality
of the information provided to Enrollees.C)
    
    A statement that the Contractor will prepare a monthly list of MMC Enrollees who have
been sent a copy of the SDOH approved letter and the SDOH approved list of Family Planning
providers, and a list of FHPIus Enrollees who have been provided with the name and
telephone number of the Designated Third Party Contractor. This information will be
available to SDOH upon request.




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D)
    
    A statement that the Contractor will provide all new employees with a
copy of these policies. A statement that the Contractors orientation programs
will include a thorough discussion of all aspects of these policies and
procedures and that annual refraining programs for all employees will be
conducted to ensure continuing compliance with these policies.E)
    
    A description of the mechanisms to provide the Designated Third
Party Contractor, SDOH, or SDOHs subcontractor with a monthly listing of all
FHPIus Enrollees within seven (7) days of receipt of the Contractors monthly
Enrollment Roster and any subsequent updates or adjustments. A copy of each
file will also be provided simultaneously to the SDOH. A description of
mechanisms to provide SDOH or SDOHs subcontractor with a list of prospective
FHPIus Enrollees within two (2) business days of the prospective Enrollee
encounter, and a list of Enrollees who call to request information within two
(2) business days of an Enrollees request.
 3.
    
    Consent and Confidentiality
 a)
    
    The Contractor must comply with federal, state, and local laws, regulations and
policies regarding informed consent and confidentiality and ensure Participating. Providers comply with all of the requirements set forth in Sections 17 and 18 of the
PHL and 10 NYCRR § 751.9 and Part 753 relating to informed consent and confidentiality.b)
    
    Participating Providers and/or the Designated Third Party Contractor Providers,
may share patient information with appropriate Contractor personnel for the purposes of
claims payment, utilization review and quality assurance, unless the provider agreement
with the Contractor provides otherwise. The Contractor must ensure that any Enrollees
use including a minors use of Family Planning and Reproductive Health services remains
confidential and is not disclosed to family members or other unauthorized parties,
without the Enrollees consent to the disclosure.




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APPENDIX L
 ******REDACTED*****