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exhibit10-1.htm

    
      
        

      

    

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    Exhibit
      10.1

     

    

    
      	
              
                STATE
                  AGENCY (Name and Address):

              

               

            	
              NYS
                Comptroller's Number: C021884

            
	
              New
                York State Department of Health 

              Office
                of  Health Insurance Programs

              Division
                of Manged Care and Program
                Evaluation

              Empire
                State Plaza 

              Corning
                Tower, Room 2074 

              Albany,
                NY 12237

               

            	
              Originating
                Agency Code: 12000

            
	
              CONTRACTOR
                (Name and Address):

               

            	
              TYPE
                OF PROGRAM: 

            
	
              
                WellCare
                  of New York, Inc.

              

              
                11
                  West 19th
                  Street

              

              New
                York, New York 10011

               

            	
              Managed
                Long-Term Care

            
	
              CHARITIES
                REGISTRATION NUMBER:

               

            	
              CONTRACT
                TERM:

            
	
              N/A

               

            	
              FROM:
                July 1,  2007

            
	
              FEDERAL
                TAX IDENTIFICATION NUMBER:

               

            	
              TO:
                December 31, 2009

            
	
              141676443

               

            	 
	
              MUNICIPALITY
                NUMBER (if applicable):

            	
              FUNDING
                AMOUNT FOR CONTRACT TERM: 

              Based
                on approved capitation rates

            
	
              N/A

               

            	 
	
              STATUS:

               

            	
              (X)
                IF MARKED HERE, THIS CONTRACT IS RENEWABLE FOR TWO ADDITIONAL ONE
                YEAR
                PERIODS SUBJECT TO THE APPROVAL OF THE NYS DEPARTMENT OF HEALTH AND
                THE
                OFFICE OF THE STATE COMPTROLLER.

            
	
              CONTRACTOR
                IS [ ] IS NOT [X] 

              A
                SECTARIAN ENTITY

               

            
	
              CONTRACTOR
                IS [ ]   IS NOT [X] A 

              NOT-FOR-PROFIT
                ORGANIZATION

               

            
	
              CONTRACTOR
                IS [X]   IS NOT [ ] 

              A
                NY STATE BUSINESS ENTERPRISE

            
	
               

              BID OPENING DATE: N/A Contractor is legislatively
                named
                in accordance with statue 4403-f

            	 

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    
 

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

    

     

    
      	
              CONTRACTOR
                SIGNATURE

            	
              STATE
                AGENCY SIGNATURE

               

            
	
              By:    /s/  Todd
                S. Farha          
                

            	
              Kathleen
                Shure

               

            
	
              Title:
                President & CEO

            	
              Title:
                Director, Division of Managed Care and Program Evaluation, Office
                of
                Health Insurance Programs

               

            
	
              Date:
                5/31/2007

            	
              Date:
                6/27/07

            
	 	
               

              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

    

    
      

      County
        of
        Hillsborough

       

    

    
      On
        the 31
        Day of May, 2007, before me personally appeared Todd S. Fahra to me known,
        who
        being by me duly sworn, did depose and say that he/she resides at Tampa,
        Florida
        that he is the President & CEO of WellCare of New York, Inc. 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
        corporations.

    

    
      

    

    
      Notary

    

    
       

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    
      APPENDICES

    

    

      
        APPENDICES
          TO THIS AGREEMENT AND INCORPORATED BY REFERENCE INTO THE
          AGREEMENT

      

      
        

        APPENDIX
          A: New York State Standard Contract Clauses, June 2006

      

      
        APPENDIX
          B: Reserved

      

      
        APPENDIX 
          C: Certification Regarding Lobbying

      

      
        APPENDIX
          D. Standard Form LLL Disclosure of Lobbying Activities

      

      
        APPENDIX
          E-1:  Proof of Workers'Compensation Coverage

      

      
        APPENDIX 
          E-2: Proof of Disability Insurance Coverage

      

      
        APPENDIX
          F: Service Area and Ages of Population Served

      

      
        APPENDIX 
          G: Managed Long Term Care Covered and Non-Covered Services

      

      
        APPENDIX
          H: Schedule of Capitation Rates

      

      
        APPENDIX
          I:  Reserved

      

      
        APPENDIX
          J: Definitions

      

      
        APPENDIX
          K:  Grievance System, Member Handbook Language and Service Authorization
          Requirements

      

      
        APPENDIX
          L: Managed Long-Term Care Enrollee Rights

      

      
        APPENDIX
          M:  Managed Long-Term Care Plan Information Requirements

      

      
        APPENDIX
          X:  Modification Agreement Form (to accompany modified appendices for
          Changes in term or consideration on an existing period or for renewal
          periods.)

      

     

    Managed
      Long-Term Contract

    
      2007

    

    
      APPENDICES

    

     

    

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        TABLE
          OF CONTENTS

      

      
        	
                
                  Article
                    I Term of Contract, Renewal and Termination

                

              	 
	
                
                  A.Term

                

              	
                
                  2

                

              
	
                
                  B.
                    Renewal

                

              	
                
                  2

                

              
	
                
                  C.Termination
                    of the Contract by the Department

                

              	
                
                  2

                

              
	
                
                  D. Termination
                    of the Contract by the Contractor

                

              	
                
                  3

                

              
	
                
                  E.  Other
                    Termination Reasons

                

              	
                
                  3

                

              
	
                
                  F.  Contract
                    Expiration and Contractor Termination/Phase-out Plan

                

              	
                
                  4

                

              
	
                
                  G.  Effect
                    of Termination on New Enrollments

                

              	
                
                  5

                

              
	
                
                  Article
                    II Statutory and Regulatory Compliance

                

              	
                
                  6

                

              
	
                
                  Article
                    III Contractor Service Area and Ages of Population to Be
                    Served

                

              	
                
                  7

                

              
	
                
                  Article
                    IV Eligibility for Managed Long-Term Care

                

              	
                
                  8

                

              
	
                
                  Article
                    V Obligations of the Contractor

                

              	
                
                  10

                

              
	
                
                  A.Provisions
                    of Benefits

                

              	
                
                  10

                

              
	
                
                  B. Eligibility
                    Activities of Contractor

                

              	
                
                  10

                

              
	
                
                  C. Enrollment
                    Process

                

              	
                
                  12

                

              
	
                
                  D. Disenrollment
                    Policy and Process

                

              	
                
                  13

                

              
	
                
                  E.  Enrollee
                    Protections

                

              	
                
                  15

                

              
	
                
                  F.  Quality
                    Assurance and Performance Improvement Program

                

              	
                
                  16

                

              
	
                
                  G.  Marketing

                

              	
                
                  18

                

              
	
                
                  H. Information
                    For Potential Enrollees, Applicants and Enrollees

                

              	
                
                  20

                

              
	
                
                  I.  Member
                    and Provider Services

                

              	
                
                  22

                

              
	
                
                  J.   Care
                    Management

                

              	
                
                  22

                

              
	
                
                  K.  Advance
                    Directives

                

              	
                
                  24

                

              
	
                
                  Article
                    VI Payment

                

              	
                
                  25

                

              
	
                
                  A. Capitation
                    Payments

                

              	
                
                  25

                

              
	
                
                  B. Modification
                    of Rates during Contract Period

                

              	
                
                  25

                

              
	
                
                  C. Rate-Setting
                    Methodology

                

              	
                
                  26

                

              
	
                
                  D. Payment
                    of Capitation

                

              	
                
                  26

                

              
	
                
                  E. Denial
                    of Capitation Payments

                

              	
                
                  27

                

              
	
                
                  F. Department
                    Right to Recover Premiums

                

              	
                
                  27

                

              
	
                
                  G. Third
                    Party Health Insurance Determination

                

              	
                
                  27

                

              
	
                
                  H.Contractor
                    Financial Liability

                

              	
                
                  28

                

              
	
                
                  I. 
                    Spenddown and Net Available Monthly Income

                

              	
                
                  28

                

              
	
                
                  J. No
                    Recourse Against Enrollees

                

              	
                
                  28

                

              
	
                
                  K. Notification
                    Requirements to LDSS Regarding Enrollees

                

              	
                
                  28

                

              
	
                
                  L. Contractor's
                    Fiscal Solvency Requirements

                

              	
                
                  29

                

              
	
                
                  Article
                    VII Contractor Relationship with
                    Subcontractors

                

              	
                
                  30

                

              
	
                
                  A.Subcontractor/Provider
                    Relations

                

              	
                
                  30

                

              
	
                
                  B.  Full
                    Responsibility Retained

                

              	
                
                  30

                

              
	
                
                  C. Required
                    Provisions

                

              	
                
                  31

                

              
	
                
                  D. List
                    of Covered Services and Subcontractors

                

              	
                
                  33

                

              
	
                
                  E.  Provider
                    Termination Notice

                

              	
                
                  33

                

              
	
                
                  F.  Recovery
                    of Over Payments to Providers

                

              	
                
                  33

                

              
	
                
                  Article
                    VIII Records, Reporting and Certification
                    Requirements

                

              	
                
                  34

                

              
	
                
                  A.
                    Maintenance of Contractor Performance Records

                

              	
                
                  34

                

              
	
                
                  B. Maintenance
                    of Financial Records and Statistical Data

                

              	
                
                  34

                

              
	
                
                  C. Access
                    to Contractor Records

                

              	
                
                  34

                

              
	
                
                  D. Retention
                    Periods

                

              	
                
                  35

                

              
	
                
                  E.  Reporting
                    Requirements

                

              	
                
                  35

                

              

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        	
                F.  Data
                  Certifications

              	
                38

              
	
                G.
                  Notification of Changes in Reporting Due Dates Requirements or
                  Formats

              	
                38

              
	
                H.Ownership
                  and Related Information Disclosure

              	
                39

              
	
                I.  Role
                  of Compliance Officer and Compliance Committee

              	
                39

              
	
                J.
                  Public Access to Records

              	
                39

              
	
                K.
                  Professional Discipline

              	
                39

              
	
                L.  Certification
                  Regarding Individuals Who have been Debarred or Suspended Federal
                  or State
                  Government

              	
                40

              
	
                M.
                  Conflict of Interest Disclosure

              	40
	
                Article
                  IX Intermediate Sanctions

              	
                41

              
	
                Article
                  X General Requirements

              	
                43

              
	
                A.
                  Authorized Representative With Respect to Contract

              	
                43

              
	
                B.
                  Confidentiality

              	
                43

              
	
                C.
                  Additional Actions and Documents

              	
                43

              
	
                D.
                  Relationship of the Parties, Status of the Contractor

              	
                44

              
	
                E.
                  Nondiscrimination

              	
                44

              
	
                F.
                  Employment Practices

              	
                44

              
	
                G.
                  Dispute Resolution

              	
                44

              
	
                H.
                  Assignment

              	
                45

              
	
                I.
                   Binding Effect

              	
                45

              
	
                J.
                  Limitation on Benefits of this Contract

              	
                45

              
	
                K.
                  Entire Contract

              	
                45

              
	
                L.
                  Conflicting Provisions

              	
                45

              
	
                M.
                  Modification

              	
                45

              
	
                N.
                  Headings

              	
                46

              
	
                O.
                  Pronouns

              	
                46

              
	
                P.
                  Notices

              	
                46

              
	
                Q.
                  Partial Invalidity

              	
                47

              
	
                R.
                  Force Majeure

              	
                47

              
	
                S.
                  Survival

              	
                47

              
	
                T.
                  State Standard Appendix A

              	
                48

              
	
                U.
                  Indemnification of the Department

              	
                48

              
	
                V.
                  Environmental Compliance

              	
                48

              
	
                W.
                  Energy Conservation

              	
                49

              
	
                X.
                  Prohibition on Use of Federal Funds for Lobbying

              	
                49

              
	
                Y.
                  Waiver of Breach

              	
                49

              
	
                Z.
                  Choice of Law

              	
                49

              
	
                AA.
                  Executory Provision and Federal Funds

              	
                50

              
	
                BB.
                  Renegotiation

              	
                50

              
	
                CC.
                  Affirmative Action

              	
                50

              
	
                DD.
                  Omnibus Procurement Act of 1992

              	
                52

              
	
                EE.
                  Fraud and Abuse

              	
                53

              
	
                FF.
                  Nondiscrimination in Employment in Northern Ireland

              	
                53

              
	
                GG.
                  Contract Insurance Requirements

              	
                53

              
	
                HH.
                  Minority And Women Owned Business Policy Statement

              	
                54

              
	
                II.
                  Provisions Related to New York State Information Security Breach
                  and
                  Notification
                  Act

              	
                55

              

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    MANAGED
      LONG-TERM CARE CONTRACT

    
      

      This
        CONTRACT is hereby made by and between the State of New York Department of
        Health, hereinafter called the "Department" and WellCare of New York, Inc.,
        hereinafter called the "Contractor" identified on the face page
        hereof.

    

    
      

      WHEREAS,
        the Department is the single State agency charged with the responsibility
        for
        administration of the New York State Medical Assistance Program (Medicaid),
        Title 11 of Article 5 of the Social Services Law; and

    

    
      

      WHEREAS,
        the Contractor has been certified as a managed long-term care plan pursuant
        to
        Section 4403 -f of Article 44 of the Public Health Law;

    

    
      

      WHEREAS,
        the Contractor represents that the Contractor is able and willing to provide
        and
        arrange for health and long-term care services on a capitated basis in
        accordance with New York State Public Health Law Section
        4403-f;

    

    
      

      NOW,
        THEREFORE, in consideration of the foregoing and of the covenants and agreements
        hereinafter set forth, the Parties hereto agree as follows:

    

    
      

      1

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    
      ARTICLE
        I

    

    
      

      TERM
        OF CONTRACT, RENEWAL AND TERMINATION

    

    
      

      A.        Term
        of Contract

    

    
      

      Term:
        The
        Contract shall begin on and, unless terminated sooner as permitted by the
        terms
        of this Contract, end on the dates identified on the face page
        hereof.

    

    
      

      B.        Renewal

    

    
      

      The
        Department, with the approval of the State Comptroller or his designee, may
        extend the term of the Contract for up to two (2) additional one (1) year
        terms.
        Standard Appendix X is the form to be used in extension of this Contract.
        The
        Department will provide written notice to the Contractor of extension of
        the
        term of the Contract at least ninety (90) days prior to the end of the
        term.

    

    
      

      C.       Termination
        of the Contract by the Department

    

    
      

      
        	
                1. 

              	
                The
                  Department shall have the right to terminate this Contract, if
                  the
                  Contractor, in the Department's
                  determination:

              

        	 	 (a.)
                Takes any action that threatens the health, safety, or welfare of
                any
                Enrollee;

        	 	 (b.)
                Has engaged in an unacceptable practice under 18 NYCRR PART
                515;

        	 	 (c.) 
                Has failed to substantially comply with applicable standards of the
                Public
                Health Law and regulations, or has had its certificate of authority
                suspended, limited, or revoked;

        	 	 (d.) 
                Materially
                breaches the Contract or fails to comply with any term or condition
                of
                this Contract and such breach or failure is not cured within twenty
                (20)
                days, or such longer period as the Department may allow, of the
                Department's notice of breach or
                noncompliance;

        	 	 (e.) 
Becomes
                unable to meet its obligations in the normal
                course of business including but not limited to circumstances beyond
                its
                control and changes to the provider network affecting Enrollee access;
                or

        	 	 (f.) 
                Brings
                a proceeding voluntarily, or has a proceeding brought against it
                involuntarily, under Title 11 of the U.S. Code (the Bankruptcy Code)
                and
                the petition is not vacated within thirty (30) days of its
                filing.

      

    

    
      
2

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    
      
        	
                2.  

              	
                The
                  Department shall give the Contractor written notice of termination
                  of this
                  Contract, specifying the applicable termination provision(s) and
                  the
                  effective date of
                  termination.

              

      

    

    
      

      
        	
                3.  

              	
                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 Finance Law 139-k was intentionally false or intentionally
                  incomplete. Upon such finding, the State may exercise its termination
                  right by providing written notification to the Contractor is accordance
                  with the written notification terms of this
                  Contract.

              

      

    

    
      

      D.   Termination
        of the
        Contract by the Contractor

       

    

    
      
        	
                1.

              	
                The
                  Contractor shall have the right to terminate this Contract, if
                  the
                  Department:

              

        	 	(a.)  fails
                to make agreed-upon payments in a timely and accurate
                manner;

        	 	(b.)
                materially breaches the Contract or fails to comply with any material
                term
                or condition of this
                Contract.

      

    

    
       

      
        	
                2.  

              	
                Contractor
                  shall allow twenty (20) days, or such longer period as the Contractor
                  may
                  permit, from the time of the Contractor's written notice of deficiency,
                  for the Department to cure the identified
                  deficiency.

              

      

    

    
      

      
        	
                3.  

              	
                The
                  Contractor shall give the Department written notice specifying
                  the
                  reason(s) for and the effective date of the termination, which
                  shall not
                  be less time than will permit an orderly disenrollment of Enrollees
                  to the
                  Medicaid fee-for-service program or transfer to another managed
                  long-term
                  care plan, but no more than 90
                  days.

              

      

    

    
      

      E.
        Other Termination Reasons

    

    
      

      
        	
                1.  

              	
                This
                  Contract may be terminated by the Contractor or the Department
                  as of the
                  last day of any month upon no more than 90 days prior written notice
                  to
                  the other Party so as to ensure an orderly transition. Notwithstanding
                  this provision, the Contractor agrees to comply with Sections F
                  and G of
                  this Article.

              

      

    

    
      

      
        	
                2.  

              	
                This
                  Contract shall be terminated immediately if federal financial
                  participation in the costs hereof becomes unavailable or if State
                  funds
                  sufficient to fulfill the obligation of the Department hereunder
                  are not
                  appropriated by the State Legislature. The Department will give
                  the
                  Contractor prompt written notice of such termination of this
                  Contract.

              

      

    

    
      

      
        	
                3.  

              	
                This
                  Contract may be terminated in accordance with the provisions of
                  Article X
                  Section BB, Renegotiation.

              

      

    

    
      

      3

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    
      F.
        Contract Expiration and Contractor Termination/Phase-Out
        Plan

    

    
      

      
        	
                1.  

              	
                The
                  Contractor hereby agrees that in the event this Contract is terminated
                  by
                  either Party that the Contractor will continue to provide Covered
                  Services
                  to Enrollees until Enrollees are reinstated to fee-for-service
                  care or
                  transferred to another managed long-term care plan. To the extent
                  that
                  such services are provided by the Contractor to Enrollees prior
                  to their
                  disenrollment into a fee-for service program, the Contractor will
                  continue
                  to be reimbursed a premium for such Enrollee. Upon expiration and
                  non­renewal, or termination of this Contract, the Contractor shall
                  comply with the termination plan that the Contractor has developed
                  and
                  that the Department has
                  approved.

              

      

    

    
      

      
        	
                2.  

              	
                In
                  the event that Contractor gives notice to terminate this Contract,
                  the
                  Contractor shall submit a termination plan for Department approval
                  with
                  the Contractor's notice of
                  termination.

              

      

    

    
      

      
        	
                3.  

              	
                In
                  the event that the Department gives notice to terminate this Contract,
                  the
                  Contractor shall submit within fifteen (15) days of notice or such
                  longer
                  period as the Department may allow a termination plan for Department
                  approval.

              

      

    

    
      

      
        	
                4.  

              	
                Sixty
                  (60) days prior to the date of termination, the Contractor shall
                  advise
                  all current Enrollees of the termination by regular first class
                  mail. In
                  the event that the termination date is established less than sixty
                  (60)
                  days in advance, letters shall be mailed by regular first class
                  mail
                  within five (5) days of the establishment of the termination
                  date.

              

      

    

    
      

      
        	
                5.  

              	
                The
                  Contractor shall communicate with LDSS(s) within fifteen (15) days
                  of the
                  establishment of the termination date to offer LDSS(s) assistance
                  and
                  information necessary to reinstate each Enrollee's Medicaid benefits
                  through the fee-for-service system or through enrollment in another
                  managed long-term care plan.

              

      

    

    
      

      
        	
                6.  

              	
                As
                  soon as a termination date has been established and appropriate
                  notice
                  given pursuant to this Contract by either the Contractor or the
                  Department:

              

      

    

    
      

      
        	
                 

              	
                a. 
                  the Contractor shall contact other community resources to determine
                  the availability of other programs to accept the Enrollees into their
                  programs;

              

      

    

    
      

      
        	
                 

              	
                b. 
                  the Contractor shall assist Enrollees by referring them, and by
                  making
                  their care management record and other Enrollee service records
                  available as appropriate to health care providers and/or
                  programs;

              

      

    

    
      

      
        	
                 

              	
                c. 
                  the Contractor shall establish a list of Enrollees that is prioritized
                  according to those Enrollees requiring the most skilled care,
                  and

              

      

    

    
      

      
        	
                 

              	
                d. 
                  based upon the Enrollee's established priority and a determination
                  of
                  the availability of alternative resources, individual care plans
                  shall be developed by the Contractor for each Enrollee in
                  collaboration with the Enrollee, the Enrollee's family and
                  appropriate community
                  resources.

              

      

    

    
      

      4

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    
      
        	
                7.

              	
                In
                  conjunction with such termination and disenrollment, the Contractor
                  shall
                  provide such other reasonable assistance as the Department may
                  request in affecting that transition.

                 

                
                  Upon
                    completion of individual care plans and reinstatement of the
                    Enrollee's
                    Medicaid benefits through the fee-for-service system or enrollment
                    in
                    another managed long-term care plan, an Enrollee shall be disenrolled
                    from
                    the Contractor's managed long-term care
                    plan.

                

              

      

    

    
       

    

    
      
        	
                8.  

              	
                Within
                  sixty (60) days of the date of termination of the Contract, an
                  accounting
                  shall be prepared and submitted to the Department by or on behalf
                  of the
                  Contractor for the establishment of a sum to be repaid to the Department
                  by the Contractor of funds advanced by the Department, if any,
                  for
                  coverage of Enrollees for periods subsequent to the date of
                  termination.

              

      

    

    
      

      
        	
                9.  

              	
                The
                  Contractor shall maintain all books, records and other documents
                  that may
                  be required pursuant to this Contract regarding the managed long-term
                  care
                  plan and make such records available to the Department and all
                  authorized
                  representatives of the State and federal government throughout
                  the period
                  that such records are required to be maintained pursuant to this
                  Contract.

              

      

    

    
      

      G.
        Effect of Termination on New Enrollments

    

    
      

      Once
        either Party has given notice of its intentions to terminate this Contract,
        the
        Contractor shall suspend enrollment into its managed long-term care
        plan.

    

    
      

      5

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    
      ARTICLE
        II 

      STATUTORY
        AND REGULATORY COMPLIANCE
 

    

    
      
        	
                A.

              	
                The
                  Contractor agrees to operate in compliance with the requirements
                  of this
                  Contract, legislative and regulatory requirements including, but not
                  limited to 42 Code of Federal Regulation (CFR) parts 434 and 438, New
                  York State Public Health Law Section 4403-f, and other applicable
                  provisions of Article 44 and Article 49 of New York State
                  Public Health Law and implementing
                  regulations.

              

      

    

    
      

      
        	
                B.

              	
                Covered
                  services provided by the Contractor under this Contract shall comply
                  with
                  all standards of the New York State Medicaid Plan established
                  pursuant to Section 363-a of the State Social Services Law and
                  satisfy all other applicable requirements of State Social Services
                  and Public Health Law.

                 

              

        	C. 	The
                Contractor agrees to comply with all applicable laws, regulations,
                and
                rules including

      

    

    
        

    

    
      
        	
                1. 

              	
                Title
                  VI of the Civil Rights Act of 1964 as implemented by regulations
                  at 45 CFR
                  part 80;

              

      

    

    
      
        	
                2. 

              	
                The
                  Age Discrimination Act of 1975 as implemented by regulations at
                  45 CFR
                  part 91;

              

        	3. 	The
                Rehabilitation Act of 1973, as implemented by regulations at 45 CFR
                part
                84;

        	4. 	The
                Americans with Disabilities Act;

        	5. 	The
                Health Insurance Portability and Accountability Act,
                and

        	6. 	Other
                laws applicable to recipients of Federal
                funds.

      

    

    
       

    

    
      
        	
                D.

              	
                The
                  Contractor is receiving federal payments under this Contract. The
                  Contractor and subcontractors paid by the Contractor to fulfill its
                  obligations under this Contract are subject to certain laws that are
                  applicable to individuals and entities receiving federal funds. The
                  Contractor agrees to inform all subcontractors that payments that
                  they
                  receive are, in whole or in part, from federal
                  funds.

              

      

    

    
      

      
        	
                E.

              	
                In
                  the event that any provisions of this Contract conflicts with the
                  provisions of any statute or regulations applicable to a Contractor,
                  the provisions of the statute or regulations shall have
                  control.

              

      

    

     

    
      6

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    
      ARTICLE
        III

      CONTRACTOR
        SERVICE AREA AND AGES OF POPULATION TO BE SERVED

    

    
      

      
        	
                A.

              	
                For
                  purposes of this Contract, the Contractor's service area shall
                  consist of
                  the geographic area described in Appendix F of this Contract, which
                  is hereby made a part of this Contract as if set forth fully herein.
                  The Contractor must request written Department approval to reduce or
                  expand its service area for purposes of providing managed long-term
                  care services. In no event, however, shall the Contractor modify its
                  service are until it has received such approval. Any modifications
                  made to Appendix F as a result of an approved request to expand and
                  reduce the Contractor's service area shall become effective
                  fifteen (15) days from the date of the written Department approval
                  without the need for further action on the part of the parties to
                  this Contract.

              

      

    

    
      

      
        	
                B.

              	
                The
                  age groups to be served by the Contractor are identified in Appendix
                  F of
                  this Contract, which is hereby made a part of this Contract as if set
                  forth fully herein. The Contractor must request written Department
                  approval to make any changes in the age groups it serves under the
                  Contract. In no event, however, shall the Contractor make such
                  a change
                  until it has received such approval. Any modifications made to
                  Appendix F as a result of an approved request to change the age
                  groups served by the Contractor under this Contract shall become
                  effective fifteen (15) days from the date of the written Department
                  approval without the need for further action on the part of the
                  parties to this Contract.

              

      

    

    
      

      7

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    
      ARTICLE
        IV

    

    
      

      ELIGIBILITY
        FOR MANAGED LONG-TERM CARE

    

    
      

      
        	
                A.

              	
                Except
                  as specified in Sections B and C of this Article, an Applicant
                  who
                  completes an enrollment agreement shall be eligible to enroll under
                  the terms of this Contract if he
                  or she:

              

        	 	1. meets
                the age requirements identified in Appendix F;

                
                  2. is
                    a resident in the Contractor's service area;

                

                
                  3.  is
                    determined eligible for Medicaid by the Local Department of Social
                    Services (LOSS);

                

                
                  4. is
                    eligible for nursing home level of care (as of the time of
                    enrollment);

                

                
                  5.  is
                    capable, at the time of enrollment of returning to or remaining
                    in his/her
                    home and community without jeopardy to his/her health and safety,
                    based
                    upon criteria provided by the Department;

                  6. is
                    expected to require at least one of the following services covered
                    by the
                    plan and care management for at least 120 days from the effective
                    date of
                    enrollment:

                    (a.) nursing
                      services in the home;

                    
                      (b.) therapies
                        in the home;

                    

                    
                      (c.)  home
                        health aide services;

                    

                    
                      (d.)  personal
                        care services in the home;

                    

                    
                      (e.) adult
                        day health care; or

                    

                    
                      (f.)  social
                        day care if used as a substitute for in-home personal care
                        services,
                        and;

                    

                  

                

              

      

    

    
      
        	
                 

              	
                
                  7.
                    has
                    a physician who agrees to collaborate with the Contractor and
                    the
                    Applicant or is willing to change to a physician who is willing to
                    collaborate with the managed long- term care plan. Collaboration by a
                    physician means the willingness to write orders for covered services
                    that allow an Applicant to receive care from network providers
                    upon enrollment.

                

              

      

    

    
      

      
        	
                B.

              	
                An
                  Applicant who is a hospital inpatient or is an inpatient or resident
                  of a
                  facility operated under the auspices of the State Office of Mental
                  Health (OMH), the Office of Alcoholism and Substance Abuse Services
                  (OASAS) or the State Office of Mental Retardation and Developmental
                  Disabilities(OMRDD) or is enrolled in another managed care plan
                  capitated by Medicaid, a Home and Community-Based Services waiver
                  program, a Comprehensive Medicaid Case Management Program (CMCM) or
                  OMRDD Day Treatment Prograrn or is receiving services from a hospice
                  may
                  be enrolled with the Contractor upon discharge or termination from
                  the
                  inpatient hospital, facility operated under the auspices of the
                  OMH, OASAS
                  or OMRDD, other managed care plan, hospice, Home and Community-Based
                  Services waiver program, CMCM or OMRDD Day Treatment
                  Program.

              

      

    

    
      

      8

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    
       

    

    
      

      
        	
                C.

              	
                Once
                  an EnroUee has been disenrolled at the Contractor's request, the
                  Contractor may reject the individual's re-enrollment with the Contractor.
                  However, if an EnroUee was previously disenrolled under Article
                  V Section
                  D.5 (a), the Contractor may not reject the individual's enrollment
                  without
                  first substantiating and maintaining written documentation that
                  the
                  circumstances which resulted in the disenrolmient have not been
                  remedied.

              

      

    

    
      

      9

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    
      ARTICLE
        V

    

    
      

      OBLIGATIONS
        OF THE CONTRACTOR

    

    
      

      A.       Provision
        of Benefits

    

    
      

      
        	
                1.  

              	
                The
                  Contractor agrees to provide covered services set forth in Appendix
                  G in
                  accordance with the coverage and authorization requirements of
                  42CFR
                  438.210; comply with professionally recognized standards of health
                  care
                  and implement practice guidelines consistent with 42CFR 438.236;
                  and
                  comply with the requirements of 438.114 regarding emergency and
                  post-stabilization services to the extent that services required
                  to treat
                  an emergency medical condition are within the scope of covered
                  services in
                  Appendix G.

              

      

    

    
      

      
        	
                2.  

              	
                Benefit
                  package services provided by the Contractor under this Contract
                  shall
                  comply with all standards of the State Medicaid Plan established
                  pursuant
                  to State Social Services Law Section 3 63-a and shall satisfy all
                  applicable requirements of the State Public Health and Social Services
                  Law. Non-covered services for which the Enrollee is eligible under
                  the
                  Medicaid Program will be paid by the Department on a fee-for-service
                  basis
                  directly to the provider of
                  service.

              

      

    

    
      

      
        	
                3.  

              	
                The
                  Contractor agrees to allow each Enrollee the choice of Participating
                  Provider of covered service to the extent possible and
                  appropriate.

              

      

    

    
      

      
        	
                4.  

              	
                The
                  Contractor agrees to maintain and demonstrate to the Department's
                  satisfaction, a sufficient and adequate network for the delivery
                  of all
                  covered services either directly or through subcontracts. The Contractor
                  shall meet the standards required by 42CFR 438.206 for availability
                  of
                  services; and 42CFR 438.207 for assurances of adequate capacity;
                  and
                  applicable sections of Public Health Law and regulations. If the
                  network
                  is unable to provide necessary services under this Contract for
                  a
                  particular Enrollee, the Contractor agrees to adequately and timely
                  furnish these services outside of the Contractor's network for
                  as long as
                  the Contractor is unable to provide them within the
                  network.

              

      

    

    
      

      B.       Eligibility
        Activities of Contractor

    

    
      

      
        	
                1.

              	
                The
                  Contractor, using the patient assessment instrument specified by
                  the
                  Department, will evaluate all Applicants to assess their eligibility
                  for nursing home level of care as of the time of
                  enrollment;

              

      

    

    
      

      
        	
                2.

              	
                The
                  Contractor will evaluate all Applicants to assess that they are
                  capable
                  of, at the time of enrollment, returning to or remaining in his/her
                  home and community without jeopardy to his/her health or safety,
                  based upon criteria provided by the Department;
                  and

              

      

    

    
      

      10

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    
      
        	
                3.

              	
                The
                  Contractor will evaluate all Applicants to assess that they are
                  expected
                  to require at least one of the following services and care management
                  for at least 120 days from the effective date of
                  enrollment:

              

      

    

    
      

      •  nursing
        services in the home;

    

    
      •  therapies
        in the home;

    

    
      •  home
        health aide services;

    

    
      •  personal
        care services in the home;

    

    
      •  adult
        day
        health care; or

    

    
      •  social
        day care if used as a substitute for in-home personal care
        services.

    

    
      

      The
        potential that an Applicant may require acute hospital inpatient services
        or
        nursing home placement during such 120 day period shall not be taken into
        consideration by the Contractor when assessing an Applicant's eligibility
        for
        enrollment.

    

    
      

      
        	
                4.

              	
                The
                  Contractor shall transmit all information and completed enrollment
                  forms,
                  including a patient assessment and all other documentation required
                  by the Department to the
                  LDSS.

              

      

    

    
      

      
        	
                5.

              	
                (i)
                  The Contractor is permitted to find that the Applicant does not
                  meet the
                  eligibility criteria
                  identified in Article IV. A.l through A.3, and B, and notify the
                  Applicant
                  of that finding without the approval of the LDSS. However, should
                  the
                  Applicant want to pursue enrollment, despite being notified of
                  the
                  Contractor's finding, the Contractor must transmit the application
                  to the
                  LDSS in accordance with B.6 of this
                  subsection.

              

      

    

    
      

      
        	
                 

              	
                (ii)
                  The Contractor also is permitted to advise the Applicant that she
                  or he
                  does not meet the eligibility criteria identified in Article IV.
                  A.4-7 and
                  C, and that the Contractor will recommend denial of enrollment
                  of the
                  Applicant to the LDSS if the Applicant does not choose to withdraw
                  his or
                  her application pursuant to B.10 of this subsection. Only the LDSS
                  may
                  deny enrollment

              

      

    

    
      

      
        	
                6.  

              	
                The
                  Applicant may choose to withdraw his or her application consistent
                  with
                  B.10 of this Article. If the Applicant states a desire to pursue
                  the
                  application, the Contractor shall transmit the completed enrollment
                  application and assessment results to the LDSS and the LDSS shall
                  issue
                  the determination of eligibility for enrollment to the Applicant
                  and the
                  Contractor.

              

      

    

    
      

      
        	
                7.  

              	
                If
                  the Contractor operates in a service area which encompasses more
                  than one
                  county and the Contractor has knowledge that an Enrollee proposes
                  to
                  change residence from one county to another within the service
                  area, the
                  Contractor must notify the original LDSS of the pending move and
                  must,
                  upon the request of the receiving LDSS, provide a new assessment
                  of the
                  Enrollee to the receiving LDSS. Continued enrollment is dependent
                  upon the
                  approval of the receiving LDSS. (The counties of New York City
                  are
                  considered one LDSS for the purposes of this
                  provision.)

              

      

    

    
      

      
        	
                8.  

              	
                An
                  individual Applicant's decision to enroll shall be voluntary. The
                  Contractor shall accept applications and enrollment agreement forms
                  in the
                  order they are received, 'without selecting among forms and without
                  regard
                  to the capitation rate the Contractor will receive for such person.
                  The
                  Contractor shall not discriminate against eligible Applicants on
                  the basis
                  of health status or need for health care
                  services.

              

      

    

    
      

      11

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    
      

      
        	
                9.  

              	
                The
                  Contractor agrees to transmit the results of its assessment of
                  the
                  Applicant, as well all other information deemed necessary by the
                  LDSS
                  relative to its enrollment of the Applicant to the LDSS on a timely
                  basis.

              

      

    

    
      

      
        	
                10.  

              	
                An
                  Applicant may withdraw an application or enrollment agreement prior
                  to the
                  effective date of enrollment by indicating his or her wishes orally
                  or in
                  writing. All withdrawals must be acknowledged in writing to the
                  Applicant
                  by the Contractor.

              

      

    

    
      

      C.   Enrollment
        Process

    

    
      

      
        	
                1.

              	
                 The
                  Contractor shall comply with enrollment procedures developed by
                  the
                  Contractor and the LDSS and approved by the Department. Such written
                  procedures shall address all aspects of application processing
                  and the
                  LDSS audit process, consistent with the requirements of 4403-f
                  of Public
                  Health Law and shall contain the enrollment forms and other materials
                  to
                  be used by the Contractor and submitted to the LDSS. The Contractor
                  agrees
                  to submit any proposed material revisions to the approved enrollment
                  procedures for Department approval prior to implementation of the
                  revised
                  procedures.

              

      

    

    
      

      
        	
                2.  

              	
                The
                  Contractor will notify enrollment referral sources, as appropriate,
                  if the
                  Applicant does not enroll. The Contractor will also send a written
                  confirmation to the Applicant if the Applicant does not enroll
                  in the
                  plan.

              

      

    

    
      

      
        	
                3.  

              	
                The
                  Contractor shall submit to the LDSS individually signed enrollment
                  agreements/attestations, completed assessment instruments as required
                  by
                  the Department, a plan of care and any other necessary information
                  on a
                  timely basis, sufficient to enable the LDSS to meet the enrollment
                  timeframes identified in Section 4403-f of Public Health
                  Law.

              

      

    

    
      

      
        	
                4.  

              	
                An
                  Enrollee shall be entitled to receive Covered Services as provided
                  for
                  herein as of the effective date of enrollment in the Contractor's
                  Plan.

              

      

    

    
      

      
        	
                5.  

              	
                The
                  Department will provide to the Contractor a WMS "Exception Report"
                  for any
                  approved applications that are not accepted by WMS, when WMS does
                  not show
                  the Applicant as Medicaid
                  eligible.

              

      

    

    
      

      
        	
                6.  

              	
                The
                  Contractor will request written permission from the Department
                  to suspend
                  enrollment when the Contractor determines that it lacks access
                  to
                  sufficient or adequate resources to provide or arrange for the
                  safe and
                  effective delivery of Covered Services to additional Enrollees.
                  Resumption
                  of enrollment will occur only with Department approval, not to
                  be
                  unreasonably delayed, after written notice from the Contractor
                  that
                  adequately describes how the situation precipitating the suspension
                  was
                  corrected.

              

      

    

    
      

      12

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    
      
        	
                7.  

              	
                The
                  Department may establish enrollment limits based either on a determination
                  of readiness or on limits established pursuant to Section 4403-f
                  of Public
                  Health Law.

              

      

    

    
      

      
        	
                8.  

              	
                The
                  Department shall send copies of all notices regarding suspension
                  and
                  resumption of enrollment to the
                  LDSS.

              

      

    

    
      

      
        	
                9.  

              	
                The
                  surplus amount (spend-down or NAMI amount) to be billed to an enrollee
                  by
                  the Contractor must be the amount for which the enrollee is responsible
                  as
                  determined by the LDSS.

              

      

    

    
      

      D.   Disenrollment
        Policy and Process

    

    
      

      1.           Disenrollment
        Policy

    

    
      

      
        	
                 

              	
                (a.)
                  The Contractor shall comply with disenrollment procedures developed
                  by the
                  Contractor and the LDSS as approved by the Department. Such written
                  procedures shall address all aspects of disenrollment processing
                  and the
                  LDSS audit process, consistent with the requirements of Section
                  4403-f of
                  Public Health Law and shall contain the disenrollment forms and
                  materials
                  used by the Contractor and the LDSS. The Contractor agrees to submit
                  any
                  proposed material revisions to the procedures for Department approval
                  prior to implementation of the revised
                  procedures.

              

      

    

    
      

      
        	
                 

              	
                (b.)
                  The effective date of disenrollment shall be the first day of the
                  month
                  following the month in which the disenrollment is processed through
                  the
                  WMS.

              

      

    

    
      

      
        	
                 

              	
                (c.)
                  Disenrollment may not be based in whole or in part on an adverse
                  change in
                  the EnroUee's health, or on the capitation rate payable to the
                  Contractor.
                  Disenrollment may not be initiated because of the EnroUee's high
                  utilization of covered medical services, diminished mental capacity,
                  or
                  uncooperative or disruptive behavior resulting from his or her
                  special
                  needs except as may be established under subsection 5 (a) of this
                  Section.

              

      

    

    
      

      
        	
                 

              	
                (d.)
                  The Contractor shall continue to provide and arrange for the provision
                  of
                  covered services until the effective date of disenrollment. The
                  Department
                  will continue to pay capitation fees for an Enrollee until the
                  effective
                  date of disenrollment.

              

      

    

    
      

      
        	
                 

              	
                (e.)
                  In consultation with the Enrollee, prior to the EnroUee's effective
                  date
                  of disenrollment, the Contractor shall make all necessary referrals
                  to
                  alternative services, for which the plan is not financially responsible,
                  to be provided subsequent to disenrollment, when necessary, and
                  advise the
                  Enrollee in writing of the proposed disenrollment
                  date.

              

      

    

    
      

      2.       Enrollee-Initiated
        Disenrollment

    

    
      

      
        	
                 

              	
                (a.)
                  An Enrollee may initiate voluntary disenrollment at any time for
                  any
                  reason upon oral or written notification to the Contractor. The
                  Contractor
                  must provide written confirmation to the Enrollee of receipt of
                  an oral
                  request and maintain a copy in
                  the

              

      

    

    
      

      13

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    
      
        	
                 

              	
                
                  Enrollee's
                    record. The Contractor shall attempt to obtain the Enrollee's
                    signature on
                    the Contractor's voluntary disenrollment form, but may not delay
                    the
                    disenrollment while it attempts to secure the Enrollee's signature
                    on the
                    disenrollment form. The effective date of disenrollment must
                    be no later
                    than the first day of the second month in which the disenrollment
                    was
                    requested.

                

              

      

    

    
      

      
        	
                 

              	
                (b.)
                  An Enrollee who elects to join and/or receive services from another
                  managed care plan capitated by Medicaid, a hospice, a Home and
                  Community
                  Based Services waiver program, OMRDD Day Treatment or a CMCM is
                  considered
                  to have initiated disenrollment from the managed long-term care
                  plan.

              

      

    

    
      

      3.       Contractor
        Initiated Disenrollment

    

    
      

      
        	
                 

              	
                (a.)
                  An involuntary disenrollment is a disenrollment initiated by the
                  Contractor without agreement from the
                  Enrollee.

              

        	 	(b.)   An
                involuntary disenrollment requires approval by the
                LDSS.

      

    

    
      
        	
                 

              	
                (c.)
                  The Contractor agrees to transmit information, pertinent to the
                  disenrollment request to the LDSS in sufficient time to permit
                  the LDSS to
                  effect the disenrollment pursuant to the requirements of 42 CFR
                  438.56
                  (e)(1).

              

      

    

    
      

      4.       Reasons
        the Contractor Must Initiate Disenrollment

    

    
      

      If
        an
        Enrollee does not request voluntary disenrollment, the Contractor must initiate
        involuntary disenrollment within five (5) business days from the
        date:

    

    
       

    

    
      
        	 	
                (a.)    the
                  Contractor knows the Enrollee no longer resides in the service
                  area;
                  or

                 

              

        	
                 

              	
                (b.)
                  the Enrollee has been absent from the service area for more than
                  60
                  consecutive days. Prior to the effective date of the disenrollment
                  the
                  Contractor must arrange and provide all necessary Covered Services,
                  or

              

      

    

    
      

      
        	
                 

              	
                (c.)
                  an Enrollee is hospitalized or enters an OMH, OMRDD or OASAS residential
                  program for 45 days or longer,
                  or

              

      

    

    
      

      
        	
                 

              	
                (d.)
                  an Enrollee clinically requires nursing home care but is not eligible
                  for
                  such care under the Medicaid Program's institutional rules,
                  or

                 

              

        	 	 (e.)    is
                no longer-eligible to receive Medicaid benefits,
                or

      

    

    
       

    

    
      
        	
                 

              	
                (f.)
                  an Enrollee who is moving to a new LDSS in the Contractor's service
                  area
                  is denied continued enrollment by the new LDSS based on the Contractor's
                  assessment of eligibility for continued enrollment as provided
                  in this
                  Article, or

              

      

    

    
      

      
        	
                 

              	
                (g.)
                  an Enrollee is no longer eligible for nursing home level of care
                  as
                  determined at the last comprehensive assessment of the calendar
                  year using
                  the assessment tool prescribed by the Department, unless the Contractor,
                  and the LDSS agree that termination of the services provided by
                  the
                  Contractor could reasonably be expected to result in the Enrollee
                  being
                  eligible for nursing home level of care (as determined with the
                  assessment
                  tool prescribed by the Department) within the succeeding six-month
                  period.
                  The Contractor shall provide the LDSS the results of its assessment
                  and
                  recommendations regarding continued enrollment or disenrollment
                  within
                  five (5) business days of the comprehensive
                  assessment.

              

      

    

    
      

      14

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

     

    
      5.    A
        Contractor May Initiate an Involuntary Disenrollment if:

    

    
      

      
        	
                 

              	
                (a.)
                  The Enrollee or the Enrollee's family member or informal caregiver
                  engages
                  in conduct or behavior that seriously impairs the Contractor's
                  ability to
                  furnish services to either that particular Enrollee or other Enrollees;
                  provided, however, the Contractor must have made and documented
                  reasonable
                  efforts to resolve the problems presented by the individual. 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
                  his or
                  her special needs.

              

      

    

    
      

      
        	
                 

              	
                (b.)
                  The Enrollee fails to pay for or make arrangements satisfactory
                  to
                  Contractor to pay the amount, as determined by the LDSS, owed to
                  the
                  Contractor as spenddown/surplus or Net Available Monthly Income
                  (NAMI))
                  within thirty (30) days after such amount first becomes due, provided
                  that
                  during that thirty (30) day period Contractor first makes a reasonable
                  effort to collect such amount, including making a written demand
                  for
                  payment, and advising the Enrollee in writing of his/her prospective
                  disenrollment.

              

      

    

    
      

      
        	
                 

              	
                (c.)
                  The Enrollee knowingly fails to complete and submit any necessary
                  consent
                  or release.

              

      

    

    
      

      
        	
                 

              	
                (d.)
                  The Enrollee provides the Contractor with false information, otherwise
                  deceives the Contractor or engages in fraudulent conduct with respect
                  to
                  any substantive aspect of his/her plan
                  membership.

              

      

    

    
      

      
        	
                 

              	
                (e.)
                  The Enrollee's physician refuses to collaborate with the Contractor
                  and
                  Enrollee on developing and implementing the plan of care. Collaboration
                  by
                  a physician means the willingness to refer to network providers
                  and write
                  orders for covered services. The Contractor must make and document
                  reasonable efforts to collaborate with an Enrollee's
                  physician.

              

      

    

    
      

      E. 
        Enrollee Protections

    

    
      

      
        	
                1.

              	
                 The
                  Contractor shall have and comply with Department-approved written
                  policies
                  and procedures regarding internal grievances, grievance appeals
                  and
                  appeals processes, that are consistent with the Department's grievance,
                  grievance appeals and appeals policies contained in Appendix K
                  of this
                  Agreement.   These include notifying Enrollee  who
                  receive
                  an adverse appeal resolution about their right to a Medicaid
                  Fair
                  Hearing and/or an External Appeal, where applicable. The Contractor
                  agrees
                  to submit any proposed material revisions to the approved policies
                  and
                  procedures for Department approval prior to implementation of the
                  revised
                  policies and procedures.

              

      

    

    
      

      15

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

     

    
      
        	
                2.

              	
                The
                  Contractor agrees to adopt and maintain arrangements satisfactory
                  to the
                  Department to protect its Enrollees from incurring liability for
                  payment of any fees that are the legal obligation of the Contractor.
                  To meet this requirement the Contractor
                  must:

              

      

    

    
      

      
        	
                 

              	
                (a.)
                  ensure that all contracts with providers prohibit the Contractor's
                  providers from holding any Enrollee liable for payment of any fees
                  that
                  are the legal obligation of the Contractor;
                  and

              

      

    

    
      

      
        	
                 

              	
                (b.)
                  indemnify the Enrollee for payment of any fees that are the legal
                  obligation of the Contractor for services furnished by providers
                  that have
                  been authorized by the Contractor to serve such Enrollee, as long
                  as the
                  Enrollee follows the Contractor's rules for accessing services
                  described
                  in the approved member
                  handbook.

              

      

    

    
      

      
        	
                3.  

              	
                The
                  Contractor shall develop and implement written policies and procedures
                  regarding Enrollee rights which fulfill the requirements of 42
                  CFR 438.100
                  and applicable State law and
                  regulation.

              

      

    

    
      

      
        	
                4.  

              	
                The
                  Contractor will distribute and otherwise make available information
                  about
                  Enrollee rights contained in Appendix L of this Agreement to all
                  Potential
                  Enrollees, Applicants and
                  Enrollees.

              

      

    

    
      

      F.    Quality
        Assurance and Performance Improvement Program

    

    
      

      
        	
                1.

              	
                The
                  Contractor must have a quality assurance and performance improvement
                  program which includes a health information system consistent with
                  the
                  requirements of 42 CFR 438.242, and a Department approved written
                  quality
                  plan for ongoing assessment, implementation, and evaluation of
                  overall
                  quality of care and services. The Contractor agrees to submit any
                  proposed
                  material revisions to the approved quality plan for Department
                  approval
                  prior to implementation of the revised plan. The quality assurance
                  and
                  performance improvement program must identify specific and measurable
                  activities to be undertaken by the Contractor. The Contractor's
                  written
                  quality plan must meet the requirements of Article 44 of Public
                  Health Law
                  and implementing regulations and address the standards in 42CFR
                  438.240
                  regarding quality assurance and performance improvement and 42
                  CFR 438.242
                  regarding the health information system and the following additional
                  elements:

              

      

    

    
      

      
        	
                 

              	
                (a.)
                  Board level accountability for overall oversight of program activities
                  and
                  review of the QA/PI program, annual review and approval of the
                  program by
                  the board and periodic feedback to the board on the review process
                  by
                  oversight committees.

              

      

    

    
      

      
        	
                 

              	
                (b.)
                  Goals and objectives that provide a framework for quality assurance
                  and
                  improvement activities, evaluation and corrective action. These
                  goals and
                  objectives should be reviewed and revised periodically, and should
                  be
                  supported by data collection activities which focus on clinical
                  and
                  functional outcomes, encounter and utilization data, and client
                  satisfaction data.

              

      

    

    
      

      16

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    
      

      
        	
                 

              	
                (c.)
                  Standards for access, availability and continuity of service including,
                  but not limited to:

              

      

    

     

    
      
        	 	 (i)       length
                of time to respond to requests for referrals, 

        	 	 (ii)      timeliness
                of receipt of covered services, 

        	 	 (iii)     timeliness
                of implementation of care plan, and

        	
                 

              	
                (iv)     telephone
                  consultation to assist Enrollees in obtaining health information
                  and, on a
                  24 hour basis, urgent care.

              

      

    

    
      

      
        	
                 

              	
                (d.)
                  Quality indicators that are objective, measurable and related to
                  the
                  entire range of services provided by the Contractor and which focus
                  on
                  potential clinical problem areas (high volume service, high risk
                  diagnoses
                  or adverse outcomes). The methodology should assure that all care
                  settings
                  (e.g. day center, nursing home and in-home settings) will be included
                  in
                  the scope of the quality assurance and performance improvement
                  program.

              

      

    

    
      

      
        	
                 

              	
                (e.)
                  A process to review the effectiveness of the Contractor's ability
                  to
                  assess EnroUee's care needs, sustain the EnroUee's informal supports,
                  identify the EnroUee's treatment goals, assess effectiveness of
                  interventions, evaluate adequacy and appropriateness of service
                  utilization, including the social and environmental supports, and
                  amend
                  the care delivery process, as
                  necessary.

              

      

    

    
      

      
        	
                 

              	
                (f.)
                  Enrollee and caregiver involvement in quality assurance and performance
                  improvement activities and evaluation of satisfaction with
                  services.

                 

              

        	 	
                (g.)    Establishment
                  of a review committee(s) to:

                 

                
                  (i)    evaluate
                    data collected pertaining to quality indicators, performance
                    standards,
                    and
                    client satisfaction; 

                  (ii)   make
                    recommendations to the board regarding the process and outcomes
                    of the
                    quality
                    assurance and performance improvement program, and 

                  (iii)
                    provide  input related  to  processes
                    to  evaluate  ethical  decision-making
                    including
                    end-of-life issues.

                   

                  (h.)    Policies
                    and procedures of the review committee should:

                   

                  (i)       define
                    qualifications of individuals participating on the
                    committee(s);

                  
                    
                      (ii)      include   a  method  for  identifying,   selecting   and  reviewing   data  and
                        information   to   be   used   in   the   quality   assurance   and   performance
                        improvement
                        program; 

                      (iii)     integrate
                        the findings of the grievance and appeals
                        process;

                    

                  

                

              

      

    

    
       

    

    
      17

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    
      
        	
                 

              	
                (iv)     define
                  a process for recommending appropriate action to resolve problems
                  identified as part of quality assurance and improvement
                  activities,  including providing feedback to appropriate staff
                  and subcontractors; for monitoring effectiveness of corrective
                  actions
                  taken; and for reporting QA/PI findings to the board on at least
                  an annual
                  basis; and

              

      

    

    
      
        	
                 

              	
                (v)
                  incorporate review of the care delivery process to include appropriate
                  clinical professionals and paraprofessionals as well as non-clinical
                  staff, as appropriate.

              

      

    

    
      

      
        	
                 

              	
                2.
                  The Contractor agrees to cooperate with any external quality review
                  conducted by or at the direction of the
                  Department.

              

      

    

    
      

      G.   Marketing

    

    
      

      
        	
                1.  

              	
                The
                  Contractor shall conduct marketing activities for Potential Enrollees
                  consistent with 42 CFR 438.104, applicable State Law and its implementing
                  regulation.

              

      

    

    
      

      
        	
                2.  

              	
                Marketing
                  materials include any information produced by or on behalf of the
                  Contractor that references managed long-term care concepts, is
                  intended
                  for general distribution and is produced in a variety of print,
                  broadcast
                  and direct marketing
                  mechanisms.

              

      

    

    
      

      
        	
                3.  

              	
                The
                  Contractor shall comply with a marketing plan which has received
                  written
                  prior approval by the Department. If there are any material changes
                  to the
                  marketing plan, they must be submitted to the Department before
                  implementation. The marketing plan shall describe marketing and
                  enrollment
                  goals, the specific activities to be undertaken to achieve the
                  enrollment
                  goals and identify the personnel who will carry out the marketing
                  functions. The marketing plan should address each of the
                  following:

              

      

    

    
      

      
        	
                 

              	
                (a.)
                  a description of how the Contractor will distribute marketing material
                  in
                  its service area approved by the
                  Department;

              

      

    

    
      

      
        	
                 

              	
                (b.)
                  a listing and copies of the specific marketing formats to be used
                  ( e.g.
                  radio announcements, letters, posters, brochures, handbooks) and
                  the
                  forums for distribution or presentation (e.g. health fairs, provider
                  offices, community events);

              

      

    

    
      

      
        	
                 

              	
                (c.)
                  evidence that the material is written in 12 point type at a minimum
                  and
                  prose written in clear, simple, understandable language at the
                  4 to 6th
                  grade
                  reading level;

              

      

    

    
      

      
        	
                 

              	
                (d.)
                  a description of how the Contractor will market to Potential Enrollees
                  who
                  speak other than English as a primary
                  language;

              

      

    

    
      

      
        	
                 

              	
                (e.)
                  the methods of making alternate formats available to persons who
                  are
                  visually and hearing
                  impaired;

              

      

    

    
      

      
        	
                 

              	
                (f.)
                  the method and timetable for updating and disseminating the list
                  of
                  Participating Providers available to Potential
                  Enrollees;,

              

      

    

    
      

      18

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    
      
        	
                 

              	
                (g.)
                  a description of how the Contractor will assure that its Participating
                  Providers comply with these
                  provisions;

              

      

    

    
      

      
        	
                 

              	
                (h.)
                  a discussion as to if or how the Contractor plans to provide nominal
                  gifts
                  for the target population;

              

      

    

    
      

      
        	
                 

              	
                (i.)
                  a description of the personnel qualifications, the training content,
                  methods and mechanisms for evaluation, supervision and reimbursement
                  of
                  marketing personnel; and

              

      

    

    
      

      
        	
                 

              	
                (j.)
                  a description of the methods to be used by the Contractor to monitor
                  and
                  assure compliance with the approved marketing
                  plan.

              

      

    

    
      

      4.    The
        Contractor shall conduct marketing activities consistent with the following
        provisions:

    

    
      

      
        	
                 

              	
                (a.)
                  The Contractor may use radio, television, billboards, newspapers,
                  leaflets, brochures, the Internet, yellow page advertisements,
                  letters,
                  posters and verbal presentations by marketing representatives as
                  well as
                  health fairs and other appropriate events to market its
                  product.

              

      

    

    
      

      
        	
                 

              	
                (b.)
                  The Contractor shall not mislead, confuse, defraud Potential Enrollees
                  or
                  misrepresent itself, the State or the Centers for Medicare and
                  Medicaid
                  Services.

              

      

    

    
      

      
        	
                 

              	
                (c.)
                  The Contractor shall not use a health assessment form or other
                  means to
                  select among otherwise eligible
                  Applicants.

              

      

    

    
      

      
        	
                 

              	
                (d.)
                  The Contractor may distribute marketing materials in local community
                  centers, pharmacies, hospitals, nursing homes, home care agencies,
                  doctors' offices and other areas where Potential Enrollees are
                  likely to
                  gather or receive long-term care
                  services.

              

      

    

    
      

      
        	
                 

              	
                (e.)
                  The Contractor may conduct marketing activities at provider sites
                  only
                  with the permission of the
                  provider.

              

      

    

    
      

      
        	
                 

              	
                (f.)
                  The Contractor may not directly or indirectly engage in door to
                  door,
                  telephone or other "Cold Call" marketing
                  activities.

              

      

    

    
      

      
        	
                 

              	
                (g.)
                  The Contractor shall ensure, through its agreements with subcontractors,
                  compliance with the provisions of this
                  Section.

              

      

    

    
      

      
        	
                 

              	
                (h.)
                  The Contractor shall, with the consent of Potential Enrollees,
                  provide for
                  the participation of family members and other informal caregivers
                  during
                  marketing encounters.

              

      

    

    
      

      
        	
                 

              	
                (i.)
                  The Contractor, in its marketing materials, shall offer only benefits
                  or
                  services that are clearly specified in this Contract and available
                  for the
                  full contract period being
                  marketed.

              

      

    

    
      

      19

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    
      
        	
                 

              	
                (j.)
                  The Contractors shall not offer monetary incentives to Medicaid
                  recipients
                  to join the plan. Nominal gifts of no more than $5.00 fair market
                  value
                  may be offered as part of promotional activities to stimulate interest
                  in
                  the plan as long as such gifts are made available to everyone regardless
                  of whether they enroll.

              

      

    

    
      

      
        	
                 

              	
                (k.)
                  Marketing representatives shall be trained in the concepts of managed
                  long-term care and all facets of the plan using the subject outline
                  of the
                  member handbook as a minimal basis for the training
                  curriculum.

              

      

    

    
      

      
        	
                 

              	
                (1.)
                  The Contractor shall not offer financial and other kinds of incentives
                  to
                  marketing representatives based on the number of Medicaid recipients
                  a
                  representative has enrolled in the
                  program.

              

      

    

    
      

      
        	
                 

              	
                (m.)
                  The Contractor may not seek to influence enrollment in conjunction
                  with
                  the sale or offering of any private
                  insurance.

              

      

    

    
      

      All
        written materials used in carrying out the functions of this Section, including
        but not limited to marketing materials, the enrollment agreement and
        attestation, and the member handbook, must be reviewed and approved by the
        Department, in consultation with the State Office for the Aging and the State
        Insurance Department prior to use. The Contractor shall comply with all requests
        from the Department for periodic reports on the performance of the Contractor's
        responsibilities pursuant to this Section. The Contractor shall submit these
        reports within thirty (30) days of receiving the request from the
        Department.

    

    
      

      Information
        For Potential Enrollees, Applicants and Enrollees

    

    
      

      The
        Contractor shall provide information to all Potential Enrollees, Applicants
        and
        Enrollees consistent with 42CFR 438.10, applicable State Law and its
        implementing regulation, and Appendix M of this Agreement.

    

    
      

      The
        Contractor must submit to the Department for prior approval a description
        of how
        the Contractor will provide information and annual notification to its Enrollees
        as required by this Section, including:

    

    
      

      
        	
                 

              	
                (a.)
                  evidence that the material is written in 12 point type at a minimum
                  and
                  prose written in clear, simple, understandable language at the
                  4  to 6l
                  grade reading
                  level;

              

      

    

    
      

      
        	
                 

              	
                (b.)the
                  methods the Contractor will use to provide information to Applicants
                  and
                  Enrollees who speak other than English as a primary
                  language;

              

      

    

    
      

      
        	
                 

              	
                (c.)
                  the methods of making alternate formats available to persons who
                  are
                  visually and hearing impaired;
                  and

              

      

    

    
      

      20

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    
      
        	
                 

              	
                (d.)
                  the method and timetable for updating and disseminating the list
                  of
                  Participating Providers.

              

      

    

    
      

      
        	
                3.

              	
                The
                  Contractor shall provide Potential Enrollees, Applicants and Enrollees
                  information consistent with the following
                  provisions.

              

      

    

    
      

      
        	
                 

              	
                (a.)
                  The Contractor shall comply with the Department's requirements
                  for
                  language and format standards for information pursuant to 42CFR
                  438.10(c)
                  and (d).

              

      

    

    
      

      
        	
                 

              	
                (b.)
                  The Contractor shall provide the State Consumer Guide to all Potential
                  Enrollees, and the member handbook and the provider network to
                  all
                  Applicants prior to enrollment and to
                  Enrollees.

              

      

    

    
      

      
        	
                 

              	
                (c.)
                  The Contractor shall give Enrollees prior written notice of significant
                  changes to the information identified in subsection H (3)(b) of
                  this
                  Section. Such notice shall be at least thirty (30) days prior to
                  the
                  effective date of the change pursuant to 42 CFR
                  438.10(f)(4).

              

      

    

    
      

      
        	
                 

              	
                (d.)
                  The Contractor shall annually notify Enrollees in writing of their
                  disenrollment rights and their right to request the information
                  specified
                  in 42CFR 438.10 (f) (6)
                  and(g).

              

      

    

    
      

      
        	
                4.

              	
                The
                  Contractor shall obtain a signed attestation from each Applicant/Enrollee
                  that the Applicant/Enrollee
                  has:

              

      

    

    
      

      
        	
                 

              	
                (a.)
                  received a member handbook which included the rules and responsibilities
                  of plan membership and which expressly delineates covered and non-covered
                  services;

              

      

    

    
      

      
        	
                 

              	
                (b.)
                  agreed to the terms and conditions for plan enrollment stated in
                  the
                  member handbook;

              

        	 	 
                
                (c.)  understood
                  that enrollment in the Contractor's plan is
                  voluntary;

              

      

    

    
      

      
        	
                 

              	
                (d.)
                  received a copy of the Contractor's current provider network listing
                  and
                  agreed to use network providers for covered services, and

                 

              

        	 	 (e.)
                has been advised of the projected date of
                enrollment.

      

    

     

    
      21

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    
      I.   Member
        and Provider Services

    

    
      

      1.      The
        Contractor is responsible to provide the following member
        services

    

    
      

      
        	
                 

              	
                (a.)
                  explaining the Contractor's rules for obtaining services and assisting
                  Enrollees in making
                  appointments;

              

      

    

    
      

      
        	
                 

              	
                (b.)
                  fielding and responding to Enrollee questions and grievances, and
                  advising
                  Enrollees of the prerogative to complain to the SDOH and/or LDSS
                  at any
                  time;

              

        	 	 
                
                (c.)
                  clarifying information in the member handbook for
                  Enrollees;

              

      

    

    
      

      
        	
                 

              	
                (d.)
                  advising Enrollees of the Contractor's grievance and appeals system,
                  the
                  service authorization process, and Enrollee's rights to a fair
                  hearing
                  and/or external review;

              

      

    

    
      

      
        	
                 

              	
                (e.)
                  accommodating Applicants and Enrollees who require language translation
                  and communications
                  assistance;

              

      

    

    
      

      
        	
                 

              	
                (f.)
                  conducting post enrollment orientation activities, including orientation
                  of Enrollees, Enrollees' families or representatives, employees,
                  management principles and operating practices; and

                 

              

        	 	 (g.)
                health promotion and wellness
                initiatives.

      

    

    
      

      
        	
                2.

              	
                The
                  Contractor shall develop and implement written procedures and protocols
                  to
                  assure that member and provider services are provided in a manner
                  that is responsive to cultural considerations and specific needs of
                  its Enrollees.

              

      

    

    
      

      J.    Care
        Management

    

    
      

      
        	
                1.

              	
                Care
                  management entails the establishment and implementation of a written
                  care
                  plan and assisting enrollees to access services authorized under the
                  care plan. Care management includes referral to and coordination of
                  other necessary medical, and social, educational, psychosocial,
                  financial and other services of the care plan irrespective of whether
                  such services are covered by the
                  plan

              

      

    

    
      

      
        	
                2.  

              	
                The
                  Contractor shall comply with policies and procedures consistent
                  with 42
                  CFR 438.210 and Appendix K of this Agreement that have received
                  prior
                  written approval from the Department. The Contractor agrees to
                  submit any
                  proposed material revisions to the approved coverage and authorization
                  of
                  services policies and procedures for Department approval prior
                  to
                  implementation of the revised
                  procedures.

              

      

    

    
      

      
        	
                3.  

              	
                The
                  Contractor shall have and comply with written policies and procedures
                  for
                  care management consistent with the coordination and continuity
                  requirements of 42CFR
                  438.208.

              

      

    

    
      

      22

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    
      
        	
                4.  

              	
                The
                  Contractor's care management system shall ensure that care provided
                  is
                  adequate to meet the needs of individual Enrollees and is appropriately
                  coordinated, and shall consist of both automated information systems
                  and
                  operational policies and
                  procedures.

              

      

    

    
      

      
        	
                5.  

              	
                A
                  comprehensive reassessment of the Enrollee and a plan of care update
                  shall
                  be performed as warranted by the Enrollee's condition but in any
                  event at
                  least once every six (6)
                  months.

              

      

    

    
      

      
        	
                6.  

              	
                The
                  Contractor shall develop a care management system consistent with
                  the
                  following provisions:

              

      

    

    
      

      
        	
                (a.)

              	
                The
                  Contractor shall arrange for health care professionals, as appropriate
                  (such as physicians, nurses, social workers, therapists) to provide
                  care
                  management services to all Enrollees. An interdisciplinary team
                  may
                  provide care management.

              

        	 (b.)    	Care
                management services include, but are not limited
                to:

        	 	 (i)   initial
                assessments of Enrollees;
                
                  (ii)  reassessments
                    of Enrollees;

                

                
                  (iii) management
                    of covered services and coordination of covered services with
non-covered
                    services and services provided by other community resources and
                    informal supports; 

                  (iv) development
                    of individual care plans, in consultation with the Enrollee and
                    her/his
                    informal supports, specifying health care goals, the types and
                    frequency
                    of   authorized covered services and non-covered services
                    and supports
                    necessary to maintain the care plan; 

                  (v) 
                    monitoring the progress of each Enrollee to evaluate whether
                    the covered
                    services
                    provided are appropriate and in accord with the care plan; and
                    

                  (vi) evaluating
                    whether the care plan continues to meet the Enrollee's
                    needs.

                

              

        	 (c.)	
                 The
                  care management system includes processes for:

                
                  
                    (i)   generating
                      and receiving referrals among providers;

                  

                  
                    (ii)  sharing
                      clinical and treatment plan information;

                  

                  
                    (iii) obtaining   consent   to   share   confidential   medical   and   treatment   plan
                      information
                      among providers consistent with all applicable state and federal
                      law
                      and regulation; 

                    (iv) providing
                      Enrollees with written notification of authorized services;

                    (v)  enlisting
                      the involvement of community organizations that are not providing
                      covered
                      services, but are otherwise important to the health and well-being
                      of
                      Enrollees,
                      and 

                    (vi) assuring
                      that the organization of and documentation included in the
                      care
                      management
                      record meet all applicable professional
                      standards.

                  

                

              

      

    

    
      
        	
                (d.)
                  

              	
                The
                  care management system requires care managers to have access to
                  participating medical and social services professionals and
                  para-professionals who on a routine basis provide direct care and
                  services
                  as required by the Enrollee's
                  status.

              

      

    

    
      

      23

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    
      K.   Advance
        Directives

    

    
      

      The
        Contractor must provide all directives and information to Enrollees with
        respect
        to their rights under New York State Public Health Law Articles 29-B and
        29-C.
        The Contractor shall, in compliance with 42CFR 438.6(i) and 422.128, maintain
        written policies and procedures for advance directives and provide written
        information to Enrollees with respect to their rights under New York State
        Public Health Law Articles 29-B and 29-C 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
        98-1.14 (f) and 700.5.

    

    
      

      24

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    
      
        	
                 

              	
                ARTICLE
                  VI 

                PAYMENT

              

      

    

    
      

      A.  Capitation
        Payments

    

    
      

      
        	
                1.  

              	
                Compensation
                  to the Contractor shall consist of a monthly capitation payment
                  for each
                  Enrollee.

              

      

    

    
      

      
        	
                2.  

              	
                In
                  compliance with Section 4403-f of NYS Public Health Law, monthly
                  capitation rates shall reflect savings to both state and local
                  governments
                  when compared to costs which would be incurred by such programs
                  if
                  Enrollees were to receive comparable health and long-term care
                  services on
                  a fee-for-service basis in the geographic region for which services
                  are
                  provided.

              

      

    

    
      

      
        	
                3.  

              	
                The
                  monthly Capitation Rates are attached hereto as Appendix H and
                  shall be
                  deemed incorporated into this Contract without further action by
                  the
                  parties.

              

      

    

    
      

      
        	
                4.  

              	
                The
                  monthly capitation payment to the Contractor shall constitute full
                  and
                  complete payments to the Contractor for all services that the Contractor
                  provides pursuant to this
                  Contract.

              

      

    

    
      

      
        	
                5.  

              	
                Capitation
                  Rates shall remain in effect until such time as modifications are
                  made
                  pursuant to Sections B and C of this
                  Article.

              

      

    

    
      

      B.  Modification
        of Rates during Contract Period

    

    
      

      
        	
                1.  

              	
                Any
                  technical modification to Capitation Rates, during the term of
                  the
                  Contract as agreed to by the Contractor, including but not limited
                  to
                  changes in Premium Groups, shall be deemed incorporated into this
                  Contract
                  without further action by the parties upon approval of such modifications
                  by the Department.

              

      

    

    
      

      
        	
                2.  

              	
                Any
                  other modification to Capitation Rates, as agreed to by the Department
                  and
                  the Contractor during the term of the Contract shall be deemed
                  incorporated into this Contract without further action by the parties
                  upon
                  approval of such modifications by the Department and the State
                  Division of
                  the Budget.

              

      

    

    
      

      
        	
                3.  

              	
                In
                  the event that the Department and the Contractor fail to reach
                  agreement
                  on modifications to the monthly Capitation Rates, the Department
                  will
                  provide formal written notice to the Contractor of the amount and
                  effective date of the modified Capitation Rates approved by the
                  State
                  Division of the Budget. The Contractor shall have the option of
                  terminating this Contract if such approved modified Capitation
                  Rates are
                  not acceptable. In such case, the Contractor shall give written
                  notice to
                  the Department and the Local Department of Social Services within
                  thirty
                  (30) days of the date of the formal written notice of the modified
                  Capitation Rates from the Department specifying the reasons for
                  and
                  effective date of termination. The effective date of termination
                  shall be
                  ninety (90) days from the date of the Contractor's written notice,
                  unless
                  the Department determines that an orderly disenrollment to Medicaid
                  fee-for-service or transfer to another managed long-term care plan.can
                  be
                  accomplished in fewer days. The terms and conditions in the Contractor's
                  phase-out plan specified in Article I must be accomplished prior
                  to
                  termination. During the period commencing with the effective date
                  of the
                  Department's modified Capitation Rates through the effective date
                  of
                  termination of the Contract, the Contractor shall have the option
                  of
                  continuing to receive capitation payments at the expired Capitation
                  Rates
                  or at the modified Capitation Rates approved by the Department
                  and the
                  State Division of the Budget for the rate
                  period.

              

      

    

    
      

      25

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    
       

    

    
      
        	
                4.

              	
                If
                  the Contractor fails to exercise its right to terminate in accordance
                  with
                  this Section, then the modified Capitation Rates, approved by the
                  Department and the State Division of the Budget, shall be deemed
                  incorporated into this Contract without further action by the parties
                  as
                  of the effective date of the modified Capitation Rates as established
                  by
                  the Department and approved by the State Division of the
                  Budget.

              

      

    

    
      

      C.       Rate-Setting
        Methodology

    

    
      

      
        	
                1.  

              	
                Capitation
                  Rates are determined using a prospective methodology whereby cost,
                  utilization and other rate-setting data available for the time
                  period
                  prior to the time period covered by the rates are used to establish
                  premiums. Capitation Rates will not be retroactively adjusted to
                  reflect
                  actual fee-for-service data or plan experience for the time period
                  covered
                  by the rates. Capitation Rates shall require an actuarial certification
                  as
                  specified in 42 CFR 438.6. The actuarial certification will be
                  the
                  responsibility of the
                  Department.

              

      

    

    
      

      
        	
                2.  

              	
                Notwithstanding
                  the provisions set forth in Section C.l above, the Department reserves
                  the
                  right to terminate this Agreement, in its entirety pursuant to
                  Article I
                  Section C of this Contract, upon determination by the Department
                  that the
                  aggregate monthly Capitation Rates are not cost effective pursuant
                  to
                  subsection 4403-F of Public Health
                  Law.

              

      

    

    
      

      D.       Payment
        of Capitation

    

    
      

      
        	
                1.  

              	
                The
                  monthly capitation payment for each Enrollee is due to the Contractor
                  from
                  the Effective Date of Enrollment until the Effective Date of Disenrollment
                  of the Enrollee or termination of this Contract, whichever occurs
                  first.
                  The Contractor shall receive a full month's capitation payment
                  for the
                  month in which disenrollment occurs. The Roster generated by the
                  Department, along with any modification communicated electronically
                  or in
                  writing by the Department or the LDSS 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. The Contractor and the LDSS
                  may
                  develop protocols for the purpose of resolving roster discrepancies
                  that
                  remain unresolved beyond the end of the
                  month.   .

              

      

    

    
      

      
        	
                2.  

              	
                Upon
                  receipt by the fiscal agent of a properly completed claim for monthly
                  capitation payments submitted by the Contractor pursuant to this
                  Contract,
                  the fiscal agent will

              

      

    

    
      

      26

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    
      
        	
                 

              	
                
                  promptly
                    process such claim for payment through eMedNY 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 State Finance Law, the State and LDSS
                    shall have no
                    liability under this Contract to the Contractor or anyone else
                    beyond
                    funds appropriated and available for payment of Medical Assistance
                    care,
                    services and supplies.

                

              

      

    

    
      

      E.  Denial
        of Capitation Payments

    

    
      

      In
        the
        event that CMS denies payment for new or existing Enrollees based upon a
        determination that the Contractor failed to comply with federal statutes
        and
        regulatory requirements, the Department will deny capitation payments to
        the
        Contractor for the same Enrollees for the period of time for which CMS denies
        payment.

    

    
      

      F.  Department
        Right to Recover Premiums

    

    
      

      
        	
                1.  

              	
                The
                  parties acknowledge and accept that the Department has a right
                  to recover
                  premiums paid to the Contractor for Enrollees listed on the monthly
                  roster
                  who are later determined, for the entire applicable payment month,
                  to have
                  been incarcerated; to have moved out of the Contractor's service
                  area; or
                  to have died. In any event, the State may only recover premiums
                  paid for
                  Medicaid Enrollees listed on a roster if it is determined by the
                  Department that the Contractor was not at risk for provision of
                  medical
                  services for any portion of the payment
                  period.

              

      

    

    
      

      
        	
                2.  

              	
                The
                  parties acknowledge and accept that the Department has the right
                  to
                  recover premiums paid to the Contractor for Enrollees listed on
                  the
                  monthly roster where the Contractor has failed to initiate involuntary
                  disenrollment in accordance with the timeframes and requirements
                  contained
                  in Section D.4.(b)-(g) of Article V. The Department may recover
                  the
                  premiums effective on the first day of the month following the
                  month in
                  which the Contractor was required to initiate the involuntary
                  disenrollment.

              

      

    

    
      

      G.  Third
        Party Health Insurance Determination

    

    
      

      The
        Contractor will make diligent efforts to determine whether Enrollees have
        third
        party health insurance (TPHI). The LDSS shall make its best efforts 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 100
        percent 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.

    

    
      

      27

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    
      H.
        Contractor Financial Liability

    

    
      

      The
        Contractor shall not be financially liable for any services rendered to an
        Enrollee prior to his or her effective date of enrollment or subsequent to
        disenrollment.

    

    
      

      I.   Spenddown
        and Net Available Monthly Income

    

    
      

      Capitation
        rates are adjusted to exclude Enrollee spenddown and NAMI as determined by
        the
        Local Department of Social Services. The Contractor's inability to collect
        funds
        from Enrollees will not change the plan's spenddown or NAMI adjustment. The
        Contractor shall report the gross amount of spenddown and NAMI for each Enrollee
        in accordance with the timeframes and in the format prescribed by the
        Department.

    

    
      

      J.    No
        Recourse Against Enrollees

    

    
      

      Except
        for the rates and payments provided for in this Contract, the Contractor
        hereby
        agrees that in no event, including but not limited to nonpayment by the Medicaid
        agency, insolvency of the Contractor, loss of funding for this program, or
        breach of this Contract, shall the Contractor or a subcontractor bill, charge,
        collect a deposit from, seek compensation, remuneration, or reimbursement
        from,
        or have any recourse against any Enrollee or person acting on his behalf
        for
        covered services furnished in accordance with this Contract.

    

    
      

      This
        Section J. shall not prohibit the Contractor or the subcontractors as specified
        in their agreements from billing for and collecting any applicable surplus
        amounts, Net Available Monthly Income (NAMI), Medicare billable expenses,
        commercial insurance, worker's compensation benefits, no-fault insurance,
        and
        coordination of benefit amounts. This Section J. supersedes any oral or written
        contrary agreement now existing or hereinafter entered into between the
        Contractor and any Enrollee or persons acting on his behalf. This provision
        shall survive termination of this Contract for any reason.

    

    
      

      K.   Notification
        Requirements to LDSS Regarding Enrollees

    

    
      

      
        	
                1.  

              	
                The
                  Contractor agrees to notify the LDSS in writing when an Enrollee
                  with a
                  monthly spenddown is admitted to an inpatient facility so the spenddown
                  can be recalculated and a determination made regarding the amount,
                  if any,
                  of the spenddown owed to the inpatient facility. The notification
                  will
                  include the Enrollee's name, Medicaid number, hospital name and
                  other
                  information as directed by the
                  Department.

              

      

    

    
      

      
        	
                2.  

              	
                The
                  Contractor agrees to notify the LDSS in writing prior to admission
                  of an
                  Enrollee to a nursing facility, to allow Medicaid eligibility to
                  be
                  redetermined using institutional eligibility rules. The notification
                  will
                  include the Enrollee's name, Medicaid number, nursing facility
                  name and
                  other information as directed by the Department. If such an Enrollee
                  is
                  determined by the LDSS to be ineligible for Medicaid nursing facility
                  services, the LDSS shall notify the Contractor of such
                  determination.

              

      

    

    
      

      28

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    
      L.    Contractor's
        Fiscal Solvency Requirements

    

    
      

      The
        Contractor shall comply with all applicable solvency requirements; including
        but
        not limited to New York State Public Health Law Article 44, Part 98 of the
        Commissioner's Rules and Regulations and the fiscal solvency requirements
        of the
        New York State Insuance Department.

    

    
      

      29

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    
      ARTICLE
        VII 

      CONTRACTOR
        RELATIONSHIP WITH SUBCONTRACTORS

    

    
      

      A.       Subcontractor/Provider
        Relations

    

    
      

      
        	
                1.  

              	
                Pursuant
                  to 42 CFR 438.206, the Contractor must maintain a network of appropriate
                  providers that is supported by written agreements and is sufficient
                  to
                  provide adequate access to all services covered under the
                  Contract.

              

      

    

    
      

      
        	
                2.  

              	
                The
                  Contractor agrees to comply with applicable sections of New York
                  State
                  Public Health Law and regulation regarding subcontract requirements,
                  provider relations and termination and federal requirements at
                  42CFR 434.6
                  and 438.6(1) regarding required subcontract provisions, 438.12
                  regarding
                  provider discrimination prohibitions, 438.102 regarding provider-Enrollee
                  communications, 438.214 regarding provider selection, 438.230 regarding
                  subcontractual relationships and
                  delegation.

              

        	3.  	 Provider
                Services 
                The
                  Contractor is responsible to provide the following provider services:
                  
                  
                    (a.)  assisting
                      providers with prior authorization and referral
                      protocols;

                  

                  
                    (b.)  assisting
                      providers with claims payment procedures;

                  

                  
                    (c.)   fielding
                      and responding to provider questions and complaints;

                  

                  
                    (d.)   orientation
                      of providers and subcontractors to program goals, and.

                  

                  
                    (e.)    provider
                      training to improve integrations and coordination of
                      care.

                  

                

              

      

    

    
       

    

    
      B.       Full
        Responsibility Retained

    

    
      

      
        	
                1.  

              	
                Notwithstanding
                  any relationship(s) that the Contractor may have with subcontractors,
                  the
                  Contractor shall maintain full responsibility for adhering to and
                  otherwise fully complying with all applicable laws and regulations,
                  this
                  Contract, all standards and procedures approved by the Department
                  for the
                  plan and the written instructions of the
                  Department.

              

      

    

    
      

      
        	
                2.  

              	
                The
                  Contractor shall oversee and is accountable to the Department for
                  all
                  functions and responsibilities that are described in this
                  Contract.

              

      

    

    
      

      
        	
                3.  

              	
                The
                  Contractor may only delegate activities or functions to a subcontractor
                  in
                  a manner consistent with requirements set forth in this Contract,
                  42CFR
                  434 and 438 and applicable State law and
                  regulations.

              

      

    

    
      

      
        	
                4.  

              	
                The
                  Contractor may only delegate management responsibilities as defined
                  by
                  State regulation by means of a Department approved management services
                  agreement. Both the proposed management services agreement and
                  the
                  proposed management entity must be approved
                  by the Department pursuant to the provisions of 10 NYCRR 98-1.11
                  before
                  any such agreement may be
                  implemented.

              

      

    

    
      

      30

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    
      C.   Required
        Provisions

    

    
      

      
        	
                1.

              	
                The
                  Contractor shall enter into subcontracts only with subcontractors
                  who are
                  in compliance with all applicable State and federal licensing,
                  certification, and other requirements, who are generally regarded as
                  having a good reputation and who have demonstrated capacity to
                  perform the needed contracted services. All subcontracts must meet
                  the requirements of this Contract and applicable State and federal
                  laws
                  and regulations.

              

      

    

    
      

      
        	
                2.  

              	
                Subcontracts
                  shall require the approval of the Department as set forth in PHL
                  4402 and
                  in 10 NYCRR Part 98.

              

      

    

    
      

      
        	
                3.  

              	
                The
                  Contractor shall impose obligations and duties on its subcontractors,
                  including its Participating Providers, that are consistent with
                  this
                  Contract, and that do not impair any rights accorded to the Department
                  or
                  DHHS.

              

      

    

    
      

      
        	
                4.  

              	
                No
                  subcontract, including any provider subcontract, shall limit or
                  terminate
                  the Contractor's duties and obligations under this
                  Contract.

              

      

    

    
      

      
        	
                5.  

              	
                Nothing
                  contained in this Contract between the Department and the Contractor
                  shall
                  create any contractual relationship between any subcontractor of
                  the
                  Contractor, including Participating Providers, and the
                  Department.

              

      

    

    
      

      
        	
                6.  

              	
                Any
                  subcontract entered into by the Contractor shall fulfill the requirements
                  of 42 CFR Part 434 and 438 that are appropriate to the service
                  or activity
                  delegated under such
                  subcontract.

              

      

    

    
      

      
        	
                7.  

              	
                The
                  Contractor shall also ensure 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 Department,
                  the
                  Enrollees, or their eligible
                  dependents.

              

      

    

    
      

      
        	
                8.  

              	
                No
                  contract between the Contractor and a health care provider shall
                  contain
                  any clause purporting to transfer to the health care provider,
                  other than
                  a medical group, by indemnification or otherwise, any liability
                  relating
                  to activity, actions or omissions of the Contractor as opposed
                  to those of
                  the health care provider.

              

      

    

    
      

      
        	
                9.  

              	
                All
                  subcontracts with providers of covered services (including management
                  agreements, if applicable), shall include the following
                  provisions:

              

      

    

    
      

      
        	
                 

              	
                (a.)
                  Any services or other activities performed by a subcontractor in
                  accordance with a contract between the subcontractor and the Contractor
                  will be consistent and comply with the Contractor's obligations
                  under this
                  Contract and applicable state and federal laws and
                  regulations.

              

      

    

    
      

      31

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    
      
        	
                 

              	
                (b.)
                  A provision that the Contractor will provide, no less than thirty
                  (30)
                  days prior to implementation, any new rules or policies and procedures
                  regarding quality improvement, service authorizations, member appeals
                  and
                  grievances and provider credentialing, or any changes thereto,
                  to a
                  provider of covered services that is a
                  subcontractor.

              

      

    

    
      

      
        	
                 

              	
                (c.)
                  No provision of the subcontract is to be construed as contrary
                  to the
                  provisions of Article 44 of the Public Health Law and implementing
                  regulations to the extent they do not conflict with federal law
                  and 42 CFR
                  Parts 434 and 43 8.

              

      

    

    
      

      
        	
                 

              	
                (d.)
                  Specific delegated activities and reporting responsibilities, including
                  the amount, duration and scope of services to be
                  provided.

              

      

    

    
      

      
        	
                 

              	
                (e.)
                  Satisfactory remedies, including termination of a subcontract when
                  the
                  Department or the Contractor determines that such parties have
                  not
                  performed adequately which includes but is not limited to egregious
                  patient harm, significant substantiated complaints, submitting
                  claims to
                  the plan for services not delivered, and refusal to participate
                  in the
                  plan's quality improvement
                  program.

              

      

    

    
      

      
        	
                 

              	
                (f.)
                  Provision for ongoing monitoring of the subcontractor's compliance
                  with
                  the subcontract by the Contractor. Such monitoring provision shall
                  specify
                  requirements for corrective action, revocation of the subcontract
                  or
                  imposing sanctions if the subcontractor's performance is
                  inadequate.

              

        	 	 
                
                (g.)     Specification
                  that either:

              

      

    

    
       

    

    
      
        	
                 

              	
                (i.)
                  the credentials of affiliated professionals or other health care
                  providers
                  will be reviewed directly by the Contractor;
                  or

              

      

    

    
      

      
        	
                 

              	
                (ii.)
                  the credentialing process of the subcontractor will be reviewed
                  and
                  approved by the Contractor and the Contractor must audit the credentialing
                  process on an ongoing basis.

              

      

    

    
      

      
        	
                 

              	
                (h.)
                  A procedure for the resolution of disputes between the Contractor
                  and its
                  subcontractors, or providers. Any and all such disputes shall be
                  resolved
                  using the Department's interpretation of the terms and provisions
                  of this
                  Contract, and portions of subcontracts executed hereunder that
                  relate to
                  services pursuant to this Contract. If a subcontract provides for
                  arbitration or mediation, it shall expressly acknowledge that the
                  Commissioner of the Department of Health is not bound by arbitration
                  or
                  mediation decisions. Arbitration or mediation must occur within
                  New York
                  State, and the subcontract shall provide that the Commissioner
                  will be
                  given notice of all issues going to arbitration or mediation, and
                  copies
                  of all decisions.

              

      

    

    
      

      32

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    
      
        	
                 

              	
                (i.)
                  A provision specifying how the subcontractor shall participate
                  in the
                  Contractor's quality assurance, service authorization and grievance
                  and
                  appeals processes, and the monitoring and evaluation of the Contractor's
                  plan.

              

      

    

    
      

      
        	
                 

              	
                (j.)
                  A provision specifying how the subcontractor will insure that pertinent
                  contracts, books, documents, papers and records of their operations
                  are
                  available to the Department, HHS, Comptroller of the State of New
                  York,
                  Comptroller General of the United States and/or their respective
                  designated representatives, for inspection, evaluation and audit,
                  through
                  six years from the final date of the subcontract or from the date
                  of
                  completion of any audit, whichever is
                  later.

              

      

    

    
      

      
        	
                10.

              	
                 The
                  Contractor agrees to comply with Section 3224-a of State Insurance
                  Law
                  pertaining to prompt payment to providers of covered
                  services.

              

      

    

    
      

      D.       List
        of Covered Services and Subcontractors

    

    
      

      
        	
                1.  

              	
                The
                  Contractor shall provide documentation to demonstrate capacity
                  to serve
                  the expected enrollment in its service area. The documentation
                  shall be at
                  such time and in such format specified by the Department and shall
                  comply
                  with the requirements of 42CFR 438.207 and applicable sections
                  of State
                  law and implementing
                  regulations.

              

      

    

    
      

      
        	
                2.  

              	
                Provider
                  services subcontracts and material amendments thereto shall require
                  the
                  approval of the Department as set forth in Public Health Law 4402
                  and 10
                  NYCRR Part 98.

              

      

    

    
      

      
        	
                3.  

              	
                Any
                  addition to or deletion from the network of providers shall be
                  communicated in writing to the Department by the Contractor, on
                  a
                  quarterly basis.

              

      

    

    
      

      E.           Provider
        Termination Notice

    

    
      

      The
        Contractor shall provide the Department at least sixty (60) days notice prior
        to
        the termination of any subcontract, the termination of which would preclude
        an
        Enrollee's access to a covered service by provider type under this Contract,
        and
        specify how services previously furnished by the subcontractor will be provided.
        In the event a subcontract is terminated on less than sixty (60) days notice,
        the Contractor shall notify the Department immediately but in no event more
        than
        seventy-two (72) hours after notice of termination is either issued or received
        by the Contractor.

    

    
      

      F.           Recovery
        of Overpayments to Providers

    

    
      

      Consistent
        with the exception language in Section 3324-b of the Insurance Law, the
        Contractor shall retain the right to audit participating providers' claims
        for a
        six year period from the date the care, services or supplies were provided
        or
        billed, whichever is later, and to recoup any overpayments discovered as
        a
        result of the audit. This six year limitation does not apply to situations
        in
        which fraud may be involved or in which the provider or an agent of the provider
        prevents or obstructs the Contractor's auditing.

    

    
      

      33

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    
      ARTICLE
        VIII

    

    
      

      RECORDS
        REPORTING AND CERTIFICATION REQUIREMENTS

    

    
      

      A.       Maintenance
        of Contractor Performance Records

    

    
      

      
        	
                1.  

              	
                The
                  Contractor shall maintain a health information system that collects,
                  analyzes, integrates and reports data that meets the requirements
                  of 42
                  CFR 438.242 and Article 44 of the Public Health
                  Law.

              

      

    

    
      

      
        	
                2.  

              	
                The
                  Contractor agrees to maintain for each EnroUee a care management
                  record.
                  The Contractor shall maintain, and shall require its subcontractors
                  to
                  maintain:

              

      

    

    
       

    

    
      
        	(a.)   	appropriate
                records related to services provided to
                Enrollees;

        	
                (b.)
                  

              	
                all
                  financial records and statistical data that the LDSS, the Department
                  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 Contract;
                  and

              

      

    

    
      
        	
                (c.)
                  

              	
                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 relevant, to bear the risk of potential
                  financial losses.

              

      

    

    
      

      
        	
                3.

              	
                Credentials
                  for subcontractors and providers used by subcontractors shall be
                  maintained on file by or in a manner accessible to the Contractor and
                  furnished to the Department,
                  upon request.

              

      

    

    
      

      B.       Maintenance
        of Financial Records and Statistical Data

    

    
      

      The
        Contractor shall maintain all financial records and statistical data according
        to generally accepted accounting principles and/or Statutory accounting
        principles where applicable.

    

    
      

      C.       Access
        to Contractor Records

    

    
      

      The
        Contractor shall provide the LDSS, SDOH, The Comptroller of the State of
        New
        York, the Attorney General 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 Contract 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.

    

    
      

      34

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    
      D.       Retention
        Periods

    

    
      

      The
        Contractor shall preserve and retain all records relating to Contractor
        performance under this Contract in readily accessible form during the term
        of
        this Contract and for a period of six (6) years thereafter. All provisions
        of
        this Contract relating to record maintenance and audit access shall survive
        the
        termination of this Contract and shall bind the Contractor until the expiration
        of a period of six (6) years commencing with termination of this Contract
        or if
        an audit is commenced, until the completion of the audit, whichever occurs
        later.

    

    
      

      E.      Reporting
        Requirements

    

    
      

      
        	
                1.  

              	
                The
                  Contractor shall be responsible for fulfilling the reporting requirements
                  of this Contract. Reports shall be filed in a format specified
                  by the
                  Department and according to the time schedules required by the
                  Department.

              

      

    

    
      

      
        	
                2.  

              	
                The
                  Contractor shall furnish all information necessary for the Department
                  to
                  assure adequate capacity and access for the enrolled population
                  and to
                  demonstrate administrative and management arrangements satisfactory
                  to the
                  Department. The Contractor shall submit periodic reports to the
                  Department
                  in a data format and according to a time schedule required by the
                  Department to fulfill the Department's administrative responsibilities
                  under Section 4403-f of Article 44 of Public Health law and other
                  applicable State and federal laws or regulations. Reports may include
                  but
                  are not limited to information on: availability, accessibility
                  and
                  acceptability of services; enrollment; Enrollee demographics;
                  disenrollment; Enrollee health and functional status (including
                  the
                  Semi-Annual Assessment of Members (SAAM) data set or any other
                  such
                  instrument the Department may request); service utilization; encounter
                  data, Enrollee satisfaction; marketing; grievance and appeals;
                  and fiscal
                  data. The Contractor shall promptly notify the Department of any
                  request
                  by a governmental entity or an organization working on behalf of
                  a
                  governmental entity for access to any records maintained by the
                  Contractor
                  or a subcontractor pursuant to this Contract.

                 

              

        	3. 	
                 The
                  Contractor shall submit the following specific reports to the
                  Department.

              

      

    

    
       

      (a.)    Annual
        Financial Statements:  

       

      In
        accordance with Part 98-1.16, the Contractor shall file in duplicate with
        both
        the Commissioner and the Superintendent of the Department of Insurance (SID)
        a
        financial statement each year in the form prescribed by the Commissioner
        known
        as the Medicaid Managed Care Operating Report (MMCOR). The MMCOR shows the
        condition at last year-end and contains the information required by Section
        4408
        of the Public Health Law. The due date for annual statements shall be April
        1
        following the report closing date.

    

    
      35

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    
      (b.)    Quarterly
        Financial Statements:

    

    
      

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

    

    
      

      (c.)     Other
        Financial Reports:

    

    
      

      Contractor
        shall submit financial reports, including certified annual financial statements,
        and make available documents relevant to its financial condition to the
        Department and SID in a timely manner as required by State laws and regulations
        including but not limited to Public Health Law § 4403-f, 4404 and 4409, Title 10
        NYCRR § 98-1.11, 98-1.16, and 98-1.17 and applicable Insurance Law §§ 304, 305,
        306, and 310.

    

    
      

      (d.)    Encounter
        Data:

    

    
      

      The
        Contractor shall prepare and submit encounter data on a monthly basis to
        Department through its 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 any contracted
        or
        directly provided 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
        Health Provider Network (HPN) to assure the submission is included in the
        fiscal
        agent's monthly production processing.

    

    
      

      (e.)    Disenrollment
        Report:

    

    
      

      This
        report is to be completed twice a year. The first report will cover the
        operation of the plan for the period January 1 through June 30. The second
        report will cover the period from July 1 through December 31. The completed
        report is to be provided to the Department within thirty (30) days after
        the
        period in a format to be specified by the Department.

    

    
      

      (f.)     Grievance
        and Appeal Reports:

    

    
      

      
        	
                 

              	
                i)
                  The Contractor must provide the Department on a quarterly basis,
                  and
                  within fifteen (15) business days of the close of the quarter,
                  a summary
                  of all grievance and appeals received during the preceding quarter
                  using a
                  data transmission method that is determined by the
                  Department.

              

      

    

    
      

      
        	
                 

              	
                ii)
                  The Contractor also agrees to provide on a quarterly basis, within
                  fifteen
                  (15) business days of the close of the quarter, the total number
                  of
                  grievance or appeals that have been unresolved for more than thirty
                  (30)
                  days.   The Contractor shall maintain records on these and
                  other grievances or appeals, which shall include all correspondence
                  related to the grievance or appeal, and an explanation of disposition.
                  These records shall be readily available for review by the Department
                  or
                  LDSS upon request.

              

      

    

    
      

      36

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    
       

    

    
      

      
        	
                 

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

              

      

    

    
      

      (g.)   Fraud
        and Abuse Reporting Requirements:

    

    
      

      
        	
                 

              	
                (i)
                  Pursuant to the program integrity requirements outlined in 42 CFR
                  438.608,
                  the Contractor shall submit reports specifying the number of complaints
                  of
                  fraud and abuse made to the Contractor that warrant preliminary
                  investigation by the Contractor. Such reports must be submitted
                  quarterly,
                  within fifteen (15) business days of the close of the quarter,
                  in a format
                  specified by the Department.

              

      

    

    
      

      
        	
                 

              	
                (ii)
                  The Contractor must also submit to the Department the following
                  on an
                  ongoing basis for each confirmed case of fraud and abuse identified
                  through complaints, organizational monitoring, subcontractors,
                  providers,
                  beneficiaries, Enrollees,
                  etc.:

              

      

    

    
                  

      
        
          
            	1.  	The
                    name of the individual or entity that committed the fraud or
                    abuse;

            	2. 	The
                    source that identified the fraud or abuse;

            	
                    3.

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

                  

            	4. 	 A
                    description of the fraud or abuse;

            	5.	 The
                    approximate range of dollars
                    involved;

          

        

        
          
            	
                    6.

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

                  

            	7. 	Other
                    data/information as prescribed by the
                    Department.

          

        

        
                

        

      

    

    
      
        	
                 

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

              

      

    

    
      

      (h.)
        Performance Improvement Projects:

    

    
      

      The
        Contractor will be required to conduct performance improvement projects that
        focus on clinical and non-clinical areas consistent with the requirements
        of 42
        CFR 438.240. The purpose of these studies will be to promote quality improvement
        within the managed long-term care plan. At least one (1) performance improvement
        project each year will be selected as a priority and approved by the Department.
        Results of each of these annual studies will be provided to the Department
        in a
        required format. Results of other performance improvement projects will be
        included in the minutes of the quality committee and reported to the Department
        upon request.

    

    
      

      37

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    
      (i.)   Enrollee
        Health and Functional Status:

    

    
      

      The
        Contractor shall submit Enrollee health and functional status data for each
        of
        their Enrollees in the format and according to the timeframes specified by
        the
        Department. The data shall consist of the Semi-Annual Assessment of Members
        (SAAM) or any other such instrument the Department may request. The data
        shall
        be submitted at least semi-annually or on a more frequent basis if requested
        by
        the Department.

    

    
      

      (j.)  Additional
        Reports:

    

    
      

      Upon
        request by the Department, 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 Department reserves
        the
        right to give thirty (30) days notice in circumstances where time is of the
        essence.

    

    
      

      F.           Data
        Certification

    

    
      

      The
        Contractor shall comply with the data certification requirements in 42 CFR
        438.604 and 438.606.

    

    
      

      
        	
                1.  

              	
                The
                  types of data subject to certification include, but are not limited
                  to,
                  enrollment information, encounter data, the premium proposal, contracts
                  and all other financial data. The certification shall be in a format
                  prescribed by the Department and must be sent at the time the report
                  or
                  data are submitted.

              

      

    

    
      

      
        	
                2.  

              	
                The
                  certification shall be signed by the Plan's Chief Executive Officer,
                  the
                  Chief Financial Officer or an individual with designated authority;
                  and,
                  the certification shall attest to the accuracy, completeness and
                  truthfulness of the data.

              

      

    

    
      

      G.           Notification
        of Changes in Reporting Due Dates Requirements or
        Formats

    

    
      

      The
        Department may extend due dates, or modify report requirements or formats
        upon a
        written request by the Contractor to the Department, where the Contractor
        has
        demonstrated a good and compelling reason for the extension or modification.
        The
        Department will issue a written response to the request for a modification
        or
        extension of the due date.

    

    
      

      38

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    
      H.
        Ownership and Related Information Disclosure

    

    
      

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

    

    
      

      I.   Role
        of Compliance Officer and Compliance Committee:

    

    
      

      It
        is the
        obligation of the plan to designate a compliance officer and establish a
        compliance committee pursuant to 42 CFR 438.608 (b) (2). It is the obligation
        of
        the compliance officer and compliance committee to:

    

    
      

      
        	
                1.  

              	
                monitor
                  the plan reporting obligations and ensure that the required reports
                  are
                  accurate and submitted in a timely
                  manner;

              

      

    

    
      
        	
                2. 

              	
                develop
                  written policies, procedures and standards of conduct that articulate
                  the
                  plan commitment to adhere to all applicable Federal and State
                  Standards;

              

        	3. 	 conduct
                appropriate staff training activities in an atmosphere of open
                communication;

        	4. 	 establish
                provisions for internal monitoring and auditing;
                and,

      

    

    
      
        	
                5.  

              	
                have
                  provisions for prompt responses to detected offenses with provisions
                  for
                  corrective action initiatives where
                  appropriate.

              

      

    

    
      

      J.    Public
        Access to Reports

    

    
      

      Any
        data,
        information, or reports collected and prepared by the Contractor and submitted
        to New York State authorities in the course of performing their duties and
        obligations under this Contract may be disclosed subject to and consistent
        with
        the requirements of Freedom of Information Law.

    

    
      

      K.
        Professional Discipline

    

    
      

      
        	
                1.

              	
                 Pursuant
                  to Public Health Law Section 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, any
                  of the
                  following:

              

      

    

    
      

      i)    the
        termination of a health care provider contract pursuant to Section 4406-d
        of the
Public
        Health Law 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 provider contract in the case
        of a determination of fraud
        or
        in a case of imminent harm to patient
        health.                                                                                                                

    

    
      39

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    
      
        	
                2.

              	
                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 State Education Law.

              

      

    

    
      
         

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

      The
        Contractor will certify to the Department 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:

    

    
      

      
        	
                1.  

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

              

      

    

    
      

      
        	
                2.  

              	
                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 managed long-term
                  care
                  plan consistent with requirements of SSA §1932
                  (d)(1).

              

      

    

    
      

      M.
        Conflict of Interest Disclosure

    

    
      

      The
        Contractor shall report to the Department in a format specified by the
        Department 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 managed long-term care plan or with any subcontract(s)
        in which the managed long-term care plan has a 5% or more ownership and
        interest, consistent with requirements of SSA § 1903 (m)(2)(a)(viii) and 42 CFR§
§455.100 and 455.104.

    

    
      

      40

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    
      ARTICLE
        IX INTERMEDIATE SANCTIONS

    

    
      

      
        	
                A.

              	
                The
                  Contractor is subject to the imposition of sanctions as authorized
                  by
                  State law and regulation, including the Department's right to impose
                  sanctions for unacceptable practices as set forth in Title 18 of the
                  Official Compilation of Codes, Rules and Regulations of the State of
                  New York (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 services.

              

      

    

    
      

      
        	
                B.

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

              

      

    

    
      

      
        	
                1.  

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

              

      

    

    
       

    

    
      
        	2. 	
                 Imposing
                  premiums or charges on Enrollees.

                 

              

        	
                3. 

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

              

      

    

    
      

      
        	
                4. 

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

              

      

    

    
      

      
        	
                5.

              	
                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.

              

      

    

    
      

      
        	
                6. 

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

                 

              

        	7. 	
                 Violating
                  any other applicable requirements of 18 NYCRR or 10 NYCRR Part
                  98.

                 

              

        	
                C.  

              	
                 Intermediate
                  Sanctions may include but are not limited
                  to:

              

        	
                1. 

              	
                Civil
                  monetary penalties.

              

        	
                2. 

              	
                Suspension
                  of all new enrollment after the effective date of the
                  sanction.

              

        	3. 	 Termination
                of the contract, pursuant to Article I of this
                Agreement.

      

    

    
      
 

    

    
      41

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

     

    
      
        	
                D.

              	
                The
                  Department shall have the right, upon notice to the LDSS, to limit,
                  suspend or terminate enrollment activities by the Contractor and/or
                  enrollment into the managed long- term care plan upon fifteen (15)
                  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 the conclusion that
                  limitation, suspension or termination of enrollment activities
                  or Enrollment in the Contractor's managed long term-care plan is
                  unnecessary. The Department reserves the right to suspend enrollment
                  immediately in situations involving imminent danger to the health and
                  safety of Enrollees. Nothing in this paragraph limits other remedies
                  available to the Department under this
                  Agreement.

              

      

    

    
      

      
        	
                E.

              	
                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).

              

      

    

    
      

      42

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    
      ARTICLE
        X 

       

      GENERAL
        REQUIREMENTS

       

    

    
      A.       Authorized
        Representatives With Respect to Contract

    

    
      

      Upon
        commencement of performance under this Contract, the Department and the
        Contractor shall each designate a contract representative under this Contract
        and shall promptly so notify the other Party in writing. The contract
        representative shall be the contact person for all matters arising under
        this
        Contract. Each Party shall notify the other Party if it designates a new
        contract representative.

    

    
      

      B.       Confidentiality

    

    
      

      
        	
                1.  

              	
                All
                  individually identifiable information relating to Applicants and
                  Enrollees
                  that is obtained by the Contractor shall be safeguarded pursuant
                  to 42CFR
                  431, subpart F and applicable sections of 45CFR parts 160 and 164,
                  42CFR
                  part 2, 42 U.S.C. Section 1396a(a)(7) (Section 1902(a)(7) of the
                  Federal
                  Social Security Act), and regulations promulgated thereunder, and
                  applicable sections of State law and regulation including but not
                  limited
                  to Section 27-F of Public Health Law, Section 369 of the Social
                  Services
                  Law, and Section 33.13 of Mental Hygiene Law. Information shall
                  be used or
                  disclosed by the Contractor pursuant to appropriate consent only
                  for a
                  purpose directly connected with performance of Contractor obligations
                  under this Contract.

              

      

    

    
      

      
        	
                2.  

              	
                Medical
                  records of Applicants and Enrollees shall be confidential and shall
                  be
                  disclosed to and by other persons within the Contractor's organization,
                  including subcontractors, only as necessary to provide health care
                  and
                  quality, peer, or complaint and appeal review of health care under
                  the
                  terms of this Contract.

              

      

    

    
      

      
        	
                3.  

              	
                The
                  provisions of this Section shall survive the termination of this
                  Contract
                  and shall bind the Contractor so long as the Contractor maintains
                  any
                  individually identifiable information relating to Applicants or
                  Enrollees.

              

      

    

    
      

      C.       Additional
        Actions and Documents

    

    
      

      Each
        Party hereby agrees to use its good faith and best efforts to cooperate with
        the
        other and to take or cause to be taken such further actions to execute, deliver,
        and file or cause to executed delivered, and filed such further documents
        and
        instrument, and to use best efforts to obtain such waivers and consents as
        may
        be necessary or as may be reasonably requested in order to effectuate fully
        the
        purposes, terms, and conditions of this Contract and the purposes of the
        plan.

    

    
      

      43

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    
      D.       Relationship
        of the Parties, Status of the Contractor

    

    
      

      The
        Parties agree that the relation of Contractor to the Department will be that
        of
        an independent Contractor. The Parties also agree and acknowledge that
        Contractor is authorized to operate and to perform its obligations under
        this
        Contract pursuant to the provisions of Article 44 of New York State Public
        Health Law, Article 43 of State Insurance Law and Section 402 of the Social
        Security Amendments of 1967, as amended by Section 222(b) of the Social Security
        Amendments of 1972, 42 U.S.C. 1395b-l. The Parties further agree and acknowledge
        that Contractor will not, by virtue of its operation, of its performance
        of its
        obligations hereunder, of its compensation hereunder, or of any other provisions
        of this Contract: (1) be deemed to be an agent or instrumentality of the
        State
        of New York, the United States, or any agency of either, or (2) be deemed
        to be
        a preferred provider organization, third party administrator, or an independent
        practice association.

    

    
      

      E.       Nondiscrimination

    

    
      

      The
        Contractor shall not unlawfully discriminate on the basis of age, race, color,
        gender, creed, religion, disability, sexual orientation, source of payment,
        type
        of illness or condition or place of origin. The Contractor shall operate
        the
        program in compliance with all applicable State and Federal non-discrimination
        laws.

    

    
      

      F.        Employment
        Practices

    

    
      

      
        	
                1.  

              	
                The
                  Contractor shall comply with the nondiscrimination clause contained
                  in
                  Federal Executive Order 11246, as amended by Federal Executive
                  Order
                  11375, relating to Equal Employment Opportunity for all persons
                  without
                  regard to race, color, religion, sex or national origin, the implementing
                  rules and regulations prescribed by the Secretary of Labor at 41
                  CFR Part
                  60 and with the Executive Law of the State of New York, Section
                  291-299
                  thereof and any rules or regulations promulgated in accordance
                  therewith.
                  The Contractor shall likewise be responsible for compliance with
                  the
                  above-mentioned standards by subcontractors with whom the Contractor
                  enters into a contractual relationship in furtherance of this
                  Contract.

              

      

    

    
      

      
        	
                2.  

              	
                The
                  Contractor shall comply with regulations issued by the Secretary
                  of Labor
                  of the United States in 20 CFR Part 741, pursuant to the provisions
                  of
                  Executive Order 11758, and with the Federal Rehabilitation Act
                  of 1973 and
                  the Americans with Disabilities Act of 1990. The Contractor shall
                  likewise
                  be responsible for compliance with the above mentioned standards
                  by
                  subcontractors with whom the Contractor enters into a contractual
                  relationship in furtherance of this
                  Contract.

              

      

    

    
      

      G.           Dispute
        Resolution

    

    
      

      The
        Contractor and the LDSS shall jointly develop and use a process for resolving
        disputes
        with   regard   to   the   accuracy   of  assessments   performed   for   enrollment,   involuntary
        disenrollments and for continued stay decisions when the Enrollee no longer
        meets the nursing home level of care as determined at the last comprehensive
        assessment of the calendar year.

    

    
      

      44

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

     

    
      H.
        Assignment

    

    
      

      This
        Contract shall not be assignable by the Contractor without the prior written
        consent of the Commissioner.

    

    
      

      I.   Binding
        Effect

    

    
      

      Subject
        to any provisions hereof restricting assignment, this Contract shall be binding
        upon and shall inure to the benefit of the Parties and their respective
        successors and permitted assignees.

    

    
      

      J.   Limitation
        on Benefits of this Contract

    

    
      

      It
        is the
        explicit intention of the Parties that no Enrollee, person or other entity,
        other than the Parties, is or shall be entitled to bring any action to enforce
        any provision of this Contract against the other Party, and that the covenants,
        undertakings, and agreements set forth in this Contract shall be solely for
        the
        benefit of, and shall be enforceable only by the Parties, or their respective
        successors and assignees, as permitted hereunder; provided, however, that
        the
        covenants, undertakings, and agreements set forth in Article VI, Section
        J
        hereof shall be construed for the benefit of the Enrollees.

    

    
      

      K.
        Entire Contract

    

    
      

      This
        Contract (including the Schedules and Appendices hereto) constitutes the
        entire
        Contract between the Parties with respect to the subject matter hereof, and
        it
        supersedes all prior oral or written agreements, commitments, or understandings
        with respect to the matters provided for herein. This Contract shall not
        be
        deemed to apply to individuals who are not Enrollees.

    

    
      

      L.
        Conflicting Provisions

    

    
      

      In
        the
        event of any conflict between the provisions of the main body of this Contract
        and the provisions of any Appendix or Schedule(s) attached hereto, the
        provisions of the main body of this Contract shall govern, unless a provision
        of
        an Appendix or a Schedule explicitly states that it shall supersede the main
        body of this Contract.

    

    
      

      M.
        Modification

    

    
      

      This
        Contract is subject to amendment or modification only upon mutual consent
        of the
        Parties reduced to writing. Attached Appendix X is the form to be used in
        modification of this Contract. Any such amendment or modification is not
        binding
        on the Parties unless and until approved by the Comptroller of the State
        of New
        York.

    

    
      

      45

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    
      N.
        Headings

    

    
      

      Article
        and Section headings contained in this Contract are inserted for convenience
        of
        reference only, shall not be deemed to be a part of this Contract for any
        purpose, and shall not, in any way, define or affect the meaning, construction,
        or scope of any of the provisions hereof.

    

    
      

      O.
        Pronouns

    

    
      

      All
        pronouns and any variations thereof shall be deemed to refer to the masculine,
        feminine, neuter, singular or plural as the identity of the person or entity
        may
        require.

    

    
      

      P.
        Notices

    

    
      

      All
        notices, demands, requests, reports, or other communications which may be
        or are
        required to be given, served or sent by either Party to the other Party pursuant
        to this Contract shall be in writing and shall be mailed by first-class
        registered or certified mail, return receipt requested, postage prepaid,
        or
        transmitted by hand delivery, or telegram, overnight package delivery, addressed
        as follows:

    

    
      

      (l)If
        to
        the Department:

    

    
      Director

    

    
      

      Division
        of Managed Care and Program Evaluation

    

    
      New
        York
        State Department of Health

    

    
      Corning
        Tower.

    

    
      Empire
        State Plaza

    

    
      Albany,
        New York 12237

    

    
      with
        a
        copy (which shall not constitute notice) to:

    

    
      

      Director

    

    
      Bureau
        of
        Continuing Care Initiatives

    

    
      Division
        of Managed Care and Program Evaluation

    

    
      

      New
        York
        State Department of Health.

    

    
      

      Room
        2084

    

    
      Corning
        Tower

    

    
      Empire
        State Plaza

    

    
      Albany,
        New York 12237

    

    
      

      (2)If
        to
        SID:

    

    
      Co-Chief

    

    
      Health
        Bureau

    

    
      New
        York
        State Insurance Department

    

    
      One
        Commerce Plaza

    

    
      Albany,
        NY 12257

    

    
      

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      (3)  If
        to Contractor:

    

    
      Chief
        Executive Officer 

      WellCare
        of New York, Inc. 

      11
        West
        19th Street 

      New
        York,
        NY 10011

    

    
      

      Each
        Party may designate by notice in writing a new address to which any notice,
        demand, request, report, or communication may be thereafter so given, served,
        or
        sent. Each notice, demand, request, report, or communication which shall
        be
        mailed, delivered, or transmitted in the manner described above shall be
        deemed
        sufficiently given, served, sent, and received for all purposes at such time
        as
        it is delivered to the addressee (with the return receipt, the delivery receipt,
        the affidavit of the messenger or the answer back or confirmation being deemed
        conclusive, but not exclusive, evidence of such delivery) or at such time
        as
        delivery is refused by the addressee upon presentation. The Parties agree
        further to copy the Department's local designee or designated contact person
        on
        any notice subject to this Section.

    

    
      

      Q.
        Partial Invalidity

    

    
      

      Should
        any provision of this Contract be declared or found to be illegal, invalid,
        ineffective, unenforceable or void, then each Party shall be relieved of
        any
        obligation arising from such provision; the balance of this Contract, if
        capable
        of performance, shall remain in full force and effect.

    

    
      

      R.
        Force Majeure

    

    
      

      Each
        Party shall use all efforts to perform its obligations under this Contract
        but
        shall be excused for failure to perform or for delay in performance hereunder
        due to unforeseeable circumstances beyond its reasonable control or which
        could
        not have been prevented by it, including but not limited to acts of God,
        floods,
        hurricanes, earthquakes, acts of war, civil unrest, or embargoes; provided,
        that
        acts of any governmental body shall be deemed not to be a force
        majeure.

    

    
      

      S.  Survival

    

    
      

      The
        termination or expiration of this Contract shall not affect vested or accrued
        rights or obligations of the Parties existing as of the date of such termination
        or expiration or other obligations expressly intended to survive the termination
        or expiration hereof. Without limiting the generality of the foregoing, the
        following provisions of this Contract shall survive any expiration or
        termination of this Contract: entire Article VI; entire Article VIII; Section
        V.
        D.; Sections I.E. I.F. and I.G; Sections X.B, X.E, X.H, X.K, X.L, X.M, X.V,
        X.AA, Appendix A and all definitional provisions of this Contract to the
        extent
        that they pertain to any other surviving provisions or
        obligations.

    

    
      

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      T.   State
        Standard Appendix A

    

    
      

      The
        Parties agree to be bound by the terms and conditions of "Standard Clauses
        for
        New York State Contracts, June 2006" attached hereto and incorporated herein
        as
        Appendix A.

    

    
      

      U.
        Indemnification of the Department

    

    
      

      
        	
                1.

              	
                The
                  Contractor shall indemnify, defend and hold harmless the Department,
                  the
                  State, its officers, agents and employees and the Enrollees and their
                  eligible dependents from:

              

      

    

    
      

      
        	
                 

              	
                (a.)
                  any and all claims and losses incurred by or accruing or resulting
                  from
                  the acts or omissions of all Contractor's, subcontractors, materialmen,
                  laborers and any other person, firm or corporation furnishing or
                  supplying
                  work, services, materials, or supplies in connection with the performance
                  of this Contract;

              

      

    

    
      

      
        	
                 

              	
                (b.)any
                  and all claims and losses incurred by, accruing, or resulting to
                  any
                  person, firm or corporation who may be injured or damaged by the
                  acts or
                  omissions of the Contractor, its officers, agents and employees
                  or
                  subcontractors, including Participating Providers, in connection
                  with the
                  performance of this Contract;
                  and

              

      

    

    
      

      
        	
                 

              	
                (c.)
                  against any liability, including costs and expenses, for violation
                  of
                  proprietary rights, copyrights, or rights of privacy, arising out
                  of
                  publication, translation, reproduction, delivery, performance,
                  use or
                  disposition of any data furnished by the Contractor under this
                  Contract or
                  based on any libelous or otherwise unlawful matter contained in
                  such
                  data.

              

      

    

    
      

      
        	
                2.  

              	
                The
                  Department shall provide the Contractor with prompt written notice
                  of any
                  claim made against the Department. The Contractor, at its sole
                  option,
                  shall defend or settle said claim. The Department shall cooperate
                  with the
                  Contractor, to the extent necessary for the Contractor to discharge
                  its
                  obligations hereunder.

              

      

    

    
      

      
        	
                3.  

              	
                The
                  Contractor shall have no obligation hereunder with respect to any
                  claim or
                  cause of action for damages to persons or property to the extent
                  caused by
                  the Department, its employees or
                  agents.

              

      

    

    
      

      V.
        Environmental Compliance

    

    
      

      The
        Contractor shall comply with all applicable standards, orders or regulations
        issued pursuant to the Clean Air Act, 42 U.S.C. 7401 et seq., and the Federal
        Water Pollution Control Act, as amended, 33 U.S.C. 1251 et seq. The Contractor
        shall report violations to the Department, Department of Health and Human
        Services (DHHS) and to the appropriate Regional Office of the Environmental
        Protection Agency.

    

    
      

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      W.
        Energy Conservation

    

    
      

      The
        Contractor shall comply with any applicable mandatory standards and policies
        relating to energy efficiency which are contained in the State Energy
        conservation plan issued in compliance with the Energy Policy and Conservation
        Act of 1975, Pub. L. 94-163 42 U.S.C. 6321 et seq., and any amendment
        thereto.

    

    
      

      X.
        Prohibition on Use of Federal Funds for Lobbying

    

    
      

      
        	
                1.  

              	
                The
                  Contractor agrees, pursuant to Section 1352, Title 31, United States
                  Code,
                  and 45 CFR Part 93 not to expend federally appropriated funds received
                  under this Contract to pay any person for influencing or attempting
                  to
                  influence an officer or employee of an agency, a member of Congress,
                  an
                  officer or employee of Congress, or an employee of a member of
                  Congress in
                  connection with the awarding of any federal contract, the making
                  of any
                  federal grant, the making of any federal loan, the entering into
                  of any
                  cooperative agreement, and the extension, continuation, renewal,
                  amendment, or

              

      

    

    
      

      
        	
                2.  

              	
                Modification
                  of any federal contract, grant, loan or cooperative agreement.
                  The
                  Contractor agrees to complete and submit the "Certification Regarding
                  Lobbying", attached hereto as Appendix C and incorporated herein,
                  if this
                  Contract exceeds $100,000.

              

      

    

    
      

      
        	
                3.  

              	
                If
                  any funds other than federally appropriated funds have been paid
                  or will
                  be paid to any person for influencing or attempting to influence
                  an
                  officer or employee of an agency, a member of Congress, an officer
                  or
                  employee of Congress, or an employee of a member of Congress in
                  connection
                  with this Contract or the underlying Federal grant and the agreement
                  exceeds $100,000 the contractor agrees to complete and submit Standard
                  Form-LLL, "Disclosure of Lobbying Activities", attached hereto
                  as Appendix
                  D and incorporated herein, in accordance with its
                  instructions.

              

      

    

    
      

      
        	
                4.  

              	
                The
                  Contractor shall include the provisions of this Section in all
                  subcontracts under this Contract and require that all subcontractors
                  whose
                  contract exceeds $100,000 certify and disclose accordingly to the
                  Contractor.

              

      

    

    
      

      Y.
        Waiver of Breach

    

    
      

      No
        term
        or provision of this Contract shall be deemed waived and no breach excused,
        unless such waiver or consent shall be in writing and signed by the Party
        claimed to have waived or consented. Any consent by a Party to, or waiver
        of, a
        breach under this Contract shall not constitute consent to, a waiver of,
        or
        excuse for any other, different or subsequent breach.

    

    
      

      Z.
        Choice of Law

    

    
      

      This
        Contract shall be interpreted according to the laws of the State of New York,
        without reference to choice of law principles. The Contractor shall be
        required to bring any legal proceeding against the Department or the State
        arising from this Contract in New York State courts.

    

    
      

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      AA.
        Executory Provision and Federal Funds

    

    
      

      The
        State
        Finance Law of the State of New York, Section 112, requires that any contract
        made by a State Department which exceeds fifteen thousand dollars ($15,000)
        in
        amount be first approved by the Comptroller of the State of New York before
        becoming effective. The Parties recognize that this Contract is wholly executory
        and not binding until and unless approved by the Comptroller of the State
        of New
        York. The Parties also agree that the effectiveness of this Contract is
        conditioned upon receipt of any approval required pursuant to federal law
        to
        permit full Federal financial participation in the costs hereof. Contractor
        agrees to comply with all applicable federal audit requirements including
        but
        not limited to OMB Circular A-8 7 and other applicable federal rules and
        procedures concerning use of federal funds.

    

    
      

      BB.
        Renegotiation

    

    
      

      In
        the
        event any part of this Contract is found to be invalid or unenforceable under
        applicable law and alters the general scope of contractual performance or
        a
        change occurs in applicable State or Federal law, rules or regulations or
        federal or State interpretations

    

    
      

      thereof
        which requires alteration of the general scope of contractual performance
        to
        remain in compliance therewith, or the Department obtains a waiver of such
        applicable Federal law, rule or regulation, either Party may initiate
        re-negotiation of the terms and conditions of this Contract to preserve the
        benefit bargained for. If the Parties are unable to agree on a revision of
        contractual terms and conditions consistent with the altered scope of
        contractual performance, either Party may terminate this Contract as of the
        last
        day of the month following the month in which written notice of termination
        is
        given, subject to the provisions of Article I, Sections F
        andG.

    

    
      

      CC.
        Affirmative Action

    

    
      

      The
        Contractor agrees to comply with all applicable Federal and State
        nondiscrimination statutes including:

    

    
      

      
        	
                1.  

              	
                The
                  Civil Rights Acts of 1964, as amended; Executive Order No. 11246
                  entitled
                  "Equal Employment Opportunity," as amended by Executive Order 11375,
                  and
                  as supplemented in Department of Labor Regulation 41 CFR Part 60;
                  Executive Law of the State of New York, Sections 290-299 thereof,
                  and any
                  rules or regulations promulgated in accordance therewith; Section
                  504 of
                  the Rehabilitation Act of 1973 and the Regulations issued pursuant
                  thereto
                  contained in 45 CFR Part 84 entitled "Nondiscrimination on the
                  Basis of
                  Handicap in Programs and Activities Receiving or Benefiting from
                  Federal
                  Financial Assistance"; and the Americans with Disabilities Act
                  (ADA) of
                  1990, 42 U.S.C. Section 12116, and regulations issued by the Equal
                  Employment Opportunity Commission which implement the employment
                  provisions of the ADA, set forth at 29 CFR Part
                  1630.

              

      

    

    
      

      
        	
                2.  

              	
                The
                  Contractor is required to demonstrate effective affirmative efforts
                  and to
                  ensure employment of protected class members. The Contractor must
                  possess
                  and may, upon request
                  be required to submit to the Department a copy of an Affirmative
                  Action
                  Plan which is in full compliance with applicable requirements of
                  federal
                  and State statutes.

              

      

    

    
      

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                3.  

              	
                Contractors
                  and subcontractors shall undertake or continue existing programs
                  of
                  affirmative action to ensure that minority group members and women
                  are
                  afforded equal employment opportunities without discrimination
                  because of
                  race, creed, religion, color, national origin, sex, age, disability
                  or
                  marital status. For these purposes, affirmative action shall apply
                  in the
                  areas of recruitment, employment, job assignment, promotion, upgrading,
                  demotion, transfer, layoff, or termination and rates of pay or
                  other forms
                  of compensation.

              

      

    

    
      

      
        	
                4.  

              	
                Prior
                  to the award of a State contract, the Contractor shall submit an
                  Equal
                  Employment Opportunity (EEO) Policy Statement to the Department
                  within the
                  time frame established by the
                  Department.

              

      

    

    
      

      
        	
                5.  

              	
                The
                  Contractor's EEO Policy Statement shall contain, but not necessarily
                  be
                  limited to, and the Contractor, as a precondition to entering into
                  a valid
                  and binding State contract, shall, during the performance of the
                  State
                  contract, agree to the
                  following:

              

      

    

    
      

      
        	
                 

              	
                (a.)
                  The Contractor will not discriminate against any employee or Applicant
                  for
                  employment because of race, creed, religion, color, national origin,
                  sex,
                  age, sexual orientation, disability or marital status, will undertake
                  or
                  continue existing programs or affirmative action to ensure that
                  minority
                  group members and women are afforded equal employment opportunities
                  without discrimination, and shall make and document its conscientious
                  and
                  active efforts to employ and utilize minority group members and
                  women in
                  its work force on State
                  contracts.

              

      

    

    
      

      
        	
                 

              	
                (b.)
                  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, religion, color, national
                  origin,
                  sex, age, disability or marital
                  status.

              

      

    

    
      

      
        	
                 

              	
                (c.)
                  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 of other agreement
                  or
                  understanding, to furnish a written statement that such employment
                  agency,
                  labor union, or representative will not discriminate on the basis
                  of race,
                  creed, religion, color, national origin, sex, age, sexual orientation,
                  disability or marital status and that such union or representative
                  will
                  affirmatively cooperate in the implementation of the Contractor's
                  obligations herein.

              

      

    

    
      

      
        	
                 

              	
                (d.)
                  Except for construction contracts, prior to an award of a State
                  contract,
                  the Contractor shall submit to the contracting agency a staffing
                  plan of
                  the anticipated work force to be utilized on the State contract
                  or, where
                  required, information on the Contractor's total work force, including
                  apprentices, broken down by specified ethnic background, gender,
                  and
                  Federal Occupational Categories or other appropriate categories
                  specified
                  by
                  the contracting agency. The form of the staffing plan shall be
                  supplied by
                  the contracting
                  agency.

              

      

    

    
      

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                (e.)
                  After an award of a State contract, the Contractor shall submit
                  to the
                  contracting agency a work force utilization report, in a form and
                  manner
                  required by the agency, of the work force actually utilized on
                  the State
                  contract, broken down by specified ethnic background, gender, and
                  Federal
                  Occupational Categories or other appropriate categories specified
                  by the
                  contracting agency.

              

      

    

    
      

      
        	
                 

              	
                (f.)
                  In the event that the Contractor is found through an administrative
                  or
                  legal action, whether brought in conjunction with this Contract
                  or any
                  other activity engaged in by the Contractor, to have violated any
                  of the
                  laws recited herein in relation to the Contractor's duty to ensure
                  equal
                  employment to protected class members, the Department may, in its
                  discretion, determine that the Contractor has breached this
                  Contract.

              

      

    

    
      

      
        	
                 

              	
                (g.)
                  Additionally, the Contractor and any of its subcontractors shall
                  be bound
                  by the applicable provisions of Article 15-A of the Executive Law,
                  including Section 316 thereof, and any rules or regulations adopted
                  pursuant thereto. The Contractor also agrees that any goal percentages
                  contained in this Contract are subject to the requirements of Article
                  15-A
                  of the Executive Law and regulations adopted pursuant thereto.
                  For
                  purposes of this Contract the goals established for
                  subcontracting/purchasing with Minority and Women-Owned business
                  enterprises are 0% to 5%. The employment goals for the hiring of
                  protected
                  class persons are 5% to 10%.

              

      

    

    
      

      The
        Contractor shall be required to submit reports as required by the Department,
        in
        a format determined by the Department, concerning the Contractor's compliance
        with the above provisions, relating to the procurement of services, equipment
        and or commodities, subcontracting, staffing plans and for achievement or
        employment goals. The Contractor agrees to make available to the Department
        upon
        request, the information and data used in compiling such
        reports.

    

    
      

      It
        is the
        policy of the Department to encourage the employment of qualified
        applicants/recipients of public assistance by both public organizations and
        private enterprises who are under contractual agreement to the Department
        for
        the provision of goods and services. The Department may require the Contractor
        to demonstrate how the Contractor has complied or will comply with the aforesaid
        policy.

    

    
      

      DD.
        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 Contractors, subcontractors, and suppliers on its procurement
        contracts. The Omnibus Procurement Act of 1992 requires that by signing this
        Contract, the Contractor certifies that whenever the total contract is greater
        than $1 million:

    

    
      

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                1.  

              	
                The
                  Contractor has made reasonable efforts to encourage the participation
                  of
                  New York State Business Enterprises as suppliers and subcontractors
                  on
                  this project, and has retained the documentation of these efforts
                  to be
                  provided upon request to the
                  State;

              

      

    

    
      

      
        	
                2.  

              	
                The
                  Contractor has complied with the Federal Equal Opportunity Act
                  of 1972
                  (Pub. L. 92-261), as amended;

              

      

    

    
      

      
        	
                3.  

              	
                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
                  such documentation upon
                  request;

              

      

    

    
      

      
        	
                4.  

              	
                The
                  Contractor acknowledges notice that New York 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.

              

      

    

    
      

      EE.
        Fraud and Abuse

    

    
      

      The
        Contractor shall comply with the program integrity requirements of 42 CFR
        438.608 and operate in a manner as to ensure a prompt organizational response
        to
        detect offenses and development of corrective action initiatives. The Contractor
        shall also establish and adhere to a process for reporting to the Department
        credible information of violations of law by the Contractor subcontractors
        or
        Enrollees for a determination as to whether criminal, civil or administrative
        action may be appropriate. With respect to Enrollees, this reporting shall
        be
        restricted to credible information on violations of law with respect to
        enrollment in the plan or the provision of, or payment for, health
        services.

    

    
      

      FF.  Nondiscrimination
        in Employment in Northern Ireland

    

    
      

      In
        accordance with Chapter 807 of the Laws of 1992, the Contractor agrees that,
        if
        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 in the Contractor, has business operations in Northern
        Ireland, the Contractor, or such individual or legal entity, shall take lawful
        steps in good faith to conduct any business operations it has in Northern
        Ireland in accordance with MacBride Fair Employment Principles relating to
        nondiscrimination in employment and freedom of workplace opportunity, and
        shall
        permit independent monitoring of its compliance with such
        Principles.

    

    
      

      GG.
        Contract Insurance Requirements.

    

    
      

      The
        Contractor must, without expense to the State, procure and maintain, for
        the
        full term of the contract, insurance of the kinds and in the amounts hereinafter
        provided, in insurance companies authorized to do such business in the State
        of
        New York covering all operations

    

    
      

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      under
        this Contract, whether performed by it or by subcontractors. Before commencing
        the work, the Contractor shall furnish to the Department of Health a certificate
        or certificates, in a form satisfactory to said Department, 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 canceled
        until thirty (30) days written notice has been given to said Department.
        The
        kinds and amounts of required insurance are:

    

    
      

      
        	
                1.  

              	
                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 Contract shall be void and of no effect
                  unless
                  the Contractor procures such policy and maintains it for the full
                  term of
                  the Contract.

              

      

    

    
      

      
        	
                2.  

              	
                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
                  proposal and the contract.

              

      

    

    
      

      
        	
                 

              	
                (b.)
                  Protective Liability Insurance issued to and covering the liability
                  of the
                  People of the State of New York with respect to all operations
                  under this
                  Contract, by the Contractor or by its subcontractors, including
                  omissions
                  and supervisory acts of the
                  State.

              

      

    

    
      

      
        	
                 

              	
                (c.)
                  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
                  Contract, by the Contractor or by its subcontractors, including
                  omissions
                  and supervisory acts of the
                  State.

              

      

    

    
      

      HH.
        Minority and Women Owned Business Policy Statement

    

    
      

      The
        New
        York State Department of Health 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 Department of Health'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 New York State Department of Health to fully execute the
        mandate of Executive Order-21 and 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.

    

    
      

      54

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    
      To
        implement this affirmative action policy statement, the Contractor agrees
        to
        file with the Department of Health within 10 days notice of award, a staffing
        plan of the anticipated work force to be utilized on this Contract or, where
        required, information on the Contractor's total work force, including
        apprentices, broken down by specified ethnic background, gender, and Federal
        occupational categories or other appropriate categories specified by the
        Department. The form of the staffing shall be supplied by the Department,
        after
        an award of this Contract, the Contractor agrees to submit to the Department
        a
        work force utilization report, in a form and manner required by the Department,
        of the work force actually utilized on this Contract, broken down by specified
        ethnic background, gender and Federal occupational categories or other
        appropriate categories or other appropriate categories specified by the
        Department.

    

    
      

      II.
        Provisions Related to New York State Information Security Breach and
        Notification Act

    

    
      

      CONTRACTOR
        shall comply with the provisions of the New York State Information Security
        Breach and Notification Act (General Business Law Section 899-aa; State
        Technology Law Section 208). CONTRACTOR shall be liable for the costs associated
        with such breach if caused by CONTRACTOR'S negligent or willful acts or
        omissions, or the negligent or willful acts or omissions of CONTRACTOR'S
        agents,
        officers, employees or subcontractors.

    

    
      

      55

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    
      
         

        APPENDIX
          A

        New
          York State Standard Contract Clauses

      

      
         

         

        
 

         

      

      
        2007

      

      
        APPENDIX
          A

      

      
        STANDARD
          CLAUSES

      

      
        -1-

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        STANDARD
          CLAUSES FOR NYS CONTRACTS

      

      
        

        APPENDIX
          A

      

      
        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 that
          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 set­off 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 this 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 the Contractor

      

      
        

        
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            1
May,
          2003

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        STANDARD
          CLAUSES FOR NYS CONTRACTS

      

      
        

        APPENDIX
          A

      

      
        

        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 (the
          "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 property 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
          furnish 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.

      

      
        

        Page
          2

        May,
          2003

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        STANDARD
          CLAUSES FOR NYS CONTRACTS

      

      
        

        APPENDIX
          A

      

       

      
        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--7lh 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.state.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.

      

      
        

        Page
          3

      

      
        May,
          2003

         

         

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

      

    

    

    
      
        	
                 

              	
                APPENDIX
                  B

                 

                RESERVED

              

      

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    
      APPENDIX
        C

    

    
      

      CERTIFICATION
        REGARDING LOBBYING

    

    
      

      The
        undersigned certified, 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 awarding of any Federal loan, the entering into any cooperative
                  agreement, or the extension, continuation, renewal, amendment,
                  or
                  modification of any Federal contract, grant, loan or
                  cooperative.

              

      

    

    
      

      
        	
                2.  

              	
                If
                  any funds other than Federal appropriated funds have been paid
                  or will be
                  paid to any person for 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 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
        placed when this transaction was made or entered into. Submission of this
        certification is a prerequisite for making or entering into this transaction
        imposed pursuant to U.S.C. 1352 The failure to file the required certification
        shall subject the violator to a civil penalty of not less than $10,000 and
        no
        more than $100,000 for each such failure.

      

    

    
      
        
          	Date:
                  5/31/2007    	
                    
                    /s/  Todd S. Farha     

                  Signature

                   

                	 
	 Name
                  (Printed): Todd S. Farha	
                   Title:
                    President & CEO

                   

                	 
	 Organization: 
                  WellCare of New York, Inc.	 	 

        

      

    

    
      

      
 

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    
      APPENDIX
        D

       

       

      Standard
        Form LLL Disclosure of Lobbying Activities

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    
      

        
          	
                  Disclosure
                    of Lobbying Activities

                  Complete
                    this form to disclose lobbying activities pursuant to 31 U.S.C.
                    1352

                  (See
                    reverse for public burden disclosure)

                
	
                  1.
                    Type of Federal Action:

                  a.
                    contract

                  ___b.
                    grant

                  c.
                    cooperative agreement

                  d.
                    loan

                  e.
                    loan guarantee

                  f.
                    loan insurance

                	
                  
                     

                    2. Status
                      of Federal Action:

                  

                  
                    a. bid/offer/application

                    b.
                      initial award

                  

                  
                    c. post-award

                  

                   

                	
                  
                    3.    Report
                      Type:

                  

                  
                                a.
                      initial filing

                  

                  
                    ______b,
                      material change

                  

                  
                     

                    For
                      material change only:

                  

                  Year
                    ____ quarter _______

                  Date
                    of last report _______

                
	
                  
                    4.  Name
                      and Address of Reporting
                      Entity:

                  

                  
                    _______Prime                                _____  Subawardee

                  

                  Tier
                    __________, if Known:

                   

                  Congressional
                    District, if known:

                   

                	
                  5.
                    If reporting Entity in No.4 is Subawardee, Enter

                  Name
                    and Address of Prime

                   

                   

                  Congressional
                    District, if known:

                   

                
	
                  6.  Federal
                    Department / Agency:

                	
                  7.
                    Federal Program Name/ Description:

                   

                  CFDA
                    Number, if applicable:________________

                
	
                  8.
                    Federal Action Number, if known

                	
                  9.
                    Award Amount, if known

                   

                
	
                  10.
                    a. Name and Address of Lobbying Registrant

                	
                  b.
                    Individuals Performing Services (including address if different from
                    No. 10a)

                  (last
                    name, first name, MI)

                   

                
	
                  11.
                    Information requested through this form is authorized by title
                    31 U.S.C.
                    section 1352. This disclosure of lobbying activities is a material
                    representation of fact upon which reliance was placed by the
                    tier above
                    when this transaction was made or entered into. This disclosure
                    is
                    required pursuant to 31 U.S.C. 1352. This information will be
                    reported to
                    the Congress semi-annually and will be available for public inspection.
                    Any person who fails to file the required disclosure shall be
                    subject to a
                    civil penalty of not less than SI0,000 and not more than $100,000
                    for each
                    such failure.

                	
                  
                     

                    Signature:________________________________

                  

                  
                     

                    Print
                      Name: _____________________________

                  

                  
                     

                    Title:
                      __________________________________

                  

                  
                     

                    Telephone
                      No.:___________________________

                  

                  
                     

                    Date:__________________________________

                  

                   

                
	 	
                  Authorized
                    for Local Reproduction Standard Form - LLL (Rev.
                    7-97)

                

        

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

        
          INSTRUCTIONS
            FOR COMPLETION OF SF-LLL, DISCLOSURE OF LOBBYING
            ACTIVITIES

        

        
          

          This
            disclosure form shall be completed by the reporting entity, whether subawardee
            or prime Federal recipient, at the initiation or receipt of a covered
            Federal
            action, or a material change to a previous filing, pursuant to title
            31 U.S.C.
            section 1352. The filing of a form is required for each payment or agreement
            to
            make payment to any lobbying entity for 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
            a covered Federal action. Complete all items that apply for both the
            initial
            filing and material change report. Refer to the implementing guidance
            published
            by the Office of Management and Budget for additional
            information.

        

        
          

          
            	
                    1.

                  	
                    Identify
                      the type of covered Federal action for which lobbying activity
                      is and/or
                      has been secured to influence the outcome of a covered Federal
                      action.

                  

            	2. 	 Identify
                    the status of the covered Federal
                    action.

          

        

        
          
            	
                    3.

                  	
                    Identify
                      the appropriate classification of this report. If this is a
                      followup
                      report caused by a material change to the information previously
                      reported,
                      enter the year and quarter in which the change occurred. Enter
                      the date of
                      the last previously submitted report by this reporting entity
                      for this
                      covered Federal action.

                  

          

        

        
          
            	
                    4.

                  	
                    Enter
                      the full name, address, city, State and zip code of the reporting
                      entity.
                      Include Congressional District, if known. Check the appropriate
                      classification of the reporting entity that designates if it
                      is, or
                      expects to be, a prime or subaward recipient. Identify the
                      tier of the
                      subawardee, e.g., the first subawardee of the prime is the
                      1st tier.
                      Subawards include but are not limited to subcontracts, subgrants
                      and
                      contract awards under grants.

                  

          

        

        
          
            	
                    5.

                  	
                    If
                      the organization filing the report in item 4 checks "Subawardee,"
                      then
                      enter the full name, address, city, State and zip code of the
                      prime
                      Federal recipient. Include Congressional District, if
                      known.

                  

          

        

        
          
            	
                    6.

                  	
                    Enter
                      the name of the federal agency making the award or loan commitment.
                      Include at least one organizational level below agency name,
                      if known. For
                      example, Department of Transportation, United States Coast
                      Guard.

                  

          

        

        
          
            	
                    7.

                  	
                    Enter
                      the Federal program name or description for the covered Federal
                      action
                      (item 1). If known, enter the full Catalog of Federal Domestic
                      Assistance
                      (CFDA) number for grants, cooperative agreements, loans, and
                      loan
                      commitments.

                  

            	 8. 	Enter
                    the most appropriate Federal identifying number available for
                    the Federal
                    action identified in item 1 (e.g., Request
                    for Proposal (RFP) number; Invitations for Bid (IFB) number;
                    grant
                    announcement number; the contract, grant, or loan award number;
                    the
                    application/proposal control number assigned by the Federal agency).
                    Included prefixes, e.g.,
                    "RFP-DE-90-001."

            	 9. 	 For
                    a covered Federal action where there has been an award or loan
                    commitment
                    by the Federal agency, enter the Federal amount of the award/loan
                    commitment for the prime entity identified in item 4 or
                    5.

            	 10.	 (a)
                    Enter the full name, address, city, State and zip code of the
                    lobbying
                    registrant under the Lobbying Disclosure Act of
                    1995 engaged by the reporting entity identified in item 4 to
                    influence the
                    covered Federal action. 
                    (b)
                      Enter the full names of the individual(s) performing services,
                      and include
                      full address if different from 10(a). Enter Last Name, First
                      Name, and
                      Middle Initial (MI).

                  

            	 11. 	 The
                    certifying official shall sign and date the form, print his/her
                    name,
                    title, and telephone number.

          

        

         

        
          According
            to the Paperwork Reduction Act, as amended, no persons are required to
            respond
            to a collection of information unless it displays a valid OMB control
            Number.
            The valid OMB control number for this information collection is OMB No.
            0348-0046. Public reporting burden for this collection of information
            is
            estimated to average 10 minutes per response, including time for reviewing
            instructions, searching existing data sources, gathering and maintaining
            the
            data needed, and completing and reviewing the collection of information.
            Send
            comments regarding the burden estimate or any other aspect of this collection
            of
            information, including suggestions for reducing this burden, to the Office
            of
            Management and Budget, Paperwork Reduction Project (0348-0046), Washington,
            DC
            20503

        

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

       

      APPENDIX
        E-l

    

    
      

      Requirements
        for Proof of Workers' Compensation 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 this
                  Appendix:

              

      

    

    
      

      
        	
                a)  

              	
                Certificate
                  of Workers' Compensation Insurance, on the Workers' Compensation
                  Board
                  form C-105.2 (naming the NYS Department of Health, Corning 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, Corning 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].

              

      

    

    
      

      NOTE:
        ACORD forms are NOT acceptable proof of
        coverage.

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    
      APPENDIX
        E-2 

       

      Requirement
        for Proof of Disability Insurance Coverage

    

    
      

      Disability
        Benefits Coverage, for which one of the following is incorporated into
        this Agreement herein as an attachment to this Appendix:

    

    
      
         

        
          
            	
                    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 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 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
        F

       

      SERVICE
        AREA AND AGES OF POPULATION TO BE SERVED

    

    
      

      The
        service area of the Contractor is comprised of the following
        counties:

    

    
      

      Bronx
        

      Kings

      New
        York

      Queens

    

    
      

      The
        Contractor will serve the following age group(s):

      ages
        18
        and older

      ages
        55
        and older

      ages
        65
        and older:  X

    

     

    
      

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

        
          APPENDIX
            G

           

        

        
          Managed
            Long-Term Care Covered/Non-Covered Services

        

        

        
          	
                  
                    Services,
                      When Provided, Would Be Covered by the Capitation
                      1 
                      2

                  

                	
                  
                    Non-Covered
                      Services;Excluded From The Capitation; Can Be Billed
                      Fee-For-Service

                  

                
	
                  
                    Services
                      Provided as Medically Necessary:

                  

                	 
	
                  
                    Care
                      Management

                  

                	
                  
                    Inpatient
                      Hospital Services

                  

                
	
                  
                    Nursing
                      Home Care

                  

                	
                  
                    Outpatient
                      Hospital Services

                  

                
	
                  
                    Home
                      Care

                  

                  
                    a.       Nursing

                  

                  
                    b.       Home
                      Health Aide

                  

                  
                    c.       Physical
                      Therapy (PT)

                  

                  
                    d.       Occupational
                      Therapy (OT)

                  

                  
                    e.       Speech
                      Pathology (SP)

                  

                  
                    f.       Medical
                      Social Services

                  

                	
                  
                    Physician
                      Services including services

                  

                  
                    provided
                      in an office setting, a clinic, a facility, or

                  

                  
                    in
                      the home.3

                  

                
	
                  
                    Adult
                      Day Health Care

                  

                	
                  
                    Laboratory
                      Services

                  

                
	
                  
                    Personal
                      Care

                  

                	
                  
                    Radiology
                      and Radioisotope Services

                  

                
	
                  
                    DME,
                      including MedicaV/Surgical Supplies, Enteral and Parenteral
                      Formula, and
                      Hearing Aid Batteries, Prosthetics, Orthotics and Othopedic
                      Footwear

                  

                	
                  
                    Emergency
                      Transportation

                  

                
	
                  
                    Personal
                      Emergency Response System

                  

                	
                  
                    Rural
                      Health Clinic Services

                  

                
	
                  
                    Non-emergent
                      Transportation

                  

                	
                  
                    Chronic
                      Renal Dialysis

                  

                
	
                  
                    Podiatry

                  

                	
                  
                    Mental
                      Health Services

                  

                
	
                  
                    Dentistry

                  

                	
                  
                    Alcohol
                      and Substance Abuse Services

                  

                
	
                  
                    Optometry/Eyeglasses

                  

                	
                  
                    OMRDD
                      Services

                  

                
	
                  
                    PT,
                      OT, SP or other therapies provided in a setting other than
                      a
                      home

                  

                	
                  
                    Family
                      Planning Services

                  

                
	
                  
                    Audiology/Hearing
                      Aids

                  

                	
                  
                    Prescription
                      and Non-Prescription Drugs, Compounded
                      Prescriptions

                  

                
	
                  
                    Respiratory
                      Therapy

                  

                	 
	
                  
                    Nutrition

                  

                	 
	
                  
                    Private
                      Duty Nursing

                  

                	 
	
                  
                    Assisted
                      Living Program4

                  

                	
                  
                    All
                      other services listed in the Title XLX State Plan

                  

                
	
                  
                    Services
                      Provided Through Care Management:

                  

                	 
	
                  
                    Home
                      Delivered or Congregate Meals

                  

                	 
	
                  
                    Social
                      Day Care

                  

                	 
	
                  
                    Social
                      and Environmental Supports

                  

                	 

        

        
          1
            The capitation
            payment includes applicable Medicare coinsurance and deductibles and
            any
            services not reimbursed by Medicare.

        

        
          2
            Any of the services
            listed in this column, when provided in a diagnostic and treatment center,
            would
            be included in and covered by the capitation payment.

        

        
          3Includes
            nurse
            practitioners and physician assistants acting as "physician
            extenders".

        

        
          4Service
            may be a
            substitute for other services in the plan of care and paid through the
            capitation.

        

         

        (Note:
          Refer to Appendix J, "Definitions" for definitions and scope of services
          identified in Appendix G.)

      

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    
      Appendix
        H

    

    
      

      WellGare
        of New York, Inc.

    

    
      Managed
        Long Term Care

    

    
      Schedule
        of Capitation Rates

    

    
      Effective
        Date: 2007

    

    

    
      	
              
                Age
                  Group

              

            	
              
                Monthly
                  Capitation Amount (PMPM)

              

            
	
              
                65+

              

            	
              
                $3,462.37

              

            

    

    
 

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

     

     

    APPENDIX
      I

     

     

    Reserved

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    
       

      APPENDIX
        J

    

    
      

      DEFINITIONS

    

    
      

      Terms
        used in this Contract, which are not otherwise defined, shall have the meanings
        set forth below.

    

    
      

      Definitions
        of covered services are intended to provide general information about the
        level
        of care available through the Medical Assistance Program. The full description
        and scope of services specified herein are established by the Medical Assistance
        Program as set forth in the applicable eMedNY Provider Manual. Managed care
        organizations may not define covered services more restrictively than the
        Medicaid Program. Contractors are expected to provide services for individual
        Enrollees as described in each Enrollee's plan of care. Services may be provided
        either directly or through a sub-contract.

    

    
      

      Abusive,
        as it relates to cause for involuntary disenrollment, means subjecting
        program staff to physical abuse or criminal activity which exposes staff
        to
        imminent danger or verbal threats which create in staff a reasonable concern
        for
        physical safety.

    

    
      

      Action
        is a denial or a limited authorization of a requested service or
        a
        reduction, suspension, or termination of a previously authorized service;
        denial, in whole or in part, of payment for a service; failure to provide
        services in a timely manner; determination that a requested service is not
        a
        covered benefit (does not include requests for services that are paid for
        fee-for-service outside the plan); or failure to make a grievance or grievance
        appeal determination within required timeframes.

    

    
      

      Alcohol
        and substance abuse services includes both inpatient and outpatient
        care. Inpatient services include but are not limited to: assessment, management
        of detoxification and withdrawal conditions, group, individual or family
        counseling, alcohol and substance abuse education, treatment planning,
        preventive counseling, discharge planning, and services to significant others
        provided in-home, office or the community. The following care is also provided:
        outpatient alcoholism rehabilitation services through programs certified
        by the
        Office of Alcohol and Substance Abuse Services (OASAS) under 14 NYCRR Part
        380.3
        or 380.8; medically supervised ambulatory substance abuse treatment in 1035
        facilities certified by OASAS under 14 NYCRR Part 1035; and Methadone
        Maintenance Treatment Program (MMTP) through facilities which provide MMTP
        as
        their principle mission and are certified by OASAS under 14 NYCRR Part
        1040.

    

    
      

      Adult
        day health care is care and services provided in a residential health
        care facility or approved extension site under the medical direction of a
        physician to a person who is functionally impaired, not homebound, and who
        requires certain preventive, diagnostic, therapeutic, rehabilitative or
        palliative items or services. Adult day health care includes the following
        services: medical, nursing, food and nutrition, social services, rehabilitation
        therapy, leisure time activities which are a planned program of diverse
        meaningful activities, dental pharmaceutical, and other ancillary
        services.

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    
      Appeal
        - a request for a review of an action taken by the
        Contractor.

    

    
      

      Applicant:
        An applicant is an individual who has expressed a desire to pursue
        enrollment in a managed long-term care plan.

    

    
      

      Audiology/hearing
        aids: Audiology services include audiometric examination or testing,
        hearing aid evaluation, conformity evaluation and hearing aid prescription
        or
        recommendations if indicated. Hearing aid services include selecting, fitting
        and dispensing of hearing aids, hearing aid checks following dispensing and
        hearing aid repairs. Products include hearing aids, earmolds, batteries,
        special
        fittings and replacement parts.

    

    
      

      Benefit
        package shall mean those medical and health-related services identified
        in Appendix G which Enrollees are entitled to receive pursuant to Article
        V. A.
        They are also known as the Benefit Package services or Covered
        Services.

    

    
      

      CMS
        means the U.S. Centers for Medicare and Medicaid Services, formerly
        known as HCFA.

    

    
      

      Care
        plan (or plan of care) is a written description in the care management
        record of member-specific health care goals to be achieved and the amount,
        duration and scope of the covered services to be provided to an Enrollee
        in
        order to achieve such goals. The care plan is based on assessment of the
        member's health care needs and developed in consultation with the member
        and
        his/her informal supports. Effectiveness of the care plan is monitored through
        reassessment and a determination as to whether the health care goals are
        being
        met. Non-covered services which interrelate with the covered services identified
        on the care plan and services of informal supports necessary to support the
        health care goals and effectiveness of the covered services should be clearly
        identified on the care plan or elsewhere in the care management
        record.

    

    
      

      Care
        management is a process that assists Enrollees to access necessary
        covered services as identified in the care plan. It also provides referral
        and
        coordination of other services in support of the care plan. Care management
        services will assist Enrollees to obtain needed medical, social, educational,
        psychosocial, financial and other services in support of the care plan
        irrespective of whether the needed services are covered under the capitation
        payment of this Agreement.

    

    
      

      Contract
        period is the term of the contract plus any
        extensions.

    

    
      

      Covered
        services shall mean those medical and health-related services
        identified in Appendix G which Enrollees are entitled to receive pursuant
        to
        Article V. A. They are also known as the Benefit Package or Benefit Package
        services.

    

    
      

      Chronic
        renal dialysis includes services provided by a renal dialysis
        center.

    

    
      

      DHHS:
        The Department of Health and Human Services of the United
        States.

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    
      Dentistry
        includes but shall not be limited to preventive, prophylactic and
        other
        dental care, services and supplies, routine exams, prophylaxis, oral surgery,
        and dental prosthetic and orthotic appliances required to alleviate a serious
        health condition including one which affects employability.

    

    
      

      Durable
        Medical Equipment (DME), includes medical/surgical supplies,
        prosthetics and orthotics, and orthopedic footwear, enteral and parenteral
        formula and hearing aid batteries. Durable medical equipment are devices
        and
        equipment, other than prosthetic or orthotic appliances and devices, which
        have
        been ordered by a practitioner in the treatment of a specific medical condition
        and which have the following characteristics:

    

    
      

      ■  can
        withstand repeated use for a protracted period of time,

    

    
      ■ are
        primarily and customarily used for medical purposes,

    

    
      ■ are
        generally not useful in the absence of an illness or injury;
        and

    

    
      ■ are
        not
        usually fitted, designed or fashioned for a particular individual's
        use.

    

    
      Where
        equipment is intended for use by only one patient, it may be either custom-made
        or customized.

    

    
      

      Medical/surgical
        supplies are items for medical use other than drugs, prosthetic or orthotic
        appliances and devices, durable medical equipment or orthopedic footwear
        which
        treat a specific medical condition and which are usually consumable,
        non-reusable, disposable, for a specific purpose and generally have no
        salvageable value.

    

    
      

      Prosthetic
        appliances and devices are appliances and devices, which replace any missing
        part of the body.

    

    
      

      Orthotic
        appliances and devices are appliances and devices used to support a weak
        or
        deformed body member or to restrict or eliminate motion in a diseased or
        injured
        part of the body.

    

    
      

      Orthopedic
        footwear are 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.

    

    
      

      Emergency
        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 reasonable expect the absence of immediate medical
        attention to result in: (a) placing the health of the person affected 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
        to such person's bodily functions; (c) serious dysfunction of any bodily
        organ
        or part of such person; or (d) serious disfigurement of such
        person.

    

    
      

      Emergency
        transportation is transportation by ambulance as a result of an
        emergency condition.r

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    
      Enrollee
        shall mean a person enrolled in the plan who is entitled to covered
        services in accordance with the provisions of this Agreement from the effective
        date of his/her enrollment until the effective date of his/her
        disenrollment.

    

    
      

      Enrollee
        agreement shall mean the written agreement provided to Enrollees, which
        agreement is to be signed by Enrollees and by the Contractor.

    

    
      

      Grievance
        - An expression of dissatisfaction by the member or provider on
        member's behalf about care and treatment that does not amount to a change
        in
        scope, amount or duration of service. A grievance can be verbal or in writing.
        Plans cannot require that members put grievances in writing. Plans must
        designate one or more qualified personnel who were not involved in any previous
        level of review or decision-making to review the grievance, and if the grievance
        pertains to clinical matters, the personnel must include licensed, certified
        or
        registered health care professionals.

    

    
      

      HCFA
        shall mean the Health Care Financing Administration of DHSS, now known as
        the
        Centers for Medicare and Medicaid Services.

    

    
      

      Home
        care includes the following services which are of a preventive,
        therapeutic rehabilitative, health guidance and/or supportive nature: nursing
        services, home health aide services, nutritional services, social work services,
        physical therapy, occupational therapy and speech/language
        pathology.

    

    
      

      Home
        health aide means a person who carries out health care tasks under the
        supervision of a registered nurse or licensed therapist and who may also
        provide
        assistance with personal hygiene, housekeeping and other related supportive
        tasks to an Enrollee with health care needs in his home. Qualifications of
        home
        health aides are defined in Section 700.2(b)(9), Title 10
        NYCRR.

    

    
      

      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) month or less. Hospice
        programs provide patients and families with palliative and supportive care
        to
        meet the special needs arising out of physical, psychological, spiritual,
        social
        and economic stresses which are experienced during the final stages of illness
        and during dying and bereavement.

    

    
      

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

    

    
      

      HPN
        shall mean the Health Provider Network, an internet based
        communications infrastructure of the New York State Department of Health
        designed to allow the secure and efficient exchange of reporting,
        surveillance, statistical, and general information with its public health
        and health provider partners.t

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    
      Inpatient
        hospital services are those items and services, provided under the
        direction of a physician, physician's assistant, nurse practitioner, or dentist,
        ordinarily furnished by the hospital for the care and treatment of inpatients.
        Inpatients hospital services include care, treatment, maintenance and nursing
        services as may be required on an inpatient hospital basis. Among other
        services, inpatient hospital service encompass a full range of necessary
        diagnostic and therapeutic care including medical, surgical, nursing,
        radiological and rehabilitative services.

    

    
      

      LDSS
        shall mean Local Department of Social Services or the Human Resources
        Administration of the City of New York.

    

    
      

      Laboratory
        services include medically necessary tests and procedures ordered by a
        qualified medical professional and listed in the Medicaid fee schedule for
        laboratory services. Physicians providing laboratory testing may perform
        specific laboratory testing procedures identified in the Physician's eMedNY
        Provider Manual.

    

    
      

      Meals:
        Home-delivered and congregate meals provided in accordance with
        each
        individual Enrollee's plan of care.

    

    
      

      Medically
        necessary shall mean necessary to prevent, diagnose, correct or cure
        conditions in the Enrollee that cause acute suffering, endanger life, result
        in
        illness or infirmity, interfere with such Enrollee's capacity for normal
        activity, or threaten some significant handicap.

    

    
      

      Medical
        social services means assessing the need for, arranging for and
        providing aid for social problems related to the maintenance of a patient
        in the
        home where such services are performed by a qualified social worker and provided
        within a plan of care. These services must be provided by a qualified social
        worker as defined in Section 700.2(b)(24) 10NYCRR.

    

    
      

      Mental
        health services include both inpatient and outpatient care. Inpatient
        services include medically necessary voluntary and involuntary admission to
        State psychiatric centers, Article 31 inpatient psychiatric hospitals and
        Article 28 hospitals. Outpatient service include but are not limited to:
        assessment (stabilization), treatment planning, discharge planning, verbal
        therapies, medication therapy and education, symptom management, case
        management services, crisis intervention (and outreach
        services), chlozapine monitoring and collateral services as certified by
        OMH, rehabilitation services in OMH licensed community residences and
        family based treatment programs certified under 14 NYCRR Part 586.3. Mental
        health service include: intensive psychiatric rehabilitation treatment
        programs under 14 NYCRR, Part 587; day treatment services certified by OMH
        under 14 NYCRR, Part 587; continuing day treatment services certified by
        OMH under 14 NYCRR, Part 587; intensive case management for seriously
        and persistently mentally ill individuals; and partial hospitalization
        services certified by OMH under 14 NYCRR, Part 587. Fee-for-service
        Medicaid does not cover inpatient mental health services in an Institution
        for Mental Disease (IMD) for individuals age 21
        through 64.

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    
      NAMI
        shall mean the amount of net available monthly income determined by the
        Department that a nursing home resident must pay monthly to the nursing home
        in
        accordance with the requirements of the medical assistance
        program.

    

    
      

      Nurse
        practitioner services mean services provided under a practice agreement
        and practice protocol with a collaborating physician (agreement and protocol
        available to the Department during Medicaid audits) which meet the definitions
        for nurse practitioner services in the eMedNY Provider Manual, generally
        services considered to be primary care.

    

    
      

      Nursing
        services include intermittent, part-time and continuous nursing
        services provided in accordance with an ordering physician's treatment plan
        as
        outlined in the physician's recommendation. Nursing services must be provided
        by
        RNs and LPNs in accordance with the Nurse Practice Act. Nursing services
        include
        care rendered directly to the individual and instructions to his family or
        caretaker in the procedures necessary for the patient's treatment or
        maintenance.

    

    
      

      Nursing
        home care is care provided to Enrollees by a licensed facility as
        specified in Chapter V, 10 NYCRR.

    

    
      

      Nutrition
        means the assessment of nutritional needs and food patterns, or the
        planning for the provision of foods and drink appropriate for the individual's
        physical and medical needs and environmental conditions, or the provision
        of
        nutrition education and counseling to meet normal and therapeutic needs.
        In
        addition, these services may include the assessment of nutritional status'
        and
        food preferences, planning for provision of appropriate dietary intake within
        the patient's home environment and cultural considerations, nutritional
        education regarding therapeutic diets as part of the treatment milieu,
        development of a nutritional treatment plan, regular evaluation and revision
        of
        nutritional plans, provision of in-service education to health agency staff
        as
        well as consultation on a specific dietary problems of patients and nutrition
        teaching to patients and families. These services must be provided by a
        qualified nutritionist as defined in Section 700.2(b)(5), 10
        NYCRR.

    

    
      

      Occupational
        therapy: Rehabilitation services provided by a licensed and registered
        occupational therapist for the purpose of maximum reduction of physical or
        mental disability and restoration of the Enrollee to his or her best function
        level.

    

    
      

      OMRDD
        (Office of Mental Retardation and Developmental Disabilities)
        services

    

    
      include:
        long term therapy services provided by Article 16 clinic treatment facilities,
        certified by OMRDD under 14 NYCRR, Part 679 or provided by Article 28 D&TCs
        explicitly certified by SDOH as serving primarily persons with developmental
        disabilities: day treatment services provided in an ICF or comparable facility
        and certified by OMRDD under 14 NYCRR, Part 690; Comprehensive Medicaid Case
        Management services; and home and community based waiver program services
        for
        the developmentally disabled.

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    
      Optometry
        includes the services of an optometrist and an ophthalmic dispenser,
        and includes eyeglasses; medical necessary contact lenses and polycarbonate
        lenses, artificial eyes (stock or custom made) low vision aids. The optometrist
        may perform an eye exam to detect visual defects and eye disease as necessary
        or
        as required by the EnroUee's condition. Examinations which include refraction
        are limited to every two years unless otherwise justified as medically
        necessary.

    

    
      

      An
        ophthalmic dispenser fills the prescription of an optometrist or
        ophthalmologist and supplies eyeglasses or other vision aids upon the order
        of
        qualified practitioner. Coverage includes the replacement of lost or destroyed
        eyeglasses. The replacement of a complete pair of eyeglasses should duplicate
        the original prescription and frames. Coverage also includes the repair or
        replacement of parts in situations where the damage is the result of causes
        other than defective workmanship. Replacement parts should duplicate the
        original prescription and frames. Repairs to and replacement of frames and/or
        lenses must be rendered as needed. Eyeglasses do not require changing more
        frequently than every two years unless medically indicated, such as a change
        in
        correction greater than lA
        diopter, or unless the glasses are lost, damaged, or
        destroyed.

    

    
      

      Outpatient
        hospital services are services which are provided by a hospital
        division or department primarily engaged in providing services for ambulatory
        patients, by or under the supervision of a physician, for the prevention,
        diagnosis or treatment of human disease, pain, injury, deformity or physical
        condition.

    

    
      

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

    

    
      

      Party
        shall mean either the Department or the Contractor.

    

    
      

      Personal
        care means some or total assistance with such activities as personal
        hygiene, dressing and feeding, and nutritional and environmental support
        function tasks. Personal care must be medically necessary, ordered by the
        EnroUee's physician and provided by a qualified person as defined in Section
        700.2(b)(14) 10 NYCRR, in accordance with a plan of care.

    

    
      

      Personal
        "Emergency Response System (PERS): PERS is an electronic devise which
        enables certain high-risk patients to secure help in the event of a physical,
        emotional or environmental emergency. A variety of electronic alert systems
        now
        exist which employ different signaling devices. Such systems are usually
        connected to a patient's phone and signal a response center once a "help"
        button
        is activated. In the event of an emergency, the signal is received and
        appropriately acted on by a response center.

    

    
      

      Physical
        therapy: Rehabilitation services provided by a licensed and registered
        physical therapist for the purpose of maximum reduction of physical or mental
        disability and restoration of the Enrollee to his or her best functional
        level.

    

    
      

      Physician
        services include the full range of preventive care services, primary
        care medical services and physician specialty services that fall within a
        physician's scope of practice
        under New York State Law. Physician services include the services of physician
        extenders, e.g., physician's assistants, social workers. Physician services
        may
        be provided in the office, home and facilities including but not limited
        to
        hospitals and diagnostic treatment centers.

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    Podiatry:
      Podiatry means services by a podiatrist which must include routine
      foot
      care when the Enrollee's physical condition poses a hazard due to the presence
      of localized illness, injury or symptoms involving the foot, or when they are
      performed as necessary and integral part of medical care such as the diagnosis
      and treatment of diabetes, ulcers, and infections. 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
      pathological condition.

    
      

      Potential
        Enrollee means a Medicaid recipient who is eligible to voluntarily
        elect to enroll in a managed long-term care plan, but is not yet an Enrollee
        of
        managed long-term care plan.

    

    
      

      Prescription
        and non-prescription drugs: Include drugs on the "New York State List
        of Medicaid Reimbursable Drugs: Non-Prescription Drugs and Prescription Drugs"
        (inclusive of those agents such as blood products) as well as supplies which
        appear on the list of "Allowable Medical and Surgical Supplies" which are
        ordered by a qualified practitioner.

    

    
      

      Private
        duty nursing services are continuous and skilled nursing care provided
        in an Enrollee's home by properly licensed registered professional or licensed
        practical nurses.

    

    
      

      Radiology
        and radioisotope 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 are performed upon the order of a qualified
        practitioner.

    

    
      

      Respiratory
        therapy means the performance of preventive, maintenance and
        rehabilitative airway-related techniques and procedures including the
        application of medical gases, humidity, and aerosols, intermittent positive
        pressure, continuous artificial ventilation, the administration of drugs
        through
        inhalation and related airway management, patient care, instruction of patients
        and provision of consultation to other health personnel. These services must
        be
        provided by a qualified respiratory therapist as defined in Section 700.2(b)(33)
        10 NYCRR.

    

    
      

      Rural
        health clinic services are services provided by a clinic certified as a
        "rural health center" under 42 CFR 491.

    

    
      

      Same
        Day Grievance means a grievance that is resolved by the Plan to the
        satisfaction of Enrollee the same day the grievance is lodged. A Same Day
        Grievance does not require written acknowledgement from the plan; however
        information about the Same Day Grievance must be documented by the plan in
        its records.'

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    
      Service
        area shall mean the geographic area for which the Contractor has been
        approved by the DOH to provide services.

    

    
      

      Social
        and environmental supports are services and items that support the
        medical needs of the Enrollees and are included in an EnroUee's plan of care.
        These services and items include but are not limited to the following: home
        maintenance tasks, homemaker/chore services, housing improvement, and respite
        care.

    

    
      

      Social
        day care is a structured, comprehensive program which provides
        functionally impaired individuals with socialization; supervision and
        monitoring; personal care; and nutrition in a protective setting during any
        part
        of the day, but for less than a 24-hour period. Additional services may include
        and are not limited to maintenance and enhancement of daily living skills,
        transportation, caregiver assistance, and case coordination and
        assistance.

    

    
      

      Social
        services are information, referral, and assistance with obtaining or
        maintaining benefits which include financial assistance, medical assistance,
        food stamps, or other support programs provided by the LDSS, Social Security
        Administration, and other sources. Social services also involves providing
        supports and addressing problems in an EnroUee's living environment and daily
        activities to assist the Enrollee to remain in the community.

    

    
      

      Speech-language
        pathology: A licensed and registered speech-language pathologist
        provides rehabilitation services for the purpose of maximum reduction of
        physical or mental disability and restoration of the Enrollee to his or her
        best
        functional level.

    

    
      

      Subcontract:
        shall mean a written contract with the Contractor pursuant to which
        a
        person or entity provides certain services or items the Contractor deems
        necessary or advisable to the operation of the plan.

    

    
      

      Subcontractor:
        shall mean a person or entity with whom the Contractor has entered
        into
        a written subcontract.

    

    
      

      Surplus
        amounts: shall mean the amount of medical expenses the Department
        determines a "medically needy" individual must incur in any period in order
        to
        be eligible for medical assistance (as currently described in 18 NYCRR 360-4.8).
        Surplus amounts are also referred to as spenddown.

    

    
      

      Transportation:
        shall mean transport by ambulance, ambulette, taxi or livery service
        or
        public transportation at the appropriate level for the EnroUee's condition
        for
        the Enrollee obtain necessary medical care and services reimbursed under
        the New
        York State Plan for Medical Assistance or the Medicare
        Program.

    

    
      

      Urgent
        care shall mean medically necessary services required in order to
        prevent a serious deterioration of an EnroUee's health that results from an
        unforeseen illness or injury.t

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    
      APPENDIX
        K

    

    
      
         

        GRIEVANCE
          SYSTEM, MEMBER HANDBOOK LANGUAGE AND SERVICE AUTHORIZATION
          REQUIREMENTS

      1.
        GRIEVANCE SYSTEM REQUIREMENTS

    

    
      

      The
        Grievance System regulations in Subpart F of 42 CFR Part 438 apply to both
        "expressions of dissatisfaction" by enrollees (grievances) and to requests
        for a
        review of an "action" (as defined in 438.400) by a managed long-term care
        plan
        (an appeal). For managed long-term care plans, the Grievance System processes
        identified in Subpart F have been combined with the grievance requirements
        in
        New York State Public Health Law (PHL) 4408-a and the utilization review
        and
        appeal requirements in Article 49 of the PHL.

    

    
      

      A.
        Grievances

    

    
      

      Grievance
        - An expression of dissatisfaction by the member or provider on member's
        behalf
        about care and treatment that does not amount to a change in scope, amount
        or
        duration of service. A grievance can be verbal or in writing. Plans cannot
        require that members put grievances in writing. Plans must designate one
        or more
        qualified personnel who were not involved in any previous level of review
        or
        decision-making to review the grievance, and if the grievance pertains to
        clinical matters, the personnel must include licensed, certified or registered
        health care professionals.

    

    
      

      Grievances
        that can be immediately (same day) decided to the member's satisfaction do
        not
        need to be responded to in writing. Plans are required to document the grievance
        and decision, and log and track the grievance and decision for quality
        improvement purposes. If the grievance cannot be decided immediately (same
        day),
        the plan must decide if grievance is expedited or standard.

    

    
      

      Expedited
        Grievance - the plan 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. A member may also request an expedited
        review of a grievance.

    

    
      

      Expedited
        and Standard Grievances

       

    

    
      
        	
                1.

              	
                Plan
                  must send written acknowledgement of grievance within 15 business
                  days of
                  receipt. If a decision is reached before the written acknowledgement
                  is
                  sent, the plan may include the written acknowledgement with the
                  notice of
                  decision (one notice).

              

        	2. 	Must
                be decided as fast as member's condition requires, but no more
                than:

  

    

    
      
        	
                a.

              	
                Expedited:   48
                  hours from receipt of all necessary information, but no more than 7
                  calendar days from the receipt of the
                  grievance.

              

      

    

    
      
        	
                b.

              	
                Standard:
                  45 calendar days from receipt of all necessary information, but no
                  more than 60 calendar days from receipt of the
                  grievance.

              

      

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    
      
        	
                3.  

              	
                Up
                  to 14 calendar day extension. Extension may be requested by member
                  or
                  provider on member's behalf (written or verbal). Plan may also
                  initiate
                  extension if it can justify need for additional information and
                  if
                  extension is in member's interest. In all cases, extensions must
                  be well
                  documented.

              

      

    

    
      

      
        	
                4.  

              	
                Plan
                  must notify the member of decision by phone for expedited grievances
                  and
                  provide written notice of decision within 3 business days of decision
                  (expedited and standard).

              

      

    

    
      

      Grievance
        Appeal - Member has 60 business days after receipt of notice of grievance
        decision to file a written appeal. Appeal may be submitted by letter or on
        a
        form supplied by the plan. Upon receipt of a written appeal, the plan must
        decide if the appeal is expedited or standard appeal. A member or provider
        may
        also request an expedited review of a grievance appeal. The determination
        of a
        grievance appeal on a non-clinical matter must be made by qualified personnel
        at
        a higher level than the personnel who made the grievance determination.
        Grievance appeal determinations with a clinical basis must be made by personnel
        qualified to review the 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.

    

    
      

      Grievance
        Appeal - Expedited and Standard

    

    
      

      
        	
                1.

              	
                Plan
                  must send written acknowledgement of grievance appeal within 15
                  business
                  days of receipt of request. If a decision is reached before the
                  written
                  acknowledgement is sent, the plan may include the written acknowledgement
                  with notice of decision (one notice).

              

        	2. 	  Must
                be decided as fast as member's condition requires, but no more
                than:

        	a.	 Expedited:   2
                business days of receipt of all necessary
                information.

        	b.	 Standard:   30
                business days receipt of necessary
                information.

          

    

    
      
        	
                3.

              	
                Plan
                  must provide written notice of decision. Notice must include reason
                  for
                  determination, and in cases where the determination has a clinical
                  basis,
                  the clinical rationale for the
                  determination.

              

        	4.
                  	 No
                further appeal.

      

    

    
      
 

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        Necessary
          Written Notices for Grievances and Grievance Appeals

         

      

      
        	
                
                  Notices

                

              	
                
                  Grievance

                

              	
                
                  Grievance
                    Appeal

                

              
	
                
                  Written
                    acknowledgement

                

                
                  •
                    Name, address and telephone number of the individual or department
                    designated by the plan to respond to the grievance or grievance
                    appeal.

                

              	
                
                  X

                

              	
                
                  X

                

                
                   

                

              
	
                
                  •
                    If a member has requested an expedited grievance or grievance appeal,
                    and the plan has decided not to expedite the grievance or grievance
                    appeal, the acknowledgement must indicate that the grievance or
                    grievance appeal will be handled on a standard
                    basis.

                

              	
                
                  X

                

              	
                
                  X

                

              
	
                
                  •
                    Must identify any additional information required by the plan from
                    any source to make a decision

                   

                

              	 	
                
                  X

                

              
	
                
                  Notice
                    of plan-initiated extension, if applicable. (May be combined
                    with
                    acknowledgement)

                

              	 	 
	
                
                  •
                    Reason for extension

                

              	
                
                  X

                

              	 
	
                
                  •
                    Explain how the delay is in the best interest of the member and
                    identify any additional information that the plan requires from any
                    source to make its determination

                   

                

              	
                
                  X

                

              	 
	
                
                  Plan
                    Decision

                

                
                  •
                    Date of grievance, summary of grievance

                

              	
                
                  X

                

              	
                
                  X

                

              
	
                
                  •
                    Reason for determination and description of any actions that have
                    been or will be taken by the plan; in cases where the determination
                    has a clinical basis, the clinical rationale for the
                    determination

                

              	
                
                  X

                

              	
                
                  X

                

              
	
                
                  •
                    Notification of availability of assistance (for language, hearing,
                    speech issues) if member wants to file appeal and how to access that
                    assistance

                

              	
                
                  X

                

              	 
	
                
                  •
                    Procedure for filing a grievance appeal including a form for
                    the filing of
                    such an appeal.

                

              	
                
                  X

                

              	 
	
                
                  •  Letter
                    indicating plan will not make a determination on the grievance
                    appeal
                    because the request was not submitted within 60 business days
                    of the
                    receipt by the member of original grievance decision

                

              	 	
                
                  X

                

              

      

      
        

        Required
          Plan Documentation on Grievances and Grievance
          Appeals

      

      
        

        The
          plan
          must maintain a file on each grievance and associated appeal, if any, that
          must
          include (at a minimum):

      

      
        
          	
                  •

                	
                  the
                    date the grievance/grievance appeal was filed and a copy of the
                    grievance/grievance appeal;

                

        

      

      
        
          	
                  •

                	
                  the
                    date of receipt of and a copy of the enrollee's acknowledgement
                    letter, if
                    any, of the grievance/grievance
                    appeal;

                

        

      

      
        
          	
                  •

                	
                  all
                    member/provider requests for expedited grievances/grievance appeals
                    and
                    plan decision about the request;

                

          	•	  necessary
                  documentation to support any extensions,
                  and

        

      

      
        
          	
                  •

                	
                  the
                    determination made by the plan, including the date of the determination,
                    titles, and in the case of a clinical determination, the credentials
                    of
                    the plan's personnel who reviewed the grievance/grievance
                    appeal.

                

        

      

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    
      B. 
        APPEALS

    

    
      

      An
        Appeal
        is a request for a review of an action taken by a plan.

    

    
      

      Expedited
        Appeal - the plan 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 or the action was the result of a concurrent
        review of a service authorization request. A member may also request an
        expedited review of an appeal. If an expedited review is not requested, the
        appeal will be treated as a standard appeal.

    

    
      

      Plans
        must designate one or more qualified personnel who were not involved in any
        previous level of review or decision-making to review the appeal, and if
        the
        appeal pertains to clinical matters, the personnel must include licensed,
        certified or registered health care professionals.

    

    
      

      The
        plan
        may deny a request for an expedited review, but it must make reasonable efforts
        to give oral notice of denial of an expedited review and send written notice
        within 2 calendar days of oral request. The appeal is then handled as a standard
        appeal. A member's disagreement with plan's decision to handle as a standard
        appeal is considered a grievance - see Grievance Procedures.

    

    
      

      An
        appeal
        may be filed orally or in writing. If oral, the plan must provide the member
        with a summary of the appeal in writing as part of acknowledgement or
        separately. The date of the oral request for both standard and expedited
        appeals
        is treated as the date of the appeal.

    

    
      

      Note:
        New
        York has elected to require that a member exhaust the plan's internal appeal
        process before an enrollee may request a State Fair Hearing.

    

    
      

      Appeal
        - Expedited and Standard

    

    
      

      
        	
                1.  

              	
                Appeal
                  must be requested within 45 days of postmark date of notice of
                  action if
                  there is no request for aid to continue or within 10 days of the
                  notice's
                  postmark date or by the intended date of the action if aid to continue
                  is
                  requested and appeal involves the termination, suspension or reduction
                  of
                  a previously authorized
                  service.

              

      

    

    
      

      
        	
                2.  

              	
                If
                  aid to continue requested, services will continue until the sooner
                  of: a)
                  appeal is withdrawn, b) the original authorization period has expired,
                  or
                  c) until 10 days after appeal decision is mailed, if the decision
                  is not
                  in the member's favor, unless a NYS Fair Hearing has been
                  requested.

              

      

    

    
      

      
        	
                3.  

              	
                Plan
                  must send written acknowledgement of appeal within 15 days of receipt.
                  If
                  a decision is reached before the written acknowledgement is sent,
                  the plan
                  may include the written acknowledgement with the notice of decision
                  (one
                  notice).

              

        	4. 	  Must
                be decided as fast as member's condition requires,
                but:

      

    

    
      
        	
                a.

              	
                Expedited:  within
                  2 business days of receipt of necessary information, but no
                  later than 3 business days of receipt of appeal
                  request.

              	
                 

              

        	        
                b.	 Standard:
                no later than 30 calendar days of receipt of appeal request.	 

      

    

    
            

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    
      
        	
                5.  

              	
                Up
                  to 14 calendar day extension. Extension may be requested by member
                  or
                  provider on member's behalf (written or verbal). Plan may also
                  initiate
                  extension if it can justify need for additional information and
                  if
                  extension is in the member's interest. In all cases, extension
                  reason must
                  be well-documented

              

      

    

    
      

      
        	
                6.  

              	
                Plan
                  must make a reasonable effort to give oral notice for expedited
                  appeals
                  and must send written notice within 2 business days of decision
                  for all
                  appeals. If dissatisfied, members may file both State Fair Hearing
                  and
                  External Appeal. If both are filed, the State Fair Hearing decision
                  is the
                  one that counts.

              

      

    

    
      

      Necessary
        Templates for Written Notices for Appeals - Expedited and
        Standard

    

    
      

      
        	
                1.  

              	
                Letter
                  indicating the plan will not make a determination on the appeal
                  because
                  the appeal request was not submitted by the member within 45 days
                  of the
                  notice of action.

              

        	2.
                 	 Written
                acknowledgement

      

    

    
      
        	
                 •

              	
                Name,
                  address and telephone number of the individual or department designated
                  by
                  the plan to respond to the
                  appeal.

              

      

    

    
      
        	
                 •

              	
                If
                  a member has requested an expedited appeal and the plan has decided
                  not to
                  expedite the appeal, the acknowledgement must indicate that the
                  appeal
                  will be handled on a standard basis, and inform the member of his/her
                  right to file a grievance and how to do
                  so.

              

      

    

    
      
        	
                 •

              	
                The
                  acknowledgement must identify any additional information required
                  by the
                  plan from any source to make the appeal
                  decision.

              

      

    

    
      
        	
                3. 
                   

              	
                Notice
                  of plan-initiated extension, if applicable (may be combined
                  with acknowledgement)

              

        	•	Reason
                for extension

        	 •	How
                the delay is in the best interest of the member

        	 •	Any
                additional information that the plan requires from any source to
                make its
                determination

        	 4.	Plan
                Decision

        	 •	 Date
                and summary of appeal

        	 •	 Date
                appeal process completed by plan

      

    

    
      
        	
                 •  

              	
                Reason
                  for determination, and in cases where the determination has a clinical
                  basis, the clinical rationale for the
                  determination

              

      

    

    
      
        	
                 •  

              	
                If
                  decision not in favor of member, State Fair Hearing notice and
                  description
                  of process for filing Fair Hearing request (and process and timeframes
                  for
                  requesting aid continuing if member is entitled to make such a
                  request as
                  a result of termination, reduction or suspension of services),
                  and how
                  member may obtain assistance from the plan with filing of Fair
                  Hearing
                  request

              

      

    

    
      
        	
                 •  

              	
                If
                  denial of appeal was due to issues of medical necessity or because
                  the
                  service was experimental or investigational, must include a clear
                  statement that the notice constitutes the final adverse determination
                  and
                  procedures for filing an External Appeal and how member may obtain
                  assistance from plan in filing External
                  Appeal.

              

      

    

    
       

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

     

    
      (Plans
        must notify members of the availability of assistance (for language, hearing,
        speech issues) if a member wants to file Fair Hearing request and/or an External
        Appeal and how to access that assistance.)

    

    
      

      Required
        Plan Documentation for Appeals

    

    
      

      The
        plan
        must maintain a file on each action and associated appeal (both expedited
        and
        standard), if any, that includes (at a minimum):

    

    
      

      • a
        copy of
        the notice of action;

      • the
        date
        the appeal was filed;

    

    
      • a
        copy of
        the appeal;

    

    
      • member/provider
        requests for expedited appeals and the plan's decision;

    

    
      • the
        date
        of receipt of and a copy of the enrollee's acknowledgment letter of the appeal
        (if any);

      
        •
the
          date of receipt of and a copy of the enrollee's acknowledgment letter of
          the
          appeal (if any);

      

      • necessary
        documentation to support any extensions, and

    

    
      •  the
        determination made by the plan, including the date of the determination,
        the
        titles and, in the case of clinical determinations, the credentials, of the
        plan's personnel who reviewed the appeal. 

    

    
      

      2.
        MODEL MEMBER HANDBOOK GRIEVANCE AND APPEAL LANGUAGE

    

    
      

      The
        following language relating to the managed long-term care demonstration
        grievance and appeal process must appear in the Contractor's Member
        Handbook.

    

    
      

      ___________ 
        (plan name) will try its best to deal with your concerns or issues as
        quickly as
        possible and to your satisfaction. You may use either our grievance process
        or
        our appeal process, depending on what kind of problem you
        have.

    

    
      

      There
        will be no change in your services or the way you are treated by (insert
        plan
        name) staff or a health care provider because you file a grievance or an
        appeal.
        We will maintain your privacy. We will give you any help you may need to
        file a
        grievance or appeal. This includes providing you with interpreter services
        or
        help if you have vision and/or hearing problems. You may choose someone (like
        a
        relative or friend or a provider) to act for you.

    

    
      

      To
        file a
        grievance or to appeal a plan action, please call: xxxxxxx or write to:
xxxxxxxx. When you contact us, you will need to give us your name,
        address, telephone number and the details of the problem.

    

    
      

      What
        isa Grievance?

    

    
      

      A
        grievance is any communication by you to us of dissatisfaction about
        the
        caye and treatment you receive from our staff or providers of covered services.
        For example, if someone was rude to you or you do not like the quality of
        care
        or services you have received from us, you can file a grievance with
        us.

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    
      The
        Grievance Process

    

    
      

      You
        may
        file a grievance orally or in writing with us. The person who receives your
        grievance will record it, and appropriate plan staff will oversee the review
        of
        the grievance. We will send you a letter telling you that we received your
        grievance and a description of our review process. We will review your grievance
        and give you a written answer within one of two timeframes.

       

    

    
      
        	
                1.  

              	
                If
                  a delay would significantly increase the risk to your health, we
                  will
                  decide within 48 hours after receipt of necessary
                  information

              

      

    

    
      
        	
                2.  

              	
                For
                  all other types of grievances, we will notify you of our decision
                  within
                  45 days of receipt of necessary information, but the process must
                  be
                  completed within 60 days of the receipt of the grievance. The review
                  period can be increased up to 14 days if you request it or if we
                  need more
                  information and the delay is in your
                  interest.

              

      

    

    
      

      Our
        answer will describe what we found when we reviewed your grievance and our
        decision about your grievance.

    

    
      

      How
        do I Appeal a Grievance Decision?

    

    
      

      If
        you
        are not satisfied with the decision we make concerning your grievance, you
        may
        request a second review of your issue by filing a grievance appeal. You must
        file a grievance appeal in writing. It must be filed within 60 business days
        of
        receipt of our initial decision about your grievance. Once we receive your
        appeal, we will send you a written acknowledgement telling you the name,
        address
        and telephone number of the individual we have designated to respond to your
        appeal. All grievance appeals will be conducted by appropriate professionals,
        including health care professionals for grievances involving clinical matters,
        who were not involved in the initial decision.

    

    
      

      For
        standard appeals, we will make the appeal decision within 30 business days
        after
        we receive all necessary information to make our decision. If a delay in
        making
        our decision would significantly increase the risk to your health, we will
        use
        the expedited grievance appeal process. For expedited grievance appeals,
        we will
        make our appeal decision within 2 business days of receipt of necessary
        information. For both standard and expedited grievance appeals, we will provide
        you with written notice of our decision. The notice will include the detailed
        reasons for our decision and, in cases involving clinical matters, the clinical
        rationale for our decision.

    

    
      

      What
        is an Action?

    

    
      

      When
        (insert plan name) denies or limits services requested by you or your provider;
        denies a request for a referral; decides that a requested service is not
        a
        covered benefit; reduces, suspends or terminates services that we already
        authorized; denies payment for services; doesn't provide timely services;
        or
        doesn't make grievance or appeal determinations within the required timeframes,
        those are considered plan "actions". An action is subject to appeal. (See
        How do
        I File an Appeal of an Action? below for more information.)

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

     

    
      Timing
        of Notice of Action

    

    
      

      If
        we
        decide to deny or limit services you requested or decide not to pay for all
        or
        part of a covered service, we will send you a notice when we make our decision.
        If we are proposing to reduce, suspend or terminate a service that is
        authorized, our letter will be sent at least 10 days before we intend to
        change
        the service.

    

    
      

      Contents
        of the Notice of Action

    

    
      

      Any
        notice we send to you about an action will:

    

    
      

      •
        Explain
        the action we have taken or intend to take;

    

    
      • Cite
        the
        reasons for the action, including the clinical rationale, if any;

      
        • Describe
          your right to file an appeal with us (including whether you may also have
          a
          right to the State's external appeal process); 

      

    

    
      
        • Describe
          how to file an internal appeal and the circumstances under which you can
          request
          that we speed up (expedite) our review of your internal appeal;

        •Describe
          the availability of the clinical review criteria relied upon in making
          the
          decision, if the action involved issues of medical necessity or whether
          the
          treatment or service in question was experimental or
          investigational;

        •
          Describe the information, if any, that must be provided by you and/or your
          provider in order for us to render a decision on appeal.

         

      

    

    
      If
        we are
        reducing, suspending or terminating an authorized service, the notice will
        also
        tell you about your right to have services continue while we decide on your
        appeal; how to request that services be continued; and the circumstances
        under
        which you might have to pay for services if they are continued while we were
        reviewing your appeal.

    

    
      

      How
        do I File an Appeal of an Action ?

    

    
      

      If
        you do
        not agree with an action that we have taken, you may appeal. When you file
        an
        appeal, it means that we must look again at the reason for our action to
        decide
        if we were correct. You can file an appeal of an action with the plan orally
        or
        in writing. When the plan sends you a letter about an action it is taking
        (like
        denying or limiting services, or not paying for services), you must file
        your
        appeal request within 45 calendar days of the date on our letter notifying
        you
        of the action. If you call us to file your request for an appeal, you must
        send
        a written request unless you ask for an expedited review.

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    
      How
        do I Contact my Plan to file an Appeal?

    

    
      

      We
        can be
        reached by calling XXX-XXX-XXXX or writing to (address). The
        person who receives your appeal will record it, and appropriate staff will
        oversee the review of the appeal. We will send a letter telling you that
        we
        received your appeal, and how we will handle it. Your appeal will be reviewed
        by
        knowledgeable clinical staff who were not involved in the plan's initial
        decision or action that you are appealing.

    

    
      

      For
        Some Actions You May Request to Continue Service During the Appeal
        Process

    

    
      

      If
        you
        are appealing a reduction, suspension or termination of services you are
        currently authorized to receive, you may request to continue to receive these
        services while we are deciding your appeal. We must continue your service
        if you
        make your request to us no later than 10 days from our mailing of the notice
        to
        you about our intent to reduce, suspend or terminate your services, or by
        the
        intended effective date of our action, and the original period covered by
        the
        service authorization has not expired. Your services will continue until
        you
        withdraw the appeal, the original authorization period for your services
        has
        been met or until 10 days after we mail your notice about our appeal decision,
        if our decision is not in your favor, unless you have requested a New York
        State
        Medicaid Fair Hearing with continuation of services. (See Fair Hearing Section
        below.)

    

    
      

      Although
        you may request a continuation of services while your appeal is under review,
        if
        your appeal is not decided in your favor, we may require you to pay for these
        services if they were provided only because you asked to continue to receive
        them while your appeal was being reviewed.

    

    
      

      How
        Long Will it Take the Plan to Decide My Appeal of an Action
        ?

    

    
      

      Unless
        you ask for an expedited review, we will review your appeal of the action
        taken
        by us as a standard appeal and send you a written decision as quickly as
        your
        health condition requires, but no later than 30 days from the day we receive
        an
        appeal. (The review period can be increased up to 14 days if you request
        an
        extension or we need more information and the delay is in your interest.)
        During
        our review you will have a chance to present your case in person and in writing.
        You will also have the chance to look at any of your records that are part
        of
        the appeal review.

    

    
      

      We
        will
        send you a notice about the decision we made about your appeal that will
        identify the decision we made and the date we reached that
        decision.

    

    
      

      If
        we
        reverse our decision to deny or limit requested services, or reduce, suspend
        or terminate services, and services were not furnished while your appeal
        was pending, we will provide you with the disputed services as quickly as
        your health condition requires. In some cases you may request an
        "expedited" appeal. (See Expedited Appeal Process Section
        below.)'

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    
      Expedited
        Appeal Process

    

    
      

      If
        you or
        your provider feels that taking the time for a standard appeal could result
        in a
        serious problem to your health or life, you may ask for an expedited review
        of
        your appeal of the action. We will respond to you with our decision within
        2
        business days after we receive all necessary information. In no event will
        the
        time for issuing our decision be more than 3 business days after we receive
        your
        appeal. (The review period can be increased up to 14 days if you request
        an
        extension or we need more information and the delay is in your
        interest.)

    

    
      

      If
        we do
        not agree with your request to expedite your appeal, we will make our best
        efforts to contact you in person to let you know that we have denied your
        request for an expedited appeal and will handle it as a standard appeal.
        Also,
        we will send you a written notice of our decision to deny your request for
        an
        expedited appeal within 2 days of receiving your request.

    

    
      

      If
        the Plan Denies My Appeal, What Can I Do?

    

    
      

      If
        our
        decision about your appeal is not totally in your favor, the notice you receive
        will explain your right to request a Medicaid Fair Hearing from New York
        State
        and how to obtain a Fair Hearing, who can appear at the Fair Hearing on your
        behalf, and for some appeals, your right to request to receive services while
        the Hearing is pending and how to make the request. If we deny your appeal
        because of issues of medical necessity or because the service in question
        was
        experimental or investigational, the notice will also explain how to ask
        New
        York State for an "external appeal" of our decision.

    

    
      

      State
        Fair Hearings

    

    
      

      If
        we did
        not decide the appeal totally in your favor, you may request a Medicaid Fair
        Hearing from New York State within 60 days of the date we sent you the notice
        about our decision on your appeal.

    

    
      

      If
        your
        appeal involved the reduction, suspension or termination of authorized services
        you are currently receiving, and you have requested a Fair Hearing, you may
        also
        request to continue to receive these services while you are waiting for the
        Fair
        Hearing decision. You must check the box on the form you submit to request
        a
        Fair Hearing to indicate that you want the services at issue to continue.
        Your
        request to continue the services must be made within 10 days of the date
        the
        appeal decision was sent by us or by the intended effective date of our action
        to reduce, suspend or terminate your services, whichever occurs later. Your
        benefits will continue until you withdraw the appeal; the original authorization
        period for your services ends; or the State Fair Hearing Officer issues a
        hearing decision that is not in your favor, whichever occurs
        first.

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    
      If
        the
        State Fair Hearing Officer reverses our decision, we must make sure that
        you
        receive the disputed services promptly, and as soon as your health condition
        requires. If you received the disputed services while your appeal was pending,
        we will be responsible for payment for the covered services ordered by the
        Fair
        Hearing Officer.

    

    
      

      Although
        you may request to continue services while you are waiting for your Fair
        Hearing
        decision, if your Fair Hearing is not decided in your favor, you may be
        responsible for paying for the services that were the subject of the Fair
        Hearing.

    

    
      

      State
        External Appeals

    

    
      

      If
        we
        deny your appeal because we determine the service is not medically necessary
        or
        is experimental or investigational, you may ask for an external appeal from
        New
        York State. The external appeal is decided by reviewers who do not work for
        us
        or New York State. These reviewers are qualified people approved by New York
        State. You do not have to pay for an external appeal.

    

    
      

      When
        we
        make a decision to deny an appeal for lack of medical necessity or on the
        basis
        that the service is experimental or investigational, we will provide you
        with
        information about how to file an external appeal, including a form on which
        to
        file the external appeal along with our decision to deny an appeal. If you
        want
        an external appeal, you must file the form with the New York State Department
        of
        Insurance within 45 days from the date we denied your appeal.

    

    
      

      Your
        external appeal will be decided within 30 days. More time (up to 5 business
        days) may be needed if the external appeal reviewer asks for more information.
        The reviewer will tell you and us of the final decision within two business
        days
        after the decision is made.

    

    
      

      You
        can
        get a faster decision if your doctor can say that a delay will cause serious
        harm to your health. This is called an expedited external appeal. The external
        appeal reviewer will decide an expedited appeal in 3 days or less. The reviewer
        will tell you and us the decision right away by phone or fax. Later, a letter
        will be sent that tells you the decision.

    

    
      

      You
        may
        ask for both a Fair Hearing and an external appeal. If you ask for a Fair
        Hearing and an external appeal, the decision of the Fair Hearing officer
        will be
        the "one that counts."

    

    
      

      3.
        SERVICE AUTHORIZATIONS

       

    

    
      A
        Prior
        Authorization is a request by the member or provider on member's behalf for
        a
        new service (whether for a new authorization period or within an existing
        authorization period) or a request to change a service as determined in the
        plan
        of care for a new authorization period.

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    
      A
        Concurrent Review is a request by a member or provider on member's behalf
        for
        additional services (i.e., more of the same) that are currently authorized
        in
        the plan of care.

    

    
      

      Expedited
        - the plan 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 member may request an expedited review of a
        Prior
        Authorization or Concurrent Review. Appeals of actions resulting from the
        concurrent review must be handled as expedited.

    

    
      

      Prior
        Authorization and Concurrent Reviews - Expedited and Standard

      
        1. 
          Plan must decide and notify member of decision by phone and in writing
          as fast
          as the member's condition requires but no more than:

        a.     Prior
          authorization

      

    

    
      i    Expedited
        - 3 business days from request for service. 

      ii   Standard
        - within 3 business days of receipt of necessary information, but no more
        than
        14 days of receipt of request for services.

    

    
      b.     Concurrent
        review

    

    
      
        i
          Expedited - within 1 business day of receipt of necessary information,
          but no
          more than 3 business days of receipt of request for services.

        ii
          Standard - within 1 business day of receipt of necessary information, but
          no
          more than 14 days of receipt of request for services.
2.  Up
        to 14
        calendar day extension. Extension may be requested by member or provider
        on
        member's behalf (written or verbal). The plan also may initiate an extension
        if
        it can justify need for additional information and if the extension is in
        the
        member's interest. In all cases, the extension reason must be well
        documented.

    

    
      3.  
        Member
        or
        provider may appeal decision - see Appeal Procedures.

    

    
      4.   If
        the
        plan denied the member's request for an expedited review, the plan will handle
        as standard review.

    

    
       

      Necessary
        Written Notices for Service Authorizations - Prior Authorizations and Concurrent
        Reviews - Expedited and Standard

    

    
      1. Notice
        to
        the member that the plan will not address request as expedited and that request
        will be handled as standard request (if applicable) if member has made a
        request
        for an expedited review.

    

    
       

      2. Notice
        of
        plan-initiated extension (if applicable)

    

    
      • Reason
        for extension

    

    
      • How
        the
        delay is in the best interest of the member

    

    
      • Any
        additional information that the plan requires from any source to make its
        determination

    

    

      3.    Notice

    

    
      a   Date
        of service request; summary of service request

    

    
      b   Reason
        for determination, and in cases where the determination has a clinical
basis,
        the clinical rationale for the determination

      c   Procedure
        for filing an internal appeal and an explanation that an expedited appeal
        can be requested if longer time frame would be injurious to member health

    

    
      d. 
        Description
        of what additional information, if any, must be obtained by the plan from
        any source for the plan to make an appeal decision if an internal
        appeal will be requested

      
        e. 
          Reference
          to the option of filing a Fair Hearing request after internal
          appeal process is exhausted, as well as an external appeal if the service
          denial is related to issues of medical necessity or experimental or
          investigational nature of service

        
          f.
            Must
            notify member of opportunity to present evidence and examine her/his case
            file during appeal

        

        
          g. Inform
            member of the availability of the clinical review criteria relied upon
            in making the decision, if the action involved medical necessity or if
            treatment or service was experimental or investigational

           

        

      

    

    
      The
        plan
        must notify members of the availability of assistance (for language, hearing,
        speech issues) if member wants to file appeal and how to access that
        assistance.

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    
      APPENDIX
        L

    

    
      

      MANAGED
        LONG-TERM CARE ENROLLEE RIGHTS

    

    
      

      The
        following identifies, at a minimum, managed long-term care demonstration
        Enrollee rights, and the language that must be used when communicating these
        rights to Potential Enrollees, Applicants and Enrollees in written
        material.

    

    
      
         

        
          

          
            	
                    ·

                  	
                    You
                      have the Right to receive
                      medically necessary
                      care.

                  

          

        

        
          

          
            	
                    ·

                  	
                    You
                      have the Right to timely
                      access to care and
                      services.

                  

          

        

        
          

          
            	
                    ·

                  	
                    You
                      have the Right to privacy
                      about your medical record and when you get
                      treatment.

                  

          

        

        
          

          
            	
                    ·

                  	
                    You
                      have the Right to get
                      information on available treatment options and alternatives
                      . presented in
                      a manner and language you
                      understand.

                  

          

        

        
          

          
            	
                    ·

                  	
                    You
                      have the Right to get
                      information in a language you understand; you can get oral
                      translation
                      services free of
                      charge.

                  

          

        

        
          

          
            	
                    ·

                  	
                    You
                      have the Right to get
                      information necessary to give informed consent before the start
                      of
                      treatment.

                  

          

        

        
          

          
            	
                    ·

                  	
                    You
                      have the Right to be treated
                      with respect and
                      dignity.

                  

          

        

        
          

          
            	
                    ·

                  	
                    You
                      have the Right to get a copy
                      of your medical records and ask that the records be amended
                      or
                      corrected.

                  

          

        

        
          

          
            	
                    ·

                  	
                    You
                      have the Right to take part
                      in decisions about your health care, including the right to
                      refuse
                      treatment.

                  

          

        

        
          

          
            	
                    ·

                  	
                    You
                      have the Right to be free
                      from any form of restraint or seclusion used as a means of coercion,
                      discipline,
                      convenience or
                      retaliation.

                  

          

        

        
          

          
            	
                    ·

                  	
                    You
                      have the Right to get care
                      without regard to sex, race, health status, color, age, national
                      origin,
                      sexual orientation, marital status or
                      religion.

                  

          

        

        
          

          
            	
                    ·

                  	
                    You
                      have the Right to be told
                      where, when and how to get the services you need from your
                      managed long
                      term care plan, including how you can get covered benefits
                      from
                      out-of-network providers if they are not available in the plan
                      network.

                  

          

        

        
          

          
            	
                    ·

                  	
                    You
                      have the Right to complain to
                      the New York State Department of Health or your Local Department
                      of Social
                      Services; and, the Right to use the New York State Fair Hearing
                      System
                      and/or a New York State External Appeal, where
                      appropriate.

                  

          

        

        
          

          
            	
                    ·

                  	
                    You
                      have the Right to appoint
                      someone to speak for you about your care and
                      treatment.

                  

          

        

      

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    
      APPENDIX
        M

    

    
      

      MANAGED
        LONG-TERM CARE PLAN INFORMATION REQUIREMENTS

    

    
      

      INFORMATION
        AND LANGUAGE REQUIREMENTS PURSUANT TO 42 CFR 438.10

    

    
       

      STATE
        AND PLAN RESPONSIBILITIES

    

    
       

      Written
        Materials

    

    
      Reg
        -
        Establish a methodology for identifying the prevalent non-English languages
        spoken by enrollees and potential enrollees throughout the State. "Prevalent"
        means a non-English language spoken by a significant number or percentage
        of
        potential enrollees and enrollees in the State. The State must make available
        written information in each prevalent non-English
        language.

    

    
      Reg
        -
        the State must require each MCO, PIHP, PAHP, and PCCM to make its written
        information available in the prevalent non-English languages in its particular
        service area.

    

    
      

      
        	
                •

              	
                For
                  Statewide materials, DOH has defined prevalent language of
                  potential enrollees for written material as primary language of 5% or
                  more of 65+ population (based on 65+ population in NYS from 2000
                  census) for potential enrollees. Those languages are English and
                  Spanish.

              

        	 	 
                
                This
                  standard applies to the State MLTC Consumer Guide which will be
                  translated
                  into Spanish. It has been distributed through SOFA, the LDSS, plans
                  and
                  included on the SDOH Website.

              

      

    

    
       

    

    
      
        	
                •  

              	
                All
                  plans are required to translate all written materials into Spanish
                  if 5%
                  or more of the population in a county which it serves speaks Spanish
                  as a
                  primary language (according to 2000 U.S. Census data). If plan
                  doesn't
                  meet census criteria for Spanish translation, but Spanish is defined
                  as a
                  prevalent language under other criteria, then plan will be required
                  to
                  translate all written materials into
                  Spanish.

              

      

    

    
      

      
        	
                •  

              	
                Additionally,
                  all plans are required to translate all written materials into
                  prevalent
                  languages.

              

      

    

    
      

      
        	
                •  

              	
                DOH
                  defines a prevalent language as a language spoken by at least 5%
                  of the
                  plan's enrolled population or 50 members, whichever is less. Census
                  data
                  are used as the basis for defining prevalent
                  languages.

              

      

    

    
      

      
        	
                •

              	
                DOH
                  requires in the MLTCP/DOH contract that plans meet the necessary
                  requirements.

              

      

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    
      Oral
        Translation

    

    
      Reg
        -
        State must make oral interpretation services available and require each MCO,
        PIHP, PAHP, and PCCM to make those services available free of charge to each
        potential enrollee and enrollee.

    

    
      

      
        	
                •  

              	
                Oral
                  interpretation services (via ATT Language Line, staff capabilities,
                  etc.)
                  are available through every LDSS. In DOH all BCCI staff have access
                  to
                  telephone interpretation
                  services.

              

      

    

    
      

      
        	
                •  

              	
                All
                  plans currently have capability for oral translation services,
                  through
                  staff, telephone translation, electronic translation device,
                  etc.

              

      

    

    
      

      
        	
                •  

              	
                DOH
                  requires in the MLTCP/DOH contract that plans meet necessary requirements
                  for oral translation
                  services.

              

      

    

    
      

      Notifying
        Potential and Actual Enrollees About Translation
        Services

    

    
      Reg
        -The State must notify enrollees and potential enrollees, and require each
        MCO,
        PIHP, PAHP, and PCCM to notify its enrollees: (i) That oral interpretation
        is
        available for any language and written information is available in prevalent
        languages and (ii) How to access those services.

    

    
      

      
        	
                •  

              	
                There
                  are statements about oral translation service availability and
                  the right
                  to free language assistance services in the State MLTC Consumer
                  Guide and
                  the plan member handbooks.

              

      

    

    
      

      
        	
                •  

              	
                DOH
                  requires in the MLTCP/DOH contract that plans meet necessary requirements
                  for notification of availability of oral translation
                  services.

              

      

    

    
      

      Alternative
        Formats

    

    
      Reg
        -
        Written material must (i) Use easily understood language and format; and
        (ii) Be
        available in alternative formats and in an appropriate manner that takes
        into
        consideration the special needs of those who, for example, are visually limited
        or have limited reading proficiency.  

    

    
      
        	• 	 DOH
                makes materials available in an alternative
                format.

        	
                • 

              	
                Plans
                  must select the alternative format(s) to be used (e.g., audiotapes,
                  reading content of written materials to prospective applicants/enrollees)
                  and obtain DOH approval of the
                  selection.

              

      

    

    
      
        	
                • 

              	
                Plans
                  will ensure that their member services staff screen calls for those
                  individuals who might need materials in alternative
                  formats.

              

        	• 	 Plan
                guidelines require written material in easily understood and readable
                formats.

      

    

    
      

       

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    
      Information
        for Potential Enrollees

    

    
      Reg:
        (l)The State or its contracted representative must provide the information
        specified in paragraph (2) to each potential enrollee as follows: (i)At the
        time
        the potential enrollee first becomes eligible to enroll in a voluntary program,
        or is first required to enroll in a mandatory enrollment program, (ii) Within
        a
        timeframe that enables the potential enrollee to use the information in choosing
        among available MCOs,PIHP,PAHPs, or PCCMs. (2) The information for potential
        enrollees must include the following: Names, locations, telephone numbers
        of,
        and non-English language spoken by current contracted
        providers.

    

    
       

      
        
          
            	• 	   DOH
                    defines potential enrollee as an individual who makes inquiry
                    of the
                    plan.

            	
                    •

                  	
                    The
                      State MLTC Consumer Guide includes a statement that indicates
                      the reader
                      should check with the plan in which s/he is interested to find
                      out which
                      languages are spoken by which providers.

                  

            	• 	 Plan
                    provider directories are required to identify the languages spoken
                    by
                    providers.

          

        

        
          
            	
                    •

                  	
                    Plan
                      handbooks also must include a statement (in Spanish and other
                      prevalent
                      languages as appropriate) that directs potential enrollees
                      to call the
                      plan to obtain the most current information about languages
                      spoken by
                      participating providers.

                  

          

        

        
          
            	
                    •

                  	
                    The
                      State MLTC Consumer Guide includes information on all plans
                      in the State,
                      their service areas and contact
                      numbers.

                  

          

        

        
          
            	
                    •

                  	
                    Plans
                      are required to provide information on all plans in the State,
                      their
                      service areas and contact numbers. This will be accomplished
                      by the plans'
                      distribution of the State MLTC Consumer Guide with their
                      handbooks.

                  

          

        

        
          
            	
                    •

                  	
                    DOH
                      requires in the MLTCP/DOH contract that plans meet necessary
                      requirements
                      for notifying potential enrollees and enrollees about the availability
                      of
                      non-English speaking
                      providers.

                  

          

        

      

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    
      APPENDIX
        X

    

    
      

      Modification
        Agreement Form

    

     

     

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    
      
        
           

          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 (hereinafter
            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

                  

                  
                    By:

                  

                	
                  
                    STATE
                      AGENCY SIGNATURE

                  

                  
                    By:

                  

                
	 
	
                  
                    Printed
                      Name 

                    Title:

                  

                	
                  
                    Printed
                      Name 

                    Title:

                  

                
	
                  
                    Date:

                  

                	
                  
                    Date:

                  

                
	 	
                  
                     

                    State
                      Agency Certification:

                  

                  
                    In
                      addition to the acceptance of this contract, I also certify
                      that original
                      copies of this signature page will be attached to all other
                      exact copies
                      of this contract.

                  

                  
                     

                  

                

        

        
           

          STATE
            OF
            NEW YORK

        

        
          County
            of
            ___________________

        

        
           

          On
            the
            ______________  day of __________ , 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)

        

        
          

          STATE
            COMPTROLLER'S SIGNATURE

           

        

        
          Title:

           

        

        
          Date:

          

        

        
          

           

        

        
          APPENDIX
            X

        

        
          2007exhibi10-2.htm

    
      
        

      

    

    Back
      to Form 8-K

     

    Exhibit
      10.2

     

    
      
        MEDICAID
          ADVANTAGE PLUS (MAP) MODEL CONTRACT MISCELLANEOUS/CONSULTANT
          SERVICES

      

      
        

        (Non-Competitive
          Award)

      

      
        

      

      
        	
                
                  STATE
                    AGENCY (Name and Address):

                

                 

              	
                NYS
                  Comptroller's Number: C021887

              
	
                New
                  York State Department of Health Office of Managed Care 

                Empire
                  State Plaza 

                Corning
                  Tower, Room 2074 

                Albany,
                  NY 12237

                 

              	
                Originating
                  Agency Code: 12000

              
	
                CONTRACTOR
                  (Name and Address):

                 

              	
                TYPE
                  OF PROGRAM:

              
	
                
                  WellCare
                    of New York, Inc.

                

                
                  11
                    West 19th
                    Street

                

                New
                  York, New York 10011

                 

              	
                Medicaid
                  Advantage Plus

              
	
                CHARITIES
                  REGISTRATION NUMBER:

                 

              	
                CONTRACT
                  TERM:

              
	
                N/A

                 

              	
                FROM:
                  July 1,2007

              
	
                FEDERAL
                  TAX IDENTIFICATION NUMBER:

                 

              	
                TO:
                  December 31, 2009

              
	
                141676443

                 

              	 
	
                MUNICIPALITY
                  NUMBER (if applicable):

              	
                FUNDING
                  AMOUNT FOR CONTRACT TERM: Based on approved capitation
                  rates

              
	
                N/A

                 

              	 
	
                STATUS:

                 

              	
                THIS
                  CONTRACT IS RENEWABLE FOR TWO ADDITIONAL ONE YEAR PERIODS SUBJECT
                  TO THE
                  APPROVAL OF THE NYS DEPARTMENT OF HEALTH, THE DEPARTMENT OF HEALTH
                  AND
                  HUMAN SERVICES AND THE OFFICE OF THE STATE COMPTROLLER.

              
	
                CONTRACTOR
                  IS [ ] IS NOT [X] A SECTARIAN ENTITY

                 

              
	
                CONTRACTOR
                  IS [ ]   IS NOT [X] A NOT-FOR-PROFIT
                  ORGANIZATION

                 

              
	
                CONTRACTOR
                  IS [X]   IS NOT [ ] ANY STATE BUSINESS
                  ENTERPRISE

              
	 	 

      

      
        

      

      
        

      

      
        Medicaid
          Advantage Plus Contract

      

      
        2007

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        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   

              	
                  
                  /s/   Kathleen Shure

              
	
                Title:
                  President & CEO

              	
                Title:
                  Director, Division of Managed Care and Program Evaluation, Office
                  of
                  Health Insurance Programs

              
	
                Date:
                  5/31/2007

              	
                Date:
                  6/27/07

              
	 	
                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

      

      
        County
          of
          Hillsborough

         

      

      
        On
          the 31
          Day of May, 2007, before me personally appeared Todd S. Fahra to me known,
          who
          being by me duly sworn, did depose and say that he/she resides at Tampa,
          Florida
          that he is the President & CEO of WellCare of New York, Inc. 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
          corporations.

      

      
        

      

      
        Notary

      

      
        

      

      
        Medicaid
          Advantage Plus Contract

      

      
        2007

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        Table
          of Contents for Medicaid Advantage Plus 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 Enrollee
          Transition Plan

      

      
        2.9 Agreement
          Close-Out Procedures

      

      
        2.10 Rights
          and Remedies

      

      
        2.11 Notices

      

      
        2.12 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 Contractor
          Financial Liability

      

      
        3.9  Spenddown
          and Net Available Monthly Income (NAMI)

      

      
        

        Section
          4. Service Area

      

      
        

        Section
          5. Eligibility For Enrollment in Medicaid Advantage Plus

      

      
        5.1  Eligibility
          to Enroll in Medicaid Advantage Plus

      

      
        5.2  Not
          Eligible to Enroll in the Medicaid Advantage Plus Program

      

      
        5.3  Change
          in Eligibility Status

      

      
        

        Section
          6. Enrollment

      

      
        6.1 Enrollment
          Requirements

      

      
        6.2  Equality
          of Access to Enrollment

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        2007

      

      
        TABLE
          OF
          CONTENTS

      

      
        -
          iii
          -

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        6.3 Enrollment
          Decisions

      

      
        6.4 Prohibition
          Against Conditions
          on Enrollment

      

      
        6.5
          Effective Date of Enrollment

      

      
        6.6 Contractor
          Liability

      

      
        6.7 Roster

      

      
        6.8 Automatic
          Re-Enrollment

      

      
        6.9 Failure
          to Enroll in Contractor's Medicare Advantage Product

      

      
        6.10 Spenddown
          and Net Available Monthly Income (NAMI)

      

      
        6.11 Enrollment
          Limits

      

      
        

        Section
          7. RESERVED

      

      
        

        Section
          8. Disenrollment

      

      
        8.1
          Disenrollment Requirements

      

      
        8.2  Disenrollment
          Prohibitions

      

      
        8.3  Disenrollment
          Requests

      

      
        8.4  Disenrollment
          Notifications

      

      
        8.5 Contractor's
          Liability

      

      
        8.6 Contractor
          Referrals to Alternative Services

      

      
        8.7 Enrollee
          Initiated Disenrollment

      

      
        8.8 Contractor
          Initiated Disenrollment

      

      
        8.9 LDSS
          Initiated Disenrollment

      

      
        

        Section
          9. RESERVED

      

      
        

        Section
          10. Benefit Package, Covered and Non-Covered Services

      

      
        10.1 Contractor
          Responsibilities

      

      
        10.2 SDOH
          Responsibilities

      

      
        10.3 Benefit
          Package and Non-Covered Services Descriptions

      

      
        10.4 Adult
          Protective Services

      

      
        10.5 Court-Ordered
          Services

      

      
        10.6 Family
          Planning and Reproductive Health Services

      

      
        10.7
          Emergency and Post
          Stabilization Care Services

      

      
        10.8
          Medicaid Utilization Thresholds (MUTS)

      

      
        10.9 Services
          for Which Enrollees Can Self-Refer

      

      
        10.10 Prevention
          and Treatment of Sexually Transmitted Diseases

      

      
        10.11 Enrollee
          Needs Relating to HIV

      

      
        10.12 Persons
          Requiring Chemical Dependence Services

      

      
        10.13 Care
          Management

      

      
        10.14
          Urgently Needed Services

      

      
        10.15 Coordination
          of Services

      

      
        

        Section
          11. Marketing

      

      
        11.1
          Marketing Requirements

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        2007

      

      
        TABLE
          OF
          CONTENTS

      

      
        -
          iv-

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        Section
          12. Member Services

      

      
        12.1 General
          Functions

      

      
        12.2 Translation
          and Oral Interpretation

      

      
        

        12.3 Communicating
          with the Visually, Hearing and Cognitively Impaired

      

      
        

        Section
          13. Enrollee Notification

      

      
        13.1 General
          Requirements

      

      
        13.2 Enrollment
          Agreement/Attestation

      

      
        13.3 Member
          ID Cards

      

      
        13.4 Enrollee
          Rights

      

      
        

        Section
          14. Organization Determinations, Actions, and Grievance
          System

      

      
        14.1
General
          Requirements

      

      
        
          14.2 
            Filing and Modification of Medicaid Advantage Plus Action Appeals and/or
            Grievance Procedures

        

      

      
        
          14.3 Medicaid
            Advantage Plus Action and
            Grievance System Additional Provisions 

        

      

      
        14.4 Complaint
          Investigation Determinations

      

      
        

        Section
          15. Access Requirements

      

      
        

        Section
          16. Quality Management and Performance Improvement

      

      
        16.1 Quality
          Management and Performance Improvement Program

      

      
        16.2 Chronic
          Care Improvement Programs

      

      
        16.3 Reporting

      

      
        16.4
Quality
          Indicators and Standards

      

      
        16.5 External
          Quality Review

      

      
        

        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

      

      
        

        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  Notification
          of Changes in Report Due Dates, Requirements or Formats

      

      
        18.5 Reporting
          Requirements

      

      
        18.6 Ownership
          and Related Information Disclosure

      

      
        18.7  Data
          Certification

      

      
        18.8 Public
          Access to Reports

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

        

      

      
        18.10 Conflict
          of Interest Disclosure

      

      
        18.11 Physician
          Incentive Plan Reporting

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        2007

      

      
        TABLE
          OF
          CONTENTS

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        Section
          19Records 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
            Applicants

        

      

      
        20.2  Confidentiality
          of Medical Records

      

      
        20.3   Length
          of Confidentiality Requirements

      

      
        

        Section
          21. Participating Providers

      

      
        21.1
General
          Requirements

      

      
        21.2  Medicaid
          Advantage Plus Network Requirements

      

      
        21.3 Professional
          Discipline

      

      
        21.4 SDOH
          Exclusion or Termination of Providers

      

      
        21.5  Payment
          in Full

      

      
        21.6  Dental
          Networks

      

      
        
           

          Section
            22. Subcontracts and Provider Agreements for Medicaid Advantage Plus
            Covered
            Services

        

      

      
        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  Recovery
          of Overpayments to Providers

      

      
        22.8  Physician
          Incentive Plan

      

      
        22.9  Provider
          Termination Notices

      

      
        

        Section
          23. Americans With Disabilities Act Compliance Plan

      

      
        

        Section
          24. Fair Hearings

      

      
        24.1 Enrollee
          Access to Fair Hearing Process

      

      
        24.2 Enrollee
          Rights to a Fair Hearing

      

      
        24.3 Contractor
          Notice to Enrollees

      

      
        24.4  Aid
          Continuing

      

      
        24.5  Contractor's
          Obligations

      

      
        

        Section
          25 External Appeal

      

      
        25.1 Basis
          for External Appeal

      

      
        25.2  Eligibility
          for External Appeal

      

      
        25.3  External
          Appeal Determination

      

      
        Medicaid
          Advantage Plus Contract

        2007

      

      
        TABLE
          OF
          CONTENTS

      

      
        -
          vi-

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        25.4 
          Compliance with External Appeal Laws and Regulations

      

      
        25.5
          Member Handbook

      

      
         

        Section
          26.  Intermediate Sanctions

      

      
        26.1  General

      

      
        26.2  Unacceptable
          Practices

      

      
        26.3  Intermediate
          Sanctions

      

      
        26.4
          Enrollment Limitations

      

      
        26.5 Due
          Process

      

      
        

        Section
          27. Environmental Compliance

      

      
         

        Section
          28. Energy Conservation

      

      
        

        Section
          29. Independent Capacity of Contractor

      

      
         

        Section
          30. No Third Party Beneficiaries

      

      
         

        Section
          31. Indemnification

      

      
        31.1 Indemnification
          by Contractor

      

      
        31.2 Indemnification
          by SDOH

      

      
        

        Section
          32. Prohibition on Use of Federal Funds for Lobbying

      

      
        32.1 Prohibition
          of Use of Federal Funds for Lobbying

      

      
        32.2  Disclosure
          Form to Report Lobbying

      

      
        32.3 Requirements
          of Subcontractors

      

      
        

        Section
          33. Non-Discrimination

      

      
        33.1 Equal
          Access to Benefit Package

      

      
        33.2 Non-Discrimination

      

      
        33.3 Equal
          Employment Opportunity

        
          33.4 
Native
            Americans Access to Services From Tribal or Urban Indian Health
            Facility

           

        

      

      
        Section
          34.  Compliance with Applicable Laws and Regulations

      

      
        34.1  Contractor
          and SDOH Compliance with Applicable Laws

      

      
        
          
            34.2 
              Nullification of Illegal, Unenforceable, Ineffective
              or Void
              Contract Provisions

          

        

      

      
        34.3  Certificate
          of Authority Requirements

      

      
        34.4 Notification
          of Changes in Certificate of Incorporation

      

      
        34.5
          Contractor's Financial Solvency Requirements

      

      
        34.6 Non-Liability
          of Enrollees for Contractor's Debts

      

      
        34.7 SDOH
          Compliance with Conflict of Interest Laws

      

      
        34.8 Compliance
          Plan

      

      
        

        Section
          35New York State Standard Contract Claus

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        2007

      

      
        TABLE
          OF
          CONTENTS

      

      
        -
          vii
          -

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        APPENDICES

      

      
        A.
          New York State Standard Contract Clauses

      

      
        B.
          Certification Regarding Lobbying

      

      
        B-1.
          Certification Regarding MacBride Fair Employment
          Principles

      

      
        C.
          New York State Department of Health Requirements for Provision of Free
          Access to
          Family Planning and Reproductive Health Services

      

      
        D.
          New York State Department of Health Medicaid Advantage Plus Marketing
          Guidelines

      

      
        E.
          New York State Department of Health Medicaid Advantage Plus Member
          Handbook Guidelines

      

      
        F.
          New York State Department of Health Medicaid Advantage Plus Action and
          Grievance
          System Requirements

      

      
        G.
          RESERVED

      

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

      

      
        I.
          RESERVED

      

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

      

      
        K.
          Medicare and Medicaid Advantage Plus Products and Non-Covered
          Services

      

      
        L.
          Approved Capitation Payment Rates

      

      
        M.
          Service Area

      

      
        N.
          RESERVED

      

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

      

      
        P.
          RESERVED

      

      
        Q.
          RESERVED

      

      
        R.
          Additional Specifications for the Medicaid Advantage Plus
          Agreement

      

      
        X.
          Modification Agreement Form

      

      
        Medicaid
          Advantage Plus Contract

        2007

      

      
        APPENDICES

      

      
        -
          viii
          -

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        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. New York 10011.

      

      
        

        RECITALS

      

      
        

        WHEREAS,
          pursuant to Title XIX of the Federal Social Security Act, codified as 42
          U.S.C.
§1396 et seq. (the Social Security Act), and Title 11 of Article 5 of the
          New
          York State Social Services Law (SSL), codified as SSL §363 et seq., a
          comprehensive program of Medical Assistance for needy persons exists in
          the
          State of New York (Medicaid); and

      

      
        

        WHEREAS,
          pursuant to Article 44 of the Public Health Law (PHL), the New York State
          Department of Health (SDOH) is authorized to issue Certificates of Authority
          to
          establish Health Maintenance Organizations (HMOs), PHL §4400 et seq., and
          Managed Long Term Care Plans (MLTCPs), PHL §4403-f; and

      

      
        

        WHEREAS,
          the State Social Services Law defines Medicaid to include payment of part
          or all
          of the cost of care and services furnished by an HMO or a MLTCP, identified
          as
          Managed Care Organizations (MCOs) in this Agreement, to Eligible Persons,
          as
          defined in this Agreement, residing in the geographic area specified in
          Appendix
          M (Service Area) when such care and services are furnished in accordance
          with an
          agreement approved by the SDOH that meets the requirements of federal law
          and
          regulations; and

      

      
        

        WHEREAS,
          the Contractor is a corporation organized under the laws of New York State
          and
          is certified under Article 44 of the State Public Health Law
          and

      

      
        

        WHEREAS,
          the Contractor has applied to participate in the Managed Long Term Care
          Program
          and the SDOH has determined that the Contractor meets the qualification
          criteria
          established for participation; and

      

      
        

        WHEREAS,
          the Contractor is an entity which has been determined to be an eligible
          Medicare
          Advantage Organization by the Administrator of the Centers for Medicare
          and
          Medicaid Services (CMS) under 42 CFR 422.503; and has entered into a contract
          with CMS pursuant to §§1851 through 1859 of the Social Security Act to operate a
          coordinated care plan, as described in its final Plan Benefit Package (PBP)
          bid
          submission proposal approved by CMS, in compliance with 42 CFR 422 and
          other
          applicable Federal statutes, regulations and policies; and

      

      
        

        WHEREAS,
          the Contractor is an entity that has amended its contract with CMS to include
          an
          agreement to offer qualified Medicare Part D coverage pursuant to §§1860D-1
          through 1860D-42 of the Social Security Act and K of 42 CFR 422 or is a
          Specialized Medicare Advantage Plan for Special Needs Individuals which
          includes
          qualified Medicare Part D prescription drug coverage; and

      

      
        

        

      

      
        Medicaid
          Advantage Plus Contract

      

      
        2007

      

      
        RECITALS

        -1-

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        WHEREAS,
          the Contractor offers a comprehensive health services plan and represents
          that
          it is able to make provision for furnishing the Medicare Plan Benefit Package
          (Medicare Part C benefit), the Medicare Voluntary Prescription Drug Benefit
          (Medicare Part D) and the Medicaid Advantage Plus Product as defined in
          this
          Agreement and has proposed to provide coverage of these Medicaid Advantage
          Plus
          products to Eligible Persons as defined in this Agreement residing in the
          geographic area specified in Appendix M.

      

      
        

        NOW
          THEREFORE, the parties agree as follows:

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        2007

      

      
        RECITALS

      

      
        -2-

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        1.
          DEFINITIONS

      

      
        

        "Applicant"
          is an individual who has expressed a desire to pursue enrollment
          in a
          managed long-term care plan

      

      
        

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

      

      
        

        "Care
          Management" is a process that assists Enrollees to access necessary
          covered services as identified in the care plan. It also provides referral
          and
          coordination of other services in support of the care plan. Care management
          services will assist Enrollees to obtain needed medical, social, educational,
          psychosocial, financial and other services in support of the care plan
          irrespective of whether the needed services are covered under the capitation
          payment of this Agreement.

      

      
        

        "Care
          Plan (or plan of care)" is a written description in the cafe management
          record of member-specific health care goals to be achieved and the amount,
          duration and scope of the covered services to be provided to an Enrollee
          in
          order to achieve such goals. The care plan is based on assessment of the
          member's health care needs and developed in consultation with the member
          and
          his/her informal supports. Effectiveness of the care plan is monitored
          through
          reassessment and a determination as to whether the health care goals are
          being
          met. Non-covered services which interrelate with the covered services identified
          on the care plan and services of informal supports necessary to support
          the
          health care goals and effectiveness of the covered services should be clearly
          identified on the care plan or elsewhere in the care management
          record.

      

      
        

        CMS
          means the U.S. Centers for Medicare and Medicaid Services, formerly
          known as HCFA.

      

      
        

        "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
          Medicare and Medicaid Advantage Plus Benefit Packages.

      

      
        

        "Days"
          means calendar days except as otherwise stated.

      

      
        

        "DHHS"
          means the U.S. Department of Health and Human
          Services.

      

      
        

        "Disenrollment"
          means the process by which an Enrollee's membership in the Contractor's
          Medicaid Advantage Plus Product terminates.

      

      
        

        "Dually
          Eligible" means eligible for both Medicare and
          Medicaid.

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        2007

      

      
        DEFINITIONS

      

      
        SECTION
          1

      

      
        -1-

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        "Effective
          Date of Disenrollment" means the date on which an Enrollee is no longer
          a member of the Contractor's Medicaid Advantage Plus Product.

      

      
        

        "Effective
          Date of Enrollment" means the date on which an Enrollee is a member of
          the Contractor's Medicaid Advantage Plus Product.

      

      
        

        "Eligible
          Person" means a person whom the LDSS, state or federal government
          determines to be eligible for Medicaid and who meets all the other conditions
          for enrollment in the Medicaid Advantage Plus Program as set forth in Section
          5.1 of 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 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 covered services that are needed to treat an Emergency
          Medical Condition. 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.

      

      
        

        "Enrollee"
          means an Eligible Person who, either personally or through an
          authorized representative, has enrolled in the Contractor's Medicaid Advantage
          Plus Product pursuant to Section 6 of this Agreement.

      

      
        

        "Enrollment"
          means the process by which an Enrollee's membership in a Contractor's
          Medicaid Advantage Plus Product begins.

      

      
        

        "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.

      

      
        

        "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 may
          include: collection of Medicaid complaint and disenrollment information;
          collection of Medicaid financial reports; collection and reporting of managed
          care provider networks systems (PNS); and the reporting of Medicaid encounter
          data systems (MEDS).

      

      
        

      

      
        Medicaid
          Advantage Plus Contract

      

      
        2007
          DEFINITIONS

      

      
        SECTION
          1

      

      
        -2-

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

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

      

      
        

        "Managed
          Care Organization" or "MCO" means a health maintenance organization
          ("HMO") or managed long-term care plan ("MLTCP") certified under Article
          44 of
          the New York State PHL.

      

      
        

        "Marketing"
          means activity of the Contractor, subcontractor or individuals
          or
          entities affiliated with the Contractor, as described in Appendix D, by
          which
          information about the Contractor is made known to Eligible Persons for
          the
          purpose of persuading such persons to enroll in the Contractor's Medicaid
          Advantage Plus Product.

      

      
        

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

      

      
        

        "Medicaid
          Advantage Plus Benefit Package" means the services and benefits
          described in Appendix K-2 of this Agreement, plus the CMS approved Medicare
          supplemental premium for the Medicare Part C benefits described in Appendix
          K-1
          of this Agreement, if any, included in the Capitation Rate paid to the
          MCO by
          the State.

      

      
        

        "
          Medicaid Advantage Plus Program" means the program that the
          State has developed to enroll persons who are nursing home certifiable
          and who
          are Dually Eligible in managed long-term care pursuant §4403-f of the Public
          Health Law.

      

      
        

        "Medicaid
          Advantage Plus Product" means the product offered by a qualified MCO to
          Eligible Persons under this Agreement as described in Appendix K-2 of this
          Agreement.

      

      
        

        "Medicaid
          Advantage Plus Covered Services" means those services included in the
          Medicaid Advantage Plus Benefit Package that are covered solely by Medicaid
          and
          which are not included in the Contractor's plan Benefit Package Bid submission
          proposal as approved by CMS.

      

      
        

        "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" as applicable to services that the Contractor determines are
          a Medicaid only benefit and to services that the Contractor determines
          are a
          benefit under both Medicare and Medicaid, 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.

      

      
        

      

      
        

      

      
        Medicaid
          Advantage Plus Contract

      

      
        2007
          DEFINITIONS

      

      
        SECTION
          1

      

      
        -3-

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        "Medicare
          Advantage Benefit Package" means all the health care services and
          supplies that are covered by the Contractor's Medicare Advantage Product
          including Medicare Part C and qualified Part D Benefits, on file with CMS,
          as
          described in Appendix K-1 of this Agreement.

      

      
        

        "Medicare
          Advantage Organization" means a public or private organization licensed
          by the State as a risk-bearing entity that is under contract with CMS to
          provide
          the Medicare Advantage Benefit Package as defined in this
          Agreement.

      

      
        

        "Medicare
          Advantage Product" means the product offered by a qualified MCO to
          Eligible Persons under this Agreement as described in Appendix K-1 of this
          Agreement.

      

      
        

        "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 Medicaid
          Advantage Plus Enrollee.

      

      
        

        "Nonconsensual
          Enrollment" means Enrollment of an Eligible Person, in a Medicaid
          Advantage Plus 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.

      

      
        

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

      

      
        

        "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
          furnished 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 an Eligible Person as defined in this Agreement who has
          not yet enrolled in the Contractor's Medicaid Advantage Plus
          Product.

      

      
        

        "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 in the
          Medicaid Advantage Plus Program for the coming month, subject to any revisions
          communicated in writing or electronically by SDOH or LDSS.

      

      
        

      

      
        

      

      
        Medicaid
          Advantage Plus Contract

      

      
        2007
          DEFINITIONS

      

      
        SECTION
          1

      

      
        -4-

         

         

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

      

      
         

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

      

      
        

        Surplus
          Amounts: shall mean the amount of medical expenses the LDSS determines
          a "medically needy" individual must incur in any period in order to be
          eligible
          for medical assistance. Surplus amounts may be referred to as spenddown
          amounts
          or the amount of net available monthly income (NAMI) determined by the
          LDSS that
          a nursing home resident must pay monthly to the nursing home in accordance
          with
          the requirements of the medical assistance program.

      

      
        

        "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 Participating Providers.

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        2007

      

      
        DEFINITIONS

      

      
        SECTION
          1

      

      
        -5-

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        
          2.1
            AGREEMENT TERM, AMENDMENTS, EXTENSIONS, AND GENERAL CONTRACT ADMINISTRATION
            PROVISIONS 

           

        

      

      
        
          	
                  
                    2.1
                      Term

                  

                	
                   

                

        

      

      
        

        
          	
                  a)

                	
                  This
                    Agreement is effective July 1, 2007 and shall remain in effect
                    until
                    December 31, 2009 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), and 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
                    two (2) additional one (1) year terms, subject to the approval
                    of the
                    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; provided,
                    however,
                    that an extension to this Agreement beyond the five (5) 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 should federal financial participation for the
Medicaid
                    Advantage Plus program
                    expire.

                

        

      

      
         

      

      
        2.2
          Amendments

      

      
        

        
          	
                   

                	
                  a)
                    This Agreement may only be modified 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.

                

        

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        2007

      

      
        AGREEMENT
          TERM, AMENDMENTS, EXTENSIONS

      

      
        AND
          GENERAL CONTRACT ADMINISTRATION PROVISIONS

      

      
        SECTION
          2

      

      
        -1-

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        
          	
                   

                	
                  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.

                

        

      

      
        

        
          	
                   

                	
                  c)
                    The Contractor will return the signed amendment or notify the
                    SDOH that it
                    does not agree with the terms of the amendment 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 or regulation.

      

      
        

        2.4
          Entire Agreement

      

      
        

        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, 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:

      

      
        

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

      

      
        2)  The
          body of this Agreement

        3) 
The
          appendices attached to the body of this Agreement, other than Appendix
          A;

        4)   The
          Contractor's approved:

      

      
        i)
          Medicaid Advantage Plus Marketing Plan, if applicable, on file with
          SDOH

      

      
        ii)Action
          and Grievance System Procedures on file with SDOH

      

      
        iii)
          ADA
          Compliance 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 the DHHS.

      

      
         

        Medicaid
          Advantage Plus Contract

      

      
        2007

      

      
        AGREEMENT
          TERM, AMENDMENTS, EXTENSIONS

      

      
        AND
          GENERAL CONTRACT ADMINISTRATION PROVISIONS

      

      
        SECTION
          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
                    Medicaid
                    Only Covered services to Enrollees, except by 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 becoming effective. Any subcontract
                    entered into
                    by Contractor shall fulfill the requirements of 42 CFR 434 and
                    438 to the
                    extent such regulations are or become effective that pertain
                    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 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 Medicaid program or
                    engaged in an unacceptable practice pursuant to Section 26.2
                    of this
                    Agreement;

                

        

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        2007

      

      
        AGREEMENT
          TERM, AMENDMENTS, EXTENSIONS

      

      
        AND
          GENERAL CONTRACT ADMINISTRATION PROVISIONS

      

      
        SECTION
          2

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

       

      
        
          	
                  C)

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

                

        

      

      
        
          	
                  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);

                

        

      

      
        
          	
                  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; or

                

        

      

      
        
          	
                  H)

                	
                   terminates
                    or fails to renew its contract with CMS pursuant to § 1851 through 1859 of
                    the Social Security Act to offer the Medicare Advantage Product,
                    including
                    Medicare Part C benefits as defined in this Agreement and qualified
                    Medicare Part D benefits, to Eligible Persons residing in the
                    service area
                    specified in Appendix M. In such instances, the Contractor shall
                    notify
                    the SDOH of the termination or failure to renew the contract
                    with CMS
                    immediately upon knowledge of the impending termination or failure
                    to
                    renew.

                

        

      

      
        

         

      

      
         

      

      
        
          	 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 the
                  termination.

          	 iii)	 
                  If SDOH suspends, limits or revokes Contractor's Certificate of
                  Authority
                  under PHL Article 44, 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

                

        

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        2007

      

      
        AGREEMENT
          TERM, AMENDMENTS, EXTENSIONS

      

      
        AND
          GENERAL CONTRACT ADMINISTRATION PROVISIONS

      

      
        SECTION
          2

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        
          	
                   

                	
                  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 Medicaid Advantage Plus Product under this Agreement
                    in any
                    designated geographic area not affected by such action, and shall
                    terminate its Medicaid Advantage Plus Product 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 from the Contractor's
                    Medicaid
                    Advantage Plus Product.

                

        

      

      
        

        
          	
                   

                	
                  vi)
                    SDOH 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 Finance Law 139-k was intentionally false or intentionally
                    incomplete. Upon such finding, the State may exercise its termination
                    right by providing written notification to the Contractor is
                    accordance
                    with the written notification terms of this
                    Agreement.

                

        

      

      
        

        b)
          Contractor and SDOH Initiated Termination

      

      
        

        
          	
                   

                	
                  i)The
                    Contractor and the SDOH each shall have the right to terminate
                    this
                    Agreement in the event that SDOH and the Contractor fail to reach
                    agreement on the monthly Capitation
                    Rates.

                

        

      

      
        

        
          	
                   

                	
                  ii)The
                    Contractor and the SDOH shall each have the right to terminate
                    this
                    Agreement in the event the Contractor terminates or fails to
                    renew its
                    contract with CMS to offer the Medicare Advantage Product, as
                    defined in
                    this Agreement, to Eligible Persons in the service area as specified
                    in
                    Appendix M.

                

        

      

      
        

        
          	
                   

                	
                  iii)
                    In such events, 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
                    disenrollment of Enrollees from the Contractor's Medicaid Advantage
                    Plus
                    Product. However, in the event that this Agreement is terminated
                    due to
                    the Contractor's failure to renew its contract with CMS to offer
                    the
                    Medicare Advantage Product, or that the Contractor's Medicare
Advantage
                    contract with CMS otherwise expires or terminates, this Agreement
                    shall
                    terminate on the effective date of the termination of the Contractor's
                    contract with CMS.

                

        

      

      
         

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        2007

      

      
        AGREEMENT
          TERM, AMENDMENTS, EXTENSIONS

      

      
        AND
          GENERAL CONTRACT ADMINISTRATION PROVISIONS 

        SECTION
          2

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

       

      
        c)
          Contractor Initiated Termination

      

      
        

        
          	
                   

                	
                  i)
                    The Contractor shall have the right to terminate this Agreement
                    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 to 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
                    disenrollment of Enrollees from the Contractor's Medicaid Advantage
                    Plus
                    Product.

                

        

      

      
        

        
          	
                   

                	
                  ii)
                    The Contractor shall have the right to terminate this Agreement
                    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
                    disenrollment of Enrollees from the Contractor's Medicaid Advantage
                    Plus
                    Product.

                

        

      

      
        

        
          	
                   

                	
                  iii)
                    The Contractor shall have the right to terminate this Agreement
                    in its
                    entirety or in specified counties of the Contractor's service
                    area if the
                    Contractor is unable to provide the Medicaid Advantage Plus Benefit
                    Package 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 Medicaid Advantage Plus 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:

                

        

      

      
        

        
          	
                  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 Medicaid
                    Advantage Plus Services; and

                

        

      

      
        
          	
                  C)

                	
                  the
                    effective date of the termination, which shall not be less time
                    than will
                    permit an orderly disenrollment of Enrollees from the Contractor's
                    Medicaid Advantage Plus
                    Product.

                

        

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        2007

      

      
        AGREEMENT
          TERM, AMENDMENTS, EXTENSIONS

      

      
        AND
          GENERAL CONTRACT ADMINISTRATION PROVISIONS

      

      
        SECTION
          2

      

      
        -6-

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        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
          Enrollee Transition Plan

      

      
        

        
          	
                  a)

                	
                  Upon
                    expiration and non-renewal, or termination of this Contract,
                    and the
                    establishment of a termination date, the Contractor shall comply
                    with the
                    phase-out plan that the Contractor has developed and that SDOH
                    has
                    approved.

                

        

      

      
        

        
          	
                   

                	
                  i)
                    The Contractor shall contact other community resources to determine
                    the
                    availability of other programs to accept the Enrollees into their
                    programs;

                

        

      

      
        

        
          	
                   

                	
                  ii)
                    The Contractor shall assist Enrollees by referring them, and
                    by making
                    their care management record and other Enrollees service records
                    available
                    as appropriate to health care providers and/or
                    programs;

                

        

      

      
        

        
          	
                   

                	
                  iii)
                    The Contractor shall establish a list of Enrollees that is prioritized
                    according to those Enrollees requiring the most skilled care;
                    and

                

        

      

      
        

        
          	
                   

                	
                  iv)
                    Based upon the Enrollee's established priority and a determination
                    of the
                    availability of alternative resources, individual care plans
                    shall be
                    developed by the Contractor for each Enrollee in collaboration
                    with the
                    Enrollee, the Enrollee's family and appropriate community
                    resources.

                

        

      

      
        

        
          	
                  b)

                	
                  In
                    conjunction with such termination and disenrollment, the Contractor
                    shall
                    provide such other reasonable assistance as the SDOH may request
                    affecting
                    that transaction.

                

        

      

      
        

        
          	
                  c)

                	
                  Upon
                    completion of individual care plans and reinstatement of the
                    Enrollee's
                    Medicaid benefits through the fee-for-service system or enrollment
                    in
                    another managed care plan, an Enrollee shall be disenrolled from
                    the
                    Contractor's Medicaid Advantage Plus
                    Product.

                

        

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        2007

      

      
        AGREEMENT
          TERM, AMENDMENTS, EXTENSIONS

      

      
        AND
          GENERAL CONTRACT ADMINISTRATION PROVISIONS

      

      
        SECTION
          2

      

      
        -7-

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        2.9
          Agreement Close-Out Procedures

      

      
        

        
          	
                  a)

                	
                  Upon
                    termination or expiration of this Agreement, in its entirety
                    or in
                    specific counties
                    in 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 the SDOH has
                    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)
                    The Contractor shall submit to SDOH, and other authorized federal,
                    state
                    or local agencies, within ninety (90) days of termination, a
                    final
                    financial statement and audit report relating to this Agreement,
                    made by a
                    certified public accountant, unless the Contractor requests of
                    SDOH and
                    receives written approval from SDOH and all other governmental
                    agencies
                    from which approval is required, for an extension of time for
                    this
                    submission;

                

        

      

      
        

        iv)    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.

                

        

      

      
         

      

      
        2.10
          Rights and Remedies

      

      
        

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

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        2007

      

      
        AGREEMENT
          TERM, AMENDMENTS, EXTENSIONS

      

      
        AND
          GENERAL CONTRACT ADMINISTRATION PROVISIONS

      

      
        SECTION
          2

      

      
        -8-

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        2.11
          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

      

      
        Corning
          Tower, Rm. 2084

      

      
        Albany,
          NY 12237-0065

      

      
        

        For
          the
          Contractor: 

        Chief
          Executive Officer 

        WellCare
          of New York, Inc. 

        11
          West
          19th Street
          New
          York, NY 10011

      

      
        

        2.12
          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.

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        2007

      

      
        AGREEMENT
          TERM, AMENDMENTS, EXTENSIONS

      

      
        AND
          GENERAL CONTRACT ADMINISTRATION PROVISIONS

      

      
        SECTION
          2

      

      
        -9-

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        3.COMPENSATION

      

      
        

        3.1 
          Capitation Payments

      

      
        

        
          	
                  a)

                	
                  Compensation
                    to the Contractor shall consist of a monthly capitation payment
                    for each
                    Enrollee as described in this
                    Section.

                

        

      

      
        

        
          	
                  b)

                	
                  The
                    monthly Capitation Rates are attached hereto as Appendix L and
                    shall be
                    deemed incorporated into this Agreement without further action
                    by the
                    parties.

                

        

      

      
        

        
          	
                  c)

                	
                  The
                    monthly capitation payments to the Contractor shall constitute
                    full and
                    complete payments to the Contractor by SDOH for all services
                    that the
                    Contractor provides pursuant to Appendix K-2 this
                    Agreement.

                

        

      

      
        

        
          	
                  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 fee-for-service data or plan experience
                    for the
                    time period covered by the
                    rates.

                

        

      

      
        

        
          	
                  b)

                	
                  Capitated
                    rates shall be certified to be actuarially sound in accordance
                    with 42 CFR
                    438.6(c).

                

        

      

      
        

        
          	
                  c)

                	
                  Notwithstanding
                    the provisions set forth in Section 3.3 (a) and (b) above, the
                    SDOH
                    reserves the right to terminate this Agreement in its entirety,
                    or for
                    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.

                

        

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        2007

      

      
        COMPENSATION

      

      
        SECTION
          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 full 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 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 6.7 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 § 41 of the State Finance Law, 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
          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, or
          an
          Enrollee, Potential 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

      

      
        

        
          	
                   

                	
                  a)
                    The parties acknowledge and accept that the SDOH has a right
                    to recover
                    premiums paid to the Contractor for Enrollees listed on the monthly
                    Roster
                    who are later determined for the entire applicable payment month,
                    to have
                    been disenrolled from the Contractor's Medicaid Advantage Plus
                    Product; to
                    have been incarcerated;
                    to have moved out of the Contractor's service area; or to have
                    died. In
                    any event, the State may only recover premiums paid for Medicaid
                    Enrollees
                    listed on a Roster if it is determined by the SDOH that the Contractor
                    was
                    not at risk for provision of Medicaid Advantage Plus Benefit
                    Package
                    services for any portion of the payment
                    period.

                

        

      

      
        

        

      

      
        
          	
                   

                	
                  Medicaid
                    Advantage Plus Contract

                

        

      

      
        
          	
                   

                	
                  2007
                    COMPENSATION

                

        

      

      
        
          	
                   

                	
                  SECTION
                    3

                

        

      

      
        
          	
                   

                	
                  -2-

                

        

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
 

      
        
          	
                   

                	
                  b.)
                    The parties acknowledge and accept that the SDOH has the right
                    to recover
                    premiums paid to the Contractor for Enrollees listed on the monthly
                    roster
                    where the Contractor has failed to initiate involuntary disenrollment
                    in
                    accordance with the timeframes and requirements contained in
                    Section 8 of
                    this Agreement. The Department may recover the premiums effective
                    on the
                    first day of the month following the month in which the Contractor
                    was
                    required to initiate the involuntary
                    disenrollment.

                

        

      

      
        

        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 Welfare Management System (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 Medicaid Advantage Plus
          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
          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 in the Contractor's Medicaid
          Advantage Plus Product.

      

      
        

        3.9
          Spenddown and Net Available Monthy Income (NAMI)

      

      
        

        Capitation
          rates will exclude all required spenddown and NAMI regardless of whether
          the
          Contractor collects the amounts. The Contractor shall report the spenddown
          and
          NAMI for each Enrollee in accordance with the time frames and in the format
          prescribed by the Department.

      

      
        

      

      
        

      

      
        Medicaid
          Advantage Plus Contract

      

      
        2007

      

      
        COMPENSATION

      

      
        SECTION
          3

      

      
        -3-

      

      
        

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

      

      
        

      

      
        

      

      
        4.   SERVICE
          AREA

      

      
        

        The
          Service Area described in Appendix M of this Agreement, which is hereby
          made a
          part of this Agreement as if set forth fully herein, is the specific geographic
          area within which Eligible Persons must reside in order to be eligible
          to enroll
          in the Contractor's Medicaid Advantage Plus Product.

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        2007

      

      
        SERVICE
          AREA

      

      
        SECTION
          4

      

      
        -1-

         

         

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

      

      
         

        5.
          ELIGIBILITY FOR ENROLLMENT IN MEDICAID ADVANTAGE
          PLUS

      

      
        

        5.1
          Eligibility to Enroll in the Medicaid Advantage Plus Program

      

      
        

        
          	
                  a)

                	
                  Except
                    as specified in Section 5.2, persons meeting the following criteria
                    shall
                    be eligible to enroll in the Contractor's Medicaid Advantage
                    Plus
                    Product:

                

        

      

      
        

        
          	
                   

                	
                  i)
                    Must have full Medicaid coverage or full Medicaid coverage with
                    Qualified
                    Medicare Beneficiary (QMB)
                    eligibility;

                

        

      

      
        

        
          	
                   

                	
                  ii)
                    Must have evidence of Medicare Part A & B coverage; or be enrolled in
                    Medicare Part C coverage;

                

        

      

      
        

        
          	
                   

                	
                  iii)
                    Must reside in the service area as defined in Appendix M of this
                    Agreement;

                

        

      

      
        

        
          	
                   

                	
                  iv)
                    Must be 18 years of age or
                    older;

                

        

      

      
        

        
          	
                   

                	
                  v)
                    Must enroll in the Contractor's Medicare Advantage Product as
                    defined in
                    Section 1 and Appendix K-l of this
                    Agreement;

                

        

      

      
        

        
          	
                   

                	
                  vi)
                    Must be eligible for nursing home level of care (as of the time
                    of
                    enrollment);

                

        

      

      
        

        
          	
                   

                	
                  vii)
                    Must be capable, at the time of enrollment of returning to or
                    remaining in
                    his/her home and community without jeopardy to his/her health
                    and safety,
                    based upon criteria provided by SDOH;
                    and

                

        

      

      
        

        
          	
                   

                	
                  viii)
                    Must require care management and be expected to need at least
                    one of the
                    following services covered by Medicaid Advantage Plus Product
                    for at least
                    120 days from the effective date of
                    enrollment;

                

        

      

      
         

      

      
        
          	(a)  	nursing
                  services in the home;

          	(b)  	therapies
                  in the home;

          	(c)    	home
                  health aide services;

          	(d)   	personal
                  care services in the home

          	(e)	adult
                  day health care; or

          	
                  (f)

                	
                  social
                    day care if used as a substitute for in-home personal care
                    services.

                

        

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        2007

      

      
        ELIGIBILITY

      

      
        SECTION
          5

      

      
        -1-

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        b)  Participation
          in the Medicaid Advantage Plus Program and enrollment in the Contractor's
          Medicaid Advantage Plus Product is voluntary for all Eligible
          Persons.

      

      
        

        5.2 
          Not Eligible to Enroll in the Medicaid Advantage Plus Program

      

      
        

        Persons
          meeting the following criteria are not eligible to enroll in the Contractor's
          Medicaid Advantage Plus Product:

      

      
        

        
          	
                  a)

                	
                  Individuals
                    who are medically determined to have End Stage Renal Disease
                    (ESRD) at the
                    time of enrollment, unless such individuals meet the exceptions
                    to
                    Medicare Advantage eligibility rules for persons who have ESRD
                    as found in
                    Section 20.2.2 of the Medicare Managed Care
                    Manual.

                

        

      

      
        
          	
                  b)

                	
                  Individuals
                    who are only eligible for the Qualified Medicare Beneficiary
                    (QMB),
                    Specified Low Income Medicare Beneficiary (SLIMB) or the Qualified
                    Individual-1 (QI-1) and are not otherwise eligible for Medical
                    Assistance.

                

        

      

      
        
          	
                  c)

                	
                  Individuals
                    who are residents of State-operated psychiatric facilities or
                    residents of
                    State-certified or voluntary treatment facilities for children
                    and
                    youth.

                

        

      

      
        
          	
                  d)

                	
                  Individuals
                    who are residents of residential health care facilities ("RHCF")
                    at the
                    time of Enrollment, if discharge back to the community is not
                    expected
                    within the first month following effective date of
                    enrollment.

                

        

      

      
        
          	
                  e)

                	
                  Individuals
                    with access to comprehensive private health care coverage, except
                    for
                    Medicare, including those already enrolled in an MCO. Such health
                    care
                    coverage purchased either partially or in full, by or on behalf
                    of the
                    individual, must be determined to be cost effective by the local
                    social
                    services district.

                

          	f) 	Individuals
                  enrolled in the Restricted Recipient Program.

          	g)	Individuals
                  with a "County of Fiscal Responsibility" code of
                  99.

          	h)	Individuals
                  admitted to a Hospice program prior to time of enrollment (if an
Enrollee
                  enters a Hospice program while enrolled in the Contractor's plan,
                  he/she
                  may remain enrolled in the Contractor's plan to maintain continuity
                  of
                  care with his/her PCP).

          	i)	Individuals
                  with a "County of Fiscal Responsibility" code of 97 (OMH in
                  eMedNY).

          	j) 	Individuals
                  with a "County of Fiscal Responsibility" code of 98 (OMRDD in eMedNY)
                  will be excluded until program features are approved by the State
                  and
                  operational at the local district level to permit these individuals
                  to
                  voluntarily enroll in Medicaid Advantage
                  Plus.

          	k)	Individuals
                  who are residents of a facility operated under the auspices of
                  the State
                  Office of Mental Health (OMH), the Office of Alcoholism and Substance
                  Abuse Services (OASAS) or the State Office of Mental Retardation
                  and
                  Developmental Disabilities (OMRDD) or is enrolled in another managed
                  care
                  plan capitated by Medicaid, a Home and Community-Based Services waiver
                  program, a Comprehensive Medicaid Case Management Program (CMCM)
                  or OMRDD
                  Day Treatment Program.

        

      

      
         

      

      
        Medicaid
          Advantage Plus Contract

      

      
        2007

      

      
        ELIGIBILITY

      

      
        SECTION
          5

      

      
        -2-

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
         

        5.3
          Change in Eligibility Status

      

      
        

        
          	
                  a)

                	
                  The
                    Contractor must report to the LDSS any change in status of its
                    Enrollees,
                    which may impact the Enrollee's eligibility for Medicaid or Medicaid
                    Advantage Plus, within five (5) business days of such information
                    becoming
                    known to the Contractor. This information includes, but is not
                    limited to:
                    change of address; incarceration; permanent placement in a residential
                    institution or program other than a nursing home, rendering the
                    individual
                    ineligible for enrollment in Medicaid Advantage Plus; death;
                    and
                    disenrollment from the Contractor's Medicare Advantage Product
                    as defined
                    in this Agreement.

                

        

      

      
        

        
          	
                  b)

                	
                  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 and/or Medicaid Advantage Plus plan eligibility
                    and enrollment.

                

        

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        2007

      

      
        ELIGIBILITY

      

      
        SECTION
          5

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        6. 
          ENROLLMENT

      

      
        

        6.1
          Enrollment Requirements

      

      
        

        The
          LDSS
          and the Contractor agree 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.

      

      
        

        6.2
          Equality of Access to Enrollment

      

      
        

        The
          Contractor shall accept Enrollments of Eligible Persons in the order in
          which
          they 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.

      

      
        

        6.3
          Enrollment Decisions

      

      
        

        An
          Eligible Person's decision to enroll in the Contractor's Medicaid Advantage
          Plus
          Product shall be voluntary. However, as a condition of eligibility for
          Medicaid
          Advantage Plus, individuals may only enroll in the Contractor's Medicaid
          Advantage Plus Product if they also enroll in the Contractor's Medicare
          Advantage Product as defined in this Agreement.

      

      
        

        6.4 
          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 in the Medicaid Advantage
          Plus
          Program upon the performance of any act or suggest in any way that failure
          to
          enroll may result in a loss of Medicaid benefits.

      

      
        

        6.5
          Effective Date of Enrollment

      

      
        

        
          	
                  a)

                	
                  At
                    the time of Enrollment, the Contractor must notify the Enrollee
                    of the
                    expected Effective Date of
                    Enrollment.

                

        

      

      
        
          	
                  b)

                	
                  To
                    the extent practicable, such notification must precede the Effective
                    Date
                    of Enrollment.

                

        

      

      
        
          	
                  c)

                	
                  In
                    the event that the actual Effective Date of Enrollment changes,
                    the
                    Contractor must notify the Enrollee of the
                    change.

                

          	d)	An
                  Enrollee's Effective Date of Enrollment shall be the first day
                  of the
                  month in which the Enrollee's name appears on the Prepaid Capitation
                  Plan
                  Roster and is enrolled in the Contractor's Medicare Advantage Product
                  for
                  that month.

        

      

      
        

      

      
        

      

      
        Medicaid
          Advantage Plus Contract

      

      
        2007

      

      
        ENROLLMENT

      

      
        SECTION
          6

      

      
        -1-

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
         

        6.6  Contractor
          Liability

      

      
        

        As
          of the
          Effective Date of Enrollment, and until the Effective Date of Disenrollment
          from
          the Contractor's Medicaid Advantage Plus Product, the Contractor shall
          be
          responsible for the provision and cost of the Medicaid Advantage Plus Benefit
          Package as described in Appendix K-2 of this Agreement for Enrollees whose
          names
          appear on the Prepaid Capitation Plan Roster.

      

      
        

        6.7
          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. If the LDSS 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 these Rosters
                    electronically.

                

        

      

      
        

        6.8 
          Automatic Re-Enrollment

      

      
        

        An
          Enrollee who is disenrolled from the Contractor's Medicaid Advantage Plus
          Product due to loss of Medicaid eligibility and who regains eligibility
          within a
          three (3) month period will be automatically re-enrolled in the Contractor's
          Medicaid Advantage Plus Product, provided that the individual remains enrolled
          in the Contractor's Medicare Advantage Product as defined in this Agreement
          unless:

      

      
        
          	
                  a)

                	
                   the
                    Contractor does not offer a Medicaid Advantage Plus Product in
                    the
                    Enrollee's county of fiscal responsibility;
                    or

                

          	 b)	the
                  Enrollee indicates in writing that he/she wishes to enroll in another
                  MLTC
                  plan, another MLTC plan's Medicaid Advantage Plus and Medicare
                  Advantage
                  Products, or receive Medicaid coverage through Medicaid
                  fee-for-service.

        

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        2007

      

      
        ENROLLMENT

      

      
        SECTION
          6

      

      
        -2-

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
         

        6.9 
          Failure to Enroll in the Contractor's Medicare Advantage
          Product

      

      
        

        If
          an
          Enrollee's enrollment in the Contractor's Medicare Advantage Product is
          rejected
          by CMS, the Contractor must notify the local social services district within
          five (5) business days of learning of CMS' rejection of the enrollment.
          In such
          instances, the LDSS shall delete the Enrollee's enrollment in the Contractor's
          Medicaid Advantage Plus Product retroactive to the Effective Date of
          Enrollment.

      

      
        

        6.10 
          Spenddown/Net Available Monthly Income (NAMI)

      

      
        

        a) The
          LDSS shall determine an Enrollee's spenddown or NAMI amount.

      

      
        

        
          	
                  b)

                	
                  The
                    Contractor agrees to notify the LDSS in writing when an Enrollee
                    with a
                    monthly spenddown is admitted to an inpatient facility so the
                    spenddown
                    can be recalculated and a determination made regarding the amount,
                    if any,
                    of the spenddown owed to the inpatient facility. The notification
                    will
                    include the Enrollee's name, Medicaid number, hospital name and
                    other
                    information as directed by the
                    Department.

                

        

      

      
        

        
          	
                  c)

                	
                  The
                    Contractor agrees to notify the LDSS in writing prior to admission
                    of an
                    Enrollee to a nursing facility, to allow Medicaid eligibility
                    to be
                    redetermined using institutional eligibility rules. The notification
                    will
                    include the Enrollee's name, Medicaid number, nursing facility
                    name and
                    other information as directed by the Department. If such an Enrollee
                    is
                    determined by the LDSS to be financially ineligible for Medicaid
                    nursing
                    facility services, the LDSS shall notify the Contractor of such
                    determination.

                

        

      

      
        

        6.11 
          Enrollment Limits

      

      
        

        
          	
                  a)

                	
                  The
                    Contractor will request written permission from the Department
                    to suspend
                    enrollment when the Contractor determines that it lacks access
                    to
                    sufficient or adequate resources to provide or arrange for the
                    safe and
                    effective delivery of Covered Services to additional Enrollees.
                    Resumption
                    of enrollment will occur only with Department approval, not to
                    be
                    unreasonably delayed, after written notice from the Contractor
                    that
                    adequately describes how the situation precipitating the suspension
                    was
                    corrected.

                

        

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        2007

      

      
        ENROLLMENT

      

      
        SECTION
          6

      

      
        -3-

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        
          	
                  b)

                	
                   The
                    Department may establish enrollment limits based either on a
                    determination
                    of readiness or on limits established pursuant to § 4403-f of Public
                    Health Law.

                

        

      

      
        

        
          	
                  c)

                	
                    The
                    Department shall send copies of all notices regarding suspension
                    and
                    resumption of enrollment to the
                    LDSS.

                

        

      

      
        

      

      
        

      

      
        Medicaid
          Advantage Plus Contract

      

      
        2007

      

      
        ENROLLMENT

      

      
        SECTION
          6

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        7.        RESERVED

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        2007

      

      
        (RESERVED)

      

      
        SECTION
          7

      

      
        -1-

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        8.
          DISENROLLMENT

      

      
        

        8.1Disenrollment
          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 processing Disenrollment requests.

      

      
        

        8.2
          Disenrollment Prohibitions

      

      
        Enrollees
          shall not be disenroUed from the Contractor's Medicaid Advantage Plus Product
          based on any of the following reasons:

      

      
        

        
          	
                  a)

                	
                  high
                    utilization of covered medical services, an existing condition
                    or a change
                    in the Enrollee's health, diminished mental capacity or uncooperative
                    or
                    disruptive behavior resulting from his or her special needs unless
                    the
                    behavior results in the Enrollee becoming ineligible for Medicaid
                    Advantage Plus continued enrollment as described in Section 8.8
                    (b)(i) of
                    this Agreement;

                

        

      

      
        

        
          	
                  b)

                	
                  any
                    of the factors listed in Section 33 (Non-Discrimination) of this
                    Agreement; or

                   

                

          	c) 	the
                  Capitation Rate payable to the
                  Contractor.

        

      

      
        

        8.3 
          Disenrollment Requests

      

      
        

        The
          LDSS
          is responsible for processing Enrollee requests for disenrollment to take
          effect
          on the first (1st) day
          of the next
          month, to the extent possible. 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.

      

      
        

        8.4 
          Disenrollment Notification

      

      
        

        
          	
                  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.

                

        

      

      
        

      

      
        

      

      
        Medicaid
          Advantage Plus Contract

      

      
        2007

      

      
        DISENROLLMENT

      

      
        SECTION
          8

      

      
        -1-

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        
          	
                  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 shall consult with the Contractor prior to Disenrollment.
                    Such
                    consultation shall not be required in cases where it is clear
                    that the
                    Contractor was not a risk for the provision of the Medicaid Advantage
                    Plus
                    Benefit Package 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
                    notifying
                    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 the Medicaid Advantage Plus Benefit
                    Package
                    during the month.

                

        

      

      
        

        8.5  Contractor's
          Liability

      

      
        

        The
          Contractor shall continue to provide and arrange for the provision of covered
          services until the effective date of disenrollment. The Department will
          continue
          to pay capitation fees for an Enrollee until the effective date of
          disenrollment. The Contractor is not responsible for providing the Medicaid
          Advantage Plus Benefit Package under this Agreement after the Effective
          Date of
          Disenrollment.

      

      
        

        8.6  Contractor
          Referrals to Alternative Services

      

      
        

        The
          Contractor, in consultation with the Enrollee, prior to the Enrollee's
          effective
          date of disenrollment, shall make all necessary referrals to alternative
          services, for which the plan is not financially responsible, to be provided
          subsequent to disenrollment, when necessary, and advise the Enrollee in
          writing
          of the proposed disenrollment date.

      

      
        

        8.7  Enrollee
          Initiated Disenrollment

      

      
        

        
          	
                  a)
                    

                	
                  An
                    Enrollee may initiate voluntary disenrollment at any time from
                    the
                    Contractor's Medicaid Advantage Plus Product for any reason upon
                    oral or
                    written notification to the Contractor. The Contractor must provide
                    written confirmation to the Enrollee of receipt of an oral request
                    and
                    maintain a copy in the Enrollee's record. The Contractor shall
                    attempt to
                    obtain the Enrollee's signature on the Contractor's voluntary
                    disenrollment form, but may not delay the disenrollment while
                    it attempts
                    to secure the Enrollee's signature on the disenrollment form.
                    The
                    effective date of disenrollment must be no later than the first
                    day of the
                    second month in which the disenrollment was
                    requested.

                

        

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        2007

      

      
        DISENROLLMENT

      

      
        SECTION
          8

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        
          	
                  b)

                	
                  An
                    Enrollee who elects to join and/or receive services from another
                    managed
                    care plan capitated by Medicaid, a Home and Community Based Services
                    waiver program, OMRDD Day Treatment or a CMCM is considered to
                    have
                    initiated disenrollment from Contractor's Medicaid Advantage
                    Plus
                    Product.

                

        

      

      
        

        8.8
          Contractor Initiated Disenrollment

      

      
        

        
          	
                  a)

                	
                  The
                    Contractor must notify the LDSS and initiate an Enrollee's Disenrollment
                    from the Contractor's Medicaid Advantage Plus Product in the
                    following
                    cases:

                

        

      

      
         

      

      
        
          	
                   

                	
                  i)
                    A change in residence makes the Enrollee ineligible to be a member
                    of the
                    plan;

                

        

      

      
        
          	
                   

                	
                  ii)
                    The Enrollee is no longer a member of the Contractor's Medicare
                    Advantage
                    Product as defined in this Agreement;

                

          	 	iii)
                  The Enrollee dies;

        

      

      
        
          	
                   

                	
                  iv)
                    The Enrollee's status changes such that he/she is no longer eligible
                    to
                    participate in Medicaid Advantage Plus Product as described in
                    Section 5
                    of this Agreement;

                

        

      

      
        
          	
                   

                	
                  v)
                    The Enrollee has been absent from the service area for more than
                    90
                    consecutive days. Prior to the effective date of the disenrollment
                    the
                    Contractor must arrange and provide all necessary Covered Services;
                    or

                

        

      

      
        
          	
                   

                	
                  vi)
                    The Enrollee is no longer eligible for nursing home level of
                    care as
                    determined at the last comprehensive assessment of the calendar
                    year using
                    the assessment tool prescribed by the SDOH, unless the Contractor,
                    and the
                    LDSS agree that termination of the services provided by the Contractor
                    could reasonably be expected to result in the Enrollee being
                    eligible for
                    nursing home level of care (as determined with the assessment
                    tool
                    prescribed by the SDOH) within the succeeding six-month period.
                    The
                    Contractor shall provide the LDSS the results of its assessment
                    and
                    recommendations regarding continued enrollment or disenrollment
                    within
                    five (5) business days of the comprehensive
                    assessment.

                

        

      

      
        

        
          	
                  b)

                	
                  The
                    Contractor may initiate an Enrollee's disenrollment from the
Contractor's
                    Medicaid Advantage Plus Product in the following
                    cases:

                

        

      

      
         

      

      
        
          	
                   

                	
                  i)
                    The Enrollee or the Enrollee's family member or informal caregiver
                    engages
                    in conduct or behavior that seriously impairs the Contractor's
                    ability to
                    furnish services to either that particular Enrollee or other
                    Enrollees;
                    provided, however, the Contractor must have made and documented
                    reasonable
                    efforts to resolve the problems presented by the
                    individual.

                

        

      

      
        

      

      
        

      

      
        Medicaid
          Advantage Plus Contract

      

      
        2007
          DISENROLLMENT

      

      
        SECTION
          8

      

      
        -3-

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        
          	
                   

                	
                  ii)
                    The Enrollee provides fraudulent information on an enrollment
                    form or the
                    Enrollee permits abuse of an enrollment card in the Medicaid
                    Advantage
                    Plus Program.

                

        

      

      
        
          	
                   

                	
                  iii)
                    The Enrollee fails to pay or make arrangements satisfactory to
                    Contractor
                    to pay the amount, as determined by the LDSS, owed to the Contractor
                    as
                    spenddown/surplus or Net Available Monthly Income (NAMI) within
                    thirty
                    (30) days after such amount first becomes due, provided that
                    during that
                    thirty (30) day period Contractor first makes a reasonable effort
                    to
                    collect such amount, including making a written demand for payment,
                    and
                    advising the Enrollee in writing of his/her prospective
                    disenrollment.

                

        

      

      
        
          	
                   

                	
                  iv)
                    The Enrollee knowingly fails to complete and submit any necessary
                    consent
                    or release.

                

        

      

      
        

        
          	
                  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,
                    the
                    Contractor may reject the individual's re-enrollment with the
                    Contractor.
                    However, if an Enrollee was previously disenrolled under Section
                    8.8 (b)
                    (i) above, the Contractor may not reject the individual's enrollment
                    without first substantiating and maintaining written documentation
                    that
                    the circumstances which resulted in the disenrollment have not
                    been
                    remedied.

                

        

      

      
        

        LDSS
          Initiated Disenrollment

      

      
        

        The
          LDSS
          is responsible for promptly initiating Disenrollment from the Contractor's
          Medicaid Advantage Plus Product when:

      

      
        

        
          	
                  a)

                	
                  an
                    Enrollee fails to enroll or stay enrolled in the Contractor's
                    Medicare
                    Advantage Product as specified in Sections 6.9 and 8.8 (a)(ii)
                    and (iv) of
                    this Agreement; or

                

        

      

      
        
          	
                  b)

                	
                  an
                    Enrollee is no longer eligible for Medicaid or Medicaid Advantage
                    Plus
                    benefits; or

                

        

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

        

        
          	d)	an
                  Enrollee becomes ineligible for Enrollment pursuant to Section
                  5.2 of this
                  Agreement, as appropriate.

        

                  

         

        Medicaid
          Advantage Plus Contract

      

      
        2007

      

      
        DISENROLLMENT

      

      
        SECTION
          8

      

      
        -4-

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        9.
          RESERVED

      

      
        

      

      
        

      

      
        Medicaid
          Advantage Plus Contract

      

      
        2007

      

      
        (RESERVED)

      

      
        SECTION
          9

      

      
        -4-

      

      
        

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        BENEFIT
          PACKAGE, COVERED AND NON-COVERED SERVICES

      

      
        

        10.1Contractor
          Responsibilities

      

      
        

        
          	
                  a)

                	
                  The
                    Contractor agrees to provide the Medicare Advantage Benefit Package,
                    as
                    described in Appendix K-l of this Agreement, to Enrollees of
                    the
                    Contractor's Medicaid Advantage Plus Product subject to any exclusions
                    or
                    limitations imposed by Federal or State law during the period
                    of this
                    Agreement. Such services and supplies shall be provided in compliance
                    with
                    the requirements of the Contractor's Medicare Advantage Coordinated
                    Care
                    Plan contract with CMS and all applicable federal statutes, regulations
                    and policies.

                

        

      

      
        

        
          	
                  b)

                	
                  The
                    Contractor agrees to provide the Medicaid Advantage Plus Benefit
                    Package,
                    as described in Appendix K-2 of this Agreement, to Enrollees
                    of the
                    Contractor's Medicaid Advantage Plus Product subject to any exclusions
                    or
                    limitations imposed by Federal or State law during the period
                    of this
                    Agreement. Such services and supplies, shall be provided in compliance
                    with the requirements of this Agreement, the State Medicaid Plan
                    established pursuant to § 363-a of the State Social Services Law, and all
                    other applicable federal and state statutes, regulations and
                    policies.

                

        

      

      
        

        10.2 
          SDOH Responsibilities

      

      
        

        SDOH
          shall assure that Medicaid services covered under the Medicaid fee-for-service
          program as described in Appendix K-3 of this Agreement which are not covered
          in
          the Medicare or Medicaid Advantage Plus Benefit Packages are available
          to, and
          accessible by, Medicaid Advantage Plus Enrollees.

      

      
        

        10.3 
          Benefit Package and Non-Covered Services Descriptions

      

      
        

        The
          Medicare and Medicaid Advantage Plus Benefit Packages and Non-Covered Services
          agreed to by the Contractor and the SDOH are contained in Appendix K, which
          is
          hereby made a part of this Agreement as if set forth fully
          herein.

      

      
        

        10.4 
          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 and all Court Ordered Services for adults to
          the
          extent such services are included in the Contractor's Medicare and Medicaid
          Advantage Plus Benefit Packages as described in Appendix K of this Agreement.
          The Contractor is responsible for payment of those services as covered
          by the
          Medicare and Medicaid Advantage Plus  Benefit Packages, even when
          provided by Non-Participating Providers. Non-Participating Providers will
          be
          reimbursed at the Medicaid fee schedule by the Contractor.

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        2007

      

      
        BENEFIT
          PACKAGE AND NON-COVERED

      

      
        SERVICES
          DESCRIPTIONS

      

      
        SECTION
          10

      

      
        -1-

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        10.5
          Court-Ordered Services

      

      
        

        
          	
                  a)

                	
                  The
                    Contractor shall provide any Medicare and Medicaid Advantage
                    Plus Benefit
                    Package services to Enrollees as ordered by a court of competent
                    jurisdiction, regardless of whether such services are 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 included
                    in
                    the Contractor's Medicare Advantage and Medicaid Advantage Plus
                    Benefit
                    Packages as described in Appendix K of this
                    Agreement.

                

        

      

      
        

        
          	
                  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 services), or other
                    Medicare and
                    Medicaid Advantage Plus covered services. The Contractor is responsible
                    for payment of those services as covered by the Contractor's
                    Medicare and
                    Medicaid Advantage Plus Benefit Packages, even when provided
                    by
                    Non-Participating Providers.

                

        

      

      
        

        10.6
          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.

                

        

      

      
        

        
          	
                  b)

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

                

        

      

      
        

        
          	
                  c)

                	
                  The
                    Contractor shall permit Enrollees to exercise their right to
                    obtain Family
                    Planning and Reproductive Health Services from either the Contractor,
                    if
                    Family Planning and Reproductive Health Services are provided
                    by the
                    Contractor, or from any appropriate Medicaid enrolled Non-Participating
                    family planning Provider, without a referral from the Enrollee's
                    PCP and
                    without approval by the
                    Contractor.

                

        

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        2007

      

      
        BENEFIT
          PACKAGE AND NON-COVERED

      

      
        SERVICES
          DESCRIPTIONS

      

      
        SECTION
          10

      

      
        -2-

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        
          	
                  d)

                	
                  If
                    Contractor provides Family Planning and Reproductive Health Services
                    to
                    its Enrollees, 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.

                

        

      

      
        

        
          	
                  e)

                	
                  If
                    Contractor does not provide Family Planning and Reproductive
                    Health
                    Services to its Enrollees, the Contractor shall comply with Part
                    C.3 of
                    Appendix C of this Agreement, including assuring that Enrollees
                    are fully
                    informed of their rights.

                

        

      

      
        

        10.7    Emergency
          and Post Stabilization Care Services

      

      
        

        
          	
                  a)

                	
                  The
                    Contractor shall provide Emergency and Post Stabilization Care
                    Services in
                    accordance with applicable federal and state requirements, including
                    42
                    CFR 422.113.

                

        

      

      
        

        
          	
                  b)

                	
                  The
                    Contractor shall ensure that Enrollees are able to access Emergency
                    Services twenty four (24) hours per day, seven (7) days per
                    week.

                

        

      

      
        

        
          	
                  c)

                	
                  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.

                

        

      

      
        

        
          	
                  d)

                	
                  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.

                

        

      

      
        

        
          	
                  e.)

                	
                   Coverage
                    and payment for Emergency Services that meet the prudent layperson
                    definition shall be covered and paid in accordance with the requirements
                    of the federal Medicare
                    program.

                

        

      

      
        

        
          	
                  f.)

                	
                   In
                    addition, the Contractor shall cover and reimburse for general
                    hospital
                    emergency department services and physician services provided
                    to an
                    Enrollee while the Enrollee is receiving general hospital  emergency
                    department services, in accordance with the following requirements
                    when
                    such services do not meet the prudent layperson
                    standard:

                

        

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        2007

      

      
        BENEFIT
          PACKAGE AND NON-COVERED

      

      
        SERVICES
          DESCRIPTIONS

      

      
        SECTION
          10

      

      
        -3-

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
         

      

      
        

        
          	
                  i)

                	
                  Participating
                    Providers

                

        

      

      
        

        
          	
                  A)

                	
                  Payment
                    by the Contractor for general hospital emergency department services
                    provided to an Enrollee by a Participating Provider shall be
                    at the rate
                    of payment specified in the contract between the Contractor and
                    the
                    general hospital for emergency
                    services.

                

        

      

      
        

        
          	
                  B)

                	
                  Payment
                    by the Contractor for physician services provided to an Enrollee
                    by a
                    Participating Provider while receiving general hospital emergency
                    department services shall be at the rate of payment specified
                    in the
                    contract between the Contractor and the
                    physician.

                

        

      

      
        

        ii)
          Non-Participating Providers

      

      
        

        
          	
                  A)

                	
                  Payment
                    by the Contractor for general hospital emergency department services
                    provided to an Enrollee by a Non-Participating Provider shall
                    be at the
                    Medicaid fee-for-service rate, inclusive of the capital component,
                    in
                    effect on the date that the service was
                    rendered.

                

        

      

      
        

        
          	
                  B)

                	
                  Payment
                    by the Contractor for physician services provided to an Enrollee
                    by a
                    Non-Participating Provider while receiving general hospital emergency
                    department services shall be at the Medicaid fee-for-service
                    rate in
                    effect on the date that the service was
                    rendered.

                

        

      

      
        

        10.8 
          Medicaid Utilization Thresholds (MUTS)

      

      
        

        Enrollees
          may be subject to MUTS for services which are billed to Medicaid
          fee-for-service. Enrollees are not otherwise subject to MUTS for services
          included in the Medicaid Advantage Plus Benefit Package.

      

      
        

        10.9 
          Services for Which Enrollees Can Self-Refer

      

      
        

        In
          addition to those covered services for which Medicare Advantage and Medicaid
          Advantage Plus Enrollees can self-refer, Medicare Advantage and Medicaid
          Advantage Plus Enrollees may self-refer to:

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        2007

      

      
        BENEFIT
          PACKAGE AND NON-COVERED

      

      
        SERVICES
          DESCRIPTIONS

      

      
        SECTION
          10

      

      
        -4-

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        
          	
                  a) 

                	
                  Public
                    health agency facilities for Tuberculosis Screening, Diagnosis
                    and
                    Treatment; including Tuberculosis Screening, Diagnosis and Treatment;
                    Directly Observed Therapy (TB/DOT) as described
                    below.

                

        

      

      
        

        
          	
                  i. 

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

                

        

      

      
        
          	
                  ii. 

                	
                  The
                    SDOH will coordinate with the Local Public Health Agency (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. SDOH and LPHAs will also be available to offer technical
                    assistance to the Contractor in establishing TB policies and
                    procedures.

                

        

      

      
        
          	
                  iii.
                    

                	
                  The
                    Contractor shall inform participating providers of their responsibility
                    to
                    report TB cases to the LPHA.

                

        

      

      
        
          	
                  iv
                    

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

                

        

      

      
        
          	
                  v 

                	
                  The
                    Contractor will make best efforts 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.

                

        

      

      
        
          	
                  vi  

                	
                  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 this Section, unless these
                    services are
                    ordered by a court of competent jurisdiction; and 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. vii)  Prior authorization for
                    inpatient hospital admissions 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.

                

        

      

      
        
          	
                  viii 

                	
                  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.

                

        

      

      
        
          	
                  ix

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

                

        

      

      
        
          	
                  x  

                	
                  The
                    Contractor will not be financially liable for Directly Observed
                    Therapy
                    (DOT) costs. While all other clinical management of tuberculosis
                    is
                    covered by the Contractor, TB/DOT, where applicable, may be billed
                    to any
                    SDOH approved fee-for-service Medicaid
                    provider.

                

        

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        2007

      

      
        BENEFIT
          PACKAGE AND NON-COVERED

      

      
        SERVICES
          DESCRIPTIONS

      

      
        SECTION
          10

      

      
        -5-

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        The
          Contractor agrees to make all reasonable efforts to ensure coordination
          with DOT
          providers regarding clinical care and services. Enrollees may use any Medicaid
          fee-for-service TB/DOT provider. xi)  HIV counseling and testing
          provided to a Medicaid Advantage Plus Enrollee during a TB related visit
          at a
          public health clinic, directly operated by a LPHA will be covered by Medicaid
          fee-for-service (FFS) at rates established by the SDOH.

      

      
        

        
          	
                  b)

                	
                  Family
                    Planning and Reproductive Health services as described in Appendix
C
                    of this Agreement.

                

        

      

      
         

      

      
        c)
          Immunizations

      

      
        
          	
                  i)  

                	
                  The
                    Contractor agrees to reimburse the LPHA when Enrollees self-refer
                    to LPHAs
                    for immunizations covered by Contractor's Medicare Advantage
                    Plan.

                

        

      

      
        
          	
                  ii)

                	
                  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, review of 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 or learns
                    that
                    immunization is needed, the LPHA is responsible for delivering
                    the service
                    as appropriate, and the Contractor will reimburse the LPHA at
                    the
                    negotiated rate or in the absence of an agreement, at rates determined
                    by
                    SDOH.

                

        

      

      
        

        10.10
          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 LPHA and cooperate in contact investigation, in accordance with
          existing state and local laws and regulations. HIV counseling and testing
          provided to an Enrollee during a 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.

      

      
        

        10.11
          Enrollee Needs Relating to HIV

      

      
        

        
          	
                  a)
                    

                	
                  To
                    adequately address the HIV prevention needs of uninfected Enrollees,
                    as
                    well as the special needs of individuals with HIV infection who
                    do enroll
                    in managed care, the Contractor shall have in place all of the
                    following:

                

        

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        2007

      

      
        BENEFIT
          PACKAGE AND NON-COVERED

      

      
        SERVICES
          DESCRIPTIONS

      

      
        SECTION
          10

      

      
        -6-

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        
          	
                  i) 

                	
                    Anonymous
                    testing may be furnished to the Enrollee without prior approval
                    by the
                    Contractor and may be conducted at anonymous testing sites available
                    to
                    clients. Services provided for HIV treatment may only be obtained
                    from the
                    Contractor during the period the Enrollee is enrolled in the
                    Contractor's
                    plan.

                

        

      

      
        

        
          	
                  ii)
                    

                	
                  Methods
                    for promoting HIV prevention to all Plan 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 drag
                    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 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
                    HIV 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
                    plan Enrollees should be informed of the availability of HIV
                    counseling,
                    testing, referral and partner notification (CTRPN)
                    services.

                

        

      

      
        

        
          	
                  iii)
                    

                	
                  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 and the
                    LPHA.

                

        

      

      
        

        
          	
                  iv)

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

                

        

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        2007

      

      
        BENEFIT
          PACKAGE AND NON-COVERED

      

      
        SERVICES
          DESCRIPTIONS

      

      
        SECTION
          10

      

      
        -7-

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        

        
          	
                  v)

                	
                  A
                    network of providers sufficient to meet the needs of its Enrollees
                    with
                    HIV. 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 the providers in its network how
                    to obtain
                    information about the availability of Experienced HIV Providers
                    and HIV
                    Specialist PCPs.

                

        

      

      
        

        
          	
                  vi)

                	
                  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
                    in-plan
                    case management, and/or, with appropriate consent of the Enrollee,
                    COBRA
                    Comprehensive Medicaid Case Management (CMCM) services and/or
                    HIV
                    community-based psychosocial case management
                    services.

                

        

      

      
        

        
          	
                  vii)

                	
                   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. Access to partner notification
                    services must be consistent with 10 NYCRR Part
                    63.

                

        

      

      
        

        
          	
                  viii)

                	
                  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.

                

        

      

      
        

        10.12  Persons
          Requiring Chemical Dependence Services

      

      
        

        
          	
                  a)  

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

                

        

      

      
        
          	
                   

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

                   

                

        

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        2007

      

      
        BENEFIT
          PACKAGE AND NON-COVERED

      

      
        SERVICES
          DESCRIPTIONS

      

      
        SECTION
          10

      

      
        -8-

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

       

      
        
          	
                   

                	
                  ii)
                    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.

                   

                

          	 	
                  iii)
                    Satisfactory case management systems.

                   

                

        

      

      
        
          	
                   

                	
                  iv)
                    Satisfactory systems for coordinating service delivery between
                    physical
                    health, chemical dependence, and mental health providers, and
                    coordinating
                    in-plan services with other services, including Social
                    Services.

                   

                

        

      

      
        
          	
                   

                	
                  v)
                    The Contractor agrees to also participate in the local planning
                    process
                    for serving persons with chemical dependence, to the extent requested
                    by
                    the 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.

                

        

      

      
        

        10.13    Care
          Management

      

      
        

        
          	
                  a)

                	
                  Care
                    management entails the establishment and implementation of a
                    written care
                    plan and assisting enrollees to access services authorized under
                    the care
                    plan. Care management includes referral to and coordination of
                    other
                    necessary medical, and social, educational, psychosocial, financial
                    and
                    other services of the care plan irrespective of whether such
                    services are
                    covered by the plan

                

        

      

      
        

        
          	
                  b)

                	
                  The
                    Contractor shall comply with policies and procedures consistent
                    with 42
                    CFR 438.210 and Appendix K of this Agreement that have received
                    prior
                    written approval from the Department. The Contractor agrees to
                    submit any
                    proposed material revisions to the approved coverage and authorization
                    of
                    services policies and procedures for Department approval prior
                    to
                    implementation of the revised
                    procedures.

                

        

      

      
        

        
          	
                  c)

                	
                  The
                    Contractor shall have and comply with written policies and procedures
                    for
                    care management consistent with the coordination and continuity
                    requirements of 42 CFR
                    438.208.

                

        

      

      
        

        
          	
                  d)

                	
                  The
                    Contractor's care management system shall ensure that care provided
                    is
                    adequate to meet the needs of individual Enrollees and is appropriately
                    coordinated, and shall consist of both automated information
                    systems and
                    operational policies and
                    procedures.

                

        

      

      
        

        
          	
                  e)

                	
                  A
                    comprehensive reassessment of the Enrollee and a plan of care
                    update shall
                    be performed as warranted by the Enrollee's condition but in
                    any event at
                    least once every six (6)
                    months.

                

        

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        2007

      

      
        BENEFIT
          PACKAGE AND NON-COVERED

      

      
        SERVICES
          DESCRIPTIONS

      

      
        SECTION
          10

      

      
        -9-

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        
          	
                  f) 

                	
                    The
                    Contractor shall develop a care management system consistent
                    with the
                    following provisions:

                

        

      

      
        

        
          	
                  i)  

                	
                  The
                    Contractor shall arrange for health care professionals, as appropriate
                    (such as physicians, nurses, social workers, therapists) to provide
                    care
                    management services to all Enrollees. An interdisciplinary team
                    may
                    provide care management.

                

          	ii)	Care
                  management services include, but are not limited
                  to:

     

      

      
        
          	A)	initial
                  assessments of Enrollees;

          	B)	reassessments
                  of Enrollees;

          	
                  C)

                	
                  management
                    of covered services and coordination of covered services with
                    non-covered
                    services and services provided by other community resources and
                    informal
                    supports;

                

        

      

      
        
          	
                  D)

                	
                  development
                    of individual care plans, in consultation with the Enrollee and
                    her/his
                    informal supports, specifying health care goals, the types and
                    frequency
                    of authorized covered services and non-covered services and supports
                    necessary to maintain the care
                    plan;

                

        

      

      
        
          	
                  
                    E)

                  

                	
                  monitoring
                    the progress of each Enrollee to evaluate whether the covered
                    services
                    provided are appropriate and in accord with the care plan;
                    and

                

        

      

      
        
          	
                  F)

                	
                  evaluating
                    whether the care plan continues to meet the Enrollee's needs.

                

        

      

      
        
          	
                   

                	
                   

                

        

      

      
        

        iii)
          The
          care management system includes processes for:

         

      

      
        
          	A)	generating
                  and receiving referrals among providers;

          	B)	sharing
                  clinical and treatment plan information;

          	C)	obtaining
                  consent to share confidential medical and treatment plan information
                  among
                  providers consistent with all applicable state and federal law
                  and
                  regulation;

          	D) 	providing
                  Enrollees with written notification of authorized
                  services;

          	
                  E)

                	
                  enlisting
                    the involvement of community organizations that are not providing
                    covered services, but are otherwise important to the health and
                    well-being of Enrollees;
                    and

                

        

      

      
        
          	
                  F)

                	
                  assuring
                    that the organization of and documentation included in the care
                    management record meet all applicable professional
                    standards.

                

        

      

      
        
          	
                   

                	
                   

                

        

      

      
        

        
          	
                  iv)
                    

                	
                  The
                    care management system requires care managers to have access
                    to
                    participating medical and social services professionals and
                    para-professionals who on a routine basis provide direct care
                    and services
                    as required by the Enrollee's
                    status.

                

        

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        2007

      

      
        BENEFIT
          PACKAGE AND NON-COVERED

      

      
        SERVICES
          DESCRIPTIONS

      

      
        SECTION
          10

      

      
        -10-

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        10.14
          Urgently Needed Services

         

        The
          Contractor is financially responsible for Urgently Needed Services.

         

        10.15 
          Coordination of Services

      

      
         

        a)The
          Contractor shall coordinate care for Enrollees 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; iv)
                    WIC;

                

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

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

        

      

      
        

        
          	
                  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
                    Enrollees.

                

        

      

      
         

      

      
        Medicaid
          Advantage Plus Contract

        2007

      

      
        BENEFIT
          PACKAGE AND NON-COVERED

      

      
        SERVICES
          DESCRIPTIONS

      

      
        SECTION
          10

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        MARKETING

      

      
        

        11.1    Marketing
          Requirements

      

      
        

        
          	
                  a)

                	
                  The
                    Contractor agrees to follow the Medicare Advantage Marketing
                    Guidelines as
                    set forth in Chapter 3 of CMS's Medicare Managed Care Manual,
                    as well as
                    all applicable statutes and regulations including and without
                    limitation §
                    1851 (h) of the Social Security Act and 42 CFR 422.80, 422.111,
                    and 423.50
                    when marketing to individuals entitled to enroll in Medicare
                    Advantage.

                

        

      

      
        

        
          	
                  b)

                	
                  The
                    Contractor shall conduct marketing activities for Potential Enrollees
                    consistent with 42 CFR 438.104, applicable State Law and its
                    implementing
                    regulations and shall comply with the Medicaid Advantage Plus
                    Marketing
                    Guidelines as defined in Appendix D of this document as if set
                    forth fully
                    herein.

                

        

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        2007

      

      
        MARKETING

      

      
        SECTION
          11

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        MEMBER
          SERVICES

      

      
        

        12.1     General
          Functions

      

      
        

        
          	
                  a)

                	
                  The
                    Contractor shall operate a Member Services function 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) 	Member
                  Services staff must be responsible for the
                  following:

        

      

      
         

      

      
        
          	
                   

                	
                  i)   Explaining
                    the benefits and covered services offered under the Medicare
                    and Medicaid
                    Advantage Plus Products, including applicable conditions and
                    limitations,
                    and any conditions associated with the receipt or use of benefits,
                    and
                    assisting Enrollees in making
                    appointments;

                

        

      

      
        

        
          	
                   

                	
                  ii)
                    Explaining the Contractor's rules for obtaining Medicare and
                    Medicaid
                    Advantage Plus Benefit Package services and additional services
                    available
                    to the Enrollee through use of his/her Medicaid benefit
                    card;

                

        

      

      
        

        
          	
                   

                	
                  iii)
                    Providing information on: the providers from whom Enrollees may
                    obtain
                    Medicare and Medicaid Advantage Plus Benefit Package Services,
                    any
                    out-of-area coverage provided by the plan, and coverage of emergency
                    services and urgently needed
                    care;

                

        

      

      
        

        
          	
                   

                	
                  iv)
                    Fielding and responding to Enrollee questions and complaints
                    regarding the
                    Contractor's Medicare and Medicaid Advantage Plus Products and
                    benefits,
                    and advising Enrollees of the prerogative to complain at any
                    time to the
                    CMS regarding the Medicare Advantage Product, and to the SDOH
                    and LDSS,
                    regarding the Medicaid Advantage Plus
                    Product;

                

        

      

      
        

        
          	
                   

                	
                  v)
                    Accommodating Applicants and Enrollees who require language translation
                    and communications
                    assistance;

                

        

      

      
        

        
          	
                   

                	
                  vi)
                    Clarifying information in the member handbooks for Enrollees
                    regarding the
                    Contractor's Medicare and Medicaid Advantage Plus Products and
                    benefits;

                

        

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        2007

      

      
        MEMBER
          SERVICES

      

      
        SECTION
          12

      

      
        1

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        
          	
                   

                	
                  vii)
                    Advising Enrollees of the Contractor's applicable complaint and
                    appeals
                    programs, utilization review processes, and the Enrollee's rights
                    to a
                    fair hearing or external
                    review;

                

        

      

      
        

        
          	
                   

                	
                  viii)
                    Clarifying an Enrollee's Disenrollment rights and responsibilities
                    under
                    the Contractor's Medicare and Medicaid Advantage Plus
                    Products;

                

        

      

      
        

        
          	
                   

                	
                  ix)
                    Conducting post enrollment orientation activities, including
                    orientation
                    of Enrollees, Enrollees' families or representatives and

                   

                

          	 	x)
                  Conducting health promotion and wellness
                  activities.

        

      

      
         

      

      
        
          	
                  C.

                	
                  The
                    Contractor shall develop and implement written procedures and
                    protocols to
                    assure that member and provider services are provided in a manner
                    that is
                    responsive to cultural considerations and specific needs of its
                    Enrollees.

                

        

      

      
        

        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 Potential Enrollees
                    of the
                    Contractor in any county of the service area speak that particular
                    language as a primary language and do not speak English as a
                    first
                    language.

                

        

      

      
        

        
          	
                  b)

                	
                  In
                    addition, verbal interpretation services must be made available
                    to
                    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.

                

        

      

       

      
        
          	
                  d)

                	
                  The
                    Contractor must inform Enrollees, Applicants and Potential Enrollees
                    that
                    oral interpretation is available for any language and written
                    information
                    is available in prevalent languages and how to access those services,
                    including notices about this available in the member
                    handbook.

                

        

      

      
        

        
          	
                  e)

                	
                  The
                    Contractor must provide Potential Enrollees, Applicants and Enrollees
                    with
                    information about the availability of non-English speaking participating
                    providers and how to access the services of a specific non-English
                    speaking participating
                    provider.

                

        

      

      
        

        
          	
                  f)

                	
                  Medicare
                    Advantage Plan and Medicaid Advantage Plus Plan provider directories
                    must
                    identify the languages spoken by participating
                    providers.

                

        

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        2007
          

        MEMBER
          SERVICES 

        SECTION
          12

      

      
        -2-

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        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.

      

      
        

         

        Medicaid
          Advantage Plus Contract

      

      
        2007

      

      
        MEMBER
          SERVICES

      

      
        SECTION
          12

        -3-

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        ENROLLEE
          NOTIFICATION

      

      
        

        13.1     General
          Requirements

      

      
        

        
          	
                  a)

                	
                  The
                    Contractor shall disclose required information to Potential Enrollees
                    and
                    Enrollees as prescribed by applicable federal and state law and
                    regulations found at 42 CFR 422.111, New York PHL §4408, and 42 CFR 438.10
                    and any specific guidance issued by CMS and SDOH. The Contractor
                    must
                    provide Enrollees with an annual notice that this information
                    is available
                    upon request.

                

        

      

      
        

        
          	
                  b)

                	
                  The
                    Contractor must submit to the Department for prior approval a
                    description
                    of how the Contractor will provide information and annual notification
                    to
                    its Enrollees as required by this Section,
                    including.

                

        

      

       

      
        
          	
                  • 
                    

                	
                  evidence
                    that the material is written in 12 point type at a minimum and
                    prose
                    written in clear, simple, understandable language at the 4th
                    to 6th
                    grade
                    reading level;

                

        

      

      
        

        
          	
                  • 
                    

                	
                  the
                    methods the Contractor will use to provide information to Applicants
                    and
                    Enrollees who speak other than English as a primary
                    language;

                

        

      

      
        

        
          	
                  • 
                    

                	
                  the
                    methods of making alternate formats available to persons who
                    are visually
                    and hearing impaired; and

                

        

      

      
        

        
          	
                  • 
                    

                	
                  the
                    method and timetable for updating and disseminating the list
                    of
                    Participating Providers.

                

        

      

       

      
        
          	
                  c)

                	
                  The
                    Contractor shall provide the materials developed by SDOH to all
                    Potential
                    Enrollees, a member handbook which is approved by SDOH and consistent
                    with
                    the Medicaid Advantage Plus Model Handbook Guidelines in Appendix
                    E, which
                    is hereby made a part of this Agreement as if set forth fully
                    herein, and
                    the provider network to all Applicants prior to enrollment and
                    to
                    Enrollees.

                

        

      

      
        

        
          	
                  d)

                	
                  The
                    Contractor shall give Enrollees prior written notice of significant
                    changes to the information identified in subsection 13.1 (c)
                    of this
                    Section. Such notice shall be at least thirty (30) days prior
                    to the
                    effective date of the change pursuant to 42 CFR
                    438.10(f)(4).

                

        

      

      
        

        
          	
                  e)

                	
                  The
                    Contractor shall annually notify Enrollees in writing of their
                    disenrollment rights and their right to request the information
                    specified
                    in 42 CFR 438.10 (f)(6) and
                    (g).

                

        

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        2007
          

        ENROLLEE
          NOTIFICATION 

        SECTION
          13

        -1-

      

      
        

      

      
        

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

      

      
        

      

      
        
          	
                  f)

                	
                  Medicaid
                    Advantage Plus enrollment notices and materials shall include,
                    but not be
                    limited to the following:

                

        

      

      
        

        Provider
          Directories

      

      
        Member
          ID
          Cards

      

      
        Member
          Handbooks

      

      
        Notice
          of
          the Effective Date of Enrollment

      

      
        Notice
          of
          Termination, Service Area Changes and Network Changes at

      

      
        least
          30
          days before the effective date of the change.

      

      
        Summary
          of Benefits

      

      
        

        
          	
                  g)

                	
                  Integrated
                    post enrollment materials including member handbooks, member
                    notices, and
                    summary of benefits targeted to Enrollees of the Contractor's
                    Medicare and
                    Medicaid Advantage Plus Products must be prior approved by the
                    CMS
                    Regional Office, in collaboration with
                    SDOH.

                

        

      

      
        

        13.2   
          Enrollment Agreement/Attestation

      

      
        

        Using
          a
          form developed by SDOH, the Contractor shall obtain a signed enrollment
          agreement/attestation from each Applicant/Enrollee that the Applicant/Enrollee
          has:

      

      
        

        
          	
                  a)

                	
                  received
                    a member handbook which includes the rules and responsibilities
                    of plan
                    membership and which expressly delineates covered and non-covered
                    services;

                

        

      

      
        

        
          	
                  b)

                	
                  agreed
                    to the terms and conditions for Medicaid Advantage Plus enrollment
                    stated
                    in the member handbook;

                

        

      

      
        

        
          	
                  c)

                	
                  understood
                    that enrollment in the Contractor's Medicaid Advantage Plus is
                    voluntary;

                

        

      

      
        

        
          	
                  d)

                	
                  received
                    a copy of the Contractor's current provider network listing and
                    agreed to
                    use network providers for covered services; and

                   

                

          	e)	has
                  been advised of the projected date of
                  enrollment.

        

      

      
              

      

      
        13.3  
          Member ID Cards

      

      
        

        The
          Contractor must issue an identification card to the Enrollee that complies
          with
          CMS and SDOH specifications.

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        2007
          

        ENROLLEE
          NOTIFICATION 

        SECTION
          13

      

      
        -2-

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        13.4
          Enrollee Rights

      

      
        

        
          	
                  a)

                	
                  The
                    Contractor shall, in compliance with the requirements of 42 CFR
                    422.128,42
                    CFR 489.100 and 102, 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 Part 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 develop and implement written policies and procedures
                    regarding Enrollee rights which fulfill the requirements of 42
                    CFR 438.100
                    and applicable State law and regulation, including the following
                    rights
                    to:

                

        

      

      
         

      

      
        
          	 i)	 receive
                  medically necessary care;

          	ii)	timely
                  access to care and services;

          	iii)	privacy
                  about medical records and treatment;

          	
                  iv)
                    

                	
                  get
                    information on available treatment options and alternatives presented
                    in
                    an understandable manner and
                    language;

                

        

      

      
        
          	
                  v) 

                	
                  get
                    information in a language the Enrollee understands and oral translation
                    services free of charge;

                

        

      

      
        
          	
                  vi)

                	
                  get
                    information necessary to give informed consent before the start
                    of
                    treatment;

                

          	vii)	be
                  treated with respect and
                  dignity;

        

      

      
        
          	
                  viii)

                	
                  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.,
                    if the
                    privacy rule, as set forth in 45 CFR 160 and 164, A and E,
                    applies;

                

        

      

      
        
          	
                  ix)
                    

                	
                  take
                    part in decisions about Enrollee health care, including the right
                    to
                    refuse treatment;

                

        

      

      
        
          	
                  x)

                	
                  be
                    free from any form of restraint or seclusion used as a means
                    of coercion,
                    discipline, convenience or
                    retaliation;

                

        

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        2007
          

        ENROLLEE
          NOTIFICATION 

        SECTION
          13

      

      
        -3-

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        
          	
                  xi)
                    

                	
                  get
                    care without regard to sex, race, health status, color, age,
                    national
                    origin, sexual orientation, marital status or
                    religion;

                

        

      

      
        
          	
                  xii)

                	
                  be
                    told where, when and how to get the services the Enrollee needs
                    from
                    Medicaid Advantage Plus, including how to get covered benefits
                    from
                    out-of-network providers if they are not available in the Medicaid
                    Advantage Plus network;

                

        

      

      
        
          	
                  xiii)
                    

                	
                  complain
                    to the New York State Department of Health or the Local Department
                    of
                    Social Services; and, the Right to use the New York State Fair
                    Hearing
                    System and/or a New York State External Appeal, where appropriate,
                    and

                

        

      

      
        
          	
                  xiv)
                    

                	
                  appoint
                    someone to speak for the Enrollee about the care the Enrollee
                    needs.

                

        

      

      
        

        
          	
                  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 13.4(b)
                    above.

                

        

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        2007

      

      
        ENROLLEE
          NOTIFICATION

      

      
        SECTION
          13

      

      
        -4-

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        14.  
          ORGANIZATION
          DETERMINATIONS, ACTIONS AND GRIEVANCE SYSTEM

      

      
        

        14.1 
          General Requirements

      

      
        

        
          	
                  a)

                	
                  The
                    Contractor agrees to comply with, and shall establish and maintain
                    written
                    Organization
                    Determination and Action procedures and a comprehensive Grievance
System,
                    as described in Appendix F, which is hereby made a part of this
                    Agreement
                    as
                    if set forth fully herein, that complies
                    with:

                

        

      

      
         

      

      
        
          	 i)	all
                  procedures and requirements of 42 CFR 422 Subpart M and Chapter
                  13 of
                  CMS's Medicare Managed Care Manual for services that the Contractor
                  determines are a Medicare only benefit.

          	
                  ii)

                	
                  all
                    procedures and requirements of 42 CFR 422 Subpart 422 and Chapter
                    13 of
                    CMS's Medicare Managed Care Manual for services the Contractor
                    determines
                    to be a benefit covered under both Medicare and Medicaid, except
                    that:

                

        

      

      
        
          	
                  A)

                	
                  The
                    Contractor will determine whether services are Medically Necessary
                    as that
                    term is defined in this Agreement;
                    and

                

        

      

      
        
          	
                  B)

                	
                  When
                    the Contractor intends to reduce, suspend, or terminate a previously
                    authorized service within an authorization period, the notification
                    provisions of paragraph F.2 (4) (a) of Appendix F of this Agreement
                    shall
                    apply.

                

        

      

      
        

        
          	
                  iii)

                	
                  all
                    procedures and requirements of the Grievance System described
                    in Appendix
                    F of this Agreement and 42 CFR 438.400 et seq., for services
                    that the
                    Contractor determines are a Medicaid only benefit. With respect
                    to
                    Medicaid-only services, nothing herein shall release the Contractor
                    from
                    its responsibilities under PHL § 4408-a or PHL Article 49 and 10 NYCRR
                    Part 98 that are not otherwise expressly established in Appendix
                    F of this
                    Agreement.

                

        

      

      
        

        
          	
                  b)

                	
                  For
                    services that the Contractor determines are a benefit under Medicare
                    and
                    Medicaid,
                    the Contractor agrees to offer Enrollees the right to pursue
                    the Medicare
                    appeal procedures or the Medicaid Advantage Plus Action Appeals
                    
                    
                      
                        and/or
                          Grievance System in the manner described and provided for
                          in Appendix F
                          of
                          this
                          Agreement.

                      

                    

                  

                

        

      

      
         

      

      
        
          	
                  14.2

                	
                    
                    Filing and Modification of Medicaid Advantage Plus Action Appeals
                    and/or
                    Grievance Procedures

                

        

      

      
         

      

      
        
          	
                  a)

                	
                  The
                    Contractor's Action and Grievance System Procedures governing
                    services
                    determined by the Contractor to be a Medicaid only benefit and
                    services
                    determined by the Contractor to be a benefit under both Medicare
                    and
                    Medicaid shall be approved by the SDOH and kept on file with
                    the
                    Contractor and SDOH.

                

        

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        2007

        ORGANIZATION
          DETERMINTION ACTIONS

      

      
        AND
          GRIEVANCE SYSTEM

      

      
        SECTION
          14

      

      
        -1-

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
         

      

      
        

        
          	
                  b)

                	
                  The
                    Contractor shall not modify its Action and Grievance System Procedures
                    without the prior written approval of
                    SDOH.

                

        

      

      
        

        14.3 
          Medicaid Advantage Plus Action and Grievance System Additional
          Provisions

      

      
        

        
          	
                  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 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, Enrollee's condition, or cost of
                    services. 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.

                

        

      

      
        

        
          	
                  e)

                	
                  The
                    Contractor shall ensure that its Medicaid Advantage Plus 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.

                

        

      

      
        

        
          	
                  f)

                	
                  The
                    Contractor shall ensure that persons with authority to require
                    corrective
                    action participate in the Medicaid Advantage Plus Grievance
                    System.

                

        

      

      
        

        
          	
                  g)

                	
                  The
                    Contractor's Grievance System Procedures for services determined
                    by the
                    Contractor to be a Medicaid only benefit and services determined
                    by the
                    Contractor to be a benefit under both Medicare and Medicaid shall
                    be
                    described in the Contractor's Medicaid Advantage Plus member
                    handbook and
                    shall be made available to all Medicaid Advantage Plus
                    Enrollees.

                

        

      

      
        

        

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        2007

      

      
        ORGANIZATION
          DETERMINTION ACTIONS

      

      
        AND
          GRIEVANCE SYSTEM

      

      
        SECTION
          14

      

      
        -2-

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        When
          the
          Contractor makes a final adverse determination about an Action it has taken,
          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 24 of
          this
          Agreement. Such procedures shall include the provision of a Medicaid notice
          in
          accordance with 42 CFR 438.210 and 438.404.

      

      
        

        When
          the
          Contractor makes a final adverse determination about an Action it has taken,
          the
          Contractor will also advise Enrollees of their right to an External Appeal,
          related to services determined by the Contractor to be a Medicaid only
          benefit
          or services determined by the Contractor to be a benefit under both Medicare
          and
          Medicaid, in accordance with Section 25 of this Agreement.

      

      
        

        
          	
                   

                	
                  The
                    Contractor will provide written notice 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, of the following Medicaid
                    Advantage
                    Plus Complaint, Complaint Appeal, Action Appeal and fair hearing
                    procedures and when such procedures may be
                    applicable:

                

        

      

      
         

      

      
        
          	 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 an External Appeal and how to request an
                    External
                    appeal;

                

        

      

      
        

        
          	
                  iii)

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

                

        

      

      
        

        
          	
                  iv)

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

                

        

      

      
        

        
          	
                  v)

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

                

        

      

      
        

        
          	
                  vi)

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

                

        

      

      
        

        
          	
                  vii)

                	
                  the
                    Enrollee's right to request continuation of benefits while an
                    Action
                    Appeal or state fair hearing of the Contractor's decision to
                    terminate,
                    reduce or suspend a service 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;

                

        

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        2007

      

      
        ORGANIZATION
          DETERMINTION ACTIONS 

        AND
          GRIEVANCE SYSTEM

      

      
        SECTION
          14

      

      
        -3-

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        
          	
                  viii)

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

                

        

      

      
        

        
          	
                  ix)

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

                

        

      

      
        

        14.4  Complaint
          Investigation Determinations

      

      
        

        The
          Contractor must adhere to determinations resulting from investigations
          regarding
          complaints filed with the SDOH.

      

      
        

        Medicaid
          Advantage Plus Contract

        2007

        ORGANIZATION
          DETERMINTION ACTIONS

      

      
        AND
          GRIEVANCE SYSTEM

      

      
        SECTION
          14

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        15.  ACCESS
          REQUIREMENTS

      

      
        

        
          	
                  a)

                	
                  The
                    Contractor agrees to provide Enrollees access to Medicare Advantage
                    Benefit Package and Medicaid Advantage Plus Benefit Package Services
                    as
                    described in Appendix K-1 and K-2 of this Agreement in a manner
                    consistent
                    with professionally recognized standards of health care and access
                    standards required by applicable federal and state
                    law.

                

        

      

      
        

        
          	
                  b)

                	
                  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.

                

        

      

      
        

        
          	
                  c)

                	
                  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.

                

        

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        2007

      

      
        ACCESS
          REQUIREMENTS

      

      
        SECTION
          15

      

      
        -1-

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        16.  QUALITY
          MANAGEMENT AND PERFORMANCE IMPROVEMENT

      

      
        

        16.1 
          Quality Management and Performance Improvement Program

      

      
        

        The
          Contractor agrees to operate an ongoing quality management and performance
          improvement program in accordance with § 1852 (e) of the Social Security Act
          ("SSA") 42 CFR 422.152 and 42 CFR 438.240, and all applicable New York
          State law
          and regulations.

      

      
        

        16.2 
          Chronic Care Improvement Program

      

      
        

        The
          Contractor agrees to conduct a Chronic Care Improvement Program (CCIP)
          relevant
          to its membership as directed by CMS and to submit the annual report on
          the
          Contractor's CCIP to CMS and SDOH.

      

      
        

        16.3 
          Reporting

      

      
        

        The
          Contractor agrees to conduct performance improvement projects and to measure
          performance using standard measures required by CMS, and to report results
          to
          CMS and SDOH, if required by CMS. Standard measures may
          include:

      

      
        

        •        Health
          Plan and Employer Data Information Set (HEDIS);

      

      
        •        Consumer
          Assessment of Health Plan Survey (CAHPS); and

      

      
        •        Health
          Outcomes Survey (HOS).

      

      
        

        16.4
          Quality Indicators and Standards

      

      
        

        The
          Contractor agrees to participate with SDOH in the development and implementation
          of quality indicators and standards specific to the long term care services
          furnished to Enrollees, pursuant to the terms of this
          Agreement.

      

      
        

        16.5
          External Quality Review

      

      
        

        The
          Contractor agrees to cooperate with any external quality review conducted
          by or
          at the direction of the Department or DHHS.

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        2007

      

      
        QUALITY
          MANAGEMENT AND

      

      
        PERFORMANCE
          IMPROVEMENT

      

      
        SECTION
          16

      

      
        -1
          -

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        17.
          MONITORING AND EVALUATION

      

      
        

        17.1
          Right to Monitor Contractor Performance

      

      
        

        The
          SDOH
          and/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
          and/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 and DHHS in any
          on-site
          review of the Contractor's operations.

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        2007

      

      
        MONITORING
          AND EVALUATION

      

      
        SECTION
          17

        -1-

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        18.
          CONTRACTOR REPORTING REQUIREMENTS

      

      
        

        18.1 
          General Requirements

      

      
        

        
          	
                  a)

                	
                  TheContractor
                    must maintain a health information system that collects, analyzes,
                    integrates
                    and reports data. The system must be sufficient to provide the
                    data
                    necessary to comply with the requirements of this
                    Agreement.

                

        

      

      
        

        
          	
                  b)

                	
                  The
                    Contractor must take steps to ensure that data entered into the
                    system,
                    particularly that received from Participating Providers, is accurate
                    and
                    complete.

                

        

      

      
        

        
          	
                  c)

                	
                  The
                    Contractor must make collected information available to CMS and
                    SDOH, as
                    requested under this
                    Agreement.

                

        

      

      
        

        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 Section 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
          Section 18.6 (a)(i) through (x) 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 
          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 the
          SDOH.

      

      
        

        18.5 
          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.

                

        

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        2007

      

      
        CONTRACTOR
          REPORTING REQUIREMENTS 

        SECTION
          18

      

      
        -1-

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
         

      

      
        

        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, State Insurance Law §§ 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.

      

      
        

        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 any contracted
          services rendered to the Enrollee in the current or any preceding months,
          including both Medicare and Medicaid covered services. 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 by CMS
          for the
          Medicare Advantage Program. Reports should be duplicative of
          reports submitted to CMS, and separate reports for the dual eligible population
          are not required.

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        2007

      

      
        CONTRACTOR
          REPORTING REQUIREMENTS

      

      
        SECTION
          18

      

      
        -2-

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

       

      
        

        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 and 42 CFR 438
                    Subpart F received during the preceding quarter related to Medicaid
                    Only
                    Covered Services and services determined by the Contractor to
                    be a benefit
                    under both Medicare and Medicaid in a manner directed by
                    SDOH.

                

        

      

      
        

        
          	
                  B)

                	
                  The
                    Contractor also agrees to provide on a quarterly basis, or in
                    a manner
                    directed by SDOH, the total number of Complaints and Action Appeals
                    subject to PHL §4408-a and 42 CFR 438 Subpart F and related to Medicaid
                    Only Covered Services and services determined by the Contractor
                    to be a
                    benefit under both Medicare and Medicaid 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.

                

        

      

      
        

        vii) 
          Fraud and Abuse Reporting Requirements:

      

      
        

        
          	
                  A)

                	
                  The
                    Contractor must submit quarterly, in a format acceptable to SDOH,
                    the
                    number of Complaints of fraud or abuse made to the Contractor
                    related to
                    Medicaid Only Covered Services identified in Appendix K-2 and
                    services
                    covered jointly by Medicare and Medicaid that warrant preliminary
                    investigation by the
                    Contractor.

                

        

      

      
        

        
          	
                  B)

                	
                  The
                    Contractor must also submit to the SDOH the following on an ongoing
                    basis
                    for each confirmed case of fraud or abuse it identifies through
                    Complaints, organizational monitoring, contractors, subcontractors,
                    providers, beneficiaries, Enrollees, etc related to Medicaid
                    Only Covered
                    Services identified in Appendix
                    K-2:

                

        

      

      

      
        
          	
                  1)

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

                

          	2) 	 The
                  source that identified the fraud or
                  abuse;

        

      

      
                        

      

      
        Medicaid
          Advantage Plus Contract

      

      
        2007
          CONTRACTOR REPORTING REQUIREMENTS

      

      
        SECTION
          18

      

      
        -3-

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        
          	
                  3)

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

                

          	4) 	A
                  description of the fraud or abuse;

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

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

          	7)	Other
                  data/information as prescribed by
                  SDOH.

        

      

      
                      

      

      
        C)
          Such
          report shall be submitted when cases of fraud or 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 or any other manner acceptable
          to SDOH, an updated provider network report on a quarterly basis for providers
          of services described in Appendix K-2. 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 Medicaid Enrollees.
          Networks must be reported separately for each county in which the Contractor
          operates.

      

      
        

        ix)
          Quality Assessment and Performance Improvement Projects:

      

      
        

        
          	
                  a)

                	
                  The
                    Contractor will submit reports to SDOH on all quality assessment
                    and
                    performance improvement projects directed by CMS for the Medicare
                    Advantage Program, including the annual report on the Contractor's
                    Chronic
                    Care Improvement Program. Reports should be duplicative of reports
                    submitted to CMS, and separate reports for the dual eligible
                    population
                    are not required.

                

          	b)	Performance
                  Improvement Projects

        

      

      
         

      

      
        The
          Contractor will be required to conduct performance improvement projects
          that
          focus on clinical and non-clinical areas consistent with the requirements
          of 42
          CFR 438.240. The purpose of these studies will be to promote quality improvement
          within the managed long-term care plan. At least one (1) performance improvement
          project each year will be selected as a priority and approved by the Department.
          Results of each of these annual studies will be provided to the Department
          in a
          required format. Results of other performance improvement projects will
          be
          included in the minutes of the quality committee and reported to the Department
          upon request.

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        
          
            2007
              CONTRACTOR REPORTING REQUIREMENTS

          

          
            SECTION
              18

          

          
            -4-

          

        

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        x) 
          Enrollee Health and Functional Status:

      

      
        

        The
          Contractor shall submit Enrollee health and functional status data for
          each of
          their Enrollees in the format and according to the timeframes specified
          by the
          SDOH. The data shall consist of Semi-Annual Assessment of Members (SAAM)
          or any
          other such instrument the SDOH may request. The data shall be submitted
          at least
          semi-annually or on a more frequent basis if requested by the
          SDOH.

      

      
        

        xi) 
          Disenrollment Report:

      

      
        

        This
          report is to be completed twice a year. The first report will cover the
          operation of the demonstration for the period January 1 through June 30.
          The
          second report will cover the period from July 1 through December 31. The
          completed report is to be provided to the SDOH within sixty (60) days after
          the
          period in a format to be specified by the SDOH.

      

      
        

        xii) 
          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.

      

      
        

        18.6 
          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) (§§ 1124 and 1903(m)(4) of the SSA).

      

      
        

        18.7 
          Data Certification

      

      
        

        The
          Contractor shall comply with the data certification requirements in 42
          CFR
          438.604 and 438.606.

      

      
        

        
          	
                  a)

                	
                  The
                    types of data subject to certification include, but are not limited
                    to,
                    enrollment information, encounter data, the premium proposal,
                    contracts
                    and all other financial data. The certification shall be in a
                    format
                    prescribed by the Department and must be sent at the time the
                    report or
                    data are submitted.

                

        

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        2007
          

        CONTRACTOR
          REPORTING REQUIREMENTS

        SECTION
          18

      

      
        -5-

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        
          	
                  b)

                	
                   The
                    certification shall be signed by the Plan's Chief Executive Officer,
                    the
                    Chief Financial Officer or an individual with designated authority;
                    and,
                    the certification shall attest to the accuracy, completeness
                    and
                    truthfulness of the data.

                

        

      

      
        

        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 program 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 Medicaid Advantage
          Plus
          Program for which the data and information is collected, reported, prepared
          and
          submitted.

      

      
        
           

          18.9 
            Certification Regarding Individuals Who Have Been Debarred Or Suspended
            By Federal,
            State, or Local Government

        

      

      
         

      

      
        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, state or local government,
          or
          otherwise excluded from participating in procurement
          activities:

      

      
        

        
          	
                  a)

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

                

        

      

      
        

        
          	
                  b)

                	
                  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 Medicaid
                    managed care
                    program, consistent with requirements of SSA § 1932
                    (d)(1).

                

        

      

      
        

        18.10  
          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 managed care
          plan,
          or with any subcontract(s) in which the managed care plan has a five percent
          (5%) or more ownership interest, consistent with requirements of SSA § 1903
          (m)(2)(a)(viii) and 42 CFR 455.100 and 455.104.

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        2007

      

      
        CONTRACTOR
          REPORTING REQUIREMENTS

      

      
        SECTION
          18

      

      
        -6-

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        18.11   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. 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.

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        2007

      

      
        CONTRACTOR
          REPORTING REQUIREMENTS

      

      
        SECTION
          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) 

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

                

        

      

      
        

        
          	
                  ii) 

                	
                  all
                    financial records and statistical data that SDOH and DHHS 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,
                    and

                

        

      

      
        

        
          	
                  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)

                	
                  Credentials
                    for subcontractors and providers used by subcontractors shall
                    be
                    maintained in a manner accessible to the Contractor and furnished
                    to the
                    Department, upon request.

                

        

      

      
        

        
          	
                  c)

                	
                  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 and/or statutory accounting principles
          where
          applicable.

      

      
        

        19.3Access
          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.

      

      
        

        
 

      

      
        
          Medicaid
            Advantage Plus Contract

          
            2007

          

          
            RECORDS
              MAINTENANCE AND AUDIT RIGHTS

          

          
            SECTION
              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.

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        2007

      

      
        RECORDS
          MAINTENANCE AND AUDIT RIGHTS

      

      
        SECTION
          19

      

      
        -2-

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        20.CONFIDENTIALITY

         

      

      
        
          20.1 
            Confidentiality of Identifying Information about Enrollees, Potential
            Enrollees
and
            Applicants

        All
          information relating to services to Enrollees, Eligible Persons and Potential
          Enrollees which is obtained by the Contractor shall be confidential pursuant
          to
          the PHL including PHL Article 27-F, the provisions of § 369(4) of the
          SSL,  42 U.S.C. § 1396a (a)(7) (§ 1902(a)(7) of SSA), § 33.13 of the
          Mental Hygiene Law, and regulations promulgated under such laws including
          42 CFR
          422.118 and 42 CFR Part 2 pertaining to Alcohol and Substance Abuse Services.
          Such information including information relating to services provided to
          Enrollees, Potential Enrollees and Applicants 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 Medicaid information.

      

      
        

        20.2 
          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.

      

      
        

        20.3 
          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
          Applicants.

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        2007

      

      
        CONFIDENTIALITY

      

      
        SECTION
          20

      

      
        -1-

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        21.  PARTICIPATING
          PROVIDERS

      

      
        

        21.1 
          General Requirements

      

      
        

        
          	
                  a)

                	
                  The
                    Contractor agrees to comply with all applicable requirements
                    and standards
                    set forth at 42 CFR 422.112, Subpart C; 422, Subpart E; 422.504(a)(6)
                    and
                    422.504(i), Subpart K; 423, Subpart C and other applicable federal
                    laws
                    and regulations related to MCO relationships with providers and
                    with
                    related entities, contractors and subcontractors for services
                    in the
                    Contractor's Medicare Advantage
                    Product.

                

        

      

      
        

        
          	
                  b)

                	
                  The
                    Contractor agrees to comply with all applicable requirements
                    and standards
                    set forth at PHL Article 44,10 NYCRR Part 98, and other applicable
                    federal
                    and state laws and regulations related to MCO relationships with
                    providers
                    and with related entities, contractors and subcontractors for
                    services in
                    the Contractor's Medicaid Advantage Plus
                    Product.

                

        

      

      
        

        21.2 
          Medicaid Advantage Plus Network Requirements

      

      
        

        
          	
                  a)

                	
                  The
                    Contractor agrees to allow each Enrollee the choice of Participating
                    Provider of covered service to the extent possible and
                    appropriate.

                

        

      

      
        

        
          	
                  b)

                	
                  The
                    Contractor agrees to maintain and demonstrate to the Department's
                    satisfaction, a sufficient and adequate network for the delivery
                    of all
                    covered services either directly or through subcontracts. The
                    Contractor
                    shall meet applicable federal and state standards regarding adequacy
                    of
                    provider network capacity. If the network is unable to provide
                    necessary
                    services under this Contract for a particular Enrollee, the Contractor
                    agrees to adequately and timely furnish these services outside
                    of the
                    Contractor's network for as long as the Contractor is unable
                    to provide
                    them within the network.

                

        

      

      
        

        
          	
                  c)

                	
                  In
                    establishing the network, the Contractor must consider the following:
                    anticipated Enrollment, expected utilization of Medicaid Advantage
                    Plus
                    services by the population to be enrolled, the number and types
                    of
                    providers necessary to furnish the services in the Medicaid Advantage
                    Plus
                    Benefit Package, the number of providers who are not accepting
                    new
                    patients, and the geographic location of the providers and
                    Enrollees.

                

        

      

      
        

        
          	
                  d)

                	
                  The
                    Contractor's Medicaid Advantage Plus Plan network must contain
                    all of the
                    provider types necessary to furnish the services identified in
                    Appendix
                    K-2.

                

        

      

       

      
        
          	
                  e)

                	
                  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.

                

        

      

      
         

      

      
        Medicaid
          Advantage Plus Contract

      

      
        2007

      

      
        PARTICIPATING
          PROVIDERS

      

      
        SECTION
          21

      

      
        -1-

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        

        
          	
                  f) 

                	
                  The
                    Contractor shall not include in its network any provider who
                    has been
                    sanctioned or prohibited from participation in Federal health
                    care
                    programs under either § 1128 or § 1128 A of the SSA, or who has had
                    his/her license suspended by the New York State Education Department
                    or
                    the SDOH Office of Professional Medical
                    Conduct.

                

        

      

      
        

        21.3 
          Professional Discipline

      

      
        

        
          	
                  a)

                	
                  Pursuant
                    to Public Health Law § 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, any of the
                    following:

                

        

      

      
        

        
          	
                   

                	
                  i)
                    the termination of a health care provider contract pursuant to
§ 4406-d of
                    the Public Health Law 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 provider contract 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 State Education Law.

                

        

      

      
        

        21.4  
          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 Medicaid Advantage Plus 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
          HPN. 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.

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        2007

      

      
        PARTICIPATING
          PROVIDERS

      

      
        SECTION
          21

      

      
        -2-

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        21.5 
          Payment in Full

      

      
        

        Contractor
          must limit participation to providers who agree that payment received from
          the
          Contractor for services included in the Medicare and Medicaid Advantage
          Plus
          Benefit Packages is payment in full for services provided to Enrollees,
          except
          for the collection of applicable co-payments from Enrollees as provided
          by
          law.

      

      
        

        21.6    Dental
          Networks

      

      
        

        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) 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.

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        2007

      

      
        PARTICIPATING
          PROVIDERS

      

      
        SECTION
          21

      

      
        -3-

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        22.
          SUBCONTRACTS AND PROVIDER AGREEMENTS FOR MEDICAID ADVANTAGE PLUS COVERED
          SERVICES

      

      
        

        22.1 
          Written Subcontracts

      

      
        

        
          	
                  a)

                	
                  Contractor
                    may not enter into any subcontracts related to the delivery of
                    the
                    services identified in Appendix K-2 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
                    this subcontract shall impair the rights of the State under this
                    Agreement. No sub-contractual relationship shall be deemed to
                    exist
                    between the subcontractor and the SDOH or the State. The Contractor
                    shall
                    oversee and is accountable to the Department for all functions
                    and
                    responsibilities that are described in this
                    Contract.

                

        

      

      
        

        
          	
                  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. The Contractor may only delegate activities or
                    functions to
                    a subcontractor in a manner consistent with requirements set
                    forth in this
                    Contract, 42 CFR 434 and 438 and applicable State law and
                    regulations.

                

        

      

      
        

        22.2 
          Permissible Subcontracts

      

      
        

        Contractor
          may subcontract for provider services as set forth in Section 2.6 and 21
          of this
          Agreement, for management services and for 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 
          Provision of Services through Provider Agreements

      

      
        

        All
          medical care and/or services covered under this Agreement, with the exception
          of
          Emergency Services, Family Planning and Reproductive Health Services, and
          services for which Enrollees can self refer, shall be provided through
          Provider
          Agreements with Participating Providers.

      

      
        

        22.4 
          Approvals

      

      
        

        
          	
                  a)

                	
                  Provider
                    Agreements related to Medicaid Only Covered Services shall require
                    the
                    approval of SDOH as set forth in PHL § 4402 and 10 NYCRR Part
                    98.

                

        

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        2007

      

      
        SUBCONTRACTS
          AND PROVIDER AGREEMENTS FOR 

        MAP
          COVERED SERVICES 

        SECTION
          22

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        
          	
                  b)

                	
                  The
                    Contractor may only delegate management responsibilities as defined
                    by
                    State regulation by means of a Department approved management
                    services
                    agreement. Both the proposed management services agreement and
                    the
                    proposed management entity must be approved by the Department
                    pursuant to
                    the provisions of 10 NYCRR Part 98-1.11 before any such agreement
                    may be
                    become effective.

                

        

      

      
        

        
          	
                  c)

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

                

        

      

      
        

        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 reporting 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 Contractor will provide, no less than thirty (30) days prior
                    to
                    implementation, any new rules or policies and procedures regarding
                    quality
                    improvement, service authorizations, member appeals and grievances
                    and
                    provider credentialing, or any changes thereto, to a the
                    subcontractor;

                

        

      

      
        
          	
                  iii) 

                	
                  that
                    the credentials of affiliated professionals or other health care
                    providers
                    will be reviewed directly by the Contractor; or the credentialing
                    process
                    of the subcontractor will be reviewed and approved by the Contractor
                    and
                    the Contractor must audit the credentialing process on an ongoing
                    basis;

                

        

      

      
        
          	
                  iv) 

                	
                  how
                    the subcontractor shall participate in the Contractor's quality
                    assurance,
                    service authorization and grievance and appeals processes;, and
                    the
                    monitoring and evaluation of the Contractor's
                    plan;

                

        

      

      
        
          	
                  v)

                	
                  how
                    the subcontractor will insure that pertinent contracts, books,
                    documents,
                    papers and records of their operations are available to the Department,
                    HHS, Comptroller of the State of New York, Comptroller General
                    of the
                    United States and/or their respective designated representatives,
                    for
                    inspection, evaluation and audit, through six years from the
                    final date of
                    the subcontract or from the date of completion of any audit,
                    whichever is
                    later; vi)  that the work performed by the subcontractor must be
                    in accordance with the terms of this Agreement,
                    and

                

        

      

      
        
          	
                  vii) 
                    

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

                

        

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        2007

      

      
        SUBCONTRACTS
          AND PROVIDER AGREEMENTS FOR

      

      
        MAP
          COVERED SERVICES

      

      
        SECTION
          22

      

      
        -2-

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        
          	
                  b)

                	
                  Any
                    services or other activities performed by a subcontractor in
                    accordance
                    with a contract between the subcontractor and the Contractor
                    will be
                    consistent and comply with the Contractor's obligations under
                    this
                    Contract and applicable state and federal laws and
                    regulations.

                

        

      

      
        

        
          	
                  c)

                	
                  No
                    contract between the Contractor and a health care provider shall
                    contain
                    any clause purporting to transfer to the health care provider,
                    other than
                    a medical group, by indemnification or otherwise, any liability
                    relating
                    to activity, actions or omissions of the Contractor as opposed
                    to those of
                    the health care provider.

                

        

      

      
        

        
          	
                  d)

                	
                  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.

                

        

      

      
        

        
          	
                  e)

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

                

        

      

      
        

        
          	
                  f)

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

                

        

      

      
        

        
          	
                  g)

                	
                  Any
                    subcontract entered into by the Contractor shall fulfill the
                    requirements
                    of 42 CFR 434 and 438 that are appropriate to the service or
                    activity
                    delegated under such
                    subcontract.

                

        

      

      
        

        
          	
                  h)

                	
                  The
                    Contractor shall also ensure 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.

                

        

      

      
        

        
          	
                  i)
                    

                	
                  The
                    Contractor shall include in every Provider Agreement a procedure
                    for the
                    resolution of disputes between the Contractor and its Participating
                    Providers. Any and all such disputes shall be resolved using
                    the
                    Department's interpretation of the terms and provisions of this
                    Contract,
                    and portions of subcontracts executed hereunder that relate to
                    services
                    pursuant to this Contract. If a subcontract provides for arbitration
                    or
                    mediation, it shall expressly acknowledge that the Commissioner
                    of the
                    Department of Health is not bound by arbitration or mediation
                    decisions.
                    Arbitration or mediation must occur within New York State, and
                    the
                    subcontract shall provide that the Commissioner will be given
                    notice of
                    all issues going to arbitration or mediation, and copies of all
                    decisions.

                

        

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        2007

      

      
        SUBCONTRACTS
          AND PROVIDER AGREEMENTS FOR

      

      
        MAP
          COVERED SERVICES 

      

      
        SECTION
          22 

        -3-

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        
          	
                  j)

                	
                  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 health care providers for items and services included
          in
          the Contractor's Medicaid Advantage Plus Product on a timely basis, consistent
          with the claims payment procedures described in SIL § 3224-a.

      

      
        

        22.7 
          Recovery of Overpayments to Providers

      

      
        

        Consistent
          with the exception language in Section 3324-b of the Insurance Law, the
          Contractor shall retain the right to audit participating providers' claims
          for a
          six year period from the date the care, services or supplies were provided
          or
          billed, whichever is later, and to recoup any overpayments discovered as
          a
          result of the audit. This six year limitation does not apply to situations
          in
          which fraud may be involved or in which the provider or an agent of the
          provider
          prevents or obstructs the Contractor's auditing.

      

      
        

        22.8 
          Physician Incentive Plan

      

      
        

        
          	
                  a)

                	
                  If
                    Contractor elects to operate a Physician Incentive Plan, Contractor
                    agrees
                    that no specific payment will be made directly or indirectly
                    under the
                    plan to 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 agreements for contracted 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.

                

        

      

      
        

        
          	
                  b)  

                	
                  In
                    the event that the incentive arrangements place the 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

                

        

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        2007

      

      
        SUBCONTRACTS
          AND PROVIDER AGREEMENTS FOR

      

      
        MAP
          COVERED SERVICES

      

      
        SECTION
          22

      

      
        -4.

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        
          	
                	
                  
                    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
                      Agreement.

                  

                

        

      

      
        

        22.9 
          Provider Termination Notice

      

      
        

        The
          Contractor shall provide the Department at least sixty (60) days notice
          prior to
          the termination of any subcontract, the termination of which would preclude
          an
          Enrollee's access to a covered service by provider type under this Agreement,
          and specify how services previously furnished by the subcontractor will
          be
          provided. In the event a subcontract is terminated on less than sixty (60)
          days
          notice, the Contractor shall notify the Department immediately but in no
          event
          more than seventy-two (72) hours after notice of termination is either
          issued or
          received by the Contractor.

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        2007

      

      
        SUBCONTRACTS
          AND PROVIDER AGREEMENTS FOR

      

      
        MAP
          COVERED SERVICES

      

      
        SECTION
          22

      

      
        -5-

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        23.  AMERICANS
          WITH DISABILITIES ACT COMPLIANCE PLAN

      

      
        

        Contractor
          must comply with Title II of the ADA and § 504 of the Rehabilitation Act of 1973
          for program accessibility, and must develop an ADA Compliance Plan consistent
          with the applicable SDOH Guidelines for Medicaid 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.

      

      
        
        

        24.  FAIR
          HEARINGS

      

      
        

        24.1 
          Enrollee Access to Fair Hearing Process

      

      
        

        Enrollees
          in the Contractor's Medicaid Advantage Plus Product may access the fair
          hearing
          process related to services determined by the Contractor to be a Medicaid
          only
          benefit or services determined by the Contractor to be a benefit under
          both
          Medicare and Medicaid in accordance with applicable federal and state laws
          and
          regulations, if the member elects to use the Medicaid appeal process. The
          Contractor must abide by and participate in New York State's Fair Hearing
          Process and comply with determinations made by a fair hearing
          officer.

      

      
        

        24.2 
          Enrollee Rights to a Fair Hearing

      

      
        

        Enrollees
          in the Contractor's Medicaid Advantage Plus Product may request a fair
          hearing
          regarding adverse LDSS determinations concerning enrollment, disenrollment
          and
          eligibility, and regarding the denial, termination, suspension or reduction
          of a
          service determined by the Contractor to be a Medicaid only benefit or a
          benefit
          under both Medicare and Medicaid, if the member elects to use the Medicaid
          appeal process.. For issues related to disputed services, Enrollees must
          have
          received a final adverse determination on Appeal from the Contractor or
          its
          approved utilization review agent confirming an initial adverse determination
          to
          deny services or terminate, suspend or reduce services the Enrollee is
          currently
          receiving during his or her service authorization period. 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 time frames established for review of grievances and
          utilization review in Articles 44 and 49 of the Public Health Law, the
          grievance
          system requirements of 42 CFR 438 and Appendix F of this
          Agreement.

      

      
        

        24.3 
          Contractor Notice to Enrollees

      

      
        

        
          	
                  a)

                	
                  Pursuant
                    to Appendix F of this Agreement, the Contractor must issue a
                    written
                    Notice of Action to any Enrollee when taking an adverse Action
                    and when
                    making an Action Appeal determination, issue a notice of the
                    right to
                    request a fair hearing within applicable timeframes when the
                    service is
                    determined by the Contractor to be a Medicaid only benefit or
                    a benefit
                    under both Medicare and
                    Medicaid. If the service is a benefit under both Medicare and
                    Medicaid,
                    the Enrollee is advised of his or her right to elect either the
                    Medicare
                    or Medicaid appeals
                    process.

                

        

      

      
        

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          Advantage Plus Contract

      

      
        2007

      

      
        SECTION
          23 - SECTION 35

      

      
        -1-

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
         

        
          	
                  b)
                    

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

                

        

      

      
        

        24.4 
          Aid Continuing

      

      
        

        
          	
                  a)

                	
                  Contractor
                    shall be required to continue the provision of services determined
by
                    the Contractor to be a Medicaid only benefit or a benefit under
                    both Medicare
                    and Medicaid that are the subject of the fair hearing to an Enrollee
                    
                    
                      
                        (hereafter
                          referred to as "aid continuing") if so ordered by the O
                          AH under the following
                          circumstances:

                      

                    

                  

                

        

      

      
         

      

      
        
          	
                   

                	
                  
                    i)
                      Contractor has or is seeking to reduce, suspend or terminate
                      such service
                      or treatment currently authorized; 

                  

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

                  iii)
                    There is a valid order for the service or treatment from a Participating
                    Provider when the requirement for such an order is identified
                    in the
                    Contractor's service authorization criteria approved by
                    SDOH.

                

        

      

      
         

      

      
        
          	
                  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 or the service or treatment 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 requests a fair hearing in a timely
                    manner,
                    Contractor shall, at the direction of the LDSS, restore the disputed
                    services and/or benefits consistent with the provisions of Section
                    24.4(a)
                    of this Agreement.

                

        

      

      
        

        24.5
          Contractor's Obligations

      

      
        

        
          	
                  a) 

                	
                  Contractor
                    shall appear at all scheduled fair hearings concerning its clinical
                    determinations and/or Contractor-initiated Disenrollments and/or
                    Contactor
                    recommended denials of enrollment 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.

                

        

      

      
         

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        2007

      

      
        SECTION
          23 - SECTION 35

        -2-

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
         

        
          	
                  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 for services determined
                    by the
                    Contractor to be a Medicaid only benefit or a benefit under both
                    Medicare
                    and Medicaid as required under state and federal laws and by
                    Section 14
                    and Appendix F of this Agreement. Enrollees may only request
                    a State fair
                    hearing and/or External Appeal as a result of the Contractor's
                    Final
                    Adverse Determinations.

                

        

      

      
        

        
          	
                  c)

                	
                  Contractor
                    shall comply with all determinations rendered by OAH at fair
                    hearings.
                    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
                    non­compliance by Contractor with a fair hearing determination or
                    Contractor's refusal to provide disputed
                    services.

                

        

      

      
        

        
          	
                  d)

                	
                  If
                    SDOH, through its Complaint investigation process, or OAH, by
                    a
                    determination after a fair hearing, directs Contractor to provide
                    a
                    service that was denied by Contractor, Contractor may either
                    directly
                    provide the service, arrange for the provision of that service
                    or pay for
                    the provision of that service by a Non-Participating Provider.
                    If the
                    services were not furnished during the period in which the fair
                    hearing
                    was pending, the Contractor must authorize and furnish the disputed
                    services promptly and as expeditiously as the Enrollee's health
                    condition
                    requires.

                

        

      

      
        

        
          	
                  e)

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

                

        

      

      
        

        
          	
                  f)

                	
                  Contractor
                    agrees to identify a contact person within its organization who
                    will serve
                    as a liaison to OAH 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 the Contractor transmitted via
                    e-mail as
                    legally valid.

                

        

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        2007

      

      
        SECTION
          23 - SECTION 35

      

      
        -3-

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        
          	
                  g)

                	
                   The
                    information describing fair hearing rights, aid continuing, Service
                    Authorization, Action Appeal, Complaint and Complaint Appeal
                    procedures
                    shall be included in all Medicaid Advantage Plus member handbooks
                    and
                    shall comply with Section 14, and Appendix F of this
                    Agreement.

                

        

      

      
        

        
          	
                  h)

                	
                   Contractor
                    shall bear the burden of proof at hearings regarding the reduction,
                    suspension or termination of ongoing services determined by the
                    Contractor
                    to be a Medicaid only benefit or a benefit under both Medicare
                    and
                    Medicaid. In the event that Contractor's final 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.

                

        

      

      
        

        25.
          EXTERNAL APPEAL

      

      
        

        25.1 
          Basis for External Appeal

      

      
        

        Enrollees
          in the Contractor's Medicaid Advantage Plus Product are eligible to request
          an
          External Appeal when one or more health care services determined by the
          Contractor to be a Medicaid only benefit or a benefit under both Medicare
          and
          Medicaid has been denied by the Contractor on the basis that the service(s)
          is
          not medically necessary or is experimental or
          investigational.

      

      
        

        25.2 
          Eligibility for External Appeal

      

      
        

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

      

      
        

        25.3 
          External Appeal Determination

      

      
        

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

      

      
        

        25.4 
          Compliance with External Appeal Laws and Regulations

      

      
        

        The
          Contractor must comply with the provisions of §§ 4910-4914 of the PHL and 10
          NYCRR Part 98 regarding the External Appeal program with respect to services
          determined by the Contractor to be a Medicaid only benefit or a benefit
          under
          both the Medicare and Medicaid programs.

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        2007

      

      
        SECTION
          23 - SECTION 35

        -4-

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        25.5
          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 Medicaid Advantage Plus Handbook.

      

      
        

        26.
          INTERMEDIATE SANCTIONS

      

      
        

        26.1 
          General

      

      
        

        Contractor
          is subject to imposition of sanctions as authorized by 42 CFR 422, Subpart
          O. In
          addition, for the Medicaid Advantage Plus Program, 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
          as
          set forth in 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.

      

      
        

        26.2 
          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 Medicaid Advantage Plus
                    Program.

                

        

      

      
        
          	
                   

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

                

        

      

      
        
          	
                   

                	
                  iv)
                    Misrepresenting or falsifying information that the Contractor
                    furnishes to
                    an Enrollee, Eligible Persons, Potential Enrollees, health care
                    providers,
                    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 CMS and the
                    State or
                    that contain false or materially misleading information.
                    

                

        

      

      
        
          	
                   

                	
                  vii)
                    Violating any other applicable requirements of SS A § § 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.

                

        

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        2007

      

      
        SECTION
          23 - SECTION 35

      

      
        -5-

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        26.3  Intermediate
          Sanctions

      

      
        

        Intermediate
          Sanctions may include, but are not limited to:

      

      
        a)Civil
          and monetary penalties.

      

      
        b) Suspension
          of all new Enrollment, after the effective date of the
          sanction.

      

      
        c) Termination
          of the Agreement, pursuant to Section 2.7 of this Agreement.

      

      
         

        26.4 
          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
          Medicaid Advantage Plus 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 the conclusion
          that limitation, suspension or termination of Enrollment activities or
          Enrollment in the Contractor's plan is unnecessary. The Department reserves
          the
          right to suspend enrollment immediately in situations involving imminent
          danger
          to the health and safety of Enrollees. Nothing in this paragraph limits
          other
          remedies available to the SDOH under this Agreement.

      

      
        

        26.5Due
          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).

      

      
        

        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 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.

      

      
        

        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.

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        2007

      

      
        SECTION
          23 - SECTION 35

      

      
        -6-

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        29. 
          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, DHHS or the SDOH.

      

      
        

        30. 
          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.

      

      
        

        31. 
          INDEMNIFICATION

      

      
        

        31.1     Indemnification
          by Contractor

      

      
        

        
          	
                  a)

                	
                  The
                    Contractor shall indemnify, defend, and hold harmless the SDOH
                    and 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,
                  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,
                    and

                

        

      

      
        
          	
                  iii)
                    

                	
                  any
                    liability, including costs and expenses, for violation of proprietary
                    rights, copyrights, or rights of privacy, 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 31.1.

                

        

      

      
        

        
          	
                  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.

                

        

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        2007

      

      
        SECTION
          23 - SECTION 35

      

      
        -7-

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        31.2  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 or 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 for the State of New York.

      

      
        

        32.  PROHIBITION
          ON USE OF FEDERAL FUNDS FOR LOBBYING

      

      
        

        32.1 
          Prohibition of Use of Federal Funds for Lobbying

      

      
        

        The
          Contractor agrees, pursuant to 31 U.S.C. § 1352 and 45 CFR 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 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.

      

      
        

        32.2 
          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.

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        2007

      

      
        SECTION
          23 - SECTION 35

      

      
        -8-

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        32.3     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.

      

      
        

        33.  NON-DISCRIMINATION

      

      
        

        33.1
          Equal Access to Benefit Package

      

      
        

        Except
          as
          otherwise provided in applicable sections of this Agreement the Contractor
          shall
          provide the Medicaid Advantage Plus Benefit Package to all Enrollees in
          the same
          manner, in accordance with the same standards, and with the same priority
          as
          Enrollees of the Contractor enrolled under any other
          contracts.

      

      
        

        33.2
          Non-Discrimination

      

      
        

        The
          Contractor shall 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 Capitation Rate that the Contractor will receive
          for such Eligible Persons or Enrollees.

      

      
        

        33.3
          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.

      

      
        

        33.4
          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 Medicaid reimbursed health services
          from
          or through a tribal health or urban Indian health facility or
          center.

      

      
        

        34.  COMPLIANCE
          WITH APPLICABLE LAWS AND REGULATIONS

      

      
        

        34.1     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 Insurance Law; the State Social Services Law; and state

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        2007

      

      
        SECTION
          23 - SECTION 35

      

      
        -9-

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        regulations
          related to the aforementioned state statutes. Such state laws and regulations
          shall not be deemed to be applicable to the extent that they are pre­empted
          by federal laws. The Contractor also shall comply with Titles XVIII and
          XIX of
          the Social Security Act and regulations promulgated thereunder, including
          but
          not limited to 42 CFR 422,423 and 438; Title VI of the Civil Rights Act
          of 1964
          and 45 CFR. 80, as amended; § 504 of the Rehabilitation Act of 1973 and 45 CFR.
          84, as amended; Age Discrimination Act of 1975 and 45 CFR. 91, as amended;
          the
          ADA; Title XIII of the Federal Public Health Services Act, 42 U.S.C. § 300e et
          seq., and the regulations promulgated there under; 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.

      

      
        

        34.2 
          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.

      

      
        

        34.3 
          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.

      

      
        

        34.4 
          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.

      

      
        

        34.5 
          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 participating
          in the Medicaid Program. 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, LDSS and the Enrollees in the event of HMO 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.

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        2007

      

      
        SECTION
          23 - SECTION 35

      

      
        -10-

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        34.6 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).

      

      
        

        34.7 
          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.

      

      
        

        34.8 
          Compliance Plan

      

      
        

        The
          Contractor agrees to implement a compliance plan in accordance with the
          requirements of 42 CFR 422.503(b)(4)(vi) and 42 CFR 438.608.

      

      
        

        35.  NEW
          YORK STATE STANDARD CONTRACT CLAUSES

      

      
        

        The
          parties agree to be bound by the standard clauses for all New York State
          contracts and standard clauses, if any, for local government contracts
          contained
          in Appendix A, attached to and incorporated into this Agreement as if set
          forth
          fully herein, and any amendment thereto.

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        2007

      

      
        SECTION
          23 - SECTION 35

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        APPENDIX
          A

        New
          York State Standard Contract Clauses

      

      
         

         

        
 

        Medicaid
          Advantage Plus Contract

      

      
        2007

      

      
        APPENDIX
          A

      

      
        STANDARD
          CLAUSES

      

      
        -1-

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        STANDARD
          CLAUSES FOR NYS CONTRACTS

      

      
        

        APPENDIX
          A

      

      

      

      
        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 that
          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 set­off 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 this 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 the Contractor

      

      
        

        
          
            Page
              1

            May,
              2003

              
                
                  
                  

                

                
                  
                  

                  
                    

                  

                

                
                  
                  

                

              

          

        

      

      
        STANDARD
          CLAUSES FOR NYS CONTRACTS

      

      
        

        APPENDIX
          A

      

       

      
        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 (the
          "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 property 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
          furnish 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.

      

      
        

        Page
          2

        May,
          2003

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        STANDARD
          CLAUSES FOR NYS CONTRACTS

      

      
        

        APPENDIX
          A

      

       

      
        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--7lh 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.state.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.

      

      
        

         

      

      
        Page
          3

      

      
        May,
          2003

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        APPENDIX
          B 

        Certification
          Regarding Lobbying

      

      
        

         

         

        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          B

      

      
        CERTIFICATION
          REGARDING LOBBYING

      

      
        2007

      

      
        1

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        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

              	
                5/31/2007

              
	
                Signature:

              	
                 
                  /s/ Todd Farha       
                  

              
	
                Title:

              	
                President
                  & CEO

              
	
                Organization:

              	
                WellCare
                  of New York, Inc.

              

      

      
        

      

      
         

      

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          B

      

      
        CERTIFICATION
          REGARDING LOBBYING

      

      
        2007

      

      
        2

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        APPENDIX
          B-l

      

      
        

        Certification
          Regarding MacBride Fair Employment Principles

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          B

      

      
        CERTIFICATION
          REGARDING LOBBYPNG

      

      
        2007

      

      
        3

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        APPENDIX
          B-l

      

      
        

        
          	
                   

                	
                  NONDISCRIMINATION
                    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

                

        

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          B

      

      
        CERTIFICATION
          REGARDING LOBBYPNG

      

      
        2007

      

      
        4

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        APPENDIX
          C

      

      
        

        New
          York
          State Department of Health

      

      
        Requirements
          for the Provision of Free Access to

      

      
        Family
          Planning and Reproductive Health Services

      

      
        

        
          	
                   

                	
                  C.l    Definitions
                    and General Requirements for the Provision of Family Planning
                    and
                    Reproductive Health Services

                

        

      

      
        

        
          	
                   

                	
                  C.2    Requirements
                    for MCOs that Provide Family Planning and Reproductive Health
                    Services

                

        

      

      
        

        
          	
                   

                	
                  C.3    Requirements
                    for MCOs That Do Not Provide Family Planning and Reproductive
                    Health
                    Services

                

        

      

      
        

        Medicaid
          Advantage Pius Contract

      

      
        APPENDIX
          C

      

      
        REQUIREMENTS
          FOR PROVISION OF FREE ACCESS

      

      
        2007

        1

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        C.l

         

      

      
        
          	
                   

                	
                  Definitions
                    and General Requirements for the Provision of Family Planning
                    and
                    Reproductive Health
                    Services

                

        

      

      
        

        1.        Family
          Planning and Reproductive Health Services

      

      
        

        
          	
                  a) 

                	
                  Family
                    Planning and Reproductive Health Services mean the offering,
                    arranging and
                    furnishing of those health services which enable Enrollees, including
                    minors who may be sexually active, to prevent or reduce the incidence
                    of
                    unwanted pregnancies.

                

        

      

      
        

        
          	
                   

                	
                  i)   Family
                    Planning and Reproductive Health Services include the following
                    medically-necessary services, related drugs and supplies which
                    are
                    furnished or administered under the supervision of a physician,
                    licensed
                    midwife or certified nurse practitioner during the course of
                    a Family
                    Planning and Reproductive Health visit for the purpose
                    of:

                

        

      

      
        

        
          	
                  A)

                	
                  contraception,
                    including all FDA-approved birth control methods, devices such
                    as
                    insertion/removal of an intrauterine device (IUD) or insertion/removal
                    of
                    contraceptive implants, and injection procedures involving Pharmaceuticals
                    such as Depo-Provera;

                   

                

          	B) 	
                  sterilization;

                   

                

          	C)   	emergency
                  contraception and follow up;

        

      

      
         

      

      
        
          	
                  D)

                	
                  screening,
                    related diagnosis, and referral to a Participating Provider for
                    pregnancy;

                

        

      

      
        

        
          	
                  E)

                	
                  medically-necessary
                    induced abortions, which are procedures, either medical or surgical,
                    that result in the termination of pregnancy. The determination
                    of medical necessity shall include positive evidence of pregnancy,
                    with an estimate of its
                    duration.

                

        

      

      
        

        
          	
                   

                	
                  ii)
                    Family Planning and Reproductive Health Services include those
                    education
                    and counseling services necessary to render the services
                    effective.

                

        

      

      
        

        
          	
                   

                	
                  iii)
                    Family Planning and Reproductive Health Services include
                    medically-necessary ordered contraceptives and
                    pharmaceuticals:

                

        

      

      
        

        
          	
                   

                	
                  A)
                    The Contractor is responsible for pharmaceuticals and medical
                    supplies
                    such as IUDS and Depo-Provera that must be furnished or administered
                    under
                    the supervision of a physician, licensed midwife, or certified
                    nurse
                    practitioner during the course of a Family Planning and Reproductive
                    Health visit and for prescription drugs included in the Contractor's
                    Medicare Part D Prescription Drug Benefit. 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 reimbursable drugs by
                    the Enrollee
                    from any appropriate eMedNY-enrolled health care provider of
                    the
                    Enrollee's choice.

                

        

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          C

      

      
        REQUIREMENTS
          FOR PROVISION OF FREE ACCESS

      

      
        2007

      

      
        2

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        

        
          	
                  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 EnroIIees

      

      
        

        
          	
                  a)

                	
                  Free
                    Access means EnroIIees 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 provides such services in its
                    Medicare
                    Advantage Benefit Package, or from any appropriate eMedNY-enrolled
                    health
                    care provider of the Enrollee's choice. No referral from the
                    PCP or
                    approval by the Contractor is required to access such
                    services.

                

        

      

      
        

        
          	
                  b)

                	
                  The
                    Family Planning and Reproductive Health Services listed above
                    are the only
                    services which are covered under the Free Access policy. Routine
                    obstetric
                    and/or gynecologic care, including hysterectomies, pre-natal,
                    delivery and
                    post-partum care are not covered under the Free Access policy,
                    and are the
                    responsibility of the
                    Contractor.

                

        

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          C

      

      
        REQUIREMENTS
          FOR PROVISION OF FREE ACCESS

      

      
        2007

      

      
        3

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        C.2

      

      
        

        Requirements
          for MCOs that Provide Family Planning and
          Reproductive

      

      
        

        Health
          Services

      

      
        

        1.
          Notification to Enrollees

      

      
        

        
          	
                  a)
                    

                	
                  If
                    the Contractor provides Family Planning and Reproductive Health
                    Services,
                    the Contractor must notify all Enrollees of reproductive age
                    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 HTV 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)
                    Enrollees must receive notification that they also have the right
                    to
                    obtain Family Planning and Reproductive Health Services in accordance
                    with
                    the Medicaid Free Access policy as defined in C.l 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 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 Health care will be fully covered, including when
                    an Enrollee
                    obtains such services in accordance with the Medicaid Free Access
                    policy.

                

        

      

      
        

        2. 
          Billing Policy

      

      
        

        
          	
                  a)

                	
                  The
                    Contractor must notify its Participating Providers that all claims
                    for
                    Family Planning and Reproductive Health Services must be billed to
                    the Contractor and not the Medicaid fee-for-service
                    program.

                

          	b)	Non-Participating
                  Providers will bill Medicaid
                  fee-for-service.

        

      

      
        

        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
                    §§ 17 and 18 of the PHL and 10 NYCRR Parts 751.9 and 753 relating
                    to
                    informed consent and
                    confidentiality.

                

        

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          C

      

      
        REQUIREMENTS
          FOR PROVISION OF FREE ACCESS

      

      
        2007

      

      
        4

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        

        
          	
                  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 Free Access as defined in
                    C.l 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.

                

        

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          C

      

      
        REQUIREMENTS
          FOR PROVISION OF FREE ACCESS

      

      
        2007

      

      
        5

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        C.3

      

      
        

        Requirements
          for MCOs That Do Not 

        Provide
          Family Planning and Reproductive Health Services

      

      
        

        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 Potential Enrollees,
                    new
                    Enrollees and current Enrollees
                    that:

                

        

      

      
        

        
          	
                  I)

                	
                  Certain
                    Family Planning and Reproductive Health Services (such as abortion,
                    sterilization and birth control) are not covered by the Contractor,
                    but
                    that routine obstetric and/or gynecologic care, including hysterectomies,
                    pre-natal, delivery and post-partum care are covered by the
                    Contractor;

                

        

      

      
        

        
          	
                  II)

                	
                  Such
                    Family Planning and Reproductive Health Services that are not
                    covered by
                    the Contractor may be obtained through fee-for-service Medicaid
                    providers
                    for Medicaid Advantage Plus
                    Enrollees;

                

        

      

      
        

        
          	
                  III)

                	
                  No
                    referral is needed for such services, and there will be no cost
                    to the
                    Enrollee for such services;

                

        

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          C

      

      
        REQUIREMENTS
          FOR PROVISION OF FREE ACCESS

      

      
        2007

      

      
        6

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        
          	
                  IV)

                	
                  HIV
                    counseling and testing services are available through the Contractor
                    and
                    are also available as part of a Family Planning and Reproductive
                    Health
                    encounter when furnished by a fee-for-service Medicaid provider
                    to
                    Medicaid Advantage Plus Enrollees; and that anonymous counseling
                    and
                    testing services are available from SDOH, Local Public Health
                    Agency
                    clinics and other New York City or 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
                    Medicaid
                    Advantage Plus Enrollees to secure such services through fee-for-service
                    Medicaid from any provider/clinic which offers these services
                    and who
                    accepts Medicaid.

                

        

      

      
        

        
          	
                  II)

                	
                  Orally
                    at the time of Enrollment and any time an inquiry is made regarding
                    Family
                    Planning and Reproductive Health
                    Services.

                

        

      

      
        

        
          	
                  III)

                	
                  By
                    inclusion on any website of the Contractor which includes information
                    concerning its Medicaid Advantage Plus product. Such information
                    shall be
                    prominently displayed and easily
                    navigated.

                

        

      

      

      
        

        
          	
                  C)

                	
                  A
                    description of the mechanisms to provide all new Medicaid Advantage
                    Plus
                    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 Potential Enrollee requests
                    information
                    about these non-covered services, the Contractor's Marketing
                    or Enrollment
                    representative or member services department will advise the
                    Enrollee or
                    Potential 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.

                

        

      

      
        

        
          	
                  II)

                	
                  Medicaid
                    Advantage Plus Enrollees can use their Medicaid card to receive
                    these
                    non-covered services from any doctor or clinic that provides
                    these
                    services and accepts
                    Medicaid.

                

        

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          C

      

      
        REQUIREMENTS
          FOR PROVISION OF FREE ACCESS

      

      
        2007

      

      
        7

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        
          	
                  III)
                    

                	
                  Each
                    Medicaid Advantage Plus Enrollee and Prospective 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)

                	
                  Enrollees
                    can call the Contractor's member services number for further
                    information
                    about how to obtain these non-covered services. Medicaid Advantage
                    Plus
                    Enrollees can also call the New York State Growing-Up-Healthy
                    Hotline
                    (1-800-522-5006) to request a copy of the list of Medicaid Family
                    Planning
                    Providers.

                

        

      

      
        

        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 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 Medicaid Advantage Plus Free Access, as defined
                    in C.l of
                    this Appendix, HIV counseling and testing; reimbursement for
                    Family
                    Planning and Reproductive Health encounters; Enrollee Family
                    Planning and
                    Reproductive Health education and
                    confidentiality.

                

        

      

      
        

        
          	
                  B)

                	
                  A
                    statement that the Contractor will inform its Participating Providers
                    that
                    they must comply with professional medical standards of practice,
                    the
                    Contractor's practice guidelines, and all applicable federal,
                    state, and
                    local laws. These include but are not limited to, standards established
                    by
                    the American College of Obstetricians and Gynecologists, the
                    American
                    Academy of Family Physicians, the U.S. Task Force on Preventive
                    Services.
                    These standards and laws recognize that Family Planning counseling
                    is an
                    integral part of primary and preventive
                    care.

                

        

      

      
        

        
          	
                  C)

                	
                  The
                    procedure(s) for informing the Contractor's Participating primary
                    care
                    providers, family practice physicians, obstetricians, 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 Medicaid Advantage Free Access policy, as defined in C.l
                    of this
                    Appendix.

                

        

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          C

      

      
        REQUIREMENTS
          FOR PROVISION OF FREE ACCESS

      

      
        2007

      

      
        8

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        
          	
                  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
                    Medicaid Advantage Plus Enrollees, they do so as a fee-for-service
                    Medicaid practitioner, 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:

                

        

      

      
        

        
          	
                  I)

                	
                  offer
                    those services to Medicaid Advantage Plus Enrollees on a fee-for-service
                    basis as an eMedNY-enrolled provider,
                    or

                

        

      

      
        

        
          	
                  II)

                	
                  provide
                    Medicaid Advantage Plus Enrollees with a copy of the SDOH approved
                    list of
                    Medicaid Family Planning Providers,
                    or

                

        

      

      
        

        
          	
                  III)

                	
                  give
                    Enrollees the Contractor's member services number to call to
                    obtain the
                    list of Medicaid Family Planning
                    Providers.

                

        

      

      
        

        
          	
                  F)

                	
                  A
                    statement that the Contractor acknowledges that the exchange
                    of
                    medical information, when indicated in accordance with generally
                    accepted standards of professional practice, is necessary for the
                    overall coordination of Enrollees' care and assist Primary Care
                    Providers in providing the highest quality care to the Contractor's
                    Enrollees, The Contractor must also acknowledge that medical record
                    information maintained by Participating Providers may
                    include information relating to Family Planning and Reproductive
                    Health Services provided under the fee-for-service Medicaid
                    program.

                

        

      

      
        

        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.

                

        

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          C

      

      
        REQUIREMENTS
          FOR PROVISION OF FREE ACCESS

      

      
        2007

      

      
        9

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        
          	
                  C)

                	
                  A
                    statement that the Contractor will prepare a monthly list of
                    Medicaid
                    Advantage Plus Enroll ees who have been sent a copy of the SDOH
                    approved
                    letter and the SDOH approved list of Family Planning providers.
                    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.

                

        

      

      
        

        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
                    that Participating Providers comply with all of the requirements
                    set forth
                    in §§ 17 and 18 of the PHL and 10 NYCRR Parts 751.9 and 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
                    disclosure.

                

        

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          C

      

      
        REQUIREMENTS
          FOR PROVISION OF FREE ACCESS

      

      
        2007

      

      
        10

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        APPENDIX
          D

      

      
        

        New
          York
          State Department of Health Medicaid Advantage Plus Marketing
          Guidelines

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          D

      

      
        MARKETING
          GUIDELINES

      

      
        2007

      

      
        

        1

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        APPENDIX
          D 

        MEDICAID
          ADVANTAGE PLUS MARKETING GUIDELINES

      

      
        

        I.       Purpose

      

      
        

        The
          purpose of these guidelines is to provide an operational framework for
          the
          development of marketing materials and the conduct of marketing activities
          for
          the Medicaid Advantage Plus Program. The marketing guidelines set forth
          in this
          Appendix do not replace the CMS marketing requirements for Medicare Advantage
          Plans; they supplement them.

      

      
        

        Marketing
          Materials

      

      
        

        A.      Definitions

      

      
        

        
          	
                  1.

                	
                  Marketing
                    materials means materials that are produced in any medium by
                    or
                    on behalf of the Contractor's Medicaid Advantage Plus Product and
                    can
                    reasonably be interpreted as intended to market to Potential
                    Enrollees. Marketing materials may not be used for a Medicaid
                    Advantage Plus Product without the prior written consent of the
                    Commissioner, the Superintendent of Insurance and the Director
                    of the
                    State Office for the Aging. Marketing materials requiring consent
                    include:

                

        

      

      
        
          	
                  a)

                	
                  advertising,
                    public service announcements, printed publications, and other
                    broadcast or
                    electronic messages designed to increase awareness of and interest
                    in, or
                    otherwise persuade an eligible person to enroll in a Medicaid
                    Advantage
                    Plus Product and

                

        

      

      
        
          	
                  b)

                	
                  any
                    information that references the Medicaid Advantage Plus is intended
                    for
                    general distribution and is produced in a variety of print, broadcast,
                    and
                    direct marketing media, including, but not limited to, scripts,
                    radio,
                    television, billboards, newspapers, leaflets, brochures, videos,
                    telephone
                    books, advertising, letters, posters and the member
                    handbook.

                

        

      

      
        
          	
                  2.

                	
                  Additional
                    materials requiring marketing approval include a listing of items
                    to
                    be provided as nominal gifts or
                    incentives.

                

        

      

      
        

        B.       Marketing
          Material Requirements

      

      
        

        In
          addition to meeting CMS' Medicare Advantage marketing requirements and
          guidance
          on marketing to individuals entitled to Medicare and
          Medicaid:

      

      
        

        
          	
                  1.

                	
                  Medicaid
                    Advantage Plus marketing materials must be written in prose that
                    is understood at a fourth-to sixth-grade reading level except when
                    the Contractor is using language required by CMS, and must be printed
                    in at least twelve (12)
                    point font.

                

        

      

      
        

        
          	
                  2.

                	
                  The
                    Contractor must make available written marketing and other
                    informational materials (e.g., member handbooks) in a language other
                    than English whenever at

                

        

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          D

      

      
        MARKETING
          GUIDELINES

      

      
        2007

      

      
        2

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        
          	
                   

                	
                  
                    least
                      five percent (5%) of the Potential 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 LDSS and
                      LDSS will
                      inform the Contractor when the 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 MCO's marketing plan. SDOH will
                      determine
                      the need for other than English translations based on county
                      specific
                      census data or other available
                      measures.

                  

                

        

      

      
        

        
          	
                  3.

                	
                  The
                    Contractor shall advise Potential Enrollees, in written materials
                    related
                    to enrollment, to verify with the medical services providers
                    they prefer,
                    or with whom they have an existing relationship with, are included
                    in
                    Contractor's provider network, and are available to serve the
                    participant.

                

        

      

      
        

        C.
          Prior
          Approvals

      

      
        

        
          	
                  1.

                	
                  The
                    CMS and SDOH will jointly review and approve Medicaid Advantage
                    Plus
                    Program marketing videos, materials for broadcast (radio, television,
                    or
                    electronic), billboards, mass transit (bus, subway or other livery)
                    and
                    statewide/regional print advertising materials in accordance
                    with CMS
                    timeframes for review of marketing materials. These materials
                    must be
                    submitted to the CMS Regional Office for review. CMS will coordinate
                    SDOH
                    input in the review process. SDOH will coordinate consultation
                    with the
                    State Insurance Department and the State Office for the
                    Aging.

                

        

      

      
        

        
          	
                  2.

                	
                  CMS
                    and SDOH will jointly review and approve the following Medicaid
                    Advantage
                    Plus Program marketing
                    materials:

                

        

      

      
        

        
          	
                  a.

                	
                  Scripts
                    or outlines of presentations and materials used at health fairs
                    and other approved types of events and
                    locations;

                

        

      

      
        

        
          	
                  b.

                	
                  All
                    pre-enrollment written marketing materials - written
                    marketing materials include brochures and leaflets, and presentation
                    materials used by marketing
                    representatives;

                

        

      

      
        

        
          	
                  c.

                	
                  All
                    direct mailing from the Contractor specifically targeted to the
                    Medicaid market.

                

        

      

      
        

        
          	
                  3.

                	
                  The
                    Contractor shall electronically submit all materials related
                    to
                    marketing Medicaid Advantage Plus to Dually Eligible persons to the
                    CMS Regional Office for prior written approval. The CMS Medicare
                    Regional Office Plan Manager will be responsible for obtaining SDOH
                    input in the review and approval process in accordance with CMS
                    timeframes for the review of marketing materials. Similarly, SDOH
                    will be responsible for coordinating consultation with the
                    State Insurance Department and the State Office for the
                    Aging.

                

        

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          D

      

      
        MARKETING
          GUIDELINES

      

      
        2007

      

      
        3

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        
          	
                  4.

                	
                  The
                    Contractor shall not distribute or use any Medicaid Advantage
                    Plus
                    marketing materials that the CMS Regional Office and the SDOH
                    have not
                    jointly approved, prior to the expiration of the required review
                    period.

                

        

      

      
        

        
          	
                  5.

                	
                  Approved
                    marketing materials shall be kept on file in the offices of the
                    Contractor, the LDSS, the SDOH, and
                    CMS.

                

        

      

      
        

        Marketing
          Activities

      

      
        

        A.     General
          Requirements

      

      
        

        
          	
                  1. 

                	
                  The
                    Contractor must follow the State's Medicaid marketing rules and
                    the
                    requirements of 42 CFR 438.104 to the extent applicable when
                    conducting
                    marketing activities that are primarily intended to sell a Medicaid
                    managed care product (i.e. Medicaid Advantage Plus). Marketing
                    activities
                    intended to sell a Medicaid managed care product shall be defined
                    as
                    activities which are conducted pursuant to a Medicaid Advantage
                    Plus
                    marketing program in which a dedicated staff of marketing representatives
                    employed by the Contractor, or by an entity with which the Contractor
                    has
                    subcontracted, are engaged in marketing activities with the primary
                    purpose of enrolling recipients in the Contractor's Medicaid
                    Advantage
                    Plus Product.

                

        

      

      
        

        
          	
                  2.

                	
                  Marketing
                    activities that do not meet the above criteria shall not be construed
                    as
                    having a primary purpose of intending to sell a Medicaid Advantage
                    Plus
                    product and shall be conducted in accordance with Medicare Advantage
                    marketing requirements. Such activities include but are not limited
                    to
                    plan sponsored events in which marketing representatives not
                    dedicated to
                    the marketing of the Medicaid Advantage Plus Product explain
                    Medicare
                    products offered by the Contractor as well as the Contractor's
                    Medicaid
                    Advantage Plus product.

                

        

      

      
        

        B.    Marketing
          at LDSS Offices

      

      
        

        With
          prior LDSS approval, MCOs may distribute CMS/SDOH approved Medicaid Advantage
          Plus marketing materials in the local social services district offices
          and
          facilities.

      

      
        

        C.    Responsibility
          for Marketing Representatives

      

      
        

        Individuals
          employed by the Contractor as marketing representatives and employees of
          marketing subcontractors must have successfully completed the Contractor's
          training program including training related to an Enrollee's rights and
          responsibilities in Medicaid Advantage Plus. The Contractor shall be responsible
          for the activities of its marketing representatives and the activities
          of any
          subcontractor or management entity.

      

      
        

        D.    Medicaid
          Advantage Plus -Specific Marketing Requirements

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          D

      

      
        MARKETPNG
          GUIDELINES

      

      
        2007

      

      
        4

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        The
          requirements in Section D apply only if marketing activities for the Medicaid
          Advantage Plus Program are conducted pursuant to a Medicaid Advantage Plus
          marketing program in which a dedicated staff of marketing representatives
          employed by the Contractor or by an entity with which the Contractor has
          a
          subcontract are engaged in marketing activities with the sole purpose of
          enrolling recipients in the Contractor's Medicaid Advantage Plus
          Product.

      

      
        

        1.   Approved
          Marketing Plan

      

      
        

        
          	
                  a.

                	
                  The
                    Contractor must submit a plan of Medicaid Advantage Plus
                    Marketing activities that meet the SDOH requirements to the
                    SDOH.

                

        

      

      
        

        
          	
                  b.

                	
                  Approved
                    Marketing plans will set forth the terms and conditions and proposed
                    activities of the Medicaid Advantage Plus dedicated staff during
                    the contract period.   The following must be included:
                    description of materials and formats to be used, distribution
                    methods; primary types of marketing locations and a listing of the
                    kinds of community service events the Contractor anticipates
                    sponsoring and/or participating in during which it will
                    provide information and/or distribute Medicaid Advantage Plus
                    marketing materials.

                

        

      

      
        

        
          	
                  c.

                	
                  An
                    approved marketing plan must be on file with the SDOH for its
                    contracted service area prior to the Contractor engaging in the
                    Medicaid Advantage Plus specific marketing
                    activities.

                

        

      

      
        

        
          	
                  d.

                	
                  The
                    plan shall include :

                

        

      

      
        

        i)   stated
          marketing goals and strategies;

      

      
        ii)
          a
          description of marketing activities, and the training, development and
          responsibilities of dedicated marketing staff; 

        iii)
          a
          staffing plan including personnel qualifications, training content and
          compensation
          methodology and levels; iv) a description of the Contractor's monitoring
          activities to ensure compliance
          with this section; and v)  identification of the primary marketing
          locations at which marketing will
          be
          conducted.

      

      
        

        
          	
                  e.

                	
                  The
                    Contractor must describe how it is able to meet the informational
                    needs related to marketing for the physical and cultural diversity
                    of
                    its potential membership. This may include, but not be limited to, a
                    description of the Contractor's other than English language
                    provisions, interpreter services, alternate communication mechanisms
                    including sign language, Braille, audio tapes, and/or use of
                    Telecommunications Devices for the Deaf
                    (TTY) services.

                

        

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          D

      

      
        MARKETING
          GUIDELINES

      

      
        2007

      

      
        5

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        
          	
                  f.

                	
                  The
                    Contractor shall describe measures for monitoring and enforcing
                    compliance
                    with these guidelines by its Marketing representatives including
                    the
                    prohibition of door to door solicitation and cold-call telephoning;
                    a
                    description of the development of pre-enrollee mailing lists that
                    maintains client confidentiality and honors the client's express
                    request
                    for direct contact by the Contractor; the selection and distribution
                    of
                    pre-enrollment gifts and incentives to prospective enrollees
                    ; and a
                    description of the training, compensation and supervision of
                    its Medicaid
                    Advantage Plus dedicated Marketing
                    representatives.

                

        

      

      
        

        2.      Compensation
          for Dedicated Medicaid Advantage Plus Marketing Staff

      

      
        

        The
          Contractor shall not offer compensation to Medicaid Advantage Plus dedicated
          Marketing Representatives, including salary increases or bonuses, based
          solely
          on the number of individuals they enroll in Medicaid Advantage Plus. However,
          the Contractor may base compensation of these 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:

      

      
        

        
          	
                  a.

                	
                  "Compensation"
                    shall mean any remuneration required to be reported as income or
                    compensation for federal tax purposes;

                

          	b.	The
                  Contractor may not pay a "commission" or fixed amount per
                  enrollment

          	c.	The
                  Contractor may not award bonuses more frequently than quarterly,
                  or
                  for an annual amount that exceeds ten percent (10%) of his/her total
                  annual compensation;

        

      

      
        
          	
                  d.

                	
                  The
                    Contractor shall keep written documentation, including
                    performance evaluations or other tools it uses as a basis for
                    awarding bonuses or increasing the salary of Marketing
                    Representatives and employees involved in marketing and make such
                    documentation available for inspection by
                    SDOH ortheLDSS.

                

        

      

      
        

        3.      Prohibition
          of Cold Call Marketing Activities

      

      
        

        Contractors
          are prohibited from directly or indirectly, engaging in door to door, telephone,
          or other cold-call marketing activities.

      

      
        

        
          	
                  4.

                	
                  Marketing
                    in Emergency Rooms, Other Patient Care Areas or Other
                    Service Delivery Sites

                   

                  Contractors
                    may not distribute materials or assist Potential Enrollees in
                    completing
                    Medicaid Advantage Plus application forms in hospital emergency
                    rooms, in
                    provider offices, or other areas where health care is delivered
                    unless
                    requested by the individual.

                

        

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          D

      

      
        MARKETING
          GUIDELINES

      

      
        2007

      

      
        6

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      5.   Enrollment
        Incentives

      
        

        Contractors
          may not offer incentives of any kind to Medicaid recipients to join Medicaid
          Advantage Plus. Incentives are defined as any type of inducement whose
          receipt
          is contingent upon the recipients joining the Contractor's
          product.

      

      
        

        E.
          General Marketing Restrictions

      

      
        

        The
          following restrictions apply anytime the Contractor markets its Medicaid
          Advantage Plus product:

      

      
        

        
          	
                  1.

                	
                  Contractors
                    are prohibited from misrepresenting the Medicaid program, the
                    Medicaid
                    Advantage Plus, or the policy requirements of the LDSS or
                    SDOH.

                

        

      

      
        

        
          	
                  2.

                	
                  Contractors
                    are prohibited from purchasing or otherwise acquiring or using
                    mailing
                    lists that specifically identify Medicaid recipients from third
                    party
                    vendors, including providers and LDSS offices, unless otherwise
                    permitted
                    by CMS. The Contractor may produce materials and cover their
                    costs of
                    mailing to Medicaid recipients if the mailing is carried out
                    by the State
                    or LDSS, without sharing specific Medicaid information with the
                    Contractor.

                

        

      

      
        

        
          	
                  3.

                	
                  Contractors
                    may not discriminate against a Potential 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 or
                    need for services of any Enrollee or their family member. 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 Potential Enrollee shall be provided with a listing
                    of all
                    participating providers and facilities in the Medicaid Advantage
                    Plus
                    network. The Contractor may respond to a Potential Enrollee's
                    question
                    about whether a particular specialist is in the network and may
                    inquire
                    about the types of specialists utilized by the Potential
                    Enrollee.

                

        

      

      
        

        
          	
                  4.

                	
                  Contractors
                    may not require participating providers to distribute Contractor
                    prepared
                    communications to their patients, including communications which
                    compare
                    the benefits of different Medicaid Advantage Plus plans, unless
                    the
                    materials have the concurrence of all Medicaid Advantage Plus
                    plans
                    involved, and have received prior approval by SDOH, and by CMS,
                    if
                    Medicare Advantage is
                    referenced.

                

        

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          D

      

      
        MARKETING
          GUIDELINES

      

      
        2007

      

      
        7

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        
          	
                  5. 

                	
                  Contractors
                    are responsible for ensuring that their Marketing representatives
                    engage
                    in professional and courteous behavior in their interactions
                    with LDSS
                    staff, staff from other Medicaid Advantage Plus plans and Medicaid
                    clients. Examples of inappropriate behavior include interfering
                    with other
                    Medicaid Advantage Plus plan presentations or talking negatively
                    about
                    another Medicaid Advantage Plus
                    plan.

                

        

      

      
        

        Marketing
          Infractions

      

      
        

        Infractions
          of Medicaid marketing guidelines, as found in Appendix D, Sections III
          D and E,
          may result in the following actions being taken by the SDOH, in consultation
          with the LDSS, to protect the interests of the program and its clients.
          These
          actions shall be taken by the SDOH in collaboration with the LDSS and the
          CMS
          Regional Office.

      

      
        

        
          	
                  1.

                	
                  If
                    the Contractor or its representative commits a first time infraction
                    of
                    marketing guidelines 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.

                

        

      

      
        

        
          	
                  2.

                	
                  If
                    the Contractor engages in Marketing activities that the SDOH
                    determines,
                    in its sole discretion, to be an intentional or serious breach
                    of the
                    Medicaid Advantage Plus Marketing Guidelines or the Contractor's
                    approved
                    Medicaid Advantage Plus 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 the SDOH within a specified timeframe. In
                    addition, or
                    alternatively, SDOH may impose sanctions, including monetary
                    penalties, as
                    permitted by law.

                

        

      

      
        

        
          	
                  3.

                	
                  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 may in addition to any other legal remedy
                    available
                    to the SDOH in law or equity:

                

        

      

      

      
        

        
          	
                  a)

                	
                  direct
                    the Contractor to suspend its Medicaid Advantage Plus Marketing
                    activities
                    for a period up to the end of the Agreement
                    period;

                

        

      

      
        

        
          	
                  b)

                	
                  suspend
                    new Medicaid Advantage Plus Enrollments, 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.

                

        

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          D

      

      
        MARKETING
          GUIDELINES

      

      
        2007

        8

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        APPENDIX
          E

      

      
        

        New
          York State Department of Health

      

      
        Medicaid
          Advantage Plus

      

      
        Member
          Handbook Guidelines

      

      
        

         

        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          E

      

      
        MEMBER
          HANDBOOK GUIDELINES

      

      
        2007

      

      
        1

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        Introduction

      

      
        

        Managed
          care organizations (MCOs) under contract to provide a Medicaid Advantage
          Plus
          Product to Dually-Eligible beneficiaries must provide Enrollees with a
          Medicaid
          Advantage Plus member handbook which is consistent with the current model
          Medicaid Advantage Plus member handbook provided by SDOH and approved by
          the CMS
          Regional Office and the SDOH. This model handbook is to be issued by the
          Contractor to Enrollees in addition to the handbook or Explanation of Coverage
          (EOC) required by CMS for Medicare Advantage. The model member handbook
          may be
          revised based on changes in the law and the changing needs of the program.
          Handbooks must be approved by the CMS Regional Office and the SDOH prior
          to
          printing and distribution by the Contractor.

      

      
        

        General
          Format

      

      
        

        Member
          handbooks must be written in a style and reading level that will accommodate
          the
          reading skills of Medicaid recipients. In general the writing should not
          exceed
          a fourth to sixth-grade reading 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 twelve (12) point font.
          The SDOH
          reserves the right to require evidence that a handbook has been tested
          against
          the sixth-grade reading-level standard. Member handbooks must be available
          in
          languages other than English whenever at least five percent (5%) of the
          Prospective Enrollees in any county in the Contractor's service area speak
          that
          particular language and do not speak English as a first language. The
          information contained in the handbook must be available from the Contractor
          in
          alternative formats to meet the needs of individuals who are visually impaired,
          etc

      

      
        

        Model
          Medicaid Advantage Plus Handbook

      

      
        

        It
          will
          be the responsibility of the SDOH to provide a copy of the current model
          Medicaid Advantage Plus member handbook to the Contractor.

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          E

      

      
        MEMBER
          HANDBOOK GUIDELINES

      

      
        2007

      

      
        2

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        APPENDIX
          F

      

      
        

        New
          York State Department of Health

      

      
        Medicaid
          Advantage Plus

      

      
        Action
          and Grievance System Requirements

      

      
        

        F.l     General
          Requirements

        F.2     Action
          Requirements

      

      
        F.3     Grievance
          System Requirements

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          F

      

      
        GRIEVANCE
          SYSTEM REQUIREMENTS

      

      
        2007

      

      
        1

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        F.l

      

      
        

        General
          Requirements 

         

        1. 
          Organization Determinations

      

      
        

        
          	
                  a)

                	
                  Organization
                    Determinations means any decision by or on behalf of a MCO regarding
                    payment or services to which an Enrollee believes he or she is
                    entitled.
                    For the purposes of this Agreement, Organization Determinations
                    are
                    synonymous with Action, as defined by this
                    Appendix.

                

        

      

      
        

        
          	
                  b)

                	
                  Organization
                    Determinations regarding services determined by the Contractor
                    to be
                    benefits covered solely by Medicare shall be conducted in accordance
                    with
                    the procedures and requirements of 42 CFR 422 Subpart M and the
                    Medicare
                    Managed Care Manual.

                

        

      

      
        

        
          	
                  c)

                	
                  Organization
                    Determinations regarding services determined by the Contractor
                    to be
                    benefits covered by both Medicare and Medicaid shall be conducted
                    in
                    accordance with the procedures and requirements of 42 CFR 422
                    Subpart M
                    and the Medicare Managed Care Manual, except that:

                   

                

          	   
                  	
                  i) 
                    the Contractor will determine whether services are Medically
                    Necessary as
                    that term is defined in this Agreement; and 

                  ii)
                    when the Contractor intends to reduce, suspend, or terminate
                    a
                    previously authorized
                    service within an authorization period, the notification provisions
                    of paragraph
                    F.2(4)(a) of this Appendix shall
                    apply.

                

        

      

      
         

      

      
        
          	
                  d)

                	
                  Organization
                    Determinations regarding services determined by the Contractor
                    to
                    be solely covered by Medicaid shall be conducted in accordance with
                    Appendix F.l of this Agreement, 42 CFR 438, Articles 44 and 49 of the
                    PHL, and 10 NYCRR Part 98, not otherwise expressly established
                    herein.

                

        

      

      
        

        2. 
          Notices, Actions, Action Appeals, Complaints and Complaint
          Appeals

      

      
        

        
          	
                  a)

                	
                  Services
                    determined by the Contractor to be benefits solely covered by
                    Medicare are
                    subject to the Medicare Advantage Complaint and Appeals Process.
                    In these
                    cases, the Contractor will follow such procedures to notify Enrollees,
                    and
                    providers as applicable, regarding Organization Determinations
                    and offer
                    the Enrollee Medicare appeal
                    rights.

                

        

      

      
        

        
          	
                  b)

                	
                  Services
                    determined by the Contractor to be solely covered by Medicaid
                    are subject
                    to the Medicaid Advantage Plus Grievance System. In these cases,
                    the
                    Contractor will follow such procedures to notify Enrollees and
                    providers
                    regarding Organization

                

        

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          F

      

      
        GRIEVANCE
          SYSTEM REQUIREMENTS

      

      
        2007

      

      
        2

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        Determinations
          and offer Action Appeal, Complaint, and Complaint Appeals rights in accordance
          with Appendices F.2 and F.3 of this Agreement and the requirements of 42
          CFR
          438, Articles 44 and 49 of the PHL, and 10 NYCRR Part 98, not otherwise
          expressly established herein.

      

      
        

        
          	
                  c)

                	
                   For
                    Organization Determinations regarding services determined by
                    the
                    Contractor to be a benefit under both Medicare and Medicaid,
                    the
                    Contractor must offer Enrollees the right to pursue either the
                    Medicare
                    appeal procedures or the Medicaid Advantage Plus Action, Action
                    Appeals,
                    Complaint, and Complaint Appeals
                    procedures.

                

        

      

      
        

        
          	
                   

                	
                  i)   As
                    part of, or attached to, the appropriate Organization Determination
                    notice
                    of Action, the Contractor must provide Enrollees with a notice
                    that
                    informs the Enrollee of his or her appeal rights under both the
                    Medicare
                    and Medicaid Advantage Plus programs, and of their right to select
                    either
                    the Medicare or Medicaid Advantage Plus appeals process, and
                    instructions
                    to make such selection. Such notice shall inform the Enrollee
                    that:

                

        

      

      
        

        
          	
                  A) 
                    

                	
                  if
                    he or she chooses to pursue the Medicare appeal procedures to
                    challenge a
                    service denial, suspension, reduction, or termination, the Enrollee
                    may
                    not pursue a Medicaid Advantage Plus appeal and may not file
                    a Fair
                    Hearing request with the state;
                    and

                

        

      

      
        

        
          	
                  B) 
                    

                	
                  if
                    he or she chooses to pursue the Medicaid Advantage Plus Medicaid
                    appeal
                    procedures to challenge a service denial, suspension, reduction,
                    or
                    termination, the Enrollee has up to 60 days from the date of
                    the
                    Contractor's Notice of Action to pursue a Medicare appeal, regardless
                    of
                    the status of the Medicaid Advantage Plus
                    appeal.

                

        

      

      
        

        
          	
                   

                	
                  ii)    
                    The Contractor will enclose with the notice described in (i)
                    above the
                    notice of Action and other attachments as may be required by
                    Appendix F.2
                    (5)(a)(iii). However, the notice of Action need not duplicate
                    information
                    provided in the Organization Determination notice it is attached
                    to.

                

        

      

      
        

        
          	
                   

                	
                  iii)    
                    If the Enrollee files an appeal, but fails to select either the
                    Medicare
                    or Medicaid Advantage Plus procedure, the default procedure will
                    be the
                    Medicaid Advantage Plus
                    procedure.

                

        

      

      
        

        Medicaid
          Advantage Plus Coniract

      

      
        APPENDIX
          F

      

      
        GRIEVANCE
          SYSTEM REQUIREMENTS

      

      
        2007

      

      
        3

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        F.2
          

        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 or for a referral to 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
                    an increase in 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 or an approval of a Service Authorization
                    Request is in an amount, duration, or scope that is less than
                    requested 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, an approval of a Service Authorization Request in
                    an amount,
                    duration, or scope that is less than requested or a reduction,
                    suspension,
                    or termination of a previously authorized service

                   

                

          	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.

        

      

      
         

      

      
         

      

      
        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          F

      

      
        GRIEVANCE
          SYSTEM REQUIREMENTS

      

      
        2007

        4

         

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

         

         

      

      
        	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.

                 

                
                  
                    Medicaid
                      Advantage Plus Contract

                  

                  
                    APPENDIX
                      F

                  

                  
                    GRIEVANCE
                      SYSTEM REQUIREMENTS

                  

                  
                    2007

                    5

                  

                

              

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        General
          Requirements

      

      
        

        
          	
                  a)
                    

                	
                  The
                    Contractor's policies and procedures for Service Authorization
                    Determinations and utilization review determinations shall comply
                    with 42
                    CFR 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 also may request
                    an
                    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 notify the Enrollee in writing that
                    the
                    request for the expedited review has been denied, and that the
                    Contractor
                    will handle the request under standard review timeframes, detailing
                    the
                    specifics of those
                    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 which is identified in Section F.2 (5)
                    of this
                    Appendix.

                

        

      

      
        

        
          	
                   

                	
                  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.

                

        

      

      
        

        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.

                

        

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          F

      

      
        GRIEVANCE
          SYSTEM REQUIREMENTS

      

      
        2007

      

      
        6

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        
          	
                  b)

                	
                  For
                    Concurrent Review Requests, the Contractor must make a Service
                    Authorization Determination and notify 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, 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 from the date the extension notice is sent
                    by
                    the Contractor, 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
                    best
                    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, and must explain in the written notice
                    to the
                    Enrollee how the extension is in the best interest of the
                    Enrollee.

                

        

      

      
        

        
          	
                  d)

                	
                  If
                    the Contractor extended its review as provided in paragraph 3(c)
                    above,
                    the Contractor must make a Service Authorization Determination and
                    notify 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.

                

        

      

      
        

        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

          	ii)	
                  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;

                

        

      

      
        

          Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          F

      

      
        GRIEVANCE
          SYSTEM REQUIREMENTS

      

      
        2007

      

      
        7

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        
          	
                  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;

                

        

      

      
        
          	
                  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.2 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 state 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
                  revised date by which the MCO will make its
                  determination;

          	 	E)
                  the right of the Enrollee to file a Complaint (as defined in Appendix
                  F.3
                  of this Agreement) regarding the
                  extension;

          	 	F)
                  the
                  process for filing a Complaint with the Contractor and the
                  timeframes within which a Complaint determination must be
                  made;

          	 	
                  G)
                    the right of an Enrollee to designate a representative to file
                    a Complaint
                    on behalf of the Enrollee;
                    and

                

        

      

      
            

        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          F

      

      
        GRIEVANCE
          SYSTEM REQUIREMENTS

      

      
        2007

      

      
        8

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        
          	
                   

                	
                  H)
                    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.3 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.

                    

            

          

          
            
              	
                      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.
                        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/in
                        vestigational";

                    

            

          

          
            
              	
                      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, and the
                        timeframes for
                        filing an External Appeal, including that if so eligible,
                        the Enrollee may
                        request an External Appeal after first filing an expedited
                        Action Appeal
                        with the Contractor and receiving notice that the Contractor
                        upholds its
                        adverse determination, or after filing a standard Action
                        Appeal with the
                        Contractor and receiving the Contractor's final adverse determination,
                        or
                        after the Contractor and the Enrollee agree to waive the
                        internal Action
                        Appeal process.

                    

            

          

        

         

        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          F

      

      
        GRIEVANCE
          SYSTEM REQUIREMENTS

      

      
        2007

      

      
        9

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        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 and the Contractor will not pay the
                    claim;

                

        

      

      
        

        
          	
                   

                	
                  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 Medicaid Advantage Plus coverage on the
                    date of
                    service;

                

        

      

      
        

        
          	
                   

                	
                  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;

                

        

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          F

      

      
        GRIEVANCE
          SYSTEM REQUIREMENTS

      

      
        2007

      

      
        10

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        
          	
                   

                	
                  iii)
                    if a duplicate claim is submitted by the Enrollee or a Participating
                    Provider for which the Contractor will not make payment, 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 Benefit
                    Package
                    and is provided to an 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.

                

        

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          F

      

      
        GRIEVANCE
          SYSTEM REQUIREMENTS

      

      
        2007

      

      
        11

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        F3
          

        Medicaid
          Advantage Plus Grievance System Requirements

      

      
        

        1. 
          Definitions

      

      
        

        
          	
                  a)

                	
                  A
                    Grievance System means the Contractor's Medicaid Advantage Plus
                    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 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:

                

        

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          F

      

      
        GRIEVANCE
          SYSTEM REQUIREMENTS

      

      
        2007

        12

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        i)   toll-free
          telephone number;

      

      
        ii)
          designated staff to receive calls;

      

      
        iii)
          "live" phone coverage at least 40 hours a week during normal business hours,
          and

      

      
        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 of an 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 forty-five
                    (45)
                    days from the date of the notice of Action to file an Action
                    Appeal. An
                    Enrollee filing an Action Appeal within ten (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
                    24.4 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 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 and, modify if needed, 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 for resolution of Action
                    Appeals. Action Appeals resulting from a Concurrent Review must
                    be handled
                    as an expedited Action
                    Appeal.

                

        

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          F

      

      
        GRIEVANCE
          SYSTEM REQUIREMENTS

      

      
        2007

      

      
        13

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
         

      

      
        

        
          	
                   

                	
                  iii)
                    The Contractor must send a written acknowledgement of the Action
                    Appeal,
                    including the name, address and telephone number of the individual
                    or
                    department handling 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. The Contract must agree
                    to expedite
                    the Appeal if the Appeal was the result of a denial of concurrent
                    Service
                    Authorization request. 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 of the request
                    for the
                    expedited review determination and indicate in the notice that
                    the
                    Contractor will be handling the request under standard action
                    appeal
                    timeframes.

                

        

      

      
        

        
          	
                   

                	
                  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.

                

        

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          F

      

      
        GRIEVANCE
          SYSTEM REQUIREMENTS

      

      
        2007

      

      
        14

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        4.
          Timeframes for Resolution of Action Appeals

      

      
        

        
          	
                   

                	
                  a)  The
                    Contractor's Action Appeals process shall indicate the following
                    specific
                    timeframes regarding Action Appeal
                    resolution:

                

        

      

      
        

        
          	
                   

                	
                  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, in either (i) or (ii)
                    above, 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.

                

        

      

      
        
          	
                  C)

                	
                  The
                    Contractor must inform the Enrollee in writing if it will be
                    taking an
                    extension and how the extension is in the best interest of the
                    Enrollee.

                

        

      

      
        

        
          	
                   

                	
                  iv)
                    The Contractor will 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.

                

        

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          F

      

      
        GRIEVANCE
          SYSTEM REQUIREMENTS

      

      
        2007

      

      
        15

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        
          	
                  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 revised date by which the MCO will make its
          determination;

        E) the
          right of the Enrollee to file a Complaint regarding the extension;

        
          F)
the
            process for filing a Complaint with the Contractor and the
            timeframes within which a Complaint determination must be
            made;

        

      

      
        H)
          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 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; including the appropriate Fair Hearing
              notice;

          

        

      

      
        
          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 insurance coverage type;

            

            
              III) 
                the procedure/service 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;
              and

        

      

      
        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          F

      

      
        GRIEVANCE
          SYSTEM REQUIREMENTS

      

      
        2007

      

      
        16

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        
          	
                  VII)

                	
                   the
                    contact person, telephone number, company name and full address
                    of the
                    utilization review agent, if the determination was made by the
                    agent.

                

        

      

      
        

        6. 
          Complaint Process

      

      
        

        
          	
                  a) 

                	
                   The
                    Contractor' Complaint process shall include the following regarding
                    the
                    handling of Enrollee
                    Complaints:

                

        

      

      
        

        a.   The
          Enrollee, or his or her designee, may file a Complaint expressing dissatisfaction
          with any aspect of his or her care other than an Action 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 report on a quarterly basis 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.

                

        

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          F

      

      
        GRIEVANCE
          SYSTEM REQUIREMENTS

      

      
        2007

      

      
        17

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        
          	
                   

                	
                  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.

                

        

      

      
        

        
          	
                  b)
                    

                	
                  Timeframes
                    for Complaint resolution may be extended for up to fourteen (14)
                    days from
                    the date the extension notice is sent by the Contractor,
                    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, and must explain in the written notice
                    to the
                    Enrollee how the extension is in the best interest of the
                    Enrollee.

                

        

      

      
        

        
          	
                   

                	
                  iii)
                    )If the Contractor extended its review as provided in paragraph
                    7(b)
                    above, the Contractor must resolve the Complaint and notice the
                    Enrollee
                    by phone and in writing as fast as the Enrollee's condition requires
                    and
                    within three (3) business days of its decision, but in no event
                    later than
                    the date the extension
                    expires.

                

        

      

      
        

        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 (except as identified in subsection (7)(a)
                    (i) above)
                    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 the allowable time to resolve the Complaint has
          expired.

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          F

      

      
        GRIEVANCE
          SYSTEM REQUIREMENTS

      

      
        2007

      

      
        18

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        
          	
                  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

      

      
        

        The
          Contractor's procedures regarding Enrollee Complaint Appeals shall include
          the
          following:

      

      
        

        
          	
                  a)

                	
                  The
                    Enrollee or designee has 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.

                

        

      

      
        

        
          	
                  b)

                	
                  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.

                

        

      

      
        

        
          	
                  c)

                	
                  Complaint
                    Appeals of clinical matters must be decided by personnel qualified
                    to
                    review the 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).

                

        

      

      
        

        
          	
                  d)

                	
                  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.

                

        

      

      
        

        
          	
                  e)

                	
                  Complaint
                    Appeals shall be decided and notification provided to the Enrollee
                    no more
                    than:

                

        

      

      
        

        
          	
                   

                	
                  i)
                    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

                

        

      

      
        
          	
                   

                	
                  ii)
                    thirty (30) business days after the receipt of all necessary
                    information
                    in all other instances.

                

        

      

      
        

        
          	
                  f)

                	
                  The
                    notice of the Contractor's Complaint Appeal determination shall
                    include:

                

        

      

      
         

      

      
        
          	 	i)
                  the detailed for the determinations;

          	
                   

                	
                  ii)
                    the clinical rationale for the determination in cases where the
                    determination has a clinical
                    basis;

                

        

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          F

      

      
        GRIEVANCE
          SYSTEM REQUIREMENTS

      

      
        2007

      

      
        19

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        
          	
                   

                	
                  iii)
                    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;

                

          	 	iv)
                  instructions for any further Appeal, if
                  applicable.

        

      

       

      
        10. 
          Records

      

      
        

        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:

      

      
        

        a)  date
          the Complaint was filed;

      

      
        b)  copy
          of the Complaint, if written;

      

      
        c)  date
          of receipt of and copy of the Enrollee's written confirmation, if
          any;

      

      
        d)  log
          of Complaint determination including the date of the determination and
          the
titles
          of
          the personnel and credentials of clinical personnel who reviewed the
          Complaint;

      

      
        e)   date
          and copy of the Enrollee's Action Appeal or Complaint
          Appeal;

      

      
        f)    Enrollee
          or provider requests for expedited Action Appeals and Complaint Appeals
          and
          the
          Contractor's determination;

      

      
        g)   necessary
          documentation to support any extensions; 

        h)  determination
          and date of determination of the Action Appeals and Complaint Appeals;

          i)  the
            titles and credentials of clinical staff who reviewed the Action Appeals
            and
            Complaint Appeals; and

        

      

      
        j)   Complaints
          unresolved for greater than forty-five (45) days.

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          F

      

      
        GRIEVANCE
          SYSTEM REQUIREMENTS

      

      
        2007

      

      
        20

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        APPENDIX
          G

      

      
        

        RESERVED

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          G

      

      
        Reserved

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        APPENDIX
          H

      

      
        

        New
          York
          State Department of Health Guidelines for the 

        Processing
          of Medicaid Advantage Plus Enrollments and Disenrollments

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          H

      

      
        GUIDELINES
          FOR ENROLLMENTS AND DISENROLLMENTS

      

      
        2007

      

      
        1

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        SDOH
          Guidelines

        For
          the
          Processing of Medicaid Advantage Plus Enrollments and Disenrollments

      

      
        

        General

      

      
        

        The
          Contractor's Enrollment and Disenrollment procedures for the Medicaid Advantage
          Plus Product shall be consistent with these requirements, except to allow
          LDSS
          and the Contractor flexibility in developing processes that will meet the
          needs
          of both parties, the SDOH may allow material modifications to timeframes
          and
          some procedures, subject to SDOH prior written approval before their
          implementation. Where an Enrollment Broker exists, the Enrollment Broker
          may be
          responsible for some or all of the LDSS responsibilities.

      

      
        

        Enrollment
          Policy

      

      
        

        
          	
                  A.

                	
                  Enrollments
                    will only be processed using the following timeframes if the Medicaid
                    eligibility of a potential enrollee has been established and
                    when Medicaid recertification is not required within 30 days of the
                    effective date
                    of enrollment.

                

        

      

      
        

        
          	
                  B.

                	
                  If
                    the enrollment application lacks information related to Medicaid
                    eligibility, and that lack of information would preclude appropriate
                    processing of the enrollment in the Welfare Management System (WMS)
                    or eMedNY, the effective date of enrollment is not required to meet
                    the new processing review timeframes. The LDSS may require additional
                    information or clarification from the Contractor in this
                    circumstance.

                

        

      

      
        

        
          	
                  C.

                	
                  Plans
                    are encouraged to submit completed enrollment applications on
                    a
                    weekly basis rather than "holding" applications until the 20th
                    day of the
                    month.

                

        

      

      
        

        
          	
                  D.

                	
                  The
                    Contractor is required to submit the following enrollment
                    application information to the
                    LDSS:

                

        

      

      
        

        
          	
                   

                	
                  i.   Enrollee
                    agreement and attestation;

                

        

      

      
        
          	
                   

                	
                  ii.   theDMS-1
                    or successor instrument;

                

        

      

      
        
          	
                   

                	
                  iii.   the
                    Semi-Annual Assessment of Members
                    (SAAM);

                

        

      

      
        
          	
                   

                	
                  iv.   the
                    plan of care developed by the Contractor,
                    and

                

        

      

      
        
          	
                   

                	
                  v.   transmittal
                    sheet(s) with any information required by the LDSS to effect
                    the
                    enrollment.

                

        

      

      
        

        The
          LDSS
          may require that the plan also submit evidence of Medicaid eligibility
          in a form
          to be approved by the SDOH.

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          H

      

      
        GUIDELINES FOR
          ENROLLMENTS AND DISENROLLMENTS

      

      
        2007

      

      
        2

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        
          	
                  E.

                	
                  In
                    most circumstances the LDSS prior enrollment review will be limited
                    to
                    assuring the completeness of the assessment and other documentation
                    described above in D. However, in certain instances, the LDSS,
                    if it
                    chooses, will review a number of cases prior to enrollment to
                    assure that
                    the eligibility criteria are
                    met.

                

        

      

      
        

        
          	
                  F.

                	
                   The
                    LDSS is responsible for processing enrollment applications until
                    the last
                    day of the month preceding the Effective Date of Enrollment,
                    to the extent
                    possible.

                

        

      

      
        

        
          	
                  G.

                	
                   If
                    the LDSS determines that the enrollment application is incomplete,
                    it may
                    delay the enrollment to secure a complete enrollment application
                    from the
                    Contractor.

                

        

      

      
        

        
          	
                  H.

                	
                   Post
                    enrollment audits will be conducted on every enrollment application
                    or a
                    sample of applications as agreed upon by the LDSS and
                    Department.

                

        

      

      
        

        
          	
                  I.

                	
                  The
                    LDSS audit must be limited to a review of the documentation identified
                    in
                    subsection D above to determine if the following enrollment criteria
                    are
                    met, and that the Applicant:

                

        

      

      
        

        i.   meets
          the age requirements approved for the Contractor;

      

      
        ii.  is
          a resident of the Contactor's service area;

      

      
        iii.
          is
          eligible for nursing home level of care;

      

      
        iv.
          is
          capable, at the time of enrollment, of returning to or remaining in his
          or
          her home and community without jeopardy to health and safety; and
          

        v.   is
          expected to require the long term care services of the Contractor for
at
          least
          120 days from the effective date of enrollment.

      

      
        

        
          	
                  J. 

                	
                  If,
                    based upon the review/audit, the LDSS determines that that the
                    enrollee
                    was inappropriately enrolled because she/he did not meet the
                    contractual
                    eligibility criteria at the time of enrollment, the LDSS must
                    notify the
                    Contractor in writing.

                

        

      

      
        

        
          	
                  K.
                    

                	
                  Any
                    disagreement between the Contractor and the LDSS about the individual's
                    eligibility will be resolved using the LDSS/Contractor Dispute
                    Resolution
                    process approved by SDOH.

                

        

      

      
        

        
          	
                  L. 

                	
                   If,
                    based on the outcome of the dispute resolution, the enrollee
                    is not found
                    to meet the eligibility criteria for enrollment, the LDSS must
                    notify the
                    Contractor in writing that it will proceed with the member's
                    disenrollment.

                

        

      

      
        

        
          	
                  M.

                	
                  The
                    LDSS will notify the enrollee of the district's intent to disenroll
                    the
                    member, based on the member's failure to meet the enrollment
                    eligibility
                    criteria. The notice will include the enrollee's right to request
                    a Fair
                    Hearing with aid continuing.

                

        

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          H

      

      
        GUIDELINES
          FOR ENROLLMENTS AND D1SENR0LLMENTS

      

      
        2007

      

      
        3

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        
          	
                  N.

                	
                   The
                    Contractor must continue to provide and arrange covered services
                    until the
                    effective date of disenrollment. The Department will continue
                    to pay
                    capitation fees for an enrollee until the effective date of
                    disenrollment.

                

        

      

      
        

        
          	
                  O.
                    

                	
                  Prior
                    to the enrollee's disenrollment, the Contractor will assist the
                    enrollee
                    by referring the enrollee, and by making their care management
                    record and
                    other enrollee service records available as appropriate to health
                    care
                    providers and/or programs.

                

        

      

      
        

        3.      SDOH
          Responsibilities

      

      
        

        
          	
                  A.

                	
                  The
                    SDOH is responsible for monitoring Local District program activities
                    and providing technical assistance to the LDSS and the Contractor
                    to
                    ensure compliance with the State's policies and
                    procedures.

                

        

      

      
        

        
          	
                  B.

                	
                  SDOH
                    reviews and approves proposed Enrollment materials prior to the
                    Contractor publishing and disseminating or otherwise using the
                    materials.

                

        

      

      
        

        4.      LDSSResponsibilities:

      

      
        

        
          	
                  A.

                	
                  The
                    LDSS has the primary responsibility for processing Medicaid Advantage
                    Plus enrollments.

                

        

      

      
        

        
          	
                  B.

                	
                  Each
                    LDSS determines Medicaid 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 and/or Medicaid Advantage Plus Product
                    eligibility.

                

        

      

      
        

        
          	
                  C.

                	
                  The
                    LDSS is responsible for processing Enrollments in Medicaid Advantage
                    Plus without edits for Medicare coverage in the Welfare Management
                    System (WMS); however the LDSS is responsible for ensuring that WMS
                    is updated with Medicare A and B coverage status for new Enrollees
                    upon review of documentation provided by the Contractor or the
                    Enrollee.

                

        

      

      
        

        
          	
                  D.

                	
                  The
                    LDSS is responsible for determining the eligibility status of
                    Medicaid
                    Advantage Plus enrollment applications. Applications will be
                    enrolled, pended or denied.

                

        

      

      
        

        
          	
                  E.

                	
                  Only
                    the LDSS may determine Enrollee spenddown and/or Net Available
                    Monthly Income (NAMI) surplus amounts and will notify the plan of the
                    amount. The Contractor's inability to collect funds from Enrollees
                    will not change the plan's spenddown or NAMI
                    adjustment.

                

        

      

      
        

        
          	
                  F.

                	
                  The
                    LDSS is responsible for notifying the Contractor about the status
                    of
                    enrollment applications that are accepted, denied or
                    pended.

                

        

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          H

      

      
        GUIDELINES
          FOR ENROLLMENTS AND DISENROLLMENTS

      

      
        2007

      

      
        4

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        G.
          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:

      

      
        

        
          	 	
                  i.   LDSS
                    directly enters data into PCP Subsystem; or

                   

                

          	
                   

                	
                  ii.  LDSS
                    or Contractor submits a tape to the State, to be edited and entered
                    into
                    PCP Subsystem; or

                

        

      

      
        

        
          	
                   

                	
                  iii.
                    LDSS electronically transfers data via a dedicated line, from
                    eMedNY to
                    the PCP Subsystem.

                

        

      

      
        

        
          	
                   

                	
                  H.
                    Extensive use of the secondary roster will be utilized to coordinate
                    the
                    Effective Dates of Enrollment for Medicare and Medicaid Advantage
                    Plus.

                

        

      

      
        

        
          	
                   

                	
                  I.   The
                    LDSS is responsible for re-enrolling an Enrollee who is disenrolled
                    from
                    the Contractor's Medicaid Advantage Plus Product due to loss
                    of Medicaid
                    eligibility, who regains eligibility within three months, in
                    the
                    Contractor's Medicaid Advantage Plus Product, provided that the
                    individual
                    remains enrolled in the Contractor's Medicare Advantage
                    Product.

                

        

      

      
        

        J.   The
          LDSS is responsible for sending the following notices to the
          Applicant:

      

      
        

        
          	
                   

                	
                  i.    
                    Enrollment Confirmation Notice: This notice indicates the Effective
                    Date
                    of Enrollment, the name of the Medicaid Advantage Plus Product
                    and the
                    individual who is being enrolled. This notice must also include
                    a
                    statement advising the individual that if his/her Medicare Advantage
                    enrollment is denied by CMS, the individual's Medicaid Advantage
                    Plus
                    Enrollment will be voided retroactively back to the Effective
                    Date of
                    Enrollment. In such instances, the individual may be responsible
                    for the
                    cost of any Medicaid Advantage Plus Benefit rendered during the
                    retroactive period if the benefit was provided by a non-Medicaid
                    participating provider.

                

        

      

      
        

        
          	
                   

                	
                  ii.   Notice
                    of Denial of Enrollment: This notice is used when an individual
                    has been
                    determined by LDSS to be ineligible for enrollment into a Medicaid
                    Advantage Plus Product. This notice must include fair hearing
                    rights.

                

        

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          H

      

      
        GUIDELINES
          FOR ENROLLMENTS AND DISENROLLMENTS

      

      
        2007

      

      
        5

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        5.   Contractor
          Responsibilities:

      

      
        

        
          	
                  A.

                	
                  The
                    Contractor, using the patient assessment instrument specified
                    by SDOH,
                    will evaluate all Applicants to
                    assess:

                

        

      

      
        

        i.    
           their eligibility for nursing home level of care at the time of
          enrollment; ii.
          that
          they are capable at the time of enrollment, of returning to or remaining
          in
their
          home and/or community without jeopardy to their health and/or
          safety,

      

      
        based
          upon criteria provided by SDOH; and iii. that they are expected to require
          at
          least one of the following services and care management
          for at least 120 days from the effective date of
          enrollment:

      

      
        •      nursing
          services in the home;

      

      
        •      therapies
          in the home;

      

      
        •      home
          health aide services;

      

      
        •      personal
          care services in the home;

      

      
        •      adult
          day health care; or

      

      
        •      social
          day care if used as a substitute for in-home personal care
          services.

      

      
        

        
          	
                  B.

                	
                  The
                    potential that an Applicant may require acute hospital inpatient
                    services
                    or nursing home placement during such 120 day period shall not be
                    taken into consideration by the Contractor when assessing an
                    Applicant's eligibility for
                    enrollment.

                

        

      

      
        

        
          	
                  C.

                	
                  If
                    the Contractor operates in an approved service area which encompasses
                    more
                    than one local department of social services (LDSS), and the
                    Contractor has knowledge that an Enrollee proposes to change
                    residence from one local social services district to another within
                    the Contractor's approved service area, the Contractor must notify
                    the
                    original LDSS of the pending move and must, upon the request of the
                    receiving LDSS, provide a new assessment of the Enrollee to the
                    receiving LDSS. Continued enrollment is dependent upon the approval
                    of the receiving LDSS.

                

        

      

      
        

        
          	
                  D.

                	
                  Applicant
                    may withdraw an application or enrollment agreement prior to
                    the
                    effective date of enrollment by indicating his or her wishes orally
                    or in writing. All withdrawals must be acknowledged by the Contractor
                    to the Applicant in writing.

                

        

      

      
        

        
          	
                  E.

                	
                  If
                    the Contractor meets face-to-face with an Applicant to discuss
                    enrollment,
                    and the Applicant chooses not to enroll, the Contractor must send a
                    written notice to the Applicant confirming
                    non-enrollment.

                

        

      

      
        

        
          	
                  F.

                	
                  The
                    Contractor may find that the Applicant does not meet the enrollment
                    criteria identified in Section 5.1 of this Agreement and may advise
                    the Applicant of such. If the Applicant wants to pursue enrollment,
                    despite being notified of the Contractor's finding, the Contractor
                    must transmit the application to the LDSS, and notify the Applicant
                    that
                    the Contractor will recommend denial of enrollment if the Applicant
                    does
                    not choose to withdraw his or her application. Only the LDSS
                    may deny
                    enrollment.

                

        

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          H

      

      
        GUIDELINES
          FOR ENROLLMENTS AND D1SENROLLMENTS

      

      
        2007

      

      
        6

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
         

      

      
        
          	
                  G.

                	
                   The
                    Contractor will notify enrollment referral sources, as appropriate,
                    if the
                    Applicant doesn't enroll.

                

        

      

      
        

        
          	
                  H.
                    

                	
                  The
                    Contractor shall comply with enrollment procedures developed
                    by the
                    Contractor and the LDSS and approved by the Department. Such
                    written
                    procedures shall address all aspects of application processing
                    and shall
                    contain the enrollment forms to be used by the Contractor. The
                    Contractor
                    agrees to submit any proposed material revisions to the approved
                    enrollment procedures in writing for SDOH approval prior to the
                    revised
                    procedures becoming
                    effective.

                

        

      

      
        

        
          	
                  I.  

                	
                   The
                    Contractor is responsible for obtaining documentation of Medicare
                    A and B
                    coverage prior to sending the Enrollment transaction to the LDSS
                    for
                    processing; the documentation must accompany the Enrollment form
                    to the
                    LDSS. Acceptable documentation includes: a current Medicare card
                    or other
                    documentation acceptable to CMS or received by the Contractor
                    from
                    interaction with CMS' data
                    systems.

                

        

      

      
        

        
          	
                  J. 

                	
                    The
                    Contractor must report any changes in status for its Enrollees
                    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 Medicaid Advantage Plus eligibility such as address
                    changes,
                    incarceration, third party insurance other than Medicare, Disenrollment
                    from the Contractor's Medicare Advantage Product,
                    etc.

                

        

      

      
        

        
          	
                  K.
                    

                	
                  If
                    an Enrollee's Enrollment in the Contractor's Medicare Advantage
                    Product is
                    rejected by CMS, the Contractor must notify the LDSS within five
                    (5)
                    business days of learning of CMS' rejection of the Enrollment.
                    In such
                    instances, the LDSS shall delete the Enrollee's Enrollment in
                    the
                    Contractor's Medicaid Advantage Plus
                    Plan.

                

        

      

      
        

        
          	
                  L. 

                	
                   The
                    Contractor shall advise potential 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 and are available to serve
                    the
                    Prospective Enrollee.

                

        

      

      
        

        
          	
                  M.
                    

                	
                  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.

                

        

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          H

      

      
        GUIDELINES
          FOR ENROLLMENTS AND DISENROLLMENTS

      

      
        2007

      

      
        7

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        6.   Newborn
          Medicaid Eligibility

      

      
        

        
          	
                  A.

                	
                  SDOH
                    Responsibilities:

                

        

      

      
        

        
          	
                   

                	
                  i)The
                    SDOH will update WMS with information on the newborn received
                    from
                    hospitals or birthing centers, consistent with the requirements
                    of Section
                    366-g of the Social Services Law 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
                    generating
                    appropriate Medicaid
                    coverage.

                

        

      

      
        

        
          	
                  B.

                	
                  LDSS
                    Responsibilities:

                

        

      

      
        

        
          	
                   

                	
                  i)
                    The LDSS is responsible for granting Medicaid eligibility for
                    newborns for
                    one (1) year if born to a woman eligible for and receiving MA
                    assistance
                    on the date of birth. (Social Services Law Section 366 (4)
                    (1))

                

        

      

      
        

        
          	
                   

                	
                  ii)
                    The LDSS is responsible for adding eligible unborns to all WMS
                    cases that
                    include a pregnant woman as soon as the pregnancy is medically
                    verified.
                    (NYS DSS Administrative Directive 85
                    ADM-33)

                

        

      

      
        

        
          	
                   

                	
                  iii)
                    In the event that the LDSS learns of an Enrollee's pregnancy
                    prior to the
                    Contractor, the LDSS is responsible for establishing Medicaid
                    eligibility
                    and enrolling the unborn into Medicaid managed care in cases
                    where an
                    enrollment form is received.

                

        

      

      
        

        
          	
                   

                	
                  iv)
                    When a newborn is enrolled in managed care, the LDSS is responsible
                    for
                    sending an Enrollment Confirmation Notice to inform the mother
                    of the
                    Effective Date of Enrollment, which is the first (1st)
                    day of the
                    month of birth, and the plan in which the newborn is
                    enrolled.

                

        

      

      
        

        
          	
                   

                	
                  v)
                    The LDSS may develop a transmittal form to be used for unborn/newborn
                    notification between the Contractor and the
                    LDSS.

                

        

      

      
        

        
          	
                  
                    C.
                      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).

                

        

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          H

      

      
        GUIDELINES
          FOR ENROLLMENTS AND D1SENR0LLMENTS

      

      
        2007

      

      
        8

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        
          	
                   

                	
                  ii)
                    Upon the newborn's birth, 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),
                    gender
                    and the date of birth.

                

        

      

      
        

        7.   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 input by the LDSS. SDOH uses data
                    contained
                    in both these files to generate the
                    Roster.

                

        

      

      
        

        
          	
                   

                	
                  ii.  SDOH
                    shall send monthly to the Contractor and LDSS (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
                    lsl
                    day of the
                    following month (First Monthly Roster). Notification to the Contractor
                    and
                    LDSS will be accomplished via paper transmission, magnetic media,
                    or the
                    HPN.

                

        

      

      
        

        
          	
                   

                	
                  iii.
                    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.

                

        

      

      
        

        
          	
                   

                	
                  iv.
                    The SDOH shall also forward an error report as necessary to the
                    Contractor
                    and LDSS.

                

        

      

      
        

        
          	
                   

                	
                  v.   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 First Roster and error report, no later
                    than the
                    end of the month. This includes, but is not limited to, new Enrollees
                    whose Enrollments in Medicaid Advantage Plus were processed subsequent
                    to
                    the pull-down date but prior to the Effective Date of Enrollment.
                    (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).

                

        

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          H

      

      
        GUIDELINES
          FOR ENROLLMENTS AND D1SENROLLMENTS

      

      
        2007

      

      
        9

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        

        
          	
                   

                	
                  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 2n
                    Rosters,
                    adjusted to add Eligible Persons enrolled by the LDSS after Roster
                    production and to remove individuals 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 sub-capitation does not
                    constitute
                    "provision of Benefit Package
                    services."

                

        

      

      
        

        8.  Disenrollment:

      

      
        

        A.
          LDSS Responsibilities:

      

      
        

        
          	
                   

                	
                  i.   Enrollees
                    may request to disenroll from the Contractor's Medicaid Advantage
                    Plus
                    Product at any time for any reason, orally or in writing. A Disenrollment
                    request may be made by the Enrollee to the LDSS or the
                    Contractor.

                

        

      

      
        

        
          	
                   

                	
                  ii.    Medicaid
                    Advantage Plus plans and the LDSS must use State-approved Disenrollment
                    forms.

                

        

      

      
        

        
          	
                   

                	
                  iii.
                    The LDSS is responsible for processing routine Disenrollment
                    requests to
                    take effect on the first (1st)
                    day of the
                    following month to the extent possible. 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, Disenrollment from the Contractor's Medicare Advantage
                    Product, or
                    loss of Medicaid eligibility. AH such Disenrollments will be
                    effective at
                    the end of the month in which the death, Effective Date of Disenrollment
                    from the Contractor's Medicare Advantage Product, or loss of
                    eligibility
                    occurs.

                

        

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        APPENDiX
          H

      

      
        GUIDELINES
          FOR ENROLLMENTS AND DISENROLLMENTS

      

      
        2007

      

      
        10

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
         

      

      
        

        
          	
                   

                	
                  v.  The
                    LDSS is responsible for promptly disenrolling an Enrollee whose
                    Medicaid
                    eligibility or status changes such that he/she is deemed by the
                    LDSS to no
                    longer be eligible for Medicaid Advantage Plus enrollment. The
                    LDSS is
                    responsible for providing Enrollees with a notice of their right
                    to
                    request a fair hearing.

                

        

      

      
        

        
          	
                   

                	
                  vi.
                    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 individual
                    is
                    deemed to have been non-consensually enrolled in the Contractor's Medicaid
                    Advantage Plus Product, is enrolled when ineligible for Enrollment,
                    or
                    when an Enrollee enters or resides in an entity or program identified
                    in
                    Section 5.1 of this Agreement under circumstances which render
                    the
                    individual ineligible; is incarcerated; is retroactively disenrolled
                    from
                    the Contractor's Medicare Advantage Product; or dies - 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.

                

        

      

      
        

        
          	
                   

                	
                  vii.
                    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.

                

        

      

      
        

        
          	
                   

                	
                  viii.
                    Generally the effective dates of Disenrollment are prospective.
                    Effective
                    dates for other than routine Disenrollments are described
                    below:

                

        

      

      
         

        
          
            	
                    a.

                  	
                    Death
                      of Enrollee - Effective Date of Disenrollment is the first
                      day of the
                      month after death.

                  

          

        

      

       

      
        
          	
                  b.

                	
                  Incarceration
                    - Effective date of disenrollment is the first day of the month
                    of incarceration (Note: the Contactor is at risk for covered services
                    only to the date of incarceration and is entitled to capitation
                    payments for the entire month in which the incarceration
                    occurs.

                

        

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          H

      

      
        GUIDELINES
          FOR ENROLLMENTS AND DISENROLLMENTS

      

      
        2007

      

      
        11

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        
          	
                  c.

                	
                  Non-consensual
                    Enrollment - Effective date of disenrollment is the first day
                    of the
                    month of Enrollment.

                

        

      

      
        

        
          	
                  d.

                	
                  Enrollee
                    moved outside of the District/County of Fiscal Responsibility
                    -
                    Effective date of disenrollment is the first day of the month after
                    the update of the system with the new address  In counties
                    outside of New York City, the LDSS 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 plan. In New York City, Enrollees 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.

                

        

      

      
        

        
          	
                  e.

                	
                  An
                    Enrollee with more than one Client Identification Number (CIN)
                    is enrolled
                    in the Contractor's Medicaid Advantage Plus Product under more than
                    one of the CINs - Effective date of disnrollment is the first day of
                    the month the duplicate Enrollment
                    began.

                

        

      

      
        

        
          	
                   

                	
                  ix.
                    The LDSS is responsible for sending a notice of Disenrollment
                    to Enrollees
                    regarding their disenrollment. These notices will advise the
                    Enrollee of
                    the LDSS's determination regarding an Enrol lee-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.

                

        

      

      
        

        
          	
                   

                	
                  x.   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 in the Contractor's Medicaid Advantage Plus
                    Product
                    until the disposition of the fair hearing, if Aid to Continue
                    is ordered
                    by the New York State Office of Administrative
                    Hearings.

                

        

      

      
        

        
          	
                   

                	
                  xi.
                    The LDSS is responsible for reviewing each Contractor-requested
                    Disenrollment in accordance with the provisions of Section 8(B)
                    of this
                    Agreement. 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.

                

        

      

      
        

        
          	
                   

                	
                  xii.
                    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.

                

        

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          H

      

      
        GUIDELPNES
          FOR ENROLLMENTS AND DISENROLLMENTS

      

      
        2007

      

      
        12

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        
          	
                   

                	
                  xiii.
                    After the LDSS receives 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.   The
                    Contractor is responsible for informing Enrollees of their right
                    to
                    disenroll at any time for any
                    reason.

                

        

      

      
        

        
          	
                   

                	
                  ii.  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 of receipt of the request
                    for
                    disenrollment from the Enrollee. During pull-down week, these
                    forms may be
                    faxed to the LDSS with the hard copy to
                    follow.

                

        

      

      
        

        
          	
                   

                	
                  iii.
                    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.

                

        

      

      
        

        
          	
                   

                	
                  iv.
                    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 enrolled members that may impact eligibility
                    for
                    Enrollment such as address changes, incarceration, death, ineligibility
                    for Medicaid Advantage Plus Enrollment, change in Medicare status,
                    etc.

                

        

      

      
        

        
          	
                   

                	
                  v.   The
                    Contractor may initiate an involuntary disenrollment for any
                    of the
                    reasons identified in Section 8.8 of this
                    Agreement.

                

        

      

      
        

        
          	
                  a.

                	
                  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.

                

        

      

      
        

        
          	
                  b.

                	
                  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.

                

        

      

      
        

        
          	
                  c.

                	
                  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.

                

        

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          H

      

      
        GUIDELINES
          FOR ENROLLMENTS AND DISENROLLMENTS

      

      
        2007

      

      
        13

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        
          	
                  d.  

                	
                  The
                    Contractor will not consider an Enrollee disenrolled without
                    confirmation
                    from the LDSS or the Roster,

                

        

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          H

      

      
        GUIDELINES
          FOR ENROLLMENTS AND DISENROLLMENTS

      

      
        2007

      

      
        14

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        APPENDIX
          I

      

      
        

        RESERVED

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          I

      

      
        (RESERVED)

      

      
        2007

      

      
        

        1

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        APPENDIX
          J

         

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

      

      
        

         

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          J

      

      
        GUIDELINES
          FOR CONTRACTOR COMPLIANCE

      

      
        2007

      

      
        1

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        GUIDELINES
          FOR MEDICAID MCO COMPLIANCE WITH THE AMERICANS WITH DISABILITIES ACT
          (ADA)

      

      
        

        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 Medicaid is a government program, health services provided
          through Medicaid Managed Care, including Medicaid Advantage Plus , must
          be
          accessible to all who qualify for the program.

      

      
        

        MCO
          responsibilities for compliance with the ADA are imposed under Title II
          and
          Section 504 when, as a contractor in a Medicaid program, a plan is providing
          a
          government service. If an individual provider under contract with the MCO
          is not
          accessible, it is the responsibility of the MCO to make arrangements to
          assure
          that alternative services are provided. The MCO 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
          contractors. 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
          program participant.

      

      
        

        MCO
          responsibilities for compliance with the ADA are also imposed under Title
          III
          when the MCO 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
          MCOs
          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 Plan Qualification Standards to qualify MCOs for participation in
          the
          Medicaid Advantage Plus Program pursuant to the state's responsibility
          to assure
          program access to all recipients, the Plan Qualification Standards require
          each
          MCO to submit an ADA

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          J

      

      
        GUIDELINES
          FOR CONTRACTOR COMPLIANCE

      

      
        2007

      

      
        2

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        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.

      

      
        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 Medicaid is a government program, health services provided
          through Medicaid Managed Care, including Medicaid Advantage Plus , must
          be
          accessible to all who qualify for the program.

      

      
        

        MCO
          responsibilities for compliance with the ADA are imposed under Title II
          and
          Section 504 when, as a contractor in a Medicaid program, a plan is providing
          a
          government service. If an individual provider under contract with the MCO
          is not
          accessible, it is the responsibility of the MCO to make arrangements to
          assure
          that alternative services are provided. The MCO 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
          contractors. 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
          program participant.

      

      
        

        MCO
          responsibilities for compliance with the ADA are also imposed under Title
          III
          when the MCO 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
          MCOs
          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 Plan Qualification Standards to qualify MCOs for participation in
          the
          Medicaid Advantage Plus Program. Pursuant to the state's responsibility
          to
          assure program access to all recipients, 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.

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          J

      

      
        GUIDELINES
          FOR CONTRACTOR COMPLIANCE

      

      
        2007

      

      
        3

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        The
          objectives of these guidelines are threefold:

      

      
        • to
          ensure that MCOs take appropriate steps to measure access and assure program
          accessibility for persons with disabilities; 

        • to
          provide a framework for managed care
          organizations (MCos) as they develop a plan to assire compliance with the
          Americans with Disabilities Act (ADA); and

      

      
        • to
          provide standards for the review of MCO 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, Brailled 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.

                

        

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          J

      

      
        GUIDELINES
          FOR CONTRACTOR COMPLIANCE

      

      
        2007

      

      
        4

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        III.      Scope
          of MCO Compliance Plan

      

      
        The
          MCO
          Compliance Plan must address accessibility to services at the MCO's program
          sites, including both participating provider sites and MCO facilities
          intended for use by enrollee.

      

      
        

        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 procedures and
          communication. Communications with individuals with disabilities are
          required to be as effective as communications with others. The MCO Compliance
          Plan must include a detailed description of how MCO 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 MCO Compliance Plan will describe the steps
          or actions the MCO will take to assure accessibility to services equivalent
          to
          those offered at the inaccessible facilities.

      

      
        

        IV.       Program
          Accessibility

      

      
        

        A.        Pre-cnrollmcnt
          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, audio tapes) 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 plan 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

                

        

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          J

      

      
        GUIDELINES
          FOR CONTRACTOR COMPLIANCE

      

      
        2007

      

      
        5

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        Compliance
          Plan
          Submission                                                                                                                                                                                                        

      

      
        
          	
                  1.

                	
                  A
                    description of methods to ensure that the MCO's marketing presentations
                    (materials and communications) are accessible to persons with
                    auditory, visual and cognitive
                    impairments

                

        

      

      
        
          	
                  2.

                	
                  A
                    description of the MCO'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

                

        

      

      
        

        IV.      Program
          Accessibility                                                                                                                                                                                                       

      

      
         

        B.        Member
          Services
          Department                                                                                                                                                                               .                  .        

      

      
        Member
          services functions include the provision to enroUees of information necessary
          to
          make informed choices about treatment options, to effectively utilize the
          health care resources, to assist enroUees 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 MCO'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>
                    V? 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
                    enrol
                    lees

                

        

      

      
        
          	
                  5.

                	
                  Waiting
                    rooms, restrooms, and other rooms used by enroUees 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.)

        

      

      
                   

      

      
        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          J

      

      
        GUIDELINES
          FOR CONTRACTOR COMPLIANCE

      

      
        2007

      

      
        6

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
         

      

      
        
          	
                  10.

                	
                  MCO
                    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 of
                    NY 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

                

        

      

      
        

        Compliance
          Plan Submission

      

      
        
          	
                  1.

                	
                  A
                    description of accessibility to the 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 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 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

        

      

      
          

      

      
        IV.       Program
          Accessibility                                                                                                                                                                                                       

      

      
        B2.      Identification
          of Enrollees with
          Disabilities                                                                                                                                                                                               

      

      
        

        Standard
          for
          Compliance:                                                                                                                                                                                                       

      

      
        MCOs
          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. MCOs may not
          discriminate against a potential enrollee based on his/her current health
          status
          or anticipated need for future health care. MCOs may not discriminate on
          the basis of disability, or perceived disability of an enrollee or their
          family
          member.

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          J

      

      
        GUIDELINES
          FOR CONTRACTOR COMPLIANCE

      

      
        2007

      

      
        7

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        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

                

        

      

      
        

        Compliance
          Plan
          Submission                                                                                                                                                                                              .         

      

      
        1.           A
          description of how the MCO 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 of enrollees
          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

      

      
        

        IV.      Program
          Accessibility 

         

        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 plan. 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]

        

      

      
        

                             

      

      
        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          J

      

      
        GUIDELINES
          FOR CONTRACTOR COMPLIANCE

      

      
        2007

      

      
        8

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

       

      
        
          	
                  4.

                	
                  Activities
                    and fairs that include sign language interpreters or the distribution
                    of a
                    written summary of the marketing script used by plan 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

        

      

      
                  

      

      
        Compliance
          Plan Submission

      

      
        1.            A
          description of how the MCO will advise enrollees with disabilities, during
          the
          new enrollee orientation on how to access care

      

      
        
          	
                  2.

                	
                  A
                    description of how the MCO 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 MCO 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 MCO will assure
                    that reasonable alternative site and services are
                    available

                

        

      

      
        
          	
                  3.

                	
                  A
                    description of how the MCO 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 MCO will identify if an enrollee with
                    a disability
                    requires on-going mental health services and how MCO will encourage
                    early
                    entry into treatment

                

          	5.  	A
                  description of how the MCO will notify enrollees with disabilities
                  as to
                  how to access transportation, where
                  applicable

        

      

      
        

                  

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          J

      

      
        GUIDELINES
          FOR CONTRACTOR COMPLIANCE

      

      
        2007

      

      
        9

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        IV.      Program
          Accessibility

      

      
        

        B4.      Complaints
          and Appeals

      

      
        

        Standard
          for Compliance:

      

      
        The
          MCO
          will establish and maintain a procedure to protect the rights and interests
          of
          both enrollees and managed care plans by receiving, processing, and resolving
          complaints and appeals in an expeditious manner, with the goal of ensuring
          resolution of complaints/appeals and access to appropriate services as
          rapidly
          as possible.

      

      
        

        All
          enrollees must be informed about the overall grievance system within their
          plan
          and the procedure for filing complaints and/or appeals. This information
          will be
          made available through the member handbook, the SDOH toll-free complaint
          line
          [l-(800) 206-8125] and the plan's complaint process annually, as well as
          when
          the MCO denies a benefit or referral. The MCO will inform enrollees of:
          the
          MCO's procedures; enrollees' right to contact the local district or SDOH
          with a
          complaint, and to file an appeal or request a fair hearing; the right to
          appoint
          a designee to handle a complaint or appeal; the toll free complaint line.
          The
          MCO will maintain designated staff to take and process complaints, and
          be
          responsible for assisting enrollees in complaint resolution.

      

      
        

        The
          MCO
          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
          appeals.

      

      
        

        Suggested
          Methods for
          Compliance                                                                                                                                                                                                         

      

      
        1.
           800 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                                                                                                                                                                                               

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          J

      

      
        GUIDELINES
          FOR CONTRACTOR COMPLIANCE

      

      
        2007

      

      
        10

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        Compliance
          Plan
          Submission                                                                                                                                                            __                           .         

      

      
        1. A
          description of how MCO's complaint and appeal procedures shall be accessible
          for
          persons with disabilities, including:

      

      
        procedures
          for complaints and 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, 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 MCOs monitor appeals and grievances related to people
          with
          disabilities.

      

      
        

        IV.       Program
          Accessibility

         

        C.        Case
          Management

      

      
        

        Standard
          for
          Compliance:                                                                                                                                                                                                     

      

      
        MCOs
          must
          have in place an 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. In addition to the care management
          requirements identified in Section 10 of this Agreement, 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 MCO in consultation with the primary care provider,
          the designated specialist and the enrollee or his/her designee), out of
          plan referrals and continuation of existing treatment relationships
          with out-of-plan 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 plan 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 MCO 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                                                                                                                                                                                              .

                

        

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          J

      

      
        GUIDELINES
          FOR CONTRACTOR COMPLIANCE

      

      
        2007

      

      
        11

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        Compliance
          Plan
          Submission                                                                                                                                                                                            

      

      
        
          	
                  1.

                	
                  A
                    description of the MCO 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 MCO'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 MCO's protocol for assignment of specialists
                    as PCP,
                    and for standing referrals to specialists and specialty centers,
                    out-of-plan referrals and continuing treatment
                    relationships

                

          	4. 	A
                  description of the MCO's notice procedures to enrollees regarding
                  the
                  availability of case management services, specialists as PCPs,
                  standing referrals to specialists and specialty centers, out-of-plan
                  referrals and continuing treatment
                  relationships

        

      

      
         

      

      
        IV.       Program
          Accessibility 

         

        D.
          Participating Providers

      

      
         

      

      
        
          
            
              
                Standard
                  for Compliance:

              

              
                MCOs
                  networks 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.

              

              
                

                Suggested
                  Methods for Compliance

                 

              

              
                
                  	
                          1.

                        	
                          Process
                            for MCO 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
                          of Wheelchair 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]

                        

                

              

              
                     

                Medicaid
                  Advantage Plus Contract

              

            

          

        

      

      
        APPENDIX
          J

      

      
        GUIDELINES
          FOR CONTRACTOR COMPLIANCE

      

      
        2007

      

      
        12

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        
          	
                  7.

                	
                  Use
                    of ADA 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 MCO 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 MCO 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 MCO's specialty network is sufficient to
                  meet the
                  needs of enrollees with disabilities

          	 3. 	  A
                  description of methods to ensure the coordination of out-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

                

        

      

      
        
          	
                  • 
                    

                	
                  MCO
                    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 ADA Compliance Summary Report (see attached - county specific/borough
                    specific for NYC) or MCO statement that data submitted to SDOH on the
                    Health Provider Network (HPN) files is an accurate reflection
                    of each
                    network's physical accessibility 

                

        

      

       

       

      Medicaid
        Advantage Plus Contract

      
        APPENDIX
          J

      

      
        GUIDELINES
          FOR CONTRACTOR COMPLIANCE

      

      
        2007

      

      
        13

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        IV.      Program
          Accessibility

      

      
        

        E.        Populations
          Special Health Care Needs

      

      
        

        Standard
          for Compliance:

      

      
        MCOs
          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. MCOs 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 plan referrals,
                        and
                        continuation of existing relationships with out-of-network
                        providers for
                        course of treatment

                    

            

          

          
            
              	
                      2.

                    	
                      Contracts
                        with school-based health
                        centers

                    

            

          

          
            
              	
                      3.

                    	
                      Linkages
                        with preschool services, child protective agencies, early
                        intervention
                        officials, behavioral health agencies, disability and advocacy
                        organizations, etc.

                    

            

          

          
            
              	
                      4.

                    	
                      Adequate
                        network of providers and subspecialists (including pediatric
                        providers and
                        sub-specialists) and contractual relationships with tertiary
                        institutions

                    

              	5.   	 for
                      assuring that these populations receive appropriate diagnostic
                      workups on
                      a timely basis

              	6. 	 Procedures
                      for assuring that these populations receive appropriate access
                      to durable
                      medical equipment on a timely basis

            

          

          
            
              	
                      7.

                    	
                      Procedures
                        for assuring that these populations receive appropriate allied
                        health
                        professionals (Physical, Occupational and Speech Therapists,
                        Audiologists)
                        on a timely basis

                    

              	8.	State
                      designation as a Well Qualified Plan to serve OMRDP population
                      and
                      look-alikes

            

          

          
                       

          

          
            Compliance
              Plan Submission

          

          
            

            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 plan referrals, and continuation
              of
              existing relationships (out-of-plan) for diagnosis and treatment of
              rare
              disorders.

             

            
              Medicaid
                Advantage Plus Contract

              
                APPENDIX
                  J

              

              
                GUIDELINES
                  FOR CONTRACTOR COMPLIANCE

              

              
                2007

              

              
                14

                 

              

            

          

        

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        V.        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 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.

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          J

      

      
        GUIDELINES
          FOR CONTRACTOR COMPLIANCE

      

      
        2007

      

      
        15

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        APPENDIX
          K

      

      
        

        Medicare
          Advantage and Medicaid Advantage Plus Products

      

      
        And
          Non-Covered Services

      

      
        

         

         

         

        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          K

      

      
        COVERED
          AND NON-COVERED SERVICES

      

      
        2007

      

      
        1

        
 

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

      

      
        APPENDIX
          K

      

      
        

        Appendix
          K is organized into three parts:

      

      
        

        I.           Appendix
          K-l

      

      
        Medicare
          Advantage Product

      

      
        

        II.           Appendix
          K-2

      

      
        Medicaid
          Advantage Plus Product

      

      
        Description
          of Medicaid Advantage Plus Covered Services

      

      
        
           

          III.    Appendix
            K-3 

          Non-Covered
            Services

         

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          K

      

      
        COVERED
          AND NON-COVERED SERVICES

      

      
        2007

      

      
        2

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        APPENDIX
          Kl

      

      

      
        	
                
                  Medicare
                    Advantage Benefit Package for Dual
                    Eligibles

                

              
	
                
                  Category
                    of Service

                

              	
                
                  Included
                    in Medicare Capitation

                

              
	
                
                  Inpatient
                    Hospital Care Including Substance Abuse and Rehabilitation
                    Services

                

              	
                
                  Up
                    to 365 days per year (366 days for leap year) with no deductible
                    or
                    co-payment

                

              
	
                
                  Inpatient
                    Mental Health

                

              	
                
                  Medically
                    necessary care with no deductible or co-payment. 190-day lifetime
                    limit in
                    a psychiatric hospital.

                

              
	
                
                  Skilled
                    Nursing Facility

                

              	
                
                  Care
                    provided in a skilled nursing facility. Covered for 100 days
                    each benefit
                    period. No prior hospital stay required. No
                    co-payment.

                

              
	
                
                  Home
                    Health

                

              	
                
                  Medically
                    necessary intermittent skilled nursing care, home health aide
                    services and
                    rehabilitation services. No co-payment.

                

              
	
                
                  PCP
                    Office Visits

                

              	
                
                  Primary
                    care doctor office visits. No co-payment.

                

              
	
                
                  Specialist
                    Office Visits

                

              	
                
                  Specialist
                    office visits. Subject to $10 co-payment for each specialist
                    office
                    visit.

                

              
	
                
                  Chiropractic

                

              	
                
                  Manual
                    manipulation of the spine to correct subluxation provided by
                    chiropractors
                    or other qualified providers. Subject to $10
                    co-payment

                

              
	
                
                  Podiatry

                

              	
                
                  Medically
                    necessary foot care, including care for medical conditions affecting
                    lower
                    limbs, subject to $10 co-payment. Visits for routine foot care
                    up to 4
                    visits per year, not subject to co-payment.

                

              
	
                
                  Outpatient
                    Mental Health

                

              	
                
                  Individual
                    and group therapy visits, subject to co-payment of $20 per individual
                    or
                    group visit. Enrollee must be able to self-refer for one assessment
                    from a
                    network provider in a twelve (12) month period.

                

              
	
                
                  Outpatient
                    Substance Abuse

                

              	
                
                  Individual
                    and group visits subject to $20 co-payment per group or individual
                    visit.
                    Enrollee must be able to self-refer for one assessment from a
                    network
                    provider in a twelve (12) month period.

                

              
	
                
                  Outpatient
                    Surgery

                

              	
                
                  Medically
                    necessary visits to an ambulatory surgery center or outpatient
                    hospital
                    facility. No co-payment.

                

              
	
                
                  Ambulance

                

              	
                
                  Transportation   provided   by   an   ambulance    service,
                    including air ambulance.  Emergency transportation if 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. Includes
                    transportation to a hospital  emergency room generated by a
                    "Dial 911". No co-payment.

                

              

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          K

      

      
        COVERED
          AND NON-COVERED SERVICES

      

      
        2007

      

      
        3

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        	
                
                  Medicare
                    Advantage Benefit Package for Dual
                    Eligibles

                

              
	
                
                  Category
                    of Service

                

              	
                
                  Included
                    in Medicare Capitation

                

              
	
                
                  Emergency
                    Room

                

              	
                
                  Care
                    provided in an emergency room subject to prudent layperson standard.
                    $50
                    co-payment per visit. Co-payment waived if admitted to the hospital
                    within
                    24 hours for the same condition.

                

              
	
                
                  Urgent
                    Care

                

              	
                
                  Urgently
                    needed care in most cases outside the plan's service area. Subject
                    to $10
                    co-payment.

                

              
	
                
                  Outpatient
                    Rehabilitation (OT, PT, Speech)

                

              	
                
                  Occupational
                    therapy, physical therapy and speech and language therapy subject
                    to $10
                    co-payment.

                

              
	
                
                  Durable      Medical      Equipment
                    (DME)

                

              	
                
                  Medicare
                    and Medicaid covered durable medical equipment, including devices
                    and
                    equipment other than medical/surgical supplies, enteral formula,
                    and
                    prosthetic or orthotic appliances having the following characteristics:
                    can withstand repeated use for a protracted period of time; are
                    primarily
                    and customarily used for medical purposes; are generally not
                    useful to a
                    person in the absence of illness or injury and are usually fitted,
                    designed or fashioned for a particular individual's use. Must
                    be ordered
                    by a qualified practitioner. No homebound prerequisite and including
                    non-Medicare DME covered by Medicaid (e.g. tub stool; grab bars).
                    No
                    co-payment or coinsurance

                

              
	
                
                  Prosthetics

                

              	
                
                  Medicare
                    and Medicaid covered prosthetics, orthotics and orthopedic footwear.
                    No
                    diabetic prerequisite for orthotics. Not subject to co-payment
                    or
                    coinsurance.

                

              
	
                
                  Diabetes
                    Monitoring

                

              	
                
                  Diabetes
                    self-monitoring, management training and supplies including coverage
                    for
                    glucose monitors, test strips, and lancets. No co-payments. OTC
                    diabetic
                    supplies such as 2x2 gauze pads, alcohol swabs/pads, insulin
                    syringes and
                    needles are covered by Part D.

                

              
	
                
                  Diagnostic
                    Testing

                

              	
                
                  Diagnostic
                    tests, x-rays, lab services and radiation therapy. No
                    co-payments.

                

              
	
                
                  Bone
                    Mass Measurement

                

              	
                
                  Bone
                    Mass Measurement for people at risk. No
                    co-payment

                

              
	
                
                  Colorectal
                    Screening

                

              	
                
                  Colorectal
                    screening for people, age 50 and older. No
                    co-payment.

                

              
	
                
                  Immunizations

                

              	
                
                  Flu,
                    hepatitis B vaccine for people who are at risk, Pneumonia vaccine.
                    No
                    co-payment.

                

              
	
                
                  Mammograms

                

              	
                
                  Annual
                    screening for women age 40 and older. No referral necessary.
                    No
                    co-payment.

                

              
	
                
                  Pap
                    Smear and Pelvic Exams

                

              	
                
                  Pap
                    smears and Pelvic Exams for women. No co-payment.

                

              
	
                
                  Prostate
                    Cancer Screening

                

              	
                
                  Prostrate
                    Cancer Screening exams for men age 50 and older. No
                    co-payment.

                

              
	
                
                  Outpatient
                    Drugs

                

              	
                
                  Medicare
                    Part B covered prescription drugs and other drugs obtained  by a
                    provider and  administered  in  a physician
                    office or clinic setting covered by
                    Medicaid.

                

              

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          K

      

      
        COVERED
          AND NON-COVERED SERVICES

      

      
        2007

      

      
        4

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        	
                
                  Medicare
                    Advantage Benefit Package for Dual
                    Eligibles

                

              
	
                
                  Category
                    of Service

                

              	
                
                  Included
                    in Medicare Capitation

                

              
	
                
                  Hearing
                    Services

                

              	
                
                  Medicare
                    and Medicaid hearing services and products when medically necessary
                    to
                    alleviate disability caused by the loss or impairment of hearing.
                    Services
                    include hearing aid selecting, fitting, and dispensing; hearing
                    aid checks
                    following dispensing, conformity evaluations and hearing aid
                    repairs;
                    audiology services including examinations and testing, hearing
                    aid
                    evaluations and hearing aid prescriptions; and hearing aid products
                    including hearing aids, earmolds, special fittings and replacement
                    parts.
                    No co-payment or limitations.

                

              
	
                
                  Vision
                    Care Services

                

              	
                
                  Services
                    of optometrists, ophthalmologists and ophthalmic dispensers including
                    eyeglasses, medically necessary contact lenses and poly-carbonate
                    lenses,
                    artificial eyes (stock or custom-made), low vision aids and low
                    vision
                    services. . Coverage also includes the repair or replacement
                    of parts.
                    Coverage also includes examinations for diagnosis and treatment
                    for visual
                    defects and/or eye disease. Examinations for refraction are limited
                    to
                    every two (2) years unless otherwise justified as medically necessary.
                    Eyeglasses do not require changing more frequently than every
                    two (2)
                    years unless medically necessary or unless the glasses are lost,
                    damaged
                    or destroyed.   No co-payment.

                

              
	
                
                  Routine
                    Physical Exam 1 /year

                

              	
                
                  Up
                    to one routine physical per year. No co-payment.

                

              
	
                
                  Health/Wellness
                    Education

                

              	
                
                  Coverage
                    for health and wellness education, including but not limited
                    to general
                    health education classes, smoking cessation classes, etc., plus
                    additional
                    benefits at plan option including but not limited to items such
                    as
                    newsletters, nutritional training, congestive heart program,
                    health club
                    membership/fitness classes, nursing hotline, disease management,
                    other
                    wellness services. No co-payments.

                

              
	
                
                  Additional
                    Part C Benefits, if any

                

              	 
	
                
                  Medicare
                    Part D Prescription Drug Benefit as Approved by CMS

                

              	 

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          K

      

      
        COVERED
          AND NON-COVERED SERVICES

      

      
        2007

      

      
        5

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        APPENDIX
          K2

      

      
        

        MEDICAID
          ADVANTAGE PLUS PRODUCT

      

      

      
        	
                
                  Medicaid
                    Advantage Plus Benefit Package for Dual
                    Eligibles

                

              
	
                
                  Category
                    of Service

                

              	
                
                  Included
                    in Medicaid Capitation

                

              
	
                
                  Inpatient
                    Mental Health

                

              	
                
                  Days
                    in excess of the Medicare 190-day lifetime
                    maximum.

                

              
	
                
                  Skilled
                    Nursing Facility

                

              	
                
                  Care
                    provided in SNF in excess of the Medicare 100 day limit per benefit
                    period.

                

              
	
                
                  Home
                    Health

                

              	
                
                  Non-Medicare
                    covered home health services, including home health aide services
                    and
                    nursing supervision to medically unstable
                    individuals.

                

              
	
                
                  Personal
                    Care Services

                

              	
                
                  Medically
                    necessary assistance with activities such as personal hygiene,
                    dressing
                    and feeding; and nutritional and environmental support function
                    tasks.

                

              
	
                
                  Specialist
                    Office Visits

                

              	
                
                  Elimination
                    of $10 co-payment.

                

              
	
                
                  Podiatry

                

              	
                
                  Elimination
                    of $10 co-payment for medically necessary
                    footcare.

                

              
	
                
                  Outpatient
                    Mental Health

                

              	
                
                  Elimination
                    of $20 co-payment.

                

              
	
                
                  Outpatient
                    Substance Abuse

                

              	
                
                  Elimination
                    of $20 co-payment.

                

              
	
                
                  Emergency
                    Room

                

              	
                
                  Elimination
                    of $50 co-payment

                

              
	
                
                  Urgent
                    Care

                

              	
                
                  Elimination
                    of $10 co-payment.

                

              
	
                
                  Outpatient
                    Rehabilitation (OT, PT, Speech)

                

              	
                
                  Elimination
                    of $10 co-payment.

                

              
	
                
                  Dental

                

              	
                
                  Medicaid
                    covered dental services including necessary preventive, prophylactic
                    and
                    other routine dental care, services and supplies and dental prosthetics
                    to
                    alleviate a serious health condition. Ambulatory or inpatient
                    surgical
                    (when not covered by Medicare) dental services

                

              
	
                
                  Transportation
                    - Non-Emergency

                

              	
                
                  Transportation
                    essential for an enrollee to obtain necessary medical care and
                    services
                    under the plan's benefits or Medicaid fee-for-service. Includes
                    ambulette,
                    invalid coach, taxicab, livery, public transportation, or other
                    means
                    appropriate to the enrollee's medical condition and a
                    transportation attendant to accompany the enrollee,
                    if
                    necessary.

                

              
	
                
                  Medicaid/SurgicaJ
                    Supplies, Enteral/Parenteral Formula and Supplements, and Hearing
                    Aid
                    Batteries

                

              	
                
                  Medically
                    necessary supplies and formula and supplements and hearing aid
                    batteries

                

              

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          K

      

      
        COVERED
          AND NON-COVERED SERVICES

      

      
        2007

      

      
        6

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        	
                
                  Medicaid
                    Advantage Plus Benefit Package for Dual
                    Eligibles

                

              
	
                
                  Category
                    of Service

                

              	
                
                  Included
                    in Medicaid Capitation

                

              
	
                
                  Private
                    Duty Nursing

                

              	
                
                  Medically
                    necessary private duty nursing services in accordance with the
                    ordering
                    physician, registered physician assistant or certified nurse
                    practitioner's written treatment plan.

                

              
	
                
                  Nutrition

                

              	
                
                  Assessment
                    of nutritional status/needs, development and evaluation of treatment
                    plans, nutrition education and counseling, in-service education.
                    Includes
                    cultural considerations.

                

              
	
                
                  Medical
                    Social Services

                

              	
                
                  Assessment,
                    arranging and providing aid for social problems related to maintaining
                    individual at home.

                

              
	
                
                  Social
                    and Environmental Supports

                

              	
                
                  Services
                    and items to support member's medical need. May include home
                    maintenance
                    tasks, homemaker/chore services, housing improvement, and respite
                    care.

                

              
	
                
                  Home
                    Delivered and Congregate Meals

                

              	
                
                  Meals
                    provided at home or in congregate settings, e.g., senior centers
                    to
                    individuals unable to prepare meals or have them
                    prepared.

                

              
	
                
                  Adult
                    Day Health Care

                

              	
                
                  Includes
                    medical, nursing, food and nutrition, social services, rehabilitation
                    therapy, leisure activities, dental, pharmaceutical, and other
                    ancillary
                    services. Services furnished in approved SNF or extension
                    site.

                

              
	
                
                  Social
                    Day Care

                

              	
                
                  Structured
                    comprehensive program providing socialization; supervision, monitoring;
                    personal care, nutrition in a protective setting.

                

              
	
                
                  Personal
                    Emergency Response Services (PERS)

                

              	
                
                  Electronic
                    device that enables individuals to secure help in a physical,
                    emotional or
                    environmental emergency.

                

              
	
                
                  Assisted
                    Living Program

                

              	
                
                  Service
                    may be a substitute for other services in the plan of care and
                    paid
                    through the capitation.

                

              

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          K

      

      
        COVERED
          AND NON-COVERED SERVICES

      

      
        2007

      

      
        7

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        DESCRIPTION
          OF MEDICAID ONLY SERVICES IN MEDICAID ADVANTAGE PLUS BENEFIT
          PACKAGE:

      

      
        

        Inpatient
          Mental Health Over 190-Day Lifetime Limit

      

      
        

        All
          inpatient mental health services, including voluntary or involuntary admissions
          for mental health services over the Medicare 190-Day Lifetime Limit. The
          Contractor may provide the covered benefit for medically necessary mental
          health
          impatient services through hospitals licensed pursuant to Article 28 of
          the New
          York State P.H.L.

      

      
        

        Non-Medicare
          Covered Care in Skilled Nursing Facility

      

      
        

        Skilled
          nursing facility days for Medicaid Advantage Plus Program.Enrollees provided
          by
          a licensed facility as specified in Chapter V, 10 NYCRR, in excess of the
          first
          100 days in the Medicare Advantage benefit period.

      

      
        

        Non-Medicare
          Covered Home Health Services

      

      
        

        Medicaid
          covered home health services include the provision of skilled services
          not
          covered by Medicare (e.g. physical therapist to supervise maintenance program
          for patients who have reached their maximum restorative potential or nurse
          to
          pre-fill syringes for disabled individuals with diabetes) and /or home
          health
          aide services as required by an approved plan: of care.

      

      
        

        Personal
          Care Services

      

      
        

        Personal
          care services (PCS) are the provision of some or total assistance with
          such
          activities as personal hygiene, dressing and feeding; and nutritional and
          environmental support function tasks (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. Personal care must be medically necessary,
          ordered by the Enrollee's physician and provided by a qualified person
          as
          defined in Part 700.2(b)(14) 10 NYCRR, in accordance with a plan of
          care.

      

      
        

        Private
          Duty Nursing Services

      

      
        

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

      

      
        

        Private
          duty nursing services are covered 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 physician, registered
          physician assistant or certified nurse practitioner's written treatment
          plan.

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          K

      

      
        COVERED
          AND NON-COVERED SERVICES

      

      
        2007

      

      
        8

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        Dental
          Services

      

      
        

        Dental
          services include, but shall not be limited to. preventive, prophylactic
          and
          other dental care, services, supplies, routine exams, prophylaxis, oral
          surgery
          (when not covered by Medicare), and   dental prosthetic and
          orthotic appliances required to alleviate a serious health condition, including
          one which affects employability.

      

      
        

        Non-Emergency
          Transportation

      

      
        

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

      

      
        

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

      

      
        

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

      

      
        

        Medical
          and Surgical Supplies, Enteral and Parenteral Formula and Hearing Aid
          Batteries

      

      
        

        These
          items are generally considered to be one-time only use, consumable items
          routinely paid for under the Durable Medical Equipment category of
          fee-for-service Medicaid.

      

      
        

        Nutrition

      

      
        

        Nutrition
          services includes the assessment of nutritional needs and food patterns,
          or the
          planning for the provision of foods and drink appropriate for the individual's
          physical and medical needs and environmental conditions, or the provision
          of
          nutrition education and counseling to meet normal and therapeutic needs.
          In
          addition, these services may include the assessment of nutritional status
          and
          food preferences, planning for provision of appropriate dietary intake
          within
          the patient's home environment and cultural considerations, nutritional
          education regarding therapeutic diets as part of the treatment milieu,
          development of a nutritional treatment plan, regular evaluation and revision
          of
          nutritional plans, provision of in-service education to health agency staff
          as
          well as consultation on specific dietary problems of patients and nutrition
          teaching to patients and families. These services must be provided by a
          qualified nutritionist as defined in Part 700.2(b)(5), 10
          NYCRR.

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          K

      

      
        COVERED
          AND NON-COVERED SERVICES

      

      
        2007

      

      
        9

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        Medical
          Social Services

      

      
        

        Medical
          social services include assessing the need for, arranging for and providing
          aid
          for social problems related to the maintenance of a patient in the home
          where
          such services are performed by a qualified social worker and provided within
          a
          plan of care. These services must be provided by a qualified social worker
          as
          defined in Section 700.2(b)(24) 10 NYCRR.

      

      
        

        Social
          and Environmental Supports

      

      
        

        Social
          and environmental supports are services and items that support the medical
          needs
          of the Enrollees and are included in an Enrollee's plan of care. These
          services
          and items include but are not limited to the following: home maintenance
          tasks,
          homemaker/chore services, housing improvement, and respite
          care.

      

      
        

        Home
          Delivered and Congregate Meals

      

      
        

        Home
          delivered and congregate meals are meals provided at home or in congregate
          settings, e.g. senior centers to individuals unable to prepare meals or
          have
          them prepared.

      

      
        

        Adult
          Day Health Care

      

      
        

        Adult
          day
          health care is care and services provided in aresidential health care facility
          or approved extension site under the medical direction of a physician to
          a
          person who is functionally impaired, not homebound, and who requires certain
          preventive, diagnostic, therapeutic, rehabilitative or palliative items
          or
          services. Adult day health care includes the following services: medical,
          nursing, food and nutrition, social services, rehabilitation therapy, leisure
          time activities which are a planned program of diverse meaningful activities,
          dental, pharmaceutical, and other ancillary services.

      

      
        

        Social
          Day Care

      

      
        

        Social
          day care is a structured, comprehensive program which provides functionally
          impaired individuals with socialization; supervision and monitoring; personal
          care; and nutrition in aprotective setting during any part of
          the day, but for less than a 24 hour period. Additional services may include
          and
          are not limited to maintenance and enhancement of daily living skills,
          transportation, care giver assistance and case coordination and
          assistance.

      

      
        

        Personal
          Emergency Response Services (PERS)

      

      
        

        Personal
          Emergency Response System (PERS) is an electronic device which enables
          certain
          high-risk patients to secure help in the event of a physical, emotional
          or
          environmental emergency. A variety of electronic alert systems now exist
          which
          employ different signaling devices. Such systems are usually connected
          to a
          patient's phone and signal a response center once a "help"
          button is activate. In the event of an emergency, the signal is received
          and
          appropriately acted upon by a response center.

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          K

      

      
        COVERED
          AND NON-COVERED SERVICES

      

      
        2007

      

      
        10

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        Assisted
          Living Program

      

      
        

        Assisted
          Living Program provides personal care, housekeeping, supervision, home
          health
          aides. Personal emergency response services, nursing, physical therapy,
          occupational therapy, speech therapy, medical supplies and equipment, adult
          day
          health care, a range of home health services and the case management services
          of
          a registered professional nurse. Services are provided in an adult home
          or
          enriched housing setting. The room and board component of the Assisted
          Living
          Program may not be covered by the plan.

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          K

      

      
        COVERED
          AND NON-COVERED SERVICES

      

      
        2007

      

      
        11

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        APPENDIX
          K3

      

      
        

        NON
          COVERED SERVICES

      

      
        

        The
          following services will not be the responsibility of the Contractor under
          the
          Medicare/Medicaid program:

      

      
        

        Services
          Covered by Direct Reimbursement from Original
          Medicare

      

      
        •   Hospice
          services provided to Medicare Advantage members

      

      
        

        Services
          Covered
          byMedicaid-Fee-for-Service

      

      
        •  
          Out of network Family Planning services under the direct access
          provisions,

      

      
        
          •  Medicaid
            Pharmacy Benefits as
            allowed by State Law (select drug categories excluded from the Medicare
            Part D
            benefit and certain medications included in the Part D benefit when the
            Enrollee
            is unable to receive them from his/her Medicare Advantage Plan)

          •    Methadone
            Maintenance Treatment Programs

        

      

      
        •   Certain
          Mental Health Services, including

      

      
        
          
            o   Intensive
              Psychiatric Rehabilitation Treatment Programs,

          

          
            o   Day
              Treatment,

          

          
            o   Continuing
              Day Treatment,

          

          
            o   Case
              Management for Seriously and Persistently Mentally 111 (sponsored by
              state or
local
              mental health units), 
              o   Partial
                Hospitalizations, 
                o   Assertive
                  Community Treatment (ACT), 
                  o   Personalized
                    Recovery Oriented Services
                    (PROS)

                

              

            

          

        

      

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

        •     Office of Mental Retardation and
          Developmental Disabilities (OMRDD) Services,

      

      
        •      Comprehensive
          Medicaid Case Management,

      

      
        •      Home
          and Community Based Waiver Program Services,

      

      
        •      Directly
          Observed Therapy for Tuberculosis Disease, and

      

      
        •      AIDS
          Adult Day Health Care

      

      
        

        Medicaid
          Advantage Pius Contract

      

      
        APPENDIX
          K

      

      
        COVERED
          AND NON-COVERED SERVICES

      

      
        2007

      

      
        12

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        DESCRIPTION
          OF NON-COVERED SERVICES

      

      
        

        The
          following services are excluded from the Contractor's Medicare and Medicaid
          Benefit Packages, and are covered, in most instances, by Medicare or Medicaid
          fee-for-service:

      

      
        

        1.           Hospice
          Services Provided to Medicare Advantage Enrollees

      

      
        

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

      

      
        

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

      

      
        

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

      

      
        

        2.           Other
          Services Deemed to be Covered by Original Medicare by
          CMS

      

      
        

        3.           Pharmacy
          Benefits as Permitted by State Law

      

      
        

        NYS
          Medicaid continues to provide coverage for certain drugs excluded from
          the
          Medicare Part D benefit such as barbiturates, benzodiazepines, and some
          prescription vitamins, and some non­prescription drugs.. NYS also provides a
          wrap around program which covers medications that are included in the Part
          D
          benefit when the recipient is unable to receive them from their Part D
          plan.
          Effective January 1, 2007, drugs which are covered through this Medicaid
          wrap-around benefit will be limited to the following four categories of
          drugs:
          atypical antipsychotics, antidepressants, anti-retroviral used in the treatment
          of HIV/AIDS, and anti-rejection drugs used in the treatment of tissue and
          organ
          transplants only when these drugs are not covered by the specific plan,
          the
          patient does not meet the plan's utilization management requirements or
          there
          are quantity limits inconsistent with the prescribed amount.

      

      
        

        4.           Out
          of Network Family Planning Services

      

      
        

        As
          described in Section 10.6 and 10.9 of this Agreement, out of network family
          planning services provided by qualified Medicaid providers to plan enrollees
          will be directly reimbursed

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          K

      

      
        COVERED
          AND NON-COVERED SERVICES

      

      
        2007

      

      
        13

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

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

      

      
        

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

      

      
        

        5.           Methadone
          Maintenance Treatment Program (MMTP)

      

      
        

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

      

      
        

        6.       Certain
          Mental Health Services

      

      
        

        Contractor
          is not responsible for the provision and payment of the following services
          which
          are reimbursed through Medicaid fee-for-service.

      

      
        

        a.             Intensive
          Psychiatric Rehabilitation Treatment Programs (IPRT)

      

      
        

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

      

      
        

        b.             Day
          Treatment

      

      
        

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

      

      
        

        c.             Continuing
          Day Treatment

      

      
        

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

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          K

      

      
        COVERED
          AND NON-COVERED SERVICES

      

      
        2007

      

      
        14

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        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.

      

      
        

        Case
          Management for Seriously and Persistently Mentally Ill Sponsored by State
          or Local Mental Health Units

      

      
        

        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) in
          this section.

      

      
        

        Partial
          Hospitalization Not Covered by Medicare

      

      
        

        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.

      

      
        

        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.

      

      
        

        Personalized
          Recovery Oriented Services (PROS)

      

      
        

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

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          K

      

      
        COVERED
          AND NON-COVERED SERVICES

      

      
        2007

      

      
        15

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      7. 
        Rehabilitation
        Services Provided to Residents of OMH Licensed Community Residences (CRs)
        and
        Family Based Treatment Programs, as follows:

       

      
        a. 
           OMH Licensed CRs*

      

      
        

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

      

      
        

        b. 
          Family-Based Treatment*

      

      
        

        Rehabilitative
          services in family-based treatment programs are intended to provide treatment
          to
          seriously emotionally disturbed children and youth to promote their successful
          functioning and integration into the natural family, community, school
          or
          independent living situations. Such services are provided in consideration
          of a
          child's developmental stage. Those children determined eligible for admission
          are placed in surrogate family homes for care and treatment. These services
          are
          certified by OMH under 14 NYCRR Parts 586.3, 594 and 595.

      

      
        

        8.
          Office of Mental Retardation and Developmental Disabilities (OMRDD)
          Services

      

      
        

        
          	
                  a.

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

                

        

      

      
        

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

      

      
        

        b.        Day
          Treatment

      

      
        

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

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          K

      

      
        COVERED
          AND NON-COVERED SERVICES

      

      
        2007

      

      
        16

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
         

        c.     Medicaid
          Service Coordination (MSC)

      

      
        

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

      

      
        

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

      

      
        

        Please
          note: See generic definition of Comprehensive Medicaid Case Management
          (CMCM) in this section.

      

      
        

        9.   Home
          and Community Based Services (HCBS) Waiver Program
          Services

      

      
        

        There
          are
          a number of Home and Community-Based Waiver Programs that provides services
          authorized pursuant to SSA Section 1915(c) waivers from DHHS. The programs
          include the Long Term Home Health Care Program, the Traumatic Brain Injury
          (TBI)
          Program, the ICF/MR Waiver, as well as Medicaid Care at Home HCBS Programs
          and
          OMRDD Care at Home Programs.

      

      
        

        10.  Comprehensive
          Medicaid CaseManagement (CMCM)

      

      
        

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

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          K

      

      
        COVERED
          AND NON-COVERED SERVICES

      

      
        2007

      

      
        17

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        11.
          Directly Observed Therapy for Tuberculosis Disease

      

      
        

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

      

      
        

        12.   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 genera] medical care and nursing services.

      

      
        

        13. HIV
          COBRA CaseManagement

      

      
        

        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.

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          K

      

      
        COVERED
          AND NON-COVERED SERVICES

      

      
        2007

      

      
        18

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        Appendix
          L 

         

        Approved
          Capitation Payment Rates

      

      
        

        WellCare
          of New York, Inc. Medicaid Advantage Plus

      

      
        

        Effective
          Date: 2007

      

      

      
        	
                
                  Age
                    Group

                

              	
                
                  Monthly
                    Capitation Amount (PMPM)

                

              
	
                
                  18-64

                

              	
                
                  $3,522.46

                

              
	
                
                  65+

                

              	
                
                  $3,522.46

                

              

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        

        APPENDIX
          L

      

      
        APPROVED
          CAPITATION PAYMENT RATES

      

      
        2007

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        APPENDIX
          M

      

      
        

        Service
          Area

      

      
        

        The
          Contractor's Medicaid Advantage Plus service area is comprised of the following
          Counties in their entirety:

      

      
        

        Bronx
          

        Kings
          

        New
          York

        Queens

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          M

      

      
        SERVICE
          AREA

      

      
        2007

      

      
        1

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        APPENDIX
          N

        Reserved

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          N

      

      
        (RESERVED)

      

      
        2007

      

      
        1

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        APPENDIX
          O

      

      
        
           

          Requirements
            for Proof of Workers' Compensation and Disability Benefits
            Coverage

         

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          O

      

      
        PROOF
          OF
          COVERAGE

      

      
        2007

      

      
        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
                    O:

                

        

      

      
        

        
          	
                  a)

                	
                  Certificate
                    of Workers' Compensation Insurance, on the Workers' Compensation
                    Board
                    form C-105.2 (naming the NYS Department of Health, Corning 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, Corning 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
                    O:

                

        

      

      
        

        
          	
                  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 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 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

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          O

      

      
        PROOF
          OF
          COVERAGE

      

      
        2007

      

      
        2

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      

      
        

         

      

      
        

        APPENDIX
          P

      

      
        Reserved

         

         

        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          P

      

      
        (RESERVED)

      

      
        2007

      

      
        

        

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

      

      

      
        

      

      
        

        APPENDIX
          Q

      

      
        
          Reserved

        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          Q

      

      
        (RESERVED)

      

      
        2007

      

      
        

         

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        APPENDIX
          R

      

      
        

        Additional
          Specifications for the Medicaid Advantage Plus Agreement

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          R

      

      
        ADDITIONAL
          SPECIFICATIONS

      

      
        2007

      

      
        

        1

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        APPENDIX
          R 

        Additional
          Specifications for the Medicaid Advantage Plus
          Agreement

      

      
        

        1.
          Contractor will give continuous attention to performance of its obligations
          herein for the duration of this Agreement and with the 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
                    the 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.

                

        

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          R

      

      
        ADDITIONAL
          SPECIFICATIONS

      

      
        2007

      

      
        2

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        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 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 essentia] to obtain social and economic
          equality and improve the functioning of the State economy.

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          R

      

      
        ADDITIONAL
          SPECIFICATIONS

      

      
        2007

      

      
        3

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        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 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.

      

      
        

        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

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          R

      

      
        ADDITIONAL
          SPECIFICATIONS

      

      
        2007

      

      
        4

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        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.

      

      
        

        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, INELIGIBILITY 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.

                

        

      

      
        

        Medicaid
          Advantage Pius Contract

      

      
        APPENDIX
          R

      

      
        ADDITIONAL
          SPECIFICATIONS

      

      
        2007

      

      
        5

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        
          	
                  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.

                

        

      

      
        

        
          	
                  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 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.

                

        

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          R

      

      
        ADDITIONAL
          SPECIFICATIONS

      

      
        2007

      

      
        6

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        
          	
                   

                	
                  (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.

                

        

      

      
        

        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.

                

        

      

      
        

        
          	
                  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.

                

        

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          R

      

      
        ADDITIONAL
          SPECIFICATIONS

      

      
        2007

      

      
        7

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        
          	
                  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.

                

        

      

      
        

        Provisions
          Related to New York State Procurement Lobbying Law

      

      
        

        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
          Finance
          Law 139-k was intentionally false or intentionally incomplete. Upon such
          finding, the State may exercise its termination right by providing written
          notification to the contractor is accordance with the written notification
          terms
          of this agreement.

      

      
        

        Provisions
          Related to New York State Information Security Breach and Notification
          Act

      

      
        

        Contractor
          shall comply with the provisions of the New York State Information Security
          Breach and Notification Act (General Business Law Section 899-aa; State
          Technology Law Section 208). Contractor shall be liable for the costs associated
          with such breach if caused by the Contractor's negligent or willful acts
          or
          omissions, or the negligent or willful acts or omissions of Contractor's
          agents,
          officers, employees or subcontractors.

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          R

      

      
        ADDITIONAL
          SPECIFICATIONS

      

      
        

        2007

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        APPENDIX
          X

        Modification
          Agreement Form

      

      
        

        Medicaid
          Advantage Plus Contract

      

      
        APPENDIX
          X

      

      
        2007

      

      
        
 

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

      

      
        
          
             

             

            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 (hereinafter
              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

                    

                    
                      By:

                    

                  	
                    
                      STATE
                        AGENCY SIGNATURE

                    

                    
                      By:

                    

                  
	 
	
                    
                      Printed
                        Name 

                      Title:

                    

                  	
                    
                      Printed
                        Name 

                      Title:

                    

                  
	
                    
                      Date:

                    

                  	
                    
                      Date:

                    

                  
	 	
                    
                       

                      State
                        Agency Certification:

                    

                    
                      In
                        addition to the acceptance of this contract, I also certify
                        that original
                        copies of this signature page will be attached to all other
                        exact copies
                        of this contract.

                    

                    
                       

                    

                  

          

          
             

             

             

            STATE
              OF
              NEW YORK

          

          
            County
              of
              ___________________

          

          
             

             

            On
              the
              ______________  day of __________ , 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)

          

          
            

            STATE
              COMPTROLLER'S SIGNATURE

            

          

          
            

            Title:

            

          

          
            

            Date:

            

          

          
            

            APPENDIX
              X

          

          
            2007

          

          
            2

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