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exhibit10-1.htm

     

      

    

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8-K

    Exhibit
10.1

    
      MISCELLANEOUS/CONSULTANT
SERVICES

    

    
      (Award
Without Formal Request For Proposal)

    

    
      

    

    
      	
              
                STATE
      AGENCY

              

              New
      York State Department of Health

              Child
      Health Plus Program

              
                ESP
      - Corning Tower - Room 1619

              

              
                Albany,
      NY 12237

              

               

            	
              
                 

                NYS COMPTROLLER'S NUMBER:
      C022813

              

               

              ORIGINATING
      AGENCY CODE: 12000

            
	
              
                CONTRACTOR
      (Name and Address):

              

              
                Wellcare
      of New York, Inc.

              

              
                11
      West 19th Street

              

              
                New
      York,  NY 10011

              

               

            	
              
                TYPE
      OF PROGRAM(S):

              

              
                 

              

              
                Child
      Health Plus Program

              

               

            
	
              CHARITIES
      REGISTRATION NUMBER

              N/A

               

              FEDERAL
      TAX IDENTIFICATION NUMBER

              14-167443

               

              MUNICIPALITY
      NO. (if applicable)

              n/a

               

            	
              
                CONTRACT
      TERM

              

               

              FROM:
      January 1, 2008 TO:  December
      31,2012

               

              
                FUNDING AMOUNT FOR CONTRACT
      TERM:        $97,398,000.00

              

               

            
	
              STATUS:

              CONTRACTOR
      IS (  ) IS NOT (  ) A SECTARIAN ENTITY

               

              CONTRACTOR
      IS (  ) IS NOT (  ) A NOT-FOR-PROFIT
      ORGANIZATION

               

              CONTRACTOR
      IS ( x ) IS NOT (  ) A NY STATE BUSINESS
    ENTERPRISE

            	
              IF
      MARKED HERE, THIS CONTRACT'S RENEWABLE FOR 5
        ADDITIONAL ONE-YEAR PERIOD(S) AT THE SOLE OPTION OF THE
      STATE AND SUBJECT TO APPROVAL OF THE OFFICE OF THE STATE
      COMPTROLLER

            
	 
      	 
      

    

    
      

    

    
      APPENDICES
ATTACHED AND PART OF THIS AGREEMENT

    

    
      

    

    
      	
              -X-

            	
              APPENDIX
      A     Standard Clauses as required by the
      Attorney General for all State contracts.

            
	
              -X-

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

            
	
              ___

            	
              APPENDIX
      Q     Modification of Standard Department of
      Health Contract Language

            
	
              -X-

            	
              STATE
      OF NEW YORK AGREE MENT

            
	
              -X-

            	
              APPENDIX
      C     Program Specific
    Requirements

            
	
              -X-

            	
                APPENDIX
      E-l   Proof of Workers'
      Compensation  coverage

            
	
              -X-

            	
              APPENDIX
      E-2   Proof of Disability Insurance
  Coverage

            
	
              -X-

            	
              APPENDIX
      H     Federal Health Insurance Portability and
      Accountability Act ("HIPAA") Business Associate Agreement
      ("Agreement")

            
	
              ___

            	
              APPENDIX
      M    Multi-year Contact Language

            
	
              ___

            	
              APPENDIX-
      ____   :

            

    

    
      

    

    
      

        
          
             

          

          
             

            
              

            

          

          
             

          

        

    

    
      

    

    
      

    

    
      

    

    
      

    

    
      

    

    
      

    

    
      IN
WITNESS THEREOF, the parties hereto have executed or approved this AGREEMENT on
the dates below their signatures.

    

    

    
      	
              
                 

                CONTRACTOR

              

               

            	
              STATE
      AGENCY

            
	
              BY:   /s/   Todd
      S. Farha

            	
              BY:  
      /s/  Judith
      Arnold

            
	
              Todd
      S. Farha

               

            	
              Judith
      Arnold

            
	
              Title:
      President & CEO

               

               

            	
              Title:
      Director

              Division
      of Coverage and Enrollment

              Office
      of Health Insurance Programs

               

            
	
              Date:
      12/19/07

            	
              Date:
      12/21/07

            
	 
      	
              
                 

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

              

               

            
	 
      	 
      
	 
      	 
      

    

    
      

      On
the 19th
Day of December
in the year 2007, before me, the
undersigned,  personally appeared Todd S. Farha, personally known to
me or proved to me on the basis of satisfactory evidence to be the individual(s)
whose name(s) is(are) subscribed to the within instrument and acknowledged to me
that he/she/they executed the same in his/her/their/ capacity(ies), and that by
his/her/their signature(s) on the instrument, the individual(s), or the person
upon behalf of which the individual(s) acted, executed the
instrument.

    

    
       

    

    
        /s/  Sara
Gallo

    

    
      (Signature
and office of the individual taking acknowledgement)

    

    
      

       

    

    
      	
              
                ATTORNEY
      GENERAL'S SIGNATURE

                STAMP

                APPROVED AS TO
      FORM NYS ATTORNEY GENERAL

                Lorraine
      Remo

              

            	
              STATE
      COMPTROLLER’S SIGNATURE

                /s/  Illegible 
       

            
	
              Title: 
      Associate Attorney

            	
              Title:

            
	
              Date:
      2/12/08

            	
              Date:
      3/7/08

            

    

    
      

      

        
          
             

          

          
             

            
              

            

          

          
             

          

        

    

    
      STATE OF
NEW YORK

    

    
      AGREEMENT

    

    
      

       

      This
AGREEMENT is hereby made by and between the State of New York agency (STATE) and
the public or private agency (CONTRACTOR) identified on the face page
hereof.

    

    
      

       

      WITNESSETH:

    

    
      

       

      WHEREAS,
the STATE has determined that it is in need of the services described in
Appendix C; and

    

    
      

       

      WHEREAS
the CONTRACTOR covenants that it is willing and able to undertake the services
and provide the necessary materials, labor and equipment in connection
therewith;

    

    
      

       

      NOW
THEREFORE, in consideration of the promises, responsibilities and covenants
herein, the STATE and the CONTRACTOR hereby agree as follows:

    

    
      

       

      I. Conditions
of Agreement

    

    
      

       

      A. This
AGREEMENT incorporates the face pages attached and all of the marked appendices identified on
the face page hereof.

    

    
      

       

      B. The
maximum compensation for the contract term of this AGREEMENT shall not exceed the amount
specified on the face page hereof.

    

    
      

       

      C. This
AGREEMENT may be renewed for additional periods (PERIODS), as specified on the face page
hereof.

    

    
      

       

      D. To
exercise any renewal option of this AGREEMENT, the parties shall prepare
new appendices, to
the extent that any require modification, and a Modification Agreement (the attached
Appendix X is the blank form to be used). Any terms of this AGREEMENT not modified,
shall remain in effect for each PERIOD of the AGREEMENT.

    

    
      

       

      The
modification agreement is subject to the approval of the Office of the State
Comptroller.

    

    
      

       

      E. Appendix
A (Standard Clauses as required by the Attorney General for all State Contracts) takes
precedence over all other parts of the AGREEMENT.

    

    
      

       

      F. For
the purposes of this AGREEMENT, the term "Proposal" includes all Appendix C documents as marked on
the face page hereof.

    

    
      

       

      II. Payment
and Reporting

    

    
      

       

      A.  The
CONTRACTOR shall submit invoices to the STATE'S designated payment office:

      NYS Child
Health Plus Program 

      Corning
Tower, Room 1656 

      Empire
State Plaza 

      Albany,
NY 12237 

       

      B. Payment
of such invoices by the State (NYS Department of Health) shall be made in
accordance with Article XI-A of the New York State Finance Law. Payment terms
will be:

    

    
      

       

      3

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      On a
monthly basis, the CONTRACTOR shall download the standard voucher through the
Health Provider Network (HPN) which reflects information contained in the
Knowledge, Information and Data System (KIDS). Such voucher shall be submitted
no later than the 10* business day of the month for which payment is being
claimed.

    

    
       

      III. Term
of Contract

    

    
       

      A. Upon
approval of the NYS Office of the State Comptroller, this AGREEMENT shall be
effective for the
term as specified on the cover page.

    

    
       

      B. This
agreement may be cancelled at any time by the STATE giving to the CONTRACTOR
not less than
thirty (30) days written notice that on or after a date therein specified this
agreement shall be
deemed terminated and cancelled.

    

    
       

      IV. 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:

    

    
       

      Workers'
Compensation, for which one of the following is incorporated into this contract
as Appendix E-l:

    

    
       

      o WC/DB-100, Affidavit For New
York Entities And Any Out-Of-State Entities With No Employees, That New York
State Workers' Compensation And/Or Disability Benefits Insurance Coverage Is Not
Required; OR

       

    

    
      o WC/DB-101, 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;
OR

       

    

    
      o C-10S.2 - Certificate of Workers' Compensation
Insurance. PLEASE NOTE: The State Insurance Fund provides its own version of
this form, the U-26.3; OR

       

    

    
      o SI-12 - Certificate of Workers' Compensation
Self-Insurance, OR GSI-105.2
- Certificate of Participation in Workers' Compensation Group
Self-Insurance.

    

    
      

    

    
      Disability
Benefits coverage, for which one of the following is incorporated into this
contract as Appendix E-2:

    

    
       

      o WC/DB-100, Affidavit For New
York Entities And Any Out-Of-State Entities With No Employees, That New York
State Workers' Compensation And/Or Disability Benefits Insurance Coverage Is Not
Required; OR

    

    
       

      o
WC/DB-101, 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; OR

    

    
       

      o
DB-120.1 - Certificate of Disability Benefits Insurance OR the DB-820/829
Certificate/Cancellation of Insurance; OR

    

    
       

      o  DB-155 - Certificate of
Disability Benefits Self-Insurance

    

    
      

       

      4

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      V.  General
Specifications

    

    
      

       

      A. The
work shall be commenced and shall be actually undertaken within such time
as the
Department of Health may direct by notice, whether by mail, telegram, or other
writing, whereupon the CONTRACTOR will give continuous attention to the work as
directed, to the end and with the intent that the work shall be completed within
such reasonable time or times, as the case may be, as the Department may
prescribe.

    

    
      

       

      B. The
Department reserves the right to stop the work covered by this contract at any
time that the Department of Health
deems the CONTRACTOR to be unable or incapable of performing the work to the satisfaction
of the Department of Health and in the event of such cessation of work, the Department of Health
shall have the right to arrange for the completion of the work in such manner as it may deem
advisable and if the cost thereof exceeds the amount of this contract, the CONTRACTOR shall be
liable to the State of New York for any such cost on account
thereof.

    

    
      

       

      C. 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 contract will possess the
qualifications, training, licenses and permits as may be required within
such jurisdiction.

    

    
      

       

      D. Work
for Hire Contract

    

    
      This
contract shall be considered a "Work for Hire Contract." The Department will be
the sole owner of all source code and any software which is developed or
included in the application software provided to the Department as a part of
this contract.

    

    
      

       

      E. Technology
Purchases Notification — The following provisions apply if this contract
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 contract is for procurement of software over $20,000, or other technology
over $50,000, or
where the department 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 contract is subject to review by the Governor's Task Force on
Information Resource Management.

    

    
      

       

      3.   The
terms and conditions of this contract may be extended to any other State agency
in New
York

    

    
      

       

      5

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      F.   YEAR
2000 WARRANTY

    

    
      

       

      1. Definitions

    

    
      

       

      For
purposes of this warranty, the following definitions shall
apply:

    

    
       

      a. "Product"
shall include, without limitation: any piece or component of equipment, hardware,
firmware, middleware, custom or commercial software, or internal
components or subroutines therein which perform any date/ time data
recognition function, calculation, comparing or sequencing. Where services are being
furnished, e.g. consulting, systems integration, code or data conversion
or data entry, the term "Product" shall include resulting
deliverables.

    

    
       

      b. "Vendor's
Product" shall include all Product delivered under this Agreement by Vendor other than
Third Party Product.

    

    
      

      c. "Third
Party Product" shall include product manufactured or developed by a corporate entity
independent from Vendor and provided by Vendor on a non-exclusive licensing
or other distribution Agreement with the third party manufacturer. "Third
Party Product" does not include product where Vendor is:

    

    
      a) a
corporate subsidiary or affiliate of the third party manufacturer/developer;
and/or

    

    
      b) the
exclusive re-seller or distributor of product manufactured or developed by said
corporate entity.

    

    
      

       

      2. Warranty
Disclosure

    

    
      

       

      At the
time of bid, Product order or Product quote, Vendor is required to disclose the
following information in writing to Authorized User:

    

    
       

      a. For
Vendor Product and for Products (including, but not limited to, Vendor and/or
Third-Party Products and/or Authorized User's Installed Product) which have been
specified to perform as a system: Compliance or
non-compliance of the Products individually or as a system with the Warranty
Statement set forth below; and

    

    
       

      b. For
Third Party Product Not Specified as Part of a System: Third Party Manufacturer's statement
of compliance or non-compliance of any Third Party Product being
delivered with Third Party Manufacturer/Developer's Year 2000 warranty. If
such Third Party Product is represented by Third Party
Manufacturer/Developer as compliant with Third Party Manufacturer/Developer's
Year 2000 Warranty, Vendor shall pass through said third party
warranty from the third party manufacturer to the Authorized User but
shall not be liable for the testing or verification of Third Party's compliance
statement.

    

    
       

      An
absence or failure to furnish the required written warranty disclosure shall be
deemed a statement of compliance of the product(s) or system(s) in question with
the year 2000 warranty statement set forth below.

    

    
      

      3. Warranty
Statement

    

    
       

      Year 2000
warranty compliance shall be defined in accordance with the following warranty
statement:

    

    
      

       

      6

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      Vendor
warrants that Product(s) furnished pursuant to this Agreement shall, when used
in accordance with the Product documentation, be able to accurately process
date/time data (including, but not limited to, calculating, comparing, and
sequencing) from, into, and between the twentieth and twenty-first centuries,
and the years 1999 and 2000, including leap year. calculations. Where a purchase
requires that specific Products must perform as a package or system, this
warranty shall apply to the Products as a system.

    

    
      

       

      In the
event of any breach of this warranty, Vendor shall restore the Product to the
same level of performance as warranted herein, or repair or replace the Product
with conforming Product so as to minimize interruption to Authorized User's
ongoing business processes, time being of the essence, at Vendor's sole cost and
expense. This warranty does not extend to correction of Authorized User's errors
in data entry or data conversion.

    

    
      

       

      This
warranty shall survive beyond termination or expiration of the Agreement.
Nothing in this warranty shall be construed to limit any rights or remedies
otherwise available under this Agreement.

    

    
      

       

      G. No
Subcontracting

    

    
       

      Subcontracting
by the contractor shall not be permitted except by prior written approval and
knowledge of the Department of Health.

    

    
       

      H.  Superintendence
by Contractor

    

    
       

      The
Contractor shall have a representative to provide supervision of the work which
Contractor employees are performing to ensure complete and satisfactory
performance with the terms of the Contract. This representative shall also be
authorized to receive and put into effect promptly all orders, directions and
instructions from the Department of Health. A confirmation in writing of such
orders or directions will be given by the Health Department when so requested
from the Contractor.

    

    
      

      I.    Sufficiency
of Personnel and Equipment

    

    
      

      If the
Department of Health is of the opinion that the services required by the
specifications cannot satisfactorily be performed because of insufficiency of
personnel, Department 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.

    

    
      

      J.   Experience
Requirements

    

    
       

      The
Contractor shall submit evidence to the satisfaction of the Department that it
possesses the necessary experience and qualifications to perform the type of
services required under this contract and must show that it is currently
performing similar services. The Contractor shall submit at least two references
to substantiate these qualifications.

    

    
       

      K.  Contract
Amendments

    

    
       

      This
agreement may be amended by written agreement signed by the parties and subject
to the laws and regulations of the State pertaining to contract amendments. This
agreement may not be amended orally.

    

    
      

       

      7

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      The
contractor shall not make any changes in the scope of work as outlined herein at
any time without prior authorization in writing from the Department of Health
and without prior approval in writing of the amount of compensation for such
changes.

    

    
      

    

    
      L.   Provisions
Upon Default

    

    
      

      1. In
the event that the Contractor, through any cause, fails to perform any of the
terms, covenants or promises of this agreement, the Department 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

    

    
       

      2. If,
in the judgment of the Department of Health, the Contractor acts in such a way
which is likely to or does impair or prejudice the interests of the State, the
Department acting 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. In such case the Contractor shall receive
equitable compensation for such services as shall, in the judgment of the State
Comptroller, have been satisfactorily performed by the Contractor up to the date
of the termination of this agreement, which such compensation shall not exceed
the total cost incurred for the work which the Contractor was engaged in at the
time of such termination, subject to audit by the State
Comptroller.

    

    
      

      M.
Termination Provision

    

    
       

      Upon
termination of this agreement, the following shall occur:

    

    
      

      1. Contractor
shall make available to the State for examination all data, records and reports
relating to this Contract; and

    

    
      2. Except
as otherwise provided in the Contract, the liability of the State for payments
to the Contractor and the liability of the Contractor for services hereunder
shall cease.

    

    
      

      N.  MINORITY
AND WOMEN OWNED BUSINESS POLICY STATEMENT

    

    
       

      The New
York State Department of Health recognizes the need to take affirmative action
to ensure that Minority and Women Owned Business Enterprises are given the
opportunity to participate in the performance of the Department of Health's
contracting program.. This opportunity for full participation in our free
enterprise system by traditionally, socially and economically disadvantaged
persons is essential to obtain social and economic equality and improve the
functioning of the State economy.

    

    
       

      It is the
intention of the New York State Department of Health to fully execute the
mandate of Executive Order-21 and provide Minority and Women Owned Business
Enterprises with equal opportunity to bid on contracts awarded by this agency in
accordance with the State Finance Law.

    

    
       

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

    

    

    
      

       

      8

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      After an
award of this contract, the contractor agrees to submit to the Department a work
force utilization report, in a form and manner required by the Department, of
the work force actually utilized on this contract, broken down by specified
ethnic background, gender and Federal occupational categories or other
appropriate. categories specified by the Department.

    

    
       

      O.  Contract
Insurance Requirements

    

    
       

      1.   The
CONTRACTOR must without expense to the State procure and maintain, until final
acceptance by the Department of Health of the work covered by this contract,
insurance of the kinds and in the amounts hereinafter provided, in insurance
companies authorized to do such business in the State of New York covering all
operations under this contract, whether performed by it or by subcontractors.
Before commencing the work, the CONTRACTOR shall furnish to the Department of
Health a certificate or certificates, in a form satisfactory to said Department,
showing that it has complied with the requirements of this section, which
certificate or certificates shall state that the policies shall not be changed
or cancelled until thirty days written notice has been given to said Department.
The kinds and amounts of required insurance are:

    

    
      

      a. A
policy covering the obligations of the successful bidder in accordance with the provisions of
Chapter 41, Laws of 1914, as amended, known as the Workers' Compensation
Law, and the contract shall be void and of no effect unless the successful
bidder procures such policy and maintains it until acceptance of the work
(reference Appendix E).

    

    
       

      b. 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.

    

    
       

      i.       Contractor's
Liability Insurance issued to and covering the liability of the successful
bidder with respect to all work performed by it under this proposal and the
contract.

    

    
       

      ii       Protective
Liability Insurance issued to and covering the liability of the People of the
State of New York with respect to all operations under this proposal and the
contract, by the successful bidder or by its subcontractors, including omissions
and supervisory acts of the State.

    

    
       

      iii      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 proposal and the
contract, by the successful bidder or by its subcontractors, including omissions
and supervisory acts of the State.

    

    
      

       

      9

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      P.
Certification Regarding Debarment and Suspension

    

    
       

      Regulations
of the Department of Health and Human Services, located at Part 16 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.

    

    
       

      Pursuant
to the above cited regulations, the New York State Department of Health (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 and exclusion from Medicare and State
health care program participation on or after August 25,1995), and the
Department of Health must require its prospective contractors, as prospective
lower tier participants, to provide the certification in Appendix B to Part 76
of Title 45 CFR, as set forth below:

    

    
       

      APPENDIX
B TO 45 CFR PART 76-CERTIFICATION REGARDING DEBARMENT, SUSPENSION, INELIGIBILITY
AND VOLUNTARY EXCLUSION-LOWER TIER COVERED TRANSACTIONS

    

    
       

      Instructions
for Certification

    

    
       

      1. By
signing and submitting this proposal, the prospective lower tier participant is
providing the certification set out below.

    

    
      

      2. 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 prospective lower tier participant knowingly rendered and
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.

    

    
       

      3. The
prospective lower tier participant shall provide immediate written notice to the
person to which this proposal is submitted if at any time the prospective lower
tier participant learns that its certification was erroneous when submitted or
had become erroneous by reason of changed circumstances.

    

    
      

      4. 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. You may contact the person to which this proposal is submitted for
assistance in obtaining a copy of those regulations.

    

    
      

      5. The
prospective lower tier participant agrees by submitting this proposal that,
should the proposed covered transaction be entered into, it shall not knowingly
enter into any lower tier covered transaction with a person who is proposed for
debarment under 48 CFR part 9, 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.

    

    
      

       

      10

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      6. The
prospective lower tier participant further agrees by submitting this proposal
that it will include this clause titled "Certification Regarding Debarment,
Suspension, Ineligibility and Voluntary Exclusion-Lower Tier Covered
Transaction," without modification, in all lower tier covered
transactions.

    

    
      

      7. A
participant in a covered transaction may rely upon a certification of a
prospective participant in a lower tier covered transaction that it is not
proposed for debarment under 48 CFRpart 9, 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 List of parties Excluded from
Federal Procurement and Non-procurement Programs.

    

    
      

      8. 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.

    

    
      

      9. Except
for transactions authorized under paragraph 5 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 part 9,
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.

    

    
       

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

    

    
       

      1. The
prospective lower tier participant certifies, by submission of this proposal,
that neither it nor its principals is presently debarred, suspended, proposed
for debarment, declared ineligible, or voluntarily exclude from participation in
this transaction by any Federal department agency.

    

    
       

      2. Where
the prospective lower tier participant is unable to certify to any of the
statements in this certification, such prospective participant shall attach an
explanation to this proposal.

    

    
      

      Q.
Confidentiality Clauses

    

    
      

      1. Any
materials, articles, papers, etc., developed by the CONTRACTOR under or in the
course of performing this AGREEMENT shall contain the following, or similar
acknowledgment: "Funded by the New York State Department of Health". Any such
materials must be reviewed and approved by the STATE for conformity with the
policies and guidelines for the New York State Department of Health 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. The Department reserves the right to disallow funding for
any educational materials not approved through its review
process.

    

    
      

      2. 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

    

    
      

       

      11

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      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 STATE or under circumstances as indicated in paragraph 1
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.

    

    
      

      3. 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.

    

    
       

      4. All
reports, data sheets, documents, etc. generated under this contract shall be the
sole and exclusive
property of the Department of Health. Upon completion or termination of
this AGREEMENT the
CONTRACTOR shall deliver to the Department of Health 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 Department of Health or
its authorized agents.

    

    
       

      5. 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.

    

    
       

      6. All
subcontracts shall contain provisions specifying:

    

    
       

      a. that
the work performed by the subcontractor must be in accordance with the terms
of this AGREEMENT,
and

    

    
       

      b. that
the subcontractor specifically agrees to be bound by the confidentiality
provisions set
forth in the AGREEMENT between the STATE and the CONTRACTOR.

    

    
       

      R.   Provision
Related to Consultant Disclosure Legislation

    

    
      

      a.   If
this contract is for the provision of consulting services as defined in
Subdivision 17 of Section 8 of the State Finance
Law, the CONTRACTOR shall submit a "State Consultant Services Form B, Contractor's Annual
Employment Report" no later than May 15th
following the end of each state fiscal year included in
this contract term. This report must be submitted to:

    

    
      

      i. The
NYS Department of Health, at the STATE'S designated payment office address
included in this AGREEMENT; and

    

    
      

      ii. The
NYS Office of the State Comptroller, Bureau of Contracts, 110 State Street,
11th
Floor, Albany NY 12236 ATTN: Consultant Reporting - or via fax at (518) 474-8030
or (518) 473-8808;
and 

    

    
       

      iii. The
NYS Department of Civil Service, Alfred E. Smith Office Building, Albany
NY

    

    
      12239,
ATTN: Consultant Reporting.

    

    
       

      S.   Provision
Related to New York State Procurement Lobbying Law

    

    
      

      1.   The
STATE reserves the right to terminate this AGREEMENT in the event it is found
that the certification filed by the CONTRACTOR in. accordance with New York
State Finance Law §139-k was intentionally false or intentionally incomplete.
Upon such finding, the STATE may exercise its termination right by providing
written notification to the CONTRACTOR in accordance with the written
notification terms of this AGREEMENT.

    

    
      

       

      12

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      T.   Provision
Related to New York State Information Security Breach and Notification
Act

    

    
      

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

    

    
       

      U.  Accessibility
of State Agency Web-based Intranet and Internet Information and
Applications

    

    
      

      1.   Any
web-based intranet and internet information and applications development,
or

    

    
      programming
delivered pursuant to the contract will comply with NYS Office for Technology
Policy PO4-002, "Accessibility of New York State Web-based Intranet and Internet
Information and Applications", and NYS Mandatory Technology Standard SO4-001, as
such policy or standard may be amended, modified or superseded, which requires
that state agency web-based intranet and internet information and applications
are accessible to persons with disabilities. Web content must conform to NYS
Mandatory Technology Standard SO4-00, as determined by quality assurance
testing. Such quality assurance testing will be conducted by Department of
Health, contractor or other, and the results of such testing must be
satisfactory to the Department of Health before web content will be considered a
qualified deliverable under the contract.

    

    
       

      V. New
York State Tax Law Section 5-a

    

    
       

      1.   Section
5-a of the Tax Law, as amended, effective April 26, 2006, requires certain
contractors awarded state contracts for commodities, services and technology
valued at more than $100,000 to certify to the New York State Department of Tax
and Finance (DTF) that they are registered to collect New York State and local
sales and compensating use taxes. The law applies to contracts where the total
amount of such contractors' sales delivered into New York State are in excess of
$300,000 for the four quarterly periods immediately preceding the quarterly
period in which the certification is made, and with respect to any affiliates
and subcontractors whose sales delivered into New York State exceeded $300,000
for the four quarterly periods immediately preceding the quarterly period in
which the certification is made.

    

    
       

      This law
imposes upon certain contractors the obligation to certify whether or not the
contractor, its affiliates, and its subcontractors are required to register to
collect sales and compensating use tax and contractors must certify to DTF that
each affiliate and subcontractor exceeding such sales threshold is registered
with DTF to collect New York State and local sales and compensating use taxes.
The law prohibits the State Comptroller, or other approving agencies, from
approving a contract awarded to an offerer meeting the registration requirements
but who is not so registered in accordance with the law.

    

    
       

      Contractor
must complete and submit directly to the New York State Taxation and Finance,
Contractor Certification Form ST-220-TD. Unless the information upon which the
ST-220-TD is based changes, this form only needs to be filed once with DTF. If
the information changes for the contractor, its affiliate(s), or its
subcontractors), a new form (ST-220-TD) must be filed with
DTF.

    

    
       

      Contractor
must complete and submit to the Department of Health the form ST-220-CA
certifying that the contractor filed the ST-220-TD with DTF. Failure to make
either of these filings may render an offerer non-responsive and
non-responsible. Offerers shall take the necessary steps to provide properly
certified forms within a timely manner to ensure compliance with the
law.

    

    
      

       

      13

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      Appendix
A

    

    
       

       

      STANDARD
CLAUSES AS REQUIRED BY THE ATTORNEY GENERAL FOR ALL STATE
CONTRACTS

    

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      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 01 to anyone else beyond funds
appropriated and available for this contract

    

    
      

    

    
      2. NON-ASSIGNMENT
CLAUSE, la accordance with Section 138 of the State Finance Law, this
contract may not be assigned by the Contractor or its light, 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 mill 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 621S of the Education Law), if this contract exceeds
SSO.OOO (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 S 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 SS5.0O0 (State Finance Law
Section 153.6\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 120-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 nor its subcontractors shall by
reason of race, creed, color, disability, sex, or national origin: (a)
discriminate in hiring against any New York State citizen who is qualified
and available to perform the work; or (b) discriminate against or
intimidate any employee hired for the performance of work
under this contract. If this is a building service contract as defined in
Section 230 of the Labor Law, then, in accordance with Section 239
thereof, Contractor agrees that neither it nor its subcontractors shall by
reason of race, creed, color, national origin, age, sex or disability: (a)
discriminate in hiring against any New York State citizen who; is
qualified and available to perform the work; or (b) discriminate  against  or  intimidate   any  employee   hired  for  the

    

    
      

    

    
      Page
1

    

    
      

      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 23° 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, metering
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 affirms, under penalty of perjury, that
its bid was arrived at independently and without collusion aimed at
restricting competition. Contractor farther affirms 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 (2NYCRB.
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 other 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 of 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

    

    
      June,
2006

    

    
      15

    

    

    
      

    

    
      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 snail rake
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 (if)
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
sate 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, Le., 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 ox 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, 110 State Street, Albany, New York
12236.

    

    
      

    

    
      12. EQUAL EMPLOYMENT
OPPORTUNITIES FOR MINORITIES AND WOMEN.
In accordance with Section 312 of the Executive Law, if this contact 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 (h) a written agreement
in excess of S 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 5100,000.00 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, them

    

    
      (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,

    

    
      

    

    
      Page
2

    

    
      

      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 wet $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 of conflict exists, the contracting agency
shall waive the applicability of Section 312 to tie 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 I !-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 he 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.

    

    
      June,
2006

    

    
      16

    

    

    
      I8. PROHIBITION OX PURCHASE OF
TROPICAL HARD
TVQODS. The Contractor certifies and warrants that ail wood products to
be used under this contract award will be in accordance with, bat 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 me 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 prune
Contractor will indicate and certify in the submitted bid proposal that the
subcontractor has been informed and is m compliance with specifications and.
provisions regarding use of tropical hardwoods as detailed k §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   EA1FLOYMENT   PRINCIPLES,      In
accordance with the MacBride Fair Employment Principles (Chapter SQ7 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
1991. It is the polity of New
York State to maximize opportunities for the participation of New York State
business enterprises, including minority and women-owned business enterprises as
bidden, subcontractors and suppliers on its procurement
contracts.

    

    
      

    

    
      Information
on the availability of New York State subcontractors and suppliers is available
from:

    

    
      NY-S
Department of Economic Development

    

    
      Division
for Small Business

    

    
      30 South
Pearl St- 7th
Floor

    

    
      Albany,
Kew York 12245

    

    
      Telephone:
51S-2P2-5220

    

    
      Fax
51S-292-58S4

    

    
      http:
,www.empire.state-ny.us

    

    
      

    

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

    

    
      KYS
Department of Economic Development

    

    
      Division
of Minority and Women's Business Development

    

    
      30 South
Pearl St - 2nd Floor

    

    
      Albany,
New York 12245

    

    
      Telephone:
51S-292-525Q

    

    
      Fax:
51S-292-5803

    

    
      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 S1 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;

    

    
      Page
3

    

    
      

      (b)   The
Contractor has complied with the Federal Equal Opportunity Act of 1972 <PL. 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. Bidden 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 6S4 and Chapter 3S3, respectively) require that they be
denied contracts which they would otherwise obtain. NOTE: As of May 15, 20O2,
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 ail manufacturing plants to be utilized by the
bidder.

    

    
      June,
2006

    

    
      17

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      APPENDIX
C

    

    
      PROGRAM
SPECIFIC REQUIREMENTS

    

    
      

       

      18

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      APPENDIX
C

    

    
      PROGRAM
SPECIFIC REQUIREMENTS

    

    
      TABLE
OF CONTENTS

    

    
      

    

    
      	
              Appendix
      A

            	
              14

            
	
              Standard
      Clauses as required by the Attorney General for all State
      Contracts

            	
              14

            
	
              SECTION
      1

            	
              24

            
	
              DEFINITIONS

            	
              24

            
	
              SECTION
      2

            	
              28

            
	
              BENEFIT
      PACKAGE

            	
              28

            
	
              2.1
      Contractor Responsibilities

            	
              28

            
	
              2.2  Provision
      of Services through Participating and Non-Participating
      Providers

            	
              28

            
	
              2.3  Direct
      Access

            	
              28

            
	
              2.4  Emergency
      Services

            	
              28

            
	
              ATTACHMENT
      A BENEFIT PACKAGE MATRIX 

            	
              30

            
	
              SECTION
      3 

            	
              39

            
	
              SERVICE
      AREA

            	
              39

            
	
              3.1 Approved
      Counties 

            	
              39

            
	
              3.2 Service Area
      Expansions

            	
              
                40

              

            
	
              3.3 Participation
      Limited to Counties Approved as Medicaid Managed Care

            	
              40

            
	
              3.4
      Removal of Counties when Participation in Medicaid Managed Care
      Stops

            	
              40

            
	
              SECTION
      4

            	
              41

            
	
              ELIGIBILITY
      CRITERIA

            	
              41

            
	
              4.1 Age

            	
              41

            
	
              4.2 New York State
      Residency

            	
              41

            
	
              4.3 Medicaid
      Eligibility

            	
              41

            
	
              4.4 Health
      Insurance

            	
              41

            
	
              4.5 Public
      Employees 

            	
              
                42

              

            
	
              4.6 Inmates of Public
      Institutions 

            	
              42

            
	
              4.7 Number of Children
      in the Household and Income

            	
              
                42

              

            
	
              4.8 Screen for
      Eligibility

            	
              
                42

              

            
	
              4.9 Twelve Months
      Continuous Coverage

            	
              
                42

              

            
	
              4.10 Crowd-Out 

            	
              
                43

              

            
	
              SECTION 5

            	
              
                45

              

            
	
              DOCUMENTATION

            	
              
                45

              

            
	
              5.1 Age

            	
              
                45

              

            
	
              5.2
      New York State Residency 

            	
              
                45

              

            
	
              5.3
      Other Health Insurance Coverage

            	
              
                45

              

            
	
              5.4 Income

            	
              
                46

              

            
	
              5.5 Date of
      Status

            	
              
                49

              

            
	
              5.6
      Date Entered the Country

            	
              
                52

              

            
	
              5.7
      Dependent Care Costs

            	
              
                53

              

            
	
              5.8 Proof of
      Pregnancy

            	
              
                53

              

            
	
              ATTACHMENT
      A-SELF-DECLARATION OF INCOME FORM

            	
              
                54

              

            
	
              ATTACHMENT
      B - DECLARATION OF
      NO INCOME FORM

            	
              
                56

              

            
	
              SECTION
      6 

            	
              
                58

              

            
	
              APPLICATION/ENROLLMENT
      PROCESSING

            	
              
                58

              

            
	
              6.1 Application
      Cut-off Dates

            	
              
                58

              

            
	
              6.2 Enrollment
      Staff 

            	
              
                58

              

            
	
              6.3 Enrollment
      Systems

            	
              
                58

              

            
	
              6.4 Subscriber
      Contract:

            	
              
                58

              

            
	
              6.5 Identification
      Card

            	
              
                58

              

            
	
              6.6 Notice of
      Enrollment Decision

            	
              
                58

              

            
	
              SECTION
      7 

            	
              
                59

              

            
	
              PRESUMPTIVE
      ENROLLMENT 

            	
              
                59

              

            
	
              7.1 Eligibility for
      Presumptive Enrollment

            	
              
                59

              

            
	
              SECTION
      8

            	
              
                60

              

            
	
              TEMPORARY
      ENROLLMENT

            	
              
                60

              

            
	
              8.1 Eligibility for
      Temporary Enrollment

            	
              
                60

              

            
	
              SECTION
      9

            	
              
                61

              

            
	
              RECERTIFICATION

            	
              
                61

              

            
	
              9.1 Annual
      Recertification

            	
              
                61

              

            
	
              9.2 Recertification
      Application

            	
              
                61

              

            

    

    
      

       

       19

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      	
              
                9.3 Recertification
      Notification 

              

            	
              
                61

              

            
	
              
                9.4 Information in the
      Recertification Notification Letter 

              

            	
              
                61

              

            
	
              
                9.5 Review of the
      Recertification Application 

              

            	
              
                61

              

            
	
              
                9.6 Documenting Income
      at Recertification 

              

            	
              
                61

              

            
	
              
                9.7 Documentation of
      Residence at Recertification 

              

            	
              
                62

              

            
	
              
                9.8 Presumptive
      Recertification Period 

              

            	
              
                62

              

            
	
              
                9.9 Temporary
      Recertification Period

              

            	
              
                62

              

            
	
              
                9.10 Late
      Recertification Applications 

              

            	
              
                62

              

            
	
              
                9.11 Recertification
      and Changing Plans 

              

            	
              
                62

              

            
	
              
                9.12 New Child Added at
      Recertification 

              

            	
              
                63

              

            
	
              
                9.13 Applicant Provides
      Range of Income on Recertification Application 

              

            	
              
                63

              

            
	
              
                9.14 Incomplete
      Recertification Application 

              

            	
              
                63

              

            
	
              
                ATTACHMENT
      A CHILD HEALTH PLUS HEALTH INSURANCE RENWEAL FORM

              

            	
              
                65

              

            
	
              
                SECTION
      10 

              

            	
              
                68

              

            
	
              
                FAMILY
      PREMIUM CONTRIBUTION

              

            	
              
                68

              

            
	
              
                10.1 Family Premium
      Contribution 

              

            	
              
                68

              

            
	
              
                10.2 Family Premium
      Contribution Notice 

              

            	
              
                68

              

            
	
              
                10.3 Family
      Contribution Due Date and Disenrollment 

              

            	
              
                68

              

            
	
              
                10.4 Collection of the
      Family Premium Contribution 

              

            	
              
                69

              

            
	
              
                10.5 Request for Review
      of the Family Premium Contribution 

              

            	
              
                69

              

            
	
              
                10.6 Disenrollment
      Notice and Disenrollment for Failure to Pay the Family Premium
      Contribution 

              

            	
              
                70

              

            
	
              
                10.7 American
      Indians/Alaskan Natives 

              

            	
              
                70

              

            
	
              
                10.8 Cost Sharing 

              

            	
              
                71

              

            
	
              
                SECTION
      11

              

            	
              
                72

              

            
	
              
                REQUIRED
      NOTICES 

              

            	
              
                72

              

            
	
              
                11.1 Information to
      Potential Applicants, Applicants and Enrollees 

              

            	
              
                72

              

            
	
              
                11.2 Public
      Schedule 

              

            	
              
                72

              

            
	
              
                11.3 Application and
      Eligibility Requirements 

              

            	
              
                72

              

            
	
              
                11.4 Full Medicaid
      Eligibility Determination 

              

            	
              
                72

              

            
	
              
                11.5 Medicaid Spend
      Down Program 

              

            	
              
                73

              

            
	
              
                11.6 Impartial
      Review 

              

            	
              
                73

              

            
	
              
                SECTION 12 

              

            	
              
                74

              

            
	
              
                DISENROLLMENT 

              

            	
              
                74

              

            
	
              
                12.1 Enrollee Initiated
      Disenrollment 

              

            	
              
                74

              

            
	
              
                12.2 Processing
      Disenrollment Requests

              

            	
              
                74

              

            
	
              
                12.3 CONTRACTOR
      Initiated Disenrollment

              

            	
              
                74

              

            
	
              
                12.4 CONTRACTOR'S
      Liability 

              

            	
              
                75

              

            
	
              
                12.5 Notice of
      Disenrollment 

              

            	
              
                75

              

            
	
              
                SECTION
      13 

              

            	
              
                76

              

            
	
              
                FACILITATED
      ENROLLMENT RESPONSIBILITIES 

              

            	
              
                76

              

            
	
              
                13.1 Interaction with
      Community-Based and Other Health Plan Facilitators 

              

            	
              
                76

              

            
	
              
                13.2 New Facilitated
      Enrollment Activities 

              

            	
              
                76

              

            
	
              
                13.3 Service Area 

              

            	
              
                76

              

            
	
              
                13.4 Accessible and
      Convenient Sites 

              

            	
              
                77

              

            
	
              
                13.5 Hours of
      Operation

              

            	
              
                77

              

            
	
              
                13.6 Staffing 

              

            	
              
                77

              

            
	
              
                13.7 Culturally and
      Linguistically Appropriate Staff 

              

            	
              
                77

              

            
	
              
                13.8 Compliance with
      Local Department of Social Services (LDSS) Procedures 

              

            	
              
                77

              

            
	
              
                13.9 Functions of
      Facilitators 

              

            	
              
                77

              

            
	
              
                13.10 Application Review
      Procedures/Quality Assurance 

              

            	
              
                78

              

            
	
              
                13.11 Transmitting
      Information 

              

            	
              
                78

              

            
	
              
                13.12 Submitting
      Applications to LDSS and other CHPlus Health Plans 

              

            	
              
                78

              

            
	
              
                13.13 Services for
      Visually or Hearing Impaired Applicants 

              

            	
              
                78

              

            
	
              
                13.14 Application
      Follow-Up 

              

            	
              
                79

              

            
	
              
                13.15 Recertification 

              

            	
              
                79

              

            
	
              
                13.16 Training
      Programs 

              

            	
              
                79

              

            
	
              
                13.17 Confidentiality
      Issues

              

            	
              
                79

              

            
	
              
                13.18 Federal and State
      Law Compliance 

              

            	
              
                79

              

            
	
              
                13.19 Site
      Visits

              

            	
              
                80

              

            
	
              
                13.20 Termination of
      Responsibilities 

              

            	
              
                80

              

            
	
              
                ATTACHMENT
      A -00 OMM/ADM 2 FACILITATED ENROLLMENT OF CHILDREN INTO MEDICAID, CHILD HEALTH PLUS
      AND WIC 

              

            	
              
                81

              

            

    

    
      

       

      20

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      	
              
                SECTION 14 

              

            	
              
                90

              

            
	
              
                FACILITATED ENROLLMENT MONITORING 

              

            	
              
                90

              

            
	
              
                14.1 Marketing/Facilitated
      Enrollment Integrity 

              

            	
              
                90

              

            
	
              
                14.2 Quality
      Assurance 

              

            	
              
                90

              

            
	
              
                14.3 Targeted
      Verification

              

            	
              
                 91

              

            
	
              
                14.4 Field
      Monitoring 

              

            	
              
                93

              

            
	
              
                14.5 Training

              

            	
              
                94

              

            
	
              
                ATTACHMENT
      A-QUALITY ASSURANCE CHECKLIST 

              

            	
              
                95

              

            
	
              
                SECTION
      15

              

            	
              
                97

              

            
	
              
                MARKETING 

              

            	
              
                97

              

            
	
              
                15.1
      Marketing Plan 

              

            	
              
                97

              

            
	
              
                15.2 CHPlus
      Logo

              

            	
              
                97

              

            
	
              
                15.3 Prior Approval of
      Marketing Materials, Procedures and Subcontracts 

              

            	
              
                97

              

            
	
              
                15.4 Marketing Material
      Requirements 

              

            	
              
                98

              

            
	
              
                15.5 Distribution of
      Marketing Materials 

              

            	
              
                98

              

            
	
              
                15.6 Marketing
      Restrictions 

              

            	
              
                98

              

            
	
              
                15.7 Use of Vans in New
      York City

              

            	
              
                99

              

            
	
              
                15.8 Incentives to
      Potential Enrollees

              

            	
              
                99

              

            
	
              
                15.9 Rewards for
      Completion of Health Goals 

              

            	
              
                100

              

            
	
              
                15.10 Behavior of
      Marketing Representatives 

              

            	
              
                100

              

            
	
              
                15.11 Compensation for
      Marketing Representatives and Enrollment Facilitators 

              

            	
              
                100

              

            
	
              
                15.12 Marketing to
      Enrollees of other Health Plans 

              

            	
              
                100

              

            
	
              
                15.13 Other Marketing
      Campaigns 

              

            	
              
                100

              

            
	
              
                SECTION
      16 

              

            	
              
                101

              

            
	
              
                REPORTING/DATA
      COLLECTION 

              

            	
              
                101

              

            
	
              
                16.1 Report
      Submissions

              

            	
              
                101

              

            
	
              
                16.2 Reporting
      Requirements

              

            	
              
                101

              

            
	
              
                16.3 Timely
      Reports/Penalties 

              

            	
              
                103

              

            
	
              
                16.4 Crowd-Out
      Data 

              

            	
              
                104

              

            
	
              
                16.5 Additional Data
      Requirements 

              

            	
              
                104

              

            
	
              
                16.6 Review of
      Reports 

              

            	
              
                104

              

            
	
              
                16.7 Rejection of
      Reports 

              

            	
              
                104

              

            
	
              
                16.8 Acceptance of
      Reports 

              

            	
              
                104

              

            
	
              
                16.9 Accuracy of
      Enrollment Data, Claims and Payment Information 

              

            	
              
                104

              

            
	
              
                16.10 Accuracy of
      Payment Data

              

            	
              
                104

              

            
	
              
                SECTION 17 

              

            	
              
                105

              

            
	
              
                AUDIT and  REVIEW 

              

            	
              
                105

              

            
	
              
                17.1 First Stage
      Audit 

              

            	
              
                105

              

            
	
              
                17.2 Second Stage
      Audit 

              

            	
              
                106

              

            
	
              
                17.3 Special
      Reviews 

              

            	
              
                107

              

            
	
              
                17.4 Facilitated
      Enrollment Integrity Reviews 

              

            	
              
                107

              

            
	
              
                17.5 Quality of Care
      Reviews 

              

            	
              
                108

              

            
	
              
                17.6 Fraud and
      Abuse 

              

            	
              
                108

              

            
	
              
                17.7 Data Access 

              

            	
              
                108

              

            
	
              
                17.8 Data Accuracy and
      Responsibility 

              

            	
              
                109

              

            
	
              
                SECTION
      18 

              

            	
              
                110

              

            
	
              
                PAYMENTS
      and BILLING 

              

            	
              
                110

              

            
	
              
                18.1 Monthly Premium
      Payment 

              

            	
              
                110

              

            
	
              
                18.2 Premium
      Modifications

              

            	
              
                110

              

            
	
              
                18.3 Payments by the
      STATE

              

            	
              
                110

              

            
	
              
                18.4 Annual
      Funding

              

            	
              
                110

              

            
	
              
                18.5 Program Enrollment
      and Annual Funding 

              

            	
              
                111

              

            
	
              
                18.6 Notification of
      Annual Enrollment 

              

            	
              
                111

              

            
	
              
                18.7 Modification of
      Maximum Funding 

              

            	
              
                111

              

            
	
              
                18.8 Monthly Updates of
      KIDS System 

              

            	
              
                111

              

            
	
              
                18.9 Accurate
      Information 

              

            	
              
                111

              

            
	
              
                18.10 Voucher
      Submission 

              

            	
              
                112

              

            
	
              
                18.11 Adjustments 

              

            	
              
                112

              

            
	
              
                18.12 Payment by the
      Office of the State Comptroller 

              

            	
              
                112

              

            
	
              
                SECTION
      19

              

            	
              
                113

              

            
	
              
                QUALITY
      ASSURANCE

              

            	
              
                113

              

            
	
              
                19.1
      Internal Quality Assurance Program 

              

            	
              
                113

              

            

    

    
      

       

      21

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      	
              
                19.2 Standards of
      Care 

              

            	
              
                113

              

            
	
              
                19.3 CHPlus Quality of
      Care Review

              

            	
              
                114

              

            
	
              
                19.4 Deficiencies in
      Quality of Care 

              

            	
              
                114

              

            
	
              
                SECTION
      20

              

            	
              
                115

              

            
	
              
                MEMBER
      SERVICES

              

            	
              
                115

              

            
	
              
                20.1 General
      Functions 

              

            	
              
                115

              

            
	
              
                20.2 Translation and
      Oral Interpretation

              

            	
              
                115

              

            
	
              
                20.3 Communicating with
      the Visually, Hearing and Cognitively Impaired 

              

            	
              
                116

              

            
	
              
                SECTION 21 

              

            	
              
                117

              

            
	
              
                PROVIDER NETWORKS 

              

            	
              
                117

              

            
	
              
                21.1 Network
      Requirements 

              

            	
              
                117

              

            
	
              
                21.2 Absence of
      Appropriate Network Provider 

              

            	
              
                117

              

            
	
              
                21.3 Suspension of
      Enrollee Assignments to Providers 

              

            	
              
                118

              

            
	
              
                21.4 Credentialing

              

            	
              
                118

              

            
	
              
                21.5 STATE Exclusion or
      Termination of Providers

              

            	
              
                118

              

            
	
              
                21.6 Application
      Procedure

              

            	
              
                119

              

            
	
              
                21.7 Evaluation
      Information

              

            	
              
                119

              

            
	
              
                21.8 Choice/Assignment
      of Primary Care Providers 

              

            	
              
                119

              

            
	
              
                21.9 Enrollee PCP
      Changes 

              

            	
              
                120

              

            
	
              
                21.10 Provider Status
      Changes 

              

            	
              
                121

              

            
	
              
                21.11 PCP
      Responsibilities 

              

            	
              
                121

              

            
	
              
                21.12 Member to Provider
      Ratios 

              

            	
              
                121

              

            
	
              
                21.13 Minimum PCP Office
      Hours 

              

            	
              
                122

              

            
	
              
                21.14 Primary Care
      Practitioners

              

            	
              
                122

              

            
	
              
                21.15 PCP Teams 

              

            	
              
                123

              

            
	
              
                21.16
      Hospitals 

              

            	
              
                123

              

            
	
              
                21.17 Dental
      Networks 

              

            	
              
                123

              

            
	
              
                21.18 Mental Health and
      Chemical Dependence Services Providers 

              

            	
              
                123

              

            
	
              
                21.19 Laboratory
      Procedures 

              

            	
              
                124

              

            
	
              
                21.20 Federally
      Qualified Health Centers (FQHCs) 

              

            	
              
                124

              

            
	
              
                21.21 Provider Services
      Function

              

            	
              
                124

              

            
	
              
                21.22 Pharmacies

              

            	
              
                124

              

            
	
              
                ATTACHMENT
      A-GUIDELINES FOR USE OF MEDICAL RESIDENTS 

              

            	
              
                126

              

            
	
              
                SECTION 22 

              

            	
              
                130

              

            
	
              
                ACCESS
      REQUIREMENTS

              

            	
              
                130

              

            
	
              
                22.1 General
      Requirement 

              

            	
              
                130

              

            
	
              
                22.2 Appointment
      Availability Standards 

              

            	
              
                130

              

            
	
              
                22.3 Twenty-Four (24)
      Hour Access 

              

            	
              
                130

              

            
	
              
                22.4 Appointment
      Waiting Times 

              

            	
              
                130

              

            
	
              
                22.5 Travel Time
      Standards 

              

            	
              
                130

              

            
	
              
                22.6 Service
      Continuation 

              

            	
              
                131

              

            
	
              
                22.7 Standing
      Referrals 

              

            	
              
                132

              

            
	
              
                22.8 Specialist as a
      Coordinator of Primary Care 

              

            	
              
                132

              

            
	
              
                22.9 Specialty Care
      Centers

              

            	
              
                132

              

            
	
              
                22.10 Cultural
      Competence

              

            	
              
                132

              

            
	
              
                SECTION 23 

              

            	
              
                133

              

            
	
              
                SUBCONTRACTS AND PROVIDER AGREEMENTS 

              

            	
              
                133

              

            
	
              
                23.1 Written
      Subcontracts 

              

            	
              
                133

              

            
	
              
                23.2 Permissible
      Subcontracts 

              

            	
              
                133

              

            
	
              
                23.3 Provision of
      Services through Provider Agreements 

              

            	
              
                133

              

            
	
              
                23.4 Approvals 

              

            	
              
                133

              

            
	
              
                23.5 Required
      Components

              

            	
              
                133

              

            
	
              
                23.6 Timely
      Payment 

              

            	
              
                134

              

            
	
              
                23.7 Recovery of
      Overpayments to Providers 

              

            	
              
                134

              

            
	
              
                23.8 Restrictions on
      Disclosure 

              

            	
              
                134

              

            
	
              
                23.9 Transfer of
      Liability

              

            	
              
                135

              

            
	
              
                23.10 Termination of
      Health Care Professional Agreements 

              

            	
              
                135

              

            
	
              
                23.11 Health Care
      Professional Hearings 

              

            	
              
                136

              

            
	
              
                23.12 Non-Renewal of
      Provider Agreements

              

            	
              
                136

              

            
	
              
                23.13 Notice of
      Participating Provider Termination 

              

            	
              
                136

              

            
	
              
                23.14 Physician
      Incentive Plan 

              

            	
              
                137

              

            
	
              
                SECTION 24 

              

            	
              
                139

              

            

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      	
              
                STATE
      RESPONSIBILITIES 

              

            	
              
                139

              

            
	
              
                24.1 Monitoring and
      Evaluation 

              

            	
              
                139

              

            
	
              
                24.2 Payment and
      Finance 

              

            	
              
                139

              

            
	
              
                24.3 Forms, Brochures
      and Other Materials

              

            	
              
                139

              

            
	
              
                24.4 Service Area
      Expansions 

              

            	
              
                140

              

            
	
              
                SECTION
      25 

              

            	
              
                141

              

            
	
              
                CONVERSION 

              

            	
              
                141

              

            
	
              
                25.1 Enrollee
      Relocation 

              

            	
              
                141

              

            
	
              
                25.2 Enrollee Turns Age
      Nineteen

              

            	
              
                141

              

            
	
              
                SECTION
      26 

              

            	
              
                142

              

            
	
              
                TERMINATION 

              

            	
              
                142

              

            
	
              
                26.1 CONTRACTOR
      Discontinues Counties in its Service Area 

              

            	
              
                142

              

            
	
              
                26.2 CONTRACTOR Delay,
      Failure or Inability to Complete the AGREEMENT 

              

            	
              
                142

              

            
	
              
                26.3 Sanctions for
      Non-Compliance Related to Facilitated Enrollment 

              

            	
              
                142

              

            
	
              
                26.4 CONTRACTOR
      Initiated Termination 

              

            	
              
                142

              

            
	
              
                26.5 State Initiated
      Termination

              

            	
              
                142

              

            
	
              
                26.6 Transition Process
      Prior to Termination 

              

            	
              
                143

              

            
	
              
                APPENDIX
      E-l

              

            	
              
                145

              

            
	
              
                PROOF
      OF WORKERS' COMPENSATION COVERAGE 

              

            	
              
                145

              

            
	
              
                APPENDIX
      E-2

              

            	
              
                146

              

            
	
              
                PROOF
      OF DISABILITY INSURANCE COVERAGE 

              

            	
              
                146

              

            
	
              
                APPENDIX
      H

              

            	
              
                147

              

            
	
              
                PRIVACY
      AND CONFIDENTIALITY

              

            	
              
                147

              

            
	
              
                APPENDIX
      X 

              

            	
              
                152

              

            

    

    
      

    

    
      

       

      23

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      SECTION
1 

      DEFINITIONS

    

    
      

       

      "Access" shall mean an enrollee's ability to
receive needed medical care and services within the CONTRACTOR'S service area
and time-frames prescribed by the STATE pursuant to section 20 of this
Appendix.

    

    
      

       

      "Advisory Memoranda" (ADM)
shall mean memoranda issued by the STATE that clarify policy
issues.

    

    
      

       

      "American Indian and Alaskan Native"
(AI/AN) shall mean 1) a member of a federally recognized Indian tribe,
band, or group, or a descendant in the first or second degree of any such
member; 2) an Eskimo or Aleut or other Alaskan Native enrolled by the Secretary
of the Interior pursuant to the Alaska Native Claims Settlement Act (43 U.S.C.
1601 et seq); 3) a person who is considered by the Secretary of the Interior to
be an Indian for any purpose; 4) a person who is determined to be an Indian
under regulations promulgated by the Secretary of the Department of Health and
Human Services.

    

    
      

       

      "Application" shall mean the
form entitled, "Growing up Healthy," "Access New York Health Care" or "Child
Health Plus Health Insurance Renewal Form" to be completed by the applicant or a
person on behalf of a child who is applying for health insurance coverage under
this AGREEMENT.

    

    
      

       

      "Benefit Package" shall mean the covered health
care services described in section 2 of this Appendix to be provided by or
through the CONTRACTOR to the enrollees.

    

    
      

       

      "Child Health Plus " (CHPlus) shall mean the child
health insurance program implemented pursuant to Title 1-A of Article 25 of the
N.Y. Public Health Law.

    

    
      

       

      "Children's Medicaid" (Medicaid)
shall mean the children's Medicaid program (formerly known as Child
Health Plus A) implemented pursuant to Title 11 of Article 5 of the N.Y. Social
Services Law.

    

    
      

       

      "CHPlus Manual" shall mean the
document issued by the STATE which contains policies and procedures regarding
the CHPlus enrollment process

    

    
      

       

      "Contract Manager" shall refer to the individual
responsible for the oversight and monitoring of the CHPlus program on behalf of
the STATE.

    

    
      

       

      "Crowd-out" shall mean the
substitution of employer based health care coverage with State subsidized health
care coverage.

    

    
      

       

      "Disenrollment" shall mean the
process by which an enrollee's enrollment with and provision of health insurance
coverage by the CONTRACTOR under this AGREEMENT terminates.

    

    
      

       

      "Emergency Medical Condition" shall mean
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.

    

    
      

       

      "Enrollment" shall mean the process by which a
child is enrolled with and provision of health insurance coverage by the
CONTRACTOR under this AGREEMENT begins.

    

    
      

       

      24

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      "Enrollee" shall mean an eligible child as
defined in section 2510 (4) of the N.Y. Public Health Law who is enrolled in
CHPlus.

    

    
      

       

      "Facilitated Enrollment" shall
mean the enrollment infrastructure and related services established by the STATE
to assist families in applying and recertifying for Family Health Plus, Medicaid
or CHPlus programs using the applications defined by this section and
recertifying for these programs as allowed by federal and State law and
regulation.

    

    
      

       

      "Facilitated Enrollment Integrity
Plan" shall mean the policies and procedures the CONTRACTOR has
instituted to prevent fraud and abuse by applicants and marketing and
facilitated enrollment staff, including corrective actions to be taken in a
timely fashion against employees engaged in fraud and abuse.

    

    
      

       

      "Facilitator" shall mean an
individual who assists families in completing the applications as defined by
this section, screens adults and children for potential Medicaid, CHPlus and
Family Health Plus eligibility, conducts the Medicaid face-to-face interview,
assists in collecting required documentation and assists in the health plan
selection process.

    

    
      

       

      "Family Premium Contribution"
shall mean a premium payment made to the CONTRACTOR on behalf of an
enrollee in accordance with section 10 of this Appendix and in amounts set forth
in section 10.1 of this Appendix or any subsequent
legislation.

    

    
      

       

      "Health Care Services" shall
mean the services of physicians, optometrists, nurses, nurse practitioners,
midwives and other related professional personnel which are provided on an
inpatient or outpatient basis, including routine well-child visits; diagnosis
and treatment of illness and injury; inpatient hospital medical or surgical
care; laboratory tests; diagnostic x-rays; prescription drugs and
nonprescription drugs; diabetic supplies and equipment; diabetic education and
home visits; maternity care; radiation therapy; chemotherapy; hemodialysis;
ambulatory surgery; durable medical equipment; physical therapy; emergency room
services; home health care services; inpatient and outpatient mental health,
alcohol and substance abuse services; preventive and routine vision care
including eyeglasses); speech and hearing services; routine and preventive
dental services; non-air­borne, pre-hospital emergency medical services
including prompt evaluation and treatment of an emergency condition and/or
non-airborne transportation to a hospital, and hospice
services.

    

    
      

       

      "Health Provider Network" "(HPN)"
shall mean a closed communication network dedicated to secure data
exchange and distribution of health related information between various health
facility providers, health plans and the STATE. HPN functions include but shall
not be limited to: collection and reporting of managed care provider networks
and the submission of CHPlus reports.

    

    
      

       

      "Knowledge, Information and Data
System" "(KIDS)" shall mean the database health plans use to report
information regarding individual children enrolled in the CHPlus
program.

    

    
      

       

      "Managed Care Organization" "(MCO)"
shall mean a health maintenance organization ("HMO") or prepaid health
service plan ("PHSP") certified under Article 44 of the N.Y. Public Health Law,
or a corporation licensed pursuant to Article 43 of the N.Y. Insurance
Law.

    

    
      

       

      "Marketing" shall mean any activity of the
CONTRACTOR, subcontractor or individuals or entities affiliated with the
CONTRACTOR by which information about the CONTRACTOR is made known to potential
enrollees for the purpose of persuading such persons to enroll with the
CONTRACTOR.

    

    
      

       

      "Medical Record" shall mean 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.

    

    
      

       

      25

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

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

    

    
      

       

      "Member Handbook" shall mean
the publication prepared by the CONTRACTOR, subject to STATE approval, which is
issued to new enrollees to inform them how to access covered health care
services and explains their rights and responsibilities as an enrollee of the
CONTRACTOR.

    

    
      

       

      "Meta Data Repository" shall
mean the listing of each data item in the KIDS file layout which includes a
description, field length, range, source, type and acceptable value of each
item. The Meta Data Repository also includes the event type code, edit type,
location and requirement for each data item.

    

    
      

       

      "Non-Participating Provider"
shall mean a provider of medical care and/or services with which the
CONTRACTOR has no provider agreement.

    

    
      

       

      "Participating Provider" shall
mean a provider of medical care and/or services that has a provider agreement
with the CONTRACTOR.

    

    
      

       

      "Physician Incentive Plan" "(PIP)"
shall mean 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
enrollees of the CONTRACTOR.

    

    
      

       

      "Premium Payments" shall mean the amounts to be
paid to the CONTRACTOR for a specified period of time for covered health care
services provided to enrollees eligible for insurance under this
AGREEMENT.

    

    
      

       

      "Presumptive Enrollment" shall
mean enrollment of a child who appears eligible for CHPlus based on a completed
and signed application but who is lacking documentation necessary to support a
complete application. An enrollee is presumptively eligible for a maximum of two
calendar months after the initial date of enrollment. Only one period of
presumptive enrollment per lifetime is allowed.

    

    
      

       

      "Presumptive Recertification"
shall mean continued enrollment of a child who appears eligible for
CHPlus at recertification but who is lacking a complete application or
documentation necessary to support a full eligibility determination. An enrollee
may be presumptively recertified for a maximum of two calendar months after the
enrollee's recertification date.

    

    
      

       

      "Preventive Care" shall mean
the care or services rendered to avert disease/illness and/or its consequences.
This shall include primary care such as immunizations, aimed at preventing
disease and secondary care, such as disease screening programs aimed at early
detection of disease. Commonly, the term "preventive care" is used to designate
prevention and early detection programs rather than treatment
programs.

    

    
      

       

      "Primary Care Provider"
("PCP") shall mean a qualified physician or certified nurse practitioner
or team of no more than four (4) qualified physicians/certified nurse
practitioners which provides all required primary care services contained in the
benefit package to enrollees.

    

    
      

       

      "Provider Agreement" shall mean any written
contract between the CONTRACTOR and participating providers to provide medical
care and/or services to CONTRACTOR'S enrollees.

    

    
      

       

      "Public Agency" shall mean any agency of the State,
county, city or other type of municipal agency including entities with which the
State contracts. This definition includes public school districts,
transportation districts, irrigation districts and any other type of public
entity.

    

    
      

       

      26

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      "Recertification" shall mean the twelve (12)
month period after the date of initial enrollment (and each twelve (12) month
period annually thereafter) at which an enrollee's eligibility for CHPlus is
redetermined and enrollment with CONTRACTOR is either continued or terminated.
All children enrolled in a household shall have the same recertification date
consistent with procedures described in section 9 of this
Appendix.

    

    
      

       

      "STATE" shall mean the people
of the state of New York acting by and through the Commissioner of the New York
State Department of Health.

    

    
      

       

      "State Health Benefits Plan"
shall mean a plan that is offered or organized by the State government on
behalf of State employees or other public agency employees within the
State.

    

    
      

       

      "Subscriber" shall mean the
parent, legally responsible adult, individual, head of household or enrollee to
whom the CONTRACTOR issues a subscriber contract to obtain health care coverage
on behalf of his/her child or children or his or herself.

    

    
      

       

      "Subscriber Contract" shall
mean the contract between the CONTRACTOR and a subscriber approved by the New
York State Insurance Department and issued to each new enrollee by the
CONTRACTOR at the time of enrollment which details the provision of health care
coverage under this AGREEMENT.

    

    
      

       

      "Subsidy Payment" shall mean the STATE'S share of the
premium cost for health care coverage provided to enrollees under provisions of
this AGREEMENT, the amount of which is subject to approval by the New York State
Insurance Department.

    

    
      

       

      "Temporary Enrollment" shall mean enrollment of
a child who was enrolled in CHPlus but appears eligible for Medicaid at
recertification based on a completed and signed application or updated income
information but is given a two month period of enrollment in CHPlus in order to
complete the Medicaid application process. Temporary enrollment shall be granted
to an enrollee once in a twelve month period, with the exceptions noted in the
CHPlus manual.

    

    
      

       

      27

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      SECTION
2

    

    
      BENEFIT
PACKAGE

    

    
      

       

      2.1
CONTRACTOR Responsibilities

       

    

    
       

      The
CONTRACTOR shall provide health care services to enrollees consistent with the
benefit package set forth in Attachment A of this section and the subscriber
contract approved by the Insurance Department and any subsequent changes in
Attachment A, State statute, ADMs and the CHPlus manual.

    

    
      

       

      2.2
Provision of Services through Participating and Non-Participating
Providers

    

    
       

      Health
care services provided to enrollees in accordance with the benefit package set
forth in Attachment A of this section shall be provided by the CONTRACTOR
through provider agreements with participating providers. With the exception of
those enrollees covered under a payment rate methodology agreement negotiated
with a general hospital, payment for inpatient hospital services shall be paid
at the same payment rate as the medical assistance program. However, the
CONTRACTOR must pay for services of non-participating providers for the
treatment of emergency medical conditions and shall arrange for medically
necessary specialty services when such specialty services are not available in
the CONTRACTOR'S participating provider network. Specialty services shall be
available and provided to enrollees in accordance with the benefit package to
monitor and treat chronic, complex or serious medical conditions. The CONTRACTOR
shall make a good faith effort to negotiate an acceptable level of reimbursement
for services provided in such instances. The CONTRACTOR shall inform the
provider, as part of the rate negotiation, that the provider is prohibited from
balance billing the enrollee.

    

    
       

      Nothing
in this paragraph shall prohibit the CONTRACTOR from arranging for the provision
of health care services to enrollees by non-participating
providers.

    

    
      

       

      2.3
Direct Access

    

    
      

       

      The
CONTRACTOR shall offer female enrollees direct access to primary and preventive
obstetrics and gynecology services, follow-up care as a result of a primary and
preventive visit, and any care related to pregnancy from the CONTRACTOR'S
network providers without referral from the PCP as set forth in N.Y. Public
Health Law Section 4406-b(l).

    

    
      

       

      2.4
Emergency Services

    

    
      

       

      a.      The
CONTRACTOR shall maintain coverage utilizing a toll free telephone number
twenty-four (24) hours per day seven (7)
days per week, with an option to speak to a live person, to advise enrollees
of procedures for
accessing services for emergency medical conditions and for accessing services
for urgent medical
conditions. Emergency mental health calls shall be triaged via telephone by a
trained mental health
professional.

    

    
      

       

      b.      The
CONTRACTOR shall not require prior authorization for services in a medical or
behavioral health
emergency. The CONTRACTOR shall inform its enrollees that access to emergency
services is not
restricted and emergency services may be obtained from a non-participating
provider without penalty. The CONTRACTOR may
require enrollees to notify the plan or their PCP within a specified time
frame after
receiving emergency care and to obtain prior authorization for any follow-up
care delivered pursuant to the emergency. The
CONTRACTOR shall not deny payment for services to treat an emergency condition if
notification is not timely. The CONTRACTOR shall pay for services for emergency
medical conditions
whether provided by a participating provider or a non-participating
provider.

    

    
      

       

      28

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      c.           The
CONTRACTOR shall advise its enrollees through the subscriber contract and/or
member handbook,
how to obtain emergency services when it is not feasible for enrollees to
receive emergency
services from a participating provider. The CONTRACTOR shall pay the cost
of providing
emergency services through non-participating providers, and is prohibited
from balance
billing the enrollee. The CONTRACTOR shall make a good faith effort to
negotiate payment
rates for emergency services with non-participating
providers.

    

    
      

       

      d.           The
CONTRACTOR shall reimburse all non-airborne emergency ground transportation based on whether a
prudent layperson, possessing an average knowledge of medical health, could reasonably expect
the absence of such transportation to result in:

    

    
      

       

      · placing
the health of the person afflicted with such condition in serious
jeopardy;

    

    
      · serious
impairment to such person's bodily functions;

    

    
      · serious
dysfunction of any bodily organ or part of such person; or

    

    
      · serious
disfigurement of such person.

    

    
      

       

      29

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      Section
2

    

    
       

       

      Attachment
A

    

    
       

       

      BENEFIT
PACKAGE MATRIX

    

    
      

       

      30

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      Child
Health Plus

    

    
       

      Benefits
Package

    

    
      

       

      No
Pre-Existing Condition Limitations Permitted

    

    
      No
Co-payments or Deductibles

    

    
      November
2005

    

    

     

    
      	
              
                General
      Coverage

              

            	
              
                Scope
      of Coverage

              

            	
              
                Level
      of Coverage

              

            
	
              
                Pediatric
      Health Promotion Visits

              

            	
              
                Well
      child care visits in accordance with visitation schedule established by
      American Academy of Pediatrics, and the Advisory Committee on Immunization
      Practices recommended immunization schedule.

              

            	
              
                Includes
      all services related to visits. Includes immunizations which must be
      provided within 90 days from publication in the Morbidity and Mortality
      Weekly Report, well child care, health education, tuberculin testing
      (mantoux), hearing testing, dental and developmental screening, clinical
      laboratory and radiological tests, eye screening, lead screening, and
      reproductive health services, with direct access to such reproductive
      health services.

              

            
	
              
                Inpatient
      Hospital or Medical or Surgical Care

              

            	
              
                As
      a registered bed patient for treatment of an illness, injury or condition
      which cannot be treated on an outpatient basis. The hospital must be a
      short-term, acute care facility and New York State
      licensed.

              

            	
              
                No
      benefits will be provided for any out-of-hospital days, or if inpatient
      care was not necessary; no benefits are provided after discharge; benefits
      are paid in full for accommodations in a semi-private room. A private room
      will be covered if medically warranted. Includes 365 days per year
      coverage for inpatient hospital services and services provided by
      physicians and other professional personnel for covered inpatient
      services: bed and board, including special diet and nutritional therapy:
      general, special and critical care nursing services, supplies and
      equipment related to surgical operations, recovery facilities, anesthesia,
      and facilities for intensive or special care; oxygen and other inhalation
      therapeutic services and supplies; drugs and medications that are not
      experimental; sera, biologicals, vaccines, intravenous preparations,
      dressings, casts, and materials for diagnostic studies; blood products,
      except when participation in a volunteer blood replacement program is
      available to the insured or covered person, and services and equipment
      related to their administration; facilities, services, supplies and
      equipment related to diagnostic studies and the monitoring of physiologic
      functions, including but not limited to laboratory, pathology,
      cardiographic, endoscopic, radiologic and electro-encephalographic studies
      and examinations; facilities, services, supplies and equipment related to
      radiation and nuclear therapy; facilities, services, supplies and
      equipment related to emergency medical care; chemotherapy; any additional
      medical, surgical, or related services, supplies and equipment that are
      customarily furnished by the hospital.

              

            
	
              
                Inpatient
      Mental Health and Alcohol and Substance Abuse
    Services

              

            	
              
                Services
      to be provided in a facility operated by OMH under sec. 7.17 of the Mental
      Hygiene Law, or a facility issued an operating certificate pursuant to
      Article 23 or Article 31 of the Mental Hygiene Law or a general hospital
      as defined in Article 28 of the Public Health Law.

              

            	
              
                A
      combined 30 days per calendar year for inpatient mental health services,
      inpatient detoxification and inpatient
    rehabilitation.

              

            
	
              
                Inpatient
      Rehabilitation

              

            	
              
                Acute
      care services provided by an Article 28 General
    Hospital

              

            	
              
                Services
      supplies and equipment related to physical medicine and occupational
      therapy and short-term
      rehabilitation.                                                                                        

              

            

    

    
      

       

      31

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      	
              
                General
      Coverage

              

            	
              
                Scope
      of Coverage

              

            	
              
                Level
      of Coverage

              

            
	
              
                Professional
      Services for Diagnosis and Treatment of Illness and
      Injury

              

            	
              
                Provides
      services on ambulatory basis by a covered provider for medically necessary
      diagnosis and treatment of sickness and injury and other conditions.
      Includes all services related to visits. Professional services are
      provided on outpatient basis and inpatient basis.

              

            	
              
                No
      limitations. Includes wound dressing and casts to immobilize fractures for
      the immediate treatment of the medical condition. Injections and
      medications provided at the time of the office visit or therapy will be
      covered. Includes audiometric testing where deemed medically
      necessary.

              

            
	
              
                Hospice
      Services and Expenses

              

            	
              
                Coordinated
      hospice program of home and inpatient services which provide non-curative
      medical and support services for persons certified by a physician to be
      terminally ill with a life expectancy of six months or
      less.

              

            	
              
                Hospice
      services include palliative and supportive care provided to a patient to
      meet the special needs arising out of physical, psychological, spiritual,
      social and economic stress which are experienced during the final stages
      of illness and during dying and bereavement. Hospice organizations must be
      certified under Article 40 of the NYS Public Health Law. All services must
      be provided by qualified employees and volunteers of the hospice or by
      qualified staff through contractual arrangements to the extent permitted
      by federal and state requirements. All services must be provided according
      to a written plan of care which reflects the changing needs of the
      patient/family. Family members are eligible for up to five visits for
      bereavement counseling.

              

            
	
              
                Outpatient
      Surgery

              

            	
              
                Procedure
      performed within the provider's office will be covered as well as
      "ambulatory surgery procedures" which may be performed in a hospital-based
      ambulatory surgery service or a freestanding ambulatory surgery
      center.

              

            	
              
                The
      utilization review process must ensure that the ambulatory surgery is
      appropriately provided.'

              

            
	
              
                Diagnostic
      and Laboratory Tests

              

            	
              
                Prescribed
      ambulatory clinical laboratory tests and diagnostic
      x-rays.

              

            	
              
                No
      limitations.

              

            
	
              
                Durable
      Medical Equipment (DME), Prosthetic Appliances and Orthotic
      Devices

              

            	
              
                Durable
      Medical Equipment means devices and equipment ordered by a practitioner
      for the treatment of a specific medical condition
which:

              

              
                -
      Can withstand repeated use for a protracted

              

              
                period
      of time;

              

              
                -   Are
      primarily and customarily used for medical

              

              
                purposes;

              

              
                -   Are
      generally not useful in the absence of illness

              

              
                or
      injury; and

              

              
                -   Are
      usually not fitted, designed or fashioned for a particular person's
      use.

              

              
                DME
      intended for use by one person may be custom-made or
      customized.

              

            	
              
                Includes
      hospital beds and accessories, oxygen and oxygen supplies, pressure pads,
      volume ventilators, therapeutic ventilators, nebulizers and other
      equipment for respiratory care, traction equipment, walkers, wheelchairs
      and accessories, commode chairs, toilet rails, apnea monitors, patient
      lifts, nutrition infusion pumps, ambulatory infusion pumps and other
      miscellaneous DME.

              

              
                DME
      coverage includes equipment servicing (labor and parts). Examples include,
      but are not limited to:

              

              
                Fitted/Customized
      leg brace

              

              
                Prosthetic
      arm

              

              
                Footplate

              

              
                Crutches

              

              
                 Wheelchair

              

              
                Not
      fitted/Customized cane

              

            
	
              
                Prosthetic
      Appliances are those appliances and devices ordered by a qualified
      practitioner which replace any missing part of the
    body.

              

            	
              
                Covered
      without limitation except that there is no coverage for cranial prosthesis
      {i.e. wigs) and
      dental prosthesis, except those made necessary due to accidental injury to
      sound, natural teeth and provided within twelve months of the accident,
      and except for dental prosthesis needed in treatment of congenital
      abnormality or as part of reconstructive
  surgery.

              

            

    

    
      

       

      32

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      	
              
                General
      Coverage

              

            	
              
                Scope
      of Coverage

              

            	
              
                Level
      of Coverage

              

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

              

            	
              
                No
      limitations on orthotic devices except that devices prescribed solely for
      use during sports are not covered.

              

            
	
              
                Therapeutic
      Services

              

            	
              
                Ambulatory
      radiation therapy, chemotherapy, injections and medications provided at
      time of therapy {i.e.
      chemotherapy) will also be covered.

              

            	
              
                No
      limitations. These therapies must be medically necessary and under the
      supervision or referral of a licensed physician. Short term physical and
      occupational therapies will be covered when ordered by a physician. No
      procedure or services considered experimental will be
      reimbursed.

              

            
	
              
                Hemodialysis

              

            	
              
                Determination
      of the need for services and whether home-based or facility-based
      treatment is appropriate.

              

            
	
              
                Speech
      and Hearing Services Including Hearing Aids

              

            	
              
                Hearing
      examinations to determine the need for corrective action and speech
      therapy performed by an audiologist, language pathologist, a speech
      therapist and/or otolaryngologist.

              

            	
              
                One
      hearing examination per calendar year is covered. If an auditory
      deficiency requires additional hearing exams and follow-up exams, these
      exams will be covered. Hearing aids, including batteries and repairs, are
      covered. If medically necessary, more than one hearing aid will be
      covered.

              

              
                Covered
      speech therapy services are those required for a condition amenable to
      significant clinical improvement within a two-month period, beginning with
      the first day of therapy.

              

            
	
              
                Pre-Surgical
      Testing

              

            	
              
                All
      tests (laboratory, x-ray, etc.) necessary prior to inpatient or outpatient
      surgery.

              

            	
              
                Benefits
      are available if a physician orders the tests: proper diagnosis and
      treatment require the tests; and the surgery takes place within seven days
      after the testing. If surgery is canceled because of pre-surgical test
      findings or as a result of a Second Opinion on Surgery, the cost of the
      tests will be covered.

              

            
	
              
                Second
      Surgical Opinion

              

            	
              
                Provided
      by a qualified physician.

              

            	
              
                No
      limitations.

              

            
	
              
                Second
      Medical Opinion

              

            	
              
                Provided
      by an appropriate specialist, including one affiliated with a specialty
      care center.

              

            	
              
                A
      second medical opinion is available in the event of a positive or negative
      diagnosis of cancer, a recurrence of cancer, or a recommendation of a
      course of treatment of cancer.

              

            
	
              
                Outpatient
      Visits for Mental Health and for the Diagnosis and Treatment of Alcoholism
      and Substance Abuse

              

            	
              
                Services
      must be provided by certified and/or licensed
      professionals.

              

            	
              
                A
      combined 60 outpatient visits per calendar year. Visits may include family
      therapy for alcohol, drug and/or mental health as long as such therapy is
      directly related to the enrolled child's alcohol, drug and/or mental
      health treatment.

              

            
	
              
                Home
      Health Care Services

              

            	
              
                The
      care and treatment of a covered person who is under the care of a
      physician but only if hospitalization or confinement in a skilled nursing
      facility would otherwise have been required if home care was not provided
      and the plan covering the home health service is established and provided
      in writing by such physician,

              

            	
              
                Home
      care shall be provided by a certified home health agency possessing a
      valid certificate of approval issued pursuant to Article 36 of the Public
      Health Law. Home care shall consist of one or more of the following:
      part-time or intermittent home health aide services which consist
      primarily of caring for the patient, physical, occupational, or speech
      therapy if provided by the home health agency and medical supplies, drugs
      and medications prescribed by a physician, and laboratory services by or
      on behalf of a certified home health agency to the extent such items would
      have been covered or provided under the contract if the covered person had
      been hospitalized or confined in a skilled nursing facility. The contract
      must provide 40 such visits in any calendar year, if such visits are
      medically necessary.

              

            

    

    
      

       

      33

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      	
              
                General
      Coverage

              

            	
              
                Scope
      of Coverage

              

            	
              
                Level
      of Coverage

              

            
	
              
                Prescription
      and Non-Prescription Drugs

              

            	
              
                Prescription
      and non-prescription medications must be authorized by a professional
      licensed to write prescriptions.

              

            	
              
                Prescriptions
      must be medically necessary. May be limited to generic medications where
      medically acceptable. Includes family planning or contraceptive
      medications or devices. All medications used for preventive and
      therapeutic purposes will be covered. Vitamins are not covered except when
      necessary to treat a diagnosed illness or condition. Coverage includes
      enteral formulas for home use for which a physician or other provider
      authorized to prescribe has issued a written order. Enteral formulas for
      the treatment of specific diseases shall be distinguished from nutritional
      supplements taken electively. Coverage for certain inherited diseases of
      amino acid and organic acid metabolism shall include modified solid food
      products that are low-protein or which contain modified protein. Coverage
      for such modified solid food products shall not exceed $2500 per calendar
      year.

              

            
	
              
                Emergency
      Medical Services

              

            	
              
                For
      services to treat an emergency medical condition in hospital facilities.
      For the purpose of this provision, "emergency condition" means a medical
      or behavioral condition, the onset of which is sudden, that manifests
      itself by symptoms of sufficient severity, including severe pain, that a
      prudent layperson, possessing an average knowledge of medicine and health,
      could reasonably expect the absence of immediate medical attention to
      result in:

              

              
                is   Placing
      the health of the person afflicted with such condition in serious
      jeopardy, or in the case of a behavioral condition placing the health of
      such person or others in serious jeopardy; us   Serious
      impairment to such person's bodily

              

              
                functions;
      B   Serious dysfunction of any bodily organ or
      part

              

              
                of
      such person; or b   Serious disfigurement of such
      person.

              

            	
              
                No
      limitations.

              

            

    

    
      

       

      34

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      	
              
                General
      Coverage

              

            	
              
                Scope
      of Coverage

              

            	
              
                Level of Coverage

              

            
	
              
                Ambulance
      Services

              

            	
              
                Pre-hospital
      emergency medical services, including prompt evaluation and treatment of
      an emergency condition and/or non-airborne transportation to a
      hospital.

              

            	
              
                Services
      must be provided by an ambulance service issued a certificate to operate
      pursuant to Section 3005 of the Public Health Law.

              

              
                Evaluation
      and treatment services must be for an emergency condition defined as 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:

              

              
                -
      Placing the health of the person afflicted with such condition in serious
      jeopardy, or in the case of a behavioral condition placing the health of
      such person or others in serious jeopardy;

              

              
                -
      Serious impairment to such person's bodily functions;

              

              
                -
      Serious dysfunction of any bodily organ or part of such person;
      or

              

              
                -
      Serious disfigurement of such person.

              

              
                Coverage
      for non-airborne emergency transportation is based on whether a prudent
      layperson, possessing an average knowledge of medicine and health, could
      reasonable expect the absence of such transportation to result
      in:

              

              
                -
      Placing the health of the person afflicted with such condition in serious
      jeopardy;

              

              
                -  Serious
      impairment to such person's bodily functions;

              

              
                -
      Serious dysfunction of any bodily organ or part of such person;
      or

              

              
                -  Serious
      disfigurement of such person.

              

            
	
              
                Maternity
      Care

              

            	
              
                Inpatient
      hospital coverage for at least 48 hours after childbirth for any delivery
      other than a C-Section and in at least 96 hours following a C-section.
      Also coverage of parent education, assistance and training in breast and
      bottle feeding and any necessary maternal and newborn clinical
      assessments. The mother shall have the option to be discharged earlier
      than the 48/96 hours, provided that at least one home care visit is
      covered post-discharge. Prenatal, labor and delivery is
      covered.

              

            	
              
                No
      limitations; (however subsidized children requiring maternity care
      services will be referred to Medicaid).

              

            
	
              
                Diabetic
      Supplies and Equipment

              

            	
              
                Coverage
      includes insulin, blood glucose monitors, blood glucose monitors for
      visually impaired, data management systems, test strips for monitors and
      visual reading, urine test strips, insulin, injection aids, cartridges for
      visually impaired, syringes, insulin pumps and appurtenances thereto,
      insulin infusion devices, oral agents.

              

            	
              
                As
      prescribed by a physician or other licensed health care provider legally
      authorized to prescribe under title eight of the education
      law.

              

            

    

    
      

       

      35

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      	
              
                General
      Coverage

              

            	
              
                Scope
      of Coverage

              

            	
              
                Level
      of Coverage

              

            
	
              
                Diabetic
      Education and Home Visits

              

            	
              
                Diabetes
      self-management education (including diet); reeducation or refresher. Home
      visits for diabetic monitoring and/or education.

              

            	
              
                Limited
      to visits medically necessary where a physician diagnoses a significant
      change in the patient's symptoms or conditions which necessitate changes
      in a patient's self-management or where reeducation is necessary. May be
      provided by a physician or other licensed health care provider legally
      authorized to prescribe under title eight of the education law, or their
      staff, as part of an office visit for diabetes diagnosis or treatment, or
      by a certified diabetes nurse educator, certified diagnosis nutritionist,
      certified dietician or registered dietician upon the referral of a
      physician or other licensed health care provider legally authorized to
      prescribe under title eight of the education law and may be limited to
      group settings wherever practicable.

              

            
	
              
                Emergency,
      Preventive and Routine Vision Care

              

            	
              
                Vision
      examinations performed by a physician, or optometrist for the purpose of
      determining the need for corrective lenses, and if needed, to provide a
      prescription.

              

            	
              
                The
      vision examination may include, but is not limited to:

              

              
                -  Case
      history

              

              
                -  Internal
      and External examination of the eye

              

              
                -  Opthalmoscopic
      exam

              

              
                -  Determination
      of refractive status

              

              
                - Binocular
      balance

              

              
                -  Tonometry
      tests for glaucoma

              

              
                -  Gross
      visual fields and color vision testing

              

              
                -  Summary
      findings and recommendations for corrective
lenses

              

            
	
              
                Prescribed
      Lenses

              

            	
              
                At
      a minimum, quality standard prescription lenses provided by a physician,
      optometrist or optician are to be covered once in any twelve month period,
      unless required more frequently with appropriate documentation. The lenses
      may be glass or plastic lenses.

              

            
	
              
                Frames

              

            	
              
                At
      a minimum, standard frames adequate to hold lenses will be covered once in
      any twelve month period, unless required more frequently with appropriate
      documentation.

              

              
                If
      medically warranted, more than one pair of glasses will be
      covered.

              

            
	
              
                Contact
      Lenses

              

            	
              
                Covered
      when medically necessary.

              

            
	
              
                Emergency,
      Preventive and Routine Dental Care

              

            	
              
                Emergency
      Dental Care

              

            	
              
                Includes
      emergency treatment required to alleviate pain and suffering caused by
      dental disease or trauma.

              

            
	
              
                Preventive
      Dental Care

              

            	
              
                Includes
      procedures which help prevent oral disease from occurring, including but
      not limited to:

              

              
                -  Prophylaxis:
      scaling and polishing the teeth at 6 month intervals

              

              
                -  Topical
      fluoride application at 6 month intervals where local water supply is
      not

              

              
                fluoridated

              

              
                -  Sealants
      on unrestored permanent molar teeth.

              

              
                -  Space
      Maintenance: unilateral or bilateral space maintainers will be covered for
      placement in a restored deciduous and/or mixed detention to maintain space
      for normally developing permanent
teeth.

              

            

    

    
      

       

      36

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      	
              
                General
      Coverage

              

            	
              
                Scope
      of Coverage

              

            	
              
                Level
      of Coverage

              

            
	 
      	
              
                Routine
      Dental Care

              

            	
              
                -  Dental
      examinations, visits and consultations covered once within 6
      month

              

              
                consecutive
      period (when primary teeth erupt)

              

              
                -  X-ray,
      full mouth x-rays at 36 month intervals, if necessary, bitewing x-rays at
      6-12

              

              
                month
      intervals, or panoramic x-rays at 36"month intervals if necessary; and
      other

              

              
                x-rays
      as required (once primary teeth erupt)

              

              
                -  All
      necessary procedures for simple extractions and other routine dental
      surgery

              

              
                not
      requiring hospitalization including preoperative care and postoperative
      care b   In office conscious sedation

              

              
                -  Amalgam,
      composite restorations and stainless steel crowns

              

              
                -  Other
      restorative materials appropriate for children

              

            
	
              
                Endodontics

              

            	
              
                Includes
      all necessary procedures for treatment of diseased pulp chamber and pulp
      canals, where hospitalization is not required!

              

            
	
              
                Prosthodontics

              

            	
              
                Removable:
      Complete or partial dentures including six months follow-up care.
      Additional services include insertion of identification slips, repairs,
      relines and rebases and treatment of cleft palate.

              

              
                Fixed:
      Fixed bridges are not covered unless

              

              
                1)
      Required for replacement of a single upper anterior (central/lateral
      incisor or cuspid) in a
      patient with an otherwise full complement of natural, functional
      and/or restored
      teeth;

              

              
                2)
      Required for cleft-palate treatment or stabilization;

              

              
                3)
      Required, as demonstrated by medical documentation, due to the presence of
      any neurologic or
      physiologic condition that would preclude the placement of a removable
      prosthesis.

              

            
	 
      	
              
                NOTE:
      Refer to the Medicaid Management Information System (MMIS) Dental Provider
      Manual for a more detailed description of
  services.

              

            

    

    
      

       

      37

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      SECTION
3

    

    
      

    

    
      SERVICE
AREA

    

    
      

       

      3.1       Approved
Counties

    

    
      

       

      For
purposes of this AGREEMENT, the CONTRACTOR'S service area shall consist of the
following counties:

    

    
      

       

      Albany,
Bronx, Columbia, Dutchess, Greene, Kings, New York, Orange, Queens, Rensselaer,
Rockland, and Ulster

    

    
      

       

      39

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      3.2
Service Area Expansions

    

    
      

       

      The
CONTRACTOR may request approval to expand and enhance its existing provider
network to provide services under CHPlus to areas of New York State for which
the CONTRACTOR is certified as a corporation or health maintenance organization
licensed under Article 43 of the Insurance Law and/or a health maintenance
organization or comprehensive health service organization certified under
Article 44 of the Public Health Law; however, in no event may the CONTRACTOR
provide services to an expanded service area beyond the currently authorized
counties under this AGREEMENT without prior written approval from the
STATE.

    

    
      

       

      3.3
Participation Limited to Counties Approved as Medicaid Managed
Care

    

    
      

       

      The STATE
reserves the right to limit the CONTRACTOR'S participation in CHPlus to those
counties where the CONTRACTOR is approved as a Medicaid managed care plan under
section 364-j of the Social Services Law.

    

    
      

       

      3.4
Removal of Counties when Participation in Medicaid Managed Care
Stops

    

    
      

       

      The STATE
reserves the right to remove a county from the CONTRACTOR'S approved CHPlus
service area if the CONTRACTOR stops participating in Medicaid managed care in
that county.

    

    
      

       

      40

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      SECTION
4

    

    
      ELIGIBILITY
CRITERIA

    

    
      

       

      The
CONTRACTOR must determine that a child meets the following criteria to be
eligible for subsidized CHPlus coverage:

    

    
      

       

      4.1 Age

    

    
      

       

      The child
must be under nineteen years of age. Age must be documented at initial
enrollment, consistent with documentation requirements in section 5 of this
Appendix and the CHPlus Manual.

    

    
      

       

      4.2 New
York State Residency

    

    
      

       

      The child
must be a New York State resident. New York State residency must be documented
at initial enrollment, consistent with documentation requirements in section 5
of this Appendix and the CHPlus manual.

    

    
      

       

      4.3 Medicaid
Eligibility

    

    
      

       

      The child
must not be enrolled in or eligible for Medicaid.

    

    
      

       

      A child
who has not yet become Medicaid eligible through Medicaid spend down is eligible
for CHPlus. As soon as the child meets his/her monthly spend down such that
he/she is eligible for Medicaid, he/she is no longer eligible for
CHPlus.

    

    
      

       

      4.4 Health
Insurance

    

    
      

       

      The child
must not have other health insurance coverage unless the policy is one of the
"Excepted Benefits" set forth in the federal Public Health Service Act. These
exceptions are as follows:

    

    
      

       

      A. Accident-only
coverage or disability income insurance;

    

    
      B. Coverage
issued as a supplement to liability insurance;

    

    
      C. Liability
insurance, including auto insurance;

    

    
      D. Workers'
compensation or similar insurance;

    

    
      E. Automobile
medical payment insurance;

    

    
      F. Credit-only
insurance;

    

    
      G. Coverage
for on-site medical clinics;

    

    
      H. Dental-only,
vision-only, or long term care insurance;

    

    
      I. Specified
disease coverage;

    

    
      J. Hospital
indemnity or other fixed dollar indemnity coverage; or

    

    
      K. Medicare
supplemental only or CHAMPUS supplemental coverage.

    

    
      

       

      Additional
exceptions for otherwise eligible children are:

    

    
      

       

      • Participation
in the Physically Handicapped Children's Program;

    

    
      

       

      • Health
insurance by a non-custodial parent in an area other than the child's county of
residence; or

    

    
      

       

      • Enrollment
in the Medicaid Family Planning Benefit program.

    

    
      

       

      Children
with other health insurance products are not eligible for CHPlus including, but
not limited to:

    

    
      

       

      • A
child with Medicare coverage; or

    

    
      

       

      • A
child insured with a college health insurance policy.

    

    
      

       

      41

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      4.5
Public Employees

    

    
      

       

      The parent or guardian of the applicant
child shall not be a public employee of the State or a public agency with access to family health
insurance coverage by a state health benefits plan and the State or public agency pays all or part of the
cost of the family health insurance coverage. The CONTRACTOR may use the following
website to determine if the public agency has access to a state health benefits plan: www.cs.state.ny.us/ebd/ebdonlinecenter/pamarket/directory.cfm. If the CONTRACTOR is uncertain if a parent has
access to such coverage, the CONTRACTOR must contact the applicant's parent or
guardian to find out if the health insurance available to the family is
that described in this
paragraph.

    

    
      

       

      4.6
Inmates of Public Institutions

    

    
      

       

      The child
must not be an inmate of a public institution as defined at 42 CFR §435.1009 or
a patient of an institution for mental diseases, as defined at 42 CFR §435.1009
at the time of initial application or any redetermination of
eligibility.

    

    
      

       

      4.7
Number of Children in the Household and Income

    

    
      

       

      Once the
CONTRACTOR determines that a child meets the above eligibility criteria for
CHPlus, the CONTRACTOR shall use the number of children in the household who are
enrolled in CHPlus and the family income to calculate the required family
contribution.

    

    
      

       

      4.8
Screen for Eligibility

    

    
      

       

      The
CONTRACTOR shall comply with the following steps to assure that children are
screened for Medicaid or CHPlus eligibility.

    

    
      

       

      New
Applications

    

    
      

       

      The
CONTRACTOR must screen all new applications for Medicaid eligibility using the
STATE developed eligibility screening worksheet or a CONTRACTOR developed
eligibility worksheet approved by the STATE. CONTRACTORS shall only enroll
children who appear eligible for Medicaid based on the screening worksheet in
CHPlus on a temporary basis, as described in section 8 of this Appendix and the
CHPlus manual.

    

    
      

       

      If the
screen indicates the child is not eligible for Medicaid, otherwise eligible
children residing in households with gross income at or below 250 percent of the
non-farm federal poverty level are eligible for subsidized coverage under
CHPlus. Children residing in households with gross income over 250 percent of
the non-farm federal poverty level are not eligible for subsidized coverage
under CHPlus but may be enrolled in CHPlus providing that they pay the full
premium amount for the health plan in which they are
enrolled.

    

    
      

       

      4.9
Twelve Months Continuous Coverage

    

    
      

       

      If the
CONTRACTOR finds a child to be CHPlus eligible, the CONTRACTOR shall enroll the
child in CHPlus. The period of eligibility shall begin on the first day of the
month an eligible child is enrolled or recertified for enrollment on an annual
basis, based on all required documentation, and shall continue for twelve (12)
months ending on the last day of the twelfth month. Presumptive enrollees are
not eligible for 12 months of continuous coverage until all required
documentation is submitted and a child is determined fully eligible for CHPlus
at which time the 12 months of continuous coverage shall run from the date
presumptive eligibility began.

       

      42

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      The
12-month period of continuous coverage is subject to the following
exclusions:

    

    
      

       

      a. The
child no longer resides in New York State.

    

    
      b. The
child turns 19 years of age.

    

    
      c. The
child has obtained other health insurance coverage.

    

    
      d. The
child has access to a State Health Benefits Plan.

    

    
      e. The
required family premium contribution is not received in accordance with
section 10 of this
Appendix.

    

    
      f. The
child becomes Medicaid eligible.

    

    
      g. The
child was not eligible either because the health plan did not comply with program rules or because
the eligibility determination was based on fraudulent information.

    

    
      

       

      Households
are not required to report a change in income within the 12-month period of
continuous coverage, however:

    

    
      

       

      a. If
a household reports an increase in income within the 12 month period of
continuous coverage, the CONTRACTOR
shall not redetermine eligibility or the required family premium
contribution.

    

    
      

       

      b. If
a household reports a decrease in income within the 12 month period of
continuous coverage, the CONTRACTOR
shall screen the child(ren) for Medicaid eligibility and redetermine the required
family premium contribution.

    

    
      

       

      4.10      Crowd-Out

    

    
      

       

      If the
STATE determines that crowd-out is occurring in excess of a percentage specified
in the State Child Health Plan established under Title XXI of the federal Social
Security Act or as may be specified by the Secretary of the federal Department
of Health and Human Services based on data collected pursuant to section 16.4 of
this Appendix, the following eligibility criterion shall be implemented for a
child residing in a household with gross income at or below two hundred fifty
percent of the non-farm federal poverty level.

    

    
      

       

      The child
must not have been covered by a group health plan based upon a family member's
employment during the six (6) month period prior to the date of application
unless one of the following exceptions applies:

    

    
      

       

      • Loss
of employment is due to factors other than voluntary
separation;

    

    
      

       

      • Death
of the family member which results in termination of coverage under a group
health plan under which the child is covered;

    

    
      

       

      • Change
to a new employer that does not provide an option for comprehensive health
benefits coverage;

    

    
      

       

      • Change
of residence so that no employer-based comprehensive health benefits coverage is
available;

    

    
      

       

      • Discontinuation
of comprehensive health benefits coverage to all employees of the applicant's
employer;

    

    
      

       

      • Expiration
of the coverage periods established by COBRA or the provisions of sections 322
l(m), 4304(k) and 4305(e) of the Insurance Law;

    

    
      

       

      43

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      • 
Termination of comprehensive health benefits coverage due to long-term
disability;

       

    

    
      • 
Cost of employment-based health insurance is more than five percent of the
family's income;

       

    

    
      •  A
child applying for coverage is pregnant; or

       

    

    
      •  A
child applying for coverage is at or below the age of five (5). Implementation
of this exception is subject to federal approval of the State's Child health
plan in accordance with Title XXI of the federal social security
act.

    

    
      

       

      44

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      SECTION
5

    

    
      DOCUMENTATION

    

    
      

       

      The
CONTRACTOR shall maintain the following documentation in the child's enrollment
file:

    

    
      

       

      5.1
Age

    

    
      

       

      Age shall
be documented by one of the following if it includes a date of birth: birth
certificate (does not have to include the first name of the child), driver's
license, official photo identification issued by Federal, state or local
government (which includes a school) that contains the date of birth and either
a photograph of the individual or other identifying information of the
individual such as name, age, sex, race, height and weight or eye color,
passport, baptismal/other religious certificate, official school record,
adoption' record, official hospital/doctor/midwife birth record, a
naturalization certificate, a marriage certificate or a New York State Medicaid
card.

    

    
      

       

      The
CONTRACTOR shall process an application if Section B lists a name for a child
which is known to be a nickname for the given name on the documentation. The
CONTRACTOR must enter the name of the child on the documentation on the KIDS
system. The CONTRACTOR may accept birth certificates that do not include the
first name of the applying child.

    

    
      

       

      The
following are not acceptable documentation of date of birth: an Acknowledgement
of Paternity form or a NY State Birth Certificate and Statewide Perinatal Data
System Quality Improvement Information form.

    

    
      

       

      5.2 New
York State Residency

    

    
      

       

      Proof of
residency must match the home address in Section A of the Growing Up Healthy or
Access New York Health Care application and must be dated within six (6) months
of the application. Proof of residency shall be documented by the following: an
identification card with address, a postmarked envelope or postcard with name
and date (this cannot be used if sent to a P.O. Box), a driver's license, a
utility bill (including oil, gas or electric, water, cable, or telephone) that
includes the street address and zip code for the service (the city name is not
required on the bill), letters/correspondence from a federal, state or local
government agency, a letter or rent receipt containing the name and street of
the tenant and the amount paid each month, as well as the name and address from
the landlord and the landlord's signature, a valid lease that contains the
applicant's name, address and amount of rent from the landlord, property tax
records or a mortgage statement.

    

    
      

       

      The
CONTRACTOR shall not accept cell-phone bills, magazine labels, bank statements,
an envelope or postcard without a street address (just a P.O. Box), an envelope
with a forwarding label from the Post Office, a window envelope or Federal or
state tax returns.

    

    
      

       

      5.3 Other
Health Insurance Coverage

    

    
      

       

      Other
health insurance, if applicable, shall be documented by a copy of the insurance
policy, a certificate of insurance, a copy of the insurance card or a copy of
the Medicare card.

    

    
      

       

      Documentation
of health insurance is necessary for CHPlus to determine if a child's coverage
or access to coverage makes them ineligible for the program. Documentation of
other health insurance is necessary for Medicaid and Family Health Plus as a
possible deduction when calculating eligibility and for coverage of future
medical bills. If the applicant indicates he/she has other health insurance
coverage, the health plan shall obtain documentation of such coverage at initial
enrollment and if different than what was stated on the initial application, at
recertification.

    

    
      

       

      If the
CONTRACTOR receives a paycheck stub as documentation of income that includes a
deduction for health insurance, the CONTRACTOR must ask the applicant who is
covered through

    

    
      

       

      45

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      the
employer based policy and note the response on the stub. If the child is
covered, in most cases, the child is not eligible for CHPlus. If only the parent
is covered, the child is eligible for CHPlus.

    

    
      

       

      In most
cases, if an applicant presents a State paycheck stub, the person will have
access to the State health benefits plan and the child will be ineligible for
CHPlus. If a person is employed by a local government or is a teacher, they may
have access to the State health benefits plan also. The CONTRACTOR must
determine if such coverage is through a State health benefits plan to determine
if a child is eligible for CHPlus. The CONTRACTOR may use the following website
to determine if the public agency has access to a State health benefits
plan:

    

    
      

       

      www.es.state.ny.us/ebd/ebdonlinecenter/pamarket/directory.cfm. If the CONTRACTOR is uncertain,
the CONTRACTOR shall call
the applicant or the employer to determine if the child has access to the State
health benefits program.

    

    
      

       

      5.4
Income

    

    
      

       

      Income
documentation must be provided for all household members listed in section B of
the Growing up Healthy or Access New York Health Care application who have
income. Income documentation must be provided for all categories listed below
that apply. The CONTRACTOR must obtain documentation of the gross income for the
four weeks preceding the application signature date for all individuals included
in the household. Unearned income that varies from month to month (i.e. interest
income) must also be documented for the four weeks prior to application.
Documentation of unearned income which does not vary on a month to month basis
does not have to be dated within the four weeks prior the application as long as
it reflects the current amount. Applicants may provide, at recertification,
their social security number in lieu of income documentation. Income shall be
documented by the following:

    

    
      

       

      a. Wages
and Salary:

    

    
      

       

      1.
Paycheck stubs for the four (4) consecutive weeks preceding the application
signature date. Paychecks may only be used if they include all information
typically contained on a pay stub, including net and gross income and
deductions;

    

    
      2. In
cases where the CONTRACTOR receives three weeks of paycheck stubs and is missing
one in between, the CONTRACTOR shall use the year to date income on the
subsequent paycheck to calculate the amount of the missing paycheck stub. In
this instance, the CONTRACTOR shall accept three paycheck stubs rather than
four;

    

    
      3. Letter
from the employer on company letterhead which is signed and dated and includes
the employer's name, address and phone number and the employee's name and gross
income. If the applicant indicates their employer does not have letterhead, the
CONTRACTOR shall accept a letter without it and note on the letter that
according to the applicant, letterhead does not exist;

    

    
      4. Signed
and dated income tax return (Federal form 1040) if used for applications prior
to April 1 of the following year; or

    

    
      5.
Business/payroll records.

    

    
      

       

      The
following are not acceptable documentation of earned income: quarterly wage
statements, W-2s and 1099s.

    

    
      

       

      If a
person has recently begun a new job or receiving some regular income and
therefore cannot document income for the last four weeks, the CONTRACTOR shall
follow the instructions in section 7 of this Appendix, presumptive eligibility.
This will involve documenting only what they have and obtaining further
documentation when the income is received.

    

    
      

       

      A joint
tax return must be signed by both filers. If an electronic tax return is used,
the family may bring a signed copy of the tax return. If the return is filed
electronically, a copy of the

    

    
      

       

      46

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      acknowledgement
form from the Internal Revenue Service, which includes a DCN number that
verifies that tax return was accepted electronically is
acceptable.

    

    
      

       

      The
CONTRACTOR shall not accept a letter from an employer that states an
"approximate" or "average" income.

    

    
      

       

      b. Self-Employment
Income:

    

    
       

      1. Signed
and dated income tax return and all schedules including Schedule C for sole
owners of a business, Schedule E for rental real estate, partnerships and S
corporations or Schedule F for farmers, Schedule K-l (Form 1065) and Form 1065
for Partnerships, and Schedule K-l (Form 1120S) and Form 1120S for S
Corporations; (See paragraph above on electronic returns); or

    

    
      2.
Records of earnings and expenses/business records. The three month
"Self-Employment worksheet" used by many local social services districts may be
used as acceptable proof as long as it is consistent with other information on
the application and appears internally consistent.

    

    
      3. If no
other form of documentation is available, a self-declaration of
income.

    

    
      

       

      c. Unemployment
Benefits:

    

    
       

      1. Award
letter or certificate;

    

    
      2. A
monthly benefit statement from the New York State Department of
Labor;

    

    
      3. A
printout of the recipient's account information from the New York State
Department of Labor's website (www.labor.state.ny.us);
or

    

    
      4.
Correspondence from the New York State Department of Labor.

    

    
      

       

      The
CONTRACTOR shall not accept the monetary determination letter as documentation
of unemployment as it is not necessarily what the person will receive in income.
If the applicant does not have any of the above, the CONTRACTOR shall enroll the
child presumptively in accordance with section 7 of this Appendix and follow-up
accordingly.

    

    
      

       

      d. Private
Pensions/Annuities:

    

    
      

       

      1.   Statement
from pension/annuity.

    

    
      

       

      e. Social
Security Retirement/Survivors/Disability Insurance:

    

    
      1. Award
letter/certificate;

    

    
      2.
Benefit check stub; or

    

    
      3.
Correspondence from the Social Security Administration.

    

    
      

       

      The
CONTRACTOR shall not accept bank statements as documentation of this amount
since they show only net income.

    

    
      

       

      f. Child
Support/Alimony

    

    
      

       

      1. Letter
from person providing support which includes the name and address of the person
providing the support, the amount of the support being provided, the name of the
person receiving the support and who the support is for. The letter must be
signed and dated;

    

    
      2. Letter
from court;

    

    
      3. Child
support/alimony check stub. If the same amount of support is received each time
and it is consistent with the child support order, it is not necessary to obtain
four weeks of check stubs. If there is any dispute or discrepancy, and
the

    

    
      

       

      47

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      child
support is not received on a consistent basis from week to week, four weeks
worth of check stubs must be submitted and averaged;

    

    
       

      4.
Monthly bank statement for those recipients that choose direct deposit for their
child support; or

    

    
       

      5. A copy
of their child support account information from the following website: www.newyorkchildsupportcom.

    

    
      

       

      g.   Worker's
Compensation

    

    
       

      1. Award
letter; or

    

    
      2. Check
stub.

    

    
      

       

      h.   Veteran's
Benefits

    

    
       

      1. Award
letter;

    

    
      2. Benefit
check stub; or

    

    
      3. Correspondence
from the Veteran's Administration.

    

    
      

       

      i.    Military
Pay

    

    
       

      1. Award
letter; or

    

    
      2. Check
stub.

    

    
      

       

      j.    Interest/Dividends/Royalties

    

    
       

      1.   Recent
statement from bank, credit union or financial institution; 

      2. Letter
from broker;

    

    
      3. Letter
from Agent; or

    

    
      4. A
1099 or tax return if no other documentation is available.

    

    
      

       

      k.   Income
from Rent or Room/Board

    

    
       

      1. Letter
from roomer, boarder or tenant including the name and address of the tenant,
roomer/boarder, the name of the landlord and the amount paid. The letter must be
signed and dated; or

    

    
      2. Check
stub.

    

    
       

      1.    Support
from other Family members

    

    
      1.   Signed
statement or letter from family member.

    

    
       

      m.  Self
Declaration of Income

    

    
       

      1.   CONTRACTOR
shall accept a Self-Declaration of Income form found in Attachment A of this
section if the applicant has no other way to document his/her income. The form
must be completed in full and may only be accepted if no other income
documentation is available.

    

    
      

      n.   Student
Stipends

    

    
       

      1.   A
letter from the school/organization providing the stipend which must include the
amount being given and any restrictions on the use of the money, if
any.

    

    
      

       

      48

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      o.   Non-Monetary
Compensation

    

    
      

       

      1. A
letter from the person providing non-monetary compensation, in lieu of wages,
including the name of the person providing the service, what service is being
provided, the type of compensation being provided (i.e. rent), the value of the
compensation on the open market and the name, signature and date of the person
providing the compensation.

    

    
      

       

      p.   No
income

    

    
      

       

      1. A
statement on the application or on the Declaration of No Income form found in
Attachment B of this section indicating how the person is supporting him/herself
with no income.

    

    
      2. This
form should only be used when a household has no income. It is not to be used if
one person in the household has income and one person in the household does
not.

    

    
      

       

      5.5 Date
of Status

    

    
      

       

      Documentation
of date of status (DOS) must be obtained for applicants who indicate they are a
qualified immigrant (those who identify as one of the "A" categories in Section
D of the Growing Up Healthy or Access New York Health Care application). The
date of status shall reflect the date when the person became a qualified
immigrant, which is not necessarily the date they entered the country.
Acceptable documentation shall include but not be limited to the
following:

    

    
      

       

      a) Lawful
Permanent Resident

    

    
      1. Permanent
Resident Card (Form 1-551) ("green card");

    

    
      2. Re-entry
permit (Form 1-327);

    

    
      3. Foreign
Passport with an 1-551 stamp showing temporary evidence of Lawful Permanent
Residency;

    

    
      4. Form
I-94/the Arrival/Departure Record; or

    

    
      5. Memorandum
of Creation of Lawful Permanent Residence with approval stamp
(1-181).

    

    
      

       

      b)
Refugee

    

    
      

       

      1. 1-94
Arrival/Departure Record or foreign passport with stamp indicating refugee
status under section 207 of the INA coded "Section 207", "Refugee," "RE1,"
"RE2," "RE3," or "RE4" and date of entry;

    

    
      2. Determination
letter from USCIS or immigration judge stating final approval for refugee
status;

    

    
      3. I
- 68 8B Employment Authorization Card annotated "8 C.F.R. 274a.
12(a)(3)";

    

    
      4. I
- 766 Employment Authorization Document annotated A-3;

    

    
      5. I
- 571 (Refugee Travel Document); or

    

    
      6. 1-551
Permanent Resident Card coded "R-8-6," "RE6," "RE7," "RE8,"
"RE9."

    

    
      

       

      c)
Victims of Trafficking

    

    
      

       

      1. Certification
letter (for adults) or eligibility letter (for children younger than 18) issued
by the Office of Refugee Settlement. The LDSS worker must call the Trafficking
Verification Line at 1-866-401-5510 to verify the letter;

    

    
      2. 1-94
Arrival/Departure Record coded "T-l," "T-2," "T-3," "T-4" or "T-5" stating
admission under Section 212(d)(5) of the INA if status is granted for at least
one year; or

    

    
      3. 1-797
Notice of Action acknowledging receipt of an 1-914, Application for T
Nonimmigrant status.

    

    
      

       

      d)
Asylee

    

    
       

      1. 1-94
showing grant of asylum under section 208 of the INA coded "Section 208" or
"asylee";

    

    
      

       

      49

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      2. Grant
letter/order from the USCIS Asylum Office or immigration judge granting
asylum;

    

    
      3. I
- 688B Employment Authorization Card annotated "8 C.F.R. 274a.
12(a)(5)";

    

    
      4. I
- 766 Employment Authorization Document annotated A-5;

    

    
      5. 1-551
Permanent Resident Card coded AS1, AS2, AS3, AS6, AS7 or AS8;
or

    

    
      6. 1-571
Refugee Travel Document.

    

    
      

       

      e. Granted
Withholding of Deportation or Removal

    

    
       

      1. 1-94
Arrival/Departure Record or foreign passport stamped "243(h)" or "Section
241(b)(3)";

    

    
      2. 1-571
Refugee Travel Document;

    

    
      3. I-688B
Employment Authorization Card annotated "8 C.F.R.
274a.l2(a)(10)";

    

    
      4. 1-766
Employment Authorization Document annotated "A-10"; or

    

    
      

       

      5. Letter/order
from USCIS or immigration judge showing the date deportation was withheld under
Section 243(h) of the INA as in effect prior to April 1,1997 or removal withheld
under Section 41(b)(3) of the INA.

    

    
      

       

      f. Cuban/Haitian
Entrant

    

    
      

       

      1. 1-94
Arrival/Departure Record with annotation "Cuban/Haitian entrant" section
212(d)(5) of the INA, CU-6 or CU-7or any other notation indicating "parole"
under 212(d)(5) on or after 10/10/80 and satisfactory evidence that the parolee
has been a citizen of Cuba or Haiti;

    

    
      2. 1-551
Permanent Resident Card coded "CU-6," "CU-7," "CH-6," "CN-P," "LB-2," "LB-6" or
LB-7;"

    

    
      3. I-688-B
Employment Authorization Card annotated "8 C.F.R. 274a. 12(c)(8)" and
satisfactory evidence that the parolee has been a citizen of Cuba or
Haiti;

    

    
      4. 1-766
Employment Authorization document annotated "C-8" and satisfactory evidence that
the person has been a citizen of Cuba or Haiti;

    

    
      5. Order
to Show Cause (OSC), I-221S or Notice to Appear (NTA), 1-862 indicating pending
exclusion, removal or deportation proceedings and satisfactory evidence that the
parolee has been a citizen of Cuba or Haiti; or

    

    
      6. Any
USCIS document indicating^ pending asylum application or filing of 1-589,
Application for Asylum, and satisfactory evidence on the document that the
person has been a citizen of Cuba or Haiti.

    

    
      

       

      g. Parolees
admitted into the United States for at least one year

    

    
      

       

      1. 1-94
with annotation "Paroled Pursuant to section 212(d)(5)" or "parole" or "PIP" or
"public interest" with the date of entry and date of expiration indicating at
least one year;

    

    
      2. I
- 688B Employment Authorization Card annotated "8 C.F.R. 274a. 12(a)(4)" or
274a.l2(c)(l 1); or

    

    
      3. 1-766
Employment Authorization Document annotated "A4" or "C-11".

    

    
      

       

      h.   Battered
or Subject to extreme cruelty in the U.S.

    

    
      

       

      The term
"battered qualified alien" includes the following immigrants described at 8
U.S.C. §1641 c":

    

    
      1. An
alien who has been battered or subjected to extreme cruelty ("abused") in the
U.S. by a spouse or parent or by a member of the spouse's or parent's family
residing in the same household as the alien;

    

    
      

       

      2. The
parent of a battered or abused child; or

    

    
      3. The
child of a battered or abused parent.

    

    
      

       

      There are
three additional requirements for obtaining battered qualified alien status: (1)
the applicant must have been battered or subjected to extreme cruelty (abuse) in
the U.S. by a spouse, parent or by a member of the spouse's or parent's family
residing in the same household; (2) there must be a substantial connection
between the battery or abuse and the applicant's need for Medicaid; and (3) the
applicant must no longer be living with the abuser.

    

    
      

       

      50

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      A
battered or abused alien may possess a variety of documents that prove or
support evidence that the alien has been battered or abused. The following list
includes, but is not limited to, acceptable forms of documentation to support
battery or abuse. The date of qualified status may be determined from one or
more of the following:

    

    
      

       

      1. 1-797
Notice of Action indicating that the alien has an approved 1-3 60 self petition
(Do not refer to DVL);

    

    
      2. 1-797
Notice of Action indicating that the alien has a pending 1-360 self-petition
that has established a prima facie case (Do not refer to
DVL);

    

    
      3. Order
from the Executive Office for Immigration Review ("EOIR") granting or finding a
prima facie case for granting, suspension of deportation or cancellation of
removal (Do not refer to DVL);

    

    
      4. 1-797
Notice of Action indicating that the alien has a pending 1-360 self petition AND
credible evidence of battery or abuse (Request alien's permission to refer to
DVL);

    

    
      5. 1-797
Notice of Action indicating the alien is the beneficiary of a pending or
approved 1-130 petition and credible evidence of battery and/or abuse (Request
alien's permission to refer to DVL);

    

    
      6. 1-94
coded K3, K4, VI V2 or V3 and credible evidence of battery or abuse (Request
alien's permission to refer to DVL);

    

    
      7. Any
other USCIS document indicating the alien has a K or V visa and a pending or
approved 1-130 petition with credible evidence of battery or abuse (Request
alien's permission to refer to DVL);

    

    
      8. 1-94
or Foreign passport annotated CR1, CR2, CR6, CR7 with credible evidence of
battery or abuse (Request alien's permission to refer to
DVL);

    

    
      9. 1-6
8 8B Employment Authorization Card annotated 274a. 12(a)(9)-children of USC or
LPR (K or V visa); 274a.l2(a)(15)-spouses and dependents of LPR (K or V visa);
274a.l2(c)(10)-applicant for suspension of deportation with credible evidence of
battery or abuse (Request alien's permission to refer to DVL);
or

    

    
      10. 1-766
Employment Authorization Document annotated A9, A15 or C10 with credible
evidence of battery or abuse (Request alien's permission to refer to
DVL).

    

    
      

       

      Referral
to a domestic violence liaison (DVL): Medicaid-only offices must refer alien
applicants and recipients who must demonstrate that they are credible victims of
domestic violence to be considered qualified for Medical assistance as "battered
aliens" to the DVL for a credibility assessment. Those applicants and recipients
who cannot document eligibility in any other category and cannot document that
the United States citizenship and Immigration Services (USCIS) or immigration
court has determined the immigrant has in fact been subject to battery or
extreme cruelty will need to see the district's DVL for a credibility
determination. If districts are unable to verify that an acceptable immigration
document has been filed with USCIS, districts can accept the alien's written
attestation and then refer the alien to an immigration attorney or legal
services for assistance. The DVL does not have the authority to determine
eligibility for assistance.

    

    
      

       

      i.    Amerasian

    

    
      

       

      1. 1-94
Arrival/Departure Record or Vietnamese passport or exit visa stamped "AMI,"
"AM2," "AM3," "AM6," "AM7," or "AM8". Derive date entered country from date of
inspection on stamp;

    

    
      2. 1-551
Permanent Resident Card coded "AMI," "AM2," "AM3," "AM6," "AM7" or
"AM8;

    

    
      3. Temporary
1-551 stamp in Vietnamese passport coded "AMI," "AM2," "AM3," "AM6," "AM7," or
"AM8;" or

    

    
      4. 1-571
Refugee Travel Document.

    

    
      

       

      j.    Conditional
Entrant (Status granted to refugees before 1980)

    

    
      

       

      1.   1-94
Arrival/Departure Record stamped "Section 203(a)(7)," or otherwise indicating
status as a conditional entrant;

    

    
      

       

      51

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      2. I-688B
Employment Authorization Card coded "274a. 12(a)(3)"; or

    

    
      3. 1-766
Employment Authorization Document coded "A-3."

    

    
      

       

      k.   Native
American born in Canada who is at least 50% Native
American

    

    
       

      1. 1-94
Arrival/Departure Record coded "S1-3";

    

    
      2. 1-551
Permanent Resident Card coded "Sl-3";

    

    
      3. .
Temporary 1-551 stamp coded "Sl-3" in a Canadian passport;

    

    
      4. Tribal
document certifying at least 50% American Indian blood as required by Section
289 of the INA or
documented member of a federally recognized tribe and satisfactory evidence of
birth in Canada,
such as a birth or baptismal certificate issued on a reservation, a letter from
the Canadian Department of Indian
Affairs or school records.

    

    
      

       

      1.    Members
of a federally recognized Native American tribe born outside of the U.
S.

    

    
      

       

      1.
Membership card or other tribal document (i.e. tribal card) membership in a U.S.
federally recognized Indian tribe under Section 4(e) of the Indian
Self-Determination and Education Assistance Act.

    

    
      

       

      m.
Persons on Active Duty in the U.S. Armed Forces:

    

    
      

       

      This
category includes aliens who are on current, full-time active duty (other than
active duty for training) in a branch of the U.S. Armed Forces (Army, Navy, Air
Force, Marine Corps or Coast Guard). Also included are the alien's spouse,
un-remarried surviving spouse and unmarried dependent children. Immediate family
members must document their relationship to the alien on active
duty.

    

    
      

       

      1. Military
Identification Card - DD Form 2 (active); or

    

    
      2. Original
or notarized copy of current orders showing the person is on full-time duty in
U.S. Armed forces.

    

    
      

       

      n.   Veterans
of the U.S. Armed Services or their immediate family members will typically
possess and acceptable documentation of date of status may include one or more
of the following :

    

    
      

       

      1. Form
DD-214, Discharge Certificate, showing "Honorable" discharge and not on account
of immigration status and not a character of discharge "Under Honorable
Conditions;" or

    

    
      2. Original
or notarized copy of the veteran's discharge papers.

    

    
      

       

      5.6 Date
Entered the Country

    

    
      

       

      Documentation
of date entered country (DEC), the date the applicant physically entered the
country, must be provided for applicants who claim to have arrived in the
country earlier than the date the DOS was established. Acceptable documentation
shall include but not be limited to the following:

    

    
      

       

      1. prior
dated bills;

    

    
      

       

      2. rent
receipts; or

    

    
      3. correspondence
with a government agency showing an address for the applicant in the United
States.

    

    
      

       

      Note:
Documentation of DOS is not required for CHPlus but is required for Medicaid. An
applicant does not have to prove DEC separately from DOS unless he/she claims to
have arrived in the country earlier than he/she established
DOS.

    

    
      

       

      52

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      5.7 Dependent
Care Costs

    

    
      

       

      Documentation
of dependent care costs must be obtained to perform the Medicaid eligibility
screen. Documentation of dependent care costs shall include but not be limited
to a written statement from a daycare center or other child/adult care provider
or a copy of cancelled checks or receipts for dependent care.

    

    
      

       

      5.8 Proof
of Pregnancy

    

    
      

       

      Documentation
of pregnancy, if applicable, must be obtained to count the pregnant woman as two
people in the household. Proof of pregnancy shall include but not be limited to
a presumptive eligibility screening worksheet completed by a qualified provider,
a statement from a medical professional with expected date of delivery or a WIC
Medical Referral form. The CONTRACTOR shall maintain such documentation in the
child's enrollment file.

       

       

      53

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      Attachment
A

    

    
      Self-Declaration
of Income Form

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      Attachment
A Self-Declaration of Income

    

    
      

    

    
      	
              Name:

            	
              Phone:_____________________

            
	
              Address:

            	 
      
	
              City,
      State,
  Zip:_______________________________________________

            
	
              
                 

                Complete
      only if you have no other means to document your income. Failure to
      complete this form in full will result in deferral or rejection of your
      application for Child Health Plus.

              

              
                 

                Check
      all boxes that apply to you.

              

               

            
	
              □ I
      do not get pay checks

              □ I
      did not file a tax return last year

            	
              □ I
      do not get pay stubs

              □ I
      cannot get a letter from my employer (explain
      why)

            
	 
      	 
      
	
              
                Explain
      where you work and how you earn your money.

              

               

            	 
      
	
              My
      cash income is $

            	
              How
      often (weekly, monthly etc.,

            
	
              Social
      Security Number:________________________

            	 
      
	
              
                 

                □ I
      do not have a Social Security Number

              

               

            	 
      

    

    
      

       

      

    

    
      

       

      Applicants
must read the following and sign below

    

    
      

       

      I certify that I have no
other way to document the above income and that all of the above information is
true and correct. I understand that this information is to be used to determine
eligibility for all public health insurance programs. I understand that program officials
may verify information on this form. I also understand that if I
intentionally misrepresent my income, I may have to repay benefits received and
may be subject to prosecution under State law.

    

    
      

       

      Signature
of
applicant:                                                                                           Date:                                             ;

    

    
      

       

      Facilitators
must read the following and sign below

    

    
      

       

      I certify that I asked the
applicant about all sources of income received by the household and, before
using this form, used best efforts to obtain other possible sources of
documentation. The information provided on this form was provided solely by the
applicant. I did not modify the information in. any way. I understand that if I
intentionally falsified information on this form that I may lose my job and be
prosecuted under State law.

    

    
      

       

      Signature
of
facilitator:                                                                                           Date:                                                

    

    
      

       

      55

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      Attachment
B

    

    
       

       

      DECLARATION
OF NO INCOME FORM

    

    
      

       

      56

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      ATTACHMENT
B

    

    
      

    

    
      Health
Insurance Program Declaration of No Income

    

    
      

    

    
      This form
should only be used by people who have no source of income to explain how they
support themselves and others dependant upon them.

    

    
      

    

    
      	
              Name:

            	
              Phone:_____________________

            
	
              Address:

            	 
      
	
              City,
      State,
  Zip:______________________________________________

            
	 
      
	
              Please
      write a statement below explaining how the person is
      supported:

            
	 
      	 
      
	 
      	 
      
	 
      	 
      
	 
      	 
      
	 
      	 
      

    

    
      

    

    
      

    

    
      

    

    
      

    

    
      Applicants
must read and sign the following:

    

    
      

       

      I certify
that I have no other way to document the above information and that all of the
above information is true and correct. I understand that this information is to
be used to determine eligibility for public health insurance programs. I
understand that program officials may verify information on this form. I also
understand that if I intentionally misrepresent my income, I may have to repay
benefits received and may be subject to prosecution under state
law.

    

    
      

       

      Signature:                                                                                Date:                                    

    

    
      

       

      57

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      SECTION
6

    

    
      APPLICATION/ENROLLMENT
PROCESSING

    

    
      

       

      6.1           Application
Cut-off Dates

    

    
      

       

      The
CONTRACTOR shall process applications received by the 20th of the
month for an enrollment effective date of the first day of the following month.
The CONTRACTOR may process applications received after the 20th of the
month but before the first of the next month for the first day of the following
month or the first day of the subsequent month. If the 20th of the
month falls on a weekend or a holiday, the CONTRACTOR shall process applications
received by the next business day after the 20th of the
month for an enrollment effective date of the first of the following month. In
no instance shall the CONTRACTOR determine eligibility later than 45 days after
receipt of a complete application. The CONTRACTOR must include, in a case file,
evidence of the date an application was received, through a date stamp, and the
date of enrollment which shall be subject to audit.

    

    
      

       

      6.2           Enrollment
Staff

    

    
      

       

      The
CONTRACTOR shall hire and train staff, as necessary, to process applications and
recertifications within the timeframes included in this
Appendix.

    

    
      

       

      6.3           Enrollment
Systems

    

    
      

       

      The
CONTRACTOR shall design, maintain and update eligibility determination
mechanisms and systems in order to process applications in accordance with this
AGREEMENT.

    

    
      

       

      6.4           Subscriber
Contract

    

    
      

       

      The
CONTRACTOR shall issue a subscriber contract to each enrollee consistent with
the current benefit package as defined in section 2 of this Appendix, and as
modified and approved by the New York State Department of Health and the State
Insurance Department. The subscriber contract shall be subject to the approval
of the State Insurance Department and shall meet all appropriate statutory and
regulatory requirements imposed by the New York State Departments of Health and
Insurance. The Subscriber Contract must include information on how to request a
review of the family premium contribution.

    

    
      

       

      6.5           Identification
Card

    

    
      

       

      The
CONTRACTOR shall issue an identification card to each enrollee that identifies
the CHPlus program through use of a, group number. The CHPlus name and/or logo
may not be displayed on the card. This card must be mailed to the enrollee
within fourteen days of the enrollee's initial enrollment with the CONTRACTOR.
The CONTRACTOR must include, in a case file, evidence of the date the card was
mailed to the family and shall be subject to audit.

    

    
      

       

      6.6           Notice
of Enrollment Decision

    

    
      

       

      The
CONTRACTOR must provide each applicant and/or enrollee with a written notice of
any eligibility determination, in a form and manner to be developed by the
CONTRACTOR and approved by the STATE. Such notice must comply with the
provisions of 42 C.F.R. §457.340(e) (1) and (2).

    

    
      

       

      58

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      SECTION
7

    

    
      PRESUMPTIVE
ENROLLMENT

    

    
      

       

      7.1        Eligibility
for Presumptive Enrollment

    

    
      

       

      Presumptive
eligibility provides health care coverage for a child who appears eligible for
CHPlus based upon a completed and signed application but is lacking
documentation necessary to make a complete eligibility determination. A child
may be enrolled presumptively for a maximum of two (2) calendar months from the
initial date of enrollment. Necessary documentation shall be accepted by the
CONTRACTOR through the last day of the second month of the presumptive
eligibility period. Failure to provide all necessary documentation within the
two month period shall be cause for disenrollment from CHPlus effective midnight
the last day of the month of the presumptive eligibility period. A child that
was enrolled, subsequently disenrolled and reapplies for coverage with the same
' health plan may not have another presumptive eligibility period if he/she was
previously presumptively enrolled. The only exception to this is that the health
plan may enroll a child presumptively because the child's income will increase
from Medicaid to CHPlus eligibility levels by the effective date of enrollment.
The CONTRACTOR may enroll a child presumptively even if the child has been
enrolled presumptively before. The period of enrollment for a child enrolled in
CHPlus beyond the presumptive period shall be inclusive of the two month
presumptive eligibility period and the child's annual recertification date shall
be based on the initial enrollment date.

    

    
      

       

      The
CONTRACTOR shall not enroll a child presumptively if the application indicates
the child or the child's parent(s) are in the country on a temporary worker (H)
visa but does not include documentation of the H visa status.

    

    
      

       

      59

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      SECTION
8

    

    
      TEMPORARY
ENROLLMENT

    

    
      

       

      8.1        Eligibility
for Temporary Enrollment

    

    
      

       

      The
CONTRACTOR shall enroll a child in CHPlus on a temporary basis if the child
appears to be eligible for Medicaid at recertification in CHPlus as described in
the CHPlus manual.

    

    
      

    

    
      

    

    
      

    

    
      

    

    
      

    

    
      60

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      SECTION
9

    

    
      RECERTIFICATION

    

    
      

       

      9.1           Annual
Recertification

    

    
      

       

      On an
annual basis, the CONTRACTOR shall recertify all children enrolled with the
CONTRACTOR for CHPlus. eligibility. The CONTRACTOR shall recertify a child
whenever they receive a complete application and supporting documentation,
regardless of when it is submitted.

    

    
      

       

      9.2           Recertification
Application

    

    
      

       

      The
CONTRACTOR shall use the STATE'S CHPlus recertification application to recertify
children. The CONTRACTOR shall include the CHPlus recertification application
with its recertification notice enrollees.

    

    
      

       

      The
CHPlus recertification application shall not be submitted to a LDSS if the
child(ren) appears Medicaid eligible. In those cases, a Growing Up Healthy or
Access New York Health Care application is required.

    

    
      

       

      The
CONTRACTOR shall process a Growing Up Healthy or Access New York Health Care
application received in the mail in lieu of the CHPlus recertification
application if the information required for renewal is
provided.

    

    
      

       

      9.3           Recertification
Notification

    

    
      

       

      The
CONTRACTOR shall send the family written notice of the child's need to recertify
for CHPlus 90 days prior to the end of the child's 12 month coverage period
unless the CONTRACTOR receives approval from the STATE to use a different method
for notification. The CONTRACTOR shall submit to the STATE for approval a draft
of the recertification letter or other written notification and any subsequent
changes, other than changes to the recertification due date.

    

    
      

       

      9.4           Information
in the Recertification Notification Letter

    

    
      

       

      The
CONTRACTOR shall advise the family, via the recertification letter, that the
recertification application and all required documentation must be received by
the CONTRACTOR one month prior to the end of the child's 12 month coverage
period to avoid the risk of a lapse in coverage. However, the CONTRACTOR shall
accept and process a recertification application received up through the last
day of coverage. If the last day of the month falls on a weekend or holiday, the
CONTRACTOR must process applications received by the next business day for
coverage effective the first of the following month.

    

    
      

       

      9.5           Review
of the Recertification Application

    

    
      

       

      The
CONTRACTOR shall review the recertification application and documentation within
10 business days from the date of receipt of the recertification
application.

    

    
      

       

      9.6           Documenting
Income at Recertification

    

    
      

       

      The
CONTRACTOR shall give each parent and/or legally responsible adult who is a
member of the child(ren)'s household and whose income is available to the
child(ren), the option to provide their social security number in lieu of income
documentation. If the parent/ responsible adult chooses not to provide their
social security number(s), the CONTRACTOR shall collect appropriate income
documentation.   The CONTRACTOR shall not require the provision
of social security numbers as a condition of a child's enrollment or eligibility
for the program.

    

    
      

       

      61

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      9.7
Documentation of Residence at Recertification

    

    
      

       

      The
CONTRACTOR shall not require documentation of residence at recertification for
CHPlus. The CONTRACTOR shall accept the address provided on the recertification
application as the enrollee's attestation of his/her current
address.

    

    
      

       

      9.8
Presumptive Recertification Period

    

    
      

       

      The
CONTRACTOR shall provide a two-month presumptive period at recertification for
enrollees who appear CHPlus eligible but are missing documentation or certain
sections of the application are incomplete as noted in the chart set forth in
Attachment A of this section. The CONTRACTOR shall disenroll the child effective
the first day of the month following the two month presumptive period if the
CONTRACTOR does not receive the missing documentation and/or information by the
end of the presumptive period. The CONTRACTOR shall send the family a written
notification regarding the missing documentation and/or information and
potential disenrollment from CHPlus if the information is not received by the
end of the presumptive period. A child may have a presumptive recertification
period on an annual basis, even if he/she was initially presumptively
enrolled.

    

    
      

       

      9.9
Temporary Recertification Period

    

    
      

       

      If the
CONTRACTOR receives a completed recertification application with or without all
required documentation, and the child appears eligible for Medicaid, the
CONTRACTOR shall enroll the child temporarily in CHPlus.   The
CONTRACTOR shall comply with requirements in the CHPlus manual regarding
temporary enrollment and required notification.

    

    
      

       

      9.10 Late
Recertification Applications

    

    
      

       

      If a
recertification application and/or required documentation is submitted after the
child's recertification date (the last day of the 12th month
of coverage) but before the 20th of the
next month or before the CONTRACTOR'S cut off date, which shall be no later than
the end of the month following the recertification date, the CONTRACTOR shall
recertify the child in the CHPlus program without a new application. The
enrollee will have a one-month lapse in coverage but will not be required to
reapply to the program.

    

    
      

       

      9.11
Recertification and Changing Plans

    

    
      

       

      If the
CONTRACTOR receives a recertification application, processes it and enters
information into the KIDS system before the 16th day of
the last month of the child's coverage period, the child will remain with the
CONTRACTOR'S plan and no other plan may enroll the child for the next
month.

    

    
      

       

      If by the
16th day of the last month of the child's coverage, the CONTRACTOR has not
reenrolled the child in CHPlus and entered the necessary data into the KIDS
system, that child may be enrolled by another health plan based upon a new
application, effective the first day of the month after the child's last month
of coverage. The CONTRACTOR must affirmatively disenroll the child after the
coverage period ends.

    

    
      

       

      If a
CONTRACTOR receives a complete recertification application for a child,
including documentation, by the last day of the child's coverage period, and the
child has not submitted an application to another health plan, the CONTRACTOR
may still process the recertification application. This information must be
submitted to the KIDS system no later than the 10th
business day of the following month in order for the CONTRACTOR to receive
payment for the child in that month.

    

    
      

       

      62

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      If a
family submits both a recertification application to the CONTRACTOR and a new
application to another health plan, the first plan to submit recertification or
initial enrollment information to the KIDS system on or after the 16th day of
the last month of the child's coverage period (12th month)
will be allowed to enroll the child.

    

    
      

       

      9.12     New
Child Added at Recertification

    

    
      

       

      If a
CONTRACTOR receives a completed recertification application from a family that
includes an additional child not currently enrolled in CHPlus, the CONTRACTOR
shall process the application for the existing enrollees only. The CONTRACTOR
shall not enroll new child(ren) until the CONTRACTOR receives from the family a
completed Growing up Healthy or Access New York Health Care application for the
new child(ren). The CONTRACTOR must send a blank Growing Up Healthy or Access
New York Health Care application and a letter to the family informing them that
the child may not be enrolled until the application is completed and required
documentation for the new child is received. When the CONTRACTOR receives the
application for the new child, the CONTRACTOR shall use that income to determine
eligibility for all children on the application.

    

    
      

       

      If a
CONTRACTOR receives a completed recertification application that provides a
social security number in lieu of documentation along with a completed
application for a new child(ren), the CONTRACTOR shall use the documented income
from the new application to assess the eligibility of both
children.

    

    
      

       

      If the
children are eligible for subsidized CHPlus coverage, the CONTRACTOR shall move
the effective date of children already enrolled to match the recertification
date of the newly enrolled children.

    

    
      

       

      If the
children appear Medicaid eligible, the CONTRACTOR shall follow the procedures
for temporary enrollment in section 8 of this Appendix and the CHPlus
manual.

    

    
      

       

      If the
newly applying child(ren) are not eligible for subsidized CHPlus coverage
because household income is too high, the CONTRACTOR shall only enroll the
child(ren) if the family pays the full premium amount. The currently enrolled
child's coverage will not be affected by the increase in income because CHPlus
coverage is continued for 12 months.

    

    
      

       

      9.13   Applicant
Provides Range of Income on Recertification Application

    

    
      

       

      If a
CONTRACTOR receives a recertification application that provides a range of
income along with the relevant social security numbers in lieu of documentation
of income, the CONTRACTOR shall use the low end of the range to determine
eligibility. The CONTRACTOR must send the family a letter informing them the
child has been recertified presumptively for a two month period and that for the
child to remain enrolled beyond that date, a specific dollar amount of the
household income must be provided within the two months. The CONTRACTOR must
send the family a copy of the recertification application and request that the
family add the specific income, initial and date the information and submit the
application back to the CONTRACTOR within the required
timeframe.

    

    
      

       

      9.14     Incomplete
Recertification Application

    

    
      

       

      In order
for the CONTRACTOR to process an incomplete recertification application and
enroll a child presumptively in accordance with section 9.8, the family is
required to provide certain information on the application but may leave certain
sections blank (specified below and organized by section of the CHPlus
Recertification Application). The CONTRACTOR shall collect information in
accordance with the chart found in Attachment A of this section, and then
process applications in accordance with section 9.8, if
appropriate.

    

    
      

       

      63

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      If a
recertification application is missing information and the child is not enrolled
presumptively, the CONTRACTOR must return the original application to the
parent/guardian for completion. If the application is not completed and returned
by the last day of the month prior to the end of the 12 month coverage period,
the CONTRACTOR must disenroll the child effective the first day of the month
following the 12 month coverage period.

    

    
      

    

    
      

    

    
      

    

    
      64

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      ATTACHMENT
A

    

    
      INCOMPLETE
CHILD HEALTH PLUS HEALTH INSURANCE RENEWAL FORM

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      ATTACHMENT
A INCOMPLETE CHILD HEALTH PLUS HEALTH INSURANCE RENEWAL FORM

    

    

     

    
      	
              
                Section
      on Recert Application

              

            	
              
                Must
      be Returned/ App Not Processed

              

            	
              
                Can
      be Left Blank/ Presumptive Recert

              

            	
              
                Can
      be Left Blank/ Process Application

              

            
	
              
                About
      You

              

            	 
      	 
      	 
      
	
              
                Contact
      Info

              

            	 
      	 
      	 
      
	
              
                First
      Name

              

            	
              
                X

              

            	 
      	 
      
	
              
                Middle
      Initial

              

            	 
      	 
      	
              
                X

              

            
	
              
                Last
      Name

              

            	
              
                X

              

            	 
      	 
      
	
              
                Primary
      Lang.

              

            	 
      	 
      	
              
                X

              

            
	
              
                Daytime
      Phone

              

            	 
      	 
      	
              
                X

              

            
	
              
                Other
      Phone

              

            	 
      	 
      	
              
                X

              

            
	
              
                Home
      Address

              

            	 
      	 
      	 
      
	
              
                Street
      Address

              

            	
              
                X

              

            	 
      	 
      
	
              
                Apt.
      Number

              

            	 
      	 
      	
              
                X

              

            
	
              
                City

              

            	
              
                X

              

            	 
      	 
      
	
              
                State

              

            	
              
                X

              

            	 
      	 
      
	
              
                Zip
      Code

              

            	 
      	
              
                X1

              

            	
              
                X1

              

            
	
              
                County

              

            	 
      	
              
                X1

              

            	
              
                X1

              

            
	
              
                Mailing
      Address

              

            	 
      	 
      	 
      
	
              
                Street
      Address

              

            	 
      	
              
                X1

              

            	
              
                X1

              

            
	
              
                Apt.
      Number

              

            	 
      	
              
                X1

              

            	
              
                X1

              

            
	
              
                City

              

            	 
      	
              
                X1

              

            	
              
                X1

              

            
	
              
                State

              

            	 
      	
              
                X1

              

            	
              
                X1

              

            
	
              
                Zip
      Code

              

            	 
      	
              
                X1

              

            	
              
                X1

              

            
	
              
                County

              

            	 
      	
              
                X1

              

            	
              
                X1

              

            
	
              
                About
      Your HH

              

            	 
      	 
      	 
      
	
              
                Name
      of HOH

              

            	
              
                X

              

            	 
      	 
      
	
              
                DOB

              

            	 
      	 
      	
              
                X

              

            
	
              
                Pregnant

              

            	 
      	 
      	
              
                X

              

            
	
              
                Renewing
      CHPlus

              

            	 
      	 
      	
              
                X

              

            
	
              
                SS#

              

            	 
      	 
      	
              
                X

              

            
	
              
                Names
      of Others in HH

              

            	
              
                X

              

            	 
      	 
      
	
              
                Relationship
      to HOH

              

            	
              
                X

              

            	 
      	 
      

    

    
      

       

      1 As long
as this information can be determined from information already available at the
CONTRACTOR. If the applicant reports a different mailing address than the one in
the enrollee's file, the child shall be presumptively enrolled for two months
while the information is obtained.

    

    
      

       

      66

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      	
              
                Section
      on Recert Application

              

            	
              
                Must be Returned/ App Not
      Processed

              

            	
              
                Can
      be Left Blank/ Presumptive Recert

              

            	
              
                Can
      be Left Blank/ Process Application

              

            
	
              
                Household
      Income

              

            	 
      	 
      	 
      
	
              
                Name

              

            	
              
                X

              

            	 
      	 
      
	
              
                Social
      Security #

              

            	 
      	 
      	
              
                X2

              

            
	
              
                Income
      Source

              

            	 
      	
              
                X

              

            	 
      
	
              
                Amount
      Rec'd

              

            	
              
                X3

              

            	 
      	
              
                X3

              

            
	
              
                How
      Often

              

            	
              
                X3

              

            	 
      	
              
                X3

              

            
	
              
                No
      Income

              

            	
              
                X4

              

            	 
      	
              
                X4

              

            
	
              
                Child/Dependent
      Care and Other Expenses

              

            	 
      	 
      	 
      
	
              
                Dependent
      Care

              

            	 
      	 
      	 
      
	
              
                Name
      of Person

              

            	 
      	
              
                X5

              

            	
              
                X5

              

            
	
              
                Amount
      Paid

              

            	 
      	
              
                X5

              

            	
              
                X5

              

            
	
              
                Frequency

              

            	 
      	
              
                X5

              

            	
              
                X5

              

            
	
              
                Health
      Insurance

              

            	 
      	 
      	 
      
	
              
                Name
      of Person

              

            	 
      	
              
                X5

              

            	
              
                X5

              

            
	
              
                Amount
      Paid

              

            	 
      	
              
                X5

              

            	
              
                X5

              

            
	
              
                Frequency

              

            	 
      	
              
                X5

              

            	
              
                X5

              

            
	
              
                Other
      Changes Since Last App

              

            	 
      	 
      	 
      
	
              
                Health
      Insurance

              

            	 
      	 
      	 
      
	
              
                Name

              

            	
              
                X6

              

            	 
      	
              
                X6

              

            
	
              
                Children
      Covered

              

            	
              
                X6

              

            	 
      	
              
                X6

              

            
	
              
                Insurance
      Co.

              

            	
              
                X6

              

            	 
      	
              
                X6

              

            
	
              
                Group/Policy
      #

              

            	 
      	 
      	 
      
	
              
                Public
      Employee

              

            	
              
                X6

              

            	 
      	
              
                X6

              

            
	
              
                Immigration
      Status

              

            	 
      	 
      	 
      
	
              
                Name
      of Child

              

            	
              
                X6

              

            	 
      	
              
                X6

              

            
	
              
                Immigration
      Status

              

            	
              
                X6

              

            	 
      	
              
                X6

              

            

    

    
      

    

    
      

    

    
      
        	
                 
      

              	
                2

              	
                If
      left blank, must document
income.

              

      

    

    
      
        	
                 
      

              	
                3

              	
                May
      be left blank if family supplied documentation but failed to write
      information on the
application.

              

      

    

    
      
        	
                 
      

              	
                4

              	
                If
      family has no income and left the no income section blank but submitted
      the Declaration of No Income form, the application shall
      be processed.

              

      

    

    
      
        	
                 
      

              	
                5

              	
                If
      the whole is section left blank, the application shall be processed. If
      applicant answers part of the question, child(ren) shall
      be enrolled for a
      two month presumptive period while other information is
      obtained.

              

      

    

    
      
        	
                 
      

              	
                6

              	
                If
      the whole section is left blank, the application shall be processed. If
      applicant answers part of the question, the application cannot
      be processed and must be returned for completion as these questions
      directly impact program eligibility.

              

      

    

    
      

       

      67

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      SECTION
10

    

    
      FAMILY
PREMIUM CONTRIBUTION

    

    
      

       

      10.1
Family Premium Contribution

    

    
      

       

      The
CONTRACTOR shall collect from subscribers any required family premium
contribution. There is no family premium contribution for children whose gross
household income is less than 160 percent of the non-farm federal poverty level
or for children who are American Indians or Alaskan Natives (AI/AN) whose gross
household income is less than 250 percent of the non-farm federal poverty
level.

    

    
      

       

      The
family premium contribution for children whose gross household income is between
160 percent and 222 percent of the non-farm federal poverty level is $9 per
child, with a family maximum of $27 per month.

    

    
      

       

      The
family premium contribution for children whose gross household income is between
223 percent and 250 percent of the non-farm federal poverty level is $15 per
child, with a family maximum of $45 per month.

    

    
      

       

      The
family premium contribution for children whose gross income is more than 250
percent of the non-farm federal poverty level varies by health plan, subject to
the approval of the New York State Departments of Insurance and
Health.

    

    
      

       

      10.2
Family Premium Contribution Notice

    

    
      

       

      The
CONTRACTOR shall mail a bill for the family premium contribution 60 days prior
to the first day of the month of coverage with the exception of the first month
of coverage when the family premium contribution shall be collected at the time
of application and the second month of coverage for which the CONTRACTOR shall
mail the bill prior to the start of the second month of coverage. The bill shall
indicate that the required family contribution is due on the last day of the
month prior to the month of coverage.

    

    
      

       

      10.3  Family
Contribution Due Date and Disenrollment

    

    
      

       

      The
CONTRACTOR shall not disenroll the child as long as the required family
contribution is received by the last day of the month of coverage. This applies
to every month of coverage including the month in which a child is due to
recertify. The CONTRACTOR shall disenroll the child effective the first day of
the month following the month of coverage if payment is not received by the last
day of the month of coverage. The CONTRACTOR shall not retroactively disenroll
the child if the family contribution is not received by such date. The
CONTRACTOR shall absorb the loss of the family contribution for that month and
shall pay for covered health care services provided to the enrollee during that
month. The STATE shall pay the applicable subsidy payment to the CONTRACTOR for
the month of coverage.

    

    
      

       

      The grace
period described above does not apply to non-subsidized enrollees. The
CONTRACTOR may choose to offer a grace period to this population as long as the
CONTRACTOR agrees to absorb the loss of the one month of premium and pays for
covered health care services provided to the enrollee during that month. Under
no circumstances shall the CONTRACTOR retroactively disenroll the child if the
family premium contribution is not received within the grace period. If the
CONTRACTOR elects not to provide a grace period for non-subsidized enrollees,
the CONTRACTOR shall disenroll the child at the end month which the child is
paid.

    

    
      

       

      68

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      10.4     Collection
of the Family Premium Contribution

    

    
      

       

      The
CONTRACTOR shall be responsible for collecting the family premium contribution
on behalf of an enrolled child or children.

    

    
      

       

      10.5     Requests
for Review of the Family Premium Contribution

    

    
      

       

      a. The
CONTRACTOR shall provide enrollees with an opportunity to show that the family
income has declined
prior to disenrollment for failure to pay the required family premium
contribution.

    

    
      The
CONTRACTOR shall include in its subscriber contract a notice to families that
provides the following information:

    

    
      

       

      1. If
their income or household size has changed which may result in a revision to the
required family premium contribution, they may request a review of such change
by filling out a form which shall be available by calling the CONTRACTOR'S 800
number or the Child Health Plus Hotline (1-800-698-4543).

    

    
      

       

      2. Documentation
of their new income or household size must be submitted along with the form so
the CONTRACTOR is able to reevaluate the required family premium contribution.
CONTRACTOR must include, in its subscriber contract, an explanation of the
income documentation requirements for a change in household
income.

    

    
      

       

      3. The
family may receive assistance with their request for review or receive a chart
of CHPlus income levels by calling the CONTRACTOR'S 800 number or the Child
Health Plus Hotline (1-800-698-4543).

    

    
      

       

      b. If
the CONTRACTOR receives the form requesting a review of the family premium
contribution, including the required
income documentation, the CONTRACTOR shall:

    

    
      

       

      • Screen
the potential enrollee for Medicaid or CHPlus eligibility;
and

    

    
      

       

      • Within 10
business days, send the family a written notice of the results of the
review,

    

    
      including
information regarding any required family contribution. The CONTRACTOR may
provide this information to a family by telephone in addition to in
writing.

    

    
      

       

      c. If
the enrollee screens potentially eligible for Medicaid, the CONTRACTOR shall
follow the procedures for temporary
enrollment in accordance with section 8 of this Appendix and the CHPlus manual. CONTRACTOR shall
also comply with the following procedures:

    

    
      

       

      1. If
the LDSS-determines the enrollee is ineligible for Medicaid based on the revised
income, the CONTRACTOR must notify the enrollee of his/her continued enrollment
in CHPlus and the amount of his/her required family premium contribution once
the CONTRACTOR is notified of such determination by the LDSS.

    

    
      

       

      2. If
the review results in no change to the required family premium contribution, the
CONTRACTOR must notify the family of such within 10 business days from receipt
of the form and require payment of the family premium contribution by the end of
the month of coverage as required by sections 10.2 and 10.3. If the CONTRACTOR
does not receive payment by the last day of the month, the CONTRACTOR must
disenroll the child effective the last day of that month.

    

    
      

       

      3. If
the review results in a lower family
contribution, the CONTRACTOR must notify the family of the lower contribution
within 10 business days from receipt of the form and apply the new amount to
coverage beginning the first day of the subsequent month. The

    

    
      

       

      69

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      CONTRACTOR
must also notify the family that the bill they receive for the following month's
coverage may be incorrect and they should pay the new amount provided in the
notice. If the CONTRACTOR does not receive payment by the last day of the month
of coverage, the CONTRACTOR must disenroll the child effective the last day of
that month.

    

    
      

       

      4. If
the income review results in no family
contribution, the CONTRACTOR must notify the family within 10 business
days from receipt of the form that they are no longer required to make a family
premium contribution. The CONTRACTOR must also notify the family that the bill
they receive for the following month's coverage may be incorrect and that they
should disregard that bill and any further bills received.

    

    
      

       

      5. If
the CONTRACTOR receives a request for review that does not include the required
income documentation, the CONTRACTOR must notify the family that the review will
not be performed until the missing documentation is received. If the missing
documentation is received within one month from the date of the notice, the
CONTRACTOR shall keep the child(ren) enrolled and process the review for the
next month. If the missing income documentation is not received within the one
month period, and the family premium contribution is not paid by the end of the
month of coverage for which a family premium contribution is due, the CONTRACTOR
shall disenroll the child(ren) at the end of that month of coverage and the
family must reapply for coverage using a new application.

    

    
      

       

      10.6 Disenrollment
Notice and Disenrollment for Failure to Pay the Family Premium
Contribution

    

    
      

       

      If the
CONTRACTOR does not receive the appropriate family premium contribution by the
first day of the month before the month of coverage, the CONTRACTOR must send a
disenrollment notice to the enrollee's family approximately 15 days prior to the
beginning of the month of coverage. The notice must state that the child will be
disenrolled if payment is not received by the last day of the month of coverage.
If the CONTRACTOR has not received the required family premium contribution by
the last day of the month of coverage, the CONTRACTOR shall disenroll the
enrollee effective the last day of the month of coverage and an additional
disenrollment notice by the CONTRACTOR is not required. If the CONTRACTOR
receives the payment for the enrollee by the last day of the month of coverage,
the CONTRACTOR must continue CHPlus coverage for the
enrollee.

    

    
      

       

      10.7 American
Indians/Alaskan Natives

    

    
      

       

      The
CONTRACTOR shall exempt eligible American Indians or Alaskan Natives whose gross
household income is less than 250% of the non-farm federal poverty level from
family premium contributions set forth in this section. To determine whether an
eligible child is an American Indian or Alaskan Native for purposes of the
exemption, the CONTRACTOR is required to collect at least one of the following
documents:

    

    
      

       

      • Identification
card from the Bureau of Indian Affairs, Tribal Health, Resolution, Long House or
Canadian Department of Indian Affairs.

    

    
      

       

      • Documentation
of roll or band number.

    

    
      

       

      • Documentation
of parents' or grandparents' roll or band number together with the applicant's
birth certificate or baptismal record indicating descendence from the parent or
grandparent.

    

    
      

       

      • Notarized
letter from a federally or state recognized American Indian/Alaska Native Tribe
or village office stating heritage.

    

    
      

       

      • A
birth certificate indicating heritage.

    

    
      

       

      70

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      The child
may be enrolled presumptively if the above documentation is missing but is
required to pay the required family premium contribution based on income until
the documentation of American Indian/Alaskan Native status is provided. Once the
parent/guardian provides documentation of the American Indian/Alaskan Native
status, the CONTRACTOR shall refund the family premium contribution to the
family and submit a billing adjustment to the STATE for the
difference.

    

    
      

       

      10.8 Cost
Sharing

    

    
      

       

      The
CONTRACTOR shall not charge an enrollee any amount other than the required
family premium contribution.

    

    
      

    

    
      

    

    
      

    

    
      71

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      SECTION
11

    

    
      REQUIRED
NOTICES

    

    
      

       

      11.1 Information
to Potential Applicants, Applicants and Enrollees

    

    
      

       

      The
CONTRACTOR shall provide the following information to potential applicants,
applicants and enrollees in accordance with guidance issued by the
STATE:

    

    
      

       

      • The
types of benefits and amount, duration and scope of benefits
available;

    

    
      • Information
concerning cost sharing under the program;

    

    
      • The
names and locations of current participating providers;

    

    
      

       

      • A
description of the procedures relating to an enrollment cap or waiting list
including the process for deciding which children will be given priority for
enrollment, how children will be informed of their status on a waiting list and
the circumstances under which enrollment will reopen, if an enrollment cap or
waiting list is in effect;

    

    
      

       

      •   Information
on physician incentive plans; and

    

    
      

       

      • Review
processes available.

    

    
      

       

      Information
must be provided in a linguistically appropriate manner and written materials
must be available in alternative formats such as large print, Braille or
audio/video cassette.

    

    
      

       

      11.2 Public
Schedule

    

    
      

       

      The
CONTRACTOR shall distribute a public schedule in accordance with guidance issued
by the STATE, which contains the following information:

    

    
      

       

      • Current
family premium contribution levels;

    

    
      • Enrollee
groups subject to the family premium contribution;

    

    
      • Cumulative
cost-sharing maximums;

    

    
      • Mechanisms
for making payments for required family premium contributions;
and

    

    
      • The
consequences for an applicant or enrollee who does not pay the required family
premium contribution, including disenrollment protections.

    

    
      

       

      The
public schedule must be available to: enrollees at the time of enrollment and
recertification and when cost-sharing charges and cumulative cost-sharing
maximums are revised; applicants at the time of application and the general
public upon request. If the public schedule is given at the time of application,
it does not have to be given again at enrollment.

    

    
      

       

      11.3 Application
and Eligibility Requirements

    

    
      

       

      At the
time of application, the CONTRACTOR must inform applicants, in writing and
orally if appropriate, about the application and eligibility requirements, the
time frame for determining eligibility and the right to review eligibility
determinations in accordance with guidance issued by the STATE. The CONTRACTOR
must provide written notice of eligibility determinations to all
applicants.

    

    
      

       

      11.4 Full
Medicaid Eligibility Determination

    

    
      

       

      At the
time of application, the CONTRACTOR must inform each applicant about their right
to a full Medicaid eligibility determination in a form and manner to be
developed or approved by the STATE.

    

    
      

       

      72

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      11.5
Medicaid Spend Down Program

    

    
      

       

      At the
time of application, the CONTRACTOR shall inform each applicant about the
medically needy spend down program in a form and manner to be developed or
approved by the STATE.

    

    
      

       

      11.6  Impartial
Review

    

    
      

       

      The
CONTRACTOR must inform applicants and enrollees of the opportunity to have an
impartial review of a denial of eligibility, the CONTRACTOR'S failure to make a
timely eligibility determination and suspension or termination of enrollment,
including disenrollment for failure to pay a family contribution. The CONTRACTOR
shall inform the applicant or enrollee of their right to an impartial review and
the process to be followed to request such a review in accordance with guidance
issued by the STATE.

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      SECTION
12

    

    
      DISENROLLMENT

    

    
      

       

      12.1 Enrollee
Initiated Disenrollment

       

    

    
      Enrollees
may request disenrollment for any reason at any time.

    

    
       

      12.2 Processing
Disenrollment Requests

    

    
      

      If the
enrollee requests disenrollment, the CONTRACTOR shall promptly process the
request effective the first day of the month following receipt of the enrollee's
request or effective on a future date if requested by the enrollee. The
CONTRACTOR shall update the KIDS system to reflect the disenrollment in
accordance with procedures defined by the STATE.

    

    
      

       

      12.3 CONTRACTOR
Initiated Disenrollment

    

    
      

       

      The
CONTRACTOR shall disenroll an enrollee under any of the following
conditions:

    

    
      

       

      a. Enrollee
fails to pay family premium contribution as described in section 16 of this Appendix;

    

    
      b. Enrollee
becomes enrolled in Medicaid;

    

    
      c. Enrollee
fails to apply for Medicaid coverage within the two month temporary enrollment
period;

    

    
      d. Enrollee
gains access to a state health benefits plan or becomes enrolled in other health
insurance;

    

    
      e. Enrollee
fails to comply with documentation requirements at the end of the two month presumptive or
presumptive recertification period;

    

    
      f. Enrollee
fails to recertify his or her eligibility prior to the 12 month enrollment period;

    

    
      g. Enrollee
reaches age 19. In this case, the enrollee shall be disenrolled on the first
day of the month
following his/her 19th
birthday;

    

    
      h. Enrollee
moves outside the CONTRACTOR'S service area;

    

    
      i. Enrollee
is enrolled based on fraudulent information or documentation;

    

    
      j. Enrollee
becomes an inmate of a public institution as defined at 42 CFR §435.1009 or a
patient in an institution for mental diseases, as defined at 42 CFR
§435.1009;

    

    
      k. Enrollee
dies.

    

    
      

       

      The
CONTRACTOR shall disenroll a child for reasons b, d, h, i, j and k (defined
above) effective the first day of the month following the CONTRACTOR'S receipt
of the information. Under no circumstance shall the CONTRACTOR retroactively
disenroll a child.

    

    
      

       

      The
CONTRACTOR shall not disenroll a child 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).

    

    
      

       

      74

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      12.4 CONTRACTOR'S
Liability

    

    
      

       

      The
CONTRACTOR is not responsible for providing benefits set forth in section 2 of
this Appendix after the effective date of disenrollment, except as hereinafter
provided:

    

    
      

       

      The
CONTRACTOR shall be liable for the cost of a hospital stay for an enrollee who
is admitted to the hospital prior to the effective date of disenrollment in the
CONTRACTOR's plan and who remains hospitalized on the effective date of
disenrollment. The CONTRACTOR'S liability shall end when the former enrollee is
transferred to a different level of care in the same facility or to a new
facility.

    

    
      

       

      12.5 Notice
of Disenrollment

    

    
      

       

      The
CONTRACTOR shall provide written notice to the enrollee about his or her pending
disenrollment in accordance with section 10.6 of this
Appendix.

    

    
      

       

      The
CONTRACTOR shall provide final notice of disenrollment in addition to any other
notice sent to the enrollee's family. Such final notice must be provided no
earlier than 15 days prior to the effective date of disenrollment. The notice
must include the reason that the enrollee will be terminated including, but not
limited to, failure to complete the recertification process, failure to comply
with the documentation requirements for presumptive eligibility within two
months, failure to complete the Medicaid application process within two months
if temporarily enrolled, the child is dually enrolled in CHPlus and
Medicaid,   failure to pay the family premium contribution, the
child is enrolled with more than one CHPlus health plan, the child obtains other
health insurance coverage making him/her ineligible for CHPlus coverage or the
child ages out of the program. The notice must include the date by which the
plan must receive a response and necessary information to remain enrolled beyond
the date of disenrollment noted in the letter. The notice must inform the family
how to re-apply for coverage in the event that the child is disenrolled and that
if a new application is received by the 20th of the
month following the termination, coverage will be reinstated on the first day of
the following month.

    

    
      

       

      75

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      SECTION
13

    

    
      FACILITATED
ENROLLMENT RESPONSIBILITIES

    

    
      

       

      13.1 Interaction
with Community-Based and Other Health Plan Facilitators

    

    
      

       

      The
CONTRACTOR shall work with other facilitators regardless of whether the
CONTRACTOR elects to perform facilitated enrollment, as
follows:

    

    
      

       

      A
CONTRACTOR shall:

    

    
      

       

      • Accept
and process applications set forth and defined in Section 1 of this Appendix,
received from community-based and health plan facilitators.

    

    
      

       

      • Provide
feedback to facilitated enrollment lead organizations and health plan
facilitators, as appropriate, regarding incomplete or incorrect
applications.

    

    
      

       

      • Provide
material about the health plan, including provider directories, to facilitated
enrollment lead organizations as specified by the STATE.

    

    
      

       

      • Provide
the names and addresses of all facilitators in the plan's area to applicants
that are referred to them.

    

    
      

       

      • Provide
facilitators with the status of CHPlus applications.

    

    
      

       

      • Provide
facilitators with a contact person to receive applications and coordinate with
organizations in developing a process and schedule for the acceptance of
applications.

    

    
      

       

      13.2 New
Facilitated Enrollment Activities

    

    
      

       

      Prior to
commencement and/or expansion of the CONTRACTOR'S facilitated enrollment
activities, the CONTRACTOR shall:

    

    
      

       

      a. Establish
policies satisfactory to the STATE regarding the processing of
applications, communications, contact
persons and interactions with health plans, if applicable.

    

    
      

       

      b. Provide
schedules of sites and times, staffing and facilitated enrollment locations for
STATE approval.

    

    
      

       

      c. Ensure
that all facilitators have undergone the required training.

    

    
      

       

      d. Submit
a written protocol between the CONTRACTOR and the appropriate LDSS for STATE
approval.

    

    
      

       

      e. Submit
the CONTRACTOR's written internal quality assurance protocol for
facilitated enrollment for STATE
approval.

    

    
      

       

      A
CONTRACTOR that performs facilitated enrollment for the Medicaid and CHPlus
programs shall meet the following requirements:

    

    
      

       

      13.3 Service
Area

    

    
      

       

      The
CONTRACTOR shall provide facilitated enrollment for children in each county of
the CONTRACTOR'S CHPlus service area in a manner approved by the STATE. The
CONTRACTOR is not required to dedicate full time facilitators in each county of
their service area but shall have the service available in every county of their
service area.

    

    
      

       

      76

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      13.4     Accessible
and Convenient Sites

    

    
      

       

      The
CONTRACTOR shall provide enrollment facilitation services at sites that are
accessible and convenient to the population being served. The CONTRACTOR shall
provide services in a wide range of sites that attract as many families as
possible, including vulnerable and hard-to-reach populations. The CONTRACTOR
shall provide the STATE with a list of the fixed sites at which it intends to
offer facilitated enrollment, including the days and hours during which
facilitators will be available at the sites. The CONTRACTOR shall report monthly
all changes in enrollment sites including changes in the days and hours of
operation of ongoing sites and on new sites or those no longer available. The
CONTRACTOR shall report to the STATE all changes in the site schedule by the
20th
day of the month preceding the change. Nothing herein shall prevent the
CONTRACTOR from offering facilitated enrollment at additional sites not provided
on the above referenced list, or if circumstances warrant, from modifying the
previously scheduled fixed enrollment facilitation
activities.

    

    
      

       

      13.5 Hours
of Operation

    

    
      

       

      In
addition to weekday hours, the CONTRACTOR shall provide facilitated enrollment
services • during early morning, evening and/or weekend
hours.

    

    
      

       

      13.6 Staffing

    

    
      

       

      The
CONTRACTOR shall limit staff involved in the facilitated enrollment process to
the following:

    

    
      

       

      1. 150
full time equivalents (FTEs) for health plans in New York
City;

    

    
      2. 75
FTEs for health plans that serve counties outside of New York City;
and

    

    
      3. 225
FTEs for health plans that serve both New York City and counties outside of New
York City, with no more than 150 operating in New York City.

    

    
      

       

      13.7 Culturally
and Linguistically Appropriate Staff

    

    
      

       

      The
CONTRACTOR shall ensure that facilitators are culturally and linguistically
reflective of the population being served.

    

    
      

       

      13.8 Compliance
with Local Department of Social Services (LDSS) Procedures

    

    
      

       

      The
CONTRACTOR shall comply with procedures that have been developed by the STATE to
assure that facilitators are authorized to perform the Medicaid face-to-face
interview.

    

    
      

       

      13.9 Functions
of Facilitators

    

    
      

       

      The
CONTRACTOR shall perform the following functions:

    

    
      

       

      • Assist
families in completing the applications set forth and defined in Section 1 of
this Appendix;

       

    

    
      • Screen
children for Medicaid or CHPlus program eligibility, as
appropriate;

       

    

    
      • Explain
documentation requirements for Medicaid and CHPlus and assist families in
obtaining such documentation;

       

    

    
      • Complete
the face-to-face interview for Medicaid in accordance with Medicaid
requirements, policies and procedures. For those LDSS offices that do not
delegate the face-to-face interview to the facilitator, the facilitator shall
act as the applicant's authorized representative at the interview with LDSS
staff.

       

    

    
      • Follow-up
with applicants and families to complete the application process;

       

    

    
      • Educate
families about managed care and how to access benefits in a managed care
environment including (1) the role of the Primary Care Provider (PCP) and (2)
the benefits

    

    
      

       

      77

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      of
preventive care. This includes the responsibility to distribute brochures and
information developed by the STATE about managed care and how to access benefits
in a managed care environment;

    

    
      

       

      • Assist
families in selecting either a Medicaid managed care or CHPlus health plan. As
part of this
function, facilitators are required to

    

    
      (1)
inquire about existing provider relationships, (2) identify the health plans in
which such providers participate to the extent such information is available to
the CONTRACTOR, and (3) describe the full choice of health plans available to
the family. The CONTRACTOR shall ensure that information is available about
providers who participate in each health plan's product that is available in the
applicant's service area;

    

    
      

       

      • Distribute
to potential enrollees at the time of application, informational materials
including brochures developed by the STATE to explain insurance coverage options
available through the Medicaid and CHPlus programs and various other public
programs designed to support self-sufficiency;

    

    
      

       

      • Provide
applicants with information about the right to complain to the LDSS or health
plan about eligibility determinations; Verbally inform each family with a
Medicaid eligible child about the availability of services under the Medicaid
Child/Teen Health Plan;

    

    
      

       

      • Provide
information on other State programs such as Healthy New York, for which
applicants may be eligible;

    

    
      

       

      • Provide
applicants with general counseling on the potential for Medicaid spenddown, when
appropriate. An applicant whose income is above the Medicaid level, but who has
on-going medical needs, may benefit from spenddown as their monthly income may
be reduced by their monthly medical expenses to a level that makes them eligible
for Medicaid; and

    

    
      

       

      • Refer
to the LDSS, those applicants who indicate they are blind or disabled and who do
not appear Medicaid eligible. The facilitator will provide the applicant with
information about the potential benefit of a full Medicaid assessment by the
LDSS.

    

    
      

       

      13.10 Application
Review Procedures/Quality Assurance

    

    
      

       

      The
CONTRACTOR shall review all applications for quality and completeness prior to
submission to the appropriate entity responsible for determining Medicaid or
CHPlus eligibility. The CONTRACTOR shall establish procedures necessary to
perform the quality reviews, approved by the STATE, including mechanisms for
identifying and rectifying deficiencies.

    

    
      

       

      13.11 Transmitting
Information

    

    
      

       

      The
CONTRACTOR shall comply with the appropriate LDSS protocols and procedures
established for transmitting a child's Medicaid managed health care plan choice
directly to the LDSS or enrollment brokers where applicable.

    

    
      

       

      13.12    Submitting
Applications to LDSS and other CHPlus Health Plans

    

    
      

       

      The
CONTRACTOR shall submit completed applications to the appropriate LDSS or CHPlus
health plan. The CONTRACTOR must follow the written protocols for the
appropriate LDSS, including the delivery and processing of completed
applications in accordance with SDOH Administrative Directives (ADM) 00
OMM/ADM-2 included in Attachment A of this Section.

    

    
      

       

      13.13    Services
for Visually or Hearing Impaired Applicants

    

    
      

       

      The
CONTRACTOR shall have mechanisms in place to communicate effectively with
applicants who are vision or hearing impaired,- e.g. the services of an
interpreter, including sign language assistance for applicants who require such
assistance, telecommunication devices for the deaf (TTY) etc. The STATE does not
expect the CONTRACTOR to have such devices in every community office but must
have such mechanisms available when requested.

    

    
      

       

      78

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      13.14 Application
Follow-Up

    

    
      

       

      The
CONTRACTOR shall collect documentation required for a pending Medicaid
application. The CONTRACTOR shall follow up on the status of all pending
Medicaid applications with the appropriate LDSS on a monthly basis. Follow up
shall begin on or about two months from the submission of a completed Medicaid
application, including documentation.

    

    
      

       

      The
CONTRACTOR shall also follow up on CHPlus applications with the appropriate
health plans to ensure applications are being processed.

    

    
      

       

      13.15 Recertification

    

    
      

       

      The
CONTRACTOR may assist families of children enrolled in Medicaid or CHPlus in
recertifying for those programs prior to the expiration of their 12-month
enrollment period when an enrollee seeks a facilitator's assistance with
renewal. Such assistance shall be provided in accordance with LDSS established
protocols. The facilitator may provide assistance in completing the
recertification application and any required documentation and return it to the
enrollee for submission.

    

    
      

       

      13.16 Training
Programs

    

    
      

       

      The
CONTRACTOR shall ensure that all facilitators participate in the STATE-sponsored
training program or other training required by the STATE. The CONTRACTOR must
ensure that its facilitators are trained either by the STATE or by the
CONTRACTOR prior to providing assistance. The CONTRACTOR shall provide ongoing
program updates, training support and technical assistance to facilitators
through regularly scheduled sessions.

    

    
      

       

      13.17 Confidentiality
Issues

    

    
      

       

      The
CONTRACTOR shall maintain confidentiality of applicant and enrollee information
in accordance with protocols developed by the CONTRACTOR and approved by the
STATE. Information obtained on the Growing Up Healthy, Access New York Health
Care or Medicaid or CHPlus Health Insurance Renewal Form and information
concerning the determination of eligibility for Medicaid may be shared by the
CONTRACTOR, its subcontractors and the programs and agencies identified in
Section H of the Application, provided that the applicant has given appropriate
written authorization on the application and provided that the release is for
the purposes of determining eligibility or evaluating the success of the
program.

    

    
      

       

      The
CONTRACTOR agrees that there will be no further disclosure of Medicaid
Confidential Data (MCD) without prior, written approval of the New York State
Department of Health, Medicaid Confidentiality Data Review Committee (MCDRC).
The CONTRACTOR shall require and ensure that any approved agreement, contract or
document contains a statement that the subcontractor or other party may not
further disclose the MCD without the prior written approval of the New York
State Department of Health, MCDRC. The CONTRACTOR shall assure that all persons
performing activities under this contract receive appropriate training in
confidentiality and that procedures are in place to sanction any such person for
violations of confidentiality.

    

    
      

       

      Upon
termination of this AGREEMENT for any reason, the CONTRACTOR shall ensure that
program data reporting is complete and shall certify that any electronic or
paper copies of MCD collected or maintained in connection with this AGREEMENT
have been removed and destroyed.

    

    
      

       

      13.18 Federal
and State Law Compliance

    

    
      

       

      The
CONTRACTOR shall comply with any applicable federal or State law, regulation and
administrative guidance issued by the STATE which may supplement or supersede
the provisions set forth in this AGREEMENT.

    

    
      

       

      79

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      13.19 Site
Visits

    

    
      

       

      The
CONTRACTOR shall cooperate with STATE monitoring efforts, including unannounced
site visits.

    

    
      

       

      13.20 Termination
of Responsibilities

    

    
      

       

      The
CONTRACTOR may terminate its facilitated enrollment responsibilities under this
AGREEMENT by providing at least 60 days written notice to the STATE. The STATE
may immediately suspend or terminate facilitated enrollment responsibilities for
due cause. Termination of facilitated enrollment responsibilities under this
section shall result in removal of the CHPlus premium add-on associated with
those functions.

    

    
      

       

      80

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      Section
13 Attachment A

    

    
      

       

      00
OMM/ADM 2

    

    
      FACILITATED
ENROLLMENT OF CHILDREN INTO MEDICAID, CHILD HEALTH PLUS AND
WIC

    

    
      

    

    
      

    

    
      

    

    
      81

    

    
      

    

    
      

    

    
      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    
      

    

    
      

    

    
      STATE
OF NEW YORK

    

    
      DEPARTMENT
OF HEALTH

    

    
      

    

    
      Corning
Tower   The Governor Nelson A. Rockefeller Empire State
Plaza  Albany, New York 12237

    

    
      

    

    
      	
              Antonia
      C. Novello, M.D., M.P.H

              Commissioner

            	 
      	
              Dennis
      P. Whalen

              Executive
      Deputy Commissioner

               

            
	
              To:
      Commissioners of Social Services

            	 
      	
              Division:
      Office of Medicaid Management

               

              Date:
      May 4, 2000

            
	
              Subject:
      Facilitated Enrollment of Children into Medicaid, Child Health Plus and
      WIC

               

            
	
              Suggested
      Distribution:

            	
              Commissioners

              Medicaid
      Directors

              Medicaid
      Staff

              Managed
      Care Staff

              Staff
      Development Coordinators

               

            
	
              Contact
      Person:

            	
              Medicaid
      Local District Liaison: (518) 474-9130

              New
      York City Representative: (212) 268-6855

              Managed
      Care County Relations Staff: (518) 473-1134

               

            
	
              Attachments:

            	
              Attachment
      I: DOH-4133 (Growing Up Healthy Application)

              Attachment
      II: DOH-4134 (Growing Up Healthy Documentation Checklist)

              Attachment
      III: Statewide List of Facilitated Enrollees

               

            
	
              FILING
      REFERENCES

               

            
	
              Previous
      ADMs/INFs

            	
              Releases
      Cancelled

            	
              Dept.
      Regs

            	
              Soc.
      Serv. Law & Other Regal Ref.

            	
              Manual
      Ref.

            	
              Misc.
      Ref

            
	
              98
      OMM/ADM-3

              91
      ADM-28

              91
      ADM-18

            	
              98
      OMM/ADM-3

            	
              360-2.1

              360-2.2

              360-2.4

            	
              PL
      105-33 Public Health Law Section 2511 (9)

            	 
      	 
      

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    

    

    
      Date: May 4, 2000

      Trans. No.  00  OMM/ADM
- 2

       

      Page No. 2

    

    
      I.
PURPOSE

    

    
      

    

    
      The
purpose of this Office of Medicaid Management/Administrative Directive (OMH/ADM)
is to:

    

    
      

       

      - advise
local social services districts (LDSS) of the requirement to coordinate their
application processes with approved community-based organizations contracting
Kith the Department to provide "facilitated enrollment" assistance to families
in applying for Medicaid, Child Health Plus (CHPlus) and the Special
Supplemental Food Program for Women, Infants, and Children (KIG) for their
eligible children? and,

    

    
      

       

      -
introduce the revised DOH-413 3, Growing Up Healthy
Application.

    

    
      

       

      II.   BACKGROUND

    

    
      

       

      In 1997,
the U.S. Congress passed the Balanced Budget Act (BPA), Public r>aw 105-3 3,
which contains several provisions relating to children's health care
coverage.  These provisions, including the newly created Title XXI of
the Social Security Act, contain the framework for states to establish state
child Health Insurance Plans (SCHIPs), to vastly expand outreach and enrollment
efforts for both Medicaid and the new SCHIPs, and to foster close coordination
between the two programs, Enhanced federal financial participation is available
for these efforts,

    

    
      

       

      Hew York
State has had its own children's health insurance program since 1990. This
program, child Health plus (CHPlus), contracts with private insurers to supply-
low-cost or free health insurance to low income children.  The BBA
recognized New York's CHPlus program, which was previously funded with
State-only money, as an acceptable SCHIF program.

    

    
      

       

      In New
York State, Chapter 2 of the Laws of 1998 was enacted to provide authority for
the Department to implement the BBA.  Chapter 2 requires the
Department to implement locally-tailored public education, outreach and
facilitated enrollment strategies targeted to children who may be eligible for
benefits under CHPlus and Medicaid.  In response, the Department
released a Request for Proposals (RFP} in March 1999, to solicit proposals from
community-based organizations to facilitate enrollment in CHPlus and Medicaid.
As a result, 34 "lead organizations" (also called lead agencies} were selected
to coordinate facilitated enrollment in community-based settings. Many of them
have sub-contracted with other community-based organizations to which they will
provide oversight. CHPlus insurers have also been given an opportunity to
facilitate enrollment in these programs.

    

    
      

       

      83

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      Date:  May
4, 2000

    

    
      Trans. No.  00
OMM/ADM-2    

       

                                                                                                            Page
No.3

    

    
      

       

      Additionally,
the State has revised the Growing Up Healthy application (DOH-4133, Attachment
I) which has been in use in pilot sites as a joint application for CHPlua,
Medicaid and WIG. This application, which includes a documentation checklist,
will be used by facilitators to assist children in accessing the appropriate
program (s).

    

    
      

       

      II.   EB.0ORRH
IMPLICATIONS:

    

    
      

       

      Facilitators
will be placed in various locations in the community, such as hospitals,
clinics, day care centers, and community centers. Chapter 2 of the Laws of 1998
requires facilitators to be available evenings and weekends.

    

    
      

       

      Facilitators
will assist families in applying for Medicaid or CHPlus and HIC. "this
assistance will include screening the applicant for the appropriate program,
completing the application, collecting the required documentation, submitting
the completed application and necessary documentation to the appropriate
program, and follow-up with families to ensure they complete the application
process. Local districts may delegate to the facilitator the authority to
conduct the Medicaid face-to-face interview with the applying family, or they
may require the facilitator to act as the family's authorized representative
during the face-to-face interview at the LOSS. The family cannot be required to
come into the LESS for the face-to-face interview. The facilitator will also
assist families in choosing a health plan for CHPlus. For Medicaid, facilitators
may assist families in pre-selecting a health plan, at the families'
option.

    

    
      

       

      The goal
of facilitated enrollment is to maximize the enrollment of eligible children in
the appropriate program and ultimately, demonstrate improved access to care and
health outcomes.  The role of the LOSS is critical to the success of
facilitated enrollment.  Some LDSs have already been involved in the
development of facilitated enrollment proposals with organizations in their
communities, while others may not have had a direct role. In either event, LDSSs
are responsible for working with approved organizations in the facilitated
enrollment process. Districts, in conjunction with the lead organizations, may
design processes/procedures which meet local needs while accommodating
applications received from facilitators.

    

    
      

       

      IV.   REQUIRED
ACTION:

    

    
      

       

      A,   Local District
Responsibilities

    

    
      

       

      The LDSS
must coordinate the application process with the approved facilitated enrollment
organizations working in their communities, it is also anticipated that
recipients who enroll in Medicaid through a facilitator will be assisted in the
recertification process by such facilitator. Attachment II provides a Statewide
listing of approved lead agencies.  The responsibilities of the LDSS
in the facilitated enrollment process include the following:

    

    
      

       

      1.   Work
with the lead organizations to develop protocols for the

    

    
      receipt
and processing of applications and recertifications. This includes developing
processes for notifying the lead organization and the applicant when additional
documentation is required and of

    

    
      

       

      84

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      Date: May
4, 2000

    

    
      Trans. No. 00
OMM/ADK-2  

       

                                                                                                                  Page
No.4

    

    
      

       

      the final
eligibility determination,  such procedure must allow for the
submission of the DOH-4133 by the lead organizations.

    

    
      

       

      2.  When
needed, provide information to lead organizations to assist facilitators in
determining a health care provider's participation in Medicaid Managed Care, as
described in Section B of this directive.

    

    
      

       

      3.  Accept
completed applications (DOH-4133) from the lead organizations and process
applications in a timely manner, but in no event later than 30 days from the
date of application. Districts must also provide notice of the results of the
eligibility determination to the applicant, and the lead organization and/or
health plan.

    

    
      

       

      4.  Accept
Medicaid Managed care enrollment forma from the facilitators, pending the
enrollment until eligibility has been established and managed care enrollment
can be completed in the PCP subsystem .

    

    
      

       

      5.  Provide
prompt feedback to the lead organization on incomplete or incorrect
applications, so that problems can be addressed in a timely
fashion.

    

    
      

       

      6.  Delegate
the Medicaid face-to-face interview to the facilitators, or establish procedures
which allow the lead organization to act as the authorized representative for
the applicant, for purposes of the face-to-face interview with LESS
staff.

    

    
      

       

      Where the
LDSS agrees to delegate the face-to-face interview to a facilitator, the
facilitator is responsible for informing the applicant of his/her rights and
responsibilities, as required by 18 NYCRR,360-2.2{f).  Where the LESS
retains responsibility for the face-to-face interview, interviews with staff
from the lead organizations should be scheduled in such a manner that several
interviews may be conducted during one appointment.

    

    
      

       

      The date
that the application is completed and signed with the facilitator is considered
the date of application for Medicaid purposes. Applications may be signed by the
applicant, or anyone the applicant designates to represent him/her in the
application process.

    

    
      

       

      NOTE:  if
there is a delay in the receipt of a completed application from a lead
organization such that the thirty day timeframe for the Medicaid determination
is compromised, local districts are advised to document this circumstance in the
case record.  This will serve to hold the district harmless in the
event of an audit or other administrative review.

    

    
      

       

      The lead
organizations and the UBSS  must
describe the above procedures, in writing, and such procedures will be made a
part of the lead organization’s contract with the Department.  These
procedures may include any standards of performance- and/or quality control
measures agreed to by both parties, and actions to be taken by the district to
correct performance that does not meet the agreed upon
standards.

    

    
      

       

      85

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      Date: May
4, 2000

    

    
      Trans. Ho.  00
OHM/ADM-2  

       

                                                                                                              Page
No. 5

    

    
      

       

      Children
who apply and are found fully eligible for Medicaid through the facilitated
enrollment process will be authorized for no less than 12 months of Medicaid
coverage, or through the end of the month in which their 19th birthday occurs,
whichever is earlier.  Upon being notified of the need to recertify
eligibility, such children will have the option of recertifying with the
LD&S or they may return to the facilitator to recertify, using the
DOH-4133.  (See Systems Implications for instructions for
identification of these cases.)

    

    
      

       

      NOTE:
Pregnant women may also apply for Medicaid using the DQH-4133. Generally,, such
pregnant women are provided coverage only until the end of the 60 day
poet-partum period and are required to recertify in order for coverage to
continue beyond such period, Procedures for authorizing coverage for pregnant
women are not changing under the facilitated enrollment process. It is
recommended that a separate case be maintained for the pregnant woman in order
to ensure recertification at the appropriate time.

    

    
      

       

      It is
anticipated that a significant number of adults may be identified as potentially
eligible for Medicaid by facilitators. Such individuals cannot complete the
application with a facilitator and should be referred by the facilitator to the
IJDSS to initiate the application process.  It is recommended that
districts establish procedures to coordinate the processing of such adult
applications with the applications received from the lead organizations for
their children.

    

    
      

       

      B.   Managed Care
Implications

    

    
      

       

      Facilitators
may be assisting Medicaid applicants in choosing a Medicaid Managed Care plan,
when appropriate. In doing so, they will be inquiring about existing provider
relationships, in an effort to identify health plans in which a child's current
provider participates. The facilitator will be responsible for providing
complete and impartial information about all participating insurers, to allow a
family to make an informed choice of which plan will meet its needs. a, primary
goal is to retain the child's current relationship with a primary care provider,
if one exists.

    

    
      

       

      Districts
must be prepared to assist lead organizations to set up procedures for access to
information regarding the most current managed care plan provider network. Where
a family has chosen a plan, the enrollment will be forwarded to the LDSS, using
the prescribed BDOH enrollment form (EOH-4175 or DOH-4097) , along with the
EOH-4133. Districts must have a written process in place, approved by the Office
of Managed Care, to pend the enrollment until such time as the child is
determined eligible for Medicaid.  (in New York City, managed care
enrollments will be forwarded to Maximus and processed only after Medicaid
eligibility has been established.)

    

    
      Districts'
written procedures must include provision for monitoring the education process
of the lead organizations to ensure the following]

    

    
      

       

      - In
mandatory counties, the education process must ensure the enrollee has
sufficient information to make an informed choice and understand the provisions
of mandatory enrollment. This may include dissemination by the facilitator of
the county's enrollment packet or other educational materials as agreed upon in
the lead agency/LDSS protocol.

    

    
      

       

      86

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      Date: May
4, 200O

    

    
      Trans. No. 00 OMM/RDM-2

       

                                                                                                                      Page
No.6

    

    
      

       

      Note 1115
counties must make assurance s that all terms and conditions mandated by the
Health Care Financing Administration will be adhered to.

    

    
      

       

      - In
voluntary counties, the education process must ensure informed choice, as well
as convey the voluntary nature of the program.

    

    
      

       

      - all
counties must have a protocol for follow-up in instances of biased marketing,
incomplete, or incorrect information disseminated by
facilitators.

    

    
      

       

      In
situations when an applicant does not choose a Managed care plan during the
interaction with the facilitator, the district's existing processes for
enrolling the individual in a managed care plan upon establishment of
eligibility are followed.

    

    
      

       

      C.   Transition of Medicaid
Eligible Children from chpLUS

    

    
      

       

      Title XXI
prohibits Medicaid eligible children from being enrolled in CHPlus. under the
Department's approved Title XXI State Plan, the State is required to ensure
efficient and effective coordination between the Medicaid and CHPlus programs.
Districts were notified in 98 ONK/ADM-3, "Medicaid Referrals from the Child
Health Plus program," of procedures whereby CHPlus insurers screen families at
the time of application and yearly recertification and, where it appears the
family income is below the Medicaid standard, refer the family to the LDSB. As
an interim process, monthly lists of families so referred have been provided to
the districts. Districts were then required to forward Medicaid application
packages to each family on the list. with the implementation of facilitated
enrollment, these processes will change.

    

    
      

       

      CHPlus
plans will identify children who appear to be Medicaid eligible based on the
previous year's income.  At least 60 days prior to the child's annual
recertification for CHPlus, the family will be instructed via a letter from
their CHPlus insurer that, unless the family income has increased, the child
must apply for Medicaid prior to the recertification due
date.  Further, the family will be informed that failure to apply for
Medicaid will result in disenrollment from CHPlus. The recertification packets
will include a list of facilitated enrollment locations and the documentation
requirements for Medicaid. Facilitators will complete the Medicaid application
process with the family (including the face-to-face interview, when the
authority has been delegated by the LOSS), provide information on all available
Medicaid Managed care plans the applicant may choose from, and complete the
state-prescribed managed care enrollment form, when appropriate, The application
package will then be forwarded to the LDSS for the eligibility
determination.

    

    
      

       

      A similar
process will be followed for new CHPlus applications mailed directly to CHPlus
insurers, when the child appears Medicaid eligible.

    

    
      

       

      Districts
are required to provide a copy of the Medicaid decision notice to the
facilitator and/or CHPlus insurer.  It is necessary for the LDSS to
notify the facilitators and the CHPlus insurers of the results of the Medicaid
determination, to enable them to follow up with applicants who have not
submitted all required documentation and to

    

    
      

       

      87

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      Data3 May
4, 200O

    

    
      Trans. No. 00 OMM/RDM-2

       

                                                                                                                   Page
No.7

    

    
      

       

      disenroll
from CHPlus children who have become Medicaid eligible, and children whose
families have failed to comply with the application process.

    

    
      

       

      The joint
application has a specific consent provision to share applicants' Medicaid
status with CHPlus insurers. Districts are permitted to release information to
facilitators under the provisions of Social Services Law, Section 13 6, which
allows disclosure to an authorized representative,  The lead
organizations are under contract with the Department, and are subject to Sand
have been trained on) the same standards of confidentiality as LDSS
staff,

    

    
      

       

      D,           Revised
DQH-4133

    

    
      

       

      The
DQH-4133, "Growing up Healthy Application," which was provided to districts in
99 OMM/AEM-l, has undergone substantial revisions as a result of recommendations
from the pilot sites. These revisions are primarily a reordering of the existing
questions. However, there are several notable changes:

    

    
      

       

      -              The
shelter information includes questions regarding whether the housing payment
includes heat, and if not, the type of heat, Completion of these questions is
optional on the part of the applicant. However, when answered, it will allow
LDSS staff to determine eligibility using Low income Family {isle)  budgeting.
If the questions are not answered, eligibility is determined using the
appropriate poverty level budgeting methodology,

    

    
      

       

      -              The
question requesting information about absent parents has been removed from the
application,  Instead, applicants will be given information regarding
the availability of child support services and the benefits to their children of
establishing paternity and/or pursuing cash/medical support from the absent
parent.

    

    
      

       

      -              Information
for non-citizens has been expanded,

    

    
      

       

      The
revised doh-4133 is included in this Directive as Attachment I. It will
eventually replace the DSS-2921-P.  Local districts should accept both
applications until further notice,

    

    
      

       

      E,           Revised DOH-417S and EOH-40
97

    

    
      

       

      The
DOH-4097, "Medicaid Managed care Program Enrollment Form" and DQH-4175,
"Medicaid Managed care Enrollment Form {voluntary counties)" are the prescribed
enrollment forms for use in the Medicaid Managed Care Program in voluntary and
mandatory counties. For voluntary counties, use of the DOH-4175 will negate the
need for a separate client attestation, as previously required with the plan
specific enrollment forms,

    

    
      

       

      V.           SYSTEM
IMPLICATIONS:

    

    
      

       

      A.   Upstate;

    

    
      

       

      As
discussed in Section IV of this directive, children who apply and are found
eligible for Medicaid through the facilitated enrollment process will be given
the option of recertifying with the LDSS, or with a facilitator, using the
DOH-4133,  A new recert call in letter and

    

    
      

       

      88

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      Date:  May
4, 2 00O

    

    
      Trans. No:  00
OMM/ADK-2    

       

                                                                                                                   Page
No.3

    

    
      

       

      reason
code is under development for the client Notices System (CUB) which will advise
the recipient of the need to recertify, and will include the DOH-4133 and
language explaining the recertification process,  In order to ensure
such cases are appropriately identified, a unique identifier must be entered in
the welfare Management system (WMS) for these cases.

    

    
      

       

      Districts
should assign their own identifier.  This may be either a unique Unit
Identifier or worker Identifier, whichever option is used, districts should be
aware of the hierarchy of the sort order of the Recertification Report (WIMR
41335.  Creating a new Unit Identifier will cause all cases with that
identifier to appear together, regardless of the worker assigned to the
case,  Creating a new Worker Identifier will designate facilitated
enrollment cases by worker, and integrate these cases into the existing unit to
which the worker is assigned,  creation of new unit/Worker Identifiers
requires districts to update their CNS Contact Data, so that the recert call in
letter will print the proper unit/Worker information,

    

    
      

       

      B.   New York
City:

    

    
      

       

      Hew York
City procedures for identifying cases which enter the agency through facilitated
enrollment will be transmitted under separate cover.

    

    
      

       

      VI.   EFFECTIVE
DATE:

    

    
      

       

      Districts
will be notified to begin processing applications from the approved agencies
once the contract between the Department and the agency has bean signed by both
parties and approved by the Office of the State Comptroller.

    

    
      

    

    
      

    

    
      

    

    
      

    

    
      _____________________________________

    

    
      Kathryn
Kuhmerker, Deputy Commissioner

    

    
      Office of
Medicaid Management

    

    
      

       

      89

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      SECTION
14

    

    
      FACILITATED
ENROLLMENT MONITORING

    

    
      

       

      14.1 Marketing/Facilitated
Enrollment Integrity

    

    
      

       

      The
CONTRACTOR shall institute policies and procedures to prevent fraud and abuse by
applicants and marketing/facilitated enrollment staff and take corrective action
in a timely fashion against employees engaged in fraud and
abuse.

    

    
      

       

      14.2 Quality
Assurance

    

    
      

       

      The
CONTRACTOR shall review all new and recertification applications for Medicaid,
Family Health Plus and CHPlus for completeness and logic. This includes those
taken by health plan marketing representatives/facilitators, those submitted by
outside facilitators, and those mailed in by applicants. Specifically, the
CONTRACTOR'S quality assurance reviewers must confirm that:

    

    
      

       

      • All
sections of the application are complete and the application is
signed.

    

    
      

       

      • The
appropriate documents are included with the application.

    

    
      

       

      • The
signature on the application appears to match the signature on any supporting
documentation, if applicable. The applicant signature must not appear to match
the signature of the marketer/facilitator in the "For Office Use Only" section
of the application.

    

    
      

       

      • No
white out was used on any documents and that information pertinent to
eligibility was not changed in any way without being initialed by the applicant.
If pertinent information has been changed without being initialed by the
applicant, the CONTRACTOR shall verify the change with the applicant prior to
enrollment. The CONTRACTOR may change and initial an applicant-initiated change
to the application provided they send the changed, initialed page to the
applicant and can document having done so. This requirement does not apply to
applications received in the mail directly from the member.

    

    
      

       

      • For
CHPlus applicants listed as undocumented immigrants, the CONTRACTOR must review
the application and supporting documentation for a Social Security Number. If a
Social Security Number for the applying child is found, the CONTRACTOR shall
verify the undocumented status with the applicant. If a Social Security Number
is listed, but the family confirms that the child is undocumented, the
CONTRACTOR may accept the family's word and note it on the application. The
CONTRACTOR shall refer any such case to the STATE for review of the Social
Security Number.

    

    
      

       

      • The
individuals listed in Section B (Household Information) are consistent with
those listed in Section E (Household
Income) to be certain that income was not overlooked. The CONTRACTOR must include
an explanation on the application (Section E) if a parent or caretaker relative
listed in Section B does not have income listed in Section E. This
requirement does
not apply to applications received in the mail directly from the
enrollee.

       

      

    

    
      •
For all applications, including child only
applications, the CONTRACTOR shall check that the household income is adequate
to support the monthly housing payment listed on the application. The question on monthly housing
payments is now required for all applicants, with the exception of mail in
applications until such time as the Growing up Healthy, Access New York Health
Care and/or Child Health
Plus Health Insurance Renewal applications are revised to incorporate this
requirement. The
CONTRACTOR must, prior to processing applications that indicate the monthly housing payment is more than 50
percent of the total monthly income, further review the application to determine how the
household is meeting its basic financial needs. This includes contacting the family for an
explanation. The CONTRACTOR must include an explanation on
a

    

    
      

       

      90

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      comment
sheet included with the application as to how the household is meeting its
financial obligations.

    

    
      

       

      • For
single parent households, the CONTRACTOR shall ensure that child support
payments are listed, or if not, that
there is a notation in the unearned income part of Section E that the
custodial parent
does not receive child support. This requirement does not apply to applications
received in the
mail directly from the enrollee.

    

    
      

       

      If any
item above is incomplete or suspect, the CONTRACTOR shall resolve the issue as
described above prior to forwarding the application for eligibility
determination within the CONTRACTOR'S plan, another health plan or to an LDSS.
If the application is signed, but the applicant appears ineligible for any
program, it must be forwarded to the appropriate eligibility determining entity
batched with the ineligible applications.

    

    
      

       

      For
applications received from other facilitated enrollment organizations (e.g.,
another plan, provider, or community-based organization), the quality assurance
review described above is the responsibility of the entity that assisted in
completing the application. In these cases, where the CONTRACTOR receives an
application from an entity that acted as a facilitator on behalf of a family,
the CONTRACTOR shall review the application for logic and completeness according
to the criteria above. However, any applications requiring verification with the
family or an employer shall be returned to the originating facilitated
enrollment entity as an incomplete application.

    

    
      

       

      The
CONTRACTOR shall attach to the application a quality assurance check list
developed by the STATE and signed by the CONTRACTOR as an attestation of
completing a quality assurance review process. The checklist shall be included
with all applications submitted to the LDSS or other health plans. The
CONTRACTOR shall maintain a copy of the checklist for their files. For CHPlus
enrollees, the check list should be included in the file which will be subject
to review at audit. Alternatively, for CHPlus applications, the CONTRACTOR may
utilize its own electronic quality assurance checklist that shall be available
for STATE review during an audit.

    

    
      

       

      14.3  Targeted
Verification

    

    
      

       

      The
CONTRACTOR shall verify the information taken by their marketers/facilitators
with the family or employer (if applicable), using a sample of applications,
which include the following three categories:

    

    
      

       

      • Applications
with non-applying children or adults (if applicable) that impact
eligibility.

    

    
      

       

      • Applications
with a self-declaration of income.

    

    
      

       

      • Applications
with a declaration of no income/letter of support. THE CONTRACTOR is not
required to conduct a verification call for households that have income and a
letter of support.

    

    
      

       

      CONTRACTORS
that do not take applications from applicants other than through the mail shall
not be required to conduct verification phone calls provided such applications
do not contain a high volume of the above three categories as determined by the
STATE. The STATE will conduct special audits of the applications taken by these
plans through the mail to determine whether additional verification is
required.

    

    
      

       

      The
CONTRACTOR shall conduct verification phone calls on a stratified sample of
applications to confirm the information provided by the applicant prior to its
being submitted to the LDSS, another health plan, or enrolled in CHPlus. The
CONTRACTOR may develop its own process for conducting the verification phone
calls. The sample may be drawn monthly or quarterly. For large plans (more than
300 applications completed by facilitators per month) the sample shall be at
least 10 percent of all applications in the period (month or quarter). Smaller
plans (less than 300 per month) will need to verify 30 applications in these
categories, collectively, per period. The CONTRACTOR is not required to
track

    

    
      

       

      91

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      applications
by the three categories above. That is one option for drawing the sample.
Another option is to take a random sample of all applications at a percent
believed to be high enough that the sample captures applications from each of
the three categories above. The CONTRACTOR'S methodology for completing the
verification phone calls shall be approved by the STATE prior to implementation
and must be based on a projected number of applications to be received within
each category.

    

    
      

       

      The
CONTRACTOR shall over sample in the categories to be verified to permit
replacement of those the plan is unable to reach. The CONTRACTOR may drop and
replace applicants they are unable to verify due to an inability to reach the
family after three attempts. There is no limit on the number that can be
replaced as long as the final sample meets the number agreed upon in the
CONTRACTOR'S plan approved by the STATE that shall be submitted pursuant to this
AGREEMENT. The CONTRACTOR is required to provide information to the STATE on the
dropped cases including the number dropped in a period, the reasons for
replacement (e.g., unable to contact, refused to cooperate). The CONTRACTOR
shall make at least three attempts to contact the family at different times of
the day (e.g., morning, afternoon, evening) prior to dropping the case. The
replacement case shall fall within the same category as the sample case. For
example, if the dropped case includes non-applying people affecting eligibility,
the replacement case shall include non-applying people.

    

    
      

       

      Applications
must be verified by the CONTRACTOR on a prospective basis, however, the
CONTRACTOR is prohibited from delaying enrollment in order to implement such
verification. The CONTRACTOR shall determine the sample and conduct the calls on
an ongoing basis so as not to delay enrollment. The CONTRACTOR shall develop a
methodology to conduct verification, based on the expected number of
applications in each category.

    

    
      

       

      If the
applicant concurs with all the information on the application, the CONTRACTOR is
not required to take additional steps to verify the information. The CONTRACTOR
must still complete the checklist.

    

    
      

       

      If the
CONTRACTOR, through a verification phone call, finds that the application
includes inaccurate information or misrepresentation of the applicant's
circumstances, the CONTRACTOR must make best efforts to determine if the
inaccuracy was due to actions of the marketer/facilitator. The CONTRACTOR must
investigate if the marketer/facilitator acted with the intent to falsify the
application. The CONTRACTOR must not enroll the applicant if the new information
renders them ineligible.

    

    
      

       

      If the
CONTRACTOR finds that the marketer/facilitator's action did result in false
information on the application, the CONTRACTOR shall remove the employee as a
facilitator immediately and follow the CONTRACTOR'S process for employee
disciplinary action. In addition, the CONTRACTOR shall review one month of prior
applications taken by that marketer/facilitator. If evidence of fraud is found
on any one of those applications, the CONTRACTOR shall review an additional two
months of prior applications taken by the
marketer/facilitator.

    

    
      

       

      If the
intent is unclear or it is determined the marketer/facilitator made a mistake,
the CONTRACTOR shall re-train the employee immediately.. The CONTRACTOR shall
review all subsequent applications submitted by the marketer/facilitator for the
next month to ensure compliance. If continued mistakes are found on those
applications, the CONTRACTOR shall remove the employee as a facilitator
immediately and follow the CONTRACTOR'S employee disciplinary action procedures.
The review of individual marketer/facilitator applications shall encompass all
applications for the period and does not need to be sorted into the three
categories above.

    

    
      

       

      Verification
of a specific facilitator's applications cannot substitute for the CONTRACTOR'S
sample review required by this section of the AGREEMENT. The CONTRACTOR must
make the appropriate adjustments to claims for CHPlus applications found to be
ineligible and must report their findings to the STATE. If Medicaid or FHPlus
applicants appear ineligible for those programs, the CONTRACTOR shall refer
those cases to the appropriate LDSS for review and action.

    

    
      

       

      The
CONTRACTOR shall protect applicants who have been subjected to facilitator
fraud. For those applications that are verified prior to enrollment the
CONTRACTOR shall:

    

    
      

       

      92

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      • Enroll
applicants or forward to the LDSS those applications in which the information is
verified by the applicant.

    

    
      

       

      • Enroll
applicants or forward with corrections to the LDSS those applications in which
information was omitted by the facilitator, but the individual is still
eligible. The CONTRACTOR may obtain the corrected information over the phone,
initial the application, and send a copy of the updated information to the
applicant.

    

    
      

       

      • Forward
all signed Medicaid applications to LDSS batched according to whether applicants
appear eligible or ineligible.

    

    
      

       

      For cases
in which the CONTRACTOR retroactively reviewed the applications of a facilitator
found to have committed fraud, the CONTRACTOR shall:

    

    
      

       

      • Do
nothing with enrollees who confirm the information on the
application.

    

    
      

       

      • Inform
the LDSS of any Medicaid enrollees who may not be eligible based on the
retrospective review.

    

    
      

       

      •  Allow
CHPlus enrollees to reapply if it appears that they may still be eligible for
coverage. Coverage for a CHPlus enrollee may be continued for two months while
the new application is completed and processed. During this time any CHPlus
applicant found to be eligible in a higher family contribution category will be
permitted to remain enrolled provided they remit the appropriate family
contribution. A new code will be added to the KIDS system to permit the
CONTRACTOR to track these children.

    

    
      

       

      •    Forward
all new Medicaid and FHPlus applications to the LDSS with an explanation of the
results of the verification.

    

    
      

       

      If during
the course of the verification process, the CONTRACTOR identifies cases of fraud
committed by applicants and/or enrollees, those cases, with supporting evidence,
shall be submitted to the STATE.

    

    
      

       

      14.4     Field
Monitoring

    

    
      

       

      The
CONTRACTOR shall conduct field monitoring of their marketers/facilitators,
including announced and unannounced observed interviews between
marketers/facilitators and applicants. If the CONTRACTOR does not have field
marketers, it shall develop a process for observing the actions of their
marketers when assisting applicants (e.g., over the telephone). This process
must be reviewed and approved by the STATE.

    

    
      

       

      The
CONTRACTOR shall conduct secret shopping of their marketers/facilitators to
ensure that marketers/facilitators are following the rules and do not coach or
condone applicants to falsify information. The CONTRACTOR may use its employees
as secret shoppers or may contract with another entity for such services. If all
application assistance by the CONTRACTOR is provided over the telephone, the
CONTRACTOR may meet the secret shopping requirement by recording telephone
conversations to ensure the accuracy of the information
provided.

    

    
      

       

      The
CONTRACTOR must immediately remove from facilitated enrollment activities any
marketing representative or facilitator found to be coaching or condoning
applicants to falsify information. The CONTRACTOR must review all applications
of any employee found to be engaged in fraud for the prior three months, make
the appropriate adjustments to claims for applicants found to be ineligible, and
report such findings to the STATE and the LDSS, if
applicable.

    

    
      

       

      93

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      The
CONTRACTOR shall submit its secret shopping plan to the STATE for approval prior
to implementation.

    

    
      

       

      14.5 Training

    

    
      

       

      All
facilitated enrollment staff hired by the CONTRACTOR after the date of this
amendment must attend the STATE sponsored training. If STATE training is not
available at that specific time, new employees may be trained by the CONTRACTOR
using the training materials developed by the STATE. New employees may begin
facilitated enrollment activities only after they are trained by the CONTRACTOR
or the STATE. Those who begin facilitated enrollment activities following
training by the CONTRACTOR shall attend the next scheduled STATE training. The
CONTRACTOR shall continue to provide semi-annual refresher training.
Additionally, the CONTRACTOR'S facilitated enrollment staff must attend any
mandatory LDSS "Integrity Training" programs. The CONTRACTOR'S training must
include:

    

    
      

       

      • Classroom
training

    

    
      • Field
training

    

    
      • Refresher
training

    

    
      • Field
monitoring

    

    
      • Probationary
period for new marketers/enrollers

    

    
      • Facilitator
exam

    

    
      

       

      The
CONTRACTOR shall require all marketers/facilitators to sign an attestation that
they attended training and that they fully understand the rules before being
permitted to provide application assistance. This applies to new employees as
well as marketers/facilitators who have been taking applications prior to the
effective date of this amendment. This attestation shall include rules about
program integrity (e.g., the facilitator knows all income must be reported
including any off the books income). The CONTRACTOR shall retain a copy of this
form in the employee's employment records. The CONTRACTOR'S attestation form
shall be approved by the STATE.

    

    
      

       

      94

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      Section
14

    

    
      

    

    
      

    

    
      Attachment
A

    

    
      

    

    
      

    

    
      QUALITY
ASSURANCE CHECKLIST

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      Quality
Assurance Checklist

       

       

    

    
      This
checklist must be completed and signed by Quality Assurance Staff or the
Facilitator Supervisor.

    

    
       

      □ All
required sections of the application are complete

    

    
      □ All
required documents are included with the application

    

    
      □ Signature
match review completed

    

    
      □ Information
pertinent to eligibility is not altered without applicant initials or
facilitator initials and notice to the applicant, as
necessary

    

    
      

       

      Internal
consistency checks completed:

    

    
      

       

      □ Household
Composition/Reported Income review and verification

    

    
      □ Housing
expenses review and verification

    

    
      □ Child
support income review and verification

    

    
      □ Undocumented
immigrant review

    

    
      

       

      Signature
of Reviewer:  ____________________________

    

    
      

       

      Print
Name:  __________________________________

    

    
      

       

      FE
Organization: _____________________________

    

    
      

       

      Date:
______________________________________

    

    
      

       

      96

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      SECTION
15

    

    
      MARKETING

    

    
      

       

      15.1 Marketing
Plan

    

    
      

       

      The
CONTRACTOR shall submit a marketing plan to the STATE for approval on an annual
basis. The marketing plan is due sixty (60) days prior to the beginning of the
calendar year. Any subsequent change to the marketing plan must be submitted to
the STATE at least thirty (30) days prior to implementation and must be approved
by the STATE prior to implementation.

    

    
      

       

      a. Medicaid
Managed Care Organizations

    

    
      

       

      A
CONTRACTOR that participates in Medicaid managed care is not required to submit
a separate CHPlus marketing plan. Instead, the CONTRACTOR must submit to the
STATE an addendum to its most recently approved Medicaid managed care/Family
Health Plus marketing plan that includes specific strategies and activities used
to reach eligible children.

    

    
      

       

      b. Non-Medicaid
Managed Care Organizations

    

    
      

       

      A
CONTRACTOR that does not participate in the Medicaid managed care program must
include the following information in its marketing plan: a stated marketing goal
and strategies, marketing activities, and staff training, development and
responsibilities. If marketing materials are to be used, the marketing plan must
include the following: distribution methods, primary 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 marketing materials.

    

    
      

       

      The
CONTRACTOR- must also include how it will 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 the use of Telecommunications Devise for the Deaf (TDD)/TTY
services.

    

    
      

       

      The
marketing plan must include measures for monitoring and enforcing compliance
with the guidelines by its marketing representatives and its providers
including: the prohibition of door-to-door solicitation and cold-call
telephoning, a description of how the CONTRACTOR develops mailing lists and
ensures that health and other information is kept confidential, the selection
and distribution of pre-enrollment gifts and incentives to consumers, and a
description of the training, compensation and supervision of its marketing
representatives.

    

    
      

       

      15.2 CHPlus
Logo

    

    
      

       

      The
CONTRACTOR shall use the STATE designated logo of the CHPlus program in
marketing and outreach activities including any printed materials. The logo must
also be included on CHPlus applications. In no instance shall the acronym "CHP"
be used to identify the CHPlus program. The full name of "Child Health Plus" or
"CHPlus" must be used in all promotional activities, and an acknowledgment
stating that the program is administered through the New York State Department
of Health shall be used in all published promotional activities and
materials.

    

    
      

       

      15.3 Prior
Approval of Marketing Materials, Procedures and Subcontracts

    

    
      

       

      The
CONTRACTOR shall submit all subcontracts, procedures and materials related to
marketing to the STATE for prior approval (with the exception of subcontracts
for the purpose of printing marketing materials). Marketing materials include
any information that references the CHPlus program, is intended for general
distribution, and is produced in a variety of print, broadcast,
and

    

    
      

       

      97

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      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. The CONTRACTOR shall not enter into any subcontracts or use any
marketing subcontractors, procedures or materials that the STATE has not
approved (with the exception of subcontracts for the purposes of printing
marketing materials).

    

    
      

       

      15.4 Marketing
Material Requirements

    

    
      

       

      a. Marketing
materials must be written in prose that is understood at a fourth-to
sixth-grade reading
level and must be printed in at least ten-(10) point type.

    

    
      

       

      b. The
CONTRACTOR must make available written marketing and other informational materials (e.g., member
handbooks) in languages other than English whenever at least five percent (5%) of the
potential enrollees of the CONTRACTOR in any county of the service area speak a particular
language and do not speak English as a first language. Marketing materials to be
translated include those key materials, such as informational brochures,
that are produced
for routine distribution, and which are included within the CONTRACTOR'S marketing
plan.

    

    
      

       

      c. Alternate
forms of communications must be provided for persons with visual, hearing, speech, physical, or
developmental disabilities. These alternate forms include Braille or audiotapes for the
visually impaired, TTY access for those with certified speech or hearing disabilities, and use of
American Sign Language and/or integrative technologies.

    

    
      

       

      d. The
CONTRACTOR'S name, mailing address (and location, if different), and toll free
phone number must
be prominently displayed on the marketing materials.

    

    
      

       

      e. Marketing
materials must not contain false, misleading, or ambiguous information-such
as "You have been
pre-approved for the XYZ Health Plan" or "You get free, unlimited
visits".

    

    
      

       

      f. The
material must accurately reflect general information which would be applicable
to a CHPlus
enrollee.

    

    
      

       

      g. The
CONTRACTOR may not use logos or wording used by government agencies if such
use could imply or
cause confusion about a connection between a governmental agency and the CONTRACTOR.

    

    
      

       

      h. Marketing
materials may not make reference to incentives that may be available to
enrollees after
they join a plan, such as "If you join the XYZ Plan, you will receive a gift
card to XYZ Store after your child completes his/her childhood
immunizations."

    

    
      

       

      15.5 Distribution
of Marketing Materials

    

    
      

       

      The
CONTRACTOR may distribute marketing materials in local community centers and
gathering places, markets, pharmacies, provider sites, hospitals, schools,
health fairs and other areas where potential applicants or enrollees are likely
to gather.

    

    
      

       

      15.6 Marketing
Restrictions

    

    
      

       

      a. The
CONTRACTOR is prohibited from door-to-door solicitation of potential enrollees
or distribution
of material, and may not engage in "cold calling" inquiries or
solicitation.

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      b. The
CONTRACTOR is prohibited from direct marketing or distribution of material
in hospital
emergency rooms including emergency room waiting areas. Marketing may not
take place in
patient rooms or treatment areas (except for waiting areas) or other prohibited
sites unless
requested by the individual. The CONTRACTOR may not market in individual homes without permission
of the individual.

    

    
      

       

      c. The
CONTRACTOR may not require its participating providers to distribute CONTRACTOR-prepared
communications to their patients.

    

    
      

       

      d. The
CONTRACTOR is prohibited from misrepresenting the CHPlus program or policy requirements of the
STATE.

    

    
      

       

      e. The
CONTRACTOR is prohibited from purchasing or otherwise acquiring or using
mailing lists of
CHPlus enrollees of other health plans from third party vendors, including
providers.

    

    
      

       

      f. The
CONTRACTOR is prohibited from using raffle tickets and event attendance or
sign-in sheets to
develop mailing lists of potential enrollees.

    

    
      

       

      g. The
CONTRACTOR shall 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 an enrollee or their
family member.
Health assessments may not be performed by the CONTRACTOR prior to enrollment. The
CONTRACTOR shall 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 including specialists
and facilities in the CONTRACTOR'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.

    

    
      

       

      For NYC
Plans Only

    

    
      

       

      15.7 Use
of Vans in New York City

    

    
      

       

      The
number of vans (RVs, small vans and trailers) that may be used for marketing and
facilitated enrollment activities shall be limited to five (5) (one per
borough). The CONTRACTOR may re­deploy vans from one borough to another,
subject to approval by the New York City Department of Health and Mental Hygiene
(NYS DOHMH), except that no more than one van may be utilized in Manhattan on
any given day. In addition, van activity shall be limited to where community
enrollment offices have been opened. Vans may be used for non-marketing
purposes.

    

    
      

       

      15.8 Incentives
to Potential Enrollees

    

    
      

       

      The
CONTRACTOR may not offer incentives of any kind to potential enrollees of CHPlus
to join a health plan. The CONTRACTOR may not offer incentives of any kind to
potential CHPlus enrollees to recertify their coverage. Incentives are defined
as any type of inducement, either monetary or in-kind which might reasonably be
expected to result in the person receiving it to join a plan. The CONTRACTOR may
offer nominal gifts of not more than five dollars ($5.00) in value as part of a
health fair or other promotional activity to stimulate interest in the CHPlus
program. These nominal gifts must be given to everyone who requests them
regardless of whether or not they intend to enroll in the plan. The CONTRACTOR
must submit a listing of intended items to be distributed at marketing
activities as nominal gifts. The submission of actual samples or photographs of
intended nominal gifts will not be routinely required, but must be made
available upon request by the STATE. Listings of item donors or co-sponsors must
be submitted along with the description of items.

    

    
      

       

      99

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      15.9 Rewards
for Completion of Health Goals

    

    
      

       

      The
CONTRACTOR may offer its enrollees rewards for completing a health goal, such as
participating in a smoking cessation program or timely completion of
immunizations or other health related programs. Such rewards may not exceed
$50.00 in fair-market value per enrollee over a twelve (12) month period, and
must be related to a health goal. The CONTRACTOR may not make reference to these
rewards in their pre-enrollment marketing materials or
discussions.

    

    
      

       

      15.10 Behavior
of Marketing Representatives

    

    
      

       

      The
CONTRACTOR is responsible for ensuring that their marketing representatives
engage in professional and courteous behavior in their interactions with staff
from other health plans and CHPlus enrollees and their
families.   Examples of inappropriate behavior include
interfering with other health plan presentations or talking negatively about
another health plan.

    

    
      

       

      15.11 Compensation
for Marketing Representatives and Enrollment Facilitators

    

    
      

       

      The
CONTRACTOR shall limit salary adjustments for marketing
representatives/facilitators to annual adjustments except where the adjustment
occurs during the first year of employment after a traditional
trainee/probationary period or in the event of a company wide adjustment. Any
annual salary adjustment that is linked to performance must comply with the same
restrictions as are applicable to bonuses and the ten percent cap described
below would apply to the combination of performance based bonuses or salary
increases.

    

    
      

       

      The
CONTRACTOR is prohibited from reducing base salaries based on failure to meet
enrollment/productivity targets.

    

    
      

       

      All
bonuses are subject to a ten percent maximum (based on regular salary exclusive
of overtime). Bonuses shall be distributed no more than quarterly and, where
enrollment/productivity is a factor in the bonus determination, shall be
structured in such a way that productivity carries a weight of no more than
thirty percent of the total bonus and that application quality/accuracy carries
a weight equal to or greater than the productivity component.

    

    
      

       

      The
CONTRACTOR is prohibited from offering sign-on bonuses.

    

    
      

       

      The
CONTRACTOR is required to have human resources policies and procedures for
earning and payment of overtime and must be able to provide documentation (such
as time sheets) to support overtime compensation.

    

    
      

       

      The
CONTRACTOR is prohibited from offering non-monetary compensation such as gifts
and trips.

    

    
      

       

      15.12 Marketing
to Enrollees of other Health Plans

    

    
      

       

      The
CONTRACTOR is prohibited from marketing to enrollees of other health plans. As
soon as the CONTRACTOR becomes aware during a marketing encounter that the
individual is enrolled in another health plan, it must terminate the marketing
encounter.

    

    
      

       

      15.13 Other
Marketing Campaigns

    

    
      

       

      The
CONTRACTOR shall continue enrollment and marketing programs as needed in
cooperation with other STATE contractors and any STATE mass media marketing
campaign, as directed by the STATE.

    

    
      

       

      100

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      SECTION
16

    

    
      REPORTING/DATA
COLLECTION

    

    
      

       

      16.1 Report
Submissions

    

    
      

       

      The
CONTRACTOR shall maintain program reports, as described in this section,
including financial, administrative, and utilization data set forth in a manner
which allows the STATE to identify expenditures, revenue and utilization
associated with health care services provided to CHPlus

    

    
      enrollees.

    

    
      

       

      Records
containing the information described in this section, including patient-specific
records, shall be available at reasonable times to the STATE upon request, and
shall be subject to audit. Patient and provider records shall be held by the
CONTRACTOR in compliance with relevant STATE and federal statutes and
regulations including the Personal Privacy Protection Act (Public Officer's Law
Article 6-A).

    

    
      

       

      16.2 Reporting
Requirements

    

    
      

       

      The
CONTRACTOR is responsible for submitting reports to the STATE as defined below.
Additional reporting requirements may be imposed based on need or State or
federal legislative requirements. The following reports are currently
required:

    

    
      

       

      Six Month Operations
Report must include an enrollment summary by income and age group,
disenrollment information, statement of revenue and expenses, and
utilization/visit data. This report is due September 15 of each year in a format
supplied by the STATE.

    

    
      

       

      Annual Operations
Report must include the same data requirements as the Six Month
Operations Report. This report is due by April 30th of each
year in a format supplied by the STATE.

    

    
      

       

      Annual Certified Financial
Statements

    

    
      

       

      Not-for-profit
health plan: Certified financial statements shall be prepared in accordance with
the requirements of the Federal Office of Management and Budget (OMB) circular
number A-133 and submitted to the Department no later than nine months after the
close of the CONTRACTOR'S fiscal year.

    

    
      

       

      For-profit
health plan: Certified financial statements shall be prepared in accordance with
accounting principles generally accepted in the United States of America and
must include a supplementary report of CHPlus revenue and expenses. In lieu of
these statements, a for-profit health plan may opt to submit certified financial
statements in accordance with the not-for-profit requirements outlined above.
The statements must be submitted no later than nine months after the close of
the CONTRACTOR'S fiscal year.

    

    
      

       

      Monthly Vouchers must
include the billing file and adjustments, if necessary. These vouchers are due
by the tenth business day of each month. The process for submitting vouchers is
set forth in section 18 of this Appendix.

    

    
      

       

      Annual Marketing Plan
- For Medicaid managed care plans, the CONTRACTOR shall submit an addendum to
the most currently approved Medicaid managed care/Family Health Plus marketing
plan which includes specific marketing activities and strategies aimed at
reaching children eligible for CHPlus. For health plans that do not participate
in Medicaid managed care, a separate marketing plan shall be submitted for
CHPlus. The content of the marketing plan shall be consistent with that required
by the Office of Managed Care (OMC) for Medicaid managed care plans and as set
forth in section 15 of this Appendix. This plan is due each year by November
1st
and shall be submitted simultaneously to the OMC (if the health plan
participates in Medicaid managed care) and the CHPlus
program.

    

    
      

       

      101

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      Monitoring Results -
The CONTRACTOR shall submit quarterly reports on the results of their
facilitated enrollment monitoring activities. The report is due 30 days
following the end of the quarter. The reports shall include the following data
broken down by applications for: adults only, children only and adults and
children:

    

    
      

       

      • The
total number of applications reviewed each month, the number of applications
requiring follow-up and the number of applications changed after
review;

    

    
      

       

      • The
number verification phone calls made for applications with 1) non-applying
children or adults. that impact eligibility, 2) a self-declaration of income or
3) a declaration of income/letter of support, the total number of applications
that are verified and the total number of applications where information was
changed based on the verification call; and

    

    
      

       

      • The
total number of telephone calls monitored, announced and unannounced observed
interviews and secret shops.

    

    
      

       

      Plan of Correction -
The Plan of Correction shall identify how the CONTRACTOR plans to correct
non-compliance noted in first stage and draft second stage audit reports
submitted in accordance with section 17 of this Appendix. Each plan must be
comprehensive and possible to achieve. The plan shall:

    

    
      

       

      • Outline
the strategies that have been or will be taken to ensure that all deficiencies
identified in each audit report will be addressed;

    

    
      

       

      • Provide
a description of the actions intended to prevent a recurrence of the
errors;

    

    
      

       

      • Describe
changes to the internal controls and procedures that prevent inappropriate
enrollment;

    

    
      

       

      • Provide a
disposition of each area of non-compliance noted in the first stage and draft
second

    

    
      stage
audit reports, including a listing of each area of non-compliance and the date
the change was made on KIDS to correct the non-compliance;
and

    

    
      

       

      • Provide
an effective date of each action included in the plan of
correction.

    

    
      

       

      Each Plan
of Correction is due 30 days after the first stage audit report and/or draft
second stage audit report is received by the CONTRACTOR, whichever is
applicable.

    

    
      

       

      Quality Assurance Report
- A report of performance data, consistent with the New York State
Department of Health Quality Assurance Reporting Requirements (QARR) data
specifications, shall be prepared, on an annual basis for the CHPlus population.
Some of the general QARR data categories that are to be reported include
membership, utilization, quality, access, member satisfaction and general plan
management. The CONTRACTOR shall contract with a National Committee on Quality
Assurance (NCQS) certified auditor to conduct a full audit of the QARR data. The
audited data shall be submitted to the STATE on a date established by the New
York State Department of Health Office of Managed Care. The New York State
Department of Health Office of Managed Care will notify the CONTRACTOR regarding
the exact due date for this report.

    

    
      

       

      Health Provider
Network - On a quarterly basis, the CONTRACTOR shall submit managed care
provider network information to the New York State Department of Health Office
of Managed Care, to assure the adequacy and appropriateness of the CONTRACTOR'S
provider network.

    

    
      

       

      Ineligible New
Applicants - The CONTRACTOR shall report:

    

    
      

       

      The
number of children whose applications are processed for CHPlus eligibility who
are ultimately determined to be not eligible for CHPlus. This includes those who
are ineligible due to age, income, other insurance coverage or access to a state
health benefits plan, failure to pay the family premium contribution, failure to
complete the application, appearing Medicaid eligible and
residency.

    

    
      

       

      The
CONTRACTOR shall collect this data on a monthly basis and report this
information by the tenth (10th)
business day of the month after the end of the month.

    

    
      

       

      102

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      Encounter Data - The
CONTRACTOR shall submit, at least annually, patient care outcomes and patient
specific medical information, including encounter data maintained by the
CONTRACTOR for purposes of quality assurance and oversight, in accordance with
guidance issued by the STATE.

    

    
      

       

      Additional Reports for
Health Plans that Participate in the Facilitated Enrollment
Program:

    

    
      

       

      New Applications - On
a monthly basis, by the 10th
business day of the month following the end of the month when applications were
taken, the CONTRACTOR shall report the total number of new applications sent to
a LDSS for an eligibility determination. The CONTRACTOR shall report the number
of new applications forwarded to a LDSS for adults only,
children only and adults and children and the total number of new applicants for
Family Health Plus, Adult Medicaid and children's Medicaid.

    

    
      

       

      Number of
Facilitators - On a monthly basis by the 10th
business day of the month, the CONTRACTOR shall submit to the STATE the total
number of facilitators employed by the CONTRACTOR.

    

    
      

       

      Facilitated Enrollment
Sites - The CONTRACTOR shall submit on a monthly basis a report of all
changes in enrollment sites including changes in the days and hours of operation
of ongoing sites and on new sites or those no longer available. The CONTRACTOR
shall notify the STATE of all changes by the 20th day of
the month preceding the change.

    

    
      

       

      16.3      Timely
Reports/Penalties

    

    
      

       

      a. The
CONTRACTOR shall provide the STATE with reports or other specific work
products pursuant
to this AGREEMENT in a timely manner subject to a schedule agreed upon by
the parties herein
or required by the STATE. AH required reports or other work products developed under this
AGREEMENT shall be completed as provided by the agreed upon or required work schedule
in order for the CONTRACTOR to be eligible for payment. If the CONTRACTOR fails to
submit any required report and information on or before the due date specified, the
CONTRACTOR'S total subsidy payment for providing covered health care services to CHPlus
enrollees, including the add-on for providing facilitated enrollment, shall be reduced by two
percent each month for a period beginning on the first day of the calendar month following the
original due date of the required report and information and continuing until the last day of
the calendar month in which the required report and information are submitted. The
CONTRACTOR shall not be subject to the two percent reduction under the following
conditions:

    

    
      

       

      • for
any new report of which the CONTRACTOR did not have at least 60 days notice of
its requirement. Such notice must include data and submission specifications,
including the report's due date, and must be sent by certified mail to the
CONTRACTOR'S chief financial officer; or,

    

    
      

       

      • for any
report upon a finding by the Commissioner that such report was not submitted on
a timely basis for good cause, which may include but not be limited to,
additional time required to modify computer data systems.

    

    
      

       

      b. If
the annual certified financial statements required by section 16.2 are not
submitted by the due date, the STATE
considers this to be substantial noncompliance with this AGREEMENT and will impose other
penalties on the CONTRACTOR, including withholding payments on any or all New York
State Department of Health contracts or recovering payments made under any or all such
contracts until the annual certified financial statements are submitted, or terminating this
AGREEMENT.

    

    
      

       

      103

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      16.4 Crowd-Out
Data

    

    
      

       

      Information
on prior health insurance coverage and crowd-out is captured on the application
for Medicaid and CHPlus which shall be collected by the CONTRACTOR and
transmitted to the STATE through the KIDS system on a monthly
basis.

    

    
      

       

      16.5 Additional
Data Requirements

    

    
      

       

      The
CONTRACTOR shall meet data/reporting requirements of any independent program
evaluator under contract with the STATE, as applicable.

    

    
      

       

      16.6 Review
of Reports

    

    
      

       

      The STATE
agrees to review all reports in a timely fashion and specifically to notify the
CONTRACTOR in writing through the CHPlus contract manager, within sixty (60)
business days of receipt of the report, if the STATE finds cause for rejection.
The rejection notice shall specify those exact portions of the report that are
deemed unsatisfactory and the manner in which they deviate from the CONTRACTOR'S
responsibilities as set forth in this AGREEMENT.

    

    
      

       

      16.7 Rejection
of Reports The STATE'S failure to notify the CONTRACTOR within sixty (60)
business days of receipt of the report shall constitute the STATE'S acceptance
of said report.

    

    
      

       

      16.8 Acceptance
of Reports

    

    
      

       

      A report
that is resubmitted due to an initial rejection by the STATE shall be processed
as an initial submittal as outlined in this section.

    

    
      

       

      16.9 Accuracy
of Enrollment Data, Claims and Payment Information

    

    
      

       

      By
signing this AGREEMENT, the CONTRACTOR certifies that it will provide to the
STATE; enrollment information and other information required by the STATE;
access to enrollee health claims and payment data by the STATE, Centers for
Medicare and Medicaid Services (CMS) or the Office of the Inspector General
(OIG) in conformance with appropriate privacy protections in State and federal
law.

    

    
      

       

      16.10 Accuracy
of Payment Data

    

    
      

       

      By
signing this AGREEMENT, the CONTRACTOR attests to the accuracy, completeness and
truthfulness of claims and payment data submitted to the STATE by the
CONTRACTOR, to the best of its knowledge, information and belief, under penalty
of perjury, and guarantees that it will not avoid costs for services by
referring enrollees to other publicly supported health care resources. This
guarantee shall not be interpreted to impair the CONTRACTOR'S ability to
contract with and refer enrollees to publicly supported providers or covered
health care services for which such providers are reimbursed by the
CONTRACTOR.

    

    
      

       

      104

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      SECTION
17

    

    
      AUDIT
and REVIEW

    

    
      

       

      Pursuant
to Public Health Law Section 2511 (12-a), the STATE shall conduct audits of the
CONTRACTOR not less than annually.

    

    
      

       

      17.1     First
Stage Audit

    

    
      

       

      The STATE
shall review selected enrollment files of the CONTRACTOR to assess policies,
practices and controls established by the CONTRACTOR to ensure the propriety of
enrollment, eligibility and billing pertinent to the CHPlus program and
compliance with applicable State and federal law and regulations, contractual
provisions, ADMs and Title XXI State Plan requirements.

    

    
      

       

      Audit
Field Work and Reporting Preliminary Audit Findings

    

    
      

       

      The STATE
shall provide advance notice of the audit and conduct the audit at the
CONTRACTOR'S location during normal business hours. After audit field work has
been completed, the auditor in charge (AIC) shall hold a closing conference with
the CONTRACTOR'S appropriate level of management concerned with the audit to
present preliminary audit findings. These audit findings shall be grouped by the
AIC into different schedules based on type and nature of the audit finding. Any
finding in Schedule I of the First Stage Audit Report is a fatal error. A fatal
error is either an eligibility error or a plan processing error, and includes
but is not limited to the following:

    

    
      

       

      • an
enrollee is ineligible for subsidized coverage;

    

    
      • an
application is incomplete;

    

    
      • a
family premium contribution is not received;

    

    
      •
documentation supporting eligibility is missing or incorrect;

    

    
      • a child was not
enrolled or referred in accordance with required timeframes;

    

    
      • the
plan failed to comply with program enrollment and other required processes,
including ADMs,
letters, and Federal and STATE laws and regulations;

    

    
      • the
insurance card was not mailed within 14 days of the effective date of
enrollment;

    

    
      • a child
remained temporarily enrolled for more than two months without evidence of the
Medicaid
application being sent to the LDSS; and

    

    
       •
An enrollee lives outside the CONTRACTOR'S approved coverage
area.

    

    
      

       

      Schedule
II errors of the First Stage Audit Report do not directly affect enrollee
eligibility. Schedule II identifies discrepancies between data submitted to the
STATE and the enrollment files maintained by the CONTRACTOR. Schedule II errors
include but are not limited to:

    

    
      

       

      • The
enrollee is eligible for subsidized coverage, however, the data entered on KIDS
is not consistent with the information on the application or documentation;
and

    

    
      

       

      • The
enrollee is eligible for subsidized coverage but the family contribution was
incorrectly determined;

    

    
      

       

      The
CONTRACTOR has 15 calendar days from the date of the closing conference to
submit additional comments and documentation to the AIC in order to resolve any
factual differences raised during the conference.

    

    
      

       

      First
Stage Audit Report

    

    
      

       

      The STATE
shall mail the First Stage Audit Report to the CONTRACTOR within 30 days from
when the CONTRACTOR submits any additional documentation to the AIC in order to
resolve any factual differences raised during the conference. This report shall
include a list of the audit findings by schedule, over/under payments resulting
from the errors, a request for a plan of correction from the CONTRACTOR if
required, and notification of the need for a Second Stage Audit. A second
stage

    

    
      

       

      105

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      audit
shall be conducted if 10 percent or more of the records reviewed include a fatal
error as reported in Schedule I of the First Stage Audit Report. This report
shall also specify the process for repayment of overpayments resulting from the
errors and plan of correction requirements. If required, the CONTRACTOR shall
submit a written response and a plan of correction within 30 calendar days of
receipt of the First Stage Audit Report.

    

    
      

       

      First
Stage Audit Recoupment

    

    
      

       

      Any
premiums paid by the STATE for ineligible children or inappropriate billing by
the CONTRACTOR which are identified in the First Stage Audit Report shall be
recouped from the CONTRACTOR by taking back premium payments paid by the STATE
under this AGREEMENT.

    

    
      

       

      17.2    Second
Stage Audit

    

    
      

       

      The STATE
shall conduct a Second Stage Audit of the CONTRACTOR if 10 percent or more of
the records reviewed include a fatal error as reported in Schedule I of the
First Stage Audit Report. This audit shall be conducted after the plan of
correction is submitted. The audit period shall be no earlier than three (3)
months following the submission of the plan of correction. The Second Stage
Audit shall be done on a statistically valid sample of records and in accordance
with Generally Accepted Government Auditing Standards. The Second Stage Audit
process shall continue until fatal errors identified in the Second Stage Audit
are less than 10 percent of the total records reviewed.

    

    
      

       

      Audit
Field Work

    

    
      

       

      The State
shall provide advance notice of an audit which shall be conducted at the
CONTRACTOR'S location during normal business hours. After audit field work has
been completed, the AIC shall hold a closing conference with the CONTRACTOR'S
appropriate level of management concerned with the audit to present the
preliminary audit findings. These audit findings shall be grouped by the AIC
into different schedules based on type and nature of the audit finding. The
CONTRACTOR shall have 15 calendar days from the date of the closing conference
to submit additional comments and documentation to the AIC in order to resolve
any factual differences that were raised during the
conference.

    

    
      

       

      Draft
Second Stage Audit Report

    

    
      

       

      The STATE
shall mail the Draft Second Stage Audit Report, along with a Stipulation of
Settlement, if required, to the CONTRACTOR. This report shall include a list of
the audit findings by schedule, over/under payments resulting from the errors, a
statistical extrapolation of the results to the total enrollment in the audit
period and, if fatal errors are found in 5 percent or more of the records
reviewed, the process for repayment and plan of correction
requirements.

    

    
      

       

      If
required, the CONTRACTOR shall submit a written response and a plan of
correction within 30 calendar days of receipt of the Draft Second Stage Audit
Report. Additionally, the CONTRACTOR shall return the signed Stipulation of
Settlement to the STATE within 30 days, if applicable.

    

    
      

       

      Exit
Conference

    

    
      

       

      At the
CONTRACTOR'S request, the STATE shall conduct an exit conference during which
the STATE staff will present and review the Draft Second Stage Audit Report, and
explain the audit sample, findings and extrapolation, to the appropriate level
of management concerned with the audit. The CONTRACTOR must submit written
comments prior to the exit conference, if one is requested.

    

    
      

       

      106

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      Final
Second Stage Audit Report

    

    
      

       

      The STATE
will issue a Final Second Stage Audit Report after the exit conference, if one
is requested. This report shall incorporate the CONTRACTOR'S written comments
provided as a result of an exit conference and make any necessary corrections to
the Draft Second Stage Audit Report. The CONTRACTOR shall return the signed
Stipulation of Settlement to the STATE within 30 days from the Final Second
Stage Audit Report, if applicable.

    

    
      

       

      Second
Stage Audit Recoupment

    

    
      

       

      The
aggregate dollar amount attributable to errors found in the Second Stage Audit
sample cases shall be extrapolated to the total enrollment of the CONTRACTOR in
the audit period. Any premiums paid by the STATE for ineligible children or
inappropriate billing by the CONTRACTOR shall be recouped from the CONTRACTOR by
withholding future premium payments by the STATE. The total extrapolated amount
shall be based on the errors found in the second stage audit sample cases, or an
amount which may be set forth in a signed Stipulation of
Settlement.

    

    
      

       

      The
Second Stage Audit process shall continue until fatal errors identified in the
second Stage Audit are less than 10 percent of the records reviewed and there
are less than 5 percent of records reviewed with eligibility errors, at which
time the first stage audit cycle will resume on no more than an annual basis..
Recoupments shall be made after each Second Stage Audit based on extrapolation
as described above unless the fatal error rate is less than 5 percent of the
records reviewed during the audit period, in which case, the STATE will only
recoup based on those records reviewed.

    

    
      

       

      17.3 Special
Reviews

    

    
      

       

      The STATE
reserves the right to conduct special reviews of selected enrollment files,
financial records, billing records and operating procedures pertinent to the
CHPlus program, as necessary. These reviews are independent of the First and
Second Stage Audit requirements and are not part of the error rate even when
such reviews are conducted in conjunction with other audits. However, any
billings identified as improper during such reviews will be recovered by the
STATE.

    

    
      

       

      17.4 Facilitated
Enrollment Integrity Reviews

    

    
      

       

      The STATE
shall conduct a review of the CONTRACTOR'S implementation of its Facilitated
Enrollment Integrity Plan. In addition, the STATE will review a sample of
applications to ensure that required quality assurances measures are being taken
by the CONTRACTOR. The STATE will also review a sample of the applications
completed by selected facilitators employed by or working on behalf of the
CONTRACTOR.

    

    
      

       

      The STATE
shall provide advance notice of the audit and conduct the audit at the
CONTRACTOR'S location during normal business hours. After audit field work has
been completed, the auditor in charge (AIC) shall hold a closing conference with
the CONTRACTOR'S appropriate level of management concerned with the audit to
present preliminary audit findings.

    

    
      

       

      The
CONTRACTOR shall have 15 calendar days from the date of the closing conference
to submit additional comments and documentation to the AIC in order to resolve
any factual differences raised during the conference.

    

    
      

       

      The STATE
shall mail the Integrity Review Report to the CONTRACTOR within 30 days from
when the CONTRACTOR submits any additional documentation to the AIC in order to
resolve any factual differences raised during the conference.

    

    
      

       

      107

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      17.5 Quality
of Care Reviews

    

    
      

       

      The STATE
reserves the right to monitor and conduct separate quality of care reviews of
services provided to CHPlus enrollees.

    

    
      

       

      The
CONTRACTOR will be required to address any deficiencies identified as a result
of such reviews in cooperation with the STATE and quality assurance contractors,
if applicable, to ensure compliance by the CONTRACTOR in providing all covered
health care services to CHPlus enrollees consistent with the benefit package
described in section 2 of this Appendix.

    

    
      

       

      The
CONTRACTOR is responsible for complying with all quality of care assurances as
stipulated in State and federal statutes and regulations.

    

    
      

       

      17.6 Fraud
and Abuse

    

    
      

       

      The
CONTRACTOR must have procedures designed to safeguard against fraud and abuse.
Such procedures must comply with Public Health Law section 4414 and section
98-1.21 of Title 10 of the Official Compilation of Codes, Rules and Regulations
of the State of New York; prohibit unsolicited personal contact with potential
enrollees by the CONTRACTOR'S employees to influence enrollment with the
CONTRACTOR and include mechanisms for the CONTRACTOR to report to the STATE
information on violations of law by subcontractors, applicants and other
individuals.

    

    
      

       

      The STATE
reserves the right to investigate and resolve suspected and apparent instances
of fraud or abuse in the CHPlus program and report or refer such cases to the
appropriate law enforcement officials. If the STATE identifies fraud and abuse,
the STATE reserves the right to review the most recent audit results to
determine if the audit results were affected by such fraud and abuse. If,
without the fraud and abuse, the error rate would have exceeded 10%, the State
reserves the right to conduct a Second stage audit.

    

    
      

       

      The
CONTRACTOR must cooperate with any investigations conducted by the U.S.
Department of Health and Human Services, Office of the Inspector General, U.S.
Attorney's Office, Department of Justice, Federal Bureau of Investigations, the
State Attorney General's Office, or the Office of the Medicaid Inspector
General. The CONTRACTOR shall make available any necessary data or program
information, as requested by the STATE or federal law enforcement officials, to
enable the STATE or federal law enforcement officials to investigate and resolve
suspected and apparent instances of fraud and abuse in a timely
manner.

    

    
      

       

      17.7 Data
Access

    

    
      

       

      The
CONTRACTOR certifies that it will provide to the STATE enrollment information
and any other information required by the STATE and provide access to enrollee
health claims data and payment data by the STATE, Centers for Medicare and
Medicaid Services (CMS), Office of the State Comptroller, or the Office of the
Inspector General (OIG) in accordance with all relevant State and federal laws
regarding patient privacy and confidentiality.

    

    
      

       

      The
CONTRACTOR shall guarantee the STATE and its authorized representatives ready
access to all of the CONTRACTOR'S project sites and all enrollment, financial,
clinical or other records and reports relating to the program and shall include
a provision in provider agreements guaranteeing the STATE ready access to all
provider sites and all enrollment, financial, clinical or other records and
reports relating to the program. The STATE shall have full access at reasonable
times during normal business hours to all patient medical records consistent
with all legal requirements regarding patient privacy and confidentiality,
including obtaining consent pursuant to section 98-1.13(1) of Title 10 of the
Official Compilation of Codes, Rules and Regulations of the State of New York,
and consistent with other STATE regulatory authority to gain access to such
information.

    

    
      

       

      108

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      The
CONTRACTOR shall make available to the STATE upon request any technical data,
information or materials developed for and related to the activities required
under this AGREEMENT. This includes, but is not limited to, enrollment forms,
copies of studies, reports, surveys, proposals, plans, maps, charts, schedules
and exhibits as may be required and appropriate to the monitoring and evaluation
of activities and services required under this AGREEMENT.

    

    
      

       

      The
CONTRACTOR shall maintain all program data, information and reports, including
financial, administrative, utilization and patient care data in such a manner as
to allow the identification of expenditures, revenue and utilization associated
with health care provided to program participants. Records containing such
information, including patient-specific records, shall be available at
reasonable times to the STATE upon request, and shall be subject to audit.
Patient and provider records shall be held by the STATE in compliance with all
relevant STATE and federal statutes and regulations including the Personal
Privacy Protection Act (Public Officer's Law Article 6-A).

    

    
      

       

      17.8      Data
Accuracy and Financial Responsibility

    

    
      

       

      The
CONTRACTOR attests to the accuracy, completeness and truthfulness of claims and
payment data submitted to the STATE by the CONTRACTOR, to the best of its
knowledge, information and belief, under penalty of perjury, and guarantees that
it will not avoid costs for services by referring enrollees to publicly
supported health care resources. This guarantee shall not be interpreted to
impair the CONTRACTOR'S ability to contract with and refer enrollees to publicly
supported providers for covered health care services for which such providers
are reimbursed by the CONTRACTOR.

    

    
      

       

      The
CONTRACTOR shall accept responsibility for compensating the STATE for any
improper billings paid on behalf of an enrollee who the CONTRACTOR
inappropriately determined eligible for and enrolled in the CHPlus program as
revealed during a site visit, desk audit, or other method performed by the STATE
or other governing entity. The CONTRACTOR will hold the enrollee harmless for
any charges incurred for inappropriately enrolled individuals unless such
enrollment was based on fraudulent information submitted by the
applicant.

    

    
      

       

      109

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      SECTION
18

    

    
       

       

      PAYMENTS
and BILLING

    

    
      

       

      18.1 Monthly
Premium Payment

    

    
      

       

      The total
monthly premium shall be the amount approved by the State Insurance Department
in consultation with the STATE in effect at the time of
enrollment.

    

    
      

       

      The STATE
shall pay the CONTRACTOR the total monthly premium for children in families with
gross household income less than 160 percent of the non-farm federal poverty
level (FPL) and children who are American Indians or Alaskan Natives
(AI/AN)whose gross household income is less than 250 percent of the
FPL.

    

    
      

       

      The STATE
shall pay the CONTRACTOR the total monthly premium less $9 for each of the first
three children in families with gross household income between 160 percent and
222 percent of the FPL. The STATE shall pay the total monthly premium for each
additional child.

    

    
      

       

      The STATE
shall pay the CONTRACTOR the total monthly premium less $15 for each of the
first three children in families with gross household income between 223 percent
and 250 percent of the FPL. The STATE shall pay the total monthly premium for
each additional child.

    

    
      

       

      18.2 Premium
Modifications

    

    
      

       

      The total
monthly premium may be modified periodically under the CFTPlus program subject
to approval of a request from the CONTRACTOR to the STATE and the State
Insurance Department. Applications for adjustments must be submitted at least 90
days prior to the requested effective date of the change and will be subject to
approval by the STATE and the State Insurance Department. Payment shall be
adjusted to cover any premium modifications approved by the STATE and the State
Insurance Department. The STATE maintains the right to eliminate an insurer from
the CHPlus program if agreement on the premium cannot be
reached.

    

    
      

       

      18.3 Payments
by the STATE

    

    
      

       

      The STATE
share of the premium payment shall be the only payment made by the STATE and
includes payments for the following types of activities: administering and
marketing the CHPlus program; enrolling children; issuing member handbooks and
subscriber contracts; providing and coordinating the provision of health care
services to enrollees; performing utilization review and quality of care
activities in conformance with this AGREEMENT; performing billing and claims
procedures and collecting and submitting data as set forth in this AGREEMENT;
and for reimbursing any subcontractor. The STATE shall make payments to the
CONTRACTOR within 30 days of receipt of the signed voucher or will be subject to
interest payments to the CONTRACTOR in accordance with prompt payment
legislation (Article XI-A, State Finance Law).

    

    
      

       

      18.4 Annual
Funding

    

    
      

       

      The
CONTRACTOR shall receive an annual funding amount to provide and administer a
CHPlus program for uninsured children in the counties identified in section 3 of
this Appendix or as modified by the STATE. The STATE'S total subsidy to the
CONTRACTOR shall be limited to the annual funding amount. Payment of this amount
is based on the CONTRACTOR meeting the responsibilities provided in this
AGREEMENT. The annual funding amount may be modified in accordance with section
18.7.

    

    
      

       

      110

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      18.5 Program
Enrollment and Annual Funding

    

    
      

       

      The
CONTRACTOR shall be entitled to enroll as many members as may be accommodated by
the amount of annual funds received from the STATE as provided in section
18.4.  The CONTRACTOR shall monitor enrollment levels such that the
amount of STATE funding authorized for a given year is not exceeded. The STATE
shall not be obligated to pay more than the annual funds set forth in section
18.4 in the event that the CONTRACTOR enrolls more members than can be
accommodated by such annual funds.

    

    
      

       

      18.6 Notification
of Maximum Enrollment

    

    
      

       

      The
CONTRACTOR shall notify the STATE in writing in a timely manner when current
enrollment and pending applications indicate that the CONTRACTOR shall reach
ninety percent (90%) of its annual allocation of funding within or by the end of
the annual funding allocation period. After receipt of notice from the
CONTRACTOR, the STATE shall provide direction to the CONTRACTOR on whether to
begin a wait list at ninety percent (90%) or continue to accept applications. If
the CONTRACTOR is directed to begin a wait list, the CONTRACTOR and the STATE
shall mutually agree in writing upon a plan of action for implementation of a
wait list. However, at a minimum, the CONTRACTOR shall include the following
factors in this plan of action:

    

    
      

       

      • Intended
start date of the wait list;

    

    
      • Effective
enrollment date when enrollment will be limited;

    

    
      • Affected
plan/catchment areas;

    

    
      • Description
of information given to the public regarding the establishment of a wait
list;

    

    
      • Plan
for enrollment of transferring and/or new enrollees; and

    

    
      • Plan
for referring applicants to other CHPlus plans in shared service
areas.

    

    
      

       

      In
addition, if a wait list is initiated, the CONTRACTOR shall provide, in writing,
a protocol (plan), acceptable to the STATE, for enrolling all applicants from
its wait list before opening enrollment to new applicants. The STATE shall
approve such protocol in writing in a timely manner.

    

    
      

       

      18.7 Modification
of Annual Funding

    

    
      

       

      The
annual funding under this AGREEMENT may be modified (increased or decreased) by
the STATE based upon a written request by the CONTRACTOR or on need as
determined by the STATE. The STATE shall provide the CONTRACTOR with a written
notice of the effective date of modification of the annual
funding.

    

    
      

       

      18.8 Monthly
Updates of KIDS System

    

    
      

       

      By no
later than 6:00 p.m. (EST) on the seventh (7th)
business day of the month for which payment is being claimed, the CONTRACTOR
shall update the KIDS database to reflect accurate information on the actual
number of children enrolled in the program during the month for which payment is
claimed by the CONTRACTOR to the STATE. Transactions shall reflect all new
enrollment, recertifications, disenrollments and enrollee information changes.
The KIDS database shall include information on each enrolled child as required
by the Meta Data Repository.

    

    
      

       

      18.9 Accurate
Information

    

    
      

       

      The
CONTRACTOR shall download, via the HPN, information on the disposition of each
transaction submitted to the KIDS system. The CONTRACTOR shall review each
transaction disposition to ensure that the KIDS system contains accurate
enrollee information.

    

    
      

       

      111

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      The
CONTRACTOR shall utilize all KIDS reports to ensure accurate payment and
enrollment information is submitted to the STATE.

    

    
      

       

      18.10 Voucher
Submission

    

    
      

       

      The
CONTRACTOR shall submit a monthly voucher by no later than the tenth (10th)
business day of each month for which payment is being claimed. The CONTRACTOR
shall download a standard voucher through the HPN which reflects the information
contained in the KIDS system. Such standard voucher shall be used by the
CONTRACTOR to receive payment for all children eligible for a subsidy payment
and shall be submitted to the STATE. Vouchers must be signed by an authorized
representative of the CONTRACTOR and accompanied by a brief cover letter that
identifies a name and phone number of a person authorized to speak on behalf of
the CONTRACTOR if questions arise. The CONTRACTOR shall submit vouchers to the
STATE'S designated payment office.

    

    
      

       

      18.11 Adjustments

    

    
      

       

      The
CONTRACTOR must submit to and be accepted by the KIDS system any necessary
adjustments for any period for which a prior claim was paid to the CONTRACTOR by
the STATE, no later than a date within the second calendar year from the
original claim and according to the following schedule: for the original claim
months of January through March, the adjustment must be reflected on the
December voucher, for the original claim months of April through June, the
adjustment must be reflected on the March voucher, for the original claim months
of July through September, the adjustment must be reflected on the June voucher,
and for the original claim months of October through December, the adjustment
must be reflected on the September voucher.

    

    
      

       

      18.12 Payment
by the Office of the State Comptroller

    

    
      

       

      The
Office of the State Comptroller shall reimburse the CONTRACTOR for an amount up
to, and not to exceed, the annual funding amount indicated in section 18.4 or as
modified in accordance with section 18.7. Payment shall be based upon the
CONTRACTOR'S submission and the STATE'S acceptance of those deliverables
identified in section 16 of this Appendix and the CONTRACTOR meeting its
responsibilities set forth in this AGREEMENT. Notwithstanding any other
provision of this AGREEMENT, in no event shall the amount paid to the CONTRACTOR
exceed the total annual funding amount stated in section 18.4 or as modified in
accordance with section 18.7.

    

    
      

       

      112

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      SECTION
19

       

    

    
      QUALITY
ASSURANCE

    

    
      

       

      19.1 Internal
Quality Assurance Program

    

    
      

       

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

    

    
      

       

      b) Where
performance is less than the statewide average or another standard as defined by
the STATE and developed in consultation with MCOs and appropriate clinical
experts, the CONTRACTOR will be required to develop and implement a plan for
improving performance that is approved by the STATE and that specifies the
expected level of improvement and timeframes for actions expected to result in
such improvement. In the event that such approved plan proves to be
impracticable or does not result in the expected level of improvement, the
CONTRACTOR shall, in consultation with STATE, develop alternative plans to
achieve improvement, to be implemented upon STATE approval. If requested by the
STATE, the CONTRACTOR agrees to meet with the STATE to review improvement plans
and quality performance.

    

    
      

       

      19.2 Standards
of Care

    

    
      

       

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

    

    
      

       

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

    

    
      

       

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

    

    
      

       

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

    

    
      

       

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

    

    
      

       

      113

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      19.3 CHPlus
Quality of Care Review

    

    
      

       

      The STATE
reserves the right to monitor and conduct a separate quality of care review
audit of services provided to enrollees participating in the CHPlus
program.

    

    
      

       

      19.4 Deficiencies
in Quality of Care

    

    
      

       

      The
CONTRACTOR will be required to address deficiencies relating to results of
Quality Assurance and utilization reviews in cooperation with the STATE and
quality assurance contractors, if applicable, to ensure compliance in the
appropriate provision of benefits to enrollees under the CHPlus
program.

    

    
      

    

    
      

    

    
      

    

    
      114

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      SECTION
20

       

    

    
      MEMBER
SERVICES

    

    
      

       

      20.1 General
Functions

    

    
      

       

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

    

    
      

       

      b) At
a minimum, the member services department must be staffed at a ratio of at least
one (1) full time equivalent member service representative for every four
thousand (4,000) or fewer enrollees.

    

    
      

       

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

    

    
      

       

      i)
Explaining the CONTRACTOR'S rules for obtaining services and assisting enrollees
in making appointments.

    

    
      

       

      ii)  Assisting
enrollees to select or change Primary Care Providers.

    

    
      

       

      iii)  Fielding
and responding to enrollee questions and complaints, and advising enrollees of
the prerogative to complain to the STATE at any time.

    

    
      

       

      iv)  Clarifying
information in the subscriber contract or member handbook for
enrollees.

    

    
      

       

      v)
Advising enrollees of the CONTRACTOR'S complaint and appeals program, the
utilization review process, and enrollee's rights to an external
review.

    

    
      

       

      20.2 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 and
potential enrollees who speak a language other than English as a primary
language. Interpreter services must be offered in person where practical, but
otherwise may be offered by telephone.

    

    
      

       

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

    

    
      

       

      115

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      20.3      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.

    

    
      

    

    
      

    

    
      

    

    
      116

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      SECTION
21

       

    

    
      PROVIDER
NETWORKS

    

    
      

       

      21.1      Network
Requirements

    

    
      

       

      a) CONTRACTOR
will establish and maintain a network of Participating
Providers.

    

    
      

       

      i) In
establishing the network, the CONTRACTOR must consider the following:
anticipated enrollment, expected utilization of services by the population to be
enrolled, the number and types of providers necessary to furnish the services in
the Benefit Package, the number of providers who are not accepting new patients,
and the geographic location of the providers and enrollees.

    

    
      

       

      ii) The
CONTRACTOR'S network must contain all of the provider types necessary to furnish
the prepaid Benefit Package, including but not limited to: hospitals, physicians
(primary care and specialists), mental health and substance abuse providers,
allied health professionals, ancillary providers, DME providers, home health
providers and pharmacies.

    

    
      

       

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

    

    
      

       

      b) The
CONTRACTOR shall not include in its network any provider:

    

    
      

       

      i) who
has been sanctioned or prohibited from participation in federal health care
programs under either section 1128 or section 1128A of the SSA;
or

    

    
      

       

      ii) who
has had his/her license suspended by the New York State Education Department or
the New York State Department of Health, Office of Professional Medical
Conduct.

    

    
      

       

      c) The
CONTRACTOR must require that Participating Providers offer hours of operation
that are no less than the hours of operation offered to commercial
members.

    

    
      

       

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

    

    
      

       

      e) CONTRACTOR
must limit participation to providers who agree that payment received from the
CONTRACTOR for services included in the benefit package is payment in full for
services provided to enrollees, except for the collection of applicable
co-payments from enrollee's, if any, as provided by law.

    

    
      

       

      21.2      Absence
of Appropriate Network Provider

    

    
      

       

      In the
event that the CONTRACTOR determines that it does not have a participating
provider with appropriate training and experience to meet the particular health
care needs of an enrollee, the CONTRACTOR shall make a referral to an
appropriate non-participating provider, pursuant to a treatment plan approved by
the CONTRACTOR in consultation with the primary care provider, the
non-participating provider and the enrollee or the enrollee's designee. The
CONTRACTOR shall pay for the cost of the services in the treatment
plan

    

    
      

       

      117

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      provided
by the non-participating provider for as long as the CONTRACTOR is unable to
provide the service through a participating provider.

    

    
      

       

      21.3 Suspension
of Enrollee Assignments To Providers

    

    
      

       

      The
CONTRACTOR shall ensure that there is sufficient capacity, consistent with the
STATE'S standards, to serve enrollees under this AGREEMENT. In the event any of
the CONTRACTOR'S participating providers are no longer able to accept assignment
of new enrollees due to capacity limitations, as determined by the STATE, the
CONTRACTOR will suspend assignment of any additional enrollees to such
participating provider until such provider is capable of further accepting
enrollees. When a participating provider has more than one (1) site, the
suspension will be made by site.

    

    
      

       

      21.4 Credentialing

    

    
      

       

      a) Credentialing/Recredentialing
Process

    

    
      

       

      The
CONTRACTOR shall have in place a formal process, consistent with the STATE'S
Recommended Guidelines for Credentialing Criteria, for credentialing
participating providers on a periodic basis (not less than once every three (3)
years) and for monitoring participating providers
performance.

    

    
      

       

      b) Licensure

    

    
      

       

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

    

    
      

       

      c) Minimum
Standards

    

    
      

       

      i)    The
CONTRACTOR agrees that all network physicians will meet at least one (1) of the
following standards, except as specified in section 21.15 (c) and Attachment A
of this section: i)   Be board-certified or board-eligible in
their area of specialty; ii)   Have completed an accredited
residency program; or

    

    
      iii) Have
admitting privileges at one (1) or more hospitals participating in the
CONTRACTOR'S network.

    

    
      

       

      21.5 STATE
Exclusion or Termination of Providers

    

    
      

       

      If the
STATE 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 CHPlus 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 STATE 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 a State
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.

    

    
      

       

      118

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      21.6
Application Procedure

    

    
      

       

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

    

    
      

       

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

    

    
      

       

      c) The
CONTRACTOR may not discriminate with regard to the participation, reimbursement,
or indemnification of any provider who is acting within the scope of his or her
license or certification under applicable State law, solely on the basis of that
license or certification. This does not preclude the CONTRACTOR from including
providers only to the extent necessary to meet its needs; or from establishing
different payment rates for different counties or different specialists; or from
establishing measures designed to maintain the quality of services and control
costs consistent with its responsibilities.

    

    
      

       

      d) If
the CONTRACTOR does not approve an individual or group of providers as
participating providers, it must give the affected providers written notice of
the reason for its decision.

    

    
      

       

      21.7
Evaluation Information

    

    
      

       

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

    

    
      

       

      21.8
Choice/Assignment of Primary Care Providers (PCPs)

    

    
      

       

      a) The
CONTRACTOR shall offer each enrollee the choice of no fewer than three (3) PCPs
within distance/travel time standards as set forth in section 22.5 of this
Appendix.

    

    
      

       

      b) CONTRACTOR
must assign a PCP to enrollees who fail to select a PCP. The assignment of a PCP
by the CONTRACTOR may occur after written notification of the enrollee by the
CONTRACTOR but in no event later than thirty (30) days after the effective date
of enrollment, and only after the CONTRACTOR has made reasonable efforts to
contact the enrollee and inform him/her of his/her right to choose a
PCP.

    

    
      

       

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

    

    
      

       

      i)  Enrollee's
geographic location;

    

    
      ii)  any
special health care needs, if known by the CONTRACTOR; and

    

    
      iii) any
special language needs, if known by the CONTRACTOR.

    

    
      

       

      119

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

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

    

    
      

       

      21.9     Enrollee
PCP Changes

    

    
      

       

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

    

    
      

       

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

    

    
      

       

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

    

    
      

       

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

    

    
      

       

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

       

    

    
      i)    The
enrollee requires specialized care for an acute or chronic condition and the
enrollee and CONTRACTOR
agree that reassignment to a different PCP is in the enrollee's
interest.

    

    
      ii)  The
enrollee's place of residence has changed such that he/she has moved beyond the
PCP travel
time/distance standard.

    

    
      iii) The
enrollee's PCP ceases to participate in the CONTRACTOR'S
network.

    

    
      iv) The
enrollee's behavior toward the PCP is disruptive and the PCP. has made all
reasonable efforts
to accommodate the enrollee.

    

    
      v)   The
enrollee has taken legal action against the PCP or the PCP has taken legal
action against the
enrollee.

    

    
      

       

      f) Whenever
initiating a change, the CONTRACTOR must offer affected enrollees the
opportunity to
select a new PCP in the manner described in section 21.8.

    

    
      

    

    
      

    

    
      

    

    
      

    

    
      120

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      21.10 Provider
Status Changes

       

    

    
      a) PCP
Changes

    

    
       

      i)   The
CONTRACTOR agrees to notify its enrollees of any of the following PCP
changes:

    

    
      

       

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

    

    
      

       

      B) If
a PCP ceases participation in the CONTRACTOR'S network, the CONTRACTOR shall
provide written notice within fifteen (15) days from the date that the
CONTRACTOR becomes aware of such change in status to each enrollee who has
chosen the provider as his or her PCP. In such cases, the notice shall describe
the procedures for choosing an alternative PCP, a list of other health plans
that participate in the enrollee's service area and the CHPlus hotline number
(1-800-698-4543) so the enrollee can determine if the PCP participates in
another health plan, and in the event that the enrollee is in an ongoing course
of treatment, the procedures for continuing care consistent with subdivision 6
(e) of PHL § 4403.

    

    
      

       

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

    

    
      

       

      b) Other
Provider Changes

    

    
      

       

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

    

    
      

       

      21.11 PCP
Responsibilities

    

    
      

       

      In
conformance with the benefit package, the PCP shall provide health counseling
and advice; conduct baseline and periodic health examinations; diagnose and
treat conditions not requiring the services of a specialist; arrange inpatient
care, consultations with specialists, and laboratory and radiological services
when medically necessary; coordinate the findings of consultants and
laboratories; and interpret such findings to the enrollee and the enrollee's
family, subject to the confidentiality provisions of this AGREEMENT, and
maintain a current medical record for the enrollee. The PCP shall also be
responsible for determining the urgency of a consultation with a specialist and
shall arrange for all consultation appointments within appropriate time
frames.

    

    
      

       

      21.12 Member
to Provider Ratios

    

    
      

       

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

    

    
      

       

      121

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

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

    

    
      

       

      ii)  No
more than 1,000 enrollees for each certified nurse
practitioner.

    

    
      

       

      b)  The
CONTRACTOR agrees that these ratios will be prorated for participating providers
who represent less than a FTE to the CONTRACTOR.

    

    
      

       

      21.13 Minimum
PCP Office Hours

       

    

    
      a) General
Requirements

    

    
       

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

    

    
       

      b) Waiver
of Minimum Hours

    

    
      

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

    

    
      

       

      12.14 Primary
Care Practitioners

    

    
      

       

      a) General
Limitations

    

    
      

       

      The
CONTRACTOR agrees to limit its PCPs to the following primary care specialties:
Family Practice, General Practice, General Pediatrics, and General Internal
Medicine except as specified in paragraphs (b), (c), and (d) of this
Section.

    

    
      

       

      b) Specialists
and Sub-specialists as PCPs

    

    
      

       

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

    

    
      

       

      c) OB/GYN
Providers as PCPs

    

    
      

       

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

    

    
      

       

      d) Certified
Nurse Practitioners as PCPs

    

    
      

       

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

    

    
      

       

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      21.15 PCP
Teams

    

    
      

       

      a) General
Requirements

    

    
      

       

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

    

    
      

       

      b) Registered
Physician Assistants as Physician Extenders

    

    
      

       

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

    

    
      

       

      c) Medical
Residents and Fellows

    

    
      

       

      The
CONTRACTOR shall comply with the STATE Guidelines for use of Medical Residents
and fellows as found in Attachment A of this section.

    

    
      

       

      21.16 Hospitals

    

    
      

       

      a) Tertiary
Services

    

    
      

       

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

    

    
      

       

      b) Emergency
Services

    

    
      

       

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

    

    
      

       

      21.17 Dental
Networks

    

    
      

       

      The
CONTRACTOR'S dental network shall include geographically accessible general
dentists sufficient to offer each enrollee a choice of two (2) primary care
dentists in their service area and to achieve a ratio of at least one (1)
primary care dentist for each 2,000 enrollees. Networks must also include at
least one (1) pediatric dentist and one (1) oral surgeon. Orthognathic surgery,
temporal mandibular disorders (TMD) and oral/maxillofacial prosthodontics must
be provided through any qualified dentist, either in-network or by referral.
Periodontists and endodontists must also be available by referral. The network
must include dentists with expertise in serving special needs populations (e.g.,
HTV+ and developmentally disabled patients).

    

    
      

       

      21.18 Mental
Health and Chemical Dependence Services Providers

    

    
      

       

      a)   The
CONTRACTOR will include a full array of mental health and chemical dependence
services providers in its network, in sufficient numbers to assure accessibility
to benefit package services for enrollees, using either individual,
appropriately licensed practitioners or New York State Office of Mental Health
(OMH) and Office of Alcohol and Substance Abuse Services (OASAS) licensed
programs and clinics, or both.

    

    
      

       

      123

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      b)   The
STATE defines mental health and chemical dependence services providers to
include the following: individual practitioners, psychiatrists, psychologists,
psychiatric nurse practitioners, psychiatric clinical nurse specialists,
licensed certified social workers, OMH and OASAS programs and clinics, and
providers of mental health and/or chemical dependence services certified or
licensed pursuant to Article 31 or 32 of the Mental Hygiene Law, as
appropriate.

    

    
      

       

      21.19 Laboratory
Procedures

    

    
      

       

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

    

    
      

       

      21.20 Federally
Qualified Health Centers (FQHCs)

    

    
      

       

      a) The
CONTRACTOR shall contract with at least one FQHC operating in each of its
counties. However, the CONTRACTOR has the option to make a written request to
the STATE for an exemption from the FQHC contracting requirement, if the
CONTRACTOR demonstrates, with supporting documentation, that it has adequate
capacity and will provide a comparable level of clinical and enabling services
(e.g., outreach, referral services, social support services, culturally
sensitive services such as training for medical and administrative staff,
medical and non-medical and case management services) to vulnerable populations
in lieu of contracting with an FQHC in each county. Written requests for
exemptions from this requirement are subject to approval by
CMS.

    

    
      

       

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

    

    
      

       

      21.21 Provider
Services Function

    

    
      

       

      a)   The
CONTRACTOR will operate a provider services function during regular business
hours.  At a minimum, the CONTRACTOR'S provider services staff must be
responsible for the following:

    

    
      

       

      i)   Assisting
providers with prior authorization and referral protocols.

    

    
      ii)  Assisting
providers with claims payment procedures.

    

    
      iii)
Fielding and responding to provider questions and complaints.

    

    
      

       

      21.22 Pharmacies

    

    
      

       

      a)   The
CONTRACTOR shall include pharmacies as participating providers in its CHPlus
product in sufficient numbers to meet the following distance/travel time
standards:

    

    
      

       

      i)   Non-Metropolitan
areas - thirty (30) miles/thirty (30) minutes from the CHPlus enrollee's
residence.

    

    
      

       

      ii)  Metropolitan
areas - thirty (30) minutes by public transportation from the CHPlus enrollee's
residence.

    

    
      

       

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

    

    
      

       

      c) The
CONTRACTOR also must contract with twenty-four (24) hour pharmacies and must
ensure that all
CHPlus enrollees have access to at least one such pharmacy within thirty (30)
minutes travel time (by car or public
transportation) from the CHPlus enrollee's residence, unless none are located
within

    

    
      

       

      124

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

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

    

    
      

       

      e) The
CONTRACTOR may make use of mail order prescription deliveries, where clinically
appropriate and desired by the CHPlus enrollee.

    

    
      

       

      f) The
CONTRACTOR may utilize formularies and may employ the services of a pharmacy
benefit manager or utilization review agent, provided that such manager or agent
covers a prescription drug benefit equivalent to the requirements for
prescription drug coverage described in section 2 of this Appendix and maintains
an internal and external review process for medical
exceptions.

    

    
      

       

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      Section
21

    

    
       

       

      Attachment
A

    

    
      

       

      GUIDELINES
FOR USE OF MEDICAL RESIDENTS

    

    
      

       

      126

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      New York
State Department of Health

    

    
      Guidelines
for Use of Medical Residents

    

    
      

       

      Medical
Residents

    

    
      

       

      (a)
Medical Residents as Primary Care Providers (PCPs). MCOs may utilize medical
residents as participants (but not designated as 'PCPs') in the care of
enrollees as long as all of the following conditions are met:

    

    
      

       

      1)
Residents are a part of patient care' teams headed by fully licensed and MCO
credentialed attending physicians serving patients in one or more training sites
in an "up weighted" or "designated priority" residency program. Residents in a
training program which was disapproved as a designated priority program solely
due to the outcome measurement requirement for graduates may be eligible to
participate in such patient care teams.

    

    
      

       

      2) Only
the attending physicians and nurse practitioners on the training team, not
residents, may be credentialed to the MCO and may be empanelled with enrollees.
Enrollees must be assigned an attending physician or certified nurse
practitioner to act as their PCP, though residents on the team may perform all
or many of the visits to the enrollee as long as the majority of these visits
are under the direct supervision of the enrollee's designated PCP. Enrollees
have the right to request care by their PCP in addition or instead of being seen
by a resident.

    

    
      

       

      3)
Residents may work with attending physicians and certified nurse practitioners
to provide continuity of care to patients under the supervision of the patient's
PCP. Patients must be made aware of the resident/attending relationship and be
informed of their rights to be cared for directly by their
PCP.

    

    
      

       

      4)
Residents eligible to be involved in a continuity relationship with patients
must be available at least 20% of the total training time in the continuity of
care setting and no less than 10% of training time in any training year must be
in the continuity of care setting and no fewer than nine (9) months a year must
be spent in the continuity of care setting.

    

    
      

       

      5)
Residents meeting these criteria provide increased capacity for enrollment to
their team according to the following formula:

    

    
      

       

      PGY-1 300perFTE

    

    
      PGY-2 750perFTE

    

    
      PGY-3 1125 per
FTE

    

    
      PGY-4 1500 per
FTE

    

    
      

       

      Only
hours spent routinely scheduled for patient care in the continuity of care
training site may count as providing capacity and are based on 1.0 FTE = 40
hours.

    

    
      

       

      6) In
order for a resident to provide continuity of care to an enrollee, both the
resident and the attending PCP must have regular hours in the continuity site
and must be scheduled to be in the site together the majority of the
time.

    

    
      

       

      7) A
preceptor/attending is required to be present a minimum of sixteen (16) hours of
combined precepting and direct patient care in the primary care setting to be
counted as a team supervising PCP and accept an increased number of enrollees
based upon the residents working on his/her team. Time spent in patient care
activities at other clinical sites or in other activities off-site is not
counted towards this requirement.

    

    
      

       

      8) A
sixteen (16) hour per week attending may have no more than four (4) residents on
their team. Attendings spending twenty-four (24) hours per week in patient
care/supervisory activity at the

    

    
      

       

      127

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      continuity
site could have six (6) residents per team. Attendings spending thirty-two (32)
hours per week could have eight (8) residents on their team. Two (2) or more
attendings may join together to form a larger team as long as the ratio of
attending to residents does not exceed 1:4 and all attendings comply with the
sixteen (16) hour minimum.

    

    
      

       

      9) Specialty
consults must be performed of directly supervised by a MCO credentialed
specialist. The specialist may be assisted by a resident or
fellow.

    

    
      

       

      10) Responsibility
for the care of the enrollee remains with the attending physician. All
attending/resident teams must provide adequate continuity of care, twenty-four
(24) hour a day, seven (7) day a week coverage, and appointment and availability
access.

    

    
      

       

      11) Residents
who do not qualify to act as continuity providers as part of an
attending/resident team may still participate in the episodic care of enrollees
as long as that care is under the supervision of an attending physician
credentialed to a MCO. Such residents would not add to the capacity of that
attending to empanel enrollees, however.

    

    
      

       

      12) Certified
nurse practitioners and registered physician's assistants may not act as
attending preceptors for resident physicians.

    

    
      

       

      (b)
Medical Residents as Specialty Care Providers

    

    
      

       

      (1) Residents
may participate in the specialty care of Medicaid managed care patients in all
settings supervised by fully licensed and MCO/Prepaid Health Services Plan
(PHSP) credentialed specialty attending physicians.

    

    
      

       

      (2) Only
the attending physicians, not residents or fellows, may be credentialed by the
MCO. Each attending must be credentialed by each MCO with which they will
participate. Residents may perform all or many of the clinical services for the
enrollee as long as these clinical services are under the supervision of an
appropriately credentialed specialty physician. Even when residents are
credentialed by their program in particular procedures, certifying their
competence to perform and teach those procedures, the overall care of each
enrollee remains the responsibility of the supervising MCO-credentialed
attending.

    

    
      

       

      It is
understood that many enrollees will identify a resident as their specialty
provider but the responsibility for all clinical decision-making remains with
the attending physician of record.

    

    
      

       

      (3) Enrollees
must be given the name of the responsible attending physician in writing and be
told how they may contact their attending physician or covering physician, if
needed. This allows enrollees to assist in the communication between their
primary care provider and specialty attending and enables them to reach the
specialty attending if an emergency arises in the course of their care.
Enrollees must be made aware of the resident/attending relationship and must
have a right to be cared for directly by the responsible attending physician, if
requested.

    

    
      

       

      (4) Enrollees
requiring ongoing specialty care must be cared for in a continuity of care
setting. This requires the ability to make follow-up appointments with a
particular resident/attending physician, or if that provider team is not
available, with a member of the provider's coverage group in order to insure
ongoing responsibility for the patient by his/her MCO credentialed specialist.
The responsible specialist and his/her specialty coverage group must be
identifiable to the patient as well as to the referring PCP.

    

    
      

       

      (5) Attending
specialists must be available for emergency consultation and care during
non-clinic hours. Emergency coverage may be provided by residents under adequate
supervision. The attending or a member of the attending's coverage group must be
available for telephone and/or in-person consultation when
necessary.

    

    
      

       

      128

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      (6) All
training programs participating in Medicaid managed care must be accredited by
the appropriate academic accrediting agency.

    

    
      

       

      (7) All
sites in which residents train must produce legible (preferably typewritten)
consultation reports. Reports must be transmitted such that they are received in
a time frame consistent with the clinical condition of the patient, the urgency
of the problem and the need for follow-up by the PCP. At a minimum, reports
should be transmitted so that they are received no later than two (2) weeks from
the date of the specialty visit.

    

    
      

       

      (8) Written
reports are required at the time of initial consultation and again with the
receipt of all major significant diagnostic information or changes in therapy.
In addition, specialists must promptly report to the referring primary care
physician any significant findings or urgent changes in therapy which result
from the specialty consultation.

    

    
      

       

      All
training sites must deliver the same standard of care to all patients
irrespective of payer.  Training sites must integrate the care of
Medicaid, uninsured and private patients in the same
settings.

    

    
      

       

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      SECTION
22

    

    
      ACCESS
REQUIREMENTS

    

    
      

       

      22.1 General
Requirement

    

    
      

       

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

    

    
      

       

      22.2 Appointment
Availability Standards

    

    
      

       

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

    

    
      

       

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

    

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

    

    
      iii)
Non-urgent "sick" visit: within forty-eight (48) to seventy-two (72) hours of
request, as clinically
indicated.

    

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

    

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

    

    
      vi)
Initial prenatal visit: within three (3) weeks during first trimester, within
two (2) weeks during
the second trimester and within one (1) week during the third
trimester.

    

    
      vii) Well
child care: within four (4) weeks of request. viii)   Initial
family planning visits: within two (2) weeks of request.

    

    
      ix)
Pursuant to an emergency or hospital discharge, mental health or substance abuse
follow-up visits with a participating provider (as included in the benefit
package): within five (5) days of
request, or as clinically indicated.

    

    
      x)  Non-urgent
mental health or substance abuse visits with a participating provider (as
included in the benefit package): within two (2) weeks of
request.

    

    
      xi)
Initial PCP office visit for newborns: within two (2) weeks of hospital
discharge.

    

    
      

       

      22.3 Twenty-Four
(24) Hour Access

    

    
      

       

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

    

    
      

       

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

    

    
      

       

      22.4 Appointment
Waiting Times

    

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

    

    
      

       

      22.5 Travel
Time Standards

    

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

    

    
      

    

    
      _________________________

    

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

    

    
      

       

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      b)  Primary
Care

    

    
      

       

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

    

    
      

       

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

    

    
      

       

      c)   Other
Providers

    

    
      

       

      Travel
time/distance to specialty care, hospitals, mental health, lab and x-ray
providers shall not exceed thirty (30) minutes/thirty (30) miles from the
enrollee's residence. Transport time and distance in rural areas to specialty
care, hospitals, mental health, lab and x-ray providers may be greater than
thirty (30) minutes/thirty (30) miles from the enrollee's residence if based on
the community standard for accessing care or if by enrollee
choice.

    

    
      

       

      22.6     Service
Continuation

    

    
      

       

      a) New
Enrollees

    

    
      

       

      i)   If
a new enrollee has an existing relationship with a health care provider who is
not a member of the CONTRACTOR'S provider network, the CONTRACTOR shall permit
the enrollee to continue an ongoing course of treatment by the non-participating
provider during a transitional period of up to sixty (60) days from the
effective date of enrollment, if, (1) the enrollee has a life-threatening
disease or condition or a degenerative and disabling disease or condition, or
(2) the enrollee has entered the second trimester of pregnancy at the effective
date of enrollment, in which case the transitional period shall include the
provision of post­partum care directly related to the delivery up until
sixty (60) days post partum. If the new enrollee elects to continue to receive
care from such non-participating provider, such care shall be authorized by the
CONTRACTOR for the transitional period only if the non-participating provider
agrees to:

    

    
      

       

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

    

    
      

       

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

    

    
      

       

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

    

    
      

       

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

    

    
      

       

      b) Enrollees
Whose Health Care Provider Leaves Network

    

    
      

       

      i)   The
CONTRACTOR shall permit an enrollee, whose health care provider has left the
CONTRACTOR'S network of providers, for reasons other than imminent harm to
patient care, a determination of fraud or a final disciplinary action by a state
licensing board that

    

    
      

       

      131

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      impairs
the health professional's ability to practice, to continue an ongoing course of
treatment with the enrollee's current health care provider during a transitional
period consistent with PHL § 4403(6)(e).

    

    
      

       

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

    

    
      

       

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

    

    
      

       

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

    

    
      

       

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

    

    
      

       

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

    

    
      

       

      22.7 Standing
Referrals

    

    
      

       

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

    

    
      

       

      22.8 Specialist
as a Coordinator of Primary Care

    

    
      

       

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

    

    
      

       

      22.9 Specialty
Care Centers

    

    
      

       

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

    

    
      

       

      22.10 Cultural
Competence

    

    
      

       

      The
CONTRACTOR will participate in the STATE'S efforts to promote the delivery of
services in a culturally competent manner to all enrollees, including those with
limited English proficiency and diverse cultural and ethnic
backgrounds.

    

    
      

       

      132

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      SECTION
23

    

    
      SUBCONTRACTS
AND PROVIDER  AGREEMENTS

    

    
      

       

      23.1 Written
Subcontracts

    

    
      

       

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

    

    
      

       

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

    

    
      

       

      c) The
delegation by the CONTRACTOR of its responsibilities under the terms of this
AGREEMENT to any subcontractors will be limited to those specified in the
subcontracts.

    

    
      

       

      23.2 Permissible
Subcontracts

    

    
      

       

      CONTRACTOR
may subcontract for provider services and management services including, but not
limited to, marketing, quality assurance and utilization review activities and
such other services as are acceptable to the STATE. The CONTRACTOR must evaluate
the prospective subcontractor's ability to perform the activities to be
delegated.

    

    
      

       

      23.3 Provision
of Services through Provider Agreements

    

    
      

       

      All
medical care and/or services covered under this AGREEMENT, with the exception of
seldom used subspecialty and emergency services and services for which enrollees
can self-refer, shall be provided through provider agreements with participating
providers.

    

    
      

       

      23.4 Approvals

    

    
      

       

      a) Provider
Agreements shall require the approval of the STATE as set forth in PHL §4402
andlONYCRRPart98.

    

    
      

       

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

    

    
      

       

      c) The
CONTRACTOR shall notify the STATE of any material amendments to any provider
agreement as set forth in 10 NYCRR Part 98.

    

    
      

       

      23.5 Required
Components

    

    
      

       

      a) All
subcontracts, including provider agreements, entered into by the CONTRACTOR to
provide
program services under this AGREEMENT shall contain provisions
specifying:

    

    
      

       

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

    

    
      

       

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

    

    
      

       

      133

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      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 the STATE or the federal Department of
Health and Human Services.

    

    
      

       

      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 STATE.

    

    
      

       

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

    

    
      

       

      f) The
CONTRACTOR shall also require that, in the event the CONTRACTOR fails to pay any
subcontractor, including any participating provider in accordance with the
subcontract or provider agreement, the subcontractor or participating provider
will not seek payment from the STATE, the enrollee 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.

    

    
      

       

      23.6 Timely
Payment

    

    
      

       

      CONTRACTOR
shall make payments to participating providers and to non-participating
providers, as applicable, for items and services covered under this AGREEMENT on
a timely basis consistent with the claims payment procedures described in the
New York State Insurance Law § 3224-a.

    

    
      

       

      23.7 Recovery
of Overpayments to Providers

    

    
      

       

      Consistent
with the exception language in section 3224-b of the Insurance Law, the
CONTRACTOR shall retain the right to audit participating providers' claims for a
six year period from the date the care, services or supplies were provided or
billed, whichever is later, and to recoup any overpayments discovered as a
result of the audit. This six year limitation does not apply to situations in
which fraud may be involved or in which the provider or an agent of the provider
prevents or obstructs the CONTRACTOR'S auditing.

    

    
      

       

      23.8 Restrictions
on Disclosure

    

    
      

       

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

    

    
      

       

      134

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      i)
Disclosing to any subscriber, enrollee, patient, designated representative or,
where appropriate, prospective enrollee any information that such provider deems
appropriate regarding:

    

    
      

       

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

    

    
      B) the
provisions, terms, or requirements of the CONTRACTOR'S CHPlus product as it
relates to the enrollee, where applicable.

    

    
      

       

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

    

    
      

       

      iii)
Advocating to the CONTRACTOR on behalf of the enrollee for approval or coverage
of a particular treatment or for the provision of health care
services.

    

    
      

       

      23.9 Transfer
of Liability

    

    
      

       

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

    

    
      

       

      23.10 Termination
of Health Care Professional Agreements

    

    
      

       

      a) General
Requirements

    

    
      

       

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

    

    
      

       

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

    

    
      

       

      b) Notice
of Health Care Professional Termination

    

    
      

       

      i)   When
the CONTRACTOR desires to terminate a contract with a health
care

    

    
      professional,
the notification of the proposed termination by the CONTRACTOR to the health
care professional shall include:

    

    
      

       

      A) the
reasons for the proposed action;

    

    
      

       

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

    

    
      

       

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

    

    
      

       

      135

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

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

    

    
      

       

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

    

    
      

       

      23.11 Health
Care Professional Hearings

    

    
      

       

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

    

    
      

       

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

    

    
      

       

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

    

    
      

       

      iii) A
decision by the hearing panel to terminate a health care professional shall
be

    

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

    

    
      

       

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

    

    
      

       

      23.12 Non-Renewal
of Provider Agreements

    

    
      

       

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

    

    
      

       

      23.13 Notice
of Participating Provider Termination

    

    
      

       

      a)   The
CONTRACTOR shall notify the STATE of any notice of termination or non-renewal of
an Independent Practice Association (IPA) or institutional network provider
agreement, or medical group provider agreement that serves five percent or more
of the enrolled population in the plan and/or when the termination or
non-renewal of the medical group provider will leave fewer than two
participating providers of that type within the plan, unless immediate
termination of the provider

    

    
      

       

      136

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      agreement
is justified. The notice shall include an impact analysis of the termination or
non-renewal with regard to enrollee access to care.

    

    
      

       

      b) The
CONTRACTOR shall provide the notification required in paragraph (a) of this
section to the STATE ninety (90) days prior to the effective date of the
termination of the provider agreement or immediately upon notice from such
participating provider if less than ninety (90) days.

    

    
      

       

      c) The
CONTRACTOR shall provide the notification required in paragraph (a) of this
section to the STATE if the CONTRACTOR and the participating providers have
failed to execute a renewal provider agreement forty-five (45) days prior to the
expiration of the current provider agreement.

    

    
      

       

      d) In
addition to the notification required in paragraph (a) of this section, the
CONTRACTOR shall submit a contingency plan to STATE, at least forty-five (45)
days prior to the termination or expiration of the provider agreement,
identifying the number of enrollees affected by the potential withdrawal of the
provider from the CONTRACTOR'S network and specifying how services previously
furnished by the participating provider will be provided in the event of its
withdrawal from the CONTRACTOR'S network. If the participating provider is a
hospital, the CONTRACTOR shall identify the number of doctors that would not
have admitting privileges in the absence of such participating
hospital.

    

    
      

       

      e) In
addition to the notification required in paragraph (a) of this section, the
CONTRACTOR shall develop a transition plan for enrollees who are patients of the
participating provider withdrawing from the CONTRACTOR'S network subject to
approval by the STATE. The STATE may direct the CONTRACTOR to provide notice to
the enrollees who are patients of PCPs or specialists including available
options for the patients, including the names and telephone numbers of other
participating CHPlus health plans and availability of continuing care,
consistent with this AGREEMENT, not less than sixty (60) days prior to the
termination or expiration of the provider agreement. In the event that provider
agreements are terminated or are not renewed with less than the notice period
required by this section, the CONTRACTOR shall immediately notify the STATE, and
develop a transition plan on an expedited basis and provide notice to affected
enrollees upon the STATE consent to the transition plan and enrollee
notice.

    

    
      

       

      f) Upon
CONTRACTOR notice of failure to renew, or termination of, a provider
agreement,  the STATE, in its sole discretion, may waive the
requirement of submission of a contingency plan upon a determination by the
STATE that:

    

    
      

       

      i)   the
impact upon enrollees is not significant, and/or

    

    
      

       

      ii)  the
CONTRACTOR and participating provider are continuing to negotiate in good faith
and consent to extend the provider agreement for a period of time necessary to
provide not less than thirty (30) days notice to enrollees.

    

    
      

       

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

    

    
      

       

      23.14   Physician
Incentive Plan

    

    
      

       

      a)   If
CONTRACTOR elects to operate a physician incentive plan, the CONTRACTOR agrees
that no specific payment will be made directly or indirectly to a participating
provider that is a physician or physician group as an inducement to reduce or
limit medically necessary services furnished to an enrollee. CONTRACTOR agrees
to submit to the STATE 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 the STATE.

    

    
      

       

      137

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      b) The
CONTRACTOR must ensure that any provider agreements for services covered by this
AGREEMENT, such as agreements between the CONTRACTOR and other entities or
between the CONTRACTOR'S subcontracted entities and their contractors, at all
levels including the physician level, include language requiring that the
physician incentive plan information be provided by the subcontractor in an
accurate and timely manner to the CONTRACTOR, in the format requested by the
STATE.

    

    
      

       

      c) In
the event that the incentive arrangements place the participating physician or
physician group at risk for services beyond those provided directly by the
physician or physician group for an amount beyond the risk threshold of
twenty-five percent (25%) of potential payments for covered health care 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 provider agreements.

    

    
      

    

    
      

    

    
      

    

    
      138

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      SECTION
24

    

    
      STATE
RESPONSIBILITIES

    

    
      

       

      24.1 Monitoring
and Evaluation The
STATE shall:

    

    
      

       

      a. Monitor
and evaluate the CONTRACTOR'S performance and compliance with this AGREEMENT.

    

    
      

       

      b. Review
in a timely .manner policies and procedures related to the enrollment, marketing, provider
network, payment process and change in premiums, which are submitted by the
CONTRACTOR, and certify that they are consistent with STATE policy.

    

    
      

       

      c. Review
and evaluate all reports to ensure that all deliverables required by this AGREEMENT are
fulfilled.

    

    
      

       

      d. Approve
all subcontractor arrangements entered into by the CONTRACTOR for the sole purpose of carrying
out the responsibilities of this AGREEMENT, as applicable.

    

    
      

       

      24.2 Payment
and Finance 

    

    
      

       

      The STATE
shall:

    

    
      

       

      a. Pay
the CONTRACTOR at premium rates approved by the State Insurance Department in
consultation with the STATE.

    

    
      

       

      b. Provide
the CONTRACTOR with a standard monthly voucher through the KIDS system, to be downloaded
through the HPN, which reflects the information contained in the KIDS system and
which shall be used by the CONTRACTOR for all children eligible for a subsidy
payment who are enrolled in the program during the month for which payment is being
claimed.

    

    
      

       

      c. Modify
(increase or decrease) maximum annual funding of CONTRACTOR based on written request by
the CONTRACTOR or as determined by the STATE.

    

    
      

       

      d. Recoup
from Medicaid any premiums paid by the CHPlus program on behalf of children who
subsequently become enrolled in Medicaid.

    

    
      

       

      e. Make
payments to the CONTRACTOR within 30 days of receipt of the signed voucher or will be
subject to interest payments to the CONTRACTOR in accordance with prompt payment
legislation (Article XI-A, State Finance Law).

    

    
      

       

      f. Conduct
annual audits in accordance with section 17 of this Appendix.

    

    
      24.3 Forms,
Brochures and Other Materials

    

    
      

       

      The STATE
shall:

    

    
      

       

      a. Provide
the CONTRACTOR with brochures describing the Medicaid program
and

    

    
      the
application process.

    

    
      

       

      139

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      b. Provide
the CONTRACTOR with all reporting forms and reports necessary for compliance with the
requirements set forth in this AGREEMENT.

    

    
      

       

      c. Provide
the CONTRACTOR with all required forms and software necessary to transmit adjustments and
enrollment transactions using the KIDS system.

    

    
      

       

      d. Provide
the CONTRACTOR with information, for distribution to potential enrollees, applicants and
enrollees, regarding the types, amount, duration and scope of benefits available in CHPlus,
cost-sharing requirements, a description of the procedures relating to an
enrollment cap or waiting list including the process for deciding which children will be given
priority for enrollment, how children will be informed of their status on a waiting list
and the circumstances under which enrollment will reopen, if an enrollment cap or
waiting list is in effect, physician incentive plans and review processes available to
applicants and enrollees.

    

    
      

       

      e. Provide
the CONTRACTOR with a public schedule that includes information on current cost-sharing
charges, enrollee groups subject to the charges, cumulative cost- sharing maximums,
mechanisms for making payments for required charges and the consequences for an
applicant or enrollee who does not pay a charge, including disenrollment
protections.

    

    
      

       

      24.4     Service
Area Expansions

    

    
      

       

      The STATE
shall review and approve requests made by the CONTRACTOR to expand and enhance
the existing provider network of the CONTRACTOR to provide services under CHPlus
to areas of New York State for which the CONTRACTOR is certified as a
corporation or health maintenance organization licensed under Article 43 of the
Insurance Law and/or a health maintenance organization or comprehensive health
service organization certified under Article 44 of the Public Health Law. The
STATE reserves the right to limit the CONTRACTOR'S participation to those
counties where the CONTRACTOR is approved as a Medicaid Managed Care plan under
section 364-j of the Social Services Law.

    

    
      

       

      140

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      SECTION
25

    

    
       CONVERSION

    

    
      

       

      25.1 Enrollee
Relocation

    

    
      

       

      In the
event an enrollee relocates out of the CONTRACTOR'S service area to a different
area within the STATE, the CONTRACTOR shall refer the enrollee to the CHPlus
contractor(s) which is/are responsible for providing services for the CHPlus
Program in the area to which the enrollee moves.

    

    
      

       

      25.2 Enrollee
Turns Age Nineteen

    

    
      

       

      In the
event an enrollee turns 19, the CONTRACTOR shall refer the enrollee to other
comparable programs with similar benefit packages. This may include, but riot be
limited to, the CONTRACTOR'S commercial product or the Family Health Plus or
Healthy New York programs.

    

    
      

       

      141

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      SECTION
26

    

    
      TERMINATION

    

    
      

       

      26.1 CONTRACTOR
Discontinues Counties in its Service Area

    

    
      

       

      In the
event a CONTRACTOR voluntarily discontinues providing CHPlus in a particular
county, the CONTRACTOR shall provide the STATE with at least 60 days written
notice. The CONTRACTOR shall provide written notice to enrollees notifying them
of its intent to discontinue coverage sixty days prior to such discontinuance.
This notice must be approved by the STATE and must include information regarding
other available health plan options.

    

    
      

       

      26.2 CONTRACTOR
Delay, Failure or Inability to Complete the AGREEMENT

    

    
      

       

      Any delay
by, or failure or inability of the CONTRACTOR to complete this AGREEMENT, either
in whole or in part, in accordance with provisions, specifications, and/or
schedules contained herein shall be excused and a   reasonable
time for performance pursuant to this AGREEMENT shall be extended to include the
period of such delay or nonperformance, if caused by or resulting from fire,
explosion, accident, labor dispute, flood, war, riot, acts of God, legal action
including injunction, present or future law, governmental order, rule or
regulation, or any other reasonable cause beyond the CONTRACTOR'S immediate and
direct control. It is agreed, however, that a cause itemized or referred to
above shall not excuse a delay, failure or inability to the CONTRACTOR to
perform if such cause arose as a result of the negligence or willful act or
omission of the CONTRACTOR which in the exercise of reasonable judgment, could
have been avoided by the CONTRACTOR. Pending the restoration, settlement or
resolution of the cause for delay, failure or inability of the CONTRACTOR to
perform, the CONTRACTOR shall continue to perform those obligations of this
AGREEMENT which are not related or subject to such cause.

    

    
      

       

      26.3 Sanctions
for Non-Compliance Related to Facilitated Enrollment

    

    
      

       

      The STATE
may suspend or terminate the CONTRACTOR'S responsibilities related to
facilitated enrollment if the CONTRACTOR is found to be out of compliance with
the terms and conditions required under sections 13, 14 and 16 of this Appendix
and any other provision of this AGREEMENT related to facilitated enrollment
activities. The STATE shall give the CONTRACTOR sixty (60) days written notice
if it determines that the CONTRACTOR's facilitated enrollment responsibilities
must be terminated.

    

    
      

       

      26.4 CONTRACTOR
Initiated Termination

    

    
      

       

      The
CONTRACTOR shall notify the STATE of circumstances resulting in the inability of
the CONTRACTOR to perform activities and services required under this AGREEMENT.
If circumstances result in the CONTRACTOR'S inability to perform services, sixty
(60) days notice of termination should be provided by the CONTRACTOR to the
STATE with notice to enrollees of the conclusion of coverage under this
AGREEMENT and the availability of conversion rights pursuant to the subscriber
contract.

    

    
      

       

      26.5 State
Initiated Termination

    

    
      

       

      The STATE
may cancel this AGREEMENT at any time without prior notice for the following
reasons: if the STATE determines the CONTRACTOR is not adhering to enrollment
procedures which result in a pattern and practice of inappropriate enrollment;
deficiencies in quality assurance; termination of participation in the STATE'S
Medicaid managed care program; or if it is determined that the CONTRACTOR does
not meet the financial requirements as specified in Article 44 of PHL and 10
N.Y.C.R.R. section 98-1.11(d).

    

    
      

       

      142

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      26.6  Transition
Process Prior to Termination

    

    
      

       

      If the
AGREEMENT between the STATE and CONTRACTOR is terminated for any reason, the
CONTRACTOR must work in conjunction with the STATE to develop a plan to
transition enrollees to another contractor in the enrollee's service area. This
plan must include notifying enrollees of other available health plan options, at
least 60 days prior to termination, and providing follow up letters to remind
families to enroll with another health plan.

    

    
      

       

      143

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      APPENDICES
ATTACHED AND PART OF THIS AGREEMENT

    

    
      

    

    
      	
              X

            	
              
                Appendix
      A

              

              
                Standard
      Clauses as required by the Attorney General for all State
      contracts

              

               

            
	
              X

            	
              
                Appendix
      C

              

              
                Program
      Specific Requirements

              

               

            
	
              X

            	
              
                Appendix
      E-l

              

              
                Proof
      of Workers' Compensation Coverage

              

               

            
	
              X

            	
              
                Appendix
      E-2

              

              
                Proof
      of Disability Insurance Coverage

              

               

            
	
              X

            	
              
                Appendix
      H

              

              
                Federal
      Health Insurance Portability and Accountability
      Act (HIPAA) Business Associate Agreement

              

               

            
	
              X

            	
              
                Appendix
      X

              

              
                Modification
      Agreement Form

              

               

            
	 
      	 
      

    

    
      

    

    
      

    

    
      144

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      APPENDIX
E-1

    

    
       

    

    
      PROOF
OF WORKERS' COMPENSATION COVERAGE

    

    
      (CONTRACTOR'S
DOCUMENTS WILL BE INSERTED)

    

    
      

    

    
      

    

    
      

    

    
      145

    

     

     

    

      
        
           

        

        
           

          
            

          

        

        
           

        

      

      

       

      

       

      STATE  OF
NEW YORK

       

      WORKERS'
COMPENSATION BOARD

       

      CERTIFICATE
OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE

      
        	
                1a.
      Legal Name & Address
      of Insured (Use street address only)

                WellCare Health Plans, Inc.
      8735 Henderson
      Road

                Tampa,
      FL 33634

                Work
      Location of Insured (Only
      required if
      coverage is specifically limited to certain locations in New York State,
      i.e. a Wrap-Up Policy)

              	
                1b.
      Business Telephone Number of Insured: 813-243-2962

                lc, NYS Unemployment Insurance
      Employer Registration Number
      of Insured

                ld.
      Federal Employer Identification Number of Insured or Social Security
      Number

                14-1676443

              
	
                2. Name and
      Address of the Entity Requesting Proof of coverage (Entity Being Listed as
      the Certificate Holder)

              	
                3a.
      Name of Insurance Carrier

              
	 
      	
                Hartford-
      Fire Insurance Company

              
	
                Bureau
      of Child Health Plus Enrollment

              	
                3b.
      Policy Number of entity listed in box "1a"

              
	
                Division
      of Coverage and Enrollment

              	
                  30
      WN MS 9880

              
	
                Corning
      Tower

              	
                3c.
      Policy Effective period

              
	
                Governor
      Nelson Rockefeller Empire State Plaza

              	
                 01/01/ 2008                              to           01/01/2009

              
	
                 Albany,
      NY 12237

              	
                 

              
	 
      	
                3d. The Proprietor,
      Partners or Executive Officers are.

              
	 
      	
                X    Included.
      (Only check box if all
      partners/officers included)

              
	 
      	
                __   all
      excluded or certain partners/officers
excluded.

              

      

      

       

       

      This certifies that
the insurance carrier indicated above in
box "3" insures the 'business
referenced above in box "la" for workers' compensation
under the New York State Workers'
Compensation Law, (To use this form, New York (NY)
must be listed under Item
3A on the INFORMATION
PAGE of the workers' compensation
insurance policy). The Insurance Carrier
or its licensed agent will send
this Certificate of Insurance to the entity listed above as the
certificate holder in box "2",

       

      The
Insurance Carrier bill also notify the
above certificate holder within 10 days IF a policy is canceled due to
nonpayment ofpremiums or within 30 days IF there are reasons other than
nonpayment of premiums that cancel the policy or eliminate the insured from the
coverage indicated on this Certificate. (These notices may be sent by
regular moil) Otherwise, ibis
Certificate is valid for one year after this form is approved by the
insurance carrier or its
licensed agent, or until the policy expiration date listed in box "3c",
whichever
is earlier.

       

      Please
Note: Upon the cancellation. of the workers' compensation policy indicated on
this form, if the business continues to be
named on a permit, license or contract issued by a certificate holder,
the business must provide that certificate holder with a new Certificate of
Workers' Compensation Coverage Or other authorized proof that the business is
complying with the mandatory coverage requirement's of the New York State
Workers' Compensation Law.

      

      Under
penalty of perjury, I. certify that I am an authorized representative or
licensed agent of the insurance carrier referenced above end that the named
insured has the coverage as depicted on this form.

      

      
        	
                Approved
      by:  Tina
      Stikeleather

                 

              	 
      
	
                Approved
      by: /s/  Tina
      Stikeleather

                 

              	
                01/28/208

                Date

              
	
                Title:  Professional
      Support Technician

              

      

      

      Telephone
Number of authorized representative or licensed agent of insurance
carrier: 704-921-4700 x6286

      

      Please Note: Only insurance carriers
and their licensed agents are authorized to truce Form C-105.2, Insurance
brokers are NOT authorized to issue
it.

      

      

      Workers'
Compensation Law

       

      Section
57. Restriction on issue of permits and the entering into contracts unless
compensation is secured.

       

      1. The
head of a state or municipal department, board, commission or office authorized
or required. by law to issue arty permit for or in connection with any work
involving the employment of employees to a hazardous employment defined by this
chapter, and notwithstanding any general or special statute requiring or
authorizing the issue of such permits, shall not issue such permit -unless proof
duly subscribed by an insurance carrier is produced in a form satisfactory to
the chair, that compensation for all employees has been secureclas provided
bythis chapter. Nothing heroin, however, shall be construed as creating any
liability on the part of such state or municipal department, board, commission or
office to pay Any
compensation to any such employee if so employed.

       

      

      2. The
head of a state or municipal department, board; commission or office authorized
or. required by law to enter into soy contract for
or in connection with any work involving the employment of employees in a
hazardous employment defined by this chapter, notwithstanding any general or
special statute requiring or authorizing any such contract, shall not enter into
any such contract unless proof duly subscribed by an insurance carrier is
produced in a form satisfactory to the chair, that compensation for all
employees has been secured as provided by this chapter

       

      
        
          
            
              	
                    

            

            

          

           

        

        
           

          
            

          

        

        
           

        

      

    
      APPENDIX
E-2

    

    
       

    

    
       

    

    
      PROOF
OF DISABILITY INSURANCE COVERAGE

    

    
       

    

    
       

    

    
      (CONTRACTOR'S
DOCUMENTS WILL BE INSERTED)

    

    
      

    

    
      

    

    
      146

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    STATE
OF NEW YORK

    WORKERS’
COMPESATION BOARD

    

    CERTIFICATE
OF INSURANCE COVERAGE UNDER THE NYS DISABILITY BENEFITS LAW

    

    PART I.
To be completed by Disability Benefits Carrier or Licensed Insurance Agent of
that Carrier.

    
      	
              1a.  Legal
      Name and Address of Insured (Use street address only)

               

              WELLCARE
      OF NEW YORK, INC.

              11
      WEST 19TH
      STREET, 3RD
      FLOOR

              NEW
      YORK,  NY 10011

            	
              1b.
      Business Telephone Number of Insured

              813
      243 2966

               

              1c.
      NYS Unemployment Insurance Employer Registration

               

              1d.
      Federal Employer Identification Number of Insured or Social Security
      Number

              14-1676443

               

            
	
              2.
      Name and Address of the Entity Requesting Proof of Coverage (Entity Being
      Listed as the Certificate Holder)

               

              NEW
      YORK DEPARTMENT OF HEALTH

              CORNING
      TOWER

              EMPIRE
      STATE PLAZA

              ALBANY,
      NY 12237

            	
              3a.
      Name of Insurance Carrier

              MUTUAL
      OF OMAHA

               

              3b.
      Policy Number of entity listed on box “1a”:

              GMNY6X007A20-0002

               

              3c.
      Policy effective period

              06/21/2007
      to 06/21/2008

               

            
	
              4.
      Policy covers:

              a.
        x  All of the
      employer’s employees eligible under the New York Disability Benefits
      Law

              b.
      ___ Only the following class or classes of the employer’s
      employees

               

              Under
      penalty of perjury, I certify that I am an authorized representative or
      licensed agent of the insurance carrier referenced above and that the
      named insured has NYS Disability Benefits insurance coverage as described
      above.

               

            
	
              Date
      Signed: 06/28/2007

            	
              By:  /s/  Illegible

            
	
              Telephone
      Number: 914
      -591-7111

            	
              Title:
      Disability
      Administrator

               

            
	
               

              IMPORTANT:

            	
              If
      box “4a” is checked, and this form is signed by the insurance carrier’s
      authorized representative or NYS Licensed Agent of that carrier, this
      certificate is COMPLETE. Mail it directly to the certificate
      holder.

              If
      box “4b” is checked, this certificate is NOT COMPLETE for purposes of
      Section 220, Subd. 8 of the Disability Benefits Law. It must be mailed3for
      completion to the Workers’ Compensation Board, DB Plans Acceptance Unit,
      20 Park Street, Albany, New York 12207

               

            
	
              PART
      2. To be completed by NYS Workers’ Compensation Board (Only if box “4b” of
      Part 1 has been checked)

            
	
               

              State
      of New York

              Workers’
      Compensation Board

               

              According
      to information maintained by the NYS Workers’ Compensation Board, the
      above-named employer has complied with the NYS Disability Benefits Law
      with respect to all of his/her employees

               

            
	
              Date
      Signed:

            	
              By:

                
      (Signature of NYS Workers’ Compensation Board Employee)

            
	
              Telephone
      Number:

            	
              Title:

            
	
              Please
      Note: Only insurance carriers licensed to write NYS Disability benefits
      insurance policies and NYS licensed insurance agents of those insurance
      carriers are authorized to issue Form DB-120.1. Insurance brokers are NOT
      authorized to issue this form.

            

    

    

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      Appendix
H

    

    
       

    

    
      PRIVACY
AND CONFIDENTIALITY

    

    
      

       

      I. The
CONTRACTOR shall comply with all applicable federal and State laws, including
the Health Insurance Portability
and Accountability Act (HIPAA) regarding the confidentiality and disclosure
of information
about enrollees. this includes individual medical records and any other health
and enrollment
information that identifies a particular enrollee.

    

    
      

       

      The
CONTRACTOR must comply with the following:

    

    
      

       

      1. In
accordance with 42 CFR Part 431, subpart F, the CONTRACTOR is prohibited from
disclosing information concerning applicants and enrollees unless such
disclosure is directly connected with the administration of the program,
including (a) establishing eligibility, (b) determining the level of family
contribution based on the household's income and the applicable Federal Poverty
Level (FPL); (c) providing services for enrollees; and (d) investigation or
prosecution related to administration of the program;

    

    
      

       

      2. The
CONTRACTOR must maintain information in a timely and accurate
manner;

    

    
      

       

      3. The
CONTRACTOR must specify and make available to any enrollee requesting it (a) the
purpose for which information is maintained or used, and (b) to whom and for
what purposes information will be disclosed outside the State;
and

    

    
      

       

      4. Except
as provided in federal and State law, the CONTRACTOR must ensure that each
enrollee may request a copy of his or her records/information and receive such
records/information in a timely manner and that an enrollee may request that his
or her records/information be supplemented or corrected.

    

    
      

       

      II. Effective
January 1, 2007, the CONTRACTOR shall comply with the following
agreement:

    

    
      

       

      147

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      Federal
Health Insurance Portability and Accountability Act (HIPAA) Business Associate
Agreement ("Agreement")

    

    
      

       

      This
Business Associate Agreement between the New York State Department of Health and
CONTRACTOR, hereinafter referred to as the Business Associate, is effective for
the contract period specified on the cover page of the
AGREEMENT.

    

    
      

       

      I. Definitions: The
terms used, but not otherwise defined, in this agreement shall have the same
meaning as those terms in the federal Health Insurance Portability and
Accountability Act of 1996 ("HIPAA") and its implementing regulations, including
those at 45 CFR Parts 160 and 164.

    

    
      

       

      II. Obligations
and Activities of the Business Associate:

    

    

    
      

       

      (a) The
Business Associate agrees to not use or further disclose Protected Health
Information other than as permitted or required by this Agreement or as required
by law.

    

    
      

       

      (b) The
Business Associate agrees to use the appropriate safeguards to prevent use or
disclosure of the Protected Health Information other than as provided for by
this Agreement and to implement administrative, physical and technical
safeguards that reasonably and appropriately protect the confidentiality,
integrity and availability of any electronic Protected Health Information that
it creates, receives, maintains or transmits on behalf of the Covered Entity
pursuant to this Agreement.

    

    
      

    

    
      (c) The
Business Associate agrees to mitigate, to the extent practicable, any harmful
effect that is known to the Business Associate of a use or disclosure of
Protected Health Information by the Business Associate in violation of the
requirements of this Agreement.

    

    
      

       

      (d) The
Business Associate agrees to report to the Covered Program, any use or
disclosure of the Protected Health Information not provided for by this
Agreement, as soon as reasonably practicable of which it becomes aware. The
Business Associate also agrees to report to the Covered Entity any security
incident of which it becomes aware.

    

    
      

       

      (e) The
Business Associate agrees to ensure that any agent, including a subcontractor,
to whom it provides Protected Health Information received from, or created or
received by the Business Associate on behalf of the Covered Program agrees to
the same restrictions and conditions that apply through this Agreement to the
Business Associate with respect to such information.

    

    
      

       

      (f) The
Covered Program does not routinely receive PHI, therefore The Business
Associate, agrees to directly Implement on behalf of the Covered Program, the
HIPAA Privacy authorization requirements (45 CFR 164.508), verifications
requirements (45 CFR 164.514 (h)), and individual rights under 45 CFR past 160
and 164 including:

    

    
      

       

      i.    Responding
to request for restrictions to use and disclosures of PHI, other than those that
would constrain the CHP program B access for purposes of handling complaints or
conducting audits, and adhering to any agreed upon restrictions to meet the
requirements of 45 CFR 164.522(a)

    

    
      ii.   Respond
to requests and accommodate reasonable requests for confidential communications
to meet the requirements of 45CFR 164.522(b).

    

    
      iii.
Providing access to Protected Health Information in a Designated Record Set, to
an Individual in order to meet the requirements under 45 CFR 164.524, if the
business associate has protected health information in a designated record
set.

    

    
      iv.
Making any amendment(s) to Protected Health Information or appending the
necessary information pursuant to an amendment request in a designated record
set at the request of an Individual, if the business associate has protected
health information in a designated record set.

    

    
      v.   Documenting
such disclosures of Protected Health Information and information related to
such

    

    
      

       

      148

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      disclosures
as would be required to respond to a request by and Individual for an accounting
of disclosures of Protected Health Information in accordance with 45 CFR 164.528
vi. Providing to the Individual information collected in accordance with this
Agreement, to respond to a request by and Individual accounting of disclosures
of Protected Health Information in accordance with 45 CFR
164.528.

    

    
      

       

      (g)    The
Business Associate agrees to maintain and retain the necessary documentation for
the

    

    
      processes
listed in (f) including policies and procedures and communications that are
provided in writing or required to be documented for a minimum of six (6)
years.

    

    
      

       

      (h)    The
Business Associate agrees to make internal practices, books, and records
relating to the use and disclosure of Protected Health Information received
from, or created or received by the Business Associate on behalf of, the Covered
Program available to the Covered Program, or to the Secretary of Health and
Human Services, in a time and manner designated by the Covered Program or the
Secretary, for purposes of the Secretary determining the Covered Program's
compliance with the Privacy Rule.

    

    
      

       

      III. Permitted Uses and
Disclosures by Business Associate

    

    
      

       

      (a) General
Use and Disclosure Provisions

    

    
      

       

      Except as
otherwise limited in this Agreement, the Business Associate may use or disclose
Protected Health Information to perform functions, activities, or services for,
or on behalf of, the Covered Entity as specified in the agreement to which this
is an addendum, provided that such use or disclosure would not violate the
Privacy Rule if done by Covered Entity.

    

    
      

       

      (b) Specific
Use and Disclosure Provisions:

    

    
      

       

      (1) Except
as otherwise limited in this Agreement, the Business Associate may disclose
Protected Health Information for the proper management and administration of the
Business Associate, provided that disclosures are required by law, or Business
Associate obtains reasonable assurances from the person to whom the information
is disclosed that it will remain confidential and used or further disclosed only
as required by law or for the purpose for which it was disclosed to the person,
and the person notifies the Business Associate of any instances of which it is
aware in which the confidentiality of the information has been
breached.

    

    
      

       

      (2) Except
as otherwise limited in this Agreement, Business Associate may use Protected
Health Information to provide Data Aggregation services to Covered Entity as
permitted by 42 CFR 164.504(e)(2)(i)(B). Data Aggregation includes the combining
of protected information created or received by a business associate through its
activities under this contract with other information gained from other
sources.

    

    
      

       

      IV. Obligations of Covered
Program

    

    
      

       

      Provisions
for the Covered Program to Inform the Business Associate of Privacy
Practices

    

    
      

       

      (a)   The
Covered Entity shall notify the Business Associate of any limitation(s) in its
notice of privacy practices of the Covered Entity in accordance with 45 CFR
164.520, to the extent that such limitation may affect the Business Associate's
use or disclosure of Protected Health Information.

    

    
      

       

      V. Permissible Requests by
Covered Entity

    

    
      

       

      The
Covered Entity shall not request the Business Associate to use or disclose
Protected Health Information in any manner that would not be permissible under
the Privacy Rule if done by Covered Entity, except if the Business Associate
will use or disclose protected health information for, and
the

    

    
      

       

      149

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      contract
includes provisions for, data aggregation or management and administrative
activities of Business Associate.

    

    
      

       

      VI. Term and
Termination

    

    
      

       

      (a) Term.
The Term of this Agreement shall be effective as of the date noted in this
Appendix L of this agreement, at which time all of the Protected Health
Information provided by Covered Entity to Business Associate, or created or
received by Business Associate on behalf of Covered Entity, shall be destroyed
or returned to Covered Entity, or, if it is infeasible to return or destroy
Protected Health Information, protections are extended to such information, in
accordance with the termination provisions in this Section.

    

    
      

       

      (b) Termination
for Cause. Upon the Covered Entity's knowledge of a material breach by Business
Associate, Covered Entity may provide an opportunity for the Business Associate
to cure the breach or end the violation and may terminate this Agreement if the
Business Associate does not cure the breach or end the violation within the time
specified by Covered Entity, or may immediately terminate this Agreement if the
Business Associate has breached a material term of this Agreement and cure is
not possible.

    

    
      

       

      (c) Effect
of Termination.

    

    

    
      

       

      (1) As
noted in section VI above, upon termination of this Agreement, for any reason,
the Business Associate shall return or destroy all Protected Health Information
received from the Covered Entity, or created or received by the Business
Associate on behalf of the Covered Entity. This provision shall apply to
Protected Health Information that is in the possession of subcontractors or
agents of the Business Associate. The Business Associate shall retain no copies
of the protected Health Information.

    

    
      

       

      (2) In
the event that the Business Associate determines that returning or destroying
the Protected Health Information is infeasible, the Business Associate shall
provide to the Covered Entity notification of the conditions that make return or
destruction infeasible. Upon mutual agreement of the Parties that return or
destruction of Protected Health Information is infeasible, the Business
Associate shall extend the protections of this Agreement to such Protected
Health Information and limit further uses and disclosures of such Protected
Health Information to those purposes that make the return or destruction
infeasible, for so long as Business Associate maintains such Protected Health
Information.

    

    
      

       

      VII. Violations

    

    
      

       

      (a) It
is further agreed that any violation of this agreement may cause irreparable
harm to the STATE, therefore the STATE may seek any other remedy, including an
injunction or specific performance for such harm, without bond, security or
necessity of demonstrating actual damages.

    

    
      

       

      (b) The
business associate shall indemnify and hold the STATE harmless against all
claims and costs resulting from acts/omissions of the business associate in
connection with the business associate's objections under this
agreement.

    

    
      

       

      150

       

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    
      VIII.
Miscellaneous

    

    
      

       

      (a) Regulatory
References. A reference in this Agreement to a section in the HIPAA Privacy Rule
means the section as in effect or as amended, and for which compliance is
required.

    

    
      (b) Amendment.
The Parties agree to take such action as is necessary to amend this Agreement
from time to time as is necessary for Covered Entity to comply with the
requirements of the Privacy Rule and the Health Insurance Portability and
Accountability Act, Public Law 104-191.

    

    
      (c) Survival.
The respective rights and obligations of the Business Associate under Section VI
(c) of this Agreement shall survive the termination of this
Agreement.

    

    
      (d) Interpretation.
Any ambiguity in this Agreement shall be resolved in favor of a meaning that
permits the Covered Entity to comply with the HIPAA Privacy
Rule.

    

    
      (e) If
anything in this agreement conflicts with a provision of any other agreement on
this matter, this agreement is controlling.

    

    
      (f) HIV/AIDS.
If HIV/AIDS information is to be disclosed under this agreement, the business
associate acknowledges that it has been informed of the confidentiality
requirements of Public Health Law Article 27-F.

    

    
      

    

    
      

    

    
      	
                /s/  Todd
      S. Farha

            	  
      /s/  Illegible  
	
              Signature
      of the covered entity

            	
              Signature
      of the covered entity

               

            
	
              12/19/08

            	12/21/07
	
              Date

            	
              Date

            

    

    
      

    

    
      

       

    

    
      

       

      

    

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      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

              

               

            	
              STATE
      AGENCY SIGNATURE

            
	
              By:

            	
              By:

            
	
              Printed
      Name:

            	
              Printed
      Name:

            
	
              Title:

            	
              Title:

            
	
              Date:

            	
              Date:

            
	 
      	
              
                 

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

              

               

            
	 
      	 
      

    

    
      

       

      STATE OF
FLORIDA

    

    
      

       

      County of
Hillsborough

    

    
      

       

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

    

    
      

    

    
      

    

    
      

    

    
      __________________________________

    

    
      Signature
and office of the individual taking acknowledgement

    

    
      

    

    
      

    

    
      STATE
COMPTROLLER’S SIGNATURE

    

    
      Title:

    

    
      Date:EX-4.1

EXHIBIT 4.1

AMENDMENT TO RIGHTS AGREEMENT

THIS AMENDMENT TO RIGHTS AGREEMENT (this “Amendment”) is entered into as of April 7,
2008, between Eclipsys Corporation, a Delaware corporation (the "Company”), and
Computershare Trust Company, N.A., a national banking association (as successor rights agent to
Equiserve and Fleet National Bank) (“Rights Agent”), with respect to the following:

A. The Company and Fleet National Bank entered into that certain Rights Agreement, dated as of
July 26, 2000 (the “Agreement”); and

B. The Board of Directors of the Company has authorized the amendment of the Agreement to
amend the Final Expiration Date; and

C. Pursuant to Section 27 of the Agreement, the Company may, and the Rights Agent shall, if
the Company so directs, supplement or amend the Agreement without the approval of the holders of
the rights.

NOW, THEREFORE, in consideration of the foregoing, the parties hereto agree as follows:

1. Section 1(o). Section 1(o) of the Agreement is deleted in its entirety and
replaced with the following:

“Final Expiration Date” shall mean the close of business on May 8, 2008.”

2. Miscellaneous.

(a) If this Amendment conflicts with or is inconsistent with any provision contained in the
Agreement, this Amendment shall control. Except as expressly amended above, the Agreement shall
continue in full force and effect in accordance with its terms.

(b) This Amendment may be executed in two or more counterparts, each of which shall be deemed
to be an original and all of which together shall be considered to be one document.

(c) All terms used but not defined herein shall have the same meaning given to them in the
Agreement.

IN WITNESS WHEREOF, the parties hereto have caused this Amendment to be duly executed as of
the date first set forth above.

	 	 	 
	ECLIPSYS CORPORATION
	By:

Name:

Title:

	 	/s/Brian W. Copple

Brian W. Copple

Secretary

	 	 	 

	 	 	 
	COMPUTERSHARE TRUST COMPANY, N.A.
	By:

Name:

Title:

	 	/s/ Tyler Haynes

Tyler Haynes

Manager

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