exv10w31w3






Exhibit 10.31.3




APPENDIX
X

[Amendment Number 9]




	 	 	 
	Agency Code 12000

	 	Contract No. C020429
	Period 10/1/08 — 9/30/10

	 	Funding Amount for Period Based on approved capitation rates





This is an AGREEMENT between THE STATE OF NEW YORK, acting by and through The New York
State Department of Health, having its principal office at
Corning Tower, Room 2001, Empire
State Plaza, Albany NY 12237, (hereinafter referred to as the STATE), and AMERIGROUP New
York, LLC, (hereinafter referred to as the CONTRACTOR), to modify Contract Number
C020429 as set forth below. The effective date of these
modifications is October 1, 2008,
unless otherwise noted below.





	 	1.	 	Amend “Table of Contents for Model Contract,” to delete “Section 21.23 Pharmacies
 — Applies to FHPlus Program Only” and add “Section 22.15 Never Events.”
	 
	 	2.	 	Amend Subsection d) of Section 3.8 “Payment for Newborns” to read as follows:






	 	d)	 	The Contractor cannot bill for a Supplemental Newborn Capitation Payment unless the newborn hospital or birthing center payment has been paid by the
Contractor. The
Contractor  must submit encounter data evidence for the newborn stay. Failure to have
supporting records may, upon an audit result in recoupment of the Supplemental Newborn
Capitation Payment by SDOH.






	 	3.	 	Amend Subsection f) of Section 3.9 “Supplemental Maternity Capitation Payment” to
read as follows:






	 	f)	 	The Contractor may not bill a Supplemental Maternity Capitation Payment until
the hospital inpatient or birthing center delivery is paid by the Contractor, and
the Contractor must submit encounter data evidence of the delivery,
plus any other
inpatient and outpatient services for the maternity care of the Enrollee to be
eligible to receive a Supplemental Maternity Capitation Payment. Failure to have
supporting records may, upon audit result in recoupment of the Supplemental Maternity
Capitation Payment by the SDOH.






	 	4.	 	Effective January 1, 2009, amend Subsection a) of Section 3.12 “Mental Health and
Chemical Dependence Stop-Loss for MMC Enrollees” to read as follows:






	 	a)	 	Effective January 1, 2009, the New York State Stop-Loss reinsurance program
will no longer cover outpatient mental health visits. Prior to
January 1, 2009, the New
York State Stop-Loss reinsurance program compensated the Contractor for medically
necessary and clinically appropriate Medicaid reimbursable mental health treatment
outpatient visits by MMC Enrollees in excess of twenty (20) visits during any calendar
year at rates set forth in contracted fee schedules. Contractors who participated in
the New York State Stop-Loss reinsurance program prior to
January 1, 2009 can submit
eligible claims, as per the guidelines in the “Managed Care
Manual Stop Loss Policy
and Procedures” for dates of service prior to January 1,
2009. Claims continue to be
held to a two-year limit for proper submission. Any Court-Ordered Services for mental
health treatment outpatient visits by MMC Enrollees which specify the use of
Non-Participating Providers shall be compensated at the Medicaid rate
of payment.





Appendix X

MMC/FHPlus Contract Amendment 

October 1, 2008

Page 1









 









 












	 	5.	 	Amend Subsection b) i) of Section 8.3 “Disenrollment Requests” to read as follows:






	 	b)	 	Non-Routine Disenrollment Requests






	 	i)	 	Enrollees with an urgent medical need to disenroll from the Contractor’s
MMC or FHPlus product may request an expedited Disenrollment by the LDSS. An MMC
Enrollee who requests a return to Medicaid fee-for-service based on his/her HIV, End
Stage Renal Disease (ESRD), or SPMI/SED status (non-SSI Enrollees only) is
categorically eligible for an expedited Disenrollment on the basis of urgent medical
need.






	 	6.	 	Amend Subsection e) of Section 10.7 “Welfare Reform — Applies to MMC Program Only”
to read as follows:






	 	e)	 	The Contractor is not responsible for the provision and payment of Chemical
Dependence Inpatient Rehabilitation and Treatment Services for MMC Enrollees mandated by
the LDSS as a condition of eligibility for Public Assistance under Welfare Reform (as
indicated by Code 83) unless such services are already under way as described in (d)
above.






	 	7.	 	Effective January 1, 2009, amend Section 10.11 “Prenatal Care” to read as follows:






	 	10.11	 	Prenatal Care
	 
	 	 	 	The Contractor is responsible for arranging for the provision of comprehensive Prenatal
Care Services to all pregnant Enrollees including all services enumerated in Subdivision
1, Section 2522 of the PHL in accordance with 10 NYCRR § 85.40 (Prenatal Care
Assistance Program) and including up to six (6) smoking cessation counseling sessions for
each pregnant Enrollee within any twelve (12) month period.






	 	8.	 	Amend Subsection b) “Vision Services” of Section 10.15 “Services for Which
Enrollees Can Self-Refer” to read as follows:






	 	b)	 	Vision Services
	 
	 	 	 	The Contractor will allow its Enrollees to self-refer to any Participating Provider of
vision services (optometrist or ophthalmologist) for refractive vision services and, for
Enrollees diagnosed with diabetes, for an annual dilated eye (retinal) examination as
described in Appendix K of this Agreement.






	 	9.	 	Amend Subsection d) iv) of Section 10.22 “Member Needs Relating to HIV” to read as
follows:






	 	d) iv)	 	 A network of providers sufficient to meet the needs of its
Enrollees with HIV.
The Contractor must identify within their network HIV experienced providers to treat
Enrollees with HIV/AIDS and explicitly list those providers in the
Provider Directory. HIV
experienced provider is defined as either:






	 	1)	 	an M.D. or a Nurse Practitioner providing ongoing direct clinical
ambulatory care of at least 20 HIV infected persons who are being treated with
antiretroviral therapy in the preceding twelve months, or
	 
	 	2)	 	a provider who has met the criteria of one of the following accrediting bodies:





Appendix X

MMC/FHPlus Contract Amendment

October 1, 2008

Page 2




 









 









	 	•	 	The HIV Medicine Association (HIVMA) definition of an HIV-experienced
provider, or
	 
	 	•	 	HIV Specialist status accorded by the American Academy
of HIV Medicine (AAHIVM), or
	 
	 	•	 	Advanced AIDS Credited Registered Nurse Credential given by
the HIV/AIDS Nursing Certification Board (HANCB).






	 	 	 	The Contractor is responsible for validating that providers meet the above
criteria. In cases where members select a non-HIV experienced provider as their
PCP and in regions where there is a shortage of HIV experienced providers, the
Contractor shall identify HIV experienced providers who will be available
to consult with non-HIV experienced PCPs of Enrollees with HIV/AIDS. The
Contractor shall inform Participating Providers about how to obtain information about the
availability of Experienced HIV Providers and HIV Specialist PCPs. In addition, the
Contractor shall include within their network and explicitly identify Designated AIDS
Center Hospitals, where available, and contracts or linkages with providers
funded under the Ryan White HIV/AIDS Treatment Act.






	 	10.	 	Delete Section 21.23 “Pharmacies — Applies to FHPlus Program Only.”
	 
	 	11.	 	Add a new Section 22.15 “Never Events” to read as follows:





	 	22.15	 	Never Events






	 	a)	 	The Contractor is required to develop claims and payment policies and
procedures regarding “never events” or “hospital acquired conditions” that are
consistent with the Medicaid program. Specifically this includes:






	 	i)	 	Development of the capacity for claims systems
to recognize the presence or absence of valid “present on admission” (POA)
indicators for each inpatient diagnosis, using codes as described by the
Centers for Medicare and Medicaid Services for Medicare, no later than June
30, 2009;
	 
	 	ii)	 	Development of the capacity for claims systems to
reject/deny claims that do not have valid POA indicators (corrected claims
can be resubmitted), with the initiation of this edit no later than June
30, 2009;
	 
	 	iii)	 	Development of policies and procedures that will reject
or modify any inpatient charges resulting from any “never event” or
“hospital acquired condition” (pursuant to the current list of implemented
items provided on the Department of Health and HPN websites), no later than
June 30, 2009;






	 	A)	 	The methodology for claims adjustment shall be
consistent with current Medicaid program guidance provided on the
Department of Health and HPN websites.
	 
	 	B)	 	In the event that payment for inpatient claims
is not based on DRGs, the Contractor shall develop a system that is
equivalent in result to the methodology developed by Medicaid
program.





Appendix X

MMC/FHPlus Contract Amendment

October 1, 2008

Page 3









 









 












	 	iv)	 	Development of an audit or review capacity to ensure that claims are
submitted accurately and adjudicated consistent with this policy.






	 	b)	 	The Contractor is required to submit inpatient claims to MEDS with
valid POA fields as of June 30, 2009.






	 	12.	 	The attached Appendix C, “New York State Department of Health Requirements for the
Provision of Family Planning and Reproductive Health Services.” is substituted for the period
beginning October 1,2008.
	 
	 	13.	 	Amend Item 5 of Appendix G, “SDOH Requirements for the Provision of Emergency Care
and Services” to read as follows:






	 	5.	 	Emergency Transportation
	 
	 	 	 	When emergency transportation is included in the Contractor’s Benefit Package,
the Contractor shall reimburse the transportation provider for all emergency
transportation services, without regard to final diagnosis or prudent layperson
standards. Payment by the Contractor for emergency transportation services provided to an
Enrollee by a Participating Provider shall be at the rate or rates of payment specified
in the contract between the Contractor and the transportation provider. Payment by the
Contractor for emergency transportation services provided to an Enrollee by a
Non-Participating Provider shall be at the Medicaid fee-for-service rate in effect on the
date the service was rendered.






	 	14.	 	Amend Item 3. d) iv) of Appendix H “New York State Department of Health Requirements for
the Processing of Enrollments and Disenrollments” to read as follows:






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






	 	15.	 	Amend Item 6. a) xii) C) of Appendix H “New York State Department of Health
Requirements for the Processing of Enrollments and Disenrollments” to read as follows:





	 	 	 
	Reason for Disenrollment

	 	Effective Date of Disenrollment
	C) Incarceration

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







	 	16.	 	The attached Appendix K, “Prepaid Benefit Package Definitions of Covered and
Non-Covered Services” is substituted for the period
beginning October 1, 2008.





Appendix X

MMC/FHPlus Contract Amendment

October 1, 2008

Page 4









 









 












	 	17.	 	The attached Appendix L, “Approved Capitation
Payment Rates,” is substituted for
the period beginning October 1, 2008.




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




Appendix X

MMC/FHPlus Contract Amendment

October 1, 2008

Page 5




 









 





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




	 	 	 	 	 	 	 	 	 
	CONTRACTOR SIGNATURE	 	 	 	STATE AGENCY SIGNATURE
	 
	 	 	 	 	 	 	 	 
	By:

	 	/s/ Robert  A. Wychulis
	 	 	 	By:	 	 
	 

	 	 
	 	 	 	 	 	 
	 

	 	Robert  A. Wychulis	 	 	 	 	 	 
	 

	 	(Printed Name)
	 	 	 	 	 	 
	 

	 	 
	 	 	 	 	 	 
	 

	 	
 	 	 	 	 	 	(Printed Name)
	 
	 	 	 	 	 	 	 	 
	Title:

	 	Preseident and Chief Executive Officer
	 	 	 	Title:	 	 
	 
	 	 	 	 	 	 	 	 
	Date:

	 	2/2/09
	 	 	 	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 ny

	 	)





On the
2 day of February in the year 2009 before me, the undersigned,
personally appeared Robert A. Wychulis personally known to me or proved to me on the
basis of satisfactory evidence to be the individual(s) whose name(s)
is (are) subscribed
to the within instrument and acknowledged to me that he/she/they executed the
same in his/her/their/ capacity(ies), and that by his/her/their signature(s) on
the instrument, the individual(s), or the person upon behalf of which the
individual(s) acted, executed the instrument.




	 	 	 	 	 	 	 	 	 
	/s/ Ereen M. Waszkiewicz	 	 	 	 	 	 
	 	 	 	 	 	 	 
	(Notary).	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	
	 
	Approved:	 	 	 	Approved:
	 
	 	 	 	 	 	 	 	 
	ATTORNEY GENERAL	 	 	 	Thomas P. DiNapoli 
STATE COMPTROLLER
	 
	 	 	 	 	 	 	 	 
	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 
	Title:

	 	 	 	 	 	Title:	 	 
	 

	 	 
	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 
	Date:

	 	 	 	 	 	Date:	 	 
	 

	 	 
	 	 	 	 	 	 





Appendix X

MMC/FHPlus Contract Amendment

October 1, 2008

Page 6




 









 






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





APPENDIX C

October 1, 2008

C-1




 









 








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)	 	medicall y-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:
	 
	 	 	 	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 emergency contraception, medical supplies, and over the





APPENDIX
C

October 1, 2008

C-2









 









 












	 	 	 	counter drugs are not the responsibility of the Contractor and are to be obtained
when covered on the New York State list of Medicaid reimbursable drugs by the
Enrollee from any appropriate eMedNY-enrolled health care provider of the Enrollee’s
choice.






	 	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 eMedNY-enrolled health care provider of the Enrollee’s choice. No referral
from the PCP or approval by the Contractor is required to access such services.
	 
	 	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 FHPlus Enrollees






	 	a)	 	FHPlus 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.





APPENDIX C

October 1, 2008

C-3









 









 











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 full range 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





APPENDIX
C

October 1, 2008

C-4









 









 












	 	 	 	charge back to the Contractor. Such charge back mechanism will comply with all
applicable patient confidentiality requirements.






	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.





APPENDIX
C.

October 1, 2008

C-5





 









 








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, Division of Managed Care, NYS Department of
Health, 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 FHPlus Enrollees;
	 
	 	III)	 	No referral is needed for such services, and there will
be no cost to the Enrollee for such services.





APPENDIX
C

October 1, 2008

C-6





 












 






	 	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 FHPlus 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 FHPlus 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 FHPlus product(s). Such information shall be prominently
displayed and easily navigated.






	 	C)	 	A description of the mechanisms to provide all new MMC Enrollees and FHPlus
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.





APPENDIX C

October 1, 2008

C-7




 









 






	 	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. FHPlus Enrollees can receive these non-covered services
through the Designated Third Party Contractor using the Enrollee’s NYS Benefit
Identification card.
	 
	 	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
FHPlus Enrollees and Prospective FHPlus Enrollees. It is the responsibility of the
Designated Third Party Contractor or such other organization designated by the SDOH to
mail to each FHPlus 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. FHPlus 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.





APPENDIX C

October 1, 2008

C-8




 









 






	 	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 FHPlus 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 post-partum 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 FHPlus Designated Third Party
Contractor and they render non-covered Family Planning and Reproductive Health
Services to FHPlus 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,





APPENDIX C

October 1, 2008

C-9




 









 






	 	 	 	certain Family Planning and Reproductive Health services not offered through the
Contractor are medically indicated in accordance with generally accepted standards
of professional practice, an appropriately trained professional should so advise
the Enrollee and either:






	 	I)	 	offer those services to MMC Enrollees on a fee-for-service basis as an
eMedNY-enrolled provider, or to FHPlus Enrollees as a Participating Provider of the
Designated Third Party Contractor; or
	 
	 	II)	 	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, or
	 
	 	III)	 	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, Division 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 FHPlus 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.





APPENDIX C

October 1, 2008

C-10




 









 






	 	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 retraining 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 FHPlus 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 FHPlus 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.





APPENDIX C

October 1, 2008

C-11




 









 





APPENDIX K




PREPAID BENEFIT PACKAGE

DEFINITIONS OF COVERED AND

NON-COVERED SERVICES




	 	 	 
	K.1

	 	Chart of Prepaid Benefit Package
	 

	 	- Medicaid Managed Care Non-SSI (MMC Non-SSI)
	 

	 	- Medicaid Managed Care SSI (MMC SSI)
	 

	 	- Medicaid Fee-for-Service (MFFS)
	 

	 	- Family Health Plus (FHPlus)
	 
	 	 
	K.2

	 	Prepaid Benefit Package
	 

	 	Definitions of Covered Services
	 
	 	 
	K.3

	 	Medicaid Managed Care Definitions of Non-Covered
Services
	 
	 	 
	K.4

	 	Family Health Plus Non-Covered Services






APPENDIX K

October 1, 2008

K-l




 









 





APPENDIX K

PREPAID BENEFIT PACKAGE

DEFINITIONS OF COVERED AND NON-COVERED SERVICES





	1.	 	General






	 	a)	 	The categories of services in the Medicaid Managed Care and Family Health Plus
Benefit Packages, including optional covered services, shall be provided by the
Contractor to MMC Enrollees and FHPlus Enrollees, respectively, when medically
necessary under the terms of this Agreement. The definitions of covered and non-covered services herein are in summary form; the full description and scope of each
covered service as established by the New York Medical Assistance Program are set forth
in the applicable NYS Medicaid Provider Manual, except for the Eye Care and Vision
benefit for FHPlus Enrollees which is described in Section 19 of Appendix
K.2.
	 
	 	b)	 	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, and emergency services, emergency transportation, Family Planning and
Reproductive Health services, 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.
	 
	 	c)	 	This Appendix contains the following sections:






	 	i)	 	K.1 — “Chart of Prepaid Benefit Package” lists the services provided by
the Contractor to all Medicaid Managed Care 

Non-SSI Enrollees, Medicaid Managed
Care SSI Enrollees, Medicaid fee-for-service coverage for carved out and wraparound
benefits, and Family Health Plus Enrollees.
	 
	 	ii)	 	K.2 — “Prepaid Benefit Package Definitions Of Covered Services” describes
the covered services, as numbered in K.1. Each service description applies to both
MMC and FHPlus Benefit Package unless otherwise noted.
	 
	 	iii)	 	K.3 — “Medicaid Managed Care Definitions of Non-Covered Services”
describes services that are not covered by the MMC Benefit Package. These services
are covered by the Medicaid fee-for-service program unless otherwise noted.
	 
	 	iv)	 	K.4 — “Family Health Plus Non-Covered Services” lists the services that
are not covered by the FHPlus Benefit Package. There is no Medicaid fee-for-service
coverage available for any service outside of the FHPlus Benefit Package.





APPENDIX K

October 1, 2008

K-2




 









 





K.1




PREPAID BENEFIT PACKAGE




	 	 	 	 	 	 	 	 	 	 	 
	*	 	Covered Services	 	MMC Non-SSI	 	MMC SSI	 	MFFS	 	FHPlus**
	1.

	 	Inpatient Hospital Services
	 	Covered, unless
admit date precedes
Effective Date of
Enrollment [see §
6.8 of this
Agreement]
	 	Covered, unless
admit date precedes
Effective Date of
Enrollment [see §
6.8  of this
Agreement]
	 	Stay covered only
when admit date
precedes Effective
Date of Enrollment
[see § 6.8 of this
Agreement]
	 	Covered, unless
admit date precedes
Effective Date of
Enrollment [see §
6.8 of this
Agreement]
	 
	 	 	 	 	 	 	 	 	 	 
	2.

	 	Inpatient Stay Pending
Alternate Level of Medical
Care
	 	Covered
	 	Covered
	 	 	 	Covered
	 
	 	 	 	 	 	 	 	 	 	 
	3.

	 	Physician Services
	 	Covered
	 	Covered
	 	 	 	Covered
	 
	 	 	 	 	 	 	 	 	 	 
	4.

	 	Nurse Practitioner Services
	 	Covered
	 	Covered
	 	 	 	Covered
	 
	 	 	 	 	 	 	 	 	 	 
	5.

	 	Midwifery Services
	 	Covered
	 	Covered
	 	 	 	Covered
	 
	 	 	 	 	 	 	 	 	 	 
	6.

	 	Preventive Health Services
	 	Covered
	 	Covered
	 	 	 	Covered
	 
	 	 	 	 	 	 	 	 	 	 
	7.

	 	Second Medical/Surgical Opinion
	 	Covered
	 	Covered
	 	 	 	Covered






 






			
	* See K.2 for Scope of Benefits
	 	
	 
	** No Medicaid fee-for service-wrap
around is available Subject to applicable co-pays.

	 
	Note: If cell is blank, there is no coverage.
	 	





APPENDIX K

October 1, 2008

K-3




 









 






	 	 	 	 	 	 	 	 	 	 	 
	*	 	Covered Services	 	MMC Non-SSI	 	MMC SSI	 	MFFS	 	FHPlus **
	8.

	 	Laboratory Services
	 	Covered
	 	Covered
	 	HIV phenotypic,
virtual phenotypic
and genotypic drug
resistance tests
and viral tropism
testing
	 	Covered
	 
	 	 	 	 	 	 	 	 	 	 
	9.

	 	Radiology Services
	 	Covered
	 	Covered
	 	 	 	Covered
	 
	 	 	 	 	 	 	 	 	 	 
	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 through the


Medicaid
fee-for-service
program, including
prescription drugs,
insulin and
diabetic supplies,
smoking
cessation-agents,
select OTCs,
hearing aid
batteries and
enteral formulae.
	 
	 	 	 	 	 	 	 	 	 	 
	11.

	 	Smoking Cessation Products
	 	 	 	 	 	Covered
	 	Covered under the


Medicaid
fee-for-service
program.
	 
	 	 	 	 	 	 	 	 	 	 
	12.

	 	Rehabilitation Services
	 	Covered
	 	Covered
	 	 	 	Covered for short
term inpatient, and
limited to 20
visits per calendar
year for outpatient
PT and OT
	 
	 	 	 	 	 	 	 	 	 	 
	13.

	 	EPSDT Services/Child Teen

Health Program (C/THP)
	 	Covered
	 	Covered
	 	 	 	Covered
	 
	 	 	 	 	 	 	 	 	 	 
	14.

	 	Home Health Services
	 	Covered
	 	Covered
	 	 	 	Covered for 40
visits in lieu of a
skilled nursing
facility stay or
hospitalization,
plus 2 post partum
home visits for
high risk women.








 





			
	* See K.2 for Scope of Benefits
	 	 
	 
	** No Medicaid fee-for service-wrap
around is available Subject to applicable co-pays.

	 
	Note: If cell is blank; there is no coverage.
	 	





APPENDIX K

October 1, 2008

K-4



 









 






	 	 	 	 	 	 	 	 	 	 	 
	*	 	Covered Services	 	MMC Non-SSI	 	MMC SSI	 	MFFS	 	FHPlus**
	15

	 	Private Duty Nursing Services
	 	Covered
	 	Covered
	 	 	 	Not covered
	 
	 	 	 	 	 	 	 	 	 	 
	16

	 	Hospice
	 	 	 	 	 	Covered
	 	Covered
	 
	 	 	 	 	 	 	 	 	 	 
	17.

	 	Emergency Services
	 	Covered
	 	Covered
	 	 	 	Covered
	 
	 	 	 	 	 	 	 	 	 	 
	 

	 	Post-Stabilization Care
Services (see also Appendix G
of this Agreement)
	 	Covered
	 	Covered
	 	 	 	Covered
	 
	 	 	 	 	 	 	 	 	 	 
	18.

	 	Foot Care Services
	 	Covered
	 	Covered
	 	 	 	Covered
	 
	 	 	 	 	 	 	 	 	 	 
	19.

	 	Eye Care and Low Vision Services
	 	Covered
	 	Covered
	 	 	 	Covered
	 
	 	 	 	 	 	 	 	 	 	 
	20.

	 	Durable Medical Equipment (DME)
	 	Covered
	 	Covered
	 	 	 	Covered
	 
	 	 	 	 	 	 	 	 	 	 
	21.

	 	Audiology, Hearing Aids

Services & Products
	 	Covered except for

hearing aid

batteries
	 	Covered except for

hearing aid

batteries
	 	Hearing aid

batteries
	 	Covered, including

hearing aid

batteries
	 
	 	 	 	 	 	 	 	 	 	 
	22.

	 	Family Planning and
Reproductive Health Services
	 	Covered if included
in Contractor’s
Benefit Package as
per Appendix M of
this Agreement
	 	Covered if included
in Contractor’s
Benefit Package as
per Appendix M of
Agreement
	 	Covered pursuant to
Appendix C of
Agreement
	 	Covered if included
in Contractor’s Benefit Package as
per Appendix M of
this Agreement or
through the DTP
Contractor
	 
	 	 	 	 	 	 	 	 	 	 
	23.

	 	Non-Emergency Transportation
	 	Covered if included
in Contractor’s
Benefit Package as
per Appendix M of
this Agreement
	 	Covered if included
in Contractor’s
Benefit Package as
per Appendix M of
this Agreement
	 	Covered if not
included in
Contractor’s
Benefit Package
	 	Not covered, except
for transportation
to C/THP services
for 19 and 20
year olds
	 
	 	 	 	 	 	 	 	 	 	 
	24

	 	Emergency Transportation
	 	Covered if included
in Contractor’s
Benefit Package as
per Appendix M of
this Agreement
	 	Covered if included
in Contractor’s
Benefit Package as
per Appendix M of
this Agreement
	 	Covered if not
included in
Contractor’s
Benefit Package
	 	Covered








 





			
	* See K.2 for Scope of Benefits
	 	 
	 
	** No Medicaid fee-for service-wrap
around is available Subject to applicable co-pays.
	 
	Note: If cell is blank, there is no coverage.
	 	 






APPENDIX K

October 1, 2008

K-5



 









 






	 	 	 	 	 	 	 	 	 	 	 
	*	 	Covered Services	 	MMC Non-SSI	 	MMC SSI	 	MFFS	 	FHPlus**
	25.

	 	Dental Services
	 	Covered if included
in Contractor’s
Benefit Package as
per Appendix M of
this Agreement,
except orthodontia
	 	Covered if included
in Contractor’s
Benefit Package as
per Appendix M of
this Agreement,
except orthodontia
	 	Covered if not
included in the
Contractor’s
Benefit Package,
Orthodontia in all
instances
	 	Covered, if
included in
Contractor’s
Benefit Package as
per Appendix  M of
this Agreement,
excluding
orthodontia
	 
	 	 	 	 	 	 	 	 	 	 
	26.

	 	Court-Ordered Services
	 	Covered, pursuant
to court order (see
also §10.9 of this
Agreement)
	 	Covered, pursuant
to court order (see
also §10.9 of this
Agreement)
	 	 	 	Covered, pursuant
to court order (see
also §10.9 of this
Agreement)
	 
	 	 	 	 	 	 	 	 	 	 
	27.

	 	Prosthetic/Orthotic

Services/Orthopedic Footwear
	 	Covered
	 	Covered
	 	 	 	Covered,

except orthopedic

shoes
	 
	 	 	 	 	 	 	 	 	 	 
	28.

	 	Mental Health Services
	 	Covered
	 	 	 	Covered for SSI

Enrollees
	 	Covered subject to
calendar year
benefit limit of 30
days inpatient, 60
visits outpatient,
combined with
chemical dependency
services
	 
	 	 	 	 	 	 	 	 	 	 
	29.

	 	Detoxification Services
	 	Covered
	 	Covered
	 	 	 	Covered
	 
	 	 	 	 	 	 	 	 	 	 
	30.

	 	Chemical Dependence Inpatient
Rehabilitation and Treatment
Services
	 	Covered subject to
stop loss
	 	 	 	Covered for SSI

recipients
	 	Covered subject to
calendar year
benefit limit 30
days combined with
mental health
services
	 
	 	 	 	 	 	 	 	 	 	 
	31

	 	Chemical Dependence Outpatient
	 	 	 	 	 	Covered
	 	Covered subject to
calendar year
benefit limits of
60 visits combined
with mental
health services
	 
	 	 	 	 	 	 	 	 	 	 
	32.

	 	Experimental and/or

Investigational  Treatment
	 	Covered on a case

by case basis
	 	Covered on a case

by case basis
	 	 	 	Covered on a case

by case basis
	 
	 	 	 	 	 	 	 	 	 	 
	33.

	 	Renal Dialysis
	 	Covered
	 	Covered
	 	 	 	Covered
	 
	 	 	 	 	 	 	 	 	 	 
	34.

	 	Residential Health Care

Facility Services (RHCF)
	 	Covered, except for

individuals in

permanent placement
	 	Covered, except for

individuals in

permanent placement	 	 	 	 








 





			
	* See K.2 for Scope of Benefits
	 	 
	 
	** No Medicaid fee-for
service-wrap around is available Subject to applicable co-pays.
	 
	Note: If cell is blank, there is no coverage.
	 	 






APPENDIX K

October 1, 2008

K-6



 












 





K.2




PREPAID BENEFIT PACKAGE

DEFINITIONS OF COVERED SERVICES




Service
definitions in this Section pertain to both MMC and FHPlus unless otherwise
indicated.





	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). Contractor will not be responsible for hospital stays that commence prior to
the Effective Date of Enrollment (see Section 6.8 of this Agreement), but will be
responsible for stays that commence prior to the Effective Date of Disenrollment
(see Section 8.5 of this Agreement). 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.
	 
	2.	 	Inpatient Stay Pending Alternate Level of Medical Care
	 
	 	 	Inpatient stay pending alternate level of medical care, or continued care in a
hospital, Article 31 mental health facility, or skilled nursing
facility pending
placement in an alternate lower medical level of care, consistent with the
provisions of 18 NYCRR § 505.20 and 

10 NYCRR Part 85.
	 
	3.	 	Physician Services






	 	a)	 	“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:






	 	i)	 	within the scope of practice of medicine as defined in law
by the New York State Education Department; and
	 
	 	ii)	 	by or under the personal supervision of an individual
licensed and currently registered by the New York State Education Department to
practice medicine.






	 	b)	 	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.
	 
	 	c)	 	The following are also included without limitations:





APPENDIX K

October 1, 2008

K-7




 









 






	 	i)	 	pharmaceuticals and medical supplies routinely furnished or administered as
part of a clinic or office visit;
	 
	 	ii)	 	physical examinations, including those which are necessary for
employment, school, and camp;
	 
	 	iii)	 	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;
	 
	 	iv)	 	health and mental health assessments for the purpose of making
recommendations regarding a Enrollee’s disability status for Federal SSI
applications;
	 
	 	v)	 	health assessments for the Infant /Child Assessment Program (ICHAP);
	 
	 	vi)	 	annual preventive health visits for adolescents;
	 
	 	vii)	 	new admission exams for school children if required by the LDSS;
	 
	 	viii)	 	health screening, assessment and treatment of refugees, including completing
SDOH/LDSS required forms;
	 
	 	ix)	 	Child/Teen Health Program (C/THP) services which are comprehensive
primary health care services provided to persons under twenty-one (21) years of
age (see Section 10 of this Agreement).






	 	d)	 	Smoking cessation counseling services for pregnant women. Up to six (6)
counseling sessions are covered within any twelve (12) month period. This Benefit
Package covered service is effective beginning January 1, 2009.






	4.	 	Certified Nurse Practitioner Services






	 	a)	 	Certified 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.
	 
	 	b)	 	The following services are also included in the certified nurse
practitioner’s scope of services, without limitation:






	 	i)	 	Child/Teen Health Program(C/THP) services which are comprehensive
primary health care services provided to persons under twenty-one (21) (see
Item 13 of this Appendix and Section 10.4 of this Agreement);
	 
	 	ii)	 	Physical examinations, including those which are necessary for
employment, school and camp. 





APPENDIX K

October 1, 2008

K-8




 









 






	5.	 	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.
	 
	6.	 	Preventive Health Services






	 	a)	 	Preventive health services means care and services to avert
disease/illness and/or its consequences. There are three (3) levels of
preventive health services: 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.
	 
	 	b)	 	The Contractor must offer the following preventive health services
essential for promoting health and preventing illness:






	 	i)	 	General health education classes.
	 
	 	ii)	 	Pneumonia and influenza immunizations for at risk populations.
	 
	 	iii)	 	Smoking cessation counseling and treatment for pregnant
women and smoking cessation classes, with targeted outreach for adolescents
and pregnant women.
	 
	 	iv)	 	Childbirth education classes.
	 
	 	v)	 	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.
	 
	 	vi)	 	Nutrition counseling, with targeted outreach for diabetics and pregnant women.
	 
	 	vii)	 	Extended care coordination, as needed, for pregnant women.
	 
	 	viii)	 	HIV counseling and testing.
	 
	 	ix)	 	Asthma self-management training for newly diagnosed
asthmatics up to ten (10) hours during a continuous twelve (12) month period
and up to two (2) hours follow-up training in subsequent years. Up to ten
(10) additional hours will be covered in a continuous twelve (12) month
period to address medically complex conditions such as exacerbation of
asthma, poor asthma control, diagnosis of a complication or co-morbidity,
post-surgery, prescription for new equipment, mental health diagnosis,
learning disability and unstable medical condition. This Benefit Package
covered service is effective beginning January 1, 2009.
	 
	 	x)	 	Diabetes self-management training for newly diagnosed
diabetics up to ten (10) hours during a continuous twelve (12) month period
and up to two (2) hours follow-up training in subsequent years. Up to ten
(10) additional hours will be covered in a continuous twelve (12) month
period to address medically complex conditions such as poor diabetes control
(A1c>8), diagnosis of a complication or





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	 	 	 	co-morbidity, post-surgery, prescription for new equipment such as an insulin pump,
mental health diagnosis, learning disability, unstable medical condition,
gestational diabetes and pregnancy. This Benefit Package covered
service is
effective beginning January 1, 2009.






	7.	 	Second Medical/Surgical Opinions
	 
	 	 	The Contractor will allow Enrollees to obtain second opinions for diagnosis of a
condition, treatment or surgical procedure by a qualified physician or appropriate
specialist, including one affiliated with a specialty care center. In the event that the
Contractor determines that it does not have a Participating Provider in its network with
appropriate training and experience qualifying the Participating Provider to provide a
second opinion, the Contractor shall make a referral to an appropriate Non-Participating
Provider. The Contractor shall pay for the cost of the services associated with obtaining
a second opinion regarding medical or surgical care, including diagnostic and evaluation
services, provided by the Non-Participating Provider.






	8.	 	Laboratory Services
	 
	 	 	18 NYCRR § 505.7(a)






	 	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.
	 
	 	b)	 	All laboratory testing sites providing services under this Agreement 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 NYS Medicaid Provider Manual.
	 
	 	c)	 	For MMC only: coverage for HIV phenotypic, HIV virtual phenotypic and HIV
genotypic drug resistance tests and viral tropism testing are covered by Medicaid fee-
for-service.






	9.	 	Radiology Services
	 
	 	 	18 NYCRR § 505.17(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.





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	10.	 	Prescription and Non-Prescription (OTC) Drugs  Medical Supplies and Enteral
Formulas






	 	a)	 	For Medicaid managed care only: Enrollees are covered for prescription drugs
through the Medicaid fee-for-service program. Medically necessary prescription and
non-prescription (OTC) drugs; medical supplies and enteral formula are covered when
ordered by a qualified provider.
	 
	 	b)	 	For Family Health Plus only: Enrollees are covered through the Medicaid
fee-for-service program. Medically necessary prescription drugs, insulin and diabetic
supplies (e.g., insulin syringes, blood glucose test strips, lancets, alcohol swabs),
smoking cessation agents, including over-the-counter (OTC) smoking cessation
products, select OTC medications covered on the Medicaid Preferred Drug List (e.g.,
Prilosec OTC, Loratadine, Zyrtec), hearing aid batteries and enteral formula are
covered when ordered by a qualified provider. Medical supplies (except for diabetic
supplies and smoking cessation agents) are not covered.
	 
	 	c)	 	For Medicaid Managed Care and Family Health Plus: Pharmaceuticals and medical
supplies routinely furnished or administered as part of a clinic or office visit are
covered by the Contractor. Self-administered injectable drugs (including those
administered by a family member) and injectable drugs administered during a home care
visit are covered by Medicaid fee-for-service if the drug is on the list of Medicaid
reimbursable drugs or covered by the Contractor, subject to medical necessity, if the
drug is not on the list of Medicaid reimbursable prescription drugs.






	11.	 	Smoking Cessation Products






	 	a)	 	Enrollees are covered for smoking cessation products through the Medicaid
fee-for-service program.






	12.	 	Rehabilitation Services
	 
	 	 	18 NYCRR § 505.11






	 	a)	 	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. For the MMC Program, 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.





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	 	b)	 	For Family Health Plus only: Outpatient visits for physical and occupational
therapy is limited to twenty (20) visits per calendar year. Coverage for speech therapy
services is limited to those required for a condition amenable to significant clinical
improvement within a two month period.






	13.	 	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 including outreach,
education, appointment scheduling, administrative case management and transportation
assistance.






	14.	 	Home Health Services
	 
	 	 	18 NYCRR § 505.23(a)(3)






	 	a)	 	Home health care services are provided to Enrollees in their homes by a home
health agency certified under Article 36 of the PHL (Certified Home Health Agency -
CHHA). Home health services mean the following services when prescribed by a
Provider and provided to a Enrollee in his or her home:






	 	i)	 	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;
	 
	 	ii)	 	physical therapy, occupational therapy, or speech pathology and
audiology services; and
	 
	 	iii)	 	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.






	 	b)	 	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.





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	 	c)	 	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.
	 
	 	d)	 	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.
	 
	 	e)	 	For Family Health Plus only: coverage is limited to forty (40) home health
care visits per calendar year in lieu of a skilled nursing facility stay or
hospitalization. Post partum home visits apply only to high risk mothers. For the
purposes of this Section, visit is defined as the delivery of a discreet service
(e.g. nursing, OT, PT, ST, audiology or home health aide). Four (4) hours of home
health aide services equals one visit.






	15.	 	Private Duty Nursing Services – For MMC Program Only






	 	a)	 	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 must be provided in the MMC Enrollee’s home and can be provided through an
approved certified home health agency, a licensed home care agency, or a private
Practitioner.
	 
	 	b)	 	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 must be provided in an Enrollee’s home in
accordance with the ordering physician’s or certified nurse practitioner’s written
treatment plan.






	16.	 	Hospice Services






	 	a)	 	Hospice Services means a coordinated hospice program of home and inpatient
services which provide non-curative medical and support services for
Enrollees
certified by a physician to be terminally ill with a life expectancy of six (6)
months or less.
	 
	 	b)	 	Hospice services include palliative and supportive care provided to an
Enrollee to meet the special needs arising out of physical, psychological,
spiritual, social and economic stress which are experienced during the final stages
of illness and during dying and bereavement. Hospices must be certified under
Article 40 of the New York State Public Health Law. 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 Enrollee and the Enrollee’s family. Family members are
eligible for up to five visits for bereavement counseling.





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	 	c)	 	Medicaid Managed Care Enrollees receive coverage for hospice services through the
Medicaid fee-for-service program.






	17.	 	Emergency Services






	 	a)	 	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. See also Appendix G of this Agreement.
	 
	 	b)	 	Post Stabilization Care Services means services related to an emergency
medical condition that are provided after an Enrollee is stabilized in order to
maintain the stabilized condition, or to improve or resolve the Enrollee’s
condition. These services are covered pursuant to Appendix G of this Agreement.






	18.	 	Foot Care Services






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





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	19.	 	Eye Care and Low Vision Services
	 
	 	 	18 NYCRR §505.6(b)(l-3)
	 	 	SSL §369-ee (l)(e)(xii)






	 	a)	 	For Medicaid Managed Care only:






	 	i)	 	Emergency, preventive and routine eye care services are covered. 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. Eye care coverage includes the replacement of lost or
destroyed eyeglasses. The replacement of a complete pair of eyeglasses must
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 must duplicate the original
prescription and frames. Repairs to, and replacements of, frames and/or lenses
must be rendered as needed.
	 
	 	ii)	 	If the Contractor does not provide upgraded eyeglass frames or additional
features (such as scratch coating, progressive lenses or photo-gray lenses) as
part of its covered vision benefit, the Contractor cannot apply the cost of its
covered eyeglass benefit to the total cost of the eyeglasses the Enrollee wants and
bill only the difference to the Enrollee. The Enrollee can choose to purchase the
upgraded frames and/or additional features by paying the entire cost of the
eyeglasses as a private customer. For example, if the Contractor covers standard
bifocal eyeglasses and the Enrollee wants no-line bifocal eyeglasses, the Enrollee
must choose between taking the standard bifocal eyeglasses or paying the full price
of the no-line bifocal eyeglasses (not just the difference between the cost of the
bifocal lenses and the no-line lenses). The Enrollee must be informed of this fact
by the vision care provider at the time that that the glasses are ordered.
	 
	 	iii)	 	Examinations for diagnosis and treatment for visual defects and/or eye
disease are provided only as necessary and as required by the Enrollee’s
particular condition. Examinations which include refraction are limited to once
every twenty four (24) months unless otherwise justified as medically necessary.
	 
	 	iv)	 	Eyeglasses do not require changing more frequently than once
every twenty four (24)
months unless medically indicated, such as a change in correction greater
than 1/2 diopter, or unless the glasses are lost, damaged, or destroyed.
	 
	 	v)	 	An ophthalmic dispenser fills the prescription of an optometrist or
ophthalmologist and supplies eyeglasses or other vision aids upon the order of a
qualified practitioner.
	 
	 	vi)	 	MMC Enrollees may self-refer to any Participating Provider of vision
services (optometrist or ophthalmologist) for refractive vision
services not more
frequently than once every twenty four (24) months, or if otherwise justified as





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	 	 	 	medically necessary or if eyeglasses are lost, damaged or destroyed as described above.
Enrollees diagnosed with diabetes may self-refer to any Participating Provider of vision
services (optometrist or ophthalmologist) for a dilated eye (retinal)
examination not more frequently than once in any twelve (12) month period.






	b)	 	For Family Health Plus only:






	 	i)	 	Covered Services include emergency vision care and the following preventive
and routine vision care provided once in any twenty four (24) month period:






	 	A)	 	one eye examination;
	 
	 	B)	 	either: one pair of prescription eyeglass lenses and a frame, or
prescription contact lenses when medically necessary; and
	 
	 	C)	 	one pair of medically necessary occupational eyeglasses.






	 	ii)	 	An ophthalmic dispenser fills the prescription of an optometrist or ophthalmologist
and supplies eyeglasses or other vision aids upon the order of a qualified practitioner.
	 
	 	iii)	 	FHPlus Enrollees may self-refer to any Participating Provider of vision services
(optometrist or ophthalmologist) for refractive vision services not more frequently than
once every twenty-four (24) months. Enrollees diagnosed with diabetes may self-refer to
any Participating Provider of vision services (optometrist or ophthalmologist) for a
dilated eye (retinal) examination not more frequently than once in any twelve (12) month
period.
	 
	 	iv)	 	If the Contractor does not provide upgraded frames or additional features that the
Enrollee wants (such as scratch coating, progressive lenses or photo-gray lenses) as part
of its covered vision benefit, the Contractor cannot apply the cost of its covered eyeglass
benefit to the total cost of the eyeglasses the Enrollee wants and bill only the difference
to the Enrollee. The Enrollee can choose to purchase the upgraded frames and/or additional
features by paying the entire cost of the eyeglasses as a private customer. For example,
if the Contractor covers standard bifocal eyeglasses and the Enrollee wants no-line bifocal
eyeglasses, the Enrollee must choose between taking the standard bifocal glasses or paying
the full price for the no-line bifocal eyeglasses (not just the difference between the cost
of bifocal lenses and no-line lenses). The Enrollee must be informed of this
fact by the vision care provider at the time that the glasses are ordered.
	 
	 	v)	 	Contact lenses are covered only when medically necessary. Contact lenses shall not be
covered solely because the FHPlus Enrollee selects contact lenses in
lieu of receiving
eyeglasses.
	 
	 	vi)	 	Coverage does not include the replacement of lost, damaged or destroyed eyeglasses.
	 
	 	vii)	 	The occupational vision benefit for FHPlus Enrollees covers the cost of job-related
eyeglasses if that need is determined by a Participating Provider through special
testing done in conjunction with a regular vision examination. Such





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	 	 	 	examination shall determine whether a special pair of eyeglasses would improve the
performance of job-related activities. Occupational eyeglasses can be provided
in addition to regular glasses but are available only in conjunction with a regular
vision benefit once in any twenty-four (24) month period. FHPlus Enrollees may
purchase an upgraded frame or lenses for occupational eyeglasses by paying the entire
cost as a private customer. Sun-sensitive and polarized lens options are not
available for occupational eyeglasses.






	20.	 	Durable Medical Equipment (DME)
	 
	 	 	18 NYCRR §505.5(a)(l) and Section 4.4 of the NYS Medicaid DME, Medical and Surgical
Supplies and Prosthetic and Orthotic Appliances Provider Manual






	 	a)	 	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.






	 	b)	 	Coverage includes equipment servicing but excludes disposable medical supplies.






	21.	 	Audiology, Hearing Aid Services and Products
	 
	 	 	18 NYCRR §505.31 (a)(l)(2) and Section 4.7 of the NYS Medicaid 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.
	 
	 	d)	 	Hearing aid batteries:






	 	i)	 	For Family Health Plus only: Hearing aid batteries are covered as part
of the prescription drug benefit.





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	 	ii)	 	For Medicaid Managed Care only: Hearing aid batteries are covered through the
Medicaid fee-for-service program.






	22.	 	Family Planning and Reproductive Health Care






	 	a)	 	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, as specified in Appendix C of this Agreement.
	 
	 	b)	 	HIV counseling and testing is included in coverage when provided as part of a
Family Planning and Reproductive Health visit.
	 
	 	c)	 	All medically necessary abortions are covered, as specified in Appendix C of
this Agreement.
	 
	 	d)	 	Fertility services are not covered.
	 
	 	e)	 	If the Contractor excludes Family Planning and Reproductive Health services
from its Benefit Package, as specified in Appendix M of this Agreement, the Contractor
is required to comply with the requirements of Appendix C.3 of this Agreement and
still provide the following services:






	 	i)	 	screening, related diagnosis, ambulatory treatment, and referral to
Participating Provider as needed for dysmenorrhea, cervical cancer or other pelvic
abnormality/pathology;
	 
	 	ii)	 	screening, related diagnosis, and referral to Participating Provider
for anemia, cervical cancer, glycosuria, proteinuria, hypertension, breast disease
and pregnancy.






	23.	 	Non-Emergency Transportation






	 	a)	 	Transportation expenses are covered for MMC Enrollees when transportation is
essential in order for a MMC 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 Medicaid fee-for-service). Non-emergent transportation
guidelines may be developed in conjunction with the LDSS, based on the LDSS’ approved
transportation plan.
	 
	 	b)	 	Transportation services means transportation by ambulance, ambulette fixed
wing or airplane transport, invalid coach, taxicab, livery, public transportation, or
other means appropriate to the MMC Enrollee’s medical condition; and a transportation
attendant to accompany the MMC 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
MMC Enrollee’s family.





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	 	c)	 	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. 
	 
	 	d)	 	Non-emergency transportation is covered for FHPlus Enrollees that are
nineteen (19)
or twenty (20) years old and are receiving C/THP services
	 
	 	e)	 	For MMC Enrollees with disabilities, the method of transportation must
reasonably
accommodate their needs, taking into account the severity and nature of the disability.






	24.	 	Emergency Transportation






	 	a)	 	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 Services while the Enrollee is being
transported.
	 
	 	b)	 	Emergency Services means the health care procedures, treatments or services
needed
to evaluate or stabilize an Emergency Medical Condition including, but not limited to,
the treatment of trauma, burns, respiratory, circulatory and obstetrical emergencies.
	 
	 	c)	 	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. Contractor shall
reimburse the transportation provider for all emergency ambulance services without
regard for final diagnosis or prudent layperson standard.






	25.	 	Dental Services






	 	a)	 	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. Orthodontic services are not covered.
	 
	 	b)	 	Dental surgery performed in an ambulatory or inpatient setting is the
responsibility of
the Contractor whether dental services are included in the Benefit Package or not.
The Contractor is responsible for the cost associated with inpatient hospitalization,
surgical suites, general anesthesia, intravenous sedation, radiological services, etc.
provided in the hospital and ambulatory surgery suite. Dental provider costs are the
Contractor’s responsibility only when dental services are included in the Benefit
Package. If the Contractor does not cover dental services, it is not responsible for the
cost associated with dental providers. The Contractor shall set up procedures to prior
approve dental services provided in inpatient and ambulatory settings.




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	 	c)	 	For Medicaid Managed Care only:






	 	i)	 	As described in Sections 10.15 and 10.27 of this Agreement, Enrollees
may self-refer to Article 28 clinics operated by academic dental centers to
obtain covered dental services if dental services are included in the Benefit
Package.
	 
	 	ii)	 	Professional services of a dentist for dental surgery performed in
an ambulatory or inpatient setting are billed Medicaid fee-for-service if the
Contractor does not include dental services in the benefit package.






	26.	 	Court Ordered Services
	 
	 	 	Court ordered services are those services ordered by a court of competent jurisdiction
which are performed by or under the supervision of a physician, dentist, or other provider
qualified under State law to furnish medical, dental, behavioral health (including
treatment for mental health and/or alcohol and/or substance abuse or dependence), or
other covered services. The Contractor is responsible for payment of those services
included in the benefit package. 






	27.	 	Prosthetic/Orthotic Orthopedic Footwear
	 
	 	 	Section 4.5, 4.6 and 4.7 of the NYS Medicaid DME, Medical and Surgical Supplies and
Prosthetic and Orthotic Appliances Provider Manual






	 	a)	 	Prosthetics are those appliances or devices 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 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)	 	Medicaid Managed Care: 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.






	28.	 	Mental Health Services






	 	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 PHL.
	 
	 	b)	 	Outpatient Services




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	 	 	 	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 the New York State Office of
Mental Health (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. 
	 
	 	c)	 	Family Health Plus Enrollees have a combined mental health/chemical dependency
benefit limit of thirty (30) days inpatient and sixty (60) outpatient visits per
calendar
year.
	 
	 	d)	 	MMC SSI Enrollees obtain all mental health services through the Medicaid
fee-for-
service program.






	29.	 	Detoxification Services 






	 	a)	 	Medically Managed Inpatient Detoxification






	 	 	 	These programs provide medically directed twenty-four (24) 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 § 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.
	 
	 	b)	 	Medically Supervised Withdrawal






	 	i)	 	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 (24)
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 §816.7.
	 
	 	ii)	 	Medically Supervised Outpatient Withdrawal




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	 	 	 	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 under Title 14 NYCRR
§816.7.






	 	c)	 	For Medicaid Managed Care only: 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 inpatient hospital stop-loss provisions specified in Section 3.11 of
this Agreement.






	30.	 	Chemical Dependence Inpatient Rehabilitation and Treatment Services






	 	a)	 	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
the New York State Office of Alcoholism and Substance Abuse Services (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.
	 
	 	b)	 	Family Health Plus Enrollees have a combined mental health/chemical dependency
benefit limit of thirty (30) days inpatient and sixty (60) outpatient visits per calendar
year.






	31.	 	Outpatient Chemical Dependency Services






	 	a)	 	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.
	 
	 	b)	 	Medically Supervised Chemical Dependence Outpatient Rehabilitation Programs




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	 	 	 	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
§ 822.9.
	 
	 	c)	 	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.
	 
	 	d)	 	Medicaid Managed Care Enrollees access outpatient chemical dependency services
through the Medicaid fee-for-service program.






	32.	 	Experimental or Investigational Treatment






	 	a)	 	Experimental and investigational treatment is covered on a case by case basis.
	 
	 	b)	 	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 the PHL under the following conditions:






	 	i)	 	The Enrollee has had coverage of a health care service denied on the basis that
such service is experimental and investigational, and
	 
	 	ii)	 	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 Contractor, or
	 
	 	C)	 	for which there exists a clinical trial, and 






	 	iii)	 	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: 




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	 	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






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






	33.	 	Renal Dialysis
	 
	 	 	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.






	34.	 	Residential Health Care Facility (RHCF) Services — For MMC Program Only






	 	a)	 	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, twenty-four (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 MMC Enrollee:






	 	i)	 	Who is diagnosed by a physician as having one or more clinically
determined illnesses or conditions that cause the MMC Enrollee to be so
incapacitated, sick, invalid, infirm, disabled, or convalescent as to require at
least medical and nursing care; and
	 
	 	ii)	 	Whose assessed health care needs, in the professional judgment of the
MMC Enrollee’s physician or a medical team:






	 	A)	 	do not require care or active treatment of the MMC Enrollee in a
general or
special hospital;
	 
	 	B)	 	cannot be met satisfactorily in the MMC 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
	 
	 	C)	 	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 MMC Enrollee in such setting in or
near his or her community.




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	 	b)	 	The Contractor is also responsible for respite days and bed hold days authorized by
the Contractor.
	 
	 	c)	 	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 MMC
Enrollees who are not in Permanent
Placement Status as determined by LDSS.




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K.3



Medicaid Managed Care Prepaid Benefit Package

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:





	1.	 	Medical Non-Covered Services






	 	a)	 	Personal Care Agency Services






	 	i)	 	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).
	 
	 	ii)	 	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 to develop a plan
of
care.






	 	b)	 	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 Status are not covered.
	 
	 	c)	 	Hospice Program






	 	i)	 	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. 
	 
	 	ii)	 	Hospices are organizations which must be certified
under Article 40 of the PHL. All services must be provided by qualified
employees and volunteers of the




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	 	 	 	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.
	 
	 	iii)	 	If an Enrollee 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.






	 	d)	 	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.






	2.	 	Non-Covered Behavioral Health Services






	 	a)	 	Chemical Dependence Services






	 	i)	 	Outpatient Rehabilitation and Treatment Services






	 	A)	 	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 OASAS under 14 NYCRR Part 828.
	 
	 	B)	 	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.




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	 	C)	 	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 § 822.9.
	 
	 	D)	 	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. 






	 	ii)	 	Chemical Dependence Services Ordered by the LDSS






	 	A)	 	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:






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






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




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	 	b)	 	Mental Health Services






	 	i)	 	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.
	 
	 	ii)	 	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.
	 
	 	iii)	 	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.
	 
	 	iv)	 	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.
	 
	 	v)	 	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.




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	 	vi)	 	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 Item 3— “Other Non-Covered
Services”.
	 
	 	vii)	 	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.
	 
	 	viii)	 	Services Provided Through OMH Designated Clinics for Children With A Diagnosis of Serious
Emotional Disturbance (SED)
	 
	 	 	 	These are services provided by designated OMH clinics to children and adolescents with a
clinical diagnosis of SED.
	 
	 	ix)	 	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.
	 
	 	x)	 	Personalized Recovery Oriented Services (PROS)
	 
	 	 	 	PROS, licensed and reimbursed pursuant to 14 NYCRR 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.




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	 	xi)	 	Risperdal Consta, an injectable mental health drug used for management of patients with
schizophrenia, furnished as part of a clinic or office visit.






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






	 	i)	 	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.
	 
	 	ii)	 	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 § 586.3, Part 594 and Part 595.






	 	d)	 	Office of Mental Retardation and Developmental Disabilities (OMRDD) Services






	 	i)	 	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.




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	 	ii)	 	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.
	 
	 	iii)	 	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 Item 3 “Other Non-Covered
Services.”
	 
	 	iv)	 	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 § 1915(c) waiver from DHHS.
	 
	 	v)	 	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





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coordination, respite and assistive technologies. Care at Home waiver
services are authorized pursuant to a SSA § 1915(c) waiver from DHHS.




	3.	 	Other Non-Covered Services






	 	a)	 	The Early Intervention Program (EIP) – Children Birth to Two (2) Years of Age






	 	i)	 	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 and Mental Hygiene; Erie
County – The Department of Youth Services; Jefferson County –the Office of
Community Services; and Ulster County – the Department of Social
Services).
	 
	 	ii)	 	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 eMedNY 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, through its
Participating Providers, 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.
	 
	 	iii)	 	SDOH will instruct the locally designated early intervention
agencies on how to identify an Enrollee and the need to contact the
Contractor or the Participating Provider to coordinate service provision.






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






	 	i)	 	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.





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	 	ii)	 	PSHSP services rendered to children three (3) through four (4) years of age in
conjunction with an approved IEP are categorized as Non-Covered.
	 
	 	iii)	 	The PSHSP services will be identified on eMedNY 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.






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






	 	i)	 	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.
	 
	 	ii)	 	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.
	 
	 	iii)	 	The SSHSP services are identified on eMedNY 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.






	 	d)	 	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 must 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.
	 
	 	e)	 	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





APPENDIX K

October 1, 2008

K-34




 









 






	 	 	 	prescribed medication regimen. While the clinical management of tuberculosis is included in the
Benefit Package, TB/DOT where applicable, can be billed directly to eMedNY by any SDOH approved
Medicaid fee-for-service TB/DOT Provider. The Contractor remains responsible for communicating,
cooperating and coordinating clinical management of TB with the TB/DOT Provider.
	 
	 	f)	 	AIDS Adult Day Health Care
	 
	 	 	 	Adult Day Health Care Programs (ADHCP) are programs designed to assist individuals with HIV
disease to live more independently in the community or eliminate the need for residential health
care services. Registrants in ADHCP require a greater range of comprehensive health care
services than can be provided in any single setting, but do not require the level of services
provided in a residential health care setting. Regulations require that a person enrolled in an
ADHCP must require at least three (3) hours of health care delivered on the basis of at least one
(1) visit per week. While health care services are broadly defined in this setting to include
general medical care, nursing care, medication management, nutritional services, rehabilitative
services, and substance abuse and mental health services, the latter two (2) cannot be the sole
reason for admission to the program. Admission criteria must include, at a minimum, the need for
general medical care and nursing services.
	 
	 	g)	 	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.
	 
	 	h)	 	Adult Day Health Care






	 	i)	 	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.
	 
	 	ii)	 	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.





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October 1, 2008

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





APPENDIX K

October 1, 2008

K-36




 









 





K.4




Family Health Plus

Non-Covered Services





	1.	 	Non-Emergent Transportation Services (except for 19 and 20 year olds receiving C/THP
Services)
	 
	2.	 	Personal Care Agency Services
	 
	3.	 	Private Duty Nursing Services
	 
	4.	 	Long Term Care — Residential Health Care Facility Services
	 
	5.	 	Pharmacy Items (covered through Medicaid fee-for-service program)
	 
	6.	 	Medical Supplies
	 
	7.	 	Alcohol and Substance Abuse (ASA) Services Ordered by the LDSS
	 
	8.	 	Office of Mental Health/ Office of Mental Retardation and Developmental Disabilities Services
	 
	9.	 	School Supportive Health Services
	 
	10.	 	Comprehensive Medicaid Case Management (CMCM)
	 
	11.	 	Directly Observed Therapy for Tuberculosis Disease
	 
	12.	 	AIDS Adult Day Health Care
	 
	13.	 	HIV COBRA Case Management
	 
	14.	 	Home and Community Based Services Waiver
	 
	15.	 	Methadone Maintenance Treatment Program
	 
	16.	 	Day Treatment
	 
	17.	 	IPRT
	 
	18.	 	Infertility Services
	 
	19.	 	Adult Day Health Care
	 
	20.	 	School Based Health Care Services
	 
	21.	 	Personal Emergency Response Systems





APPENDIX K

October 1, 2008

K-37




 









 





APPENDIX L




Approved Capitation Payment Rates




APPENDIX L

October 1, 2008

L-1




 









 





AMERIGROUP NEW YORK, LLC




Medicaid Managed Care Rates




****REDACTED****




 









 





	 	 	 
	AMERIGROUP NEW YORK, LLC	 	 
	 	 	 
	Family Health Plus Rates	 	 
	Effective October 1, 2008
	 	Optional
	 	 	 
	****REDACTED****