Document:

EX-10.1

    
      

    

    Back to Form 8-K

    Exhibit
      10.1

     

     

    MEDICAID
      ADVANTAGE CONTRACT ATTESTATION

     

    I  Todd
      S. Farha        being
      an
      individual authorized to execute agreements on
      behalf
      of WellCare of New York, Inc. (hereafter "MCO"), hereby attest that
      the Medicaid
      Advantage contract submitted by MCO to the New York State Department of Health,
      follows the latest model Medicaid Advantage contract provided to us by the
      New
      York State Department of Health. This executed contract contains no deviations
      from the aforementioned model contract language.

    

    
      	
               
                2/24/06   

              (Date)

            	
              /s/
                Todd S. Farha

              (Signature)
                

               

            
	 	
               Todd
                S. Farha

              (Print
                Name in Full) 

               

            
	 	
              President
                and CEO 

              (Title)
                

            
	
              /s/
                Rebecca McNeely 

              (Notary
                Seal and Signature) 

            	 

    

    

     

    MISCELLANEOUS/CONSULTANT
      SERVICES

     (Non-Competitive
      Award)

    

      
        	
                STATE
                  AGENCY (Name and Address): 

                 

                New
                  York State Department of Health Office of Managed Care Empire State
                  Plaza
                  Corning Tower, Room 2074

                Albany,
                  NY 12237

                 

              	
                NYS
                  Comptroller's Number: C021236

                 

                 

                Originating
                  Agency Code: 12000

              
	
                _________________________________

                CONTRACTOR
                  (Name and Address): 

                WellCare
                  of New York, Inc.

                11
                  West 19th
                  Street 

                New
                  York, New York 10011

                 

              	
                _________________________________

                TYPE
                  OF PROGRAM:

                 

                Medicaid
                  Advantage

              
	
                CHARITIES
                  REGISTRATION NUMBER: 

                 

                N/A
                  

                 

                FEDERAL
                  TAX IDENTIFICATION NUMBER:

                 

                141676443
                  

                 

                MUNICIPALITY
                  NUMBER (if applicable): 

                 

                N/A

              	
                CONTRACT
                  TERM 

                 

                FROM:
                  April 1,2006

                TO:
                  December 31,2006 

                 

                 

                 

                FUNDING
                  AMOUNT FOR:

                Based
                  on approved capitation rates

              
	
                ____________________________

                STATUS:

                 

              	
                __________________________________________

                THIS
                  CONTRACT IS RENEWABLE FOR FOUR 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

              
	 	 

      

       

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    APPENDICES
      TO THIS AGREEMENT AND INCORPORATED BY REFERENCE INTO THE
      AGREEMENT

     

    -X-
      Appendix A.
      New York
      State Standard Contract Clauses

     

    -X-
      Appendix B.
      Certification Regarding Lobbying

     

    -X-
      Appendix B-l.
      Certification Regarding MacBride Fair Employment Principles

     

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

     

    -X-
      Appendix D.
      New York
      State Department of Health Medicaid Advantage Marketing Guidelines

     

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

     

    -X-
      Appendix F.
      New York
      State Department of Health Medicaid Advantage Action and Grievance System
      Requirements

     

    -X-
      Appendix G.
      RESERVED

     

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

     

    -X-
      Appendix I.
      RESERVED

     

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

     

    -X-
      Appendix K.
      Medicare
      and Medicaid Advantage Products and Non-Covered Services

     

    -X-
      Appendix L.
      Approved
      Capitation Payment Rates

     

    -X-
      Appendix M.
      Service
      Area

     

    -X-
      Appendix N.
      RESERVED

     

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

     

    -X-
      Appendix P.
      RESERVED

     

    -X-
      Appendix Q.
      RESERVED

     

    -X-
      Appendix R.
      Additional Specifications for the Medicaid Advantage Agreement

     

    -X-
      Appendix X.
      Modification Agreement Form

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

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

    

    

    

    
      	
              CONTRACTOR
                SIGNATURE

               

              By:
                /s/  
                Todd S. Farha 

            	
              STATE
                AGENCY SIGNATURE

               

              By:
                /s/
                Donna Frescatore 

            
	
              Todd
                S. Farha

              (print
                name)

            	
              Donna
                Frescatore

              (print
                name)

               

            
	
              Title:
                President
                and Chief Executive Officer

            	
              Title:
                Deputy Director, OMC

            
	
              Date:
                2/24/06

            	
              Date:
                3/22/06

            
	 	
               

              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 24
                day of February
                2006,
                before me personally appeared  Todd
                S. Farha ,
                to
                me known, who being by me duly sworn, did depose and say that he/she
                resides at Tampa,
                Florida ,
                that he/she is the
                President and CEO of
                WellCare of New York , 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.

               

            
	
              /s/
                Rebecca McNeely   

              (Notary)

            	 
	 	 
	ATTORNEY
              GENERAL'S SIGNATURE	
              STATE
                COMPTROLLER’S SIGNATURE

              ___________________________________

            
	
              Title: 
                

            	
              Title

            
	
              Date

            	
              Date

            

    

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    

     

    

    MEDICAID
      ADVANTAGE 

    MODEL
      CONTRACT

     

    January
      1, 2006

     

    State
      Model

     

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    Table
      of Contents for Medicaid Advantage Model Contract

     

    Recitals

     

    Section
      1 Definitions

     

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

    Administration
      Provisions

    2.1 Term

    2.2
      Amendments

    2.3
      Approvals

    2.4
      Entire Agreement

    2.5
      Renegotiation

    2.6
      Assignment and Subcontracting

    2.7
      Termination

    a.
      SDOH
      Initiated Termination

    b.
      Contractor and SDOH Initiated Termination

    c.
      Contractor Initiated Termination

    d.
      Termination Due to Loss of Funding

    2.8
      Close-Out Procedures

    2.9
      Rights and Remedies

    2.10
      Notices

    2.11
      Severability

     

    Section
      3
      Compensation

    3.1
      Capitation Payments

    3.2
      Modification of Rates During Contract Period

    3.3
      Rate
      Setting Methodology

    3.4
      Payment of Capitation

    3.5
      Denial of Capitation Payments

    3.6
      SDOH
      Right to Recover Premiums

    3.7
      Third
      Party Health Insurance Determination

    3.8
      Contractor Financial Liability

    3.9
      Tracking Services Provided by Indian Health Clinics

     

    Section
      4
      Service Area

     

    Section
      5
      Eligibility For Enrollment in Medicaid Advantage

    5.1
      Eligible to Enroll in the Medicaid Advantage Program

    5.2
      Not
      Eligible to Enroll
      in
      the
      Medicaid
      Advantage Program

    5.3
      Change in Eligibility Status

     

    Section
      6
      Enrollment

    6.1
      Enrollment Requirements

    6.2
      Equality of Access to Enrollment

    6.3
      Enrollment Decisions

    6.4
      Prohibition Against Conditions on Enrollment

     

    

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    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
      Medicaid Managed Care Enrollees Who Will Gain Medicare Eligibility

    6.11
      Newborn Enrollment

     

    RESERVED

     

    Disenrollment

    8.1
      Disenrollment Requirements

    8.2
      Disenrollment Prohibitions

    8.3
      Disenrollment Requests

    a.
      Routine Disenrollment Requests b. Non-Routine Disenrollment
      Requests

    8.4
      Contractor Notification of Disenrollments

    8.5
      Contractor's Liability

    8.6
      Enrollee Initiated Disenrollment

    8.7
      Contractor Initiated Disenrollment

    8.8LDSS
      Initiated Disenrollment

     

    Guaranteed
      Eligibility

    9.1
      General Requirements

    9.2
      Right
      to Guaranteed Eligibility

    9.3
      Covered Services During Guaranteed Eligibility

    9.4
      Disenrollment During Guaranteed Eligibility

     

    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 

    a.
      Diagnosis and Treatment of Tuberculosis 

    b.
      Family
      Planning and Reproductive Health Services 

    c.
      Article 28 Clinics Operated by Academic Dental Centers

    10.10
      Coordination with Local Public Health Agencies

    10.11
      Public Health Services

    a.
      Tuberculosis Screening, Diagnosis and Treatment; Directly Observed Therapy
      (TB/DOT)

    

    

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      Advantage Contract 

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      OF
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      2006 

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    b.
      Immunizations 

    c.
      Prevention and Treatment of Sexually Transmitted Diseases

    10.12
      Adults with Chronic Illnesses and Physical or Developmental
      Disabilities

    10.13
      Persons Requiring Ongoing Mental Health Services

    10.14
      Member Needs Relating to HI V

    10.15
      Persons Requiring Chemical Dependence Services

    10.16
      Native Americans

    10.17
      Urgently Needed Services

    10.18
      Dental Services Provided by Article 28 Clinics Operated by Academic Dental
      Centers Not Participating in Contractor's Network

    10.19
      Coordination of Services

     

    Section
      11 Marketing

    11.1
      Marketing Requirements

     

    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
      Member ID Cards

    13.3
      Member Handbooks

     

    Section
      14 Organization Determinations, Actions, and Grievance System

    14.1
      General Requirements

    14.2
      Filing and Modification of Medicaid Advantage Action and Grievance System
      Procedures

    14.3
      Medicaid Advantage Action and Grievance System Additional
      Provisions

    14.4
      Notification of Medicaid Advantage Action and Grievance System
      Procedures

    14.5
      Complaint, Complaint Appeal and Action Appeal Investigation
      Determinations

    

    Section
      15 Access Requirements 

    Section
      16 Quality Management and Performance Improvement

    Section
      17 Monitoring and Evaluation

    17.1
      Right To Monitor Contractor Performance

    17.2
      Cooperation During Monitoring And Evaluation

    17.3
      Cooperation During On-Site Reviews

    17.4
      Cooperation During Review of Services by External Review Agency

     

    

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    Section
      18 Contractor Reporting Requirements

    18.1
      General Requirements

    18.2
      Time
      Frames for Report Submissions

    18.3
      SDOH
      Instructions for Report Submissions

    18.4
      Liquidated Damages

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

    18.6
      Reporting Requirements

    18.7
      Ownership and Related Information Disclosure

    18.8
      Public Access to Reports

    18.9
      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

     

    Section
      19 Records Maintenance and Audit Rights

    19.1
      Maintenance of Contractor Performance Records

    19.2
      Maintenance of Financial Records and Statistical Data

    19.3
      Access to Contractor Records

    19.4
      Retention Periods

     

    Section
      20 Confidentiality

    20.1
      Confidentiality of Identifying Information about Enrollees, Eligible Persons
      and
      Prospective Enrollees

    20.2
      Confidentiality of Medical Records

    20.3
      Length of Confidentiality Requirements

     

    Section
      21 Participating Providers

    21.1
      General Requirements

    21.2
      Medicaid Advantage Network Requirements

    21.3
      SDOH
      Exclusion or Termination of Providers

    21.4
      Payment in Full

    21.5
      Dental Networks

     

    Section
      22 Subcontracts and Provider Agreements for Medicaid Only 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
      Physician Incentive Plan

     

    Section
      23 Americans With Disabilities Act Compliance Plan

    

    

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    Section
      24 Fair Hearings

    24.1
      Enrollee Accessto
      Fair
      Hearing
      Process

    24.2
      Enrollee Rights to a Fair Hearing

    24.3
      Contractor Notice to Enrollees

    24.4
      Aid
      Continuing

    24.5
      Responsibilities of SDOH

    24.6
      Contractor's Obligations

     

    Section
      25 External Appeal

    25.1
      Basis for External Appeal

    25.2
      Eligibility for External Appeal

    25.3
      External Appeal Determination

    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

    

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      Advantage Contract 

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    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 ofEnrollees for Contractor's Debts

    34.7
      SDOH
      Compliance with Conflict of Interest Laws

    34.8
      Compliance Plan

     

    Section
      35 New York State Standard Contract Clauses

    

    
 

    

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      2006 

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    Table
      of
      Contents for Medicaid Advantage Model Contract 

    APPENDICES

     

    A.
      New
      York State Standard Contract Clauses

     

    B.
      Certification Regarding Lobbying

     

    B-l.
      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 HealthMedicaid Advantage Marketing
      Guidelines

     

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

     

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

     

    G.
      RESERVED

     

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

     

    I.
      RESERVED

     

    J.
      New
      York State Department of Health Guidelines of Federal Americans with
      Disabilities Act

     

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

     

    L.
      Approved Capitation Payment Rates

     

    M.
      Service Area

     

    N.
      RESERVED

     

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

     

    P.
      RESERVED

     

    Q.
      RESERVED

     

    R.
      Additional Specifications for the Medicaid Advantage Agreement

    

    Medicaid
      Advantage Contract

    TABLE
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      2006 

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    Table
      of Contents for Medicaid AdvantageModel
      Contract

     

    X. Modification
      Agreement Form

    

    

    

    

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    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.
      Section 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 Section 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 Section 4400 et seq.,
      and
      Prepaid Health Services Plans (PHSPs), PHL Section 4403-a; 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 PHSP, 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 or Article 43
      of
      the NYS Insurance Law; and

     

    WHEREAS,
      the Contractor has applied to participate in the Medicaid Managed 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 Sections 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 Part
      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 sections
      1860D-1 through 1860D-42 of the Social Security Act and Subpart K of 42 CFR
      Part
      422 or is a Specialized Medicare Advantage Plan for Special Needs Individuals
      which includes qualified Medicare Part D prescription drug coverage;
      and

    

     

    Medicaid
      Advantage Contract 

    RECITALS

    State
      2006 

    Page
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    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 prescription drug benefit) and the Medicaid Advantage Product
      as defined in this Agreement and has proposed to provide coverage of these
      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 Contract 

    RECITALS

    State
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    1.
      DEFINITIONS

     

    "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 Benefit
      Package.

     

    "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 Benefit Packages.

     

    "Days"
      means
      calendar days except as otherwise stated.

     

    "Department
      of Health and Mental Hygiene" or "DOHMH"
      means
      the New York City Department of Health and Mental Hygiene.

     

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

     

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

     

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

     

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

     

    Medicaid
      Advantage Contract

    SECTION
      1

    (DEFINITIONS)
      

    State
      2006

    1-1

    

    "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 Product pursuant to Section
      6 of this Agreement.

     

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

     

    "Enrollment
      Broker"
      means
      the state and/or county-contracted entity that provides enrollment, education,
      and outreach services; effectuates Enrollments and Disenrollments in the
      Medicaid Advantage Program; and provides other contracted services on behalf
      of
      the SDOH and the LDSS.

     

    "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.

     

    "Guaranteed
      Eligibility"
      means
      the period beginning on the Enrollee's Effective Date of Enrollment in the
      Contractor's Medicaid Advantage Product and ending six (6) months thereafter,
      during which the Enrollee, who remains enrolled in the Contractor's Medicare
      Advantage Product, may be entitled to continued enrollment in the Contractor's
      Medicaid Advantage Product despite the loss of Medicaid eligibility as set
      forth
      in Section 9 of this Agreement.

     

    "Health
      Provider
      Network"
      or "HPN" means a closed communication network dedicated to secure data exchange
      and distribution of health related information between various health facility
      providers and the SDOH. HPN functions include: collection of 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).

     

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

     

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

     

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

     

    Medicaid
      Advantage Contract

    SECTION
      1

    (DEFINITIONS)
      

    State
      2006 

    1-2

    

    "Marketing"
      means
      activity of the Contractor, subcontractor or individuals or entities affiliated
      with the Contractor, as described in AppendixD,
      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 Product.

     

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

     

    "Medicaid
      Advantage 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-l of this Agreement, if any, included in the Capitation
      Rate paid to the MCO by the State.

     

    "Medicaid
      Advantage Program"
      means
      the program that the State has developed to enroll persons who are Dually
      Eligible in Medicaid managed care pursuant 364-j of the Social Services
      Law.

     

    "Medicaid
      Advantage 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
      Only
      Covered
      Services" means those services included in the Medicaid Advantage 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.

     

    "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-l 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.

     

    Medicaid
      Advantage Contract 

    SECTION
      1

    (DEFINITIONS)

    State
      2006

    1-3

    

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

     

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

     

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

     

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

     

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

     

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

     

    "Prospective
      Enrollee"
      means
      any Eligible Person as defined in this Agreement that has not yet enrolled
      in
      the Contractor's Medicaid Advantage Product.

     

    

    Medicaid
      Advantage Contract 

    SECTION
      1

    (DEFINITIONS)
      

    State
      2006

    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.

     

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

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

    

    

    

    Medicaid
      Advantage Contract 

    SECTION
      1

    (DEFINITIONS)
      

    State
      2006

    1-5

     

     

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

     

    2.1
      Term

     

    a)
      This
      Agreement is effective April 1, 2006 and shall remain in effect until December
      31, 2006 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 four 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 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
      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.

     

    b)
      SDOH
      will make reasonable efforts to provide the Contractor with notice and
      opportunity to comment with regard to proposed amendment of
      this

     

    Medicaid
      Advantage Contract

    SECTION
      2

    (AGREEMENT
      TERM, AMENDMENTS, EXTENSIONS,

    AND
      GENERAL CONTRACT ADMINISTRATION PROVISIONS)

    State
      2006

    2-1

    

    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. SDOH will provide a notice of such
      approvals to the Contractor.

     

    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 and/or LDSS pursuant
      to this Agreement, contains all the terms and conditions agreed upon by the
      parties, and no other Agreement, oral or otherwise, regarding the subject matter
      of this Agreement shall be deemed to exist or to bind any of the parties or
      vary
      any of the terms contained in this Agreement. In the event of any inconsistency
      or conflict among the document elements of this Agreement, such inconsistency
      or
      conflict shall be resolved by giving precedence to the document elements in
      the
      following order:

     

    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 Marketing Plan, if applicable, on file with SDOH and
      LDSS

    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

     

    Medicaid
      Advantage Contract 

    SECTION
      2

    (AGREEMENT
      TERM, AMENDMENTS, EXTENSIONS, 

    AND
      GENERAL CONTRACT ADMINISTRATION PROVISIONS) 

    State
      2006 

    2-2

    

    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.

     

    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 Parts 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 Contract 

    SECTION
      2

    (AGREEMENT
      TERM, AMENDMENTS, EXTENSIONS, 

    AND
      GENERAL CONTRACT ADMINISTRATION PROVISIONS) 

    State
      2006 

    2-3

    

    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, ofSDOH'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 Sections 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
§ 4404, and:

     

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

     

    B.
      If
      such action results in the Contractor retaining authority to serve some portion
      of the contracted service area, the Contractor shall continue to offer its
      Medicaid Advantage Product under this Agreement in any designated geographic
      area not affected by such action, and shall terminate its Medicaid Advantage
      Product in the geographic areas where the Contractor ceases to have authority
      to
      serve.

    

     

    Medicaid
      Advantage Contract 

    SECTION
      2

    (AGREEMENT
      TERM, AMENDMENTS, EXTENSIONS, 

    AND
      GENERAL CONTRACT ADMINISTRATION PROVISIONS) 

    State
      2006 

    2-4

    

     

    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 Product.

     

    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 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.

     

    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

     

    Medicaid
      Advantage Contract 

    SECTION
      2

    (AGREEMENT
      TERM, AMENDMENTS, EXTENSIONS, AND

    GENERAL
      CONTRACT ADMINISTRATION PROVISIONS)

    State
      2006 

    2-5

    

    orderly
      disenrollment of Enrollees from the Contractor's Medicaid Advantage
      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 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 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 Only Covered 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
      Only
      Covered 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
      Product.

     

    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.

    

    Medicaid
      Advantage Contract 

    SECTION
      2

    (AGREEMENT
      TERM, AMENDMENTS, EXTENSIONS, 

    AND
      GENERAL CONTRACT ADMINISTRATION PROVISIONS) 

    State
      2006 

    2-6

    

    2.8
      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 that the LDSS, and
      the
      SDOH have approved. The close-out procedures shall include the
      following:

     

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

     

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

     

    iii)
      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)
      The
      Contractor shall establish an appropriate plan acceptable to and prior approved
      by the SDOH for the orderly disenrollment of Enrollees from the Contractor's
      Medicaid Advantage Product;

     

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

     

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

     

    2.9
      Rights and Remedies

     

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

     

    Medicaid
      Advantage Contract SECTION
      2

    (AGREEMENT
      TERM, AMENDMENTS, EXTENSIONS, 

    AND
      GENERAL CONTRACT ADMINISTRATION PROVISIONS) 

    State
      2006 

    2-7

    

    2.10
      Notices

     

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

     

    For
      SDOH:

    New
      York
      State Department of Health Empire State Plaza Corning Tower, Rm. 2074 Albany,
      NY
      12237-0065

     

    For
      the
      Contractor:

    Chief
      Executive Officer WellCare of New York, Inc. 11 West 19th
      Street
      New York, New York 10011

     

    2.11 Severability

     

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

     

    Medicaid
      Advantage Contract

    SECTION
      2

    (AGREEMENT
      TERM, AMENDMENTS, EXTENSIONS, 

    AND
      GENERAL CONTRACT ADMINISTRATION PROVISIONS) 

    State
      2006 

    2-8

    

    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 for all services that the Contractor provides
      pursuant to 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 in effect as of April 1, 2006 and thereafter, 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.

     

    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

     

    Medicaid
      Advantage Contract 

    SECTION
      3

    (COMPENSATION)

    State
      2006 

    3-1

     

    

    for
      the
      month in which Disenrollment occurs. The Roster generated by SDOH with any
      modification communicated electronically or in writing by the LDSS or the
      Enrollment Broker prior to the end of the month in which the Roster is
      generated, shall be the Enrollment list for purposes of eMedNY premium billing
      and payment, as discussed in Section 6.7 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 Section 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, the
      Enrollment Broker, or an Enrollee, Prospective Enrollee, or health care
      provider, or failed to comply with federal requirements (i.e. 42 CFR § 422.208
      and 42 CFR § 438.6 (h)) relating to the Physician Incentive Plans, SDOH and LDSS
      will deny capitation payments to the Contractor for the same Enrollees for
      the
      period of time for which CMS denies such payment.

     

    3.6
      SDOH
      Right to Recover Premiums

     

    The
      parties acknowledge and accept that the SDOH has a right to recover premiums
      paid to the Contractor for Enrollees listed on the monthly Roster who are later
      determined for the entire applicable payment month, to have been disenrolled
      from the Contractor's Medicare Advantage Product; to have been in an
      institution; to have been incarcerated; to have moved out of the Contractor's
      service area subject to any time remaining in the Enrollee's Guaranteed
      Eligibility period; 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 Benefit Package
      services for any portion of the payment period.

     

    Medicaid
      Advantage Contract 

    SECTION
      3

    (COMPENSATION)
      

    State
      2006 

    3-2

    

    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 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 Product.

     

    3.9
      Tracking Services Provided by Indian Health Clinics

     

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

     

    Medicaid
      Advantage Contract

    SECTION
      3

    (COMPENSATION)
      

    State
      2006 

    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 to enroll in the Contractor's
      Medicaid Advantage Product.

     

    

    Medicaid
      Advantage Contract 

    SECTION
      4

    (SERVICE
      AREA) 

    State
      2006 

    4-1

     

    

    5.
      ELIGIBILITY FOR ENROLLMENT IN MEDICAID ADVANTAGE

     

    5.1
      Eligible to Enroll in the Medicaid Advantage 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 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 21 years of age or older; and

     

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

     

    b)
      Participation in the Medicaid Advantage Program and enrollment in the
      Contractor's Medicaid Advantage Product shall be voluntary for all Eligible
      Persons.

     

    5.2
      Not
      Eligible to Enroll in the Medicaid Advantage Program

     

    Persons
      meeting the following criteria are not eligible to enroll in the Contractor's
      Medicaid Advantage 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 become eligible for Medical Assistance only after spending
      down
      a portion of their income.

     

    

    Medicaid
      Advantage Contract 

    SECTION
      5

    (ELIGIBLE,
      EXEMPT AND EXCLUDED POPULATIONS)

    State
      2006 

    5-1

     

    

    d)
      Individuals who are residents of State-operated psychiatric facilities or
      residents of State-certified or voluntary treatment facilities for children
      and
      youth.

     

    e)
      Individuals who are residents of Residential Health Care Facilities ("RHCF")
      at
      the time of Enrollment, and Enrollees whose stay in a RHCF is classified as
      permanent upon entry into the RHCF or is classified as permanent at a time
      subsequent to entry.

     

    f)
      Individuals enrolled in managed long term care demonstrations authorized under
      Article 4403-fofthe New York State PHL.

     

    g)
      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.

     

    h)
      Individuals expected to be eligible for Medicaid for less than six (6) "months,
      except for pregnant women (e.g., seasonal agricultural•workers).

     

    i)
      Individuals in receipt of long-term care services through Long Term Home Health
      Care programs (except ICF services for the ,Developmentally
      Disabled).

     

    j)
      Individuals eligible for Medical Assistance benefits only with respect to TB
      related services.

    

    k)
      Individuals placed in State Office of Mental Health licensed family care homes
      pursuant to NYS Mental Hygiene Law, Section 31.03.

    

    1)
      Individuals enrolled in the Restricted Recipient Program. 

    

    m)
      Individuals with a "County of Fiscal Responsibility" code of 99.

     

    n)
      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).

     

    o)
      Individuals with a "County of Fiscal Responsibility" code of 97 (OMH in
      eMedNY).

    

     

    Medicaid
      Advantage Contract

    SECTION
      5

    (ELIGIBLE,
      EXEMPT AND EXCLUDED POPULATIONS) 

    State
      2006 

    5-2

    

    p)
      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 managed care.

     

    q)
      Individuals receiving family planning services pursuant to Section 366(l)(a)(ll)
      of the Social Services Law who are not otherwise eligible for medical assistance
      and whose net available income is 200% or less of the federal poverty
      level.

     

    r)
      Individuals who are eligible for Medical Assistance pursuant to the "Medicaid
      buy-in for the working disabled" (subparagraphs twelve or thirteen of paragraph
      (a) of subdivision one of Section 366 of the Social Services Law), and who,
      pursuant to subdivision 12 of Section 367-a of the Social Services Law, are
      required to pay a premium.

     

    s)
      Individuals who are eligible for Medical Assistance pursuant to paragraph (v)
      of
      subdivision four of Section 366 of the Social Services Law (persons who are
      under 65 years of age, have been screened for breast and/or cervical cancer
      under the Centers for Disease Control and Prevention Breast and Cervical Cancer
      Early Detection Program and need treatment for breast or cervical cancer, and
      are not otherwise covered under creditable coverage as defined in the Federal
      Public Health Service Act).

     

    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, 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 nursing home or other residential
      institution or program rendering the individual ineligible for enrollment in
      Medicaid Advantage; 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 plan eligibility and enrollment.

     

    Medicaid
      Advantage Contract SECTION
      5

    (ELIGIBLE,
      EXEMPT AND EXCLUDED POPULATIONS)

    State
      2006 

    5-3

    

    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
      Product shall be voluntary. However, as a condition of eligibility for Medicaid
      Advantage, individuals may only enroll in the Contractor's Medicaid Advantage
      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
      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 and the LDSS 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
      and
      the LDSS must notify the Enrollee of the change.

     

    

    Medicaid
      Advantage Contract 

    SECTION
      6

    (ENROLLMENT)
      

    State
      2006 

    6-1

    d)
      An
      Enrollee's Effective Date of Enrollment shall be the first day of the month
      on
      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.

     

    6.6
      Contractor Liability

     

    As
      of the
      Effective Date of Enrollment, and until the Effective Date of Disenrollment
      from
      the Contractor's product, the Contractor shall be responsible for the provision
      and cost of the Medicaid Advantage 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 or the Enrollment Broker. If the LDSS or Enrollment
      Broker notifies the Contractor in writing or electronically of changes in the
      Roster and provides supporting information as necessary prior to the effective
      date of the Roster, the Contractor will accept that notification in the same
      manner as the Roster.

     

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

     

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

     

    6.8
      Automatic Re-Enrollment

     

    An
      Enrollee who is disenrolled from the Contractor's Medicaid Advantage Product
      due
      to loss of Medicaid eligibility and who regains eligibility within a three
      (3)
      month period will be automatically prospectively re-enrolled in the Contractor's
      Medicaid Advantage Product, provided that the individual remains enrolled in
      the
      Contractor's Medicare Advantage Product as defined in this Agreement
      unless:

    

     

    Medicaid
      Advantage Contract 

    SECTION
      6

    (ENROLLMENT)
      

    State
      2006 

    6-2

     

    

    i)
      the
      Contractor does not offer a Medicaid Advantage product in the Enrollee's county
      of fiscal responsibility; or

    ii)
      the
      Enrollee indicates in writing that he/she wishes to enroll in another MCO's
      Medicaid and Medicare Advantage Products, or receive Medicaid coverage through
      Medicaid fee-for-service.

     

    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 Product retroactive to the Effective Date of
      Enrollment.

     

    6.10
      Medicaid Managed Care Enrollees Who Will Gain Medicare Eligibility

     

    Medicaid
      managed care enrollees who will gain Medicare coverage may elect to transfer
      to
      the Contractor's Medicaid and Medicare Advantage Products or to enroll in
      another MCO's Medicaid and Medicare Advantage Products for dually eligible
      individuals. A new enrollment must be processed by the LDSS or the Enrollment
      Broker to transfer a member of the Contractor's Medicaid managed care product
      to
      the Contractor's Medicaid Advantage Product. To the extent possible, such
      enrollments shall be made effective the first day of the month that the
      Enrollee's Medicare Advantage coverage is effective.

     

    6.11
      Newborn Enrollment

     

    a)
      A
      pregnant Enrollee in the Contractor's Medicaid Advantage Product may choose
      to
      pre-enroll her unborn in any available Medicaid managed care health plan in
      the
      social services district in which she resides.

     

    b)
      The
      Contractor shall notify the local district in writing of any enrollee that
      is
      pregnant within 30 days of knowledge of the pregnancy. Notification shall
      include the pregnant woman's name, CIN, and expected date of
      confinement.

     

    c)
      Upon
      the newborn's birth, the Contractor must send identification of the infant's
      demographic data to the LDSS within 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 available), sex and the date of birth.

     

    d)
      The
      SDOH and LDSS shall be responsible for ensuring that timely Medicaid eligibility
      determination and Enrollment of the newborn is effected consistent

    

    Medicaid
      Advantage Contract

    SECTION
      6

    (ENROLLMENT)
      

    State
      2006 

    6-3

    

    with
      state laws, regulations, and policy with the newborn Enrollment requirements
      set
      forth in Appendix H of this Agreement.

    

     

    Medicaid
      Advantage Contract 

    SECTION
      6

    (ENROLLMENT)
      

    State
      2006 

    6-4

     

    

    7. RESERVED

    

    

     

    Medicaid
      Advantage Contract 

    SECTION
      7

    (LOCK-IN
      PROVISIONS)

    State
      2006 

    7-1

    

    8.
      DISENROLLMENT

     

    8.1
      Disenrollment Requirements

     

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

     

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

     

    8.2
      Disenrollment Prohibitions

     

    Enrollees
      shall not be disenrolled from the Contractor's Medicaid Advantage Product based
      on any of the following reasons:

     

    i)
      an
      existing condition or a change in the Enrollee's health which would necessitate
      disenrollment pursuant to the terms of this Agreement, unless the change results
      in the Enrollee becoming ineligible for Medicaid Advantage enrollment as
      described in Section 5 of this Agreement;

     

    ii)
      any
      of the factors listed in Section 33 (Non-Discrimination) of this Agreement;
      or

     

    iii)
      the
      Capitation Rate payable to the Contractor.

     

    8.3
      Disenrollment Requests

     

    a)
      Routine Disenrollment Requests

     

    The
      LDSS
      or the Enrollment Broker is responsible for processing routine Disenrollment
      requests 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.

     

    b)
      Non-Routine Disenrollment Requests

     

    i)
      Enrollees with an urgent medical need to disenroll from the Contractor's
      Medicaid Advantage Product may request an expedited Disenrollment by the LDSS.
      Enrollees who have HIV, ESRD or SPMI/SED status are categorically eligible
      for
      expedited Disenrollment on the basis of urgent medical need.

    ii)
      Enrollees with a complaint of Non-consensual Enrollment may request an expedited
      Disenrollment by the LDSS.

     

    Medicaid
      Advantage Contract 

    SECTION
      8

    (DISENROLLMENT)

    State
      2006 

    8-1

    

    iii)
      Homeless Enrollees residing in the shelter system may request an expedited
      disenrollment by the LDSS.

    iv)
      An
      expedited Disenrollment from the Contractor's Medicaid Advantage Product may
      also be warranted in instances when the LDSS leams that an Enrollee is
      disenrolling from the Contractor's Medicare Advantage Product. In such
      instances, the LDSS will disenroll the individual effective concurrent with
      the
      Effective Date of Disenrollment from the Contractor's Medicare Advantage
      Product. 

    v)
      Retroactive Disenrollments from the Contractor's Medicaid Advantage Product
      may
      be warranted in rare instances and may be • requested of the LDSS as described
      in Appendix H of this Agreement. 

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

     

    8.4
      Contractor Notification of Disenrollments

     

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

     

    b)
      In the
      event that the LDSS intends to retroactively disenroll an Enrollee on a date
      prior to the first day of the month of the disenrollment request, the LDSS
      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 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 Benefit Package during the month.

     

    8.5
      Contractor's Liability

     

    a)
      The
      Contractor is not responsible for providing the Medicaid Advantage Benefit
      Package under this Agreement after the Effective Date of
      Disenrollment.

    

    Medicaid
      Advantage Contract 

    SECTION
      8

    (DISENROLLMENT)
      

    State
      2006 

    8-2

    8.6
      Enrollee Initiated Disenrollment

     

    An
      Enrollee may disenroll from the Contractor's Medicaid Advantage Plan for any
      reason. Disenrollments generally shall be effective on the first of the month
      following receipt of the complete written Disenrollment request.

     

    8.7
      Contractor Initiated Disenrollment

     

    a)
      The
      Contractor must notify the LDSS and initiate an Enrollee's Disenrollment from
      the Contractor's Medicaid Advantage Product in the following cases:

     

    i)
      A
      change in residence makes the Enrollee ineligible to be a member of the
      plan;

    ii)
      The
      Enrollee disenrolls from 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 as described in Section 5 of this Agreement.

     

    b)
      The
      Contractor may initiate an Enrollee's disenrollment from the Contractor's
      Medicaid Advantage Product in the following cases:

     

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

    ii)
      The
      Enrollee provides fraudulent information on an enrollment form or the Enrollee
      permits abuse of an enrollment card in the Medicaid Advantage Program except
      when the Enrollee is no longer eligible for Medicaid and is in his/her
      Guaranteed Eligibility period.

    iii)
      Consistent with 42 CFR 438.56 (b), the Contractor may not request Disenrollment
      because of an adverse change in the Enrollee's health status, or because of
      the
      Enrollee's utilization of medical services, diminished mental capacity, or
      uncooperative or disruptive behavior resulting from the Enrollee's special
      needs
      (except where continued enrollment in the Contractor's plan seriously impairs
      the Contractor's ability to furnish services to either the Enrollee or other
      Enrollees).

     

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

     

    Medicaid
      Advantage Contract

    SECTION
      8

    (DISENROLLMENT)
      

    State
      2006

    8-3

    

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

     

    8.8
      LDSS
      Initiated Disenrollment

     

    a)
      The
      LDSS is responsible for promptly initiating Disenrollment from the Contractor's
      Medicaid Advantage Product when:

     

    i)
      an
      Enrollee fails to enroll or stay enrolled in the Contractor's Medicare Advantage
      Product as specified in Sections 6.9 and 8.3(b)(iv) of this Agreement; or

     

    ii)
      an
      Enrollee is no longer eligible for Medicaid or Medicaid Advantage; benefits;
      or

     

    iii)
      the
      Guaranteed Eligibility period ends (See Section 9) and an Enrollee, is no longer
      eligible for any Medicaid benefits; or 

     

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

     

    v)
      an
      Enrollee becomes ineligible for Enrollment pursuant to Section 5.2 of this
      Agreement, as appropriate.

     

     

    Medicaid
      Advantage Contract 

    SECTION
      8

    (DISENROLLMENT)
      

    State
      2006 

    8-4

    

    9.
      GUARANTEED ELIGIBILITY

     

    9.1
      General Requirements

     

    SDOH
      and
      the Contractor will follow the policies in this section subject to state and
      federal laws and regulations.

     

    9.2
      Right
      to Guaranteed Eligibility

     

    a)
      New
      Enrollees, other than those identified in Section 9.2 who would otherwise lose
      Medicaid eligibility during the first six (6) months of enrollment, will retain
      the right to remain enrolled in the Contractor's Medicaid Advantage Product
      under this Agreement for a period of six (6) months from their Effective Date
      of
      Enrollment as long as they also remain enrolled in the Contractor's Medicare
      Advantage Product as defined in this Agreement.

     

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

     

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

     

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

     

    c)
      If,
      during the first six (6) months of enrollment in the Contractor's Medicaid
      Advantage Product, an Enrollee becomes eligible for Medicaid only as a
      spend-down, the Enrollee will be eligible to remain enrolled in the Contractor's
      Medicaid Advantage Product for the remainder of the six (6) month Guaranteed
      Eligibility period as long as he/she also remains enrolled in the Contractor's
      Medicare Advantage Product. During the six (6) month Guaranteed Eligibility
      period, an Enrollee eligible for spend-down has the option of spending down
      to
      gain full Medicaid eligibility. If the Enrollee spends down to gain full
      Medicaid eligibility, the Enrollee will no longer be in guarantee status and
      the
      LDSS will manually set coverage codes as appropriate.

     

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

     

    Medicaid
      Advantage Contract

    SECTION
      9

    (GUARANTEED
      ELIGIBILITY) 

    State
      2006 

    9-1

     

    9.3
      Covered Services During Guaranteed Eligibility

     

    The
      services covered during the Guaranteed Eligibility period shall be those
      contained in the Medicaid Advantage Benefit Package, as specified in Appendix
      K-2, and free access to family planning and reproductive health services as
      set
      forth in Section 10.6 of this Agreement. During the Guaranteed Eligibility
      period Enrollees are also eligible for pharmacy services not covered by the
      Medicare Advantage Product (Part B and Part D pharmacy benefits) on a Medicaid
      fee-for-service basis.

     

    9.4
      Disenrollment During Guaranteed Eligibility

     

    a)
      An
      Enrollee-initiated disenrollment from the Contractor's Medicare or Medicaid
      Advantage Product terminates the Enrollee's Guaranteed Eligibility
      period.

     

    b)
      During
      the guarantee period, an Enrollee may not change health plans. An Enrollee
      may
      choose to disenroll from the Contractor's Medicaid Advantage Product during
      the
      guarantee period but is not eligible to enroll in another MCO's Medicaid
      Advantage Product because he/she has lost eligibility for Medicaid.

     

    Medicaid
      Advantage Contract 

    SECTION
      9

    (GUARANTEED
      ELIGIBILITY) 

    State
      2006 

    9-2

    10.
      BENEFIT PACKAGE, COVERED AND NON-COVERED SERVICES

     

    10.1
      Contractor 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 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 Benefit Package, as
      described in Appendix K-2 of this Agreement, to Enrollees of the Contractor's
      Medicaid Advantage 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 Section 363-a of
      the
      State Social Services Law, and all 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 Benefit Packages are available to, and
      accessible by, Medicaid Advantage Enrollees.

     

    10.3
      Benefit Package and Non-Covered Services Descriptions

     

    The
      Medicare and Medicaid Advantage 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 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 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 Contract 

    SECTION
      10

    (BENEFIT
      PACKAGE, COVERED AND NON-COVERED SERVICES) 

    State
      2006 

    10-1

    

    10.5
      Court-Ordered Services

     

    a)
      The
      Contractor shall provide any Medicare and Medicaid Advantage 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 and Medicaid Advantage 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
      covered services. The Contractor is responsible for payment of those services
      as
      covered by the Contractor's Medicare and Medicaid Advantage 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.

     

    i)
      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.

     

    b)
      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.

     

    c)
      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.

     

    Medicaid
      Advantage Contract 

    SECTION
      10

    (BENEFIT
      PACKAGE, COVERED AND NON-COVERED SERVICES) 

    State
      2006

    10-2

    

    d)
      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)
      Triage
      Fees: For emergency room services that do not meet the definition of Emergency
      Medical Conditions and for which the Contractor denies the Medicare Benefit,
      the
      Contractor shall pay the hospital a triage fee of $40.00 in the absence of
      a
      negotiated rate. Non-participating emergency departments cannot be denied a
      payment on the basis of non-notification.

     

    10.8
      Medicaid Utilization Thresholds (MUTS)

     

    Enrollees
      may be subject to MUTS for services which are billed to Medicaid fee-for-service
      and for dental services provided without referral at Article 28 clinics operated
      by academic dental centers as described in Section 10.18 of this Agreement.
      Enrollees are not otherwise subject to MUTS for services included in the
      Medicaid Advantage Benefit Package.

     

    Medicaid
      Advantage Contract 

    SECTION
      10

    (BENEFIT
      PACKAGE, COVERED AND NON-COVERED SERVICES) 

    State
      2006 

    10-3

    

    10.9
      Services for Which Enrollees Can Self-Refer

     

    In
      addition to those services for which Medicare Advantage Enrollees can
      self-refer, Medicaid Advantage Enrollees may self-refer to:

     

    a)
      Public
      health agency facilities for the diagnosis and/or treatment of TB as described
      in Section 10.11 (a) (i) of this Agreement.

     

    b)
      Family
      Planning and Reproductive Health services as described in Section 10.6 and
      Appendix C of this Agreement.

     

    c)
      Article 28 clinics operated by academic dental centers to obtain covered dental
      services as described in Section 10.18 of this Agreement.

     

    10.10
      Coordination with Local Public Health Agencies

     

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

     

    10.11
      Public Health Services

     

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

     

    i)
      Consistent with New York State law, public health clinics are required to
      provide or arrange for treatment to individuals presenting with tuberculosis,
      regardless of the person's insurance or enrollment status.

    ii)
      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.

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

    iv)
      The
      Contractor shall inform participating providers of their responsibility to
      report TB cases to the LPHA.

     

     

    Medicaid
      Advantage Contract 

    SECTION
      10

    (BENEFIT
      PACKAGE, COVERED AND NON-COVERED SERVICES) 

    State
      2006 

    10-4

     

    v)
      Enrollees may self-refer to public health agency facilities for the diagnosis
      and/or treatment ofTB.

    A.
      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.

    B.
      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.

    C.
      The
      LPHA is responsible for: 1) giving notification to the Contractor before
      delivering TB-related services, if so required in the public health agreement
      established pursuant to Section 10.10, 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.

    D.
      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.

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

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

    

    vi)
      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. 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. vii)
      HIV counseling and testing provided to a Medicaid Advantage 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.

     

    

    Medicaid
      Advantage Contract 

    SECTION
      10

    (BENEFIT
      PACKAGE, COVERED AND NON-COVERED SERVICES) 

    State
      2006 

    10-5

    

    b)
      Immunizations

    i)
      The
      Contractor agrees to reimburse the Local Public Health Agency when Enrollees
      self-refer to Local Public Health Agencies 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 leams 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.

     

    c)
      Prevention and Treatment of Sexually Transmitted Diseases

     

    The
      Contractor will be responsible for ensuring that its Participating Providers
      educate their Enrollees about the risk and prevention of sexually transmitted
      disease (STD). The Contractor also will be responsible for ensuring that its
      Participating Providers screen and treat Enrollees for STDs and report cases
      of
      STD to the 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.

     

    10.12
      Adults with Chronic Illnesses and Physical or Developmental
      Disabilities

     

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

    

    i)
      Satisfactory methods for ensuring that the Contractor is in compliance with
      the
      ADA and Section 504 of the Rehabilitation Act of 1973. Program accessibility
      for
      persons with disabilities shall be in accordance with Section 23 of this
      Agreement.

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

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

     

    Medicaid
      Advantage Contract 

    SECTION
      10

    (BENEFIT
      PACKAGE, COVERED AND NON-COVERED SERVICES) 

    State
      2006 

    10-6

    

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

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

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

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

    iv)
      Guidelines for determining specific needs of Enrollees in case management,
      including specialist physician referrals, durable medical equipment, home health
      services, self management education and training, etc.

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

     

    10.13
      Persons Requiring Ongoing Mental Health Services

     

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

     

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

    ii)
      Satisfactory case management systems or satisfactory case
      management.

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

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

     

    10.14
      Member 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:

    i)
      Anonymous testing may be furnished to the Enrollee without prior approval by
      the
      Contractor and may be conducted at anonymous testing

     

     

    Medicaid
      Advantage Contract 

    SECTION
      10

    (BENEFIT
      PACKAGE, COVERED AND NON-COVERED SERVICES) 

    State
      2006 

    10-7

    

    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 drug use and sexual
      risk activities), and should be culturally and linguistically appropriate.
      HIV
      primary prevention means the reduction or control of causative factors for
      HIV,
      including the reduction of risk factors. HIV Primary prevention includes
      strategies to help prevent uninfected Enrollees from acquiring HIV, i.e.,
      behavior counseling for HIV negative Enrollees with risk behavior. Primary
      prevention also includes strategies to help prevent infected Enrollees from
      transmitting HIV infection, i.e., behavior counseling with an HIV infected
      Enrollee to reduce risky sexual behavior or providing antiviral therapy to
      a
      pregnant, HIV infected female to prevent transmission of HIV infection to a
      newborn. HIV Secondary Prevention means promotion of early detection and
      treatment of 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 EPHA.

     

    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 Contract 

    SECTION
      10

    (BENEFIT
      PACKAGE, COVERED AND NON-COVERED SERVICES) 

    State
      2006 

    10-8

    

    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.

     

    10.15
      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).

    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.

     

    Medicaid
      Advantage Contract 

    SECTION
      10

    (BENEFIT
      PACKAGE, COVERED AND NON-COVERED SERVICES) 

    State
      2006 

    10-9

    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.

     

    10.16
      Native Americans

     

    If
      an
      Enrollee is a Native American and the Enrollee chooses to access primary care
      or
      other services through their tribal health center, the PCP authorized by the
      Contractor to refer the Enrollee for Medicare or Medicaid Advantage Product
      benefits must develop a relationship with the Enrollee's PCP at the tribal
      health center to coordinate services for said Native American
      Enrollee.

     

    10.17
      Urgently Needed Services

     

    The
      Contractor is financially responsible for Urgently Needed Services.

     

    10.18
      Dental Services Provided by Article 28 Clinics Operated by Academic Dental
      Centers Not Participating in Contractor's Network

     

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

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

     

    10.19
      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;

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

    iv)
      WIC;

    v)
      programs funded through the Ryan White CARE Act;

    vi)
      other
      pertinent entities that provide services out of network;

     

    Medicaid
      Advantage Contract 

    SECTION
      10

    (BENEFIT
      PACKAGE, COVERED AND NON-COVERED SERVICES) 

    State
      2006 

    10-10

    

    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 Contract 

    SECTION
      10

    (BENEFIT
      PACKAGE, COVERED AND NON-COVERED SERVICES) 

    State
      2006

    10-11

    

    11. MARKETING

     

    11.1
      Marketing Requirements

     

    a)
      The
      Contractor agrees to follow the Medicare Advantage Marketing Guidelines as
      set
      forth in Chapter 3 ofCMS's Medicare Managed Care Manual, as well as all
      applicable statutes and regulations including and without limitation Section
      1851 (h) of the Social Security Act and 42 CFR Sections 422.80, 422.111, and
      423.50 when marketing to individuals entitled to enroll in Medicare
      Advantage.

     

    b)
      In
      developing marketing materials and conducting marketing activities for the
      Medicaid Advantage Program, the Contractor shall comply with the Medicaid
      Advantage Marketing Guidelines as defined in Appendix D of this document as
      if
      set forth mlly herein.

     

     

    Medicaid
      Advantage Contract 

    SECTION
      11

    (MARKETING)

    State
      2006

    11-1

    12.
      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 Products, including applicable conditions and limitations,
      and any conditions associated with the receipt or use of benefits.

     

    ii)
      Explaining the Contractor's rules for obtaining Medicare and Medicaid Advantage
      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 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 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 Product.

     

    v)
      Clarifying information in the member handbooks for Enrollees regarding the
      Contractor's Medicare and Medicaid Advantage Products and benefits.

     

    vi)
      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.

     

    vii)
      Clarifying an Enrollee's Disenrollment rights and responsibilities under the
      Contractor's Medicare and Medicaid Advantage Products.

     

     

    Medicaid
      Advantage Contract 

    SECTION
      12

    (MEMBER
      SERVICES) 

    State
      2006 

    12-1

     

    

    12.2
      Translation and Oral Interpretation

     

    a)
      The
      Contractor must make available written marketing and other informational
      materials (e.g., member handbooks) in a language other than English whenever
      at
      least five percent (5%) of the Prospective Enrollees of the Contractor in any
      county of the service area speak that particular language and do not speak
      English as a first language.

     

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

     

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

     

    12.3
      Communicating with the Visually, Hearing and Cognitively Impaired

     

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

     

    Medicaid
      Advantage Contract 

    SECTION
      12

    (MEMBER
      SERVICES) 

    State
      2006 

    12-2

    13.
      ENROLLEE NOTIFICATION

     

    13.1
      General Requirements

     

    a)
      The
      Contractor shall disclose required information to Prospective Enrollees and
      Enrollees as prescribed by applicable federal and state law and regulations
      found at 42 CFR 422.111, New York PHL 4408, SSL 364-j, and 42 CFR §438.10 (e),
      (f) and (g), and any specific guidance issued by CMS and SDOH.

     

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

     

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

     

    d)
      Medicaid Advantage post 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
      the Effective Date of Benefit Package Changes

    Notice
      of
      Termination, Service Area Changes and Network Changes

    Summary
      of Benefits

     

    e)
      Integrated post enrollment materials including member handbooks, member notices,
      and summary of benefits targeted to Enrollees of the Contractor's Medicare
      and
      Medicaid Advantage Products must be prior approved by the CMS Regional Office;
      in collaboration with SDOH.

     

    13.2
      Member ID Cards

     

    The
      Contractor must issue an identification card to the Enrollee that complies
      with
      CMS and SDOH specifications.

     

    13.3
      Member Handbooks

     

    The
      Contractor shall issue to a new Enrollee no later than fourteen (14) days
      following the Effective Date of Enrollment a Medicaid Advantage Member Handbook,
      which is approved by SDOH and consistent with the Medicaid Advantage Model
      Handbook Guidelines in Appendix E, which is hereby made a part of this Agreement
      as if set forth fully herein.

     

    Medicaid
      Advantage Contract

    SECTION
      13 

    (ENROLLEE
      NOTIFICATION) 

    State
      2006 

    13-1

    13.4
      Enrollee Rights

     

    a)
      The
      Contractor shall,in
      compliance with the requirements of 42 CFR § 438.6(i)(l) and 42 CFR Part 489
      Subpart 1, maintain written policies and procedures regarding advance directives
      and inform each Enrollee in writing at the time of enrollment of an individual's
      rights under State law to formulate advance directives and of the Contractor's
      policies regarding the implementation of such rights. The Contractor shall
      include in such written notice to the Enrollee materials relating to advance
      directives and health care proxies as specified in 10 NYCRR Part 98 and § 700.5.
      The written information must reflect changes in State law as soon as possible,
      but no later than ninety (90) days after the effective date of the
      change.

     

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

     

    i)
      receive information about the Contractor and managed care;

     

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

     

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

     

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

     

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

     

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

     

    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 Contract 

    SECTION
      13 

    (ENROLLEE
      NOTIFICATION) 

    State
      2006 

    13-2

     

    

    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 Subpart M of Part 422 and Chapter 13
      ofCMS's Medicare Managed Care Manual for services that the Contractor determines
      are a Medicare only benefit.

     

    ii)
      all
      procedures and requirements of 42 CFR Subpart M of Part 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 Medicaid Advantage Action and Medicaid
      Advantage Grievance System requirements described in Appendix F of this
      Agreement and 42 CFR Section 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 both Medicare and
      Medicaid, the Contractor agrees to offer Enrollees the right to pursue either
      the Medicare appeal procedures or the Medicaid Advantage Action Appeal and
      Grievance System in the manner described and provided for in Appendix F of
      this
      Agreement.

     

    14.2
      Filing and Modification of Medicaid Advantage Action and Grievance Systems
      Procedures

     

    a)
      The
      Contractor's Action and Grievance System Procedures governing services
      determined by the Contractor to be a Medicaid only benefit and
      services

     

    Medicaid
      Advantage Contract 

    SECTION
      4

    (COMPLAINT
      AND APPEAL PROCEDURE) 

    State
      2006 

    14-1

    

    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.

     

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

     

    14.3
      Medicaid Advantage 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 Determination and utilization management activities is
      not
      structured to include incentives that would result in the denial, limiting,
      or
      discontinuance of Medically Necessary services to Enrollees.

     

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

     

    e)
      The
      Contractor shall ensure that its Medicaid Advantage 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 Grievance System.

     

    Medicaid
      Advantage Contract 

    SECTION
      14

    (COMPLAINT
      AND APPEAL PROCEDURE) 

    State
      2006 

    14-2

    

    14.4
      Notification ofMedicaid Advantage Action and Grievance System
      Procedures

     

    a)
      The
      Contractor's specific Action and 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 member handbook and
      shall be made available to all Medicaid Advantage Enrollees.

     

    b)
      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 Sections 438.210 and 438.404.

     

    c)
      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.

     

    d)
      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 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 file Complaints, Complaint Appeals and Action Appeals and
      the process and timeframes for filing;

     

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

     

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

     

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

     

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

     

    Medicaid
      Advantage Contract 

    SECTION
      14

    (COMPLAINT
      AND APPEAL PROCEDURE) 

    State
      2006 

    14-3

    

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

     

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

     

    14.5
      Complaint, Complaint Appeal and Action Appeal Investigation
      Determinations

     

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

     

    Medicaid
      Advantage Contract

    SECTION
      14

    (COMPLAINT
      AND APPEAL PROCEDURE) 

    State
      2006 

    14-4

    

    15. ACCESS
      REQUIREMENTS

     

    a)
      The
      Contractor agrees to provide Enrollees access to Medicare Advantage Benefit
      Package and Medicaid Only Covered Services as described in Appendix K-l and
      K-2
      of this Agreement in a manner consistent with professionally recognized
      standards of health care and access standards required by 42 CFR Section 422.112
      and applicable state law, respectively.

     

    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 Contract 

    SECTION
      15

    (EQUALITY
      OF ACCESS AND TREATMENT) 

    State
      2006 

    15-1

    

    16.
      QUALITY MANAGEMENT AND PERFORMANCE IMPROVEMENT

     

    16.1
      The
      Contractor agrees to operate an ongoing quality management and performance
      improvement program in accordance with Section 1852 (e) of the SSA and 42 CFR
      Section 422.152.

     

    16.2
      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
      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. Standard Measures will include, but not be limited
      to:

     

    •
Health
      Plan and Employer Data Information Set (HEDIS);

    •
      Consumer Assessment of Health Plan Satisfaction (CAHPS); and

    •
Health
      Outcomes Survey (HOS).

     

    Medicaid
      Advantage Contract

    SECTION
      16 

    (QUALITY
      ASSURANCE) 

    State 2006 

    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.

     

    17.4
      Cooperation During Review of Services by External Review Agency

     

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

     

    Medicaid
      Advantage Contract 

    SECTION
      17

    (MONITORING
      AND EVALUATION) 

    State
      2006 

    17-1

    18.
      CONTRACTOR REPORTING REQUIREMENTS

     

    18.1
      General Requirements

     

    a)
      The
      Contractor must maintain a health information system that collects, analyzes,
      integrates and reports data. The system must 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
      Liquidated Damages

     

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

     

    Medicaid
      Advantage Contract 

    SECTION
      8

    (CONTRACTOR
      REPORTING REQUIREMENTS) 

    State
      2006

    18-1

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

     

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

     

    18.6
      Reportin g Requirements

     

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

     

    i)
      Annual
      Financial Statements:

     

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

     

    ii)
      Quarterly Financial Statements:

     

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

     

    iii)
      Other Financial Reports:

     

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

     

    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

     

    Medicaid
      Advantage Contract 

    SECTION
      18

    (CONTRACTOR
      REPORTING REQUIREMENTS) 

    State
      2006 

    18-2

    

    the
      Contractor has received and processed from provider encounter or claim records
      of any contractedservices 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 including Medicare HEDIS results and Medicare CAHPS.
      Reports should be duplicative of reports submitted to CMS, and separate reports
      for the dual eligible population are not required.

     

    vi)
      Complaint and Action Appeal Reports:

     

    A)
      The
      Contractor must provide the SDOH on a quarterly basis, and within fifteen (15)
      business days of the close of the quarter, a summary of all Complaints and
      Action Appeals subject to PHL §4408-a received during the preceding quarter via
      the Summary Complaint Form on the HPN related to Medicaid Only Covered Services
      and services determined by the Contractor to be a benefit under both Medicare
      and Medicaid.

     

    B)
      The
      Contractor also agrees to provide on a quarterly basis, via the Summary
      Complaint form on the HPN, the total number of Complaints and Action Appeals
      subject to PHL §4408-a 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, via the HPN Complaint reporting format, the
      number of Complaints of fraud or abuse made to the Contractor related to
      Medicaid Only Covered Services that warrant preliminary investigation by the
      Contractor.

     

    Medicaid
      Advantage Contract 

    SECTION
      18

    (CONTRACTOR
      REPORTING REQUIREMENTS)

    State
      2006

    18-3

    

    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:

    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 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, an updated provider network
      report on a quarterly basis for providers of Medicaid Only Covered Services
      as
      defined in this Agreement and described in Appendix IC-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. The report submission must comply with the Managed Care
      Provider Network Data Dictionary. Networks must be reported separately for
      each
      county in which the Contractor operates.

     

    ix)
      Quality Assessment and Performance Improvement Projects

    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.

     

    x)
      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

     

     

    Medicaid
      Advantage Contract

    SECTION
      18

    (CONTRACTOR
      REPORTING REQUIREMENTS)

    State
      2006

    18-4

    

    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.

     

    18.7
      Ownership and Related Information Disclosure

     

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

     

    18.8
      Public Access to Reports

     

    Any
      data,
      information, or reports collected and prepared by the Contractor and submitted
      to NYS authorities in the course of performing their duties and obligation
      under
      this 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
      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)(l).

     

    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%)

     

     

    Medicaid
      Advantage Contract

    SECTION
      18

    (CONTRACTOR
      REPORTING REQUIREMENTS) 

    State
      2006 

    18-5

    

    or
      more
      ownership interest, consistent with requirements of SSA § 1903 (m)(2)(a)(viii)
      and 42 CFR §§ 455.100 - 455.104.

     

    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 Contract

    SECTION
      18

    (CONTRACTOR
      REPORTING REQUIREMENTS)

    State
      2006 

    18-6

    

    19.
      RECORDS MAINTENANCE
      AND AUDIT RIGHTS

     

    19.1
      Maintenance of Contractor Performance Records

     

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

     

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

     

    ii)
      all
      financial records and statistical data that 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;

     

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

     

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

     

    19.2
      Maintenance of Financial Records and Statistical Data

     

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

     

    19.3
      Access to Contractor Records

     

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

     

    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

     

    Medicaid
      Advantage Contract 

    SECTION
      19

    (RECORDS
      MAINTENANCE AND AUDIT RIGHTS) 

    State
      2006

    19-1

    

    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 Contract 

    SECTION
      19

    (RECORDS
      MAINTENANCE AND AUDIT RIGHTS) 

    State
      2006

    19-2

    

    20.
      CONFIDENTIALITY

     

    20.1
      Confidentiality of Identifying Information about Enrollees, Eligible Persons,
      and Prospective Enrollees

     

    All
      information relating to services to Enrollees, Eligible Persons and Prospective
      Enrollees which is obtained by the Contractor shall be confidential pursuant
      to
      the PHL including PHL Article 27-F, the provisions of Section 369(4) of the
      SSL,
      42 U.S.C. § 1396a (a)(7) (Section 1902(a)(7) of SSA), Section 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, Eligible Persons and Prospective Enrollees under this Agreement
      shall
      be used or disclosed by the Contractor only for a purpose directly connected
      with performance of the Contractor's obligations. It shall be the responsibility
      of the Contractor to inform its employees and contractors of the confidential
      nature of 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, Eligible Persons and Prospective
      Enrollees.

    

     

    Medicaid
      Advantage Contract

    SECTION
      20 

    (CONFIDENTIALITY)
      

    State
      2006

    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 Section 422.112, Subpart C; Part 422, Subpart E; Section
      422.504(a)(6) and 422.504(i), Subpart K; Part 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 Product.

     

    21.2
      Medicaid Advantage Network Requirements

     

    a)
      The
      Contractor will establish and maintain a network of Participating Providers
      that
      is supported by written agreements and is sufficient to provide adequate access
      to covered services to meet the needs ofEnrollees.

     

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

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

     

    c)
      The
      Contractor's Medicaid Advantage Plan network must contain all of the provider
      types necessary to furnish Medicaid Only Covered Services to Enrollees,
      including inpatient mental health services beyond the 190-day lifetime limit;
      non-Medicare covered home health services; private duty nursing services, and
      dental health services and non-emergency transportation services when included
      in the Contractor's Medicaid Advantage Product.

     

    d)
      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.

     

    e)
      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
      Section 1128 or Section 1128A 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.

     

    Medicaid
      Advantage Contract

    SECTION
      21

    (PROVIDER
      NETWORK AND AGREEMENTS) 

    State
      2006 

    21-1

     

    21.3
      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 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.

     

    21.4
      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 Benefit
      Package is payment in full for services provided to Enrollees, except for the
      collection of applicable co-payments from Enrollees as provided by
      law.

     

    21.5
      Dental Networks

     

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

     

    Dental
      surgery performed in an ambulatory or inpatient setting is covered by the
      Contractor's Medicare Advantage Product.

     

    Medicaid
      Advantage Contract 

    SECTION
      21

    (PROVIDER
      NETWORK AND AGREEMENTS) 

    State
      2006 

    21-2

    

    22.
      SUBCONTRACTS AND PROVIDER AGREEMENTS FOR MEDICAID ONLY COVERED
      SERVICES

     

    22.1
      Written Subcontracts

     

    a)
      Contractor may not enter into any subcontracts related to the delivery of
      Medicaid Only Covered Services to Enrollees, except by a written
      agreement.

     

    b)
      If the
      Contractor enters into subcontracts for the performance of work pursuant to
      this
      Agreement, the Contractor shall retain full responsibility for performance
      of
      the subcontracted services. Nothing in 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.

     

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

     

    22.2
      Permissible Subcontracts

     

    Contractor'may
      subcontract for provider services as set forth in 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.

     

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

     

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

    

    Medicaid
      Advantage Contract 

    SECTION
      22 

    (PROVIDER
      AGREEMENTS) 

    State
      2006 

    22-1

     

    

    22.5
      Required Components

     

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

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

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

     

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

     

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

     

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

     

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

     

    f)
      The
      Contractor shall also 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.

     

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

     

    h)
      The
      Contractor 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.

     

    

    Medicaid
      Advantage Contract 

    SECTION
      22 

    (PROVIDER
      AGREEMENTS) 

    State
      2006

    22-2

    

    22.6
      Timely Payment

     

    Contractor
      shall make payments to health care providers for items and services included
      in
      the Contractor's Medicaid Advantage Product on a timely basis, consistent with
      the claims payment procedures described in SIL § 3224-a.

     

    22.7
      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.

     

    c)
      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 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.

    

     

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    (PROVIDER
      AGREEMENTS) 

    State
      2006 

    22-3

    

    23.
      AMERICANS WITH DISABILITIES ACT COMPLIANCE PLAN

     

    Contractor
      must comply with Title II of the ADA and Section 504 of the Rehabilitation
      Act
      of 1973 for program accessibility, and must develop an ADA Compliance Plan
      consistent with the 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 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. 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 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. For issues related to disputed services,
      Enrollees must have received an adverse determination from the Contractor or
      its
      approved utilization review agent either overriding a recommendation to provide
      services by a Participating Provider or confirming the decision of a
      Participating Provider to deny those services. An Enrollee may also seek a
      fair
      hearing for a failure by the Contractor to act with reasonable promptness with
      respect to such services. Reasonable promptness shall mean compliance with
      the
      time frames established for review of grievances and utilization review in
      Sections 44 and 49 of the Public Health Law, the grievance system requirements
      of 42 CFR Part 438 and Appendix F of this Agreement.

     

    24.3
      Contractor Notice to Enrollees

     

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

    

    

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      -

     

    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 OAH under the following
      circumstances:

     

    i)
      Contractor has or is seeking to reduce, suspend or terminate such service or
      treatment currently being provided;

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

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

     

    b)
      Contractor shall provide aid continuing until the matter has been resolved
      to
      the Enrollee's satisfaction or until the administrative process is completed
      and
      there is a determination from OAH that Enrollee is not entitled to receive
      the
      service, the Enrollee withdraws the request for aid continuing and/or the fair
      hearing in writing, or the 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 either SDOH or LDSS, restore the disputed services and/or
      benefits consistent with the provisions of Section 24.4 of this
      Agreement.

     

    24.5
      Responsibilities of SDOH

     

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

     

    24.6
      Contractor's Obligations

     

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

     

    

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    business
      day prior to the hearing, otherwise Contractor must appear in person.
      Notwithstanding the above provisions. Contractor may be required to make a
      personal appearance at the discretion of the hearing officer and/or
      SDOH.

     

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

     

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

     

    d)
      If
      SDOH investigates a Complaint that has as its basis the same dispute that is
      the
      subject of a pending fair hearing and, as a result of its investigation,
      concludes that the disputed services and/or benefits should be provided to
      the
      Enrollee, Contractor shall comply with SDOH's directive to provide those
      services and/or benefits and provide notice to OAH and Enrollee as required
      by
      Section 24.6(b) of this Agreement.

     

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

     

    f)
      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.

     

    

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

     

    h)
      The
      information describing fair hearing rights, aid continuing. Service
      Authorization, Action Appeal, Complaint and Complaint Appeal procedures shall
      be
      included in all Medicaid Advantage member handbooks and shall comply with
      Section 14, and Appendix F of this Agreement.

     

    i)
      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 initial adverse determination is upheld as a result
      of a
      fair hearing, any aid continuing provided pursuant to that hearing request,
      may
      be recouped by Contractor.

     

    25.
      EXTERNAL APPEAL

     

    25.1
      Basis for External Appeal

     

    Enrollees
      in the Contractor's Medicaid Advantage Product are eligible to request an
      External Appeal when one or more health care service 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 for an expedited internal Action
      Appeal, 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 supercedes an external appeal determination for Medicaid
      Advantage Enrollees.

     

    

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      Advantage Contract 

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    25.4
      Compliance with External Appeal Laws and Regulations

     

    The
      Contractor must comply with the provisions of Sections 4910-4914 of the PHL
      and
      10 NYCRR Part 98 regarding the External Appeal program with respect to services
      determined by the Contractor to be a Medicaid only benefit or a benefit under
      both the Medicare and Medicaid programs.

     

    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 Handbook;

     

    26.
      INTERMEDIATE SANCTIONS

     

    26.1
      General

     

    Contractor
      is subject to imposition of sanctions as authorized by 42 CFR 422, Subpart
      0. In
      addition, for the Medicaid Advantage 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 43 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 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, Prospective 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. 

    

     

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

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

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

     

    26.3
      Intermediate Sanctions

     

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

    i)
      Civil
      and monetary penalties.

    ii)
      Suspension of all new Enrollment, after the effective date of the
      sanction.

    iii)
      Termination of the Agreement, pursuant to Section 2.7 of this
      Agreement.

     

    26.4
      Enrollment Limitations

     

    a)
      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 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. Nothing in this paragraph
      limits other remedies available to the SDOH under this Agreement.

     

    26.5
      Due
      Process

     

    The
      Contractor will be afforded due process pursuant to federal and state law and
      regulations (42 CFR § 438.710,18 NYCRR Part 516, and Article 44 of the
      PHL).

     

    27.
      ENVIRONMENTAL COMPLIANCE

     

    The
      Contractor shall comply with all applicable standards, orders, or requirements
      issued under Section 306 of the Clean Air Act (42 U.S.C. § 1857(h)), Section 508
      of the Federal Water Pollution Control Act as amended (33 U.S.C. § 1368),
      Executive Order 11738, and the Environmental Protection Agency ("EPA")
      regulations (40 CFR, Part 15) that prohibit the use of the facilities included
      on the EPA List of Violating Facilities. The Contractor shall report violations
      to SDOH and to the Assistant Administrator for Enforcement of the
      EPA.

    
 

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      Advantage Contract

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    28.
      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.

     

    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;

     

    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.

    

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    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.

     

    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 Part 93, that no
      Federally appropriated funds have been paid or will be paid to any person by
      or
      on behalf of the Contractor for the purpose of influencing or attempting to
      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.

     

    

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    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 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 regulations
      related to the aforementioned state statutes. Such state laws and

    

     

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    regulations
      shall not be deemed to be applicable to the extent that they are pre-empted
      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 43 CFR Part 422 and Part 423; Title VI of the Civil Rights Act of
      1964 and 45 C.F.R. Part 80, as amended; Section 504 of the Rehabilitation Act
      of
      1973 and 45 C.F.R. Part 84, as amended; Age Discrimination Act of 1975 and
      45
      C.F.R. Part 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(1 )(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.

    

    

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    34.6
      Non-Liability ofEnrollees 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.

    

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      d
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    APPENDIX
      A

     

     

    New
      York State Standard Contract Clauses

    

    

    

    

    

    

    

    Medicaid
      Advantage Contract 

    APPENDIX
      A 

    State
      2006

     

    

    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 die work; or (b) discriminate against or intimidate any employee hired
      for the performance
      of work under this contract. Contractor is subject to fines of $50.00 per person
      per day for any violation of Section 220-e or Section 239 as well as possible
      termination of this contract and forfeiture of all moneys due hereunder for
      a
      second or subsequent violation.

     

    6.
      WAGE
      AND HOURS PROVISIONS.
      If this
      is a public work

    contract
      covered by Article 8 of the Labor Law or a building service contract covered
      by
      Article 9 thereof, neither Contractor's employees nor the employees of its
      subcontractors may be required or permitted to work more than the number of
      hours or days stated in said statutes, except as otherwise provided in the
      Labor
      Law and as set forth in prevailing wage and supplement schedules issued by
      the
      State Labor Department. Furthermore, Contractor and its subcontractors must
      pay
      at least the prevailing wage rate and pay or provide the prevailing supplements,
      including the premium rates for overtime pay, as determined by the State Labor
      Department in accordance with the Labor Law.

     

    7.
      NON-COLLUSIVE BIDDING CERTIFICATION.
      In
      accordance

    with
      Section 139-d of the State Finance Law, if this contract was awarded based
      upon
      the submission of bids. Contractor warrants, under penalty of perjury, that
      its
      bid was arrived at independently and without collusion aimed at restricting
      competition. Contractor further warrants that, at the time Contractor submitted
      its bid, an authorized and responsible person executed and delivered to the
      State a non-collusive bidding certification on Contractor's behalf.

     

    8.
      INTERNATIONAL
      BOYCOTT PROHIBITION.
      In
      accordance

    with
      Section 220-f of the Labor Law and Section 139-h of the State Finance Law,
      if
      this contract exceeds $5,000, the Contractor agrees, as a material condition
      of
      the contract, that neither the Contractor nor any substantially owned or
      affiliated person, firm, partnership or corporation has participated, is
      participating, or shall participate in an international boycott in violation
      of
      the federal Export Administration Act of 1979 (50 USC App. Sections 2401 et
      seq.) or regulations thereunder. If such Contractor, or any of the aforesaid
      affiliates of Contractor, is convicted or is otherwise found to have violated
      said laws or regulations upon the final determination of the United States
      Commerce Department or any other appropriate agency of the United States
      subsequent to the contract's execution, such contract, amendment or modification
      thereto shall be rendered forfeit and void. The Contractor shall so notify
      the
      State Comptroller within five (5) business days of such conviction,
      determination or disposition of appeal (2NYCRR 105.4).

     

    9.
      SET-OFF
      RIGHTS.
      The
      State shall have all of its common law, equitable and statutory rights of
      set-off. These rights shall include, but not be limited to, the State's option
      to withhold for the purposes of set-off any moneys due to the Contractor under
      this contract up to any amounts due and owing to the State with regard to this
      contract, any other contract with any State department or agency, including
      any
      contract for a term commencing prior to the term of this contract, plus any
      amounts due and owing to the State for any other reason including, without
      limitation, tax delinquencies, fee delinquencies or monetary penalties relative
      thereto. The State shall exercise its set-off rights in accordance with normal
      State practices including, in cases of set-off pursuant to an audit, the
      finalization of such audit by the State agency, its representatives, or the
      State Comptroller.

     

    10.
      RECORDS.
      The
      Contractor shall establish and maintain complete and
      accurate books, records, documents, accounts and other evidence directly
      pertinent to performance under 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

     

    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.

     

    May,2003

    STANDARD
      CLAUSES FOR NYSCONTRACTS

    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 - 7th
      Floor

    Albany,
      New York 12245 

    Telephone:
      518-292-5220

     

    A
      directory of certified minority and women-owned business enterprises is
      available from:

     

    NYS
      Department of Economic Development

    Division
      of Minority and Women's Business Development

    30
      South
      Pearl St - 2nd Floor

    Albany,
      New York 12245

    http://www.empire.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.

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    

    APPENDIX
      B

     

    Certification
      Regarding Lobbying

    

    

    

    Medicaid
      Advantage Contract 

    APPENDIX
      B 

    State
      2006 

    B-l

     

    

    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:
      2/24/06

    

    SIGNATURE:
      /s/
      Todd S. Farha 

    

    TITLE: President
      & CEO 

    

    ORGANIZATION:
      WellCare
      of New York. Inc.

     

     

    

    Medicaid
      Advantage Contract 

    APPENDIX
      B

    State
      2006

    B-2

     

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    APPENDIX
      B-l

     

    Certification
      Regarding MacBride Fair Employment Principles

    

     

    

    Medicaid
      Advantage Contract 

    APPENDIX
      B-1 

    State
      2006 

    B-l
      

    Page 1

     

    

    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 T

     

    •
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 Contract 

    APPENDIX
      B-1

    State
      2006

    B-l

    Page
      2

     

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    Appendix
      C

     

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

     

    C.I
      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 Contract 

    APPENDIX
      C

    State
      2006 

    C-l

     

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    C.I

    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 purposeof:

     

    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 followup;

     

    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

    
 

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    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.

     

    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 Enrolles

     

    a)
      Free
      Access means Enrolles 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.

    

    

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    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 HIV counseling and testing
      when performed as part of a Family Planning and Reproductive Health encounter,
      from the Contractor's Participating Provider without referral, approval or
      notification.

     

    ii)
      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.I of this Appendix.

     

    iii)
      A
      current list of qualified Participating Family Planning Providers who provide
      the full range of Family Planning and Reproductive Health Services within the
      Enrollee's geographic area, including addresses and telephone numbers. The
      Contractor may also provide 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

    

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    Providers
      comply with all of the requirements set forth in Sections 17 and 18 of the
      PHL
      and 10 NYCRR Section 751.9 and Part 753 relating to informed consent and
      confidentiality.

     

    b)
      Participating Providers may share patient information with appropriate
      Contractor personnel for the purposes of claims payment, utilization review
      and
      quality assurance, unless the provider agreement with the Contractor provides
      otherwise. The Contractor must ensure that an Enrollee's use of Family Planning
      and Reproductive Health services remains confidential and is not disclosed
      to
      family members or other unauthorized parties, without the Enrollee's consent
      to
      the disclosure.

     

    4.
      Informing and Standards

     

    a)
      The
      Contractor will inform its Participating Providers and administrative personnel
      about policies concerning Free Access as defined in C. 1 of this Appendix,
      where
      applicable; HIV counseling and testing; reimbursement for Family Planning and
      Reproductive Health encounters; Enrollee Family Planning and Reproductive Health
      education and confidentiality.

     

    b)
      The
      Contractor will inform its Participating Providers that they must comply with
      professional medical standards of practice, the Contractor's practice
      guidelines, and all applicable federal, state, and local laws. These include
      but
      are not limited to, standards established by the American College of
      Obstetricians and Gynecologists, the American Academy of Family Physicians,
      the
      U.S. Task Force on Preventive Services and the New York State Child/Teen Health
      Program. These standards and laws recognize that Family Planning counseling
      is
      an integral part of primary and preventive care.

    

     

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      C

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      2006 

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    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 Prospective Enrollees, new Enrollees
      and current Enrollees that:

     

    I)
      Certain Family Planning and Reproductive Health Services (such as abortion,
      sterilization and birth control) are not covered by the Contractor, but that
      routine obstetric and/or gynecologic care, including hysterectomies, pre-natal,
      delivery and post-partum care are covered by the Contractor;

     

    II)
      Such
      Family Planning and Reproductive Health Services that are not covered by the
      Contractor may be obtained through fee-for-service Medicaid providers for
      Medicaid Advantage Enrollees;

     

    III)
      No
      referral is needed for such services, and there will be no cost to the Enrollee
      for such services;

    

     

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    IV)HIV
      counseling and testing services are available through the Contractor and are
      also available as part of a Family Planning and Reproductive Health encounter
      when furnished by a fee-for-service Medicaid provider to Medicaid Advantage
      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 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 web site of the Contractor which includes information
      concerning its Medicaid Advantage product. Such information shall be prominently
      displayed and easily navigated.

     

    C)
      A
      description of the mechanisms to provide all new Medicaid Advantage Enrollees
      with an SDOH approved letter explaining how to access Family Planning and
      Reproductive Health Services and the SDOH approved list of Family Planning
      providers. This material will be furnished by SDOH and mailed to the Enrollee
      no
      later than fourteen (14) days after the Effective Date of
      Enrollment.

     

    D)
      A
      statement that if an Enrollee or Prospective Enrollee requests information
      about
      these non-covered services, the Contractor's Marketing or Enrollment
      representative or member services department will advise the Enrollee or
      Prospective Enrollee as follows:

     

    I)
      Family
      Planning and Reproductive Health Services such as abortion, sterilization and
      birth control are not covered by the Contractor and that only routine obstetric
      and/or gynecologic care, including hysterectomies, pre-natal, delivery and
      post-partum care are the responsibility of the Contractor.

     

    II)
      Medicaid Advantage Enrollees can use their Medicaid card to receive these
      non-covered services from any doctor or clinic that provides these services
      and
      accepts Medicaid.

     

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      2006

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    III)
      Each
      Medicaid Advantage 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 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 Free Access, as defined in C.I of this Appendix, H1V
      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.I of this Appendix.

     

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    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 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 Enrollees on a fee-for-service basis as
      an
      eMedNY-enrolled provider, or

     

    II)
      provide Medicaid Advantage 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.

    

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      C 

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      2006 

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    C)
      A
      statement that the Contractor will prepare a monthly list of Medicaid Advantage
      Enrollees 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
      Sections 17 and 18 of the PHL and 10 NYCRR § 751.9 and Part 753 relating to
      informed consent and confidentiality.

     

    b)
      Participating Providers may share patient information with appropriate
      Contractor personnel for the purposes of claims payment, utilization review
      and
      quality assurance, unless the provider agreement with the Contractor provides
      otherwise. The Contractor must ensure that an Enrollee's use of Family Planning
      and Reproductive Health Services remains confidential and is not disclosed
      to
      family members or other unauthorized parties, without the Enrollee's consent
      to
      disclosure.

     

    Medicaid
      Advantage Contract 

    APPENDIX
      C 

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      2006 

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    Appendix
      D

     

    New
      York State Department of Health Medicaid Advantage Marketing
      Guidelines

    

    

    

    

    

    

    Medicaid
      Advantage Contract 

    APPENDIX
      D 

    State
      2006 

    D-l

     

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    MEDICAID
      ADVANTAGE MARKETING GUIDELINES

     

    I.
      Purpose

     

    The
      purpose of these guidelines is to provide an operational framework for the
      Medicaid managed care organizations (MCOs) in the development of marketing
      materials and the conduct of marketing activities for the Medicaid Advantage
      Program. The marketing guidelines set forth in this Appendix do not replace
      the
      CMS marketing requirements for Medicare Advantage Plans;

    they
      supplement them.

     

    II.
      Marketing Materials

     

    A.
      Definitions

     

    1.
      Marketing materials generally include the concepts of advertising, public
      service announcements, printed publications, and other broadcast or electronic
      messages designed to increase awareness and interest in a Contractor's Medicaid
      Advantage product. The target audience for these marketing materials is Eligible
      Persons as defined in Section 5.1 of this Agreement living in the defined
      service area.

     

    2.
      For
      purposes of this Agreement, marketing materials include any information that
      references the Contractor's Medicaid Advantage Product and which is intended
      for
      distribution to Dual Eligibles, and is produced in a variety of print,
      broadcast, and direct marketing mediums. These generally include: radio,
      television, billboards, newspapers, leaflets, informational brochures, videos,
      telephone book yellow page ads, letters, and posters. Additional materials
      requiring marketing approval include a listing of items to be provided as
      nominal gifts or incentives.

     

    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 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
      least five percent (5%) of the Prospective Enrollees of the Contractor in any
      county of the service area speak that particular language and do not speak
      English as a first language. SDOH will inform the LDSS and LDSS will inform
      the
      Contractor when the 5% threshold has been reached. Marketing materials to
      be

    

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    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 have
      an existing relationship with, that such medical services providers participate
      in the selected managed care provider's network and are available to serve
      the
      participant.

     

    C.
      Prior
      Approvals

     

    1.
      The
      CMS and SDOH will jointly review and approve Medicaid Advantage marketing
      videos, materials for broadcast (radio, television, or electronic), billboards,
      mass transit (bus, subway or other livery) and statewide/regional print
      advertising materialsin
      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 just as SDOH will coordinate LDSS
      input in the review process.

     

    2.
      CMS
      and SDOH will jointly review and approve the following Medicaid Advantage
      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 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 obtaining LDSS input in the review and approval
      process.

     

    4.
      The
      Contractor shall not distribute or use any Medicaid Advantage marketing
      materials that the CMS Regional Office and the SDOH have not jointly approved,
      prior to the expiration of the required review period.

     

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      D 

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    5.
      Approved marketing materials shall be kept on file in the offices of the
      Contractor, the LDSS, the SDOH, and CMS.

     

    D.
      Dissemination of Outreach Materials to LDSS

     

    1.
      Upon
      request, the Contractor shall provide to the LDSS and/or Enrollment Broker,
      sufficient quantities of approved Marketing materials or alternative
      informational materials that describe coverage in the LDSS
      jurisdiction.

     

    2.
      The
      Contractor shall, upon request, submit to the LDSS or Enrollment Broker, a
      current provider directory, together with information that describes how to
      determine whether a provider is presently available.

     

    III.
      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). Marketing activities intended to sell a Medicaid managed
      care product shall be defined as activities which are conducted pursuant to
      a
      Medicaid Advantage 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
      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 managed care 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 product explain Medicare products offered by the Contractor
      as well as the Contractor's Medicaid Advantage product.

     

    B.
      Marketing at LDSS Offices

     

    With
      prior LDSS approval, MCOs may distribute CMS/SDOH approved Medicaid Advantage
      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

     

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      Advantage Contract 

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      D 

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    program
      including training related to an Enrollee's rights and responsibilities in
      Medicaid Advantage. The Contractor shall be responsible for the activities
      of
      its marketing representatives and the activities of any subcontractor or
      management entity.

     

    D.
      Medicaid Advantage Specific Marketing Requirements

     

    The
      requirements in Section D apply only if marketing activities for the Medicaid
      Advantage Program are conducted pursuant to a Medicaid Advantage 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 product.

     

    1.
      Approved Marketing Plan

     

    a.
      The
      Contractor must submit a plan of Medicaid Advantage Marketing activities that
      meet the SDOH requirements to the SDOH.

     

    b.
      The
      SDOH is responsible for the review and approval of Medicaid Advantage Marketing
      plans, using a SDOH and CMS approved checklist.

     

    c.
      Approved Marketing plans will set forth the terms and conditions and proposed
      activities of the Medicaid Advantage dedicated staff during the contract period.
      The following must be included: description of materials 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 marketing materials.

     

    d.
      An
      approved marketing plan must be on file with the SDOH and each LDSS in its
      contracted service area prior to the Contractor engaging in the Medicaid
      Advantage specific marketing activities.

     

    e.
      The
      plan shall include stated marketing goal and strategies, marketing activities,
      and the training, development and responsibilities of dedicated marketing
      staff.

     

    f.
      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.

    

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    g.
      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 dedicated Marketing
      representatives.

     

    2.
      Compensation for Dedicated Medicaid Advantage Marketing Staff

     

    The
      Contractor shall not offer compensation to Medicaid Advantage dedicated
      Marketing Representatives, including salary increases or bonuses, based solely
      on the number of individuals they enroll in Medicaid Advantage. 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 or the LDSS;

     

    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 or Other Patient Care Areas

     

    Contractors
      may not distribute materials or assist prospective Enrollees in completing
      Medicaid Advantage application forms in hospital emergency rooms, in provider
      offices, or other areas where health care is delivered unless requested by the
      individual.

     

    

    Medicaid
      Advantage Contract 

    APPENDIX
      D 

    State
      2006 

    D-6

     

    5.
      Enrollment Incentives

     

    Contractors
      may not offer incentives of any kind to Medicaid recipients to join Medicaid
      Advantage. Incentives are defined as any type of inducement whose receipt is
      contingent upon the recipients joining the Contractor's Medicaid Advantage
      product.

     

    E.
      General Marketing Restrictions

     

    The
      following restrictions apply anytime the Contractor markets its Medicaid
      Advantage product:

     

    1.
      Contractors are prohibited from misrepresenting the Medicaid program, the
      Medicaid Advantage Program 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 of
      any
      Enrollee or their family member. Health assessments may not be performed by
      the
      Contractor prior to enrollment. The Contractor may inquire about existing
      primary care relationships of the applicant and explain whether and how such
      relationships may be maintained. Upon request, each potential Enrollee shall
      be
      provided with a listing of all participating providers and facilities in the
      MCO's network. The Contractor may respond to a potential Enrollee's question
      about whether a particular specialist is in the network. However, the Contractor
      is prohibited from inquiring about the types of specialists utilized by the
      potential Enrollee.

     

    4.
      Contractors may not require participating providers to distribute plan prepared
      communications to their patients, including communications which compare the
      benefits of different health plans, unless the materials have the concurrence
      of
      all MCOs involved, and have received prior approval by SDOH, and by CMS, if
      Medicare Advantage is referenced.

     

    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 health plans and Medicaid clients. Examples of
      inappropriate behavior include interfering with other health plan presentations
      or talking negatively about another health plan.

    

    Medicaid
      Advantage Contract 

    APPENDIX
      D 

    State
      2006 

    D-7

     

    

    IV.
      Marketing Infractions

     

    A.
      Infractions ofMedicaid 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
      Marketing Guidelines or the Contractor's approved Medicaid Advantage 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, in consultation
      with the LDSS, 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 Marketing activities for a
      period up to the end of the Agreement period;

     

    b)
      suspend new Medicaid Advantage 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 Contract 

    APPENDIX
      D

    State
      2006 

    D-8

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    Appendix
      E

     

    New
      York State Department of Health Medicaid Advantage Model Member Handbook
      Guidelines

    

    

    

    

    

    

    

    Medicaid
      Advantage Contract 

    APPENDIX
      E 

    State
      2006 

    E-l

    

     

    Introduction

     

    Managed
      care organizations (MCOs) under contract to provide a Medicaid Advantage Product
      to Dually Eligible beneficiaries must provide Enrollees with a Medicaid
      Advantage member handbook which is consistent with the current model Medicaid
      Advantage 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.

     

    Model
      Medicaid Advantage Handbook

     

    It
      will
      be the responsibility of the SDOH to provide a copy of the current model
      Medicaid Advantage member handbook to the Contractor.

     

    

    Medicaid
      Advantage Contract

    APPENDIX
      E 

    State
      2006 

    E-2

     

    

    APPENDIX
      F

     

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

     

    F.I General
      Requirements

     

    F.2 Medicaid
      Advantage Action Requirements

     

    F.3 Medicaid
      Advantage Grievance System Requirements

    

    

    Medicaid
      Advantage Contract APPENDIX F 

    State
      2006 

    F-l

    

    F.I

     

    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 Subpart M of Part 422, and the Medicare
      Managed Care Manual.

     

    c)
      Organization Determinations regarding services determined by the Contractor
      to
      be benefits covered by Medicare and Medicaid shall be conducted in accordance
      with the procedures and requirements of 42 CFR Subpart M of Part 422 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.I
      of this Agreement, and Articles 44 and 49 of the PHL, and 10 NYCRR Part 98,
      not
      otherwise expressly established herein.

     

    2.
      Notices, 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 Grievance System. In these cases, the
      Contractor will follow such procedures to notify Enrollees and providers
      regarding Organization 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 Articles 44 and 49 of the PHL, and 10 NYCRR
      Part 98, not otherwise expressly established herein.

     

    

    Medicaid
      Advantage Contract 

    APPENDIX
      F 

    State
      2006 

    F-2

    

    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 Action Appeals, Complaint, and Complaint Appeals
      procedures.

     

    i)
      As
      part of, or attached to, the appropriate Organization Determination notice,
      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 programs,
      and of their right to select either the Medicare or Medicaid Advantage 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 appeal and may not file a Fair Hearing request with the
      state; and

    B)
      if he
      or she chooses to pursue the Medicaid Advantage appeal procedures to challenge
      a
      service denial, suspension, reduction, or termination, the Enrollee has up
      to 60
      days from the day of the Contractor's notice of denial of coverage to pursue
      a
      Medicare appeal, regardless of the status of the Medicaid Advantage
      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 procedure, the default procedure will be the Medicaid
      Advantage procedure.

    

     

    Medicaid
      Advantage Contract 

    APPENDIX
      F 

    State
      2006

    F-3

     

    

    F.
      2

     

    Medicaid
      Advantage Action Requirements

     

    1. Definitions

     

    a)
      Service Authorization Request means a request by an Enrollee or a provider
      on
      the Enrollee's behalf, to the Contractor for the provision of a service,
      including a request for a referral or for a non-covered service.

     

    i)
      Prior
      Authorization Request is a Service Authorization Request by the Enrollee, or
      a
      provider on the Enrollee's behalf, for coverage of a new service, whether for
      a
      new authorization period or within an existing authorization period, before
      such
      service is provided to the Enrollee.

     

    ii)
      Concurrent Review Request is a Service Authorization Request by an Enrollee,
      or
      a provider on Enrollee's behalf, for continued, extended or more of an
      authorized service than what is currently authorized by the
      Contractor.

     

    b)
      Service Authorization Determination means the Contractor's approval or denial
      of
      a Service Authorization Request.

     

    c)
      Adverse Determination means a denial of a Service Authorization Request by
      the
      Contractor on the basis that the requested service is not Medically Necessary
      or
      an approval of a Service Authorization Request is in an amount, duration, or
      scope that is less than requested.

     

    d)
      An
      Action means an activity of a Contractor or its subcontractor that results
      in:

     

    i)
      the
      denial or limited authorization of a Service Authorization Request, including
      the type or level of service;

     

    ii)
      the
      reduction, suspension, or termination of a previously authorized
      service;

     

    iii)
      the
      denial, in whole or in part, of payment for a service;

     

    iv)
      failure to provide services in a timely manner as defined by applicable State
      law and regulation and Section 15 of this Agreement; or

     

    v)
      failure of the Contractor to act within the timeframes for resolution and
      notification of determinations regarding Complaints, Action Appeals and
      Complaint Appeals provided in this Appendix.

     

    Medicaid
      Advantage Contract 

    APPENDIX
      F

    State
      2006 

    F-4

    

    2.
      General Requirements

     

    a)
      The
      Contractor's policies and procedures for Service Authorization Determinations
      and utilization review determinations shall comply with 42 CFR Part 438 and
      Article 49 of the PHL, including but not limited to the following:

     

    i)
      Expedited review of a Service Authorization Request must be conducted when
      the
      Contractor determines or the provider indicates that a delay would seriously
      jeopardize the Enrollee's life or health or ability to attain, maintain, or
      regain maximum function. The Enrollee may request expedited review of a Prior
      Authorization Request or Concurrent Review Request. If the Contractor denies
      the
      Enrollee's request for expedited review, the Contractor must handle the request
      under standard review timeframes.

     

    ii)
      Any
      determination to deny a Service Authorization Request or to authorize a service
      in an amount, duration, or scope that is less than requested, must be made
      by a
      licensed, certified, or registered health care professional. If such Adverse
      Determination was based on medical necessity, the determination must be made
      by
      a clinical peer reviewer as defined by PHL §4900(2)(a).

     

    iii)
      The
      Contractor is required to provide notice by phone and in writing to the Enrollee
      and to the provider of Service Authorization Determinations, whether adverse
      or
      not, within the timeframe specified in Section 3 below. Notice to the provider
      must contain the same information as the Notice of Action for the
      Enrollee.

     

    iv)
      The
      Contractor is required to provide the Enrollee written notice of any Action
      other than a Service Authorization Determinations within the timeframe specified
      in Section 4 below.

     

    3.
      Timeframes for Service Authorization Determinations

     

    a)
      For
      Prior Authorization Requests, the Contractor must make a Service Authorization
      Determination and notice the Enrollee of the determination by phone and in
      writing as fast as the Enrollee's condition requires and no more
      than:

     

    i)
      In the
      case of an expedited review, three (3) business days after receipt of the
      Service Authorization Request; or

     

    ii)
      In
      all other cases, within three (3) business days of receipt of necessary
      information, but no more than fourteen (14) days after receipt of the Service
      Authorization request.

    

     

    Medicaid
      Advantage Contract 

    APPENDIX
      F

    State
      2006 

    F-5

     

    

    b)
      For
      Concurrent Review Requests, the Contractor must make a Service Authorization
      Determination and notice the Enrollee of the determination by phone and in
      writing as fast as the Enrollee's condition requires and no more
      than:

    

    i)
      In the
      case of an expedited review, one (1) business day after receipt of necessary
      information but no more than three (3) business days after receipt of the
      Service Authorization Request; or

     

    ii)
      In
      all other cases, within one (1) business day of receipt of necessary
      information, but no more than fourteen (14) days after receipt of the Service
      Authorization Request.

     

    c)
      Timeframes for Service Authorization Determinations may be extended for up
      to
      fourteen (14) days if:

     

    i)
      the
      Enrollee, the Enrollee's designee, or the Enrollee's provider requests an
      extension orally or in writing; or

     

    ii)
      The
      Contractor can demonstrate or substantiate that there is a need for additional
      information and how the extension is in the Enrollee's interest. The Contractor
      must send notice of the extension to the Enrollee. The Contractor must maintain
      sufficient documentation of extension determinations to demonstrate, upon SDOH's
      request, that the extension was justified.

     

    d)
      If the
      Contractor extended its review as provided in paragraph 3(c) above, the
      Contractor must make a Service Authorization Determination and notice the
      Enrollee by phone and in writing as fast as the Enrollee's condition requires
      and within three (3) business days after receipt of necessary information for
      Prior Authorization Requests or within one (1) business day after receipt of
      necessary information for Concurrent Review Requests, but in no event later
      than
      the date the extension expires.

     

    4.
      Timeframes for Notices of Actions Other Than Service Authorizations
      Determinations

     

    a)
      When
      the Contractor intends to reduce, suspend, or terminate a previously authorized
      service within an authorization period, it must provide the Enrollee with a
      written notice at least ten (10) days prior to the intended Action,
      except:

    

    i)
      the
      period of advance notice is shortened to five (5) days in cases of confirmed
      Enrollee fraud; or ii) the Contractor may mail notice not later than date of
      the
      Action for the following:

    A)
      the
      death of the Enrollee;

    B)
      a
      signed written statement from the Enrollee requesting service termination or
      giving information requiring termination or reduction of services (where the
      Enrollee understands that this must be the result of supplying the
      information);

    C)
      the
      Enrollee's admission to an institution where the Enrollee is ineligible for
      further services;

    

    

    

    Medicaid
      Advantage Contract 

    APPENDIX
      F

    State
      2006

    F-6

     

    

    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 include that the request will be reviewed under standard
      timeframes, including a description of the timeframes.

     

    ii)
      Notice to the Enrollee regarding a Contractor-initiated extension shall
      include:

    A)
      the
      reason for the extension;

    B)
      an
      explanation of how the delay is in the best interest of the
      Enrollee;

    C)
      any
      additional information the Contractor requires from any source to make its
      determination;

    D)
      the
      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 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;

     

    Medicaid
      Advantage Contract 

    APPENDIX
      F

    State
      2006

    F-7

    

    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, containing the Enrollee's
      fair hearing and aid continuing rights. 

    I)
      For
      Actions based on issues of Medical Necessity or an experimental or
      investigational treatment, the notice of Action shall also include:

    

    I)
      a
      clear statement that the notice constitutes the initial adverse determination
      and specific use of the terms "medical necessity" or
      "experimental/investigational;"

    II)
      a
      statement that the specific clinical review criteria relied upon in making
      the
      determination is available upon request; and

    III)
      a
      statement that the Enrollee may be eligible for, 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.

     

    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;

     

     

    Medicaid
      Advantage Contract 

    APPENDIX
      F

    State
      2006 

    F-8

     

    

    ii)
      the
      Contractor determines that a service does not have appropriate
      authorization;

     

    iii)
      the
      Contractor denies a claim for services provided by a Non-Participating Provider
      for any reason;

     

    iv)
      the
      Contractor denies a claim or service due to medical necessity;

     

    v)
      the
      Contractor rejects a claim or denies payment due to a late claim
      submission;

     

    vi)
      the
      Contractor denies a claim because it has determined that the Enrollee was not
      eligible for Medicaid Advantage 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;

     

    iii)
      if a
      duplicate claim is submitted by the Enrollee or a Participating Provider, no
      notice is required, provided an initial notice has been issued;

     

    iv)
      if
      the claim is for a service that is carved-out of the 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

    

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      F 

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      2006

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    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 Contract

    APPENDIX
      F 

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      2006

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    F.3

     

    Medicaid
      Advantage Grievance System Requirements

     

    1.
      Definitions

     

    a)
      A
      Grievance System means the Contractor's Medicaid Advantage 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 a.s 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:

     

    i)
      toll-free telephone number;

    

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    ii)
      designated staff to receive calls;

     

    iii)
      "live" phone coverage at least 40 hours a week during normal business
      hours;

     

    iv)
      a
      mechanism to receive after hours calls, including either:

    A)
      a
      telephone system available to take calls and a plan to respond to all such
      calls
      no later than on the next business day after the calls were recorded;
      or

    B)
      a
      mechanism to have available on a twenty-four (24) hour, seven (7) day a week
      basis designated staff to accept telephone Complaints, whenever a delay would
      significantly increase the risk to an Enrollee's health.

     

    f)
      The
      Contractor must ensure that personnel making determinations regarding
      Complaints, Complaint Appeals and Action Appeals were not involved in previous
      levels of review or decision-making. If any of the following applies,
      determinations must be made by qualified clinical personnel as specified in
      this
      Appendix:

    

    i)
      A
      denial 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 sixty (60) business
      days and no more than 90 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, signed, Action Appeal. The Contractor
      may
      provide a written summary of an oral Action Appeal to the Enrollee (with the
      acknowledgement or separately) for the Enrollee to review, modify if needed,
      sign and return to the Contractor. If the Enrollee or provider requests
      expedited resolution of the Action Appeal, the oral Action Appeal does not
      need
      to be confirmed in writing. The date of the oral filing of the Action Appeal
      will be the date of the Action Appeal for the purposes of the timeframes for
      resolution of Action Appeals. Action Appeals resulting from a Concurrent Review
      must be handled as an expedited Action Appeal.

    

     

    

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      Advantage Contract 

    APPENDIX
      F 

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      2006

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    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. If the Contractor
      denies the Enrollee's request for an expedited review, the Contractor must
      handle the request under standard Action Appeal resolution timeframes, make
      reasonable efforts to provide prompt oral notice of the denial to the Enrollee
      and send written notice of the denial within two (2) days of the denial
      determination.

     

    vi)
      The
      Contractor must ensure that punitive action is not taken against a provider
      who
      either requests an expedited resolution or supports an Enrollee's
      Appeal.

     

    vii)
      Action Appeals of clinical matters must be decided by personnel qualified to
      review the Action Appeal, including licensed, certified or registered health
      care professionals who did not make the initial determination, at least one
      of
      whom must be a clinical peer reviewer, as defined by PHL §4900(2)(a). Action
      Appeals of non-clinical matters shall be determined by qualified personnel
      at a
      higher level than the personnel who made the original
      determination.

     

    4.
      Timeframes for Resolution of Action Appeals

     

    a)
      The
      Contractor's Action Appeals process shall indicate the following specific
      timeframes regarding Action Appeal resolution:

     

    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.

     

     

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      Advantage Contract

    APPENDIX
      F

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      2006 

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    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.

     

    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.

     

    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;

    

     

    Medicaid
      Advantage Contract 

    APPENDIX
      F 

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      2006 

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    G)
      the
      right of an Enrollee to designate a representative to file a Complaint on behalf
      of the Enrollee; and H) the right of the Enrollee to contact the New York State
      Department of Health regarding his or her their Complaint, including the SDOH's
      toll-free number for Complaints.

     

    iii)
      Notice to the Enrollee of Action Appeal Determination shall
      include:

    A)
      Date
      the Action Appeal was filed and a summary of the Action Appeal;

    B)
      Date
      the Action Appeal process was completed;

    C)
      the
      results and the reasons for the determination, including the clinical rationale,
      if any;

    D)
      If the
      determination was not in favor of the Enrollee, a description of Enrollee's
      fair
      hearing rights, if applicable;

    E)
      the
      right of the Enrollee to contact the New York State Department of Health
      regarding his or her Complaint, including the SDOH's toll-free number for
      Complaints; and 

    F)
      For
      Action Appeals involving Medical Necessity or an experimental or investigational
      treatment, the notice must also include:

    I)
      a
      clear statement that the notice constitutes the final adverse determination
      and
      specifically use the terms "medical necessity" or
      "experimental/investigational;"

    II)
      the
      Enrollee's coverage type;

    III)
      the
      procedure in question, and if available and applicable the name of the provider
      and developer/manufacturer of the health care service;

    IV)
      statement that the Enrollee is eligible to file an External Appeal and the
      timeframe for filing;

    V)
      a copy
      of the "Standard Description and Instructions for Health Care Consumers to
      Request an External Appeal" and the External Appeal application
      form;

    VI)
      the
      Contractor's contact person and telephone number;

    VII)
      the
      contact person, telephone number, company name and full address of the
      utilization review agent, if the determination was made by the agent;
      and

    VIII)
      if
      the Contractor has a second level internal review process, the notice shall
      contain instructions on how to file a second level Action Appeal and a statement
      in bold text that the timeframe for requesting an External Appeal begins upon
      receipt of the final adverse determination of the first level Action Appeal,
      regardless of whether or not a second level of Action Appeal is requested,
      and
      that by choosing to request a second level Action Appeal, the time may expire
      for the Enrollee to request an External Appeal.

     

    6.
      Complaint Process

     

    a)
      The
      Contractor' Complaint process shall include the following regarding the handling
      of Enrollee Complaints:

    

     

    

    Medicaid
      Advantage Contract 

    APPENDIX
      F 

    State
      2006 

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    i)
      The
      Enrollee, or his or her designee, may file a Complaint regarding any dispute
      with the Contractor orally or in writing. The Contractor may have requirements
      for accepting written Complaints either by letter or Contractor supplied form.
      The Contractor cannot require an Enrollee to file a Complaint in
      writing.

     

    ii)
      The
      Contractor must provide written acknowledgment of any Complaint not immediately
      resolved, including the name, address and telephone number of the individual
      or
      department handling the Complaint, within fifteen (15) business days of receipt
      of the Complaint. The acknowledgement must identify any additional information
      required by the Contractor from any source to make a determination. If a
      Complaint determination is made before the written acknowledgement is sent,
      the
      Contractor may include the acknowledgement with the notice of the determination
      (one notice).

     

    iii)
      Complaints shall be reviewed by one or more qualified personnel.

     

    iv)
      Complaints pertaining to clinical matters shall be reviewed by one or more
      licensed, certified or registered health care professionals in addition to
      whichever non-clinical personnel the Contractor designates.

     

    7.
      Timeframes for Complaint Resolution by the Contractor

     

    a)
      The
      Contractor's Complaint process shall indicate the following specific timeframes
      regarding Complaint resolution:

     

    i)
      If the
      Contractor immediately resolves an oral Complaint to the Enrollee's
      satisfaction, that Complaint may be considered resolved without any additional
      written notification to the Enrollee. Such Complaints must be logged by the
      Contractor and included in the Contractor's quarterly HPN Complaint report
      submitted to SDOH in accordance with Section 18 of this Agreement.

     

    ii)
      Whenever a delay would significantly increase the risk to an Enrollee's health,
      Complaints shall be resolved within forty-eight (48) hours after receipt of
      all
      necessary information and no more than seven (7) days from the receipt of the
      Complaint.

     

    iii)
      All
      other Complaints shall be resolved within forty-five (45) days after the receipt
      of all necessary information and no more than sixty (60) days from receipt
      of
      the Complaint. The Contractor shall maintain reports of Complaints unresolved
      after forty-five (45) days in accordance with Section 18 of this
      Agreement.

     

    8.
      Complaint Determination Notices

     

    a)
      The
      Contractor's procedures regarding the resolution of Enrollee Complaints shall
      include the following:

    

    Medicaid
      Advantage Contract 

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      F 

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      2006

    F-16

     

    

    i)
      Complaint Determinations by the Contractor shall be made in writing to the
      Enrollee or his/her designee and include:

    A)
      the
      detailed reasons for the determination;

    B)
      in
      cases where the determination has a clinical basis, the clinical rationale
      for
      the determination;

    C)
      the
      procedures for the filing of an appeal of the determination, including a form,
      if used by the Contractor, for the filing of such a Complaint Appeal; and notice
      of the right of the Enrollee to contact the State Department of Health regarding
      his or her Complaint, including SDOH's toll-free number for
      Complaints.

     

    ii)
      If
      the Contractor was unable to make a Complaint determination because insufficient
      information was presented or available to reach a determination, the Contractor
      will send a written statement that a determination could not be made to the
      Enrollee on the date the allowable time to resolve the Complaint has
      expired.

     

    iii)
      In
      cases where delay would significantly increase the risk to an Enrollee's health,
      the Contractor shall provide notice of a determination by telephone directly
      to
      the Enrollee or to the Enrollee's designee, or when no phone is available,
      some
      other method of communication, with written notice to follow within three (3)
      business days.

     

    9.
      Complaint Appeals

     

    a)
      The
      Contractor's procedures regarding Enrollee Complaint Appeals shall include
      the
      following:

     

    i)
      The
      Enrollee or designee has no less than sixty (60) business days after receipt
      of
      the notice of the Complaint determination to file a written Complaint Appeal.
      Complaint Appeals may be submitted by letter or by a form provided by the
      Contractor.

     

    ii)
      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.

     

    iii)
      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).

     

    iv)
      Complaint Appeals of non-clinical matters shall be determined by qualified
      personnel at a higher level than the personnel who made the original Complaint
      determination.

     

    

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      Advantage Contract 

    APPENDIX
      F 

    State
      2006 

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    v)
      Complaint Appeals shall be decided and notification provided to the Enrollee
      no
      more than:

    A)
      two
      (2) business days after the receipt of all necessary information when a delay
      would significantly increase the risk to an Enrollee's health; or

    B)
      thirty
      (30) business days after the receipt of all necessary information in all other
      instances.

     

    vi)
      The
      notice of the Contractor's Complaint Appeal determination shall
      include:

    A)
      the
      detailed reasons for the determination;

    B)
      the
      clinical rationale for
      the
      determination in cases where the determination has a clinical
      basis;

    C)
      the
      notice shall also inform the Enrollee of his/her option to also contact the
      State Department of Health with his/her Complaint, including the SDOH's
      toll-free number for Complaints;

    D)
      instructions for any further Appeal, if applicable.

     

    10. Records

     

    a)
      The
      Contractor shall maintain a file on each Complaint, Action Appeal and Complaint
      Appeal. These records shall be readily available for review by the SDOH, upon
      request. The file shall include:

     

    i)
      date
      the Complaint was filed;

     

    ii)
      copy
      of the Complaint, if written;

     

    iii)
      date
      of receipt of and copy of the Enrollee's written confirmation, if
      any;

     

    iv)
      log
      of Complaint determination including the date of the determination and the
      titles of the personnel and credentials of clinical personnel who reviewed
      the
      Complaint;

     

    v)
      date
      and copy of the Enrollee's Action Appeal or Complaint Appeal;

     

    vi)
      Enrollee or provider requests for expedited Action Appeals and Complaint Appeals
      and the Contractor's determination;

     

    vii)
      necessary documentation to support any extensions;

     

    viii)
      determination and date of determination of the Action Appeals and Complaint
      Appeals;

     

    ix)
      the
      titles and credentials of clinical staff who reviewed the Action Appeals and
      Complaint Appeals; and

     

    

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      F 

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      2006

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    x)
      Complaints unresolved for greater than forty-five (45) days.

    

    

    

    Medicaid
      Advantage Contract 

    APPENDIX
      F 

    State
      2006 

    F-19

     

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    APPENDIX
      G

     

    Reserved

     

    Medicaid
      Advantage Contract 

    APPENDIX
      G

    State
      2006 G-l

     

    
 

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    APPENDIX
      H

     

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

    

    

    Medicaid
      Advantage Contract APPENDIX H 

    State
      2006 

    H-l

    

    Appendix
      H 

    SDOH
      Guidelines

    For
      the Processing of Medicaid Advantage Enrollments and
      Disenrollments

     

    1.
      General

     

    The
      Contractor's Enrollment and Disenrollment procedures for Medicaid Advantage
      shall be consistent with these requirements, except that to allow LDSS and
      the
      Contractor flexibility in developing processes that will meet the needs of
      both
      parties, the SDOH may allow modifications to timeframes and some procedures.
      Where an Enrollment Broker exists, the Enrollment Broker may be responsible
      for
      some or all of the LDSS responsibilities.

     

    2.
      Enrollment

     

    a)
      SDOH Responsibilities.

     

    i)
      The
      SDOH is responsible for monitoring Local District program activities and
      providing technical assistance to the LDSS and the Contractor to ensure
      compliance with the State's policies and procedures.

     

    ii)
      SDOH
      reviews and approves proposed Enrollment materials prior to the Contractor
      publishing and disseminating or otherwise using the materials.

     

    b)
      LDSS Responsibilities:

     

    i)
      The
      LDSS has the primary responsibility for processing Medicaid Advantage
      enrollments.

     

    ii)
      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 eligibility.

     

    iii)
      LDSS
      is responsible for providing pre-enrollment information on Medicaid Advantage
      to
      Dually Eligible beneficiaries, consistent with Social Services Law, Section
      364-j(4)(e)(iv) and train persons providing enrollment counseling to Eligible
      Persons.

     

    iv)
      The
      LDSS is responsible for informing Eligible Persons of the availability of
      Medicaid Advantage Products, the scope of services covered by each, and that
      enrollment is voluntary.

    

    

    

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      Advantage Contract 

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      H 

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      2006 

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    v)
      The
      LDSS is responsible for informing Eligible Persons of the right to confidential
      face-to-face enrollment counseling and will make confidential face-to-face
      sessions available upon request.

     

    vi)
      The
      LDSS is responsible for instructing Eligible Persons, to verify with the medical
      services providers they prefer, or have an existing relationship with, that
      such
      medical services providers are Participating Providers of the selected MCO
      and
      are available to serve the Enrollee. The LDSS includes such written instructions
      to Eligible Persons in its written materials related to Enrollment.

     

    vii)
      For
      Enrollments made during face-to-face counseling, if the Prospective Enrollee
      has
      a preference for particular medical services providers, Enrollment counselors
      shall verify with the medical services providers that such medical services
      providers whom the prospective Enrollee prefers are Participating Providers
      of
      the selected MCO and are available to serve the Prospective
      Enrollee.

     

    viii)
      The
      LDSS is responsible for the timely processing of Medicaid Advantage Enrollment
      applications received from participating health plans.

     

    ix)
      The
      LDSS is responsible for processing Enrollments in Medicaid Advantage 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.

     

    x)
      The
      LDSS is responsible for determining the eligibility status of Medicaid Advantage
      enrollment applications. Applications will be enrolled, pended or
      denied.

     

    xi)
      The
      LDSS is responsible for processing Medicaid Advantage enrollment applications
      until the last day of the month preceding the Effective Date of Enrollment,
      to
      the extent possible.

     

    xii)
      The
      LDSS is responsible for notifying the Contractor of plan-assisted enrollment
      applications that are accepted, pended or denied.

     

    xiii)
      The
      LDSS is responsible for entering individual enrollment form data and
      transmitting that data to the State's Prepaid Capitation Plan (PCP) Subsystem.
      The transfer of enrollment information may be accomplished by any of the
      following:

    

    

    

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      Advantage Contract

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      H 

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      2006 

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    A)
      LDSS
      directly enters data into PCP Subsystem; or

     

    B)
      LDSS
      or Contractor submits a tape to the State, to be edited and entered into PCP
      Subsystem; or

     

    C)
      LDSS
      electronically transfers data via a dedicated line, from eMedNY to the PCP
      Subsystem.

     

    xiv)
      Extensive use of the secondary roster will be utilized to coordinate the
      Effective Dates of Enrollment for Medicaid and Medicare Advantage.

     

    xv)
      The
      LDSS is responsible for prospectively re-enrolling an Enrollee who is
      disenrolled from the Contractor's Medicaid Advantage Product due to loss of
      Medicaid eligibility, who regains eligibility within three months, in the
      Contractor's Medicaid Advantage Product, provided that the individual remains
      enrolled in the Contractor's Medicare Advantage Product.

     

    xvi)
      The
      LDSS is responsible for processing new Enrollment applications to transfer
      a
      member of the Contractor's Medicaid managed care product to the Contractor's
      Medicaid Advantage Product if the Enrollee, upon gaining Medicare eligibility,
      wishes to enroll in the Contractor's Medicaid Advantage Product. To the extent
      possible, such Enrollments shall be made effective the first day of the month
      that the Enrollee's Medicare Advantage Coverage is effective.

     

    xvii)
      The
      LDSS is responsible for sending the following notices to Eligible
      Persons:

     

    A)
      Enrollment Confirmation Notice: This notice indicates the Effective Date
      of
      Enrollment, the name of the Medicaid Advantage 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 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 Benefit rendered during
      the
      retroactive period if the benefit was provided by a non-Medicaid participating
      provider.

     

    B)
      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
      Product. This notice must include fair hearing rights.

    

     

    Medicaid
      Advantage Contract

    APPENDIX
      H 

    State
      2006 

    H-4

     

    

    c)
      Contractor Responsibilities:

     

    i)
      To the
      extent permitted by law and regulation, the Contractor is responsible for
      assisting Dually Eligible persons eligible for enrollment in Medicaid Advantage
      to complete the Enrollment application. The Contractor will submit plan
      Enrollments to the LDSS, within a maximum of five (5) business days from the
      day
      the Enrollment is received by the Contractor (unless otherwise agreed to by
      SDOH
      and LDSS).

     

    ii)
      The
      Contractor is responsible for obtaining documentation of Medicare A and B
      coverage prior to sending the Enrollment transaction to the LDSS for processing.
      In all areas where Enrollments are not processed by the Enrollment Broker,
      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.

     

    iii)
      In
      areas where Enrollments are submitted electronically to the Enrollment Broker,
      the Contractor is responsible for forwarding the documentation of current
      Medicare A and B coverage to the Enrollment Broker within five (5) business
      days
      of learning from the Enrollment Broker that evidence of Medicare A and B
      coverage is not reflected in the WMS system.

     

    iv)
      The
      Contractor must notify new Enrollees of their Effective Date of Enrollment.
      To
      the extent practicable, such notification must precede the Effective Date of
      Enrollment. 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 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 Benefit rendered during the retroactive period
      if
      the benefit was provided by a non-Medicaid participating provider.

     

    v)
      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 eligibility such as address changes,
      incarceration, third party insurance other than Medicare, Disenrollment from
      the
      Contractor's Medicare Advantage Product, etc.

     

    vi)
      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.

     

    

    Medicaid
      Advantage Contract 

    APPENDIX
      H

    State
      2006 

    H-5

     

    

    In
      such
      instances, the LDSS shall delete the Enrollee's Enrollment in the Contractor's
      Medicaid Advantage Plan.

     

    vii)
      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.

     

    viii)
      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.

     

    3.
      Newborn Enrollments:

     

    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 leams of an Enrollee's pregnancy prior to the
      Contractor, the LDSS is responsible for establishing MA eligibility and
      enrolling the unborn into Medicaid managed care in cases where an enrollment
      form is received or other members of the family are enrolled in a mainstream
      plan.

     

    iv)
      When
      a newborn is enrolled in managed care, the LDSS is responsible for sending
      an
      Enrollment Confirmation Notice to inform the mother of

    

    

    Medicaid
      Advantage Contract 

    APPENDIX
      H 

    State
      2006 

    H-6

     

    

    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).

     

    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), sex and the date of birth.

     

    4.
      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 1st
      of the
      following month (First Monthly Roster). Notification to the Contractor and
      LDSS
      will be accomplished via paper transmission, magnetic media, or the
      HPN.

     

    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
      LDSSs 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.

    

    

    Medicaid
      Advantage Contract 

    APPENDIX
      H 

    State
      2006

    H-7

     

    

    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 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).

     

    ii)
      Enrollment and eligibility issues are reconciled by the LDSS to the extent
      possible, through manual adjustments to the PCP subsystem Enrollment and WMS
      eligibility files, if appropriate.

     

    d)
      Contractor Responsibilities:

     

    i)
      The
      Contractor is at risk for providing Benefit Package services for those Enrollees
      listed on the 1st
      and
      2nd
      Rosters
      for the month in which the 2nd
      Roster
      is generated. Contractor is not at risk for providing services to Enrollees
      who
      appear on the monthly Disenrollment report.

     

    ii)
      The
      Contractor must submit claims to the State's Fiscal Agent for all Eligible
      Persons that are on the 1st
      and
      2nd
      Rosters
      (see Appendix H, page 7), 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."

    

    

    Medicaid
      Advantage Contract 

    APPENDIX
      H 

    State
      2006 

    H-8

     

    

    5.
      Disenrollment:

     

    a)
      LDSS Responsibilities:

     

    i)
      Enrollees may request to disenroll from the Contractor's Medicaid Advantage
      Product at any time for any reason. Disenrollment requests may be made by
      Enrollees to the LDSS, the Enrollment Broker, or the Contractor.

     

    ii)
      Medicaid Advantage Plans, LDSSs, and the Enrollment Broker must utilize
      State-approved Disenrollment forms.

     

    iii)
      The
      LDSS will accept requests for Disenrollment directly from the Enrollee or from
      the Contractor.

     

    iv)
      Enrollees may initiate a request for an expedited Disenrollment to the LDSS.
      The
      LDSS is responsible for expediting the Disenrollment process in those cases
      where an Enrollee's request for Disenrollment involves concurrent Disenrollment
      from the Contractor's Medicare Advantage Product, an urgent medical need, a
      complaint of non-consensual enrollment or, in New York City, homeless
      individuals in the shelter system. If approved, the LDSS will manually process
      the Disenrollment through the PCP Subsystem. Enrollees who request to be
      disenrolled from Medicaid Advantage based on their documented HIV, ESRD, or
      SPMI/SED status are categorically eligible for an expedited Disenrollment on
      the
      basis of urgent medical need.

     

    v)
      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.

     

    vi)
      The
      LDSS is responsible for disenrolling Enrollees automatically upon death,
      Disenrollment from the Contractor's Medicare Advantage Product, or loss of
      Medicaid eligibility. All 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, or
      at
      the end of the last month of Guaranteed Eligibility, where
      applicable.

     

    vii)
      The
      LDSS is responsible for promptly disenrolling an Enrollee whose managed care
      eligibility or status changes such that he/she is deemed by the LDSS to no
      longer be eligible for Medicaid Advantage Enrollment. The LDSS is responsible
      for providing Enrollees with a notice of their right to request a fair
      hearing.

    

    Medicaid
      Advantage Contract 

    APPENDIX
      H 

    State
      2006

    H-9

    viii)
      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 Product, is enrolled when
      ineligible for Enrollment, or when an Enrollee enters or resides in a
      residential institution 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.

     

    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.

     

    ix)
      Generally the effective dates of Disenrollment are prospective. Effective dates
      for other than routine Disenrollments are described below:

    

     

    

    Medicaid
      Advantage Contract 

    APPENDIX
      H 

    State
      2006 

    H-10

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    

    
      	
               

              Reason
                for Disenrollment

            	
               

              Effective
                Date of Disenrollment

            
	
               

              •
                Death of Enrollee

            	
               

              •
                First day of the month after death

            
	
               

              •
                Incarceration

            	
               

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

            
	
               

              •
                Enrollee entered or stayed in a residential institution under
                circumstances which rendered the individual ineligible for enrollment
                in
                Medicaid Advantage or is in receipt ofwaivered services through the
                Long
                Term Home Health Care Program (LTHHCP), including when an Enrollee
                is
                admitted to a hospital that 1) is certified by Medicare as a long-term
                care hospital and 2) has an average length of stay for all patients
                greater than ninety-five (95) days as reported in the Statewide Planning
                and Research Cooperative System (SPARCS) Annual Report
                2002.

            	
               

              •
                First day of the month of entry or first day of the month of
                classification of the stay as permanent, subsequent to entry
                (note-Contractor is at risk for covered services only to the date
                of entry
                or classification of the stay as permanent subsequent to entry, and
                is
                entitled to the capitation payment for the month of entry or
                classification of the stay as permanent subsequent to
                entry).

            
	
               

              •
                Individual enrolled while ineligible for enrollment

            	
               

              •
                Effective Date of Enrollment in the Contractor's Plan.

            
	
               

              •
                Non-consensual Enrollment

            	
               

              •
                Retroactive to the first day of the month of Enrollment

            
	
               

              •
                Enrollee moved outside of the District/County of Fiscal
                Responsibility

            	
               

              •
                First day of the month after the update of the system with the new
                address*

            
	
               

              •
                Urgent medical need

            	
               

              •
                First day of the next month after determination except where medical
                need
                requires an earlier Disenrollment

            
	
               

              •
                Homeless Enrollees in Medicaid Advantage residing in the shelter
                system in
                NYC

            	
               

              •
                Retroactive to the first day of the month of

               

              the
                request

            
	
               

              •
                An Enrollee with more than one Client Identification Number (CIN)
                is
                enrolled in the Contractor's Medicaid Advantage Product under more
                than
                one of the CINs.

            	
               

              •
                First day of the month the duplicate Enrollment
                began.

            

    

     

    *
      In
      counties outside of New York City, LDSSs should work together to ensure
      continuity of care through the Contractor if the Contractor's service area
      includes the county to which the Enrollee has moved and the Enrollee, with
      continuous eligibility, wishes to stay enrolled in the Contractor's plan. In
      New
      York City, Enrollees, not in guaranteed status, who move out of the
      Contractor's

     

    Medicaid
      Advantage Contract 

    APPENDIX
      H

    State
      2006 

    H-ll

    

    

    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.

     

    x)
      The
      LDSS is responsible for informing Enrollees of their right to disenroll at
      any
      time for any reason.

     

    xi)
      The
      LDSS will render a decision within five (5) days of the receipt of a fully
      documented request for Disenrollment.

     

    xii)
      To
      the extent possible, the LDSS is responsible for processing an expedited
      disenrollment within two (2) business days of its determination that an
      expedited Dissenrollment is warranted.

     

    xiii)
      The
      LDSS is responsible for sending the following notices to Enrollees regarding
      their Disenrollment status. Where practicable, the process will allow for timely
      notification to Enrollees unless there is "good cause" to disenroll more
      expeditiously.

     

    A)
      Notice
      of Disenrollment: These notices will advise the Enrollee of the LDSS's
      determination regarding an Enrollee-initiated, LDSS-initiated or
      Contractor-initiated Disenrollment and will include the Effective Date of
      Disenrollment. In cases where the Enrollee is being involuntarily disenrolled,
      the notice must contain fair hearing rights.

     

    B)
      When
      the LDSS denies any Enrollee's request for Disenrollment pursuant to Section
      8
      of this Agreement, the LDSS is responsible for informing the Enrollee in writing
      explaining the reason for the denial, stating the facts upon which the denial
      is
      based, citing the statutory and regulatory authority and advising the Enrollee
      of his/her right to a fair hearing pursuant to 18 NYCRR Part 358.

     

    C)
      Notice
      of Change to "Guarantee Coverage": This notice will advise the Enrollee that
      his
      or her Medicaid coverage is ending and how this affects his or her enrollment
      in
      the Medicaid Advantage Product. This notice contains pertinent information
      regarding "Guaranteed Eligibility" benefits and dates of coverage. If an
      Enrollee is not eligible for guarantee, this notice is not
      necessary.

     

    xiv)
      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 Product until the disposition of the fair
      hearing, if Aid to Continue is ordered by the New York State Office of
      Administrative Hearings.

     

     

    Medicaid
      Advantage Contract 

    APPENDIX
      H 

    State
      2006

    H-12

     

    

    xv)
      The
      LDSS is responsible for reviewing each Contractor requested Disenrollment in
      accordance with the provisions of Section 8.7 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.

     

    xvi)
      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.

     

    xvii)
      After the LDSS receives and, if appropriate, approves the request for
      Disenrollment either from the Enrollee or the Contractor, the LDSS is
      responsible for updating the PCP subsystem file with an end date. The Enrollee
      is removed from the Contractor's Roster.

     

    b)
      Contractor Responsibilities:

     

    i)
      In
      those instances where the Contractor directly receives Disenrollment forms,
      the
      Contractor will forward these Disenrollments to the LDSS for processing within
      five (5) business days (or according to Section 5 of this Appendix). During
      pull-down week, these forms may be faxed to the LDSS with the hard copy to
      follow.

     

    ii)
      The
      Contractor must accept and transmit all requests for voluntary Disenrollments
      from its Enrollees to the LDSS, and shall not impose any barriers to
      Disenrollment requests. The Contractor may require that a Disenrollment request
      be in writing, contain the signature of the Enrollee, and state the Enrollee's
      correct Contractor or Medicaid identification number.

     

    iii)
      Following LDSS procedures, the Contractor will refer cases which are appropriate
      for an LDSS-initiated Disenrollment and will submit supporting documentation
      to
      the LDSS. This includes, but is not limited to, changes in status for its
      enrolled members that may impact eligibility for Enrollment in an MCO such
      as
      address changes, incarceration, death, ineligibility for Medicaid Advantage
      Enrollment, change in Medicare status, etc.

     

    iv)
      With
      respect to Contractor-initiated Disenrollments:

     

    A)
      The
      Contractor may initiate an involuntary Disenrollment if the
      Enrollee:

    

    i)
      engages in conduct or behavior that seriously impairs the Contractor's ability
      to furnish services to either the Enrollee or other Enrollee's, provided that
      the Contractor has made

     

     

    

    Medicaid
      Advantage Contract 

    APPENDIX
      H

    State
      2006

    H-13

     

    

    and
      documented reasonable efforts to resolve the problems presented by the Enrollee;
      or

    

    ii)
      provides fraudulent information on an enrollment form or permits abuse of an
      enrollment card except when the Enrollee is no longer eligible for Medicaid
      and
      is in his/her Guaranteed Eligibility period.

     

    B)
      The
      Contractor may not request Disenrollment because of an adverse change in the
      Enrollee's health status, or because of the Enrollee's utilization of medical
      services, diminished mental capacity, or uncooperative or disruptive behavior
      resulting from the Enrollee's special needs (except where continued enrollment
      in the Contractor's plan seriously impairs the Contractor's ability to furnish
      services to either the Enrollee or other Enrollees).

     

    C)
      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.

     

    D)
      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.

     

    E)
      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.

     

    v)
      The
      Contractor will not consider an Enrollee disenrolled without confirmation from
      the LDSS or the Roster (as described in Section 4 of this
      Appendix).

    

     

    Medicaid
      Advantage Contract 

    APPENDIX
      H 

    State
      2006

    H-14

     

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    APPENDIX
      I

     

    Reserved

    

    

    

    

    

    

    Medicaid
      Advantage Contract APPENDIX 1

    State
      2006 

    1-1

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    APPENDIX
      J

     

    New
      York State Department of Health Guidelines of Federal Americans with
      Disabilities Act

    

    

    

    

    

    

    

    Medicaid
      Advantage Contract 

    APPENDIX
      J 

    State
      2006

    J-l

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    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, 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 Managed Care 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

    

    Medicaid
      Advantage Contract 

    APPENDIX
      J

    State
      ,2006 

    J-2

    

    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.

     

    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 assure 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, Brailed 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.

    

     

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      Advantage Contract

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      J

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      ,2006

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    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-enrollment Marketing and Education

    Standard
      for Compliance:

    Marketing
      staff, activities and materials will be made available to persons with
      disabilities. Marketing materials will be made available in alternative formats
      (such as Braille, large print, 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.)

     

    

    Medicaid
      Advantage Contract

    APPENDIX
      J

    State
      ,2006

    J-4

     

    

    6.
      Policy
      statement that marketing representatives will offer to read or summarize to
      blind or vision impaired individuals any written material that is typically
      distributed to all enrollees

    7.
      Staff/resources available to assist individuals with cognitive impairments
      in
      understanding materials

    

    Compliance
      Plan Submission

    

    1.
      A
      description of methods to ensure that the 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 enrollees of information necessary
      to make informed choices about treatment options, to effectively utilize the
      health care resources, to assist enrollees in making appointments, and to field
      questions and complaints, to assist enrollees with the complaint
      process.

     

    B1. 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 dropoffs

    3. Routes
      of
      travel into the facility are stable, slip-resistant, with all steps > '/2"
      ramped, doorways with minimum 32" opening

    4. Interior
      halls and passageways providing a clear and unobstructed path or travel at
      least
      36" wide to bathrooms and other rooms commonly
      used by enrollees

    5. Waiting
      rooms, restrooms, and other rooms used by enrollees are accessible to people
      with disabilities

    6. Sign
      language interpreters and other auxiliary aids and services provided in
      appropriate circumstances

    

    

    Medicaid
      Advantage Contract

    APPENDIX
      J

    State,
      2006

    J-5

     

    

    7.
      Materials available in alternative formats, such as Braille, large print, audio
      tapes

    8.
      Staff
      training which includes sensitivity training related to disability issues
      [Resources and technical assistance are available through the NYS Office of
      Advocate for Persons with Disabilities - V/TTY (800) 522-4369; and the NYC
      Mayor's Office for People with Disabilities-(212) 788-2830 or TTY
      (212)788-2838]

    9.
      Availability of activities and educational materials tailored to specific
      conditions/illnesses and secondary conditions that affect these populations
      (e.g. secondary infection prevention, decubitus prevention, special exercise
      programs, etc.) 10. 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. Health assessment
      forms may not be used by plans prior to enrollment. ( Once a plan has been
      chosen, a health assessment form may be used to assess the person's health
      care
      needs.)

    

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      Advantage Contract

    APPENDIX
      J

    State
      ,2006

    J-6

    

    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

    

    

    Medicaid
      Advantage Contract

    APPENDIX
      J

    State
      ,2006

    J-7

    

    Through
      the NYS Office of Advocate for Persons with Disabilities - V/TTY (800) 522-4369;
      and the NYC Major’s Office for People with Disabilities- (212) 788-2830 or TTY
      (212)788-2838] .

     

    4.
      Activities and fairs that include sign language interpreters or the distribution
      of a written summary of the marketing script used by plan marketing
      representatives

     

    5.
      Include in written/audio materials available to enrollees information regarding
      how and where people with disabilities can access help in getting services,
      for
      example help with making appointment 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) m 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 deal or hard o( 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

    

    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
      grievances and complaints in an expeditious manner, with the goal of ensuring
      resolution of complaints and access to appropriate

    

    Medicaid
      Advantage Contract

    APPENDIX
      J

    State
      ,2006

    J-8

    

    services
      as rapidly as possible.

     

    All
      enrollees must be informed about the complaint process within their plan and
      the
      procedure for filing complaints. This information will be made available through
      the member handbook, the SDOH toll-free complaint line [1-(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 complaint procedure-
      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 complaint process 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

     

    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 complaints and grievances related to people
      with
      disabilities. Also, as part of the Compliance ____Plan, MCOs must submit a
      summary report based on the MCO's most recent year's complaint
      data.

    

    Medicaid
      Advantage Contract

    APPENDIX
      J

    State
      ,2006

    J-9

     

    

    IV.
      PROGRAM ACCESSIBILITY

     

    C. Case
      Management

     

    Standard
      for Compliance: 

    MCOs
      must
      have m place adequate case management systems to identify the service needs
      of
      all enrollees, including enrollees with chronic illness and enrollees with
      disabilities, and ensure that medically necessary covered benefits are delivered
      on a timely basis. These systems may 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 fur case management

    5.
      Procedures for informing enrollees about the availability of case management
      services

     

    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

    

    

    Medicaid
      Advantage Contract 

    APPENDIX
      J

    January
      1,2006 

    J-10

     

    

    IV.
      PROGRAM ACCESSIBILITY

     

    Participating
      Providers

     

    Standard
      for Compliance:

    MCO
      networks will include all the provider types necessary to finish 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]

    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
                

            

    

    

    Medicaid
      Advantage Contract 

    APPENDIX
      J

    January
      1,2006 

    J-11

    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

     

    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 witlh 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

    

    Medicaid
      Advantage Contract 

    APPENDIX
      J

    January
      1,2006 

    J-12

    

    5.
      Procedures 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 OMRDD population and
      look-alikes

     

    Compliance
      Plan Submission

    1.
      a
description
      of arrangements to ensure access to specialty care providers and centers in
      and
      out of New York State, standing referrals, specialist physicians to function
      as
      PCP, out of plan referrals, and continuation of existing relationships
      (out-of-plan) diagnosis and treatment of rare disorders. 

     

    2
      A
      description of appropriate service delivery for children with disabilities.
      This
      may include a description of methods for interacting with school districts,
      preschool services, child protective service agencies, early intervention
      officials, behavioral health, and disability and advocacy organizations and
      School Based Health Centers. 

     

    3.
      A
      description of the pediatric provider and sub-specialist network, including
      contractual relationships with tertiary institutions to meet the health care
      needs of children with disabilities.

    

    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

    

    Medicaid
      Advantage Contract 

    APPENDIX
      J

    January
      1,2006 

    J-13

     

    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.icaid Advantage Contract 

     

    

    Medicaid
      Advantage Contract 

    APPENDIX
      J

    January
      1,2006

    J-14

     

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    APPENDIX
      K

     

    Medicare
      and Medicaid Advantage Products And Non-Covered Services

    

    

    

    

    

    

    Medicaid
      Advantage Contract 

    APPENDIX

    State
      2006l

    K
      1

     

     

    APPENDIX
      K

     

    Appendix
      K is organized into three parts:

     

    I.
      Appendix K-l

     

    Medicare
      Advantage Product

     

    II.
      Appendix K-2

     

    Medicaid
      Advantage Product

     

    Contractor/County
      Election of Coverage for Optional Services

     

    Description
      of Medicaid Only Covered Services

     

    III.
      Appendix K-3

     

    Non-Covered
      Services

    

    

    Medicaid
      Advantage Contract 

    APPENDIX
      K

    State
      2006

    K-2

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    APPENDIX
      K.1

    MEDICARE
      ADVANTAGE PRODUCT

    

    
      	
              Medicare
                Advantage Benefit Package for Dual Eligibles - Upstate
                Counties

            
	
              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 a leap year) $300 per stay
                co-payment

            
	
              Inpatient
                Mental Health

              Inpatient
                Mental Health

            	
              Medically
                necessary care. $300 per stay 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. $10 per visit co-payment.

            
	
              PCP
                Office Visits

            	
              Primary
                care doctor office visits. Subject to $10 co-payment per
                visit.

            
	
              Specialist
                Office Visits

            	
              Specialist
                office visits. Subject to $20 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 $20 co-payment.
                

            
	
              Podiatry

            	
              Medically
                necessary foot care, including care for medical conditions affecting
                lower
                limbs, subject to $20 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. $35 per visit to ambulatory surgery or outpatient
                hospital.

            
	
              Ambulance

            	
              Transportation
                provided by an ambulance service, including air ambulance. Emergency
                transportation if for the purpose of obtaining hospital service for
                an
                enrollee who suffers from severe, life-threatening or potentially
                disabling conditions

            

    

    

     

     

    Medicaid
      Advantage Contract 

    APPENDIX
      K

    State
      2006

    K-3

     

    

    
      	
              Medicare
                Advantage Benefit Package for Dual Eligibles - Upstate
                Counties

            
	
               

              Category
                of Service

            	
               

              Included
                in Medicare Capitation

            
	 	
               

              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." $50 co-payment. 

            
	
              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 $20
                co-payment.

            
	
              Outpatient
                Rehabilitation (OT, PT, Speech)

            	
              Occupational
                therapy, physical therapy and speech and language therapy subject
                to $20
                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 or temporary impairment prerequisite for orthotics. Not
                subject
                to co-payment or coinsurance.

            
	
              Diabetes
                Monitoring

            	
              Diabetes
                self-monitoring training and supplies including coverage for glucose
                monitors, test strips, lancets and self-management training. No
                co-payment.

            
	
              Diagnostic
                Testing

            	
              Diagnostic
                tests, x-rays, lab services and radiation therapy. No
                co-payment.

            
	
              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.
                Vaccines/Toxoids. 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

            	
              Prostate
                Cancer Screening exams for men age 50 and older.

              No
                co-payment

            

    

     

    

     

    Medicaid
      Advantage Contract

    APPENDIX
      K

    State
      2006

    K-4

     

    

    
      	
              Medicare
                Advantage Benefit Package for Dual Eligibles -
                Upstate Counties

            
	
               

              Category
                of Service

            	
               

              Included
                in Medicare Capitation

            
	
              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.

            
	
              Hearing
                Services

            	
              Medicaid
                and Medicare 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, ear-molds, 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 includes the replacement of lost or destroyed
                glasses.
                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 prerequisite of cataract surgery. No co-payment.

            
	
              Routine
                Physical Exam 1/year

            	
              Up
                to one routine physical per year. Subject to $10 co-payment per visit.
                

            
	
              Health/Wellness
                Education

            	
              Coverage
                for the following: general health education classes, parenting classes,
                smoking cessation classes, childbirth education and nutrition counseling,
                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 Contract 

    APPENDIX
      K

    State
      2006

    K-5

     

    

    
      	
              Medicare
                Advantage Benefit Package for Dual Eligibles - NYC,
                Nassau, Suffolk, Westchester, Rockland, Orange and Putnam
                Counties

            
	
              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 Contract

     APPENDIX
      K

    State
      2006

    K-6

     

    

    
      	
              Medicare
                Advantage Benefit Package for Dual Eligibles - NYC,
                Nassau, Suffolk, Westchester, Rockland, Orange and Putnam
                Counties

            
	
               

              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 not 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 bar).
                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 training and supplies including coverage for glucose
                monitors, test strips, lancets and self-management training. No
                co-payments.

            
	
              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.

            
	
              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.

            

    

     

    

    

    Medicaid
      Advantage Contract 

    APPENDIX
      K

    January
      1,2006

    K-7

     

    

    
      	
              Medicare
                Advantage Benefit Package for Dual Eligibles -  NYC,
                Nassau, Suffolk, Westchester, Rockland, Orange and Putnam
                Counties

            
	
              Category
                of Service

            	
              Included
                in Medicare Capitation

            
	 	
               

            
	
              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 includes the replacement of lost or destroyed
                glasses.
                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 prerequisite of cataract services. No co-payment.

            
	
              Routine
                Physical Exam I/year

            	
              Up
                to one routine physical per year. No co-payment.

            
	
              Health/Wellness
                Education

            	
              Coverage
                for the following: general health education classes, parenting classes,
                smoking cessation classes, childbirth education and nutrition counseling,
                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 Contract

    APPENDIX
      K.

    State,
      2006

    K-8

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    APPENDIX
      K2

    MEDICAID
      ADVANTAGE PRODUCT

     

    
      	
              Medicaid
                Advantage Benefit Package for Dual Eligibles - Upstate
                Counties

            
	
               
                Category of Service

            	
              Included
                in Medicaid Capitation

            
	
              Inpatient
                Hospital Care Including Substance Abuse and Rehabilitation
                Services

            	
              Elimination
                of $300 per stay co-payment.

            
	
              Inpatient
                Mental Health

            	
              Elimination
                of $300 per stay co-payment, plus days in excess of the 190-day lifetime
                maximum.

            
	
              Home
                Health

            	
              Elimination
                of $10 co-payment per Medicare covered visit, plus value of Medicare
                non-covered visits including home health aid services with nursing
                supervision to medically unstable individuals. 

            
	
              PCP
                Office Visits

            	
              Elimination
                of $10 co-payment

            
	
              Specialist
                Office Visits

            	
              Elimination
                of $20 co-payment

            
	
              Podiatry

            	
              Elimination
                of $20 co-payment for medically necessary foot care

            
	
              Outpatient
                Mental Health

            	
              Elimination
                of $20 co-payment

            
	
              Outpatient
                Substance Abuse

            	
              Elimination
                of $20 co-payment

            
	
              Outpatient
                Surgery

            	
              Elimination
                of $35 co-payment

            
	
              Ambulance

            	
              Elimination
                of $50 co-payment

            
	
              Emergency
                Room

            	
              Elimination
                of $50 co-payment

            
	
              Urgent
                Care

            	
              Elimination
                of $20 co-payment

            
	
              Outpatient
                Rehabilitation (OT, PT, Speech)

            	
              Elimination
                of $20 co-payment

            
	
              Dental
                (Optional
                benefit)

            	
              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
                dental services subject to prior authorization. 

            
	
              Routine
                Physical Exam I/year

            	
              Elimination
                of $10 co-payment

            
	
              Transportation
                - Routine (Optional
                benefit)

            	
              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.

            
	
              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.

            

    

     

    

    Medicaid
      Advantage Contract 

    APPENDIX
      K

    State,
      2006

    K-9

     

    

    
      	
              Medicaid
                Advantage Benefit Package for Dual Eligibles- NYC,
                Nassau, Suffolk, Westchester, Rockland, Orange and Putnam
                Counties

            
	
              Category
                of Service

            	
              Included
                in Medicaid Capitation

            
	
              Inpatient
                Mental Health

            	
              Days
                in excess of the 190-day lifetime maximum.

            
	
              Home
                Health

            	
              Non-Medicare
                covered home health services, including home health aid services
                and
                nursing supervision to medically unstable individuals.

            
	
              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
                (Optional
                benefit outside of NYC )

            	
              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
                dental services subject to prior authorization.

            
	
              Transportation
                - Routine (Optional
                benefit outside of NYC)

            	
              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.

            
	
              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.

            

    

     

    Medicaid
      Advantage Contract

    APPENDIX
      K

    January
      1,2006

    K-10

     

    

    MCO
      COVERAGE 

    OF
      OPTIONAL SERVICES 

    MEDICAID
      ADVANTAGE BENEFIT PACKAGE

     

    MCO: WellCare
      of New York. Inc.

     

    
      	
               

              Service
                Area

            	
              Medicaid
                Advantage Coverage Status

            
	
              Dental
                Services

            	
              Non-Emergency
                Transporation

            
	
              Albany

            	
              Not
                Covered

            	
              Not
                Covered

            

    

    

     

    

    Medicaid
      Advantage Contract 

    APPENDIX
      K

    January
      1,2006

    K-11

     

    DESCRIPTION
      OF MEDICAID ONLY SERVICES IN MEDICAID ADVANTAGE 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 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 developed by a certified
      home health agency.

     

    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 or in the hospital.

     

    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.

     

    Dental
      Services (optional benefit outside of NYC)

     

    Dental
      care includes preventive, prophylactic and other routine dental care, services,
      supplies and dental prosthetics required to alleviate a serious health
      condition, including one which affects employability.

     

    Dental
      surgery performed in an ambulatory or inpatient setting is the responsibility
      of
      the Contractor whether dental services are a covered plan benefit, or not.
      Inpatient claims and referred ambulatory claims for dental services provided
      in
      an inpatient or outpatient hospital setting for surgery, anesthesiology, x-rays,
      etc. are the responsibility of the Contractor. In these situations, the
      professional services of the dentist are covered by Medicaid fee-for-service.
      The Contractor should set up procedures to prior approve dental services
      provided in inpatient and ambulatory settings.

     

     

    Medicaid
      Advantage Contract 

    APPENDIX
      K

    State
      2006

    K-12

    
 

    As
      described in Sections 10.9 and 10.18 of this Agreement. Enrollees may self-refer
      to Article 28 clinics operated by academic dental centers to obtain covered
      dental services.

     

    If
      Contractor's Benefit Package excludes dental services:

     

    i)
      Enrollees may obtain routine exams, orthodontic services and appliances, dental
      office surgery, fillings, prophylaxis, and other Medicaid covered dental
      services from any qualified Medicaid provider who shall claim reimbursement
      from
      eMedNY; and

     

    ii)
      Inpatient and referred ambulatory claims for medical services provided in an
      inpatient or outpatient hospital setting in conjunction with a dental procedure
      (e.g. anesthesiology, x-rays), are the responsibility of the Contractor. In
      these situations, the professional services of the dentist are covered Medicaid
      fee-for-service.

     

    Non-Emergency
      Transportation (optional benefit outside of NYC)

     

    Transportation
      expenses arc 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 a member of the
      Enrollee's family.

     

    When
      the
      Contractor is capitated for non-emergency transportation, the Contractor is
      also
      responsible for providing transportation to Medicaid covered services that
      are
      not part of the Contractor's Benefit Package.

     

    For
      Contractors that cover non-emergency transportation in the Medicaid Advantage
      Benefit Package, transportation costs to MMTP services may be reimbursed by
      Medicaid FFS in accordance with the LDSS transportation policies in local
      districts where there is a systematic^ method to discretely identify and
      reimburse such transportation costs.

     

    For
      Enrollees with disabilities, the method of transportation must reasonably
      accommodate their needs, taking into account the severity and nature of the
      disability.

    

     

    

    Medicaid
      Advantage Contract 

    APPENDIX
      K

    State,
      2006

    K-13

     

    

    APPENDIX
      K.3

     

    NON
      COVERED SERVICES

     

    The
      following services will not be the responsibility of the MCO under the
      Medicare/Medicaid program:

     

    Services
      Covered by Direct Reimbursement from Original Medicare

     

    •
Hospice
      services provided to Medicare Advantage members

     

    •
Other
      services deemed to be covered by Original Medicare by CMS

     

    Services
      Covered by Medicaid Fee for Service

     

    •
Out
      of
      network Family Planning services under the direct access provisions of the
      waiver

    •
Skilled
      Nursing Facility (SNF) days not covered by Medicare

     

    •
      Personal Care Services

    •
      Medicaid-Covered Prescription and Non-Prescription (OTC) Drugs, Medical Supplies
      and Enteral Formula not covered under Medicare Part B or the MCO's Medicare
      Part
      D Prescription Drug Benefit approved by CMS.

     

    •
      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

    •
      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

    •
      Directly
      Observed Therapy for Tuberculosis Disease

     

    •
AIDS
      Adult Day Health Care

    •
HIV
      COBRA Case Management

    •
Adult
      Day Health Care

     

    Medicaid
      Advantage Program Optional Benefits

    Optional
      benefits will be covered Medicaid fee for service if the MCO elects not to
      cover
      these services in their Medicaid Advantage Product. Currently the only 2
      optional benefits are:

     

    •
      Non-Emergency Transportation Services

     

    •
Dental
      Service

     

    These
      services are mandatory in NYC.

    

    

    Medicaid
      Advantage Contract 

    APPENDIX
      K

    State,
      2006

    K-14

     

    

    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 Medicaid Advantage EnroIIees

     

    Hospice
      services provided to Medicare Advantage EnroIIees 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 P.H.L.
      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.
      Personal Care Agency Services

     

    Personal
      care services (PCS) are the provision of some or total assistance with personal
      hygiene, dressing and feeding; and nutritional and environmental support (meal
      preparation and housekeeping). Such services must be essential to the
      maintenance of the Enrollee's health and safety in his or her own home. The
      service has to be ordered by a physician, and there has to be a medical need
      for
      the service. Licensed home care services agencies, as opposed to certified
      home
      health agencies, are the primary providers of PCS. EnroIIees receiving PCS
      have
      to have a v
      stable
      medical condition and are generally expected to be in receipt of such services
      for an extended period of time (years).

     

    Services
      rendered by a personal care agency which are approved by the LDSS are not
      covered under the Medicare or Medicaid Benefit Packages. Should it be medically
      necessary for the PCP to order personal care agency services, the PCP (or the
      Contractor on the physician's behalf) must first contact the Enrollee's LDSS
      contact person for personal care. The district will determine the Enrollee's
      need for personal care agency services and coordinate with the personal care
      agency a plan of care.

     

    

    Medicaid
      Advantage Contract 

    APPENDIX
      K

    State,
      2006

    K-15

     

    

    4.
      Skilled Nursing Facility Days Not Covered by Medicare

     

    Skilled
      nursing facility days for Medicaid Advantage Enrollees in excess of the first
      100 days in the benefit period are covered by Medicaid on a fee for service
      basis.

     

    5.
      Prescription and Non-Prescription (OTC) Drugs, Medical Supplies, and
      Enteral

    Formula
      Not Covered by Medicare Part B and the Medicare Advantage Organization's
      Medicare Part D Prescription Drug Benefit approved by CMS

     

    Coverage
      for drugs dispensed by community pharmacies, over the counter drugs,
      medical/surgical supplies and enteral formula covered by Medicaid and not
      included in the Contractor's Medicare Advantage Benefit Package will be paid
      for
      by Medicaid fee-for-service. Medical/surgical supplies are items other than
      drugs, prosthetic or orthotic appliances, or DME which have been ordered by
      a
      qualified practitioner in the treatment of a specific medical condition and
      which are: consumable, non-reusable, disposable, or for a specific rather than
      incidental purpose, and generally have no salvageable value (e.g. gauze pads,
      bandages and diapers). Pharmaceuticals and medical supplies routinely furnished
      or administered as part of a clinic or office visit are covered by the
      Contractor.

     

    6.
      Out of Network Family Planning Services

     

    As
      described in Section 10.9 and 10.7 of this Agreement, out of network family
      planning services provided by qualified Medicaid providers to plan enrollees
      will be directly reimbursed 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.

     

    7.
      Dental (when
      not in benefit package)

     

    (see
      description in Appendix K-2)

    

    8.
      Non-Emergency Transportation (when not in benefit package)

    (see
      description in Appendix K-2)

     

    9.
      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

     

    

    Medicaid
      Advantage Contract 

    APPENDIX
      K.

    State,
      2006

    K-16

     

    

    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.

     

    10.
      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.

     

    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 

     

    d.
      Case
      .Management for Seriously and Persistently Mentally 111 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 symptom logy 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.

    

    

    Medicaid
      Advantage Contract 

    APPENDIX
      K

    State,
      2006

    K-17

    

    Please
      note: See generic definition of Comprehensive Medicaid Case Management (CMCM)
      in
      this section.

     

    e.
      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.

     

    f
      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.

     

    g.
      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.

     

    11.
      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.

     

     

    

    Medicaid
      Advantage Contract 

    APPENDIX
      K

    State,
      2006

    K-18

    

    

    *These
      services are certified by OMH under 14 NYCRR Part 586.3, 594 and
      595.

     

    12.
      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.

     

    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.

    

    Medicaid
      Advantage Contract 

    APPENDIX
      K

    State,
      2006

    K-19

     

    

    Please
      note: See generic definition of Comprehensive Medicaid Case Management (CMCM)
      in
      this section.

     

    d.
      Home
      And Community Based Services Waivers (HCBS)

     

    The
      Home
      and Community-Based Services Waiver serves persons with developmental
      disabilities who would otherwise be admitted to an ICF/MR if waiver services
      were not provided. HCBS waivers services include residential habilitation,
      day
      habilitation, prevocational, supported work, respite, adaptive devices,
      consolidated supports and services, environmental modifications, family
      education and training, live-in caregiver, and plan of care support services.
      These services are authorized pursuant to a SSA Section 1915(c) waiver from
      DHHS.

     

    e.
      Services Provided Through the Care At Home Program (OMRDD)

     

    The
      OMRDD
      Care at Home 111, Care at Home IV, and Care at Home VI waivers, serve children
      who would otherwise not be eligible for Medicaid because of their parents'
      income and resources, and who would otherwise be eligible for an ICF/MR level
      of
      care. Care at Home waiver services include service coordination, respite and
      assistive technologies. Care at Home waiver services are authorized pursuant
      to
      a SSA section 1915(c) waiver from DHHS.

     

    13.
      Comprehensive Medicaid Case Management (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.

     

    14.
      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 MM1S
      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.

    

    Medicaid
      Advantage Contract 

    APPENDIX
      K

    State,
      2006

    K-20

    

    15.
      AIDS Adult Day Health Care

     

    Adult
      Day
      Health Care Programs (ADHCP) are programs designed to assist individuals with
      HIV disease to live more independently in the community or eliminate the need
      for residential health care services. Registrants in ADHCP require a greater
      range of comprehensive health care services than can be provided in any single
      setting, but do not require the level of services provided in a residential
      health care setting. Regulations require that a person enrolled in an ADHCP
      must
      require at least three (3) hours of health care delivered on the basis of at
      least one (1) visit per week. While health care services are broadly defined
      in
      this setting to include general medical care, nursing care, medication
      management, nutritional services, rehabilitative services, and substance abuse
      and mental health services, the latter two (2) cannot be the sole reason for
      admission to the program. Admission criteria must include, at a minimum, the
      need for general medical care and nursing services.

     

    16.
      HIV COBRA Case Management

     

    The
      HP/
      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.

     

    17.
      Adult Day Health Care

     

    Adult
      Day Health
      Care
      means care and services provided to a registrant in a residential health care
      facility or approved extension site under the medical direction of a physician
      and which is provided by personnel of the adult day health care program in
      accordance with a comprehensive assessment of care needs and individualized
      health care plan, ongoing implementation and coordination of the health care
      plan, and transportation.

     

    Registrant
      means a
      person who is a nonresident of the residential health care facility who is
      functionally impaired and not homebound and who requires certain preventive,
      diagnostic, therapeutic, rehabilitative or palliative items or services provided
      by a general hospital, or residential health care facility; and whose assessed
      social and health care needs, in the professional judgment of the physician
      of
      record, nursing staff, Social Services and other professional personnel of
      the
      adult day health care program can be met in whole or in part satisfactorily
      by
      delivery of appropriate services in such program.

     

    18.
      Personal Emergency Response
      Services (PERS)

     

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

    

    

    Medicaid
      Advantage Contract 

    APPENDIX
      K

    State,
      2006

    K-21

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    APPENDIX
      L

     

    Approved
      Capitation Payment Rates

     

    

     

    

     

    

    Medicaid
      Advantage Contract 

    APPENDIX
      L 

    State
      2006 

    L-l

     

    

    WellCare
      of New York, Inc.

    

    Dual
      Eligible Medicaid Managed Care Rates

    

    
      	
               

              MMSI
                ID#: 02645710 Effective Date: 01/01/06

               

              Region:
                Upstate

               

              County:
                Albany

            

    

    

    

    
      	
               

              RATE
                CODE

            	
               

              PREMIUM
                GROUP

            	
               

              RATE
                AMOUNT

            
	
               

              2370

            	
               

              DUALLY
                ELIGIBLE SSI 21-64 MAKE/FEMALE

            	
               

              $83.79

            
	
               

              2371

            	
               

              DUALLY
                ELIGIBLE SSI 65+ MALE/FEMALE

            	
               

              $91.22

            

    

    

     

    Optional
      Benefits Offered:

    

    £
      Dental

    £
      Non-Emergent Transportation

     

    Box
      will
      be checked if the optional benefit is covered by the plan

     

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    APPENDIX
      M

     

    Service
      Area

    

    

    

    Medicaid
      Advantage Contract 

    APPENDIX
      M

    State
      2006

    M-l

    

    The
      Contractor's Medicaid Advantage service area is comprised of the following
      Counties
      in their entirety: 

     

    Albany

    
 

    Medicaid
      Advantage Contract 

    APPENDIX
      M 

    State
      2006

    M-2

     

    

    APPENDIX
      N

     

    Reserved

     

    Medicaid
      AdvantageContract
      

    APPENDIX
      N 

    State
      2006 

    N-l

     

    

    APPENDIX
      0

     

    Requirements
      for Proof of Workers’ Compensation and Disability Benefits
      Coverage

    

     

    Medicaid
      Advantage Contract 

    APPENDIX
      0

    State
      2006 

    0-1

     

    

    ReQuirements
      for Proof of Coverage

     

    Unless
      the Contractor is a political sub-division of New York State, the Contractor
      shall provide proof, completed by the Contractor's insurance carrier and/or
      the
      Workers' Compensation Board, of coverage for:

     

    1.
      Workers' Compensation,
      for
      which one of the following is incorporated into this Agreement herein as an
      attachment to Appendix 0:

     

    a)
      Certificate of Workers' Compensation Insurance, on the Workers' Compensation
      Board form C-105.2 (naming the NYS Department of Health, Coming Tower, Rm.
      1325,
      Albany, 12237-0016),
      or
      Certificate of Workers' Compensation Insurance, on the State Insurance Fund
      form
      U-26.3 (naming the NYS Department of Health, 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 0:

     

    a)
      Certificate of Disability Benefits Insurance, form DB-120.1;
      or Certificate/Cancellation
      of Insurance, form DB-820/829; or

     

    b)
      Certificate of Disability Benefits Self-Insurance, form DB-155;
      or

     

    c)
      Affidavit for New York Entities And Any Out Of State Entities With No Employees,
      That New York State Workers' Compensation And/Or Disability Benefits Coverage
      Is
      Not Required, form WC/DB-100, completed for Disability Benefits;
      or
      Affidavit That An OUT-OF-STATE OR FOREIGN EMPLOYER Working 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 Contract 

    APPENDIX
      0 

    State
      2006 

    0-2

     

    

    APPENDIX
      P

     

    Reserved

    

    

    

     

    Medicaid
      Advantage Contract 

    APPENDIX
      P

    State
      2006 

    P-l

     

    

    APPENDIX
      Q

     

    

     

    Reserved

    

    

    

     

    Medicaid
      Advantage Contract 

    APPENDIX
      Q 

    State
      2006

    Q-l

     

    

    APPENDIX
      R

    Additional
      Specifications for the Medicaid Advantage Agreement

    

    

    

    

    

    

    Medicaid
      Advantage Contract APPENDIX R 

    State
      2006

    R-l

    

    Additional
      Specifications for the Medicaid Advantage Agreement

     

    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.

     

    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.

     

    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.

     

    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.

     

    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 approyal of such third parties
      and the scope of the work to be

    

    Medicaid
      Advantage Contract 

    APPENDIX
      R

    State
      2006 

    R-2

     

    

    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 essential to obtain social and economic
      equality and improve the functioning of the State economy.

     

    It
      is the
      intention of the SDOH to provide Minority and Women Owned Business Enterprises
      with equal opportunity to bid on contracts awarded by this agency in accordance
      with the State Finance Law.

     

    9.
      Insurance Requirements

     

    a)
      The
      Contractor must without expense to the State procure and maintain, until final
      acceptance by the SDOH of the work covered by this Agreement, insurance of
      the
      kinds and in the amounts hereinafter provided, by insurance companies authorized
      to

    

    

    Medicaid
      Advantage Contract 

    APPENDIX
      R

    State
      2006 

    R-3

     

    

    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.

     

    10.
      Certification Regarding Debarment and Suspension

     

    a)
      Regulations of the U.S. Department of Health and Human Services, located at
      Part
      76 of Title 45 of the Code of Federal Regulations (CFR), implement Executive
      Orders 12549 and 12689 concerning debarment and suspension of participants
      in
      Federal program and activities. Executive Order 12549 provides that, to the
      extent permitted by law. Executive departments and agencies shall participate
      in
      a government wide system for non-procurement debarment and suspension. Executive
      Order 12689 extends the debarment and suspension policy to procurement
      activities of the Federal Government. A person who is debarred or suspended
      by a
      Federal agency is excluded from Federal financial and non-financial assistance
      and benefits under Federal programs and activities, both directly (primary
      covered transaction) and indirectly (lower tier covered transactions). Debarment
      or suspension by one Federal agency has government wide effect.

    

    

    

    Medicaid
      Advantage Contract 

    APPENDIX
      R 

    State
      2006

    R-4

     

    

    b)
      Pursuant to the above cited regulations, the SDOH (as a participant in a primary
      covered transaction) may not knowingly do business with a person who is
      debarred, suspended, proposed for debarment, or subject to other government
      wide
      exclusion (including an exclusion from Medicare and State health care program
      participation on or after August 25, 1995), and the SDOH must require its
      contractors, as lower tier participants, to provide the certification as set
      forth below:

     

    i)
      CERTIFICATION REGARDING DEBARMENT, SUSPENSION, 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 leams that its certification was erroneous
      when submitted or had become erroneous by reason of changed
      circumstances,

     

    D)
      The
      terms covered transaction, debarred, suspended, ineligible, lower tier covered
      transaction, participant, person, primary covered transaction, principal,
      proposal, and voluntarily excluded, as used in this clause, have the meaning
      set
      out in the Definitions and Coverage sections of rules implementing Executive
      Order 12549. The Contractor may contact the SDOH for assistance in obtaining
      a
      copy of those regulations.

     

    E)
      The
      lower tier participant agrees that it shall not knowingly enter into any lower
      tier covered transaction with a person who is proposed for debarment under
      48
      CFR Subpart 9.4, debarred, suspended, declared ineligible, or voluntarily
      excluded from participation in this covered transaction, unless authorized
      by
      the department or agency with which this transaction originated.

     

    F)
      The
      lower tier participant farther 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.

    

    

    Medicaid
      Advantage Contract 

    APPENDIX
      R

    State
      2006 

    R-5

     

    

    G)
      A
      participant in a covered transaction may rely upon a certification of a
      participant in a lower tier covered transaction that it is not proposed for
      debarment under 48 CFR Subpart 9.4, debarred, suspended, ineligible, or
      voluntarily excluded from covered transactions, unless it knows that the
      certification is erroneous. A participant may decide the method and frequency
      by
      which it determines the eligibility of its principals. Each participant may,
      but
      is not required to, check the Excluded Parties List System.

     

    H)
      Nothing contained in the foregoing shall be construed to require establishment
      of a system of records in order to render in good faith the certification
      required by this clause. The knowledge and information of a participant is
      not
      required to exceed that which is normally possessed by a prudent person in
      the
      ordinary course of business dealings.

     

    I)
      Except
      for transactions authorized under paragraph E of these instructions, if a
      participant in a covered transaction knowingly enters into a lower tier covered
      transaction with a person who is proposed for debarment under 48 CFR Subpart
      9.4, suspended, debarred, ineligible, or voluntarily excluded from participation
      in this transaction, in addition to other remedies available to the Federal
      Government, the department or agency with which this transaction originated
      may
      pursue available remedies, including suspension and/or debarment.

     

    ii)
      Certification Regarding Debarment, Suspension, Ineligibility and Voluntary
      Exclusion - Lower Tier Covered Transactions

     

    A)
      The
      lower tier participant certifies, by signing this Agreement, that neither it
      nor
      its principals is presently debarred, suspended, proposed for debarment,
      declared ineligible, or voluntarily excluded from participation in this
      transaction by any Federal department agency.

     

    B)
      Where
      the lower tier participant is unable to certify to any of the statements in
      this
      certification, such participant shall attach an explanation to this
      Agreement.

     

    11.
      Reports and Publications

     

    a)
      Any
      materials, articles, papers, etc., developed by the Contractor pertaining to
      the
      MMC Program or FHPlus Program must be reviewed and approved by the SDOH for
      conformity with the policies and guidelines of the SDOH prior to dissemination
      and/or publication. It is agreed that such review will be conducted in an
      expeditious manner. Should the review result in any unresolved disagreements
      regarding content, the Contractor shall be free to publish in scholarly journals
      along with a disclaimer that the views within the Article or the policies
      reflected are not necessarily those of the New York State Department of
      Health.

     

    
 

    Medicaid
      Advantage Contract

    APPENDIX
      R 

    State
      2006

    R-6

     

    

    b)
      Any
      publishable or otherwise reproducible material developed under or in the course
      of performing this Agreement, dealing with any aspect of performance under
      this
      Agreement, or of the results and accomplishments attained in such performance,
      shall be the sole and exclusive property of the State, and shall not be
      published or otherwise disseminated by the Contractor to any other party unless
      prior written approval is secured from the SDOH or under circumstances as
      indicated in paragraph (a) above. Any and all net proceeds obtained by the
      Contractor resulting from any such publication shall belong to and be paid
      over
      to the State. The State shall have a perpetual royalty-free, non-exclusive
      and
      irrevocable right to reproduce, publish or otherwise use, and to authorize
      others to use, any such material for governmental purposes.

     

    c)
      No
      report, document or other data produced in whole or in part with the funds
      provided under this Agreement may be copyrighted by the Contractor or any of
      its
      employees, nor shall any notice of copyright be registered by the Contractor
      or
      any of its employees in connection with any report, document or other data
      developed pursuant to this Agreement.

     

    d)
      All
      reports, data sheets, documents, etc. generated under this Agreement shall
      be
      the sole and exclusive property of the SDOH. Upon completion or termination
      of
      this Agreement the Contractor shall deliver to the SDOH upon its demand all
      copies of materials relating to or pertaining to this Agreement. The Contractor
      shall have no right to disclose or use any of such material and documentation
      for any purpose whatsoever, without the prior written approval of the SDOH
      or
      its authorized agents.

     

    e)
      The
      Contractor, its officers, agents and employees and subcontractors shall treat
      all information, which is obtained by it through its performance under this
      Agreement, as confidential information to the extent required by the laws and
      regulations of the United States and laws and regulations of the State of New
      York.

     

    12.
      Provisions Related to New York State Executive Order Number 127

     

    a)
      If
      applicable, the Contractor certifies that all information provided to the State
      with respect to New York State Executive Order Number 127, signed by Governor
      Pataki on June 16,2003, is complete, true, and accurate.

     

    b)
      The
      State reserves the right to terminate this Agreement in the event it is found
      that the certification filed by the Contractor, in accordance with New York
      State Executive Order Number 127, was intentionally false or intentionally
      incomplete. Upon such finding, the State may exercise its termination right
      by
      providing written notification to the Contractor in accordance with the written
      notification terms of this Agreement.

    

    

    Medicaid
      Advantage Contract 

    APPENDIX
      R 

    State
      2006

    R-7

     

    

    APPENDIX
      X

     

    Modification
      Agreement Form

    

    

    

    

    

    APPENDIX
      X

    State
      2006

    X-l

    

    APPENDIX
      X

    

    

    
      	
              Agency
                Code 

            	
              Contract
                No.

            
	
              Period

            	
              Funding
                Amount for Period

            

    

     

    

     

    This
      is
      an AGREEMENT between THE STATE OF NEW YORK, acting by and through ____________________,
      having its principal office at _____________ (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:
                ____________________________________

                   Printed
                Name

            	
               

              STATE
                AGENCY SIGNATURE 

               

              By
                __________________________________

              Printed
                Name

            
	
               

              Title:
                _______________________________________

            	
               

              Title:
                _______________________________________

            
	
               

              Date:
                _______________________________________

            	
               

              Date:
                _______________________________________

            
	 	
              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 _______________________ 20___, before me personally
      appeared ______________________________________, to me known, who 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:
                ___________________________________Exhibit 10.2

    
      

    

    Back to Form 8-K

    Exhibit
      10.2

     

    

      STATE
        OF ILLINOIS 

      

      DEPARTMENT
        OF HEALTHCARE AND FAMILY SERVICES

       

      

       

      CONTRACT
        FOR FURNISHING HEALTH SERVICES 

       

      BY
        A 

       

      MANAGED
        CARE ORGANIZATION

      

      

      August
        1,
        2006

      

      

      Illinois
        Department of Healthcare and Family Services 

      Division
        of Medical Programs

      Bureau
        of
        Contract Management 

      201
        South
        Grand Avenue East 

      Springfield,
        Illinois 62763-0001

      

      

      

      Barry
        S. Maram 

      Director

      

      

      

      Anne
        Marie Murphy 

      Medicaid
        Director

       

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      TABLE
        OF CONTENTS

       

       

      ARTICLE
        I
        DEFINITIONS............................................................................1

       

      ARTICLE
        II TERMS AND CONDITIONS.................................................
        9

       

      2.1
        Specification.........................................................................................
        9

       

      2.2
        Rules
        of
        Construction.........................................................................
        9

       

      2.3
        Performance of Services and
        Duties................................................ 10

       

      2.4
        Language
        Requirements....................................................................
        10

       

      (a)
        Key
        Oral
        Contacts...........................................................................
        10

       

      (b)
        Written
        Material...............................................................................
        10

       

      (c)
        Oral
        Interpretation............................................................................
        11

       

      2.5
        List
        of Individuals in Administrative Capacity................................
        11

       

      2.6
        Certificate of
        Authority........................................................................
        11

       

      2.7
        Obligation to Comply with other Laws
        ............................................. 11

       

      2.8
        Provision of Covered Services Through Affiliated Providers........
        11

       

      ARTICLE
        III
        ELIGIBILITY..............................................................................
        12

       

      3.1
        Determination of
        Eligibility...................................................................
        12

       

      3.2
        Enrollment
        Generally..............................................................................
        12

       

      3.3
        Enrollment
        Limits.....................................................................................
        12

       

      3.4
        Expansion to Other Contracting
        Areas................................................ 13

       

      3.5
        Discontinuation of Services in One or More Contracting Area.......
        13

       

      ARTICLE
        IV ENROLLMENT, COVERAGE AND TERMINATION 

      OF
        COVERAGE..................................................................................................
        14

       

      4.1
        Enrollment
        Process..................................................................................
        14

       

      4.2
        Initial
        Coverage.........................................................................................
        16

       

      4.3
        Period of
        Enrollment.................................................................................
        16

       

      4.4
        Termination of
        Coverage.........................................................................
        16

       

      4.5
        Preexisting Conditions and
        Treatment................................................... 18

       

      4.6
        Continuity of
        Care.....................................................................................
        18

       

      4.7
        Change of Site and Primary Care Provider or Women's 

      Health
        Care
        Provider........................................................................................
        19

       

      i

       

      

      TABLE
        OF CONTENTS

       

       

      ARTICLE
        V
        DUTIES OF CONTRACTOR..........................................................
        20

       

      5.1
        Services.........................................................................................................
        20

       

      (a)
        Amount, Duration and Scope of Coverage.........................................
        20

       

      (b)
        Enumerated Covered
        Services..............................................................
        20

       

      (c)
        Behavioral Health
        Services....................................................................
        22

       

      (d)
        Services to Prevent Illness and Promote Health................................
        23

       

      (e)
        Exclusions from Covered
        Services....................................................... 23

       

      (f)
        Limitations on Covered
        Services..........................................................
        24

       

      (g)
        Right
        of
        Conscience...............................................................................
        25

       

      (h)
        Emergency
        Services...............................................................................
        25

       

      (i)
        Post-Stabilization
        Services.....................................................................
        26

       

      (j)
        Additional Services or
        Benefits..............................................................
        26

       

      (k)
        Telephone Access
        ..................................................................................
        26

       

      5.2
        Network
        Adequacy......................................................................................
        27

       

      5.3
        Marketing......................................................................................................
        27

       

      5.4
        Inappropriate Marketing
        Activities............................................................31

       

      5.5
        Obligation to Provide
        Information..............................................................
        32

       

      5.6
        Quality Assurance, Utilization Review and Peer Review ........................
        34

       

      5.7
        Physician Incentive Plan
        Regulations.........................................................
        35

       

      5.8
        Prohibited Affiliations
        ...................................................................................
        35

       

      5.9
        Records.............................................................................................................
        35

       

      (a)
        Maintenance of Business
        Records...........................................................
        35

       

      (b)
        Availability of Business
        Records.............................................................
        36

       

      (c)
        Patient Records
        ...........................................................................................
        36

       

      5.10
        Computer System
        Requirements..................................................................
        37

       

      5.11
        Regular Information Reporting
        Requirements............................................ 38

       

      5.12
        Health
        Education.............................................................................................
        45

       

      5.13
        Required Minimum Standards of
        Care.......................................................... 46

       

      (a)
        EPSDT
        Services to Enrollees Under Twenty-One (21) Years ................
        46

       

      ii

       

      

      TABLE
        OF CONTENTS

      (continued)

       

      (b)
        Preventive Medicine Schedule (Services to Enrollees Twenty-

      One
        (21)
        Years of Age and
        Over)...................................................................
        48

       

      (c)
        Maternity
        Care............................................................................................
        49

       

      (d)
        Complex and Serious Medical Conditions
        ............................................ 51

       

      (e)
        Access Standards
        ....................................................................................
        51

       

      (f)
        Coordination with Other Service
        Providers........................................... 52

       

      5.14
        Authorization of Services
        .........................................................................
        53

       

      5.15
        Case
        Management......................................................................................
        53

       

      5.16
        Children with Special Health Care Needs
        ............................................... 54

       

      5.17
        Choice of
        Physicians..................................................................................
        54

       

      5.18
        Timely Payments to
        Providers....................................................................
        55

       

      5.19
        Grievance Procedure and Appeal Procedure
        ........................................... 56

       

      5.20
        Enrollee Satisfaction
        Survey.......................................................................
        58

       

      5.21
        Provider Agreements and
        Subcontracts................................................... 58

       

      5.22
        Site
        Registration and Primary Care Provider/Women's Health Care 

      Provider
        Approval and
        Credentialing................................................................
        60

       

      5.23
        Advance
        Directives.......................................................................................61

       

      5.24
        Fees
        to Enrollees Prohibited
        .......................................................................
        61

       

      5.25
        Fraud and Abuse Procedures
        .....................................................................
        61

       

      5.26
        Misrepresentation
        Procedures.....................................................................
        62

       

      5.27
        Enrollee-Provider
        Communications..............................................................
        62

       

      5.28
        HIPAA
        Compliance.........................................................................................
        63

       

      ARTICLE
        VI DUTIES OF THE DEPARTMENT.....................................................
        64

       

      6.1
        Enrollment...........................................................................................................
        64

       

      6.2
        Payment...............................................................................................................
        64

       

      6.3
        Department Review of Marketing Materials
        ................................................. 64

       

      6.4
        HIPAA
        Compliance............................................................................................
        64

       

      ARTICLE
        VII PAYMENT AND
        FUNDING...............................................................
        65

       

      7.1
        Capitation
        Payment..............................................................................................65

       

      7.2
        Hospital Delivery Case Rate
        Payment..............................................................
        65

       

      iii

       

      

      TABLE
        OF CONTENTS

      (continued)

       

       

      7.3 Actuarially
        Sound Rate
        Representation..........................................................
        65

       

      7.4 New
        Covered
        Services.......................................................................................
        65

       

      7.5 Adjustments.........................................................................................................
        65

       

      7.6 Copayments..........................................................................................................
        65

       

      7.7 Availability
        of Funds
        ..........................................................................................
        66

       

      7.8 Quality
        Performance
        Payment............................................................................
        66

       

      7.9 Denial
        of
        Payment Sanction by
        CMS................................................................
        68

       

      7.10 Hold
        Harmless
        ....................................................................................................
        68

       

      7.11 Payment
        in
        Full....................................................................................................
        68

       

      7.12 820
        Payment
        File..................................................................................................
        68

       

      7.13 Medical
        Loss Ratio
        Guarantee............................................................................
        68

       

      ARTICLE
        VIII TERM RENEWAL AND TERMINATION ........................................
        70

       

      8.1 Term.........................................................................................................................
        70

       

      8.2 Continuing
        Duties in the Event of
        Termination................................................ 70

       

      8.3 Termination
        With and Without
        Cause...............................................................
        70

       

      8.4 Temporary
        Management......................................................................................
        70

       

      8.5 Termination
        for Breach of HIPAA Compliance Obligations..........................
        70

       

      8.6 Automatic
        Termination..........................................................................................71

       

      8.7 Reimbursement
        in the Event of Termination.....................................................
        71

       

      ARTICLE
        IX GENERAL
        TERMS...................................................................................
        72

       

      9.1 Records
        Retention, Audits, and
        Reviews...........................................................
        72

       

      9.2 Nondiscrimination..................................................................................................
        73

       

      9.3 Confidentiality
        of
        Information..............................................................................
        73

       

      9.4 Notices.....................................................................................................................
        74

       

      9.5 Required
        Disclosures..............................................................................................
        74

       

      (a)
        Conflict of
        Interest...............................................................................................
        74

       

      (b)
        Disclosure of
        Interest..........................................................................................
        75

       

      9.6 CMS
        Prior
        Approval................................................................................................
        76

       

      iv

      TABLE
        OF CONTENTS

      (continued)

       

       

      9.7
        Assignment
        ..........................................................................................................76

       

      9.8
        Similar
        Services.....................................................................................................
        76

       

      9.9
        Amendments..........................................................................................................
        76

       

      9.10
        Sanctions..............................................................................................................
        76

       

      (a)
        Failure to Report or
        Submit...............................................................................
        77

       

      (b)
        Failure to Submit Encounter
        Data....................................................................
        77

       

      (c)
        Failure to Meet Minimum Standards of
        Care.................................................. 77

       

      (d)
        Failure to Submit Quality and Performance
        Measures................................. 77

       

      (e)
        Failure to Participate in the Performance Improvement Project...................
        77

       

      (f)
        Failure to Demonstrate Improvement in Areas of Deficiencies ...................
        78

       

      (g)
        Imposition of Prohibited
        Charges....................................................................
        78

       

      (h)
        Misrepresentation or Falsification of
        Information........................................ 78

       

      (i)
        Failure to Comply with the Physician Incentive Plan Requirements ..........
        78

       

      (j)
        Failure to Meet Access and Provider Ratio
        Standards................................. 78

       

      (k)
        Failure to Provide Covered
        Services..............................................................
        78

       

      (1)
        Discrimination Related to Pre-Existing Conditions and/or Medical

      History......................................................................................................................
        79

       

      (m)
        Pattern of Marketing
        Failures.........................................................................
        79

       

      (n)
        Other
        Failures....................................................................................................
        79

       

      9.11
        Sale
        or
        Transfer...................................................................................................
        79

       

      9.12
        Coordination of Benefits for
        Enrollees............................................................
        79

       

      9.13
        Subrogation.........................................................................................................
        80

       

      9.14
        Agreement to Obey All
        Laws...........................................................................
        80

       

      9.15
        Severability..........................................................................................................
        80

       

      9.16
        Contractor's Disputes With Other
        Providers................................................. 80

       

      9.17
        Choice of
        Law......................................................................................................
        80

       

      9.18
        Debarment
        Certification.....................................................................................
        81

       

      9.19
        Child Support, State Income Tax and Student Loan Requirements ............
        81

       

      9.20
        Payment of Dues and
        Fees................................................................................
        81

       

      9.21
        Federal Taxpayer
        Identification........................................................................
        81

       

      

      TABLE
        OF CONTENTS 

      (continued)

       

      9.22 Dmg
        Free
        Workplace.........................................................................................
        81

       

      9.23 Lobbying.............................................................................................................
        81

       

      9.24 Early
        Retirement..................................................................................................
        82

       

      9.25 Sexual
        Harassment..............................................................................................
        82

       

      9.26 Independent
        Contractor.....................................................................................
        82

       

      9.27 Solicitation
        of
        Employees...................................................................................
        82

       

      9.28 Nonsolicitation....................................................................................................
        83

       

      9.29 Ownership
        of Work
        Product..............................................................................
        83

       

      9.30 Bribery
        Certification............................................................................................
        83

       

      9.31 Nonparticipation
        in International Boycott.......................................................
        83

       

      9.32 Computational
        Error............................................................................................
        84

       

      9.33 Survival
        of
        Obligations.......................................................................................
        84

       

      9.34 Clean
        Air
        Act and Clean Water Act Certification...........................................
        84

       

      9.35 Non-Waiver..........................................................................................................
        84

       

      9.36 Notice
        of
        Change in
        Circumstances..................................................................
        84

       

      9.37 Public
        Release of Information
        ...........................................................................
        84

       

      9.38 Payment
        in Absence of Federal Financial Participation.................................
        84

       

      9.39 Employment
        Reporting........................................................................................
        85

       

      9.40 Certification
        of
        Participation................................................................................
        85

       

      9.41 Indemnification......................................................................................................
        85

       

      9.42 Gifts..........................................................................................................................
        85

       

      9.43 Business
        Enterprise for Minorities, Females and Persons with Disabilities..
        86

       

      9.44 Non-Delinquency
        Certification.............................................................................
        86

       

      9.45 Litigation..................................................................................................................
        86

       

      9.46 Insolvency...............................................................................................................
        86

       

      Attachment
        I -
        Rate
        Sheets

      Attachment
        II -
        Drug
        Free Workplace Agreement

      Attachment
        III - HIPAA Compliance Obligations

      Attachment
        IV - Business Enterprise Program Contracting Goal

       

      Exhibit
        A: Quality Assurance

      Exhibit
        B: Utilization Review/Peer Review

      Exhibit
        C: Summary of Required Reports and Submissions

      Exhibit
        D: Data Telecommunication Configuration Requirements

       

       

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      

      STATE
        OF ILLINOIS DEPARTMENT OF HEALTHCARE AND FAMILY SERVICES

       

      CONTRACT
        FOR FURNISHING HEALTH SERVICES

       

      THIS
        CONTRACT FOR FURNISHING HEALTH SERVICES ("Contract") made, pursuant to Section
        5-11 of the Illinois Public Aid Code (305 ILCS 5/5-11), is by and between
        the
        Illinois Department of Healthcare and Family Services
        ("Department"), acting by and through its Director, and
        Harmony Health Plan of Illinois, Inc.
        ("Contractor"), who certifies that it is a managed care organization and
        whose
        principal office is located at 200 West Adams Street, Chicago, IL
        60606.

       

      RECITALS

       

      WHEREAS,
        the Contractor is a health maintenance organization operating pursuant to
        a
        Certificate of Authority issued by the Illinois Department of Financial and
        Professional Regulation and wishes to provide Covered Services to Potential
        Enrollees (as defined herein);

       

      WHEREAS,
        the Department, pursuant to the laws of the State of Illinois, provides for
        medical assistance under the HFS Medical Program to Participants wherein
        Potential Enrollees may enroll with the Contractor to receive Covered Services;
        and

       

      WHEREAS,
        the Contractor warrants that it is able to provide and/or arrange to provide
        the
        Covered Services set forth in this Contract to Enrollees under the terms
        and
        conditions set forth herein;

       

      NOW,
        THEREFORE, in consideration of the mutual covenants and promises contained
        herein, the parties agree as follows:

       

      ARTICLE
        I

       

      DEFINITIONS

       

      The
        following terms as used in this Contract and the attachments, exhibits and
        amendments hereto shall be construed and interpreted as follows, unless the
        context otherwise expressly requires a different construction and
        interpretation:

       

      820
        Payment File
        means
        the HIPAA transaction that the Contractor electronically retrieves from the
        Department which identifies each Enrollee for whom payment was
        made.

       

      834
        Audit File
        means
        the electronic HIPAA transaction that the Contractor retrieves monthly from
        the
        Department that reflects the Enrollees for the following calendar
        month.

       

      834
        Daily File
        means
        the electronic HIPAA transaction that the Contractor retrieves from the
        Department each day that reflects changes in enrollment subsequent to the
        previous 834 Audit File.

       

    

    1

    
 

    Abuse
      means a
      manner of operation that results in excessive or unreasonable costs to the
      Federal and/or State health care programs.

     

    Action
      means a
      (i) denial or limitation of authorization of a requested service; (ii)
      reduction, suspension, or termination of a previously authorized service; (iii)
      denial of payment for a service; (iv) failure to provide services in a timely
      manner; (v) failure to respond to an appeal in a timely manner; and (vi) solely
      with respect to a MCO that is the only Contractor serving a rural area, the
      denial of an Enrollee's request to obtain services outside of the Contracting
      Area.

     

    Administrative
      Rules
      means
      the rules promulgated by the Department governing the HFS Medical
      Program.

     

    Affiliated
      means
      associated with another party for the purpose of providing health care services
      under a Contractor's Plan pursuant to a written contract.

     

    Appeal
      means a
      request for review of a decision made by the Contractor with respect to an
      Action.

     

    Authorized
      Person
      means a
      representative of the Office of Inspector General for the Department, the
      Illinois Mcdicaid Fraud Control Unit, the United States Department of Health
      and
      Human Services, a representative of other State and federal agencies with
      monitoring authority related to the HFS Medical Program, and a representative
      of
      any EQRO under contract with the Department.

     

    CAHPS
      means
      Consumer Assessment of Health Plans Survey.

     

    CMS
      means
      the Centers for Medicare & Medicaid Services under the United States
      Department of Health and Human Services.

     

    Capitation
      means
      the reimbursement arrangement in which a fixed rate of payment per Enrollec
      per
      month is made to the Contractor for the performance of all of the Contractor's
      duties and obligations pursuant to this Contract, except those services
      reimbursed through the Hospital Delivery Case Rate.

     

    Case
      means
      individuals who have been grouped together and assigned a common identification
      number by the Department or the Department of Human Services of which at least
      one individual in that grouping has been determined by the Department to be
      a
      Potential Enrollee. An individual is added to a Case when the Client Information
      System maintained by the Illinois Department of Human Services reflects the
      individual is in the Case.

     

    Children
      with Special Health Care Needs (CSHCN)
      means
      children who have serious medical or chronic conditions, or who are identified
      with special health care needs.

     

    Contract
      means
      this document, inclusive of all attachments, exhibits, schedules and any
      subsequent amendments hereto.

     

    Contracting
      Area
      means
      the area(s) from which the Contractor may enroll Potential Enrollees as set
      forth in Attachment I.

     

    

     

    2

    

    Covered
      Services
      means
      those benefits and services described in Article V, Section 5.1.

     

    EPSDT
      means
      the Early and Periodic, Screening, Diagnostic and Treatment services provided
      to
      children under Title XIX of the Social Security Act (42 U.S.C. § 1396, et seq.).
      The preventive component of this program is referred to as the "Healthy Kids"
      program.

     

    EQRO
      means an
      "External Quality Review Organization" that has a contract with the Department
      to perform federally required external oversight and monitoring of the quality
      assurance component of managed care. External oversight and monitoring of
      quality assurance shall include, but is not limited to, onsite review,
      attendance at quality assurance meetings, as directed by the Department;
      validation of performance measures; validation of performance improvement
      projects; ongoing monitoring of quality outcomes and timeliness of, and access
      to, the Covered Services.

     

    Early
      Intervention
      means
      the program described at 325 ILCS 20/1 et scq.,
      which
      authorizes the provision of services to infants and toddlers, birth through
      two
      years of age, who have a disability due to developmental delay or a physical
      or
      mental condition that has a high probability of resulting in developmental
      delay
      or being at risk of having substantial developmental delays due to a combination
      of serious factors.

     

    Effective
      Date
      shall be
      August 1, 2006.

     

    Emergency
      Medical Condition
      means a
      medical condition manifesting itself by acute symptoms of sufficient severity
      (including, but not limited to, severe pain) such that a prudent lay person,
      who
      possesses an average knowledge of health and medicine, could reasonably expect
      the absence of immediate medical attention to result in (i) placing the health
      of the individual (or, with respect to a pregnant woman, the health of the
      woman
      or her unborn child) in serious jeopardy, (ii) serious impairment to bodily
      functions, or (iii) serious dysfunction of any bodily organ or
      part.

     

    Emergency
      Services
      means
      those inpatient and outpatient health care services that are Covered Services,
      including transportation, needed to evaluate or stabilize an Emergency Medical
      Condition, which are furnished by a Provider qualified to furnish emergency
      services.

     

    Encounter
      means an
      individual service or procedure provided to an Enrollee that would result in
      a
      claim if the service or procedure were to be reimbursed fee-for-service under
      the HFS Medical Program.

     

    Encounter
      Data
      means
      the compilation of data elements, as specified by the Department in written
      notice to the Contractor, identifying an Encounter that includes information
      similar to that required in a claim for fee-for-service payment under the HFS
      Medical Program.

     

    Enrollee
      means
      any Potential Enrollee whose coverage under the Plan has begun and remains
      in
      effect pursuant to this Contract.

    

    

    3

    

    Family
      Case Management Provider
      means
      any agency contracting with the Illinois Department of Human Services or its
      successor agency to provide Family Case Management Services.

     

    Family
      Case Management Services
      means
      the program described at 77 111. Adm. Code 630.220.

     

    Federally
      Qualified HMO
      means an
      HMO that CMS has determined to be a qualified HMO under Section 1310(d) of
      the
      Public Health Service Act.

     

    Federally
      Qualified Health Center
      or FQHC
      means a
      health center that meets the requirements of 89 111. Adm. Code 140.46
      l(d).

     

    Fraud
      means
      knowing and willful deception, or a reckless disregard of the facts, with the
      intent to receive an unauthorized benefit.

     

    Grievance
      means an
      Enrollees expression of dissatisfaction, including complaints, about any matter
      other than a matter that is properly the subject of an Appeal.

     

    Head
      of Case
      means
      the individual in whose name the Case is registered and to whom the HFS medical
      card is mailed.

     

    HEDIS
      means
      the Health Plan Employer Data and Information Set.

     

    HFS
      Medical Program
      means
      the Illinois Medical Assistance Program administered under Article V of the
      Illinois Public Aid Code (305 ILCS 5/5-1 et seq.) or its successor program
      and
      Titles XIX (42 USC 1396 et scq.) and XXI (42 USC 1397aa ct seq.) of the Social
      Security Act and Section 12-4.35 of the Illinois Public Aid Code (305 ILCS
      5/12-435); the State Children's Health Insurance Program administered under
      215
      ILCS 106 and Title XXI of the Social Security Act (42 USC 1397 aa et
      seq.).

     

    Hospital
      Delivery Case Rate
      means a
      fixed payment made to the Contractor for Physician and hospital services
      associated with an Enrollee's delivery of a newborn in a hospital. The Hospital
      Delivery Case Rate will apply to deliveries of stillborn infants if the
      procedure groups into the appropriate diagnosis related grouping (DRG) code
      identified in this Contract.

     

    Ineligible
      Person
      means a
      Person which: (i) under either Section 1128 or Section 1128A of the Social
      Security Act, is or has been terminated, barred, suspended or otherwise excluded
      from participation in or has voluntarily withdrawn from participating in, as
      the
      result of a settlement agreement, any program under federal law including any
      program under Titles XVIII, XIX, XX or XXI of the Social Security Act; (ii)
      has
      not been reinstated in the Medical Assistance Program or Federal health care
      programs after a period of exclusion, suspension, debarment, or ineligibility;
      or (iii) has been convicted of a criminal offense related to the provision
      of
      health care items or services in the last ten (10) years.

     

    MCO
      means a
      "managed care organization" that is: (i) a Federally Qualified HMO which meets
      the advance directives requirements ofsubpart I of part 489 of 42 C.F.R. and
      set

     

    4

    

    forth
      in
      Article V, Section 5.23 or (ii) any public or private entity that meets the
      advance directives requirements of subpart I of part 489 of 42 C.F.R. and set
      forth in Article V, Section 5.23 and is determined to meet the following
      conditions: (A) is organized primarily for the purpose of providing health
      care
      services, (B) makes the services it provides to its Medicaid Enrollees as
      accessible (in terms of timeliness, amount, duration and scope) as those
      services are to other Medicaid participants within the area served by the entity
      and (C) meets the solvency standards of regulations promulgated under 42 C.F.R.
      Part 438.

     

    Marketing
      means
      any activities, procedures, materials, information or incentives used to
      encourage or promote the enrollment of Potential Enrollees with the
      Contractor.

     

    Marketing
      Materials
      means
      materials that are produced in any medium, by or on behalf of a MCO, are used
      by
      the MCO to communicate with Potential Enrollees or Enrollees, and can reasonably
      be interpreted as intended to influence them to enroll with that particular
      MCO.

     

    Medically
      Necessary
      means
      that a service, supply or medicine is appropriate and meets the standards of
      good medical practice in the medical community for the diagnosis or treatment
      of
      a covered illness or injury, the prevention of future disease, to assist in
      the
      Enrollee's ability to attain, maintain, or regain functional capacity, or to
      achieve age-appropriate growth, as determined by the Provider in accordance
      with
      the Contractor's guidelines, policies and/or procedures.

     

    Misconduct
      means
      any activity by an employee of the Contractor which is violative of any
      provisions related to Marketing.

     

    Misrepresentation
      means a
      statement an employee of the Contractor's Marketing staff knows to be false
      or
      misleading, or does not believe to be true and accurate, and makes with an
      intent to deceive or be unfair to a Potential Enrollec or Enrollee.

     

    National
      Provider Identification Number
      (NP1)
      means
      the national standard identifier for healthcare providers for use in the
      healthcare industry.

     

    NCQA
      means
      the National Committee for Quality Assurance.

     

    Office
      of Inspector General or OIG
      means
      the Office of Inspector General for the Illinois Department of Healthcare and
      Family Services as set forth in 305 ILCS 5/12-13.1.

     

    Participant
      means
      any individual receiving benefits under the HFS Medical Program.

     

    Person
      means
      any individual, corporation, proprietorship, firm, partnership, limited
      liability company, limited partnership, trust, association, governmental
      authority or other entity, whether acting in an individual, fiduciary or other
      capacity.

     

    Person
      With an Ownership or Controlling Interest
      means a
      Person that: has a direct or indirect, singly or in combination, ownership
      interest equal to five percent (5%) or more in the Contractor; owns an interest
      of five percent (5%) or more in any mortgage, deed of trust, note or other
      obligations secured by the Contractor if that interest equals at least five
      percent (5%) of the value of the property or assets of the Contractor; is an
      officer or director of a Contractor that is

     

    5

    

    organized
      as a corporation, is a member of the Contractor that is organized as a limited
      liability company or is a partner in the Contractor that is organized as a
      partnership.

     

    Physician
      means a
      person licensed to practice medicine in all its branches under the Medical
      Practice Act of 1987.

     

    Plan
      means
      the Contractor's program for providing Covered Services pursuant to this
      Contract.

     

    Post-Stabilization
      Services
      means
      medically necessary non-emergency services furnished to an Enrollcc after the
      Enrollee is Stabilized, in order to maintain such Stabilization, following
      an
      Emergency Medical Condition.

     

    Potential
      Enrollee
      means a
      Participant, except one who:

     

    •
is
      receiving Medical Assistance under Aid to the Aged, Blind and Disabled; as
      provided by Title XIX of the Social Security Act (42 U.S.C. §1383c) and 305 ILCS
      5/3-1 etseq.;

     

    •
is
      under age 21 and receiving Supplemental Security Income;

     

    •
is
      eligible only through the Refugee Assistance programs under Title XIX
      of

    the
      Social Security Act (42 U.S.C. 1396 ct seq.):

     

    •
is
      age
      19 or older and eligible only through the State Family and Children Assistance
      or Transitional Assistance Programs (305 ILCS 5/6-11);

     

    •
is
      receiving services from the Department of Children and Family
      Services;

     

    •
is
      residing in a long term care facility including State of Illinois operated
      facilities or is residing in a Supported Living Facility;

     

    •
has
      Medicare coverage under Title XVIII of the Social Security Act (42 U.S.C. 1395
      et se^);

     

    •
has
      significant medical coverage through a third party;

     

    •
is
      eligible only through the Medicaid Presumptive Eligibility for Pregnant Women
      program under Title XIX of the Social Security Act (42 U.S.C. 1396r-l) or
      through the Children's Presumptive Eligibility program;

     

    •
is
      eligible for Medical Assistance only through meeting a spend-down
      obligation;

     

    •
is
      eligible only through the Illinois Healthy Women program;

     

    •
is
      eligible only through the Illinois Cares Rx program;

     

    6

    

    •
is
      eligible only through the All Kids Rebate program;

     

    •
is
      receiving services under a Section 1915(c) Home and Community-Based
      Waiver;

     

    •
is
      registered with the Department as an American Indian or Alaska
      Native;

     

    •
is
      a
      non-citizen receiving only emergency Medical Assistance; or

     

    •
is
      identified with an "R" in the eighth position of a Case identification
      number.

     

    Primary
      Care Provider
      means a
      Physician, specializing by certification or training in obstetrics, gynccology,
      general practice, pediatrics, internal medicine or family practice who agrees
      to
      be responsible for directing, tracking and monitoring the health care needs
      of,
      and authorizing and coordinating care for, Enrollees.

     

    Prospective
      Enrollee
      means a
      Potential Enrollee who has begun the process of enrollment with the Contractor
      but whose coverage under the Plan has not yet begun.

     

    Provider
      means a
      Person who is approved by the Department to furnish medical, educational or
      rehabilitative services to Participants under the HFS Medical Program.
      Contractor is not a Provider.

     

    Rural
      Health Clinic or RHC
      means a
      Provider that has been designated by the Public

    Health
      Service, the U.S. Department of Health and Human Services, or the Governor
      of
      the State of Illinois, and approved by the Public Health Service, in accordance
      with the Rural Health Clinics Act (sec Public Law 95-210) as a RHC.

     

    Service
      Authorization Request
      means a
      request by an Enrollee for the provision of a medical service.

     

    Site
      means
      any contracted Provider (IPA, PHO, FQHC, individual physician, physician groups,
      etc.) through which the Contractor arranges the provision of primary care to
      Enrollees.

     

    Stabilization
      or Stabilized
      means,
      with respect to an Emergency Medical Condition, and as determined by an
      attending emergency room Physician or other treating Provider within reasonable
      medical probability, that no material deterioration of the condition is likely
      to result upon discharge or transfer to another facility.

     

    State
      means
      the State of Illinois.

     

    Tertiary
      Care
      means
      medical care requiring a setting outside of the routine, community standard,
      which care shall be provided within a regional medical center by highly
      specialized Providers (specialists and subspecialists) who require complex
      technological, diagnostic, treatment and support facilities to provide such
      care.

     

    7

     

    

    Title
      X Family Planning Provider
      means an
      agency that receives grants from the Illinois Department of Human Services
      to
      provide comprehensive family planning services pursuant to Title X of the Public
      Health Services Act, 42 U.S.C. 300 and 77 111. Adm. Code 635.

     

    Women's
      Health Care Provider
      means a
      Physician, specializing by certification or training in obstetrics, gynecology
      or family practice.

    

     

    8

     

    
 

    ARTICLE
      II 

    TERMS
      AND CONDITIONS

     

    2.1 Specification.
      This
      Contract is for the delivery of Covered Services to Enrollees and the
      administrative responsibilities attendant thereto. The terms and conditions
      of
      this Contract, along with the applicable Administrative Rules and the
      Departmental materials described in this Article II, Section 2.3 below, shall
      constitute the entire and present agreement between the parties. This Contract,
      including all attachments, exhibits and amendments constitutes a total
      integration of all rights, benefits and obligations of both parties for the
      performance of all duties and obligations hereunder including, but not limited
      to, the provision of, and payment for Covered Services under this Contract.
      This
      Contract is contingent upon receipt of approval from CMS.

     

    There
      are
      no extrinsic conditions or collateral agreements or undertakings of any kind
      with respect to matters addressed in this Contract. It is the express intention
      of both the Department and the Contractor that any and all prior or
      contemporaneous agreements, promises, negotiations or representations, cither
      oral or written, except as provided herein are to have no force, effect or
      legal
      consequences of any kind, nor shall any such agreements, promises, negotiations
      or representations, either oral or written, have any bearing upon this Contract
      or the duties or obligations hereunder. This Contract and any amendment hereto
      shall be deemed the full and final expression of the parties'
      agreement.

     

    2.2
      Rules
      of Construction.

     

    (a)
      Unless the context otherwise requires:

     

    (1)
      Provisions apply to successive events and transactions;

     

    (2)
      "Or"
      is not exclusive;

     

    (3)
      Unless otherwise specified, references to statutes, regulations, and rules
      include subsequent amendments and successors thereto;

     

    (4)
      The
      various headings of this Contract are provided for convenience only and shall
      not affect the meaning or interpretation of this Contract or any provision
      hereof;

     

    (5)
      If
      any payment or delivery hereunder between the Contractor and the Department
      shall be due on any day that is not a business day, such payment or delivery
      shall be made on the next succeeding business day;

     

    (6)
      Words
      in the plural that should be singular by context shall be so read, and words
      in
      the singular shall be read as plural where the context dictates;

     

    (7)
      Days
      shall mean calendar days unless otherwise designated by the context;
      and

     

    (8)
      References to masculine or feminine pronouns shall be interchangeable where
      the
      context requires.

     

     

    9

     

     

    (b)
      References in the Contract to Potential Enrollee, Prospective Enrollee and
      Enrollee shall include the parent, caretaker relative or guardian where such
      Potential Enrollee, Prospective Enrollee or Enrollee is a minor child or an
      adult for whom a guardian has been named; provided, however, that the Contractor
      is not obligated to cover services for any individual who is not enrolled as
      an
      Enrollee with the Contractor.

     

    2.3
      Performance
      of Services and Duties.
      The
      Contractor shall perform all services and other duties as set forth in this
      Contract in accordance with, and subject to, the Administrative Rules and
      Departmental materials, including, but not limited to, Departmental policies,
      Department Provider Notices, Provider Handbooks and any other rules and
      regulations that may be issued or promulgated from time to time during the
      term
      of this Contract. The Department shall provide copies of such materials to
      the
      Contractor upon the Contractor's written request, if such are in existence
      upon
      the Effective Date, or upon issuance or promulgation if issued or promulgated
      after the Effective Date. Changes in such materials after the Effective Date
      shall be binding on the parties hereto but shall not be considered amendments
      to
      the Contract. To the extent the Department proposes a change in policy that
      may
      have a material impact on the Contractor's ability to perform under this
      Contract, the proposed change will be subject to good faith negotiations between
      both parties before it shall be binding pursuant to this Article II, Section
      2.3.

     

    2.4
      Language
      Repuirements.

     

    (a)
      Key
      Oral Contacts.
      The
      Contractor shall conduct Key Oral Contacts (as described below) with Potential
      Enrollees, Prospective Enrollces or Enrollecs in a language the Potential
      Enrollces, Prospective Enrollces and Enrollecs understand. Where the language
      is
      other than English, the Contractor shall offer and, if accepted by the Potential
      Enrollee, Prospective Enrollee or Enrollee, shall supply interpretive services.
      Such services may not be rendered by any individual who is under the age of
      eighteen (18). "Key Oral Contacts" include, but are not limited to: Marketing
      contacts; enrollment communications; explanations of benefits; Site, Primary
      Care and Women's Health Care Provider selection activity; educational
      information; telephone calls to the toll-free hotline(s) described in Article
      V,
      Section 5.1(k); and face-to-face encounters with Providers rendering
      care.

     

    (b)
      Written
      Material.
      Marketing Materials, Enrollee Handbooks, Basic Information, and any information
      or notices required to be distributed to Potential Enrollees, Prospective
      Enrollees or Enrollees by the Department or regulations promulgated from time
      to
      time under 42 C.F.R. Part 438 (collectively, "Written Materials") shall be
      easily understood by individuals who have a sixth grade reading level. Such
      Written Materials shall be available in alternative formats that take into
      account the special needs (e.g., vision impairment) of Potential Enrollees,
      Prospective Enrollees or Enrollees. The Contractor shall have in place a
      mechanism to help Potential Enrollees, Prospective Enrollees and Enrollees
      understand the requirements and benefits of the Plan. Where there is a prevalent
      single-language minority within the low income households in the relevant
      Department of Human Services local office area (which for purposes of this
      Contract shall exist when five percent (5%) or more such families speak a
      language other than English, as determined by the Department according to
      published Census Bureau data), the

     

    

     

    10

     

    

    Contractor's
      written materials provided to Potential Enrollees,
      Prospective Em-ollees
      or
Enrollees
      must
      be
      available
      in that
      language as well as English. Translations of written material are subject to
      prior approval by the Department and must be accompanied by a certification
      that
      the translation is accurate and complete.

     

    (c) Oral
      Interpretation.
      The
      Contractor must make oral interpretation services available free of charge
      in
      all languages to all Potential Enrollees, Prospective Enrollees or Enrollees
      who
      need assistance understanding Key Oral Contacts or Written Materials. The
      Contractor must include in all Key Oral Contacts and Written Materials
      notification
      that such oral interpretation services are available, and provide a telephone
      number that can be used to obtain such services.

     

    2.5 List
      of Individuals in an Administrative Capacity.
      Upon
      execution of this Contract, the Contractor shall provide the Department with
      a
      list of individuals who have responsibility for monitoring and ensuring the
      performance of each of the duties and obligations under this Contract. This
      list
      shall be updated throughout the term of this Contract as necessary and as
      changes occur, and written notice of such changes shall be given to the
      Department within ten (10) business days of such changes occurring.

     

    2.6 Certificate
      of Authority.
      The
      Contractor must obtain and maintain during the term of the Contract a valid
      Certificate
      of
      Authority as a health maintenance organization under 215 ILCS
      125/1-1.
etseq..

     

    2.7 Obligation
      to Comply with other Laws.
      No
      obligation imposed herein on the Contractor shall relieve
      the
      Contractor of any other obligation imposed
      by law
      or regulation, including, but not limited to, those imposed by The
      Managed
      Care
      Reform
      and
      Patient Rights Act (215 ILCS 134/1 et seq.),
      the
      federal
      Balanced
      Budget
      Act of 1997 (Public Law 105-33) and regulations
      promulgated by the Illinois Department of Financial and Professional
      Regulation,
      the Illinois Department of Public Health or CMS.
      The
      Department shall report all information it receives indicating a violation
      of a
      law or regulation to the appropriate agency.

     

    (a)
      If
      the Contractor believes that it is impossible to comply with a provision of
      this
      Contract because of a contradictory provision of applicable State or federal
      law, the Contractor shall immediately notify the Department. The Department
      then
      will make a determination of whether a contract amendment is necessary. The
      fact
      that either the Contract or an applicable law imposes a more stringent standard
      than the other does not, in and of itself, render it impossible to comply with
      both.

     

    2.8 Provision
      of Covered Services Through Affiliated Providers.
      Where
      the Contractor does not employ Physicians or other Providers to provide direct
      health care services, every provision in this Contract by which the
      Contractor is obligated to provide Covered Services of any type to Enrollees,
      including but not limited to provisions stating that the Contractor will
      "provide Covered Services," "provide quality care," or provide a
      specific
      type of
      health care service, such as the enumerated Covered Services in Article V,
      Section 5.1 (i.e., health screenings, prenatal care or behavioral health
      assessments) shall be interpreted to mean that the Contractor arranges for
      the
      provision of those
      Covered
      Services through its network of Affiliated
      Providers.

     

    11

     

    

    

    ARTICLE
      III

    ELIGIBILITY

     

    3.1 Determination
      of Eligibility.
      The
      State has the exclusive right to determine an individual's eligibility for
      the
      HFS Medical Program and eligibility to become an Enrollee. Such determination
      shall be final and is not subject to review or appeal by the Contractor. Nothing
      in this Article III, Section 3.1 prevents the Contractor from providing the
      Department with information the Contractor believes indicates that an Enrollee's
      eligibility has changed.

     

    3.2 Enrollment
      Generally.
      Any
      Potential Enrollee who resides, at the time of enrollment, in the Contracting
      Area shall be eligible to become an Enrollee. Enrollment shall be voluntary.
      Except as provided herein, enrollment shall be open during the entire period
      of
      this Contract until the enrollment limit of the Contractor, as set forth in
      Attachment I, is reached. The Contractor must continue to accept enrollment
      until such enrollment limit is reached. Such enrollment shall be without
      restriction and in the order in which Potential Enrollees apply. The Contractor
      shall not discriminate against Potential Enrollees on the basis of such
      individuals' health status or need for health services. Similarly, Contractor
      will not discriminate against Potential Enrollees on the basis of race, color,
      or national origin, and will not use any policy or practice that has the effect
      of discriminating on the basis of race, color, or national origin. The
      Contractor shall accept each Enrollee whose name appears on the 834 Audit
      File.

     

    3.3
      Enrollment
      Limits.

     

    a)
      The
      Department will limit the number of Enrollees enrolled with the Contractor
      by
      Contracting Area to a level that will not exceed its physical and professional
      capacity. In its determination of capacity, the Department will only consider
      Providers that are approved by the Department. When the capacity is reached,
      no
      further applications for enrollment will be accepted by the Department unless
      termination or disenrollment of Enrollees create room for additions. The
      capacity limits for the Contractor are specified in Attachment I.

     

    b)
      The
      Department will perform a review of the enrollment limit(s) set forth in
      Attachment I upon the occurrence of any of the following
      conditions:

     

    1)
      the
      Contractor requests a review and the Department agrees to such review;
      or

     

    2)
      the
      Department determines that the Contractor's operating or financial performance
      reasonably indicates a lack of Provider or administrative capacity.

     

    c)
      This
      review shall examine the Contractor's Provider and administrative capacity
      in
      each Contracting Area. The Department's standards for the review shall be
      reasonable and timely and be consistent with the terms of this Contract. The
      Department shall use its best efforts to complete the review before the
      Contractor reaches the enrollment limit(s) set forth in Attachment I. Should
      the
      Department determine that the Contractor does not have the necessary Provider
      and administrative capacity to service any additional enrollments, the
      Department may freeze enrollment until such time that the Plan's Provider and
      administrative capacity have increased to the Department's
      satisfaction.

     

    12

    

    

    d)
      Nothing in this Contract shall be deemed to be a guarantee of any Potential
      Enrollee's enrollment in the Contractor's Plan.

     

    3.4 Expansion
      to Other Contracting Areas.
      The
      Contractor may, during the term of this Contract and any renewal thereof,
      request of the Department the opportunity to offer Covered Services to Potential
      Enrollees in areas other than the Contracting Area(s) specified in Attachment
      I.
      The Contractor must make this request in writing to the Department. The
      Department will provide an application and instructions for completion within
      ten (10) business days after receipt of written request. Upon receipt of a
      completed application from the Contractor, the Department shall review the
      information in a timely manner and may, at any time, request additional
      information of the Contractor. It is in the sole discretion of the Department,
      upon review of the Contractor's application for expansion and assessing the
      needs of the Potential Enrollee population and other factors as determined
      by
      the Department, to grant the Contractor's request for expansion. Should the
      Department agree in writing to the expansion request, the Department's approval
      letter including an amended Attachment I shall be incorporated in and become
      a
      part of the Contract.

     

    3.5
      Discontinuation
      of Services in One or More Contracting Area.
      The

    Contractor
      may, during the term of this Contract and any renewal thereof, request of the
      Department the opportunity to discontinue offering Covered Services to Enrollees
      in one or more Contracting Area specified in Attachment I. The Contractor must
      make this request in writing to the Department. The Department will advise
      the
      Contractor of all information that must be submitted to the Department. Upon
      receipt of such information from the Contractor, the Department shall review
      the
      information in a timely manner and may, at any time, request additional
      information of the Contractor. It is in the sole discretion of the Department
      to
      grant the Contractor's request to discontinue offering Covered Services in
      one
      or more Contracting Areas. Should the Department agree to the request to
      discontinue offering Covered Services, the Department and the Contractor shall
      agree to execute an amendment to Attachment I of the Contract to reflect the
      appropriate Contracting Area(s) in which the Contractor will provide Covered
      Services.

     

     

    13

     

    

    

    ARTICLE
      IV 

    ENROLLMENT,
      COVERAGE AND TERMINATION OF COVERAGE

     

    4.1
      Enrollment
      Process.

     

    (a)
      The
      Department, acting directly or through its agent, shall be responsible for
      the
      enrollment of Potential Enrollees.

     

    (1)
      When
      the Contractor enrolls a Potential Enrollee, the Contractor shall initiate
      the
      processing of the enrollment by completing a Managed Care Enrollment Form in
      accordance with Department instructions and signed by the individual who is
      recognized as the Head of Case by the Department. This form will be supplied
      to
      the Contractor by the Department. The Contractor may enroll a Potential Enrollee
      without a completed and signed Managed Care Enrollment Form prior to September
      30, 2006 if the Potential Enrollee was enrolled with an MCO that ended its
      contract with the Department on July 31, 2006. The Contractor shall submit
      a
      weekly report to the Department of all enrollments submitted without a signed
      form. The Contractor shall be required to submit all enrollment information
      electronically to the Department or its designee and retain the original forms
      for at least six (6) years. The Contractor shall submit enrollments via the
      834
      Daily File.

     

    (2)
      Only
      a Head of Case may enroll another Potential Enrollee. A Head of Case may enroll
      all other Potential Enrollees in his Case. An adult Potential Enrollee, who
      is
      not a Head of Case, may enroll himself only.

     

    (3)
      A
      member of the Contractor's management staff may correct a Managed Care
      Enrollment Form only in accordance with Department instructions. The corrections
      must be initialed by the Contractor's manager or his designated staff
      person.

     

    (b)
      It is
      the intent of the Department to contract with a Client Enrollment Broker (CEB)
      during the term of this contract. The CEB enrollment process shall serve to
      enhance and facilitate Potential Enrollees' choice of health coverage program
      options, and shall not act to give preference to one option over others.
      Department shall collaborate with Contractor on the design of the CEB enrollment
      and disenrollment processes and subsequent changes that affect Contractor's
      outreach, marketing, enrollment and disenrollment functions. The Department
      shall monitor the CEB process and consult with the Contractor to identify any
      unintended obstacles that hinder Potential Enrollees from selecting an MCO
      and
      work in good faith with the CEB to remove those obstacles. When the CEB is
      ready
      to implement its enrollment process, the process set forth in subsection (a)
      will be replaced by the CEB process.

     

    (c)
      The
      Contractor shall conduct enrollment activities that include the information
      distribution requirements of Article V, Section 5.5 hereof and are designed
      and
      implemented so as to maximize Eligible Enrollees' understanding of the
      following:

     

    (1)
      that
      all Covered Services must be received from or through the Plan with the
      exception of family planning and other Medical Assistance services as
      described

     

     

    14

    

    in
      Article V, Section 5.1(e) with provisions made to clarify when such services
      may
      also be obtained elsewhere;

     

    (2)
      that
      once enrolled, the Enrollees will receive a card from the Department;
      and

     

    (3)
      that
      the Contractor must inform Potential Enrollees of any Covered Services that
      will
      not be offered by the Contractor due to the Contractor's exercise of a right
      of
      conscience.

     

    (d)
      Upon
      the Contractor's request, the Department may refuse enrollment for at least
      a
      six-month period to those former Enrollees previously terminated from coverage
      by the Contractor for "good cause," as specified in Article IV, Section
      4.4(a)(l).

     

    (e)
      When
      an Enrollee, who is a Head of Case, gives birth and the newborn is added to
      the
      Case before the newborn is forty-five (45) days old, the newborn shall be
      automatically enrolled with the Contractor. Coverage shall be retroactive to
      the
      date of birth.

     

    (f)
      Potential Enrollees age 46 days through age 1 who are added to a Case in which
      the mother is the Head of Case and an Enrollee will be enrolled with the
      Contractor automatically. Coverage shall be prospective as described in Article
      IV, Section 4.2 of this Contract.

     

    (g)
      Potential Enrollees through age eighteen (18) who are added to a Case in which
      all members of the Case are enrolled with the Contractor will be enrolled with
      the Contractor automatically. Coverage shall be prospective as described in
      Article IV, Section 4.2 of this Contract.

     

    (h)
      No
      later than ten (10) business days following receipt of the 834 Audit File,
      the
      Contractor must send new Enrollees an identification card bearing the name
      of
      the Contractor's Plan; the effective date of coverage; the twenty-four hour
      telephone number to confirm eligibility for benefits and authorization for
      services and the name and phone number of the Primary Care Provider and, if
      applicable, the Women's Health Care Provider. The Contractor shall make
      reasonable efforts to send the identification cards no later than five (5)
      business days following receipt of the 834 Audit File. Samples of the
      identification cards described herein shall be submitted for Department approval
      by the Contractor prior to use by the Contractor and as revised. The Contractor
      shall not be required to submit for prior approval format changes, provided
      there is no change in the information conveyed.

     

    (1)
      If
      the Contractor requires a female Enrollee who wishes to use a Women's Health
      Care Provider to designate a specific Women's Health Care Provider and if a
      female Enrollee does so designate a Women's Health Care Provider, the name
      and
      phone number of that Women's Health Care Provider must appear on the
      identification card.

     

    (i)
      Within three (3) business days following receipt of the 834 Daily File, the
      Contractor must update all electronic systems maintained by the Contractor
      to
      reflect the information contained in the 834 Daily File.

     

     

    15

     

    

    

    4.2
      Initial Coverage.
      Coverage
      shall begin as designated by the Department on the first day of a calendar
      month
      no later than three (3) calendar months from the date the enrollment is accepted
      by the Department's database. Enrollment other than automatic enrollment can
      occur only upon the Prospective Enrollee's selection of a Site and the
      communication of that Site by the Contractor to the Department.

     

    (a)
      The
      Contractor shall provide coordination of care assistance to Prospective
      Enrollees to access a Primary Care Provider or Women's Health Care Provider
      before the Contractor's coverage becomes effective, if requested to do so by
      Prospective Enrollees or if the Contractor has knowledge of the need for such
      assistance. Any payment for those services rendered to Prospective Enrollees
      described herein shall be made directly by the Department to such Providers
      under the provisions of the HFS Medical Program.

     

    4.3
      Period
      of Enrollment.
      Every
      Enrollee shall remain enrolled until the Enrollee's coverage is ended pursuant
      to Article IV, Section 4.4.

     

    4.4
      Termination
      of Coverage.

     

    (a)
      An
      Enrollee's coverage shall be terminated, subject to Department approval, upon
      the occurrence of any of the following conditions:

     

    (1)
      dismissal from the Plan by the Contractor for "good cause" shown may only occur
      upon receipt by the Contractor of written approval of such termination by the
      Department. The Contractor shall give the Enrollee at least 10 days notice
      before termination of coverage for "good cause"; except the notice period is
      shortened to 5 days if probable Enrollee fraud has been verified. For purposes
      of this paragraph, "good cause" may include, but is not limited to fraud or
      other misrepresentation by an Enrollee, threats or physical acts constituting
      battery to the Contractor, the Contractor's personnel or the Contractor's
      participating Providers and staff, chronic abuse of emergency rooms, theft
      of
      property from the Contractor's Affiliated Sites, an Enrollee's sustained
      noncompliance with the Plan physician's treatment recommendations (excluding
      preventive care recommendations) after repeated and aggressive outreach attempts
      are made by the Plan or other acts of an Enrollee presented and documented
      to
      the Department by the Contractor which the Department determines constitute
      "good cause";

     

    (2)
      when
      the Department determines that the Enrollee no longer qualifies as a Potential
      Enrollee. For Enrollees under age 21 who are terminated due to the receipt
      ofSSI, such termination shall be retroactive to the date ofSSI
      coverage;

     

    (3)
      upon
      the Enrollee's death. Termination of coverage shall take effect at 11:59 p.m.
      on
      the last day of the month in which the Enrollee dies. Such termination may
      be
      retroactive to this date;

     

    (4)
      when
      an Enrollee elects to terminate coverage by so informing the Contractor or
      the
      Department. Enrollees may elect to disenroll at any time. The Contractor shall
      comply with any Department policies then in effect to promote and allow
      interaction between the Contractor and the Enrollee seeking disenrollment prior
      to the disenrollment. The Contractor shall, within three (3) business days
      of
      the request,

     

     

    16

    

    send
      to
      the Enrollee the Managed Care Disenrollment Form, DPA Form 2575B, and shall
      not
      delay the provision or processing of this form for the purpose of arranging
      informational interviews with the Em-ollees, or for any other purpose. The
      Contractor shall submit the disenrollment to the Department via the 834 Daily
      File within three (3) business days of Contractor's receipt of a complete
      disenrollment form. The Department shall make available an error file each
      day
      which the Contractor must review in order to know if the disenrollment was
      rejected. If the disenrollment was rejected by the Department, the Contractor
      must submit a corrected disenrollment transaction within two (2) business
      days;

     

    (5)
      when
      an Enrollee no longer resides in the Contractor's Contracting Area, unless
      waiver of this subparagraph is approved in writing by the Department and
      assented to by the Contractor and Enrollee. If an Enrollee is to be disenrolled
      at the request of a Contractor, the Contractor first must provide documentation
      satisfactory to the Department that the Enrollee no longer resides in the
      Contractor's Contracting Area. Termination of coverage shall take effect at
      11:59 p.m. on the last day of the month prior to the month in which the
      Department determines that the Enrollee no longer resides in the Contractor's
      Contracting Area. This date may be retroactive if the Department can determine
      the month in which the Enrollee moved from the Contractor's Contracting
      Area;

     

    (6)
      when
      the Department determines, pursuant to Article IX, that an Enrollee has other
      significant insurance coverage. The Contractor shall be notified by the
      Department of such disenrollment on the 834 Daily File.

     

    (b)
      In
      conjunction with a request by the Contractor to disenroll an Enrollee, the
      Contractor shall furnish to the Department all information requested regarding
      the basis for disenrollment and all information regarding the utilization of
      services by that Enrollee.

     

    (c)
      The
      Contractor shall not seek to terminate enrollment because of an adverse change
      in the Enrollec's health status or because of the Enrollce's (i) utilization
      of
      Covered Services, (ii) diminished mental capacity, (iii)
      uncooperative/disruptive behavior resulting from such Enrollee's special needs
      (except to the extent such Enrollec's continued enrollment in the Plan seriously
      impairs the Contractor's ability to furnish Covered Services to the Enrollee
      or
      other Enrollees) or (iv) action in connection with exercising his/her Appeal
      or
      Grievance rights. Such attempts to seek to terminate enrollment will be
      considered in violation of the terms of this Contract.

     

    (d)
      The
      termination of this Contract terminates coverage for all persons who become
      Enrollees under it. Termination of coverage under this provision will take
      effect at 11:59 p.m. on the last day of the last month for which the Contractor
      receives payment, unless otherwise agreed to, in writing, by the parties to
      this
      Contract.

     

    (e)
      Except as otherwise provided in this Article IV, Section 4.6, termination of
      Enrollee coverage shall take effect no later than 11:59 p.m. on the last day
      of
      the month following the month the disenrollment is processed by the
      Department.

     

    17

    
 

    

    (f)
      Any
      Enrollee whose coverage has been terminated by the Department solely because
      such Enrollee no longer qualifies as a Potential Enrollee, who subsequently
      qualifies as a Potential Enrollee within a two (2) month period following the
      date of termination, shall be automatically re-enrolled with the
      Contractor.

     

    (g)
      Upon
      implementation of the mandatory Primary Care Case Management program, the
      disenrollment process will be replaced by the Client Enrollment Broker
      process.

     

    4.5
      Preexisting
      Conditions and Treatment.
      The
      Contractor shall assume, upon the effective date of coverage, full
      responsibility for any medical conditions that may have been preexisting prior
      to enrollment in the Contractor's Plan and for any existing treatment plans
      under which an Enrollee is currently receiving medical care provided that the
      Enrollee's current in-Plan physician determines that such treatment plan is
      medically necessary for the health and well-being of the Enrollee.

     

    4.6
      Continuity
      of Care.

     

    a)
      If an
      Enrollee is receiving medical care or treatment as an inpatient in an acute
      care
      hospital on the effective date of enrollment, the Contractor shall assume
      responsibility for the management of such care and shall be liable for all
      claims for Covered Services from that date. For hospital stays that would
      otherwise be reimbursed under the HFS Medical Program by DRGs, the Contractor's
      liability for the hospital stay is retroactive to the admission date. For
      hospital stays that would otherwise be reimbursed under the HFS Medical Program
      on a per diem basis, the Contractor's liability shall begin on the effective
      date of enrollment.

     

    b)
      If an
      Enrollee is receiving medical care or treatment as an inpatient in an acute
      care
      hospital at the time coverage under this Contract is terminated, the Contractor
      shall arrange for the continuity of care or treatment for the current episode
      of
      illness until such medical care or treatment has been fully transferred to
      a
      treating provider who has agreed to assume responsibility for such medical
      care
      or treatment for the remainder of that hospital episode and subsequent follow
      up
      care. The Contractor must maintain documentation of such transfer of
      responsibility of medical care or treatment. For hospital stays that would
      otherwise be reimbursed under the HFS Medical Program by DRGs, the Contractor
      shall not be liable for payment for any inpatient medical care or treatment
      provided to an Enrollee where discharge date is after the effective date of
      disenrollment. For hospital stays that would otherwise be reimbursed under
      the
      HFS Medical Program on a per diem basis, the Contractor shall be liable for
      payment for any medical care or treatment provided to an Enrollee until the
      effective date of disenrollment.

     

    c)
      If
      Contractor becomes insolvent or is subject to insolvency proceedings as set
      forth in 215 ILCS 125/1-1 et seq.. the Contractor shall be liable for all claims
      for Covered

    Services
      for the duration of the period for which payment has been made to the Contractor
      by the Department and shall remain responsible for the management of care
      provided to all Enrollees until the Contract is terminated (in the latter case
      the terms of subsection (a) of this Section 4.6 shall control).

     

    d)
      The
      Contractor must provide for transition of services in accordance with Section
      25
      of the Managed Care and Patients Rights Act (215 IECS 134/25).

     

     

    18

     

    

    

    4.7
      Change
      of Site and Primary Care Provider or Women's Health Care
      Provider.
      The
      Contractor shall permit an Enrollee to change Site, Primary Care Provider and
      Women's Health Care Provider upon request. The Contractor shall process such
      changes within thirty (30) days of receipt of an Enrollee's
      request.

     

    (a)
      Within three (3) business days of processing such change, the Contractor shall
      submit a Site transfer record to the Department via the 834 Daily File. Such
      record shall contain the following data fields: Case name and identification
      number; Enrollee name and identification number; current Site number on the
      Department's database; and new Site number. The Department shall make available
      an error file each day which the Contractor must review in order to know if
      the
      Site transfer was rejected by the Department. If the Site transfer was rejected
      by the Department, the Contractor must submit a corrected Site transfer
      transaction within two (2) business days. The Department will provide the
      Contractor with no less than one hundred twenty (120) days advance notification
      prior to imposing a requirement that the Contractor electronically communicate
      old and new Primary Care Provider numbers and old and new Women's Health Care
      Provider numbers with this record.

     

    19

     

    

    

    ARTICLE
      V

     

    DUTIES
      OF CONTRACTOR

     

    5.1 Services.

     

    (a)
      Amount,
      Duration and Scope of Coverage.
      The
      Contractor shall comply with the terms of 42 C.F.R. §438.206(b) and provide or
      arrange to have provided to all Enrollees all services described in 89 111.
      Adm.
      Code, Part 140 as amended from time to time and not specifically excluded
      therein or in this Article V, Section 5.1 in accordance with the terms of this
      Contract. Covered Services shall be provided in the amount, duration and scope
      as set forth in 89 111. Adm. Code, Part 140 and this Contract, and shall be
      sufficient to achieve the purposes for which such Covered Services are
      furnished. This duty shall commence at the time of initial coverage as to each
      Enrollee. The Contractor shall, at all times, cover the appropriate level of
      service (i.e., triage, urgent) for all Emergency Services provided in an
      emergency room setting. The Contractor shall notify the Department in writing
      within five (5) days following a change in the Contractor's network of
      Affiliated Providers that renders the Contractor unable to provide one (1)
      or
      more Covered Servicc(s) in any Contracting Area. The Contractor shall not refer
      Enrollees to publicly supported health care entities to receive Covered
      Services, for which the Contractor receives payment from the Department, unless
      such entities are Affiliated with the Contractor's Plan. Such publicly supported
      health care entities include, but are not limited to, Chicago Department of
      Public Health and its clinics, Cook County Bureau of Health Services, and local
      health departments. The Contractor shall provide a mechanism for an Enrollee
      to
      obtain a second opinion from a qualified Provider, whether Affiliated or
      non-Affiliated, at no cost to the Enrollee.

     

    (b)
      Enumerated
      Covered Services.
      The
      Contractor shall have a sufficient number of Affiliated Providers (including
      Tertiary Care hospital(s) and, where appropriate, advanced practice nurses)
      in
      place to provide all of the following services and benefits (which shall be
      specifically included as Covered Services under this Contract) to Enrollees
      at
      all times during the term of this Contract, whenever Medically Necessary, except
      to the extent services are identified as excluded services pursuant to
      subsection (e) of this Section 5.1:

     

    •
      Assistive/augmentative communication devices;

     

    •
      Audiology services, physical therapy, occupational therapy and speech
      therapy;

     

    •
      Behavioral health services, including subacute alcohol and substance abuse
      services and mental health services, in accordance with subsection (c)
      hereof;

     

    •
Blood,
      blood components and the administration thereof;

     

    •
      Certified hospice services;

     

    •
      Chiropractic services;

     

    •
Clinic
      services (as described in 89 111. Adm. Code, Part 140.460);

     

    20

    

    • Diagnosis
      and treatment of medical conditions of the eye;

     

    • Durable
      and nondurable medical equipment and supplies;

     

    • Emergency
      Services;

     

    • Family
      planning services;

     

    • Home
      health care services;

     

    • Inpatient
      hospital services (including dental hospitalization in case of trauma or
      when
      related to a medical condition or acute medical
      detoxification);

     

    • Inpatient
      psychiatric care;

     

    • Laboratory
      and x-ray services; *

     

    • Medical
      procedures performed by a dentist;

     

    • Nurse
      midwives services;

     

    • Nursing
      facility services for the first ninety (90) days;**

     

    • Orthotic/prosthetic
      devices, including prosthetic devices or reconstructive surgery incident to
      a
      mastectomy;

     

    • Outpatient
      hospital services (excluding outpatient behavioral health
      services);

     

    • Physicians'
      services, including psychiatric care;

     

    • Podiatnc
      services;

     

    • Pharmaceutical
      products provided by an entity other than a pharmacy;

     

    • Routine
      care in conjunction with certain investigational cancer treatments, as provided
      in Public Act 91-0406;

     

    *The
      drawing of blood for lead screening shall take place within the Contractor's
      Affiliated facilities or elsewhere at the Contractor's expense. All laboratory
      tests for children being screened for lead must be sent for analysis to the
      Illinois Department of Public Health's laboratory.

     

    **Contractors
      will be responsible for covering up to a maximum of ninety (90) days nursing
      facility care (or equivalent care provided at home because a skilled nursing
      facility is not available) annually per Enrollee. Periods in excess of ninety
      (90) days annually will be paid by the Department according to its prevailing
      reimbursement system.

     

     

    21

     

    

    

    •
EPSDT
      Services;

     

    •
      Services to Prevent Illness and Promote Health in accordance with subsection
      (d)
      hereof;

     

    •
      Transplants covered under 89 111. Adm. Code 148.82 (using transplant providers
      certified by the Department, if the procedure is performed in the State);
      and

     

    •
      Transportation to secure Covered Services.

     

    (c)
      Behavioral
      Health Services.

     

    (1)
      The
      Contractor will provide the following behavioral health services, which are
      Covered Services:

     

    •
      Inpatient psychiatric or substance abuse services that are provided in general
      hospital medical units;

     

    •
      Inpatient psychiatric services provided in a hospital that is a psychiatric
      hospital or a distinct psychiatric unit, as defined in 89 111. Adm. Code
      148.40(a)(l);

     

    •
      Inpatient acute alcoholism and substance abuse treatment
      (detoxification);

     

    •
      Hospital-based organized clinic services referred to as outpatient treatment
      psychiatric services for Type A and Type B Psychiatric Clinic Services, as
      defined in 89 111. Adm. Code 148.140(b)(l)(E); and

     

    •
      Behavioral health services provided by FQHCs, RHCs, and Physicians, including
      psychiatrists; and

     

    •
      Laboratory services provided on an outpatient basis for behavioral health,
      even
      if ordered by a behavioral health provider in connection with the provision
      of
      treatment that is excluded from Covered Services.

     

    (2)
      If an
      Enrollee presents himself to the Contractor for behavioral health services,
      or
      is referred through a third party, the Contractor will complete a behavioral
      health assessment.

     

    •
If
      the
      assessment indicates that all services needed are within the scope of Covered
      Services, the Contractor will arrange for the provision of all such Covered
      Services.

     

    22

     

    

    

    •
If
      the
      assessment indicates that outpatient services are needed beyond the scope of
      Covered Services, the Contractor will explain to the Enrollee the services
      needed and the importance of obtaining them and provide the Enrollee with a
      list
      of Community Behavioral Health Providers (CBHP). The Contractor will assist
      the
      Enrollee in contacting a CBHP chosen by the Enrollee, unless the Enrollee
      objects.

     

    •
If
      a
      Enrollee obtains needed comprehensive services through a CBHP, the Contractor
      will be responsible for payment for laboratory services in connection with
      the
      comprehensive services provided by the CBHP. The Contractor shall not be liable
      for other Covered Services provided by the CBHP. The Contractor may require
      that
      laboratory services are provided by Providers that are Affiliated with
      Contractor.

     

    (d)
      Services
      to Prevent Illness and Promote Health.
      The
      Contractor shall make documented efforts to provide initial health screenings
      and preventive care to all Enrollees. The Contractor shall provide, or arrange
      to provide, the following Covered Services to all Enrollees, as appropriate,
      to
      prevent illness and promote health:

     

    (1)
      EPSDT
      services in accordance with 89 111. Adm. Code 140.485 and described in this
      Article V, Section 5.13(a);

     

    (2)
      Preventive Medicine Schedule which shall address preventive health care issues
      for Enrollees twenty-one (21) years of age or older (Article V, Section
      5.13(b));

     

    (3)
      Maternity care for pregnant Enrollees (Article V, Section 5.13(c));
      and

     

    (4)
      Family planning services and supplies, including physical examination and
      counseling provided during the visit, annual physical examination for family
      planning purposes, pregnancy testing, voluntary sterilization, insertion or
      injection of contraceptive drugs or devices, and related laboratory and
      diagnostic testing (except to the extent an Enrollee has chosen to obtain such
      services and supplies from a non-Affiliated Provider, in which case the
      Department shall be responsible for providing payment for such
      services).

     

    (e)
      Exclusions
      from Covered Services.
      In
      addition to those services and benefits excluded from Covered Services by 89
      111. Adm. Code, Part 140, as amended from time to time, the following services
      and benefits shall NOT be included as Covered Services:

     

    (1)
      Dental services;

     

    (2)
      Pharmacy services provided by a pharmacy;

     

    (3)
      Mental health clinic services as provided through a community behavioral health
      provider as identified in 89 111. Adm. Code 140.452 and 140.454 and

     

    23

    

    

    further
      defined in 59 111. Adm. Code, Part 132 "Medicaid Community Mental Health
      Services Program."

     

    (4)
      Subacute alcoholism and substance abuse treatment services as provided through
      a
      community behavioral health provider as identified in 89 111. Adm. Code
      148.340(a) and farther defined in 77 111. Adm. Code 2090.

     

    (5)
      Routine examinations to determine visual acuity and the refractive state of
      the
      eye, eyeglasses, other devices to correct vision, and any associated supplies
      and equipment. The Contractor shall refer Enrollees needing such services to
      Providers participating in the HFS Medical Programs who are able to provide
      such
      services, or to a central referral entity that maintains a list of such
      Providers.

     

    (6)
      Nursing facility services, or equivalent care provided at home because a skilled
      nursing facility is unavailable, beginning on the ninety-first (91st) day of
      service in a calendar year;

     

    (7)
      Services provided in an Intermediate Care Facility for the Mentally
      Retarded/Developmcntally Disabled and services provided in a nursing facility
      to
      mentally retarded or developmentally disabled Participants;

     

    (8)
      Early
      intervention services, including case management, provided pursuant to the
      Early
      Intervention Services System Act (325 ILCS 20 et seq.);

     

    (9)
      Services provided through school-based clinics as such clinics are defined
      by
      the Department;

     

    (10)
      Services provided through local education agencies that are enrolled with the
      Department under an approved individual education plan (IEP);

     

    (11)
      Services funded through the Juvenile Rehabilitation Services Medicaid Matching
      Fund;

     

    (12)
      Services that are experimental and/or investigational in nature;

     

    (13)
      Services provided by a non-Affiliated Provider and not authorized by the
      Contractor, unless this Contract specifically requires that such services be
      covered;

     

    (14)
      Services that are provided without first obtaining a required referral or prior
      authorization as set forth in the Enrollee handbook;

     

    (15)
      Medical and/or surgical services provided solely for cosmetic purposes;
      and

     

    (16)
      Diagnostic and/or therapeutic procedures related to
      infertility/sterility.

     

    (f)
      Limitations
      on Covered Services.
      The
      following services and benefits shall be limited as Covered
      Services:

     

    24

    

    

    (1)
      Termination of pregnancy shall be provided only as allowed by applicable State
      and federal law (42 C.F.R. Part 441, Subpart E). In any such case, the
      requirements of such laws must be fully complied with and Form HFS 2390 must
      be
      completed and filed in the Enrollee's medical record. Termination of pregnancy
      shall not be provided to Enrollees eligible under the State Childrens Health
      Insurance Program (215 ILCS 106).

     

    (2)
      Sterilization services may be provided only as allowed by State and federal
      law
      (see 42 C.F.R. Part 441, Subpart F). In any such case, the requirements of
      such
      laws must be fully complied with and a DPA Form 2189 must be completed and
      filed
      in the Enrollee's medical record.

     

    (3)
      If a
      hysterectomy is provided, a DPA Form 1977 must be completed and filed in the
      Enrollee's medical record.

     

    (g)
      Right
      of Conscience.
      The
      parties acknowledge that pursuant to 745 ILCS 70/1 et scq.,
      a
      Contractor may choose to exercise a right of conscience by not rendering certain
      Covered Services. Should the Contractor choose to exercise this right, the
      Contractor must promptly notify the Department of its intent to exercise its
      right of conscience in writing. Such notification shall contain the services
      that the Contractor is unable to render pursuant to the exercise of the right
      of
      conscience. The parties agree that at that time the Department shall adjust
      the
      Capitation payment to the Contractor and amend the contract
      accordingly.

     

    Should
      the Contractor choose to exercise this right, the Contractor must notify
      Potential Enrollees, Prospective Enrollees and Enrollees that it has chosen
      to
      not render certain Covered Services, as follows:

     

    (1)
      To
      Potential Enrollees, prior to enrollment;

     

    (2)
      To
      Prospective Enrollees, during enrollment; and

     

    (3)
      To
      Enrollees, within ninety (90) days after adopting a policy with respect to
      any
      particular service that previously was a Covered Service.

     

    (h)
      Emergency
      Services.

     

    (1)
      The
      Contractor shall cover Emergency Services for all Enrollees whether the
      Emergency Services are provided by an Affiliated or non-Affiliated
      Provider.

     

    (2)
      The
      Contractor shall not impose any requirements for prior approval of Emergency
      Services. If an Enrollee calls the Contractor to request Emergency Services,
      such call shall receive an immediate response.

     

    (3)
      The
      Contractor shall cover Emergency Services for Enrollees who are temporarily
      away
      from their residence and outside the Contracting Area for all Emergency Services
      to which they would be entitled within the Contracting Area.

     

    (4)
      The
      Contractor shall have no obligation to cover medical services provided on an
      emergency basis that are not Covered Services under this Contract.

     

    25

     

    

    

    (5)
      Elective care or care required as a result of circumstances that could
      reasonably have been foreseen prior to the Enrollee's departure from the
      Contracting Area are not covered. Unexpected hospitahzation due to complications
      of pregnancy shall be covered. Routine delivery at term outside the Contracting
      Area, however, shall not be covered if the Enrollee is outside the Contracting
      Area against medical advice unless the Enrollee is outside of the Contracting
      Area due to circumstances beyond her control. The Contractor must educate the
      Enrollee of the medical and financial implications of leaving the Contracting
      Area and the importance of staying near the treating Provider throughout the
      last month of pregnancy.

     

    (6)
      The
      Contractor shall provide ongoing education to Enrollees regarding the
      appropriate use of Emergency Services.

     

    (7)
      The
      Contractor shall not condition coverage for Emergency Services on the treating
      Provider notifying the Contractor of the Enrollee's screening and treatment
      within ten (10) calendar days of presentation for Emergency
      Services.

     

    (8)
      The
      determination of whether or not an Enrollee is sufficiently Stabilized for
      discharge or transfer to another facility shall be binding on the
      Contractor.

     

    (i)
      Post-Stabilization
      Services.
      The
      Contractor shall cover Post-Stabilization Services provided by an Affiliated
      or
      non-Affiliated Provider in any the following situations: (a) the Contractor
      authorized such services; (b) such services were administered to maintain the
      Enrollee's stabilized condition within one (1) hour of a request to the
      Contractor for authorization of further Post-Stabilization Services; or (c)
      the
      Contractor does not respond to a request to authorize further Post-Stabilization
      Services within one (1) hour, the Contractor could not be contacted, or the
      Contractor and the treating Provider cannot reach an agreement concerning the
      Enrollee's care and an Affiliated Provider is unavailable for a consultation,
      in
      which case the treating Provider must be permitted to continue the care of
      the
      Enrollee until an Affiliated Provider is reached and either concurs with the
      treating Provider's plan of care or assumes responsibility for the Enrollee's
      care.

     

    (]')
      Additional
      Services or Benefits.
      The
      Contractor shall obtain prior approval from the Department before offering
      any
      additional service or benefit not required under this Contract to Enrollees.
      The
      Contractor shall notify Enrollees and Prospective Enrollees before discontinuing
      an additional service or benefit. The notice must be approved in advance by
      the
      Department. The Contractor shall continue any ongoing course of treatment for
      an
      Enrollee then receiving such service or benefit. All additional services or
      benefits approved by the Department under a previous contract must be
      resubmitted to the Department for approval within thirty (30) days of the
      Effective Date. Contractor may continue to use all additional services and
      benefits approved under a previous contract until the Department completes
      its
      review and notifies the Contractor that an added service or benefit is no longer
      approved.

     

    (k)
      Telephone
      Access.
      The
      Contractor shall establish a toll-free twenty-four (24) hour telephone number
      to
      confirm eligibility for benefits and seek prior approval for treatment where
      required under the Plan, and shall assure twenty-four (24) hour access, via
      telephone(s), to medical professionals, either to the Plan directly or to the
      Primary Care Providers, for consultation to obtain medical care. The Contractor
      must also make a toll-free

     

    26

    

    

    number
      available, at a minimum during the business hours of 9:00 a.m. until 5:00 p.m.
      Central Time on regular business days. This number also will be used to confirm
      eligibility for benefits, for approval for non-emergency services and for
      Enrollees to call to request Site, Primary Care Provider, or Women's Health
      Care
      Provider changes, to make complaints or grievances, to request disenrollment
      and
      to ask questions. The Contractor may use one toll-free number for these purposes
      or may establish two separate numbers.

     

    5.2 Network
      Adequacy.
      The
      Contractor must establish, maintain and monitor a network of Affiliated
      Providers, including hospitals, that is sufficient to provide adequate access
      to
      all services under the Contract taking into consideration:

     

    (a)
      The
      anticipated number of Enrollees;

     

    (b)
      The
      expected utilization of services, in light of the characteristics and health
      care needs of the Contractor's Enrollees

     

    (c)
      The
      number and types of Providers required to furnish the Covered
      Services.

     

    (d)
      The
      number of Affiliated Providers who are not accepting new patients;
      and

     

    (e)
      The
      geographic location of Providers and Enrollees, taking into account distance,
      travel time, the means of transportation and whether the location provides
      physical access for Enrollees with disabilities.

     

    It
      is
      understood that in some instances Enrollees will require specialty care not
      available from an Affiliated Provider and that the Contractor will arrange
      that
      such services by provided by an non-Affiliated Provider.

     

    5.3 Marketing.
      The
      Contractor shall, initially and as revised, submit to the Department for the
      Department's review and prior written approval all of the following materials:
      Certificate of Coverage or Document of Coverage; Enrollee Handbooks; Marketing
      Materials, including Marketing brochures and fliers; Marketing plans, including
      descriptions of proposed Marketing approaches and Marketing procedures; training
      materials and training schedules relating to services under this Contract;
      and
      all other materials and procedures utilized by the Contractor in connection
      with
      Marketing and training. Any substantive revisions to the foregoing materials
      that will either directly or indirectly affect interpretation of benefits,
      the
      delivery of services or the administration of benefits are subject to the
      Department's prior written approval as set forth in this paragraph.

     

    Marketing
      by mail, mass media advertising and community oriented Marketing directed at
      Potential Enrollees will be allowed subject to the Department's prior approval.
      The Contractor shall be responsible for all costs of mailing, including labor
      costs. The Department reserves the right to determine and set the sole process
      of, cost, and payment for Marketing by mail, using names and addresses of
      Participants supplied by the Department, including the right to limit Marketing
      by mail to a vendor under contract to the Department and the terms and
      conditions set forth in that vendor contract. To the extent permitted by law
      and
      approved by the

     

    27

     

    

    

    Department,
      the Contractor may distribute Marketing materials selectively by eligibility
      category, by Contracting Area, by county, by city or by other geographic
      area.

     

    The
      Contractor agrees to be bound by the following requirements for
      Marketing:

     

    (a)
      The
      Contractor shall not engage in Marketing practices that mislead, confuse or
      defraud either Potential Enrollees or the Department;

     

    (b)
      Marketing Materials must be clear and must include, at a minimum, the
      information required in Article V, Section 5.4;

     

    (c)
      Marketing Materials shall not include any assertion or statement that the
      Contractor is endorsed by CMS or the Department, and neither the Contractor
      nor
      its Marketing personnel shall make such assertions or statements, whether in
      writing or orally;

     

    (d)
      Potential Enrollees shall be solicited from a geographic area that does not
      exceed the Contracting Area(s);

     

    (e)
      Potential Enrollees may not be discriminated against on the basis of health
      status or need for health care services or on any illegal basis;

     

    (f)
      The
      Contractor's Marketing shall be designed to reach a distribution of Potential
      Enrollees across age and sex categories, as such categories are established
      for
      rates as set forth in Attachment I, in the Contracting Area(s). The Contractor's
      Marketing shall not be designed to achieve favorable reimbursement by enrolling
      a disproportionate percentage of individuals from a particular age and sex
      category or family income level;

     

    (g)
      The
      Contractor shall not actively facilitate disenrollment of Enrollees from other
      plans, by providing Managed Care Disenrollment Forms or otherwise, including
      transporting Enrollees for the purpose of their disenrollment. The Contractor
      may educate Enrollees on the disenrollment process. The Contractor shall not
      offer gifts or incentives to Enrollees of other plans that are not offered
      to
      all Potential Enrollees. This Section 5.3(g) will be repealed upon
      implementation of the mandatory Primary Care Case Management
      program;

     

    (h)
      Marketing personnel who engage in Marketing services under this Contract are
      considered the agents of the Contractor, whether they are employees, independent
      contractors, or independent insurance brokers. The Contractor shall be held
      responsible for any Misrepresentation or inappropriate activities by such
      Marketing personnel. All Marketing personnel are required to participate in
      training sessions that may be developed and presented by the Department, and
      which sessions set forth the Department requirements, expectations and
      limitations on Marketing practices in which the Contractor's personnel will
      engage. The individual salaries, benefits or other compensation paid by the
      Contractor to each of its Marketing personnel shall consist of no less than
      seventy-five percent (75%) salary and benefits and no more than twenty-five
      percent (25%) commission in cash or kind. The salary, benefit and other
      compensation schedules for such personnel are subject to audits by the
      Department, Office of Inspector General and as set forth in Article IX, Section
      9.1. All salary schedules shall be kept by the Contractor to enable the
      Department or any Authorized Persons to identify a specific enunciation of
      each
      Marketing personnel's total salary, benefit and other compensation,
      the

     

    28

     

    

    

    percentage
      of that salary, benefits or other compensation that was based on commission
      and
      the basis for such commission. The Contractor shall hold the Department harmless
      for any and all claims, complaints or causes of action that shall arise as
      a
      result of this contractually imposed salary, benefit and other compensation
      structure for Marketing personnel.

     

    Compensation
      of independent insurance brokers who hold a producers license issued by the
      State of Illinois Department of Financial and Professional Regulation is not
      subject to the limitations on commission described in the above paragraph.
      All
      other provisions of the Contract regarding Marketing shall apply to the
      Contractor with respect to the activities of independent insurance
      brokers.

     

    (i)
      It
      shall be the duty and obligation of the Contractor to credential, and where
      necessary or appropriate, recrcdential all Marketing personnel, including
      trainers and field supervisors. Recredentialing shall be performed at the time
      the Department of Financial and Professional Regulation renews the individual's
      license or certification. Recredentialing activity that changes the status
      of
      Marketing personnel shall be submitted to the Department as changes occur.
      No
      current or future personnel of the Contractor may engage in Marketing activities
      hereunder without first meeting all credcntialing requirements set forth herein
      as well as in the regulations, guidelines or policies of the Department. At
      a
      minimum, all Marketing personnel of the Contractor, including independent
      insurance brokers, must meet the following credentialing
      requirements:

     

    (1)
      must
      have been trained in all provisions of the Contractor's Department approved
      training manual for marketers;

     

    (2)
      must
      hold a valid license or certification as issued by the State of Illinois,
      Department of Financial and Professional Regulation, a copy of which must be
      submitted to the Department prior to any Marketing personnel's engaging in
      Marketing activities hereunder;

     

    (3)
      may
      not engage in Marketing activities for any other MCO that has a contract with
      the Department;

     

    (4)
      may
      not also be Providers of medical services;

     

    (5)
      may
      not have been convicted of any felony within the last ten (10)
      years;

     

    (6)
      may
      not have been terminated from employment in the previous twelve (12) months
      by
      any MCO for engaging in any prohibited Marketing practices or Misconduct
      associated with or related to Marketing activities. The Contractor shall obtain
      a written consent from all Marketing personnel for prior employers to release
      employment information to the Contractor concerning any prior or current
      employment in which Marketing activities were performed by any Marketing
      personnel and contact the previous employer(s). The Contractor may use any
      other
      employment practices it deems appropriate to obtain and meet these credentialing
      requirements; and

     

    

    (7)
      must
      not be an Ineligible Person. 

     

    29

    

    (j)
      The
      Department may at any time, in its own discretion and without notification
      to
      the Contractor, attend any Marketing training session conducted by the
      Contractor.

     

    (k)
      The
      Contractor must immediately notify the Department, in writing, of any individual
      who is hired by the Contractor who has previously been employed by an agent
      for
      the Department responsible for the education of Potential Enrollees about
      managed care.

     

    (1)
      The
      Contractor shall immediately notify the Department and the Office of Inspector
      General, in writing, of any inappropriate Marketing activities.

     

    (m)
      Before any individual may engage in any Marketing activity under this Contract,
      the Contractor shall provide, in a format designated by the Department, the
      name
      and Social Security number and a copy of the Department of Financial and
      Professional Regulation license or certification of that individual to the
      Department and certify to the Department that the individual meets the minimum
      credentialing requirements above. The Department must provide written approval
      of such individual before the individual may engage in any Marketing activity
      under this Contract.

     

    Thereafter,
      on a monthly basis, the Contractor shall report, in a format designated by
      the
      Department, the name and Social Security numbers of all Marketing personnel
      to
      the Department. It is the obligation of the Contractor to ensure that the
      Department has a current list of all Marketing personnel. The Contractor must
      immediately notify the Department, in writing, of any Marketing personnel who
      terminate employment with the Contractor either voluntarily or involuntarily.
      If
      termination is involuntary, the Contractor must notify the Department if the
      reason for termination is related to Misconduct under this
      Contract.

     

    (n)
      The
      Contractor shall not engage in any Marketing activities directed at enrolling
      Potential Enrollees while they are admitted to any inpatient
      facilities.

     

    (o)
      Marketing in or immediately outside of any Department or Department of Human
      Services field office is strictly prohibited.

     

    (p)
      Marketing at Provider offices or facilities is permissible under the following
      circumstances:

     

    (1)
      the
      Contractor must have a written agreement with the Provider, signed by the
      Provider or his designee, a copy of which shall be kept on file by the
      Contractor and submitted to the Department annually and thereafter upon request.
      Such written agreement shall set forth specifically what Marketing may be
      conducted at that Provider office or facility, the frequency with which those
      Marketing activities may occur and a description of the setting in which the
      Marketing activities will occur;

     

    (2)
      no
      Marketing activities may be conducted in emergency room waiting areas or in
      treatment areas at any Provider office or facility; and

     

    30

     

    

    

    (3)
      at no
      time shall any Marketing personnel have access to a Participant's medical
      records regardless of whether such Marketing activity is conducted at the
      Provider office or facility or another location.

     

    (q)
      Direct or indirect door-to-door, telephonic, or other cold call Marketing is
      strictly prohibited. Door-to-door Marketing is direct or indirect "cold call"
      or
      unsolicited Marketing activities at an individual's residence. "Cold call"
      Marketing means any unsolicited personal contact by MCO personnel with the
      Potential Enrollee for the purpose of influencing the individual to enroll
      with
      that MCO and includes unsolicited telephone contact, contact at the individual's
      residence and any other type of contact made without the individual's consent.
      Consent for telephone contact or contact at the individual's residence must
      be
      in writing and may be obtained at the initiation of contact as long as the
      Contractor has obtained the individual's oral consent prior to the visit and
      has
      documented such consent in a written form that identifies the person granting
      the consent and the person receiving the consent, as well as the date, time
      and
      place that the oral consent was given. Any contacts at the individual's
      residence must be made within thirty (30) days from the date the individual
      gave
      oral consent. Soliciting individuals to provide the names of other Potential
      Enrollees is also strictly prohibited. Nothing in this section shall prohibit
      the Contractor from distributing unsolicited Marketing materials via the United
      States Postal Service or a commercial delivery service where such service is
      unrelated to the Contractor.

     

    (r)
      All
      gifts or incentives approved by the Department under a previous contract must
      be
      resubmitted to the Department for approval within thirty (30) days of the
      Effective Date. Contractor may continue to use all gifts and incentives approved
      under a previous contract until the Department completes its review and notifies
      the Contractor that a gift or incentive is no longer approved.

     

    (s)
      Prior
      to conducting any Marketing activities, the Contractor must obtain an
      authorization to use or disclose an individual's "protected health information"
      (as defined in Attachment III to this Contract) for such purposes. To the extent
      such Marketing activities involve direct or indirect remuneration to the
      Contractor from a third-party, the authorization shall clearly state the
      existence of such remuneration. The restrictions of this Article V, Section
      5.2(r) shall not apply to Marketing activities that are related to the
      following: (i) a description of medical services that are included in the plan
      of benefits offered by the Contractor pursuant to this Contract, including
      communications concerning the network of Providers, replacement of or
      enhancements to the Contractor's plan of benefits, and health-related products
      or services that are available only to Enrollee, which add value but are not
      part of the plan of benefits; (ii) communications for treatment of the
      individual; (iii) communications for case management or care coordination for
      the individual or to direct or recommend alternative treatments, therapies,
      Providers, or settings of care for an Enrollee; (iv) in-person communications
      of
      any kind between the Contractor and a Potential Enrollee, Prospective Enrollee,
      or Enrollee; or (v) the provision of a gift or incentive that complies with
      Section 5.4 of this Contract.

     

    5.4 Inappropriate
      Marketing Activities.
      The
      Contractor shall not:

     

    (a)
      provide cash to Potential Enrollees, Prospective Enrollees or Enrollees, except
      for stipends, in an amount approved by the Department, and reimbursement of
      expenses provided to Enrollees for participation on committees or advisory
      groups;

     

    31

     

    

    

    (b)
      provide gifts or incentives to Potential Enrollees or Prospective Enrollees
      unless such gifts or incentives: (1) are also provided to the general public;
      (2) do not exceed ten dollars ($10) per individual gift or incentive; and (3)
      have been pre-approved by the Department;

     

    (c)
      provide non health-related gifts or incentives to Enrollees unless such gifts
      or
      incentives (1) are provided conditionally based on the Enrollee receiving
      preventive care; (2) arc not used in Marketing to Potential Enrollees; (3)
      arc
      not in the form of cash or an instrument that may be converted to cash; and
      (4)
      have been pre-approved by the Department;

     

    (d)
      provide health-related gifts or incentives to Enrollees unless such gifts or
      incentives (1) are provided conditionally based on the Enrollee receiving
      preventive care; (2) are not in the form of cash or an instrument that may
      be
      converted to cash; and (3) have been pre-approved by the
      Department;

     

    (e)
      seek
      to influence a Potential Enrollee's enrollment with the Contractor in
      conjunction with the sale of any other insurance;

     

    (f)
      induce providers or employees of the Department or the Department of Human
      Services to reveal confidential information regarding Participants or otherwise
      use such confidential information in a fraudulent manner;

     

    (g)
      threaten, coerce or make untruthful or misleading statements to Potential
      Enrollees, Prospective Enrollees or Enrollees regarding the merits of enrollment
      in the Contractor's Plan or any other plan; or

     

    (h)
      present an incomplete Managed Care Enrollment Form to a Potential Enrollee
      for
      his signature.

     

    5.5 Obligation
      to Provide Information.
      The
      Contractor agrees to have written policies and to provide Basic Information
      to
      the individuals, and to notify such individuals that translated materials are
      available and how to obtain them, and at the times described below:

     

    (a)
      to
      each Enrollee or Prospective Enrollee within thirty (30) days after it receives
      notice of the individual's enrollment and within thirty (30) days following
      a
      significant change;

     

    (b)
      to
      any Potential Enrollee who requests it; or

     

    (c)
      once
      a year Contractor must notify its Enrollees of their right to request and obtain
      the Basic Information.

     

    (d)
      "Basic Information" as used herein shall mean:

     

    (1)
      types
      of benefits, and amount, duration and scope of such benefits available under
      the
      Plan. There must be sufficient detail to ensure Enrollees understand the
      benefits that they are entitled to receive as Covered Services, including
      pharmaceuticals and behavioral health services;

     

    32

    

    

    (2)
      procedures for obtaining Covered Services, including authorization and approval
      requirements, if any;

     

    (3)
      information, as provided by the Department, regarding any benefits to which
      an
      Enrollee may be entitled under the HFS Medical Program that are not provided
      under the Plan and specific instructions on where and how to obtain those
      benefits, including how transportation is provided and that family planning
      services may be obtained from an Affiliated or non-Affiliated
      Provider;

     

    (4)
      any
      restrictions on an Enrollee's freedom of choice among Affiliated
      Providers;

     

    (5)
      the
      extent to which after-hours coverage and Emergency Services are provided,
      including the following specific information: (a) definitions of "Emergency
      Medical Condition," "Emergency Services," and "Post-Stabilization Services"
      that
      reference the definitions set forth herein; (b) the fact that prior
      authorization is not required for Emergency Services; (c) the fact that, subject
      to the provisions of this Contract, an Enrollee has a right to use any hospital
      or other setting to receive Emergency Services; (d) the process and procedures
      for obtaining Emergency Services; and (e) the location of Emergency Services
      and/or Post-Stabilization Services Providers that are Affiliated
      Providers.

     

    (6)
      the
      procedures for obtaining Post-Stabilization Services in accordance with the
      terms set forth Article V, Section 5.1(i);

     

    (7)
      policy on referrals for specialty care and for Covered Services not furnished
      by
      an Enrollee's Primary Care Provider;

     

    (8)
      cost
      sharing, if any;

     

    (9)
      the
      rights, protections, and responsibilities of an Enrollee as specified in 42
      C.F.R. §438.100, such as those pertaining to enrollment and discnrollment and
      those provided under State and Federal law;

     

    (10)
      Grievance and fair hearing procedures and timeframes, provided that such
      information must be pre-approvcd before distribution;

     

    (11)
      Appeal rights and procedures and timeframes, provided that such information
      must
      be pre-approved before distribution;

     

    (12)
      names, locations, telephone numbers, and non-English languages spoken by current
      Affiliated Providers, including identification of those who are not accepting
      new patients; and

     

    (13)
      a
      copy of the Contractor's Certificate of Coverage or Document of
      Coverage.

     

    (e)
      The
      following additional information must be provided by Contractor upon request
      to
      any Enrollee, Prospective Enrollee, and Potential Enrollee:

     

    33

    

    (1)
      MCO
      and health care facility licensure;

     

    (2)
      practice guidelines maintained by the Contractor in accordance with Article
      V,
      Section 5.6; and

     

    (3)
      information about Affiliated Providers of health care services, including
      education, Board certification and reccrtification, if appropriate.

     

    (f)
      The
      Contractor must make a good faith effort to give written notice of termination
      of a Provider, within fifteen (15) days following such termination, to each
      Enrollee who received his or her primary care from, or was seen on a regular
      basis by, the terminated Provider.

     

    5.6
      Quality
      Assurance, Utilization Review and Peer Review.

     

    (a)
      All
      services provided by or arranged for by the Contractor to be provided shall
      be
      in accordance with prevailing community standards. The Contractor must have
      in
      effect a program consistent with the utilization control requirements of 42
      C.F.R. Part 456. This program will include, when so required by the regulations,
      written plans of care and certifications of need of care.

     

    (b)
      The
      Contractor shall adopt practice guidelines that meet the following criteria:

     

    (1)
      Are
      based on valid and reliable clinical evidence or a consensus of health care
      professionals in a particular field;

     

    (2)
      Consider the needs of the Enrollees;

     

    (3)
      Are
      adopted in consultation with Affiliated Providers;

     

    (4)
      Are
      reviewed and updated periodically, as appropriate; and

     

    (5)
      Are
      disseminated to all affected Affiliated Providers and, upon request, to
      Enrollees and Potential Enrollees.

     

    (c)
      The
      Contractor shall have a Utilization Review Program that includes a utilization
      review plan, a utilization review committee, and appropriate mechanisms covering
      preauthorization and review requirements.

     

    (d)
      The
      Contractor shall establish and maintain a Peer Review Program approved by the
      Department to review the quality of care being offered by the Contractor,
      employees and subcontractors.

     

    (e)
      The
      Contractor agrees to comply with the quality assurance standards attached hereto
      as Exhibit
      A.

     

    (f)
      The
      Contractor agrees to comply with the utilization review standards and peer
      review standards attached hereto as Exhibit
      B.

     

    34

     

    

    

    (g)
      The
      Contractor agrees to conduct a program of ongoing review that evaluates the
      effectiveness of its quality assurance and performance improvement strategies
      designed in accordance with the terms of this Article V, Section 5.6, and to
      report to the Department the results of such review as provided in Article
      V,
      Section 5.11 herein.

     

    (h)
      The
      Contractor shall not compensate individuals or entities that conduct utilization
      review activities on its behalf in a manner that is structure to provide
      incentives for the individuals or entities to deny, limit,
      or
      discontinue Covered Services that are Medically Necessary for any
      Enrollee.

     

    5.7
      Physician
      Incentive Plan Regulations.
      The
      Contractor shall comply with the provisions of 42 C.F.R. 422.208 and 422.210.
      If, to conform with these regulations, the Contractor performs Enrollee
      satisfaction surveys, such surveys may be combined with those required by the
      Department pursuant to Article V, Section 5.20 of this Contract.

     

    5.8
      Prohibited
      Affiliations.

     

    (a)
      The
      Contractor shall assure that all Affiliated Providers, including out-of-State
      Providers, are enrolled in the HFS Medical Program, if such enrollment is
      required for such Provider by Department rules or policy in order to submit
      claims for reimbursement or otherwise participate in the HFS Medical Program.
      The Contractor shall assure that any non-Affiliated Provider billing for
      services rendered in Illinois is enrolled in the HFS Medical Program prior
      to
      paying claims.

     

    (b)
      The
      Contractor shall not employ, subcontract with, or affiliate itself with or
      otherwise accept any Ineligible Person into its network.

     

    (c)
      The
      Contractor shall screen all current and prospective employees, contractors,
      and
      sub-contractors, prior to engaging their services under this Contract
      by:

    (i)
      requiring them to disclose whether they are Ineligible Persons; (ii) reviewing
      the OIG's list of sanctioned persons (available on the World Wide Web at
      http://www.arnet.gov/epls) and the HHS/OIG List of Excluded Individuals/Entities
      (available on the World Wide Web at http://www.dhhs.gov/oig). The Contractor
      shall annually screen all current employees, contractors and sub-contractors
      providing services under this Contract. The Contractor shall screen out-of-State
      non-Affiliated Providers billing for Covered Services prior to payment and
      shall
      not pay such Providers who meet the definition of Ineligible
      Persons.

     

    (d)
      The
      Contractor shall terminate its relations with any Ineligible Person immediately
      upon learning that such Person or Provider meets the definition of an Ineligible
      Person and notify the OIG of the termination.

     

    5.9
      Records.

     

    (a)
      Maintenance
      of Business Records.
      The
      Contractor shall maintain all business and professional records that are
      required by the Department in accordance with generally accepted business and
      accounting principles. Such records shall contain all pertinent information
      about the Enrollee including, but not limited to, the information required
      under
      this

     

    35

     

    

    

    Article
      V, Section 5.9. Medical records reporting requirements shall be adequate to
      ensure acceptable continuity of care to Enrollees.

     

    (b)
      Availability
      of Business Records.
      Records
      shall be made available in Illinois to the Department and Authorized Persons
      for
      inspection, audit, and/or reproduction as required in Article IX, Section 9.1.
      These records will be maintained as required by 45 C.F.R. Part 74. As a part
      of
      these requirements, the Contractor will retain one copy in any format of all
      records for at least six (6) years after final payment is made under the
      Contract. If an audit, litigation or other action involving the records is
      started before the end of the six-year (6 year) period, the records must be
      retained until all issues arising out of the action are resolved.

     

    (c)
      Patient
      Records.

     

    (1)
      Treatment
      Plans.
      The
      Contractor must develop and use treatment plans for chronic disease follow-up
      care that are tailored to the individual Enrollee. The purpose of the plan
      is to
      assure appropriate ongoing treatment reflecting the prevailing community
      standards of medical care designed to minimize further deterioration and
      complications. Treatment plans shall be on file with the permanent record for
      each Enrollee with a chronic disease and with sufficient information to explain
      the progress of treatment.

     

    (2)
      Permanent
      Records.
      Immediately upon notification of an Enrollee's enrollment with the Contractor,
      the Contractor shall create and maintain at the Enrollee's Primary Care Site
      an
      Enrollee file containing biographical and enrollment information relating to
      the
      Enrollee, including copies of all materials pertaining to the Enrollee provided
      by the Department. A permanent medical record shall be maintained at the Primary
      Care Site for every Enrollee and be available to the Primary Care Provider,
      Women's Health Care Provider and other Providers. Copies of the medical record
      shall be sent to any new Site to which the Enrollee transfers. The Contractor
      shall make documented efforts to obtain such consent. Copies of records shall
      be
      released only to Authorized Individuals. Original medical records shall be
      released only in accordance with Federal or State law, court orders, subpoenas,
      or a valid records release form executed by an Enrollee. The Contractor shall
      ensure that Enrollees have timely access to the records. The Contractor shall
      protect the confidentiality and privacy of minors, and abide by all Federal
      and
      State laws regarding the confidentiality and disclosure of medical records,
      mental health records, and any other information about Enrollee. The Contractor
      shall produce such records for the Department upon request. Medical records
      must
      include Provider identification and Enrollee identification. All entries in
      the
      medical record must be legible and dated, and the following, where applicable,
      shall be included:

     

    •
patient
      identification;

     

    •
      personal health, social history and family history, with updates as
      needed;

     

    •
risk
      assessment;

     

    •
      obstetrical history (if any) and/or profile;

    36

    

    •
      hospital admissions and discharges;

     

    •
      relevant history of current illness or injury (if any) and physical
      findings;

     

    •
      diagnostic and therapeutic orders;

     

    •
      clinical observations, including results of treatment;

     

    •
reports
      of procedure, tests and results;

     

    •
      diagnostic impressions;

     

    •
patient
      disposition and pertinent instructions to patient for follow-up
      care;

     

    •
      immunization record;

     

    •
allergy
      history;

     

    •
      periodic exam record;

     

    •
weight
      and height information and, as appropriate, growth chart;

     

    •
      referral information, if any;

     

    •
health
      education and anticipatory guidance provided; and

     

    •
family
      planning and/or counseling. 

     

    5.10
      Computer
      System Requirements.

     

    (a)
      The
      Contractor must establish and maintain a computer system compatible with the
      Department's system, and, if required, execute an electronic communication
      agreement provided by the Department. All costs associated with the data
      exchange software shall be borne by the Contractor.

     

    (b)
      The
      Contractor shall establish and maintain a communication link with the Department
      as specified in Exhibit D.

     

    (c)
      The
      Contractor must provide staff with proficient knowledge in telecommunications
      to
      ensure communication connectivity is established and maintained. The Contractor
      shall be responsible for performing Network Address Translation ("NAT") to
      facilitate connectivity and security protecting the Contractor's
      network.

     

    (d)
      The
      Contractor shall work with the Department to implement changes in technology
      as
      they become available to the Department. Any costs associated with the
      Contractor's side of processing, connectivity and/or changes to the manner
      in
      which the Contractor processes data for the Department shall be borne solely
      by
      the Contractor. The Contractor will work with the Department to resolve any
      issues related to these changes.

     

    37

     

    

    

    (e)
      The
      Contractor shall retrieve and process all HIPAA transactions made available
      by
      the Department, including the 997, 824 and TA1 functional acknowledgments and
      820 and 834 and, when implemented, the 835 remittance advice.

     

    (f)
      The
      Contractor shall submit to the Department or its designee, in a format and
      medium designated by the Department, a monthly electronic file of the
      Contractor's Primary Care Providers including, but not limited to the following
      information:

     

    (1)
      Provider name. Provider number, office address, and telephone number;

     

    (2)
      Type
      of specialty (e.g., family practitioner, internist, oncologist, etc.),
      subspecialty if applicable, and treatment age ranges;

     

    (3)
      Identification of group practice, if applicable;

     

    (4)
      Geographic service area;

     

    (5)
      Areas
      of board-certification, if applicable;

     

    (6)
      Language(s) spoken by Provider and/or office staff;

     

    (7)
      Office hours and days of operation;

     

    (8)
      Special services offered to the deaf or hearing impaired (i.e., sign language,
      TDD/TTY, etc.);

     

    (9)
      Wheelchair accessibility status (e.g., parking, ramps, elevators, automatic
      doors, personal transfer assistance, etc.).

     

    (10)
      PCP
      indicator;

     

    (11)
      PCP
      gender and panel status (open or closed); and

     

    (12)
      PCP
      hospital affiliations, including information about where the PCP has admitting
      privileges or admitting arrangements and delivery privileges (as
      appropriate).

     

    Contractor
      shall electronically submit changes to the file as changes occur.

     

    (g)
      The
      Contractor shall submit to the Department or its designee, in a format and
      medium designated by the Department, a monthly electronic file of the
      Contractor's Affiliated hospital names and Provider number.

     

    5.11
      Regular
      Information Reporting Requirements.

     

    (a)
      The
      Contractor shall submit to the Department regular reports and additional
      information as set forth in this Section. The Contractor shall ensure that
      data
      received from Providers and included in reports is accurate and complete by
      (1)
      verifying the accuracy

     

    38

     

    

    

    and
      timeliness of reported data; (2) screening the data for completeness, logic,
      and
      consistency; and
      (3)
      collecting service information in standardized formats to the extent feasible
      and appropriate. All data collected by the Contractor shall be available to
      the
      Department and, upon request, to CMS. Such reports and information shall be
      submitted in a format and medium designated by the Department. A schedule of
      all
      reports and information submissions and the frequency required for each under
      this Contract is provided in Exhibit
      C.
      For
      purposes of this Article V, Section 5.10, the following terms shall have the
      following meanings: "annual" shall be defined by the State fiscal year beginning
      July first of each year and ending on but including June thirtieth of the
      following year; and "quarter" shall be defined as three consecutive calendar
      months of the State's fiscal year. The Department shall advise the Contractor
      of
      the appropriate format for such reports and information submissions in a written
      communication.

     

    (1)
      Administrative

     

    (A)
      Disclosure
      Statements.
      The
      Contractor shall submit disclosure statements to the Department initially,
      annually, on request and as changes occur.

     

    (B)
      Encounter
      Data.

     

    1.
      Submission.
      The
      Contractor must report, in accordance with Subsections (2) and (3) of this
      Article V, Section 5.1 l(a)(l)(B), all services received by Enrollees including
      services reimbursed by Contractor through a capitation arrangement. On a monthly
      basis, the Contractor shall provide the Department with HIPAA Compliant
      transactions, including the 8371 and the 83 7P, in the format and medium
      designated by the Department, prepared with claims level detail as required
      herein for all non-institutional provider services received by Enrollees during
      a given month. For institutional provider services, only those services paid
      by
      or on behalf of the Contractor may be provided to the Department. This data
      must
      be accepted by the Department within one hundred twenty (120) days of the
      Contractor's payment or final rejection of the claim or, for services paid
      through a capitation arrangement, within 150 days of the date of service, except
      as specified in Article VII, Section 7.2. Any claims processed by the Contractor
      for services provided in a given report month subsequent to submission of the
      monthly Encounter Data Report shall be reported on the next submission of the
      monthly Encounter Data Report.

     

    2.
      Testing.
      Upon
      receipt of each submitted data file, the Department shall perform two distinct
      levels of review:

     

    a.
      The
      first level of review and edits performed by the Department shall check the
      data
      file format. These edits shall include, but are not limited to the following:
      check the data file for completeness of records; correct sort

     

    39

    

    order
      of
      records; proper field length and composition; and correct file length. The
      format of the file, to be accepted by the Department, must be one hundred
      percent (100%) correct.

     

    b.
      If the
      format is correct, the Department shall then perform the second level of review.
      This second review shall be for standard claims processing edits. These edits
      shall include, but are not limited to the following: correct
      Provider numbers; valid recipient numbers; valid procedure and diagnosis codes;
      cross checks to assure Provider and recipient numbers match their names; and
      the
      procedures performed are correct for the age and sex of the recipient. The
      acceptable error rate of claims processing edits of the encounter data provided
      by the Contractor shall be determined by the Department. Once an acceptable
      error rate has been achieved, as determined by the Department, the Contractor
      shall be instructed that the testing phase is complete and that data should
      be
      sent in production.

     

    3.
      Production.
      Once the
      Contractor's testing of data specified in Section 5.11(a)(l)(B)(l) above is
      completed, the Contractor will be certified for production. Once certified
      for
      production, the data shall continue to be submitted in accordance with this
      Section. The data will continue to be reviewed for correct format and quality.
      The Contractor shall submit as many files as possible in a time frame agreed
      upon by the Department and the Contractor, to ensure all data is
      current.

     

    4.
      Records that fail the edits described above in (2) or (3) will be returned
      to
      the Contractor for correction. Corrected data must be returned to the Department
      for re-processing.

     

    (C)
      Financial
      Reports.
      The
      Contractor shall provide the Department with copies of all financial reports
      the
      Contractor is required to file with the Department of Financial and Professional
      Regulation.

     

    (D)
      Report
      of Transactions with Parties of Interest.
      The
      Contractor shall report to the Department all "transactions" with a "party
      of
      interest" (as such terms are defined in Section 1903(m)(4)(A) of the Social
      Security Act and SMM 2087.6(A-B)), as required by Section 1903(m)(4)(A) of
      the
      Social Security Act.

     

    (E)
      Encounter
      Data Certification.
      In a
      format determined by the Department, the Contractor shall certify by the
      5th
      day of
      each month that all electronic data submitted during the previous calendar
      month
      is accurate, complete and true.

     

    40

    

    (2)
      Enrollee
      Materials.
      (In
      addition to the submission requirements described below, the Contractor must
      maintain documentation verifying that the information conveyed in the following
      categories of Enrollee materials are reviewed on an ongoing basis for accuracy
      and updated at least annually)

     

    (A)
      Certificate
      or Document of Coverage and Any Changes or Amendments.
      The
      Contractor shall submit these documents to the Department for prior approval
      initially and as revised.

     

    (B)
      Enrollee
      Handbook.
      The
      Contractor shall submit the handbook to the Department for prior approval
      initially and as revised. The Contractor shall not be required to submit for
      prior approval format changes, provided there is no change in the information
      conveyed.

     

    (C)
      Identification
      Card.
      The
      Contractor shall submit the identification card to the Department for prior
      approval initially and as revised. The Contractor shall not be required to
      submit for prior approval format changes, provided there is no change in the
      information conveyed.

     

    (D)
      Provider
      Directory.
      The
      Contractor shall submit the Provider Directory applicable to Enrollees to the
      Department for review initially, and annually thereafter.

     

    (3)
      Fraud/Abuse

     

    (A)
      Fraud
      and Abuse Report.
      The
      Contractor shall report all suspected Fraud and Abuse as required under Article
      V, Section 5.25 of this Contract.

     

    (4)
      Marketing

     

    (A)
      Marketing
      Allegation Investigations. On
      a
      monthly basis, the Contractor shall complete and submit the Investigation
      Results Form summarizing the results of investigations of allegations of Fraud,
      Abuse, Misconduct and Misrepresentation regarding Marketing conducted by the
      Contractor.

     

    (B)
      Marketing
      Allegation Notification.
      On a
      weekly basis, the Contractor shall complete and submit the Marketing Allegation
      Notification Form identifying current marketing allegations of Fraud, Abuse,
      Misconduct and Misrepresentation involving Marketing and originating through
      the
      Contractor.

     

    (C)
      Marketing
      Gifts and Incentives.
      The
      Contractor shall submit all Marketing Materials to the Department for prior
      approval initially and as revised.

     

    (D)
      Marketing
      Materials.
      The
      Contractor shall submit all Marketing Materials to the Department for prior
      approval initially and as revised.

     

    

     

    41

     

    

    The
      Contractor shall not be required to submit for prior approval format changes,
      provided there is no change in the information conveyed.

     

    (E)
      Marketing
      Plans and Procedures.
      The
      Contractor shall submit descriptions of proposed Marketing concepts, strategies,
      and procedures for approval initially and as revised.

     

    (F)
      Marketing
      Representative Listing.
      On a
      monthly basis, on the first day of the month for that month, the Contractor
      shall provide the Department with a list of all Marketing personnel who are
      active as well as any Marketing personnel for whom a change of status has
      occurred since the last report month.

     

    (G)
      Marketing
      Representative Terminations.
      The
      Contractor shall submit names of Marketing personnel who have terminated
      employment or association with the Contractor as such terminations occur, but
      no
      later than ten (10) business days after termination. The submission shall
      indicate whether the termination was voluntary or involuntary and, if
      involuntary, shall state whether the reason for termination was related to
      Misconduct, Fraud or Forgery under this Contract.

     

    (H)
      Marketing
      at Sites:

     

    1.
      Written
      Statement.
      To the
      extent the Contractor conducts marketing activities at one or more Sites, the
      Contractor shall submit, on an annual basis and throughout the year as Sites
      are
      included or deleted from the Contractor's marketing schedule, a written
      statement or letter from each Site setting forth in detail the understanding
      between the parties including, but not limited to, the following information:
      what marketing activities may be conducted at the Site; the frequency with
      which
      those marketing activities may occur; and a description of the setting in which
      the marketing activities will occur.

     

    2.
      Schedule.
      To the
      extent the Contractor conducts marketing activities at one or more Sites, the
      Contractor shall submit, on a monthly basis, a schedule that reflects which
      of
      the Contractor's marketing representatives will market at such Site(s) and
      the
      dates and times when such activities will occur.

     

    (I)
      Marketing
      at Retail Locations Schedule.
      The
      Contractor shall submit, on a monthly basis, a report of all retail
      establishments where Marketing is scheduled, which includes the dates and times
      of the Marketing activities and the locations of the retail establishments.
      Contractor shall report cancellations of scheduled Marketing as changes occur
      during the month. Contractor need not report additions to the Marketing schedule
      during the month.

     

    42

     

    

    

    (J)
      Marketing
      Training Materials.
      The
      Contractor shall submit Marketing training materials relating to Marketing
      activities performed by the Contractor's marketing representatives under this
      Contract, including Marketing trainer scripts and marketing representative
      presentations scripts, to the Department for prior approval initially and as
      revised.

     

    (K)
      Marketer
      Training Schedule and Agenda.
      On a
      quarterly basis, two weeks prior to the beginning of the report quarter, the
      Contractor shall provide the Department with its schedule for training of
      Marketing personnel. The model agenda for each type of training must accompany
      the schedule. The Contractor shall provide the Department with written notice
      of
      any changes to the quarterly schedule at least seventy-two (72) hours prior
      to
      the scheduled training.

     

    (5)
      Provider
      Network

     

    (A)
      PCP
      and Affiliated Specialists File. The Contractor shall submit to the Department
      or its designee, in a format and medium designated by the Department, an
      electronic file of the Contractor's PCPs as detailed in Section
      5.9(f).

     

    (B)
      Affiliated Hospital File. The Contractor shall submit to the Department or
      its
      designee, in a format and medium designated by the Department, a monthly
      electronic file of the Contractor's Affiliated hospitals' names and Provider
      numbers.

     

    (C)
      Provider
      Network Submissions.
      The
      Contractor shall submit to the Department, in a format and medium designated
      by
      the Department, Provider network reports that shall include, without limitation,
      the following:

    monthly
      Provider Affiliation with Sites as set forth in the format given to the
      Contractor by the Department; monthly updating of all Providers who have either
      become a Provider in the Contractor's network or who have left the network
      since
      the last report; New Site Provider Affiliations as new Sites arc added; Site
      terminations immediately as they occur; and Enrollcc Site Transfers as they
      occur. New Site/PCP information shall be reported in a format and medium as
      required by the Department.

     

    (6)
      Quality
      Assurance/Medical

     

    (A)
      Grievance
      Procedures.
      The
      Contractor shall submit Grievance Procedures to the Department for prior
      approval initially and as revised. The Contractor shall not be required to
      submit for prior approval format changes, provided there is no change in the
      information conveyed.

     

    (B)
      Primary
      Care Provider Ratio Report.
      The
      Contractor shall submit a quarterly report that provides the number of Enrollees
      assigned to each Primary Care Provider and Women's Health Care Provider (by
      Site) and the Affiliated and unaffiliatcd hospitals to which the PCP has
      admitting and/or delivery privileges in a format provided by the
      Department.

     

    43

    

    (C)
      Quality
      Assurance, Utilization Review and Peer Review Annual Report (QA/UR/PR Annual
      Report).
      The
      Contractor shall submit a QA/UR/PR Annual Report on a yearly basis, no later
      than sixty (60) days following the close of the Contractor's reporting period.
      This report shall provide a summary review of the effectiveness of the
      Contractor's Quality Assurance Plan. The summary review shall contain the
      Contractor's processes for quality assurance, utilization review and peer
      review. Included with this report shall be a comprehensive description of the
      Contractor's network and an annual workplan outlining the Contractor's intended
      activities relating to quality assurance, utilization review, peer review and
      health education. The report's content, as determined by the Department is
      detailed in Exhibit
      A.

     

    (D)
      QA/UR/PR
      Committee Meeting Minutes.
      The
      Contractor shall submit the minutes of these meetings to the Department on
      a
      quarterly basis.

     

    (E)
      Quality
      Assurance, Utilization Review, Peer Review and Health Education
      Plans.
      The
      Contractor shall submit such plans to the Department for prior approval
      initially and as revised. The Contractor shall not be required to submit for
      prior approval format changes, provided there is no change in the information
      conveyed.

     

    (F)
      Summary
      of Grievances or Appeals and their Resolutions and External Independent Reviews
      and Resolutions.
      This
      quarterly report shall provide a summary of the Grievances or Appeals filed
      by
      Enrollees and the resolution of such Grievances or Appeals as well as a summary
      of all external independent reviews and the resolution of such reviews in a
      format provided by the Department. Such report shall include types of Grievances
      or Appeals and external independent reviews by category and totals, the number
      and levels at which the Grievances or Appeals were resolved, the types of
      resolutions and the number pending resolution by category.

     

    (G)
      Case
      Management Enrollees.
      The
      Contractor shall submit an electronic report of all Enrollees who are case
      managed by the Contractor on a monthly basis.

     

    (H)
      Case
      Management Plan.
      The
      Contractor shall submit such plan to the Department for prior approval initially
      and as revised. The Contractor shall not be required to submit for prior
      approval format changes, provided there is no change in the information
      conveyed.

     

    (I)
      CSHCN
      Enrollees.
      The
      Contractor shall submit an electronic report of all Enrollees who are case
      managed by the Contractor on a monthly basis.

     

    (J)
      CSHCN
      Plan.
      The
      Contractor shall submit such plan to the Department for prior approval initially
      and as revised. The Contractor shall not be required to submit for prior
      approval format changes, provided there is no change in the information
      conveyed.

    

     

    44

    

    

    (7)
      Subcontracts
      and Provider Agreements

     

    (A)
      Executed
      Subcontracts and Provider Agreements.
      The
      Contractor shall provide copies of any subcontract and Provider agreement to
      the
      Department upon request.

     

    (B)
      Model
      Subcontracts and Provider Agreements.
      The
      Contractor shall provide copies of model subcontracts and Provider agreements
      related to Covered Services, assignment of risk and data reporting functions,
      including the form of all proposed schedules or exhibits, intended to be used
      therewith, and any substantial deviations from these model subcontracts and
      Provider agreements to the Department initially and as revised.

     

    (b)
      Additional
      Reports.
      The
      Contractor shall submit to the Department additional reports or submissions
      at
      the frequency set forth in Exhibit
      C
      and all
      other reports and information required by the provisions of this
      Contract.

     

    (c)
      Unless otherwise specified, the Contractor shall submit all reports to the
      Department within thirty (30) days from the last day of the reporting period
      or
      as defined in Exhibit
      C.
      All
      reports and submissions listed in this Article V, Section 5.11 must be submitted
      to the Department in a Department designated format and at the intervals set
      forth in Exhibit
      C. The
      Department may require additional reports throughout the term of this Contract.
      The Department will provide adequate notice before requiring production of
      any
      new reports or information, and will consider concerns raised by Contractors
      about potential burdens associated with producing the proposed additional
      reports. The Department will provide the basis (reason) for any such request.
      Failure of the Contractor to follow reporting requirements shall subject the
      Contractor to the sanctions in Article IX, Section 9.10.

     

    5.12 Health
      Education.
      The
      Contractor shall establish and maintain an ongoing program of health education
      as delineated in its written plan and submitted annually to the Department.
      The
      health education program will advise Enrollees concerning appropriate health
      care practices and the contributions they can make to the maintenance of their
      own health. All health education materials must be approved by the Contractor's
      medical director. Providing material during Marketing and enrollment does not
      satisfy the requirements of this Article V, Section 5.12. The Contractor must
      make documented efforts to educate Primary Care Providers on the importance
      of
      being active participants in the health education program and to ensure that
      such Primary Care Providers participate in the health education program. The
      health education program shall provide, at a minimum, the
      following:

     

    (a)
      Information on how to use the Plan, including information on how to receive
      Emergency Services in and out of the Contracting Area.

     

    (b)
      Information on preventive care including the value and need for screening and
      preventive maintenance.

     

    (c)
      Information on the need for pre- and interconceptional care to improve birth
      outcomes and on the need to seek prenatal care as early as
      possible.

     

    45

     

    

    (d)
      Counseling and patient education as to the health risks of obesity, smoking,
      alcoholism, substance abuse and improper nutrition, and specific information
      for
      persons who have a specific disease.

     

    (e)
      Information on disease states, that may affect the general
      population.

     

    (f)
      Educational material in the form of printed, audio, visual or personal
      communication.

     

    (g)
      Information will be provided in language that the Enrollee understands and
      that
      meets the requirements set forth in Article II, Section 2.4.

     

    (h)
      A
      single individual appointed by the Contractor to be responsible for the
      coordination and implementation of the program.

     

    The
      Contractor further agrees to review the health education program, at regular
      intervals, for the purpose of amending same, in order to improve said program.
      The Contractor further agrees to supply the Department or its designee with
      the
      information and reports prescribed in its approved health education program
      or
      the status of such program.

     

    5.13
      Required
      Minimum Standards of Care.
      The
      Contractor shall provide or arrange to provide to all Enrollccs medical care
      consistent with prevailing community standards at locations serving the
      Contracting Area that assure availability and accessibility to
      Enrollecs.

     

    The
      Contractor will provide a system to notify Enrollees on an ongoing basis of
      the
      need for and benefits of health screenings and physical examinations. The
      Contractor will provide or arrange to provide such examinations to all of its
      Enrollees.

     

    The
      Contractor shall not be in violation of this Contract if a particular Enrollee
      or group of Enrollees do not receive one of the services listed in Section
      5.1(d) or in this Section 5.13(a) through (d) if Contractor requires its
      Affiliated Providers to offer those services and has documented its efforts
      to
      educate Enrollees about the availability of coverage for such
      services.

     

    (a)
      EPSDT
      Services to Enrollees Under Twenty-One (21) Years.
      All
      Enrollees under twenty-one (21) years of age should receive screening
      examinations including appropriate childhood immunizations at intervals as
      specified by the EPSDT Program as set forth in §§1902(a)(43)and 1905(a)(4)(B) of
      the Social Security Act and 89 111. Adm. Code 140.485.

     

    (1)
      Well
      child visits shall consist of age appropriate component parts
      including

     

    •
      comprehensive health history;

     

    •
      nutritional assessment;

     

    •
height
      and weight and growth charting;

     

    •
      comprehensive unclothed physical examination;

     

    46

     

    

    

    •
      immunizations;

     

    •
      laboratory procedures, including lead toxicity testing;

     

    •
      periodic objective developmental screening using a recognized, standardized
      developmental screening tool, as approved by the Department. Children under
      age
      three who are screened at-risk for, or with developmental delay, shall be
      referred to the State's Early Intervention Program for further
      assessment;

     

    •
      periodic objective screening for social emotional development using a
      recognized, standardized tool, as approved by the Department. Social emotional
      screening for infants shall include perinatal depression screening of the mother
      in the most appropriate clinical setting, e.g., at the pediatric, behavioral
      health or OB/GYN visit;

     

    •
      objective vision and hearing screening; and

     

    •
risk
      assessment and anticipatory guidance.

     

    (2)
      The
      Contractor shall employ strategies to ensure that children received
      comprehensive child health services, according to the Department's recommended
      periodicity schedule or more frequently, as needed, and shall perform provider
      training to ensure that best practice guidelines arc followed in relation to
      well child services and care for acute and chronic health care
      needs.

     

    (3)
      Any
      condition discovered during the screening examination or screening test
      requiring further diagnostic study or treatment must be provided if within
      the
      scope of Covered Services. The Contractor shall refer the Enrollec to an
      appropriate source of care for any required services that are not Covered
      Services. If, as a result of EPSDT services, the Contractor determines an
      Enrollec is in need of services that arc not Covered Services but arc services
      otherwise provided for under the HFS Medical Program, the Contractor will ensure
      that the Enrollee is referred to an appropriate source of care. The Contractor
      shall have no obligation to pay for services that are not Covered
      Services.

     

    (4)
      At a
      minimum, the Contractor shall provide or arrange to provide all appropriate
      screening and vaccinations in accordance with OBRA 1989 guidelines to eighty
      percent (80%) of Enrollees younger than twenty-one (21) years of age. The
      Contractor shall track and monitor this provision on an ongoing basis and shall
      have in place a quality improvement initiative addressing compliance until
      such
      time as this performance goal is achieved and maintained. The Contractor must
      implement an ongoing recall system and outreach services, at a minimum
      specifically targeting those Enrollees under age twenty-one (21) who are not
      up
      to date with EPSDT well child screening services.

     

    47

     

    

    

    (b)
      Preventive
      Medicine Schedule (Services to Enrollccs Twenty-One (21) Years of Age and
      Over)
      The
      following preventive medicine services and age schedule is the minimum
      acceptable range and scope of required services for adults. The Contractor
      may
      substitute an alternate schedule for adult preventive medicine services as
      long
      as such schedule is based upon recognized guidelines such as those recommended
      by the current U.S. Preventive Services Task Force's "Guide to Clinical
      Preventive Services" and the Contractor submits the schedule to the Department
      and receives the Department's written approval for the alternate schedule prior
      to implementing it.

     

    The
      Contractor shall ensure that a complete health history and physical examination
      is provided to each Enrollcc initially within the first twelve (12) months
      of
      enrollment. Thereafter, for Enrollees between ages Twenty-One (21) and
      Sixty-Four (64), the Contractor shall ensure that a complete health history
      and
      physical examination is conducted every 1-3 years, as indicated by Enrollee
      need
      and clinical care guidelines. For Enrollees aged Sixty-Five (65) and older,
      the
      Contractor shall ensure that a complete health history and physical examination
      is conducted annually.

     

    For
      purposes of this Section 5.13(b), a "complete health history and physical
      examination" shall include, at a minimum, the following health services as
      appropriate for the age and gender of each Enrollee:

     

    •
      Appropriate initial and interval history;

     

    •
Height
      and weight measurement;

     

    •
      Nutrition assessment and counseling;

     

    •
      Appropriate lifestyle and risk counseling

     

    •
Health
      education and anticipatory guidance (including, without limitation, education
      on
      the need to monitor visual acuity for Enrollees ages 65 and older);

     

    •
Blood
      pressure;

     

    •
Hearing
      evaluation (ages 65 and older);

     

    •
Annual
      Papanicolaou (Pap) smear test or cervical smear and pelvic exam for female
      Enrollees (after three (3) or more consecutive satisfactory normal annual
      examinations, the Pap smear may be performed at the Physician's discretion
      based
      upon the Enrollee's risk assessment, but no less frequently than every three
      (3)
      years);

     

    •
      Clinical breast examination for female Enrollees;

     

    •
      Baseline mammogram for female Enrollees (ages 35-39) and annually for female
      Enrollees ages 40 and older (or earlier, as indicated for female Enrollees
      with
      a personal of family history of breast disease);

     

    

     

    48

     

    

    

    •
Rectal
      occult blood testing (ages 50 and older); sigmoidoscopy or colonoscopy should
      be
      considered every 5-10 years;

     

    •
Digital
      rectal examination and a prostate-specific antigen test annually based upon
      the
      Physician's recommendation for male Enrollees as follows:

     

    
      	 ̈  	
              African-American
                male Enrollees (ages 40 and older)

            

    

     

    
      	 ̈  	
              Male
                Enrollees of national origin other than African-American with a family
                history of prostate cancer (ages 40 and
                older)

            

    

     

    
      	 ̈  	
              Asymptomatic
                male Enrollees of national origin other than African-American (ages
                50 and
                older)

            

    

     

    •
      Non-fasting or fasting total blood cholesterol test, at least every 5
      years;

     

    •
      Dipstick urinalysis (ages 65 and older);

     

    •
Thyroid
      function tests for female Enrollees (ages 65 and older);

     

    •
      Tetanus-diptheria (Td) booster shot every 10 years, unless
      contraindicated;

     

    •
      Pneumococcal vaccine (ages 65 and older), unless contraindicated;
      and

     

    •
      Influenza vaccine annually (ages 65 and older), unless
      contraindicated.

     

    Any
      known
      condition or condition discovered during the complete health history and
      physical examination requiring further Medically Necessary diagnostic study
      or
      treatment must be provided if within the scope of Covered Services.

     

    At
      a
      minimum, the Contractor shall provide or arrange to provide the initial history
      and physical examination to fifty percent (50%) of all Enrollees in their first
      twelve (12) months of coverage, to seventy percent (70%) of all Enrollees in
      their second twelve (12) months of coverage and eighty percent (80%) of all
      Enrollees in their third twelve (12) months of coverage or more. For purposes
      of
      this subsection, "twelve (12) months of coverage" may include up to forty-five
      (45) days interrupted coverage. The Contractor shall track and monitor this
      provision on an ongoing basis and shall have in place a quality improvement
      initiative addressing compliance until such time as this performance goal is
      achieved and maintained.

     

    (c)
      Maternity
      Care.
      The
      Contractor shall provide or arrange to provide quality care for pregnant
      Enrollees. At a minimum, the Contractor shall provide, or arrange to provide,
      and document:

     

    (1)
      A
      comprehensive prenatal evaluation and care in accordance with the latest
      standards published by the American College of Obstetrics and Gynecology or
      the
      American Academy of Family Physicians. The specific areas to be addressed in
      regard to the provision of care include, but are not limited to, the following
      items: content of the initial assessment, including history, physical, lab
      tests
      and risk assessment including

     

    49

    

    HIV
      counseling and voluntary II1V testing; follow-up laboratory testing; nutritional
      assessment and counseling; frequency of visits; content of follow-up visits;
      anticipatory guidance and appropriate referral activities.

     

    (2)
      During the first year of this Contract, at least seventy percent (70%) of all
      pregnant Enrollees shall receive the minimum level of prenatal visits adjusted
      for the date of coverage under the Plan. During the second year of this
      Contract, the percentage in the preceding sentence shall increase to at least
      eighty percent (80%). For the exclusive purpose of calculating these rates,
      women who deliver within sixty (60) days of the first day of coverage under
      the
      Plan shall be excluded. The Contractor shall track and monitor this provision
      on
      an ongoing basis and shall have in place a quality improvement initiative
      addressing compliance until such time as this performance goal is achieved
      and
      maintained.

     

    (3)
      The
      Contractor shall provide risk assessment and depression screening and treatment
      for depression as needed during pregnancy and up to one year following
      delivery.

     

    (4)
      During the first year of this Contract, the Contractor shall ensure that at
      least seventy percent (70%) of all Enrollees who deliver shall receive at least
      one post-partum visit. During the second year of this Contract, the percentage
      in the preceding sentence shall increase to at least eighty percent (80%).
      For
      the exclusive purpose of calculating these rates, women who deliver within
      sixty
      (60) days of the first day of coverage under the Plan shall be excluded. The
      Contractor shall track and monitor this provision on an ongoing basis and shall
      have in place a quality improvement initiative addressing compliance until
      such
      time as this performance goal is achieved and maintained.

     

    (5)
      The
      Contractor shall provide preconceptional and interconceptional health care
      services that address pregnancy planning and care of medical
      conditions.

     

    (6)
      The
      Contractor shall provide or arrange to provide nutritional assessment and
      counseling to all pregnant Enrollees. Individualized diet counseling is to
      be
      provided as indicated.

     

    (7)
      The
      Contractor shall require its Primary Care Providers and Women's Health Care
      Providers to identify maternity cases presenting the potential for high-risk
      maternal or neonatal complications and arrange appropriate referral to physician
      specialist or transfer to Level III perinatal facilities as required. The
      Contractor shall utilize, for such high-risk consultation or referrals, the
      standards of care promulgated by the Statewide Perinatal Program of the Illinois
      Department of Human Services. Risk appropriate care shall be ongoing during
      the
      perinatal period. The Contractor shall provide a plan to the Department on
      how
      it will ensure that maternity care is received at the appropriate perinatal
      facility for the level of risk associated with each pregnancy.

     

    (8)
      The
      consulting physician at the perinatal center will determine the management
      of
      the Enrollee at that point in time. Should transport be required, the consultant
      at the perinatal center will identify the most appropriate mode of transport
      for

     

    50

     

    such
      a
      transfer. Should the perinatal center be unable to accept the Enrollee due
      to
      bed unavailability, that center will arrange for admission of the Enrollee
      to an
      alternate Level III perinatal center. All records required for appropriate
      management of the high-risk Enrollee receiving consultation or referral to
      a
      perinatal center will be provided to the consulting physician as indicated.
      The
      Contractor will obtain from the consulting physician all necessary
      correspondence to enable the Primary Care Provider to provide, or arrange for
      the provision of, appropriate follow-up care for the mother or neonate following
      discharge.

     

    (9)
      The
      Contractor shall employ strategies to ensure that pregnant women receive
      maternity care and shall provide training to Providers to ensure that best
      practice guidelines are followed to address the medical needs.

     

    (d)
      Complex
      and Serious Medical Conditions.

     

    (1)
      The
      Contractor shall provide or arrange to provide quality care for Enrollees with
      complex and serious medical conditions. At a minimum, the Contractor shall
      provide and document the following:

     

    (A)
      Timely identification of Enrollees with complex and serious medical
      conditions.

     

    (B)
      Assessment of such conditions and identification of appropriate medical
      procedures for monitoring or treating them.

     

    (C)
      A
      Chronic Care Action Plan that is symptom-based and developed in conjunction
      with
      the Enrollee or if a child, with the parent, guardian or care-taker relative,
      as
      appropriate, and a copy of this Chronic Care Action Plan shall be provided
      to
      the Enrollee.

     

    (D)
      Implementation of a treatment plan in accordance with this Article V, Section
      5.9(c)(l).

     

    (2)
      The
      Contractor shall have procedures in place to identify Enrollees with special
      health care needs in order to identify any ongoing special conditions of the
      Enrollee that require a course of treatment or regular care monitoring.
      Appropriate health care professionals shall make such assessments. Such
      procedures must be delineated in the Contractor's Quality Assurance Plan, and
      ongoing monitoring shall occur in compliance with Exhibit
      A,
      Section
      4.a.iv(d)(2).

     

    (3)
      The
      Contractor shall have a mechanism in place to allow Enrollees with special
      health care needs as defined by the Contractor to have direct access to a
      specialist as appropriate for each Enrollee's condition and identified
      needs.

     

    (e)
      Access
      Standards.

     

    (1)
      Appointments.
      Time
      specific appointments for routine, preventive care shall be made available
      within five (5) weeks from the date of request for such care

     

    51

    

    

    but
      within 2 weeks for infants under 6 months. Enrollces with more serious problems
      not deemed Emergency Medical Conditions shall be triaged and, if necessary,
      provided within 24 hours. Enrollces with problems or complaints that are not
      deemed serious shall be seen within three (3) weeks from the date of request
      for
      such care. Initial prenatal visits without expressed problems shall be made
      available within two (2) weeks for Enrollees in their first trimester, within
      one (1) week for Enrollees in their second trimester, and within three (3)
      days
      for Enrollces in their third trimester. The Contractor shall have an established
      policy that scheduled Enrollces shall not routinely wait for more than one
      (1)
      hour to be seen by a Provider and no more than six (6) scheduled appointments
      shall be made for each Primary Care Provider per hour. Notwithstanding this
      limit, the Department recognizes that physicians supervising other licensed
      health care Providers may routinely account for more than six (6) appointments
      per hour.

     

    (2)
      Services
      Requiring Prior Authorization.
      The
      Contractor shall provide, or arrange for the provision of, Covered Services
      as
      cxpcditiously as the Enrollcc's health condition requires. Ordinarily, Covered
      Services shall be provided within fourteen (14) calendar days after receiving
      the request for service from a Provider, with a possible extension of up to
      fourteen (14) calendar days, if the Enrollee requests the extension or the
      Contractor provides written justification to the Department that there is a
      need
      for additional information and the Enrollee will not be harmed by the extension.
      If the Physician indicates, or the Contractor determines that following the
      ordinary time frame could seriously jeopardize the Enrollcc's life or health,
      the Contractor shall provide, or arrange for the provision of, the Covered
      Service no later than seventy-two (72) hours after receipt of the request for
      service, with a possible extension of up to fourteen (14) calendar days, if
      the
      Enrollee requests the extension or the Contractor provides written justification
      to the Department that there is a need for additional information and the
      Enrollee will not be harmed by the extension.

     

    (f)
      Coordination
      with Other Service Providers.

     

    (1)
      The
      Contractor shall encourage the Plan Providers and subcontractors to cooperate
      and communicate with other service providers who serve Enrollees. Such other
      service providers may include: Community Behavioral Health Providers; Special
      Supplemental Nutrition Programs for Women, Infants, and Children (commonly
      referred to as "WIC" programs); Head Start programs; Early Intervention
      programs; Public Health providers; local health departments; school-based
      clinics; and school systems. Such cooperation may include performing annual
      physical examinations for school and the sharing of information (with the
      consent of the Enrollee).

     

    (2)
      The
      Contractor shall participate in the Family Case Management Program, which shall
      include, but is not limited to:

     

    (A)
      Coordinating services and sharing information with existing Family Case
      Management Providers for its Enrollees;

     

    (B)
      Developing internal policies, procedures, and protocols for the organization
      and
      its provider network for use with Family Case Management Providers serving
      Enrollees; and

     

    52

    
 

    (C)
      Conducting periodic meetings with Family Case Management Providers performing
      problem resolution and handling of grievances and issues, including policy
      review and technical assistance.

     

    (g)
      The
      Contractor and the Department shall agree on an implementation schedule for
      any
      quality assurance or quality improvement requirements in this Contract that
      were
      not contained in the contract between Contractor and the Department that was
      in
      place immediately preceding this Contract. Further, the Contractor and the
      Department shall review all quality assurance and quality improvement provisions
      of this Contract to determine whether changes to the requirements should be
      made
      in order to achieve all of the goals of those provisions in a cost effective
      manner.

     

    5.14
      Authorization of
      Services.
      The
      Contractor shall have in place and follow written policies and procedures when
      processing requests for initial and continuing authorizations of Covered
      Services. Such policies and procedures shall ensure consistent application
      of
      review criteria for authorization decisions by a health care professional or
      professionals with expertise in treating the Enrollee's condition or disease
      and
      provide that the Contractor shall consult with the Provider requesting such
      authorization when appropriate. If the Contractor declines to authorize Covered
      Services that are requested by a Provider or authorizes one or more services
      in
      an amount, scope, or duration that are less than that requested, the Contractor
      shall notify the Provider orally or in writing and shall furnish the Enrollee
      with written notice of such decision. Such notice shall meet the requirements
      set forth in 42 C.F.R. 438.404.

     

    5.15
      Case
      Management.
      The
      Contractor must offer and provide case management services which coordinate
      and
      monitor the care of members with specific diagnoses, or who require high-cost
      and/or extensive services.

     

    (a)
      MCOs
      must inform all members and contracting providers of the MCOs case management
      services.

     

    (b)
      The
      MCO's case management system must include, at a minimum, the following
      components:

     

    (1)
      specification of the criteria used by the MCO to identify those potentially
      eligible for case management services, including diagnosis, cost threshold
      and/or amount of service utilization, and the methodology or process (e.g.
      administrative data, provider referrals, self-referrals) used to identify the
      members who meet the criteria for case management;

     

    (2)
      a
      process for comprehensive assessment of the member's health condition to confirm
      the results of a positive identification, and determine the need for case
      management, including information regarding the credentials of the staff
      performing the assessments of CSHCN;

     

    (3)
      a
      process to inform members and their PCPs in writing that they have been
      identified as meeting the criteria for case management, including their
      enrollment into case management services;

     

    53

     

    

    

    (4)
      the
      procedure by which the MCO will assure the timely development of a care
      treatment plan for any member receiving case management services; offer both
      the
      member and the member's PCP/specialist the opportunity to participate in the
      care treatment plan's development based on the health needs assessment; and
      provide for the periodic review of the member's need for case management and
      updating of the care treatment plan; and

     

    (5)
      a
      process to facilitate, maintain, and coordinate communication between service
      providers, and member/family, including an accountable point of contact to
      help
      obtain medically necessary care, assist with health-related services and
      coordinate care needs.

     

    5.16 Children
      with Special Health Care Needs (CSHCN).
      The
      Contractor must establish a CSI-ICN program with the goal of conducting timely
      identification and screening, assuring a thorough and comprehensive assessment,
      and providing appropriate and targeted case management services for any CSHCN.
      All CSHCN children shall receive case management services.

     

    (a)
      Identification of CSHCN. The Contractor must implement mechanisms to identify
      CSHCNs who are in need of a follow-up assessment including: PCP referrals;
      outreach;

    and
      contacting newly-enrolled children.

     

    (b)
      Assessment of CSHCN. The Contractor must implement mechanisms to assess children
      with a positive identification as a CSHCN including, but not limited to the
      following:

     

    (1)
      Use
      of a CSHCN Standard Assessment Tool;

     

    (2)
      Completion of the assessment by a physician, physician assistant, RN, LPN,
      licensed social worker, or a graduate of a two or four year allied health
      program; and

     

    (3)
      Oversight and monitoring by either a registered nurse or a physician, if another
      medical professional completes the assessment.

     

    (c)
      Case
      Management of CSHCN. The Contractor must implement mechanisms to provide case
      management services for all CSHCN with a positive assessment including the
      components required for Case Management and the elements listed in the Case
      Management requirements.

     

    (d)
      Access to Specialists for CSHCN. The Contractor must implement mechanisms to
      notify all CSHCN with a positive assessment and determined to need case
      management of their right to directly access a specialist. Such access may
      be
      assured through, for example, a standing referral or an approved number of
      visits, and documented in the care treatment plan.

     

    5.17 Choice
      of Physicians.
      The
      Contractor shall afford to each Enrollee a choice of Primary Care Provider
      and,
      where appropriate, a Women's Health Care Provider.

     

    54

    

    (a)
      In
      each Contracting Area, there shall be at least one(l) full-time equivalent
      Physician for each 1,200 Enrollees, including one(l) full-time equivalent
      Primary Care Provider for each 2,000 Enrollees. In each Contracting Area, there
      shall be at least one (1) Women's Health Care Provider for each 2,000 female
      Enrollees between the ages of nineteen (19) and forty-four (44), at least one(l)
      Physician specializing in obstetrics for each 300 pregnant female Enrollees
      and
      at least one (1) pediatrician for each 2,000 Enrollees under age nineteen (19).
      All Physicians providing services shall have and maintain admitting privileges
      and, as appropriate, delivery privileges at an Affiliated or nearby hospital;
      or, in lieu of these admitting and delivery privileges, the Physicians shall
      have a written referral agreement with a Physician who is in the Contractor's
      network and who has such privileges at an Affiliated or nearby hospital. When
      cnrollccs arc admitted to a non-affiliated hospital by a plan physician,
      Contractor is obligated to pay the hospital at a rate negotiated between the
      hospital and the Contractor. The agreement must provide for the transfer of
      medical records and coordination of care between Physicians.

     

    (b)
      In
      any Contracting Area in which the Contractor does not satisfy the full-time
      equivalent provider requirements set forth above, the Contractor may demonstrate
      compliance with these requirements by demonstrating that (i) the Contractor's
      full time equivalent Physician ratios exceed ninety percent (90%) of the
      requirements set forth above, and (ii) that Covered Services are being provided
      in such Contracting Area in a manner which is timely and otherwise satisfactory.
      The Contractor shall comply with Section 1932(b)(7) of the Social Security
      Act.

     

    5.18 Timely
      Payments to Providers.
      The
      Contractor shall make payments to Providers for Covered Services on a timely
      basis consistent with the Claims Payment Procedure described at 42 U.S.C. §
1396a(a)(37)(A) and Illinois Public Act 91-0605. Complaints and/or disputes
      concerning payments for the provision of services as described in this paragraph
      shall be subject to the Contractor's Provider grievance resolution system.
      In
      particular, the Contractor must pay 90 percent (90%) of all "clean claims"
      from
      Providers within thirty (30) days following receipt. Further, the Contractor
      must pay 99 percent (99%) of all "clean claims" from Providers within ninety
      (90) days following receipt. For purposes of this Section 5.15, a "clean claim"
      means one that can be processed without obtaining additional information from
      the Provider who provided the service or from a third party, except that it
      shall not mean a claim submitted by or on behalf of a Provider who is under
      investigation for fraud or abuse, or a claim that is under review for medical
      necessity.

     

    The
      Contractor shall pay for all appropriate Emergency Services rendered by a
      non-Affiliated Provider within thirty (30) days of receipt of a complete and
      correct claim. If the Contractor determines it does not have sufficient
      information to make payment, the Contractor shall request all necessary
      information from the non-Affiliated Provider within thirty (30) days of
      receiving the claim, and shall pay the non-Affiliated Provider within thirty
      (30) days after receiving such information. Such payment shall be made at the
      same rate the Department would pay for such services according to the level
      of
      services provided. Determination of appropriate levels of service for payment
      shall be based upon the symptoms and condition of the Enrollee at the time
      the
      Enrollee is initially examined by the non-Affiliated Provider and not upon
      the
      final determination of the Enrollee's actual medical condition, unless the
      actual medical condition is more
      severe. Within the time limitation stated above, the Contractor may review
      the
      need for, and the intensity of, the services provided by non-Affiliated
      Providers.

     

    55

    

     

    The
      Contractor shall pay for all Post-Stabilization Services as a Covered Service
      in
      any the following situations: (a) the Contractor authorized such services;
      (b)
      such services were administered to maintain the Enrollee's stabilized condition
      within one (1) hour of a request to the Contractor for authorization of further
      Post-Stabilization Services; or (c) the Contractor did not respond to a request
      to authorize such services within one (1) hour, the Contractor could not be
      contacted, or, if the treating Provider is a non-Affiliated Provider, the
      Contractor and the treating Provider could not reach an agreement concerning
      the
      Enrollee's care and an Affiliated Provider was unavailable for a consultation,
      in which case the Contractor must pay for such services rendered by the treating
      non-Affiliated Provider until an Affiliated Provider was reached and either
      concurred with the treating non-Affiliated Provider's plan of care or assumed
      responsibility for the Enrollee's care.

     

    The
      Contractor shall pay for all Emergency Services and Post-Stabilization Services
      rendered by a non-Affiliated Provider, for which the Contractor would pay if
      rendered by an Affiliated Provider, at the same rate the Department would pay
      for such services exclusive of disproportionate share payments and Mcdicaid
      percentage adjustments, unless a different rate was agreed upon by the
      Contractor and non-Affiliated Provider.

     

    The
      Contractor shall accept claims from non-Affiliated Providers for at least one
      (1) year after the date the services arc provided. The Contractor shall not
      be
      required to pay for claims initially submitted by such non-Affiliated Providers
      more than one(l) year after the date of service.

     

    5.19
      Grievance
      Procedure and Appeal Procedure.

     

    (a)
      Grievance.
      The
      Contractor shall establish and maintain a procedure for reviewing Grievances
      registered by Enrollces. All Grievances shall be registered initially with
      the
      Contractor and may later be appealed to the Department. The Contractor's
      procedures must:

    (1)be
      submitted to the Department in writing and approved in writing by the
      Department;

    (2)
      provide for prompt resolution, and (3) assure the participation of individuals
      with authority to require corrective action. The Contractor must have a
      Grievance Committee for reviewing Grievances registered by its Enrollees, and
      Enrollees must be represented on the Grievance Committee. At a minimum, the
      following elements must be included in the Grievance process:

     

    (1)
      An
      informal system, available internally, to attempt to resolve all
      Grievances;

     

    (2)
      A
      formally structured Grievance system that is compliant with Section 45 of the
      Managed Care Reform and Patient Rights Act and 42 C.F.R. Part 438 Subpart F
      to
      handle all Grievances subject to the provisions of such sections of the Act
      and
      regulations (including, without limitation, procedures to ensure expedited
      decision making when an Enrollee's health so necessitates);

     

    (3)
      A
      formally structured Grievance Committee must be available for Enrollees whose
      Grievances cannot be handled informally and are not appropriate for
      the

     

    56

    

    

    procedures
      set up under the Managed Care Reform and Patient Rights Act. All Enrollecs
      must
      be informed that such a system exists. Grievances at this stage must be in
      writing and sent to the Grievance Committee for review;

     

    (4)
      The
      Grievance Committee must have at least twenty-five percent (25%) representation
      by members of Contractor's prepaid plans, with at least one (1) Enrollee of
      Contractor's services under this Contract on the Committee. The Department
      may
      require that one(l) member of the Grievance Committee be a representative of
      the
      Department;

     

    (5)
      Final
      decisions under the Managed Care Reform and Patient Rights Act procedures and
      those of the Grievance Committee may be appealed by the Enrollee to the
      Department under its Fair Hearings system;

     

    (6)
      A
      summary of all Grievances heard by the Grievance Committee and by independent
      external reviewers and the responses and disposition of those matters must
      be
      submitted to the Department quarterly;

     

    (7)
      An
      Enrollee may appoint a guardian, caretaker relative, Primary Care Provider,
      Women's Health Care Provider, or other Physician treating the Enrollee to
      represent him throughout the Grievance process.

     

    (b)
      Appeals. The Contractor shall establish and maintain a procedure for reviewing
      Appeals made by Enrollecs or Providers on behalf of Enrollecs. All Appeals
      shall
      be registered initially with the Contractor and may later be appealed to the
      Department. The Contractor's procedures must: (l)be submitted to the Department
      in writing and approved in writing by the Department; (2) provide for prompt
      resolution, and (3) assure the participation of individuals with authority
      to
      require corrective action. The Contractor must have a committee in place for
      reviewing Appeals made by its Enrollecs. At a minimum, the following elements
      must be included in the Appeal process:

     

    (1)
      A
      system that allows an Enrollee or Provider to file an Appeal either orally
      or in
      writing, within a reasonable period of time following the date of the notice
      of
      action that generates such Appeal, which reasonable period of time shall not
      be
      less than twenty (20) days nor more than ninety (90) days; provided that the
      Contractor may require an Enrollee or Provider to follow an oral Appeal with
      a
      written, signed Appeal unless the Enrollee or Provider has requested review
      on
      an expedited basis;

     

    (2)
      A
      formally structured Appeals system that is compliant with Section 45 of the
      Managed Care Reform and Patient Rights Act and Subpart F of Section 438 of the
      Code of Federal Regulations to handle all Appeals subject to the provisions
      of
      such sections of the Act and C.F.R. (including, without limitation, procedures
      to ensure expedited decision making when an Enrollee's health so necessitates
      and procedures allowing for an external independent review of Appeals that
      are
      denied by the Contractor);

     

    (3)
      Final
      decisions of Appeals not resolved wholly in favor of the Enrollee may be
      appealed by the Enrollee to the Department under its Fair Hearings
      system;

     

    57

    

    

    (4)
      A
      summary of all Appeals filed by Enrollees and the responses and disposition
      of
      those matters (including decisions made following an external independent
      review) must be submitted to the Department quarterly;

     

    (5)
      An
      Enrollee may appoint a guardian, caretaker relative, Primary Care Provider,
      Women's Health Care Provider, or other Physician treating the Enrollee to
      represent him throughout the Appeal process.

     

    (c)
      The
      Contractor agrees to review its Grievance and Appeal procedures, at regular
      intervals, for the purpose of amending same when necessary. The Contractor
      shall
      amend the procedures only upon receiving the prior written consent of the
      Department. The Contractor farther agrees to supply the Department and/or its
      designee with the information and reports prescribed in its approved procedure.
      This information shall be furnished to the Department upon its
      request.

     

    (d)
      The
      Contractor shall establish a complaint and resolution system for Providers
      that
      includes a Provider dispute process.

     

    5.20
      Enrollee
      Satisfaction Survey.
      The
      Contractor shall annually conduct a Consumer Assessment of Health Plans (CAHPS)
      survey as approved by the Department. The survey sampling and administration
      must follow specifications contained in the most current HEDIS volume.
      Contractor must contract with an NCQA-Ccrtificd HEDIS Survey Vendor to
      administer the survey and submit results according to the HEDIS survey
      specifications. The Contractor shall submit its findings and explain what
      actions it will take on its findings as part of the comprehensive Annual
      QA/UR/PR Report.

     

    5.21
      Provider
      Agreements and Subcontracts.

     

    (a)
      The
      Contractor may provide or arrange to provide any Covered Services identified
      in
      Article V, Section 5.1 with Affiliated Providers or fulfill any other
      obligations under this Contract by means ofsubcontractual
      relationships.

     

    (1)
      All
      Provider agreements and/or subcontracts entered into by the Contractor must
      be
      in writing and are subject to the following conditions:

     

    (A)
      The
      Affiliated Providers and subcontractors shall be bound by the terms and
      conditions of this Contract that are appropriate to the service or activity
      delegated under the subcontract. Such requirements include, but arc not limited
      to, the record keeping and audit provisions of this Contract, such that the
      Department or Authorized Persons shall have the same rights to audit and inspect
      subcontractors as they have to audit and inspect the Contractor.

     

    (B)
      The
      Contractor shall remain responsible for the performance of any of its
      responsibilities delegated to Affiliated Providers or
      subcontractors.

     

    58

    

    

    (C)
      No
      Provider agreement or subcontract can terminate the legal responsibilities
      of
      the Contractor to the Department to assure that all the activities under this
      Contract will be carried out.

     

    (D)
      All
      Affiliated Providers providing Covered Services for the Contractor under this
      Contract must currently be enrolled as Providers in the HFS Medical Program.
      The
      Contractor shall not contract or subcontract with an Ineligible Person or a
      Person who has voluntarily withdrawn from the HFS Medical Program as the result
      of a settlement agreement.

     

    (E)
      All
      Provider agreements and subcontracts must comply with the Lobbying Certification
      contained in Article IX, Section 9.22 of this Contract.

     

    (F)
      All
      Affiliated Providers shall be furnished with information about the Contractor's
      Grievance and Appeal procedures at the time the Provider enters into an
      agreement with the Contractor and within fifteen (15) days following any
      substantive change to such procedures.

     

    (G)
      The
      Contractor must retain the right to terminate any Provider agreement and/or
      subcontract, or impose other sanctions, if the performance of the Affiliated
      Provider or subcontractor is inadequate.

     

    (b)
      With
      respect to all Provider agreements and subcontracts made by the Contractor,
      the
      Contractor further warrants:

     

    (1)
      That
      such Provider agreements and subcontracts are binding;

     

    (2)
      That
      it will promptly terminate all contracts with Providers and/or subcontractors,
      or impose other sanctions, if the performance of the Affiliated Provider or
      subcontractor is inadequate;

     

    (3)
      That
      it will promptly terminate contracts with Providers who are terminated, barred,
      suspended, or have voluntarily withdrawn as a result of a settlement agreement,
      under cither Section 1128 or Section 1128A of the Social Security Act, from
      participating in any program under federal law including any program under
      Titles XVIII, XIX, XX or XXI of the Social Security Act or are otherwise
      excluded from participation in the HFS Medical Program;

     

    (4)
      That
      all laboratory testing Sites providing services under this Contract must possess
      a valid Clinical Laboratory Improvement Amendments ("CLIA") certificate and
      comply with the CLIA regulations found at 42 C.F.R. Part 493; and

     

    (5)
      That
      it will monitor the performance of all Affiliated Providers and subcontractors
      on an ongoing basis, subject each Affiliated Provider and subcontractor to
      formal review on a triennial basis, and, to the extent deficiencies or areas
      for
      improvement are identified during an informal or formal review, require that
      the
      Affiliated Provider or subcontractor take appropriate corrective
      action.

     

    59

    

    (c)
      The
      Contractor will submit to the Department copies of model Provider agreements
      and/or subcontracts, initially and revised, that relate to Covered Services,
      assignment of risk and data reporting functions and any substantial deviations
      from these model Provider agreements or subcontracts. The Contractor shall
      provide copies of any other model Provider agreement or subcontract or any
      actual Provider agreement or subcontract to the Department upon request. The
      Department reserves the right to require the Contractor to amend any Provider
      agreement or subcontract as necessary to conform with the Contractor's duties
      and obligations under this Contract.

     

    The
      Contractor may designate in writing certain information disclosed under this
      Article V, Section 5.21 as confidential and proprietary. If the Contractor
      makes
      such a designation, the Department shall consider said information exempt from
      copying and inspection under Section 7(l)(b) or (g) of the State Freedom of
      Information Act (5 ILCS 140/1 et seq.). If the Department receives a request
      for
      said information under the State Freedom of Information Act, however, it may
      require the Contractor to submit justification for asserting the exemption.
      Additionally, the Department may honor a properly executed criminal or civil
      subpoena for such documents without such being deemed a breach of this Contract
      or any subsequent amendment hereto.

     

    (d)
      Prior
      to entering into a Provider agreement or subcontract, the Contractor shall
      submit a disclosure statement to the Department specifying any Provider
      agreement or subcontract and Providers or subcontractors in which any of the
      following have a five percent (5%) or more financial interest:

     

    (1)
      any
      Person also having a five percent (5%) or more financial interest in the
      Contractor or its affiliates as defined by 42 C.F.R. 455.101;

     

    (2)
      any
      director, officer, trustee, partner or employee of the Contractor or its
      affiliates; or

     

    (3)
      any
      member of the immediate family of any Person designated in (1)
      or(2)above.

     

    (e)
      Any
      contract or subcontract between the Contractor and a FQHC or a RHC shall be
      executed in accordance with 1902(a)(13)(C) and 1903(m)(2)(A)(ix) of the Social
      Security Act, as amended by the Balanced Budget Act of 1997 and shall provide
      payment that is not less than the level and amount of payment which the
      Contractor would make for the Covered Services if the services were furnished
      by
      a Provider which is not an FQHC or a RHC.

     

    5.22
      Site
      Registration and Primary Care Provider/Women's Health Care Provider Approval
      and
      Credentialing.

     

    (a)
      The
      Contractor shall register with the Department each Site prior to assigning
      Enrollees to that Site to receive primary care. A fully executed Provider
      agreement must be in place between the Contractor and the Site prior to
      registration of the Site. All FQHCs and RHCs must be registered as unique sites,
      and all Enrollees receiving Covered Services at those unique sites must be
      reflected in those Sites in the Department's system. The Contractor must give
      advance notice to the Department as soon as practicable of the anticipated
      closing of a Site.
      If
      it is not possible to give advance notice of a closing of a Site, the Contractor
      shall notify the Department immediately when a Site is
      closed.

     

    60

     

    (b)
      The
      Contractor shall submit to the Department for approval the name, license
      numbers, and other information requested in a format designated by the
      Department of all proposed Primary Care Providers and Women's Health Care
      Providers, as such new Primary Care Providers and Women's Health Care Providers
      are added to the Contractor's network through executed Provider agreements.
      A
      Primary Care Provider or Women's Health Care Provider may not be offered to
      Enrollees until the Department has given its written approval of the Primary
      Care Provider or Women's Health Care Provider.

     

    (c)
      All
      Primary Care Providers and Women's Health Care Providers must be crcdcntialed
      by
      the Contractor. The crcdentialing process may be two-tiered, and the Contractor
      may assign Enrollees to a Primary Care Provider or Women's Health Care Provider
      following preliminary credentialing, provided that full crcdentialing is
      completed within a reasonable time following the assignment of Enrollees to
      the
      Primary Care Provider or Women's Health Care Provider. The Contractor must
      notify the Department when the crcdentialing process is completed and the
      results of the process. If the Contractor utilizes a single tiered credentialing
      process, the Contractor shall
      not
      assign
      Enrollees to a Primary Care Provider or Women's Health Care Provider until
      such
      Provider has been fully credentialed.

     

    (d)
      The
      Contractor's Provider selection policies and procedures shall not discriminate
      against particular Providers that serve high-risk populations or specialize
      in
      conditions that require costly treatment.

     

    (e)
      The
      Department, at its sole discretion, may eliminate or modify the requirement
      for
      Site reporting at any time during the term of this Contract.

     

    5.23
      Advance
      Directives.
      The
      Contractor shall comply with all rules concerning the maintenance of written
      policies and procedures with respect to advance directives as promulgated by
      CMS
      as set forth in 42 C.F.R. §422.128. The Contractor shall provide adult Enrollees
      with oral and written information on advance directives policies, and include
      a
      description of applicable State law. Such information shall reflect changes
      in
      State law as soon as possible, but no later than ninety (90) days after the
      effective date of the change.

     

    5.24
      Fees
      to Enrollees Prohibited.
      Neither
      the Contractor, its Affiliated Providers, or non-Affiliated Providers shall
      seek
      or obtain funding through fees or charges to any Enrollee receiving Covered
      Services pursuant to this Contract, except as permitted or required by the
      Department in 89 111. Adm. Code 125 and/or the Department's fee-for-service
      copayment policy then in effect. The Contractor acknowledges that imposing
      charges in excess of those permitted under this Contract is a violation of
      §1128B(d) of the Social Security Act and subjects the Contractor to criminal
      penalties. The Contractor shall have language in all of its Provider
      subcontracts reflecting this requirement.

     

    5.25
      Fraud
      and Abuse Procedures.

     

    (a)
      The
      Contractor shall have an affirmative duty to timely report suspected Fraud,
      Abuse or criminal acts in the HFS Medical Program by Participants, Providers,
      the

     

    61

    

    

    Contractor's
      employees, or Department employees to the Healthcare and Family Services Office
      of Inspector General. To this end, the Contractor shall establish the following
      procedures, in writing:

     

    (1)
      the
      Contractor shall form a compliance committee and appoint a single individual
      to
      serve as liaison to the Department regarding the reporting of suspected Fraud
      or
      Abuse;

     

    (2)
      the
      Contractor's procedure shall ensure that any of Contractor's personnel or
      subcontractors who identify suspected Fraud or Abuse shall make a report to
      Contractor's liaison;

     

    (3)
      the
      Contractor's procedure shall ensure that the Contractor's liaison shall provide
      notice of any suspected Fraud or Abuse to the OIG immediately upon receiving
      such report.

     

    (4)
      the
      Contractor shall submit a quarterly report certifying that the report includes
      all instances of suspected Fraud or Abuse or shall certify that there was no
      suspected Fraud or Abuse during that quarter. Reports shall be considered timely
      if they are made as soon as the Contractor knew or should have known of the
      suspected Fraud or Abuse and the certification is received within thirty (30)
      days after the end of the quarter;

     

    (5)
      the
      Contractor shall ensure that all its personnel and subcontractors receive notice
      of these procedures.

     

    (b)
      The
      Contractor shall not conduct any investigation of the suspected Fraud or Abuse
      of Department personnel, but shall report all incidents immediately to the
      OIG.

     

    (c)
      The
      Contractor may conduct investigations of suspected Fraud or Abuse of its
      personnel, Providers, subcontractors, or Enrollees. If so directed by the OIG
      or
      if the investigation discloses potential criminal acts, the Contractor shall
      immediately cease its internal investigation notify the OIG.

     

    (d)
      The
      Contractor shall cooperate with all OIG investigations of suspected Fraud or
      Abuse.

     

    5.26 Misrepresentation
      Procedures.
      If an
      Enrollee states that one of the Contractor's Marketing representatives made
      a
      Misrepresentation, the Contractor shall conduct a retention interview with
      the
      Enrollee either at the time the allegation is made, if the Enrollee is on the
      telephone, or as soon as possible thereafter, if the Enrollee must be contacted.
      If, during the retention interview, the Enrollee requests disenrollment from
      the
      Contractor, the Contractor shall send a disenrollment form to the Enrollee
      within three (3) business days following the date of the request. The Contractor
      shall notify the Department in accordance with the terms of this Article V,
      Section 5. ll(a)(4).

     

    5.27 Enrollee-Provider
      Communications.
      Subject
      to this Article V, Section 5.1 (g), and in accordance with the Managed Care
      Reform and Patient Rights Act, the Contractor shall not prohibit or otherwise
      restrict a Provider from advising an Enrollee about the health status
      of

     

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    the
      Enrollee or medical care or treatment for the Enrollee's condition or disease
      regardless of whether benefits for such care or treatment are provided under
      this Contract, if the Provider is acting within the lawful scope of practice,
      and shall not retaliate against a Provider for so advising an
      Enrollee.

    5.28
      HIPAA
      Compliance.
      Contractor shall comply with the terms of Sections B and C of the HIPAA
      Compliance Obligations set forth in Attachment III.

    

    

    63

    

    

    ARTICLE
      VI 

    DUTIES
      OF THE DEPARTMENT

     

    6.1 Enrollment.
      Once the
      Department has determined that an individual is a Potential Enrollee and after
      the Potential Enrollee has selected the Contractor's Plan, such individual
      shall
      become a Prospective Enrollee. A Prospective Enrollee shall become an Enrollee
      on the effective date of coverage. Coverage shall begin as specified in Article
      IV, Section 4.2. The Department shall make available to the Contractor, prior
      to
      the first day of each month, an 834 Audit File.

     

    6.2 Payment.
      The
      Department shall pay the Contractor for the performance of the Contractor's
      duties and obligations hereunder. Such payment amounts shall be as set forth
      in
      Article VII of this Contract and Attachment 1 hereto. Unless specifically
      provided herein, no payment shall be made by the Department for extra charges,
      supplies or expenses, including, but not limited to, Marketing costs incurred
      by
      the Contractor.

     

    6.3 Department
      Review of Marketing Materials.
      Review
      of all Marketing Materials required by this Contract to be submitted to the
      Department for prior approval shall be completed by the Department on a timely
      basis not to exceed thirty (30) days from the date of receipt by the Department;
      provided, however, that if the Department fails to notify the Contractor of
      approval or disapproval of submitted materials within thirty (30) days after
      receiving such materials, the Contractor may begin to use such materials. The
      Department, at any time, reserves the right to disapprove any materials that
      the
      Contractor used and/or distributed prior to receiving the Department's express
      written approval. In the event the Department disapproves any materials, the
      Contractor immediately shall cease use and/or distribution of such
      materials.

     

    6.4 HIPAA
      Compliance.
      The
      Department shall comply with the terms of Section D of the HIPAA Compliance
      Obligations set forth in Attachment III.

     

    64

     

    

    

    ARTICLE
      VII 

    PAYMENT
      AND FUNDING

     

    7.1 Capitation
      Payment.
      The
      Department shall pay the Contractor on a Capitation basis, based on the age
      and
      gender categories of the Enrollcc as shown on the table in Attachment I, a
      sum
      equal to the product of the approved Capitation rate and the number of Enrollees
      enrolled in that category as of the first day of that month. Rates reflected
      in
      Attachment I are for the period August 1, 2006 through July 31, 2008. At the
      end
      of the two year period, the Department will develop an update to the rates
      which
      will be offered to the Contractor through an amendment to the
      Contract.

     

    7.2 Hospital
      Delivery Case Rate Payment.
      The
      Department shall pay the Contractor a Hospital Delivery Case Rate as shown
      in
      Attachment I for each hospital delivery paid by the Contractor. This payment
      will be generated upon receipt of the hospital Encounter Data that groups to
      a
      diagnostic related grouping (DRG) of 370, 371, 372, 373, 374 or 375 and is
      accepted by the Department within 15 months of the date of service. These
      payments will be generated on a monthly basis only for the Encounter Data that
      is accepted by the Department. Rates reflected in Attachment I are for the
      period August 1, 2006 through July 31, 2008. At the end of the two year period,
      the Department will develop an update to the rates which will be offered to
      the
      Contractor through an amendment to the Contract.

     

    7.3 Actuarially
      Sound Rate Representation.
      The
      Department represents that actuarially sound Capitation rates and Hospital
      Delivery Case Rates were developed by the Department's contracted actuarial
      firm. The rates were developed from the fcc-for-scrvicc equivalent values to
      be
      consistent with the Federal regulations promulgated pursuant to the Balanced
      Budget Act of 1997. The fee-for-service equivalent values were modified to
      reflect the following adjustments: projection of future medical cost increases
      for the two-year rate period beginning August 1, 2006, managed care utilization
      and cost adjustments, and an administration allowance for compliance with CMS
      rate setting guidelines and actuarial principles.

     

    7.4
      New
      Covered Services.
      The
      financial impact of any new Covered Services added to the Contractor's
      responsibilities under this Contract will be evaluated from an actuarial
      perspective by the Department and, if deemed material, in the Department's
      sole
      opinion, the rates set forth in this Contract shall be amended
      accordingly.

     

    7.5 Adjustments.
      Payments
      to the Contractor will be adjusted for retroactive disenrollments of Enrollees,
      retroactive Enrollments of newboms, changes to Enrollee information that affect
      the Capitation and Hospital Delivery Case rates (i.e., region of residence,
      eligibility classification, age, gender), financial sanctions imposed in
      accordance with Article IX, Section 9.10, rate changes in accordance with
      amendments to Attachment 1 or third-party liability collections received by
      the
      Contractor, or other miscellaneous adjustments provided for herein. Adjustments
      shall be retroactive only to eighteen (18) months, unless otherwise provided
      for
      in writing by the Department.

     

    7.6 Copayments
      The
      Contractor may charge copayments to Enrollees in a manner consistent with 89
      111. Adm. Code, Part 125 and/or the Department's fee-for-service
      copayment

     

     

    65

    

    

    policy
      then in effect. If the Contractor desires to charge such copayments, the
      Contractor must provide written notice to the Department before charging such
      copayments. Such written notice to the Department shall include a copy of the
      policy the Contractor intends to give the Providers in its network. This policy
      must set forth the amount, manner, and circumstances in which copayments may
      be
      charged. Such policy is subject to the prior written approval of the Department.
      In the event the Contractor wishes to impose a charge for copayments after
      enrollment of a Participant, it must first provide at least sixty (60) days
      prior written notice to such Participant. The Contractor shall be responsible
      for promptly refunding to a Participant any copayment that, in the sole
      discretion of the Department, has been inappropriately collected for Covered
      Services. The Contractor shall not charge copayments to any Enrollee who is
      an
      American Indian or Alaska Native. The Department will prospectivcly identify
      Enrollees who are American Indians or Alaska Natives.

     

    7.7 Availability
      of Funds.
      Payment
      of obligations of the Department under this Contract are subject to the
      availability of funds and the appropriation authority as provided by law.
      Obligations of the State will cease immediately without penalty of further
      payment being required if in any State fiscal year the Illinois General Assembly
      or federal funding source fails to appropriate or otherwise make available
      sufficient funds for this Contract within thirty (30) days of the end of the
      State's fiscal year.

     

    (a)
      If
      State funds become unavailable, as set forth herein, to meet the Department's
      obligations under this Contract in whole or in part, the Department will provide
      the Contractor with written notice thereof prior to the unavailability of such
      funds, or as soon thereafter as the Department can provide written
      notice.

     

    (b)
      In
      the event that funds become unavailable to fund this Contract in whole, this
      Contract shall terminate; in accordance with Article VIII, Section 8.6(c) of
      this Contract. In the event that funds become unavailable to fund this Contract
      in part, it is agreed by both parties that this Contract may be renegotiated
      (as
      to premium or scope of services) or amended in accordance with Article IX,
      Section 9.9(c). Should the Contractor be unable or unwilling to provide fewer
      Covered Services at a reduced Capitation rate, or otherwise be unwilling or
      unable to amend this Contract within ten (10) business days after receipt of
      a
      proposed amendment, the Contract shall be terminated on a date set by the
      Department not to exceed thirty (30) days from the date of such
      notice.

     

    7.8 Quality
      Performance Payment.
      During
      year one of this Contract, the Department shall withhold one-half of one percent
      (0.5%) of each Capitation payment. During years two and three, the withhold
      shall be one percent (1%) of each Capitation payment. These funds will be used
      to make quality performance payments to assess performance of certain quality
      of
      care indicators. The quality performance payments will be made as
      follows:

     

    (a)
      Calendar year 2005 HEDIS Scores will be used as the baseline to measure
      improvement in calendar year 2006 HEDIS Scores to determine quality performance
      payments made following the end of Contract year one. For years two and three
      of
      the Contract, the HEDIS Scores measurement year will be 2007 and 2008,
      respectively. The previous year's score will be the baseline for each year.
      The
      lack of a HEDIS Score for a particular measure for either a baseline year or
      a
      measurement year will result in the withheld amount for the measurement year
      being retained by the Department.

     

     

    66

     

    

    

    (b)
      The
      HEDIS measures used to determine the quality performance payments
      are:

     

    •
      Childhood Immunization Status - Combo 2;

     

    •
      Well-Child Visits in the First 15 Months of Life - 6 or more
      Visits;

     

    •
      Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of
      Life;

     

    •
Breast
      Cancer Screening;

     

    •
      Cervical Cancer Screening;

     

    •
      Timeliness of Prenatal Care;

     

    •
Use
      of
      Appropriate Medications for People with Asthma - Ages Combined; and

     

    •
      Comprehensive Diabetes Care - HbA 1 C Testing.

     

    The
      Department may, in its sole discretion, revise the quality performance payment
      measures. The Department will notify the Contractor of such revision at least
      two (2) months prior to the beginning of the calendar year on which the
      measurement will be based. Any measures used will be a subset of those listed
      in
      Exhibit A, paragraph 13.

     

    (c)
      Funds
      withheld from the Contractor that are not paid out through quality performance
      payments will be retained by the Department.

     

    (d)
      If
      the Contract is terminated on a date when the Department has withheld fees
      for a
      measurement year that has not ended, HEDIS scores will be calculated based
      on
      the twelve (12) months of operation prior to termination. Any expense for such
      a
      measurement will be borne by the Contractor.

     

    (e)
      One-eighth of the withheld money will be allotted to each measure in this
      Section 7.8(b). The withheld amount for each measure will be paid to the
      Contractor if the Contractor achieves the improvement in HEDIS score required
      for that measure as follows:

     

    (1)
      If
      the Contractor's baseline year measure is below 30 %, the Contractor's
      measurement year score must exceed the Contractor's baseline year score by
      15
      percentage points.

     

    (2)
      If
      the Contractor's baseline year measure is between 30% and 50%, the Contractor's
      measurement year score must exceed the Contractor's baseline year score ten
      percentage points.

     

    (3)
      If
      the Contractor's baseline year measure is above 50%, the Contractor's
      measurement year score must exceed the Contractor's baseline year score by
      five
      percentage points.

     

     

    67

     

    

    

    (4)
      Whenever the Contractor's baseline year measure is above the 50th
      percentile
      for the baseline year's HEDIS Medicaid Benchmarks, regardless of the percentage
      score, the Contractor's measurement year score must exceed the Contractor's
      baseline year score by two and one-half percentage points.

     

    (5)
      Whenever the Contractor's baseline year measure is above the 75th
      percentile
      for the baseline year's HEDIS Medicaid Benchmarks, regardless of the percentage
      score, the Contractor need only maintain a score above the 75 percentile
      benchmark of the baseline year.

     

    7.9 Denial
      of Payment Sanction by CMS.
      The
      Department shall deny payments otherwise provided for under this Contract for
      new Enrollees when, and for so long as, payment for those Enrollees is denied
      by
      CMS under 42 C.F.R. §438.726.

     

    7.10 Hold
      Harmless.
      The
      Contractor shall indemnify and hold the Department harmless from any and all
      claims, complaints or causes of action which arise as a result of the
      Contractor's failure to pay either any Provider for rendering Covered Services
      to Enrollees or any vendor, subcontractor, or the Department's mail vendor,
      cither on a timely basis or at all, regardless of the reason or for any dispute
      arising between the Contractor and a vendor, mail vendor, Provider, or
      subcontractor; provided, however, that this provision will not nullify the
      Department's obligation under Article V, Section 5.1 to cover services that
      are
      not Covered Services under this Contract, but that are eligible for payment
      by
      the Department.

     

    The
      Contractor warrants that Enrollees will not be liable for any of the
      Contractor's debts should the Contractor become insolvent or subject to
      insolvency proceedings as set forth in 215 ILCS 125/1-1 ctsca.

     

    7.11 Payment
      in Full.
      Acceptance of payment of the rates specified in this Article VII for any
      Enrollcc is payment in full for all Covered Services provided to that Enrollcc,
      except to the extent the Contractor charges such Enrolice a copayment as
      permitted in this Contract.

     

    7.12
       820
      Payment File.
      For each
      payment made, the Department will make available an 820 Payment File. This
      file
      will include, but is not limited to, identification of each Enrollee for whom
      payment is being made. This file is to be electronically retrieved by the
      Contractor.

     

    7.13 Medical Loss
      Ratio Guarantee

     

    (a)
      For
      each calendar quarter beginning July 1, 2006 during which the Contractor was
      under contract to the Department, if the Contractor's Medical Eoss Ratio (MER)
      is less than 82%, the Department may recover by deduction from future payments
      a
      percentage of the quarter's premium revenue equal to the difference between
      the
      reported MER and 82%.

     

    (b)
      Medical Eoss Ratio shall be calculated by dividing total hospital and medical
      expenses incurred in Illinois by premium revenue paid by the Department. Premium
      revenue for a quarter shall be the premium revenue accrued, including Hospital
      Delivery Case Rate Payments. Expenses reported as Incurred But Not Reported
      (IBNR) shall be subject to review by the Department for actuarial soundness.
      All
      elements of reports used to calculate MER are subject to audit by the
      Department. Audits may be ordered by the Department within 30
      days
      of Departmental receipt of each quarterly report, and audits shall encompass
      the
      total subject matter of that report.

     

    68

    

     

    (c)
      Hospital and medical expenses are the incurred costs of providing direct care
      to
      Enrollees for Covered Services. Outreach and general education are not included
      in medical expenses.

     

    (d)
      At
      the end of the eight quarters ending each June 2008, the Department will review
      the Contractor's MLR for the full eight quarters and may recover or reconcile
      previous recoveries so that the Department has recovered the percentage of
      the
      total premium revenue for the eight quarters equal to the difference between
      the
      cumulative MLR below 82% and 82%. Reconciliation shall consist of payment by
      the
      Contractor of any difference below the annualized 82% MLR not previously
      deducted, or repayment to the Contractor of deductions over the annualized
      82%
      MLR previously made by the Department. A similar reconciliation may be performed
      at the end of the four quarters ending June 2009 or the termination of any
      contractual relationship betv/ccn the parties. Notwithstanding the provisions
      of
      section 7.12(b), the Department may order an audit of the reporting for the
      full
      eight quarters within 45 days of Departmental receipt of a cumulative report
      of
      the eight quarters.

    (e)
      The
      Contractor shall report all information necessary to effectuate this section
      pursuant to NAIC quidclines in a format and on a schedule consistent with NAIC
      guidelines. The Department may request additional supporting information
      necessary to effectuate this section, and the Contractor shall report this
      information to the Department in a timely manner.

    

    

    69

    

    

    ARTICLE
      VIII

     

    TERM
      RENEWAL AND TERMINATION

     

    8.1 Term.
      This
      Contract shall take effect on August 1, 2006 and shall continue for a period
      of
      one year.
      This Contract shall renew automatically for two consecutive one-year terms,
      unless either party
      gives
      the other party written notice ninety (90) days prior to the end of the
      then-current term.
      Once
      either party receives notice of the other party's intent not to renew, such
      nonrenewal shall be irrevocable.

     

    8.2 Continuing
      Duties in the Event of Termination.
      Upon
      termination of this Contract, the parties are obligated to perform those duties
      which remain under this Contract. Such duties include, but are not limited
      to,
      payment to Affiliated or non-Affiliated Providers, completion of customer
      satisfaction surveys, cooperation with medical records review, all reports
      for
      periods of operation, including Encounter Data, and retention of records.
      Termination of this Contract does not eliminate the Contractor's responsibility
      to the Department for overpayments which the Department determines in a
      subsequent audit may have been made to the Contractor, nor docs it eliminate
      any
      responsibility the Department may have for underpayments to the Contractor.
      The
      Contractor warrants that if this Contract is terminated, the Contractor shall
      promptly supply all information in its possession or that may be reasonably
      obtained, which is necessary for the orderly transition ofEnrollees and
      completion of all Contract responsibilities.

     

    8.3
      Termination
      With and Without Cause.

     

    (a)
      This
      Contract may be terminated by the Department with cause upon, at least, fifteen
      (15) days written notice to the Contractor for any reason set forth in Section
      1932(e)(4)(A) of the Social Security Act. In the event such notice is given,
      the
      Contractor may request in writing a hearing, in accordance with Section 1932
      of
      the Social Security Act by the date specified in the notice. If such a request
      is made by the date specified, then a hearing under procedures determined by
      the
      Department will be provided prior to termination. The Department reserves the
      right to notify Enrollccs of the hearing and its purpose, to inform them that
      they may discnroll, and to suspend further enrollment with the Contractor during
      the pendency of the hearing and any related proceedings.

     

    (b)
      This
      Contract may be terminated by the Department or the Contractor without cause
      upon sixty (60) days written notice to the other party. Any such date of
      termination established by the Contractor shall coincide with the last day
      of a
      coverage month.

     

    8.4 Temporary
      Management.
      While
      one or more agencies within the State of Illinois have the authority and retain
      the power to impose temporary management upon Contractor for repeated violations
      of the Contract, the Department will exercise its option to terminate the
      Contract prior to imposing temporary management. This does not preclude other
      state agencies from exercising such power at their discretion.

     

    8.5 Termination
      for Breach of HIPAA Compliance Obligations.
      Upon the
      Department's learning of a material breach of the terms of the HIPAA Compliance
      Obligations, set forth in Attachment 111 ("HIPAA Compliance Obligations"),
      incorporated by reference and made a part hereof, the Department
      shall:

     

    70

    

    

    (1)
      provide the Contractor with an opportunity to cure the breach or end the
      violation, and terminate this Contract if the Contractor does not cure the
      breach or end the violation within the time specified by the Department;
      or

     

    (2)
      immediately terminate this Contract if the Contractor has breached a material
      term of the HIPAA Compliance Obligations and cure is not possible;
      or

     

    (3)
      report the violation to the Secretary of the U.S. Department of Health and
      Human
      Services, if neither termination nor cure by the Contractor is
      feasible.

     

    8.6 Automatic
      Termination.
      This
      Contract may, in the sole discretion of the Department, automatically terminate
      on a date set by the Department for any of the following reasons:

     

    (a)
      refusal by the Contractor to sign an amendment to this Contract as described
      in
      Article IX, Section 9.9(c); or

     

    (b)
      legislation or regulations are enacted or a court of competent jurisdiction
      interprets a law so as to prohibit the continuance of this Contract or the
      HFS
      Medical Program; or

     

    (c)
      funds
      become unavailable as set forth in Article VII, Section 7.7(b); or

     

    (d)
      the
      Contractor fails to maintain a Certificate of Authority, as required by Article
      II, Section 2.6.

     

    8.7 Reimbursement
      in the Event of Termination.
      In the
      event of termination of this Contract, reimbursement for any and all claims
      for
      Covered Services rendered to Enrollees prior to the effective termination date
      shall be the Contractor's responsibility.

     

    71

     

    

    

    ARTICLE
      IX 

    GENERAL
      TERMS

     

    9.1 Records
      Retention, Audits, and Reviews.
      The
      Contractor shall maintain all business, professional and other records in
      accordance with 45 C.F.R. Part 74, 45 C.F.R. Part 160 and 45 C.F.R. Part 164
      subparts A and E, the specific terms and conditions of this Contract, and
      pursuant to generally accepted accounting and medical practice. The Contractor
      shall maintain, for a minimum of six (6) years after completion of the Contract
      and after final payment is made under the Contract, adequate books, records,
      and
      supporting documents to verify the amounts, recipients, and uses of all
      disbursements of funds passing in conjunction with the Contract. If an audit,
      litigation or other action involving the records is started before the end
      of
      the six (6) year period, the records must be retained until all issues arising
      out of the action are resolved. Failure to maintain the books, records, and
      supporting documents required by this Section shall establish a presumption
      in
      favor of the State for the recovery of any funds paid by the State under the
      Contract for which adequate books, records, and supporting documentation are
      not
      available, in Illinois, to support their purported disbursement.

     

    The
      Contract and all books, records, and supporting documents related to the
      Contract shall be made available, at no charge, in Illinois, by the Contractor
      for review and audit by the Department, the United States Department of 1-Icalth
      and Human Services, the Auditor General or other Authorized Persons. The
      Contractor agrees to cooperate fully with any such review or audit and to
      provide full access in Illinois to all relevant materials.

     

    The
      Contractor shall provide any information necessary to disclose the nature and
      extent of all expenditures made under this Contract. Such information must
      be
      sufficient to fully disclose all compensation of Marketing personnel pursuant
      to
      Article V, Section 5.2(g). The Department, the Auditor General or other
      Authorized Persons may inspect and audit any financial records of the Contractor
      or its subcontractors relating to the Contractor's capacity to bear the risk
      of
      financial losses.

     

    The
      Department, the Auditor General or other Authorized Persons may also evaluate,
      through inspection or other means, the quality, appropriateness, and timeliness
      of services performed under this Contract.

     

    The
      Department shall perform quality assurance reviews to determine whether the
      Contractor is providing quality and accessible health care to Enrollces under
      this Contract. The reviews may include, but are not limited to, a sample review
      of medical records of Enrollees, Enrollee surveys and examination by consultants
      or reviews and assessments performed by the Contractor. The specific points
      of
      quality assurance which will be reviewed include, but are not limited
      to:

     

    (1)
      legibility of records

    (2)
      completeness of records

    (3)
      peer
      review and quality control provisions

    (4)
      utilization review

    (5)
      availability, timeliness, and accessibility of care

    (6)
      continuity of care

    

    

     

    72

     

    

    

    (7)
      utilization reporting

    (8)
      use
      of services

    (9)
      quality and outcomes of medical care

    (10)
      quality improvement initiatives

     

    The
      Department shall provide for an annual (as appropriate) external independent
      review of the above that is conducted by a qualified independent entity, such
      as
      the Department's EQRO.

     

    The
      Department shall adjust future payments or final payments if the findings of
      a
      Department audit indicate underpayments or overpayments to the Contractor.
      If no
      payments are due and owing to the Contractor, or if the overpaymcnt(s) exceed
      the amount otherwise due to the Contractor, the Contractor shall immediately
      refund all amounts which may be due the Department.

     

    9.2
      Nondiscrimination.

     

    (a)
      The
      Contractor shall abide by all Federal and state laws, regulations, and orders
      that prohibit discrimination because of race, color, religion, sex, national
      origin, ancestry, age, physical or mental disability, including, but not limited
      to, the Federal Civil Rights Act of 1964, the Americans with Disabilities Act
      of
      1990, the Federal Rehabilitation Act of 1973, Title IX of the Education
      Amendments of 1972 (regarding education programs and activities), the Age
      Discrimination Act of 1975, the Illinois Human Rights Act, and Executive Orders
      11246 and 11375. The Contractor further agrees to take affirmative action to
      ensure that no unlawful discrimination is committed in any manner including,
      but
      not limited to, the delivery of services under this Contract.

     

    (b)
      The
      Contractor will not discriminate against Potential Enrollees, Prospective
      Enrollees, or Enrollees on the basis of health status or need for health
      services.

     

    (c)
      The
      Contractor may not discriminate against any Provider who is acting within the
      scope of his/her liiccnsure solely on the basis of that liccnsure or
      certification.

     

    (d)
      The
      Contractor will provide each Provider or group of Providers whom it declines
      to
      include in its network written notice of the reason for its
      decision.

     

    (e)
      Nothing in subparagraph (c) or (d), above, may be construed to require the
      Contractor to contract with Providers beyond the number necessary to meet the
      needs of its enrollees; preclude the Contractor from using different
      reimbursement amounts for different specialties or for different practitioners
      in the same specialty; or preclude the Contractor from establishing measures
      that are designed to maintain quality of services and control costs and are
      consistent with its responsibilities to enrollees.

     

    9.3 Confidentiality
      of Information.
      All
      information, records, data and data elements collected and maintained for the
      operation of the Plan and pertaining to Providers, Enrollees, applicants for
      public assistance, facilities, and associations shall be protected by the
      Contractor and the Department from unauthorized disclosure, pursuant to 305
      ILCS
      5/11.9, 5/11.10, and 5/11.12; 42 U.S.C. 654(2)(b); 42 C.F.R. Part 431, Subpart
      F; and 45 C.F.R. Part 303.21.

    

     

    73

     

     

    9.4 Notices.
      Notices
      required or desired to be given either party under this Contract, unless
      specifically required to be given by a specific method, may be given by any
      of
      the following methods: 1) United States mail, certified, return receipt
      requested; 2) a recognized overnight delivery service; or 3) via facsimile.
      Notices shall be deemed given on the date sent and shall be addressed as
      follows:

     

    Contractor:
      Thad Bereday

    General
      Counsel

    Harmony
      Health Plan of Illinois, Inc.

    8735
      Hcnderson Road, Rcn 2

    Tampa.FL
      33634

    Facsimile:
      (813)290-6210

     

    With
      Copy
      to: Keith Kudia

    President,
      Illinois Operations Harmony Health Plan of Illinois, Inc.

    200
      West
      Adams Street, Suite 800 Chicago,IL 60606 Facsimile: (312)630-2022

     

    Department:
      Illinois Department ofHealthcare and Family Services Kclly Carter, Chief Bureau
      of Contract Management

    201
      South
      Grand Avenue East Springfield, Illinois 62763-0001 Facsimile: (217)
      524-7535

     

    9.5
      Required
      Disclosures.

     

    (a)
      Conflict
      of Interest.

     

    (1)
      The
      Contractor, by signing this Contract, covenants that the Contractor is not
      prohibited from contracting with State on any of the bases provided in 30 ILCS
      500/50-13. The Contractor further covenants that it neither has nor shall
      acquire any interest, public or private, direct or indirect, which conflicts
      in
      any manner with the performance of Contractor's services and obligations under
      this Contract. The Contractor further covenants that it shall not employ any
      person having such an interest in connection with the Contractors performance
      hercunder. The Contractor shall be under a continuing obligation to disclose
      any
      conflicts to the Department, which shall, in its discretion, determine whether
      any conflict is cause for the nonexecution or termination of this Contract
      and
      any amendments hereto.

     

    (2)
      The
      Contractor will provide information intended to identify any potential conflicts
      of interest regarding its ability to perform the duties of this Contract through
      the filing of a disclosure statement upon the execution of this Contract,
      annually

    

     

    74

     

    on
      or
      before the anniversary date of this Contract, and within thirty-five (35) days
      of any change occurring or of any request by the Department. The disclosure
      statement shall contain the following information:

     

    (A)
      The
      identities of any Persons that directly or indirectly provide service or
      supplies to the HFS Medical Program with which the Contractor has any type
      of
      business or financial relationship; and

     

    (B)
      A
      statement describing how the Contractor will avoid any potential conflict of
      interest with such Persons related to its duties under this
      Contract.

     

    (b)
      Disclosure
      of Interest.
      The
      Contractor shall comply with the disclosure requirements specified in 42 C.F.R.
      Part 455, including, but not limited to, filing with the Department upon the
      execution of this Contract and within thirty-five (35) days of a change
      occurring, a disclosure statement containing the following:

     

    (1)
      The
      name, FEIN and address of each Person With An Ownership Or Controlling Interest
      in the Contractor, and for individuals include home address, work address,
      date
      of birth, Social Security number and gender.

     

    (2)
      Whether any of the individuals so identified are related to another so
      identified as the individual's spouse, child, brother, sister or
      parent.

     

    (3)
      The
      name of any Person With an Ownership or Controlling Interest in the Contractor
      who also is a Person With an Ownership or Controlling Interest in another
      managed care organization that has a contract with the Department to furnish
      services under the HFS Medical Program, and the name or names of the other
      managed care organization.

     

    (4)
      The
      name and address of any Person With an Ownership or Controlling Interest in
      the
      Contractor or who is an agent or employee of the Contractor who has been
      convicted of a criminal offense related to that Person With an Ownership or
      Controlling Interest's involvement in any program under Federal law including
      any program under Titles XVIII, XIX, XX or XXI of the Social Security Act,
      since
      the inception of such programs.

     

    (5)
      Whether any Person identified in subsections (1) through (4) of this section,
      is
      currently terminated, suspended, barred or otherwise excluded from
      participation, or has voluntarily withdrawn as the result of a settlement
      agreement, in any program under Federal law including any program under Titles
      XVIII, XIX, XX or XXI of the Social Security Act or has within the last five
      (5)
      years been reinstated to participation in any program under Federal law
      including any program under Titles XVIII, XIX, XX or XXI of the Social Security
      Act and prior to said reinstatement had been terminated, suspended, barred
      or
      otherwise excluded from participation or has voluntarily withdrawn as the result
      to a settlement agreement in such programs.

     

    (6)
      Whether the Medical Director of the Plan is a Person With an Ownership or
      Controlling Interest.

     

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    9.6 CMS
      Prior Approval.
      The
      parties acknowledge that the terms of this Contract and any amendments must
      receive the prior approval of CMS, and that failure of CMS to approve any
      provision of this Contract will render that provision null and void. The parties
      understand and agree that the Department's duties and obligations under this
      Contract are contingent upon such approval.

     

    9.7 Assignment.
      This
      Contract, including the rights, benefits and duties hereunder, shall not be
      assignable by either party without the prior written consent of the other
      party.

     

    9.8 Similar Services.
      Nothing
      in this Contract shall prevent the Contractor from performing similar services
      for other parties. However, the Contractor warrants that at no time will the
      compensation paid by the Department for services rendered under this Contract
      exceed the rate the Contractor charges for the rendering of a similar benefit
      package of services to others in the Contracting Area. The Contractor also
      warrants that the services it provides to its Enrollees will be as accessible
      to
      them (in terms of timeliness, amount, duration and scope) as those services
      are
      to nonenrolled Participants within the Contracting Area.

     

    9.9
      Amendments.

     

    (a)
      This
      Contract may be modified or amended by the mutual consent of both parties at
      any
      time during its term. Amendments to this Contract must be in writing and signed
      by authorized representatives of both parties.

     

    (b)
      No
      change in, addition to or waiver of any term or condition of this Contract
      shall
      be binding on the Department or the Contractor unless approved in writing by
      authorized representatives of both parties.

     

    (c)
      The
      Contractor shall, upon request by the Department and upon receipt of a proposed
      amendment to this Contract, amend this Contract, if and when required in the
      opinion of the Department, to comply with federal or State laws or regulations.
      If the Contractor refuses to sign such amendment by the date specified by the
      Department, which may not be less than ten (10) business days after receipt,
      this Contract may terminate as provided in Article VIII, Section
      8.6(a).

     

    9.10
      Sanctions.
      In
      addition to termination for cause pursuant to Article VIII, Section 8.3(a),
      the
      Department may impose sanctions on the Contractor for the Contractor's failure
      to substantially comply with the terms of this Contract. Monetary sanctions
      imposed pursuant to this section may be collected by deducting the amount of
      the
      sanction from any payments due to the Contractor or by demanding immediate
      payment by the Contractor. The Department, at its sole discretion, may establish
      an installment payment plan for payment of any sanction. The determination
      of
      the amount of any sanction shall be at the sole discretion of the Department,
      within the ranges set forth below. Self-reporting by the Contractor will be
      taken into consideration in determining the sanction amount.

     

    76

     

    

    

    The
      Department shall not impose any sanction where the noncompliance is directly
      caused by the Department's action or failure to act or where a.
      force majeure
      delays
      performance by the Contractor. The Department, in its sole discretion, may
      waive
      the imposition of sanctions for failures that it judges to be minor or
      insignificant.

     

    Upon
      determination of substantial noncompliance, the Department shall give written
      notice to the Contractor describing the noncompliance, the opportunity to cure
      the noncompliance where a cure is allowed under this Contract and the sanction
      which the Department will impose hereunder.

     

    (a)
      Failure
      to Report or Submit.
      If the
      Contractor fails to submit any report or other material required by the Contract
      to be submitted to the Department, other than Encounter Data, by the date due,
      the Department will give notice to the Contractor of the late report or material
      and the Contractor must submit it within thirty (30) days following the notice.
      If the report or other material has not been submitted within thirty (30) days
      following the notice, the Department may, at its sole discretion, impose a
      sanction of $1,000.00 to $5,000.00 for the late report.

     

    (b)
      Failure
      to Submit Encounter Data.
      If the
      Department determines that the Contractor has not demonstrated substantial
      progress towards compliance with the requirements of Article V, Section 5.11
      (a)(l)(B) regarding Encounter Data, the Department will send the Contractor
      a
      notice of non-compliance. If the Contractor does not demonstrate substantial
      progress towards compliance with these requirements by the end of the thirty
      (30) day period following the notice, the Department, without further notice,
      may impose a sanction of $ 1,000.00 to $5,000.00. At the end of each subsequent
      period of thirty (30) days in which no demonstrated progress is made towards
      compliance, the Department may, without further notice, impose an additional
      sanction of $1,000.00 to $5,000.00.

     

    (c)
      Failure
      to Meet Minimum Standards of Care.
      If the
      Department determines that the Contractor has not demonstrated progress towards
      compliance with the requirements of Article V, Section 5.13 regarding minimum
      standards of care, the Department will send the Contractor a notice of
      noncompliance. If the Contractor does not demonstrate progress towards
      compliance with these requirements by the end of the thirty (30) day period
      following the notice, the Department, without further notice, may impose a
      sanction of $1,000.00 to $5,000.00. At the end of each subsequent period of
      thirty (30) days in which no demonstrated progress is made towards compliance,
      the Department may, without further notice, impose an additional sanction of
      $1,000.00 to $5,000.00.

     

    (d)
      Failure
      to Submit Quality and Performance Measures.
      If the
      Department determines that the Contractor has not accurately conducted and
      submitted quality and performance measures as required in Exhibit A, paragraph
      13, the Department will send the Contractor a notice of noncompliance. If the
      Contractor has not met these requirements by the end of the sixty (60) day
      period following the notice and the Department reasonably determines the failure
      is sanctionable, the Department may, without further notice, impose a sanction
      of $1,000.00 to $5,000.00 per each measure not accurately conducted or
      submitted.

     

    (e)
      Failure
      to Participate in the Performance Improvement Projects.
      If the
      Department determines that the Contractor has not fully participated in the
      Performance

     

    77

     

    

    

    Improvement
      Project, the Department will send the Contractor a notice ofnoncompliance.
      If
      the Contractor does not demonstrate progress towards substantial compliance
      with
      these requirements by the end of the thirty (30) day period following the notice
      and the Department reasonably determines the failure is sanctionable, the
      Department, without further notice, may impose a sanction of $1,000.00 to
      $5,000.00. At the end of each subsequent period of thirty (30) days in which
      no
      demonstrated progress is made towards full compliance, the Department may,
      without further notice, impose an additional sanction of $1,000.00 to
      $5,000.00.

     

    (f)
      Failure
      to Demonstrate Improvement in Areas of Deficiencies.
      If the
      Department determines that the Contractor has not made significant progress
      in
      monitoring, carrying out its quality improvement plan and demonstrating
      improvement in areas of deficiencies, as identified in its HEDIS results,
      quality monitoring, or Performance Improvement Project, the Department will
      send
      the Contractor a notice of noncompliance. If the Contractor does not demonstrate
      progress towards compliance with these requirements by the end of the thirty
      (30) day period following the notice and the Department reasonably determines
      the failure is sanctionable, the Department, without further notice, may impose
      a sanction of $1,000.00 to $5,000.00. At the end of each subsequent period
      of
      thirty (30) days in which no demonstrated progress is made towards full
      compliance, the Department may, without further notice, impose an additional
      sanction of $1,000.00 to $5,000.00.

     

    (g)
      Imposition
      of Prohibited Charges.
      If the
      Department determines that the Contractor has imposed a charge on an Enrollee
      that is prohibited by this Contract, the Department may impose a sanction of
      $1,000.00 to $5,000.00.

     

    (h)
      Misrepresentation
      or Falsification of Information.
      If the
      Department determines that the Contractor has misrepresented or falsified
      information furnished to a Potential Enrollee, Prospective Enrollee, Enrollee,
      Provider, the Department or CMS, the Department may impose a sanction of
      $1,000.00 to $5,000.00.

     

    (i)
      Failure
      to Comply with the Physician Incentive Plan Requirements.
      If the
      Department determines that the Contractor has failed to comply with the
      Physician Incentive Plan requirements of Article V, Section 5.7, the Department
      may impose a sanction of $1,000.00 to $5,000.00.

     

    (j)
      Failure
      to Meet Access and Provider Ratio Standards.
      If the
      Department determines that the Contractor has not met the Provider to Enrollee
      access standards established in Article V, Sections 5.13(e) and/or 5.17 the
      Department will send the Contractor a notice of noncompliance. If the Contractor
      has not met these requirements by the end of the thirty (30) day period
      following the notice the Department may, without further notice, (i) impose
      a
      sanction of $1,000.00 to $5,000.00, (ii) suspend enrollment of Potential
      Enrollees with the Contractor, or (iii) impose both sanctions. At the end of
      each subsequent period of thirty (30) days in which no demonstrated progress
      is
      made towards compliance, the Department may, without further notice, impose
      additional sanctions of $1,000.00 to $5,000.00.

     

    (k)
      Failure
      to Provide Covered Services.
      If the
      Department determines that the Contractor has failed to provide, or arrange
      to
      provide, a medically necessary service that the Contractor is required to
      provide under law or this Contract, the Department may (i) impose a

     

    78

    

    sanction
      of $5,000.00 to $25,000.00, (ii) suspend enrollment of Potential Enrollees
      with
      the Contractor, or (iii) impose both sanctions.

     

    (1)
      Discrimination
      Related to Pre-Existing Conditions and/or Medical History.
      If the
      Department determines that discrimination has occurred in relation to an
      Enrollee's pre-existing condition or medical history indicating a probable
      need
      for substantial medical services in the future has occurred, the Department
      may
      (i) impose a sanction of $5,000.00 to $25,000.00, (ii) suspend enrollment of
      Potential Enrollees with the Contractor or (iii) impose both
      sanctions.

     

    (m)
      Pattern
      of Marketing Failures.
      Where
      the Department determines a pattern of Marketing failures, the Department may
      (i) impose a sanction of $5,000.00 to $25,000.00, (ii) suspend enrollment of
      Potential Enrollees with the Contractor, or (iii) impose both
      sanctions.

     

    (n)
      Other
      Failures.
      If the
      Department determines that the Contractor is in substantial noncompliancc with
      any material terms of this Contract or any state or federal laws affecting
      the
      Contractors conduct under this Contract, which are not specifically enunciated
      in this Article IX but which the Department reasonably deems sanctionable,
      the
      Department shall provide written notice to the Contractor setting forth the
      specific failure or noncompliant activity. If the Contractor does not correct
      the noncompliance within thirty (30) days of the notice the Department, without
      further notice, may (i) impose a sanction of $1,000.00 to $5,000.00, (ii)
      suspend enrollment of Potential Enrollees with the Contractor, or (iii) impose
      both sanctions.

     

    9.11
      Sale
      or Transfer.
      The
      Contractor shall provide the Department with the earliest possible actual notice
      of any sale or transfer of the Contractor's business as it relates to this
      Contract. If the Contractor is otherwise subject to SEC rules and regulations,
      actual notice shall be given to the Department as soon as those SEC rules and
      regulations permit. The Department agrees that any such notice shall be held
      in
      the strictest confidence until such sale or transfer is publicly announced
      or
      consummated. The Department shall have the right to terminate the Contract
      and
      any amendments thereto, without cause, upon notification of such sale or
      transfer, in accordance with Article VIII, Section 8.3(b).

     

    9.12
      Coordination
      of Benefits for Enrollees.

     

    (a)
      The
      Department is responsible for the identification of Enrollees with health
      insurance coverage provided by a third party and ascertaining whether third
      parties are liable for medical services provided to such Enrollees. Money which
      the Department receives as a result of these collection activities shall belong
      to the Department to the extent the Department has incurred any expense or
      paid
      any claim and thereafter any excess receipts shall belong to the Contractor,
      to
      the extent the Contractor has incurred any expense or paid any claim, as
      permitted by law.

     

    (b)
      The
      Contractor will conduct a data match for the Department to identify Participants
      with active private health insurance through the Contractor. The Department
      will
      assume the reasonable and customary costs of these semi-annual matches. The
      discovery of a third party liability match will prevent the Department from
      paying premiums for recipients already covered by the Contractor. The Contractor
      will further make available to the Department

     

    79

     

    a
      contact
      person from whom the Department can request to make third party liability
      inquiries for the purpose of maintaining accurate eligibility information for
      these recipients.

     

    (c)
      Upon
      the Department's verification that an Enrollee has third party coverage for
      major medical benefits, the Department shall disenroll such Enrollee from the
      Contractor's Plan as specified in Section 6.1 of the Contract. The Capitation
      payments shall be adjusted accordingly. The Contractor shall be notified of
      the
      disenrollment on the 834 Daily File.

     

    (d)
      The
      Contractor shall report with the reported Encounter Data any and all third
      party
      liability collections it receives so the Department can offset the next month's
      Capitation payment accordingly.

     

    (e)
      The
      Contractor shall report to the Department any health insurance coverage for
      Enrollees it discovers at any time.

     

    9.13 Subrogation.
      In the
      event an Enrollee is injured by the act or omission of a third party, the
      Contractor shall have the right to pursue subrogation and recover reimbursement
      from third parties for all Covered Services the Contractor provided for Enrollee
      in exchange for the Capitation paid hereunder. Upon receiving payment from
      the
      responsible party, the Contractor shall refund to the Department the Capitation
      payment(s) received on behalf of the Enrollee for the Covered Services involved,
      and shall be entitled to retain any payments received in excess of that
      amount.

     

    9.14 Agreement
      to Obey All Laws.
      The
      Contractor's obligations and services hereunder are hereby made and must be
      performed in compliance with all applicable federal and State laws, including,
      but not limited to, applicable provisions of 45 C.F.R. Part 74 not hereto
      specified. In the provision of services under this Contract, the Contractor
      and
      its subcontractors shall comply with all applicable Federal and state statutes
      and regulations, and all amendments thereto, that are in effect when this
      Contract is signed, or that come into effect during the term of this Contract.
      This includes, but is not limited to Title XIX of the Social Security Act and
      Title 42 of the Code of Federal Regulations.

     

    9.15 Severability.
      Invalidity of any provision, term or condition of this Contract for any reason
      shall not render any other provision, term or condition of this Contract invalid
      or unenforceable.

     

    9.16 Contractor's
      Disputes With Providers.
      All
      disputes between the Contractor and any Affiliated or non-Affiliated Provider,
      or between the Contractor and any other subcontractor, shall be solely between
      such Provider or subcontractor and the Contractor except to the extent that
      the
      Department determines that the Contractor has not fulfilled its duties under
      the
      Contract.

     

    9.17 Choice
      of Law.
      This
      Contract shall be governed and construed in accordance with the laws of the
      State of Illinois. Should any provision of this Contract require judicial
      interpretation, the parties agree and stipulate that the court interpreting
      or
      considering this Contract shall not apply any presumption that the terms of
      this
      Contract shall be more strictly construed against a party who itself or through
      its agents prepared this Contract. The parties

     

    80

     

    

    

    acknowledge
      that all parties hereto have participated in the preparation of this Contract
      either through drafting or negotiation and that each party has had full
      opportunity to consult legal counsel of choice before execution of this
      Contract. Any claim against the Department arising out of this Contract must
      be
      filed exclusively with the Illinois Court of Claims (as defined in 705 ILCS
      505/1), if jurisdiction is not accepted by that court, with the appropriate
      State or federal court located in Sangamon County, Illinois. The State does
      not
      waive sovereign immunity by entering into this Contract.

     

    9.18 Debarment
      Certification.
      The
      Contractor certifies that it is not barred from being awarded a contract or
      subcontract under Section 50-5 of the Illinois Procurement Code (30 ILCS
      500/1-1).

     

    The
      Contractor certifies that it has not been barred from contracting with a unit
      of
      State or local government as a result of a violation of 720 ILCS 5/33-E3 or
      5/33-E4.

     

    9.19
      Child
      Support, State Income Tax and Student Loan
      Requirements.
      The

    Contractor
      certifies that its officers, directors and partners are not in default on an
      educational loan as provided in 5 ILCS 385/0.01 et seq., and is in compliance
      with State income tax requirements and with child support payments imposed
      upon
      it pursuant to a court or administrative order of this or any state. The
      Contractor will not be considered out of compliance with this requirement if
      (a)
      the Contractor provides proof of payment of past due amounts in full or (b)
      the
      alleged obligation of past due amounts is being contested through appropriate
      court or administrative agency proceedings and the Contractor provides proof
      of
      the pendency of such proceedings or (c) the Contractor provides proof of entry
      into payment arrangements acceptable to the appropriate State agency are entered
      into. For purposes of this paragraph, a partnership shall be considered barred
      if any partner is in default.

     

    9.20 Payment
      of Dnes and
      Fees.
      The
      Contractor certifies that it is not prohibited from selling goods or services
      to
      the State because it pays dues or fees on behalf of its employees or agents
      or
      subsidizes or otherwise reimburses them for payment of dues or fees to any
      club
      which unlawfully discriminates (see 775 ILCS 25/1-25/3).

     

    9.21 Federal
      Taxpayer Identification.
      Under
      penalties of perjury, the Contractor certifies that it has affixed its correct
      Federal Taxpayer Identification Number on the signature page of this Contract.
      The Contractor certifies that it is not: 1) a foreign corporation, partnership,
      limited liability company, estate, or trust; or 2) a nonresident alien
      individual except for those corporations registered in Illinois as a foreign
      corporation.

     

    9.22 Dru2
      Free Workplace.
      The
      Contractor certifies that it is in compliance with the requirements of 30 ILCS
      580/1 etsec[., and has completed Attachment II to this Contract.

     

    9.23 Lobbying.
      The
      Contractor certifies to the best of his knowledge and belief, that:

     

    (a)
      No
      federal appropriated funds have been paid or will be paid by or on behalf of
      the
      Contractor, to any Person 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 the awarding
      of any federal contract, the making of any federal loan or grant, the entering
      into of any cooperative agreement, or the

     

    81

    

    extension,
      continuation, renewal, amendment, or modification of any federal contract,
      grant, loan, or cooperative agreement.

     

    (b)
      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 any agency, a Member of Congress, an officer or employee of Congress, or
      an
      employee of a Member of Congress in connection with this Federal contract,
      grant, loan, or cooperative agreement, the Contractor shall complete and submit
      a Federal Standard Form LLL, "Disclosure Form to Report Lobbying," in accordance
      with its instructions. Such Disclosure Form may be obtained by request from
      the
      Illinois Department of Healthcare and Family Services, Bureau of Fiscal
      Operations.

     

    (c)
      The
      Contractor shall require that the language of this certification be included
      in
      all subcontracts and shall ensure that such subcontracts disclose
      accordingly.

     

    This
      certification is a material representation of fact upon which reliance was
      placed when this Contract was entered into. Submission of this certification
      is
      a prerequisite for making or entering into the transaction imposed by 31 U.S.C.
      §1352. Any person who fails to file the required certification shall be subject
      to a civil penalty of not less than ten thousand dollars ($10,000.00) and not
      more than one hundred thousand dollars ($100,000.00) for each such
      failure.

     

    9.24 Early
      Retirement.
      If the
      Contractor is an individual, the Contractor certifies that he has informed
      the
      director of the Department in writing if he was formerly employed by the
      Department and received an early retirement incentive under Section 14-108.3 or
      Section 16-133.3 of the Illinois Pension Code (40 ILCS 5/13 ct scq.). Contractor
      acknowledges and agrees that if such early retirement incentive was received,
      this Contract is not valid unless the official executing the Contract has made
      the appropriate filing with the Auditor General prior to execution, pursuant
      to
      30 ILCS 105/15a.

     

    9.25 Sexual
      Harassment.
      The
      Contractor shall have written sexual harassment policies that shall comply
      with
      the requirements of 75 ILCS 5/2-105.

     

    9.26 Independent
      Contractor.
      The
      Contractor is an independent contractor for all purposes under this Contract
      and
      is not a Provider as defined by the Public Aid Code and the Administrative
      Rules. Employees of the Contractor are not employees of the State of Illinois,
      and are, therefore, not entitled to any benefits provided employees of the
      State
      under the Personnel Code and regulations or other laws of the State of Illinois
      nor are they eligible for indemnity under the State Employee Indemnity Act
      (5
      ILCS 350/1 et seq.) The Contractor shall be responsible for accounting for
      the
      reporting of State and Federal Income Tax and Social Security Taxes, if
      applicable.

     

    9.27 Solicitation
      of Employees.
      The
      Contractor and the Department agree that they shall not, during the term of
      this
      Contract and for a period of one (1) year after its termination, solicit for
      employment or employ, whether as employee or independent contractor, any person
      who is or has been employed by the other during the term of this Contract,
      in a
      managerial or policy-making role relating to the duties and obligations under
      this Contract, without written notice to the other. However, should an employee
      of the Contractor, without the prior

     

    82

    

    

    knowledge
      of the management of the Department, take and pass all required employment
      examinations and meet all relevant employment qualifications, the Department
      may
      employ that individual and no breach of this Contract shall be deemed to have
      occurred. The Contractor shall immediately notify the Department's Ethics
      Officer in writing if the Contractor solicits or intends to solicit for
      employment any of the Department's employees during the term of this Contract.
      The Department will be responsible for keeping the Contractor informed as to
      the
      name and address of the Ethics Officer.

     

    9.28 Nonsolicitation.
      The
      Contractor warrants that it has not employed or retained any company or person,
      other than a bona fide employee working solely for the Contractor, to solicit
      or
      secure this Contract, and that he has not paid or agreed to pay any company
      or
      person, other than a bona fide employee working solely for the Contractor,
      any
      fee, commission, percentage, brokerage fee, gifts or any other consideration
      contingent upon or resulting from the award or making of this Contract. For
      breach or violation of this warranty, the Department shall have the right to
      annul this Contract without liability, or in its discretion, to deduct from
      compensation otherwise due the Contractor the commission, percentage, brokerage
      fee, gift or contingent fee.

     

    9.29 Ownership
      of Work Product.
      Any
      documents prepared by the Contractor solely for the Department upon the
      Department's request or as required under this Contract, shall be the property
      of the Department, except that the Contractor is hereby granted permission
      to
      use, without payment, all such materials as it may desire. Standard documents
      and reports, claims processing data and Enrollee files and information prepared
      or maintained by the Contractor in order to perform under this Contract are
      and
      shall remain the property of the Contractor, subject to applicable
      confidentiality statutes; however, the Department shall be entitled to copies
      of
      all such documents, reports or claims processing information which relate to
      Enrollees or services performed hcrcunder. In the event of any termination
      of
      the Contract, the Contractor shall cooperate with the Department in supplying
      any required data in order to ensure a smooth termination and provide for
      continuity of care of all Enrollees enrolled with the Contractor.
      Notwithstanding anything to the contrary contained in this Contract, all
      computer programs, electronic data bases, electronic data processing
      documentation and source materials collected, developed, purchased or used
      by
      the Contractor in order to perform its duties under this Contract, shall be
      and
      remain the sole property of the Contractor.

     

    9.30 Bribery
      Certification.
      By
      signing this Contract, the Contractor certifies that neither it nor any of
      its
      officers, directors, partners, or subcontractors have been convicted of bribery
      or attempting to bribe an officer or employee of the State of Illinois, nor
      has
      the Contractor, its officers, directors, or partners made an admission of guilt
      of such conduct which is a matter of record, nor has an official, agent, or
      employee of the Contractor committed bribery or attempted bribery on behalf
      of
      the Contractor, its officers, directors, partners or subcontractors and pursuant
      to the direction or authorization of any responsible official of the Contractor.
      The Contractor further certifies that it will not subcontract with any
      subcontractors who have been convicted of bribery or attempted
      bribery.

     

    9.31 Nonparticipation
      in International Boycott.
      The
      Contractor certifies that neither it nor any substantially owned Affiliated
      company is participating or shall participate in an

     

    83

    

    international
      boycott in violation of the provisions of the U.S. Export Administration Act
      of
      1979 or the regulations of the U.S. Department of Commerce promulgated under
      that Act.

     

    9.32 Computational
      Error.
      The
      Department reserves the right to correct any mathematical or computational
      error
      in payment subtotals or total contractual obligation. The Department will notify
      the Contractor of any such corrections.

     

    9.33
      Survival
      of Obligations.
      The
      Contractor's and the Department's obligations under this Contract that by their
      nature are intended to continue beyond the termination or expiration of this
      Contract will survive the termination or expiration of this
      Contract.

     

    9.34 Clean
      Air Act and Clean
      Water Act Certification.
      The
      Contractor certifies that it is in compliance 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 Department shall report violations to the United States Department
      of
      Health and Human Services and the appropriate Regional Office of the United
      States Environmental Protection Agency.

     

    9.35 Non-Waiver.
      Failure
      of either party to insist on performance of any term or condition of this
      Contract or to exercise any right or privilege hcreundcr shall not be construed
      as a continuing or future waiver of such term, condition, right, or
      privilege.

     

    9.36 Notice
      of Change in Circumstances.
      In the
      event the Contractor, its parent or related corporate entity becomes a party
      to
      any litigation, investigation, or transaction that may reasonably be considered
      to have a material impact on the Contractor's ability to perform under this
      Contract, the Contractor will immediately notify the Department in
      writing.

     

    9.37 Public
      Release of Information.
      News
      releases directly pertaining to this Contract or the services or project to
      which it relates shall not be made without prior approval by, and in
      coordination with, the Department, subject however, to any disclosure
      obligations of the Contractor under applicable law, rule or
      regulation.

     

    The
      parties will cooperate in connection with media inquiries and in regard to
      media
      campaigns or media initiatives involving this project.

     

    The
      Contractor shall not disseminate any publication, presentation, technical paper
      or other information related to the Contractor's duties and obligations under
      this Contract unless such dissemination has been approved in writing by the
      Department.

     

    9.38 Payment
      in Absence of Federal Financial Participation.
      In
      addition to any assessment of sanctions, pursuit of actual damages, or
      termination or nonextension of this Contract, if any failure of the Contractor
      to meet the requirements, including time frames, of this Contract results in
      the
      deferring or disallowance of federal funds from the State, the Department will
      withhold and retain an equivalent amount from payment(s) to the Contractor
      until
      such federal funds are released to the State (at which time the Department
      will
      release to the Contractor such funds as the Department was retaining as a result
      thereof).

     

    84

    

    

    9.39 Employment
      Reporting.
      The
      Contractor certifies that it shall comply with the requirements of 820 ILCS
      405/1801.1, concerning newly hired employees.

     

    9.40 Certification
      of Participation.

     

    (a)
      The
      Contractor certifies that neither it, nor any employees, partners, officers
      or
      shareholders owning at least five percent (5%) of said Contractor is currently
      barred, suspended or terminated from participation in the Medicaid or Medicare
      programs, nor are any of the above persons currently under sanction for, or
      serving a sentence for conviction of any Medicaid or Medicare program
      offenses.

     

    (b)
      If
      Contractor, any employee, partner, officer or shareholder owning at least five
      percent (5%) was ever (but is not currently) barred, suspended or terminated
      from participation in the Medicaid or Medicare programs or was ever sanctioned
      for or convicted of any Medicaid or Medicare program offenses, the Contractor
      must immediately report to the Department in writing, including for each
      offense, the date the offense occurred, the action causing the offense, the
      penalty or sentence assessed and the date the penalty was paid or the sentence
      completed.

     

    9.41 Indemnification.
      To the
      extent allowed by law, the Contractor and the Department agree to indemnify,
      defend and hold harmless the other party, its officers, agents, dcsignccs,
      and
      employees from any and all claims and losses accruing or resulting in connection
      with the performance of this Contract which are due to the negligent or willful
      acts or omission of the other party. In the event cither party becomes involved
      as a party to litigation in connection with services or products provided under
      this Contract, that party agrees to immediately give the other party written
      notice. The Party so notified, at its sole election and cost, may enter into
      such litigation to protect its interests.

     

    This
      indemnification is conditioned upon (1) the right of the Department or the
      Contractor when such party is the indemnifying party pursuant to this Article
      IX, Section 9.40 ("indemnifying party") to defend against any such action or
      claim and to settle, compromise or defend same in the sole discretion of the
      indemnifying party; (2) receipt of written notice by the indemnifying party
      as
      soon as practicable after the party seeking indemnification's first notice
      of an
      action or claim for which indemnification is sought hereunder; and (3) the
      full
      cooperation of the party seeking indemnification in defense or handling of
      any
      such action or claim.

     

    9.42 Gifts.

     

    (a)
      The
      Contractor and the Contractor's principals, employees, and subcontractors are
      prohibited from giving gifts to employees of the Department, and are prohibited
      from giving gifts to, or accepting gifts from, any Person who has a
      contemporaneous contract with the Department involving duties or obligations
      related to the Contract.

     

    (b)
      The
      Contractor will provide the Department with advance notice of the Contractor's
      providing gifts, excluding charitable donations, given as incentives to
      community-based organizations in Illinois and Participants or KidCare
      Participants in Illinois to assist the Contractor in carrying out its
      responsibilities under this Contract.

     

     

    85

     

    

    

    9.43
      Business
      Enterprise for Minorities, Females and Persons with
      Disabilities.

    The
      Contractor certifies that it is in compliance with 30 ILCS 575/0.01 et seq..
      and
      has completed Attachment IV.

     

    9.44 Non-Delinquency
      Certification.
      Contractor certifies that Contractor is not delinquent in the payment of any
      debt to the State and, therefore, is not barred from being awarded a contract
      under 30 ILCS 500/50-11. Contractor acknowledges that the Department may declare
      the Contract void if this certification is false, or if Contractor is determined
      to be delinquent in the payment of any debt to the State during the term of
      the
      Contract.

     

    9.45 Litigation.
      In the
      event the Contractor, its parent or related corporate entity becomes a party
      to
      litigation in any state or in federal court involving allegations of fraud
      or
      false claims, the Contractor shall immediately notify the Department in
      writing.

     

    9.46
      Insolvency.
      In the
      event the Contractor, its parent or related corporate entity becomes insolvent
      or the subject of insolvency proceedings in any state, the Contractor shall
      immediately notify the Department in writing.

     

    IN
      WITNESS WHEREOF, the Department and the Contractor hereby execute and deliver
      this Contract effective as of the Effective Date.

     

    

    
      	
              STATE
                OF ILLINOIS 

              DEPARTMENT
                OF HEALTHCARE AND FAMILY SERVICES

            
	
              By:
                /s/ Barry Maram   

              Barry
                S. Maram, Director

              Date:
                July 26, 2006

               

            
	
              HARMONY
                HEALTH PLAN OF ILLINOIS, INC.

            
	
              By:
                /s/ Todd Farha     

            
	
              Title:
                President & CEO

            
	
              Date:
                July 21, 2006

            
	
              FEIN:
                36-4050495

            

    

     

    86

     

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    

    ATTACHMENT
      I 

    RATE
      SHEETS

    (a)
      Contractor Name: Harmony Health Plan of Illinois, Inc.

    Address:
      200 West Adams Street Chicago, IL 60606

     

    (b)
      Contracting Area(s) Covered by the Contractor and Enrollment Limit:

     

    
      	
              Contracting
                Area

            	
              Enrollment
                Limit

            
	
               

              Region
                III - St. Clair, Madison, Perry, Randolph, and Washington
                Counties

            	
               

              50,000

            
	
               

              Region
                IV

            	
               

              100,000

            

    

     

    (c)
      Total
      Enrollment Limit for all Contracting Areas: 150,000

     

    (e)
      Standard Capitation Rates for Enrollees, effective
      August 1, 2006
      through
      July 31, 2008:*

     

    
      	
              Age/Gender
                

              Mo
                = month 

              Yr
                =
                year

            	
              Region
                I (N.W.
                Illinois) 

              PMPM

            	
              Region
                II (Central Illinois) PMPM

            	
              Region
                III (Southern Illinois) PMPM

            	
              Region
                IV (Cook County) PMPM

            	
              Region
                V (Collar Counties) PMPM

            
	
               

              0-3Mo

            	
               

              $1,290.99

            	
               

              $1
                047.86

            	
               

              $1,214.79

            	
               

              $1,383.98

            	
               

              $1,008.88

            
	
               

              4Mo-lYr

            	
               

              $122.07

            	
               

              $124.58

            	
               

              $147.56

            	
               

              $139.60

            	
               

              $131.27

            
	
               

              2Yr-5Yr

            	
               

              $51.37

            	
               

              $55.46

            	
               

              $64.68

            	
               

              $59.00

            	
               

              $49.44

            
	
               

              6Yr-13Yr

            	
               

              $43.52

            	
               

              $50.34

            	
               

              $55.12

            	
               

              $43.63

            	
               

              $40.03

            
	
               

              14Yr-20Yr,
                Male

            	
               

              $75.31

            	
               

              $83.05

            	
               

              $78.87

            	
               

              $64.90

            	
               

              $82.39

            
	
               

              14Yr-20Y,
                Female

            	
               

              $117.55

            	
               

              $118.15

            	
               

              $136.31

            	
               

              $100.33

            	
               

              $98.16

            
	
               

              21Yr-44Yr,Male

            	
               

              $114.27

            	
               

              $136.04

            	
               

              $123.73

            	
               

              $127.39

            	
               

              $166.05

            
	
               

              2
                lYr-44Yr, Female

            	
               

              $157.98

            	
               

              $157.44

            	
               

              $166.17

            	
               

              $149.48

            	
               

              $151.36

            
	
               

              45Yr+
                Male and Female

            	
               

              $227.11

            	
               

              $255.07

            	
               

              $256.05

            	
               

              $239.45

            	
               

              $253.90

            

    

    *
      Capitation rates listed are 100% of actuarially certified rates, but only 99.5%
      will be paid in year one of the Contract and 99% in year two of the Contract
      in
      accordance with Section 7.8.

     

    (f)
      Hospital Delivery Case Rate, effective
      August 1,2006
      through
      July 31,2008:

     

    
      	
               

              Hospital
                Delivery Case Rate (per delivery)

            	
               

              $3,501.90

            	
               

              $3,424.73

            	
               

              $3,591.08

            	
               

              $3,977.36

            	
               

              $3,645.96

            

    

     

    II-1

     

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    

    ATTACHMENT
      II 

    DRUG
      FREE WORKPLACE AGREEMENT

     

    The
      Contractor certifies that he/she/it will not engage in the unlawful manufacture,
      distribution, dispensation, possession, or use of a controlled substance in the
      performance of the Contract.

     

    CHECK
      THE
      BOX THAT APPLIES:

     

    
      	 ̈  	
              This
                business or corporation does not have twenty-five (25) or more
                employees.

            

    

     

    
      	x  	
              This
                business or corporation has twenty-five (25) or more employees, and
                the
                Contractor certifies and agrees that it will provide a drug free
                workplace
                by:

            

    

     

    A)
      Publishing a statement:

     

    1)
      Notifying employees that the unlawful manufacture, distribution, dispensation,
      possession or use of a controlled substance, including cannabis, is prohibited
      in the grantee's or Contractor's workplace.

     

    2)
      Specifying the actions that will be taken against employees for violations
      of
      such prohibition.

     

    3)
      Notifying the employees that, as a condition of employment on such contract,
      the
      employee will:

     

    a)
      abide
      by the terms of the statement; and

     

    b)
      notify
      the employer of any criminal drug statute conviction for a violation occurring
      in the workplace no later than five (5) days after such conviction.

     

    B)
      Establishing a drug free awareness program to inform employees
      about:

     

    1)
      the
      dangers of drug abuse in the workplace;

     

    2)
      the
      Contractor's policy of maintaining a drug free workplace;

     

    3)
      any
      available drug counseling, rehabilitation, and employee assistance programs;
      and

     

    4)
      the
      penalties that may be imposed upon an employee for drug violations.

     

    C)
      Providing a copy of the statement required by subparagraph (a) to each employee
      engaged in the performance of the contract or grant and to post the statement
      in
      a prominent place in the workplace.

     

    II-2

    

    

    D)
      Notifying the contracting or granting agency within ten (10) days after
      receiving notice under part (B) or paragraph (3) of subsection (a) above from
      an
      employee or otherwise receiving actual notice of such conviction.

     

    E)
      Imposing a sanction on, or requiring the satisfactory participation in a drug
      abuse assistance or rehabilitation program by, any employee who is so convicted,
      as required by section 5 of the Drug Free Workplace Act, 1992 Illinois Compiled
      Statute, 30 ILCS 580/5.

     

    F)
      Assisting employees in selecting a course of action in the event drug
      counseling, treatment, and rehabilitation is required and indicating that a
      trained referral team is in place.

     

    G)
      Making
      a good faith effort to continue to maintain a drug free workplace through
      implementation of me Drug Free Workplace Act, 1992 Illinois Compiled Statute,
      30
      ILCS 580/1 et
      seq.

     

    

     

    THE
      UNDERSIGNED AFFIRMS, UNDER PENALTIES OF PERJURY, THAT HE OR SHE IS AUTHORIZED
      TO
      EXECUTE THIS CERTIFICATION ON BEHALF OF THE DESIGNATED
      ORGANIZATION.

     

    

    
      	
              Harmony
                Health Plan of Illinois, Inc.

              Printed
                Name of Organization

            
	
               

              /s/
                Todd S. Farha

              Signature
                of Authorized Representative

            
	
              _______________________________

              Requisition/Contract/Grant
                ID Number

            
	
               

              Todd
                Farha, President and CEO

              Printed
                Name and Title

            
	
               

              July
                21, 2006

              Date

            
	 

    

     

     

    II-3

     

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    

    ATTACHMENT
      III 

    HIPAA
      COMPLIANCE OBLIGATIONS

     

    A.
      Definitions.

     

    (1)
      "Designated Record Set" shall have the same meaning as the term "designated
      record set" in 45 C.F.R. 164.501.

     

    (2)
      "HIPAA" means the federal Health Insurance Portability and Accountability Act,
      Public Law 104-191.

     

    (3)
      "Individual" shall have the same meaning as the term "individual" in 45 C.F.R.
      164.501 and shall include a person who qualifies as a personal representative
      in
      accordance with 45 C.F.R. 164.502(g).

     

    (4)
      "PHI"
      means Protected Health Information, which shall have the same meaning as the
      term "protected health information" in 45 C.F.R. 164.501, limited to the
      information created or received by the Contractor/Provider from or on behalf
      of
      the Department.

     

    (5)
      "Privacy Rule" shall mean the Standards for Privacy of Individually Identifiable
      Health Information at 45 C.F.R. Part 160 and 45 C.F.R. Part 164 subparts A
      and
      E.

     

    (6)
      "Required by law" shall have the same meaning as the term "required by law"
      in
      45 C.F.R. 164.501.

     

    B.
      Contractor's
      Permitted Uses and Disclosures.

     

    (1)
      Except as otherwise limited by this Contract, the Contractor may use or disclose
      PHI to perform functions, activities, or services for, or on behalf of, the
      Department as specified in this Contract, provided that such use or disclosure
      would not violate the Privacy Rule if done by the Department.

     

    (2)
      Except as otherwise limited by this Contract, the Contractor may use PHI for
      the
      proper management and administration of the Contractor or to carry out the
      legal
      responsibilities of the Contractor.

     

    (3)
      Except as otherwise limited by this Contract, the Contractor may disclose PHI
      for the proper management and administration of Contractor, provided that the
      disclosures are required by law, or the Contractor obtains reasonable assurances
      from the person to whom the PHI is disclosed that the PHI will remain
      confidential and used or further disclosed only as required by law or for the
      purpose for which it was disclosed to the person. The Contractor shall require
      the person to whom the PHI was disclosed to notify the Contractor of any
      instances of which the person is aware in which the confidentiality of the
      PHI
      has been breached.

     

    III-l

     

    

    

    (4)
      Except as otherwise limited by this Contract, the Contractor may use PHI to
      provide data aggregation services to the Department as permitted by 45 C.F.R.
      164.504(e)(2)(i)(B).

     

    (5)
      The
      Contractor may use PHI to report violations of law to appropriate federal and
      state authorities, consistent with 45 C.F.R. 164.502(j)(l).

     

    C.
      Limitations
      on the Contractor's Uses and Disclosures.
      The
      Contractor shall:

     

    (6)
      Not
      use or further disclose PHI other than as permitted or required by the Contract
      or as required by law;

     

    (7)
      Use
      appropriate safeguards to prevent use or disclosure of PHI other than as
      provided for by this Contract;

     

    (8)
      Mitigate, to the extent practicable, any harmful effect that is known to the
      Contractor of a use or disclosure of PHI by the Contractor in violation of
      the
      requirements of this Contract;

     

    (9)
      Report to the Department any use or disclosure of PHI not provided for by this
      Contract of which the Contractor becomes aware;

     

    (10)
      Ensure that any agents, including a subcontractor, to whom the Contractor
      provides PHI received from the Department or created or received by the
      Contractor on behalf of the Department, agree to the same restrictions and
      conditions that apply through this Contract to the Contractor with respect
      to
      such information;

     

    (11)
      Provide access to PHI in a Designated Record Set to the Department or to another
      individual whom the Department names, in order to meet the requirements of
      45
      C.F.R. 164.524, at the Department's request, and in the time and manner
      specified by the Department.

     

    (12)
      Make
      available PHI in a Designated Record Set for amendment and to incorporate any
      amendments to PHI in a Designated Record Set that the Department directs or
      that
      the Contractor agrees to pursuant to 45 C.F.R. 164.526 at the request of the
      Department or an individual, and in a time and manner specified by the
      Department;

     

    (13)
      Make
      the Contractor's internal practices, books, and records, including policies
      and
      procedures and PHI, relating to the use and disclosure of PHI received from
      the
      Department or created or received by the Contractor on behalf of the Department
      available to the Department and to the Secretary of Health and Human Services
      for purposes of determining the Department's compliance with the Privacy
      Rule;

     

    (14)
      Document disclosures of PHI and information related to disclosures of PHI as
      would be required for the Department to respond to a request by an individual
      for an accounting of disclosures of PHI in accordance with 45 C.F.R.
      165.528;

     

    III-2

     

    

    

    (15)
      Provide to the Department or to an individual, in a time and manner specified
      by
      the Department, information collected in accordance with the terms of this
      Contract to permit the Department to respond to a request by an individual
      for
      an accounting of disclosures of PHI in accordance with 45 C.F.R.
      165.528;

     

    (16)
      Return or destroy all PHI received from the Department or created or received
      by
      the Contractor on behalf of the Department that the Contractor still maintains
      in any form, and to retain no copies of such PHI, upon termination of this
      Contract for any reason. If such return or destruction is not feasible, the
      Contractor shall provide the Department with notice of such purposes that make
      return or destruction infeasible, and upon the parties' written agreement that
      return or destruction is infeasible, the Contractor shall extend the protections
      of the Contracts to the PHI and limit further uses and disclosures to those
      purposes that make the return or destruction of the PHI infeasible. This
      provision shall apply equally to PHI that is in the possession of the Contractor
      and to PHI that is in the possession of subcontractors or agents of the
      Contractors.

     

    D.
      Department
      Obligations.
      The
      Department shall:

     

    (17)
      Provide the Contractor with the Department's Notice of Privacy Practices and
      notify the Contractor of any changes to said Notice;

     

    (18)
      Notify the Contractor of any changes in or revocation of permission by an
      individual to use or disclose PHI, to the extent that such changes may affect
      the Contractor's permitted or required uses and disclosures of PHI;

     

    (19)
      Notify the Contractor of any restriction to the use or disclosure of PHI that
      the Department had agreed to in accordance with 45 C.F.R. 165.522, to the extent
      that such restriction may affect the Contractor's use or disclosure of
      PHI;

     

    (20)
      Not
      request that the Contractor use or disclose PHI in any manner that would not
      be
      permissible under the Privacy Rule if done by the Department.

     

    E.
      Interpretation.
      Any
      ambiguity in this Contract shall be resolved in favor of a meaning that permits
      the Department to comply with the Privacy Rule.

     

    III-3

     

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    

    ATTACHMENT
      IV 

    BUSINESS
      ENTERPRISE PROGRAM CONTRACTING GOAL

     

    The
      Business Enterprise Program Act for Minorities, Females and Persons with
      Disabilities (30 ILCS 575/1) establishes a goal that not less than 12% of the
      total dollar amount of State contracts be awarded to businesses owned and
      controlled by persons who arc minority, female or who have disabilities (the
      percentages are 5%/5%/2% respectively) and have been certified as such ("BEPs").
      This goal can be met by contracts let directly to such businesses by the State,
      or indirectly by the State's contractor ordering goods or services from BEPs
      when suppliers or subcontractors are needed to fulfill the contract. Call the
      Business Enterprise Program at 312/814-4190 (Voice & TDD), 800/356-9206
      (Toll Free), or 800/526-0844 (Illinois Relay Center for Hearing Impaired) for
      a
      list of certified businesses appropriate for the particular
      contract.

     

    1.
      If you
      are a BEP, please identify which agency certified the business and in what
      capacity by checking the applicable blanks:

     

    
      	
              Certifying
                Agency:

            	
              Capacity

            
	
              __
                Department of Central Management Services 

            	
              __
                Minority

            
	
              __
                Women's Business Development Center 

            	
              __
                Female

            
	
              __
                Chicago Minority Business Development Council 

            	
              __
                Person with Disability

            
	
              __
                Illinois Department of Transportation 

            	
              __
                Disadvantaged

            
	
              __
                Other (identify)

            	 

    

     

    2.
      If the
      "Capacity" blank is not checked, do you have a written policy or goal regarding
      contracting with BEPs?

     

    Yes
      __ No
T

     

    •
If
      "Yes", please attach a copy.

     

    •
If
      "No", will you make a commitment to contact BEPs and consider their
      proposals?

     

    Yes
      T
      No __

    Will
      consider offers

     

    3.
      Do you
      plan on ordering supplies or services in furtherance of this project from
      BEPs?

     

    Yes
      __ No
T

     

    •
If
      "Yes", please identify what you plan to order, the estimated value as a
      percentage of your total proposal, and the names of the BEPs you plan to
      use.

     

    This
      information is submitted on behalf of____________________________

    (Name
      of
      Vendor) 

     

    
      	
              Name
                (printed): Todd Farha

            
	
              Title:
                President and CEO

            
	
              Signature:
                /s/
                Todd S. Farha

            
	
              Date:
                July 21, 2006

            

    

    

     

    IV-1

     

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    

    EXHIBIT
      A 

    QUALITY
      ASSURANCE (QA)

     

    1.
      All
      services provided by or arranged by the Contractor to be provided shall be
      in
      accordance with prevailing professional community standards. The Contractor
      shall establish a program that systematically and routinely collects data to
      review that includes quality oversight and monitoring performance and patient
      results. The program shall include provision for the interpretation of such
      data
      to the Contractor's practitioners. The program shall be designed to perform
      quantitative and qualitative analytical activities to assess opportunities
      to
      improve efficiency, effectiveness, appropriate health care utilization and
      health status and shall be updated no less frequently than annually. The
      Contractor shall ensure that data received from Providers and included in
      reports is accurate and complete by (1) verifying the accuracy and timeliness
      of
      reported data; (2) screening the data for completeness, logic, and consistency;
      and (3) collecting service information in standardized formats to the extent
      feasible and appropriate. The Contractor shall have in effect a program
      consistent with the utilization control requirements of 42 C.F.R. Part 456.
      This
      program will include, when required by the regulations, written plans of care
      and certifications of need of care.

     

    2.
      The
      Contractor shall establish procedures such that the Contractor shall be able
      to
      demonstrate that it meets the requirements of the HMO Federal qualification
      regulations (42 C.F.R. 417.106) and/or the Medicare HMO/CMP regulations (42
      C.F.R. 417.418(c)), as well as the regulations promulgated pursuant to the
      Balanced Budget Act of 1997 (42 C.F.R. 438.200 et seq.). These regulations
      require that the Contractor have an ongoing fully implemented Quality Assurance
      program for health services that:

     

    a.
      incorporates practice guidelines that meet the following criteria, and are
      distributed to Affiliated Providers, as appropriate, and to Enrollees and
      Potential Enrollees, upon request:

    i.
      are
      based on valid and reliable clinical evidence or a consensus of Providers in
      the
      particular field;

    ii.
      consider the needs of Enrollees;

    iii.
      are
      adopted in consultation with Affiliated Providers; and 

    iv.
      are
      reviewed and updated periodically as appropriate.

     

    b.
      Monitors the health care services the Contractor provides, including assessing
      the appropriateness and quality of care;

     

    c.
      stresses health outcomes;

     

    d.
      provides review by Physicians and other health professionals of the process
      followed in the provision of health services;

     

    e.
      includes fraud control provisions;

     

    A-l

     

    

    

    f.
      establishes and monitors access standards;

     

    g.
      uses
      systematic data collection of performance and patient results, provides
      interpretation of these data to its practitioners (including, without
      limitation, patient-specific and aggregate data provided by the Department,
      such
      as childhood immunization data, pregnancy status and/or child profile
      information), and institutes needed changes; and

     

    h.
      includes written procedures for taking appropriate remedial action whenever,
      as
      determined under the quality assurance program, inappropriate or substandard
      services have been furnished or services that should have been furnished have
      not been provided.

     

    3.
      The
      Contractor shall provide to the Department a written description of its Quality
      Assurance Plan (QAP) for the provision of clinical services (e.g., medical,
      medically related services and behavioral health services). This written
      description must meet federal and State requirements:

     

    a.
      Goals
      and objectives — The written description shall contain a detailed set of QA
      objectives that are developed annually and include a workplan and timetable
      for
      implementation and accomplishment.

     

    b.
      Scope
— The scope of the QAP shall be comprehensive, addressing both the quality of
      clinical care and the quality of non-clinical aspects of service, such as and
      including: availability, accessibility, coordination, and continuity of
      care.

     

    c.
      Methodology — The QAP methodology shall provide for review of the entire range
      of care provided, by assuring that all demographic groups, care settings, (e.g.,
      inpaticnt, ambulatory, and home care), and types of services (e.g., preventive,
      primary, specialty care, behavioral health and ancillary services) are included
      in the scope of the review. Documentation of the monitoring and evaluation
      plan
      shall be provided to Department.

     

    d.
      Activities — The written description shall specify quality of care studies and
      other activities to be undertaken over a prescribed period of time, and
      methodologies and organizational arrangements to be used to accomplish them.
      Individuals responsible for the studies and other activities shall be clearly
      identified in the written workplan and shall be appropriately skilled or trained
      to undertake such tasks. The written description shall provide for continuous
      performance of the activities, including tracking of issues over
      time.

     

    e.
      Provider review — The written description shall document how Physicians licensed
      to practice medicine in all its branches and other health professionals will
      be
      involved in reviewing quality of care and the provision of health services
      and
      how feedback to health professionals and the Contractor staff regarding
      performance and patient results will be provided.

     

    f.
      Focus
      on health outcomes — The QAP methodology shall address health outcomes; a
      complete description of the methodology shall be fully documented and provided
      to Department.

     

    A-2

     

    

    

    g.
      Systematic process of quality assessment and improvement — The QAP shall
      objectively and systematically monitor and evaluate the quality, appropriateness
      of, and timely access to, care and service to members, and pursue opportunities
      for improvement on an ongoing basis. Documentation of the monitoring activities
      and evaluation plan shall be provided to the Department.

     

    4.
      The
      Contractor shall provide the Department with the QAP written guidelines which
      delineate the QA process, specifying:

     

    a.
      Clinical areas to be monitored:

     

    i.
      The
      monitoring and evaluation of clinical care shall reflect the population served
      by the Contractor in terms of age groups, disease categories, and special risk
      status, and shall include quality improvement initiatives, as determined
      appropriate by the Contractor or as required by the Department.

     

    ii.
      The
      QAP shall, at a minimum, monitor and evaluate care and services in certain
      priority clinical areas of interest specified by the Department.

     

    iii.
      At
      its discretion and/or as required by the Department, the Contractor's QAP must
      monitor and evaluate other important aspects of care and service.

     

    iv.
      At a
      minimum, the following areas shall be monitored:

     

    (a)
      for
      pregnant women:

     

    (1)
      number of prenatal visits;

    (2)
      provision of ACOG recommended prenatal screening tests;

    (3)
      neonatal deaths;

    (4)
      birth
      outcomes;

    (5)
      length ofhospitalization for the mother; and

    (6)
      length of newborn hospital stay for the infant.

     

    (b)
      for
      children:

     

    (1)
      number of well-child visits appropriate for age;

    (2)
      immunization status;

    (3)
      lead
      screening status;

    (4)
      number of hospitalizations;

    (5)
      length of hospitalizations; and

    (6)
      medical management for a limited number of medically complicated conditions
      as
      agreed to by the Contractor and Department.

     

    (c)
      for
      adults:

     

    (1)
      preventive health care (e.g., initial health history and physical exam;
      mammography; papanicolaou smear).

     

    A-3

     

    

    

    (d)
      for
      medically complicated conditions/chronic care (such conditions specifically
      including, without limitation, diabetes and asthma):

     

    (1)
      appropriate treatment, follow-up care, and coordination of care for Enrollees
      of
      all ages; and

    (2)
      identification of Enrollees with special health care needs and processes in
      place to assure adequate, ongoing assessments, treatment plans developed with
      the Enrollcc's participation in consultation with any specialists caring for
      the
      Enrollee, the appropriateness and quality of care, and if approval is required,
      such approval occurs in a timely manner.

    (3)
      case
      management plan; and

    (4)
      chronic care action plan.

     

    (e)
      for
      behavioral health:

     

    (1)
      behavioral health network adequate to serve the behavioral health care needs
      of
      Enrollees, including services specifically for Enrollees under age 21 and
      pregnant women;

    (1)
      enrollcc access to timely behavioral health services;

    (2)
      an
      individualized plan or treatment and provision of appropriate level of
      care;

    (3)
      coordination of care between the CBHPs, MCO behavioral health subcontractor
      or
      internal program and the PCP;

    (4)
      provision of follow up services and continuity of care

    (5)
      involvement of the PCP in aftercare;

    (6)
      member satisfaction with access to and quality of behavioral health services;
      and behavioral health service utilization.

     

     

    b.
      Use of
      Quality Indicators — Quality indicators are measurable variables relating to a
      specified clinical area, which are reviewed over a period of time to monitor
      the
      process of outcomes of care delivered in that clinical area:

     

    i.
      The
      Contractor shall identify and use quality indicators that are objective,
      measurable, and based on current knowledge and clinical experience.

     

    ii.
      The
      Contractor shall document that methods and frequency of data collected are
      appropriate and sufficient to detect need for program change.

     

    iii.
      For
      the priority clinical areas specified by Department, the Contractor shall
      monitor and evaluate quality of care through studies which address, but are
      not
      limited to, the quality indicators also specified by Department.

     

    A-4

     

    

    

    c.
      Analysis of clinical care and related services, including behavioral health
      services:

     

    i.
      Appropriate clinicians shall monitor and evaluate quality through review of
      individual cases where there are questions about care, and through studies
      analyzing patterns of clinical care and related service.

     

    ii.
      Multi
      disciplinary teams shall be used, where indicated, to analyze and address
      systems issues.

     

    iii.
      Clinical and related service areas requiring improvement shall be identified
      and
      documented with a corrective action plan developed and monitored.

     

    d.
      Conduct Quality Improvement Projects - Quality Improvement Projects shall be
      designed to achieve, through ongoing measurements and intervention, significant
      improvement of the quality of care rendered, sustained over time, and resulting
      in a favorable effect on health outcome and Enrollee satisfaction. Performance
      measurements and interventions shall be submitted to the Department annually
      as
      part of the QA/UR/PR Annual Report and at other times throughout the year upon
      request by the Department. If the Contractor implements a Quality Improvement
      Project that spans more than one (1) year, the Contractor shall report annually
      the status of such project and the results thus far.

     

    e.
      Implementation of Remedial/Corrective Actions — The QAP shall include written
      procedures for taking appropriate remedial action whenever, as determined under
      the QAP, inappropriate or substandard services are furnished, including in
      the
      area of behavioral health, or services that should have been furnished were
      not.
      Quality assurance actions that result in remedial or corrective actions shall
      be
      forwarded by the Contractor to the Department on a timely basis.

     

    Written
      remedial/corrective action procedures shall include:

     

    i.
      specification of the types of problems requiring remedial/corrective
      action;

     

    ii.
      specification of the person(s) or body responsible for making the final
      determinations regarding quality problems;

     

    iii.
      specific actions to be taken;

     

    iv.
      a
      provision for feedback to appropriate health professionals, providers and
      staff;

     

    v.
      the
      schedule and accountability for implementing corrective actions;

     

    vi.
      the
      approach to modifying the corrective action if improvements do not occur;
      and

     

    vii.
      procedures for notifying a Primary Care Provider group that a particular
      Physician licensed to practice medicine in all its branches is no longer
      eligible to provide services to Enrollees.

     

    A-5

     

     

    f.
      Assessment of Effectiveness of Corrective Actions — The Contractor shall monitor
      and evaluate corrective actions taken to assure that appropriate changes have
      been made. The Contractor shall assure follow-up on identified issues to ensure
      that actions for improvement have been effective and provide documentation
      of
      same.

     

    g.
      Evaluation of Continuity and Effectiveness of the QAP:

     

    i.
      The
      Contractor shall conduct a regular (minimum annual) examination of the scope
      and
      content of the QAP to ensure that it covers all types of services, including
      behavioral health services, in all settings, as required.

     

    ii.
      At
      the end of each year, a written report on the QAP shall be prepared by the
      Contractor and submitted to the Department as a component part of the QA/UR/PR
      Annual Report identified in Exhibit
      C,
      which
      report shall include, without limitation:

     

    (a)
      QA/UR/PR Plan

     

    (1)
      Summary of Quality Assurance, Utilization Review, and Peer Review (QA/UR/PR)
      activities during the fiscal year;

    (2)
      Summary of changes in QA/UR/PR Plan that will be reflected in the next fiscal
      year;

    (3)
      Areas
      of deficiency and recommendations for corrective action;

    (4)
      Evaluation of the overall effectiveness of the QAP; and

    (5)
      Detailed Workplan for the next fiscal year

     

    (b)
      Provider Network Adequacy — Application of a geographical mapping software that
      has been approved by the Department, and identifies and evaluates
      network:

     

    (1)
      PCPs;

    (2)
      WHCPs;

    (3)
      Specialists;

    (4)
      Pharmacies;

    (5)
      Tertiary care facilities (i.e., perinatal and children's
      hospitals);

    (6)
      Ancillary services; and

    (7)
      Behavioral health network

     

    The
      report shall include all Providers and each Provider's admitting and, as
      appropriate, delivery privileges at Affiliated or nearby hospitals or, in the
      alternative, if the Provider does not have

     

    A-6

     

    

    

    such
      admitting and/or delivery privileges, a detailed description of the written
      referral agreement with a Provider who is in the Contractor's network and who
      has such privileges at an Affiliated or nearby hospital. The report shall also
      include the updated Provider Directory and a summary of
      credentialing/recredentialing and peer review activities.

     

    (c)
      Outreach and Health Education

     

    (1)
      Summary and outcomes of outreach activities; and

    (2)
      Description of health education initiatives during fiscal year

     

    (d)
      Coordination with Other Service Providers and Care Coordination
      Activities

     

    (1)
      Description of coordination with other service providers; and

     

    (2)
      Description of care coordination initiatives and outcomes

     

    (e)
      Studies, Outcomes, and Relevant Statistics

     

    (1)
      Results of medical record reviews and quality studies;

    (2)
      Performance Improvement Projects results;

    (3)
      Contractor's progress toward meeting the Department's preventive care
      participation goals as set forth in Article V, Section 5.12 (a), (b), and (c)
      of
      the Contract;

    (4)
      Aggregated data on utilization of services;

    (5)
      HED1S
      or Department-defined reporting;

    (6)
      Trending and comparison of health outcomes;

    (7)
      Outcomes of A-3 iv(a), A-3 iv(b), A-3 iv(c), A-3 iv(d), and A-3
      iv(e);

    (8)
      Enrollee Satisfaction Survey analysis; and

    (9)
      Description of the way in which Department-generated data supplied to the
      Contractor was utilized, accurate, and effective in
      developing ongoing quality improvement strategies.

     

    (f)
      Summary of Quality Improvement Activities

     

    (1)
      Quality indicators and methodologies for measuring quality
      indicators;

    (2)
      Quality improvement activities implemented;

    (3)
      Results and demonstrated improvements; and

    (4)
      Quality improvement ongoing workplan, including goals and
      objectives.

     

    A-7

     

     

    (g)
      Monitoring of Delegated Activities

     

    (1)
      Description of the Contractor's oversight and monitoring activities, including
      a
      summary of findings relative to each subcontractor's ability to perform the
      required functions;

    (2)
      Summary of deficiencies and quality improvement activities developed as a result
      of the ongoing monitoring and periodic formal reviews, including the workplan
      for implementation of the QI activities;

    (3)
      Workplan for MCO monitoring of its subcontractors, including schedule for formal
      reviews

     

    5.
      The
      Contractor shall have a governing body to which the QAP shall be held
      accountable ("Governing Body"). The Governing Body of the Contractor shall
      be
      the Board of Directors or, where the Board's participation with quality
      improvement issues is not direct, a designated committee of the senior
      management of the Contractor. This Board of Directors or Governing Body shall
      be
      ultimately responsible for the execution of the QAP. However, changes to the
      medical quality assurance program shall be made by the chair of the QA
      Committee.

     

    Responsibilities
      of the Governing Body include:

     

    a.
      Oversight of QAP — The Contractor shall document that the Governing Body has
      approved the overall QAP and an annual QA plan.

     

    b.
      Oversight Entity — The Governing Body shall document that it has formally
      designated an accountable entity or entities within the organization to provide
      oversight of QA, or has formally decided to provide such oversight as a
      committee of the whole.

     

    c.
      QAP
      Progress Reports — The Governing Body shall routinely receive written reports
      from the QAP describing actions taken, progress in meeting QA objectives, and
      improvements made.

     

    d.
      Annual
      QAP Review — The Governing Body shall formally review on a periodic basis (but
      no less frequently than annually) a written report on the QAP which
      includes:

    studies
      undertaken, results, subsequent actions, and aggregate data on utilization
      and
      quantity of services rendered, to assess the QAP's continuity, effectiveness
      and
      current acceptability. Behavioral health shall be included in the Annual QAP
      Review.

     

    e.
      Program Modification — Upon receipt of regular written reports from the QAP
      delineating actions taken and improvements made, the Governing Body shall take
      action when appropriate and direct that the operational QAP be modified on
      an
      ongoing basis to accommodate review findings and issues of concern within the
      Contractor. This activity shall be documented in the minutes of the meetings
      of
      the Governing Board in sufficient detail to demonstrate that it has directed
      and
      followed up on necessary actions pertaining to Quality Assurance.

     

    A-8

     

    6.
      The
      QAP shall delineate an identifiable structure responsible for performing QA
      functions within the Contractor. This committee or other structure shall
      have:

     

    a.
      Regular Meetings — The structure/committee shall meet on a regular basis with
      specified frequency to oversee QAP activities. This frequency shall be
      sufficient to demonstrate that the structure/committee is following-up on all
      findings and required actions, but in no case shall such meetings be held less
      frequently than quarterly. A copy of the meeting summaries/minutes shall be
      submitted to the Department no later than thirty (30) days after the close
      of
      the quarterly reporting period.

     

    b.
      Established Parameters for Operating — The role, structure and function of the
      structure/committee shall be specified.

     

    c.
      Documentation — There shall be records kept documenting the
      structure's/committee's activities, findings, recommendations and
      actions.

     

    d.
      Accountability — The QAP committee shall be accountable to the Governing Body
      and report to it (or its designee) on a scheduled basis on activities, findings,
      recommendations and actions.

     

    e.
      Membership — There shall be active participation in the QA committee from Plan
      Providers, who are representative of the composition of the Plan's Providers.
      There shall be a majority of Contractor-Affiliated practicing Physicians
      licensed to practice medicine in all its branches.

     

    7.
      There
      shall be a designated senior executive who will be responsible for program
      implementation. The Contractor's Medical Director shall have substantial
      involvement in QA activities and shall be responsible for the required
      reports.

     

    a.
      Adequate Resources — The QAP shall have sufficient material resources, and staff
      with the necessary education, experience, or training, to effectively carry
      out
      its specified activities.

     

    b.
      Provider Participation in the QAP -

     

    i.
      Participating Physicians licensed to practice medicine in all its branches
      and
      other Providers shall be kept informed about the written QA plan.

     

    ii.
      The
      Contractor shall include in all its Provider subcontracts and employment
      agreements a requirement securing cooperation with the QAP for both Physicians
      licensed to practice medicine in all its branches and non-physician
      Providers.

     

    iii.
      Contracts shall specify that hospitals and other subcontractors will allow
      access to the medical records of its Enrollees to the Contractor.

     

    A-9

     

    

    

    8.
      The
      Contractor shall remain accountable for all QAP functions, even if certain
      functions are delegated to other entities. If the Contractor delegates any
      QA
      activities to subcontractors:

     

    a.
      There
      shall be a written description of the following: the delegated activities;
      the
      delegate's accountability for these activities; and the frequency of reporting
      to the Contractor.

     

    b.
      The
      Contractor shall have written procedures for monitoring and evaluating the
      implementation of the delegated functions and for verifying the actual quality
      of care being provided.

     

    c.
      There
      shall be evidence of continuous and ongoing evaluation of delegated activities,
      including approval of quality improvement plans and regular specified reports,
      as well as a formal review of such activities conducted on no less than an
      annual basis.

     

    d.
      If the
      Contractor or subcontractor identifies deficiencies or areas requiring
      improvement, the Contractor and subcontractor shall take corrective action
      and
      implement a quality improvement initiative, as appropriate.

     

    9.
      The
      QAP shall contain provisions to assure that Physicians licensed to practice
      medicine in all its branches and other health care professionals, who are
      licensed by the State and who are under contract with the Contractor, are
      qualified to perform their services and credentialed by the Contractor.
      Recredcntialing shall occur at least once every three (3) years. The
      Contractor's written policies shall include procedures for selection and
      retention of Physicians and other Providers.

     

    10.
      The
      Contractor shall put a basic system in place which promotes continuity of care
      and case management. The Contractor shall provide documentation on:

     

    a.
      Monitoring the quality of care across all services and all treatment
      modalities.

     

    b.
      Studies, reports, protocols, standards, worksheets, minutes, or such other
      documentation as may be appropriate, concerning its QA activities and corrective
      actions and make such documentation available to the Department upon
      request.

     

    11.
      The
      findings, conclusions, recommendations, actions taken, and results of the
      actions taken as a result of QA activity, shall be documented and reported
      to
      appropriate individuals within the organization and through the established
      QA
      channels. The Contractor shall document coordination ofQA activities and other
      management activities.

     

    a.
      QA
      information shall be used in recredentialing, recontracting and/or annual
      performance evaluations.

     

    b.
      QA
      activities shall be coordinated with other performance monitoring activities,
      including utilization management, risk management, and resolution and monitoring
      of member complaints and grievances.

     

    A-10

    

    

    c.
      There
      shall be a linkage between QA and the other management functions of the Plan
      such as:

     

    i.
      network changes;

     

    ii.
      benefits redesign;

     

    iii.
      medical management systems (e.g., pre-certification);

     

    iv.
      practice feedback to Physicians licensed to practice medicine in all its
      branches; and

     

    v.
      patient education.

    

     

    d.
      In the
      aggregate, without reference to individual Physicians licensed to practice
      medicine in all its branches or Enrollee identifying information, all Quality
      Assurance findings, conclusions, recommendations, actions taken, results or
      other documentation relative to QA shall be reported to Department on a
      quarterly basis or as requested by the Department. The Department shall be
      notified of any Physician licensed to practice medicine in all its branches
      terminated from a subcontract with the Contractor for a quality of care
      issue.

     

    12.
      The
      Contractor shall, at the direction of the Department, cooperate with the
      external, independent quality review process conducted by the EQRO. The
      Contractor shall address the findings of the external review through its Quality
      Assurance program by developing and implementing performance improvement goals,
      objectives and activities, which shall be documented in the next quarterly
      report submitted by the Contractor following the EQRO's findings.

     

    13.
      The
      Contractor shall perform and report the quality and utilization measures
      identified in the following chart using a complete HEDIS study, as directed
      by
      the Department. The Contractor shall not modify the reporting methodology
      prescribed by the Department without first obtaining the Department's written
      approval. The Contractor must obtain an independent validation of its HEDIS
      findings by a recognized entity, e.g., NCQA-certified auditor, as approved
      by
      the Department.

     

    
      	
              Beginning
                Contract Year

            	
              Indicator

            	
              Methodology

            
	
              Year
                l

            	
              Effectiveness
                of Care: Childhood Immunization Status

            	
              HEDIS

            
	
              Year
                l

            	
              Effectiveness
                of Care: Breast Cancer Screen

            	
              HEDIS

            
	
              Year
                l

            	
              Effectiveness
                of Care: Cervical Cancer Screening

            	
              HEDIS

            
	
              Year
                l

            	
              Effectiveness
                of Care: Use of Appropriate Medications for Enrollees with
                Asthma

            	
              HEDIS

            
	
              Year
                l

            	
              Effectiveness
                of Care: Comprehensive Diabetes Care

            	
              HEDIS

            
	
              Year
                l

            	
              Effectiveness
                of Care: Controlling High Blood Pressure

            	
              HEDIS

            

    

     

    A-ll

     

    

    

    
      	
               Beginning
                Contract Year

            	
               Indicator

            	
               Methodology

            
	
              Year
                l

            	
              Effectiveness
                of Care: Chlamydia Screening in Women

            	
              HEDIS

            
	
              Year
                l

            	
              Effectiveness
                of Care: Medical Assistance with Smoking Cessation

            	
              HEDIS

            
	
              Year
                l

            	
              Effectiveness
                of Care: Follow-up after hospitalization
                for mental illness

            	
              HEDIS

            
	
              Year
                l

            	
              Access/Availability
                of Care: Prenatal and Postpartum Care

            	
              HEDIS

            
	
              Year
                l

            	
              Access/Availability
                of Care: Adult access to Preventive/Ambulatory Health
                Services

            	
              HEDIS

            
	
              Year
                l

            	
              Access/Availability
                of Care: Initiation and Engagement of Alcohol and Other Drug Dependence
                Treatment

            	
              HEDIS

            
	
              Year
                l

            	
              Use
                of Services: Well Child Visits during first 15 months of
                life

            	
              HEDIS

            
	
              Year
                l

            	
              Use
                of Services: Well Child Visits in the Third, Fourth, Fifth, and Sixth
                years of life

            	
              HEDIS

            
	
              Year
                l

            	
              Use
                of Services: Adolescent Well Care Visits

            	
              HEDIS

            
	
              Year
                l

            	
              Use
                of Services; Frequency of Ongoing Prenatal Care

            	
              HEDIS

            
	
              Year
                l

            	
              Use
                of Services: Births and Average Length of Stay,
                Newborns

            	
              HEDIS

            
	
              Year
                1

            	
              Use
                of Services: Discharges and Average Length of Stay - Maternity
                Care

            	
              HEDIS

            
	
              Year
                1

            	
              Use
                of Services: Mental Health Utilization (percentage ofEnrollees receiving
                inpatient, day/night, and ambulatory services)

            	
              HEDIS

            
	
              Year
                l

            	
              Use
                of Services: Mental Health Utilization (inpatient discharges and
                average
                length of stay)

            	
              HEDIS

            
	
              Year
                l

            	
              Use
                of Services: Chemical Dependency Utilization (inpatient discharges
                and
                average length of stay)

            	
              HEDIS

            
	
              Year
                l

            	
              Enrollee
                Satisfaction Surveys for Adults and Children

            	
              HEDIS
                CAHPS 3.OH

            
	
              Year
                2

            	
              Effectiveness
                of Care: Adolescent Immunization Status

            	
              HEDIS

            
	
              Year
                2

            	
              Effectiveness
                of Care: Appropriate Treatment for Children with Upper Respiratory
                Infection

            	
              HEDIS

            
	
              Year
                2

            	
              Effectiveness
                of Care; Antidepressant Medication Management

            	
              HEDIS

            
	
              Year
                2

            	
              Access/Availability
                of Care: Children and Adolescents' access to Primary Care
                Providers

            	
              HEDIS

            
	
              Year
                2

            	
              Use
                of Services: Childhood Lead Screening

            	
              HEDIS
                or Department-defined

            
	
              Year
                2

            	
              Use
                of Services: Outpatient Drug Utilization

            	
              HEDIS

            

    

     

    A-12

     

    

    

    
      	
               Beginning Contract
                Year

            	  Indicator	  Methodology
	
              Year
                2

            	
              Use
                of Services: Inpatient Utilization - General Hospital/Acute
                Care

            	
              HEDIS

            
	
              Year
                2

            	
              Use
                of Services: Ambulatory Care

            	
              HEDIS

            
	
              Year
                2

            	
              Use
                of Services: Frequency of Selected Procedures

            	
              HEDIS

            
	
              Year
                2

            	
              Identification
                of Alcohol and Other Drug Services

            	
              HEDIS

            
	
              Year
                2

            	
              Descriptive
                Information: Board Certification

            	
              HEDIS

            
	
              Year
                2

            	
              Descriptive
                Information: Weeks of Pregnancy at Time of Enrollment in
                MCO

            	
              HEDIS

            

    

     

    14.
      The
      Contractor shall monitor other performance measures as required by CMS in
      accordance with notification by the Department.

     

    A-13

     

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    

    EXHIBIT
      B UTILIZATION REVIEW/PEER REVIEW

     

    1.
      The
      Contractor shall have a utilization review and peer review committee(s) whose
      purpose will be to review data gathered and the appropriateness and quality
      of
      care. The committee(s) shall review and make recommendations for changes when
      problem areas are identified and report suspected Fraud and Abuse in the HFS
      Medical Program to the Department's Office of Inspector General. The committees
      shall keep minutes of all meetings, the results of each review and any
      appropriate action taken. A copy of the minutes shall be submitted to the
      Department no later than thirty (30) days after the close of the quarterly
      reporting period. At a minimum, these programs must meet all applicable federal
      and State requirements for utilization review. The Contractor and Department
      may
      further define these programs.

     

    2.
      The
      Contractor shall implement a Utilization Review Plan, including peer review.
      The
      Contractor shall provide the Department with documentation of its utilization
      review process. The process shall include:

     

    a.
      Written program description — The Contractor shall have a written utilization
      management program description which includes, at a minimum, procedures to
      evaluate medical necessity criteria used and the process used to review and
      approve the provision of medical services.

     

    b.
      Scope
— The program shall have mechanisms to detect under-utilization as well as
      over-utilization.

     

    c.
      Preauthorization and concurrent review requirements — For organizations with
      preauthorization and concurrent review programs:

     

    i.
      Have
      in effect mechanisms to ensure consistent application of review criteria for
      authorization decisions;

     

    ii.
      Utilize practice guidelines that have been adopted, pursuant to Exhibit
      A

     

    iii.
      review decisions shall be supervised by qualified medical professionals and
      any
      decision 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 health
      care professional who has appropriate clinical expertise in treating the
      Enrollee's condition or disease;

     

    iv.
      efforts shall be made to obtain all necessary information, including pertinent
      clinical information, and consultation with the treating Physician licensed
      to
      practice medicine in all its branches as appropriate;

     

    v.
      the
      reasons for decisions shall be clearly documented and available to the Enrollee
      and the requesting Provider, provided, however, that any decision to
      deny

     

    B-l

    

    

    a
      service
      request or to authorize a service in an amount, duration or scope that is less
      than requested shall be furnished in writing to the Enrollee;

     

    vi.
      there
      shall be written well-publicized and readily available appeals mechanisms for
      both Providers and patients;

     

    vii.
      decisions and appeals shall be made in a timely manner as required by the
      circumstances of the situation and shall be made in accordance with the
      timeframes specified in the Contract for standard and expedited
      authorizations;

     

    viii.
      there shall be mechanisms to evaluate the effects of the program using data
      on
      member satisfaction, provider satisfaction or other appropriate
      measures;

     

    ix.
      if
      the organization delegates responsibility for utilization management, it shall
      have mechanisms to ensure that these standards are met by the
      delegate.

     

    3.
      The
      Contractor further agrees to review the utilization review procedures, at
      regular intervals, but no less frequently than annually, for the purpose of
      amending same, as necessary in order to improve said procedures. All amendments
      must be approved by the Department. The Contractor further agrees to supply
      the
      Department and/or its designce with the utilization information and data, and
      reports prescribed in its approved utilization review system or the status
      of
      such system. This information shall be furnished upon request by the
      Department.

     

    4.
      The
      Contractor shall establish and maintain a peer review program approved by the
      Department to review the quality of care being offered by the Contractor,
      employees and subcontractors. This program shall provide, at a minimum, the
      following:

     

    a.
      A peer
      review committee comprised of Physicians licensed to practice medicine in all
      its branches, formed to organize and proceed with the required reviews for
      both
      the health professionals of the Contractor's staff and any contracted Providers
      which include:

     

    i.
      A
      regular schedule for review;

     

    ii.
      A
      system to evaluate the process and methods by which care is given;
      and

     

    iii.
      A
      medical record review process.

     

    b.
      The
      Contractor shall maintain records of the actions taken by the peer review
      committee with respect to providers and those records shall be available to
      the
      Department upon request.

     

    c.
      A
      system of internal medical review, including behavioral health services, medical
      evaluation studies, peer review, a system for evaluating the processes and
      outcomes of care, health education, systems for correcting deficiencies, and
      utilization review.

     

    B-2

     

    

    

    d.
      At
      least two medical evaluation studies must be completed yearly that analyze
      pressing problems identified by the Contractor, the results of such studies
      and
      appropriate action taken. One of the studies may address an administrative
      problem noted by the Contractor and one may address a clinical problem or
      diagnostic category. One brief follow-up study shall take place for each medical
      evaluation study in order to assess the actual effect of any action taken.
      The
      Department must approve the Contractor's medical evaluation studies'topic and
      design.

     

    e.
      The
      Contractor shall participate in the annual collaborative Performance Improvement
      Project, as mutually agreed upon and directed by the Department.

     

    5.
      The
      Contractor further agrees to review the peer review procedures, at regular
      intervals, but no less frequently than annually, for the purpose of amending
      same in order to improve said procedures. All amendments must be approved by
      the
      Department. The Contractor further agrees to supply the Department and/or its
      designee with the information and reports related to its peer review program
      upon request.

     

    6.
      The
      Department may request that peer review be initiated on specific
      providers.

     

    7.
      The
      Department will conduct its own peer reviews at its discretion.

     

    B-3

     

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    

    EXHIBIT
      C 

    SUMMARY
      OF REQUIRED REPORTS AND SUBMISSIONS

     

    Report
      names, information submission requirements and corresponding frequencies are
      listed herein. These shall be due to the Department no later than thirty (30)
      days after the close of the reporting period unless otherwise stated. Reports
      and submissions include hard copy reports and/or any electronic medium as
      designated by the Department.

     

    Report
      frequencies are defined as follows:

     

    Annually
      - The State fiscal year of July 1 - June 30. 

    Quarterly
      - The last day of the fiscal quarter grouped as: J/A/S (1stqtr),
      O/N/D
      (2ndqtr),
      J/F/M
      (3rd qtr),
      and
      A/M/J (4th qtr).
      

    Monthly
      -
      The last day of a calendar month.

    

    
      	
              Name
                of Report/Submission

               

            	
              Frequency

            	
              HFS
                Prior Approval

            
	
              Administrative

            	 	 
	
              Disclosure
                Statements

            	
              Initially,
                Annually, on request and as changes occur

            	
              No

            
	
              Encounter
                Data Report

            	
              At
                least monthly

            	
              No

            
	
              Financial
                Reports

            	
              Concurrent
                with submissions to Department of Financial and Professional
                Regulation

            	
              No

            
	
              Report
                of Transactions with Parties of Interest

            	
              Annually

            	
              No

            
	
              Electronic
                Data Certification

            	
              Monthly,
                no later than 5 days after the close of the reporting
                month

            	
              No

            
	
               

              Enrollee
                Materials

            	 	 
	
              Certificate
                or Document of Coverage and Any Changes or Amendments

            	
              Initially
                and as revised

            	
              Yes

            
	
              Enrollee
                Handbook

            	
              Initially
                and as revised 

            	
              Yes

            
	
              Identification
                Card 

            	
              Initially
                and as revised 

            	
              Yes
                

            
	
              Provider
                Directory

            	
              Initially
                and annually

            	
              Yes
                (only initially)

            
	 	 	 

    

     

     

     

    C-l

    

    
      	
              Name
                of Report/Submission

            	
              Frequency

            	
              HFS
                Prior Approval

               

            
	
              Fraud/Abuse

            	 	 
	
              Fraud
                and Abuse Report

            	
              Immediately
                upon identification or N/A knowledge of suspected Fraud or Abuse;
                and
                quarterly as specified in Section 5.25.

            	
              N/A

            
	
              Marketing

            	 	 
	
              Marketing
                Allegation Investigation Disclosure

            	
              Monthly,
                on the first day of each month

            	
              No

            
	
              Marketing
                Allegation Notification

            	
              Weekly

            	
              No

            
	
              Marketing
                Gifts and Incentives

            	
              Initially
                and upon request

            	
              Yes

            
	
              Marketing
                Materials

            	
              Initially
                and as revised

            	
              Yes

            
	
              Marketing
                Plans and Procedures

            	
              Initially
                and as revised

            	
              Yes

            
	
              Marketing
                Representative Listing

            	
              Monthly,
                on the first day of each month

            	
              No

            
	
              Marketing
                Representative Termination Notification

            	
              As
                they occur

            	
              No

            
	
              Marketing
                at Site Permission Statement

            	
              Annually

            	
              No

            
	
              Marketing
                at Site Schedule

            	
              Monthly,
                on the first day of each month, and as revised

            	
              No
                

            
	
              Marketing
                Schedule at Retail Locations

            	
              Monthly,
                on the first day of each No month, and as cancellations occur during
                the
                month

            	
              No

            
	
              Marketing
                Training Manuals

            	
              Initially
                and as revised

            	
              Yes

            

    

    

    

    C-2

     

     

    
      	
              Name
                of Report/Submission

            	
              Frequency

            	
              HFS
                Prior Approval

               

            
	
              Marketing
                Training Schedule and Agenda

            	
              Quarterly,
                2 weeks prior to the No beginning of each quarter, and as
                revised

            	
              No

            
	
              Provider
                Network

            	 	 
	
              PCP
                and Affiliated Specialist File (electronic)

            	
              Monthly
                and daily updates and only when changes occur

            	
              Yes

            
	
              Affiliated
                Hospital File (electronic)

            	
              Monthly

            	
              Yes

            
	
              Enrollee
                Site Transfer

            	
              As
                each occurs

            	
              No

            
	
              New
                Site Provider Affiliation File (electronic)

            	
              Initially,
                and as new sites/PCPs are Yes added

            	
              Yes

            
	
              Provider
                Affiliation with Site Report

            	
              Montly,
                on the first day of each month

            	
              No

            
	
              Site/PCP
                Approvals (paper format-A&B forms)

            	
              Initially,
                and as new sites/PCPs are added

            	
              Yes

            
	
              Site
                Terminations

            	 	
              No

            
	
              Quality
                Assurance/Medical

            	 	 
	
              Grievance
                Procedures

            	
              Initially,
                and as revised

            	
              Yes

            
	
              PCP
                Ratio Report

            	
              Quarterly

            	
              N/A

            
	
              QA/UR/PR
                Annual Report

            	
              Annually,
                no later than 60 days after close of reporting period

            	
              N/A

            
	
              QA/UR/PR
                Committee Meeting Minutes

            	
              Quarterly

            	
              No

            
	
              Behavioral
                Health Report

            	
              Quarterly,
                no later than 60 days after close of reporting period

            	
              N/A

            
	
              Quality
                Assurance, Utilization Review and Initially and as 

              revised
                Peer Review Plan (includes health education plan)

            	
              Initially
                and as revised

            	
              Yes

            

    

     

    

     

    C-3

     

    

    
      	
              Name
                of Report/Submission

            	
              Frequency

            	
              HFS
                Prior Approval

            
	
              Summary
                of Grievances or Appeals and Resolutions and External Independent
                Reviews
                and Resolutions

            	
              Quarterly

            	
              N/A

            
	
              Case
                Management Enrollees

            	
              Monthly,
                no later than 5 days after the close of the reporting
                month

            	
              No

            
	
              Case
                Management Program Report

            	
              Initially
                and annually

            	
              Yes

            
	
              Case
                Management Enrollees

            	
              Montly
                no later than 5 days after the close of the reporting
                month

            	
              No

            
	
              CSHCN
                Program Report

            	
              Initially
                and annually

            	
              Yes

            
	
              Subcontracts
                and Provider Agreements

            	 	 
	
              Copies
                of Executed Subcontractor agreements

            	
              Upon
                request

            	
              N/A

            
	
              Model
                Subcontractor Agreements

            	
              Initially
                and as revised

            	
              N/A

            

    

     

    

     

    C-4

     

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    

    EXHIBIT
      D

     

    Data
      Telecommunication Configuration Requirements

     

    Third
      Party Network (TPN) or Internet Connection

     

    The
      line
      connection to the Illinois Department of Central Management Services (DCMS)
      data
      center must either be through the private State telecommunications network
      to
      the DCMS Third Party Network (TPN) or through a secure connection via the
      Internet. The secure connection over the Internet will be via Site-to-Site
      Virtual Private Network (VPN).

     

    Private
      State Telecommunications Network Requirements

     

    If
      the
      Vendor chooses to connect through the private State telecommunications network,
      the Department must submit the orders to DCMS for processing, design,
      installation and configuration of the connection for the Vendor. The Vendor
      must
      supply information concerning the circuit termination point, on-site contact,
      and other information required for the order to be submitted to DCMS for
      processing and installation by the appropriate DCMS contractor. The Vendor
      must
      provide authorized Department personnel access to the location and the phone
      demark for the location where the circuit is to be installed.

     

    Internet
      Site-to-Site VPN Requirements

     

    If
      the
      Vendor chooses to connect through secure connections via the Internet, the
      connection must be made using Site-to-Site VPN. In this type of connection,
      the
      Vendor will be responsible for the cost of the connection between the Vendor
      and
      it's Internet Service Provider (ISP), troubleshooting and any redundancy
      requirements associated with the Vendor's connection to the Internet or for
      disaster recovery.

     

    The
      Department will coordinate with the Vendor to ensure that any
      authorization/certificate paperwork required for the establishment of the VPN
      connection is completed.

     

    DCMS
      currently utilizes a Cisco PIX model 520 firewall to provide VPN connections
      to
      the DCMS data center. For VPN authentication, DCMS uses "pre-shared keys".
      DCMS
      performs a Network Address Translation (NAT) of all external addresses to make
      the connection conform to its IP addressing structure. Only STATIC IP addresses,
      no subnet pool addresses, from the Vendor's network are allowed by
      DCMS.

     

    DCMS
      Supported Encryption Configurations

     

    Phase
      1
      IKE Properties (ISAKMP Protection Suites)

     

    •
      Encryption Algorithm:

     

    •
      Triple-DES (3DES) supported only.

     

    D-l

     

    

    

    •
Data
      Integrity:

     

    •
Hashing
      Algorithm: SHA or MD5 supported (SHA is preferred)

     

    •
      Diffie-Hellman Group: Group 2 supported only.

     

    •
      Security Association Lifetime: 86400 seconds

     

    Phase
      2
      IPSEC Properties:

     

    •
      Encryption Algorithm:

     

    •
      Triple-DES (3DES) supported only.

     

    •
Data
      Integrity:

     

    •
Hashing
      Algorithm: SHA or MD5 supported (SHA is preferred)

     

    •
Perfect
      Forward Secrecy: Disabled

     

    Exchanging
      Configuration Information

     

    The
      Department will work with the Vendor to determine the configuration and define
      any connection parameters between the Vendor and the DCMS data center. This
      will
      include any security requirements DCMS requires for the specific connection
      type
      the Vendor is using. The Vendor is required to work with both the Department
      and
      DCMS in exchanging configuration information required to make the connection
      secure and functional for all parties.

     

    Transmission
      Control Protocol/Internet Protocol
      (TCP/IP)

     

    The
      Vendor shall cooperate in the coordination of the interface with DCMS and the
      Department. TCP/IP (Transmission Control Protocol/Internet Protocol) must be
      used for all connections from the Vendor to the DCMS data center.

     

    Firewall
      Devices

     

    The
      Vendor shall be responsible for the installation, configuration, and
      troubleshooting of any firewall devices required on the Vendor's side of the
      data communication link.

     

    D-2

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