Exhibit 10.1

                                                                                        Exhibit
    10.1

    


    


    


    


    


    MEDICAID
      MANAGED CARE 

    


    AND
      FAMILY HEALTH PLUS

    


    MODEL
      CONTRACT

    


    October
      1, 2005

    



    Table
      of Contents for Model Contract

    


    Recitals

    


    Section
      1
 Definitions

    


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

    
      	 	
              2.1
                

            	
              Term

            


    

    
      	 	
              2.2
                

            	
              Amendments

            


    

    
      	 	
              2.3
                

            	
              Approvals

            


    

    
      	 	
              2.4
                

            	
              Entire
                Agreement

            


    

    
      	 	
              2.5
                

            	
              Renegotiation

            


    

    
      	 	
              2.6
                

            	
              Assignment
                and Subcontracting

            


    

    
      	 	
              2.7
                

            	
              Termination

            


    

    a.
      SDOH
      Initiated Termination

    b.
      Contractor and SDOH Initiated Termination

    c.
      Contractor Initiated Termination

    d.
      Termination Due to Loss of Funding

    
      	 	
              2.8
                

            	
              Close-Out
                Procedures

            


    

    
      	 	
              2.9
                

            	
              Rights
                and Remedies

            


    

    
      	 	
              2.10
                

            	
              Notices

            


    

    
      	 	
              2.11
                

            	
              Severability

            


    

    


    Section
      3
 Compensation

    
      	 	
              3.1
                

            	
              Capitation
                Payments

            


    

    
      	 	
              3.2
                

            	
              Modification
                of Rates During Contract
                Period

            


    

    
      	 	
              3.3
                

            	
              Rate
                Setting Methodology

            


    

    
      	 	
              3.4
                

            	
              Payment
                of Capitation

            


    

    
      	 	
              3.5
                

            	
              Denial
                of Capitation Payments

            


    

    
      	 	
              3.6
                

            	
              SDOH
                Right to Recover Premiums

            


    

    
      	 	
              3.7
                

            	
              Third
                Party Health Insurance
                Determination

            


    

    
      	 	
              3.8
                

            	
              Payment
                for Newborns

            


    

    
      	 	
              3.9
                

            	
              Supplemental
                Maternity Capitation Payment

            


    

    
      	 	
              3.10
                

            	
              Contractor
                Financial Liability

            


    

    3.11
       Inpatient
      Hospital
      Stop-Loss Insurance for Medicaid
      Managed
      Care

    (MMC) Enrollees

    3.12
       Mental
      Health and Chemical Dependence Stop-Loss for MMC Enrollees

    3.13
       Residential
      Health Care Facility Stop-Loss for MMC Enrollees

    3.14
       Stop-Loss
      Documentation and Procedures for the MMC Program

    3.15
       Family
      Health Plus (FHPlus)
      Reinsurance

    3.16
       Tracking
      Visits Provided by Indian Health Clinics - Applies to MMC 

    Program
      Only

    


    Section
      4
 Service
      Area

    


    Section
      5 Reserved

    


    


    TABLE
      OF
      CONTENTS

    October
      1, 2005

    1

    



    Table
      of Contents for Model Contract

    


    Section
      6
 Enrollment

    
      	 	
              6.1
                

            	
              Populations
                Eligible for Enrollment

            


    

    
      	 	
              6.2
                

            	
              Enrollment
                Requirements

            


    

    
      	 	
              6.3
                

            	
              Equality
                of Access to Enrollment

            


    

    
      	 	
              6.4
                

            	
              Enrollment
                Decisions

            


    

    
      	 	
              6.5
                

            	
              Auto
                Assignment - For MMC
                Program Only

            


    

    
      	 	
              6.6
                

            	
              Prohibition
                Against Conditions on Enrollment

            


    

    
      	 	
              6.7
                

            	
              Newborn
                Enrollment

            


    

    
      	 	
              6.8
                

            	
              Effective
                Date of Enrollment

            


    

    
      	 	
              6.9
                

            	
              Roster

            


    

    
      	 	
              6.10
                

            	
              Automatic
                Re-Enrollment

            


    

    


    Section
      7
 Lock-In
      Provisions

    
      	 	
              7.1
                

            	
              Lock-In
                Provisions in MMC Mandatory Counties and for Family Health
                Plus

            


    

    
      	 	
              7.2
                

            	
              Disenrollment
                During a Lock-In Period

            


    

    
      	 	
              7.3
                

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

            


    

    
      	 	
              7.4
                

            	
              Lock-In
                and Change in Eligibility Status

            


    

    


    Section
      8
 Disenrollment

    
      	 	
              8.1
                

            	
              Disenrollment
                Requirements

            


    

    
      	 	
              8.2
                

            	
              Disenrollment
                Prohibitions

            


    

    
      	 	
              8.3
                

            	
              Disenrollment
                Requests

            


    

    
      	 	
              a.
                

            	
              Routine
                Disenrollment Requests 

            


    

    
      	 	
              b. 

            	
              Non-Routine
                Disenrollment Requests

            


    

    
      	 	
              8.4
                

            	
              Contractor
                Notification of Disenrollments

            


    

    
      	 	
              8.5
                

            	
              Contractor's
                Liability

            


    

    
      	 	
              8.6
                

            	
              Enrollee
                Initiated Disenrollment

            


    

    
      	 	
              8.7
                

            	
              Contractor
                Initiated Disenrollment

            


    

    
      	 	
              8.8
                

            	
              LDSS
                Initiated Disenrollment

            


    

    


    Section
      9
 Guaranteed
      Eligibility

    
      	 	
              9.1
                

            	
              General
                Requirements

            


    

    
      	 	
              9.2
                

            	
              Right
                to Guaranteed Eligibility

            


    

    
      	 	
              9.3
                

            	
              Covered
                Services During Guaranteed
                Eligibility

            


    

    
      	 	
              9.4
                

            	
              Disenrollment
                During Guaranteed Eligibility

            


    

    


    Section
      10  Benefit
      Package Requirements

    
      	 	
              10.1
                

            	
              Contractor
                Responsibilities

            


    

    
      	 	
              10.2
                

            	
              Compliance
                with State Medicaid
                Plan and Applicable Laws

            


    

    
      	 	
              10.3
                

            	
              Definitions

            


    

    
      	 	
              10.4
                

            	
              Child
                Teen Health Program/Adolescent
                Preventive Services

            


    

    
      	 	
              10.5
                

            	
              Foster
                Care Children - Applies to MMC Program
                Only

            


    

    
      	 	
              10.6
                

            	
              Child
                Protective Services

            


    

    
      	 	
              10.7
                

            	
              Welfare
                Reform - Applies to MMC Program
                Only

            


    

    
      	 	
              10.8
                

            	
              Adult
                Protective Services

            


    

    
      	 	
              10.9
                

            	
              Court-Ordered
                Services

            


    

    


    


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      OF
      CONTENTS October 1, 2005

    2

    



    Table
      of Contents for Model Contract

    


    
      	 	
              10.10
                

            	
              Family
                Planning and Reproductive Health
                Services

            


    

    
      	 	
              10.11
                

            	
              Prenatal
                Care

            


    

    
      	 	
              10.12
                

            	
              Direct
                Access

            


    

    
      	 	
              10.13
                

            	
              Emergency
                Services

            


    

    
      	 	
              10.14
                

            	
              Medicaid
                Utilization Thresholds (MUTS)

            


    

    
      	 	
              10.15
                

            	
              Services
                for Which Enrollees
                Can Self-Refer

            


    

    
      	 	
              a.
                

            	
              Mental
                Health and Chemical Dependence
                Services

            


    

    
      	 	
              b. 

            	
              Vision
                Services

            


    

    
      	 	
              c. 

            	
              Diagnosis
                and Treatment of Tuberculosis

            


    

    
      	 	
              d. 

            	
              Family
                Planning and Reproductive Health
                Services

            


    

    
      	 	
              e. 

            	
              Article
                28 Clinics Operated by Academic Dental
                Centers

            


    

    
      	 	
              10.16
                

            	
              Second
                Opinions for Medical or Surgical
                Care

            


    

    
      	 	
              10.17
                

            	
              Coordination
                with Local Public Health Agencies

            


    

    
      	 	
              10.18
                

            	
              Public
                Health Services

            


    

    
      	 	
              a.
                

            	
              Tuberculosis
                Screening, Diagnosis and Treatment;
                Directly

            


    

    Observed
      Therapy (TB/DOT)
      

    
      	 	
              b.
                

            	
              Immunizations

            


    

    
      	 	
              c.
                

            	
              Prevention
                and Treatment of Sexually Transmitted Diseases


            


    

    
      	 	
              d.
                

            	
              Lead
                Poisoning - Applies to MMC
                Program Only

            


    

    
      	 	
              10.19
                

            	
              Adults
                with Chronic Illnesses and Physical or Developmental
                Disabilities

            


    

    
      	 	
              10.20
                

            	
              Children
                with Special Health Care Needs

            


    

    
      	 	
              10.21
                

            	
              Persons
                Requiring Ongoing Mental Health
                Services

            


    

    
      	 	
              10.22
                

            	
              Member
                Needs Relating to HIV

            


    

    
      	 	
              10.23
                

            	
              Persons
                Requiring Chemical Dependence
                Services

            


    

    
      	 	
              10.24
                

            	
              Native
                Americans

            


    

    
      	 	
              10.25
                

            	
              Women,
                Infants, and Children (WIC)

            


    

    
      	 	
              10.26
                

            	
              Urgently
                Needed Services

            


    

    
      	 	
              10.27
                

            	
              Dental
                Services Provided by Article 28 Clinics Operated by Academic
                

            


    

    Dental
      Centers Not Participating in Contractor's Network- Applies to 

    MMC
      Program Only

    
      	 	
              10.28
                

            	
              Hospice
                Services

            


    

    
      	 	
              10.29
                

            	
              Prospective
                Benefit Package Change for Retroactive SSI
                Determinations -Applies to MMC Program
                Only

            


    

    
      	 	
              10.30
                

            	
              Coordination
                of Services

            


    

    


    Section
      11  Marketing

    
      	 	
              11.1
                

            	
              Information
                Requirements

            


    

    
      	 	
              11.2
                

            	
              Marketing
                Plan

            


    

    
      	 	
              11.3
                

            	
              Marketing
                Activities

            


    

    
      	 	
              11.4
                

            	
              Prior
                Approval of Marketing Materials and
                Procedures

            


    

    
      	 	
              11.5
                

            	
              Corrective
                and Remedial Actions

            


    

    


    Section
      12  Member
      Services

    
      	 	
              12.1
                

            	
              General
                Functions

            


    

    
      	 	
              12.2
                

            	
              Translation
                and Oral Interpretation

            


    

    
      	 	
              12.3
                

            	
              Communicating
                with the Visually, Hearing and Cognitively
                Impaired

            


    

    


    


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      CONTENTS October 1, 2005

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    Table
      of Contents for Model Contract

    


    Section
      13  Enrollee
      Rights
      and Notification

    
      	 	
              13.1
                

            	
              Information
                Requirements

            


    

    
      	 	
              13.2
                

            	
              Provider
                Directories/Office Hours for Participating
                Providers

            


    

    
      	 	
              13.3
                

            	
              Member ID
                Cards

            


    

    
      	 	
              13.4
                

            	
              Member
                Handbooks

            


    

    
      	 	
              13.5
                

            	
              Notification
                of Effective Date of Enrollment

            


    

    
      	 	
              13.6
                

            	
              Notification
                of Enrollee Rights

            


    

    
      	 	
              13.7
                

            	
              Enrollee's
                Rights

            


    

    
      	 	
              13.8
                

            	
              Approval
                of Written Notices

            


    

    
      	 	
              13.9
                

            	
              Contractor's
                Duty to Report Lack of Contact

            


    

    
      	 	
              13.10
                

            	
              LDSS
                Notification of Enrollee's Change in
                Address

            


    

    
      	 	
              13.11
                

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

            


    

    
      	 	
              13.12
                

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

            


    

    


    Section
      14  Action
      and Grievance System

    14.1
       General
      Requirements

    14.2
       Actions

    14.3
       Grievance
      System

    14.4
       Notification
      of Action and Grievance System Procedures

    14.5
       Complaint,
      Complaint Appeal and Action Appeal Investigation Determinations

    


    Section
      15  Access
      Requirements

    
      	 	
              15.1
                

            	
              General
                Requirement

            


    

    
      	 	
              15.2
                

            	
              Appointment
                Availability Standards

            


    

    
      	 	
              15.3
                

            	
              Twenty-Four
                (24) Hour Access

            


    

    
      	 	
              15.4
                

            	
              Appointment
                Waiting Times

            


    

    
      	 	
              15.5
                

            	
              Travel
                Time Standards

            


    

    
      	 	
              15.6
                

            	
              Service
                Continuation 

            


    

    a.
      New
Enrollees
      

    b.
      Enrollees Whose Health Care Provider Leaves Network

    
      	 	
              15.7
                

            	
              Standing
                Referrals

            


    

    
      	 	
              15.8
                

            	
              Specialist
                as a Coordinator of Primary Care

            


    

    
      	 	
              15.9
                

            	
              Specialty
                Care Centers 15.10 Cultural
                Competence

            


    

    


    Section
      16  Quality
      Assurance

    
      	 	
              16.1
                

            	
              Internal
                Quality Assurance Program

            


    

    
      	 	
              16.2
                

            	
              Standards
                of Care

            


    

    


    Section
      17 Monitoring and Evaluation

    
      	 	
              17.1
                

            	
              Right
                To Monitor Contractor Performance

            


    

    
      	 	
              17.2
                

            	
              Cooperation
                During Monitoring And Evaluation

            


    

    
      	 	
              17.3
                

            	
              Cooperation
                During On-Site
                Reviews

            


    

    
      	 	
              17.4
                

            	
              Cooperation
                During Review of Services by External Review
                Agency

            


    

    


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      OF
      CONTENTS October 1, 2005 

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    Table
      of Contents for Model Contract

    Section
      18  Contractor
      Reporting Requirements

    
      	 	
              18.1
                

            	
              General
                Requirements

            


    

    
      	 	
              18.2
                

            	
              Time
                Frames for Report Submissions

            


    

    
      	 	
              18.3
                

            	
              SDOH
                Instructions for Report Submissions

            


    

    
      	 	
              18.4
                

            	
              Liquidated
                Damages

            


    

    
      	 	
              18.5
                

            	
              Notification
                of Changes in Report Due Dates, Requirements or
                Formats

            


    

    
      	 	
              18.6
                

            	
              Reporting
                Requirements

            


    

    
      	 	
              18.7
                

            	
              Ownership
                and Related Information Disclosure

            


    

    
      	 	
              18.8
                

            	
              Public
                Access to
                Reports

            


    

    
      	 	
              18.9
                

            	
              Professional
                Discipline

            


    

    
      	 	
              18.10
                

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

            


    

    
      	 	
              18.11
                

            	
              Conflict
                of Interest Disclosure

            


    

    
      	 	
              18.12
                

            	
              Physician
                Incentive Plan Reporting

            


    

    


    Section
      19  Records
      Maintenance and Audit Rights

    
      	 	
              19.1
                

            	
              Maintenance
                of Contractor Performance Records

            


    

    
      	 	
              19.2
                

            	
              Maintenance
                of Financial Records and Statistical
                Data

            


    

    
      	 	
              19.3
                

            	
              Access
                to Contractor Records

            


    

    
      	 	
              19.4
                

            	
              Retention
                Periods

            


    

    


    Section
      20  Confidentiality

    
      	 	
              20.1
                

            	
              Confidentiality
                of Identifying Information about Enrollees,
                Potential Enrollees,
                and Prospective Enrollees

            


    

    
      	 	
              20.2
                

            	
              Medical
                Records of Foster Children

            


    

    
      	 	
              20.3
                

            	
              Confidentiality
                of Medical Records

            


    

    
      	 	
              20.4
                

            	
              Length
                of Confidentiality Requirements

            


    

    


    Section
      21  Provider
      Network

    
      	 	
              21.1
                

            	
              Network
                Requirements

            


    

    
      	 	
              21.2
                

            	
              Absence
                of Appropriate Network Provider

            


    

    
      	 	
              21.3
                

            	
              Suspension
                of Enrollee
                Assignments to Providers

            


    

    
      	 	
              21.4
                

            	
              Credentialing

            


    

    
      	 	
              21.5
                

            	
              SDOH
                Exclusion or Termination of
                Providers

            


    

    
      	 	
              21.6
                

            	
              Application
                Procedure

            


    

    
      	 	
              21.7
                

            	
              Evaluation
                Information

            


    

    
      	 	
              21.8
                

            	
              Choice/Assignment
                of Primary Care Providers (PCPs)

            


    

    
      	 	
              21.9
                

            	
              Enrollee
                PCP
                Changes

            


    

    
      	 	
              21.10
                

            	
              Provider
                Status Changes

            


    

    
      	 	
              21.11
                

            	
              PCP
                Responsibilities

            


    

    
      	 	
              21.12
                

            	
              Member
                to Provider Ratios

            


    

    
      	 	
              21.13
                

            	
              Minimum
                PCP Office Hours 

            


    

    a.
      General Requirements 

    b.
      Waiver
      of Minimum Hours

    
      	 	
              21.14
                

            	
              Primary
                Care Practitioners 

            


    

    a.
      General Limitations

    


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    Table
      of Contents for Model Contract

    
      	 	
              b. 

            	
              Specialists
                and Sub-specialists as PCPs

            


    

    
      	 	
              c. 

            	
              OB/GYN
                Providers as PCPs

            


    

    
      	 	
              d. 

            	
              Certified
                Nurse Practitioners as PCPs

            


    

    
      	 	
              21.15
                

            	
              PCP
                Teams

            


    

    
      	 	
              a.
                

            	
              General
                Requirements

            


    

    
      	 	
              b.
                

            	
              Registered
                Physician Assistants as Physician
                Extenders

            


    

    
      	 	
              c.
                

            	
              Medical
                Residents and Fellows

            


    

    
      	 	
              21.16
                

            	
              Hospitals

            


    

    
      	 	
              a. 

            	
              Tertiary
                Services 

            


    

    
      	 	
              b.
                

            	
              Emergency
                Services

            


    

    
      	 	
              21.17
                

            	
              Dental
                Networks

            


    

    
      	 	
              21.18
                

            	
              Presumptive
                Eligibility Providers

            


    

    
      	 	
              21.19
                

            	
              Mental
                Health and Chemical Dependence Services
                Providers

            


    

    
      	 	
              21.20
                

            	
              Laboratory
                Procedures

            


    

    
      	 	
              21.21
                

            	
              Federally
                Qualified Health Centers (FQHCs)

            


    

    
      	 	
              21.22
                

            	
              Provider
                Services Function

            


    

    
      	 	
              21.23
                

            	
              Pharmacies
                - Applies to FHPlus
                Program Only

            


    

    


    Section
      22  Subcontracts
      and Provider Agreements

    
      	 	
              22.1
                

            	
              Written
                Subcontracts

            


    

    
      	 	
              22.2
                

            	
              Permissible
                Subcontracts

            


    

    
      	 	
              22.3
                

            	
              Provision
                of Services Through Provider
                Agreements

            


    

    
      	 	
              22.4
                

            	
              Approvals

            


    

    
      	 	
              22.5
                

            	
              Required
                Components

            


    

    
      	 	
              22.6
                

            	
              Timely
                Payment

            


    

    
      	 	
              22.7
                

            	
              Restrictions
                on Disclosure

            


    

    
      	 	
              22.8
                

            	
              Transfer
                of Liability

            


    

    
      	 	
              22.9
                

            	
              Termination
                of Health Care Professional
                Agreements

            


    

    
      	 	
              22.10
                

            	
              Health
                Care Professional Hearings

            


    

    
      	 	
              22.11
                

            	
              Non-Renewal
                of Provider Agreements

            


    

    
      	 	
              22.12
                

            	
              Notice
                of Participating Provider
                Termination

            


    

    
      	 	
              22.13
                

            	
              Physician
                Incentive Plan

            


    

    


    Section
      23  Fraud
      and
      Abuse

    
      	 	
              23.1
                

            	
              General
                Requirements

            


    

    
      	 	
              23.2
                

            	
              Prevention
                Plans and Special Investigation
                Units

            


    

    


    Section
      24  Americans
      With Disabilities Act (ADA) Compliance Plan

    


    Section
      25  Fair
      Hearings

    25.1
      Enrollee
      Access
      to Fair Hearing Process

    25.2
      Enrollee Rights to a Fair Hearing

    25.3
      Contractor Notice to Enrollees

    25.4
      Aid
      Continuing

    25.5
      Responsibilities of SDOH

    25.6
      Contractor's Obligations

    


    TABLE
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      1, 2005

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    Table
      of Contents for Model Contract

    Section
      26  External
      Appeal

    26.1
       Basis
      for
      External
      Appeal

    26.2
       Eligibility
      For External Appeal

    26.3
       External
      Appeal Determination

    26.4
       Compliance
      With External Appeal Laws and Regulations

    26.5
       Member
      Handbook

    


    Section
      27  Intermediate
      Sanctions

    27.1
       General

    27.2
       Unacceptable
      Practices

    27.3
       Intermediate
      Sanctions

    27.4
       Enrollment
      Limitations

    27.5
       Due
      Process

    


    Section
      28  Environmental
      Compliance 

    


    Section
      29  Energy
      Conservation 

    


    Section
      30  Independent
      Capacity of Contractor 

    


    Section
      31  No
      Third
      Party Beneficiaries 

    


    Section
      32  Indemnification

    32.1
       Indemnification
      by Contractor

    32.2
       Indemnification
      by SDOH

    


    Section
      33  Prohibition
      on Use of Federal Funds for Lobbying

    33.1
       Prohibition
      of Use of Federal Funds for Lobbying

    33.2
       Disclosure
      Form to Report Lobbying

    33.3
       Requirements
      of Subcontractors

    


    Section
      34  Non-Discrimination

    
      	 	
              34.1
                

            	
              Equal
                Access to Benefit Package

            


    

    
      	 	
              34.2
                

            	
              Non-Discrimination

            


    

    
      	 	
              34.3
                

            	
              Equal
                Employment Opportunity

            


    

    
      	 	
              34.4
                

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

            


    

    


    Section
      35  Compliance
      with
      Applicable Laws

    
      	 	
              35.1
                

            	
              Contractor
                and SDOH Compliance With Applicable
                Laws

            


    

    
      	 	
              35.2
                

            	
              Nullification
                of Illegal, Unenforceable, Ineffective or Void Contract
                Provisions

            


    

    
      	 	
              35.3
                

            	
              Certificate
                of Authority Requirements

            


    

    
      	 	
              35.4
                

            	
              Notification
                of Changes In Certificate
                of Incorporation

            


    

    
      	 	
              35.5
                

            	
              Contractor's
                Financial Solvency Requirements

            


    

    
      	 	
              35.6
                

            	
              Compliance
                With Care For Maternity
                Patients

            


    

    
      	 	
              35.7
                

            	
              Informed
                Consent Procedures for Hysterectomy and
                Sterilization

            


    

    


    TABLE
      OF
      CONTENTS 

    October
      1, 2005

    7

    



    Table
      of Contents for Model Contract 

    


    35.8 Non-Liability
      of Enrollees For Contractor’s Debts

    35.9 SDOH
      Compliance With Conflict of Interest Laws

    35.10 Compliance
      With Public Health Law (PHL) Regarding

    External
      Appeals

    


    Section
      36 New
      York
      State Standard Contract Clauses

    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    TABLE
      OF
      CONTENTS 

    October
      1, 2005

    8

    Table
      of Contents for Model Contract 

    


    APPENDICES

    


    A.
       New
      York
      State Standard Clauses 

    


    B.  Certification
      Regarding Lobbying 

    


    B-l.  Certification
      Regarding MacBride
      Fair
      Employment Principles

    


    C.  New
      York
      State Department of Health
      Requirements for the Provision of Family 

    Planning
      and Reproductive Health Services

    


    D.  New
      York
      State Department of Health Marketing Guidelines 

    


    E.  New
      York
      State Department of Health Member Handbook Guidelines

    


    F.  New
      York
      State Department of Health Action and Grievance System Requirements for


    the
      MMC
      and
FHPlus
      Programs

    


    G.  New
      York
      State Department of Health Requirements for the Provision of Emergency


    Care
      and
      Services

    


    H.  New
      York
      State Department of Health Requirements for the Processing of Enrollments


    and
      Disenrollments
      in the
      MMC and FHPlus Programs

    


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


    Fellows

    


    J.  New
      York
      State Department of Health Guidelines for Contractor Compliance with the


    Federal
      ADA

    


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

    


    L.  Approved
      Capitation Payment Rates

    


    M.  Service
      Area, Benefit Options and Enrollment Elections

    


    N.  RESERVED

    


    O.
       Requirements
      for Proof of Workers' Compensation and Disability Benefits Coverage

    


    
      	
              P.
                

            	
              Facilitated
                Enrollment and Federal Health Insurance Portability and Accountability
                Act
                

            


    

    
      	 	
              (HIPAA)
                Business Associate Agreements

            


    

    


    Q.  RESERVED
      

    


    R.  Additional
      Specifications for the MMC and FHPlus Agreement

    TABLE
      OF
      CONTENTS 

    October
      1, 2005

    9

    



    Table
      of Contents for Model Contract

    


    X.  Modification
      Agreement Form

    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    TABLE
      OF
      CONTENTS 

    October
      1, 2005

    10

    APPENDICES
      TO THIS AGREEMENT AND 

    INCORPORATED
      BY REFERENCE INTO THE AGREEMENT

    


    -X-
       Appendix
      A.
      New York
      State Standard Clauses

    


    
      	
              -X-
                

            	
              Appendix
                B.
                Certification Regarding Lobbying

            


    

    


    
      	
              -X-
                

            	
              Appendix
                B-l.
                Certification Regarding MacBride
                Fair Employment Principles

            


    

    


    
      	
              -X-
                

            	
              Appendix
                C.
                New York State Department of Health Requirements for the Provision
                of
                

            


    

    
      	 	
              Family
                Planning and Reproductive Health
                Services

            


    

    


    
      	
              -X-
                

            	
              Appendix
                D.
                New York State Department of Health Marketing
                Guidelines

            


    

    


    
      	
              -X-
                

            	
              Appendix
                E.
                New York State Department of Health Member Handbook
                Guidelines

            


    

    


    
      	
              -X-
                

            	
              Appendix
                F.
                New York State Department of Health Action and Grievance System
                Requirements for the MMC
                and FHPlus
                Programs

            


    

    


    
      	
              -X-
                

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

            


    

    


    
      	
              -X-
                

            	
              Appendix
                H.
                New York State Department of Health Requirements for the Processing
                of
                Enrollments and Disenrollments
                in
                the MMC and FHPlus Programs

            


    

    


    
      	
              -X-
                

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

            


    

    
      	 	
              Residents
                and Fellows

            


    

    


    
      	
              -X-
                

            	
              Appendix
                J.
                New York State Department of Health Guidelines for Contractor Compliance
                with the Federal Americans with Disabilities
                Act

            


    

    


    
      	
              -X-
                

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

            


    

    


    
      	
              -X-
                

            	
              Appendix
                L.
                Approved Capitation Payment Rates

            


    

    


    
      	
              -X-
                

            	
              Appendix
                M.
                Service Area, Benefit Options and Enrollment
                Elections

            


    

    


    
      	
              -X-
                

            	
              Appendix
                N.
                RESERVED

            


    

    


    
      	
              -X-
                

            	
              Appendix
                0.
                Requirements for Proof of Workers' Compensation and Disability Benefits
                

            


    

    
      	 	
              Coverage

            


    

    


    
      	
              -X-
                

            	
              Appendix
                P.
                Facilitated Enrollment and Federal Health Insurance Portability and
                Accountability Act ("HIPAA")
                Business Associate Agreements

            


    

    


    
      	
              -X-
                

            	
              Appendix
                Q.
                RESERVED

            


    

    


    
      	
              -X-
                

            	
              Appendix
                R.
                Additional Specifications for the MMC and FHPlus
                Agreement

            


    

    


    
      	
              -X-
                

            	
              Appendix
                X.
                Modification Agreement Form

            


    

    



    MISCELLANEOUS/CONSULTANT
      SERVICES

    (Non-Competitive
      Award)

    


    


    STATE
      AGENCY (Name and Address):   NYS
      Comptroller’s Number: C020454

    


    New
      York
      State Department of Health

    Office
      of
      Managed Care

    Empire
      State Plaza     Originating
      Agency Code: 12000

    Corning
      Tower, Room 2074

    Albany,
      NY 12237

    ___________________________________  _________________________________

    CONTRACTOR
      (Name and Address):   TYPE
      OF
      PROGRAM(S):

    


    WellCare
      of New York, Inc.    Medicaid
      Managed Care and/or

    11
      West
      19th
      Street     Family
      Health Plus

    New
      York,
      NY 10011

    


    


    ___________________________________  _________________________________

    CHARITIES
      REGISTRATION NUMBER:  CONTRACT
      TERM:

    


    FROM:
      October 1, 2005

    TO:
      September 30, 2008

    


    FEDERAL
      TAX IDENTIFICATION NUMBER:

    141676443

    


    FUNDING
      AMOUNT FOR CONTRACT TERM:

    MUNICIPALITY
      NUMBER (if applicable):  Based
      on
      approved capitation rates

    N/A

    ___________________________________  __________________________________

    STATUS:      THIS
      CONTRACT IS RENEWABLE FOR ONE

    ADDITIONAL
      TWO-YEAR PERIOD SUBJECT

    CONTRACTOR
      IS [ ] IS NOT [X]   TO
      THE
      APPROVAL OF THE NYS

    A
      SECTARIAN ENTITY    DEPARTMENT
      OF HEALTH, THE

    DEPARTMENT
      OF HEALTH AND HUMAN

    CONTRACTOR
      IS [ ] IS NOT [X]   SERVICES
      AND THE OFFICE OF THE STATE

    A
      NOT-FOR-PROFIT ORGANIZATION  COMPTROLLER.

    


    CONTRACTOR
      IS [X] IS NOT [ ]

    ANY
      STATE
      BUSINESS ENTERPRISE

    


    __________________________________  __________________________________


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

    


    


    
      	
              CONTRACTOR
                SIGNATURE

            	
              STATE
                AGENCY SIGNATURE

            
	 	 
	
              By:
                /s/
                Todd S. Farha_____________

            	
              By:
                /s/ Donna
                Frescatore___________

            
	
              _Todd
                S. Farha_______________

            	
               Donna
                Frescatore __________

            
	
              Printed
                Name

            	
              Printed
                Name

            
	
              Title:
                President
                & Chief Executive Officer

              Date:
                 ______7/26/05____________

            	
              Title:
                Deputy
                Director, OMC________

              Date:
                _ 9/26/05_________________

            


    

    


    


    
      	 	
              State
                Agency Certification:

              In
                addition to the acceptance of this contract, I

              also
                certify that original copies of this

              signature
                page will be attached to all other

              exact
                copies of this contract.

            


    

    


    


    STATE
      OF
      FLORIDA )

    ) SS.:

    County
      of
      Hillsborough )

    


    On
      the
      26th
      day of
      July, 2005, before me personally appeared Todd
      S. Farha,
      to me
      known, who being by me duly sworn, did depose and say that he resides at
Tampa,
      Florida, the
      he is
      the President
      and CEO
      of
WellCare
      of New York,
      the
      corporation described herein which executed the foregoing instrument; and that
      he signed his name thereto by order of the board of director of said
      corporation.

    


    Kathleen
      R. Casey

    (Notary)

    


    ATTORNEY
      GENERAL’S SIGNATURE STATE
      COMPTROLLER’S SIGNATURE

    


    ___________________________________ _____________________________________

    


    Title:
      ______________________________ Title:
      ________________________________

    


    Date:
      ______________________________ Date:
      ________________________________

    


    


    


    


    


    


    


    


    


    


    


    


    


    STATE
      OF NEW YORK

    MEDICAID
      AND FAMILY HEALTH PLUS

    PARTICIPATING
      MANAGED CARE PLAN AGREEMENT

    


    This
      AGREEMENT is hereby made by and between the New York State Department of Health
      ("SDOH")
      and
WellCare
      of
      New York. Inc.
      ("Contractor") located at:

    11
      West 19th Street,
      New
      York. NY
      10011.

    


    RECITALS

    


    WHEREAS,
      pursuant to Title XIX of the Federal Social Security Act, codified
      as 42
U.S.C.
      Section
      1396 et seq.
      (the
      "Social Security Act"), and Title 11 of Article 5 of the New York State Social
      Services Law ("SSL"),
      a
      comprehensive program of medical assistance for needy persons exists in the
      State of New York ("Medicaid");
      and

    


    WHEREAS,
      pursuant to Title 11 of Article 5 of the SSL, the Commissioner of Health has
      established a managed care program under the medical assistance program, known
      as the Medicaid Managed Care ("MMC")
      Program;
      and

    


    WHEREAS,
      pursuant to Title 11-D
      of
      Article 5 of the SSL, a health insurance program known as Family Health Plus
      ("FHPlus")
      has been
      created for eligible persons who do not qualify for Medicaid; and

    


    WHEREAS,
      organizations certified
      under
      Article 44 of the New York State Public Health Law ("PHL")
      are
      eligible to provide comprehensive health services through comprehensive health
      services plans to Eligible Persons as defined
      in
      Titles 11 and 11-D of the SSL, Medicaid Managed Care and Family Health Plus
      Programs, respectively; and

    


    WHEREAS,
      the Contractor is organized under the laws of New York State and is
      certified
      under
      Article 44 of the PHL and has offered to provide covered health services to
      Eligible Persons residing in the geographic area specified
      in
      Appendix M
      of this
      Agreement (Service Area, Benefit Package Options, and Enrollment Elections);
      and

    


    WHEREAS,
      the SDOH has determined that the Contractor meets the qualifications established
      for participation in the Medicaid Managed Care Program or the Family Health
      Plus
      Program or both to provide the applicable health care coverage to Eligible
      Persons in the geographic area specified
      in
      Appendix M of this Agreement.

    


    NOW
      THEREFORE,
      the
      parties agree as follows:

    


    


    


    


    


    


    


    


    


    RECITALS

    October
      1, 2005

    Page
      1 of
      30

    1.
       DEFINITIONS

    


    "Auto-assignment"
      means a
      process by which an MMC
      Eligible
      Person, as this term is defined in this Agreement, who is mandated to enroll
      in
      the MMC Program, but who has not selected and enrolled in an MCO
      within
      sixty (60) days of receipt of the mandatory notice sent by the LDSS,
      is
      assigned to an MCO offering a MMC product in the MMC Eligible Person's county
      of
      fiscal responsibility in accordance with the auto-assignment algorithm
      determined by the SDOH.

    


    "Behavioral
      Health Services"
      means
      services to address mental health disorders and/or
      chemical dependence. 

    


    "Benefit
      Package"
      means
      the covered services for the MMC and/or
      FHPlus
      Programs, described in Appendix K
      of this
      Agreement, to be provided to the Enrollee,
      as
Enrollee
      is
      defined in this Agreement,
      by or
      through the Contractor, including optional Benefit Package services, if any,
      as
      specified in Appendix M
      of this
      Agreement.

    


    "Capitation
      Rate"
      means
      the fixed monthly amount that the Contractor receives for an Enrollee to provide
      that Enrollee with the Benefit Package.

    


    "Chemical
      Dependence
      Services" means examination, diagnosis, level of care determination, treatment,
      rehabilitation, or habilitation
      of
      persons suffering from chemical abuse or dependence, and includes the provision
      of alcohol and/or
      substance abuse services.

    


    "Child/Teen
      Health Program" or "C/THP"
      means
      the program of early and periodic screening, including inter-periodic,
      diagnostic and treatment services (EPSDT)
      that New
      York State offers all Eligible Persons under twenty-one (21) years of age.
      Care
      and services are provided in accordance with the periodicity schedule and
      guidelines developed by the New York State Department of Health. The services
      include administrative services designed to help families obtain services for
      children including outreach, information, appointment scheduling, administrative
      case management and transportation assistance, to the extent that transportation
      is included in the Benefit Package.

    


    "Comprehensive
      HIV
      Special Needs Plan" or "HIV SNP"
      means an
      MCO certified pursuant to Section forty-four hundred three-c (4403-c)
      of
      Article 44 of the PHL
      which,
      in addition to providing or arranging for the provision of comprehensive health
      services on a capitated
      basis,
      including those for which Medical Assistance payment is authorized pursuant
      to
      Section three hundred sixty-five-a (365-a)
      of the
SSL,
      also
      provides or arranges for the provision of specialized HP/
      care to
      HIV positive persons eligible to receive benefits under Title XIX of the federal
      Social Security Act or other public programs.

    


    


    


    


    


    


    


    


    


    


    SECTION
      1

    (DEFINITIONS)

    Octobern1,
      2005

    1-1

    "Court-Ordered
      Services"
      means
      those services that the Contractor is required to provide to Enrollees
      pursuant
      to orders of courts of competent jurisdiction, provided however, that such
      ordered services are within the Contractor's Benefit Package and reimbursable
      under Title XIX of the Federal Social Security Act (SSA), SSL
      364-j(4)(r).

    


    "Days"
      means
      calendar days except as otherwise stated.

    


    "Designated
      Third Party Contractor"
      means a
MCO
      with
      which the SDOH
      has
      contracted to provide Family Planning and Reproductive Health Services for
      FHPlus
      Enrollees
      of a MCO that does not include such services in its Benefit
      Package.

    


    "Detoxification
      Services"
      means
      Medically Managed Detoxification Services and Medically Supervised Inpatient
      and
      Outpatient Withdrawal Services as defined in Appendix K
      of this
      Agreement.

    


    "Disenrollment"
      means
      the process by which an Enrollee's
      membership in the Contractor's MMC
      or
      FHPlus product terminates.

    


    "Effective
      Date of Disenrollment"
      means
      the date on which an Enrollee
      may no
      longer receive services from the Contractor, pursuant to Section 8.5 and
      Appendix H
      of this
      Agreement.

    


    "Effective
      Date of Enrollment"
      means
      the date on which an Enrollee may begin to receive services from the Contractor,
      pursuant to Section 6.8(e) and Appendix H of this Agreement.

    


    "Eligible
      Person"
      means
      either an MMC Eligible Person or an FHPlus Eligible Person as these terms are
      defined in this Agreement.

    


    "eMedNY"
      means
      the electronic Medicaid
      system
      of New York State for eligibility verification and Medicaid provider claim
      submission and payments.

    


    "Emergency
      Medical Condition"
      means a
      medical or behavioral condition, the onset of which is sudden, that
      manifests 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 immediate medical attention to result
      in:

    (i)
      placing
      the health of the person afflicted with such condition in serious jeopardy,
      or
      in the case of a pregnant woman, the health of the woman or her unborn child
      or,
      in the case of a behavioral condition, placing the health of the person or
      others in serious jeopardy;

    or
      (ii)
      serious
      impairment to such person's bodily functions; or (iii)
      serious
      dysfunction of any bodily organ or part of such person; or (iv)
      serious
      disfigurement of such person.

    


    "Emergency
      Services"
      means
      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.

    


    


    


    


    


    


    SECTION
      1

    (DEFINITIONS)

    Octobern1,
      2005

    1-2

    



    "Enrollee"
      means
      either an MMC Enrollee
      or
FHPlus Enrollee
      as these
      terms are defined in this
      Agreement.

    


    "Enrollment"
      means
      the process by which an Enrollee's
      membership in the Contractor's MMC or FHPlus product begins.

    


    "Enrollment
      Broker"
      means
      the state and/or
      county-contracted entity that provides Enrollment, education, and outreach
      services to Eligible Persons; effectuates Enrollments and Disenrolhnents
      in MMC
      and FHPlus; and provides other contracted services on behalf of the SDOH
      and the
LDSS.

    


    "Enrollment
      Facilitator"
      means an
      entity under contract with SDOH, and its agents, that assists children and
      adults to complete the Medicaid,
      Family
      Health Plus, Child Health Plus, Special Supplemental Food Program for
WIC,
      and
      Prenatal Care Assistance Program (PCAP)
      application and the enrollment and recertification
      processes, to the extent permitted by federal and state law and regulation.
      This
      includes assisting individuals in completing the required application form,
      conducting the face-to-face interview, assisting in the collection of required
      documentation, assisting in the MCO
      selection
      process, and referring individuals to WIC or other appropriate
      sites.

    


    "Experienced
      HIV
      Provider"
      means an
      entity grant-funded by the SDOH AIDS Institute to provide clinical
      and/or
      supportive services or an entity licensed or certified
      by the
      SDOH to provide HIV/AEDS
      services.

    


    "Facilitated
      Enrollment"
      means
the
      enrollment infrastructure established by SDOH to assist children and adults
      in
      applying for Medicaid, Family Health Plus, Child Health Plus, WIC, or PCAP
      using
      a joint application, and recertifying for these programs, as allowed by federal
      and state law and regulation.

    


    "Family
      Health Plus" or "FHPlus"
      means
      the health insurance program established under Title 11-D
      of
      Article 5 of the SSL.

    


    "FHPlus
      Eligible Person"
      means a
      person whom the LDSS, state or federal government determines to have met the
      qualifications established in state or federal law necessary to receive FHPlus
      benefits
      under
      Title 11-D
      of the
      SSL and who meets all the other conditions for enrollment in the FHPlus
      Program.

    


    "FHPlus
      Enrollee"
      means a
      FHPlus Eligible Person who either personally or through an authorized
      representative, has enrolled in the Contractor's FHPlus product.

    


    "Fiscal
      Agent"
      means
      the entity that processes or pays vendor claims on behalf of the
      Medicaid state agency pursuant to an agreement between the entity and such
      agency.

    


    SECTION
      1

    (DEFINITIONS)

    Octobern1,
      2005

    1-3

    



    "Guaranteed
      Eligibility"
      means
      the period beginning on the Enrollee's
      Effective Date of Enrollment with the Contractor and ending six (6) months
      thereafter, during which the Enrollee
      may be
      entitled to continued Enrollment in the Contractor's MMC
      or
FHPlus
      product,
      as applicable, despite the loss of eligibility as set forth in Section 9 of
      this
      Agreement.

    


    "Health
      Provider Network" or "HPN"
      means a
      closed communication network dedicated to secure data exchange and distribution
      of health related information between various health facility providers and
      the
SDOH.
      HPN
      functions include: collection of Complaint and Disenrollment
      information; collection of financial reports; collection and reporting of
      managed care provider networks systems (PNS);
      and the
      reporting of encounter data systems (MEDS).

    


    "HIV
      Specialist PCP"
      means a
      Primary
      Care
      Provider that meets the qualifications for HIV
      Specialist as defined by the Medical Care Criteria Committee of the SDOH AIDS
      Institute.

    


    "Inpatient
      Stay Pending Alternate Level of Medical Care"
      means
      continued care in a hospital pending placement in an alternate lower medical
      level of care, consistent with the provisions of 18 NYCRR§
505.20
      and 10 NYCRR
      Part
      85.

    


    "Institution
      for Mental Disease" or "IMD"
      means a
      hospital, nursing facility, or other institution of more than sixteen (16)
      beds
      that is primarily engaged in providing diagnosis, treatment or care of persons
      with mental diseases, including medical attention, nursing care and related
      services. Whether an institution is an Institution for Mental Disease is
      determined by its overall character as that of a facility established and
      maintained primarily for the care and treatment of individuals with mental
      diseases, whether or not it is licensed as such. An institution for the mentally
      retarded is not an Institution for Mental Diseases.

    


    "Local
      Public Health Agency" or "LPHA"
      means
      the city or county government
      agency responsible for monitoring the population's health, promoting the health
      and safety of the public, delivering public health services and intervening
      when
      necessary to protect the health and safety of the public.

    


    "Local
      Department of Social Services" or "LDSS"
      means a
      city or county social services district as constituted by Section 61 of the
      SSL.

    


    "Lock-In
      Period"
      means
the
      period
      of time during which an Enrollee may not change MCOs,
      unless
      the Enrollee can demonstrate Good Cause as established in state law and
      specified in Appendix H
      of this
      Agreement.

    


    "Managed
      Care Organization" or "MCO"
      means a
      health maintenance organization ("HMO")
      or
      prepaid health service plan ("PHSP")
      certified under Article 44 of the PHL.

    


    


    


    


    SECTION
      1

    (DEFINITIONS)

    Octobern1,
      2005

    1-4

    


    


    


    


    


    


    "Marketing"
      means
      any activity of the Contractor, subcontractor or individuals or entities
      affiliated with the Contractor by which information about the Contractor is
      made
      known to Eligible Persons or Prospective Enrollees
      for the
      purpose of persuading such persons to enroll with the Contractor.

    


    "Marketing
      Representative"
      means
      any individual or entity engaged by the Contractor to market on behalf of the
      Contractor.

    


    "Medical
      Record"
      means a
      complete record of care rendered by a provider documenting the care rendered
      to
      the Enrollee,
      including inpatient,
      outpatient, and emergency care, in accordance with all applicable federal,
      state
      and local laws, rules and regulations. Such record shall be signed by the
      medical professional rendering the services.

    


    "Medically
      Necessary"
      means
      health care and services that are necessary to prevent, diagnose, manage or
      treat conditions in the person that cause acute suffering, endanger life, result
      in illness or infirmity, interfere with such person's capacity for normal
      activity, or threaten
      some significant handicap.

    


    "Member
      Handbook"
      means
      the publication prepared by the
      Contractor and issued to Enrollees to inform them of their benefits and
      services, how to access health care services and to explain their rights and
      responsibilities as a MMC
      Enrollee
      or FHPlus
      Enrollee.

    


    "MMC
      Eligible Person"
      means a
      person whom the LDSS,
      state or
      federal government determines to have met the qualifications established in
      state or federal law necessary to receive medical assistance under Title 11
      of
      the SSL
      and who
      meets all the other conditions for enrollment in the MMC Program.

    


    "MMC
      Enrollee"
      means an
      MMC Eligible Person who either personally or through
      an
      authorized representative, has enrolled in, or has been auto-assigned to, me
      Contractor's MMC product.

    


    "Native
      American"
      means,
      for purposes of this
      Agreement,
      a person
      identified in the Medicaid
      eligibility system as a Native American.

    


    "Nonconsensual
      Enrollment"
      means
      Enrollment of an Eligible Person, other than through Auto-assignment,
      newborn
      Enrollment or case addition, in a MCO's
      MMC or
      FHPlus product without the consent of the Eligible Person or consent of a person
      with the legal authority to act on behalf of the Eligible Person at the time
      of
      Enrollment.

    


    "Non-Participating
      Provider"
      means a
      provider of medical care and/or
      services with which the Contractor has no Provider Agreement,
      as this
      term is defined in this Agreement.

    


    "Participating
      Provider"
      means a
      provider of medical care and/or
      services that has a Provider Agreement with the Contractor.

    


    SECTION
      1

    (DEFINITIONS)

    Octobern1,
      2005

    1-5

    



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

    


    "Physician
      Incentive Plan" or "PIP"
      means
      any compensation arrangement between the Contractor or one of its contracting
      entities and a physician or physician group that may directly or indirectly
      have
      the effect of reducing or limiting services famished to the Contractor's
Enrollees.

    


    "Post-stabilization
      Care Services"
      means
      covered 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.

    


    "Potential
      Enrollee"
      means a
MMC
      Eligible
      Person who is not yet enrolled in a MCO
      that
      is
      participating in the MMC Program.

    


    "Prepaid
      Capitation Plan Roster" or "Roster"
      means
      the Enrollment list generated on a monthly basis by SDOH
      by which
      LDSS and Contractor are informed of specifically which Eligible Persons the
      Contractor will be serving for the coming month, subject to any revisions
      communicated in writing or electronically by SDOH, LDSS, or the Enrollment
      Broker.

    


    "Presumptive
      Eligibility Provider"
      means a
      provider designated by the SDOH as qualified to determine the presumptive
      eligibility for pregnant women to allow them to receive prenatal services
      immediately. These providers assist such women with the completion of the fall
      application for Medicaid
      and they
      may be comprehensive Prenatal Care Programs, Local Public Health Agencies,
      Certified Home Health Agencies, Public Health Nursing Services, Article 28
      facilities, and individually licensed physicians and certified nurse
      practitioners.

    


    "Preventive
      Care"
      means
      the care or services rendered to avert disease/illness and/or its consequences.
      There are three levels of preventive care: primary, such as immunizations,
      aimed
      at preventing disease; secondary, such as disease screening programs aimed
      at
      early detection of disease; and 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 treatment programs.

    


    "Primary
      Care Provider" or "PCP"
      means a
      qualified physician, or certified nurse practitioner or team of no more than
      four (4) qualified
      physicians/certified nurse practitioners which provides all required primary
      care services contained in the Benefit Package to Enrollees.

    


    "Prospective
      Enrollee"
      means
      any individual residing in the Contractor's Service Area that has not yet
      enrolled in a MCO's
      MMC or
FHPlus
      product.

    


    SECTION
      1

    (DEFINITIONS)

    Octobern1,
      2005

    1-6

    



    "Provider
      Agreement"
      means
      any written contract between the Contractor and Participating Providers to
      provide medical care and/or
      services to Contractor's Enrollees.

    


    "School
      Based Health Centers" or "SBHC"
      means
SDOH
      approved
      centers which provide comprehensive primary and mental health services including
      health assessments, diagnosis and treatment of acute illnesses, screenings
      and
      immunizations, routine management of chronic diseases, health education, mental
      health counseling and treatment on-site
      in
      schools. Services are offered by multi-disciplinary staff from sponsoring
      Article 28 licensed hospitals and community health centers.

    


    "Seriously
      Emotionally Disturbed"
      or "SED"
      means,
      an individual through seventeen (17) years of age who meets the criteria
      established by the Commissioner of Mental Health, including children and
      adolescents who have a designated diagnosis of mental illness under the most
      recent edition of the diagnostic and statistical manual of mental disorders,
      and
      (1) whose severity and duration of mental illness results in substantial
      functional disability or (2) who require mental health services on more than
      an
      incidental basis.

    


    "Seriously
      and Persistently Mentally III" or "SPMI"
      means an
      individual eighteen (18) years or older who meets the criteria established
      by
      the Commissioner of Mental Health, including persons who have a designated
      diagnosis of mental illness under the most recent edition of the diagnostic
      and
      statistical manual of mental disorders, and (1) whose severity and duration
      of
      mental illness results in substantial functional disability or (2) who require
      mental health services on more than an incidental basis.

    


    "Supplemental
      Maternity Capitation Payment"
      means
      the fixed amount paid to the Contractor for the prenatal and postpartum
      physician care and hospital or birthing center delivery costs, limited to those
      cases in which the Contractor has paid the hospital or birthing center for
      the
      maternity stay, and can produce evidence of such payment.

    


    "Supplemental
      Newborn Capitation Payment"
      means
      the fixed amount paid to the Contractor for the inpatient
      birthing
      costs for a newborn enrolled in the Contractor's MMC
      product,
      limited to those cases in which the Contractor has paid the hospital or birthing
      center for the newborn stay, and can produce evidence of such
      payment.

    


    "Tuberculosis
      Directly Observed Therapy" or "TB/DOT"
      means
      the direct observation of ingestion
      of oral
TB medications
      to assure patient compliance with the physician's prescribed medication
      regimen.

    


    "Urgently
      Needed Services"
      means
      covered services that are not Emergency Services as defined in this Section,
      provided when an Enrollee
      is
      temporarily absent from the Contractor's service area, when the services are
      medically necessary and immediately required: (1) as a result of an unforeseen
      illness, injury, or condition; and (2) it was not reasonable given the
      circumstances to obtain the services through the Contractor's MMC or
FHPlus
      Participating Provider.

    


    


    


    SECTION
      1

    (DEFINITIONS)

    Octobern1,
      2005

    1-7

    



    2.
       AGREEMENT
      TERM, AMENDMENTS, EXTENSIONS, AND GENERAL  CONTRACT
      ADMINISTRATION PROVISIONS

    


    2.1 Term

    


    
      	 	
              a)
                

            	
              This
                Agreement is effective October 1,
                2005 and shall remain in effect until September 30, 2008; or until
                the
                execution of an extension, renewal or successor Agreement approved
                by the
                SDOH,
                the Office of the New York State Attorney General (OAG),
                the New York State Office of the State Comptroller (OSC),
                the US Department of Health and Human Services (DHHS),
                and any other entities as required by law or regulation, whichever
                occurs
                first.

            


    

    


    b)  This
      Agreement shall not be automatically renewed at its expiration. The parties
      to
      the Agreement shall have the option to renew this Agreement for an additional
      two (2) year term, subject to the approval of SDOH, OAG, OSC, DHHS, and any
      other entities as required by law or regulation.

    


    c)  The
      maximum duration of this Agreement is five (5) years. An extension to this
      Agreement beyond the five year maximum may be granted for reasons including,
      but
      not limited to, the following;

    


    
      	 	
              i) 

            	
              Negotiations
                for a successor agreement will not be completed by the expiration
                date of
                the current Agreement; or

            


    

    


    
      	 	
              ii) 

            	
              The
                Contractor has submitted a termination notice and transition of
                Enrollees
                will not be completed by the expiration date of the current
                Agreement.

            


    

    


    d)  Notwithstanding
      the foregoing, this Agreement will automatically terminate, in its entirety,
      or
      in relevant part, should federal financial participation for the MMC
      and/or
      FHPlus
      Program
      expire.

    


    2.2
       Amendments

    


    a)
       This
      Agreement may be modified only in writing. Unless otherwise specified in this
      Agreement, modifications must be signed by the parties and approved by the
      OAG,
      OSC and any other entities as required by law or regulation, and approved by
      the
      DHHS prior to the end of the quarter in which the amendment is to be
      effective.

    


    b)
       SDOH
      will
      make reasonable efforts to provide the Contractor with notice and opportunity
      to
      comment with regard to proposed amendment of this Agreement except when
      provision of advance notice would result in the SDOH being out of compliance
      with state or federal law.

    


    


    


    


    SECTION
      2

    (AGREEMENT
      TERM,
      AMENDMENTS, EXTENSIONS, 

    AND
      GENERAL CONTRACT ADMINISTRATION
      PROVISIONS) October 1, 2005 

    2-1

    



    c)  The
      Contractor will return the signed amendment or notify SDOH
      that it
      does not agree within ten (10) business days of the date of the Contractor's
      receipt of the proposed amendment.

    


    2.3
       Approvals

    


    This
      Agreement and any amendments to this Agreement shall not be effective or binding
      unless and until approved, in writing, by the OAG, OSC, DHHS,
      and any
      other entity as required in law and regulation. SDOH will provide a notice
      of
      such approval to the Contractor.

    


    2.4
       Entire
      Agreement

    


    a)
       This
      Agreement, including those attachments, schedules, appendices, exhibits, and
      addenda that have been specifically incorporated herein and written plans
      submitted by the Contractor and maintained on file by SDOH and/or
      LDSS
      pursuant
      to this Agreement, contains all the terms and conditions agreed upon by the
      parties, and no other Agreement, oral or otherwise, regarding the subject matter
      of this Agreement shall be deemed to exist or to bind any of the parties or
      vary
      any of the terms contained in this Agreement. In the event of any inconsistency
      or conflict among the document elements of this Agreement, such inconsistency
      or
      conflict shall be resolved by giving precedence to the document elements in
      the
      following order:

    
      	 	
              i) 

            	
              Appendix
                A, Standard Clauses for all New York State
                Contracts;

            


    

    
      	 	
              ii) 

            	
              The
                body of this Agreement;

            


    

    
      	 	
              iii) 

            	
              The
                appendices attached to the body of this Agreement,
                other than

            


    

    Appendix
      A 

    
      	 	
              iv) 

            	
              The
                Contractor's approved:

            


    

    A)
       Marketing
      Plan on file with SDOH and LDSS

    B)  Action
      and Grievance System Procedures on file with SDOH

    C)
       Quality
      Assurance Plan on file with SDOH

    D)  ADA
      Compliance Plan on file with SDOH

    E)  Fraud
      and
      Abuse Prevention Plan on file with SDOH.

    


    
      	 	
              2.5
                

            	
              Renegotiation

            


    

    


    The
      parties to this Agreement shall have the right to renegotiate the terms and
      conditions of this Agreement in the event applicable local, state or federal
      law, regulations or policy are altered from those existing at the time of this
      Agreement in order to be in continuous compliance therewith. This Section shall
      not limit the right of the parties to this Agreement from renegotiating or
      amending other terms and conditions of this agreement. Such changes shall only
      be made with the consent of the parties and the prior approval of the OAG,
      OSC,
      and DHHS.

    


    


    


    


    


    


    SECTION
      2

    (AGREEMENT
      TERM,
      AMENDMENTS, EXTENSIONS, 

    AND
      GENERAL CONTRACT ADMINISTRATION
      PROVISIONS) October 1, 2005 

    2-2

    2.6
       Assignment
      and Subcontracting

    


    a)
       The
      Contractor shall not,
      without
SDOH's
      prior
      written consent, assign, transfer, convey, sublet, or otherwise dispose of
      this
      Agreement; of the Contractor's right, title, interest, obligations, or duties
      under the Agreement; of the Contractor's power to execute the Agreement; or,
      by
      power of attorney or otherwise, of any of the Contractor's rights to receive
      monies due or to become due under this Agreement. SDOH
      agrees
      that it will not unreasonably withhold consent of the Contractor's assignment
      of
      this Agreement, in whole or in part,
      to a
      parent, affiliate
      or
      subsidiary corporation, or to a transferee of all or substantially all of its
      assets. Any assignment, transfer, conveyance, sublease, or other disposition
      without SDOH's consent shall be void.

    


    b)  Contractor
      may not enter into any subcontracts related to the delivery of services to
      Enrollees,
      except
      by a written agreement, as set forth in Section 22 of this Agreement. The
      Contractor may subcontract for provider services and management services. If
      such written agreement would be between Contractor and a provider of health
      care
      or ancillary health services or between Contractor and an independent practice
      association, the agreement must be in a form previously approved by SDOH. If
      such subcontract is for management services under 10 NYCRR
      Part 98,
      it must be approved by SDOH prior to its becoming effective. Any subcontract
      entered into by Contractor shall fulfill the requirements of 42 CFR
      Parts
      434 and 438 to the extent such regulations are or become effective that are
      appropriate to the service or activity delegated under such subcontract.
      Contractor agrees that it shall remain legally responsible to SDOH for carrying
      out all activities under this Agreement and that no subcontract shall limit
      or
      terminate Contractor's responsibility.

    


    2.7
       Termination

    


    a)
       SDOH
      Initiated Termination

    


    
      	 	
              i) 

            	
              SDOH
                shall have the right to terminate this Agreement,
                in
                whole or in part; for either the Contractor's MMC
                or
                FHPlus
                product; or for either or both products in specified counties of
                Contractor's service area, if the
                Contractor:

            


    

    A)
       takes
      any
      action that threatens the health, safety, or welfare of its
      Enrollees;

    B)
       has
      engaged in an unacceptable practice under 18 NYCRR Part 515, that affects the
      fiscal integrity of the MMC or FHPlus Program or engaged in an unacceptable
      practice pursuant to Section 27.2 of this Agreement;

    C)  has
      its
      Certificate of Authority suspended, limited or revoked by SDOH;

    


    


    


    


    


    


    


    


    


    SECTION
      2

    (AGREEMENT
      TERM,
      AMENDMENTS, EXTENSIONS, 

    AND
      GENERAL CONTRACT ADMINISTRATION
      PROVISIONS) October 1, 2005 

    2-3

    



    D)  materially
      breaches the Agreement or fails to comply with any term or condition of this
      Agreement that is not cured within twenty (20) days, or to such longer period
      as
the
      parties may agree, of SDOH's
      written
      request for compliance;

    E)  becomes
      insolvent;

    F)  brings
      a
      proceeding voluntarily, or has a proceeding brought against it involuntarily,
      under Title 11 of the U.S. Code (the Bankruptcy Code);

    or

    G)  knowingly
      has a director, officer,
      partner or person owning or controlling more than five percent (5%) of the
      Contractor's equity, or has an employment, consulting, or other
      agreement with such a person for the provision of items and/or
      services that are significant to the Contractor's contractual obligation who
      has
      been debarred or suspended by the federal, state or local government, or
      otherwise excluded from participating in procurement activities.

    


    
      	 	
              ii) 

            	
              The
                SDOH
                will notify the Contractor of its intent to terminate this Agreement
                for
                the Contractor's failure to meet the requirements of this Agreement
                and
                provide Contractor with a hearing prior to me
                termination.

            


    

    


    
      	 	
              iii) 

            	
              If
                SDOH suspends, limits or revokes Contractor's Certificate of Authority
                under PHL§
                4404, and:

            


    

    A)
       if
      such
      action results in the Contractor ceasing to have authority to serve the entire
      contracted service area, as defined by Appendix M
      of this
      Agreement, this Agreement shall terminate on the date the Contractor ceases
      to
      have such authority; or

    B)  if
      such
      action results in the Contractor retaining authority to serve some portion
      of
      the contracted service area,
      the
      Contractor shall continue to offer its MMC
      and/or
      FHPlus
      products
      under this Agreement in any designated geographic areas not affected
      by
      such action, and shall terminate its MMC and/or
      FHPlus
      products in the geographic areas where the Contractor ceases to have authority
      to serve.

    


    
      	 	
              iv) 

            	
              No
                hearing will be required if this Agreement terminates due to SDOH
                suspension, limitation or revocation of the Contractor's Certificate
                of
                Authority.

            


    

    


    
      	 	
              v) 

            	
              Prior
                to the effective date of the termination the SDOH shall notify
                Enrollees
                of
                the termination, or delegate responsibility for such notification
                to the Contractor, and such notice shall include a statement that
                Enrollees may disenroll
                immediately without cause.

            


    

    


    SECTION
      2

    (AGREEMENT
      TERM,
      AMENDMENTS, EXTENSIONS, 

    AND
      GENERAL CONTRACT ADMINISTRATION
      PROVISIONS) October 1, 2005 

    2-4

    


    



    b)  Contractor
      and SDOH
      Initiated Termination

    


    The
      Contractor and the SDOH each shall have the right to terminate this Agreement
      in
      its entirety, for either the Contractor's MMC
      or
FHPlus
      product,
      or
      for
      either or both products in specified counties of the Contractor's service area,
      in the event that SDOH and the Contractor fail to reach agreement on the monthly
      Capitation Rates. In such event, the party exercising its right shall give
      the
      other party written notice specifying the reason for and the effective date
      of
      termination, which shall not be less time than will permit an orderly transition
      of
      Enrollees,
      but no
      more than ninety (90) days.

    


    c)  Contractor
      Initiated Termination

    


    
      	 	
              i) 

            	
              The
                Contractor shall have the right to terminate this Agreement
                in its entirety, for either the Contractor's MMC or FHPlus product,
                or for
                either or both products in specified counties of the Contractor's
                service
                area, in the event that SDOH materially breaches the Agreement or
                fails to
                comply with any term or condition of this Agreement that is not cured
                within
                twenty (20) days, or within such longer period as the parties may
                agree,
                of the Contractor's written request for compliance. The Contractor
                shall
                give SDOH written notice specifying the reason for and the effective
                date
                of the termination, which shall not be less time than will permit
                an
                orderly transition of Enrollees, but no more than ninety (90)
                days.

            


    

    


    
      	 	
              ii) 

            	
              The
                Contractor shall have the right to terminate this Agreement, in its
                entirety, for either the Contractor's MMC or FHPlus product, or for
                either
                or both products in specified counties of the
                Contractor's service area in the event that its obligations are materially
                changed by modifications to this Agreement and its Appendices by
                SDOH. In
                such event, Contractor shall give SDOH written notice within thirty
                (30)
                days of notification of changes to the Agreement or Appendices specifying
                the reason and the effective date of termination, which shall not
                be less
                time than will permit an orderly transition of Enrollees, but no
                more than
                ninety (90) days.

            


    

    


    
      	 	
              iii) 

            	
              The
                Contractor shall have the right to terminate this Agreement in its
                entirety, for either the Contractor's MMC or FHPlus product,
                or
                for either or both products in specified counties of the Contractor's
                service area, if the Contractor is unable to provide services pursuant
                to
                this Agreement because of a natural disaster and/or
                an act of God to such a degree that Enrollees
                cannot obtain reasonable access to services within the Contractor's
                organization, and, after diligent efforts, the Contractor cannot
                make
                other provisions for the delivery of such services. The Contractor
                shall
                give SDOH written notice of any such termination that
                specifies:

            


    

    


    SECTION
      2

    (AGREEMENT
      TERM,
      AMENDMENTS, EXTENSIONS, 

    AND
      GENERAL CONTRACT ADMINISTRATION
      PROVISIONS) October 1, 2005 

    2-5

    



    A)
       the
      reason for the termination, with appropriate documentation of the circumstances
      arising from a natural disaster and/or
      an act
      of God that preclude reasonable access to services;

    B)  the
      Contractor's attempts to make other provision for the delivery of services;
      and

    C)  the
      effective date of the termination, which shall not be less time than will permit
      an orderly transition of
      Enrollees,
      but no
      more than
      ninety
      (90)days.

    


    d)  Termination
      Due To Loss of Funding

    


    In
      the
      event that State and/or
      Federal funding used to pay for services under this Agreement is reduced so
      that
      payments cannot be made in full, this Agreement shall automatically terminate,
      unless both parties agree to a modification of the obligations under this
      Agreement. The effective date of such termination shall be ninety (90) days
      after the Contractor receives written notice of the reduction in payment, unless
      available funds are insufficient to continue payments in full during the ninety
      (90) day period, in which case SDOH
      shall
      give the Contractor written notice of the earlier date upon which the Agreement
      shall terminate. A reduction in State and/or
      Federal funding cannot reduce monies due and owing to the Contractor on or
      before the effective date of the
      termination of the Agreement.

    


    2.8
       Close-Out
      Procedures

    


    a)
       Upon
      termination or expiration of this Agreement in its entirety, for either the
      Contractor's MMC
      or
FHPlus
      product,
      or for either or both products in specified counties of the Contractor's service
      area, and in the event that it is not scheduled for renewal, the Contractor
      shall comply with close-out procedures that the Contractor develops in
      conjunction with LDSS and that the LDSS, and the SDOH have approved. The
      close-out procedures shall include the following:

    


    
      	 	
              i) 

            	
              The
                Contractor shall promptly account for and repay funds advanced by
                SDOH for
                coverage of Enrollees
                for periods subsequent to the effective date of
                termination;

            


    

    


    
      	 	
              ii) 

            	
              The
                Contractor shall give SDOH, and other authorized federal, state or
                local
                agencies access to all books, records, and other documents and upon
                request, portions of such books, records, or documents that may be
                required by such agencies pursuant to the terms of this
                Agreement;

            


    

    


    
      	 	
              iii) 

            	
              If
                this Agreement is terminated in its entirety, the Contractor shall
                submit
                to SDOH, and authorized federal, state or local agencies, within
                ninety
                (90) days of termination, a final financial statement,
                made by a certified public accountant or a licensed public
                accountant,
                unless the Contractor requests of SDOH
                and 

            


    

    


    SECTION
      2

    (AGREEMENT
      TERM,
      AMENDMENTS, EXTENSIONS, 

    AND
      GENERAL CONTRACT ADMINISTRATION
      PROVISIONS) October 1, 2005 

    2-6

    


    



    receives
      written approval from SDOH
      and all
      other governmental agencies from which approval is required, for an extension
      of
      time for this submission;

    


    
      	 	
              iv) 

            	
              The
                Contractor shall establish an appropriate plan acceptable to and
                prior
                approved by the SDOH for the orderly transition of Enrollees.
                This plan shall include the provision of pertinent information to
                identified
                Enrollees who are: pregnant; currently receiving treatment for a
                chronic
                or life threatening condition; prior approved for services or surgery;
                or
                whose care is being monitored by a case manager to assist them in
                making
                decisions which will promote continuity of care;
                and

            


    

    


    
      	 	
              v)
                

            	
              SDOH
                shall promptly pay all claims and amounts owed to the
                Contractor.

            


    

    


    b)  Any
      termination of this Agreement by either the Contractor or SDOH shall be done
      by
      amendment to this Agreement, unless the Agreement is terminated by the SDOH
      due
      to conditions in Section 2.7 (a)(i) or Appendix A of this
      Agreement.

    


    2.9
       Rights
      and Remedies

    


    The
      rights and remedies of SDOH and the Contractor provided expressly in this
      Section shall not be exclusive and are in addition to all other rights and
      remedies provided by law or under this Agreement.

    


    2.10
       Notices

    


    All
      notices to be given under this Agreement shall be in writing and shall be deemed
      to have been given when mailed to, or, if personally delivered, when received
      by
      the Contractor and the SDOH at the following addresses:

    


    For
      SDOH:

    New
      York
      State Department of Health Empire State Plaza Coming Tower, Room 2074 Albany,
      NY
      12237-0065

    


    For
      the
      Contractor:

    WellCare
      of New
      York, Inc.

    Attention:
      President & Chief Executive Officer

    11
      West
      19th Street

    New
      York,
      NY 10011

    


    


    SECTION
      2

    (AGREEMENT
      TERM,
      AMENDMENTS, EXTENSIONS, 

    AND
      GENERAL CONTRACT ADMINISTRATION
      PROVISIONS) October 1, 2005 

    2-7

    



    2.11 Severability

    


    If
      this
      Agreement contains any
      unlawful provision that is not an essential part of this Agreement and that
      was
      not a controlling or material inducement to enter into this Agreement, the
      provision shall have no effect and, upon notice by either party, shall be deemed
      stricken from this Agreement without affecting the binding force of the
      remainder of this Agreement.

    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    SECTION
      2

    (AGREEMENT
      TERM,
      AMENDMENTS, EXTENSIONS, 

    AND
      GENERAL CONTRACT ADMINISTRATION
      PROVISIONS) October 1, 2005 

    2-8

    



    3.
       COMPENSATION

    


    
      	 	
              3.1
                

            	
              Capitation
                Payments

            


    

    


    a)
       Compensation
      to the Contractor shall consist of a monthly capitation payment for each
Enrollee
      and the
      Supplemental Capitation Payments as described in Section 3.1 (d),
      where
      applicable.

    


    b)  The
      monthly Capitation Rates are attached hereto as Appendix L,
      which is
      hereby made a part of this Agreement as if set forth fully herein.

    


    c)  The
      monthly capitation payments, and the Supplemental Newborn Capitation Payment
      and
      the Supplemental Maternity Capitation Payment, when applicable, to the
      Contractor shall constitute mil
      and
      complete payments to the Contractor for all services that the Contractor
      provides, except for payments due the Contractor as set forth in Sections 3.11,
      3.12, and 3.13 of this Agreement for MMC Enrollees.

    


    d)
       Capitation
      Rates shall be effective for the entire contract period, except as described
      in
      Section 3.2.

    


    
      	 	
              3.2
                

            	
              Modification
                of Rates During Contract Period

            


    

    


    Modification
      to Capitation Rates during the term of this Agreement shall be subject to
      approval by the New York State Division of the Budget (DOB) and shall be
      incorporated into this
      Agreement by written amendment mutually agreed upon by the
      SDOH
      and the
      Contractor, as specified in Section 2.2 of this Agreement.

    


    
      	 	
              3.3
                

            	
              Rate
                Setting Methodology

            


    

    


    a)
      Capitation rates shall be determined prospectively
      and
      shall not be retroactively adjusted to reflect actual Medicaid fee-for-service
      data or
      Contractor experience for the time period covered by the rates. Capitated
      rates
      in
      effect as of April 1, 2006 and thereafter, shall be certified to be actuarially
      sound in
      accordance with 42 CFR§
      438.6(c).

    


    b)
       Notwithstanding
      the provisions set forth in Section 3.3(a) above, the SDOH reserves the right
      to
      terminate this Agreement, in its entirety for either the Contractor's MMC or
      FHPlus
      product,
      or for either or both products in specified counties of the Contractor's service
      area, pursuant to Section 2.7 of this Agreement, upon determination by SDOH
      that
      the aggregate monthly Capitation Rates are not cost effective.

    


    


    


    SECTION
      3

    (COMPENSATION)

    October
      1, 2005 

    3-1

    



    
      	 	
              3.4
                

            	
              Payment
                of Capitation

            


    

    


    a)
       The
      monthly capitation payments for each Enrollee
      are due
      to the Contractor from the Effective Date of Enrollment until the Effective
      Date
      of Disenrollment
      of the
      Enrollee or termination of this Agreement, whichever occurs first. The
      Contractor shall receive a mil
      month's
      capitation payment for the month in which Disenrollment occurs. The Roster
      generated by SDOH
      with any
      modification communicated electronically or in writing by the LDSS
      or the
      Enrollment Broker prior to the end of the month in which the Roster is
      generated, shall be the Enrollment list for purposes of eMedNY
      premium
      billing and payment,
      as
      discussed in Section 6.9 and Appendix H
      of this
      Agreement.

    


    b)  Upon
      receipt by the Fiscal Agent of a properly completed claim for monthly capitation
      payments submitted by the Contractor pursuant to this Agreement, the Fiscal
      Agent will promptly process such claim for payment and use its best efforts
      to
      complete such processing within thirty
      (30) business days from date of receipt of the claim by the Fiscal Agent.
      Processing of Contractor claims shall be in compliance with the requirements
      of
      42 CFR§
447.45.
      The Fiscal Agent will also use its best efforts to resolve any billing problem
      relating to the Contractor's claims as soon as possible. In accordance with
      Section 41 of the New York State Finance Law (SFL),
      the
      State and LDSS shall have no liability under this Agreement to the Contractor
      or
      anyone else beyond funds appropriated and available for this
      Agreement.

    


    
      	 	
              3.5
                

            	
              Denial
                of Capitation Payments

            


    

    


    If
      the US
      Centers for Medicare and Medicaid
      Services
(CMS)
      denies
      payment for new Enrollees,
      as
      authorized by SSA§
      1903(m)(5) and 42 CFR § 438.730 (e),
      or such
      other applicable federal statutes or regulations, based upon a determination
      that Contractor failed substantially to provide medically necessary items and
      services, imposed premium amounts or charges in excess of permitted payments,
      engaged in discriminatory practices as described in SSA § 1932(e)(l)(A)(iii),
      misrepresented or falsified information submitted to CMS, SDOH, LDSS, the
      Enrollment Broker, or an Enrollee, Prospective Enrollee, or health care
      provider, or failed to comply with federal requirements (i.e. 42 CFR § 422.208
      and 42 CFR § 438.6 (h)
      relating
      to the Physician Incentive Plans, SDOH and LDSS will deny capitation payments
      to
      the Contractor for the same Enrollees for the period of time for which CMS
      denies such payment.

    


    3.6
       SDOH
      Right to Recover Premiums

    


    The
      parties acknowledge and accept that the SDOH has a right to recover premiums
      paid to the Contractor for MMC
      Enrollees listed on the monthly Roster who are later determined for the entire
      applicable payment month, to have been 

    


    SECTION
      3

    (COMPENSATION)

    October
      1, 2005 

    3-2

    



    in
      an
      institution; to have been incarcerated; to have moved out of the Contractor's
      service area subject to any time remaining in the MMC Enrollee's
      Guaranteed Eligibility period; or to have died. SDOH
      has a
      right to recover premiums for FHPlus Enrollees
      listed
      on the Roster who are determined to have been incarcerated; to have moved out
      of
      the Contractor's service area or their county of fiscal responsibility; or
      to
      have died. In any event, the State may only recover premiums paid for MMC
      and/or
      FHPlus
      Enrollees listed on a Roster if it is determined by the SDOH that the Contractor
      was not at risk for provision of Benefit Package services for any portion of
      the
      payment period.

    


    
      	 	
              3.7
                

            	
              Third
                Party Health Insurance
                Determination

            


    

    


    The
      Contractor will make diligent efforts to determine whether Enrollees have third
      party health insurance (TPHI).
      The
LDSS
      is also
      responsible for making diligent efforts to determine if Enrollees have TPHI
      and
      to maintain third party information on the WMS/eMedNY
      Third
      Party Resource System. The Contractor shall make good faith efforts to
      coordinate benefits with and collect TPHI recoveries from other insurers, and
      must inform the LDSS of any known changes in status of TPHI insurance
      eligibility within thirty (30) days of learning of a change in TPHI. The
      Contractor may use the Roster as one method to determine TPHI information.
      The
      Contractor will be permitted to retain one hundred percent (100%) of any
      reimbursement for Benefit Package services obtained from TPHI. Capitation Rates
      are net of TPHI recoveries. In no instances may an Enrollee
      be held
      responsible for disputes over these recoveries.

    


    3.8
       Payment
      For Newboms

    


    a)
       The
      Contractor shall be responsible for all costs and services included in the
      Benefit Package associated with an Enrollee's
      newborn,
      unless the child is Excluded from Medicaid
      Managed
      Care pursuant to Appendix H
      of this
      Agreement, or the Contractor does not offer a MMC product in the mother's county
      of fiscal responsibility.

    


    b)  The
      Contractor shall receive a capitation payment from the first day of the
newbom's
      month of
      birth and, in instances where the Contractor pays the hospital or birthing
      center for the newborn stay, a Supplemental Newborn
      Capitation
      Payment.

    


    c)  Capitation
      Rate and Supplemental Newborn Capitation Payment for a newborn will begin the
      month following certification of the newborn's
      eligibility
      and enrollment,
      retroactive to the first day of the month in which the child was
      born.

    


    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 maintain on file evidence of payment to the

    


    SECTION
      3

    (COMPENSATION)

    October
      1, 2005 

    3-3

    


    



    hospital
      or birthing center of the claim for the newborn stay. Failure to have supporting
      records may, upon an audit, result in recoupment of the Supplemental Newborn
      Capitation Payment by SDOH.

    


    
      	 	
              3.9
                

            	
              Supplemental
                Maternity Capitation Payment

            


    

    


    a)
       The
      Contractor shall be responsible for all costs and services included in the
      Benefit Package associated with the maternity care of an Enrollee.

    


    b)  In
      instances where the Enrollee is enrolled in the Contractor's MMC
      or
FHPlus
      product
      on the date of the delivery of a child, the Contractor shall be entitled to
      receive a Supplemental Maternity Capitation Payment. The Supplemental Maternity
      Capitation Payment reimburses the Contractor for the inpatient
      and
      outpatient costs of services normally provided as part of maternity care,
      including antepartum
      care,
      delivery and post-partum
      care.
      The Supplemental Maternity Capitation Payment is in addition to the monthly
      Capitation Rate paid by the SDOH to the Contractor for the
      Enrollee.

    


    c)
      In
      instances where the
      Enrollee was enrolled in the Contractor's MMC or FHPlus product for only part
      of
      the pregnancy, but was enrolled on the date of the delivery of the child, the
      Contractor shall be entitled to receive the entire Supplemental Maternity
      Capitation Payment. The Supplemental Capitation payment shall not be pro-rated
      to reflect that the Enrollee was not enrolled in the Contractor's MMC or FHPlus
      product for the entire duration of the pregnancy.

    


    d)  In
      instances where the Enrollee was enrolled in the Contractor's MMC or FHPlus
      product for part of the pregnancy, but was not enrolled on the date of the
      delivery of the child, the Contractor shall not be entitled to receive the
      Supplemental Maternity Capitation Payment, or any portion thereof.

    


    e)  Costs
      of
      inpatient and outpatient
      care associated with maternity cases that end in termination or miscarriage
      shall be reimbursed to the Contractor through the monthly Capitation Rate for
      the Enrollee and the Contractor shall not receive the Supplemental Maternity
      Capitation Payment.

    


    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 maintain on file evidence of payment 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.

    


    


    


    


    SECTION
      3

    (COMPENSATION)

    October
      1, 2005 

    3-4

    


    3.10
       Contractor
      Financial Liability

    


    Contractor
      shall not be financially
      liable for any services rendered to an Enrollee
      prior
      to
      his or her Effective Date of Enrollment.

    


    
      	 	
              3.11
                

            	
              Inpatient
                Hospital Stop-Loss Insurance for Medicaid
                Managed Care (MMC)
                Enrollees

            


    

    


    a)
       The
      Contractor must obtain stop-loss coverage for inpatient
      hospital
      services for MMC Enrollees. A Contractor may elect to purchase stop-loss
      coverage from New York State. In such cases, the Capitation Rates paid to the
      Contractor shall be adjusted to reflect the cost of such stop-loss coverage.
      The
      cost of such coverage shall be determined by SDOH.

    


    b)  Under
      NYS
      stop-loss coverage, if the hospital inpatient expenses incurred by the
      Contractor for an individual MMC Enrollee during any calendar year reaches
      $50,000, the Contractor shall be compensated for eighty percent (80%) of the
      cost of hospital inpatient services in excess of this amount up to a maximum
      of
      $250,000. Above that amount, the Contractor will be compensated for one hundred
      percent (100%) of cost. All compensation shall be based on the lower of the
      Contractor's negotiated hospital rate or Medicaid rates of payment.

    


    [
      ] The
      Contractor has elected to have NYS provide stop-loss reinsurance

    for
      MMC
      Enrollees.

    


    OR

    


    [X]
      The
      Contractor has not elected to have NYS provide stop-loss

     
      reinsurance for MMC Enrollees.

    


    
      	 	
              3.12
                

            	
              Mental
                Health and Chemical Dependence Stop-Loss for MMC
                Enrollees

            


    

    


    a)
       The
      Contractor will be compensated 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. 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.

    


    b)
       The
      Contractor will be compensated for medically necessary and clinically
      appropriate inpatient mental health services and/or Chemical Dependence
      Inpatient Rehabilitation and Treatment Services to MMC Enrollees, as


    


    


    SECTION
      3

    (COMPENSATION)

    October
      1, 2005 

    3-5

    



    defined
      in
      Appendix K
      of this
      Agreement, in excess of a combined total of thirty (30) days during a calendar
      year at the lower of the Contractor's negotiated inpatient
      rate or
Medicaid
      rate of
      payment.

    


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

    


    
      	 	
              3.13
                

            	
              Residential
                Health Care Facility Stop-Loss for MMC
                Enrollees

            


    

    


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

    


    
      	 	
              3.14
                

            	
              Stop-Loss
                Documentation and Procedures for the MMC
                Program

            


    

    


    The
      Contractor must follow procedures and documentation requirements in accordance
      with the New York State Department of Health stop-loss policy and procedure
      manual. The State has the right to recover from the Contractor any stop-loss
      payments that are later found not to conform to these SDOH
      requirements.

    


    
      	 	
              3.15
                

            	
              Family
                Health Plus (FHPlus)
                Reinsurance

            


    

    


    The
      Contractor shall purchase reinsurance coverage unless it can demonstrate to
      SDOH's
      satisfaction the ability to self insure.

    


    
      	 	
              3.16
                

            	
              Tracking
                Visits Provided by Indian Health Clinics - Applies to MMC Program
                Only

            


    

    


    The
      SDOH
      shall monitor all visits provided by tribal or Indian health clinics or urban
      Indian health facilities or centers to enrolled Native Americans, so that the
      SDOH can reconcile payment made for those services, should it be deemed
      necessary to do so.

    


    


    


    


    


    


    


    


    


    


    


    


    


    SECTION
      3

    (COMPENSATION)

    October
      1, 2005 

    3-6

    



    4.
       SERVICE
      AREA

    


    The
      Contractor's service area for Medicaid
      Managed
      Care and/or
      FHPlus
      shall
      consist of the county(ies)
      described in Appendix M
      of this
      Agreement, which is hereby made a part of this Agreement as if set forth fully
      herein. Such service area is the specific geographic area within which Eligible
      Persons must reside to enroll in either the Contractor's Medicaid Managed Care
      or FHPlus product.

    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    SECTION
      4

    (SERVICE
      AREA)

    October
      1, 2005 

    4-1

    



    5.  RESERVED

    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    SECTION
      5

    (RESERVED)

    October
      1, 2005 

    5-1

    



    6.
       ENROLLMENT

    


    
      	 	
              6.1
                

            	
              Populations
                Eligible for Enrollment

            


    

    


    a)
       Medicaid
      Managed
      Care Populations

    


    All
      Eligible Persons who meet the criteria in Section 364-j
      of the
SSL
      and/or
      New
      York State's Operational Protocol for the Partnership Plan and who reside in
      the
      Contractor's service area, as specified in Appendix M
      of this
      Agreement,
      shall be
      eligible for Enrollment in the Contractor's Medicaid Managed Care
      product.

    


    b)  Family
      Health Plus Populations

    


    All
      Eligible Persons who meet the criteria listed in Section 369-ee
      of the
      SSL and/or New York State's Operational Protocol for the Partnership Plan and
      who reside in the Contractor's service area, as specified in Appendix M of
      this
      Agreement, shall be eligible for Enrollment in the Contractor's Family Health
      Plus product.

    


    
      	 	
              6.2
                

            	
              Enrollment
                Requirements

            


    

    


    The
      Contractor agrees to conduct Enrollment of Eligible Persons in accordance with
      the policies and procedures set forth in Appendix H
      of this
      Agreement, which is hereby made a part of this Agreement as if set forth
fully
      herein.

    


    6.3
       Equality
      of Access to Enrollment

    


    The
      Contractor shall accept Enrollments of Eligible Persons in the order in which
      the Enrollment applications are received without restriction and without regard
      to the Eligible Person's age, sex, race, creed, physical or mental
      handicap/developmental disability, national origin, sexual orientation, type
      of
      illness or condition, need for health services or to the Capitation Rate that
      the Contractor will receive for such Eligible Person.

    


    6.4
       Enrollment
      Decisions

    


    An
      Eligible Person's decision to enroll in the Contractor's MMC
      or
FHPlus
      product
      shall be voluntary except as otherwise provided in Section 6.5 of this
      Agreement.

    


    


    SECTION
      6

    (ENROLLMENT)

    October
      1, 2005 

    6-1

    



    
      	 	
              6.5
                

            	
              Auto
                Assignment - For MMC
                Program Only

            


    

    


    An
      MMC
      Eligible Person whose Enrollment is mandatory under the Medicaid
      Managed
      Care Program and who fails to select and enroll in a MCO
      within
      sixty (60) days of receipt of notice of mandatory Enrollment may be assigned
      by
      the SDOH
      or the
LDSS
      to the
      Contractor's MMC product pursuant to SSL§364-j
      and in accordance with Appendix H
      of this
      Agreement.

    


    
      	 	
              6.6
                

            	
              Prohibition
                Against Conditions on Enrollment

            


    

    


    
      	 	 	
              Unless
                otherwise required by law or this Agreement, neither
                the Contractor nor LDSS shall condition any Eligible Person's Enrollment
                into the Contractor's MMC or FHPlus
                product upon the performance of any act. Neither the Contractor nor
                the
                LDSS shall suggest in any way that failure to enroll in the Contractor's
                MMC or FHPlus product may result in a loss of benefits,
                except in the case of the FHPlus Program when the Contractor is the
                sole
                MCO offering a FHPlus product in the Enrollee's
                county of fiscal responsibility.

            


    

    


    
      	 	
              6.7
                

            	
              Newborn
                Enrollment

            


    

    


    a)
       All
      newborn children not Excluded from Enrollment in the MMC Program pursuant to
      Appendix H of this Agreement, shall be enrolled in the MCO in which the
      newborn's
      mother
      is an Enrollee,
      effective from the first day of the child's month of birth, unless the MCO
      in
      which the mother is enrolled does not offer a MMC product in the mother's county
      of fiscal responsibility.

    


    b)  In
      addition to the responsibilities set forth in Appendix H of this
      Agreement,
      the
      Contractor is responsible for coordinating with the LDSS the efforts to ensure
      that all newborns
      are
      enrolled in the Contractor's MMC product, if applicable.

    


    c)  The
      SDOH
      and LDSS shall be responsible for ensuring that timely Medicaid eligibility
      determination and Enrollment of the newborns
      is
      effected consistent with state laws, regulations, and policy and with the
      newborn Enrollment requirements set forth in Appendix H of this
      Agreement.

    


    6.8
      Effective Date of Enrollment

    


    a)
       For
      MMC
Enrollees,
      the
      Contractor and the LDSS are responsible for notifying the MMC Enrollee of the
      expected Effective Date of Enrollment.

    


    b)
       For
      FHPlus Enrollees, the Contractor must notify the FHPlus Enrollee of the
      Effective Date of Enrollment

    


    


    


    


    


    


    SECTION
      6

    (ENROLLMENT)

    October
      1, 2005 

    6-2

    



    c)  Notification
      may be accomplished through a "Welcome Letter." To the extent practicable,
      such
      notification must precede the Effective Date of Enrollment.

    


    d)  In
      the
      event that the actual Effective Date of Enrollment changes, the Contractor,
      and
      for MMC Enrollees
      the
LDSS,
      must
      notify the Enrollee
      of the
      change.

    


    e)  As
      of the
      Effective Date of Enrollment, and until the
      Effective Date of Disenrollment,
      the
      Contractor shall be responsible for the provision and cost of all care and
      services covered by the Benefit Package and provided to Enrollees whose names
      appear on the Prepaid Capitation Plan Roster, except as hereinafter
      provided.

    


    
      	 	
              i) 

            	
              Contractor
                shall not be liable for the cost of any services rendered to an Enrollee
                prior to his or her Effective Date of
                Enrollment.

            


    

    


    
      	 	
              ii) 

            	
              Contractor
                shall not be liable for any part of the cost of a hospital stay for
                a MMC
                Enrollee who is admitted to the hospital prior to the Effective Date
                of
                Enrollment in the Contractor's MMC product and who remains
                hospitalized
                on the Effective Date of Enrollment; except when the MMC Enrollee,
                on or
                after the Effective Date of Enrollment, 1) is transferred from one
                hospital to another; or 2) is discharged from one unit in the hospital
                to
                another unit in the same facility and under Medicaid fee-for-service
                payment rules, the method of payment changes from: a) Diagnostic
                Related
                Group (DRG)
                case-based rate of payment per discharge to a per diem rate of payment
                exempt from DRG case-based payment rates, or b)
                from a per diem payment rate exempt from DRG case-based payment rates
                either to another per diem rate, or a DRG case-based payment rate.
                In such
                instances, the Contractor shall be liable for the cost of the consecutive
                stay.

            


    

    


    
      	 	
              iii) 

            	
              Contractor
                shall not be liable for any part of the cost of a hospital stay for
                a
                FHPlus
                Enrollee who is admitted to the hospital prior to the Effective Date
                of
                Enrollment in the Contractor's FHPlus product and who has not been
                discharged as of the Effective Date of Enrollment,
                up
                to the date the FHPlus Enrollee is
                discharged.

            


    

    


    
      	 	
              iv) 

            	
              Except
                for newborns,
                an
                Enrollee's
                Effective Date of Enrollment shall be the first day of the month
                on which the Enrollee's name appears on the Roster for that
                month.

            


    

    


    


    


    


    


    


    


    


    


    


    


    


    


    SECTION
      6

    (ENROLLMENT)

    October
      1, 2005 

    6-3

    



    
      	 	
              6.9
                

            	
              Roster

            


    

    


    a)
       The
      first
      and second monthly Rosters generated by SDOH
      in
      combination shall serve as the official Contractor Enrollment list for purposes
      of eMedNY
      premium
      billing and payment,
      subject
      to ongoing eligibility of the Enrollees
      as
      of the
      first (1st)
      day of
      the Enrollment month. Modifications to the Roster may be made electronically
      or
      in writing by the LDSS
      or the
      Enrollment Broker. If the LDSS or Enrollment Broker notifies the Contractor
      in
      writing or electronically of changes in the Roster and provides supporting
      information as necessary prior to the effective date of the Roster, the
      Contractor will accept that notification in the same manner as the
      Roster.

    


    b)  The
      LDSS
      is responsible for making data on eligibility determinations available to the
      Contractor and SDOH to resolve discrepancies that may arise between the Roster
      and the Contractor's Enrollment files in accordance with the provisions in
      Appendix H
      of this
      Agreement.

    


    c)  All
      Contractors must have the ability to receive Rosters electronically.


    


    
      	 	
              6.10
                

            	
              Automatic
                Re-Enrollment

            


    

    


    a)
       An
      Enrollee
      who
      loses Medicaid
      or
FHPlus
      eligibility and who regains eligibility for either Medicaid or FHPlus within
      a
      three (3) month period, will be automatically prospective ly
      re-enrolled in the Contractor's MMC
      or
      FHPlus product unless:

    
      	 	
              i) 

            	
              the
                Contractor does not offer such product in the Enrollee's
                county of fiscal responsibility; or

            


    

    
      	 	
              ii) 

            	
              the
                Enrollee indicates in writing that he/she wishes to enroll in another
                MCO
                or, if permitted, receive coverage under Medicaid fee-for-service.

            


    

    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    SECTION
      6

    (ENROLLMENT)

    October
      1, 2005 

    6-4

    



    7.
       LOCK-IN
      PROVISIONS

    


    7.1
       Lock-In
      Provisions in MMC
      Mandatory Counties and for Family Health Plus

    


    All
      MMC
Enrollees
      residing
      in local social service districts where Enrollment in the MMC Program is
      mandatory and all FHPlus
      Enrollees are subject to a twelve (12) month Lock-In Period following the
      Effective Date of Enrollment, with an initial ninety (90) day grace period
      in
      which to disenroll
      without
      cause and enroll in another MCO's
      MMC or
      FHPlus product, if available.

    


    7.2
       Disenrollment
      During a
      Lock-In Period

    


    An
      Enrollee
      subject
      to Lock-In may disenroll from the Contractor's MMC or FHPlus product during
      the
      Lock-In Period for Good Cause as defined in Appendix H
      of this
      Agreement.

    


    7.3
       Notification
      Regarding Lock-In and End of Lock-In Period

    


    The
      LDSS,
      either
      directly or through the Enrollment Broker, is responsible for notifying
      Enrollees of their right to change MCOs
      in the
      Enrollment confirmation notice sent to individuals after they have selected
      an
MCO
      or been
      auto-assigned (the latter being applicable to areas where the mandatory MMC
      Program is in effect). The SDOH
      or its
designee
      will be
      responsible for providing a notice of end of Lock-In and the
      right
      to change MCOs at least sixty (60) days prior to the first Enrollment
      anniversary date as outlined in Appendix H of this Agreement.

    


    7.4
       Lock-In
      and Change in Eligibility Status

    


    Enrollees
      who lose Medicaid
      or
      FHPlus eligibility and regain eligibility for either Medicaid
      or
      FHPlus within a three (3) month period, will not be subject to a new Lock-in
      Period unless they opt to change MCOs pursuant to Section 6.10 of this
      Agreement.

    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    SECTION
      7

    (LOCK-IN
      PROVISIONS)

    October
      1, 2005 

    7-1

    


    8.
       DISENROLLMENT

    


    8.1
       Disenrollment
      Requirements

    


    a)
       The
      Contractor agrees to conduct Disenrollment of an Enrollee
      in
      accordance with the policies and procedures for Disenrollment set forth in
      Appendix H
      of this
      Agreement.

    


    b)  LDSSs
      are
      responsible for making the final determination concerning Disenrollment
      requests.

    


    8.2
       Disenrollment
      Prohibitions

    


    Enrollees
      shall
      not be disenrolled
      from the
      Contractor's MMC
      or
FHPlus
      product
      based on any of the factors listed in Section 34 (Non-Discrimination) of this
      Agreement.

    


    8.3
       Disenrollment
      Requests

    


    a)
       Routine
      Disenrollment Requests

    


    The
      LDSS
      is
      responsible for processing Routine Disenrollment requests to take effect as
      specified in Appendix H of this Agreement. In no event shall the Effective
      Date
      of Disenrollment be later than the first (1st)
      day of
      the second (2nd)
      month
      after the month in which an Enrollee requests a Disenrollment.

    


    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 is categorically eligible for an expedited Disenrollment on
                the
                basis of urgent medical need.

            


    

    


    
      	 	
              ii) 

            	
              Enrollees
                with a complaint of Nonconsensual
                Enrollment may request an expedited Disenrollment by the
                LDSS.

            


    

    


    
      	 	
              iii) 

            	
              In
                districts where homeless individuals are Exempt, as described in
                Appendices H and M
                of
                this Agreement, homeless MMC Enrollees residing in the shelter system
                may
                request an expedited Disenrollment by the
                LDSS.

            


    

    


    


    


    


    


    


    


    


    


    


    SECTION
      8

    (DISENROLLMENT)

    October
      1, 2005 

    8


    
      	 	
              iv) 

            	
              Retroactive
                Disenrollments
                may be warranted in rare instances and may be requested of the
                LDSS
                as
                described in Appendix H
                of
                this Agreement.

            


    

    


    
      	 	
              v) 

            	
              Substantiation
                of non-routine Disenrollment
                requests by the LDSS will result in Disenrollment in accordance with
                the
                timeframes
                as
                set forth in Appendix H of this
                Agreement.

            


    

    


    8.4
       Contractor
      Notification of Disenrollments

    


    a)
       Notwithstanding
      anything herein to the contrary, the Roster, along with any changes sent by
      the
      LDSS to the Contractor in writing or electronically, shall serve as official
      notice to the Contractor of Disenrollment of an Enrollee.
      In cases
      of expedited and retroactive Disenrollment, the Contractor shall be notified
      of
      the Enrollee's
      Effective Date of Disenrollment by the LDSS.

    


    b)  In
      the
      event that the LDSS intends to retroactively disenroll
      an
      Enrollee on a date prior to the first day of the month of the Disenrollment
      request, the LDSS is responsible for consulting with the Contractor prior to
      Disenrollment. Such consultation shall not be required for the retroactive
      Disenrollment of Supplemental Security Income (SSI)
      infants
      where it is clear that the Contractor was not a risk for the provision of
      Benefit Package services for any portion of the retroactive period.

    


    c)  In
      all
      cases of retroactive Disenrollment, including Disenrollments effective the
      first
      day of the current month, the LDSS is responsible for noticing the Contractor
      at
      the time of Disenrollment of the Contractor's responsibility to submit to the
      SDOH's
      Fiscal
      Agent voided premium claims for any months of retroactive Disenrollment where
      the Contractor was not at risk for the provision of Benefit Package services
      during the
      month.

    


    8.5
       Contractor's
      Liability

    


    a)
       The
      Contractor is not responsible for providing the Benefit Package under this
      Agreement on or after the Effective Date of Disenrollment except as hereinafter
      provided:

    


    
      	 	
              i) 

            	
              The
                Contractor shall be liable for any part of the cost of a hospital
                stay for
                a MMC
                Enrollee who is admitted to the hospital prior to the Effective Date
                of
                Disenrollment from the Contractor's MMC product and who remains
                hospitalized on the Effective Date of Disenrollment; except when
                the MMC
                Enrollee, on or after the Effective Date of Disenrollment, 1) is
                transferred from one hospital to another; or 2) is discharged from
                one
                unit in the hospital to another unit in the same facility and under
                Medicaid fee-for-service
                payment rules, the method of payment changes from: a) DRG
                case-based
                rate of payment per discharge to a per diem rate of payment exempt
                from
                DRG
                case-based payment rates, or b) 

            


    

    


    


    


    SECTION
      8

    (DISENROLLMENT)

    October
      1, 2005 

    8-2

    


    


    


    from
      a
      per diem payment rate exempt from DRG case-based payment rates to either another
      per diem rate, or a DRG case-based payment rate. In such instances, the
      Contractor shall not be liable for the cost of the consecutive stay. For the
      purposes of this paragraph, "hospital stay" does not include a stay in a
      hospital that
      is a)
      certified by Medicare as a long-term care hospital and b) has an average length
      of stay for all patients greater than ninety-five (95) days as reported in
      the
      Statewide Planning and Research Cooperative System (SPARCS)
      Annual
      Report 2002; in such instances, Contractor liability will cease on the Effective
      Date of
      Disenrollment.

    


    
      	 	
              ii) 

            	
              The
                Contractor shall be liable for any part of the cost of a hospital
                stay for
                a FHPlus Enrollee
                who is admitted to the hospital prior to the Effective Date of
                Disenrollment
                from the Contractor's FHPlus product and who has not been discharged
                as of
                the Effective Date of Disenrollment, up to the date the FHPlus Enrollee
                is
                discharged.

            


    

    


    b)
       The
      Contractor shall notify the LDSS
      that the
      Enrollee remains in the hospital and provide the LDSS with information regarding
      his or her medical status. The Contractor is required to cooperate with the
      Enrollee and the new MCO
      (if
      applicable) on a timely basis to ensure a smooth transition and continuity
      of
      care.

    


    8.6
       Enrollee
      Initiated Disenrollment

    


    a)
       An
      Enrollee subject to Lock-In as described in Section 7 of this Agreement may
      initiate Disenrollment from the Contractor's MMC
      or
      FHPlus product for Good Cause as defined in Appendix H
      of this
      Agreement at any time during the Lock-In period by filing an oral or written
      request with the LDSS.

    


    b)
       Once
      the
      Lock-In Period has expired, the Enrollee may disenroll
      from the
      Contractor's MMC or FHPlus product at any time, for any reason.

    


    8.7
       Contractor
      Initiated Disenrollment

    


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

    


    b)
       Consistent
      with 42 CFR§
438.56
      (b), the Contractor may not request Disenrollment because of an adverse change
      in the Enrollee's
      health
      status,
      or because of the Enrollee's
      utilization of medical services, diminished mental capacity, or uncooperative
      or
      disruptive behavior resulting from the Enrollee's special needs (except where
      continued Enrollment
      in
      the Contractor's MMC

    


    


    


    


    SECTION
      8

    (DISENROLLMENT)

    October
      1, 2005 

    8-3

    


    



    or
      FHPlus
      product
      seriously impairs the Contractor's ability to furnish services to either the
      Enrollee
      or other
Enrollees).

    


    c)  Contractor
      initiated Disenrollments
      must be
      carried out in accordance with the requirements and timeframes
      described in Appendix H
      of this
      Agreement.

    


    d)  Once
      an
      Enrollee has been disenrolled
      at the
      Contractor's request, he/she will not be re-enrolled with the Contractor's
      MMC
      or
      FHPlus product unless the Contractor first agrees to such
      re-enrollment.

    


    8.8
       LDSS
      Initiated Disenrollment

    


    a)
       The
      LDSS
      is responsible for promptly initiating Disenrollment
      when:

    


    
      	 	
              i) 

            	
              an
                Enrollee is no longer eligible for MMC or FHPlus;
                or

            


    

    


    
      	 	
              ii) 

            	
              the
                Guaranteed Eligibility period ends and an Enrollee is no longer eligible
                for MMC or FHPlus benefits;
                or

            


    

    


    
      	 	
              iii) 

            	
              an
                Enrollee is no longer the financial responsibility of the LDSS;
                or

            


    

    


    
      	 	
              iv) 

            	
              an
                Enrollee becomes ineligible for Enrollment pursuant to Section 6.1
                of this
                Agreement; or

            


    

    


    
      	 	
              v) 

            	
              an
                Enrollee has moved outside the service area covered by this Agreement,
                unless Contractor can demonstrate
                that:

            


    

    


    A)
       the
      Enrollee has made an informed choice to continue Enrollment with the Contractor
      and that Enrollee will have sufficient access to the
      Contractor's provider network; and

    


    B)  fiscal
      responsibility for Medicaid
      or
      FHPlus coverage remains in the county of origin.

    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    SECTION
      8

    (DISENROLLMENT)

    October
      1, 2005 

    8-4

    



    9.
       GUARANTEED
      ELIGIBILITY

    


    9.1
       General
      Requirements

    


    SDOH
      and the
      Contractor will follow the
      policies
      in this
      section subject to state and federal law and regulation.

    


    9.2
       Right
      to
      Guaranteed Eligibility

    


    a)
       New
      Enrollees,
      other
      than those identified in Section 9.2(b)
      below,
      who would otherwise
      lose Medicaid
      or
FHPlus
      eligibility during the first six (6) months of Enrollment will retain the right
      to remain enrolled in the Contractor's MMC
      or
      FHPlus
      product, as applicable, under this Agreement for a period of six (6) months
      from
      their Effective
      Date of Enrollment.

    


    b)  Guaranteed
      Eligibility is not available to the following Enrollees:

    


    
      	 	
              i) 

            	
              Enrollees
                who lose eligibility due to death, moving out of State, or
                incarceration;

            


    

    


    
      	 	
              ii) 

            	
              Female
                MMC Enrollees with a net available income in excess of medically
                necessary
                income but at or below two hundred percent (200%) of the federal
                poverty
                level who are only eligible for Medicaid while they are pregnant
                and then
                through the end of the month in which the sixtieth (60 )
                day following the end of the pregnancy
                occurs.

            


    

    


    c)  If,
      during the first six (6) months of Enrollment in the Contractor's MMC product,
      an MMC Enrollee
      becomes
      eligible for Medicaid only as a spend-down, the MMC Enrollee will be eligible
      to
      remain enrolled in the Contractor's MMC product for the remainder of the six
      (6)
      month Guaranteed Eligibility period. During the six (6) month Guaranteed
      Eligibility period, an MMC Enrollee eligible for spend-down and in need of
      wrap-around services has the option of spending down to gain full Medicaid
      eligibility for the wrap-around services. In this situation, the LDSS
      is
      responsible for monitoring the MMC Enrollee's
      need for
      wrap-around services and manually setting coverage codes as
      appropriate.

    


    d)  FHPlus
      Enrollees who become eligible for Medicaid benefits without an income or
      resource spend-down will not be entitled to a Guaranteed Eligibility
      period.

    


    e)  Enrollees
      who lose and regain Medicaid or FHPlus eligibility within a three (3) month
      period will not be entitled to a new period of six (6) months Guaranteed
      Eligibility.

    


    


    


    


    


    


    SECTION
      9

    (GUARANTEED
      LIABILITY)

    October
      1, 2005 

    9-1

    



    9.3
       Covered
      Services During Guaranteed Eligibility

    


    The
      services covered during the Guaranteed Eligibility period shall be those
      contained in the Benefit Package, as specified in Appendix K
      of this
      Agreement. MMC enrollees
      shall
      also be eligible to receive Free Access to family planning and reproductive
      services as set forth in Section 10.10 of this Agreement and pharmacy services
      on a Medicaid fee-for-service
      basis
      during the Guaranteed Eligibility period.

    


    9.4
       Disenrollment
      During
      Guaranteed Eligibility

    


    a)
       An
      Enrollee-initiated
      Disenrollment from the Contractor's MMC or FHPlus
      product
      terminates the Guaranteed Eligibility period.

    


    b)  During
      the Guarantee Eligibility period, an Enrollee
      may not
      change MCOs.

    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    SECTION
      9

    (GUARANTEED
      ELIGIBILILTY)

    October
      1, 2005 

    9-2

    



    10.
       BENEFIT
      PACKAGE REQUIREMENTS

    


    10.1
       Contractor
      Responsibilities

    


    Contractor
      must provide or arrange for the provision of all services set forth in the
      Benefit Package for MMC Enrollees
      and
FHPlus Enrollees
      subject
      to any exclusions or limitations imposed by Federal or State Law during the
      period of this Agreement. SDOH
      shall
      assure that Medicaid
      services
      covered under the Medicaid fee-for-service
      program
      but not covered in the Benefit Package are available to and accessible by MMC
      Enrollees.

    


    10.2
       Compliance
      with State Medicaid Plan and Applicable Laws

    


    a)
       All
      services provided under the Benefit Package to MMC Enrollees must comply with
      all the standards of the State Medicaid Plan established pursuant to Section
      363-a
      of the
SSL
      and
      shall satisfy all other applicable requirements of
      the
      SSL and PHL.

    


    b)  Benefit
      Package Services provided by the Contractor through its FHPlus product shall
      comply with all applicable requirements of the PHL
      and
      SSL.

    


    10.3
       Definitions

    


    The
      Contractor
      agrees to the definitions of "Benefit Package" and "Non-Covered
      Services" contained in Appendix K,
      which is
      incorporated by reference as if set forth fully herein.

    


    10.4
       Child
      Teen Health Program/Adolescent
      Preventive Services

    


    a)
       The
      Contractor and its Participating Providers are required to provide the
      Child
      Teen Health Program (C/THP)
      services
      outlined in Appendix K of this Agreement and comply with applicable Early
      Periodic Screening and Diagnostic Testing (EPSDT)
      requirements specified in 42 CFR
      Part
      441, sub-part B, 18NYCRR Part 508 and the New York State Department of Health
      C/THP manual. The Contractor and its Participating Providers are required to
      provide C/THP services to Enrollees under twenty-one (21) years of age
      when:

    


    
      	 	
              i) 

            	
              The
                care or services are essential to prevent, diagnose, prevent the
                worsening
                of, alleviate or ameliorate the effects of an illness, injury, disability,
                disorder or condition.

            


    

    


    
      	 	
              ii) 

            	
              The
                care or services are essential to the overall physical, cognitive
                and
                mental growth and developmental needs of the Enrollee.

            


    

    


    


    


    


    


    


    


    SECTION
      10

    (BENEFIT
      PACKAGE REQUIREMENTS)

    October
      1, 2005 

    10-1

    



    
      	 	
              iii) 

            	
              The
                care or service will assist the Enrollee
                to
                achieve or maintain maximum functional capacity in performing daily
                activities, taking into account both the functional capacity of the
                Enrollee and those functional capacities that are appropriate for
                individuals of the same age as the
                Enrollee.

            


    

    


    b)  The
      Contractor shall base its determination on medical and other relevant
      information provided by the Enrollee's PCP,
      other
      health care providers, school, local social services, and/or
      local
      public health officials that have evaluated the Enrollee.

    


    c)  The
      Contractor and its Participating Providers must comply with the C/THP
      program
      standards and must do at least the following with respect to all Enrollees
      under
      age 21:

    


    
      	 	
              i) 

            	
              Educate
                Enrollees who are pregnant women or who are parents of Enrollees
                under age
                21 about the program and its importance to a child's or adolescent's
                health.

            


    

    


    
      	 	
              ii) 

            	
              Educate
                Participating Providers about the program and their responsibilities
                under it.

            


    

    


    
      	 	
              iii)
                

            	
              Conduct
                outreach, including by mail, telephone, and through home visits (where
                appropriate), to ensure children are kept current with respect to
                their
                periodicity schedules.

            


    

    


    
      	 	
              iv) 

            	
              Schedule
                appointments for children and adolescents pursuant to the periodicity
                schedule, assist with referrals, and conduct follow-up with children
                and
                adolescents who miss or cancel
                appointments.

            


    

    


    
      	 	
              v) 

            	
              Ensure
                that all appropriate diagnostic and treatment services, including
                specialist referrals, are furnished pursuant to findings from a C/THP
                screen.

            


    

    


    
      	 	
              vi) 

            	
              Achieve
                and maintain an acceptable compliance rate for screening schedules
                during
                the contract period.

            


    

    


    d)  In
      addition to C/THP requirements, the Contractor and its Participating Providers
      are required to comply with the American Medical Association's Guidelines for
      Adolescent Preventive Services which require annual well adolescent preventive
      visits which focus on health guidance, immunizations, and screening for
      physical, emotional, and behavioral conditions.

    


    


    


    


    


    


    


    


    


    


    SECTION
      10

    (BENEFIT
      PACKAGE REQUIREMENTS)

    October
      1, 2005 

    10-2

    



    10.5
       Foster
      Care Children - Applies to MMC
      Program
      Only

    


    The
      Contractor shall comply with the
      health
      requirements for foster children specified in 18 NYCRR§
441.22
      and Part 507 and any subsequent amendments thereto. These requirements include
      thirty (30) day obligations for a comprehensive physical and behavioral health
      assessment and assessment of the risk that the child may be HIV+
      and
      should be tested.

    


    10.6
       Child
      Protective Services

    


    The
      Contractor shall comply with the requirements specified for child protective
      examinations, provision of medical information to the child protective services
      investigation and court ordered services as specified in 18 NYCRR Part 432,
      and
      any subsequent amendments thereto. Medically necessary services must be covered,
      whether provided by the
      Contractor's Participating Providers or not. Non-Participating Providers will
      be
      reimbursed at the Medicaid
      fee
      schedule by the Contractor.

    


    10.7
       Welfare
      Reform - Applies to MMC Program only

    


    a)
       The
      LDSS
      is
      responsible for determining whether each public assistance or combined public
      assistance/Medicaid
      applicant is incapacitated or can participate in work activities. As part of
      this work determination process, the LDSS may require medical documentation
      and/or
      an
      initial mental and/or
      physical examination to determine whether an individual has a mental or physical
      impairment that limits his/her
      ability to engage in work (12 NYCRR §1300.2(d)(13)(i)).
      The LDSS
      may not require the Contractor to provide the initial district mandated or
      requested medical examination necessary for an Enrollee
      to meet
      welfare reform work participation requirements.

    


    b)  The
      Contractor shall require that the Participating Providers in its MMC product,
      upon MMC Enrollee consent, provide medical documentation and health, mental
      health and chemical dependence assessments as follows:

    


    
      	 	
              i) 

            	
              Within
                ten (10) days of a request of an MMC Enrollee or a former MMC Enrollee,
                currently receiving public assistance or who is applying for public
                assistance, the MMC Enrollee's
                or
                former MMC Enrollee's PCP
                or
                specialist provider, as appropriate, shall provide medical documentation
                concerning the MMC Enrollee or former MMC Enrollee's health or mental
                health status to the LDSS or to the LDSS' designee.
                Medical documentation includes but is not limited to drug prescriptions
                and reports from the MMC Enrollee's PCP or specialist provider. The
                Contractor shall include the foregoing as a responsibility of the
                PCP and
                specialist provider in its provider contracts or in their provider
                manuals.

            


    

    


    


    


    


    


    


    SECTION
      10

    (BENEFIT
      PACKAGE REQUIREMENTS)

    October
      1, 2005 

    10-3

    


    


    


    
      	 	
              ii) 

            	
              Within
                ten (10) days of a request of an MMC Enrollee,
                who has already undergone, or is scheduled to undergo, an initial
                LDSS
                required mental and/or physical examination, the MMC Enrollee's PCP
                shall provide a health, or mental health and/or
                chemical dependence assessment, examination or other services as
                appropriate to identify or quantify an MMC Enrollee's level of
                incapacitation.
                Such assessment must contain a specific diagnosis resulting from
                any
                medically appropriate tests and specify any work limitations. The
                LDSS,
                may, upon written notice to the Contractor, specify the
                format and instructions for such an
                assessment.

            


    

    


    c)  The
      Contractor shall designate a Welfare Reform liaison who shall work with the
      LDSS
      or its designee
      to (1)
      ensure that MMC Enrollees
      receive
      timely access to assessments and services specified in this Agreement and (2)
      ensure completion of reports containing medical documentation required by the
      LDSS.

    


    d)  The
      Contractor will continue to be responsible for the provision and payment of
      Chemical Dependence Services in the Benefit Package for MMC Enrollees mandated
      by the LDSS under Welfare Reform if such services are already underway and
      the
      LDSS is satisfied with the level of care and services.

    


    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 or Medicaid
      under
      Welfare Reform (as indicated by Code 83) unless such services are already under
      way as described in (d) above.

    


    f)  The
      Contractor is not responsible for the provision and payment of Medically
      Supervised Inpatient and Outpatient Withdrawal Services for MMC Enrollees
      mandated by the LDSS under Welfare Reform (as indicated by Code 83) unless
      such
      services are already under way as described in (d) above.

    


    g)  The
      Contractor is responsible for the provision and payment of Medically Managed
      Detoxification Services ordered by the LDSS under Welfare Reform.

    


    h)  The
      Contractor is responsible for the provision of services in Sections 10.9, 10.15
      (a) and 10.23 of this Agreement for MMC Enrollees requiring LDSS mandated
      Chemical Dependence Services.

    


    10.8
       Adult
      Protective Services

    


    The
      Contractor shall cooperate with
      LDSS in
      the implementation of 18 NYCRR
      Part
      457
      and any subsequent amendments thereto with regard to medically necessary health
      and mental health services including referrals for mental health and/or
      chemical dependency evaluations and all Court Ordered Services for adults.
      Court-ordered services that are 

    


    SECTION
      10

    (BENEFIT
      PACKAGE REQUIREMENTS)

    October
      1, 2005 

    10-4

    



    included
      in the Benefit Package must be covered, whether provided by the Contractor's
      Participating Provider or not. Non-Participating Providers will be reimbursed
      at
      the Medicaid
      fee
      schedule by the Contractor.

    


    10.9
       Court-Ordered
      Services

    


    a)
       The
      Contractor shall provide any Benefit Package services to Enrollees
      as
      ordered by a court of competent jurisdiction, regardless of whether the court
      order requires such services to be provided by a Participating Provider or
      by a
      Non-Participating Provider. Non-Participating Providers shall be reimbursed
      by
      the Contractor at the Medicaid fee schedule. The Contractor is responsible
      for
      court-ordered services to the extent that such court-ordered services are
      covered by the Benefit Package and reimbursable by Medicaid or Family Health
      Plus, as applicable.

    


    b)  Court
      Ordered Services are those services ordered by the court performed by, or under
      the supervision of a physician, dentist,
      or other
      provider qualified under State law to furnish medical, dental, behavioral health
      (including mental health and/or Chemical Dependence), or other Benefit Package
      covered services. The Contractor is responsible for payment of those services
      as
      covered by the Benefit
      Package, even when provided by Non-Participating Providers.

    


    10.10
       Family
      Planning and Reproductive Health Services

    


    a)
       Nothing
      in this Agreement shall restrict the right of Enrollees to receive Family
      Planning and Reproductive Health services, as defined
      in
      Appendix C
      of
      this
      Agreement, which is hereby made a part of this Agreement as if set forth fully
      herein.

    


    
      	 	
              i) 

            	
              MMC
                Enrollees may receive such
                services
                from any qualified Medicaid provider, regardless of whether the provider
                is a Participating or a Non-Participating Provider, without referral
                from
                the MMC Enrollee's PCP
                and without approval from the
                Contractor.

            


    

    


    
      	 	
              ii) 

            	
              FHPlus
                Enrollees may receive such services from any Participating Provider
                if the
                Contractor includes Family Planning and Reproductive Health services
                in
                its Benefit Package, or directly from a provider affiliated with
                the
                Designated Third Party Contractor if such services are not included
                in the
                Contractor's Benefit Package, as specified in Appendix M
                of
                this Agreement, without referral from the FHP Enrollee's
                PCP and without approval from the
                Contractor.

            


    

    


    b)
       The
      Contractor shall permit Enrollees to exercise their right to obtain Family
      Planning and Reproductive Health services.

    


    


    


    


    


    SECTION
      10

    (BENEFIT
      PACKAGE
      REQUIREMENTS)

    October
      1, 2005

    10-5

    


    


    


    
      	 	
              i) 

            	
              If
                the Contractor includes Family Planning and Reproductive Health services
                in its Benefit Package, the Contractor shall comply with the requirements
                in Part C.2 of Appendix C
                of
                this Agreement, including assuring that Enrollees
                are fully informed of their rights.

            


    

    


    
      	 	
              ii) 

            	
              If
                the Contractor does not include Family Planning and Reproductive
                Health
                services in its Benefit Package, the Contractor shall comply with
                the
                requirements of Part C.3 of Appendix C of this Agreement, including
                assuring that Enrollees are fully informed of their
                rights.

            


    

    


    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).

    


    10.12
       Direct
      Access

    


    The
      Contractor shall offer female Enrollees direct access to primary and preventive
      obstetrics and gynecology
      services, follow-up care as a result of a primary and preventive visit, and
      any
      care related to pregnancy from Participating Providers of her choice, without
      referral from the PCP
      as set
      forth in PHL § 4406-b(l).

    


    10.13
       Emergency
      Services

    


    a)
       The
      Contractor shall maintain coverage utilizing a toll free telephone number
      twenty-four (24) hours per day seven (7) days per week, answered by a live
      voice, to advise Enrollees of procedures for accessing services for Emergency
      Medical Conditions and for accessing Urgently Needed Services. Emergency mental
      health calls must be triaged
      via
      telephone by a trained mental health professional.

    


    b)  The
      Contractor agrees that it will not require prior authorization for services
      in a
      medical or behavioral health emergency. The Contractor agrees to inform its
      Enrollees that access to Emergency Services is not restricted and that Emergency
      Services may be obtained from a Non-Participating Provider without penalty.
      Nothing herein precludes the Contractor from entering into contracts with
      providers or facilities that require providers or facilities to provide
      notification to the Contractor after Enrollees present for Emergency Services
      and are subsequently stabilized. The Contractor must pay for services for
      Emergency Medical Conditions whether provided by a Participating Provider or
      a
      Non-Participating Provider, and may not deny payments for failure of the
      Emergency Services provider or Enrollee
      to give
      notice.

    


    


    SECTION
      10

    (BENEFIT
      PACKAGE
      REQUIREMENTS)

    October
      1, 2005

    10-6

    


    


    


    


    


    c)  Emergency
      Services rendered by Non-Participating Providers: The Contractor shall advise
      its Enrollees
      how to
      obtain Emergency Services when it is not feasible for Enrollees to receive
      Emergency Services from or through a Participating Provider. The Contractor
      shall bear the cost of providing Emergency Services through Non-Participating
      Providers.

    


    d)  The
      Contractor agrees to abide by requirements for the provision and payment of
      Emergency Services and Post-stabilization Care Services which are specified
      in
      Appendix G,
      which is
      hereby made a part of this Agreement as if set forth fully herein.

    


    10.14
       Medicaid
      Utilization Thresholds (MUTS)

    


    MMC
      Enrollees may be subject to MUTS for outpatient pharmacy services which are
      billed Medicaid fee-for-service
      and for
      dental services provided without referral at Article 28 clinics operated by
      academic dental centers as described in Section 10.27 of this Agreement. MMC
      Enrollees are not otherwise subject to MUTS for services included in the Benefit
      Package.

    


    10.15
       Services
      for Which Enrollees Can Self-Refer

    


    a)
       Mental
      Health and Chemical Dependence Services

    


    
      	 	
              i) 

            	
              The
                Contractor will allow Enrollees to make a self referral for one mental
                health assessment from a Participating Provider and one chemical
                dependence assessment from a Detoxification or Chemical Dependence
                Participating Provider in any calendar year period without requiring
                preauthorization
                or
                referral from the Enrollee's
                Primary Care Provider. For the MMC Program, in the case of children,
                such
                self-referrals may originate at the request of a school guidance
                counselor
                (with parental or guardian consent,
                or
                pursuant to procedures set forth in Section 33.21 of the Mental Hygiene
                Law), LDSS
                Official, Judicial Official, Probation Officer, parent or similar
                source.

            


    

    


    
      	 	
              ii) 

            	
              The
                Contractor shall make available to all Enrollees a complete listing
                of
                their participating mental health and Chemical Dependence Services
                providers. The listing should specify which provider groups or
                practitioners specialize in children's mental health
                services.

            


    

    


    
      	 	
              iii) 

            	
              The
                Contractor will also ensure that its Participating Providers have
                available and use formal assessment instruments to identify Enrollees
                requiring mental health and Chemical Dependence Services, and to
                determine
                the types of services that should be
                furnished.

            


    

    


    


    


    SECTION
      10

    (BENEFIT
      PACKAGE
      REQUIREMENTS)

    October
      1, 2005

    10-7

    


    


    


    


    


    
      	 	
              iv) 

            	
              The
                Contractor will implement policies and procedures to ensure that
                Enrollees
                receive follow-up Benefit Package services from appropriate providers
                based on the findings of their mental health and/or
                Chemical Dependence assessments),
                consistent with Section 15.2(a)(x) and (xi)
                of
                this Agreement.

            


    

    


    
      	 	
              v) 

            	
              The
                Contractor will implement policies and procedures to ensure that
                Enrollees
                are referred to appropriate Chemical Dependence providers based on
                the
                findings of the Chemical Dependence assessment by the Contractor's
                Participating Provider, consistent with Section 15.2(a)(x) and (xi)
                of
                this Agreement.

            


    

    


    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 as described in Appendix K
      of this
      Agreement.

    


    c)  Diagnosis
      and Treatment of Tuberculosis

    


    Enrollees
      may self-refer to public health agency facilities for the diagnosis
      and/or
      treatment of TB
      as
      described in Section 10.18(a) of this Agreement.

    


    d)  Family
      Planning and Reproductive Health Services

    


    Enrollees
      may self-refer to family planning and reproductive health services as described
      in Section 10.10 and Appendix C of this Agreement.

    


    e)  Article
      28 Clinics Operated by Academic Dental Centers

    


    MMC
      Enrollees may self-refer to Article 28 clinics operated by academic dental
      centers to obtain covered dental services as described in Section 10.27 of
      this
      Agreement.

    


    10.16
       Second
      Opinions for Medical or Surgical Care

    


    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 

    


    SECTION
      10

    (BENEFIT
      PACKAGE
      REQUIREMENTS)

    October
      1, 2005

    10-8

    


    



    second
      opinion regarding medical or surgical care, including diagnostic and evaluation
      services, provided by the Non-Participating Provider.

    


    10.17
       Coordination
      with Local Public Health Agencies

    


    The
      Contractor will coordinate its public health-related activities with the Local
      Public Health Agency (LPHA)
      consistent with the SDOH MCO
      and
      Public Health Guidelines. Coordination mechanisms and operational protocols
      for
      addressing public health issues will be negotiated with the LPHA and
LDSS
      and be
      customized to reflect local public health priorities. Negotiations must result
      in agreements regarding required Contractor activities related to public health.
      The outcome of negotiations may take the form of an informal agreement among
      the
      parties which may include memos
      or a
      separate memorandum of understanding signed by the LPHA, LDSS, and the
      Contractor.

    


    10.18
       Public
      Health Services

    


    a)
       Tuberculosis
      Screening, Diagnosis and Treatment; Directly Observed Therapy (TB\DOT):

    


    
      	 	
              i) 

            	
              Tuberculosis
                Screening, Diagnosis and Treatment services are included in the Benefit
                Package as set forth in Appendix KL3
                (3) (e)
                of
                this Agreement.

            


    

    A)
       It
      is the
      State's preference that Enrollees
      receive
TB
      diagnosis and treatment through the Contractor to the extent that Participating
      Providers experienced in this type of care are available.

    


    B)  The
      SDOH
      will coordinate with the LPHA to evaluate the Contractor's protocols against
      State and local guidelines and to review the tuberculosis treatment protocols
      and networks of Participating Providers to verify their readiness to treat
      Tuberculosis patients. State and local departments of health will also be
      available to offer technical assistance to the Contractor in establishing TB
      policies and procedures.

    


    C)  The
      Contractor is responsible for screening, diagnosis and treatment of
      TB,
      except
      for TB/DOT
      services.

    


    D)  The
      Contractor shall inform all Participating Providers of their responsibility
      to
      report TB cases to the LPHA.

    


    
      	 	
              ii) 

            	
              Enrollees
                may self-refer to LPHA facilities for the diagnosis and/or
                treatment of TB.

            


    

    


    A)
       The
      Contractor agrees to reimburse public health clinics when physician visit and
      patient management or laboratory and radiology services are rendered to
Enrollees,
      within
the
      context
      of TB
      diagnosis and treatment.

    


    


    


    


    SECTION
      10

    (BENEFIT
      PACKAGE
      REQUIREMENTS)

    October
      1, 2005

    10-9

    


    


    


    


    B)  The
      Contractor will make best effort to negotiate fees for these services with
      the
LPHA.
      If no
      agreement has been reached, the Contractor agrees to reimburse the public health
      clinics for these services at rates determined by SDOH.

    


    C)  The
      LPHA
      is responsible for: 1) giving notification to the Contractor before delivering
      TB related services, if so required in the public health agreement established
      pursuant to Section 10.17 of this Agreement, unless these services are ordered
      by a court of competent jurisdiction; 2) making reasonable efforts to verify
      with the Enrollee's
      PCP
      that
      he/she has not already provided TB care and treatment; and 3) providing
      documentation of services rendered along with the claim.

    


    D)  Prior
      authorization for hospital admission may not be required by the Contractor
      for
      an admission pursuant to a court order or an order of detention issued by the
      local commissioner or director of public health.

    


    E)  The
      Contractor shall provide the LPHA with access to health care practitioners
      on a
      twenty-four (24) hour a day, seven (7) day a week basis who can authorize
inpatient
      hospital
      admissions. The Contractor shall respond to the LPHA's
      request
      for authorization within
      the
      same day.

    


    F)  The
      Contractor will not be financially liable for treatments rendered to Enrollees
      who have been institutionalized as a result of a local health commissioner's
      order due to non-compliance with TB care regimens.

    


    
      	 	
              iii) 

            	
              Directly
                Observed Therapy (TB/DOT)
                is
                not included in the Benefit Package as set forth in Appendix K.3
                (3) (e)
                and K..4
                of this Agreement.

            


    

    


    A)
       The
      Contractor will not be capitated
      or
      financially liable for these costs.

    


    B)
       The
      Contractor agrees to make all reasonable efforts to ensure communication,
      cooperation and coordination with TB/DOT
      providers regarding clinical care and services.

    


    C)
       MMC
      Enrollees may use any Medicaid fee-for-service
      TB/DOT
      provider.

    


    
      	 	
              iv) 

            	
              HIV
                counseling and testing provided to a MMC Enrollee
                during a TB related visit at a public health clinic, directly operated
                by
                a LPHA, will be covered by Medicaid fee for service at rates established
                by SDOH.

            


    

    


    


    


    SECTION
      10

    (BENEFIT
      PACKAGE
      REQUIREMENTS)

    October
      1, 2005

    10-10

    



    b)  Immunizations

    


    
      	 	
              i) 

            	
              Immunizations
                are included in the Benefit Package as provided in Appendix K
                of
                

            


    

    
      	 	 	
              this
                Agreement.

            


    

    A)
       The
      Contractor is responsible for all costs associated with vaccine purchase and
      administration
      associated with adult immunizations.

    


    B)
       The
      Contractor is responsible for all costs associated with vaccine administration
      associated with childhood immunizations. The Contractor is not responsible
      for
      vaccine purchase costs associated with childhood immunizations and will inform
      all Participating Providers that the vaccines may be obtained free of charge
      from me Vaccine for Children Program.

    


    
      	 	
              ii) 

            	
              Enrollees
                may self refer to the LPHA
                facilities for their immunizations.

            


    

    A)
       The
      Contractor agrees to reimburse the LPHA when an Enrollee
      has self
      referred for immunizations.

    


    B)
       The
      Contractor will make best effort to negotiate fees for these services with
      the
      LPHA. If no agreement has been reached, the Contractor agrees to
      reimburse the public health clinics for these services at rates determined
      by
SDOH

    


    C)  The
      LPHA
      is responsible for making reasonable efforts to

    
      	 	
              (1)
                

            	
              determine
                the Enrollee's
                managed care membership status; and

            


    

    
      	 	
              (2)
                

            	
              ascertain
                the Enrollee's immunization status. Reasonable efforts shall consist
                of
                client interviews, medical records and, when available, access to
                the
                Immunization Registry. When an Enrollee presents a membership card
                with a
                PCP's
                name, the LPHA is responsible for calling the PCP.
                If
                the LPHA is unable to verify the immunization status from the PCP,
                the
                LPHA is responsible for delivering the service as
                appropriate.

            


    

    


    c)  Prevention
      and Treatment of Sexually Transmitted Diseases

    


    The
      Contractor will be responsible for ensuring that its Participating Providers
      educate their Enrollees about the risk and prevention of sexually transmitted
      disease (STD).
      The
      Contractor also will be responsible for ensuring that its Participating
      Providers screen and treat Enrollees for STDs
      and
      report cases of STD to the LPA
      and
      cooperate in contact investigation, in accordance with existing state and local
      laws and regulations. HIV
      counseling and testing provided to an MMC
      Enrollee
      during an STD related visit at a public health clinic, directly operated by
      a
      LPHA, will be covered by Medicaid fee-for-service
      at rates
      established by SDOH.

    


    


    


    SECTION
      10

    (BENEFIT
      PACKAGE
      REQUIREMENTS)

    October
      1, 2005

    10-11

    



    d)  Lead
      Poisoning - Applies to MMC
      Program
      Only

    


    The
      Contractor will be responsible for carrying out and ensuring that its
      Participating Providers comply with lead poisoning screening and follow-up
      as
      specified in 10 NYCRR
      Sub-part
      67-1. The Contractor shall require its Participating Providers to coordinate
      with the LPHA
      to
      assure appropriate follow-up in terms of environmental investigation, risk
      management and reporting requirements.

    


    10.19
       Adults
      with Chronic Illnesses and Physical or Developmental Disabilities

    


    a)
       The
      Contractor will implement all of the following to meet the needs of its adult
      Enrollees
      with
      chronic illnesses and physical or developmental disabilities:

    


    
      	 	
              i) 

            	
              Satisfactory
                methods for ensuring that the Contractor is in compliance with the
                ADA and
                Section 504 of the Rehabilitation Act of 1973. Program accessibility
                for
                persons with disabilities shall be in accordance with Section 24
                of this
                Agreement.

            


    

    


    
      	 	
              ii) 

            	
              Clinical
                case management which uses satisfactory methods/guidelines for identifying
                persons at risk of, or having, chronic diseases and disabilities
                and
                determining their specific
                needs in terms of specialist physician referrals, durable medical
                equipment, home health services, self-management education and training,
                etc. The Contractor shall:

            


    

    


    A)
       develop
      protocols describing the Contractor's case management services and minimum
      qualification requirements for case management staff;

    


    B)  develop
      and implement protocols for monitoring effectiveness of case management based
      on
      patient outcomes;

    


    C)  develop
      and implement protocols for monitoring service utilization, including emergency
      room visits and hospitalizations,
      with
      adjustment of severity of patient conditions;

    


    D)
       provide
      regular information to Participating Providers on the case management services
      available to Enrollees and the criteria for referring Enrollees for case
      management services.

    


    
      	 	
              iii) 

            	
              Satisfactory
                methods/guidelines for determining which patients are in need of
                case
                management services, including establishment of severity thresholds,
                and
                methods for identification of patients including monitoring of
                hospitalizations and ER
                visits, provider referrals, new Enrollee
                health screenings ands
                self referrals by Enrollees.

            


    

    


    
      	 	
              iv) 

            	
              Guidelines
                for determining specific needs of Enrollees in case management, including
                specialist physician referrals, durable medical equipment, home
                health

            


    

    


    


    SECTION
      10

    (BENEFIT
      PACKAGE
      REQUIREMENTS)

    October
      1, 2005

    10-12

    



    
      	 	 	
              services,
                self management education and training,
                etc.

            


    

    
      	 	
              v) 

            	
              Satisfactory
                systems for coordinating service delivery with Non-Participating
                Providers, including behavioral health providers for all Enrollees.

            


    

    
      	 	
              vi) 

            	
              Policies
                and procedures to allow for the continuation of existing relationships
                with Non-Participating Providers, consistent with PHL
                §
                4403(6)(e) and Section 15.6 of this
                Agreement.

            


    

    


    10.20
       Children
      with Special Health Care Needs

    


    a)
       Children
      with special health care needs are those who have or are suspected of having
      a
      serious or chronic physical, developmental, behavioral, or emotional condition
      and who also require health and
      related
      services of a type or amount beyond that required by children generally. The
      Contractor will be responsible for performing all of the same activities for
      this population as for adults. In addition, the Contractor will implement the
      following for these children:

    


    
      	 	
              i) 

            	
              Satisfactory
                methods for interacting with school districts, preschool services,
                child
                protective service agencies, early intervention officials, behavioral
                health, and developmental disabilities service organizations for
                the
                purpose of coordinating and assuring appropriate service
                delivery.

            


    

    


    
      	 	
              ii) 

            	
              An
                adequate network of pediatric
                providers and sub-specialists, and contractual relationships with
                tertiary
                institutions, to meet such children's medical
                needs.

            


    

    


    
      	 	
              iii) 

            	
              Satisfactory
                methods for assuring that children with serious, chronic, and rare
                disorders receive appropriate diagnostic work-ups
                on
                a timely basis.

            


    

    


    
      	 	
              iv) 

            	
              Satisfactory
                arrangements for assuring access to specialty centers in and out
                of New
                York State for diagnosis and treatment of rare
                disorders.

            


    

    


    
      	 	
              v)
                

            	
              A
                satisfactory approach for assuring access to allied health professionals
                (Physical Therapists, Occupational Therapists, Speech Therapists,
                and
                Audiologists)
                experienced in dealing with children and
                families.

            


    

    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    SECTION
      10

    (BENEFIT
      PACKAGE
      REQUIREMENTS)

    October
      1, 2005

    10-13

    


    



    10.21
       Persons
      Requiring Ongoing Mental Health Services

    


    a)
       The
      Contractor will implement all of the following for its Enrollees
      with
      chronic or ongoing mental health service needs:

    


    
      	 	
              i) 

            	
              Inclusion
                of all of the required provider types listed in Section 21 of this
                Agreement.

            


    

    


    
      	 	
              ii) 

            	
              Satisfactory
                methods
                for identifying Enrollees requiring such services and encouraging
                self-referral and early entry into
                treatment.

            


    

    


    
      	 	
              iii) 

            	
              Satisfactory
                case management systems or satisfactory case
                management.

            


    

    


    
      	 	
              iv) 

            	
              Satisfactory
                systems for coordinating service delivery between physical
                health,
                chemical dependence, and mental health providers, and coordinating
                services with other available services, including Social
                Services.

            


    

    


    
      	 	
              v) 

            	
              The
                Contractor agrees to participate in the local planning process for
                serving
                Enrollees with mental health needs to the extent requested by the
                LDSS.
                At
                the LDSS'
                discretion, the Contractor will develop linkages with local governmental
                units on coordination, procedures and standards related to mental
                health
                services and related activities.

            


    

    


    10.22
       Member
      Needs Relating to HIV

    


    a)
       The
      Contractor must inform MMC
      Enrollees newly diagnosed with HIV infection or AIDS, who are known to the
      Contractor, of their enrollment options including the ability to return to
      the
Medicaid fee-for-service
      program
      or to disenroll
      from the
      Contractor's MMC product and to enroll into HIV SNPs,
      if such
      plan is available.

    


    b)  The
      Contractor will inform Enrollees about HIV counseling and testing services
      available through the Contractor's Participating Provider network; HIV
      counseling and testing services available when performed as part of a Family
      Planning and Reproductive Health encounter; and anonymous counseling and testing
      services available from SDOH,
      Local
      Public Health Agency clinics and other county programs. Counseling and testing
      rendered outside of a Family Planning and Reproductive Health encounter, as
      well
      as services provided as the result of an HIV+ diagnosis, will be furnished
      by
      the Contractor in accordance with standards of care.

    


    c)  The
      Contractor agrees that anonymous testing may be famished to the Enrollee
      without
      prior approval by the Contractor and may be conducted at anonymous testing
      sites. Services provided for HIV treatment may only be obtained from the
      Contractor

    


    SECTION
      10

    (BENEFIT
      PACKAGE
      REQUIREMENTS)

    October
      1, 2005

    10-14

    


    



    during
      the period the
      Enrollee
      is
      enrolled in the Contractor's MMC
      or
FHPlus
      product.

    


    d)  To
      adequately address the HIV
      prevention needs of uninfected Enrollees,
      as well
      as the special needs of Enrollees with HIV infection, the Contractor shall
      have
      in place all of the following:

    


    
      	 	
              i) 

            	
              Methods
                for promoting HIV prevention to all Enrollees. HIV prevention information,
                both primary as well as secondary, should be tailored to the Enrollee's
                age, sex, and risk factor(s)
                (e.g., injection drug use and sexual risk activities), and should
                be
                culturally and linguistically appropriate. HIV primary prevention
                means
                the reduction or control of causative factors for HIV, including
                the
                reduction of risk factors. HIV Primary prevention includes strategies
                to
                help prevent uninfected Enrollees from acquiring HIV, i.e., behavior
                counseling for HIV negative Enrollees with risk behavior. Primary
                prevention also includes strategies to help prevent infected Enrollees
                from transmitting HIV infection, i.e.,
                behavior counseling with an HIV infected Enrollee to reduce risky
                sexual
                behavior or providing antiviral therapy to a pregnant, HIV infected
                female
                to prevent transmission of HIV infection to a newborn. HIV Secondary
                Prevention means promotion of early detection and treatment of
                HFV
                disease
                in an asymptomatic Enrollee to prevent the development of symptomatic
                disease. This includes: regular medical assessments; routine immunization
                for preventable infections; prophylaxis for opportunistic infections;
                regular dental, optical, dermatological
                and gynecological care; optimal diet/nutritional
                supplementation; and partner notification services which lead to
                the early
                detection and treatment of other infected persons. All Enrollees
                should be
                informed of the availability of HIV counseling, testing, referral
                and
                partner notification (CTRPN)
                services.

            


    

    


    
      	 	
              ii) 

            	
              Policies
                and procedures promoting the early identification of HIV infection
                in
                Enrollees. Such policies and procedures shall include at a minimum:
                assessment methods for recognizing the early signs and symptoms of
                HIV
                disease; initial and routine screening for HIV risk factors through
                administration of sexual behavior and drug and alcohol use assessments;
                and the provision of information to all Enrollees regarding the
                availability of HIV CTRPN services from Participating Providers or
                as part
                of a Family Planning and Reproductive Health services visit pursuant
                to
                Appendix C
                of
                this Agreement, and the availability of anonymous CTRPN services
                from New
                York State, New York City and the LPHA.

            


    

    


    
      	 	
              iii) 

            	
              Policies
                and procedures that require Participating Providers to provide HIV
                counseling and recommend HIV testing to pregnant women in their care.
                The
                HIV counseling and testing provided shall be done in accordance with
                Article 27-F
                of
                the PHL.
                Such policies and procedures shall also direct
                Participating

            


    

    


    


    


    


    


    


    SECTION
      10

    (BENEFIT
      PACKAGE
      REQUIREMENTS)

    October
      1, 2005

    10-15

    



    Providers
      to refer any HIV
      positive
      women in their care to clinically appropriate services for both the women and
      their newborns.

    


    
      	 	
              iv) 

            	
              A
                network of providers sufficient to meet the needs of its Enrollees
                with HP/.
                Satisfaction of the network requirement may be accomplished by inclusion
                of HIV specialists within the network or the provision of HIV specialist
                consultation to non-HIV
                specialists serving as PCPs
                for persons with HIV infection; inclusion of Designated AIDS Center
                Hospitals or other hospitals experienced in HIV care in the Contractor's
                network; and contracts or linkages with providers funded under the
                Ryan
                White CARE Act. The Contractor shall inform Participating Providers
                about
                how to obtain information about the availability of Experienced HIV
                Providers and HIV Specialist PCPs.

            


    

    


    
      	 	
              v) 

            	
              Case
                Management Assessment for Enrollees with HIV Infection. The Contractor
                shall establish policies and procedures to ensure that Enrollees
                who have
                been identified as having HIV infection are assessed for case management
                services. The Contractor shall arrange for any Enrollee
                identified
                as having HIV infection and needing case management services to be
                referred to an appropriate case management services provider, including
                Contractor provided case management, and/or,
                with appropriate consent of the Enrollee, HIV community-based psychosocial
                case management services and/or
                COBRA Comprehensive Medicaid
                Case Management (CMCM)
                services for MMC
                Enrollees.

            


    

    


    
      	 	
              vi) 

            	
              The
                Contractor shall require its Participating Providers to report positive
                HIV test results and diagnoses and known contacts of such persons
                to the
                New York State Commissioner of Health. In New York City, these shall
                be
                reported to the New York City Commissioner of Health. Access to partner
                notification services must be consistent with 10 NYCRR
                Part 63.

            


    

    


    
      	 	
              vii)

            	
              The
                Contractor's Medical Director shall review Contractor's HIV practice
                guidelines at least annually and update them as necessary for compliance
                with recommended SDOH
                AIDS Institute and federal government clinical standards. The Contractor
                will disseminate the HIV Practice Guidelines or revised guidelines
                to
                Participating Providers at least annually, or more frequently as
                appropriate.

            


    

    


    10.23
       Persons
      Requiring Chemical Dependence Services

    


    a)
       The
      Contractor will have in place all of the following for its Enrollees requiring
      Chemical Dependence Services:

    


    
      	 	
              i) 

            	
              A
                Participating Provider network which includes of all the required
                provider
                types listed in Section 21 of this
                Agreement.

            


    

    


    


    SECTION
      10

    (BENEFIT
      PACKAGE
      REQUIREMENTS)

    October
      1, 2005

    10-16

    



    
      	 	
              ii) 

            	
              Satisfactory
                methods for identifying Enrollees
                requiring such services and encouraging self-referral and early entry
                into
                treatment and methods for referring Enrollees to the New York State
                Office
                of Alcoholism and Substance Abuse Services (OASAS)
                for appropriate services beyond the Contractor's Benefit Package
                (e.g.,
                halfway houses).

            


    

    


    
      	 	
              iii) 

            	
              Satisfactory
                systems of care, including Participating Provider networks and referral
                processes sufficient to ensure that emergency services, including
                crisis
                services, can be provided in a timely
                manner.

            


    

    


    
      	 	
              iv) 

            	
              Satisfactory
                case management systems.

            


    

    


    
      	 	
              v) 

            	
              Satisfactory
                systems for coordinating service delivery between physical health,
                chemical dependence, and mental health providers, and coordinating
                services received from Participating Providers with other services,
                including Social Services.

            


    

    


    
      	 	
              vi) 

            	
              The
                Contractor also agrees to participate in the local planning process
                for
                serving persons with chemical dependence, to the extent requested
                by an
                LDSS.
                At
                the LDSS's
                discretion, the Contractor will develop linkages with local governmental
                units on coordination procedures and standards related to Chemical
                Dependence Services and related
                activities.

            


    

    


    10.24
       Native
      Americans

    


    If
      an
Enrollee
      is a
      Native American and the Enrollee
      chooses
      to access primary care services through his/her
      tribal health
      center,
      the PCP
      authorized by the Contractor to refer the
      Enrollee for services included in the Benefit Package must develop a
      relationship with the Enrollee's
      PCP at
      the tribal health center to coordinate services for said Native American
      Enrollee.

    


    10.25
       Women,
      Infants, and
      Children
(WIC)

    


    The
      Contractor shall develop linkage agreements or other mechanisms to refer
      Enrollees who are pregnant and Enrollees with children younger than five (5)
      years of age to WIC local agencies for nutritional assessments and
      supplements.

    


    10.26
       Urgently
      Needed Services

    


    The
      Contractor is financially responsible for Urgently Needed Services. Urgently
      Needed Services are covered only in the United States, the
      Commonwealth of Puerto Rico, the U.S. Virgin Islands, Guam, American Samoa,
      the
      Northern Mariana Islands and Canada. The Contractor may require the Enrollee
      or
      the Enrollee's designee
      to
      coordinate with the Contractor or the Enrollee's PCP prior to receiving
      care.

    


    


    


    SECTION
      10

    (BENEFIT
      PACKAGE
      REQUIREMENTS)

    October
      1, 2005

    10-17

    


    



    
      	 	
              10.27
                

            	
              Dental
                Services Provided by Article 28 Clinics Operated by Academic Dental
                Centers Not Participating in Contractor's Network - Applies to
                MMC
                Program Only

            


    

    


    a)
       Consistent
      with Chapter 697 of Laws of 2003 amending Section 364-j
      of the
      Social Services Law, dental services provided by Article 28 clinics operated
      by
      academic dental centers may be accessed directly by MMC Enrollees
      without
      prior approval and without regard to network participation.

    


    b)  If
      dental
      services are part of the Contractor's Benefit Package, the Contractor will
      reimburse non-participating Article 28 clinics operated by academic dental
      centers for covered dental services provided to MMC Enrollees at approved
      Article 28 Medicaid
      clinic
      rates in accordance with the protocols issued by the SDOH.

    


    10.28
       Hospice
      Services

    


    a)
       For
      FHPlus
      only:
      the Contractor shall provide a coordinated hospice program of home and
inpatient
      services
      which provides non-curative medical and support services for FHPlus Enrollees
      certified by a physician to be terminally ill with a life expectancy of six
      months or less. Hospices must be certified under Article 40 of the New York
      State Public Health Law.

    


    b)
       MMC
      Enrollees receive coverage for hospice services through the Medicaid
fee-for-service
      program.

    


    
      	 	
              10.29
                

            	
              Prospective
                Benefit Package Change for Retroactive SSI
                Determinations -Applies to MMC Program
                Only

            


    

    


    The
      Benefit Package and associated Capitation Rate for MMC Enrollees who become
      SSI
      or SSI related retroactively shall be changed prospectively
      as of
      the effective date of the Roster on which the Enrollee's
      status
      change appears.

    


    10.30
       Coordination
      of Services

    


    a)
       The
      Contractor shall coordinate care for Enrollees, as applicable,
      with:

    


    
      	 	
              i) 

            	
              the
                court system (for court ordered evaluations and
                treatment);

            


    

    


    
      	 	
              ii) 

            	
              specialized
                providers of health
                care for the homeless, and other providers of services for victims
                of
                domestic violence;

            


    

    


    
      	 	
              iii) 

            	
              family
                planning clinics, community health centers, migrant health centers,
                rural
                health centers;

            


    

    


    


    


    


    


    SECTION
      10

    (BENEFIT
      PACKAGE
      REQUIREMENTS)

    October
      1, 2005

    10-18

    


    



    
      	 	
              iv) 

            	
              WIC,
                Head Start, Early Intervention;

            


    

    


    
      	 	
              v) 

            	
              programs
                funded through the Ryan
                White CARE Act;

            


    

    


    
      	 	
              vi) 

            	
              other
                pertinent entities that provide services out of
                network;

            


    

    


    vii)
      Prenatal
      Care Assistance Program (PCAP)
      Providers;

    


    viii)
      local
      governmental units responsible for public health, mental health, mental
      retardation or Chemical Dependence Services;

    


    
      	 	
              ix) 

            	
              specialized
                providers of long term care for people with developmental disabilities;
                and

            


    

    


    
      	 	
              x) 

            	
              School-based
                health centers.

            


    

    


    b)  Coordination
      may involve contracts or linkage agreements (if entities are willing to enter
      into such an agreement), or other mechanisms to ensure coordinated care for
      Enrollees,
      such as
      protocols for reciprocal referral and communication of data and clinical
      information on MCO Enrollees.

    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    SECTION
      10

    (BENEFIT
      PACKAGE
      REQUIREMENTS)

    October
      1, 2005

    10-19

    


    


    


    11.
       MARKETING

    


    11.1
       Information
      Requirements

    


    a)
       The
      Contractor shall provide Prospective Enrollees,
      upon
      request,
      with
pre-enrollment
      and
      post-enrollment information pursuant to PHL§
4408
      and SSL
      §364-j.

    


    b)  The
      Contractor shall provide Prospective Enrollees, upon request, with the most
      current and complete listing of Participating Providers, as described in Section
      13.2(a) of this Agreement, in hardcopy,
      along
      with any updates to that listing.

    


    c)  The
      Contractor shall provide Potential Enrollees with pre-enrollment
      and
      post-enrollment information pursuant to 42 CFR§
438.10
      (e).

    


    d)  The
      Contractor must inform Potential Enrollees that oral interpretation service
      is
      available for any language and that information is available in alternate
      formats and how to access these formats.

    


    11.2
       Marketing
      Plan

    


    a)
       The
      Contractor shall have a Marketing plan, that has been prior-approved by the
      SDOH
      that
      describes the Marketing activities the Contractor will undertake within the
      service area, as specified in Appendix M
      of this
      Agreement, during the term of this Agreement.

    


    b)
       The
      Marketing plan and all Marketing activities must comply with the Marketing
      Guidelines which are set forth in Appendix D, which is hereby made a part of
      this Agreement as if set forth fully herein.

    


    c)
       The
      Marketing plan shall be kept on file in the offices of the Contractor, each
      LDSS
      in the
      Contractor's service area, and the SDOH. The Marketing plan may be modified
      by
      the Contractor subject to prior written approval by the SDOH. The SDOH must
      take
      action on the changes submitted within sixty (60) calendar days of submission
      or
      the Contractor may deem the changes approved.

    


    11.3
       Marketing
      Activities

    


    Marketing
      activities by the
      Contractor shall conform to the approved Marketing Plan.

    


    


    SECTION
      11

    (MARKETING)

    October
      1, 2005

    11-1

    



    11.4
       Prior
      Approval of Marketing Materials and Procedures

    


    The
      Contractor shall submit all procedures and materials related to Marketing to
      Prospective Enrollees
      to the
SDOH
      for
      prior written approval, as described in Appendix D
      of this
      Agreement. The Contractor shall not use any procedures or materials that the
      SDOH has not approved. Marketing materials shall be made available by the
      Contractor throughout its entire service area. Marketing materials may be
      customized for specific counties and populations within the Contractor's service
      area. All Marketing activities should provide for equitable distribution of
      materials without bias toward or against any group.

    


    11.5
       Corrective
      and Remedial Actions

    


    a)
       If
      the
      Contractor's Marketing activities do not comply with the Marketing Guidelines
      set forth in Appendix D of this Agreement or the Contractor's approved Marketing
      plan, the SDOH, in consultation with the LDSS,
      may take
      any of the following actions as it, in its sole discretion, deems necessary
      to
      protect the interests of Enrollees and the integrity of the MMC
      and
FHPlus
      Programs.
      The Contractor shall take the corrective and remedial actions directed by the
      SDOH within the specified timeframes.

    


    
      	 	
              i) 

            	
              If
                the Contractor or its representative commits a first time infraction
                of
                the Marketing Guidelines and/or
                the Contractor's approved Marketing plan, and the SDOH, in consultation
                with the LDSS, deems the infraction to be minor or unintentional
                in
                nature, the SDOH and/or
                the LDSS may issue a warning letter to the
                Contractor.

            


    

    


    
      	 	
              ii) 

            	
              If
                the Contractor engages in Marketing activities that SDOH determines,
                in it
                sole discretion, to be an intentional or serious breach of the Marketing
                Guidelines or the Contractor's approved Marketing plan, or a pattern
                of
                minor breaches, SDOH, in consultation with the LDSS, may require
                the
                Contractor to, and the Contractor shall, prepare and implement a
                corrective action plan acceptable to SDOH within a specified timeframe.
                In
                addition, or alternatively, SDOH may impose sanctions, including
                monetary
                penalties, as permitted by law.

            


    

    


    
      	 	
              iii) 

            	
              If
                the Contractor commits further infractions, fails to pay monetary
                penalties within the specified timeframe, fails to implement a corrective
                action plan in a timely manner or commits an egregious first-time
                infraction, the SDOH, in consultation with the LDSS, may in addition
                to
                any other legal remedy available to SDOH in law or
                equity:

            


    

    


    A)
       direct
      the Contractor to suspend its Marketing activities for a period up to the end
      of
      the Agreement period;

    


    


    


    


    SECTION
      11

    (MARKETING)

    October
      1, 2005

    11-2

    



    B)  suspend
      new Enrollments, other than newborns,
      for a
      period up to the remainder of the Agreement period; or

    


    C)  terminate
      this Agreement pursuant to termination procedures described in Section 2.7
      of
      this Agreement.

    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    SECTION
      11

    (MARKETING)

    October
      1, 2005

    11-3

    



    12.
       MEMBER
      SERVICES

    


    
      	 	
              12.1
                

            	
              General
                Functions

            


    

    


    a)
       The
      Contractor shall operate a Member Services Department during regular business
      hours, which must be accessible to Enrollees
      via a
      toll-free telephone line. Personnel must also be available via a toll-free
      telephone line (which can be the member services toll-free line or separate
      toll-free lines) not less than during regular business hours to address
      complaints and utilization review inquiries. In addition, the Contractor must
      have a telephone system capable of accepting, recording or providing instruction
      in response to incoming calls regarding complaints and utilization review during
      other than normal business hours and measures in place to ensure a response
      to
      those calls the next business day after the
      call
      was received.

    


    b)  At
      a
      minimum, the Member Services Department must be staffed at a ratio of at least
      one (1) full time equivalent Member Service Representative for every four
      thousand (4,000) or fewer Enrollees.

    


    c)  Member
      Services staff must be responsible for the following:

    


    
      	 	
              i) 

            	
              Explaining
                the Contractor's rules for obtaining services and assisting Enrollees
                in
                making appointments.

            


    

    


    
      	 	
              ii) 

            	
              Assisting
                Enrollees to select or change Primary Care
                Providers.

            


    

    


    
      	 	
              iii) 

            	
              Fielding
                and responding to Enrollee
                questions and complaints, and advising Enrollees of the prerogative
                to
                complain to the SDOH
                and LDSS
                at
                any time.

            


    

    


    
      	 	
              iv) 

            	
              Clarifying
                information in the member handbook for
                Enrollees.

            


    

    


    
      	 	
              v) 

            	
              Advising
                Enrollees of the Contractor's complaint and appeals program, the
                utilization review process, and Enrollee's
                rights to a fair hearing or external
                review.

            


    

    


    
      	 	
              vi) 

            	
              Clarifying
                for MMC
                Enrollees current categories of exemptions and exclusions. The Contractor
                may refer to the LDSS or the Enrollment Broker, where one is in place,
                if
                necessary, for more information on exemptions and
                exclusions.

            


    

    


    
      	 	
              12.2
                

            	
              Translation
                and Oral Interpretation

            


    

    


    a)
       The
      Contractor must make available written marketing and other informational
      materials (e.g., member handbooks) in a language other than English whenever
      at
      least five percent (5%) of the Prospective Enrollees of the Contractor in any
      county

    


    SECTION
      12

    (MEMBER
      SERVICES)

    October
      1, 2005

    12-1

    



    of
      the
      service area speak that particular language and do not speak English as a first
      language.

    


    b)  In
      addition, verbal interpretation services must be made available to Enrollees
      and
      Potential Enrollees who speak a language other than English as a primary
      language. Interpreter services must be offered in person where practical, but
      otherwise may be offered by telephone.

    


    c)  The
      SDOH
      will
      determine the need for other than English translations based on county-specific
      census data or other available measures.

    


    12.3
       Communicating
      with the Visually, Hearing and Cognitively
      Impaired

    


    The
      Contractor also must have in place appropriate alternative mechanisms for
      communicating effectively with persons with visual, hearing, speech, physical
      or
      developmental disabilities. These alternative mechanisms include Braille or
      audio tapes for the visually impaired, TTY
      access
      for those with certified speech or hearing disabilities, and use of American
      Sign Language and/or
      integrative
      technologies.

    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    SECTION
      12

    (MEMBER
      SERVICES)

    October
      1, 2005

    12-2

    



    13.
       ENROLLEE
      RIGHTS AND NOTIFICATION

    


    13.1
       Information
      Requirements

    


    a)
       The
      Contractor shall provide new Enrollees
      with the
      information identified in PHL§
4408,
      SSL§364-j, SSL§369-ee
      and 42
CFR§
438.10
      (f)
      and
(g).

    b)  The
      Contractor shall provide such information to the Enrollee
      within
      fourteen (14) days of the Effective Date of Enrollment. The Contractor may
      provide such information to the Enrollee through the Member Handbook referenced
      in Section 13.4 of this Agreement.

    


    c)  The
      Contractor must provide Enrollees with an annual notice that this information
      is
      available to them upon request.

    


    d)  The
      Contractor must inform Enrollees that oral interpretation service is available
      for any language and that information is available in alternative formats and
      how to access these formats.

    


    13.2
       Provider
      Directories/Office Hours for Participating Providers

    


    a)
       The
      Contractor shall maintain and update, on a quarterly basis, a listing by
      specialty of the names, addresses and telephone numbers of all Participating
      Providers, including facilities. Such a list/directory
      shall include names, office addresses, telephone numbers, board certification
      for physicians, information on language capabilities and wheelchair
      accessibility of Participating Providers. The list should also identify
      providers that are not accepting new patients.

    


    b)
       New
      Enrollees must receive the most current complete listing in hardcopy,
      along
      with any updates to such listing.

    


    c)
       Enrollees
      must be notified of updates in writing at least annually in one of the following
      methods: (1) provide updates in hardcopy; (2) provide a new complete
      listing/directory in hardcopy; or (3) provide written notification that a new
      complete listing/directory is available and will be provided upon request either
      in hardcopy, or electronically if the Contractor has the capability of providing
      such data in an electronic format and the data is requested in that format
      by an
      Enrollee.

    


    d)
       In
      addition, the Contractor must make available to the LDSS
      the
      office hours for Participating Providers. This requirement may be satisfied
      by
      providing a copy of the list or Provider Directory described in this Section
      with the addition of office hours or by providing a separate listing of office
      hours for Participating Providers.

    


    


    


    


    SECTION
      13

    (ENROLLEE
      RIGHTS AND NOTIFICATION)

    October
      1, 2005

    13-1

    


    


    


    


    13.3
       Member
      ID
      Cards

    


    a)
       The
      Contractor must issue an identification card to the Enrollee
      containing the following information:

    


    
      	 	
              i) 

            	
              the
                name of the Enrollee's
                clinic (if applicable);

            


    

    


    
      	 	
              ii) 

            	
              the
                name of the
                Enrollee's PCP
                and the PCP's
                telephone number (if an

            


    

    
      	 	 	
              Enrollee
                is being served by a PCP team, the name of the individual
                shown

            


    

    
      	 	 	
              on
                the card should be the lead
                provider);

            


    

    


    
      	 	
              iii) 

            	
              the
                member services toll free telephone
                number;

            


    

    


    
      	 	
              iv) 

            	
              the
                twenty-four (24) hour toll free telephone number that Enrollees
                may

            


    

    
      	 	 	
              use
                to access information on obtaining services when his/her PCP
                is not

            


    

    
      	 	 	
              available;
                and

            


    

    


    
      	 	
              v) 

            	
              for
                ID Cards issued after October 1, 2004, the Enrollee's
                Client

            


    

    
      	 	 	
              Identification
                Number (CIN).

            


    

    


    b)  PCP
      information may be embossed on the card or affixed to the card by a
      sticker.

    


    c)  The
      Contractor shall issue an identification card within fourteen (14) days of
      an
      Enrollee's Effective Date of Enrollment. If unforeseen circumstances, such
      as
      the lack of identification of a PCP, prevent the Contractor from forwarding
      the
      official identification card to new Enrollees within the fourteen (14) day
      period, alternative measures by which Enrollees may identify themselves such
      as
      use of a Welcome Letter or a temporary identification card shall be deemed
      acceptable until such time as a PCP is either chosen by the Enrollee or auto
      assigned by the Contractor. The Contractor agrees to implement an alternative
      method by which individuals may identify himself/herself
      as Enrollees prior to receiving the card (e.g., using a "welcome letter" from
      the Contractor) and to update PCP information on the identification card.
Newborns
      of
      Enrollees need not present ID cards in order to receive Benefit Package services
      from the Contractor and its Participating Providers. The Contractor is not
      responsible for providing Benefit Package services to newborns
      Excluded
      from the MMC
      Program
      pursuant to Appendix H
      of this
      Agreement, or when the Contractor does not offer an MMC product in the mother's
      county of fiscal responsibility.

    


    13.4
       Member
      Handbooks

    


    The
      Contractor shall issue to a new Enrollee within fourteen (14) days of the
      Effective Date of Enrollment a Member Handbook, which is consistent with
the
      SDOH
      guidelines described in Appendix E,
      which is
      hereby made a part of this Agreement as if set forth fully herein.

    


    SECTION
      13

    (ENROLLEE
      RIGHTS AND NOTIFICATION)

    October
      1, 2005

    13-2

    


    



    13.5
       Notification
      of Effective
      Date of Enrollment

    


    The
      Contractor shall inform each Enrollee
      in
      writing within fourteen (14) days of the Effective Date of Enrollment of any
      restriction on the Enrollee's
      right to
      terminate enrollment. The initial enrollment information and the Member Handbook
      shall be adequate to convey this notice.

    


    13.6
       Notification
      of Enrollee Rights

    


    a)
       The
      Contractor agrees to make all reasonable efforts to contact new Enrollees,
      in
      person, by telephone, or by mail, within thirty (30) days of their Effective
      Date of Enrollment. "Reasonable efforts" are defined to mean at least three
      (3)
      attempts, with more than one method of contact being employed. Upon contacting
      the new Enrollee(s),
      the
      Contractor agrees to do at least the following:

    


    
      	 	
              i) 

            	
              Inform
                the Enrollee about the Contractor's policies with respect to obtaining
                medical services, including services for which the Enrollee may self-refer
                pursuant to Section 10.15 of this Agreement, and what to do in an
                emergency.

            


    

    


    
      	 	
              ii) 

            	
              Conduct
                a brief health screening to assess the Enrollee's need for any special
                health care (e.g., prenatal or behavioral health services) or
                lannguage/communication needs. If a special need is identified, the
                Contractor shall assist the Enrollee in arranging for an appointment
                with
                his/her
                PCP
                or
                other appropriate provider.

            


    

    


    
      	 	
              iii) 

            	
              Offer
                assistance in arranging an initial visit to the Enrollee's PCP for
                a
                baseline physical and other preventive services, including an assessment
                of the Enrollee's potential risk, if any, for specific diseases or
                conditions.

            


    

    


    
      	 	
              iv) 

            	
              Inform
                new Enrollees about their rights for continuation of certain existing
                services.

            


    

    


    
      	 	
              v) 

            	
              Provide
                the Enrollee with the Contractor's toll free telephone number that
                may be
                called twenty-four (24) hours a day, seven (7) days a week if the
                Enrollee
                has questions about obtaining services and cannot reach his/her
                PCP (this telephone number need not be the Member Services line and
                need
                not be staffed to respond to Member Services-related inquiries).
                The
                Contractor must have appropriate mechanisms in place to accommodate
                Enrollees who do not have telephones and therefore cannot readily
                receive
                a call back.

            


    

    


    


    


    


    


    


    


    


    


    


    SECTION
      13

    (ENROLLEE
      RIGHTS AND NOTIFICATION)

    October
      1, 2005

    13-3

    (vi)
      Advise
Enrollee
      about
      opportunities available to learn about the Contractor's policies and benefits
      in
      greater detail (e.g., welcome meeting, Enrollee orientation and education
      sessions).

    


    vii)
      Assist
      the Enrollee in selecting a primary care provider if one has not already been
      chosen.

    


    13.7
       Enrollee's
      Rights

    


    a)
       The
      Contractor shall,
      in
      compliance with the requirements of 42 CFR
      §
      438.6(i)(l) and 42 CFR Part 489 Subpart
      I,
      maintain written policies and procedures regarding advance directives and inform
      each Enrollee in writing at the time of enrollment of an individual's rights
      under State law to formulate advance directives and of the Contractor's policies
      regarding the implementation of such rights. The Contractor shall include in
      such written notice to the Enrollee materials relating to advance directives
      and
      health care proxies as specified in 10 NYCRR
      Part 98
      and § 700.5. The written information must reflect changes in State law as soon
      as possible, but no later than ninety (90) days after the effective date of
      the
      change.

    


    b)  The
      Contractor shall have policies and procedures that protect the Enrollee's right
      to:

    


    
      	 	
              i) 

            	
              receive
                information about the Contractor and managed
                care;

            


    

    


    
      	 	
              ii) 

            	
              be
                treated with respect and due consideration for his or her dignity
                and
                privacy;

            


    

    


    
      	 	
              iii) 

            	
              receive
                information on available treatment options and alternatives, presented
                in
                a manner appropriate to the Enrollee's condition and ability to
                understand;

            


    

    


    
      	 	
              iv) 

            	
              participate
                in decisions regarding his or her health care, including the right
                to
                refuse treatment;

            


    

    


    
      	 	
              v) 

            	
              be
                free from any form of restraint or seclusion used as a means of coercion,
                discipline, convenience or retaliation, as specified
                in Federal regulations on the use of restraints and seclusion;
                and

            


    

    


    
      	 	
              vi)
                

            	
              If
                the privacy rule, as set forth in 45 CFR Parts 160 and 164, Subparts
                A
                and E,
                applies, request and receive a copy of his or her medical records
                and
                request that they be amended or corrected, as specified in 45 CFR
                §§
                164.524 and 164.526.

            


    

    


    


    


    


    


    


    


    


    


    


    


    SECTION
      13

    (ENROLLEE
      RIGHTS AND NOTIFICATION)

    October
      1, 2005

    13--4

    



    c)  The
      Contractor's policies and procedures must require that neither the Contractor
      nor its Participating Providers adversely regard an Enrollee
      who
      exercises his/her rights in 13.7(0)
      above.

    


    13.8
       Approval
      of Written Notices

    


    The
      Contractor shall submit the format and content of all written notifications
      described in this Section to SDOH
      for
      review and prior approval by SDOH
      in
      consultation with LDSS.
      All
      written notifications must be written at a fourth (4th)
      to
      sixth (6th)
      grade
      level and in at least ten (10) point print.

    


    13.9
       Contractor's
      Duty to Report Lack of Contact

    


    The
      Contractor must inform the LDSS of any Enrollee it is unable to contact within
      ninety (90) days of Enrollment using reasonable efforts as defined in Section
      13.6 of the Agreement and who have not presented for any health care services
      through the Contractor or its Participating Providers.

    


    13.10
       LDSS
      Notification of Enrollee's
      Change
      in Address

    


    The
      LDSS
      is responsible for notifying the Contractor of any known change in address
      of
      Enrollees.

    


    
      	 	
              13.11
                

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

            


    

    


    
      	 	 	
              The
                Contractor must provide written notification of the effective
                date of any Contractor-initiated, SDOH-approved
                Benefit Package change to Enrollees.
                Notification
                to Enrollees must be provided at least thirty (30) days in advance
                of the
                effective date of such change.

            


    

    


    
      	 	
              13.12
                

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

            


    

    


    a)
       With
      prior
      notice to and approval of the SDOH, the Contractor shall inform each Enrollee
      in
      writing of any withdrawal by the Contractor from the MMC
      or
      FHPlus
      Program
      pursuant to Section 2.7 of this Agreement, withdrawal from the service area
      encompassing the Enrollee's zip code, and/or
      significant changes to the Contractor's Participating Provider network pursuant
      to Section 21.1(d) of this Agreement, except that the Contractor need not notify
      Enrollees who will not be affected by such changes.

    


    b)  The
      Contractor shall provide the notifications within the timeframes
      specified by SDOH, and shall obtain the prior approval of the notification
      from
      SDOH.

    


    SECTION
      13

    (ENROLLEE
      RIGHTS AND NOTIFICATION)

    October
      1, 2005

    13-5

    



    14.
       ACTION
      AND GRIEVANCE SYSTEM

    


    14.1
       General
      Requirements

    


    a)
       The
      Contractor shall establish and maintain written Action procedures and a
      comprehensive Grievance System that complies with the Managed Care Action and
      Grievance System Requirements for MMC
      and
FHPlus
      Programs
      described in Appendix F,
      which is
      hereby made a part of this Agreement as if set forth fully herein. Nothing
      herein shall release the Contractor from its responsibilities under PHL§4408-a
      or
PHL
      Article
      49 and 10 NYCRR
      Part
      98
      that is not otherwise expressly established in Appendix F.

    


    b)  The
      Contractor's Action procedure and Grievance System shall be approved by the
      SDOH
      and kept on file with the Contractor and SDOH.

    


    c)  The
      Contractor shall not modify its Action procedure or Grievance System without
      the
      prior written approval of SDOH, and shall provide SDOH with a copy of the
      approved modification within fifteen (15) days of its approval.

    


    14.2
       Actions

    


    a)
       The
      Contractor must have in place effective mechanisms to ensure consistent
      application of review criteria for Service Authorization Determinations and
      consult with the requesting provider when appropriate.

    


    b)
       If
      the
      Contractor subcontracts for Service Authorization Determinations and utilization
      review, the Contractor must ensure that its subcontractors have in place and
      follow written policies and procedures for delegated activities regarding
      processing requests for initial and continuing authorization of services
      consistent with Article 49 of the PHL, 10 NYCRR Part 98, 42 CFR
      Part
      438,
      Appendix F of this Agreement, and the Contractor's policies and
      procedures.

    


    c)
       The
      Contractor must ensure that compensation to individuals or entities that perform
      Service Authorization Determination and utilization management activities is
      not
      structured to include incentives that would result in the denial, limiting,
      or
      discontinuance of medically necessary services to Enrollees.

    


    d)  The
      Contractor or its subcontractors may not arbitrarily deny or reduce the amount,
      duration, or scope of a covered service solely because of the diagnosis, type
      of
      illness, or Enrollee's
      condition. The Contractor may place appropriate limits on a service on the
      basis
      of criteria such as medical necessity or utilization control, provided that
      the
      services furnished can reasonably be expected to achieve their
      purpose.

    


    


    


    


    


    


    SECTION
      14

    (ACTION
      AND GRIEVANCE SYSTEM)

    October
      1, 2005

    14-1

    


    14.3
       Grievance
      System

    


    a)
       The
      Contractor shall ensure that its Grievance System includes methods for prompt
      internal
      adjudication
      of
Enrollee
      Complaints, Complaint Appeals and Action Appeals and provides for the
      maintenance of a written record of all Complaints, Complaint Appeals and Action
      Appeals received and reviewed and their disposition, as specified in Appendix
      F
      of this
      Agreement.

    


    b)  The
      Contractor shall ensure that persons with authority to require corrective action
      participate in the Grievance System.

    


    14.4
       Notification
      of Action and Grievance System Procedures

    


    a)
       The
      Contractor will advise Enrollees
      of their
      right to a fair hearing as appropriate and comply with the procedures
      established by SDOH
      for the
      Contractor to participate in the fair hearing process, as set forth in Section
      25 of this Agreement. The Contractor will also advise Enrollees of their right
      to an External
      Appeal, in accordance with Section 26 of this Agreement.

    


    b)
       The
      Contractor will provide written notice of the following Complaint, Complaint
      Appeal, Action Appeal and fair hearing procedures to all Participating
      Providers, and subcontractors to whom the Contractor has delegated utilization
      review and Service Authorization Determination procedures, at the time they
      enter into an agreement with the Contractor:

    


    
      	 	
              i) 

            	
              the
                Enrollee's
                right to a fair hearing, how to obtain a fair hearing, and representation
                rules at a hearing;

            


    

    


    
      	 	
              ii) 

            	
              the
                Enrollee's right to file Complaints, Complaint Appeals and Action
                Appeals
                and the process and timeframes
                for filing;

            


    

    


    
      	 	
              iii) 

            	
              the
                Enrollee's right to designate a representative to file Complaints,
                Complaint Appeals and Action Appeals on his/her
                behalf;

            


    

    


    
      	 	
              iv) 

            	
              the
                availability of assistance from the Contractor for filing Complaints,
                Complaint Appeals and Action
                Appeals;

            


    

    


    
      	 	
              v) 

            	
              the
                toll-free numbers to file oral Complaints, Complaint Appeals and
                Action
                Appeals;

            


    

    


    
      	 	
              vi) 

            	
              the
                Enrollee's right to request continuation of benefits while an Action
                Appeal or state fair hearing is pending, and that if the Contractor's
                Action is upheld in a hearing, the Enrollee may be liable for the
                cost of
                any continued benefits;

            


    

    


    


    


    


    


    SECTION
      14

    (ACTION
      AND GRIEVANCE SYSTEM)

    October
      1, 2005

    14-2

    



    vii)
      the
      right of the provider to reconsideration of an Adverse Determination pursuant
      to
      Section 4903(6) of the PHL;
      and

    


    viii)
      the
      right of the provider to appeal a retrospective Adverse Determination pursuant
      to Section 4904(1) of the PHL.

    


    14.5
       Complaint,
      Complaint Appeal and Action Appeal Investigation Determinations

    


    The
      Contractor must adhere to determinations resulting from Complaint, Complaint
      Appeal and Action Appeal investigations conducted by SDOH.

    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    SECTION
      14

    (ACTION
      AND GRIEVANCE SYSTEM)

    October
      1, 2005

    14-3

    



    15.
      ACCESS REQUIREMENTS

    


    15.1
       General
      Requirement

    


    The
      Contractor will establish and implement mechanisms to ensure that Participating
      Providers comply with timely access requirements, monitor regularly to determine
      compliance and take corrective action if there is a failure to
      comply.

    


    15.2
       Appointment
      Availability Standards

    


    a)
       The
      Contractor shall comply with the following minimum appointment availability
      standards, as applicable1.

    


    i)  For
      emergency care: immediately upon presentation at a service delivery

    site.

    ii)  For
      urgent care: within twenty-four (24) hours of request.

    iii)  Non-urgent
      "sick" visit: within forty-eight (48) to seventy-two (72)

    hours
      of
      request, as clinically indicated

    iv)  Routine
      non-urgent, preventive appointments: within four (4) weeks of

    request.
      

    v)  Specialist
      referrals (not urgent): within four (4) to six (6) weeks of

    request.

     vi)  nitial
      prenatal visit: within three (3) weeks during first trimester,
      within

    two
      (2)
      weeks during the second trimester and within one (1) week

    during
      the third trimester. 

    vii)  Adult
      Baseline and routine physicals: within twelve (12) weeks from

    enrollment.
      (Adults >21 years). 

    viii)  Well
      child care: within four (4) weeks of request. 

    ix)  nitial
      family planning visits: within two (2) weeks of request. 

    x)  Pursuant
      to an emergency or hospital discharge, mental health or

    substance
      abuse follow-up visits with a Participating Provider (as

    included
      in the Benefit Package): within five (5) days of request, or as

    clinically
      indicated. 

    xi)  Non-urgent
      mental health or substance abuse visits with a Participating

    Provider
      (as included in the Benefit Package): within two (2) weeks of

    request.
      

    xii)  Initial
      PCP
      office
      visit for newborns:
      within
      two (2) weeks of hospital

    discharge.
      

    xiii)  Provider
      visits to make health, mental health and substance abuse assessments for the
      purpose of making recommendations regarding a

    


    _________________________

    1
      These
      are general standards and are not intended to supersede sound clinical judgment
      as to the necessity for care and services on a more expedient basis, when judged
      clinically necessary and appropriate.

    


    SECTION
      15

    (ACCESS
      REQUIREMENTS)

    October
      1, 2005

    


    15-1

    



    recipient's
      ability to perform work when requested by a LDSS:
      within
      ten (10) days of request by an MMC Enrollee,
      in
      accordance with Section 10.7 of this Agreement.

    


    15.3
       Twenty-Four
      (24) Hour Access

    


    a)
       The
      Contractor must provide access to medical services and coverage to Enrollees,
      either
      directly or through their PCPs
      and
OB/GYNs,
      on a
      twenty-four (24) hour a day, seven (7) day a week basis. The Contractor must
      instruct Enrollees on what to do to obtain services after business hours and
      on
      weekends.

    


    b)  The
      Contractor may satisfy the requirement in Section 15.3(a) by requiring their
      PCPs and OB/GYNs to have primary responsibility for serving as an after hours
      "on-call"
      telephone resource to members with medical problems. Under no circumstances
      may
      the Contractor routinely refer calls to an emergency room.

    


    15.4
       Appointment
      Waiting Times

    


    Enrollees
      with appointments shall not routinely be made to wait longer than one
      hour.

    


    15.5
       Travel
      Time Standards

    


    a)
       The
      Contractor will maintain a network that is geographically accessible to the
      population to be served.

    


    b)
       Primary
      Care

    


    i)  Travel
      time/distance to primary care sites shall not exceed thirty (30) minutes from
      the Enrollee's
      residence in metropolitan areas or thirty (30) minutes/thirty (30) miles from
      the Enrollee's
      residence in non-metropolitan areas. Transport time and distance in rural areas
      to primary care sites may be greater than thirty (30) minutes/thirty (30) miles
      from the Enrollee's residence if based on the community standard for accessing
      care or if by Enrollee choice.

    


    ii)  Enrollees
      may, at their discretion, select participating PCPs located farther from their
      homes as long as they are able to arrange and pay for transportation to the
      PCP
      themselves.

    


    c)  Other
      Providers

    


    Travel
      time/distance to specialty care, hospitals, mental health, lab and x-ray
      providers shall not exceed thirty (30) minutes/thirty (30) miles from
      the

    


    SECTION
      15

    (ACCESS
      REQUIREMENTS)

    October
      1, 2005

    15-2

    



    Enrollee's
      residence. Transport time and distance in rural areas to specialty care,
      hospitals, mental health, lab and x-ray providers may be greater than thirty
      (30) minutes/thirty (30) miles from the Enrollee's residence if based on the
      community standard for accessing care or if by Enrollee
      choice.

    


    15.6
       Service
      Continuation

    


    a)
       New
      Enrollees

    


    
      	 	
              i) 

            	
              If
                a new Enrollee has an existing relationship with a health care provider
                who is not a member of the Contractor's provider network, the contractor
                shall permit the Enrollee to continue an ongoing course of treatment
                by
                the Non-Participating Provider during a transitional period of up
                to sixty
                (60) days from the Effective Date of Enrollment, if, (1) the Enrollee
                has
                a life-threatening disease or condition or a degenerative and disabling
                disease or condition, or (2) the Enrollee has entered the second
                trimester
                of pregnancy at the Effective Date of Enrollment, in which case the
                transitional period shall include the provision of post-partum
                care directly related to the delivery up until sixty (60) days post
                partum.
                If
                the new Enrollee elects to continue to receive care from such
                Non-Participating Provider, such care shall be authorized by the
                Contractor for the transitional period only if the Non-Participating
                Provider agrees to:

            


    

    


    A)
       accept
      reimbursement from the Contractor at rates established by the Contractor as
      payment in mil,
      which
      rates shall be no more than the level of reimbursement applicable to similar
      providers within the Contractor's network for such services; and

    


    B)  adhere
      to
      the Contractor's quality assurance requirements and agrees to provide to the
      Contractor necessary medical information related to such care; and

    


    C)  otherwise
      adhere to the Contractor's
      policies and procedures including, but not limited to procedures regarding
      referrals and obtaining pre-authorization
      in a
      treatment plan approved by the Contractor.

    


    
      	 	
              ii) 

            	
              In
                no event shall this requirement be construed to require the Contractor
                to
                provide coverage for benefits not otherwise
                covered.

            


    

    


    b)  Enrollees
      Whose Health Care Provider Leaves Network

    


    
      	 	
              i)
                

            	
              The
                Contractor shall permit an Enrollee, whose health care provider has
                left
                the Contractor's network of providers, for reasons other than imminent
                harm to patient care, a determination of fraud or a final disciplinary
                action by a state licensing board that impairs the health professional's
                ability to practice, to continue an ongoing course of treatment with
                the
                Enrollee's

            


    

    


    


    


    


    SECTION
      15

    (ACCESS
      REQUIREMENTS)

    October
      1, 2005

    15-3

    



    current
      health care provider during a transitional period, consistent with PHL§
      4403(6)(e).

    


    
      	 	
              ii)

            	
              The
                transitional period shall continue up to ninety (90) days from the
                date
                the provider's contractual obligation to provide services to the
                Contractor's Enrollees
                terminates; or, if the Enrollee
                has entered the second trimester of pregnancy, for a transitional
                period
                that includes the provision of post-partum
                care directly related to the delivery through sixty (60) days post
                partum.
                If
                the Enrollee elects to continue to receive care from such
                Non-Participating Provider, such care shall be authorized by the
                Contractor for the transitional period only if the Non-Participating
                Provider agrees to:

            


    

    


    A)
       accept
      reimbursement from the Contractor at rates established by the Contractor as
      payment in full, which rates shall be no more than the level of reimbursement
      applicable to similar providers within the Contractor's network for such
      services;

    


    B)  adhere
      to
      the Contractor's quality assurance requirements and agrees to provide to the
      Contractor necessary medical information related to such care; and

    


    C)  otherwise
      adhere to the Contractor's policies and procedures including, but not limited
      to
      procedures regarding referrals and obtaining pre-authorization
      in a
      treatment plan approved by the Contractor.

    


    
      	 	
              iii) 

            	
              In
                no event shall this requirement be construed to require the Contractor
                to
                provide coverage for benefits not otherwise
                covered.

            


    

    


    15.7
       Standing
      Referrals

    


    The
      Contractor will implement policies and procedures to allow for standing
      referrals to specialist physicians for Enrollees who have ongoing needs for
      care
      from such specialists, consistent with PHL § 4403 (6)(b).

    


    15.8
       Specialist
      as a Coordinator of Primary Care

    


    The
      Contractor will implement policies and procedures to allow Enrollees with a
      life-threatening or degenerative and disabling disease or condition, which
      requires prolonged specialized medical care, to receive a referral to a
      specialist, who will then function as the coordinator of primary and specialty
      care for that Enrollee, consistent with PHL § 4403(6)(c).

    


    


    SECTION
      15

    (ACCESS
      REQUIREMENTS)

    October
      1, 2005

    15-4

    



    15.9
       Specialty
      Care Centers

    


    The
      Contractor will implement policies and procedures to allow Enrollees
      with a
      life-threatening or a degenerative and disabling condition or disease, which
      requires prolonged specialized medical care to receive a referral to an
      accredited or designated specialty care center with expertise in treating the
      life-threatening or degenerative and disabling disease
      or
      condition, consistent with PHL
      §
      4403(6)(d).

    


    15.10
       Cultural
      Competence

    


    The
      Contractor will participate in the State's efforts to promote the delivery
      of
      services in a culturally competent manner to all Enrollees, including those
      with
      limited English proficiency and diverse cultural and ethnic
      backgrounds.

    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    SECTION
      15

    (ACCESS
      REQUIREMENTS)

    October
      1, 2005

    15-5

    



    16.
       QUALITY ASSURANCE

    


    16.1
       Internal
      Quality Assurance Program

    


    a)
       Contractor
      must operate a quality assurance program which is approved by SDOH
      and
      which includes methods and procedures to control the utilization of services
      consistent with Article 49 of the PHL
      and 42
CFR
      Part
      456. Enrollee's
      records
      must include information needed to perform utilization review as
      specified
      in 42
      CFR §§
      456.111
      and 456.211. The Contractor's approved quality assurance program must be kept
      on
      file by the Contractor. The Contractor shall not modify the quality assurance
      program without the prior written approval of the SDOH.

    b)  The
      Contractor shall incorporate the findings from reports in Section 18 of this
      Agreement into its quality assurance program. Where performance is less than
      the
      statewide average or another standard as defined by the SDOH and developed
      in
      consultation with MCOs
      and
      appropriate clinical experts, the Contractor will be required to develop and
      implement a plan for improving performance that is approved by the SDOH and
      that
      specifies the expected level of improvement and timeframes
      for
      actions expected to result in such improvement,
      hi
      the
      event that such approved plan proves to be impracticable or does not result
      in
      the expected level of improvement, the Contractor shall, in consultation with
      SDOH, develop alternative plans to achieve improvement, to be implemented upon
      SDOH approval. If requested by SDOH, the Contractor agrees to meet with the
      SDOH
      to review improvement plans and quality performance.

    


    16.2
       Standards
      of Care

    


    a)
       The
      Contractor must adopt practice guidelines consistent with current standards
      of
      care, complying with recommendations of professional specialty groups or the
      guidelines of programs such as the American Academy of Pediatrics, the American
      Academy of Family Physicians, the US Task Force on Preventive Care, the New
      York
      State Child/Teen
      Health Program (C/THP)
      standards
      for provision of care to individuals under age twenty-one (21), the American
      Medical Association's Guidelines for Adolescent and Preventive Services, the
      US
      Department of Health and Human Services Center for Substance Abuse Treatment,
      the American College of Obstetricians and Gynecologists, the American Diabetes
      Association, and the AIDS Institute clinical standards for adult, adolescent,
      and pediatric
      care.

    


    b)
       The
      Contractor must ensure that its decisions for utilization management,
enrollee
      education, coverage of services, and other areas to which the practice
      guidelines apply are consistent with the guidelines.

    


    SECTION
      16

    (QUALITY
      ASSURANCE)

    October
      1, 2005

    16-1

    



    c)  The
      Contractor must have mechanisms in place to disseminate any changes in practice
      guidelines to its Participating Providers at least annually, or more frequently,
      as appropriate.

    


    d)  The
      Contractor shall develop and implement protocols for identifying Participating
      Providers who do not adhere to practice guidelines and for making reasonable
      efforts to improve the performance of these providers.

    


    e)  Annually,
      the Contractor shall select a minimum of two practice guidelines and monitor
      the
      performance of appropriate Participating Providers (or a sample of providers)
      against such guidelines.

    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    SECTION
      16

    (QUALITY
      ASSURANCE)

    October
      1, 2005

    16-2

    



    17.
       MONITORING
      AND EVALUATION

    


    17.1
       Right
      to
      Monitor Contractor Performance

    


    The
      SDOH
      or its
designee,
      and
DHHS
      shall
      each have the right, during the Contractor's normal operating hours, and at
      any
      other time a Contractor function or activity is being conducted,
      to
      monitor and evaluate, through inspection or other means, the Contractor's
      performance, including, but not limited to, the quality, appropriateness, and
      timeliness of
      services provided under this Agreement.

    


    17.2
       Cooperation
      During Monitoring and Evaluation

    


    The
      Contractor shall cooperate with and provide reasonable assistance to the SDOH
      or
      its designee, and DHHS in the monitoring and evaluation of the services provided
      under this Agreement.

    


    17.3
       Cooperation
      During On-Site
      Reviews

    


    The
      Contractor shall cooperate with SDOH and/or
      its
      designee in any on-site
      review
      of
      the Contractor's operations. SDOH shall give the Contractor notification of
      the
      date(s) and survey format for any full operational review at least forty-five
      (45) days prior to the site visit. This requirement shall not preclude SDOH
      or
      its designee from site visits upon shorter notice for other monitoring
      purposes.

    


    17.4
       Cooperation
      During Review of Services by External Review Agency

    


    The
      Contractor shall comply with all requirements associated with any review of
      the
      quality of services rendered to its Enrollees
      to be
      performed by an external review agent selected by the SDOH.

    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    SECTION
      17

    (MONITORING
      AND EVALUATION)

    October
      1, 2005

    17-1

    



    18.
       CONTRACTOR
      REPORTING REQUIREMENTS

    


    18.1
       General
      Requirements

    


    a)
       The
      Contractor must maintain a health information system that collects, analyzes,
      integrates, and reports data. The system must provide information on areas,
      including but not limited to, utilization.
      Complaints and Appeals, and Disenrollments
      for
      other than loss of Medicaid
      or
FHPlus
      eligibility. The system must be sufficient
      to
      provide the data necessary to comply with the requirements of this
      Agreement.

    


    b)  The
      Contractor must take the following steps to ensure that data received from
      Participating Providers is accurate and complete: verify the accuracy and
      timeliness of reported data; screen the data for completeness, logic and
      consistency; and collect utilization data in standardized formats as requested
      by SDOH.

    


    18.2
       Time
      Frames for Report Submissions

    


    Except
      as
      otherwise specified herein, the Contractor shall prepare and submit to SDOH
      the
      reports required under this Agreement in an agreed media format within sixty
      (60) days of the close of the applicable semi-annual or annual reporting period,
      and within fifteen (15) business days of the close of the applicable quarterly
      reporting period.

    


    18.3
       SDOH
      Instructions for Report Submissions

    


    SDOH
      will
      provide Contractor with instructions for submitting the reports required by
      SDOH
      in Section 18.6 of this Agreement, including time frames, and requisite formats.
      The instructions, time frames and formats may be modified by SDOH upon sixty
      (60) days written notice to the Contractor.

    


    18.4
       Liquidated
      Damages

    


    The
      Contractor shall pay liquidated damages of $2,500 to SDOH if any report required
      pursuant to this Section is materially incomplete, contains material
misstatements
      or
      inaccurate information, or is not submitted in the requested format. The
      Contractor shall pay liquidated damages of $2,500 to the SDOH if its monthly
      encounter data submission is not received by the Fiscal Agent by the due date
      specified in Section 18.6 (a) (iv)
      of this
      Agreement. The Contractor shall pay liquidated damages of $500 to SDOH for
      each
      day other reports required by this Section are late. The SDOH shall not impose
      liquidated damages for a first time infraction by the Contractor unless the
      SDOH
      deems the infraction to be a material misrepresentation of fact or the
      Contractor fails to cure the first infraction within a reasonable period of
      time
      upon notice from the SDOH. Liquidated damages may be waived at the sole
      discretion of SDOH. Nothing in this Section

    


    


    


    


    


    


    SECTION
      18

    (CONTRACTOR
      REPORTING REQUIREMENTS)

    October
      1, 2005

    18-1

    



    shall
      limit other remedies or rights available to SDOH
      relating
      to the timeliness, completeness and/or
      accuracy of Contractor's reporting submission.

    


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

    


    SDOH
      may
      extend due dates, or modify report requirements or formats upon a written
      request by the Contractor to the SDOH, where the Contractor has demonstrated
      a
      good and compelling reason for the extension or modification. The determination
      to grant a modification or extension of time shall be made by SDOH.

    


    18.6
       Reporting
      Requirements

    


    a)
       The
      Contractor shall submit the following reports to SDOH (unless
      otherwise specified). The Contractor will certify the data submitted pursuant
      to
      this section as required by SDOH. The certification shall be in the manner
      and
      format established by SDOH and must attest, based on best knowledge,
      information, and belief to the accuracy, completeness and truthfulness of the
      data being submitted.

    


    
      	 	
              i) 

            	
              Annual
                Financial Statements:

            


    

    


    
      	 	 	
              Contractor
                shall submit Annual Financial Statements to SDOH. The due date for
                annual
                statements shall be April 1 following the report closing
                date.

            


    

    


    
      	 	
              ii) 

            	
              Quarterly
                Financial Statements:

            


    

    


    
      	 	 	
              Contractor
                shall submit Quarterly Financial Statements to SDOH. The due date
                for
                quarterly reports shall be forty-five (45) days after the end of
                the
                calendar quarter.

            


    

    


    
      	 	
              iii) 

            	
              Other
                Financial Reports:

            


    

    


    
      	 	 	
              Contractor
                shall submit financial reports, including certified annual financial
                statements, and make available documents relevant to its financial
                condition to SDOH and the State Insurance Department (SID)
                in
                a timely manner as required by State laws and regulations, including
                but
                not limited to PHL §§ 4403-a,
                4404 and 4409, Title 10 NYCRR
                Part 98; and when applicable, SIL §§
                304, 305, 306, and 310. The SDOH may require the Contractor to submit
                such
                relevant financial reports and documents related to its financial
                condition to the LDSS.

            


    

    


    


    


    


    


    


    


    


    


    


    


    SECTION
      18

    (CONTRACTOR
      REPORTING REQUIREMENTS)

    October
      1, 2005

    18-2

    



    
      	 	
              iv) 

            	
              Encounter
                Data:

            


    

    


    The
      Contractor shall prepare and submit encounter data on a monthly basis to
SDOH
      through
SDOH's
      designated Fiscal Agent. Each provider is required to have a unique identifier.
      Submissions shall be comprised of encounter records or adjustments to previously
      submitted records, which the Contractor has received and processed from provider
      encounter or claim records of all contracted services rendered to the
Enrollee
      in the
      current or any preceding months. Monthly submissions must be received by the
      Fiscal Agent in accordance with the time frames specified in the MEDS
      II data
      dictionary on the HPN
      to
      assure the submission is included in the Fiscal Agent's monthly production
      processing.

    


    
      	 	
              v) 

            	
              Quality
                of Care Performance Measures:

            


    

    


    The
      Contractor shall prepare and submit reports to SDOH, as specified in the Quality
      Assurance Reporting Requirements (QARR).
      The
      Contractor must arrange for an NCQA-certified
      entity
      to audit the QARR data prior to its submission to the SDOH unless this
      requirement is specifically waived by the SDOH. The SDOH will select the
      measures which will be audited.

    


    
      	 	
              vi) 

            	
              Complaint
                and Action Appeal Reports:

            


    

    


    A)
       The
      Contractor must provide the SDOH on a quarterly basis, and within fifteen (15)
      business days of the close of the quarter, a summary of all Complaints and
      Action Appeals subject to PHL§4408-a
      received
      during the preceding quarter via the Summary Complaint Form on the Health
      Provider Network. The Summary Complaint Form has been developed by the SDOH
      to
      categorize the type of Complaints and Action Appeals subject to PHL § 4408-a
      received by the Contractor.

    


    B)  The
      Contractor agrees to provide on a quarterly basis, via Summary Complaint Form
      on
      the HPN, the total number of Complaints and Action Appeals subject to PHL §
4408-a that have been unresolved for more than forty-five (45) days. The
      Contractor shall maintain records on these and other Complaints, Complaint
      Appeals and Action Appeals pursuant to Appendix F
      of this
      Agreement.

    


    C)  Nothing
      in this Section is intended to limit the right of the SDOH or its designee
      to
      obtain information immediately from a Contractor pursuant to investigating
      a
      particular Enrollee or provider Complaint, Complaint Appeal or Action
      Appeal.

    


    


    


    


    


    


    


    SECTION
      18

    (CONTRACTOR
      REPORTING REQUIREMENTS)

    October
      1, 2005

    18-3

    



    vii)
      Fraud
      and Abuse Reporting Requirements:

    


    A)
       The
      Contractor must submit quarterly, via the HPN
      Complaint reporting format, the number of Complaints of fraud or abuse made
      to
      the Contractor that warrant preliminary investigation by the
      Contractor.

    


    B)  The
      Contractor also
      must
      submit to the SDOH
      the
      following information on an ongoing basis for each confirmed case of fraud
      and
      abuse it identifies through Complaints, organizational monitoring, contractors,
      subcontractors, providers, beneficiaries, Enrollees,
      or any
      other source:

    


    I)
       The
      name
      of the individual or entity that committed the fraud or abuse;

    II)
       The
      source that identified the fraud or abuse;

    III)
       The
      type
      of provider, entity or organization
      that committed the fraud or abuse;

    IV)
       A
      description of the fraud or abuse;

    V)
       The
      approximate dollar amount of the fraud or abuse;

    VI)
       The
      legal
      and administrative disposition of the case, if available, including actions
      taken by law enforcement officials to whom the case has been referred;
      and

    VII)
       Other
      data/information
      as prescribed by SDOH.

    


    C)  Such
      report shall be submitted when cases of fraud and abuse are confirmed, and
      shall
      be reviewed and signed by an executive officer of the Contractor.

    


    viii)
      Participating Provider Network Reports:

    


    The
      Contractor shall submit electronically, to the HPN, an updated provider network
      report on a quarterly basis. The Contractor shall submit an annual notarized
      attestation that the providers listed in each submission have executed an
      agreement with the Contractor to serve Contractor's MMC
      and/or
      FHPlus
      Enrollees, as applicable. The report submission must comply with the Managed
      Care Provider Network Data Dictionary. Networks must be reported separately
      for
      each county in which the Contractor operates.

    


    
      	 	
              ix) 

            	
              Appointment
                Availability/Twenty-four
                (24) Hour Access and Availability

            


    

    Surveys:

    


    The
      Contractor will conduct a county specific (or service area if appropriate)
      review of appointment availability and twenty-four (24) hour

    


    


    


    


    


    


    


    


    SECTION
      18

    (CONTRACTOR
      REPORTING REQUIREMENTS)

    October
      1, 2005

    18-4

    



    access
      and availability surveys annually. Results of such surveys must be kept on
      file
      and be readily available for review by the SDOH
      or
LDSS,
      upon
      request.

    


    
      	 	
              x) 

            	
              Clinical
                Studies:

            


    

    


    A)
       The
      Contractor will participate in up to four (4) SDOH sponsored focused clinical
      studies annually. The purpose of these studies will be to promote quality
      improvement.

    


    B)  The
      Contractor is required to conduct at least one (1) internal performance
      improvement project each year in a priority topic area of its choosing with
      the
      mutual agreement of the SDOH and SDOH's
      external
      quality review organization. The Contractor may conduct its performance
      improvement project in conjunction with one or more MCOs.
      The
      purpose of these projects will be to promote quality improvement within the
      Contractor's MMC
      and/or
      FHPlus
      product.
      SDOH will provide guidelines which address study structure and reporting format.
      Written reports of these projects will be provided to the SDOH and validated
      by
      the external quality review organization.

    


    
      	 	
              xi) 

            	
              Independent
                Audits:

            


    

    


    The
      Contractor must submit copies of all certified financial statements and
QARR
      validation audits by auditors independent of the Contractor to the SDOH within
      thirty (30) days of receipt by the Contractor.

    


    xii)New
      Enrollee
      Health
      Screening Completion Report-The
      Contractor shall submit a quarterly report within thirty (30) days of the close
      of the quarter showing the percentage of new Enrollees
      for
      which the Contractor was able to complete a health screening consistent with
      Section 13.6(a)(ii) of this Agreement.

    


    xiii)
      Additional Reports:

    


    Upon
      request by the SDOH, the Contractor shall prepare and submit other operational
      data reports. Such requests will be limited to situations in which the desired
      data is considered essential and cannot be obtained through existing Contractor
      reports. Whenever possible, the Contractor will be provided with ninety (90)
      days notice and the opportunity to discuss and comment on the proposed
      requirements before work is begun. However, the SDOH reserves the right to
      give
      thirty (30) days notice in circumstances where time is of the
      essence.

    


    


    


    


    


    


    


    


    


    SECTION
      18

    (CONTRACTOR
      REPORTING REQUIREMENTS)

    October
      1, 2005

    18-5

    18.7
       Ownership
      and Related Information Disclosure

    


    The
      Contractor shall report ownership and related information to SDOH,
      and upon
      request to the Secretary of Health and Human Services and the Inspector General
      of Health and Human Services, in accordance with 42 U.S.C. §§
      1320a-3
      and 1396b(m)(4) (Sections 1124 and 1903(m)(4)
      of
      the SSA).

    


    18.8
       Public
      Access to Reports

    


    Any
      data,
      information, or reports collected and prepared by the Contractor and submitted
      to NYS
      authorities in the course of performing their duties and obligation under this
      Agreement will be deemed to be a record of the SDOH subject to and consistent
      with the requirements of Freedom of Information Law. This provision is made
      in
      consideration of the Contractor's participation in the MMC
      and/or
      FHPlus
      Program
      for which the data and information is collected, reported, prepared and
      submitted.

    


    18.9
       Professional
      Discipline

    


    a)
       Pursuant
      to PHL§4405-b,
      the
      Contractor shall have in place policies and procedures to report to the
      appropriate professional disciplinary agency within thirty (30) days of
      occurrence of any of the following:

    


    
      	 	
              i) 

            	
              the
                termination of
                a health care Provider Agreement pursuant to Section 4406-d
                of
                the PHL for reasons relating to alleged mental and physical
                impairment,
                misconduct or impairment of patient safety or
                welfare;

            


    

    


    
      	 	
              ii) 

            	
              the
                voluntary or involuntary termination of a contract or employment
                or other
                affiliation with such Contractor to
                avoid the imposition of disciplinary measures;
                or

            


    

    


    
      	 	
              iii) 

            	
              the
                termination of a health care Participating Provider Agreement in
                the case
                of a determination of fraud or in a case of imminent harm to patient
                health.

            


    

    


    b)  The
      Contractor shall make a report to the appropriate professional disciplinary
      agency within thirty (30) days of obtaining knowledge of any information that
      reasonably appears to show that a health professional is guilty of professional
      misconduct as defined in Articles 130 and 131-A of the New York State Education
      Law (Education Law).

    


    


    


    


    


    


    


    


    


    


    


    SECTION
      18

    (CONTRACTOR
      REPORTING REQUIREMENTS)

    October
      1, 2005

    18-6

    



    
      	 	
              18.10
                

            	
              Certification
                Regarding Individuals Who Have Been Debarred Or Suspended By Federal
                or
                State Government

            


    

    


    a)
       Contractor
      will certify to the SDOH
      initially and immediately upon changed circumstances from the last such
      certification that it does not knowingly have an individual who has been
      debarred or suspended by the federal or state government,
      or
      otherwise excluded from participating in procurement activities:

    


    
      	 	
              i) 

            	
              as
                a director, officer, partner or person with beneficial ownership
                of more
                than five percent (5%) of the Contractor's equity;
                or

            


    

    


    
      	 	
              ii) 

            	
              As
                a party to an employment, consulting or other agreement with the
                Contractor for the provision of items and services that are significant
                and material to the Contractor's obligations in the MMC
                Program and/or
                the FHPlus
                Program, consistent with requirements ofSSA§
                1932 (d)(l).

            


    

    


    18.11
       Conflict
      of Interest Disclosure

    


    Contractor
      shall report to SDOH, in a format specified by SDOH, documentation, including
      but not limited to, the identity of and financial statements of person(s) or
      corporation(s)
      with an ownership or contract interest in the Contractor, or with any
      subcontracts)
      in
      which the Contractor has a five percent (5%) or more ownership interest,
      consistent with requirements of SSA§
1903
      (m)(2)(a)(viii)
      and
      42 CFR§§
      455.100 - 455.104.

    


    18.12
       Physician
      Incentive Plan Reporting

    


    The
      Contractor shall submit to SDOH annual reports containing the information on
      all
      of its Physician Incentive Plan arrangements in accordance with 42 CFR
      §
      438.6(h) or, if no such arrangements are in place, attest to that fact. The
      contents and time frame of such reports shall comply with the
      requirements of 42 CFR §§
      422.208
      and 422.210 and be in a format provided by SDOH.

    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    SECTION
      18

    (CONTRACTOR
      REPORTING REQUIREMENTS)

    October
      1, 2005

    18-7

    



    19.
       RECORDS MAINTENANCE
      AND AUDIT RIGHTS

    


    19.1
       Maintenance
      of Contractor Performance Records

    


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

    


    
      	 	
              i) 

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

            


    

    


    
      	 	
              ii) 

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

            


    

    


    
      	 	
              iii) 

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

            


    

    


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

    


    19.2
       Maintenance
      of Financial Records and Statistical Data

    


    The
      Contractor shall maintain all financial records and statistical data according
      to generally accepted accounting principles.

    


    19.3
       Access
      to
      Contractor Records

    


    The
      Contractor shall provide SDOH, the Comptroller of the State of New York,
DHHS,
      the
      Comptroller General of the United States, and their authorized representatives
      with access to all records relating to Contractor performance under this
      Agreement for the purposes of examination, audit, and copying (at reasonable
      cost to the requesting party) of such records. The Contractor shall give access
      to such records on two (2) business days prior written notice, during normal
      business hours, unless otherwise provided or permitted by applicable laws,
      rules, or regulations.

    


    


    


    


    


    


    


    


    


    


    SECTION
      19

    (RECORDS
      MAINTENANCE AND AUDIT RIGHTS)

    October
      1, 2005

    19-1

    


    19.4
       Retention
      Periods

    


    The
      Contractor shall preserve and retain all records relating to Contractor
      performance under this Agreement in readily accessible form during the term
      of
      this Agreement and for a period of six (6) years thereafter except that the
      Contractor shall retain Enrollees'
      medical
      records that are in the custody of the Contractor for six (6) years after the
      date of service rendered to the Enrollee
      or
      cessation of Contractor operation, and in the case of a minor, for six (6)
      years
      after majority. The Contractor shall require and make reasonable efforts to
      assure that Enrollees'
      medical
      records are retained by providers for six (6) years after the date of service
      rendered to the Enrollee or cessation of Contractor operation, and in the case
      of a minor, for six (6) years after majority. All provisions of this Agreement
      relating to record maintenance and audit access shall survive the termination
      of
      this Agreement and shall bind the Contractor until the expiration of a period
      of
      six (6) years commencing with termination of this Agreement or if an audit
      is
      commenced, until the completion of the audit, whichever occurs later. If the
      Contractor becomes aware of any litigation, claim, financial management review
      or audit that is started before the expiration of the six (6) year period,
      the
      records shall be retained until all litigation, claims, financial management
      reviews or audit findings involved in the record have been resolved and final
      action taken.

    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    SECTION
      19

    (RECORDS
      MAINTENANCE AND AUDIT RIGHTS)

    October
      1, 2005

    19-2

    



    20.
       CONFIDENTIALITY

    


    
      	 	
              20.1
                

            	
              Confidentiality
                of Identifying Information about Enrollees,
                Potential Enrollees
                and
                Prospective Enrollees

            


    

    


    All
      information relating to services to Enrollees, Potential Enrollees and
      Prospective Enrollees which is obtained by the Contractor, shall be
      confidential
      pursuant to the PHL,
      including PHL
      Article
27-F,
      the
      provisions of Section 369(4) of the
      SSL,
      42
U.S.C.§
      1396a(a)(7) (Section 1902(a)(7) of the SSA),
      Section
      33.13 of the Mental Hygiene Law, and regulations promulgated under such laws
      including 42 CFR
      Part 2
      pertaining to Alcohol and Substance Abuse Services. Such information, including
      information relating to services provided to Enrollees, Potential Enrollees
      and
      Prospective Enrollees under this Agreement, shall be used or disclosed by the
      Contractor only for a purpose directly connected with performance of the
      Contractor's obligations. It shall be the responsibility of the Contractor
      to
      inform its employees and contractors of the confidential nature of
      MMC
      and/or
      FHPlus
      information, as applicable.

    


    
      	 	
              20.2
                

            	
              Medical
                Records of Foster Children

            


    

    


    Medical
      records of Enrollees enrolled in foster care programs shall be disclosed to
      local social service officials in accordance with Sections 358-a, 384-a
      and 392
      of the SSL and 18 NYCRR§
      507.1.

    


    
      	 	
              20.3
                

            	
              Confidentiality
                of Medical Records

            


    

    


    Medical
      records of Enrollees pursuant to this Agreement shall be confidential and shall
      be disclosed to and by other persons within the Contractor's organization,
      including Participating Providers, only as necessary to provide medical care,
      to
      conduct quality assurance functions and peer review functions, or as necessary
      to respond to a complaint and appeal under the terms of this
      Agreement.

    


    
      	 	
              20.4
                

            	
              Length
                of Confidentiality Requirements

            


    

    


    The
      provisions of this Section shall survive the termination of this Agreement
      and
      shall bind the Contractor so long as the Contractor maintains any individually
      identifiable information relating to Enrollees, Potential Enrollees and
      Prospective Enrollees.

    


    


    


    


    


    


    


    


    


    


    


    


    SECTION
      20

    (CONFIDENTIALITY)

    October
      1, 2005

    20-1


    21.  PROVIDER
      NETWORK

    


    
      	 	
              21.1
                

            	
              Network
                Requirements

            


    

    


    a)
       The
      Contractor will establish and maintain a network of Participating
      Providers.

    


    
      	 	
              i) 

            	
              In
                establishing the network, the Contractor must consider the
                following:

            


    

    
      	 	 	
              anticipated
                Enrollment, expected utilization
                of services by the population to be enrolled, the number and types
                of
                providers necessary to furnish the services in the Benefit Package,
                the
                number of providers who are not accepting
                new patients, and the geographic location of the providers and
                Enrollees.

            


    

    


    
      	 	
              ii) 

            	
              The
                Contractor's network must contain all of the provider types necessary
                to
                furnish the prepaid Benefit Package, including but not limited
                to:

            


    

    
      	 	 	
              hospitals,
                physicians (primary care and specialists), mental health and substance
                abuse providers, allied health professionals, ancillary providers,
                DME
                providers, home health providers, and pharmacies, if
                applicable.

            


    

    


    
      	 	
              iii) 

            	
              To
                be considered accessible, the network must contain a sufficient number
                and
                array of providers to meet the diverse needs of the Enrollee
                population.
                This includes being geographically accessible (meeting time/distance
                standards) and being accessible for the
                disabled.

            


    

    


    b)  The
      Contractor shall not include in its network any provider

    


    
      	 	
              i)

            	
              who
                has been sanctioned or prohibited from participation in Federal health
                care programs under either Section 1128 or Section 1128A of the
                SSA;
                or

            


    

    


    
      	 	
              ii)
                

            	
              who
                has had his/her
                licensed suspended by the New York State Education Department or
                the
                SDOH
                Office of Professional Medical
                Conduct.

            


    

    


    c)  The
      Contractor must require that Participating Providers offer hours of operation
      that are no less than the hours of operation offered to commercial members
      or,
      if the provider serves only MMC
      Enrollees and/or
      FHPlus
      Enrollees,
      comparable to hours offered for Medicaid fee-for-service
      patients.

    


    d)  The
      Contractor shall submit its network for SDOH to assess for adequacy through
      the
HPN
      prior to
      execution of this Agreement, quarterly thereafter throughout the term of this
      Agreement, and upon request by SDOH when SDOH determines there has been a
      significant change that could affect adequate capacity and quarterly
      thereafter.

    


    e)  Contractor
      must limit participation to providers who agree that payment received from
      the
      Contractor for services included in the Benefit Package is

    


    


    


    


    


    SECTION
      21

    (PROVIDER
      NETWORK)

    October
      1, 2005

    21-1

    



    payment
      in full for services provided to Enrollees,
      except
      for the collection of applicable co-payments from Enrollees as provided by
      law.

    


    21.2
       Absence
      of Appropriate Network Provider

    


    In
      the
      event that the Contractor determines that it does not have a Participating
      Provider with appropriate training and experience to meet the particular health
      care needs of an Enrollee,
      the
      Contractor shall make a referral to an appropriate Non-Participating Provider,
      pursuant to a treatment plan approved by the Contractor in consultation with
      the
      Primary Care Provider, the Non-Participating Provider and the Enrollee or the
      Enrollee's designee.
      The
      Contractor shall pay for the cost of the services in the treatment plan provided
      by the Non-Participating Provider for as long as the Contractor is unable to
      provide the service through a Participating Provider.

    


    21.3
       Suspension
      of Enrollee Assignments To Providers

    


    The
      Contractor shall ensure that there is sufficient capacity, consistent with
      SDOH
      standards, to serve Enrollees under this Agreement. In the event any of the
      Contractor's Participating Providers are no longer able to accept assignment
      of
      new Enrollees due to capacity limitations, as determined by the SDOH, the
      Contractor will suspend assignment of any additional Enrollees to such
      Participating Provider until such provider is capable of further accepting
      Enrollees. When a Participating Provider has more than one (1) site, the
      suspension will be made by site.

    


    21.4
       Credentialing

    


    a)
       Credentialing/Recredentialing
      Process

    


    The
      Contractor shall have in place a formal process, consistent with SDOH
      Recommended Guidelines for Credentialing Criteria,
      for
credentialing
      Participating
      Providers on a periodic basis (not less than once every three (3) years) and
      for
      monitoring Participating Providers performance.

    


    b)  Licensure

    


    The
      Contractor shall ensure, in accordance with Article 44 of the PHL,
      that
      persons and entities providing care and services for the Contractor in the
      capacity of physician, dentist, physician assistant, registered nurse, other
      medical professional or paraprofessional,
      or other
      such person or entity satisfy all applicable licensing, certification, or
      qualification requirements under New York law and that the functions and
      responsibilities of such persons and entities in providing Benefit Package
      services under this Agreement do not exceed those permissible under New York
      law.

    


    


    


    


    SECTION
      21

    (PROVIDER
      NETWORK)

    October
      1, 2005

    21-2


    c)  Minimum
      Standards

    


    
      	 	
              i) 

            	
              The
                Contractor agrees that all network physicians will meet at least
                one (1)
                of the following standards, except as specified in Section 21.15
                (c) and
                Appendix I of this Agreement:

            


    

    A)
       Be
      board-certified or board-eligible in their area of specialty;

    B)  Have
      completed an accredited residency program; or

    C)
       Have
      admitting privileges at one (1) or more hospitals participating in the
      Contractor's network.

    


    21.5
       SDOH
      Exclusion or Termination of Providers

    


    If
      SDOH
      excludes or terminates a provider from its Medicaid
      program,
      the Contractor shall, upon learning of such exclusion or termination,
      immediately terminate the Provider Agreement with the Participating Provider
      with respect to the Contractor's MMC
      and/or
      FHPlus
      product,
      and agrees to no longer utilize the services of the subject provider, as
      applicable. The Contractor shall access information pertaining to excluded
      Medicaid providers through the SDOH Health Provider Network. Such information
      available to the Contractor on the HPN
      shall be
      deemed to constitute constructive notice. The HPN should not be the sole basis
      for identifying current exclusions or termination of previously approved
      providers. Should the Contractor become aware, through the HPN or any other
      source, of an SDOH exclusion or termination, the Contractor shall validate
      this
      information with the Office
      of
      Medicaid Management,
      Bureau
      of Enforcement Activities and comply with the provisions of this
      Section.

    


    21.6
       Application
      Procedure

    


    a)
       The
      Contractor shall establish a written application procedure to be used by a
      health care professional interested in serving as a Participating Provider
      with
      the Contractor. The criteria for selecting providers, including the minimum
      qualification requirements that a health care professional must meet to be
      considered by the Contractor, must be defined in writing and developed in
      consultation with appropriately qualified health care professionals. Upon
      request,
      the
      application procedures and minimum qualification requirements must be made
      available to health care professionals.

    


    b)  The
      selection process may not discriminate against particular providers that serve
      high-risk populations or specialize in conditions that require costly
      treatment.

    


    c)
       The
      Contractor may not
      discriminate with regard to the participation, reimbursement, or indemnification
      of any provider who is acting within the scope of his or her license or
      certification under applicable State law, solely on the basis of that license
      or
      certification. This does not preclude the Contractor from including providers
      only to the extent necessary to meet its

    


    


    


    


    


    SECTION
      21

    (PROVIDER
      NETWORK)

    October
      1, 2005

    21-3


    
      	 	 	
              needs;
                or from establishing different payment rates for different counties
                or
                different specialists; or from establishing measures designed to
                maintain
                the quality of services and control costs consistent with its
                responsibilities.

            


    

    


    
      	 	
              d) 

            	
              If
                the Contractor does not approve an individual or group of providers
                as
                Participating Providers, it must give the affected providers written
                notice of the reason for its
                decision.

            


    

    


    21.7
       Evaluation
      Information

    


    The
      Contractor shall develop and implement policies and procedures to ensure that
      Participating Providers are regularly advised of information maintained by
      the
      Contractor to evaluate their performance or practice. The Contractor shall
      consult with health care professionals in developing methodologies to collect
      and analyze Participating Providers profiling data. The Contractor shall provide
      any such information and profiling data and analysis to its Participating
      Providers. Such information, data or analysis shall be provided on a periodic
      basis appropriate to the nature and amount of data and the volume and scope
      of
      services provided. Any profiling data used to evaluate the performance or
      practice of a Participating Provider shall be measured against stated criteria
      and an appropriate group of health care professionals using similar treatment
      modalities serving a comparable patient population. Upon presentation of such
      information or data, each Participating Provider shall be given the opportunity
      to discuss the unique nature of his or her patient population which may have
      a
      bearing on the Participating Provider's profile and to work cooperatively with
      the Contractor to improve performance.

    


    21.8
       Choice/Assignment
      of Primary Care Providers (PCPs)

    


    a)
       The
      Contractor shall offer each Enrollee
      the
      choice of no fewer than three (3) Primary Care Providers within distance/travel
      time standards as set forth in Section 15.5 of this Agreement.

    


    b)  Contractor
      must assign a PCP
      to
Enrollees
      who fail
      to select a PCP.
      The
      assignment of a PCP by the Contractor may occur after written notification
      to
      the Contractor of the Enrollment (through Roster or other method) and after
      written notification of the Enrollee by the Contractor but in no event later
      than thirty (30) days after notification of Enrollment, and only after the
      Contractor has made reasonable efforts as set forth in Section 13.6 of this
      Agreement to contact the Enrollee and inform him/her
      of
      his/her
      right
      to choose a PCP.

    


    c)  PCP
      assignments should be made taking into consideration the following:

    
      	 	
              i) 

            	
              Enrollee's
                geographic location;

            


    

    
      	 	
              ii) 

            	
              any
                special health care needs, if known by the Contractor;
                and

            


    

    
      	 	
              iii) 

            	
              any
                special language needs, if known by the
                Contractor.

            


    

    


    


    


    


    SECTION
      21

    (PROVIDER
      NETWORK)

    October
      1, 2005

    21-4


    d)  In
      circumstances where the Contractor operates or contracts with a multi-provider
      clinic to deliver primary care services, the
      Enrollee
      must
      choose or be assigned a specific provider or provider team within the clinic
      to
      serve as his/her
      PCP.
      This
      "lead" provider will be held accountable for performing the PCP
      duties.

    


    21.9
       Enrollee
      PCP Changes

    


    a)
       The
      Contractor must allow Enrollees
      the
      freedom to change PCPs,
      without
      cause, within thirty (30) days of the Enrollee's
      first
      appointment with the PCP. After the first thirty (30) days, the Contractor
      may
      elect to limit the Enrollee to changing PCPs every six (6) months without
      cause.

    


    b)  The
      Contractor must process a request to change PCPs and advise the Enrollee of
      the
      effective date of the change within forty-five (45) days of receipt of the
      request. The change must be effective no later than the first (1st)
      day of
      the second (2nd)
      month
      following the month in which the request is made.

    


    c)  The
      Contractor will provide Enrollees with an opportunity to select a new PCP in
      the
      event that the Enrollee's current PCP leaves the network or otherwise becomes
      unavailable. Such changes shall not be considered in the calculation of changes
      for cause allowed within a six (6) month period.

    


    d)
       In
      the
      event that
      an
      assignment of a new PCP is necessary due to the unavailability of the Enrollee's
      former PCP, such assignment shall be made in accordance with the requirements
      of
      Section 21.8 of this Agreement.

    


    e)  In
      addition
      to those conditions and circumstances under which the Contractor may assign
      an
      Enrollee a PCP when the Enrollee fails to make an affirmative choice of a PCP,
      the Contractor may initiate a PCP change for an Enrollee under the following
      circumstances:

    


    
      	 	
              i) 

            	
              The
                Enrollee requires specialized care for an acute or chronic
                condition

            


    

    
      	 	 	
              and
                the Enrollee and Contractor agree that reassignment to a different
                PCP

            


    

    
      	 	 	
              is
                in the Enrollee's interest. 

            


    

    
      	 	
              ii) 

            	
              The
                Enrollee's place of residence has changed such that he/she has
                moved

            


    

    
      	 	 	
              beyond
                the PCP travel time/distance standard.


            


    

    
      	 	
              iii) 

            	
              The
                Enrollee's PCP ceases to participate in the Contractor's
                network.

            


    

    
      	 	
               iv) 

            	
              The
                Enrollee's behavior toward the PCP is disruptive and the PCP
                has

            


    

    
      	 	 	
              made
                all reasonable efforts to accommodate the Enrollee.
                

            


    

    
      	 	
              v) 

            	
              The
                Enrollee has taken legal action against the PCP or the PCP has
                taken

            


    

    
      	 	 	
              legal
                action against the Enrollee.

            


    

    


    f)  Whenever
      initiating a change, the Contractor must offer affected Enrollees the
      opportunity to select a new PCP in the manner described in this
      Section.

    


    SECTION
      21

    (PROVIDER
      NETWORK)

    October
      1, 2005

    21-5


    21.10
       Provider
      Status Changes

    


    a)
       PCP
      Changes

    


    
      	 	
              i) 

            	
              The
                Contractor agrees to notify its Enrollees
                of
                any of the following PCP changes:

            


    

    


    A)
       Enrollees
      will be notified within fifteen (15) days from the date on which the Contractor
      becomes aware that such Enrollee's
      PCP has
      changed his or her office address or telephone number.

    


    B)  If
      a PCP
      ceases participation in the Contractor's network, the Contractor shall provide
      written notice within fifteen (15) days from the date that the Contractor
      becomes aware of such change in status to each Enrollee
      who has
      chosen the provider as his or her PCP. In such cases, the notice shall describe
      the procedures for choosing an alternative PCP and, in the event that the
      Enrollee is in an ongoing course of treatment, the procedures for continuing
      care consistent with subdivision 6 (e) of
      PHL§
      4403.

    


    C)  Where
      an
      Enrollee's PCP ceases participation with the Contractor, the Contractor must
      ensure that the Enrollee selects or is asigned
      to a new
      PCP is assigned within thirty (30) days of the date of the notice to the
      Enrollee.

    


    b)  Other
      Provider Changes

    


    In
      the
      event that an Enrollee is in an ongoing course of treatment with another
      Participating Provider who becomes unavailable to continue to provide services
      to such Enrollee, the Contractor shall provide written notice to the Enrollee
      within fifteen (15) days from the date on which the Contractor becomes aware
      of
      the Participating Provider's unavailability to the Enrollee. In such cases,
      the
      notice shall describe the procedures for continuing care consistent with
PHL§
      4403(6)(e) and for choosing an alternative Participating Provider.

    


    21.11  PCP
      Responsibilities

    


    In
      conformance
      with the
      Benefit Package, the PCP shall provide health counseling and advice; conduct
      baseline and periodic health examinations; diagnose and treat conditions not
      requiring the services of a specialist; arrange inpatient
      care,
      consultations with specialists, and laboratory and radiological services when
      medically necessary; coordinate the findings of consultants and laboratories;
      and interpret such findings to the Enrollee and the Enrollee's family, subject
      to the confidentiality provisions of Section 20 of this Agreement,
      and

    


    


    


    


    


    


    SECTION
      21

    (PROVIDER
      NETWORK)

    October
      1, 2005

    21-6


    maintain
      a current medical record for the Enrollee.
      The
PCP
      shall
      also be responsible for determining the urgency of a consultation with a
      specialist and shall arrange for all consultation appointments within
      appropriate time frames.

    


    21.12
       Member
      to
      Provider Ratios

    


    a)
       The
      Contractor agrees to adhere to the member-to-PCP
      ratios
      shown below. These ratios are Contractor-specific, and assume the practitioner
      is a mil
      time
      equivalent (FTE)
      (defined
      as a provider practicing forty (40) hours per week for the
      Contractor):

    


    
      	 	
              i) 

            	
              No
                more than 1,500 Enrollees
                for each physician, or 2,400 for a physician practicing in combination
                with a registered physician assistant or a certified nurse
                practitioner.

            


    

    


    
      	 	
              ii) 

            	
              No
                more than 1,000 Enrollees for each certified nurse
                practitioner.

            


    

    


    b)  The
      Contractor agrees that these ratios will be prorated for Participating Providers
      who represent less than a FTE to the Contractor.

    


    21.13
       Minimum
      PCP Office Hours

    


    a)
       General
      Requirements

    


    A
      PCP
      must practice a minimum of sixteen (16) hours a week at each primary care
      site.

    


    b)
       Waiver
      of
      Minimum Hours

    


    The
      minimum office hours requirement may be waived under certain circumstances.
      A
      request for a waiver must be submitted by the Contractor to the Medical Director
      of the Office of Managed Care for review and approval; and the physician must
      be
      available at least eight hours/week; the physician must be practicing in a
      Health Provider Shortage Area (HPSA)
      or other
      similarly determined shortage area; the physician must be able to fulfill the
      other responsibilities of a PCP (as described in this Section); and the waiver
      request must demonstrate there are systems in place to guarantee continuity
      of
      care and to meet all access and availability standards (24-hour/7 days per
      week
      coverage, appointment availability, etc.).

    


    21.14
       Primary
      Care Practitioners 

    


    a)
       General
      Limitations

    


    The
      Contractor agrees to limit its PCPs
      to the
      following primary care specialties: Family Practice, General Practice, General
      Pediatrics, and General

    


    


    


    


    


    


    SECTION
      21

    (PROVIDER
      NETWORK)

    October
      1, 2005

    21-7


    Internal
      Medicine except as specified in paragraphs (b), (c),
      and
(d).
      of this
      Section.

    


    b)
       Specialist
      and Sub-specialist as PCPs

    


    The
      Contractor is permitted to use specialist and sub-specialist physicians as
      PCPs
      when such an action is considered by the Contractor to be medically appropriate
      and cost-effective. As an alternative, the Contractor may restrict its
PCP
      network
      to primary care specialties only, and rely on standing referrals to specialists
      and sub-specialists for Enrollees
      who
      require regular visits to such physicians.

    


    c)
       OB/GYN
      Providers as PCPs

    


    The
      Contractor, at its option, is permitted to use OB/GYN providers as PCPs, subject
      to SDOH
      qualifications.

    


    d)
       Certified
      Nurse Practitioners as PCPs

    


    The
      Contractor is permitted to use certified nurse practitioners as PCPs,
      subject
      to their scope of practice limitations under New York State Law.

    


    21.15  PCP
      Teams

    


    a)
       General
      Requirements

    


    The
      Contractor may designate teams of physicians/certified nurse practitioners
      to
      serve as PCPs for Enrollees. Such teams may include no more than four (4)
      physicians/certified nurse practitioners and, when an Enrollee chooses or is
      assigned to a team, one of the practitioners must be designated as "lead
      provider" for that Enrollee. In the case of teams comprised of medical residents
      under the supervision of an attending physician, the attending physician must
      be
      designated as the lead physician.

    


    b)
       Registered
      Physician Assistants as Physician Extenders

    


    The
      Contractor is permitted to use registered physician assistants as
      physician-extenders, subject to their scope of practice limitations under New
      York State Law.

    


    c)
       Medical
      Residents and Fellows

    


    The
      Contractor shall comply with SDOH Guidelines for use of Medical Residents and
      fellows as found in Appendix I, which is hereby made a part of this Agreement
      as
      if set forth fully herein.

    


    


    


    


    


    


    


    SECTION
      21

    (PROVIDER
      NETWORK)

    October
      1, 2005

    21-8

    



    21.16
       Hospitals

    


    a)
       Tertiary
      Services

    


    The
      Contractor will establish hospital networks capable of furnishing the full
      range
      of tertiary services to Enrollees.
      Contractors shall ensure that all Enrollees
      have
      access to at least one (1) general acute care hospital within thirty (30)
      minutes/thirty (30) miles travel time (by car or public transportation) from
      the
Enrollee's
      residence unless none are located within such a distance. If none are located
      within thirty (30) minutes travel time/
      thirty
      (30) miles travel distance, the Contractor must include the next closest site
      in
      its network.

    


    b)  Emergency
      Services

    


    The
      Contractor shall ensure and demonstrate that it maintains relationships with
      hospital emergency facilities, including comprehensive psychiatric emergency
      programs (where available) within and around its service area to provide
      Emergency Services.

    


    21.17
       Dental
      Networks

    


    a)
       If
      the
      Contractor includes dental services in its Benefit Package, the Contractor's
      dental network shall include geographically accessible general dentists
      sufficient to offer each Enrollee
      a choice
      of two (2) primary care dentists in their Service Area and to achieve a ratio
      of
      at least one (1) primary care dentist for each 2,000 Enrollees. Networks must
      also include at least one (1) pediatric
      dentist
      and one (1) oral surgeon. Orthognathic
      surgery,
      temporal mandibular
      disorders
      (TMD)
      and
oral/maxillofacial prosthodontics
      must be
      provided through any qualified dentist, either in-network
      or by
      referral. Periodontists
      and
endodontists
      must
      also be available by referral. The network should include dentists with
      expertise in serving special needs populations (e.g., HIV+ and developmentally
      disabled
      patients).

    


    b)
       Dental
      surgery performed in an ambulatory or inpatient
      setting
      is the responsibility of the Contractor whether dental services are a covered
      benefit or not,
      as set
      forth in Appendix K.2
      (25),
      Dental Services, of this Agreement.

    


    21.18
       Presumptive
      Eligibility Providers

    


    The
      Contractor must offer
      Presumptive Eligibility Providers the opportunity to be Participating Providers
      in its MMC
      product.
      The terms of the contract must be at least as favorable as the terms offered
      to
      other Participating Providers performing equivalent services (prenatal care).
      Contractors need not contract with every Presumptive Eligibility Provider in
      their counties, but must contract with a

    


    


    


    SECTION
      21

    (PROVIDER
      NETWORK)

    October
      1, 2005

    21-9

    



    sufficient
      number to meet the distance/travel time standards defined for primary
      care.

    


    21.19
       Mental
      Health and Chemical Dependence Services Providers

    


    a)
       The
      Contractor will include a full array of mental health and Chemical Dependence
      Services providers in its networks, in sufficient
      numbers to assure accessibility to Benefit Package services for both children
      and adults, using either individual, appropriately licensed practitioners or
      New
      York State Office of Mental Health (OMH)
      and
      Office of Alcohol and Substance Abuse Services (OASAS)
      licensed
      programs and clinics, or both.

    


    b)  The
      State
      defines mental health and Chemical Dependence Services providers to include
      the
      following: Individual Practitioners, Psychiatrists, Psychologists, Psychiatric
      Nurse Practitioners, Psychiatric Clinical Nurse Specialists, Licensed Certified
      Social Workers, OMH and OASAS Programs and Clinics, and providers of mental
      health and/or
      Chemical Dependence Services certified or licensed pursuant to Article 31 or
      32
      of the Mental Hygiene Law, as appropriate.

    


    21.20
       Laboratory
      Procedures

    


    The
      Contractor agrees to restrict its laboratory provider network to entities having
      either a CLIA
      certificate of registration or a CLIA
      certificate of waiver.

    


    21.21
       Federally
      Qualified Health Centers (FQHCs)

    


    a)
       In
      a county
      where Enrollment in the Contractor's MMC
      product
      is voluntary, the Contractor is not required to contract with FQHCs. However,
      when an FQHC
      is a
      Participating Provider of the Contractor network, the Provider Agreement must
      include a provision whereby the Contractor agrees to compensate the FQHC for
      services provided to Enrollees
      at a
      payment rate that is not less than the level and amount that the Contractor
      would pay another Participating Provider that is not an FQHC for a similar
      set
      of services.

    


    b)
       In
      a
      county where Enrollment in the Contractor's MMC product is mandatory
      and/or
      the
      Contractor offers a FHPlus
      product,
      the Contractor shall contract with FQHCs operating in that county. However,
      the
      Contractor has the option to make a written request to the SDOH
      for an
      exemption from the FQHC contracting requirement, if the Contractor can
      demonstrate, with supporting documentation, that it has adequate capacity and
      will provide a comparable level of clinical and enabling services (e.g.,
      outreach, referral services, social support services, culturally sensitive
      services such as training for medical and administrative staff, medical and
      non-medical and case management services) to vulnerable populations in lieu
      of
      contracting with an FQHC in the county.

    


    


    


    


    SECTION
      21

    (PROVIDER
      NETWORK)

    October
      1, 2005

    21-10


    Written
      requests for exemption from this requirement are subject to approval
by
      CMS.

    


    c)  When
      the
      Contractor is participating in a county where an MCO
      that is
      sponsored, owned and/or
      operated by one or more FQHCs
      exists,
      the Contractor is not required to include any FQHCs within its network in that
      county.

    


    21.22
       Provider
      Services Function

    


    a)
       The
      Contractor will operate a Provider Services function during regular business
      hours. At a minimum, the Contractor's Provider Services staff must be
      responsible for the following:

    


    
      	 	
              i) 

            	
              Assisting
                providers with prior authorization and referral
                protocols.

            


    

    


    
      	 	
              ii) 

            	
              Assisting
                providers with claims payment
                procedures.

            


    

    


    
      	 	
              iii) 

            	
              Fielding
                and responding to provider questions and
                complaints.

            


    

    


    21.23
       Pharmacies
      - Applies to FHPlus
      Program
      Only

    


    a)
       For
      those
      counties in which the
      Contractor offers a FHPlus product as specified in Appendix M
      of this
      Agreement, the Contractor shall include pharmacies as Participating Providers
      in
      its FHPlus product in sufficient
      numbers to meet the following distance/travel time standards:

    


    
      	 	
              i)
                

            	
              Non-Metropolitan
                areas - thirty (30) miles/thirty (30) minutes from the FHPlus Enrollee's
                residence.

            


    

    


    
      	 	
              ii)
                

            	
              Metropolitan
                areas - thirty (30) minutes from the FHPlus Enrollee's residence
                by public
                transportation from the FHPlus Enrollee's
                residence.

            


    

    


    b)  Transport
      time and distance in rural areas may be greater than thirty (30) minutes or
      thirty (30) miles from the FHPlus Enrollee's residence only if based on the
      community standard for accessing care or if by FHPlus Enrollee
      choice.
      Where the transport time and/or
      distances are greater, the exceptions must be justified and documented by
SDOH
      on the
      basis of community standards.

    


    c)
       The
      Contractor also must contract with twenty-four (24) hour pharmacies and must
      ensure that all FHPlus Enrollees
      have
      access to at least one such pharmacy within thirty
      (30) minutes travel time (by car or public transportation) from the FHPlus
      Enrollee's residence, unless none are located within such a distance. If none
      are located within thirty (30) minutes travel time from the
      FHPlus
      Enrollee's residence, the Contractor must include the closest site in its
      network.

    


    


    


    SECTION
      21

    (PROVIDER
      NETWORK)

    October
      1, 2005

    21-11


    d)  For
      certain conditions, such as hemophilia, PKU,
      and
      cystic fibrosis,
      the
      Contractor is encouraged to make pharmacy arrangements with specialty centers
      treating these conditions, when such centers are able to demonstrate quality
      and
      cost effectiveness.

    


    e)  The
      Contractor may make use of mail order prescription deliveries, where clinically
      appropriate and desired by the FHPlus Enrollee.

    


    f)  The
      Contractor may utilize formularies
      and may
      employ the services of a pharmacy benefit manager or utilization review agent,
      provided that such manager or agent covers a prescription drug benefit
      equivalent to the requirements for prescription drug coverage described in
      Appendix K
      of this
      Agreement and maintains an internal and external review process for medical
      exceptions.

    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    SECTION
      21

    (PROVIDER
      NETWORK)

    October
      1, 2005

    21-12


    22.
       SUBCONTRACTS
      AND PROVIDER AGREEMENTS

    


    22.1
       Written
      Subcontracts

    


    a)
       The
      Contractor may not enter into any subcontracts related to the delivery of
      services to Enrollees,
      except
      by a written agreement.

    


    b)  If
      the
      Contractor enters into subcontracts for the performance of work pursuant to
      this
      Agreement, the Contractor shall retain full responsibility for performance
      of
      the subcontracted services. Nothing in the subcontract shall impair the rights
      of the
      State
      under this Agreement. No contractual relationship shall be deemed to exist
      between the subcontractor and the State.

    


    c)  The
      delegation by the Contractor of its responsibilities assumed by this Agreement
      to any subcontractors will be limited to those specified in the
      subcontracts.

    


    22.2
       Permissible
      Subcontracts

    


    Contractor
      may subcontract for provider services as set forth in Sections 2.6 and 21 of
      this Agreement and management services including, but not limited to, marketing,
      quality
      assurance and utilization review activities and such other services as are
      acceptable to the SDOH.
      The
      Contractor must evaluate the prospective subcontractor's ability to perform
      the
      activities to be delegated.

    


    22.3
       Provisions
      of Services through Provider Agreements

    


    All
      medical care and/or
      services covered under this Agreement,
      with the
      exception of seldom used subspecialty
      and
      Emergency Services, Family Planning Services, and services for which Enrollees
      can self refer, pursuant to Section 10.15 of this Agreement, shall be provided
      through Provider Agreements with Participating Providers.

    


    22.4
       Approvals

    


    a)
       Provider
      Agreements shall require the approval of SDOH as set forth in PHL
      §4402
      and
      10 NYCRR
      Part
      98.

    


    b)
       If
      a
      subcontract is for management services under 10 NYCRR Part 98, it must be
      approved by SDOH prior to its becoming effective.

    


    c)
       The
      Contractor shall notify SDOH of any material amendments to any Provider
      Agreement as set forth in 10 NYCRR Part 98.

    


    SECTION
      22

    (SUBCONTRACTS
      AND PROVIDER AGREEMENTS)

    October
      1, 2005

    22-1

    



    22.5
       Required
      Components

    


    a)
       All
      subcontracts, including Provider Agreements, entered into by the Contractor
      to
      provide program services under this Agreement shall contain provisions
      specifying:

    


    
      	 	
              i) 

            	
              the
                activities and report responsibilities delegated to the subcontractor;
                and
                provide for revoking the delegation, in whole or in part, and imposing
                other sanctions if the subcontractor's performance does not satisfy
                standards set forth in this Agreement,
                and an obligation for the provider to take corrective
                action.

            


    

    


    
      	 	
              ii) 

            	
              that
                the work performed by the subcontractor must be in accordance with
                the
                terms of this Agreement;
                and

            


    

    


    
      	 	
              iii) 

            	
              that
                the subcontractor specifically agrees to be bound by the confidentiality
                provisions set forth in this
                Agreement.

            


    

    


    b)  The
      Contractor shall impose obligations and duties on its subcontractors, including
      its Participating Providers, that are consistent with this Agreement,
      and
      that
      do not impair any rights accorded to LDSS, SDOH,
      or
DHHS.

    


    c)  No
      subcontract,
      including any Provider Agreement, shall limit or terminate the Contractor's
      duties and obligations under this Agreement.

    


    d)  Nothing
      contained in this Agreement shall create any contractual relationship between
      any subcontractor of the Contractor, including its Participating Providers,
      and
      SDOH.

    


    e)  Any
      subcontract entered into by the Contractor shall fulfill the requirements of
      42
CFR
      Part 438
      that are appropriate to the service or activity delegated under such
      subcontract.

    


    f)  The
      Contractor shall also require that, in the event the Contractor fails to pay
      any
      subcontractor, including any Participating Provider in accordance with the
      subcontract or Provider Agreement, the subcontractor or Participating Provider
      will not seek payment from the SDOH, LDSS, the Enrollees,
      or
      persons acting on an Enrollee's
      behalf.

    


    g)  The
      Contractor shall include in every Provider Agreement a procedure for the
      resolution of disputes between the Contractor and its Participating
      Providers.

    


    h)  The
      Contractor shall ensure that all Provider Agreements entered into with Providers
      require acceptance of a woman's Enrollment in the Contractor's MMC
      or
FHPlus
      product
      as sufficient to provide services to her newborn,

    


    


    


    


    


    SECTION
      22

    (SUBCONTRACTS
      AND PROVIDER AGREEMENTS)

    October
      1, 2005

    22-2

    



    unless
      the
      newborn
      is
      excluded from Enrollment in the MMC
      Program
      pursuant to Section 6.1 of this Agreement, or the Contractor does not offer
      a
      MMC product in the mother's county of fiscal responsibility.

    


    
      	 	
              i) 

            	
              The
                Contractor must monitor the subcontractor's performance on an ongoing
                basis and subject it to formal review according to time frames
                established by the State, consistent with State laws and regulations,
                and
                the terms of this Agreement. When deficiencies or areas for improvement
                are identified, the Contractor and subcontractor must take corrective
                action.

            


    

    


    22.6
       Timely
      Payment

    


    Contractor
      shall make payments to Participating Providers and to Non-Participating
      Providers, as applicable, for items and services covered under this Agreement
      on
      a timely basis, consistent with the claims payment procedures described in
      SIL§3224-a.

    


    22.7
       Restrictions
      on Disclosure

    


    a)
       The
      Contractor shall not by contract or written policy or written procedure prohibit
      or restrict any health care provider from the following:

    


    
      	 	
              i)
                

            	
              Disclosing
                to any subscriber, Enrollee,
                patient,
                designated representative or, where appropriate, Prospective Enrollee
                any
                information that such provider deems appropriate
                regarding:

            


    

    


    A)
       a
      condition or a course of treatment with such subscriber, Enrollee,
      patient,
      designated representative or Prospective Enrollee, including the availability
      of
      other therapies,
      consultations, or tests; or

    


    B)  the
      provisions, terms, or requirements of the Contractor's MMC or FHPlus
      products
      as they relate to the Enrollee, where applicable.

    


    
      	 	
              ii) 

            	
              Filing
                a complaint, making a report or comment to an appropriate governmental
                body regarding the policies or practices of the Contractor when he
                or she
                believes that the policies or practices negatively impact upon the
                quality
                of, or access to, patient care.

            


    

    


    
      	 	
              iii) 

            	
              Advocating
                to the Contractor on behalf of the Enrollee for approval or coverage
                of a
                particular treatment or for the provision of health care
                services.

            


    

    


    22.8
       Transfer
      of Liability

    


    No
      contract or agreement between the Contractor and a Participating Provider shall
      contain any clause purporting to transfer to the Participating Provider, other
      than a medical group, by indemnification or otherwise, any liability relating
      to

    


    


    SECTION
      22

    (SUBCONTRACTS
      AND PROVIDER AGREEMENTS)

    October
      1, 2005

    22-3

    


    


    activities,
      actions or omissions of the Contractor as opposed to those of the Participating
      Provider.

    


    22.9
       Termination
      of Health Care Professional Agreements

    


    a)
       General
      Requirements

    


    
      	 	
              i) 

            	
              The
                Contractor shall not terminate a contract with a health care professional
                unless the Contractor provides to the health care professional a
                written
                explanation of the reasons for the proposed termination and
                an opportunity for a review or hearing as hereinafter provided. For
                purposes of this Section, a health care professional is an individual
                licensed, registered or certified pursuant to Title VII of the Education
                Law.

            


    

    


    
      	 	
              ii) 

            	
              These
                requirements shall not apply in cases involving imminent harm to
                patient
                care, a determination of fraud, or a final disciplinary action by
                a state
                licensing board or other governmental agency that impairs the health
                care
                professional's ability to practice.

            


    

    


    b)  Notice
      of
      Health Care Professional Termination

    


    
      	 	
              i)
                

            	
              When
                the Contractor desires to terminate a contract with a health care
                professional, the
                notification of the proposed termination by the Contractor to the
                health
                care professional
                shall include:

            


    

    


    A)
       the
      reasons for the proposed action;

    


    B)
       notice
      that the health care professional has the right to request a hearing or review,
      at the provider's discretion, before
      a panel
      appointed by the Contractor;

    


    C)  a
      time
      limit of not less than thirty (30) days within which a health care professional
      may request a hearing; and

    


    D)  a
      time
      limit for a hearing date which must be held within thirty (30) days after the
      date of receipt of a request for a hearing.

    


    c)  No
      contract or agreement between the Contractor and a health care professional
      shall contain any provision which shall supersede or impair a health care
      professional's right to notice of reasons for termination and the opportunity
      for a hearing or review concerning such termination.

    


    


    


    


    


    


    SECTION
      22

    (SUBCONTRACTS
      AND PROVIDER AGREEMENTS)

    October
      1, 2005

    22-4

    



    22.10
       Health
      Care Professional Hearings

    


    a)
       A
      health
      care professional that has been notified of his or her proposed termination
      must
      be allowed a hearing. The procedures for this hearing must meet the following
      standards:

    


    
      	 	
              i) 

            	
              The
                hearing panel shall be comprised of at least three persons appointed
                by
                the Contractor. At least one person on such panel shall be a. clinical
                peer in the same discipline and the same or similar specialty as
                the
                health care professional under review. The hearing panel may consist
                of
                more than three persons, provided however, that the number of clinical
                peers on such panel shall constitute one-third or more of the total
                membership of the panel.

            


    

    


    
      	 	
              ii) 

            	
              The
                hearing panel shall render a decision on the proposed action in a
                timely
                manner. Such decision shall include reinstatement of the health care
                professional by the Contractor, provisional reinstatement subject
                to
                conditions set forth by the Contractor or termination of the health
                care
                professional. Such decision shall be provided in writing to the
                health
                care professional.

            


    

    


    
      	 	
              iii) 

            	
              A
                decision by the hearing panel to terminate a health care professional
                shall be effective not less than thirty (30) days after the receipt
                by the
                health care professional of the hearing panel's decision. Notwithstanding
                the termination of a health care professional for cause or pursuant
                to a
                hearing, the Contractor shall permit an Enrollee
                to
                continue an on-going course of treatment for a transition period
                of up to
                ninety (90) days, and post-partum
                care, subject to the provider's agreement,
                pursuant to PHL
                §
                4403(6)(e).

            


    

    


    
      	 	
              iv) 

            	
              In
                no event shall termination be effective earlier than sixty (60) days
                from
                the receipt of the notice of
                termination.

            


    

    


    22.11
       Non-Renewal
      of Provider Agreements

    


    Either
      party to a Provider Agreement may exercise a right of non-renewal at the
      expiration of the Provider Agreement period set forth therein or, for a Provider
      Agreement without a specific expiration date, on each January first occurring
      after the Provider Agreement has been in effect for at least one year, upon
      sixty (60) days notice to the other party; provided, however, that any
non-renewal
      shall
      not constitute a termination for the purposes of this Section.

    


    


    


    


    


    


    


    


    SECTION
      22

    (SUBCONTRACTS
      AND PROVIDER AGREEMENTS)

    October
      1, 2005

    22-5

    



    22.12
       Notice
      of
      Participating Provider Termination

    


    a) The
      Contractor shall notify SDOH
      of any
      notice of termination or non-renewal of an IPA
      or
      institutional network Provider Agreement, or medical group Provider Agreement
      that serves five percent or more of the enrolled population in a LDSS
      and/or
      when
      the termination or non-renewal of the medical group provider will leave fewer
      than two Participating Providers of that type within the LDSS, unless immediate
      termination of the Provider Agreement is justified. The notice shall include
      an
      impact analysis of the termination or non-renewal with regard to Enrollee
      access
      to care.

    


    b)  The
      Contractor shall provide the notification required in (a) above to the SDOH
      ninety (90) days prior to the effective date of the termination of the Provider
      Agreement or immediately upon notice from such Participating Provider if less
      than ninety (90) days.

    


    c)  The
      Contractor shall provide the notification required in (a) above to the SDOH
      if
      the Contractor and the Participating Providers have failed to execute a renewal
      Provider Agreement forty-five (45) days prior to the expiration of the current
      Provider Agreement.

    


    d)  In
      addition to the notification required in (a) above, the Contractor shall submit
      a contingency plan to SDOH, at least forty-five (45) days prior to the
      termination or expiration of the Provider Agreement, identifying the number
      of
Enrollees
      affected
      by the potential withdrawal of the provider from the Contractor's network and
      specifying how services previously furnished by the Participating Provider
      will
      be provided in the event of its withdrawal from the Contractor's network. If
      the
      Participating Provider is a hospital, the Contractor shall identify the number
      of doctors that would not have admitting privileges in the absence of such
      Participating hospital.

    


    e)  In
      addition to the notification required in (a) above, the Contractor shall develop
      a transition plan for Enrollees who are patients of the Participating Provider
      withdrawing from the Contractor's network subject to approval by SDOH. SDOH
      may
      direct the Contractor to provide notice to the Enrollees who are patients of
      PCPs
      or
      specialists including available options for the patients, and availability
      of
      continuing care, consistent with Section 13.8 of this Agreement,
      not less
      than thirty (30) days prior to the termination or expiration of the Provider
      Agreement,
      hi
      the
      event that Provider Agreements are terminated or are not renewed with less
      than
      the notice period required by this Section, the Contractor shall immediately
      notify SDOH, and develop a transition plan on an expedited basis and provide
      notice to affected Enrollees upon SDOH consent to the transition plan and
      Enrollee notice.

    


    


    


    


    


    


    


    SECTION
      22

    (SUBCONTRACTS
      AND PROVIDER AGREEMENTS)

    October
      1, 2005

    22-6

    


    f)  Upon
      Contractor notice of failure to renew, or termination of, a Provider Agreement,
      the SDOH,
      in its
      sole discretion, may waive the requirement of submission of a contingency plan
      upon a determination by the SDOH that:

    


    
      	 	
              i) 

            	
              the
                impact upon Enrollees
                is
                not significant,
                and/or

            


    

    


    
      	 	
              ii) 

            	
              he
                Contractor and Participating Provider are continuing to negotiate
                in good
                faith and consent to extend the Provider Agreement for a period of
                time
                necessary to provide not less than thirty (30) days notice to
                Enrollees.

            


    

    


    g)  SDOH
      reserves the
      right
      to take any other action permitted by this Agreement and under regulatory or
      statutory authority, including but not limited to terminating this
      Agreement.

    


    22.13
       Physician
      Incentive Plan

    


    a)
       If
      Contractor elects to operate a Physician Incentive Plan, the Contractor agrees
      that no specific
      payment
      will be made directly or indirectly to a Participating Provider that is a
      physician or physician group as an inducement to reduce or limit medically
      necessary services furnished to an Enrollee.
      Contractor
      agrees to submit to SDOH annual reports containing the information on its
      Physician Incentive Plan in accordance with 42 CFR
      §
      438.6(h). The contents of such reports shall comply with the requirements of
      42
      CFR §§
      422.208
      and 422.210 and be in a format to be provided by SDOH.

    


    b)  The
      Contractor must ensure that any Provider Agreements for services covered by
      this
      Agreement, such as agreements between the Contractor and other entities or
      between the Contractor's subcontracted entities and their contractors, at all
      levels including the physician level, include language requiring that the
      Physician Incentive Plan information be provided by the sub-contractor in an
      accurate and timely manner to the Contractor, in the format requested by
      SDOH.

    


    c)  In
      the
      event that the incentive arrangements place the Participating physician or
      physician group at risk for services beyond those provided directly by the
      physician or physician group for an amount beyond the risk threshold of
      twenty-five percent (25%) of potential payments for covered services
      (substantial financial risk), the Contractor must comply with all additional
      requirements listed in regulation, such as: conduct Enrollee/disenrollee
      satisfaction
      surveys; disclose the requirements for the Physician Incentive Plans to its
      beneficiaries
      upon request; and ensure that all physicians and physician groups at substantial
      financial risk have adequate stop-loss protection. Any of these additional
      requirements that are passed on to the subcontractors must be clearly stated
      in
      their Provider Agreement.

    


    SECTION
      22

    (SUBCONTRACTS
      AND PROVIDER AGREEMENTS)

    October
      1, 2005

    22-7

    



    23.
       FRAUD
      AND ABUSE

    


    23.1
       General
      Requirements

    


    The
      Contractor shall comply with the
      Federal
      fraud and abuse requirements of 42 CFR§
      438.608.

    


    23.2
       Prevention
      Plans and Special Investigation Units

    


    If
      the
      Contractor has over 10,000 Enrollees
      in the
      aggregate in any given year, the Contractor must file a Fraud and Abuse
      Prevention Plan with the Commissioner of Health and develop a special
      investigation unit for the detection,
      investigation and prevention of fraudulent activities to the extent required
      by
PHL§
4414
      and SDOH
      regulations.

    


    24.
       AMERICANS
      WITH DISABILITIES ACT COMPLIANCE PLAN

    


    Contractor
      must comply with Title II of the ADA and Section 504 of the Rehabilitation
      Act
      of 1973 for program accessibility, and must develop an ADA Compliance Plan
      consistent with the SDOH Guidelines for MCO
      Compliance with the ADA set forth in Appendix J,
      which is
      hereby made a part of this Agreement as if set forth fully herein. Said plan
      must be approved by the SDOH, be filed with the SDOH, and be kept on file by
      the
      Contractor.

    


    25.
       FAIR
      HEARINGS

    


    25.1
       Enrollee
      Access
      to Fair Hearing Process

    


    Enrollees
      may access the fair hearing process in accordance with
      applicable federal and state laws and regulations. Contractors must abide by
      and
      participate in New York State's Fair Hearing Process and comply with
      determinations made by a fair hearing officer.

    


    25.2
       Enrollee
      Rights to a Fair Hearing

    


    Enrollees
      may request a fair hearing regarding adverse LDSS
      determinations concerning enrollment, disenrollment
      and
      eligibility, and regarding the denial, termination, suspension or reduction
      of a
      clinical treatment or other Benefit Package services by the Contractor. For
      issues related to disputed services, Enrollees must have received an adverse
      determination from the Contractor or its approved utilization review agent
      either overriding a recommendation to provide services by a Participating
      Provider or confirming the decision of a Participating Provider to deny those
      services. An Enrollee may also seek a fair hearing for a failure by the
      Contractor to act with reasonable promptness with respect to such services.
      Reasonable promptness shall mean compliance with the timeframes
      established
      for review of grievances and utilization review in Sections 44 and
      49

    


    


    


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    of
      the
      Public Health Law, the grievance system requirements of 42 CFR
      Part 438
      and Appendix F
      of this
      Agreement.

    


    25.3
       Contractor
      Notice to Enrollees

    


    a)
       Contractor
      must issue a written notice of Action and right to fair hearing within
      applicable timeframes
      to any
Enrollee
      when
      taking an adverse Action and when making an Appeal determination as provided
      in
      Appendix F of this Agreement.

    


    b)  Contractor
      agrees to serve notice on affected Enrollees by mail and must maintain
      documentation of such.

    


    25.4
       Aid
      Continuing

    


    a)
       Contractor
      shall be required to continue the provision of the Benefit Package services
      that
      are the subject of the fair hearing to an Enrollee (hereafter referred to as
      "aid continuing") if so ordered by the NYS
      Office
      of Administrative Hearings (OAH)
      under
      the following circumstances:

    


    
      	 	
              i) 

            	
              Contractor
                has or is seeking to reduce, suspend or terminate a treatment or
                Benefit
                Package service currently being
                provided;

            


    

    


    
      	 	
              ii) 

            	
              Enrollee
                has filed a timely request for a fair hearing with OAH;
                and

            


    

    


    
      	 	
              iii) 

            	
              There
                is a valid order for the treatment or service from a Participating
                Provider.

            


    

    


    b)
       Contractor
      shall provide aid continuing until the matter has been resolved to the
      Enrollee's
      satisfaction or until the administrative process is completed and there is
      a
      determination from OAH that Enrollee is not entitled to receive the service;
      the
      Enrollee withdraws the request for aid continuing and/or
      the
      fair hearing in writing; or the treatment or service originally ordered by
      the
      provider has been completed, whichever occurs first.

    


    c)  If
      the
      services and/or
      benefits in dispute have been terminated, suspended or reduced and the Enrollee
      timely requests a fair hearing.
      Contractor shall, at the direction of either SDOH
      or
LDSS,
      restore
      the disputed services and/or
      benefits consistent with the provisions of Section 25.4 (b) of this
      Agreement.

    


    25.5
       Responsibilities
      of SDOH

    


    SDOH
      will
      make every reasonable effort to ensure that the Contractor receives timely
      notice in writing by fax,
      or
      e-mail, of all requests, schedules .and
      directives regarding fair hearings.

    


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    25.6
       Contractor's
      Obligations

    


    a)
       Contractor
      shall appear at all scheduled fair hearings concerning its clinical
      determinations and/or
      Contractor-initiated disenrollments
      to
      present evidence as justification for its determination or submit written
      evidence as justification for its determination regarding the disputed benefits
      and/or services. If Contractor will not be making a personal appearance at
      the
      fair hearing, the written material must be submitted to OAH
      and
Enrollee
      or
Enrollee's
      representative
      at least three (3) business days prior to the scheduled hearing. If the hearing
      is scheduled fewer than three (3) business days after the request, Contractor
      must deliver the evidence to the hearing site no later than one (1) business
      day
      prior to the hearing, otherwise Contractor must appear in person.
      Notwithstanding the above provisions, Contractor may be required to make a
      personal appearance at the discretion of the hearing officer and/or
      SDOH.

    


    b)  Despite
      an Enrollee's request for a State fair hearing in any given dispute, Contractor
      is required to maintain and operate in good faith its own internal Complaint
      and
      Appeal processes as required under state and federal laws and by Section 14
      and
      Appendix F
      of this
      Agreement. Enrollees
      may seek
      redress of Adverse Determinations simultaneously through Contractor's internal
      process and the
      State
      fair hearing process. If Contractor has reversed its initial determination
      and
      provided the service to the Enrollee, Contractor may request a waiver from
      appearing at the hearing and, in submitted papers, explain that
      it
      has withdrawn its initial determination and is providing the service or
      treatment formerly in dispute.

    


    c)  Contractor
      shall comply with all determinations rendered by OAH at fair hearings.
      Contractor shall cooperate with SDOH efforts to ensure that Contractor is in
      compliance with fair hearing determinations. Failure by Contractor to maintain
      such compliance shall constitute breach of this Agreement. Nothing in this
      Section shall limit the remedies available to SDOH, LDSS
      or the
      federal government relating to any non-compliance by Contractor with a fair
      hearing determination or Contractor's refusal to provide disputed
      services.

    


    d)  If
      SDOH
      investigates a Complaint that has as its basis the same dispute that is the
      subject of a pending fair hearing and, as a result of its investigation,
      concludes that the disputed services and/or
      benefits should be provided to the Enrollee, Contractor shall comply with
SDOH's
      directive to provide those services and/or
      benefits and provide notice to OAH and Enrollee as required by Section
      25.6(b)
      of this
      Agreement.

    


    e)  If
      SDOH,
      through its Complaint investigation process, or OAH, by a determination after
      a
      fair hearing, directs Contractor to provide a service that was initially denied
      by Contractor, Contractor may either directly provide the service, arrange
      for
      the provision of that service or pay for the provision of

    


    SECTION
      23 - SECTION 36

    October
      1, 2005

    -3-

    



    that
      service by a Non-Participating Provider. If the services were not famished
      during the period the fair hearing was pending, the Contractor must authorize
      or
      furnish
      the
      disputed services promptly and as expeditiously
      as the
Enrollee's
      health
      condition requires.

    


    f)  Contractor
      agrees to abide by changes made to this Section of the Agreement with respect
      to
      the fair hearing, Action, Service Authorization, Complaint and Appeal processes
      by SDOH
      in order
      to comply with any amendments to applicable state or federal statutes or
      regulations.

    


    g)  Contractor
      agrees to identify a contact person within its organization who will serve
      as a
      liaison to SDOH for the purpose of receiving fair hearing requests, scheduled
      fair hearing dates and adjourned fair hearing dates and compliance with State
      directives. Such individual: shall be accessible to the State by e-mail; shall
      monitor e-mail for correspondence from the State at least once every business
      day; and shall agree, on behalf of Contractor, to accept notices to Contractor
      transmitted via e-mail as legally valid.

    


    h)  The
      information describing fair hearing rights, aid continuing.
      Action,
      Service Authorization, utilization review.
      Complaint and Appeal procedures shall be included in all MMC
      and
FHPlus
      member
      handbooks and shall comply with Section 14, Appendices E
      and F of
      this Agreement.

    


    i)  Contractor
      shall bear the burden of proof at hearings regarding the reduction, suspension
      or termination of ongoing services. In the event that Contractor's initial
      adverse determination is upheld as a result of a fair hearing, any aid
      continuing provided pursuant to that hearing request,
      may be
      recouped by Contractor.

    


    26.
       EXTERNAL
      APPEAL

    


    26.1
       Basis
      for
      External Appeal

    


    Enrollees
      are
      eligible to request an External Appeal when one or more covered health care
      services have been denied by the Contractor on the basis that the service(s)
      is
      not medically necessary or is experimental or investigational.

    


    26.2
       Eligibility
      for External Appeal

    


    An
      Enrollee
      is
      eligible for an External Appeal when the Enrollee
      has
      exhausted the Contractor's internal utilization review procedure, has received
      a
      final adverse determination from the Contractor, or the Enrollee and the
      Contractor have agreed to waive internal Appeal procedures in accordance with
      PHL§
      4914(2)2(a).
      A provider is also eligible for an External Appeal of retrospective
      denials.

    


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      23 - SECTION 36

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      1, 2005

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    26.3
       External
      Appeal
      Determination

    


    The
      External
      Appeal
      determination is binding on the Contractor; however, a fair hearing
      determination supersedes an External Appeal determination for Enrollees.

    


    26.4
       Compliance
      with External Appeal Laws and Regulations

    


    The
      Contractor must comply with the provisions of Sections 4910-4914 of the
PHL
      and 10
NYCRR
      Part 98
      regarding the External Appeal program.

    


    26.5
       Member
      Handbook

    


    The
      Contractor shall describe its Action and utilization review policies and
      procedures, including a notice of the right to an External Appeal together
      with
      a description of the External Appeal process and the timeframes
      for
      External Appeal, in the Member Handbook. The Member Handbook shall comply with
      Section 13 and the
      Member
      Handbook Guidelines, Appendix E,
      of this
      Agreement.

    


    27.
       INTERMEDIATE
      SANCTIONS

    


    27.1  General

    


    The
      Contractor is subject to the imposition of sanctions as authorized by State
      and
      Federal law and regulation, including the SDOH's
      right to
      impose sanctions for unacceptable practices as set forth in 18 NYCRR Part 515
      and civil and monetary penalties pursuant to 18 NYCRR Part 516 and 42
CFR§
      438.700, and such other sanctions and penalties as are authorized by local
      laws
      and ordinances and resultant administrative codes, rules and regulations related
      to the Medical Assistance Program or to the delivery of the contracted for
      services.

    


    27.2
       Unacceptable
      Practices

    


    a)
       Unacceptable
      practices for which the Contractor may be sanctioned include but are not limited
      to:

    


    
      	 	
              i) 

            	
              Failing
                to provide medically necessary services that the Contractor is required
                to
                provide under its contract with the
                State.

            


    

    


    
      	 	
              ii) 

            	
              Imposing
                premiums or charges on Enrollees that are in excess of the premiums
                or
                charges permitted under the MMC
                Program or FHPlus
                Program.

            


    

    


    
      	 	
              iii) 

            	
              Discriminating
                among Enrollees on the basis of their health
                status or need for health care
                services.

            


    

    


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      23 - SECTION 36

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              iv) 

            	
              Misrepresenting
                or falsifying information that it furnishes to an Enrollee,
                Potential
                Enrollee, health care provider, the State or to CMS.

            


    

    


    
      	 	
              v) 

            	
              Failing
                to comply with
                the requirements for Physician Incentive Plans, as set forth in 42
                CFR §§
                422.208 and 422.210.

            


    

    


    
      	 	
              vi) 

            	
              Distributing
                directly or through any agent or independent contractor, Marketing
                materials that have not been approved by the State or that
                contain
                false or materially misleading
                information.

            


    

    


    vii)
      Violating any other applicable requirements of
      SSA §§
      1903(m)
      or 1932 and any implementing regulations.

    


    viii)
      Violating any other
      applicable requirements of 18 NYCRR
      or 10
NYCRR
      Part
      98.

    


    ix)
      Failing
      to comply with the terms of this Agreement.

    


    27.3
       Intermediate
      Sanctions

    


    a)
       Intermediate
      Sanctions may include but are not limited to:

    


    
      	 	
              i) 

            	
              Civil
                monetary penalties.

            


    

    


    
      	 	
              ii) 

            	
              Suspension
                of all new enrollment, including auto assignments, after the effective
                date of the sanction.

            


    

    


    
      	 	
              iii) 

            	
              Termination
                of the contract,
                pursuant to Section 2.7 of this
                Agreement.

            


    

    


    27.4
       Enrollment
      Limitations

    


    The
      SDOH
      shall
      have the right, upon notice to the LDSS,
      to
      limit, suspend or terminate Enrollment activities by the Contractor
      and/or
      Enrollment into the Contractor's MMC
      and/or
      FHPlus
      product
      upon ten (10) days written notice to the Contractor. The written notice shall
      specify the action(s) contemplated and the reason(s) for such action(s)
      and
      shall provide the Contractor
      with
      an opportunity to submit additional information that would support me conclusion
      that limitation, suspension or termination of Enrollment activities or
      Enrollment in the Contractor's MMC and/or
      FHPlus
      product is unnecessary. Nothing in this paragraph limits other remedies
      available to the SDOH or the LDSS under this Agreement.

    


    


    


    


    


    


    


    


    


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      23 - SECTION 36

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              27.5
                

            	
              Due
                Process

            


    

    


    The
      Contractor will be afforded
      due
      process pursuant to Federal and
      State
      Law and Regulations (42 CFR§438.710,
      18 NYCRR
      Part
      516, and Article 44 of the PHL).

    


    28.
       ENVIRONMENTAL
      COMPLIANCE

    


    The
      Contractor shall comply with all applicable standards, orders, or requirements
      issued under Section 306 of the Clean Air Act (42 U.S.C.§
      1857(h)),
      Section
      508 of the Federal Water Pollution Control Act as amended (33 U.S.C. § 1368),
      Executive Order 11738, and the Environmental Protection Agency ("EPA")
      regulations (40 CFR Part 15) that prohibit the use of the facilities included
      on
      the EPA List of Violating Facilities. The Contractor shall report violations
      to
SDOH
      and to
      the Assistant Administrator for Enforcement of the EPA.

    


    29.
       ENERGY
      CONSERVATION

    


    The
      Contractor shall comply with any applicable mandatory standards and policies
      relating to energy efficiency that are contained in the State Energy
      Conservation regulation issued in compliance with the Energy Policy and
      Conservation Act of 1975 (Pub. L.
      94-165)
      and any amendment to the Act.

    


    30.
       INDEPENDENT
      CAPACITY OF CONTRACTOR

    


    The
      parties agree that the Contractor is an independent Contractor and that the
      Contractor, its agents, officers,
      and
      employees act in an independent capacity and not as officers or employees
of
      LDSS,
      SDOH or
      the DHHS.

    


    31.
       NO
      THIRD PARTY BENEFICIARIES

    


    Only
      the
      parties to this Agreement and their successors in interest and assigns have
      any
      rights or remedies under or by reason of this Agreement.

    


    32.
       INDEMNIFICATION

    


    32.1
       Indemnification
      by Contractor

    


    a)
       The
      Contractor shall indemnify, defend, and hold harmless the SDOH and the
LDSS,
      and
      their officers, agents, and employees, and the Enrollees
      and
      their eligible dependents from:

    


    
      	 	
              i) 

            	
              any
                and all claims and losses accruing or resulting to any and all
                Contractors, subcontractors, materialmen,
                laborers, and any other person,

            


    

    


    


    SECTION
      23 - SECTION 36

    October
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    -7-

    



    firm,
      or
      corporation furnishing or supplying work, services, materials, or supplies
      in
      connection with the performance of this Agreement;

    


    
      	 	
              ii) 

            	
              any
                and all claims and losses accruing or resulting to any person, firm,
                or
                corporation that may be injured or damaged by the Contractor, its
                officers, agents, employees, or subcontractors, including Participating
                Providers, in connection with the performance of this
                Agreement;

            


    

    


    
      	 	
              iii) 

            	
              any
                liability, including costs and expenses, for violation of proprietary
                rights, copyrights, or rights of privacy by the Contractor, its officers,
                agents, employees or subcontractors, arising out of the publication,
                translation, reproduction, delivery, performance, use, or disposition
                of
                any data furnished under this Agreement, or based on any libelous
                or
                otherwise unlawful matter contained in such
                data.

            


    

    


    b)  The
      SDOH
      will
      provide the Contractor with prompt written notice of any claim made against
      the
      SDOH, and the Contractor, at its sole option, shall defend or settle said claim.
      The SDOH shall cooperate with the Contractor to the extent necessary for the
      Contractor to discharge its obligation under Section 32.1 (a).

    


    c)  The
      Contractor shall have no obligation under this section with respect to any
      claim
      or cause of action for damages to persons or property solely caused by the
      negligence of SDOH, its employees, or agents.

    


    32.2
       Indemnification
      by SDOH

    


    Subject
      to the availability of lawful
      appropriations as required by State Finance Law § 41, the SDOH agrees to
      indemnify and hold the Contractor harmless from any liability, loss, damages,
      claim, suit or judgment, and all allowable costs and expenses of any kind or
      nature, as determined by the New York State Court of Claims and arising out
      of
      the actions or the omissions of the SDOH, its officers, agents or employees
      in
      connection with this Agreement. Provisions concerning the SDOH's
      responsibility for any claims for liability as may arise during the term of
      this
      Agreement are set forth in the New York State Court of Claims Act, and any
      damages arising for such liability shall issue from the New York State Court
      of
      Claims Fund or any applicable, annual appropriation of the Legislature of the
      State of New York.

    


    33.
       PROHIBITION
      ON USE OF FEDERAL FUNDS FOR LOBBYING

    


    33.1
       Prohibition
      of Use of Federal Funds for Lobbying

    


    The
      Contractor agrees, pursuant to 31 U.S.C.§
1352
      and 45 CFR
      Part 93,
      that no Federally appropriated funds have been paid or will be paid to any
      person by or on behalf of the Contractor for the purpose of influencing or
      attempting to

    


    SECTION
      23 - SECTION 36

    October
      1, 2005

    -8-

    



    influence
      an officer or employee of any agency, a Member of Congress, an officer or
      employee of Congress, or an employee of a Member of Congress in connection
      with
      the award of any Federal contract, the making of any federal grant,
      the
      making of any Federal loan, the entering into of any cooperative agreement,
      or
      the extension, continuation, renewal,
      amendment, or modification of any Federal contract, grant, loan, or cooperative
      agreement. The Contractor agrees to complete and submit the "Certification
      Regarding Lobbying," Appendix B
      attached
      hereto and incorporated herein, if this Agreement exceeds $100,000.

    


    33.2
       Disclosure
      Form to Report Lobbying

    


    If
      any
      funds other than Federally appropriated funds have been paid or will be paid
      to
      any person for the purpose of influencing or attempting to influence an officer
      or employee of any agency, a Member of Congress, an officer or employee of
      Congress, or an employee of a Member of Congress in connection with the award
      of
      any Federal contract, the making of any Federal grant, the
      making
      of any Federal loan, the entering into of any cooperative agreement,
      or the
      extension, continuation, renewal, amendment, or modification
      of
      any Federal contract, grant, loan, or cooperative agreement,
      and the
      Agreement exceeds $100,000, the Contractor shall complete and submit Standard
      Form-LLL
      "Disclosure Form to Report Lobbying," in accordance with its
      instructions.

    


    33.3
       Requirements
      of Subcontractors

    


    The
      Contractor shall include the provisions of this Section in its subcontracts,
      including its Provider Agreements. For all subcontracts, including Provider
      Agreements, that exceed $100,000, the Contractor shall require the
      subcontractor, including any Participating Provider to certify and disclose
      accordingly to the Contractor.

    


    34.
       NON-DISCRIMINATION

    


    34.1
       Equal
      Access to Benefit Package

    


    Except
      as
      otherwise provided in applicable sections of this Agreement the Contractor
      shall
      provide the Medicaid
      Managed
      Care and/or
      Family
      Health Plus Benefit Package(s) to MMC
      and/or
      FHPlus Enrollees,
      respectively, in the same manner, in accordance with the same standards, and
      with the same priority as members of the Contractor enrolled under any other
      contracts.

    


    34.2
       Non-Discrimination

    


    The
      Contractor shall not discriminate against Eligible Persons or Enrollees for
      Medicaid Managed Care and/or
      Family
      Health Plus on the
      basis
      of age, sex, race, creed, physical or mental handicap/developmental disability,
      national origin, sexual orientation, type of illness or condition, need for
      health services, or

    


    


    SECTION
      23 - SECTION 36

    October
      1, 2005

    -9-

    



    Capitation
      Rate that the Contractor will receive for such Eligible Persons or Enrollees.

    


    34.3
       Equal
      Employment Opportunity

    


    Contractor
      must comply with Executive Order 11246, entitled "Equal Employment Opportunity",
      as amended by Executive Order 11375, and as supplemented in Department of Labor
      regulations.

    


    
      	 	
              34.4
                

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

            


    

    


    
      	 	 	
              The
                Contractor shall not prohibit, restrict or discourage enrolled Native
                Americans from receiving care from or accessing: a) Medicaid
                reimbursed health services from or through a tribal health or urban
                Indian
                health facility or center and/or
                b)
                Family Health Plus covered benefits from or through a tribal
                health
                or urban Indian health facility or center which is included in the
                Contractor's network.

            


    

    


    35.
       COMPLIANCE
      WITH APPLICABLE LAWS

    


    35.1
       Contractor
      and SDOH
      Compliance With Applicable Laws

    


    Notwithstanding
      any inconsistent provisions in this Agreement,
      the
      Contractor and SDOH shall comply with all applicable requirements of the State
      Public Health Law; the State Social Services Law; Title XIX of the Social
      Security Act; Title VI of the Civil Rights Act of 1964 and 45 CFR
      Part 80,
      as amended; Title IX of the Education Amendments of 1972; Section 504 of the
      Rehabilitation Act of 1973 and 45 CFR Part 84, as amended; the Age
      Discrimination Act of 1975 and 45 CFR Part 91, as amended; the ADA; Title XIII
      of the Federal Public Health Services Act, 42 U.S.C§
300e
      et seq.,
      regulations promulgated thereunder; the Health Insurance Portability and
      Accountability Act of 1996 (P.L.
      104-191)
      and related regulations; and all other applicable legal and regulatory
      requirements in effect at the time that this Agreement is signed and as adopted
      or amended during the term of this Agreement. The parties agree that this
      Agreement shall be interpreted according to the laws of the State of New
      York.

    


    
      	 	
              35.2
                

            	
              Nullification
                of Illegal,
                Unenforceable, Ineffective or Void Contract
                Provisions

            


    

    


    
      	 	 	
              Should
                any provision of this Agreement be declared or found to be illegal
                or
                unenforceable, ineffective or
                void, then each party shall be relieved of any obligation arising
                from
                such provision; the balance of this Agreement, if capable of performance,
                shall remain in full force and
                effect.

            


    

    


    SECTION
      23 - SECTION 36

    October
      1, 2005

    -10-

    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    35.3
       Certificate
      of Authority Requirements

    


    The
      Contractor must satisfy conditions for issuance of a certificate of authority,
      including proof of financial solvency, as specified in 10 NYCRR
      Part
      98.

    


    35.4
       Notification
      of Changes in Certificate of Incorporation

    


    The
      Contractor shall notify SDOH
      of any
      amendment to its Certificate of Incorporation or Articles of Organization
      pursuant to 10 NYCRR Part 98.

    


    35.5
       Contractor's
      Financial Solvency Requirements

    


    The
      Contractor, for the duration of this Agreement, shall remain in compliance
      with
      all applicable state requirements for financial solvency for MCOs
      offering
Medicaid
      Managed
      Care and/or
      Family
      Health Plus products, as applicable. The Contractor shall continue to be
      financially responsible as defined in PHL
      §
4403
      (l)(c) and shall comply with the contingent reserve fund and escrow deposit
      requirements of 10 NYCRR Part 98 and must meet minimum net worth requirements
      established by SDOH and the State Insurance Department. The Contractor shall
      make provision, satisfactory to SDOH, for protections for SDOH, LDSSs
      and the
Enrollees
      in the
      event of Contractor or subcontractor insolvency, including but not limited
      to,
      hold harmless and continuation of treatment provisions in all provider
      agreements which protect SDOH, LDSSs and Enrollees from costs of treatment
      and
      assures continued access to care for Enrollees.

    


    35.6
       Compliance
      With Care for Maternity Patients

    


    Contractor
      must comply with §2803-n
      of the
      PHL and § 3216 (i)
      (10) (a)
      of the State Insurance Law related to hospital care for maternity
      patients.

    


    
      	 	
              35.7
                

            	
              Informed
                Consent Procedures for Hysterectomy and
                Sterilization

            


    

    


    The
      Contractor is required and shall require Participating Providers to comply
      with
      the informed consent procedures for Hysterectomy and Sterilization specified
      in
      42 CFR
      Part
      441, sub-part F,
      and 18
      NYCRR § 505.13.

    


    
      	 	
              35.8
                

            	
              Non-Liability
                of Enrollees for Contractor's Debts

            


    

    


    Contractor
      agrees that in no event shall the Enrollee
      become
      liable for the Contractor's debts as set forth in SSA§
      1932(b)(6).

    


    


    


    


    


    


    


    SECTION
      23 - SECTION 36

    October
      1, 2005

    -11-

    


    


    


    35.9
       SDOH
      Compliance With Conflict of Interest Laws

    


    SDOH
      and its
      employees shall comply with Article 18 of the General Municipal Law and all
      other appropriate provisions of New York State law, local laws and ordinances
      and all resultant codes, rules and regulations pertaining to conflicts of
      interest.

    


    35.10
       Compliance
      With PHL
      Regarding External Appeals

    


    Contractor
      must comply with Article 49 Title II of me PHL regarding external appeal of
      adverse determinations.

    


    36.
       NEW
      YORK STATE STANDARD CONTRACT CLAUSES

    


    Appendix
      A (Standard Clauses as required by the Attorney General for all State contracts)
      is attached and incorporated by reference as if set forth fully herein and
      any
      amendment thereto, and takes precedence over all other parts of this
      Agreement.

    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    SECTION
      23 - SECTION 36

    October
      1, 2005

    -12-

    



    APPENDIX
      A

    


    New
      York State Standard Clauses

    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    APPENDIX
      A

    October
      1, 2005

    


    



    


    


    STANDARD
      CLAUSES FOR NYS
      CONTRACTS

    


    The
      parties to the attached contract,
      license,
      lease, amendment or other agreement of any kind (hereinafter, "the contract"
      or
      "this contract") agree to be bound by the following clauses which are hereby
      made a part of the contract (the word "Contractor" herein refers to any party
      other than the State, whether a contractor, licenser, licensee, lessor, lessee
      or any other party):

    


    1.
      EXECUTORY
      CLAUSE.
      In
      accordance with Section 41 of the State Finance Law, the State shall have no
      liability under this contract to the Contractor or to anyone else beyond funds
      appropriated and available for this contract.

    


    2.
      NON-ASSIGNMENT
      CLAUSE.
      In
      accordance with Section 138 of the State Finance Law, this contract may not
      be
      assigned by the Contractor or its right,
      title or
      interest therein assigned,
      transferred, conveyed, sublet or otherwise disposed of without the previous
      consent,
      in
      writing,
      of the
      State and any attempts to assign the contract without the State's written
      consent are null and void. The Contractor may, however, assign its right to
      receive payment without the State's prior written consent unless this contract
      concerns Certificates of Participation pursuant to Article 5-A
      of the
      State Finance Law.

    


    3.
      COMPTROLLER'S
      APPROVAL.
      In
      accordance with Section 112 of the State Finance Law (or, if this contract
      is
      with the State University or City University of New York,
      Section
      355 or Section 6218 of the Education Law), if this contract exceeds $15,000
      (or
      the minimum thresholds agreed to by the Office of the State Comptroller for
      certain S.U.N.Y. and C.U.N.Y. contracts), or if this is an amendment for any
      amount to a contract which,
      as so
      amended,
      exceeds
      said statutory amount, or if, by this contract,
      the
      State agrees to give something other than money when the value or reasonably
      estimated value of such consideration exceeds $10,000, it shall not be valid,
      effective or binding upon the State until it has been approved by the State
      Comptroller and filed in his office. Comptroller's approval of contracts let
      by
      the Office of General Services is required when such contracts exceed $30,000
      (State Finance Law Section
      163.6.a).

    


    4.
      WORKERS'
      COMPENSATION BENEFITS. In
      accordance with Section 142 of the
      State
      Finance Law, this contract shall be void and of no force and effect unless
      the
      Contractor shall provide and maintain coverage during the life of this contract
      for the benefit of such employees as are required to be covered by the
      provisions of the Workers' Compensation Law.

    


    5.
      NON-DISCRIMINATION
      REQUIREMENTS.
      To the
      extent required by Article 15 of the Executive Law (also known as the Human
      Rights Law) and all other State and Federal statutory and constitutional
      non-discrimination provisions, the Contractor will not discriminate against
      any
      employee or applicant for employment because of race, creed,
      color,
      sex, national origin,
      sexual
      orientation,
      age,
      disability, genetic predisposition or carrier status, or marital status.
      Furthermore, in accordance with Section 220-e
      of the
      Labor Law, if this is a contract for the construction,
      alteration or repair of any public building or public work or for the
      manufacture, sale or distribution of materials, equipment or supplies, and
      to
      the extent that this contract shall be performed within the State of New
      York,
      Contractor agrees mat neither it not its subcontractors shall, by reason of
      race, creed, color, disability, sex,
      or
      national origin: (a) discriminate in hiring against any New York State citizen
      who is qualified and available to perform the work;
      or
(b)
      discriminate
      against or intimidate any employee hired for the performance of work under
      this
      contract
      If this
      is a building service contract as defined in Section 230 of the Labor Law,
      then,
      in
      accordance with Section 239 thereof.
      Contractor agrees that neither it nor its subcontractors shall by reason of
      race, creed,
      color,
      national origin,
      age, sex
      or disability: (a) discriminate in hiring against any New York State citizen
      who
      is qualified and available to perform the work;
      or (b)
      discriminate against or intimidate any employee hired for the
      performance of work under this contract. Contractor is subject to fines of
      $50.00 per person per day for any violation of Section 220-e or Section 239
      as
      well as possible termination of this contract and forfeiture of all moneys
      due
hereunder
      for a
      second or subsequent violation.

    


    6.
      WAGE
      AND
      HOURS PROVISIONS.
      If this
      is a public work contract covered by Article 8 of the Labor Law or a building
      service contract covered by Article 9 thereof,
      neither
      Contractor's employees nor the employees of its subcontractors may be required
      or permitted to work more than the number of hours or days stated in said
      statutes, except as otherwise provided in the Labor Law and as set forth in
      prevailing wage and supplement schedules issued by the State Labor Department
      Furthermore, Contractor and its subcontractors must pay at least the prevailing
      wage rate and pay
      or
      provide the prevailing supplements, including the premium rates for overtime
      pay, as determined by the State Labor Department in accordance with
      the Labor
      Law.

    


    7.
      NON-COLLUSIVE
      BIDDING
      CERTIFICATION.
      In
      accordance with Section 139-d
      of the
      State Finance Law, if this contract was awarded based upon the submission of
      bids, Contractor warrants, under penalty of perjury, that its bid was arrived
      at
      independently and without collusion aimed at restricting competition. Contractor
      further warrants that,
      at the
      time Contractor submitted its bid, an authorized and responsible person executed
      and delivered to the State a non-collusive bidding certification
      on
Contractor's
      behalf.

    


    8.
      INTERNATIONAL
      BOYCOTT PROHIBITION.
      In
      accordance with Section 220-f
      of the
      Labor Law and Section 139-h
      of the
      State Finance
      Law, if this contract exceeds $5,000, the Contractor agrees, as a material
      condition of the contract,
      that
      neither the Contractor nor any substantially owned or affiliated person, firm,
      partnership or corporation has participated,
      is
      participating, or shall participate in an international boycott in violation
      of
      the federal Export Administration Act of 1979 (50 USC App.
      Sections
      2401 et seq.)
      or
      regulations thereunder. If such Contractor, or any of the aforesaid affiliates
      of Contractor, is convicted or is otherwise found to have violated said laws
      or
      regulations upon the
      final
      determination of the United
      States Commerce Department or any other appropriate
      agency of the United States subsequent to the contract's execution, such
      contract,
      amendment or modification thereto shall be rendered forfeit and void. The
      Contractor shall so notify the State Comptroller within five (5) business days
      of such conviction, determination or disposition of appeal (2NYCRR
      105.4).

    


    9.
      SET-OFF
      RIGHTS.
      The
      State shall have all of its common law, equitable and statutory rights of
      set-off.
      These rights shall include, but not be limited to, the State's option to
      withhold for the purposes of set-off any moneys due to the Contractor under
      this
      contract up to any amounts due and owing to the State with regard to this
      contract,
      any
      other contract with any State department or agency, including any
      contract
      for a
      term commencing prior to the term of this contract,
      plus any
      amounts due and owing to the State for any other reason including, without
      limitation,
      tax
      delinquencies, fee delinquencies or monetary penalties relative thereto. The
      State shall exercise its set-off
      rights in accordance with normal State practices including, in cases of set-off
      pursuant to an audit,
      the
finalization
      of such
      audit by the State agency, its representatives, or the State
      Comptroller.

    


    10.
      RECORDS.
      The
      Contractor shall establish and maintain complete and accurate books, records,
      documents, accounts and other evidence directly pertinent to performance under
      mis contract (hereinafter, collectively, "the Records").
      The
      Records
      must be kept for the balance of the calendar year in which they were made and
      for six (6) additional years thereafter. The State Comptroller, the Attorney
      General and any other person or entity authorized to conduct an examination,
      as
      well as the agency or agencies involved in this contract,
      shall
      have access to the Records during normal business
      hours at an office of me Contractor within the State of New York or, if no
      such
      office is available, at a mutually agreeable and reasonable venue within the
      State, for the term specified
      above
      for the purposes of inspection,
      auditing
      and copying. The
      State
      shall take reasonable steps to protect from public disclosure any of the Records
      which are exempt from disclosure under Section 87 of the Public Officers
      Law
      (me "Statute") provided that: (i)
      the
      Contractor shall timely inform an appropriate State official, in writing, that
      said records should not be disclosed; and (ii)
      said
      records shall be sufficiently identified;
      and
(iii)
      designation of said records as exempt under the Statute is reasonable. Nothing
      contained herein shall diminish,
      or in
      any way adversely affect,
      the
      State's right to discovery in any pending or future litigation.

    


    11.
      IDENTIFYING
      INFORMATION AND PRIVACY NOTIFICATION,
      (a)
      FEDERAL EMPLOYER
      IDENTIFICATION NUMBER and/or
      FEDERAL SOCIAL SECURITY NUMBER.
      All
      invoices or New York State standard vouchers submitted for payment for the
      sale
      of goods or services or the lease of real or personal property to a New York
      State agency must include the payee's identification number, i.e., the seller's
      or lessor's
      identification number. The number is either the payee's Federal employer
      identification number or Federal social security number, or both such numbers
      when the payee has both such numbers. Failure to include this number or numbers
      may delay payment. Where the payee does not have such number or numbers, the
      payee, on its invoice or New York State standard voucher, must give the reason
      or reasons why the payee does not have such number or numbers.

    


    (b)
      PRIVACY
      NOTIFICATION.
      (1) The authority to request the above personal information from a seller of
      goods or services or a lessor of real or personal property, and the authority
      to
      maintain such information, is found in Section 5 of the State Tax Law.
      Disclosure of this information by the seller or lessor to the State is
      mandatory. The principal purpose for which the information is collected is
      to
      enable the State
      to
      identify individuals, businesses and others who have been delinquent in filing
      tax returns or may have understated their tax liabilities and to generally
      identify persons affected
      by
      the taxes administered by the Commissioner of Taxation and Finance. The
      information will be used for tax administration purposes
      and for any other purpose authorized by law.

    (2)
      The
      personal information is requested by the purchasing unit of the agency
      contracting to purchase the goods or services or lease the real or personal
      property covered by this contract or lease. The information is maintained in
      New
      York State's Central Accounting System by the Director of Accounting Operations,
      Office of the State Comptroller, AESOB,
      Albany,
      New York 12236.

    


    12.
      EQUAL
      EMPLOYMENT OPPORTUNITIES FOR MINORITIES AND
      WOMEN.
      In
      accordance with Section 312 of the Executive Law, if this contract is: (i)
      a
      written agreement or purchase order instrument,
      providing for a total expenditure in excess of $25,000.00, whereby a contracting
      agency is committed to expend or does expend funds in return for labor,
      services, supplies, equipment,
      materials
      or any combination of the foregoing,
      to be
      performed for, or rendered or furnished to the contracting agency; or (ii)
      a
      written agreement in excess of $100,000.00 whereby a contracting agency is
      committed to expend or does expend funds for the acquisition, construction,
      demolition,
      replacement,
      major
      repair or renovation of real property and improvements thereon; or (iii) a
      written agreement in excess of $100,000.00 whereby the owner of a State assisted
      housing project is committed to expend or does expend funds for the
      acquisition,
      construction,
      demolition, replacement,
      major
      repair or renovation of real properly and improvements thereon for such
      project,
      then:

    


    (a)
      The
      Contractor will not discriminate against employees or applicants for employment
      because of race, creed,
      color,
      national origin,
      sex.
      age,
      disability or marital status, and will undertake or continue [existing
      programs of affirmative action to ensure that minority group members and women
      are afforded equal employment opportunities without
      discrimination. Affirmative action shall mean recruitment,

    employment,
      job
      assignment,
      promotion, upgradings,
      demotion, transfer, layoff, or termination and rates of pay or other forms
      of
      compensation;

    


    (b)
      at
      the request of the contracting agency, the Contractor shall request each
      employment agency, labor union,
      or
      authorized representative
      of workers with which it has a collective bargaining or other agreement or
      understanding, to famish a written statement that such employment agency, labor
      union or representative will not discriminate on the basis of race, creed,
      color, national origin, sex,
      age, disability
      or marital status and that such union or representative will affirmatively
      cooperate in the implementation
      of the contractor's obligations herein; and

    


    (c)
      the
      Contractor shall state, in all solicitations or advertisements for employees,
      that,
      in the
      performance of the State contract, all qualified applicants will be afforded
      equal employment opportunities without discrimination because of race, creed,
      color, national origin, sex,
      age,
      disability or marital status.

    


    Contractor
      will include the provisions of "a", "b", and "c" above, in every subcontract
      over $25,000.00 for the construction, demolition, replacement,
      major
      repair, renovation,
      planning
      or design of real property and improvements thereon (the "Work") except where
      the Work is for the beneficial use of the Contractor. Section 312 does not
      apply
      to: (i) work,
      goods or
      services unrelated to this contract;
      or (ii)
      employment outside New York State; or (iii) banking services, insurance policies
      or the sale of securities. The State shall consider compliance by a contractor
      or subcontractor with the requirements of any federal law concerning equal
      employment opportunity which effectuates the purpose of this section. The
      contracting agency shall determine whether the imposition of the requirements
      of
      the provisions hereof duplicate or conflict with any such federal law and if
      such duplication or conflict exists, the contracting agency shall waive the
      applicability of Section 312 to the extent of such duplication or conflict.
      Contractor will comply with all duly promulgated and lawful rules and
      regulations of the Governor's Office of Minority and Women's Business
      Development pertaining hereto

    


    13.
      CONFLICTING
      TERMS.
      In the
      event of a conflict between the terms of the contract (including any and all
      attachments thereto and amendments thereof) and the terms of this Appendix
      A,
      the terms of this Appendix A shall control.

    


    14.
      GOVERNING
      LAW.
      This
      contract shall be governed by the laws of the State of New York except
      where
      the Federal supremacy clause requires otherwise.

    


    15.
      LATE
      PAYMENT.
      Timeliness of payment and any interest to be paid to Contractor for late payment
      shall be governed by Article 11-A
      of the
      State Finance Law to the extent required by law.

    


    16. NO
      ARBITRATION.
      Disputes
      involving this contract,
      including the breach or alleged breach thereof, may not be submitted to binding
      arbitration (except where statutorily
      authorized), but must,
      instead,
      be heard in a court of competent jurisdiction of the State of New
      York.

    


    17.
      SERVICE
      OF PROCESS,
      In
      addition to the methods of service allowed by the State Civil Practice Law
&
Rules ("CPLR"),
      Contractor hereby consents to service of process upon it by registered or
      certified mail, return receipt requested. Service hereunder
      shall be
      complete upon Contractor's actual receipt of process or upon the State's receipt
      of the return thereof by the United States Postal Service as refused or
undeliverable.
      Contractor must promptly notify the State, in writing,
      of each
      and every change of address to which service of process can be made. Service
      by
      the State to the last known address shall be sufficient. Contractor will have
      thirty (30) calendar days after service hereunder is complete in which to
      respond.

    


    18.
      PROHIBITION
      ON PURCHASE
      OF TROPICAL

    HARDWOODS.
      The
      Contractor certifies and warrants that all wood products to be used under this
      contract award will be in accordance with, but not limited to, the
      specifications and provisions of State Finance Law §165. (Use of Tropical
      Hardwoods) which prohibits purchase and use of tropical hardwoods, unless
      specifically exempted,
      by the
      State or any governmental agency or political subdivision or public benefit
      corporation. Qualification for an exemption
      under
      this law will be the responsibility of the contractor to establish to meet
      with
      the approval of the State.

    


    In
      addition,
      when any
      portion of this contract involving the use of woods, whether supply or
      installation, is to be performed by any subcontractor, the prime Contractor
      will
      indicate and certify in the submitted bid proposal that the subcontractor has
      been informed and is in compliance with specifications and provisions regarding
      use of tropical hardwoods as detailed in §165 State Finance Law. Any such use
      must meet with the approval of the State;
      otherwise, the bid may not be considered responsive. Under bidder
      certifications, proof of qualification for exemption will be the responsibility
      of the Contractor to meet with the approval of the State.

    


    19.
      MACBRIDE
      FAIR EMPLOYMENT PRINCIPLES, In
      accordance with the MacBride
      Fair
      Employment Principles (Chapter 807 of the Laws of 1992), the Contractor hereby
      stipulates that the Contractor either (a) has no business operations in Northern
      Ireland, or (b)
      shall
      take lawful steps in good faith to conduct any business operations in Northern
      Ireland in accordance with the MacBride Fair Employment Principles (as described
      in Section 165 of the New York State Finance Law), and shall permit independent
      monitoring of compliance with such principles.

    


    20.
      OMNIBUS
      PROCUREMENT ACT OF 1992.
      It is
      the policy
      of New
      York State to maximize opportunities for the participation of New York State
      business enterprises, including minority and women-owned business enterprises
      as
      bidders, subcontractors and suppliers on
      its
      procurement contracts.

    


    Information
      on the availability of New York State subcontractors and suppliers is available
      from;

    


    NYS
      Department of Economic Development

    Division
      for Small Business 

    30
      South
      Pearl St
      -
      7th
      Floor


    Albany,
      New York 12245 

    Telephone:
      518-292-5220

    


    A
      directory of certified minority and women-owned
      business enterprises is available from:

    


    NYS
      Department of Economic Development

    Division
      of Minority and Women's Business  Development

    30
      South
      Pearl
      St - 2nd Floor

    Albany,
      New York 12245

    http://www.empire.sta.te.ny.us

    


    The
      Omnibus Procurement Act of 1992 requires that by signing this bid proposal
      or
      contract,
      as applicable,
      Contractors certify that whenever the total bid amount
      is
      greater than $1 million:

    


    (a)
      The
      Contractor has made reasonable efforts to encourage the participation of New
      York State Business Enterprises as suppliers and subcontractors, including
      certified minority and women-owned
      business enterprises, on this project,
      and has
      retained the documentation of these
      efforts to be provided upon request to the State;

    


    (b)
      The
      Contractor has complied with the Federal Equal Opportunity Act of 1972
(P.L.
      92-261), as amended;
      (c)
      The
      Contractor
      agrees to make reasonable efforts to provide notification to New York State
      residents of employment opportunities on this project through listing any such
      positions with the Job Service Division of the New York State Department of
      Labor, or providing such notification in such manner as is consistent with
      existing collective bargaining contracts or agreements. The Contractor agrees
      to
      document these efforts and to provide said documentation to the State upon
      request; and

    


    (d)
      The
      Contractor acknowledges notice that the State may seek to obtain offset
      credits from foreign countries as a result of this contract and agrees to
      cooperate with the State in these efforts.

    


    21.
      RECIPROCITY
      AND SANCTIONS
      PROVISIONS.
      Bidders
      are hereby notified that if their principal place of business is located in
      a
      country, nation,
      province, state or political subdivision that penalizes New York State vendors,
      and if the goods or services they offer will be substantially produced or
      performed outside New York State, the Omnibus Procurement Act 1994 and 2000
      amendments (Chapter 684 and Chapter 383, respectively) require that they be
      denied contracts which they would otherwise obtain. NOTE: As of May 15, 2002,
      the list of discriminatory jurisdictions subject to this provision includes
      the
      states of South Carolina,
      Alaska,
      West
      Virginia,
      Wyoming,
      Louisiana and Hawaii. Contact NYS Department of Economic Development for a
      current list of jurisdictions subject to this provision.

    


    22.
      PURCHASES
      OF APPAREL.
      In
      accordance with State Finance Law 162 (4-a),
      the
      State shall not purchase any apparel from any vendor unable or unwilling to
      certify that: (i)
      such
      apparel was manufactured in compliance with all applicable labor and
      occupational safety laws, including, but not limited to, child labor laws,
      wage
      and hours laws and workplace safety laws, and (ii)
      vendor
      will supply, with its bid (or, if not a bid situation, prior to or at the time
      of signing a contract with the State), if known,
      the
      names and addresses of each subcontractor and a list of all manufacturing plants
      to be utilized by the bidder. 

    



    


    


    


    


    APPENDIX
      B

    


    Certification
      Regarding Lobbying

    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    APPENDIX
      B

    October
      1, 2005

    APPENDIX
      B

     CERTIFICATION
      REGARDING LOBBYING

    


    


    The
      undersigned certifies, to the best of his or her knowledge, that:

    


    
      	
              1. 

            	
              No
                Federal appropriated funds have been paid or will be paid to any
                person by
                or on behalf of the Contractor for the purpose of influencing or
                attempting to influence an officer or employee of any agency, a Member
                of
                Congress, an officer or employee of a Member of Congress in connection
                with the award of any Federal loan, the entering into of any cooperative
                agreement, or the extension, continuation, renewal, amendment, or
                modification of any Federal contract, grant, loan, or cooperative
                agreement.

            


    

    


    
      	
              2.
                

            	
              If
                any funds other than Federal appropriated funds have been paid or
                will be
                paid to any person for the purpose
                of
                influencing or attempting to influence an officer or employee of
                any
                agency, a Member of Congress in connection with the award of any
                Federal
                contract, the making of any Federal grant, the making of any Federal
                loan,
                the entering into of any cooperative agreement, or the extension,
                continuation, renewal, amendment, or modification of any Federal
                contract,
                grant, loan, or cooperative agreement, and the Agreement exceeds
                $100,000,
                the Contractor shall complete and submit Standard Form -LLL
                "Disclosure Form to Report Lobbying", in accordance with its
                instructions.

            


    

    


    
      	
              3.
                

            	
              The
                Contractor shall include the provisions of this section in all provider
                Agreements under this Agreement and require all Participating providers
                whose Provider Agreements exceed $100,000 to certify and disclose
                accordingly to the Contractor.

            


    

    


    


    This
      certification is a material representation of fact upon which reliance was
      place
      when this transaction was made or entered into. Submission of this certification
      is a prerequisite for making or entering into this transaction pursuant to
      U.S.C.
      Section
      1352. The failure to file the required certification shall subject the violator
      to a civil penalty of not less than $10,000 and not more than $100,000 for
      each
      such failure.

    


    


    


    DATE:
      _______7/26/05_________________________________________________

    


    SIGNATURE:
      Todd
      S. Farha_____________________________________________

    


    


    TITLE:
      President
      and Chief Executive Officer_______________________________

    


    


    ORGANIZATION:
      ____WellCare
      of New York, Inc.__________________________

    


    


    


    


    APPENDIX
      B

    October
      1, 2005

    B-1


    


    APPENDIX
      B -1 

    


    Certification
      Regarding Lobbying

    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    APPENDIX
      B-1

    October
      1, 2005

    B-1
      Page
      1

    


    



    APPENDIX
      B-l

    


    


    NONDISCMMINATION
      IN EMPLOYMENT IN NORTHERN IRELAND:

    MacBRIDE
      FAIR EMPLOYMENT PRINCIPLES

    


    


    Note:
      Failure to stipulate to these principles may result in the contract being
      awarded to another bidder. Governmental and non-profit organizations are
      exempted from this stipulation requirement.

    


    In
      accordance with Chapter 807 of the Laws of 1992 (State Finance Law Section
      174-b),
      the
      Contractor, by signing this Agreement, certifies that it or any individual
      or
      legal entity in which the Contractor holds a 10% or greater ownership interest,
      or any individual or legal entity that
      holds
      a 10% or greater ownership interest in the Contractor, either:

    


    • has
      business operations in Northern Ireland: Y__ N_X_

    


    
      	
              •

            	
              if
                yes to above, shall take lawful steps in good faith to conduct any
                business operations they have in Northern Ireland in accordance with
                the
                MacBride
                Fair Employment Principles relating to non-discrimination in employment
                and freedom of workplace opportunity regarding such operations in
                Northern
                Ireland, and shall permit independent monitoring of their compliance
                with
                such Principles:

            


    

    Y__ N__

    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    APPENDIX
      B-1

    October
      1, 2005

    B-1
      Page
      2

    


    


    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, 2005

    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
      famishing 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
                famished 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 insertion/removal
      of an intrauterine
      device
      (IUD),
      insertion/removal
      of contraceptive implants, and injection procedures involving Pharmaceuticals
      such as
Depo-Provera;

    


    B)  sterilization;

    


    C)  screening,
      related diagnosis, and referral to a Participating Provider for
      pregnancy;

    


    D)  medically-necessary
      induced abortions, which are procedures, either medical or surgical, that result
      in the termination of pregnancy. The determination of medical necessity shall
      include positive evidence of pregnancy, with an estimate of its
      duration.

    


    
      	 	
              ii) 

            	
              Family
                Planning and Reproductive Health services include those education
                and
                counseling services necessary to render the services
                effective.

            


    

    


    
      	 	
              iii) 

            	
              Family
                Planning and Reproductive Health services include medically-necessary
                ordered contraceptives and pharmaceuticals:

            


    

    


    A)
       For
      MMC
      Enrollees - The contractor is responsible for pharmaceuticals and medical
      supplies such as IUDS
      and
      Depo-Provera that must be famished 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, medical supplies, and over the counter drugs are not the
      responsibility of the Contractor and are to be obtained when covered on the
      New
      York State list of Medicaid

    


    


    


    


    


    APPENDIX
      C

    October
      1, 2005

    C-2

    


    



    reimbursable
      drugs by the Enrollee from any appropriate eMedNY-enrolled health care provider
      of the Enrollee’s choice.

    


    B)  For
      FHPlus Enrollees
      - The
      Contractor, if it includes such services in its Benefit Package, or the
      Designated Third Party Contractor that provides such services to FHPlus
      Enrollees when the Contractor does not provide Family Planning and Reproductive
      Health services, is responsible for prescription contraceptives provided by
      a
      Participating pharmacy, consistent with the pharmacy benefit package as
      described in Appendix K.
      The
      Contractor or the Designated Third Party Contractor must cover at least one
      of
      every type of the following methods of contraception:

    


    I)
       Oral

    II)
       Oral,
      emergency

    III)
       Injectable

    IV)
       Transdermal

    V)
       Intravaginal

    VI)
       Intravaginal,
      systemic

    VII)
       Implantable

    


    b)  When
      clinically indicated, the following services may be provided as a part of a
      Family Planning and Reproductive Health visit:

    


    
      	 	
              i) 

            	
              Screening,
                related diagnosis, ambulatory treatment and referral as needed for
                dysmenorrhea,
                cervical cancer, or other pelvic
                abnormality/pathology.

            


    

    


    
      	 	
              ii) 

            	
              Screening,
                related diagnosis and referral for anemia, cervical cancer, glycosuria,
                proteinuria,
                hypertension and breast disease.

            


    

    


    
      	 	
              iii) 

            	
              Screening
                and treatment for sexually transmissible disease.
                

            


    

    


    
      	 	
              iv) 

            	
              HIV
                blood 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
      blood
      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

    


    


    


    


    


    APPENDIX
      C

    October
      1, 2005

    C-3

    



    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
      blood
      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, 2005

    C-4

    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.I 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, 2005

    C-5

    


    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 an Enrollee'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.I 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, 2005

    C-6

    


    


    


    


    C.3

    


    Requirements
      for MCOs
      That Do Not

    Include
      Family Planning Services and Reproductive Health Services in Their


    Benefit
      Package

    


    1.
       Requirements

    


    a)
       The
      Contractor agrees to comply with the policies and procedures stated in the
      SDOH-approved
      statement described in Section 2 below.

    


    b)  Within
      ninety (90) days of signing this Agreement, the
      Contractor shall submit to the SDOH
      a policy
      and procedure statement that the Contractor will use to ensure that its
Enrollees
      are
      fully informed of their rights to access a full range of Family Planning and
      Reproductive Health services, using the following guidelines. The statement
      must
      be sent to the Director, Office of Managed Care, NYS
      Department of Health, Coming 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 either through fee-for-service
      Medicaid
      providers for MMC
      Enrollees; and/or,
      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, 2005

    C-7

    



    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.

    


    Ill)
       By
      inclusion on any web site of the Contractor which includes information
      concerning its MMC or FHPlus produces).
      Such
      information shall be prominently displayed and easily navigated.

    


    C)  A
      description of the mechanisms to provide all new MMC 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, 2005

    C-8

    



    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 under contract with SDOH
      in
      the
Enrollee's
      geographic area.

    


    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 under SDOH contract to provide such services to FHPlus Enrollees
      and
      Prospective FHPlus Enrollees. It is the responsibility of the Designated Third
      Party Contractor 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 and Pharmacies in the Designated Third Party Contractor's
      network. The Designated Third Party Contractor 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-Healfhy
      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
      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.

    


    
      	 	
              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 denned in C.I of this Appendix, and/or
      the
      FHPlus Designated Third Party Contractor for FHPlus Enrollees, HIV
      counseling
      and testing; reimbursement for Family Planning and Reproductive

    


    


    


    


    


    


    


    APPENDIX
      C

    October
      1, 2005

    C-9

    



    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, obstetricians, and gynecologists 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.I 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 in the FHPlus Designated Third Party Contractor's
                network and they render non-covered Family Planning and Reproductive
                Health Services to FHPlus Enrollees, they do so as a participating
                provider with that MCO,
                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,
      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:

    


    


    


    


    


    


    


    


    APPENDIX
      C

    October
      1, 2005

    C-10

    



    
      	 	
              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 me highest quality care to the
      Contractor's Enrollees. The Contractor must also acknowledge that medical record
      information maintained by Participating Providers may include information
      relating to Family Planning and Reproductive Health services provided under
      the
      fee-for-service Medicaid program or under the Designated Third Party contract
      with SDOH.

    


    
      	 	
              iii) 

            	
              Quality
                Assurance Initiatives

            


    

    


    A)
       A
      statement that the Contractor will submit any materials to be furnished to
      Enrollees and providers relating to access to non-covered Family Planning and
      Reproductive Health services to SDOH, Office of Managed Care for its review
      and
      approval before issuance. Such materials include, but are not limited to, Member
      Handbooks, provider manuals, and Marketing materials.

    


    B)  A
      description of monitoring mechanisms the Contractor will use to assess the
      quality of the information provided to Enrollees.

    


    C)  A
      statement that the Contractor will prepare a monthly list of MMC Enrollees
      who
      have been sent a copy of the SDOH approved letter and the SDOH approved list
      of
      Family Planning providers, and a list of FHPlus Enrollees who have been provided
      with the name and telephone number of the Designated Third Party Contractor
      in
      their geographic area. This information will be available to SDOH upon
      request.

    


    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.

    


    


    


    


    


    


    APPENDIX
      C

    October
      1, 2005

    C-11

    


    E)  A
      description of the mechanisms to provide the Designated Third Party Contractor
      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.

    


    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 an Enrollee'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, 2005

    C-12

    


    Appendix
      D

    


    New
      York State Department of Health Marketing Guidelines

    


    D.1 Marketing
      Plans

    D.2 Marketing
      Materials

    D.3 Marketing
      Activities

    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    APPENDIX
      D

    October
      1, 2005

    D-1

    


    MARKETING
      GUIDELINES

    


    1. General

    


    a)
       The
      purpose of these guidelines is to provide an operational framework for
      localities and managed care organizations
      (MCOs)
      offering
MMC
      or
FHPlus
      products
      in me development of MCO
      Marketing plans, materials, and activities and to describe SDOH's
      Marketing rules, MCO Marketing requirements, and prohibited
      practices.

    


    b)  If
      the
      Contractor's Marketing activities do not comply with the Marketing Guidelines
      set forth in this Appendix or the Contractor's approved Marketing plan, the
      SDOH,
      in
      consultation with the LDSS,
      may take
      any action pursuant to Section 11.5 of this Agreement it, in its sole
      discretion, deems necessary to protect the interests of Prospective Enrollees,
      Potential Enrollees
      and
Enrollees
      and the
      integrity of the MMC and FHPlus Programs.

    


    c)  This
      Appendix contains the following sections:

    


    
      	 	
              i) 

            	
              D.
                1,
                Marketing Plans;

            


    

    


    ii)  D.2,
      Marketing Materials; and 

    


    iii)
       D.3,
      Marketing Activities.

    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    APPENDIX
      D

    October
      1, 2005

    D-2

    


    D.1

    Marketing
      Plans

    


    
      	
              1. 

            	
              The
                Contractor shall develop a Marketing plan that meets SDOH
                guidelines.

            


    

    


    
      	
              2.
                

            	
              The
                SDOH is responsible for the
                review and approval of the Contractor's
                Marketing plan.

            


    

    


    
      	
              3.
                

            	
              Approved
                Marketing plans set forth the allowable terms and conditions and
                the
                proposed activities that the Contractor intends to undertake during
                the
                contract period.

            


    

    


    
      	
              4.
                

            	
              The
                Contractor must have on file with the SDOH and each LDSS
                in
                its contracted service area,
                an
                SDOH-approved
                Marketing plan, prior to the contract award date or before Marketing
                and
                enrollment begin, whichever is sooner. Subsequent changes to the
                Marketing
                plan must be submitted to SDOH for approval at least sixty (60) days
                before implementation.

            


    

    


    
      	
              5.
                

            	
              The
                Marketing plan shall include: a stated Marketing goal and strategies;
                Marketing activities; a description of the information provided by
                marketers, including an overview of managed care; and staff training,
                development and responsibilities. The following must be included
                in the
                Contractor's description of materials to be used: distribution methods;
                primary Marketing locations, and a listing of the kinds of community
                service events the Contractor anticipates sponsoring and/or
                participating in for the purposes of providing information and/or
                distributing Marketing materials.

            


    

    


    
      	
              6.
                

            	
              The
                Contractor must describe how it is able to meet the informational
                needs,
                related to Marketing, for the physical and cultural diversity of
                Prospective Enrollees.
                This may include, but not be limited to: a description of the Contractor's
                provisions for Non-English speaking Prospective Enrollees, interpreter
                services, alternate communication mechanisms, including sign language,
                Braille, audio tapes, and/or
                use of Telecommunications Device for the Deaf (TDD)/TTY
                services and how the Contractor will make oral interpretation services
                available to Potential Enrollees and Enrollees free of
                charge.

            


    

    


    
      	
              7.
                

            	
              The
                Contractor shall describe measures for monitoring and enforcing compliance
                with these Guidelines by its Marketing Representatives and its
                Participating Providers including: the prohibition of door-to-door
                solicitation and cold-call telephoning; a description of the development
                of mailing lists of Prospective Enrollees that maintains client
                confidentiality and that honors the client's express request for
                direct
                contact by the Contractor; a description and planned means of distribution
                of pre-enrollment
                gifts and incentives to Prospective Enrollees; and a description
                of the
                training, compensation and supervision of its Marketing
                Representatives.

            


    

    


    


    


    


    


    


    


    


    


    


    


    APPENDIX
      D

    October
      1, 2005

    D-3

    


    D.2
      

    Marketing
      Materials

    


    1. Definitions

    


    a)
       Marketing
      materials generally include the concepts of advertising, public service
      announcements, printed publications, and other broadcast or electronic messages
      designed to increase awareness and interest in the Medicaid
      Managed
      Care Program or the FHPlus
      Program
      and/or
      the
      Contractor's MMC
      or
FHPlus
      product.
      The target audience for MMC Marketing materials is MMC Eligible Persons who
      are
      not enrolled in a MCO
      offering
      a MMC product, and who are living in the Contractor's service area, if the
      Contractor offers a MMC product. The target audience for FHPlus Marketing
      materials is low-income uninsured people who do not qualify for Medicaid, who
      are living in the Contractor's service area,
      if the
      Contractor offers a FHPlus product.

    


    b)  Marketing
      materials include any information that references the MMC or FHPlus Program,
      is
      intended for general distribution, and is produced in a variety of print,
      broadcast, and direct Marketing mediums. These generally include: radio,
      television, billboards, newspapers, leaflets, informational brochures, videos,
      telephone book yellow page ads, letters, and posters. Additional materials
      requiring Marketing approval include a listing of items to be provided as
      nominal gifts or incentives.

    


    2.
       Marketing
      Material Requirements

    


    a)
       Marketing
      materials must be written in prose that is understood at a fourth-to
      sixth-grade reading level and must be printed in at least ten (10) point
      type.

    


    b)
       Marketing
      materials must be made available throughout the Contractor's entire service
      area. Materials may be customized for specific counties and populations within
      the Contractor's service area. All Marketing activities should provide for
      equitable distribution of materials without bias toward or against any
      group.

    


    c)  The
      Contractor must make available written Marketing and other informational
      materials (e.g., member handbooks) in a language other than English whenever
      at
      least five percent (5%) of the Prospective Enrollees
      of the
      Contractor in any county of the service area speak that particular language
      and
      do not speak English as a first language. SDOH
      will
      inform the Contractor when the five percent (5%) threshold has been reached.
      Marketing materials to be translated include those key materials, such as
      informational brochures, that are produced for routine distribution, and which
      are included within the Contractor's Marketing plan. SDOH will determine the
      need for other-than-English
      translations based on county-specific census data or other available
      measures.

    


    d)  Alternate
      forms of communications must be provided for persons with visual, hearing,
      speech, physical, or developmental disabilities. These alternate
      forms

    


    


    


    


    APPENDIX
      D

    October
      1, 2005

    D-4

    


    


    include
      Braille or audiotapes
      for the
      visually impaired, TTY
      access
      for those with certified speech or hearing disabilities, and use of American
      Sign Language and/or integrative
      technologies.

    


    e)  The
      Contractor's name, mailing address (and location, if different), and toll-free
      phone number must be prominently displayed on the cover of all multi-paged
      Marketing materials.

    


    f)  Marketing
      materials must not contain false, misleading, or ambiguous
      information-such
      as
      "You have been pre-approved
      for the
XYZ
      Health
      Plan," or "If you do not choose a plan you will lose your Medicaid
      coverage," or "You get free, unlimited visits." Materials must not use broad,
      sweeping statements.

    


    g)  The
      material must accurately reflect general information, which is applicable to
      the
      average consumer of the MMC
      Program
      or FHPlus
      Program.

    


    h)  The
      Contractor may not use logos or wording used by government agencies if such
      use
      could imply or cause confusion about a connection between a governmental agency
      and the Contractor.

    


    i)  Marketing
      materials may not make reference to incentives that may be available to
Enrollees
      after
      they enroll in the Contractor's MMC or FHPlus product,
      such as
      "If you join the XYZ Plan, you will receive a free baby carriage after you
      complete eight prenatal visits."

    


    j)  Marketing
      materials that are prepared for distribution or presentation by the LDSS,
      Enrollment
      Broker, or SDOH-approved
      Enrollment Facilitators, must be provided in a manner that is easily understood
      and appropriate to the target audience. The material covered must include
      sufficient information to assist the individual in making an informed choice
      ofMCO.

    


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

    


    1)
       Marketing
      materials shall not mention other MCOs
      offering
      MMC or FHPlus products by name except for materials approved by SDOH
      and
      developed to present available MCO choices in an unbiased manner, or as part
      of
      a transition of Enrollees from an MCO that withdraws from the MMC or FHPlus
      Program.

    


    3.
       Prior
      Approvals

    


    a)
       The
      SDOH
      will review and approve the Contractor's Marketing plan and all Marketing
      materials and advertising.

    


    


    


    


    APPENDIX
      D

    October
      1, 2005

    D-5

    



    i)  The
      SDOH
      will
      coordinate its review and approval of materials that are specific to one local
      district with the affected LDSS.

    


    
      	 	
              b) 

            	
              The
                SDOH will adhere to a sixty (60) day "file and use" policy, whereby
                materials submitted by the Contractor must be reviewed and commented
                on
                within sixty (60) days of submission or the Contractor may assume
                the
                materials have been approved if the reviewer has not submitted any
                written
                comment.

            


    

    


    4.
       Dissemination
      of Outreach Materials

    


    a)
       Upon
      request,
      the
      Contractor shall provide to the LDSS, Enrollment Broker and/or
      SDOH-approved
      Enrollment Facilitators, sufficient quantities of approved Marketing materials
      or alternative informational materials that describe coverage in the LDSS
      jurisdiction.

    


    b)
       The
      Contractor shall, upon request,
      submit
      to the LDSS, Enrollment Broker, or SDOH-approved Enrollment Facilitators,
      current provider directories, as described in Section 13.2 of this Agreement,
      together with information that describes how to determine whether
      a
      provider is presently available.

    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    APPENDIX
      D

    October
      1, 2005

    D-6

    



    D.3
      

    


    Marketing
      Activities

    


    1.
       Description
      and Requirements

    


    a)
       Marketing
      includes any occasion during which Marketing information and material regarding
      MMC
      and
FHPlus
      Programs
      and information about the Contractor's MMC
      or
      FHPlus
      products are presented to Prospective Enrollees.
      Marketing activities include verbal presentations or distribution of written
      materials, which may or may not be accompanied by the giving away of nominal
      gifts.

    


    b)  With
      prior LDSS
      approval, the
      Contractor may engage in Marketing activities that include community-sponsored
      social gatherings, provider-hosted informational sessions, or
      Contractor-sponsored events. Events may include such activities as
      health
      fairs
      workshops on health promotion, holiday parties, after school programs, raffles,
      etc. These events must not be restricted to Potential Enrollees.

    


    c)  The
      Contractor may conduct media campaigns (i.e.,
      distribution of information/materials
      regarding the MMC and/or
      FHPlus
      Programs and/or
      its
      specific MMC and/or
      FHPlus
      products to encourage Prospective Enrollees to enroll in its MMC or FHPlus
      product.) All media materials, including television, radio, billboards, subway
      and bus posters, and electronic messages, must be pre-approved
      by
      the
SDOH
      at least
      thirty (30) days prior to the campaign.

    


    d)  The
      Contractor will be forthright in its presentations to allow Prospective
      Enrollees to exercise an informed choice.

    


    e)  If
      Contractor does not include Family Planning and Reproductive services in its
      Benefit Package, as specified in Appendix M
      of this
      Agreement,
      the
      Marketing Representative must tell Prospective 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) 

            	
              whenever
                needed.
                Family Planning and Reproductive Health services may be obtained
                by MMC
                Enrollees through fee-for-service Medicaid
                from any provider who accepts Medicaid, and by FHPlus Enrollees from
                the
                Designated Third-Party Contractor (including the name and phone number
                of
                the Designated Third Party Contractor for the Prospective Enrollee's
                geographic area);

            


    

    


    iii)  no
      referral is needed for Family Planning and Reproductive Health services;
      and

    


    
      	 	
              iv) 

            	
              there
                will be no cost to the Enrollee
                for Family Planning and Reproductive Health
                services.

            


    

    


    APPENDIX
      D

    October
      1, 2005

    D-7

    


    


    2.
       Marketing
      Sites

    


    a)
       With
      prior LDSS
      approval, the Contractor may distribute approved Marketing material in such
      places as: an income support maintenance center, community centers, markets,
      pharmacies, hospitals and other provider sites, schools, health fairs, a
      resource center established by the LDSS or the Enrollment Broker, and other
      areas where Prospective Enrollees
      are
      likely to gather. The LDSS may require the Contractor to provide a minimum
      of
      two weeks notice to the LDSS regarding marketing at approved locations so that
      the LDSS may fulfill its role in monitoring Contractor marketing
      activities.

    


    b)  The
      Contractor shall comply with the applicable restrictions on Marketing
      established in SSL§
      364-j(4)(e), SSL§369-ee
      and the
SDOH
      Marketing Guidelines. The Contractor shall not engage in practices prohibited
      by
      law and regulation, including cold call Marketing or door-to-door solicitation.
      Cold Call Marketing means any unsolicited personal contact by the Contractor
      with a Prospective Enrollee
      for the
      purpose of Marketing. The Contractor shall not market to Prospective Enrollees
      at their homes without the permission of the Prospective Enrollee.

    


    
      	 	
              c) 

            	
              The
                Contractor shall comply with LDSS written requirements regarding
                scheduling, staffing, and on-site
                procedures when marketing at LDSS
                sites.

            


    

    


    
      	 	
              d) 

            	
              The
                Contractor shall neither conduct Marketing nor distribute Marketing
                materials in hospital emergency rooms including the emergency room
                waiting
                areas, patient rooms or treatment areas (except for waiting areas)
                or
                other sites as are prohibited by the Commissioner of Health pursuant
                to
                SSL § 364-j(4)(e) or SSL § 369-ee for FHPlus.

            


    

    


    
      	 	
              e) 

            	
              The
                Contractor may not require its Participating Providers to distribute
                Contractor-prepared communications to their
                patients.

            


    

    


    
      	 	
              f) 

            	
              The
                Contractor shall instruct its Participating Providers regarding the
                following requirements applicable to communications with their patients
                about the MMC
                and FHPlus products offered by the Contractor and other MCOs
                with which the Participating Providers may have
                contracts:

            


    

    


    
      	 	
              i) 

            	
              Participating
                Providers who wish to let their patients know of their affiliations
                with
                one or more MCOs must list each MCO
                with whom they have contracts.

            


    

    


    
      	 	
              ii) 

            	
              Participating
                Providers may display the Contractor's Marketing materials provided
                that
                appropriate notice is conspicuously posted for all other MCOs with
                whom
                the Provider has a contract.

            


    

    


    


    


    


    


    


    


    


    APPENDIX
      D

    October
      1, 2005

    D-8

    



    
      	 	
              iii)
                

            	
              Upon
                termination of a Provider Agreement with the Contractor, a provider
                that
                has contracts with other MCOs
                that offer
                MMC
                or
                FHPlus
                products may notify their
                patients of the change in status and the impact of such change on
                the
                patient.

            


    

    


    
      	
              3.
                

            	
              Marketing
                Representatives

            


    

    


    a)
       The
      Contractor shall require its Marketing Representatives, including employees
      assigned to market its MMC and FHPlus products, and employees of Marketing
      subcontractors, to successfully complete a training program about the basic
      concepts of managed care and the Enrollees'
      rights
      and responsibilities relating to Enrollment in an MCO's
      MMC or
      FHPlus product. The Contractor shall submit a copy of the training curriculum
      for its Marketing Representatives to SDOH
      as part
      of the Marketing plan. The Contractor shall be responsible for the activities
      of
      its Marketing Representatives and the Marketing activities of any subcontractor
      or management entity.

    


    b)  The
      Contractor shall ensure that its Marketing Representatives engage in
      professional and courteous behavior in their interactions with LDSS
      staff,
      staff from other health plans, Eligible Persons and Prospective Enrollees.
      The
      Contractor shall neither participate nor encourage nor accept inappropriate
      behavior by its Marketing Representatives, including but not limited to
      interference with other MCO
      presentations,
      talking negatively about another MCO, or participating in a Medicaid
      or
      FHPlus
      client's verification interview with LDSS staff.

    


    c)  The
      Contractor shall not offer compensation to Marketing Representatives, including
      salary increases or bonuses, based solely on the number of individuals they
      enroll. However, the Contractor may base compensation of Marketing
      Representatives on periodic performance evaluations which consider Enrollment
      productivity as one of several performance factors during a performance period,
      subject to the following requirements:

    


    
      	 	
              i) 

            	
              "Compensation"
                shall mean any remuneration required to be reported as income or
                compensation for federal tax
                purposes;

            


    

    


    
      	 	
              ii) 

            	
              The
                Contractor may not pay a "commission" or fixed amount per
                enrollment;

            


    

    


    
      	 	
              iii)
                

            	
              The
                Contractor may not award bonuses more frequently than quarterly,
                or for an
                annual amount that exceeds ten percent (10%) of a Marketing
                Representative's total annual
                compensation.

            


    

    


    d)  The
      Contractor shall keep written documentation, including performance evaluations
      tools, of the basis it uses for awarding bonuses or increasing the salary of
      Marketing Representatives and employees involved in Marketing and make such
      documentation available for inspection by SDOH or the LDSS.

    


    


    


    


    


    


    


    APPENDIX
      D

    October
      1, 2005

    D-9

    


    


    4.
       Restricted
      Marketing Activities

    


    a)
       The
      Contractor shall not engage in the following practices:

    


    
      	 	
              i) 

            	
              misrepresenting
                the Medicaid fee-for-service, MMC
                Program or FHPlus
                Program, or the program or policy requirements of the LDSS
                or
                the SDOH,
                in
                Marketing encounters or materials;

            


    

    


    
      	 	
              ii) 

            	
              purchasing
                or otherwise acquiring or using mailing lists of Eligible Persons
                from
                third party vendors, including providers and LDSS
                offices;

            


    

    


    
      	 	
              iii) 

            	
              using
                raffle tickets or event attendance or sign-in sheets to develop mailing
                lists of Prospective Enrollees;

            


    

    


    
      	 	
              iv) 

            	
              offering
                incentives (i.e., any type of inducement whose receipt is contingent
                upon
                the individual's Enrollment) of any kind to Prospective Enrollees
                to
                enroll in the Contractor's MMC or FHPlus
                product.

            


    

    


    b)  The
      Contractor may not discriminate against Eligible Persons or Enrollees on the
      basis of age; sex; race; creed; physical or mental handicap/developmental
      disability; national origin; sexual orientation; type of illness or condition;
      need for health services; or the Capitation Rate the Contractor will receive
      for
      such Eligible Person. Health assessments may not be performed by the Contractor
      prior to Enrollment. The Contractor may inquire about existing primary care
      relationships of the applicant and explain whether and how such relationships
      may be maintained. Upon request, each Prospective Enrollee
      shall be
      provided with a listing of all the Contractor's Participating Providers
      including, PCPs,
      specialists and facilities in the Contractor's network. The Contractor may
      respond to a Prospective Enrollee's
      question
      about whether a particular PCP,
      specialist or facility is a Participating Provider of the Contractor in the
      network. However, the Contractor shall not inquire about the types of
      specialists utilized by the Prospective Enrollee.

    


    c)  The
      Contractor may offer nominal gifts of not more than five dollars ($5.00) in
      fair-market value as part of a health fair or other Marketing activity to
      stimulate interest in the MMC or FHPlus Program and/or
      the
      Contractor. Such gifts must be pre-approved
      by
      the
      SDOH, and offered without regard to Enrollment. The Contractor must submit
      a
      listing and description of intended items to be distributed at Marketing
      activities as nominal gifts, including a listing of item donors or co-sponsors
      for approval. The submission of actual samples or photographs of intended
      nominal gifts will not be routinely required, but must be made available upon
      request by the SDOH reviewer.

    


    d)  The
      Contractor may offer its Enrollees rewards for completing a health goal, such
      as
      finishing all prenatal visits, participating in a smoking cessation session,
      attending initial orientation sessions upon enrollment,
      and
      timely completion of immunizations or other health related programs. Such
      rewards may not exceed fifty dollars ($50.00)

    


    APPENDIX
      D

    October
      1, 2005

    D-10

    


    


    


    


    


    in
      fair-market value per Enrollee
      over a
      twelve (12) month period, and must be related to a health goal. The Contractor
      may not make reference to these rewards in their pre-enrollment
      Marketing materials or discussions and all such rewards must be approved by
      the
SDOH.

    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    APPENDIX
      D

    October
      1, 2005

    D-11

    


    Appendix
      E

    


    New
      York State Department of Health 

    Member
      Handbook Guidelines

    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    APPENDIX
      E

    October
      1, 2005

    E-1

    



    Member
      Handbook Guidelines

    


    1.
       Purpose

    


    a)
       This
      document contains Member Handbook guidelines for use by the
      Contractor to develop handbooks for MMC
      and
FHPlus Enrollees
      covered
      under this Agreement.

    


    b)  These
      guidelines reflect the review criteria used by the SDOH
      Office
      of Managed Care in its review of all MMC and FHPlus Member Handbooks. Member
      Handbooks and addenda must be approved by SDOH prior to printing and
      distribution by the Contractor.

    


    2.
       SDOH
      Model Member Handbook

    


    a)
       The
      SDOH
      Model Member Handbook includes all required information specified in this
      Appendix, written at an acceptable reading level. The Contractor may adapt
      the
      SDOH Model Member Handbook to reflect its specific policies and procedures
      for
      its MMC or FHPlus product

    


    b)
       SDOH
      strongly recommends the Contractor use the SDOH Model Member Handbook language
      for the following required disclosure areas in the Contractor's Member
      Handbook:

    


    
      	 	
              i) 

            	
              access
                to Family Planning and Reproductive Health
                services;

            


    

    


    
      	 	
              ii) 

            	
              self
                referral policies;

            


    

    


    
      	 	
              iii) 

            	
              obtaining
                OB/GYN
                services;

            


    

    


    
      	 	
              iv) 

            	
              the
                definitions of medical necessity and Emergency
                Services;

            


    

    


    
      	 	
              v) 

            	
              protocols
                for Action, utilization review, Complaints, Complaint Appeals, Action
                Appeals, External Appeals, and fair
                hearings;

            


    

    


    
      	 	
              vi) 

            	
              protocol
                for newborn Enrollment; and

            


    

    


    vii)
      listing
      of Enrollee
      entitlements, including benefits, rights and responsibilities, and information
      available upon request.

    


    c)  A
      copy of
      the SDOH Model Member Handbook is available from the SDOH Office of Managed
      Care, Bureau of Intergovernmental Affairs.

    


    


    


    


    


    


    


    


    


    APPENDIX
      E

    October
      1, 2005

    E-2

    



    3.
       General
      Format

    


    a)
       It
      is
      expected that most MCOs
      will
      develop separate handbooks for their MMC
      and
FHPlus Enrollees.
      The
      Contractor must include the required contents as per Section 4 of this Appendix
      for both the MMC and FHPlus Programs, as applicable, and list the information
      available upon request in accordance with Section 5 of this Appendix in their
      Member Handbooks.

    


    b)  The
      Contractor must write Member Handbooks in a style and reading level that will
      accommodate the reading skills of many MMC and FHPlus Enrollees. In general
      the
      writing should be at no higher than a sixth-grade level, taking into
      consideration the need to incorporate and explain certain technical or
      unfamiliar terms to assure accuracy. The text must be printed in at least
      ten-point font,
      preferably twelve-point font. The SDOH
      reserves
      the right to require evidence that a handbook has been tested against the
      sixth-grade reading-level standard.

    


    c)  The
      Contractor must make Member handbooks available in languages other than English
      whenever at least five percent (5%) of the Prospective Enrollees of the
      Contractor in any county in the Contractor's service area speak a language
      other
      than English as a first language. Member handbooks must be made accessible
      to
      non-English speaking and visually and hearing impaired Enrollees.

    


    4.
       Requirements
      for Handbook Contents

    


    a)
       General
      Overview (how the MMC or FHPlus product works)

    


    
      	 	
              i) 

            	
              Explanation
                of the Contractor's MMC or FHPlus product, including what happens
                when an
                Eligible Person enrolls.

            


    

    


    
      	 	
              ii) 

            	
              Explanation
                of the Contractor-issued Enrollee
                ED
                card, obtaining routine medical care, help by telephone, and general
                information pertaining to the Contractor's MMC or FHPlus
                product,
                i.e.,
                location of the Contractor, providers,
                etc.

            


    

    


    
      	 	
              iii)

            	
              Invitation
                to attend scheduled orientation sessions and other educational and
                outreach activities.

            


    

    


    b)
       Provider
      Listings

    


    
      	 	
              i)
                

            	
              The
                Contractor may include the following information in the handbook,
                as an
                insert to the handbook, or produce this information as a separate
                document
                and reference such document in the handbook.


            


    

    


    A)
       A
      current
      listing of providers, including facilities and site locations.

    


    


    


    


    


    


    


    APPENDIX
      E

    October
      1, 2005

    E-3

    



    B)  Separate
      listings of Participating Providers that are Primary Care Providers and
      specialty providers; including location, phone number, and board certification
      status.

    


    C)  Listing
      also must include a notice of how to determine if a Participating Provider
      is
      accepting new patients.

    


    c)  Voluntary
      or Mandatory Enrollment - For MMC
      Program
      Only 

    


    
      	 	
              i) 

            	
              Must
                indicate whether Enrollment is voluntary or
                mandatory.

            


    

    


    
      	 	
              ii) 

            	
              If
                the Contractor offers a MMC product in both mandatory and voluntary
                counties, an explanation of the difference, i.e., Disenrollment
                rules, etc.

            


    

    


    d)  Choice
      of
      Primary Care Provider

    


    
      	 	
              i)
                

            	
              Explanation
                of the role of PCP
                as
                a coordinator of care, giving some examples, and how to choose one
                for
                self and family

            


    

    .

    
      	 	
              ii)
                

            	
              How
                to make an appointment with the PCP, importance of base line physical,
                immunizations and well-child care

            


    

    .

    
      	 	
              iii) 

            	
              Explanation
                of different types of PCPs,
                i.e.,
                family practice, pediatricians,
                internists,
                etc.

            


    

    


    
      	 	
              iv) 

            	
              Notification
                that the Contractor will assign the Enrollee
                to
                a PCP if one is not chosen in thirty (30)
                days.

            


    

    


    
      	 	
              v) 

            	
              OB/GYN
                choice rules for women.

            


    

    


    e)  Changing
      Primary Care Provider

    


    
      	 	
              i)
                

            	
              Explanation
                of the Contractor's policy, timeframes,
                and process related to an Enrollee changing his or her PCP. (Enrollees
                may change PCPs thirty (30) days after the initial appointment with
                their
                PCP, and the
                Contractor may elect to limit the Enrollee to changing PCPs without
                cause
                once every six months.)

            


    

    


    
      	 	
              ii)
                

            	
              Explanation
                of process for changing OB/GYN when applicable.


            


    

    


    
      	 	
              iii)
                

            	
              Explanation
                of requirements for choosing a specialist as
                PCP.

            


    

    


    f)  Referrals
      to Specialists (Participating or Non-Participating)

    


    
      	 	
              i)
                

            	
              Explanation
                of specialist care and how referrals are
                accomplished.

            


    

     

    
      	 	
              ii)
                

            	
              Explanation
                of the process for changing
                specialists.

            


    

    


    


    APPENDIX
      E

    October
      1, 2005

    E-4

    



    
      	 	
              iii) 

            	
              Explanation
                of self-referral services, i.e., OB/GYN
                services, HIV
                counseling and testing, eye exams,
                etc.

            


    

    


    
      	 	
              iv) 

            	
              Notice
                that an Enrollee
                may obtain a referral to a Non-Participating Provider when the Contractor
                does not have a Participating Provider with appropriate training
                or
                experience to meet the needs of the Enrollee; and the procedure for
                obtaining such referrals.

            


    

    


    
      	 	
              v) 

            	
              Notice
                that an Enrollee with a condition that requires ongoing care from
                a
                specialist may request a standing referral to such a specialist;
                procedure
                for obtaining such referrals.

            


    

    


    
      	 	
              vi) 

            	
              Notice
                that an Enrollee with a life-threatening condition or disease, or
                a
                degenerative and disabling condition or disease, either of which
                requires
                specialized medical care over a prolonged period of time, may request
                access to a specialist possessing the credentials to be responsible
                for
                providing or coordinating the Enrollee's
                medical care; and the procedure for obtaining such a
                specialist.

            


    

    


    vii)
      Notice
      that an Enrollee with
      a
      life-threatening condition or disease, or a degenerative and disabling condition
      or disease, either of which requires specialized medical care over a prolonged
      period of time, may request access to a specialty care center; and the procedure
      for obtaining such access.

    


    g)  Covered
      and Non-Covered Services

    


    
      	 	
              i) 

            	
              Benefits
                and services covered by the Contractor's MMC
                or
                FHPlus
                product, including benefit maximums
                and limits.

            


    

    


    ii)
      Definition of medical necessity, as defined in this Agreement, and its use
      to
      determine whether benefits will be covered.

    


    
      	 	
              iii)
                

            	
              Medicaid
                covered services that are not covered by the
                Contractor's MMC product or are excluded from the MMC Program, and
                how to
                access these services. (MMC Program Member Handbooks
                only.)

            


    

    


    
      	 	
              iv)
                

            	
              A
                description of services not covered by MMC, Medicaid fee-for-service
                or
                the FHPlus Programs.

            


    

    


    v)
      Prior
      Authorization and other requirements for obtaining treatments and
      services.

    


    
      	 	
              vi)
                

            	
              Access
                to Family Planning and Reproductive Health services, and for MMC
                Program
                Member Handbooks, the Free Access policy for MMC Enrollees,
                pursuant
                to Appendix C
                of
                this Agreement.

            


    

    


    


    


    


    


    


    APPENDIX
      E

    October
      1, 2005

    E-5

    



    vii) HIV
      counseling and testing free access policy. (MMC
      Program
      Member Handbooks only.)

    


    viii)
      Direct
      access policy for dental services provided at Article 28 clinics operated by
      academic dental centers when dental is in the Benefit Package. (MMC Program
      Member Handbooks only.)

    


    
      	 	
              ix) 

            	
              The
                Contractor's policy relating to emergent and non-emergent transportation,
                including who to call and what to do if the Contractor's MMC product
                does
                not cover emergent or non-emergent transportation. (MMC Program Member
                Handbooks only.)

            


    

    


    x)
      For
FHPlus
      Program
      Member Handbooks, coverage of emergent transportation and what to do if
      needed.

    


    xi)
      Contractor's toll-free number for Enrollee
      to call
      for more information. 

    


    xii)
      Any
      cost-sharing (e.g. copays
      for
      Contractor covered services). 

    


    h)  Out
      of
      Area Coverage

    


    Explanation
      of what to do and who to call if medical care is required when Enrollee is
      out
      of his or her county of fiscal responsibility or the Contractor's service
      area.

    


    i)  Emergency
      and Post Stabilization Care Access

    


    
      	 	
              i) 

            	
              Definition
                of Emergency Services, as defined in law and regulation including
                examples
                of situations that constitute an emergency and situations that do
                not.

            


    

    


    
      	 	
              ii) 

            	
              What
                to do in an emergency, including notice that services in a true emergency
                are not subject to prior approval.

            


    

    


    
      	 	
              iii) 

            	
              A
                phone number to call if
                PCP
                is
                not available. 

            


    

    


    
      	 	
              iv) 

            	
              Explanation
                of what to do in non-emergency situations (PCP,
                urgent care, etc.).

            


    

    


    
      	 	
              v) 

            	
              Locations
                where the Contractor provides Emergency Services and Post-stabilization
                Care Services.

            


    

    


    
      	 	
              vi) 

            	
              Notice
                to Enrollees
                that in a true emergency they may access services at any provider
                of
                Emergency Services.

            


    

    


    vii)
      Definition of Post-Stabilization care services and how to access
      them.

    


    APPENDIX
      E

    October
      1, 2005

    E-6

    


    


    


    


    


    


    


    


    


    


    


    


    j)
      Actions
      and Utilization Review

    


    
      	 	
              i) 

            	
              Circumstances
                under which Actions and utilization review will be undertaken (in
                accordance with Appendix F
                of
                this Agreement).

            


    

    


    
      	 	
              ii) 

            	
              Toll-free
                telephone number of the utilization review department or
                subcontractor.

            


    

    


    
      	 	
              iii) 

            	
              Time
                frames in which Actions and UR
                determinations must be made for prospective, retrospective, and concurrent
                reviews.

            


    

    


    
      	 	
              iv) 

            	
              Right
                to reconsideration.

            


    

    


    
      	 	
              v) 

            	
              Right
                to file an Action Appeal, orally or in writing, including expedited
                and
                standard Action Appeals processes and the timeframes
                for Action Appeals.

            


    

    


    
      	 	
              vi) 

            	
              Right
                to designate a representative.

            


    

    


    
      	 	
              vii)

            	
              A
                notice that all Adverse Determinations will be made by qualified
                clinical
                personnel and that all notices will include information about the
                basis of
                the determination, and farther Action Appeal rights (if
                any).

            


    

    


    k)  Enrollment
      and Disenrollment
      Procedures

    


    
      	 	
              i)
                

            	
              Where
                appropriate, explanation of Lock-In requirements and when an Enrollee
                may
                change to another
                MCO,
                or
                for MMC Enrollees
                if
                permitted, return to Medicaid fee-for-service,
                for Good Cause, as defined in Appendix H
                of
                this Agreement.

            


    

    


    
      	 	
              ii)
                

            	
              Procedures
                for Disenrollment.

            


    

    


    
      	 	
              iii)
                

            	
              LDSS,
                or
                Enrollment Broker as appropriate, phone number for information on
                Enrollment and Disenrollment.

            


    

    


    1)
       Rights
      and Responsibilities of Enrollees

    


    
      	 	
              i)
                

            	
              Explanation
                of what an Enrollee has the right to expect from the Contractor in
                the way
                of medical care and treatment of the Enrollee as specified in Section
                13.7
                of this Agreement.

            


    

    


    
      	 	
              ii)
                

            	
              General
                responsibilities of the Enrollee.

            


    

    


    
      	 	
              iii)
                

            	
              Enrollee's
                potential financial responsibility for payment when services are
                furnished
                by a Non-Participating Provider or are famished by any provider without
                required authorization, or when a procedure, treatment, or service
                is not
                a covered benefit. Also note exceptions such as family planning and
                HIV
                counseling/testing.

            


    

    


    APPENDIX
      E

    October
      1, 2005

    E-7

    



    
      	 	
              iv) 

            	
              Enrollee's
                rights under State law to formulate advance
                directives.

            


    

    


    v)
      The
      manner in which Enrollees
      may
      participate in the development of Contractor policies.

    


    m)  Language

    


    Description
      of how the Contractor addresses the needs of non-English speaking
      Enrollees.

    


    n)  Grievance
      Procedures (Complaints)

    


    
      	 	
              i) 

            	
              Right
                to file a Complaint regarding any dispute between the Contractor
                and an
                Enrollee
                (in accordance with Appendix F
                of
                the Agreement).

            


    

    


    
      	 	
              ii) 

            	
              Right
                to file a Complaint orally.

            


    

    


    
      	 	
              iii) 

            	
              The
                Contractor's toll-free number for filing oral
                Complaints.

            


    

    


    
      	 	
              iv)
                

            	
              Time
                frames and circumstances for expedited and standard
                Complaints.

            


    

    


    
      	 	
              v)
                

            	
              Right
                to appeal a Complaint determination and the procedures for filing
                a
                Complaint Appeal.

            


    

    


    
      	 	
              vi) 

            	
              Time
                frames and circumstances for expedited and standard Complaint Appeals.
                

            


    

    


    vii)
      Right to
      designate a representative.

    


    viii)A
      notice that all determination involving clinical disputes will be made by
      qualified clinical personnel and that all notices will include information
      about
      the basis of the determination, and further appeal rights (if any).

    


    ix) SDOH's
      toll-free number for medically related Complaints.

    


    
      	 	
              x) 

            	
              New
                York State Insurance Department number for certain complaints relating
                to
                billing.

            


    

    


    o)  Fan-Hearing

    


    
      	 	
              i)
                

            	
              Explanation
                that the Enrollee has a right to a State fair hearing and aid to
                continue
                in some situations and that the Enrollee may be required to repay
                the
                Contractor for services received if the fair hearing decision is
                adverse
                to the Enrollee.

            


    

    


    
      	 	
              ii)
                

            	
              Describe
                situations when the Enrollee may ask for a fair hearing as described
                in
                Section 25 of this Agreement including: SDOH
                or
                LDSS
                decision about the Enrollee staying in or leaving the Contractor's
                MMC
                or
                FHPlus
                product;

            


    

    


    APPENDIX
      E

    October
      1, 2005

    E-8

    



    Contractor
      determination that stops or limits Medicaid
      benefits; and Contractor's Complaint determination that upholds a provider's
      decision not to order Enrollee-requested
      services.

    


    
      	 	
              iii) 

            	
              Describe
                how to request a fair hearing (assistance through member services,
                LDSS,
                State fair hearing contact).

            


    

    


    p)  External
      Appeals

    


    
      	 	
              i) 

            	
              Description
                of circumstances under which an Enrollee
                may request an External Appeal.

            


    

    


    
      	 	
              ii) 

            	
              Timeframes
                for applying for External Appeal and for
                decision-making.

            


    

    


    
      	 	
              iii)
                

            	
              How
                and where to apply.

            


    

    


    
      	 	
              iv) 

            	
              Describe
                expedited External Appeal timeframe.

            


    

    


    
      	 	
              v) 

            	
              Process
                for Contractor and Enrollee to agree on waiving the Contractor's
                internal
                UR
                Appeals process.

            


    

    


    q)  Payment
      Methodologies

    


    Description
      prepared annually of the types of methodologies the Contractor uses to reimburse
      providers, specifying the type of methodology used to reimburse particular
      types
      of providers or for the provision of particular types of services.

    


    r)  Physician
      Incentive Plan Arrangements

    


    The
      Member Handbook must contain a statement indicating the Enrollees
      and
      Prospective Enrollees are entitled to ask if the Contractor has special
      financial arrangements with physicians that can affect the use of referrals
      and
      other services that they might need and how to obtain this
      information.

    


    s)  How
      and
      Where to Get More Information

    


    
      	 	
              i)
                

            	
              How
                to access a member services representative through a toll-free number.
                ii)
                How and when to contact LDSS for assistance.


            


    

    


    5.
       Other
      Information Available Upon Enrollee's
      Request

    


    a)
       Information
      on the structure and operation of the Contractor's organization. List of the
      names, business addresses, and official positions of the membership of the
      board
      of directors, officers, controlling persons, owners or partners of the
      Contractor.

    


    


    


    


    APPENDIX
      E

    October
      1, 2005

    E-9

    


    


    


    b)  Copy
      of
the
      most
      recent annual certified financial statement of the Contractor, including a
      balance sheet and summary of receipts and disbursements prepared by a
CPA.

    


    c)  Copy
      of
      the most recent individual, direct pay subscriber contracts.

    


    d)  Information
      relating to consumer complaints compiled pursuant to Section 210 of the
      Insurance Law.

    


    e)  Procedures
      for protecting the confidentiality of medical records and other Enrollee
      information.

    f)  Written
      description of the organizational arrangements and ongoing procedures of the
      Contractor's quality assurance program.

    


    g)  Description
      of the procedures followed by the Contractor in making determinations about
      the
      experimental or investigational
      nature
      of medical devices, or treatments in clinical trials.

    


    h)  Individual
      health
      practitioner affiliations with
      Participating hospitals.

    


    i)  Specific
      written clinical review criteria relating to a particular condition or disease
      and, where appropriate, other clinical information which the Contractor might
      consider in its Service Authorization or utilization review
      process.

    


    j)  Written
      application procedures and minimum qualification requirements for health care
      providers to be considered by the Contractor.

    


    k)  Upon
      request, the Contractor is required to provide the following information on
      the
      incentive arrangements affecting Participating Providers to Enrollees,
      previous
Enrollees
      and
      Prospective Enrollees:

    


    
      	 	
              i)
                

            	
              Whether
                the Contractor's Provider Agreements or subcontracts include Physician
                Incentive Plans (PIP) that affect the use of referral
                services.

            


    

    


    
      	 	
              ii) 

            	
              Information
                on the type of incentive arrangements
                used.

            


    

    


     iii)
      Whether
      stop-loss protection is provided for physicians and physicians
      groups.

    


    
      	 	
              iv) 

            	
              If
                the Contractor is at substantial financial risk, as defined in the
                PIP
                regulations, a summary of the required customer satisfaction survey
                results.

            


    

    


    


    


    


    


    


    


    


    


    


    


    APPENDIX
      E

    October
      1, 2005

    E10

    


    APPENDIXE
      F

    


    New
      York State Department of Health 

    Action
      and Grievance System Requirements 

    for
      MMC
      and FHPlus
      Programs

    


    


    


    


    F.I
       Action
      Requirements 

    


    F.2
       Grievance
      System Requirements

    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    APPENDIX
      F

    October
      1, 2005

    F-1

    


    



    F.1

    


    Action
      Requirements

    


    1. Definitions

    


    a)
       Service
      Authorization Request means a request by an Enrollee,
      or a
      provider on the Enrollee's
      behalf,
      to the Contractor for the provision of a service, including a request for a
      referral or for a non-covered service.

    


    
      	 	
              i) 

            	
              Prior
                Authorization Request is a Service Authorization Request by the Enrollee,
                or a provider on the Enrollee's behalf, for coverage of a new service,
                whether for a new authorization period or within an existing authorization
                period, before such service is provided to the
                Enrollee.

            


    

    


    
      	 	
              ii) 

            	
              Concurrent
                Review Request is a Service Authorization Request by an Enrollee,
                or a
                provider on Enrollee's behalf, for continued, extended or more of
                an
                authorized service than what is currently authorized by the
                Contractor.

            


    

    


    b)  Service
      Authorization Determination means the Contractor's approval or denial of a
      Service Authorization Request.

    


    c)  Adverse
      Determination means a denial of a Service Authorization Request by the
      Contractor on the basis that the requested service is not Medically Necessary
      or
      an approval of a Service Authorization Request is in an amount, duration, or
      scope that is less than requested.

    


    d)  An
      Action
      means an activity of a Contractor or its subcontractor that results
      in:

    


    
      	 	
              i)
                

            	
              the
                denial or limited authorization of a Service Authorization
                Request,
                including the type or level of
                service;

            


    

    


    
      	 	
              ii)
                

            	
              the
                reduction, suspension, or termination of a previously authorized
                service;

            


    

    


    
      	 	
              iii) 

            	
              the
                denial, in whole or in part, of payment for a
                service;

            


    

    


    
      	 	
              iv) 

            	
              failure
                to provide services in a timely manner as defined by applicable State
                law
                and regulation and Section 15 of this Agreement;
                or

            


    

    


    
      	 	
              v) 

            	
              failure
                of the Contractor to act within the timeframes
                for resolution and notification of determinations regarding Complaints,
                Action Appeals and Complaint Appeals provided in this
                Appendix.

            


    

    


    


    


    


    


    


    


    APPENDIX
      F

    October
      1, 2005

    F-2

    



    2.
       General
      Requirements

    


    a)
       The
      Contractor's policies and procedures for Service Authorization Determinations
      and utilization review determinations shall comply with 42 CFR
      Part 438
      and Article 49 of the PHL,
      including but not limited to the following:

    


    
      	 	
              i) 

            	
              Expedited
                review of a Service Authorization Request must be conducted when
                the
                Contractor determines or the provider indicates that a delay would
                seriously jeopardize the Enrollee's
                life or health or ability to attain, maintain, or regain maximum
                function.
                The Enrollee
                may request expedited review of a Prior Authorization Request or
                Concurrent Review Request. If the Contractor denies the
                Enrollee's
                request for expedited review, the Contractor must handle the request
                under
                standard review timeframes.

            


    

    


    
      	 	
              ii) 

            	
              Any
                determination to deny a Service Authorization Request or to authorize
                a
                service in an amount, duration, or scope that is less than requested,
                must
                be made by a licensed, certified, or registered health care professional.
                If such Adverse Determination was based on medical necessity, the
                determination must be made by a clinical peer reviewer as defined
                by PHL
                §4900(2)(a).

            


    

    


    
      	 	
              iii) 

            	
              The
                Contractor is required to provide notice by phone and in writing
                to the
                Enrollee and to the provider of Service Authorization Determinations,
                whether adverse or not, within the timeframe
                specified in Section 3 below. Notice to the provider must contain
                the same
                information as the Notice of Action for the
                Enrollee.

            


    

    


    
      	 	
              iv) 

            	
              The
                Contractor is required to provide the Enrollee written notice of
                any
                Action other than a Service Authorization Determinations within the
                timeframe specified in Section 4
                below.

            


    

    


    3.
       Timeframes
      for Service Authorization Determinations

    


    a)
       For
      Prior
      Authorization Requests, the Contractor must make a Service Authorization
      Determination and notice the Enrollee of the determination by phone and in
      writing as fast as the Enrollee's
      condition requires and no more than:

    


    
      	 	
              i)
                

            	
              In
                the case of an expedited review, three (3) business days after receipt
                of
                the Service Authorization Request;
                or

            


    

    


    
      	 	
              ii)
                

            	
              In
                all other cases, within three (3) business days of receipt of necessary
                information, but no more than fourteen (14) days after receipt of
                the
                Service Authorization request.

            


    

    


    b)  For
      Concurrent Review Requests, the Contractor must make a Service Authorization
      Determination and notice the Enrollee of the determination by phone and in
      writing as fast as the Enrollee's
      condition requires and no more than:

    


    


    APPENDIX
      F

    October
      1, 2005

    F-3

    


    


    


    


    


    
      	 	
              i) 

            	
              In
                the case of an expedited review, one (1) business day after receipt
                of
                necessary information but no more than three (3) business days after
                receipt of the Service Authorization Request;
                or

            


    

    


    
      	 	
              ii) 

            	
              In
                all other cases, within one (1) business day of receipt of necessary
                information, but no more than fourteen (14) days after receipt of
                the
                Service Authorization Request.

            


    

    


    c)  Timeframes
      for
      Service Authorization Determinations may be extended for up to fourteen (14)
      days if:

    


    
      	 	
              i)
                

            	
              the
                Enrollee,
                the Enrollee's designee,
                or
                the Enrollee's
                provider requests an extension orally or in writing;
                or

            


    

    


    
      	 	
              ii)
                

            	
              The
                Contractor can demonstrate or substantiate that there is a need for
                additional information and how the extension is in the Enrollee's
                interest. The Contractor must send notice of the extension to the
                Enrollee. The Contractor must maintain sufficient
                documentation of extension determinations to demonstrate, upon
                SDOH's
                request,
                that the extension was justified.

            


    

    


    d)  If
      the
      Contractor extended its review as provided in paragraph 3(c) above, the
      Contractor must make a Service Authorization Determination and notice the
      Enrollee by phone and in writing as fast as the Enrollee's condition requires
      and within three (3) business days after receipt of necessary information for
      Prior Authorization Requests or within one (1) business day after receipt of
      necessary information for Concurrent Review Requests, but in no event later
      than
      the date the extension expires.

    


    
      	
              4.
                

            	
              Timeframes
                for Notices of Actions Other Than Service Authorizations
                Determinations

            


    

    


    a)
       When
      the
      Contractor intends to reduce, suspend, or terminate a previously authorized
      service within an authorization period, it must provide the Enrollee with a
      written notice at least ten (10) days prior to the intended Action,
      except:

    
      	 	
              i)
                

            	
              the
                period of advance notice is shortened to five (5) days in cases of
                confirmed Enrollee fraud; or 

            


    

    
      	 	
              ii)
                

            	
              the
                Contractor may mail notice not later than date of the Action for
                the
                following:

            


    

    A)
       the
      death
      of the Enrollee;

    B)  a
      signed
      written statement from the Enrollee requesting service termination or giving
      information requiring termination or reduction of services (where the Enrollee
      understands that this must be the result of supplying the
      information);

    C)
       the
      Enrollee's admission to an institution where the Enrollee is ineligible for
      further services;

    D)
       the
      Enrollee's address is unknown and mail directed to the Enrollee is returned
      stating that there is no forwarding address;

    


    


    


    


    


    


    


    


    APPENDIX
      F

    October
      1, 2005

    F-4

    



    E)  the
      Enrollee
      has been
      accepted for Medicaid
      services
      by another jurisdiction;

    or
      

    F)  the
      Enrollee's physician prescribes a change in the level of medical
      care.

    


    b)  The
      Contractor must mail written notice to the Enrollee on the date of the Action
      when the Action is denial of payment,
      in whole
      or in part, except as provided in paragraph F. 1 6(b) below.

    


    c)  When
      the
      Contractor does not reach a determination within the Service Authorization
      Determination timeframes
      described above, it is considered an Adverse Determination, and the Contractor
      must send notice of Action to the Enrollee on the date the timeframes
      expire.

    


    5.
       Format
      and Content of Notices

    


    a)
       The
      Contractor shall ensure that all notices are in writing, in easily understood
      language and are accessible to non-English speaking and visually impaired
Enrollees.
      Notices
      shall include that oral interpretation and alternate formats of written material
      for Enrollees with special needs are available and how to access the alternate
      formats.

    


    
      	 	
              i) 

            	
              Notice
                to the Enrollee that the Enrollee's request for an expedited review
                has
                been denied shall include that the request will be reviewed under
                standard
                timeframes, including a description of the
                timeframes.

            


    

    


    
      	 	
              ii) 

            	
              Notice
                to the Enrollee regarding a Contractor-initiated extension shall
                include:

            


    

    A)
       the
      reason for the extension;

    B) 
      an
      explanation of how the delay is in the best interest of the
      Enrollee;

    C)
       any
      additional information the Contractor requires from any source to make its
      determination;

    D)  the
      right
      of the Enrollee to file a Complaint (as defined in Appendix F.2 of

    this
      Agreement)
      regarding
      the
      extension;

    E)
       the
      process for filing a Complaint with the Contractor and the
      timeframes

    within
      which a Complaint determination must be made;

    F)
       the
      right
      of an Enrollee to designate a representative to file a Complaint on

    behalf
      of
      the Enrollee; and 

    G)  the
      right
      of the Enrollee to contact the New York State Department of Health

    regarding
      his or her Complaint,
      including the SDOH's
      toll-free number for

    Complaints.

    


    
      	 	
              iii) 

            	
              Notice
                to the Enrollee of an Action shall
                include:

            


    

    A)
       the
      description of the Action the Contractor has taken or intends to
      take;

    B)
       the
      reasons for the Action, including the clinical rationale, if any;

    C)
       the
      Enrollee's right to file an Action Appeal (as defined in Appendix F.2 of this
      Agreement),
      including:

    
      	 	
              I)
                

            	
              The
                fact that the Contractor will not retaliate or take any discriminatory
                action against the Enrollee because he/she filed an Action
                Appeal.

            


    

    


    


    


    


    


    APPENDIX
      F

    October
      1, 2005

    F-5

    



    
      	 	
              II)
                

            	
              The
                right of the Enrollee
                to
                designate a representative to file Action Appeals on his/her
                behalf;

            


    

    
      	 	
              D) 

            	
              the
                process and timeframe
                for filing an Action Appeal with the
                Contractor,

            


    

    
      	 	 	
              including
                an explanation that an expedited review of the Action Appeal can
                be

            


    

    
      	 	 	
              requested
                if a delay would significantly increase the risk to an Enrollee's

            


    

    
      	 	 	
              health,
                a toll-free number for filing an oral Action Appeal and a form, if
                used

            


    

    
      	 	 	
              by
                the Contractor, for filing a written Action
                Appeal;

            


    

    
      	 	
              E) 

            	
              a
                description of what additional information, if any, must be obtained
                by
                the

            


    

    
      	 	 	
              Contractor
                from any source in order for the Contractor to make an
                Appeal

            


    

    
      	 	 	
              determination;

            


    

    
      	 	
              F) 

            	
              the
                timeframes
                within which the Action Appeal determination must be
                made;

            


    

    
      	 	
              G) 

            	
              the
                right of the Enrollee to contact the New York State Department of
                Health

            


    

    
      	 	 	
              with
                his or her Complaint, including the SDOH's
                toll-free number for

            


    

    
      	 	 	
              Complaints;
                and 

            


    

    
      	 	
              H) 

            	
              the
                notice entitled "Managed Care Action Taken" for denial of benefits
                or
                for

            


    

    
      	 	 	
              termination
                or reduction in benefits, as applicable, containing the
                Enrollee's

            


    

    
      	 	 	
              fair
                hearing and aid continuing rights. 

            


    

    
      	 	
              I)
                

            	
              For
                Actions based on issues of Medical Necessity or an experimental
                or

            


    

    investigational
      treatment,
      the
      notice of Action shall also include:

    
      	 	
              I)
                

            	
              a
                clear statement that the notice constitutes the initial adverse
                determination and specific use of the terms "medical necessity" or
                "experimental/investigational";

            


    

    
      	 	
              II)
                

            	
              a
                statement that the specific clinical review criteria relied upon
                in making
                the determination is available upon request;
                and

            


    

    
      	 	
              III)
                

            	
              a
                statement that the Enrollee may be eligible for an External
                Appeal.

            


    

    


    6.
       Contractor
      Obligation
      to Notice

    


    a)
       The
      Contractor must provide written Notice of Action to Enrollees
      and
      providers in accordance with the requirements of this Appendix,
      including, but not limited to, the following circumstances (except as provided
      for in paragraph 6(b)
      below):

    


    
      	 	
              i) 

            	
              the
                Contractor makes a coverage determination or denies a request for
                a
                referral, regardless of whether the Enrollee has received the
                benefit;

            


    

    


    
      	 	
              ii) 

            	
              the
                Contractor determines that a service does not have appropriate
                authorization;

            


    

    


    
      	 	
              iii) 

            	
              the
                Contractor denies a claim for services provided by a Non-Participating
                Provider for any reason;

            


    

    


    
      	 	
              iv) 

            	
              the
                Contractor denies a claim or service due to medical
                necessity;

            


    

    


    
      	 	
              v) 

            	
              the
                Contractor rejects a claim or denies payment due to a late claim
                submission;

            


    

    


    
      	 	
              vi) 

            	
              the
                Contractor denies a claim because it has determined that the Enrollee
                was
                not eligible for MMC
                or
                FHPlus
                coverage on the date of service;

            


    

    


    


    


    


    APPENDIX
      F

    October
      1, 2005

    F-6

    


    vii)
      the
      Contractor denies a claim for service rendered by a Participating Provider
      due
      to lack of a referral;

    


    viii)
      the
      Contractor denies a claim because it has determined it is not the appropriate
      payor;
      or

    


    
      	 	
              ix) 

            	
              the
                Contractor denies a claim due to a Participating Provider billing
                for
                Benefit Package services not included in the Provider Agreement between
                the Contractor and the Participating
                Provider.

            


    

    


    b)  The
      Contractor is not required to provide written Notice of Action to Enrollees
      in the
      following circumstances:

    


    
      	 	
              i) 

            	
              When
                there is a prepaid capitation arrangement with a Participating Provider
                and the Participating Provider submits a fee-for-service
                claim to the Contractor for a service that falls within the capitation
                payment;

            


    

    


    
      	 	
              ii) 

            	
              if
                a Participating Provider of the Contractor itemizes or "unbundles"
                a claim for services encompassed by a previously negotiated global
                fee
                arrangement;

            


    

    


    
      	 	
              iii) 

            	
              if
                a duplicate claim is submitted by the Enrollee
                or
                a Participating Provider, no notice is required, provided an initial
                notice has been issued;

            


    

    


    
      	 	
              iv) 

            	
              if
                the claim is for a service that is carved-out
                of
                the MMC
                Benefit Package and is provided to a MMC Enrollee through Medicaid
                fee-for-service, however, the Contractor should notify the provider
                to
                submit the claim to Medicaid;

            


    

    


    
      	 	
              v) 

            	
              if
                the Contractor makes a coding adjustment to a claim (up-coding or
                down-coding) and its Provider Agreement with the Participating Provider
                includes a provision allowing the Contractor to make such
                adjustments;

            


    

    


    
      	 	
              vi)

            	
              if
                the Contractor has paid the negotiated amount reflected in the Provider
                Agreement with a Participating Provider for the services provided
                to the
                Enrollee and denies the Participating Provider's request for additional
                payment; or

            


    

    


    vii)
      if
      the Contractor has not yet adjudicated the claim. If the Contractor has
pended
      the
      claim
      while requesting additional information, a notice is not required until the
      coverage determination has been made.

    


    


    


    


    


    


    


    


    


    


    


    


    APPENDIX
      F

    October
      1, 2005

    F-7

    



    


    F.2

    


    Grievance
      System Requirements

    


    1.
       Definitions

    


    a)
       A
      Grievance System means the Contractor's Complaint and Appeal process, and
      includes a Complaint and Complaint Appeal process, a process to appeal Actions,
      and access to the State's fair hearing system.

    


    b)  For
      the
      purposes of this Agreement,
      a
      Complaint means an Enrollee's
      expression of dissatisfaction with any aspect of his or her care other than
      an
      Action. A "Complaint" means the same as a "grievance" as defined
      by 42
CFR§438.400
      (b).

    


    c)  An
      Action
      Appeal means a request for a review of an Action.

    


    d)  A
      Complaint Appeal means a request for a review of a Complaint
      determination.

    


    e)  An
      Inquiry means a written or verbal question or request for information posed
      to
      the Contractor with regard to such issues as benefits, contracts, and
      organization rules. Neither Enrollee
      Complaints nor disagreements with Contractor determinations are
      Inquiries.

    


    2.
       Grievance
      System - General Requirements

    


    a)
       The
      Contractor shall describe its Grievance System in the Member Handbook, and
      it
      must be accessible to non-English speaking, visually, and hearing impaired
      Enrollees.
      The
      handbook shall comply with Section 13.4 and The Member Handbook Guidelines
      (Appendix E) of this Agreement

    


    b)
       The
      Contractor will provide Enrollees with any reasonable assistance in completing
      forms and other procedural steps for filing a Complaint, Complaint Appeal or
      Action Appeal, including, but not limited to, providing interpreter services
      and
      toll-free numbers with TTY/TDD
      and
      interpreter capability.

    


    c)
       The
      Enrollee may designate a representative to file Complaints, Complaint Appeals
      and Action Appeals on his/her
      behalf.

    


    d)
       The
      Contractor will not retaliate or take any discriminatory action against the
      Enrollee because he/she filed a Complaint,
      Complaint Appeal or Action Appeal.

    


    e)
       The
      Contractor's procedures for accepting Complaints, Complaint Appeals and Action
      Appeals shall include:

    APPENDIX
      F

    October
      1, 2005

    F-8

    



    
      	 	
              i) 

            	
              toll-free
                telephone number;

            


    

    


    
      	 	
              ii) 

            	
              designated
                staff to receive calls;

            


    

    


    iii)
      "live"
      phone coverage at least forty (40) hours a week during normal business
      hours;

    


    
      	 	
              iv) 

            	
              a
                mechanism to receive after hours calls, including
                either:

            


    

    A)
       a
      telephone system available to take calls and a plan to respond to all such
      calls
      no later than on the next business day after the calls were recorded;
      or

    B)  a
      mechanism to have available on a twenty-four (24) hour, seven (7) day a week
      basis designated staff to accept telephone Complaints, whenever a delay would
      significantly
      increase the risk to an Enrollee's
      health.

    


    f)  The
      Contractor must ensure that personnel making determinations regarding
      Complaints, Complaint Appeals and Action Appeals were not involved in previous
      levels of review or decision-making. If any of the following applies,
      determinations must be made by qualified
      clinical personnel as specified
      in
      this Appendix:

    


    
      	 	
              i)
                

            	
              A
                denial Action Appeal based on lack of medical
                necessity

            


    

    .

    
      	 	
              ii)
                

            	
              A
                Complaint regarding denial of expedited resolution of an Action
                Appeal.

            


    

    


    
      	 	
              iii)
                

            	
              A
                Complaint, Complaint Appeal, or Action Appeal that involves clinical
                issues.

            


    

    


    3.
       Action
      Appeals Process

    


    a)
       The
      Contractor's Action Appeals process shall indicate the following regarding
      resolution of Appeals of an Action:

    


    
      	 	
              i)
                

            	
              The
                Enrollee,
                or
                his or her designee,
                will have no less than sixty (60) business days from the date of
                the
                notice of Action to file
                an Action Appeal. An Enrollee filing an Action Appeal within 10 days
                of
                the notice of Action or by the intended date of an Action, whichever
                is
                later, that involves the reduction, suspension, or termination of
                previously approved services may request "aid continuing" in accordance
                with Section 25.4 of this
                Agreement.

            


    

    


    
      	 	
              ii)
                

            	
              The
                Enrollee may file a written Action Appeal or an oral Action Appeal.
                Oral
                Action Appeals must be followed by a written, signed.
                Action Appeal. The Contractor may provide a written summary of an
                oral
                Action Appeal to the Enrollee (with the acknowledgement or separately)
                for
                the Enrollee to review, modify if needed, sign and return to the
                Contractor. If the Enrollee or provider requests expedited resolution
                of
                the Action Appeal, the oral Action Appeal does not need to be
                confirmed
                in writing. The date of the oral filing of the Action Appeal will
                be the
                date of the Action Appeal for the purposes of the timeframes

            


    

    APPENDIX
      F

    October
      1, 2005

    F-9

    



    for
      resolution of Action Appeals. Action Appeals resulting from a Concurrent Review
      must be handled as an expedited Action Appeal.

    


    
      	 	
              iii) 

            	
              The
                Contractor must send a written acknowledgement of the Action Appeal
                within
                fifteen (15) days of receipt. If a determination is reached before
                the
                written acknowledgement is sent,
                the Contractor may include the written acknowledgement with the notice
                of
                Action Appeal determination (one
                notice).

            


    

    


    
      	 	
              iv) 

            	
              The
                Contractor must provide the Enrollee
                reasonable opportunity to present evidence, and allegations of fact
                or
                law, in person as well as in writing. The Contractor must inform
                the
                Enrollee of the limited time to present such evidence in the case
                of an
                expedited Action Appeal. The Contractor must allow the Enrollee or
                his or
                her designee,
                both before and during the Action Appeals process, to examine the
                Enrollee's
                case file, including medical records and any other documents and
                records
                considered during the Action Appeals process. The Contractor will
                consider
                the Enrollee, his or her designee, or legal estate representative
                of a
                deceased Enrollee a party to the Action
                Appeal.

            


    

    


    
      	 	
              v) 

            	
              The
                Contractor must have a process for handling expedited Action Appeals.
                Expedited resolution of the Action Appeal must be conducted when
                the
                Contractor determines or the provider indicates that a delay would
                seriously jeopardize the Enrollee's
                life or health or ability to attain, maintain, or regain maximum
                function.
                The Enrollee may request an expedited review of an Action Appeal.
                If the
                Contractor denies the Enrollee's
                request for an expedited review, the Contractor must handle the request
                under standard Action Appeal resolution timeframes,
                make reasonable efforts to provide prompt oral notice of the denial
                to the
                Enrollee and send written notice of the denial within two (2) days
                of the
                denial determination.

            


    

    


    
      	 	
              vi) 

            	
              The
                Contractor must ensure that punitive action is not taken against
                a
                provider who either requests an expedited resolution or supports
                an
                Enrollee's
                Appeal.

            


    

    


    vii)
      Action
      Appeals of clinical matters must be decided by personnel qualified to review
      the
      Action Appeal, including licensed, certified or registered health care
      professionals who did not make the initial determination, at least one of whom
      must be a clinical peer reviewer, as defined by PHL§4900(2)(a).
      Action Appeals of non-clinical matters shall be determined by qualified
      personnel at a higher level than the personnel who made the original
      determination.

    


    4.
       Timeframes
      for Resolution of Action Appeals

    


    a)
       The
      Contractor's Action Appeals process shall indicate the following specific
      timeframes regarding Action Appeal resolution:

    


    


    


    


    


    


    


    APPENDIX
      F

    October
      1, 2005

    F-10

    


    


    


    


    


    


    


    
      	 	
              i) 

            	
              The
                Contractor will resolve Action Appeals as fast as the Enrollee's
                condition requires, and no later than thirty (30) days from the date
                of
                the receipt of the Action Appeal.

            


    

    


    
      	 	
              ii) 

            	
              The
                Contractor will resolve expedited Action Appeals as fast as the Enrollee's
                condition requires, within two (2) business days of receipt of necessary
                information and no later than three (3) business days of the date
                of the
                receipt of the Action Appeal.

            


    

    


    
      	 	
              iii) 

            	
              Timeframes
                for Action Appeal resolution may be extended for up to fourteen (14)
                days
                if:

            


    

    
      	 	
              A)
                

            	
              the
                Enrollee,
                his or her designee,
                or
                the provider requests an extension orally or in writing;
                or

            


    

    
      	 	
              B) 

            	
              the
                Contractor can demonstrate or substantiate that there is a need for
                additional information and the extension is in the Enrollee's interest.
                The Contractor must send notice of the extension to the Enrollee.
                The
                Contractor must maintain sufficient documentation of extension
                determinations to demonstrate, upon SDOH's
                request, that the extension was
                justified.

            


    

    


    
      	 	
              iv) 

            	
              The
                Contractor make a reasonable effort to provide oral notice to the
                Enrollee, his or her designee, and the provider where appropriate,
                for
                expedited Action Appeals at the time the Action Appeal determination
                is
                made.

            


    

    


    
      	 	
              v) 

            	
              The
                Contractor must send written notice to the Enrollee, his or her designee,
                and the provider where appropriate, within two (2) business days
                of the
                Action Appeal determination.

            


    

    


    5.
       Action
      Appeal Notices

    


    a)
       The
      Contractor shall ensure that all notices are in writing and in easily understood
      language and are accessible to non-English speaking and visually impaired
Enrollees.
      Notices
      shall include that oral interpretation and alternate formats of written material
      for Enrollees with special needs are available and how to access the alternate
      formats.

    


    
      	 	
              i)
                

            	
              Notice
                to the Enrollee that the Enrollee's request for an expedited Action
                Appeal
                has been denied shall include that the request will be reviewed under
                standard Action Appeal timeframes,
                including a description of the timeframes.
                This notice may be combined with the
                acknowledgement.

            


    

    


    
      	 	
              ii)
                

            	
              Notice
                to the Enrollee regarding an Contractor-initiated extension shall
                include:

            


    

    A)
       the
      reason for the extension;

    B)
       an
      explanation of how the delay is in the best interest of the
      Enrollee;

    C)  any
      additional information the Contractor requires from any source to make its
      determination;

    D)  the
      right
      of the Enrollee to file a Complaint regarding the extension;

    APPENDIX
      F

    October
      1, 2005

    F-11

    



    E)  the
      process for filing a Complaint with the Contractor and the timeframes

    within
      which
      a Complaint determination must be made;

    F)  the
      right
      of an Enrollee
      to
      designate a representative to file a Complaint on

    behalf
      of
      the Enrollee; and 

    G)  the
      right
      of the Enrollee to contact the New York State Department of Health

    regarding
      his or her their Complaint, including the SDOH's
      toll-free number

    for
      Complaints.

    


    
      	 	
              iii) 

            	
              Notice
                to the Enrollee of Action Appeal Determination shall
                include:

            


    

    A)
       Date
      the
      Action Appeal was filed and a summary of the Action Appeal;

    B)  Date
      the
      Action Appeal process was completed;

    C)  the
      results and the reasons for the determination, including the clinical rationale,
      if any;

    D)  If
      the
      determination was not in favor of the Enrollee, a description of

    Enrollee's
      fair
      hearing rights, if applicable;

    E)
       the
      right
      of the Enrollee to contact the New York State Department of Health

    regarding
      his or her Complaint, including the SDOH's toll-free number for

    Complaints;
      and 

    F)
       For
      Action Appeals involving Medical Necessity or an experimental or

    investigational
      treatment, the notice must also include:

    I)
       a
      clear
      statement that the notice constitutes the final adverse determination and
      specifically use the terms "medical necessity"
      or
"experimental/investigational;"

    II)
       the
      Enrollee's coverage type;

    III)
       the
      procedure in question, and if available and applicable the name of the provider
      and developer/manufacturer of the health care service;

    IV)
       statement
      that the Enrollee is eligible to file an External Appeal and the timeframe
      for
      filing;

    V)
       a
      copy of
      the "Standard Description and Instructions for Health Care Consumers to Request
      an External Appeal" and the External Appeal application form;

    VI)
       the
      Contractor's contact person and telephone number;

    VII)
       the
      contact person, telephone number, company name and full address of the
      utilization review agent,
      if the
      determination was made by the agent;

    and

    VIII)
       if
      the
      Contractor has a second level internal review process, the notice shall contain
      instructions on how to file a second level Action Appeal and a statement in
      bold
      text that the timeframe for requesting an External Appeal begins upon receipt
      of
      the final adverse determination of the first level Action Appeal, regardless
      of
      whether or not a second level of Action Appeal is requested, and that by
      choosing to request a second level Action Appeal, the time may expire for the
      Enrollee to request an External Appeal.

    APPENDIX
      F

    October
      1, 2005

    F-12

    



    6.
       Complaint
      Process

    


    a)
       The
      Contractor'
      Complaint process shall include the following regarding the handling
of
      Enrollee
      Complaints:

    


    
      	 	
              i) 

            	
              The
                Enrollee,
                or
                his or her designee,
                may file a Complaint regarding any dispute with the Contractor orally
                or
                in writing. The Contractor may have requirements for accepting written
                Complaints either by letter or Contractor supplied form. The Contractor
                cannot require an Enrollee to file a Complaint in
                writing.

            


    

    


    
      	 	
              ii) 

            	
              The
                Contractor must provide written acknowledgment of any Complaint not
                immediately resolved, including the name, address and telephone number
                of
                the individual or department handling the Complaint, within fifteen
                (15)
                business days of receipt of the Complaint. The acknowledgement must
                identify any additional information required by the Contractor from
                any
                source to make a determination. If a Complaint determination is made
                before the written acknowledgement is sent,
                the Contractor may include the acknowledgement with the notice of
                the
                determination (one notice).

            


    

    


    
      	 	
              iii) 

            	
              Complaints
                shall be reviewed by one or more qualified
                personnel.

            


    

    


    
      	 	
              iv) 

            	
              Complaints
                pertaining to clinical matters shall be reviewed by one or more licensed,
                certified or registered health care professionals in addition to
                whichever
                non-clinical personnel the Contractor
                designates.

            


    

    


    7.
       Timeframes
      for Complaint Resolution by the Contractor

    


    a)
       The
      Contractor's Complaint process shall indicate the following specific
timeframes
      regarding
      Complaint resolution:

    


    
      	 	
              i)
                

            	
              If
                the Contractor immediately resolves an oral Complaint to the Enrollee's
                satisfaction,
                that Complaint may be considered resolved without any additional
                written
                notification to the Enrollee. Such Complaints must be logged by the
                Contractor and included in the Contractor's quarterly HPN
                Complaint report submitted to SDOH
                in
                accordance with Section 18 of this
                Agreement.

            


    

    


    
      	 	
              ii)
                

            	
              Whenever
                a delay would significantly increase the risk to an Enrollee's health,
                Complaints shall be resolved within forty-eight (48) hours after
                receipt
                of all necessary information and no more than seven (7) days from
                the
                receipt of the Complaint.

            


    

    


    
      	 	
              iii)
                

            	
              All
                other Complaints shall be resolved within forty-five (45) days after
                the
                receipt of all necessary information and no more than sixty (60)
                days from
                receipt of the Complaint. The Contractor shall maintain reports of
                Complaints unresolved after forty-five (45) days in accordance with
                Section 18 of this Agreement.

            


    

    


    


    APPENDIX
      F

    October
      1, 2005

    F-13

    


    


    


    


    


    


    8. Complaint
      Determination Notices

    


    
      	 	
              a)

            	
              The
                Contractor's procedures regarding the resolution of Enrollee Complaints
                shall include the following:

            


    

    


    
      	 	
              i)

            	
              Complaint
                Determinations by the Contractor shall be made in writing to the
                Enrollee
                or his/her designee and include:

            


    

    


    
      	 	
              A)

            	
              the
                detailed reasons for the
                determination;

            


    

    


    
      	 	
              B)

            	
              in
                cases where the determination has a clinical basis, the clinical
                rationale
                for the determination;

            


    

    


    
      	 	
              C)

            	
              the
                procedures for the filing of an appeal of the determination, including
                a
                form, if used by the Contractor, for the filing of such a Complaint
                Appeal; and notice of the right of the Enrollee to contact the State
                Department of Health regarding his or her Complaint, including SDOH's
                toll-free number for Complaints.

            


    

    


    
      	ii)  	
              If
                the Contractor was unable to make a Complaint determination because
                insufficient information was presented or available to reach a
                determination, the Contractor will send a written statement that
                a
                determination could not be made to the Enrollee on the date me allowable
                time to resolve the Complaint has
                expired.

            


    

    


    iii) In
      cases
      where delay would significantly increase the risk to an Enrollee's health,
      the
      Contractor shall provide notice of a determination by telephone directly to
      the
      Enrollee or to the Enrollee's designee, or when no phone is available, some
      other method of communication, with written notice to follow within three (3)
      business days.

    


    9. Complaint
      Appeals

    


    
      	 	
              a)

            	
              The
                Contractor's procedures regarding Enrollee Complaint Appeals shall
                include
                the following:

            


    

    


    
      	i)  	
              The
                Enrollee or designee has no less than sixty (60) business days after
                receipt of the notice of the Complaint determination to file a written
                Complaint Appeal. Complaint Appeals may be submitted by letter or
                by a
                form provided by the Contractor.

            


    

    


    
      	iii)  	
              Within
                fifteen (15) business days of receipt of the Complaint Appeal, the
                Contractor shall provide written acknowledgment of the Complaint
                Appeal,
                including the name, address and telephone number of the individual
                designated to respond to the Appeal. The Contractor shall indicate
                what
                additional information, if any, must be provided for the Contractor
                to
                render a determination.

            


    

    


    
      	iv)  	
              Complaint
                Appeals of clinical matters must be decided by personnel qualified
                to
                review the Appeal, including licensed, certified or registered health
                care

            


    

    


    APPENDIX
      F 

    October
      1, 2005 

    F-14

    



    professionals
      who did not make the initial determination, at least one of whom must be a
      clinical peer reviewer, as defined by PHL §4900(2)(a). iv) Complaint Appeals of
      non-clinical matters shall be determined by qualified personnel at a higher
      level than the personnel who made the original Complaint
      determination.

    


    
      	v)  	
              Complaint
                Appeals shall be decided and notification provided to the Enrollee
                no more
                than:

            


    

    


    A) two
      (2)
      business days after the receipt of all necessary information when a delay would
      significantly increase the risk to an Enrollee's health; or

    B)
      thirty
      (30) business days after the receipt of all necessary information in all other
      instances.

    


    
      	vi)  	
              The
                notice of the Contractor's Complaint Appeal determination shall
                include:

            


    

    


    A) `the
      detailed reasons for the determination;

    B) the
      clinical rationale for the determination in cases where the determination has
      a
      clinical basis;

    C) the
      notice shall also inform the Enrollee of his/her option to also contact the
      State Department of Health with his/her Complaint, including the SDOH's
      toll-free number for Complaints;

    D) instructions
      for any further Appeal, if applicable.

    


    10. Records

    


    
      	a)  	
              The
                Contractor shall maintain a file on each Complaint, Action Appeal
                and
                Complaint Appeal. These records shall be readily available for review
                by
                the SDOH, upon request. The file shall
                include:

            


    

    


    
      	i)  	
              date
                the Complaint was filed;

            


    

    


    
      	ii)  	
              copy
                of the Complaint, if written;

            


    

    


    
      	iii)  	
              date
                of receipt of and copy of the Enrollee's written confirmation, if
                any;

            


    

    


    
      	iv)  	
              log
                of Complaint determination including the date of the determination
                and the
                titles 

            


    

    


    
      	v)  	
              of
                the personnel and credentials of clinical personnel who reviewed
                the
                Complaint;

            


    

    


    
      	vi)  	
              date
                and copy of the Enrollee's Action Appeal or Complaint
                Appeal;

            


    

    


    
      	vii)  	
              Enrollee
                or provider requests for expedited Action Appeals and Complaint Appeals
                and the Contractor's determination;

            


    

    


    
      	viii)  	
              necessary
                documentation to support any
                extensions;

            


    

    


    APPENDIX
      F 

    October
      1, 2005 

    F-15

    



    
      	ix)  	
              determination
                and date of determination of the Action Appeals and Complaint
                Appeals;

            


    

    


    
      	x)  	
              the
                titles and credentials of clinical staff who reviewed the Action
                Appeals
                and Complaint Appeals; and

            


    

    


    
      	xi)  	
              Complaints
                unresolved for greater than forty-five (45)
                days.

            


    

    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    APPENDIX
      F 

    October
      1, 2005

    F-16

    



    APPENDIX
      G

    


    


    SDOH
      Requirements For The Provision 

    Of
      Emergency Care and Services

    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    APPENDIX
      G 

    October
      1, 2005

    G-l

    



    SDOH
      Requirements for the 

    Provision
      of Emergency Care and Services

    


    


    1. Definitions

    


    a) "Emergency
      Medical Condition"
      means a
      medical or behavioral condition, the onset of which is sudden, that manifests
      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 immediate medical attention to result
      in:

    


    
      	i)  	
              placing
                the health of the person afflicted with such condition in serious
                jeopardy
                or, in the case of a pregnant woman, the health of the woman or her
                unborn
                child or, in the case of a behavioral condition, placing the health
                of the
                person or others in serious jeopardy;
                or

            


    

     

    
      	ii)  	
              serious
                impairment to such person's bodily functions;
                or

            


    

     

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

            


    

     

    
      	iv)  	
              serious
                disfigurement of such person.

            


    

     

    b) "Emergency
      Services"
      means
      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.

     

    c) "Post-stabilization
      Care Services"
      means
      covered services, related to an emergency medical condition, that are provided
      after an Enrollee is stabilized in order to maintain the stabilized condition,
      or, under the circumstances described in Section 3 below, to improve or resolve
      the Enrollee's condition.

     

    2. Coverage
      and Payment of Emergency Services

    


    a) The
      Contractor must cover and pay for Emergency Services regardless of whether
      the
      provider that furnishes the services has a contract with the
      Contractor.

     

    b) The
      Contractor must advise Enrollees that they may access Emergency Services at
      any
      Emergency Services provider.

     

    c) Prior
      authorization for treatment of an Emergency Medical Condition is never
      required.

     

    


    


    


    


    


    


    


    APPENDIX
      G

    October
      1, 2005

    G-2

    



    d) The
      Contractor may not deny payment for treatment obtained in either of the
      following circumstances:

     

    
      	i)  	
              An
                Enrollee had an Emergency Medical Condition, including cases in which
                the
                absence of immediate medical attention would not have had the outcomes
                specified in the definition of Emergency Medical Condition
                above.

            


    

     

    
      	ii)  	
              A
                representative of the Contractor instructs the Enrollee to seek Emergency
                Services.

            


    

     

    e) A
      Contractor may not:

     

    
      	i)  	
              limit
                what constitutes an Emergency Medical Condition based on lists of
                diagnoses or symptoms; or

            


    

     

    
      	ii)  	
              refuse
                to cover emergency room services based on the failure of the provider
                or
                the Enrollee to give the Contractor notice of the emergency room
                visit.

            


    

     

    f) An
      Enrollee who has an Emergency Medical Condition may not be held liable for
      payment of subsequent screening and treatment needed to diagnose the specific
      condition or stabilize the patient.

     

    g) The
      attending emergency physician, or the provider actually treating the Enrollee,
      is responsible for determining when the Enrollee is sufficiently stabilized
      for
      transfer or discharge, and that determination is binding on the Contractor
      for
      payment.

     

    3. Coverage
      and Payment of Post-stabilization Care Services

    


    a) The
      Contractor is financially responsible for Post-stabilization Care Services
      furnished by a provider within or outside the Contractor's network
      when:

     

    
      	i)  	
              they
                are pre-approved by a Participating Provider, as authorized by the
                Contractor, or other authorized Contractor
                representative;

            


    

     

    
      	ii)  	
              they
                are not pre-approved by a Participating Provider, as authorized by
                the
                Contractor, or other authorized Contractor representative, but
                administered to maintain the Enrollee's stabilized condition within
                one
                (1) hour of a request to the Contractor for pre-approval of further
                Post-stabilization Care Services;

            


    

     

    
      	iii)  	
              they
                are not pre-approved by a Participating Provider, as authorized by
                the
                Contractor, or other authorized Contractor representative, but
                administered to maintain, improve or resolve the Enrollee's stabilized
                condition if:

            


    

     

    
      	 	
              A)

            	
              The
                Contractor does not respond to a request for pre-approval within
                one
                (1)hour;

            


    

    
      	 	
              B)

            	
              The
                Contractor cannot be contacted; or

            


    

    


    


    APPENDIX
      G

    October
      1, 2005

    G-3

    



    
      	C)  	
              The
                Contractor's representative and the treating physician cannot reach
                an
                agreement concerning the Enrollee's care and a plan physician is
                not
                available for consultation. In this situation, the Contractor must
                give
                the treating physician the opportunity to consult with a plan physician
                and the treating physician may continue with care of the patient
                until a
                plan physician is reached or one of the criteria in 3(b) is
                met.

            


    

    


    
      	iv)  	
              The
                Contractor must limit charges to Enrollees for Post-stabilization
                Care
                Services to an amount no greater than what the organization would
                charge
                the Enrollee if he or she had obtained the services through the
                Contractor.

            


    

     

    b) The
      Contractor's financial responsibility to the treating emergency provider for
      Post-stabilization Care Services it has not pre-approved ends when:

     

    
      	i)  	
              A
                plan physician with privileges at the treating hospital assumes
                responsibility for the Enrollee's
                care;

            


    

     

    
      	ii)  	
              A
                plan physician assumes responsibility for the Enrollee's care through
                transfer;

            


    

     

    
      	iii)  	
              A
                Contractor representative and the treating physician reach an agreement
                concerning the Enrollee's care or

            


    

     

    
      	iv)  	
              The
                Enrollee is discharged.

            


    

     

    4. Protocol
      for Acceptable Transfer Between Facilities

    


    a) All
      relevant COBRA requirements must be met.

     

    b) The
      Contractor must provide for an appropriate (as determined by the emergency
      department physician) transfer method/level with personnel as
      needed.

     

    c) The
      Contractor must contact/arrange for an available, accepting physician and
      patient bed at the receiving institution.

     

    d) If
      a
      patient is not transferred within eight (8) hours to an appropriate inpatient
      setting after the decision to admit has been made, then admission at the
      original facility is deemed authorized.

     

    5. Triage
      Fees

    


    For
      emergency room services that do not meet the definition of Emergency Medical
      Condition, the Contractor shall pay the hospital a triage fee of $40.00 in
      the
      absence of a negotiated rate.

    


    


    


    


    


    


    


    


    APPENDIX
      G

    October
      1, 2005

    G-4

    



    6.  Emergency
      Transportation

    


    When
      emergency transportation is included in the Contractor's Benefit Package, the
      Contractor shall reimburse the transportation provider for all emergency
      ambulance services without regard to final diagnosis or prudent layperson
      standards.

    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    APPENDIX
      G

    October
      1, 2005

    G-5


    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    


    APPENDIX
      H

    


    New
      York State Department of Health Requirements

    for
      the Processing of Enrollments and Disenrollments

    in
      the MMC and FHPlus Programs

    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    APPENDIX
      H 

    October
      1, 2005

    H-l

    



    SDOH
      Requirements

    for
      the Processing of Enrollments and Disenrollments in the MMC and FHPlus
      Programs

    


    


    1.  General

    


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

    


    2. Enrollment

    


    a) SDOH
      Responsibilities:

    


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

            


    

     

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

            


    

     

    b) LDSS
      Responsibilities:

    


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

            


    

     

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

            


    

     

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

            


    

     

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

            


    

     

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

            


    

     

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

            


    

     

    APPENDIX
      H

    October
      1, 2005

    H-2


    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    


    


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

            


    

     

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

            


    

     

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

            


    

     

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

            


    

     

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

            


    

     

    
      	 	
              A)

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

            


    

    


    
      	 	
              B)

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

            


    

    


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

            


    

     

    
      	 	
              A)

            	
              Foster
                care children in the direct care of
                LDSS;

            


    

    
      	 	
              B)

            	
              Homeless
                persons living in shelters outside of New York
                City.

            


    

    


    


    


    


    


    APPENDIX
      H 

    October
      1, 2005

    H-3


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

            


    

     

    A) LDSS
      directly enters data into PCP Subsystem; or

     

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

     

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

     

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

            


    

     

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

     

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

     

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

     

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

     

    E) For
      MMC
      program only - Exemption Request Forms: Exemption forms are provided to MMC
      Eligible Persons upon request if they wish to apply for an Exemption.
      Individuals preceded on the system as meeting Exemption or

     

    


    


    


    


    


    APPENDIX
      H 

    October
      1, 2005

    H-4


    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    


    


    Exclusion
      criteria do not need to complete an Exemption request form. This notice is
      required for mandatory MMC Eligible Persons.

    


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

     

    c) Contractor
      Responsibilities:

    


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

            


    

     

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

            


    

     

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

            


    

     

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

            


    

     

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

            


    

     

    


     

    


     

    APPENDIX
      H 

    October
      1, 2005

    H-5


    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    


    


    3. Newborn
      Enrollments

    


    
      	 	
              a)

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

            


    

     

    b) SDOH
      Responsibilities:

     

    
      	i)  	
              The
                SDOH will update WMS with information on the newborn received from
                hospitals, consistent with the requirements of Section 366-g of the
                SSL as
                amended by Chapter 412 of the Laws of
                1999.

            


    

     

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

            


    

     

    c) LDSS
      Responsibilities:

     

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

            


    

     

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

            


    

     

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

            


    

     

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

            


    

     

    


    


    


    APPENDIX
      H 

    October
      1, 2005

    H-6


    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    


    


    d) Contractor
      Responsibilities:

     

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

            


    

     

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

            


    

     

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

            


    

     

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

            


    

     

    
      	v)  	
              The
                Contractor is responsible for provision of services to a newborn
                and
                payment of the hospital or birthing center bill if the mother is
                an
                Enrollee at the time of the newborn's birth, even if the newborn
                is not
                yet on the Roster, unless the Contractor does not offer a MMC product
                in
                the mother's county of fiscal responsibility or the newborn is Excluded
                from the MMC Program pursuant to Section 2(b)(xi) of this
                Appendix.

            


    

     

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

            


    

     

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

            


    

     

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

            


    

     

    


     

    APPENDIX
      H 

    October
      1, 2005

    H-7


    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    


    


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

    


     

    
      	 	
              a)

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

            


    

     

    
      	 	
              b)

            	
              SDOH
                Responsibilities:

            


    

     

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

            


    

     

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

            


    

     

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

            


    

     

    
      	 	
              c)

            	
              LDSS
                Responsibilities:

            


    

     

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

            


    

     

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

            


    

     

    
      	 	
              d)

            	
              Contractor
                Responsibilities:

            


    

     

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

            


    

     

    5. Roster
      Reconciliation:

    


    
      	 	
              a)

            	
              All
                Enrollments are effective the first of the
                month.

            


    

     

    
      	 	
              b)

            	
              SDOH
                Responsibilities:

            


    

     

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

            


    

     

    


     

    APPENDIX
      H 

    October
      1, 2005

    H-8


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

     

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

     

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

     

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

     

    
      	 	
              c)

            	
              LDSS
                Responsibilities:

            


    

     

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

            


    

     

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

            


    

     

    d)
      Contractor Responsibilities:

     

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

            


    

     

    
      	ii)  	
              The
                Contractor must submit claims to the State's Fiscal Agent for all
                Eligible
                Persons that are on the 1st
                and 2nd
                Rosters, adjusted to add Eligible Persons enrolled by the LDSS after
                Roster production and to remove
                individuals

            


    

     

    


    


    APPENDIX
      H 

    October
      1, 2005

    H-9


    disenrolled
      by LDSS after Roster production (as notified to the Contractor). In the cases
      of
      retroactive Disenrollments, the Contractor is responsible for submitting an
      adjustment to void any previously paid premiums for the period of retroactive
      Disenrollment, where the Contractor was not at risk for the provision of Benefit
      Package services. Payment of subcapitation does not constitute "provision of
      Benefit Package services."

     

    6 Disenrollment:

    


    
      	 	
              a)

            	
              DSS
                Responsibilities:

            


    

     

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

            


    

     

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

            


    

     

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

            


    

     

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

            


    

     

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

            


    

     

    


    


    APPENDIX
      H 

    October
      1, 2005

    H-10


    Disenrollment
      request is denied. Such notice must include the reason(s) for the denial. An
      Enrollee has Good Cause to disenroll if:

     

    A) The
      Contractor has failed to famish accessible and appropriate medical care services
      or supplies to which the Enrollee is entitled under the terms of the contract
      under which the Contractor has agreed to provide services. This includes, but
      is
      not limited to the failure to:

    I) provide
      primary care services;

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

    III) arrange
      for consultation appointments;

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

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

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

     

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

     

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

     

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

     

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

     

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

     

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

     

    H) The
      Contractor is a primary care partial capitation provider that does not have
      a
      utilization review process in accordance with Title I of Article 49 of the
      PHL
      and the Enrollee requests Enrollment in an MCO that has such a utilization
      review process; or

     

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

     

    J) The
      Enrollee's medical condition requires related services to be performed at the
      same time but all such related services cannot be arranged by the

     

    


    APPENDIX
      H 

    October
      1, 2005

    H-11


    Contractor
      because the Contractor has elected not to cover one of the services the Enrollee
      seeks, and the Enrollee's Primary Care Provider or another provider determines
      that receiving the services separately would subject the Enrollee to unnecessary
      risk; or

     

    K) An
      FHPlus
      Enrollee is pregnant.

     

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

            


    

     

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

            


    

     

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

            


    

     

    
      	ix)  	
              The
                LDSS is responsible for ensuring that retroactive Disenrollments
                are used
                only when absolutely necessary. Circumstances warranting a retroactive
                Disenrollment are rare and include when an Enrollee is determined
                to have
                been non-consensually enrolled in a MCO; he or she enters or resides
                in a
                residential institution under circumstances which render the individual
                Excluded from the MMC program; is incarcerated; is an SSI infant
                less than
                six (6) months of age; is simultaneously in receipt of comprehensive
                health care coverage from an MCO and is Enrolled in either the MMC
                or
                FHPlus product of the same MCO; it is determined that an Enrollee
                with
                more than one Client Identification Number (CIN) is enrolled in an
                MCO's
                MMC or FHPlus product under more than one of the CINs; or he or she
                has
                died - as long as the Contractor was not at risk for provision of
                Benefit
                Package services for any portion of the retroactive period. Payment
                of
                subcapitation does not constitute "provision of Benefit Package services."
                The LDSS is responsible for notifying the Contractor of the retroactive
                Disenrollment prior to the action. The LDSS is responsible for finding
                out
                if the Contractor has made payments to providers on behalf of the
                Enrollee
                prior to Disenrollment. After this information is obtained, the LDSS
                and
                Contractor will agree on a retroactive Disenrollment or prospective
                Disenrollment date. In all cases of retroactive Disenrollment, including
                Disenrollments effective the first day of the current month, the
                LDSS is
                responsible for sending notice to the Contractor at the time of
                Disenrollment, of the Contractor's responsibility to submit to the
                SDOH's
                Fiscal Agent voided premium claims for any full months of retroactive
                Disenrollment where the Contractor was not at risk for the provision
                of
                Benefit Package services during the month. However, failure by the
                LDSS to
                so notify the Contractor does not affect the right of the SDOH to
                recover
                the premium payment as authorized by Section 3.6 of this
                Agreement.

            


    

     

    


    


    


    APPENDIX
      H 

    October
      1, 2005

    H-12


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

            


    

     

    
      	
              Reason
                for Disenrollment

            	
              Effective
                Date of Disenrollment

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

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

            
	
              B) Death
                ofEnrollee

            	
              First
                day of the month after death

            
	
              C) Incarceration

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

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

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

            
	
              E) Individual's
                effective date of Enrollment or autoassignment into a MMC product
                occurred
                while meeting institutional criteria in (D) above

            	
              Effective
                Date of Enrollment in the Contractor's Plan

            
	
              F) Non-consensual
                Enrollment

            	
              Retroactive
                to the first day of the month of Enrollment

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

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

            
	
              H) Urgent
                medical need

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

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

            	
              Retroactive
                to the first day of the month of the request

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

            	
              First
                day of the month after simultaneous coverage began

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

            	
              First
                day of the month the duplicate Enrollment
                began

            


    

    


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

    APPENDIX
      H 

    October
      1, 2005

    H-13


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

            


    

     

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

            


    

     

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

            


    

     

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

     

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

     

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

     

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

     

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

            


    

     

    APPENDIX
      H 

    October
      1, 2005

    H-14


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

            


    

     

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

            


    

     

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

            


    

     

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

            


    

     

    
      	 	
              b)

            	
              Contractor
                Responsibilities:

            


    

     

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

            


    

     

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

            


    

     

    
      	iii)  	
              Following
                LDSS procedures, the Contractor will refer cases which are appropriate
                for
                an LDSS-initiated Disenrollment and will submit supporting documentation
                to the LDSS. This includes, but is not limited to, changes in status
                for
                its Enrollees that may impact eligibility for Enrollment such as
                address
                changes, incarceration, death. Exclusion from the MMC program,
                etc.

            


    

     

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

            


    

     

    


    


    


    APPENDIX
      H 

    October
      1, 2005

    H-15


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

            


    

     

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

            


    

     

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

            


    

     

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

            


    

     

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

            


    

     

    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    APPENDIX
      H 

    October
      1, 2005

    H-16


    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    


    APPENDIX
      I

    


    New
      York State Department of Health

    Guidelines
      for Use of Medical Residents and Fellows

    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    APPENDIX
      I 

    October
      1, 2005 

    I-1

    



    Medical
      Residents and Fellows

    


    


    1. Medical
      Residents and Fellows for Primary Care.

    


    
      	 	
              a)

            	
              The
                Contractor may utilize medical residents and fellows as participants
                (but
                not designated as 'primary care providers') in the care of Enrollees
                as
                long as all of the following conditions are
                met:

            


    

     

    i) Residents/fellows
      are a part of patient care teams headed by fully licensed and Contractor
      credentialed attending physicians serving patients in one or more training
      sites
      in an "up weighted" or "designated priority" residency program.
      Residents/fellows in a training program which was disapproved as a designated
      priority program solely due to the outcome measurement requirement for graduates
      may be eligible to participate in such patient care teams.

     

    ii) Only
      the
      attending physicians and certified nurse practitioners on the training team,
      not
      residents/fellows, may be credentialed to the Contractor and may be empanelled
      with Enrollees. Enrollees must be assigned an attending physician or certified
      nurse practitioner to act as their PCP, though residente/fellows on the team
      may
      provide care during all or many of the visits to the Enrollee as long as the
      majority of these visits are under the direct supervision of the Enrollee's
      designated PCP. Enrollees have the right to request and receive care by their
      PCP in addition or instead of being seen by a resident or fellow.

     

    iii) Residents/fellows
      may work with attending physicians and certified nurse practitioners to provide
      continuity of care to patients under the supervision of the patient's PCP.
      Patients must be made aware of the resident/fellow and attending PCP
      relationship and be informed of their rights to be cared for directly by their
      PCP.

     

    iv) Residents/fellows
      eligible to be involved in a continuity relationship with patients must be
      available at least twenty percent (20%) of the total training time in the
      continuity of care setting and no less than ten percent (10%) of training time
      in any training year must be in the continuity of care setting and no fewer
      than
      nine (9) months a year must be spent in the continuity of care
      setting.

     

    v) Residents/fellows
      meeting these criteria provide increased capacity for Enrollment to their team
      according to the formula below. Only hours spent routinely scheduled for patient
      care in the continuity of care training site may count as providing capacity
      and
      are based on 1.0 FTE=40 hours.

     

    PGY-1 300
      per
      FTE 

    PGY-2 750
      per
      FTE

    PGY-3 1125
      per
      FTE

    PGY-4
      and
      above 1500
      per
      FTE

    


    


    


    


    APPENDIX
      I

    October
      1, 2005

    I-2

    


    vi) In
      order
      for a resident/fellow to provide continuity of care to an Enrollee, both the
      resident/fellow and the attending PCP must have regular hours in the continuity
      site and must be scheduled to be in the site together the majority of the
      time.

     

    vii) A
      preceptor/attending is required to be present a minimum of sixteen (16) hours
      of
      combined precepting and direct patient care in the primary care setting to
      be
      counted as a team supervising PCP and accept an increased number of Enrollees
      based upon the residents/fellows working on his/her team. Time spent in patient
      care activities at other clinical sites or in other activities off-site is
      not
      counted towards this requirement.

     

    viii) A
      sixteen
      (16) hour per week attending may have no more than four (4) residents/fellows
      on
      their team. Attendings spending twenty-four (24) hours per week in patient
      care/supervisory activity at the continuity site may have six (6)
      residents/fellows per team. Attendings spending thirty-two (32) hours per week
      may have eight (8) residents/fellows on their team. Two (2) or more attendings
      may join together to form a larger team as long as the ratio of attending to
      residents/fellows does not exceed 1:4 and all attendings comply with the sixteen
      (16) hour minimum.

     

    ix) Responsibility
      for the care of the Enrollee remains with the attending physician. All attending
      and resident/fellow teams must provide adequate continuity of care, twenty-four
      (24) hour a day, seven (7) days a week coverage, and appointment and
      availability access. Enrollees must be given the name of the responsible primary
      care physician (attending) in writing and be told how he or she may contact
      the
      attending physician or covering physician, if needed.

     

    x) Residents/fellows
      who do not qualify to act as continuity providers as part of an attending and
      resident/fellow team may still participate in the episodic care of Enrollees
      as
      long as that care is under the supervision of an attending physician
      credentialed to the Contractor. Such residents/fellows do not add to the
      capacity of that attending to empanel Enrollees.

     

    xi) Certified
      nurse practitioners and registered physician's assistants may not act as
      attending preceptors for resident physicians or fellows.

     

    2. Medical
      Residents and Fellows as Specialty Care Providers

    


    
      	 	
              a)

            	
              Residents/fellows
                may participate in the specialty care of Enrollees in all settings
                supervised by fully licensed and Contractor credentialed specialty
                attending physicians.

            


    

     

    
      	 	
              b)

            	
              Only
                the attending physicians, not residents or fellows, may be credentialed
                by
                the Contractor. Each attending must be credentialed by each MCO with
                which
                he or she will participate. Residents/fellows may perform all or
                many of
                the clinical services for

            


    

     

    


    


    


    


    


    APPENDIX
      I 

    October
      1, 2005 

    I-3

    



    the
      Enrollee as long as these clinical services are under the supervision of an
      appropriately credentialed specialty physician. Even when residents/fellows
      are
      credentialed by their program in particular procedures, certifying their
      competence to perform and teach those procedures, the overall care of each
      Enrollee remains the responsibility of the supervising Contractor credentialed
      attending.

     

    
      	 	
              c)

            	
              The
                Contractor agrees that although many Enrollees will identify a resident
                or
                fellow as their specialty provider, the responsibility for all clinical
                decision-making remains ultimately with the attending physician of
                record.

            


    

     

    
      	 	
              d)

            	
              Enrollees
                must be given the name of the responsible attending physician in
                writing
                and be told how they may contact their attending physician or covering
                physician, if needed. This allows Enrollees to assist in the communication
                between their primary care provider and specialty attending and enables
                them to reach the specialty attending if an emergency arises in the
                course
                of their care. Enrollees must be made aware of the resident/fellow
                and
                attending relationship and must have a right to be cared for directly
                by
                the responsible attending physician, if
                requested.

            


    

     

    
      	 	
              e)

            	
              Enrollees
                requiring ongoing specialty care must be cared for in a continuity
                of care
                setting. This requires the ability to make follow-up appointments
                with a
                particular resident/fellow and attending physician team, or if that
                provider team is not available, with a member of the provider's coverage
                group in order to insure ongoing responsibility for the patient by
                his/her
                Contractor credentialed specialist. The responsible specialist and
                his/her
                specialty coverage group must be identifiable to the patient as well
                as to
                the referring primary care
                provider.

            


    

     

    
      	 	
              f)

            	
              Attending
                specialists must be available for emergency consultation and care
                during
                non-clinic hours. Emergency coverage may be provided by residents/fellows
                under adequate supervision. The attending or a member of the attending's
                coverage group must be available for telephone and/or in-person
                consultation when necessary.

            


    

     

    
      	 	
              g)

            	
              All
                training programs participating in the MMC or FHPlus Program must
                be
                accredited by the appropriate academic accrediting
                agency.

            


    

     

    
      	 	
              h)

            	
              All
                sites in which residents/fellows train must produce legible (preferably
                typewritten) consultation reports. Reports must be transmitted such
                that
                they are received in a time frame consistent with the clinical condition
                of the patient, the urgency of the problem and the need for follow-up
                by
                the primary care physician. At a minimum, reports should be transmitted
                so
                that they are received no later than two (2) weeks from the date
                of the
                specialty visit.

            


    

     

    
      	 	
              i)

            	
              Written
                reports are required at the time of initial consultation and again
                with
                the receipt of all major significant diagnostic information or changes
                in
                therapy. In addition, specialists must promptly report to the referring
                primary care physician any significant findings or urgent changes
                in
                therapy which result from the specialty
                consultation.

            


    

     

    


    


    


    


    


    APPENDIX
      I 

    October
      1, 2005 

    I-4


    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    


    


    3. Training
      Sites

    


    All
      training sites must deliver the same standard of care to all patients
      irrespective of payor. Training sites must integrate the care of Medicaid,
      FHPlus, uninsured and private patients in the same settings.

    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    APPENDIX
      I 

    October
      1, 2005 

    I-5

    



    APPENDIX
      J

    


    New
      York State Department of Health Guidelines for Contractor

    Compliance
      with the Federal Americans with Disabilities Act

    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    APPENDIX
      J

    October
      1, 2005

    J-l


    


    I. OBJECTIVES

    


    Title
      II
      of the Americans With Disabilities Act (ADA) and Section 504 of the
      Rehabilitation Act of 1973 (Section 504) provides that no qualified individual
      with a disability shall, by reason of such disability, be excluded from
      participation in or denied access to the benefits of services, programs or
      activities of a public entity, or be subject to discrimination by such an
      entity. Public entities include State and local government and ADA and Section
      504 requirements extend to all programs and services provided by State and
      local
      government. Since MMC and FHPlus are government programs, health services
      provided through MMC and FHPlus Programs must be accessible to all that qualify
      for them.

     

    Contractor
      responsibilities for compliance with the ADA are imposed under Title II and
      Section 504 when, as a Contractor in a MMC or FHPlus Program, a Contractor
      is
      providing a government service. If an individual provider under contract with
      the Contractor is not accessible, it is the responsibility of the Contractor
      to
      make arrangements to assure that alternative services are provided. The
      Contractor may determine it is expedient to make arrangements with other
      providers, or to describe reasonable alternative means and methods to make
      these
      services accessible through its existing Participating Providers. The goals
      of
      compliance with ADA Title II requirements are to offer a level of services
      that
      allows people with disabilities access to the program in its entirety, and
      the
      ability to achieve the same health care results as any Enrollee.

     

    Contractor
      responsibilities for compliance with the ADA are also imposed under Title III
      when the Contractor functions as a public accommodation providing services
      to
      individuals (e.g. program areas and sites such as Marketing, education, member
      services, orientation. Complaints and Appeals). The goals of compliance with
      ADA
      Title III requirements are to offer a level of services that allows people
      with
      disabilities full and equal enjoyment of the goods, services, facilities or
      accommodations that the entity provides for its customers or clients. New and
      altered areas and facilities must be as accessible as possible. Whenever
      Contractors engage in new construction or renovation, compliance is also
      required with accessible design and construction standards promulgated pursuant
      to the ADA as well as State and local laws. Title III also requires that public
      accommodations undertake "readily achievable barrier removal" in existing
      facilities where architectural and communications barriers can be removed easily
      and without much difficulty or expense.

     

    The
      State
      uses MCO Qualification Standards to qualify MCOs for participation in the MMC
      and FHPlus Programs. Pursuant to the State's responsibility to assure program
      access to all Enrollees, the Plan Qualification Standards require each MCO
      to
      submit an ADA Compliance Plan that describes in detail how the MCO will make
      services, programs and activities readily accessible and useable by individuals
      with disabilities. In the event that certain program sites are not readily
      accessible, the MCO must describe reasonable alternative methods for making
      the
      services or activities accessible and usable.

     

    


    


    


    


    


    


    


    APPENDIX
      J

    October
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    J-2


    The
      objectives of these guidelines are threefold:

     

    
      	·  	
              To
                ensure that Contractors take appropriate steps to measure access
                and
                assure program accessibility for persons with
                disabilities;

            


    

    
      	·  	
              To
                provide a framework for Contractors as they develop a plan to assure
                compliance with the Americans with Disabilities Act (ADA);
                and

            


    

    
      	·  	
              To
                provide standards for the review of the Contractor Compliance
                Plans.

            


    

     

    These
      guidelines include a general standard followed by a discussion of specific
      considerations and suggestions of methods for assuring compliance. Please be
      advised that, although these guidelines and any subsequent reviews by State
      and
      local governments can give the Contractor guidance, it is ultimately the
      Contractor's obligation to ensure that it complies with its Contractual
      obligations, as well as with the requirements of the ADA, Section 504, and
      other
      federal, state and local laws. Other federal, state and local statutes and
      regulations also prohibit discrimination on the basis of disability and may
      impose requirements in addition to those established under ADA. For example,
      while the ADA covers those impairments that "substantially" limit one or more
      of
      the major life activities of an individual. New York City Human Rights Law
      deletes the modifier "substantially".

     

    II. DEFINITIONS

     

    A. "Auxiliary
      aids and services" may include qualified interpreters, note takers,
      computer-aided transcription services, written materials, telephone handset
      amplifiers, assistive listening systems, telephones compatible with hearing
      aids, closed caption decoders, open and closed captioning, telecommunications
      devices for Enrollees who are deaf or hard of hearing (TTY/TDD), video test
      displays, and other effective methods of making aurally delivered materials
      available to individuals with hearing impairments; qualified readers, taped
      texts, audio recordings. Braille materials, large print materials, or other
      effective methods of making visually delivered materials available to
      individuals with visual impairments.

     

    B. "Disability"
      means a mental or physical impairment that substantially limits one or more
      of
      the major life activities of an individual; a record of such impairment; or
      being regarded as having such an impairment.

     

    III. SCOPE
      OF CONTRACTOR COMPLIANCE PLAN

     

    The
      Contractor Compliance Plan must address accessibility to services at
      Contractor's program sites, including both Participating Provider sites and
      Contractor facilities intended for use by Enrollees.

     

    IV. PROGRAM
      ACCESSIBILITY

     

    Public
      programs and services, when viewed in their entirety must be readily accessible
      to and useable by individuals with disabilities. This standard includes physical
      access, non-discrimination in policies and 

     

    


    


    


    


    


    


    APPENDIX
      J

    October
      1, 2005

    J-3


    procedures
      and communication. Communications with individuals with disabilities are
      required to be as effective as communications with others. The Contractor
      Compliance Plan must include a detailed description of how Contractor services,
      programs, and activities are readily accessible and usable by individuals with
      disabilities. In the event that full physical accessibility is not readily
      available for people with disabilities, the Contractor Compliance Plan will
      describe the steps or actions the Contractor will take to assure accessibility
      to services equivalent to those offered at the inaccessible
      facilities.

     

    
      	
              A.

            	
              PRE-ENROLLMENT
                MARKETING AND EDUCATION

            


    

     

    STANDARD
      FOR COMPLIANCE

     

    Marketing
      staff, activities and materials will be made available to persons with
      disabilities. Marketing materials will be made available in alternative formats
      (such as Braille, large print, and audiotapes) so that they are readily usable
      by people with disabilities.

     

    SUGGESTED
      METHODS FOR COMPLIANCE

     

    1. Activities
      held in physically accessible location, or staff at activities available to
      meet
      with person in an accessible location as necessary

     

    2. Materials
      available in alternative formats, such as Braille, large print, audio
      tapes

     

    3. Staff
      training which includes training and information regarding attitudinal barriers
      related to disability

     

    4. Activities
      and fairs that include sign language interpreters or the distribution of a
      written summary of the marketing script used by Contractor marketing
      representatives

     

    5. Enrollee
      health promotion material/activities targeted specifically to persons with
      disabilities (e.g. secondary infection prevention, decubitus prevention, special
      exercise programs, etc.)

     

    6. Policy
      statement that Marketing Representatives will offer to read or summarize to
      blind or vision impaired individuals any written material that is typically
      distributed to all Enrollees

     

    7.
      Staff/resources available to assist individuals with cognitive impairments
      in
      understanding materials

     

    COMPLIANCE
      PLAN SUBMISSION

     

    1. A
      description of methods to ensure that the Contractor's Marketing presentations
      (materials and communications) are accessible to persons with auditory, visual
      and cognitive impairments

     

    2. A
      description of the Contractor's policies and procedures, including Marketing
      training, to ensure that Marketing Representatives neither screen health status
      nor ask questions about health status or prior health care services

     

    


    


    


    APPENDIX
      J

    October
      1, 2005

    J-4


    
      	
              B.

            	
              MEMBER
                SERVICES DEPARTMENT

            


    

     

    Member
      services functions include the provision to Enrollees of information necessary
      to make informed choices about treatment options, to effectively utilize the
      health care resources, to assist Enrollees in making appointments, and to field
      questions and Complaints, to assist Enrollees with the Complaint
      process.

     

    Bl. ACCESSIBILITY

     

    STANDARD
      FOR COMPLIANCE

     

    Member
      Services sites and functions will be made accessible to and usable by, people
      with disabilities.

     

    SUGGESTED
      METHODS FOR COMPLIANCE
      (include, but are not limited to those identified below):

     

    1. Exterior
      routes of travel, at least 36" wide, from parking areas or public transportation
      stops into the Contractor's facility

    2. If
      parking is provided, spaces reserved for people with disabilities, pedestrian
      ramps at sidewalks, and drop-offs

    3. Routes
      of
      travel into the facility are stable, slip-resistant, with all steps
>Vi"
      ramped,
      doorways with minimum 32" opening

    4. Interior
      halls and passageways providing a clear and unobstructed path or travel at
      least
      36" wide to bathrooms and other rooms commonly used by Enrollees

    5. Waiting
      rooms, restrooms, and other rooms used by Enrollees are accessible to people
      with disabilities

    6. Sign
      language interpreters and other auxiliary aids and services provided in
      appropriate circumstances

    7. Materials
      available in alternative formats, such as Braille, large print, audio
      tapes

    8. Staff
      training which includes sensitivity training related to disability issues
      [Resources and technical assistance are available through the NYS Office of
      Advocate for Persons with Disabilities - V/TTY (800) 522-4369; and the NYC
      Mayor's Office for People with Disabilities - (212) 788-2830 or TTY
      (212)788-2838]

    9. Availability
      of activities and educational materials tailored to specific
      conditions/illnesses and secondary conditions that affect these populations
      (e.g. secondary infection prevention, decubitus prevention, special exercise
      programs, etc.)

    10. Contractor
      staff trained in the use of telecommunication devices for Enrollees who are
      deaf
      or hard of hearing (TTY/TDD) as well as in the use ofNY Relay for phone
      communication

    11. New
      Enrollee orientation available in audio or by interpreter services

    12. Policy
      that when member services staff receive calls through the NY Relay, they will
      offer to return the call utilizing a direct TTY/TDD connection

    


    


    


    


    


    


    


    APPENDIX
      J

    October
      1, 2005

    J-5


    COMPLIANCE
      PLAN SUBMISSION

     

    1. A
      description of accessibility to the Contractor's member services department
      or
      reasonable alternative means to access member services for Enrollees using
      wheelchairs (or other mobility aids)

     

    2. A
      description of the methods the Contractor's member services department will
      use
      to communicate with Enrollees who have visual or hearing impairments, including
      any necessary auxiliary aid/services for Enrollees who are deaf or hard of
      hearing, and TTY/TDD technology or NY Relay service available through a
      toll-free telephone number

     

    3. A
      description of the training provided to the Contractor's member services staff
      to assure that staff adequately understands how to implement the requirements
      of
      the program, and of these guidelines, and are sensitive to the needs of persons
      with disabilities

     

    B2. IDENTIFICATION
      OF ENROLLEES WITH DISABILITIES 

     

    STANDARD
      FOR COMPLIANCE

     

    The
      Contractor must have in place satisfactory methods/guidelines for identifying
      persons at risk of, or having, chronic diseases and disabilities and determining
      their specific needs in terms of specialist physician referrals, durable medical
      equipment, medical supplies, home health services etc. The Contractor may not
      discriminate against a Prospective Enrollee based on his/her current health
      status or anticipated need for future health care. The Contractor may not
      discriminate on the basis of disability, or perceived disability of an Enrollee
      or their family member. Health assessment forms may not be used by me Contractor
      prior to Enrollment. Once a MCO has been chosen, a health assessment form may
      be
      used to assess the person's health care needs.

     

    SUGGESTED
      METHODS FOR COMPLIANCE

     

    1. Appropriate
      post Enrollment health screening for each Enrollee, using an appropriate health
      screening tool

     

    2. Patient
      profiles by condition/disease for comparative analysis to national norms, with
      appropriate outreach and education

     

    3. Process
      for follow-up of needs identified by initial screening; e.g. referrals,
      assignment of case manager, assistance with scheduling/keeping
      appointments

     

    4. Enrolled
      population disability assessment survey

     

    5. Process
      for Enrollees who acquire a disability subsequent to Enrollment to access
      appropriate services

     

    


    


    


    


    


    


    


    APPENDIX
      J

    October
      1, 2005

    J-6


    COMPLIANCE
      PLAN SUBMISSION

     

    A
      description of how the Contractor will identify special health care, physical
      access or communication needs of Enrollees on a timely basis, including but
      not
      limited to the health care needs ofEnrollees who:

     

    
      	·  	
              are
                blind or have visual impairments, including the type of auxiliary
                aids and
                services required by the Enrollee

            


    

    
      	·  	
              are
                deaf or hard of hearing, including the type of auxiliary aids and
                services
                required by the Enrollee

            


    

    
      	·  	
              have
                mobility impairments, including the extent, if any, to which they
                can
                ambulate

            


    

    
      	·  	
              have
                other physical or mental impairments or disabilities, including cognitive
                impairments

            


    

    
      	·  	
              have
                conditions which may require more intensive case
                management

            


    

     

    B3.
      NEW ENROLLEE ORIENTATION 

     

    STANDARD
      FOR COMPLIANCE

     

    Enrollees
      will be given information sufficient to ensure that they understand how to
      access medical care through the Contractor. This information will be made
      accessible to and usable by people with disabilities.

     

    SUGGESTED
      METHODS FOR COMPLIANCE

     

    1. Activities
      held in physically accessible location, or staff at activities available to
      meet
      with person in an accessible location as necessary

    2. Materials
      available in alternative formats, such as Braille, large print, audio
      tapes

    3. Staff
      training which includes sensitivity training related to disability issues
      [Resources and technical assistance are available through the NYS Office of
      Advocate for Persons with Disabilities - V/TTY (800) 522-4369; and the NYC
      Mayor's Office for People with Disabilities - (212) 788-2830 or TTY
      (212)788-2838]

    4. Activities
      and fairs that include sign language interpreters or the distribution of a
      written summary of the Marketing script used by Contractor marketing
      representatives

    5. Include
      in written/audio materials available to all Enrollees information regarding
      how
      and where people with disabilities can access help in getting services, for
      example help with making appointments or for arranging special transportation,
      an interpreter or assistive communication devices

    6. Staff/resources
      available to assist individuals with cognitive impairments in understanding
      materials

    


    


    


    


    


    


    


    


    


    


    


    


    


    APPENDIX
      J

    October
      1, 2005

    J-7l


    COMPLIANCE
      PLAN SUBMISSION

     

    1. A
      description of how the Contractor will advise Enrollees with disabilities,
      during the new Enrollee orientation on how to access care

     

    2. A
      description of how the Contractor will assist new Enrollees with disabilities
      (as well as current Enrollees who acquire a disability) in selecting or
      arranging an appointment with a Primary Care Practitioner (PCP)

     

    
      	·  	
              This
                should include a description of how the Contractor will assure and
                provide
                notice to Enrollees who are deaf or hard of hearing, blind or who
                have
                visual impairments, of their right to obtain necessary auxiliary
                aids and
                services during appointments and in scheduling appointments and follow-up
                treatment with Participating
                Providers

            


    

    
      	·  	
              In
                the event that certain provider sites are not physically accessible
                to
                Enrollees with mobility impairments, the Contractor will assure that
                reasonable alternative site and services are
                available

            


    

    3. A
      description of how the Contractor will determine the specific needs of an
      Enrollee with or at risk of having a disability/chronic disease, in terms of
      specialist physician referrals, durable medical equipment (including assistive
      technology and adaptive equipment), medical supplies and home health services
      and will assure that such contractual services are provided

     

    4. A
      description of how the Contractor will identify if an Enrollee with a disability
      requires on-going mental health services and how the Contractor will encourage
      early entry into treatment

     

    5. A
      description of how the Contractor will notify Enrollees with disabilities as
      to
      how to access transportation, where applicable

     

    B4. COMPLAINTS,
      COMPLAINT APPEALS AND ACTION APPEALS 

     

    STANDARD
      FOR COMPLIANCE

     

    The
      Contractor will establish and maintain a procedure to protect the rights and
      interests of both Enrollees and the Contractor by receiving, processing, and
      resolving Complaints, Complaint Appeals and Action Appeals in an expeditious
      manner, with the goal of ensuring resolution of Complaints, Complaint Appeals,
      and Action Appeals and access to appropriate services as rapidly as
      possible.

     

    All
      Enrollees must be informed about the Grievance System within their Contractor
      and the procedure for filing Complaints, Complaint Appeals and Action Appeals.
      This information will be made available through the Member Handbook, SDOH
      toll-free Complaint line [1-(800) 206-8125] and the Contractor's Complaint
      process annually, as well as when the Contractor denies a benefit or referral.
      The Contractor will inform Enrollees of the Contractor's Grievance System;
      Enrollees' right to contact the LDSS or SDOH with a Complaint, and to file
      a
      Complaint Appeal, Action Appeal or request a fan-hearing; the right to appoint
      a
      designee to handle a Complaint, Complaint Appeal or Action Appeal; and the
      toll
      free Complaint line. The Contractor will maintain designated staff to take
      and
      process Complaints, Complaint

     

    


    


    


    


    


    APPENDIX
      J

    October
      1, 2005

    J-8


    Appeals
      and Action Appeals, and be responsible for assisting Enrollees in Complaint,
      Complaint Appeal or Action Appeal resolution.

     

    The
      Contractor will make all information regarding the Grievance System available
      to
      and usable by people with disabilities, and will assure that people with
      disabilities have access to sites where Enrollees typically file Complaints
      and
      requests for Complaint Appeals and Action Appeals.

     

    SUGGESTED
      METHODS FOR COMPLIANCE

     

    1. Toll-free
      Complaint phone line with TDD/TTY capability

    2. Staff
      trained in Complaint process, and able to provide interpretive or assistive
      support to Enrollee during the Complaint process

    3. Notification
      materials and Complaint forms in alternative formats for Enrollees with visual
      or hearing impairments

    4. Availability
      of physically accessible sites, e.g. member services department
      sites

    5. Assistance
      for individuals with cognitive impairments

     

    COMPLIANCE
      PLAN SUBMISSION

     

    
      	
              1.

            	
              A
                description of how the Contractor's Complaint, Complaint Appeals
                and
                Action Appeal procedures shall be accessible for persons with
                disabilities, including:

            


    

    
      	·  	
              procedures
                for Complaints, Complaint Appeals and Action Appeals to be made in
                person
                at sites accessible to persons with mobility
                impairments

            


    

    
      	·  	
              procedures
                accessible to persons with sensory or other impairments who wish
                to make
                verbal Complaints, Complaint Appeals or Action Appeals, and to communicate
                with such persons on an ongoing basis as to the status or their Complaints
                and rights to further appeals

            


    

    
      	·  	
              description
                of methods to ensure notification material is available in alternative
                formats for Enrollees with vision and hearing
                impairments

            


    

    2. A
      description of how the Contractor monitors Complaints, Complaint Appeals and
      Action Appeals related to people with disabilities. Also, as part of the
      Compliance Plan, the Contractor must submit a summary report based on me
      Contractor's most recent year's Complaints, Complaint Appeals and Action Appeals
      data.

     

    C. CASE
      MANAGEMENT

     

    STANDARD
      FOR COMPLIANCE

     

    The
      Contractor must have in place adequate case management systems to identify
      the
      service needs of all Enrollees, including Enrollees with chronic illness and
      Enrollees with disabilities, and ensure that medically necessary covered
      benefits are delivered on a timely basis. These systems must include procedures
      for standing referrals, specialists as PCPs, and referrals to specialty centers
      for Enrollees who require specialized medical care over a prolonged period
      of
      time (as determined by a treatment plan approved by the Contractor in
      consultation with the primary care 

    


    


    


    


    


    APPENDIX
      J

    October
      1, 2005

    J-9l


    provider,
      the designated specialist and the Enrollee or his/her designee), out-of-network
      referrals and continuation of existing treatment relationships with
      out-of-network providers (during transitional period).

     

    SUGGESTED
      METHODS FOR COMPLIANCE

     

    1. Procedures
      for requesting specialist physicians to function as PCP

    2. Procedures
      for requesting standing referrals to specialists and/or specialty centers,
      out-of-network referrals, and continuation of existing treatment
      relationships

    3. Procedures
      to meet Enrollee needs for, durable medical equipment, medical supplies, home
      visits as appropriate

    4. Appropriately
      trained Contractor staff to function as case managers for special needs
      populations, or sub-contract arrangements for case management

    5. Procedures
      for informing Enrollees about the availability of case management
      services

     

    COMPLIANCE
      PLAN SUBMISSION

     

    1. A
      description of the Contractor case management program for people
      with

    disabilities,
      including case management functions, procedures for qualifying for and being
      assigned a case manager, and description of case management staff
      qualifications

    2. A
      description of the Contractor's model protocol to enable Participating
      Providers, at their point of service, to identify Enrollees who require a case
      manager

    3. A
      description of the Contractor's protocol for assignment of specialists as PCP,
      and for standing referrals to specialists and specialty centers, out-of-network
      referrals and continuing treatment relationships

    4. A
      description of the Contractor's notice procedures to Enrollees regarding the
      availability of case management services, specialists as PCPs, standing
      referrals to specialists and specialty centers, out-of-network referrals and
      continuing treatment relationships

     

    D. PARTICIPATING
      PROVIDERS 

     

    STANDARD
      FOR COMPLIANCE

     

    The
      Contractor's network will include all the provider types necessary to furnish
      the Benefit Package, to assure appropriate and timely health care to all
      Enrollees, including those with chronic illness and/or disabilities. Physical
      accessibility is not limited to entry to a provider site, but also includes
      access to services within the site, e.g. exam tables and medical
      equipment.

    


    


    


    


    


    


    


    


    


    


    


    


    APPENDIX
      J

    October
      1, 2005

    J-10 


    SUGGESTED
      METHODS FOR COMPLIANCE

     

    1. Process
      for the Contractor to evaluate provider network to ascertain the degree of
      provider accessibility to persons with disabilities, to identify barriers to
      access and required modifications to policies/procedures

    2. Model
      protocol to assist Participating Providers, at their point of service, to
      identify Enrollees who require case manager, audio, visual, mobility aids,
      or
      other accommodations

    3. Model
      protocol for determining needs of Enrollees with mental
      disabilities

    4. Use
      ofWheelchair Accessibility Certification Form (see attached)

    5. Submission
      of map of physically accessible sites

    6. Training
      for providers re: compliance with Title III of ADA, e.g. site access
      requirements for door widths, wheelchair ramps, accessible diagnostic/treatment
      rooms and equipment; communication issues; attitudinal barriers related to
      disability, etc. [Resources and technical assistance are available through
      the
      NYS Office of Advocate for Persons with Disabilities -V/TTY (800) 522-4369;
      and
      the
      NYC Mayor's
      Office for People with Disabilities - (212) 788-2830 or TTY (212)
      788-2838].

    7. Use
      of
      NYS Office of Persons with Disabilities (OAPD) ADA Accessibility Checklist
      for
      Existing Facilities and NYC Addendum to OAPD ADA Accessibility Checklist as
      guides for evaluating existing facilities and for new construction and/or
      alteration.

     

    COMPLIANCE
      PLAN SUBMISSION

     

    1. A
      description of how the Contractor will ensure that its Participating Provider
      network is accessible to persons with disabilities. This includes the
      following:

    
      	·  	
              Policies
                and procedures to prevent discrimination on the basis of disability
                or
                type of illness or condition

            


    

    
      	·  	
              Identification
                of Participating Provider sites which are accessible by people with
                mobility impairments, including people using mobility devices. If
                certain
                provider sites are not physically accessible to persons with disabilities,
                the Contractor shall describe reasonable, alternative means that
                result in
                making the provider services readily
                accessible.

            


    

    
      	·  	
              Identification
                of Participating Provider sites which do not have access to sign
                language
                interpreters or reasonable alternative means to communicate with
                Enrollees
                who are deaf or hard of hearing; and for those sites describe reasonable
                alternative methods to ensure that services will be made
                accessible

            


    

    
      	·  	
              Identification
                of Participating Providers which do not have adequate communication
                systems for Enrollees who are blind or have vision impairments (e.g.
                raised symbol and lettering or visual signal appliances), and for
                those
                sites describe reasonable alternative methods to ensure that services
                will
                be made accessible

            


    

    2. A
      description of how the Contractor's specialty network is sufficient to meet
      the
      needs of Enrollees with disabilities

     

    


    


    


    


    


    


    


    


    APPENDIX
      J

    October
      1, 2005

    J-11l


    3. A
      description of methods to ensure the coordination ofout-of-network providers
      to
      meet the needs of the Enrollees with disabilities

    
      	·  	
              This
                may include the implementation of a referral system to ensure that
                the
                health care needs of Enrollees with disabilities are met
                appropriately

            


    

    
      	·  	
              The
                Contractor shall describe policies and procedures to allow for the
                continuation of existing relationships with out-of-network providers,
                when
                in the best interest of the Enrollee with a
                disability

            


    

    4. Submission
      of me ADA Compliance Summary Report or Contractor statement that data submitted
      to SDOH on the Health Provider Network (HPN) files is an accurate reflection
      of
      each network's physical accessibility

     

    E. POPULATIONS
      WITH SPECIAL HEALTH CARE NEEDS 

     

    STANDARD
      FOR COMPLIANCE

     

    The
      Contractor will have satisfactory methods for identifying persons at risk of,
      or
      having, chronic disabilities and determining their specific needs in terms
      of
      specialist physician referrals, durable medical equipment, medical supplies,
      home health services, etc. The Contractor will have satisfactory systems for
      coordinating service delivery and, if necessary, procedures to allow
      continuation of existing relationships with out-of-network provider for course
      of treatment.

     

    SUGGESTED
      METHODS FOR COMPLIANCE

     

    1. Procedures
      for requesting standing referrals to specialists and/or specialty centers,
      specialist physicians to function as PCP, out-of-network referrals, and
      continuation of existing relationships with out-of-network providers for course
      of treatment

    2. Linkages
      with behavioral health agencies, disability and advocacy organizations,
      etc.

    3. Adequate
      network of providers and sub-specialists (including pediatric providers and
      sub-specialists) and contractual relationships with tertiary
      institutions

    4. Procedures
      for assuring that these populations receive appropriate diagnostic work-ups
      on a
      timely basis

    5. Procedures
      for assuring that these populations receive appropriate access to durable
      medical equipment on a timely basis

    6. Procedures
      for assuring that these populations receive appropriate allied health
      professionals (Physical, Occupational and Speech Therapists, Audiologists)
      on a
      timely basis

    7. State
      designation as a Well Qualified Plan to serve the OMRDD population and
      look-alikes

     

    COMPLIANCE
      PLAN SUBMISSION

     

    1. A
      description of arrangements to ensure access to specialty care providers and
      centers in and out of New York State, standing referrals, specialist physicians
      to function as PCP, out-of-

    


    


    


    


    


    


    


    


    APPENDIX
      J

    October
      1, 2005

    J-12
      


    network
      referrals, and continuation of existing relationships (out-of-network) for
      diagnosis and treatment of rare disorders

    2. A
      description of appropriate service delivery for children with disabilities.
      This
      may include a description of methods for interacting with school districts,
      child protective service agencies, early intervention officials, behavioral
      health, and disability and advocacy organizations.

    3. A
      description of the sub-specialist network, including contractual relationships
      with tertiary institutions to meet the health care needs of people with
      disabilities

     

    F. ADDITIONAL
      ADA RESPONSIBILITIES FOR PUBLIC ACCOMMODATIONS

     

    Please
      note that Title III of the ADA applies to all non-governmental providers of
      health care. Title III of the Americans with Disabilities Act prohibits
      discrimination on the basis of disability in the full and equal enjoyment of
      goods, services, facilities, privileges, advantages or accommodations of any
      place of public accommodation. A public accommodation is a private entity that
      owns, leases or leases to, or operates a place of public accommodation. Places
      of public accommodation identified by the ADA include, but are not limited
      to,
      stores (including pharmacies) offices (including doctors' offices), hospitals,
      health care providers, and social service centers.

     

    New
      and
      altered areas and facilities must be as accessible as possible. Barriers must
      be
      removed from existing facilities when it is readily achievable, defined by
      the
      ADA as easily accomplishable without much difficulty or expense. Factors to
      be
      considered when determining if barrier removal is readily achievable include
      the
      cost of the action, the financial resources of the site involved, and, if
      applicable, the overall financial resources of any parent corporation or entity.
      If barrier removal is not readily achievable, the ADA requires alternate methods
      of making goods and services available. New facilities must be accessible unless
      structurally impracticable.

     

    Title
      III
      also requires places of public accommodation to provide any auxiliary aids
      and
      services that are needed to ensure equal access to the services it offers,
      unless a fundamental alteration in the nature of services or an undue burden
      would result. Auxiliary aids include but are not limited to qualified sign
      interpreters, assistive listening systems, readers, large print materials,
      etc.
      Undue burden is defined as "significant difficulty or expense". The factors
      to
      be considered in determining "undue burden" include, but are not limited to,
      the
      nature and cost of the action required and the overall financial resources
      of
      the provider. "Undue burden" is a higher standard than "readily achievable"
      in
      that it requires a greater level of effort on the part of the public
      accommodation.

     

    Please
      note also that the ADA is not the only law applicable for people with
      disabilities. In some cases. State or local laws require more than the ADA.
      For
      example. New York City's Human Rights Law, which also prohibits discrimination
      against people with disabilities, includes people whose impairments are not
      as
      "substantial" as the narrower ADA and uses the higher "undue burden"
      ("reasonable") standard where the ADA requires only that which is "readily
      achievable". New York City's Building Code does not permit access waivers for
      newly constructed facilities and requires incorporation of access features
      as

     

    


    


    


    


    


    


    APPENDIX
      J

    October
      1, 2005

    J-13


    existing
      facilities are renovated. Finally, the State Hospital code sets a higher
      standard than the ADA for provision of communication (such as sign language
      interpreters) for services provided at most hospitals, even on an outpatient
      basis.

     

    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    APPENDIX
      J

    October
      1, 2005

    J-14

    


    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, 2005 

    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 mil 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
      KL2.

     

    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, 2005 

    K-2

    



    K.1

    


    PREPAID
      BENEFIT PACKAGE

    


    
      	
              *

            	
              Covered
                Services

            	
              MMC
                Non-SSI

            	
              MMC
                SSI

            	
              MFFS

            	 	
              FHPlus
                **

            
	 	
              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 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]

            
	 	
              Inpatient
                Stay Pending Alternate Level of Medical Care

               

            	
              Covered

            	
              Covered

            	 	 	
              Covered

            
	 	
              Physician
                Services

               

            	
              Covered

            	
              Covered

            	 	 	
              Covered

            
	 	
              Nurse
                Practitioner Services

               

            	
              Covered

            	
              Covered

            	 	 	
              Covered

            
	 	
              Midwifery
                Services

               

            	
              Covered

            	
              Covered

            	 	 	
              Covered

            
	 	
              Preventive
                Health Services

               

            	
              Covered

            	
              Covered

            	 	 	
              Covered

            
	 	
              Second
                Medical/Surgical Opinion

               

            	
              Covered

            	
              Covered

            	 	 	
              Covered

            
	 	
              Laboratory
                Services

               

            	
              Covered

            	
              Covered

            	
              HIV
                phenotypic virtual phenotypic and genotypic drug resistant
                tests

            	 	
              Covered

            
	 	
              Radiology
                Services

               

            	
              Covered

            	
              Covered

            	 	 	
              Covered

            
	 	
              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

               

            	
              Pharmaceuticals
                and medical supplies routinely furnished or administered as part
                of a
                clinic or office visit

            	
              Covered
                outpatient drugs from the list of Medicaid reimbursable prescription
                drugs, subject to any applicable co-payments

            	 	
              Covered,
                may be limited to generic. Vitamins (except to treat an illness or
                condition), OTCs, and medical supplies are not covered

            
	 	
              Smoking
                Cessation Products

               

            	 	 	
              Covered

            	 	
              Covered

            
	 	
              Rehabilitation
                Services

               

            	
              Covered

               

            	
              Covered

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

            
	 	
              EPSDT
                Services/Child Teen Health Program (C/THP)

            	
              Covered

               

            	
              Covered

               

            	
              Covered

               

            	 	
              Covered

               

            


    

    


    APPENDIX
      K

    October
      1, 2005

    K-3

    *See
      K.2
      for Scope of Benefits **No
      Medicad fee-for service-wrap around

    is
      available. Subject to applicable co-pays.

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

    


    
      	
              *

            	
              Covered
                Services

            	
              MMC
                Non-SSI

            	
              MMC
                SSI

            	
              MFFS

            	 	
              FHPlus
                **

            
	 	
              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

            
	 	
              Private
                Duty Nursing Services

               

            	
              Covered

               

            	
              Covered

               

            	 	 	
              Not
                covered

               

            
	 	
              Hospice

               

            	 	 	
              Covered

               

            	 	
              Covered

               

            
	 	
              Emergency
                Services

               

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

               

            	
              Covered

               

              Covered

               

            	
              Covered

               

              Covered

               

            	 	 	
              Covered

               

              Covered

               

            
	 	
              Foot
                Care Services

               

            	
              Covered

               

            	
              Covered

               

            	 	 	
              Covered

               

            
	 	
              Eye
                Care and Low vision Services

               

            	
              Covered

               

            	
              Covered

               

            	 	 	
              Covered

               

            
	 	
              Durable
                Medical Equipment (DME)

               

            	
              Covered

               

            	
              Covered

               

            	 	 	
              Covered

               

            
	 	
              Audiology,
                Hearing Aids Services and Products

               

            	
              Covered
                except for hearing aid batteries

               

            	
              Covered
                except for hearing aid batteries

               

            	
              Hearing
                aid batteries

               

            	 	
              Covered
                including hearing aid batteries

               

            
	 	
              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 this
                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

               

            
	 	
              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

               

            
	 	
              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

               

            


    

    


    APPENDIX
      K

    October
      1, 2005

    K-4

    *See
      K.2
      for Scope of Benefits **No
      Medicad fee-for service-wrap around

    is
      available. Subject to applicable co-pays.

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

    



    
      	 	 	 	 	 	 	 
	
              *

            	
              Covered
                Services

            	
              MMC
                Non-SSI

            	
              MMC
                SSI

            	
              MFFS

            	 	
              FHPlus
                **

            
	 	
              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 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

            
	 	
              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)

            
	 	
              Prosthetic/Orthotic
                Services/Orthopedic Footwear

               

            	
              Covered

            	
              Covered

            	 	 	
              Covered,
                except orthopedic shoes

            
	 	
              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

               

            
	 	
              Detoxification
                Services

            	
              Covered

            	
              Covered

            	 	 	
              Covered

            
	 	
              Chemical
                Dependency 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

               

            
	 	
              Chemical
                Dependence Outpatient

            	 	 	
              Covered

               

            	 	
              Covered
                subject to calendar year benefit limits of 60 visits combined with
                mental
                health services

               

            
	 	
              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

               

            
	 	
              Renal
                Dialysis

            	
              Covered

            	
              Covered

            	 	 	
              Covered

            
	 	
              Residential
                Health Care Facility Services (RHCF)

            	
              Covered,
                except for individuals in permanent placement

               

            	
              Covered,
                except for individuals in permanent placement

            	 	 	 


    

    APPENDIX
      K

    October
      1, 2005

    K-5

    *See
      K.2 for Scope of Benefits **No
      Medicad fee-for service-wrap around

    is
      available. Subject to applicable co-pays.

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

    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
                PlusBenefit 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 KL2.

            


    

    


    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
                ManagedCare 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, 2005

    K-2

    



    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

    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 fall 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:

            


    

    


    
      	 	
              i)

            	
              pharmaceuticals
                and medical supplies routinely famished or administered as part of
                a
                clinic or office visit-

            


    

    


    


    APPENDIX
      K

    October
      1, 2005

    K-6

    



    
      	 	
              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).

    


    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, 2005

    K-7

    


    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 and preventing
                illness:

            


    

    


    
      	 	
              i)

            	
              General
                health education classes.

            


    

    
      	 	
              ii)

            	
              Pneumonia
                and influenza immunizations for at risk
                populations.

            


    

    
      	 	
              iii)

            	
              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.

    


    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.

    


    


    


    APPENDIX
      K

    October
      1, 2005

    K-8

    



    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 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.

    


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

    


    
      	 	
              a)

            	
              For
                Medicaid fee-for-service only: Medically necessary prescription and
                non-prescription OTC) drugs, medical supplies and enteral formula
                are
                covered when ordered by a qualified
                provider.

            


    

    


    
      	 	
              b)

            	
              MMC
                Enrollees are covered for prescription drugs through the Medicaid
                fee-for-service program. Pharmaceuticals and medical supplies routinely
                furnished or administered as part of a clinic or office visit are
                covered
                by the MMC Program. 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 prescription drugs or covered
                by the
                Contractor, subject to medical necessity, if the drug is not on the
                list
                of Medicaid reimbursable prescription
                drugs.

            


    

    


    


    


    


    APPENDIX
      K

    October
      1, 2005

    K-9

    



    
      	 	
              c)

            	
              For
                Family Health Plus only:

            


    

    


    
      	 	
              i)

            	
              Prescription
                drugs are covered, but may be limited to generic medications where
                medically acceptable. All medications used for preventive and therapeutic
                purposes are covered, as well as family planning or contraceptive
                medications or devices.

            


    

    


    
      	 	
              ii)

            	
              Coverage
                includes enteral formulas for home use for which a physician or other
                provider authorized to prescribe has issued a written order. Enteral
                formulas for the treatment of specific diseases shall be distinguished
                from nutritional supplements taken electively. Coverage for certain
                inherited diseases of amino acid and organic acid metabolism shall
                include
                modified solid food products that are low-protein or which contain
                modified protein. Vitamins are not covered except when necessary
                to treat
                a diagnosed illness or condition.

            


    

    


    
      	 	
              iii)

            	
              Experimental
                investigational drugs are generally excluded, except where approved
                in the
                course of experimental/investigational
                treatment.

            


    

    


    
      	 	
              iv)

            	
              Drugs
                prescribed for cosmetic purposes are
                excluded.

            


    

    


    
      	 	
              v)

            	
              Over-the-counter
                items are excluded with the exception of diabetic supplies, including
                insulin and smoking cessation agents. Non-prescription (OTC) drugs
                and
                medical supplies are not covered.

            


    

    


    11. Smoking
      Cessation Products

    


    
      	 	
              a)

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

            


    

    


    
      	 	
              b)

            	
              For
                Family Health Plus only: At least two courses of smoking cessation
                therapy
                per person per year, as medically necessary are covered. A course
                of
                therapy is defined as no more than a ninety (90)-day supply, (an
                original
                prescription and two (2) refills, even if less than a thirty (30)-day
                supply is dispensed in any fill). Duplicative use of one agent is
                not
                allowed (i.e., same drug/same dosage form/same strength). Both
                prescription and over-the-counter therapies/agents are covered; tills
                includes nicotine patches, inhalers, nasal sprays, gum, and Zyban
                (bupropion).

            


    

    


    12. Rehabilitation
      Services

    18
      NYCRR505.11

    


    
      	 	
              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

            


    

    


    


    APPENDIX
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    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.

    


    
      	 	
              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 me 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
      NYCRR505.23(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

            


    

    APPENDIX
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    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.

            


    

    


    
      	 	
              c)

            	
              Services
                include care rendered directly to me 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 can be provided through an approved certified home health agency,
      a
      licensed home care agency, or a private Practitioner. The location of nursing
      services may be in the MMC Enrollee's home or in the hospital.

    


    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 provided in accordance with the ordering physicians,
      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

    


    APPENDIX
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    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.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.

    


    APPENDIX
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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 me 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 V^.
                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

            


    

    


    APPENDIX
      K

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    medically
      necessary or if eyeglasses are lost, damaged or destroyed as described
      above.

    


    
      	 	
              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.

    


    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 me 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
      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

    APPENDIX
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    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.

            


    

    


    
      	 	
              ii)

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

            


    

    


    


    APPENDIX
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    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.

    


    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.

    


    


    APPENDIX
      K

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    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.

    


    d) Non-emergency
      transportation is covered for FHPlus Enrollees that are nineteen
      (19)

    or
      twenty
      (20) years old and are receiving C/THP services.

    


    24. Emergency
      Transportation

    


    a) Emergency
      transportation can only be provided by an ambulance service including air
      ambulance service. Emergency ambulance transportation means me 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, bums, 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. Inpatient claims and referred ambulatory claims for dental services
      provided in an inpatient or outpatient hospital setting for surgery,
      anesthesiology. X-rays, etc. are the responsibility of the Contractor. The
      Contractor shall set up procedures to prior approve dental services provided
      in
      inpatient and ambulatory settings.

    


    


    APPENDK
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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.

            


    

    


    d) For
      Family Health Plus only: professional services of a dentist for dental surgery
      performed in an ambulatory or inpatient setting are not covered.

    


    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.

    


    


    APPENDIX
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    b) Outpatient
      Services

    


    Outpatient
      services including but not limited to: assessment, stabilization, treatment
      planning, discharge planning, verbal therapies, education, symptom
      management,case management services, crisis intervention and outreach services,
      chlozapine monitoring and collateral services as certified by 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, io-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.

            


    

    


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              ii)

            	
              Medically
                Supervised Outpatient Withdrawal

            


    

    


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

    


    


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    b) 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.

    


    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.

    


    APPENDIX
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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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    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.

    


    
      	 	
              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

    


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

    


    


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    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.

            


    

    


    
      	 	
              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.

            


    

    


    


    APPENDIX
      K 

    October
      1, 2005 

    K-32

    



    
      	 	
              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 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

    


    APPENDIX
      K 

    October
      1, 2005 

    K-33

    



    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.

            


    

    


    APPENDIX
      K 

    October
      1, 2005 

    K-34

    



    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, 2005 

    K-35

    



    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. Non-Prescription
      (OTC) Drugs and Medical Supplies

    6. Alcohol
      and Substance Abuse (ASA) Services Ordered by the LDSS

    7. Office
      of
      Mental Health/ Office of Mental Retardation and Developmental
      Disabilities

    Services

    8. School
      Supportive Health Services

    9. Comprehensive
      Medicaid Case Management (CMCM)

    10. Directly
      Observed Therapy for Tuberculosis Disease

    11. AIDS
      Adult Day Health Care

    12. HIV
      COBRA
      Case Management

    13. Home
      and Community Based
      Services
      Waiver

    14. Methadone
      Maintenance Treatment Program

    15. Day
      Treatment

    16. IPRT

    17. Infertility
      Services

    18. Adult
      Day
      Health Care

    19. School
      Based Health Care Services

    20. Personal
      Emergency Response Systems

    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    APPENDIX
      K 

    October
      1, 2005 

    K-36

    


    APPENDIX
      L

    


    Approved
      Capitation Payment Rates

    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    APPENDIX
      L

    October
      1, 2005 

    L-l

    


    


    WELLCARE
      OF NEW YORK, INC.

    


    
      	
              Medicaid
                Managed Care RatesMMIS ID#:  01182503

              Approved
                by DOB: Yes

              DOH
                HMO #:  05-023

              Reinsurance:  No

            	
              Effective
                Date:  04/01/05

              Region:  Northeast

              County:  ALBANY

              Status:   Mandatory

            


    

    


    


    


    Premium
      Group      Rate
      Amount

    


    TANF/SN
      <6mo M/F      
      $232.65

    TANF/SN
      6mo - 14 F      
      $75.11

    TANF/SN
      15 - 20 F      
      $131.81

    TANF/SN
      6mo - 20 M     
      $96.02

    TANF
      21+
      M/F      
      $197.01

    SN
      21 -
      29 M/F      
      $232.88

    SN
      30+
      M/F       
      $339.28

    SSI
      6mo -
      20 M/F      
      $195.51

    SSI
      21 -
      64 M/F      
      $465.91

    SSI
      65+
      M/F       
      $345.06

    Maternity
      Kick Payment     $4,661.82

    Newborn
      Kick Payment     $2,067.67

    


    


    Optional
      Benefits Offered:

    


    þ
      Emergency Transportation    ̈
      Dental

    


    þ
      Non-Emergent Transportation   þ
      Family
      Planning

    


    


    


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

    


    


    


    


    


    


    


    


    


    


    


    
      	
              MMIS
                ID#:  01182503

              Approved
                by DOB: Yes

              DOH
                HMO #:  05-023

              Reinsurance:  No

            	
              Effective
                Date:  04/01/05

              Region:  Central
                

              County:  COLUMBIA

              Status:   Mandatory

            


    

    


    


    


    Premium
      Group      Rate
      Amount

    


    TANF/SN
      <6mo M/F      
      $210.18

    TANF/SN
      6mo - 14 F      
      $72.08

    TANF/SN
      15 - 20 F      
      $175.97

    TANF/SN
      6mo - 20 M     
      $78.23

    TANF
      21+
      M/F      
      $194.23

    SN
      21 -
      29 M/F      
      $197.59

    SN
      30+
      M/F       
      $296.31

    SSI
      6mo -
      20 M/F      
      $171.34

    SSI
      21 -
      64 M/F      
      $375.09

    SSI
      65+
      M/F       
      $333.50

    Maternity
      Kick Payment     $4,661.82

    Newborn
      Kick Payment     $2,445.52

    


    


    Optional
      Benefits Offered:

    


    þ
      Emergency Transportation    ̈
      Dental

    


    þ
      Non-Emergent Transportation   þ
      Family
      Planning

    


    


    


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

    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    
      	
              MMIS
                ID#:  01182503

              Approved
                by DOB: Yes

              DOH
                HMO #:  05-023

              Reinsurance:  No

            	
              Effective
                Date:  04/01/05

              Region:  Mid-Hudson

              County:  DUTCHESS

              Status:   Voluntary

            


    

    


    


    


    Premium
      Group      Rate
      Amount

    


    TANF/SN
      <6mo M/F      
      $220.94

    TANF/SN
      6mo - 14 F      
      $76.56

    TANF/SN
      15 - 20 F      
      $138.80

    TANF/SN
      6mo - 20 M     
      $89.20

    TANF
      21+
      M/F      
      $186.33

    SN
      21 -
      29 M/F      
      $200.13

    SN
      30+
      M/F       
      $361.68

    SSI
      6mo -
      20 M/F      
      $205.86

    SSI
      21 -
      64 M/F      
      $388.60

    SSI
      65+
      M/F       
      $268.04

    Maternity
      Kick Payment     $4,661.82

    Newborn
      Kick Payment     $2,408.73

    


    


    Optional
      Benefits Offered:

    


    þ
      Emergency Transportation    ̈
      Dental

    


     ̈
      Non-Emergent Transportation   þ
      Family
      Planning

    


    


    


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

    


    


    


    


    


    


    


    


    


    


    


    


    


    


    
      	
              MMIS
                ID#:  01182503

              Approved
                by DOB: Yes

              DOH
                HMO #:  05-023

              Reinsurance:  No

            	
              Effective
                Date:  04/01/05

              Region:  Central

              County:  GREENE

              Status:   Mandatory

            


    

    


    


    


    Premium
      Group      Rate
      Amount

    


    TANF/SN
      <6mo M/F      
      $208.54

    TANF/SN
      6mo - 14 F      
      $70.95

    TANF/SN
      15 - 20 F      
      $173.60

    TANF/SN
      6mo - 20 M     
      $76.90

    TANF
      21+
      M/F      
      $192.76

    SN
      21 -
      29 M/F      
      $193.93

    SN
      30+
      M/F       
      $291.58

    SSI
      6mo -
      20 M/F      
      $167.47

    SSI
      21 -
      64 M/F      
      $370.15

    SSI
      65+
      M/F       
      $313.07

    Maternity
      Kick Payment     $4,661.82

    Newborn
      Kick Payment     $2,445.52

    


    


    Optional
      Benefits Offered:

    


    þ
      Emergency Transportation    ̈
      Dental

    


    þ
      Non-Emergent Transportation   þ
      Family
      Planning

    


    


    


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

    


    


    


    


    


    


    


    


    


    


    


    


    


    


    
      	
              MMIS
                ID#:  01182503

              Approved
                by DOB: Yes

              DOH
                HMO #:  05-023

              Reinsurance:  No

            	
              Effective
                Date:  04/01/05

              Region:  Mid-Hudson

              County:  ORANGE

              Status:   Voluntary

            


    

    


    


    


    Premium
      Group      Rate
      Amount

    


    TANF/SN
      <6mo M/F      
      $220.79

    TANF/SN
      6mo - 14 F      
      $76.47

    TANF/SN
      15 - 20 F      
      $138.72

    TANF/SN
      6mo - 20 M     
      $89.15

    TANF
      21+
      M/F      
      $186.16

    SN
      21 -
      29 M/F      
      $198.93

    SN
      30+
      M/F       
      $361.46

    SSI
      6mo -
      20 M/F      
      $205.74

    SSI
      21 -
      64 M/F      
      $388.21

    SSI
      65+
      M/F       
      $267.82

    Maternity
      Kick Payment     $4,661.82

    Newborn
      Kick Payment     $2,408.73

    


    


    Optional
      Benefits Offered:

    


     ̈
      Emergency Transportation    ̈
      Dental

    


     ̈
      Non-Emergent Transportation   þ
      Family
      Planning

    


    


    


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

    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    
      	
              MMIS
                ID#:  01182503

              Approved
                by DOB: Yes

              DOH
                HMO #:  05-023

              Reinsurance:  No

            	
              Effective
                Date:  04/01/05

              Region:  Northeast

              County:  RENSSELAER

              Status:   Mandatory

            


    

    


    


    


    Premium
      Group      Rate
      Amount

    


    TANF/SN
      <6mo M/F      
      $230.90

    TANF/SN
      6mo - 14 F      
      $73.20

    TANF/SN
      15 - 20 F      
      $129.76

    TANF/SN
      6mo - 20 M     
      $94.65

    TANF
      21+
      M/F      
      $195.14

    SN
      21 -
      29 M/F      
      $231.83

    SN
      30+
      M/F       
      $331.78

    SSI
      6mo -
      20 M/F      
      $187.47

    SSI
      21 -
      64 M/F      
      $463.52

    SSI
      65+
      M/F       
      $339.22

    Maternity
      Kick Payment     $4,661.82

    Newborn
      Kick Payment     $2,067.67

    


    


    Optional
      Benefits Offered:

    


    þ
      Emergency Transportation    ̈
      Dental

    


     ̈
      Non-Emergent Transportation   þ
      Family
      Planning

    


    


    


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

    


    


    


    


    


    


    


    


    


    


    


    


    


    


    
      	
              MMIS
                ID#:  01182503

              Approved
                by DOB: Yes

              DOH
                HMO #:  05-023

              Reinsurance:  No

            	
              Effective
                Date:  04/01/05

              Region:  Northern
                Metro

              County:  ROCKLAND

              Status:   Mandatory

            


    

    


    


    


    Premium
      Group      Rate
      Amount

    


    TANF/SN
      <6mo M/F      
      $187.63

    TANF/SN
      6mo - 14 F      
      $73.64

    TANF/SN
      15 - 20 F      
      $119.97

    TANF/SN
      6mo - 20 M     
      $88.39

    TANF
      21+
      M/F      
      $178.80

    SN
      21 -
      29 M/F      
      $229.53

    SN
      30+
      M/F       
      $285.40

    SSI
      6mo -
      20 M/F      
      $238.42

    SSI
      21 -
      64 M/F      
      $442.24

    SSI
      65+
      M/F       
      $320.96

    Maternity
      Kick Payment     $4,661.82

    Newborn
      Kick Payment     $2,017.16

    


    


    Optional
      Benefits Offered:

    


    þ
      Emergency Transportation    ̈
      Dental

    


     ̈
      Non-Emergent Transportation   þ
      Family
      Planning

    


    


    


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

    


    


    


    


    


    


    


    


    
      	
              MMIS
                ID#:  01182503

              Approved
                by DOB: Yes

              DOH
                HMO #:  05-023

              Reinsurance:  No

            	
              Effective
                Date:  04/01/05

              Region:  Mid-Hudson

              County:  SULLIVAN

              Status:   Voluntary

            


    

    


    


    


    Premium
      Group      Rate
      Amount

    


    TANF/SN
      <6mo M/F      
      $220.79

    TANF/SN
      6mo - 14 F      
      $76.47

    TANF/SN
      15 - 20 F      
      $138.72

    TANF/SN
      6mo - 20 M     
      $89.15

    TANF
      21+
      M/F      
      $186.16

    SN
      21 -
      29 M/F      
      $198.93

    SN
      30+
      M/F       
      $361.46

    SSI
      6mo -
      20 M/F      
      $205.74

    SSI
      21 -
      64 M/F      
      $388.21

    SSI
      65+
      M/F       
      $267.82

    Maternity
      Kick Payment     $4,661.82

    Newborn
      Kick Payment     $2,408.73

    


    


    Optional
      Benefits Offered:

    


     ̈
      Emergency Transportation    ̈
      Dental

    


     ̈
      Non-Emergent Transportation   þ
      Family
      Planning

    


    


    


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

    


    


    


    


    


    


    


    


    


    


    


    


    


    
      	
              MMIS
                ID#:  01182503

              Approved
                by DOB: Yes

              DOH
                HMO #:  05-023

              Reinsurance:  No

            	
              Effective
                Date:  04/01/05

              Region:  Mid-Hudson

              County:  ULSTER

              Status:   Voluntary

            


    

    


    


    


    Premium
      Group      Rate
      Amount

    


    TANF/SN
      <6mo M/F      
      $220.79

    TANF/SN
      6mo - 14 F      
      $76.47

    TANF/SN
      15 - 20 F      
      $138.72

    TANF/SN
      6mo - 20 M     
      $89.15

    TANF
      21+
      M/F      
      $186.16

    SN
      21 -
      29 M/F      
      $198.93

    SN
      30+
      M/F       
      $361.46

    SSI
      6mo -
      20 M/F      
      $205.74

    SSI
      21 -
      64 M/F      
      $388.21

    SSI
      65+
      M/F       
      $267.82

    Maternity
      Kick Payment     $4,661.82

    Newborn
      Kick Payment     $2,408.73

    


    


    Optional
      Benefits Offered:

    


     ̈
      Emergency Transportation    ̈
      Dental

    


     ̈
      Non-Emergent Transportation   þ
      Family
      Planning

    


    


    


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

    


    


    


    


    


    


    


    


    


    


    


    


    


    


    WELLCARE
      OF NEW YORK, INC.

    Family
      Health Plus Rates Effective October 1, 2005

    


    


    


    
      	 	 	 	 	
              Optional

              benefits
                covered

            
	
              County
                  Adults
                with

                 Children
                19 - 64

            	
              Adults
                without 

              Children
                19-29

            	
              Adults
                without Children 30 - 64

            	
              Maternity
                Kick

            	
              Family

              Planning

            	
              Dental

            
	
              ALBANY  $246.73

            	
              $305.42

            	
              $352.78

            	
              $4,661.82

            	
              Yes

            	
              Yes

            
	
              COLUMBIA
                  $272.07

            	
              $303.71

            	
              $418.02

            	
              $4,661.82

            	
              Yes

            	
              Yes

            
	
              DUTCHESS
                  $221.42

            	
              $272.22

            	
              $329.06

            	
              $4,661.82

            	
              Yes

            	
              Yes

            
	
              GREENE
                  $272.07

            	
              $303.71

            	
              $418.02

            	
              $4,661.82

            	
              Yes

            	
              Yes

            
	
              ORANGE
                  $221.42

            	
              $272.22

            	
              $329.06

            	
              $4,661.82

            	
              Yes

            	
              Yes

            
	
              RENSSELAER
                 $246.73

            	
              $305.42

            	
              $352.78

            	
              $4,661.82

            	
              Yes

            	
              Yes

            
	
              ROCKLAND
                  $250.79

            	
              $302.16

            	
              $322.43

            	
              $4,661.82

            	
              Yes

            	
              Yes

            
	
              ULSTER
                  $221.42

            	
              $272.22
                

            	
              $329.06

            	
              $4,661.82

            	
              Yes

            	
              Yes

            
	
              NEW
                YORK CITY  $206.17

            	
              $200.83

            	
              $302.31

            	
              $4,834.20

            	
              Yes

            	
              Yes

            


    

    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    APPENDIX
      M

    


    


    Service
      Area, Benefit Options, and Enrollment Elections

    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    APPENDIX
      M

    October
      1,2005

    M-l

    


    


    


    


    


    


    Schedule
      1 of Appendix M

    


    Service
      Area, Program Participation and

    Prepaid
      Benefit Package Optional Covered Services

    


    1. Service
      Area

    


    The
      Contractor's service area is comprised of the counties listed in Column A of
      this schedule in their entirety.

    


    2. Program
      Participation and Optional Benefit Package Covered
      Services

    


    a)
      For
      each county listed in Column A below, an entry of "yes" in the subsections
      of
      Columns B and C means the Contractor offers the MMC and/or FHPlus product and/or
      includes the optional service indicated in its Benefit Package.

    


    b)
      For
      each county listed in Column A below, an entry of "no" in the subsections of
      Columns B and C means the Contractor does not offer the MMC and/or FHPlus
      product and/or does not include the optional service indicated in its Benefit
      Package.

    


    c)
      In the
      schedule below, an entry of "N/A" means not applicable for the purposes of
      this
      Agreement.

    


    
      	3.  	
              Effective
                Date

            


    

    


    The
      effective date of this Schedule is October 1, 2005

    


    
      	
              Contractor:
                WellCare of New York, Inc.

            
	
              Column
                A 

              County

            	
              Column
                B 

              Medicaid
                Managed Care

            	
              Column
                C 

              FHPlus

            
	
              Contractor
                Participates

            	
              Dental

            	
              Family
                Planning

            	
              Non-Emergency
                Transportation

            	
              Emergency
                Transportation

            	
              Contractor
                Participates

            	
              Dental

            	
              Family
                Planning

            
	
              Albany

            	
              Yes

            	
              No

            	
              Yes

            	
              Yes

            	
              Yes

            	
              Yes

            	
              Yes

            	
              Yes

            
	
              Columbia

            	
              Yes

            	
              No

            	
              Yes

            	
              Yes

            	
              Yes

            	
              Yes

            	
              Yes

            	
              Yes

            
	
              Dutchess

            	
              Yes

            	
              No

            	
              Yes

            	
              No

            	
              Yes

            	
              Yes

            	
              Yes

            	
              Yes

            
	
              Greene

            	
              Yes

            	
              No

            	
              Yes

            	
              No

            	
              Yes

            	
              Yes

            	
              Yes

            	
              Yes

            
	
              New
                York City - Bronx 

            	
              N/A

            	
              N/A

            	
              N/A

            	
              N/A

            	
              N/A

            	
              Yes

            	
              Yes

            	
              Yes

            
	
              New
                York City - Kings 

            	
              N/A

            	
              N/A

            	
              N/A

            	
              N/A

            	
              N/A

            	
              Yes

            	
              Yes

            	
              Yes

            
	
              New
                York City - New York 

            	
              N/A

            	
              N/A

            	
              N/A

            	
              N/A

            	
              N/A

            	
              Yes

            	
              Yes

            	
              Yes

            
	
              New
                York City - Queens

            	
              N/A

            	
              N/A

            	
              N/A

            	
              N/A

            	
              N/A

            	
              Yes

            	
              Yes

            	
              Yes

            


    

    APPENDIX
      M

    October
      1, 2005

    M-2

    


    


    


    


    


    


    
      	
              Contractor:
                WellCare of New York, Inc.

            
	
              Column
                A 

              County

            	
              Column
                B 

              Medicaid
                Managed Care

            	
              Column
                C 

              FHPlus

            
	
              Contractor
                Participates

            	
              Dental

            	
              Family
                Planning

            	
              Non-Emergency
                Transportation

            	
              Emergency
                Transportation

            	
              Contractor
                Participates

            	
              Dental

            	
              Family
                Planning

            
	
              Orange

            	
              Yes

            	
              No

            	
              Yes

            	
              No

            	
              No

            	
              Yes

            	
              Yes

            	
              Yes

            
	
              Rensselaer

            	
              Yes

            	
              No

            	
              Yes

            	
              No

            	
              Yes

            	
              Yes

            	
              Yes

            	
              Yes

            
	
              Rockland

            	
              Yes

            	
              No

            	
              Yes

            	
              No

            	
              Yes

            	
              Yes

            	
              Yes

            	
              Yes

            
	
              Sullivan

            	
              Yes

            	
              No

            	
              Yes

            	
              No

            	
              No

            	
              No

            	
              No

            	
              No

            
	
              Ulster

            	
              Yes

            	
              No

            	
              Yes

            	
              No

            	
              No

            	
              Yes

            	
              Yes

            	
              Yes

            


    

    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    Schedule
      2 of Appendix M

    


    LDSS
      Election of Enrollment in Medicaid Managed Care For Foster Care Children and
      Homeless Persons

    


    


    


    
      	 	
              1.

            	
              Effective
                October 1, 2005, in the Contractor's service area, Medicaid Eligible
                Persons in the following categories will be eligible for Enrollment
                in the
                Contractor's Medicaid Managed Care product at LDSS's option as described
                in (a) and (b) as follows, and indicated by an "X" in the chart
                below:

            


    

    


    a)
      Options for foster care children in the direct care of LDSS:

    i)
      Children in LDSS direct care are mandatorily enrolled in MMC
      (mandatory

    counties
      only);

    ii)
      Children in LDSS direct care are enrolled in on a case by case basis in
      MMC

    (mandatory
      or voluntary counties);

    iii)
      All
      foster care children are Excluded from Enrollment in MMC (mandatory
      or

    voluntary
      counties).

    


    b)
      Options for homeless persons living in shelters outside of New York
      City:

    i)
      Homeless persons are mandatorily enrolled in MMC (mandatory counties
      only);

    ii)
      Homeless persons are enrolled in on a case by case basis in MMC (mandatory
      or

    voluntary
      counties);

    iii)
      All
      homeless persons are Excluded from Enrollment in MMC (mandatory or

    voluntary
      counties).

    


    c)
      In the
      schedule below, an entry of "N/A" means not applicable for the purposes of
      this
      Agreement.

    


    
      	
              Contractor:
                WellCare of New York, Inc.

            
	
              County

            	
              Foster
                Care Children

            	
              Homeless
                Persons

            
	
              Mandatorily
                Enrolled

            	
              Enrolled
                on Case by Case Basis

            	
              Excluded
                from Enrollment

            	
              Mandatorily
                Enrolled

            	
              Enrolled
                on Case by Case Basis

            	
              Excluded
                from Enrollment

            
	
              Albany

            	 	
              X

            	 	 	
              X

            	 
	
              Columbia

            	 	
              X

            	 	 	
              X

            	 
	
              Dutchess

            	 	
              X

            	 	 	
              X

            	 
	
              Greene

            	
              X

            	 	 	
              X

            	 	 
	
              Orange

            	 	
              X

            	 	 	
              X

            	 
	
              Rensselaer

            	 	
              X

            	 	 	
              X

            	 
	
              Rockland

            	 	
              X

            	 	 	
              X

            	 
	
              Sullivan

            	 	 	
              X

            	 	
              X

            	 
	
              Ulster

            	 	 	
              X

            	 	
              X

            	 


    

    


    


    


    


    APPENDIX
      M 

    October
      1, 2005 

    M-4

    


    


    


    


    Schedule
      2 of Appendix M

    


    LDSS
      Election of Enrollment in Medicaid Managed Care For Foster Care Children and
      Homeless Persons

    


    


    


    
      	 	
              1.

            	
              Effective
                October 1, 2005, in the Contractor's service area, Medicaid Eligible
                Persons in the following categories will be eligible for Enrollment
                in the
                Contractor's Medicaid Managed Care product at LDSS's option as described
                in (a) and (b) as follows, and indicated by an "X" in the chart
                below:

            


    

    


    a)
      Options for foster care children in the direct care of LDSS:

    i)
      Children in LDSS direct care are mandatorily enrolled in MMC
      (mandatory

    counties
      only);

    ii)
      Children in LDSS direct care are enrolled in on a case by case basis in
      MMC

    (mandatory
      or voluntary counties);

    iii)
      All
      foster care children are Excluded from Enrollment in MMC (mandatory
      or

    voluntary
      counties).

    


    b)
      Options for homeless persons living in shelters outside of New York
      City:

    i)
      Homeless persons are mandatorily enrolled in MMC (mandatory counties
      only);

    ii)
      Homeless persons are enrolled in on a case by case basis in MMC (mandatory
      or

    voluntary
      counties);

    iii)
      All
      homeless persons are Excluded from Enrollment in MMC (mandatory or

    voluntary
      counties).

    


    c)
      In the
      schedule below, an entry of "N/A" means not applicable for the purposes of
      this
      Agreement.

    


    
      	
              Contractor:
                WellCare of New York, Inc.

            
	
              County

            	
              Foster
                Care Children

            	
              Homeless
                Persons

            
	
              Mandatorily
                Enrolled

            	
              Enrolled
                on Case by Case Basis

            	
              Excluded
                from Enrollment

            	
              Mandatorily
                Enrolled

            	
              Enrolled
                on Case by Case Basis

            	
              Excluded
                from Enrollment

            
	
              Albany

            	 	
              X

            	 	 	
              X

            	 
	
              Columbia

            	 	
              X

            	 	 	
              X

            	 
	
              Dutchess

            	 	
              X

            	 	 	
              X

            	 
	
              Greene

            	
              X

            	 	 	
              X

            	 	 
	
              Orange

            	 	
              X

            	 	 	
              X

            	 
	
              Rensselaer

            	 	
              X

            	 	 	
              X

            	 
	
              Rockland

            	 	
              X

            	 	 	
              X

            	 
	
              Sullivan

            	 	 	
              X

            	 	
              X

            	 
	
              Ulster

            	 	 	
              X

            	 	
              X

            	 


    

    


    


    


    APPENDIX
      M 

    October
      1, 2005 

    M-4

    


    


    


    


    


    Appendix
      O

    


    Requirements
      for Proof of Workers' Compensation 

    and
      Disability Benefits Coverage

    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    Appendix
      O

    October
      1, 2005 

    O-1

    



    Requirements
      for Proof of Coverage

     

    Unless
      the Contractor is a political sub-division of New York State, the Contractor
      shall provide proof, completed by the Contractor's insurance carrier and/or
      the
      Workers' Compensation Board, of coverage for:

     

    
      	
              1.

            	
              Workers'
                Compensation,
                for which one of the following is incorporated into this Agreement
                herein
                as an attachment to Appendix 0:

            


    

     

    a) Certificate
      of Workers' Compensation Insurance, on the Workers' Compensation Board form
      C-105.2 (naming the NYS Department of Health, Coming Tower, Rm. 1325, Albany,
      12237-0016),
      or
      Certificate of Workers' Compensation Insurance, on the State Insurance Fund
      form
      U-26.3 (naming the NYS Department of Health, Coming Tower, Rm. 1325, Albany,
      12237-0016);
      or

     

    b) Certificate
      of Workers Compensation Self-Insurance, form SI-12,
      or
      Certificate of Group Workers' Compensation Self-Insurance, form
      GSI-105.2;
      or

     

    c) Affidavit
      for New York Entities And Any Out Of State Entities With No Employees, That
      New
      York State Workers' Compensation And/Or Disability Benefits Coverage Is Not
      Required, form WC/DB-100, completed for Workers' Compensation;
      or Affidavit
      That An OUT-OF-STATE OR FOREIGN EMPLOYER Working In New York State Does Not
      Require Specific New York State Workers' Compensation And/Or Disability Benefits
      Insurance Coverage, form WC/DB-101, completed for Workers' Compensation;
      [Affidavits must be notarized and stamped as received by the NYS Workers'
      Compensation Board]; and

     

    
      	
              2.

            	
              Disability
                Benefits Coverage,
                for which one of the following is incorporated into this Agreement
                herein
                as an attachment to Appendix 0:

            


    

     

    a) Certificate
      of Disability Benefits Insurance, form DB-120.1; or Certificate/Cancellation
      of
      Insurance, form DB-820/829;
      or

     

    b) Certificate
      of Disability Benefits Self-Insurance, form DB-155;
      or

     

    c) Affidavit
      for New York Entities And Any Out Of State Entities With No Employees, That
      New
      York State Workers' Compensation And/Or Disability Benefits Coverage Is Not
      Required, form WC/DB-100, completed for Disability Benefits;
      or
      Affidavit That An OUT-OF-STATE OR FOREIGN EMPLOYER Working m New York State
      Does
      Not Require Specific New York State Workers' Compensation And/Or Disability
      Benefits Insurance Coverage, form WC/DB-101, completed for Disability Benefits;
      [Affidavits must be notarized and stamped as received by the NYS Workers'
      Compensation Board].

     

    NOTE:
      ACORD forms are NOT acceptable proof of coverage.

     

    


    


    


    


    Appendix
      O

    October
      1, 2005 

    O-2


    APPENDIX
      P

    


    Facilitated
      Enrollment and Federal Health Insurance Portability and Accountability Act
      ("HIPAA") Business Associate Agreements

    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    APPENDIX
      P

    October
      1, 2005

    P-l

    



    P.I

    


    Facilitated
      Enrollment Agreement

    


    


    1. Effective
      Date of Agreement/Service Area

     

    
      	 	
              a)

            	
              This
                Appendix shall become effective on the date specified in the written
                notice from SDOH to the Contractor to initiate Facilitated Enrollment
                services for the MMC and FHPlus Programs. The Contractor will perform
                Facilitated Enrollment in the counties/boroughs identified by the
                Department by written notice.

            


    

     

    
      	 	
              b)

            	
              This
                Appendix shall be effective subject to statutory authority to conduct
                Facilitated Enrollment for the MMC and/or FHPlus Program. The Contractor
                agrees to discontinue Facilitated Enrollment activities in either
                or both
                programs upon SDOH notice of loss of such statutory
                authority.

            


    

     

    2. Facilitated
      Enrollment Standards

     

    The
      Contractor agrees to perform Facilitated Enrollment for the MMC and FHPlus
      Programs in accordance with the following standards:

     

    
      	 	
              a)

            	
              To
                provide an efficient and cost effective Facilitated Enrollment process
                approved by SDOH, including use of the "train-the-trainer"
                approach.

            


    

     

    
      	 	
              b)

            	
              To
                assure that all facilitators participate in the SDOH-sponsored training
                program for the MMC and FHPlus programs to be conducted by a private
                contractor to be selected by SDOH or other training approved by
                SDOH.

            


    

     

    
      	 	
              c)

            	
              To
                provide a sufficient number of facilitators at sites accessible and
                convenient to the population being served to assure applicants have
                timely
                access to Facilitated Enrollment The Contractor will provide SDOH
                and the
                LDSS with a list of the fixed Enrollment facilitation sites and must
                update the list on a monthly basis. Subject to SDOH and LDSS approval,
                the
                Contractor may offer Facilitated Enrollment at additional sites not
                on the
                list that has already been submitted to SDOH and
                LDSS.

            


    

     

    
      	 	
              d)

            	
              To
                offer Facilitated Enrollment during hours that accommodate the patterns
                of
                the community being served, which must include early morning, evening,
                and/or weekend hours.

            


    

     

    
      	 	
              e)

            	
              To
                hire staffer designate existing staff who are culturally and
                linguistically reflective of the community the Contractor serves,
                including facilitators who are able to communicate to vulnerable
                and
                hard-to-reach populations (e.g., non-English
                speaking).

            


    

     

    


    


    


    


    


    


    APPENDIX
      P

    October
      1, 2005

    P-2

    



    
      	 	
              f)

            	
              To
                have mechanisms in place to communicate effectively with applicants
                who
                are vision or hearing impaired, e.g., the services of an interpreter,
                including sign language assistance for applicants who require such
                assistance, telecommunication devices for the deaf(TTY),
                etc.

            


    

     

    
      	 	
              g)

            	
              To
                conduct the face-to-face interview in accordance with Medicaid
                requirements, policies and procedures. In any LDSS in which the personal
                interview is not delegated to the facilitator, one of the Contractor's
                facilitators shall act as the enrollee's authorized representative
                at the
                personal interview, which will be conducted by an LDSS representative
                with
                the facilitator.

            


    

     

    
      	 	
              h)

            	
              To
                comply with procedures and protocols that have been established by
                the
                LDSS and approved by SDOH and LDSS pursuant to Medicaid Administrative
                Directive 00 OMM/ADM-2 ("Facilitated Enrollment of Children into
                Medicaid,
                Quid Health Plus and WIC") and any other directives issued by SDOH
                to
                assure that facilitators are authorized to perform the Medicaid
                face-to-face interview. To assist applicants to complete the
                FHPhis/MA/CHPlus joint application, and screen adults and family
                applicants to assess their potential eligibility for various programs
                using a documentation checklist and screening
                tool.

            


    

     

    
      	 	
              i)

            	
              To
                explain the application and documentation required and to help applicants
                obtain required documentation. The Contractor will also follow-up
                with
                applicants to ensure application/Enrollment and documentation
                completion.

            


    

     

    
      	 	
              j)

            	
              To
                educate all applicants that appear to be eligible for Enrollment,
                including adults and families, about managed care and how to access
                benefits in a managed care environment This will include the distribution
                of SDOH approved material in English and other languages reflective
                of the
                community regarding all of New York State's health insurance coverage.
                This includes brochures and information developed by SDOH to explain
                health insurance coverage options available through FHPlus, CHPlus,
                and
                Medicaid Programs and various other public programs designed to support
                self sufficiency.

            


    

     

    
      	 	
              k)

            	
              To
                counsel all applicants that appear to be eligible for Enrollment,
                including adult individuals and families regarding selection of a
                participating MCO, and describe the important role of a Primary Care
                Provider (PCP) and the benefits of preventive health care. Facilitators
                must help applicants to determine the appropriate MCO to select based
                on
                their current health care needs and PCP availability. The Contractor
                will
                ensure that facilitators have information available about the providers
                who participate in each MCO's product available in the applicant's
                LDSS
                jurisdiction and have established procedures for inquiring into existing
                relationships with health care providers in order that the facilitators
                are able to provide assistance with PCP selection and enable applicants
                to
                maintain existing relationships with providers to the fullest extent
                possible.

            


    

     

    


    


    


    


    


    


    


    


    APPENDIX
      P

    October
      1, 2005

    P-3

    



    
      	 	
              1)

            	
              To
                ensure that facilitators perform Facilitated Enrollment counseling
                in a
                neutral manner so that every applicant is able to make an informed
                decision in selecting the appropriate MCO for the applicant's
                needs.

            


    

     

    
      	 	
              m)

            	
              To
                comply with LDSS protocols for transmitting the FHPlus or MMC applicant's
                MCO choice directly to the appropriate LDSS or Enrollment Broker,
                when
                applicable.

            


    

     

    
      	 	
              n)

            	
              To
                follow-up on each application after a prescribed period of time with
                the
                appropriate LDSS to ensure that applications are being processed
                and that
                applicants are able to enroll and receive services in a timely
                manner.

            


    

     

    
      	 	
              o)

            	
              To
                provide all applicants with information about their rights regarding
                making a complaint to the LDSS about an eligibility determination
                and
                making a complaint to the MCO, LDSS or SDOH about a service
                decision.

            


    

     

    
      	 	
              p)

            	
              To
                submit the completed application and required documentation directly
                to
                the appropriate LDSS responsible for processing the application and
                making
                the eligibility determination.

            


    

     

    
      	 	
              q)

            	
              To
                assist individuals and families with recertifying or renewing their
                coverage prior to the expiration of their 12-month enrollment period
                (Lock-In period, pursuant to Section 7 of the Agreement to which
                this is
                an addendum), including assisting in the completion of the renewal
                form
                and collection of the required documentation on a timely basis, when
                an
                enrollee seeks a facilitator's assistance with
                renewal.

            


    

     

    
      	 	
              r)

            	
              To
                cooperate with SDOH and LDSS monitoring efforts, including unannounced
                site visits.

            


    

     

    
      	 	
              s)

            	
              To
                comply with all applicable federal or state law, regulation, and/or
                administrative guidance, including any authority which supplements
                or
                supersedes the provisions set forth
                herein.

            


    

     

    3. SDOH
      Responsibilities

     

    
      	 	
              a)

            	
              SDOH
                will be responsible for ensuring that the Contractor's policies and
                procedures related to Enrollment and marketing are appropriate to
                meet the
                needs of applicants and comply with state and federal laws, regulations,
                and administrative guidance.

            


    

     

    
      	 	
              b)

            	
              Prior
                to commencement and/or expansion of the Contractor's Facilitated
                Enrollment to program applicants, SDOH
                will:

            


    

     

    
      	 	
              i)

            	
              Conduct
                a review to assure that the Contractor has established policies and
                procedures satisfactory to SDOH regarding the processing of applications,
                communications, contact persons, and interactions with other MCOs,
                if
                applicable.

            


    

    


    


    


    


    


    


    


    


    APPENDIX
      P

    October
      1, 2005

    P-4

    


    


    
      	 	
              ii)

            	
              Review
                schedules of sites and times, staffing, and Facilitated Enrollment
                locations. 

            


    

     

    iii)
      Ensure that all Contractor facilitators have undergone the required
      training.

     

    
      	 	
              iv)

            	
              Approve
                amended written protocols between the LDSS and the Contractor, which
                detail MMC/FHPlus operations and practices to assure that the unique
                needs
                and concerns of the local districts are
                addressed.

            


    

     

    
      	 	
              v)

            	
              Assess
                the Contractor's MCO selection process to assure that applicants
                are
                presented with unbiased information regarding MCO
                selection.

            


    

     

    
      	 	
              vi)

            	
              Approve
                all subcontracting arrangements and all publicity and educational
                materials submitted by the Contractor to assure that Enrollment
                information is comprehensive.

            


    

     

    
      	 	
              vii)

            	
              Monitor
                Facilitated Enrollment through fixed site monitoring, complaint monitoring
                and surveys of individuals enrolled in MMC or FHPlus as a result
                of
                Facilitated Enrollment.

            


    

     

    viii)
      Approve the Contractor's written internal quality assurance protocols for
      Facilitated Enrollment.

     

    4. Quality
      Assurance

     

    a) The
      Contractor will establish a quality assurance plan, including protocols to
      be
      reviewed and approved by SDOH, which ensures timely access to Facilitated
      Enrollment counseling for applicants. The Contractor will ensure that all
      applications completed with the assistance of the Contractor's facilitators
      are
      reviewed for quality and completed prior to being submitted to the LDSS, and
      are
      completed and submitted to me LDSS within the time frames required by the
      protocols.

     

    b) SDOH
      will
      monitor and evaluate the Contractor's performance of Facilitated Enrollment
      in
      accordance with the terms and conditions contained in Section 3 above. SDOH
      may,
      at its discretion, conduct targeted reviews to assess the performance of
      facilitators, including reviews of incomplete or erroneous
      applications.

     

    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    APPENDIX
      P

    October
      1, 2005

    P-5

    


    5. Confidentiality

    a) The
      Contractor shall maintain confidentiality of applicant and Enrollee information
      in accordance with protocols developed by the Contractor and approved by
      SDOH.

     

    b) Information
      concerning the determination of eligibility for MMC, CHPlus, and FHPlus may
      be
      shared by the Contractor (including its employees and/or subcontractors) and
      the
      SDOH, LDSS, and the Enrollment Broker, provided that the applicant has given
      appropriate written authorization on the application and that the release of
      information is being provided solely for purposes of determining eligibility
      or
      evaluating the success of the program.

     

    c) Contractor
      acknowledges that any other disclosure of Medicaid Confidential Data ("MCD")
      without prior, written approval of the SDOH MCD Review Committee ("MCDRC")
      is
      prohibited. Accordingly, the Contractor will require and ensure that any
      approved agreement or contract pertaining to the above programs contains a
      statement that the subcontractor or other contracting party may not further
      disclose the MCD without such approval.

     

    d) Contractor
      assures that all persons performing Facilitated Enrollment activities will
      receive appropriate training regarding the confidentiality of MCD and provide
      SDOH with a copy of the procedures that Contractor has developed to sanction
      such persons for any violation of MCD confidentiality.

     

    e) Upon
      termination of this Agreement for any reason, Contractor shall ensure that
      program data reporting is complete and shall certify that any electronic or
      paper copies of MCD collected or maintained in connection with this Agreement
      have been removed and destroyed.

     

    6. Outreach
      and Information Dissemination

     

    a) Contractor
      agrees to comply with the following restrictions regarding Facilitated
      Enrollment:

     

    
      	 	
              i)

            	
              No
                Facilitated Enrollment will be permitted in emergency rooms or treatment
                areas; Facilitated Enrollment may be permitted in patient rooms only
                upon
                request by the patient or their
                representative.

            


    

     

    
      	 	
              ii)

            	
              No
                telephone cold-calling, door-to-door solicitations at the homes of
                prospective Enrollees;

            


    

     

    
      	 	
              iii)

            	
              No
                incentives to Prospective Enrollees to enroll in an MCO are
                allowed.

            


    

     

    


    


    


    


    


    


    


    


    


    


    APPENDIX
      P

    October
      1, 2005

    P-6

    



    b) The
      Contractor is responsible for local publicity regarding locations and hours
      of
      operation of Facilitated Enrollment sites.

     

    c) The
      Contractor may use only SDOH approved information in conducting Facilitated
      Enrollment; but the Contractor can tailor materials to the needs of individual
      communities, subject to SDOH approval of any such modifications.

     

    7. Sanctions
      for Non-Compliance

     

    If
      the
      Contractor is found to be out of compliance with the terms and conditions
      required under Facilitated Enrollment, SDOH may terminate the Contractor's
      responsibilities relating to Facilitated Enrollment. SDOH will give the
      Contractor sixty (60) days written notice if it determines that the Contractor's
      Facilitated Enrollment responsibilities must be terminated.

     

    8. Contractor
      Termination of Facilitated Enrollment

     

    The
      Contractor may terminate its Facilitated Enrollment responsibilities under
      this
      Agreement upon sixty (60) day written notice to the SDOH.

    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    APPENDIX
      P

    October
      1, 2005

    P-7

    


    P.2

    


    Federal
      Health Insurance Portability and Accountability Act ("HIPAA")


    Business
      Associate Agreement ("Agreement")

    


    


    With
      respect to its performance of Facilitated Enrollment services for Family Health
      Plus and Medicaid, the Contractor shall comply with the following:

     

    1. Definitions

     

    a) "Business
      Associate" shall mean the Contractor.

     

    b) "Covered
      Program" shall mean the State.

     

    c) Other
      terms used, but not otherwise defined, in this Agreement shall have me same
      meaning as those terms in the federal Health Insurance Portability and
      Accountability Act of 1996 ("HIPAA") and its implementing regulations, including
      those at 45 CFR Parts 160 and 164.

     

    2. Obligations
      and Activities of the Business Associate

     

    a) The
      Business Associate agrees to not use or further disclose Protected Health
      Information other than as permitted or required by this Agreement or as required
      by law.

     

    b) The
      Business Associate agrees to use the appropriate safeguards to prevent use
      or
      disclosure of the Protected Health Information other than as provided for by
      this Agreement and to implement administrative physical, and technical
      safeguards that reasonably and appropriately protect the confidentiality,
      integrity and availability of any electronic Protected Health Information that
      it creates, receives, maintains or transmits on behalf of the Covered Entity
      pursuant to this Agreement.

     

    c) The
      Business Associate agrees to mitigate, to the extent practicable, any harmful
      effect that is known to the Business Associate of a use or disclosure of
      Protected Health Information by the Business Associate in violation of the
      requirements of this Agreement.

     

    d) The
      Business Associate agrees to report to the Covered Program, any use or
      disclosure of the Protected Health Information not provided for by this
      Agreement, as soon as reasonably practicable of which it becomes aware. The
      Business Associate also agrees to report to the Covered Entity any security
      incident of which it becomes aware.

     

    e) The
      Business Associate agrees to ensure that any agent, including a subcontractor,
      to whom it provides Protected Health Information received from, or created
      or
      received by the Business Associate on behalf of the Covered Program agrees
      to
      the same restrictions

     

    


    


    


    


    APPENDIX
      P

    October
      1, 2005

    P-8

    


    


    and
      conditions that apply through this Agreement to the Business Associate with
      respect to such information.

     

    f) The
      Business Associate agrees to provide access, at the request of the Covered
      Program, and in the time and manner designated by the Covered Program, to
      Protected Health Information in a Designated Record Set, to the Covered Program
      or, as directed by the Covered Program, to an Individual in order to meet the
      requirements under 45 CFR §164.524, if me Business Associate has Protected
      Health Information in a designated record set.

     

    g) The
      Business Associate agrees to make any amendments) to Protected Health
      Information in a designated record set that the Covered Program directs or
      agrees to pursuant to 45 CFR §164.526 at the request of the Covered Program or
      an Individual, and in the time and manner designated by Covered Program, if
      the
      Business Associate has Protected Health Information in a designated record
      set.

     

    h) The
      Business Associate agrees to make internal practices, books, and records
      relating to the use and disclosure of Protected Health Information received
      from, or created or received by the Business Associate on behalf of, the Covered
      Program available to the Covered Program, or to the Secretary of Health and
      Human Services, in a time and manner designated by the Covered Program or the
      Secretary, for purposes of the Secretary determining the Covered Program's
      compliance with the Privacy Rule.

     

    i) The
      Business Associate agrees to document such disclosures of Protected Health
      Information and information related to such disclosures as would be required
      for
      Covered Program to respond to a request by an Individual for an accounting
      of
      disclosures of Protected Health Information in accordance with 45 CFR
§164.528.

     

    j) The
      Business Associate agrees to provide to the Covered Program or an Individual,
      in
      time and manner designated by Covered Program, information collected in
      accordance with this Agreement, to permit Covered Program to respond to a
      request by an Individual for an accounting of disclosures of Protected Health
      Information in accordance with 45 CFR §164.528.

     

    3. Permitted
      Uses and Disclosures by Business Associate

     

    a) General
      Use and Disclosure Provisions. Except as otherwise limited in this Agreement,
      the Business Associate may use or disclose Protected Health Information to
      perform functions, activities, or services for, or on behalf of, the Covered
      Program as specified in the Agreement to which this is an addendum, provided
      that such use or disclosure would not violate the Privacy Rule if done by
      Covered Program.

     

    


    


    


    


    


    


    


    


    APPENDIX
      P

    October
      1, 2005

    P-9

    


    b) Specific
      Use and Disclosure Provisions

     

    
      	 	
              i)

            	
              Except
                as otherwise limited in this Agreement, the Business Associate may
                disclose Protected Health Information for me proper management and
                administration of the Business Associate, provided that disclosures
                are
                required by law, or Business Associate obtains reasonable assurances
                from
                the person to whom the information is disclosed that it will remain
                confidential and used or further disclosed only as required by law
                or for
                the purpose for which it was disclosed to the person, and the person
                notifies the Business Associate of any instances of which it is aware
                in
                which the confidentiality of the information has been
                breached.

            


    

     

    
      	 	
              ii)

            	
              Except
                as otherwise limited in this Agreement, Business Associate may use
                Protected Health Information for the proper management and administration
                of the Business Associate or to carry out its legal responsibilities
                and
                to provide Data Aggregation services to Covered Program as permitted
                by 45
                CFR §164.504(e)(2)(i)(B). Data Aggregation includes the combining of
                protected information created or received by a Business Associate
                through
                its activities under this Agreement with other information gained
                from
                other sources.

            


    

     

    
      	 	
              iii)

            	
              The
                Business Associate may use Protected Health Information to report
                violations of law to appropriate federal and State authorities, consistent
                with 45 CFR §164.5020X1).

            


    

     

    4. Obligations
      of Covered Program

     

    a) Provisions
      for the Covered Program to Inform the Business Associate of Privacy Practices
      and Restrictions

     

    
      	 	
              i)

            	
              The
                Covered Program shall notify the Business Associate of any limitation(s)
                in its notice of privacy practices of the Covered Program in accordance
                with 45 CFR § 164.520, to the extent that such limitation may affect the
                Business Associate's use or disclosure of Protected Health
                Information.

            


    

     

    
      	 	
              ii)

            	
              The
                Covered Program shall notify the Business Associate of any changes
                in, or
                revocation of, permission by the Individual to use or disclose Protected
                Health Information, to the extent that such changes may affect the
                Business Associate's use or disclosure of Protected Health
                Information.

            


    

     

    
      	 	
              iii)

            	
              The
                Covered Program shall notify the Business Associate of any restriction
                to
                the use or disclosure of Protected Health Information that the Covered
                Program has agreed to in accordance with 45 CFR §164.522, to the extent
                that such restriction may affect the Business Associate's use or
                disclosure of Protected Health
                Information.

            


    

     

    


    


    


    


    


    


    


    APPENDIX
      P

    October
      1, 2005

    P-10

    


    


    


    5. Permissible
      Requests by Covered Program

     

    The
      Covered Program shall not request the Business Associate to use or disclose
      Protected Health Information in any manner that would not be permissible under
      the Privacy Rule if done by Covered Program, except if the Business Associate
      will use or disclose protected health information for, and the contract includes
      provisions for, data aggregation or management and administrative activities
      of
      Business Associate.

     

    6. Term
      and Termination

     

    a) This
      Agreement shall be effective as of the date noted in Section P.I (1) of this
      Appendix.

     

    b) Termination
      for Cause. Upon the Covered Program's knowledge of a material breach by Business
      Associate, Covered Program may provide an opportunity for the Business Associate
      to cure the breach and end the violation or may terminate this Agreement and
      the
      master Agreement if the Business Associate does not cure the breach and end
      the
      violation within the time specified by Covered Program, or the Covered Program
      may immediately terminate this Agreement and the master Agreement if the
      Business Associate has breached a material term of this Agreement and cure
      is
      not possible. If the Covered Program terminates this Agreement for cause under
      this paragraph, all Protected Health Information provided by Covered Program
      to
      Business Associate, or created or received by Business Associate on behalf
      of
      Covered Program, shall be destroyed or returned to the Covered Program in
      accordance with paragraph (c) of this section.

     

    c) Effect
      of
      Termination.

     

    
      	 	
              i)

            	
              Upon
                termination of this Agreement for any reason all of the Protected
                Health
                Information provided by Covered Program to Business Associate, or
                created
                or received by Business Associate on behalf of Covered Program, shall
                be
                destroyed or returned to Covered Program in accordance with the
                following:

            


    

     

    A) Protected
      Health Information provided to Business Associate on either the Growing
      Up Healthy or Access New York Health Care
      applications that have been fully processed by Business Associate shall be
      destroyed by Business Associate, or, if it is infeasible for Business Associate
      to destroy such information. Business Associate shall provide to the Covered
      Program notification of the conditions that make destruction infeasible and,
      upon mutual agreement of the Parties, return Protected Health Information to
      the
      Covered Program.

     

    B) Upon
      termination of this Agreement for any reason. Protected Health Information
      provided to Business Associate on either the Growing
      Up Healthy or Access New York Health
      Care
      applications that have not been fully processed by Business Associate shall
      be
      returned to the Covered Program.

     

    


    


    


    


    


    APPENDIX
      P

    October
      1, 2005

    P-1l

    


    


    C) No
      copies
      of the Protected Health Information shall be retained by the Business Associate
      once this Agreement has been terminated.

     

    7. Violations

     

    a)
      It is
      farther agreed that any violation of this Agreement may cause irreparable harm
      to the State; therefore, the State may seek any other remedy, including an
      injunction or specific performance for such harm, without bond, security or
      necessity of demonstrating actual damages.

     

    b)
      The
      Business Associate shall indemnify and hold the State harmless against all
      claims and costs resulting from acts/omissions of the Business Associate in
      connection with the Business Associate's obligations under this
      Agreement.

     

    8. Miscellaneous

     

    a) Regulatory
      References. A reference in this Agreement to a section in the
      HIPAA
      Privacy Rule means the section as in effect or as amended, and for which
      compliance is required.

     

    b) Amendment.
      The Parties agree to take such action as is necessary to amend this Agreement
      from time to time as is necessary for Covered Program to comply with the
      requirements of the Privacy Rule and the Health Insurance Portability and
      Accountability Act, Public Law 104-191.

     

    c) Survival.
      The respective rights and obligations of the Business Associate under Section
      6
      of this Appendix shall survive the termination of this Agreement.

     

    d) Interpretation.
      Any ambiguity in this Appendix shall be resolved in favor of a meaning that
      permits the Covered Program to comply with the HIPAA Privacy Rule.

     

    e) If
      anything in this Agreement conflicts with a provision of any other agreement
      on
      this matter, this Agreement is controlling.

     

    f) HIV/AIDS.
      If HIV/AIDS information is to be disclosed under this Agreement, the Business
      Associate acknowledges that it has been informed of the confidentiality
      requirements of Article 27-F of the PHL.

     

    


    


    


    


    


    


    


    


    


    


    


    


    APPENDIX
      P

    October
      1, 2005

    P-12

    


    APPENDIX
      R

    


    Additional
      Specifications for the MMC and FHPlus Agreement

    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    APPENDIX
      R 

    October
      1, 2005

    R-l

    



    Additional
      Specifications for the MMC and FHPlus Agreement

    


    
      	
              1.

            	
              Contractor
                will give continuous attention to performance of its obligations
                herein
                for the duration of this Agreement and with me intent that the contracted
                services shall be provided and reports submitted in a timely manner
                as
                SDOH may prescribe.

            


    

     

    
      	
              2.

            	
              Contractor
                will possess, at no cost to the State, all qualifications, licenses
                and
                permits to engage in the required business as may be required within
                the
                jurisdiction where the work specified is to be performed. Workers
                to be
                employed in the performance of this Agreement will possess the
                qualifications, training, licenses and permits as may be required
                within
                such jurisdiction.

            


    

     

    
      	
              3.

            	
              Work
                for Hire Contract

            


    

     

    If
      pursuant to this Agreement the Contractor will provide the SDOH with software
      or
      other copyrightable materials, this Agreement shall be considered a "Work for
      Hire Contract" The SDOH will be the sole owner of all source code and any
      software which is developed or included in the application software provided
      to
      the SDOH as a part of this Agreement.

     

    
      	
              4.

            	
              Technology
                Purchases Notification -- The following provisions apply if this
                Agreement
                procures only "Technology"

            


    

     

    a) For
      me
      purposes of this policy, "technology" applies to all services and commodities,
      voice/data/video and/or any related requirement, major software acquisitions,
      systems modifications or upgrades, etc., that result in a technical method
      of
      achieving a practical purpose or in improvements of productivity. The purchase
      can be as simple as an order for new or replacement personal computers, or
      for a
      consultant to design a new system, or as complex as a major systems improvement
      or innovation that changes how an agency conducts its business
      practices.

     

    b) If
      this
      Agreement is for procurement of software over $20,000, or other technology
      over
      $50,000, or where the SDOH determines that the potential exists for coordinating
      purchases among State agencies and/or the purchase may be of interest to one
      or
      more other State agencies, PRIOR TO APPROVAL by OSC, this Agreement is subject
      to review by the Governor's Task Force on Information Resource
      Management.

     

    c) The
      terms
      and conditions of this Agreement may be extended to any other State agency
      in
      New York.

     

    5. Subcontracting

     

    The
      Contractor agrees not to enter into any agreements with third party
      organizations for the performance of its obligations, in whole or in part,
      under
      this Agreement without the State's prior written approval of such third parties
      and the scope of the work to be performed by them. The 

    


    


    


    


    


    


    APPENDIX
      R 

    October
      1, 2005

    R-2


    State's
      approval of the scope of work and the subcontractor does not relieve the
      Contractor of its obligation to perform fully under this Agreement.

     

    6. Sufficiency
      of Personnel and Equipment

     

    If
      SDOH
      is of the opinion that the services required by the specifications cannot
      satisfactorily be performed because of insufficiency of personnel, SDOH shall
      have the authority to require the Contractor to use such additional personnel
      to
      take such steps necessary to perform the services satisfactorily at no
      additional cost to the State.

     

    7. Provisions
      Upon Default

     

    a) The
      services to be performed by the Contractor shall be at all times subject to
      the
      direction and control of the SDOH as to all matters arising in connection with
      or relating to this Agreement.

    b) In
      the
      event that the Contractor, through any cause, fails to perform any of the terms,
      covenants or promises of this Agreement, the SDOH acting for and on behalf
      of
      the State, shall thereupon have the right to terminate this Agreement by giving
      notice in writing of the fact and date of such termination to the Contractor,
      pursuant to Section 2 of this Agreement.

    c) If,
      in
      the judgment of the SDOH, the Contractor acts in such a way which is likely
      to
      or does impair or prejudice the interests of the State, the SDOH acting for
      and
      on behalf of the State, shall thereupon have the right to terminate this
      Agreement by giving notice in writing of the fact and date of such termination
      to the Contractor, pursuant to Section 2 of this Agreement.

    8. Minority
      And Women Owned Business Policy Statement

     

    The
      SDOH
      recognizes the need to take affirmative action to ensure that Minority and
      Women
      Owned Business Enterprises are given the opportunity to participate in the
      performance of the SDOH's contracting program. This opportunity for full
      participation in our free enterprise system by traditionally socially and
      economically disadvantaged persons is essential to obtain social and economic
      equality and improve the functioning of the State economy.

     

    It
      is the
      intention of the SDOH to provide Minority and Women Owned Business Enterprises
      with equal opportunity to bid on contracts awarded by this agency in accordance
      with the State Finance Law.

     

    9. Insurance
      Requirements

     

    a) The
      Contractor must without expense to the State procure and maintain, until final
      acceptance by the SDOH of the work covered by this Agreement, insurance of
      the
      kinds and in the amounts hereinafter provided, by insurance companies authorized
      to do such business in the

    


    


    


    


    


    


    


    


    


    APPENDIX
      R 

    October
      1, 2005

    R-3


    State
      of
      New York covering all operations under this Agreement, whether performed by
      it
      or by subcontractors. Before commencing the work, the Contractor shall furnish
      to the SDOH a certificate or certificates, in a form satisfactory to SDOH,
      showing that it has complied with the requirements of this section, which
      certificate or certificates shall state that the policies shall not be changed
      or cancelled until thirty days written notice has been given to SDOH. The kinds
      and amounts of required insurance are:

     

    
      	 	
              i)

            	
              A
                policy covering the obligations of the Contractor in accordance with
                the
                provisions of Chapter 41, Laws of 1914, as amended, known as the
                Workers'
                Compensation Law, and the Agreement shall be void and of no effect
                unless
                the Contractor procures such policy and maintains it until acceptance
                of
                the work.

            


    

     

    
      	 	
              ii)

            	
              Policies
                of Bodily Injury Liability and Property Damage Liability Insurance
                of the
                types hereinafter specified, each within limits of not less than
                $500,000
                for all damages arising out of bodily injury, including death at
                any time
                resulting therefrom sustained by one person in any one occurrence,
                and
                subject to that limit for that person, not less than $1,000,000 for
                all
                damages arising out of bodily injury, including death at any time
                resulting therefrom sustained by two or more persons in any one
                occurrence, and not less than $500,000 for damages arising out of
                damage
                to or destruction of property during any single occurrence and not
                less
                than $1,000,000 aggregate for damages arising out of damage to or
                destruction of property during the policy
                period.

            


    

     

    A) Contractor's
      Liability Insurance issued to and covering the liability of the Contractor
      with
      respect to all work performed by it under this Agreement.

     

    B) Automobile
      Liability Insurance issued to and covering the liability of the People of the
      State of New York with respect to all operations under this Agreement, by the
      Contractor or by its subcontractors, including omissions and supervisory acts
      of
      the State.

     

    10. Certification
      Regarding Debarment and Suspension

     

    a) Regulations
      of the U.S. Department of Health and Human Services, located at Part 76 of
      Title
      45 of the Code of Federal Regulations (CFR), implement Executive Orders 12549
      and 12689 concerning debarment and suspension of participants in Federal program
      and activities. Executive Order 12549 provides that, to the extent permitted
      by
      law. Executive departments and agencies shall participate in a government wide
      system for non-procurement debarment and suspension. Executive Order 12689
      extends the debarment and suspension policy to procurement activities of the
      Federal Government. A person who is debarred or suspended by a Federal agency
      is
      excluded from Federal financial and non-financial assistance and benefits under
      Federal programs and activities, both directly (primary covered transaction)
      and
      indirectly (lower tier covered transactions). Debarment or suspension by one
      Federal agency has government wide effect.

    


    


    


    


    


    


    APPENDIX
      R 

    October
      1, 2005

    R-4


    b) Pursuant
      to the above cited regulations, the SDOH (as a participant in a primary covered
      transaction) may not knowingly do business with a person who is debarred,
      suspended, proposed for debarment, or subject to other government wide exclusion
      (including an exclusion from Medicare and State health care program
      participation on or after August 25, 1995), and the SDOH must require its
      contractors, as lower tier participants, to provide the certification as set
      forth below:

     

    
      	 	
              i)

            	
              CERTIFICATION
                REGARDING DEBARMENT, SUSPENSION, INELIGBILITY AND VOLUNTARY
                EXCLUSION-LOWER TIER COVERED
                TRANSACTIONS

            


    

     

    Instructions
      for Certification

     

    A) By
      signing this Agreement, the Contractor, as a lower tier participant, is
      providing the certification set out below.

     

    B) The
      certification in this clause is a material representation of fact upon which
      reliance was placed when this transaction was entered into. If it is later
      determined that the lower tier participant knowingly rendered an erroneous
      certification, in addition to other remedies available to the Federal
      Government, the department or agency with which this transaction originated
      may
      pursue available remedies, including suspension and/or debarment.

     

    C) The
      lower
      tier participant shall provide immediate written notice to the SDOH if at any
      time the lower tier participant learns that its certification was erroneous
      when
      submitted or had become erroneous by reason of changed
      circumstances.

     

    D) The
      terms
      covered transaction, debarred, suspended, ineligible, lower tier covered
      transaction, participant, person, primary covered transaction, principal,
      proposal, and voluntarily excluded, as used in this clause, have the meaning
      set
      out in the Definitions and Coverage sections of rules implementing Executive
      Order 12549. The Contractor may contact the SDOH for assistance in obtaining
      a
      copy of those regulations.

     

    E) The
      lower
      tier participant agrees that it shall not knowingly enter into any lower tier
      covered transaction with a person who is proposed for debarment under 48 CFR
      Subpart 9.4, debarred, suspended, declared ineligible, or voluntarily excluded
      from participation in this covered transaction, unless authorized by the
      department or agency with which this transaction originated.

     

    F) The
      lower
      tier participant further agrees that it will include this clause titled
      "Certification Regarding Debarment, Suspension, Ineligibility and Voluntary
      Exclusion-Lower Tier Covered Transactions," without modification, in all lower
      tier covered transactions.

     

    


    


    


    


    


    APPENDIX
      R 

    October
      1, 2005

    R-5


    G) A
      participant in a covered transaction may rely upon a certification of a
      participant in a lower tier covered transaction that it is not proposed for
      debarment under 48 CFR Subpart 9.4, debarred, suspended, ineligible, or
      voluntarily excluded from covered transactions, unless it knows that the
      certification is erroneous. A participant may decide the method and frequency
      by
      which it determines the eligibility of its principals. Each participant may,
      but
      is not required to, check the Excluded Parties List System.

     

    H) Nothing
      contained in the foregoing shall be construed to require establishment of a
      system of records in order to render in good faith the certification required
      by
      this clause. The knowledge and information of a participant is not required
      to
      exceed that which is normally possessed by a prudent person in the ordinary
      course of business dealings.

     

    I) Except
      for transactions authorized under paragraph E of these instructions, if a
      participant in a covered transaction knowingly enters into a lower tier covered
      transaction with a person who is proposed for debarment under 48 CFR Subpart
      9.4, suspended, debarred, ineligible, or voluntarily excluded from participation
      in this transaction, in addition to other remedies available to the Federal
      Government, the department or agency with which this transaction originated
      may
      pursue available remedies, including suspension and/or debarment.

     

    
      	 	
              ii)

            	
              Certification
                Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion
                -
                Lower Tier Covered Transactions

            


    

     

    A) The
      lower
      tier participant certifies, by signing this Agreement, that neither it nor
      its
      principals is presently debarred, suspended, proposed for debarment, declared
      ineligible, or voluntarily excluded from participation in this transaction
      by
      any Federal department agency.

     

    B) Where
      the
      lower tier participant is unable to certify to any of the statements in this
      certification, such participant shall attach an explanation to this
      Agreement.

     

    11. Reports
      and Publications

     

    a) Any
      materials, articles, papers, etc., developed by the Contractor pertaining to
      the
      MMC Program or FHPlus Program must be reviewed and approved by the SDOH for
      conformity with the policies and guidelines of the SDOH prior to dissemination
      and/or publication. It is agreed that such review will be conducted in an
      expeditious manner. Should the review result in any unresolved disagreements
      regarding content, the Contractor shall be free to publish in scholarly journals
      along with a disclaimer that the views within the Article or the policies
      reflected are not necessarily those of the New York State Department of
      Health.

     

    APPENDIX
      R October 1,2005 

    R-6

    



    b) Any
      publishable or otherwise reproducible material developed under or in the course
      of performing this Agreement, dealing with any aspect of performance under
      this
      Agreement, or of the results and accomplishments attained in such performance,
      shall be the sole and exclusive property of the State, and shall not be
      published or otherwise disseminated by the Contractor to any other party unless
      prior written approval is secured from the SDOH or under circumstances as
      indicated in paragraph (a) above. Any and all net proceeds obtained by the
      Contractor resulting from any such publication shall belong to and be paid
      over
      to the State. The State shall have a perpetual royalty-free, non-exclusive
      and
      irrevocable right to reproduce, publish or otherwise use, and to authorize
      others to use, any such material for governmental purposes.

     

    c) No
      report, document or other data produced in whole or in part with the funds
      provided under this Agreement may be copyrighted by the Contractor or any of
      its
      employees, nor shall any notice of copyright be registered by the Contractor
      or
      any of its employees in connection with any report, document or other data
      developed pursuant to this Agreement.

     

    d) All
      reports, data sheets, documents, etc. generated under this Agreement shall
      be
      the sole and exclusive property of the SDOH. Upon completion or termination
      of
      this Agreement the Contractor shall deliver to the SDOH upon its demand all
      copies of materials relating to or pertaining to this Agreement. The Contractor
      shall have no right to disclose or use any of such material and documentation
      for any purpose whatsoever, without the prior written approval of the SDOH
      or
      its authorized agents.

     

    e) The
      Contractor, its officers, agents and employees and subcontractors shall treat
      all information, which is obtained by it through its performance under this
      Agreement, as confidential information to the extent required by the laws and
      regulations of the United States and laws and regulations of the State of New
      York.

     

    12. Provisions
      Related to New York State Executive Order Number 127

     

    a) If
      applicable, the Contractor certifies that all information provided to the State
      with respect to New York State Executive Order Number 127, signed by Governor
      Pataki on June 16,2003, is complete, true, and accurate.

     

    b) The
      State
      reserves the right to terminate this Agreement in the event it is found that
      the
      certification filed by the Contractor, in accordance with New York State
      Executive Order Number 127, was intentionally false or intentionally incomplete.
      Upon such finding, the State may exercise its termination right by providing
      written notification to the Contractor in accordance with the written
      notification terms of this Agreement

     

    


    


    


    APPENDIX
      R 

    October
      1, 2005

    R-7


    MMC
      AND FHPLUS MODEL CONTRACT ATTESTATION

    


    


    


    I
       Todd
      S. Farha  
      being an
      individual authorized to execute agreements

     

    on
      behalf
      of  WellCare
      of New York, Inc.  
      (hereafter "MCO"), hereby attest that the

    (Name
      of
      Managed Care Organization)

     

    contract
      submitted by MCO to the New York State Department of Health, follows the latest
      

     

    model
      contract provided to us by the New York State Department of Health. This
      executed 

     

    contract
      contains no deviations from the aforementioned model contract
      language.

     

    


    7/2/05 

    (Date)

    [Missing
      Graphic Reference]

    (Signature)

    


    


    Todd
      S. Farha  

    (Print
      Name In Full)

    


    


    


    


    


    President
      and CEO  

    (Title)

    


    


    


    /s/
      Kathleen R. Casey  

    (Notary
      Seal and Signature)

    


    



    


    APPENDIX
      X

    


    Modification
      Agreement Form

    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    


    APPENDIX
      X

    October
      1, 2005

    X-l

    



    APPENDIX
      X

    


    Agency
      Code   Contract
      No.  

    Period
        Funding
      Amount for Period  

    


    This
      is
      an AGREEMENT between THE STATE OF NEW YORK, acting by and through

    ,
      having
      its principal office at  ,

    (herein
      referred to as the STATE), and  ,

    (hereinafter
      referred to as the CONTRACTOR), for modification of Contract Number  

    as
      amended in attached Appendix(ices).

    


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

    


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

    


    
      	
              CONTRACTOR
                SIGNATURE

               

            	 	
              STATE
                AGENCY SIGNATURE

               

            
	
              By:  

               

            	 	
              By:  

            
	
              Printed
                Name

               

            	 	
              Printed
                Name

            
	
              Title:  

               

            	 	
              Title:  

            
	
              Date:  

               

            	 	
              Date:  

               

              State
                Agency Certification:

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

            


    

    


    STATE
      OF
      NEW YORK )

    ) SS.:

    County
      of
  )

    


    On
      the
 
      day of
 
      20
 ,
      before
      me personally appeared _____________________________________, to me known,
      who
      being by me duly sworn, did depose and say that he/she resides at    ,
      

    that
      he/she is the   
      of
  ,
      the
      corporation described herein which executed the foregoing instrument; and that
      he/she signed his/her name thereto by order of the board of directors of said
      corporation.

    


    (Notary)

    


    
      	
              CONTRACTOR
                SIGNATURE

               

            	 	
              Title:  

            
	 	 	
              Date:  

            


    

    


    APPENDIX
      X

    October
      1, 2005

    X-2