Document:

ex10_4.htm

    DEBT
SUBORDINATION AGREEMENT

    

    Presidential
Financial Corporation (“Presidential”)

    Caller
Service #105100

    Tucker,
GA  30085-5100

    

    Gentlemen:

    

    In consideration of the line of credit
to OE SOURCE,
L.C.,
(hereinafter called "Debtor"), undersigned hereby agrees that any and all
liability that said Debtor may now or hereafter owe to undersigned shall be
subordinate and junior to any and all liability said Debtor may now or hereafter
owe to you direct or contingent.  Undersigned also agree that any
collateral that undersigned shall have to secure its indebtedness will be
subordinate and junior to you.

    

    The undersigned will require no
payments from the Debtor on liability hereby subordinated as long as said Debtor
is liable to you in any amount, direct or contingent. Should any such payment be
received by undersigned, or should any dividend or other distribution be
received by undersigned in any bankruptcy, receivership, liquidation or other
proceeding on account of the liability hereby subordinated; such payment,
dividend or other distribution will be received and held in trust for you and
will be paid over to you to apply on the liability of said Debtor to you until
the same is paid in full, and for this purpose said liabilities are hereby
assigned to you.

    

    Undersigned also agrees that he will
take no action to enforce any security interest in any property of the Debtor,
nor will he declare a default in any obligations owed to him by the Debtor, or
otherwise accelerate or attempt to accelerate the indebtedness owed to him by
the Debtor.

    

    This subordination shall take effect
without any notice from you to the undersigned of the acceptance thereof or of
the extension of credit to or the purchase of liabilities of said
Debtor.  Should the undersigned elect to convert to equity the
indebtedness owed to it by Debtor, this subordination agreement shall
terminate.

    

    IN WITNESS WHEREOF, this instrument has
been signed and sealed by the undersigned this 26th day of August,
2008.

    
    

     

    
      	 	

              GENERAL
      AUTOMOTIVE COMPANY

            
	 	 
	 	

              

                By:      
      

              

            
	 	
              Name:  Harry
      Christenson

            
	 	

              Title:   
      Chief
      Financial Officer

            

    

     

    
      	
              WITNESS:

            	 
	 
      	 
	
              By:

            	 

    

     

    
      	 	
              ACCEPTED
      BY:

              PRESIDENTIAL
      FINANCIAL CORPORATION

            
	 
	
               

            	

              By:     
      

            
	 	
              

                Name:
      Raymond Alberti

              

            
	
               

            	
              

                Title: Senior
      Vice
Presidentnycamendment3.htm

Back to Form 8-K

    MEDICAID
ADVANTAGE MODEL CONTRACT

     

    Amendment
of Agreement

    Between

    The
City of New York

    And

    WellCare
of New York, Inc.

     

    This
Amendment, effective January 1, 2008, amends the Medicaid Advantage Model
Contract (hereinafter referred to as the "Agreement") made by and between the
City of New York, acting through the New York City Department of Health and
Mental Hygiene (hereinafter referred to as "LDSS" or "DOHMH") and WellCare of
New York, Inc. (hereinafter referred to as "Contractor" or "MCO").

     

    WHEREAS
the parties entered into an Agreement effective April 1, 2006 for the purpose of
providing Medicare and Medicaid Advantage Products to eligible recipients
residing in the Contractor's Medicaid Advantage Service Area; and

     

    WHEREAS
the parties desire to amend said Agreement to modify certain provisions to
reflect current circumstances and intentions, and, as authorized in Section 2.1
of the Agreement, to extend the term of the Agreement until December 31,
2009;

    

    NOW
THEREFORE, effective January 1, 2008, it is mutually agreed by the parties to
amend this Agreement as follows:

    

    
      	
               
      

            	
              1.

            	
              Amend Section 19.1 of
      the "Table of Contents for Model Contract," to read, "Section 19.1
      Maintenance of
      Contractor Performance Records, Records Evidencing Enrollment Fraud and
      Documentation
      Concerning Duplicate CINs."

            

    

    

    
      	
               
      

            	
              2.

            	
              Amend Section 3.6,
      "SDOH Right to Recover Premiums," to read as
    follows:

            

    

    

    
      	
               
      

            	
              3.6

            	
              SDOH
      Right to Recover Premiums

            

    

    

    
      	
               
      

            	
              The
      parties acknowledge and accept that the SDOH has a right to recover
      premiums paid to the Contractor for Enrollees listed on the monthly Roster
      who are later determined for the entire applicable payment month to have
      been disenrolled from the Contractor's Medicare Advantage Product; to have
      been in an institution; to have been incarcerated; to have moved out of
      the Contractor's service area subject to any time remaining in the
      Enrollee's Guaranteed Eligibility period; or to have died. In any event,
      the State may only recover premiums paid for Medicaid Enrollees listed on
      a Roster if it is determined by the SDOH that the Contractor was not at
      risk for provision of Benefit Package services for any portion of the
      payment period. Notwithstanding the foregoing, the SDOH always has the
      right to recover duplicate Medicaid Advantage premiums paid for persons
      enrolled under more than one Client Identification Number (CIN) in the
      Contractor's Medicaid Advantage product whether or not the Contractor has
      made payments to providers.

            

    

    
      
         
Medicaid
Advantage Contract Amendment

          NYC
January 1, 2008

          Page
1

        

      

      
         

        
          

        

      

      
         

      

    

    
      	
               
      

            	
              3.

            	
              Amend Section 19.1,
      "Maintenance of Contractor Performance Records," to read as
      follows:

            

    

    

    
      	
               
      

            	
              19.1

            	
              Maintenance
      of Contractor Performance Records, Records Evidencing Enrollment Fraud and
      Documentation Concerning Duplicate
CINs

            

    

     

    
      	
               
      

            	
              a)

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

            

    

     

    
      	
               
      

            	
              i)

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

            

    

     

    
      	
               
      

            	
              ii)

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

            

    

     

    
      	
               
      

            	
              iii)

            	
              all
      documents concerning enrollment fraud or the fraudulent use of any
      CIN;

            

    

     

    
      	
               
      

            	
              iv)

            	
              all
      documents concerning duplicate
CINs;

            

    

     

    
      	
               
      

            	
              v)

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

            

    

     

    
      	
               
      

            	
              b)

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

            

    

    

    
      	
               
      

            	
              4.

            	
              Amend Section 19.3,
      “Access to Contractor Records, “to read as
  follows:

            

    

    

    
      	
               
      

            	
              19.3

            	
              Access
      to Contractor Records

            

    

    

    
      	
               
      

            	
              The
      Contractor shall provide DOHMH, SDOH, the Comptroller of the State of New
      York, DHHS, the Comptroller General of the United States, and their
      authorized representatives with access to all records relating to
      Contractor performance under this Agreement for the purposes of
      examination, audit, and copying (at reasonable cost to the requesting
      party). The Contractor shall give access to such records on two (2)
      business days prior written notice, during normal business hours, unless
      otherwise provided or permitted by applicable laws, rules, or regulations.
      Notwithstanding the foregoing, when records are sought in connection with
      a "fraud" or "abuse" investigation, as defined respectively in 10 NYCRR
      §98.1.21 (a) (1) and (a) (2), all costs associated with production and
      reproduction shall be the responsibility of the
  Contractor.

            

    

    

    
      	
               
      

            	
              5.

            	
              Amend Section 22.7
      "Recover of Over. payments to Providers" to read as
      follows:

            

    

    

    
      	
               
      

            	
              22.7

            	
              Recovery
      of Overpayments to Providers

            
	 	 	
               

              Consistent
      with the exception language in Section 3224-b of the Insurance Law, the
      Contractor shall have and 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.

            

    

     

     

    
 

    
      
        
           
Medicaid
Advantage Contract Amendment

          NYC
January 1, 2008

          Page
2

        

      

      
         

        
          

        

      

      
         

      

    

     

    
      	
               
      

            	
              6.

            	
              The
      attached Appendix D, "New York State Department of Health Medicaid
      Advantage Marketing Guidelines," is substituted for the period beginning
      January 1, 2008.

            

    

    

    
      	
               
      

            	
              7.

            	
              The
      attached Appendix H, "New York State Department of Health Guidelines for
      the Processing of Medicaid Advantage Enrollments and Disenrollments," is
      substituted for the period beginning January 1,
  2008.

            

    

    

    
      	
               
      

            	
              8.

            	
              The
      attached Appendix K, "Medicare and Medicaid Advantage Products and
      Non-Covered Services," is substituted for the period beginning January 1,
      2008.

            

    

    

    
      	
               
      

            	
              9.

            	
              The
      attached Appendix N "New York City Specific Contracting Requirements" is
      substituted for the period beginning January 1,
  2008.

            

    

     

    
      
         Medicaid
Advantage Contract Amendment

          NYC
January 1, 2008

          Page  3

        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    This
Amendment is effective January 1, 2008 and the Agreement, including the
modifications made by this Amendment, shall remain in effect until December 31,
2009 or until an extension, renewal or successor Agreement is entered into as
provided for in Section 2.1 of the Agreement.

     

    IN
WITNESS WHEREOF, the parties have duly executed this Amendment to the Agreement
on the dates appearing below their respective signatures.

     

    
      	
              CONTRACTOR

               

               

               

            	
              CITY
      OF NEW YORK

            
	
              By    /s/ Heath
      Schiesser             
      

                     
       (Signature)

                   

                 
           Heath
      Schiesser                  
      

                  
          (Printed Name) 

               

              Title
      President and
      CEO        
            

                    
        WellCare of New York,
      Inc.

            	
              By  
      /s/ Andrew Rein 
                
            

                      (Signature)

               

                     
      Andrew
      Rein                        

                      (Printed
      Name)

               

              Title
      Chief Operating
      Officer      

                      (NYC DOHMH)

            
	
               

              Date 6/2/08                                  
         

            	
               

              Date 7/18/08                           
            
  

            

    

     

    
      
        
          Medicaid
Advantage Contract Amendment

          NYC
January 1, 2008

          Page  4

        

      

      
         

        
          

        

      

      
         

      

    

     

    STATE OF
FLORIDA

    

    COUNTY OF
HILLSBOROUGH

                                    

    On this
6th  day
of June,
2008, Heath Schiesser came
before me, to me known and known to be the President and CEO of
WellCare of New York, Inc., who is duly authorized to execute the
foregoing instrument on behalf of said corporation and s/he acknowledged to me
that s/he executed the same for the purpose therein mentioned.

    

    /s/ Sara
Gallo

    NOTARY
PUBLIC

    

    STATE OF
NEW YORK)

    SS:

    COUNTY OF
NEW YORK

    

    On this
18th day of July, 2008, Andrew
Rein came
before me, to me known and known to be the Chief Operating Officer  in the
New York City Department of Health and Mental Hygiene, who is duly authorized to
execute the foregoing instrument on behalf of the City and s/he acknowledged to
me that s/he executed the same for the purpose therein
mentioned.

     

                                                                                                                                                  
/s/ Frank
Lane        

                                                                                                                                                   NOTARY
PUBLIC

    
      
        
        

      

      
         

        
          

        

      

      
         

      

    

    Appendix
D

     

    New
York State Department of Health

    Medicaid
Advantage Marketing Guidelines

    
      
         Medicaid
Advantage Contract

          APPENDIX
D

          NYC
January 1, 2008

          D-1

        

      

      
         

        
          

        

      

      
         

      

    

    MEDICAID
ADVANTAGE MEETING GUIDELINES

    

    I.           Purpose

     

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

    

    II.           Marketing
Materials

     

    A.           Definitions

     

    
      	
               
      

            	
              1.

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

            

    

     

    
      	
               
      

            	
              2.

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

            

    

     

    B.           Marketing
Material Requirements

     

    In
addition to meeting CMS' Medicare Advantage marketing requirements and guidance
on marketing to individuals entitled to Medicare and Medicaid:

     

    
      	
               
      

            	
              1.

            	
              Medicaid
      Advantage marketing materials must be written in prose that is understood
      at a fourth-to sixth-grade reading level except when the Contractor is
      using language required by CMS, and must be printed in at least twelve
      (12) point font.

            

    

     

    
      	
               
      

            	
              2.

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

                and
      do not speak English as a first language. SDOH will inform the DOHMH and
      the DOHMH will the Contractor when the 5% threshold has been reached.
      Marketing materials tobe translated include those key materials, such as
      informational brochures, that are produced for routine distribution, and
      which are included within the MCO's marketing plan. SDOH will determine
      the need for other than English translations based on county specific
      census data or other available
measures.

              

            

    

    
      
        
          Medicaid
Advantage Contract

          APPENDIX
D

          NYC
January 1, 2008

          D- 2

        

      

      
         

        
          

        

      

      
         

      

    

     

    
      	
               
      

            	
              3.

            	
              The
      Contractor shall advise potential Enrollees, in written materials related
      to enrollment, to verify with the medical services providers they prefer,
      or have an existing relationship with, that such medical services
      providers participate in the selected managed care provider's network and
      are available to serve the
participant.

            

    

     

    C.           Prior
Approvals

     

    
      	
               
      

            	
              1.

            	
              The
      CMS and SDOH will jointly review and approve Medicaid Advantage marketing
      videos, materials fpr broadcast (radio, television, or electronic),
      billboards, mass transit (bus, subway or other livery) and
      statewide/regional print advertising materials in accordance with CMS
      timeframes for review of marketing materials. These materials must be
      submitted to the CMS Regional Office for review. CMS will coordinate SDOH
      input in the review process just as SDOH will coordinate DOHMH input in
      the review process.

            

    

     

    
      	
               
      

            	
              2.

            	
              CMS
      and SDOH will jointly review and approve the following Medicaid Advantage
      marketing materials:

            

    

     

    
      	
               
      

            	
              a.

            	
              Scripts
      or outlines of presentations and materials used at health fairs and other
      approved types of events and
locations;

            

    

     

    
      	
               
      

            	
              b.

            	
              All
      pre-enrollment written marketing materials – written marketing materials
      include brochures and leaflets, and presentation materials used by
      marketing representatives;

            	
              -

            

    

     

    
      	
               
      

            	
              c.

            	
              All
      direct mailing from the Contractor specifically targeted to the Medicaid
      market.

            

    

     

    
    

     

    
      	
               
      

            	
              3.

            	
              The
      Contractor shall electronically submit all materials related to marketing
      Medicaid Advantage to Dually Eligible persons to the CMS Regional Office
      for prior written approval. The CMS Medicare Regional Office Plan Manager
      will be responsible for obtaining SDOH input in the review and approval
      process in accordance with CMS timeframes for the review of marketing
      materials. Similarly, SDOH will be responsible for obtaining DOHMH input
      in the review and approval process.

            

    

     

    
    

    
      	
               
      

            	
              4.

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

            

    

    
      
        
           Medicaid
Advantage Contract

            APPENDIX
D

            NYC
January 1, 2008

            D- 3

          

        

         

      

      
         

        
          

        

      

      
         

      

    

     

    
      	
               
      

            	
              5.

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

            

    

     

    D.           Dissemination
of Outreach Materials to LDSS

     

    
      	
               
      

            	
              1.

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

            

    

     

    
      	
               
      

            	
              2.

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

            

    

    

    III.           Marketing
Activities

     

    A.           General
Requirements

     

    
      	
               
      

            	
              1.

            	
              The
      Contractor must follow the State's Medicaid marketing rules and the
      requirements of 42 CFR 438.104 to the extent applicable when conducting
      marketing activities that are primarily intended to sell a Medicaid
      managed care product (i.e., Medicaid Advantage). Marketing activities
      intended to sell a Medicaid managed care product shall be defined as
      activities which are conducted pursuant to a Medicaid Advantage marketing
      program in which a dedicated staff of marketing representatives employed
      by the Contractor, or by an entity with which the Contractor has
      subcontracted, are engaged in marketing activities with the primary
      purpose of enrolling recipients in the Contractor's Medicaid Advantage
      product.

            

    

     

    
      	
               
      

            	
              2.

            	
              Marketing
      activities that do not meet the above criteria shall not be construed as
      having a primary purpose of intending to sell a Medicaid managed care
      product and shall be conducted in accordance with Medicare Advantage
      marketing requirements. Such activities include but are not limited to
      plan sponsored events in which marketing representatives not dedicated to
      the marketing of the Medicaid Advantage product explain Medicare products
      offered by the Contractor as well as the Contractor's Medicaid Advantage
      product.

            

    

     

    B.           Marketing
at LDSS Offices

     

    With
prior LDSS approval, MCOs may distribute CMS/SDOH approved Medicaid Advantage
marketing materials in the local social services district offices and
facilities.

     

    C.           Responsibility
for Marketing Representatives

     

    Individuals
employed by the Contractor as marketing representatives and employees of
marketing subcontractors must have successfully completed the Contractor's
training program
including training related to an Enrollee's rights and responsibilities in
Medicaid Advantage. The Contractor shall be responsible for the activities of
its marketing representatives and the activities of any subcontractor or
management entity.

    
      
        
          
            	
                     Medicaid
      Advantage Contract 

                      APPENDIX
      D

                      NYC
      January 1, 2008

                      D-4 
      

                    

                  

          

           

        

      

      
        
          

        

      

      
         

      

    

     

    D.           Medicaid
Advantage Specific Marketing Requirements

     

    The
requirements in Section D apply only if marketing activities for the Medicaid
Advantage Program are conducted pursuant to a Medicaid Advantage marketing
program in which a dedicated staff of marketing representatives employed by the
Contractor or by an entity with which the Contractor has a subcontract are
engaged in marketing activities with the sole purpose of enrolling recipients in
the Contractor's Medicaid Advantage product.

     

    
      	
               
      

            	
              1.

            	
              Approved
      Marketing Plan

            

    

     

    
      	
               
      

            	
              a.

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

            

    

     

    
      	
               
      

            	
              b.

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

            

    

     

    
      	
               
      

            	
              c.

            	
              Approved
      Marketing plans will set forth the terms and conditions and proposed
      activities of the Medicaid Advantage dedicated staff during the contract
      period. The following must be included: description of materials to be
      used, distribution methods; primary types of marketing locations and a
      listing of the kinds of community service events the Contractor
      anticipates sponsoring and/or participating in during which it will
      provide information and/or distribute Medicaid Advantage marketing
      materials.

            

    

     

    
      	
               
      

            	
              d.

            	
              An
      approved marketing plan must be on file with the SDOH and the DOHMH prior
      to the Contractor engaging in the Medicaid Advantage specific marketing
      activities.

            

    

     

    
      	
               
      

            	
              e.

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

            

    

     

    
      	
               
      

            	
              f.

            	
              The
      Contractor must describe how it is able to meet the informational needs
      related to marketing for the physical and cultural diversity of its
      potential membership. This may include, but not be limited to, a
      description of the Contractor's other than English language provisions,
      interpreter services, alternate communication mechanisms including sign
      language, Braille, audio tapes, and/or use of Telecommunications Devices
      for the Deaf (TTY)
services. 

            

    

    
      
        
          Medicaid
Advantage Contract

          APPENDIX
D

          NYC
January 1, 2008

          D-5   

        

      

      
         

        
          

        

      

      
         

      

    

     

    
      	 	
               g.

            	
               The
      Contractor shall describe measures for monitoring and enforcing compliance
      with these guidelines by its Marketing representatives including the
      prohibition of door to door solicitation and cold-call telephoning; a
      description of the development of pre-enrollee mailing lists that
      maintains client confidentiality and honors the client's express request
      for direct contact by. the Contractor; the selection and distribution of
      pre-enrollment gifts and incentives to prospective enrollees ; and a
      description of the training, compensation and supervision of its Medicaid
      Advantage dedicated Marketing
representatives.

            

    

     

    
      	
               
      

            	
              2.

            	
              Prohibition
      of Cold Call Marketing Activities

            

    

     

    Contractors
are prohibited from directly or indirectly, engaging in door to door, telephone,
or other cold-call marketing activities.

     

    
      	
               
      

            	
              3.

            	
              Marketing
      in Emergency Rooms or Other Patient Care
Areas

            

    

     

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

     

    
      	
               
      

            	
              4.

            	
              Enrollment
      Incentives

            

    

     

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

     

    E.           General
Marketing Restrictions

     

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

     

    
      	
               
      

            	
              1.

            	
              Contractors
      are prohibited from misrepresenting the Medicaid program, the Medicaid
      Advantage Program or the policy requirements of the LDSS or
      SDOH.

            

    

     

    
      	
               
      

            	
              2.

            	
              Contractors
      are prohibited from purchasing or otherwise acquiring or using mailing
      lists that specifically identify Medicaid recipients from third party
      vendors, including providers and LDSS offices, Unless otherwise permitted
      by CMS. The Contractor may produce materials and cover their costs of
      mailing to Medicaid recipients if the mailing is carried out by the State
      or LDSS, without sharing specific Medicaid information with the
      Contractor.

            

    

     

    
      	
            	
              3.

            	
              Contractors
      may not discriminate against a potential Enrollee based on his/her current
      health status or anticipated need for future health care. The Contractor
      may not discriminate on the basis of disability or perceived disability of
      any Enrollee or their family member. Health assessments may not be
      performed by the Contractor prior to enrollment. The Contractor may
      inquire about existing primary care relationships of the applicant and
      explain whether and how such relationships may be maintained. Upon
      request, each potential Enrollee shall be provided with a listing of all
      participating providers and facilities in the MCO's network. The
      Contractor may respond to a potential Enrollee's question about whether a
      particular specialist is in the network. However, the Contractor is
      prohibited from inquiring about the types of specialists utilized by the
      potential Enrollee.

            

    

     

    
      
        
          Medicaid
Advantage Contract

          APPENDIX
D

          NYC
January 1, 2008

          D-6   

        

      

      
         

        
          

        

      

      
         

      

    

     

    
      	
               
      

            	
              4.

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

            

    

     

    
      	
               
      

            	
              5.

            	
              Contractors
      are responsible for ensuring that their Marketing representatives engage
      in professional and courteous behavior in their interactions with LDSS and
      DOHMH staff, staff from other health plans and Medicaid clients. Examples
      of inappropriate behavior include interfering with other health plan
      presentations or talking negatively about another health
    plan.

            

    

     

    
      	
               
      

            	
              6.

            	
              The
      Contractor shall not market to enrollees of other health plans. If the
      Contractor becomes aware during a marketing encounter that an individual
      is enrolled in another health plan, the marketing encounter must be
      promptly terminated, unless the individual voluntarily suggests
      dissatisfaction with the health plan in which he or she is
      enrolled.

            

    

     

    
      	
               
      

            	
              7.

            	
              The
      Contractor shall not offer compensation including salary increases or
      bonuses, based solely on the number of individuals enrolled by Marketing
      Representatives who are licensed to offer Medicare products only,
      including Medicaid Advantage, and who also market Medicaid, Family Health
      Plus and Child Health Plus. However, the Contractor may base compensation
      of these Marketing Representatives on periodic performance evaluations
      which consider enrollment productivity as one of several performance
      factors during a performance period, subject to the following
      requirements:

            

    

     

    
      	
               
      

            	
              a.

            	
              "Compensation"
      shall mean any remuneration required to be reported as income or
      compensation for federal tax
purposes;

            

    

     

    
      	
               
      

            	
              b.

            	
              The
      Contractor may not pay a "commission" or fixed amount per
      enrollment;

            

    

     

    
      	
            	
              c.

            	
              The
      Contractor may not award bonuses more frequently than quarterly, or for an
      annual amount that exceeds ten percent (10%) of a Marketing
      Representative's total annual compensation;

            

    

     

    
      
        
          Medicaid
Advantage Contract

          APPENDIX
D

          NYC
January 1, 2008

          D-7   

        

      

      
         

        
          

        

      

      
         

      

    

     

    
    

    
      	
            	
              d.

            	
              
                Sign
      on bonuses for Marketing Representatives are
    prohibited;

              

            

    

     

    
      	
               
      

            	
              e.

            	
              Where
      productivity is a factor in the bonus determination, bonuses must be
      structured in such a way that productivity carries a weight of no more
      than 30% of the total bonus and that application quality/accuracy must
      carry a weight equal to or greater than the productivity
      component;

            

    

     

    
      	
               
      

            	
              f.

            	
              The
      Contractor must limit salary adjustments for Marketing Representatives 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;

            

    

     

    
      	
               
      

            	
              g.

            	
              The
      Contractor is prohibited from reducing base salaries for Marketing
      Representatives for failure to meet productivity
  targets;

            

    

     

    
      	
               
      

            	
              h.

            	
              The
      Contractor is prohibited from offering non-monetary compensation such as
      gifts and trips to Marketing
Representatives;

            

    

     

    
      	
               
      

            	
              i.

            	
              The
      Contractor shall have human resource policies and procedures for the
      earning and payment of overtime and must be able to produce documentation
      (such as time sheets) to support overtime compensation;
  and

            

    

     

    
      	
               
      

            	
              The
      Contractor shall keep written documentation, including performance
      evaluations or other tools it uses as a basis for awarding bonuses or
      increasing the salary of Marketing Representatives and employees involved
      in Marketing and make such documentation available for inspection by SDOH
      or the DOHMH.

            

    

    

    IV.           Marketing
Infractions

     

    
      	
               
      

            	
              A.

            	
              Infractions
      of Medicaid marketing guidelines, as found in Appendix D, Sections III D
      and E, may result in the following actions being taken by the SDOH and/or
      the DOHMH to protect the interests of the program and its clients. These
      actions shall be taken by the SDOH and/or DOHMH in collaboration with the
      CMS Regional Office.

            

    

     

    
      	
               
      

            	
              1.

            	
              If
      the Contractor or its representative commits a first time infraction of
      marketing guidelines and the SDOH and/or the DOHMH deems the infraction to
      be minor or unintentional in nature, the SDOH and/or the DOHMH may issue a
      warning letter to the Contractor.

            

    

     

    
      	
               
      

            	
              2.

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

            

    

     

    
      
        
          
            Medicaid
Advantage Contract

            APPENDIX
D

            NYC
January 1, 2008

            D-8   

          

        

        
           

          
            

          

        

        
           

        

      

    

     

    
      	
               
      

            	
              3.

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

            

    

     

    
      	
               
      

            	
              a)

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

            

    

     

    
      	
               
      

            	
              b)

            	
              suspend
      new Medicaid Advantage Enrollments, for a period up to the remainder of
      the Agreement period; or

            

    

     

    
      	
               
      

            	
              c)

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

            

    

    
      
        
          Medicaid
Advantage Contract

          APPENDIX
D

          NYC
January 1, 2008

          D-9   

        

      

      
         

        
          

        

      

      
         

      

    

    APPENDIX
H

     

    New
York State Department of Health Guidelines for the 

    Processing
of Medicaid Advantage Enrollments and Disenrollments

    
      
        
          Medicaid
Advantage Contract

          APPENDIX
H

          NYC
January 1, 2008

          H-1   

        

      

      
         

        
          

        

      

      
         

      

    

     

    Appendix
H

    SDOH
Guidelines

    For
the Processing of Medicaid Advantage Enrollments and

    Disenrollments

     

    
      	
              1.

            	
              General

            

    

     

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

     

    
      	
              2.

            	
              Enrollment

            

    

    

    
      	
              a)

            	
              SDOH
      Responsibilities:

            

    

    

    
      	
               
      

            	
              i)

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

            

    

    

    
      	
               
      

            	
              ii)

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

            

    

     

    
      	
              b)

            	
              LDSS
      Responsibilities:

            

    

    
      	
               
      

            	
              i)

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

            

    

    

    
      	
               
      

            	
              ii)

            	
              Each
      LDSS determines Medicaid eligibility. To the extent practicable, the LDSS
      will follow up with Enrollees when the Contractor provides documentation
      of any change in status which may affect the Enrollee's Medicaid and/or
      Medicaid Advantage eligibility.

            

    

    

    
      	
               
      

            	
              iii)

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

            

    

    
      
         
Medicaid
Advantage Contract

          APPENDIX
H

          NYC
January 1, 2008

          H-2 

        

      

      
         

        
          

        

      

      
         

      

    

    
      	
               
      

            	
              iv)

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

            

    

    

    
      	
               
      

            	
              v)

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

            

    

    

    
      	
               
      

            	
              vi)

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

            

    

    

    
      	
               
      

            	
              vii)

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

            

    

    

    
      	
               
      

            	
              viii)

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

            

    

    

    
      	
               
      

            	
              ix)

            	
              The
      LDSS is responsible for processing Enrollments in Medicaid Advantage
      without edits for Medicare coverage in the Welfare Management System
      (WMS); however the LDSS is responsible for ensuring that WMS is updated
      with Medicare A and B coverage status for new Enrollees upon review of
      documentation provided by the Contractor or the
  Enrollee.

            

    

    

    
      	
               
      

            	
              x)

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

            

    

    

    
      	
               
      

            	
              xi)

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

            

    

    

    
      	
               
      

            	
              xii)

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

            

    

    

    
      	
               
      

            	
              xiii)

            	
              The
      LDSS is responsible for entering individual enrollment form data and
      transmitting that data to the State's Prepaid Capitation Plan (PCP)
      Subsystem.

            

    

    
      
        
          Medicaid
Advantage Contract

          APPENDIX
H

          NYC
January 1, 2008

          H-3   

        

      

      
         

        
          

        

      

      
         

      

    

    
      	
               
      

            	
              The
      transfer of enrollment information may be accomplished by any of the
      following:

            

    

     

    
      	
               
      

            	
              A)

            	
              LDSS
      directly enters data into PCP Subsystem;
or

            

    

     

    
      	
               
      

            	
              B)

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

            

    

     

    
      	
               
      

            	
              C)

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

            

    

    

    
      	
               
      

            	
              xiv)

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

            

    

    

    
      	
               
      

            	
              xv)

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

            

    

    

    
      	
               
      

            	
              xvi)

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

            

    

    

    
      	
               
      

            	
              xvii)

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

            

    

     

    
      	
               
      

            	
              A)

            	
              Enrollment
      Confirmation Notice: This notice indicates the Effective Date of
      Enrollment, the name of the Medicaid Advantage Product and the individual
      who is being enrolled. This notice must also include a statement advising
      the individual that if his/her Medicare Advantage enrollment is denied by
      CMS, the individual's Medicaid Advantage Enrollment will be voided
      retroactively back to the Effective Date of Enrollment. In such instances,
      the individual may be responsible for the cost of any Medicaid Advantage
      Benefit rendered during the retroactive period if the benefit was provided
      by a non-Medicaid participating
provider.

            

    

     

    
      	 	
              B)

            	
               
      Notice of Denial of Enrollment: This notice is used when an individual has
      been determined by LDSS to be ineligible for enrollment into a
      Medicaid   

                Advantage
      Product. This notice must include fair hearing
  rights.

            

    

    
      
        
          Medicaid
Advantage Contract

          APPENDIX
H

          NYC
January 1, 2008

          H-4   

        

      

      
         

        
          

        

      

      
         

      

    

     

    
      	
              c)

            	
              Contractor
      Responsibilities:

            

    

    
      	
               
      

            	
              i)

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

            

    

    

    
      	
               
      

            	
              ii)

            	
              The
      Contractor is responsible for obtaining documentation of Medicare A and B
      coverage prior to sending the Enrollment transaction to the LDSS for
      processing. In all areas where Enrollments are not processed by the
      Enrollment Broker, the documentation must accompany the Enrollment form to
      the LDSS. Acceptable documentation includes: a current Medicare card or
      other documentation acceptable to CMS or received by the Contractor from
      interaction with CMS' data systems.

            

    

    

    
      	
               
      

            	
              iii)

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

            

    

    

    
      	
               
      

            	
              iv)

            	
              The
      Contractor must notify new Enrollees of their Effective Date of
      Enrollment. To the extent practicable, such notification must precede the
      Effective Date of Enrollment. This notice must also include a statement
      advising the individual that if his/her Medicare Advantage enrollment is
      denied by CMS, the individual's Medicaid Advantage Enrollment will be
      voided retroactively back to the Effective Date of Enrollment. In such
      instances, the individual may be responsible for the cost of any Medicaid
      Advantage Benefit rendered during the retroactive period if the benefit
      was provided by a non-Medicaid participating
  provider.

            

    

    

    
      	
               
      

            	 v)	
              The
      Contractor must report any changes that affect or may affect the Medicaid
      or Medicaid Advantage eligibility status of its Enrollees to the LDSS
      within five (5) business days of such information becoming known to the
      Contractor. This includes, but is not limited to, address changes,
      incarceration, third party insurance other than Medicare, Disenrollment
      from the Contractor's Medicare Advantage Product,
  etc.

            

    

    
      
        
          Medicaid
Advantage Contract

          APPENDIX
H

          NYC
January 1, 2008

          H-5   

        

      

      
         

        
          

        

      

      
         

      

    

    
      	
               
      

            	
              vi)

            	
              If
      an Enrollee's Enrollment in the Contractor's Medicare Advantage Product is
      rejected by CMS, the Contractor must notify the LDSS within five (5)
      business days of learning of CMS' rejection of the Enrollment. In such
      instances, the LDSS shall delete the Enrollee's Enrollment in the
      Contractor's Medicaid Advantage
Plan.

            

    

    

    
      	
               
      

            	
              vii)

            	
              The
      Contractor, within five (5) business days of identifying cases where a
      person may be enrolled in the Contractor's Medicaid Advantage product
      under more than one MI, must convey that information in writing to the LDS
      S .

            

    

    

    
      	
               
      

            	
              viii)

            	
              The
      Contractor shall advise potential Enrollees, in written materials related
      to enrollment, to verify with the medical services providers they prefer,
      or have an existing relationship with, that such medical services
      providers are Participating Providers and are available to serve the
      Prospective Enrollee.

            

    

    

    
      	
               
      

            	
              ix)

            	
              The
      Contractor shall accept all Enrollments as ordered by the Office of
      Temporary and Disability Assistance's Office of Administrative Hearings
      due to fair hearing requests or
decisions.

            

    

     

    3.           Newborn
Enrollments:

     

    
      	
              a)

            	
              SDOH
      Responsibilities:

            

    

    

    
      	
               
      

            	
              i)

            	
              The
      SDOH will update WMS with information on the newborn received from
      hospitals or birthing centers, consistent with the requirements of Section
      366-g of the Social Services Law as

            

    

    
      	
               
      

            	
              amended
      by Chapter 412 of the Laws of 1999.

            

    

    

    
      	
               
      

            	
              ii)

            	
              Upon
      notification of the birth by the hospital or birthing center, the SDOH
      will update WMS with the demographic data for the newborn generating
      appropriate Medicaid coverage.

            

    

     

    
      	
              b)

            	
              LDSS
      Responsibilities:

            

    

    
      	
               
      

            	
              i)

            	
              The
      LDSS is responsible for granting Medicaid eligibility for newborns for one
      (1) year if born to a woman eligible for and receiving MA assistance on
      the date of birth. (Social Services Law Section 366 (4)
    (1))

            

    

    

    
      	
               
      

            	
              ii)

            	
              The
      LDSS is responsible for adding eligible unborns to all WMS cases that
      include a pregnant woman as soon as the pregnancy is medically verified.
      (NYS DSS Administrative Directive 85
ADM-33)

            

    

    
      
        
          Medicaid
Advantage Contract

          APPENDIX
H

          NYC
January 1, 2008

          H-6

        

      

      
         

        
          

        

      

      
         

      

    

    
      	
               
      

            	
              iii)

            	
              In
      the event that the LDSS learns of an Enrollee's pregnancy prior to the
      Contractor, the LDSS is to establish MA eligibility and pre-enroll the
      unborn into Medicaid managed care in cases where an enrollment form is
      received.

            

    

    

    
      	
               
      

            	
              iv)

            	
              When
      a newborn is enrolled in managed care, the LDSS is responsible for sending
      an Enrollment Confirmation Notice to inform the mother of the Effective
      Date of Enrollment, which is the first (1st) day of the month of birth,
      and the plan in which the newborn is
enrolled.

            

    

    

    
      	
               
      

            	
              v)

            	
              The
      LDSS may develop a transmittal form to be used
  for

            

    

    
      	
               
      

            	
              unborn/newborn
      notification between the Contractor and the
  LDSS.

            

    

     

    
      	
              c)

            	
              Contractor
      Responsibilities:

            

    

    
      	
               
      

            	
              i)

            	
              The
      Contractor must notify the LDSS in writing of any Enrollee that is
      pregnant within thirty (30) days of knowledge of the pregnancy.
      Notifications should be transmitted to the LDSS at least monthly. The
      notifications should contain the pregnant woman's name, Client ID Number
      (CIN), and the expected date of confinement
  (EDC).

            

    

    

    
      	
               
      

            	
              ii)

            	
              Upon
      the newborn's birth, the Contractor must send verifications of infant's
      demographic data to the LDSS, within five (5) days after knowledge of the
      birth. The demographic data must include: the mother's name and CIN, the
      newborn's name and CIN (if newborn has a CIN), sex and the date of
      birth.

            

    

    4.Roster
Reconciliation:

     

    
      	
              a)

            	
              All
      Enrollments are effective the first of the
  month.

            

    

     

    
      	
              b)

            	
              SDOH
      Responsibilities:

            

    

    
      	
               
      

            	
              i)

            	
              The
      SDOH maintains both the PCP subsystem Enrollment files and the WMS
      eligibility files, using data input by the LDSS. SDOH uses data contained
      in both these files to generate the
Roster.

            

    

    

    
      	
               
      

            	
              ii)

            	
              SDOH
      shall send monthly to the Contractor and LDSS (according to a schedule
      established by SDOH) a complete list of all Enrollees for which the
      Contractor is expected to assume medical risk beginning on the 1st of the
      following month (First Monthly Roster). Notification to the Contractor and
      LDSS will be accomplished via paper transmission, magnetic media, or the
      HPN.

            

    

    

    
      	
               
      

            	
              iii)

            	
              SDOH
      shall send the Contractor and LDSS monthly, at the time of the first
      monthly roster production, a Disenrollment Report listing those 

                Enrollees
      from the previous month's roster who were disenrolled, transferred to
      another MCO, or whose Enrollments were deleted from the file. Notification
      to the Contractor and LDSSs will be accomplished via paper transmission,
      magnetic media, or the
HPN.

              

            

    

    
      
         
Medicaid
Advantage Contract

          APPENDIX
H

          NYC
January 1, 2008

          H-7 

        

      

      
         

        
          

        

      

      
         

      

    

    
    

    

    
      	
               
      

            	
              iv)

            	
              The
      SDOH shall also forward an error report as necessary to the Contractor and
      LDSS.

            

    

    

    
      	
               
      

            	
              v)

            	
              On
      the first (1st) weekend after the first (1st) day of the month following
      the generation of the first (1st) Roster, SDOH shall send the Contractor
      and LDSS a second Roster which contains any additional Enrollees that the
      LDSS has added for Enrollment for the current month. The SDOH will also
      include any additions to the error report that have occurred since the
      initial error report was generated.

            

    

     

    
      	
              c)

            	
              LDSS
      Responsibilities:

            

    

    
      	
               
      

            	
              i)

            	
              The
      LDSS is responsible for notifying the Contractor electronically or in
      writing of changes in the First Roster and error report, no later than the
      end of the month. This includes, but is not limited to, new Enrollees
      whose Enrollments in Medicaid Advantage were processed subsequent to the
      pull-down date but prior to the Effective Date of Enrollment. (Note: To
      the extent practicable the date specified must allow for timely notice to
      Enrollees regarding their Enrollment status. The Contractor and the LDSS
      may develop protocols for the purpose of resolving Roster discrepancies
      that remain unresolved beyond the end of the
  month).

            

    

    

    
      	
               
      

            	
              ii)

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

            

    

     

    
      	
              d)

            	
              Contractor
      Responsibilities:

            

    

    
      	
               
      

            	
              i)

            	
              The
      Contractor is at risk for providing Benefit Package services for those
      Enrollees listed on the 1St and 2nd Rosters for the month in which the
      211d Roster is generated. Contractor is not at risk for providing services
      to Enrollees who appear on the monthly Disenrollment
    report.

            

    

    

    
      	
               
      

            	
              ii)

            	
              The
      Contractor must submit claims to the State's Fiscal Agent for all Eligible
      Persons that are on the 1st and 2"d Rosters (see Appendix H, page 7),
      adjusted to add Eligible Persons enrolled by the LDSS after Roster
      production and to remove individuals disenrolled by LDSS after Roster
      production (as notified to the Contractor). In the cases of retroactive
      Disenrollments, the Contractor is responsible for submitting
      an adjustment to void any previously paid premiums for the period of
      retroactive Disenrollment, where the Contractor was not at risk for
      theprovision of Benefit Package services. Payment of sub-capitation does
      not constitute "provision of Benefit Package
    services."

            

    

    
      
         
Medicaid
Advantage Contract

          APPENDIX
H

          NYC
January 1, 2008

          H-8 

        

      

      
         

        
          

        

      

      
         

      

    

    
    

    5.           
Disenrollment:

     

    
      	
              a)

            	
              LDSS
      Responsibilities:

            

    

    
      	
               
      

            	
              i)

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

            

    

    

    
      	
               
      

            	
              ii)

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

            

    

    

    
      	
               
      

            	
              iii)

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

            

    

    

    
      	
               
      

            	
              iv)

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

            

    

    

    
      	
               
      

            	
              v)

            	
              The
      LDSS is responsible for processing routine Disenrollment requests to take
      effect on the first (1st)
      day of the following month to the extent possible. In no event shall the
      Effective Date of Disenrollment be later than the first (1st) day
      of the second month after the month in which an Enrollee requests a
      Disenrollment.

            

    

    

    
      	
               
      

            	
              vi)

            	
              The
      LDSS is responsible for disenrolling Enrollees automatically upon death,
      Disenrollment from the Contractor's Medicare Advantage Product, or loss of
      Medicaid eligibility. All such Disenrollments will be effective at the end
      of the month in which the death, Effective Date of Disenrollment from the
      Contractor's Medicare Advantage Product, or loss of eligibility occurs, or
      at the end of the last month of Guaranteed Eligibility, where
      applicable.

            

    

     

    
      	
            	
              vii)

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

              

            

    

     

    
      
        
          Medicaid
Advantage Contract

          APPENDIX
H

          NYC
January 1, 2008

          H-9   

        

      

      
         

        
          

        

      

      
         

      

    

     

    
      	
               
      

            	
              viii)

            	
              The
      LDSS is responsible for ensuring that Retroactive Disenrollments are used
      only when absolutely necessary. Circumstances warranting a retroactive
      Disenrollment are rare and include when an individual is deemed to have
      been non-consensually enrolled in the Contractor's Medicaid Advantage
      Product, is enrolled when ineligible for Enrollment, or when an Enrollee
      enters or resides in a residential institution under circumstances which
      render the individual ineligible; is incarcerated; is retroactively
      disenrolled from the Contractor's Medicare Advantage Product, or dies - as
      long as the Contractor was not at risk for provision of Benefit Package
      services for any portion of the retroactive period. Payment of
      subcapitation does not constitute "provision of Benefit Package services."
      Notwithstanding the foregoing, the SDOH always has the right to recover
      duplicate Medicaid Advantage premiums paid for persons enrolled under more
      than one Client Identification Number (CIN) in the Contractor's Medicaid
      Advantage product whether or not the Contractor has made payments to
      providers.

            

    

    

    
      	
               
      

            	
              ix)

            	
              The
      SDOH may recover premiums paid for Medicaid Advantage Enrollees whose
      eligibility for this program was based on false information, when such
      false information was provided as a result of intentional actions or
      failures to act on the part of an employee of the Contractor; and the
      Contractor shall have no right of recourse against the Enrollee or a
      provider of services for the cost of services provided to the Enrollee for
      the period covered by such
premiums.

            

    

    

    
      	
               
      

            	
              x)

            	
              The
      LDSS is responsible for notifying the Contractor of the retroactive
      disenrollment prior to the action. The LDSS is responsible for finding out
      if the Contractor has made payments to providers on behalf of the Enrollee
      prior to Disenrollment. After this information is obtained, the LDSS and
      Contractor will agree on a retroactive Disenrollment or prospective
      Disenrollment date.

            

    

    

    
      	
               
      

            	
              In
      all cases of retroactive Disenrollment, including Disenrollments effective
      the first day of the current month, the LDSS is responsible for sending
      notice to the Contractor at the time of Disenrollment, of the Contractor's
      responsibility to submit to the SDOH's Fiscal Agent voided premium claims
      within thirty (30) business days of notification from the LDSS for any
      full months of retroactive Disenrollment where the Contractor was not at
      risk for the provision 

                of
      Benefit Package services during the month. Notwithstanding the foregoing,
      the SDOH always has the right to recover duplicate Medicaid Advantage
      premiums paid for persons enrolled under more than one Client
      Identification Number (CIN) in the Contractor's Medicaid Advantage product
      whether or notthe Contractor has made payments to providers. Failure by
      the LDSS to notify the Contractor does not affect the right of the SDOH to
      recover the premium payment as authorized by Section 3.6 of this Agreement
      or for the State Attorney General to bring legal action to recover any
      overpayment.

              

            

    

    
      
        
          Medicaid
Advantage Contract

          APPENDIX
H

          NYC
January 1, 2008

          H-10   

        

      

      
         

        
          

        

      

      
         

      

    

    
    

    

    
      	
               
      

            	
              xi)

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

            

    

    

    
      	
              Reason
      for Disenrollment

            	
              Effective
      Date of Disenrollment

            
	
              ●

            	
              Death
      of Enrollee

            	
              
                ●

              

            	
              First
      day of the month after death

            
	
              ●

            	
              Incarceration

            	
              
                ●

              

            	
               
        First day of the month of incarceration (note-Contractor is at risk
      for covered    

                
       services only to the date of incarceration and is entitled to the
      capitation  

                 
      payment for the month of incarceration).

            
	
              
                
                  ●

                

              

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

            	
              
                ●

              

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

               -

            
	
              
                ●

              

            	
              Individual
      enrolled while ineligible for enrollment

            	
              
                ●

              

            	
              Effective
      Date of Enrollment in the Contractor's Plan.

            
	
              
                ●

              

            	
              Non-consensual
      Enrollment

            	
              
                ●

              

            	
              Retroactive
      to the first day of the month of Enrollment

            
	
              
                
                  ●

                

              

            	
              Enrollee
      moved outside of the District/County of Fiscal
    Responsibility

            	
              
                ●

              

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

            
	
              
                ●

              

            	
              Urgent
      medical need

            	
              
                ●

              

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

            
	
              
                ●

              

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

            	
              
                ●

              

            	
              Retroactive
      to the first day of the month of the request

            
	 
      

              ●

            	
                 
      An
      Enrollee with more than one Client Identification Number (CIN) is enrolled
      in the

                  Contractor's
      Medicaid Advantage Product under more than one of the
CINs.

            	
               

                        
      ●

            	   
      First day of the month the duplicate Enrollment
  began.

    

    

    
      
         
Medicaid
Advantage Contract

          APPENDIX
H

          NYC
January 1, 2008

          H-11 

        

      

      
         

        
          

        

      

      
         

      

    

     

    
      	
              *
      In counties outside of New York City, LDSSs should work together to ensure
      continuity of care through the Contractor if the Contractor's service area
      includes the county to which the Enrollee has moved and the Enrollee, with
      continuous eligibility, wishes to stay enrolled in the Contractor's plan.
      In New York City, Enrollees, not in guaranteed status, who move out of the
      Contractor's Service Area but not outside, of the City of New York (e.g.,
      move from one borough to another), will not be involuntarily disenrolled,
      but must request a Disenrollment or transfer. These Disenrollments will be
      performed on a routine basis unless there is an urgent medical need to
      expedite the Disenrollment.

            

    

    

    
      	
               
      

            	
              xii)

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

            

    

    

    
      	
               
      

            	
              xiii)

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

            

    

    

    
      	
               
      

            	
              xiv)

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

            

    

    

    
      	
               
      

            	
              xv)

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

            

    

     

    
      	
               
      

            	
              A)

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

            

    

     

    
      	
               
      

            	
              B)

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

            

    

     

    
      	
            	
              C)

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

            

    

     

    
      
        
          Medicaid
Advantage Contract

          APPENDIX
H

          NYC
January 1, 2008

          H-12   

        

      

      
         

        
          

        

      

      
         

      

    

     

    
      	
               
      

            	
              xvi)

            	
              In
      those instances where the LDSS approves the Contractor's request to
      disenroll an Enrollee, and the Enrollee requests a fair hearing, the
      Enrollee will remain in the Contractor's Medicaid Advantage Product until
      the disposition of the fair hearing, if Aid to Continue is ordered by the
      New York State Office of Administrative
  Hearings.

            

    

    

    
      	
               
      

            	
              xvii)

            	
              The
      LDSS is responsible for reviewing each Contractor requested Disenrollment
      in accordance with the provisions of Section 8.7 of this Agreement. Where
      applicable, the LDSS may consult with local mental health and substance
      abuse authorities in the district when making the determination to approve
      or disapprove the request.

            

    

    

    
      	
               
      

            	
              xviii)

            	
              The
      LDSS is responsible for establishing procedures whereby the Contractor
      refers cases which are appropriate for an LDSS-initiated Disenrollment and
      submits supporting documentation to the
LDSS.

            

    

    

    
      	
               
      

            	
              xix)

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

            

    

     

    
      	
              b)

            	
              Contractor
      Responsibilities:

            

    

    

    
      	
               
      

            	
              i)

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

            

    

    

    
      	
               
      

            	
              ii)

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

            

    

     

    
      	
            	
              iii)

            	
              The
      Contractor will make a good faith effort to identify cases which may be
      appropriate for an LDSS-initiated Disenrollment. Within five, (5) business
      days of identifying such cases and following LDSS procedures, the
      Contractor will, in writing, refer cases which are appropriate for an
      LDSS-initiated Disenrollment and will submit supporting documentation to
      the LDSS. This includes, but is not limited to, changes in status for its
      enrolled members that may impact eligibility for Enrollment in an MCO such
      as address changes, incarceration, death, ineligibility for Medicaid
      Advantage Enrollment, change in Medicare status, the apparent enrollment
      of a member in the Contractor's Medicaid Advantage product under more than
      one CIN, etc.

            

    

     

    
      
        
          Medicaid
Advantage Contract

          APPENDIX
H

          NYC
January 1, 2008

          H-13

        

      

      
         

        
          

        

      

      
         

      

    

    
    

     

    
      	
               
      

            	
              iv)

            	
              With
      respect to Contractor-initiated
Disenrollments:

            

    

     

    
      	
               
      

            	
              A)

            	
              The
      Contractor may initiate an involuntary Disenrollment if the
      Enrollee:

            

    

    

    
      	
               
      

            	
              i)

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

            

    

    

    
      	
               
      

            	
              ii)

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

            

    

     

    
      	
               
      

            	
              B)

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

            

    

     

    
      	
               
      

            	
              C)

            	
              The
      Contractor must make a reasonable effort to identify for the Enrollee,
      both verbally and in writing, those actions of the Enrollee that have
      interfered with the effective provision of covered services as well as
      explain what actions or procedures are
  acceptable.

            

    

     

    
      	
            	
              D)

            	
              The
      Contractor shall give prior verbal and written notice to the Enrollee,
      with a copy to the LDSS, of its intent to request Disenrollment. The
      written notice shall advise the Enrollee that the request has been
      forwarded to the LDSS for review and approval. The written notice must
      include the mailing address and telephone number of the
    LDSS.

            

       

      
        	
                 
      

              	
                E)

              	
                The
      Contractor shall keep the LDSS informed of decisions related to all
      complaints filed by an Enrollee as a result of, or subsequent to, the
      notice of intent to
disenroll.

              

      

    

     

    
      	
            	
              v)

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

            

    

     

    
      
        
          Medicaid
Advantage Contract

          APPENDIX
H

          NYC
January 1, 2008

          H-14 

        

      

      
         

        
          

        

      

      
         

      

    

     

    APPENDIX K

     

    
    

    
      Medicare
and Medicaid Advantage Products

      
        And
Non-Covered Services

      

    

     

    
      
        
          Medicaid
Advantage Contract

          APPENDIX
K

          NYC
January 1, 2008

          K-1   

        

      

      
         

        
          

        

      

      
         

      

    

    APPEDNIX
K

     

    

    Appendix
K is organized into three parts:

    

    I.           
Appendix K-1

     

     
Medicare Advantage Product

     

    II.           Appendix
K-2

     

     
Medicaid Advantage Product

     

      
Description of Medicaid Only Covered Services

     

    III.          Appendix
K-3

     

      
Non-Covered Services

    
      
        
          Medicaid
Advantage Contract

          APPENDIX
K

          NYC
January 1, 2008

          K-2   

        

      

      
         

        
          

        

      

      
         

      

    

    

    APPENDIX
K1

     

    MEDICARE
ADVANTAGE PRODUCT

     

    
      	
              Medicare
      Advantage Benefit Package for Dual Eligibles

            
	
              Category
      of Service

            	
              Included
      in Medicare Capitation

            
	
              Inpatient
      Hospital Care Including Substance Abuse and Rehabilitation
      Services

            	
              Up
      to 365 days per year (366 days for leap year) with no deductible or
      co-payment

            
	
              Inpatient
      Mental Health

            	
              Medically
      necessary care with no deductible or co-payment. 190-day lifetime limit in
      a psychiatric hospital.

            
	
              Skilled
      Nursing Facility

            	
              Care
      provided in a skilled nursing facility. Covered for 100 days each benefit
      period. No prior hospital stay required. No co-payment.

            
	
              Home
      Health

            	
              Medically
      necessary intermittent skilled nursing care, home health aide services and
      rehabilitation services. No co-payment.

            
	
              PCP
      Office Visits

            	
              Primary
      care doctor office visits. No co-payment.

            
	
              Specialist
      Office Visits

            	
              Specialist
      office visits.  Subject to $10 co-payment for each

              specialist
      office visit.

            
	
              Chiropractic

            	
              Manual
      manipulation of the spine to correct subluxation provided by chiropractors
      or other qualified providers. Subject to $10
co-payment.

            
	
              Podiatry

            	
              Medically
      necessary foot care, including care for medical conditions affecting lower
      limbs, subject to $10 co-payment. Visits for routine foot care up to 4
      visits per year, not subject to co-payment.

            
	
              Outpatient
      Mental Health

            	
              Individual
      and group therapy visits, subject to co-payment of $20 per individual or
      group visit. Enrollee must be able to self-refer for one assessment from a
      network provider in a twelve (12) month period.

            
	
              Outpatient
      Substance Abuse

            	
              Individual
      and group visits subject to $20 co-payment per group or individual visit.
      Enrollee must be able to self-refer for one assessment from a network
      provider in a twelve (12) month period.

            
	
              Outpatient
      Surgery

            	
              Medically
      necessary visits to an ambulatory surgery center or outpatient hospital
      facility. No co-payment.

            
	
              Ambulance

            	
              Transportation
      provided by an ambulance service, including air ambulance. Emergency
      transportation if for the purpose of obtaining hospital services for an
      enrollee who suffers from severe, life-threatening or potentially
      disabling conditions which require the provision of emergency services
      while the enrollee
      is being transported.  Includes transportation to a hospital
      emergency room generated by a "Dial 911". No co-payment.

            

    

    
      
        
          Medicaid
Advantage Contract

          APPENDIX
K

          NYC
January 1, 2008

          K- 3

        

      

      
         

        
          

        

      

      
         

      

    

    
      	
              Medicare
      Advantage Benefit Package for Dual Eligibles

            
	
              Category
      of Service

            	
              Included
      in Medicare Capitation

            
	 
      	
               

            
	
              Emergency
      Room

            	
              Care
      provided in an emergency room subject to prudent layperson standard. $50
      co-payment per visit. Co-payment waived if admitted to the hospital within
      24 hours for the same condition.

            
	
              Urgent
      Care

            	
              Urgently
      needed care in most cases outside the plan's service area. Subject to $10
      co-payment.

            
	
              Outpatient
      Rehabilitation (OT, PT, Speech)

            	
              Occupational
      therapy, physical therapy and speech and language
      therapy subject to $10 co-payment.

            
	
              Durable
      Medical Equipment (DME)

            	
              Medicare
      and Medicaid covered durable medical equipment, including devices and
      equipment other than medical/surgical supplies, enteral formula, and
      prosthetic or orthotic appliances having the following characteristics:can
      withstand repeated use
      for a protracted period of time; are primarily and customarily used for
      medical purposes; are generally not useful to a person in the absence of
      illness or injury and are usually not fitted, designed or fashioned for a
      particular individual's
      use. Must be ordered by a qualified practitioner. No homebound
      prerequisite and including non-Medicare DME covered by Medicaid (e.g., tub
      stool; grab bar). No co-payment or coinsurance.

            
	
              Prosthetics

            	
              Medicare
      and Medicaid covered prosthetics, orthotics and orthopedic footwear. No
      diabetic prerequisite for orthotics. Not subject to co-payment or
      coinsurance.

            
	
              Diabetes
      Monitoring

            	
              Diabetes
      self-monitoring and management training - and supplies including coverage
      for glucose monitors, test strips, and lancets. None of which are subject
      to co-payments. OTC diabetic supplies such as 2x2 gauze pads, alcohol
      swabs/pads, insulin syringes and needles are covered by Part
      D.

            
	
              Diagnostic
      Testing

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

            
	
              Bone
      Mass Measurement

            	
              Bone
      Mass Measurement for people at risk. No co-payment

            
	
              Colorectal
      Screening

            	
              Colorectal
      screening for people, age 50 and older.No co-payment.

            
	
              Immunizations                                             .

            	
              Flu,
      hepatitis B vaccine for people who are at risk, Pneumonia vaccine. No
      co-payment.

            
	
              Mammograms

            	
              Annual
      screening for women age 40 and older.No referral necessary.
      No co-payment.

            
	
              Pap
      Smear and Pelvic Exams

            	
              Pap
      smears and Pelvic Exams for women. No co-payment.

            
	   
      Prostate Cancer Screening	 Prostrate
      Cancer Screening exams for men age 50 and older.  No
      co-payment.

    

    
      
        
          Medicaid
Advantage Contract

          APPENDIX
K

          NYC
January 1, 2008

          K-4 

        

      

      
         

        
          

        

      

      
         

      

    

    
      	
              Medicare
      Advantage Benefit Package for Dual Eligibles

            
	
              Category
      of Service

            	
              Included
      in Medicare Capitation

            
	
              Outpatient
      Drugs

            	
              Medicare
      Part B covered prescription drugs and other drugs obtained by a provider
      and administered in a physician office or clinic setting that are covered
      by Medicaid. (No Part D).

            
	
              Hearing
      Services

            	
              Medicare
      and Medicaid hearing services and products when medically necessary to
      alleviate disability caused by the loss or impairment of hearing. Services
      include hearing aid selecting, fitting, and dispensing; hearing aid checks
      following dispensing, conformity evaluations and hearing aid repairs;
      audiology services including examinations and testing, hearing aid
      evaluations and hearing aid prescriptions; and hearing aid products
      including hearing aids, eannolds, special fittings and replacement parts.
      No co-payment or limitations.

            
	
              Vision
      Care Services

            	
              Services
      of optometrists, ophthalmologists and ophthalmic dispensers including
      eyeglasses, medically necessary contact lenses and poly-carbonate lenses,
      artificial eyes (stock or custom-made), low vision aidsand low
      visionservices.  Coverage
      includes the replacement of lost or destroyed glasses and the repair or
      replacement of parts. Coverage also includes examinations for diagnosis
      and treatment for visual defects and/or eye disease. Examinations for
      refraction are limited to every two (2) years unless otherwise justified
      as medically necessary.  Eyeglasses
      do notrequirechanging more frequently
      than every two (2) years unless medically necessary or
      unless the glasses are lost, damaged or destroyed.  No prerequisite
      of cataract services. No co-payment.

            
	
              Routine
      Physical Exam 1/year

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

            
	
              Health/Wellness
      Education

            	
              
                Coverage
      for the following:  general health education classes, parenting
      classes, smoking cessation classes, childbirth education and
      nutrition counseling, plus additional benefits at plan option including
      but not limited to items such as newsletters, nutritional training,
      congestive heart program, health club membership/fitness classes,
      nursing hotline, disease management, other wellness services. No
      co-payments.

              

            
	
              Additional
      Part C Benefits, if any

            	 
      
	
              Medicare
      Part D Prescription Drug Benefit as Approved by CMS

            	 
      

    

    
      
        
          Medicaid
Advantage Contract

          APPENDIX
K

          NYC
January 1, 2008

          K-5

        

      

      
         

        
          

        

      

      
         

      

    

     

    APPENDIX K2

     

    MEDICAID
ADVANTAGE PRODUCT

     

    
      	
              Medicaid
      Advantage Benefit Package for Dual Eligibles

            
	
              Category
      of Service

            	
              Included
      in Medicaid Capitation

            
	
              Inpatient
      Mental Health

            	
              Days in excess
      of the Medicare 190-day lifetime maximum.

            
	
              Home
      Health

            	
              Non-Medicare
      covered home health services (e.g. home health aide services with nursing
      supervision to medically unstable individuals).

            
	
              Specialist
      Office Visits

            	
              Elimination
      of $10 co-payment.

            
	
              Podiatry

            	
              Elimination
      of $10 co-payment for medically necessary footcare.

            
	
              Outpatient
      Mental Health

            	
              Elimination
      of $20 co-payment.

            
	
              Outpatient
      Substance Abuse

            	
              Elimination
      of $20 co-payment.

            
	
              Emergency
      Room

            	
              Elimination
      of $50 co-payment

            
	
              Urgent
      Care

            	
              Elimination
      of $10 co-payment.

            
	
              Outpatient
      Rehabilitation (OT, PT, Speech)

            	
              Elimination
      of $10 co-payment.

            
	
              Dental

              (Optional benefit
      outside of NYC)

            	
              Medicaid
      covered dental services including necessary preventive, prophylactic and
      other routine dental care, services and supplies and dental prosthetics to
      alleviate a serious health condition. Ambulatory or inpatient surgical
      dental services subject to prior authorization.

            
	
              Transportation – Routine
      (Optional
      benefit outside
      of NYC)

            	
              Transportation
      essential for an enrollee to obtain necessary medical care and services
      under the plan's benefits or Medicaid fee-for-service. Includes ambulette,
      invalid coach, taxicab, livery, public transportation, or other means
      appropriate to the enrollee's medical condition and a transportation
      attendant to accompany the enrollee, if necessary.

            
	
              Private
      Duty Nursing

            	
              Medically necessary
      private duty nursing services in accordance
      with the ordering physician, registered physician assistant or certified
      nurse practitioner's written treatment
plan.

            

    

    
      
        
          Medicaid
Advantage Contract

          APPENDIX
K

          NYC
January 1, 2008

          K-6 

        

      

      
         

        
          

        

      

      
         

      

    

    DESCRIPTION
OF MEDICAID ONLY SERVICES IN

    MEDICAID
ADVANTAGE BENEFIT PACKAGE:

     

    Inpatient
Mental Health Over 190-Day Lifetime Limit

     

    All
inpatient mental health services, including voluntary or involuntary admissions
for mental health services over the Medicare 190-Day Lifetime Limit. The
Contractor may provide the covered benefit for medically necessary mental health
impatient services through hospitals licensed pursuant to Article 28 of the New
York State P.H.L.

     

    Non-Medicare
Covered Home Health Services

     

    Medicaid
covered home health services include the provision of skilled services not
covered by Medicare (e.g. physical therapist to supervise maintenance program
for patients who have reached their maximum restorative potential or nurse to
pre-fill syringes for disabled individuals with diabetes) . and for home health
aide services as required by an approved plan of care developed by a certified
home health agency.

     

    Private
Duty Nursing Services

     

    Private
duty nursing services provided by a person possessing a license and current
registration from the NYS Education Department to practice as a registered
professional nurse or licensed practical nurse. Private duty nursing services
can be provided through an approved certified home health agency, a licensed
home care agency, or a private Practitioner.

     

    Private
duty nursing services are covered when determined by the attending physician to
be medically necessary. Nursing services may be intermittent, part-time or
continuous and must be provided in an Enrollee's home in accordance with the
ordering physician, registered physician assistant or certified nurse
practitioner's written treatment plan.

     

    Dental
Services (optional benefit outside of NYC)

     

    Dental
services include, but shall not be limited to, preventive, prophylactic and
other routine dental care, services, supplies and dental prosthetics required to
alleviate a serious health condition, including one which affects
employability.

     

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

    
      
         
Medicaid
Advantage Contract

          APPENDIX
K

          NYC
January 1, 2008

          K-7

        

      

      
         

        
          

        

      

      
         

      

    

     

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

     

    If
Contractor's Benefit Package excludes dental services:

     

    
      	
              i)

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

            

    

    
      	
              ii)

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

            

    

     

    Non-Emergency
Transportation (optional benefit outside of NYC)

     

    Transportation
expenses are covered when transportation is essential in order for an Enrollee
to obtain necessary medical care and services which are covered under the
Medicaid program (either as part of the Contractor's Benefit Package or by
fee-for-service Medicaid). Non-emergent transportation guidelines may be
developed in conjunction with the LDSS, based on the LDSS' approved
transportation plan.

     

    Transportation
services means transportation by ambulance, ambulette, fixed wing or airplane
transport, invalid coach, taxicab, livery, public transportation, or other means
appropriate to the Enrollee's medical condition; and a transportation attendant
to accompany the Enrollee, if necessary. Such services may include the
transportation attendant's transportation, meals, lodging and salary; however,
no salary will be paid to a transportation attendant who is a member of the
Enrollee's family.

     

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

     

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

     

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

    
      
        
          Medicaid
Advantage Contract

          APPENDIX
K

          NYC
January 1, 2008

          K- 8

        

      

      
         

        
          

        

      

      
         

      

    

     

    APPENDIX K3

     

    NON
COVERED SERVICES

     

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

     

    Services
Covered by Direct Reimbursement from Original Medicare

    ·      Hospice
services provided to Medicare Advantage members

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

     

    Services
Covered by Medicaid Fee for Service

    
      	
              ·

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

            

    

    
      	
              ·

            	
              Skilled
      Nursing Facility (SNF) days not covered by
  Medicare

            

    

    
      	
              ·

            	
              Personal
      Care Services

            

    

    
      	
              ·

            	
              Medicaid
      Pharmacy Benefits allowed by State Law (select drug categories excluded
      from the Medicare Part D benefit and certain medications included in the
      Part D benefit when the Enrollee is unable to receive them from his/her
      Medicare Advantage Plan), also certain Medical Supplies and Enteral
      Formula when not covered by
Medicare.

            

    

    
      	
              ·

            	
              Methadone
      Maintenance Treatment Programs

            

    

    
      	
              ·

            	
              Certain
      Mental Health Services, including:

            

    

    
      	 	o       	Intensive
      Psychiatric Rehabilitation Treatment Programs
	 	o       	 Day
      Treatment
	 	o       	 Continuing
      Day Treatment
	
               
      

            	
              o

            	
              Case
      Management for Seriously and Persistently Mentally Ill (sponsored by state
      or local mental health units)

            

    

    
      	
               
      

            	
              o

            	
              Partial
      Hospitalizations

            

    

    
      	
               
      

            	
              o

            	
              Assertive
      Community Treatment (ACT)

            

    

    
      	
               
      

            	
              o

            	
              Personalized
      Recovery Oriented Services (PROS)

            

    

    
      	
              ·

            	
              Rehabilitation
      Services Provided to Residents of OMH Licensed Community Residences (CRs)
      and Family Based Treatment Programs

            

    

    
      	
              ·

            	
              Office
      of Mental Retardation and Developmental Disabilities (OMRDD)
      Services

            

    

    
      	
              ·

            	
              Comprehensive
      Medicaid Case Management

            

    

    
      	
              ·

            	
              Directly
      Observed Therapy for Tuberculosis
Disease

            

    

    
      	
              ·

            	
              AIDS
      Adult Day Health Care

            

    

    
      	
              ·

            	
              HIV
      COBRA Case Management

            

    

    
      	
              ·

            	
              Adult
      Day Health Care

            

    

    
      	
              ·

            	
              Personal
      Emergency Response Services
(PERS)

            

    

    
      
        
          Medicaid
Advantage Contract

          APPENDIX
K

          NYC
January 1, 2008

          K-9 

        

      

      
         

        
          

        

      

      
         

      

    

     

    Medicaid
Advantage Program Optional Benefits

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

              
                ●  
      Non-Emergency Transportation Services

              

              
                ●  
      Dental Service

              

            

    

     

    Both of
these services, however, are mandatory in NYC.

    
      
        
          Medicaid
Advantage Contract

          APPENDIX
K

          NYC
January 1, 2008

          K-10 

        

      

      
         

        
          

        

      

      
         

      

    

     

    DESCRIPTION
OF NON-COVERED SERVICES

     

    The
following services are excluded from the Contractor's Medicare and Medicaid
Benefit Packages, and are covered, in most instances, by Medicare or Medicaid
fee-for-service:

     

    1.         
  Hospice Services Provided to Medicaid Advantage
Enrollees

     

    Hospice
services provided to Medicare Advantage Enrollees by Medicare approved hospice
providers are directly reimbursed by Medicare. Hospice is a coordinated program
of home and inpatient care that provides non-curative medical and support
services for persons certified by a physician to be terminally ill with a life
expectancy of six (6) months or less. Hospice programs provide patients and
families with palliative and supportive care to meet the special needs arising
out of physical, psychological, spiritual, social and economic stresses which
are experienced during the final stages of illness and during dying and
bereavement.

     

    Hospices
are organizations which must be certified under Article 40 of the NYS P.H.L. and
approved by Medicare. All services must be provided by qualified employees and
volunteers of the hospice or by qualified staff through contractual arrangements
to the extent permitted by federal and state requirements. All services must be
provided according to a written plan of care which reflects the changing needs
of the patient/family.

     

    If an
Enrollee in the Contractor's plan becomes terminally ill and receives Hospice
Program services, he or she may remain enrolled and continue to access the
Contractor's Benefit Package while Hospice costs are paid for by Medicare
fee-for-service.

     

    2.           
Other Services Deemed to be Covered by Original Medicare by CMS 

     

    3.           
Personal Care Agency Services

     

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

     

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

    
      
        
          Medicaid
Advantage Contract

          APPENDIX
K

          NYC
January 1, 2008

          K-11 

        

      

      
         

        
          

        

      

      
         

      

    

     

    
      	
              4.

            	
              Skilled
      Nursing Facility Days Not Covered by
Medicare

            

    

     

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

     

    
      	
              5.

            	
              Prescription
      Drugs Permitted by State Law, Certain Medical Supplies and Enteral
      Formulas Not Covered by Medicare

            

    

     

    NYS
Medicaid continues to provide coverage for categories of drugs excluded from the
Medicare Part D benefit such as barbiturates, benzodiazepines, and some
prescription vitamins, and some non-prescription drugs. NYS also provides a wrap
around program which covers medications that are included in the Part D benefit
when the recipient is unable to receive them from his or her Part D plan.
Effective January 1, 2007, drugs which are covered through this Medicaid
wrap-around benefit will be limited to the following four categories of drugs:
1) atypical antipsychotics, 2) antidepressants, 3) antiretrovirals used in the
treatment of HIV/AIDS, and 4) anti-rejection drugs used in the treatment of
tissue and organ transplants, but only when 1) these drugs are not covered by
the specific plan, 2) the patient does not meet the plan's utilization
management requirements, or 3) there are quantity limits inconsistent with the
prescribed amount. Certain medical/surgical supplies and enteral formula covered
by Medicaid and not included in the Contractor's Medicare Advantage Benefit
Package also will be paid for by Medicaid fee-for-service. Medical/surgical
supplies are items other than drugs, prosthetic or orthotic appliances, or DME,
which have been ordered by a qualified practitioner in the treatment of a
specific medical condition and which are: consumable, non-reusable, disposable,
or for a specific rather than incidental purpose, and generally have no
salvageable value (e.g. gauze pads, bandages and diapers). Pharmaceuticals and
medical supplies routinely furnished or administered as part of a clinic or
office visit are covered by the Contractor.

     

    
      	
              6.

            	
              Out
      of Network Family Planning Services

            

    

     

    As
described in Sections 10.6 and 10.9 of this Agreement, out of network family
planning services provided by qualified Medicaid providers to plan enrollees
will be directly reimbursed by Medicaid fee-for-service at the Medicaid fee
schedule. "Family Planning and Reproductive Health Services" means those health
services which enable Enrollees, including minors who may be sexually active, to
prevent or reduce the incidence of unwanted pregnancy. These include: diagnosis
and all medically necessary treatment, sterilization, screening and treatment
for sexually transmissible diseases and screening for disease and
pregnancy.

     

    Also
included are HIV counseling and testing when provided as part of a family
planning visit. Additionally, reproductive health care includes coverage of all
medically necessary abortions. Elective induced abortions must be covered for
New York City recipients. Fertility services are not covered.

     

    
      	
              7.

            	
              Dental
      (when not in benefit package)

            

    

     

    (See
description in Appendix K-2)

     

    
      
        
          Medicaid
Advantage Contract

          APPENDIX
K

          NYC
January 1, 2008

          K-12

        

      

      
         

        
          

        

      

      
         

      

    

     

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

     

    (See
description in Appendix K-2)

     

    9.            
Methadone Maintenance Treatment Program (MMTP)

     

    MMTP
consists of drug detoxification, drug dependence counseling, and rehabilitation
services which include chemical management of the patient with methadone.
Facilities authorized to provide methadone maintenance treatment certified by
the Office of Alcohol and Substance Abuse Services (OASAS) under Part 828 of 14
NYCRR.

     

    10.          Certain
Mental Health Services

     

    The
Contractor is not responsible for the provision and payment of the following
services, which are reimbursed through Medicaid fee-for-service.

     

    
      	
              a.

            	
              Intensive
      Psychiatric Rehabilitation Treatment Programs
  (IPRT)

            

    

     

    IPRT is a
time-limited active psychiatric rehabilitation designed to assist a patient in
forming and achieving mutually agreed upon goals in living, learning, working
and social environments and to intervene with psychiatric rehabilitative
technologies to overcome functional disabilities. IPRT services are certified by
OMH under Part 587 of 14 NYCRR.

     

    b.    Day
Treatment

     

    Day
Treatment is a combination of diagnostic, treatment, and rehabilitative
procedures which, through supervised and planned activities and extensive
client-staff interaction, provides the services of the clinic treatment program,
as well as social training, task and skill training and socialization
activities. These services are certified by OMH under Part 587 of 14
NYCRR.

     

    c.   
  Continuing Day Treatment

     

    Continuing
Day Treatment is designed to maintain or enhance current levels of functioning
and skills, maintain community living, and develop self-awareness and
self-esteem. It includes: assessment and treatment planning, discharge planning,
medication therapy, medication education, case management, health screening and
referral, rehabilitative readiness development, psychiatric rehabilitative
readiness determination and referral, and symptom management. These services are
certified by OMH under Part 587 of 14 NYCRR.

     

    
      	
              d.

            	
              Case
      Management for Seriously and Persistently Mentally Ill Sponsored by State
      or Local Mental Health Units

            

    

     

    The
target population consists of individuals who are seriously and persistently
mentally ill (SPMI), require intensive, personal and proactive intervention to
help them obtain those services which will permit functioning in the community
and either have symptomology which is difficult to treat in the existing mental
health care system or are unwilling or unable to adapt to the existing mental
health care system. Three case management models are currently operated pursuant
to an agreement with OMH or a local governmental unit, and receive Medicaid
reimbursement pursuant to Part 506 of 14 NYCRR.

    
      
        
          Medicaid
Advantage Contract

          APPENDIX
K

          NYC
January 1, 2008

          K-13

        

      

      
         

        
          

        

      

      
         

      

    

     

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

     

    e. 
   Partial Hospitalization Not Covered by Medicare

     

    Provides
active treatment designed to stabilize and ameliorate acute systems, serves as
an alternative to inpatient hospitalization, or reduces the length of a hospital
stay within a medically supervised program by providing the following:
assessment and treatment planning; health screening and referral; symptom
management; medication therapy; medication education; verbal therapy; case
management; psychiatric rehabilitative readiness determination and referral and
crisis intervention. These services are certified by OMH under Part 587 of 14
NYCRR.

     

    f.  
   Assertive Community Treatment (ACT)

     

    ACT is a
mobile team-based approach to delivering comprehensive and flexible treatment,
rehabilitation, case management and support services to individuals in their
natural living setting. ACT programs deliver integrated services to recipients
and adjust services over time to meet the recipient's goals and changing needs.
They are operated pursuant to approval or certification by OMH; and receive
Medicaid reimbursement pursuant to Part 508 of 14 NYCRR.

     

    g.    
Personalized Recovery Oriented Services (PROS)

     

    PROS,
licensed and reimbursed pursuant to Part 512 of 14 NYCRR, are designed to assist
individuals in recovery from the disabling effects of mental illness through the
coordinated delivery of a customized array of rehabilitation, treatment, and
support services in traditional settings and in off-site locations. Specific
components of PROS include Community Rehabilitation and Support, Intensive
Rehabilitation, Ongoing Rehabilitation and Support and Clinical
Treatment.

     

    
      	
              11.       
         Rehabilitation Services Provided to Residents of OMH Licensed
      Community Residences (CRs) and Family Based Treatment Programs, as
      follows:

            

    

     

    a.     OMH
Licensed CRs*

     

    Rehabilitative
services in community residences are interventions, therapies and activities
which are medically therapeutic and remedial in nature, and are medically
necessary for the maximum reduction of functional and adaptive behavior defects
associated with a person's mental illness.

     

    b. 
   Family-Based Treatment*

     

    Rehabilitative
services in family-based treatment programs are intended to provide treatment to
seriously emotionally disturbed children and youth to promote their successful
functioning and integration into the family, community, school or independent
living situations. Such services are provided in consideration of a child's
developmental stage. Children detelllined eligible for admission are placed in
surrogate family homes for care and treatment. These services are certified by
OMH under Section 586.3, and Parts 594 and 595 of 14 NYCRR .

    
      
        
          Medicaid
Advantage Contract

          APPENDIX
K

          NYC
January 1, 2008

          K- 14

        

      

      
         

        
          

        

      

      
         

      

    

     

    12.
Office of Mental Retardation and Developmental Disabilities (OMRDD)
Services

     

    
      	
              a.

            	
              Long
      Term Therapy Services Provided by Article 16-Clinic Treatment Facilities
      or Article 28 Facilities

            

    

     

    These
services are provided to persons with developmental disabilities including
medical or remedial services recommended by a physician or other licensed
practitioner of the healing arts for a maximum reduction of the effects of
physical or mental disability and restoration of the person to his or her best
possible functional level. It also includes the fitting, training, and
modification of assistive devices by licensed practitioners or trained others
under their direct supervision. Such services are designed to ameliorate or
limit the disabling condition and to allow the person to remain in or move to,
the least restrictive residential and/or day setting. These services are
certified by OMRDD under Part 679 of 14 NYCRR (or they are provided by Article
28 Diagnostic and Treatment Centers that are explicitly designated by the SDOH
as serving primarily persons with developmental disabilities). If care of this
nature is provided in facilities other than Article 28 or Article 16 centers, it
is a covered service.

     

    
      	
              b.

            	
              Day
      Treatment

            

    

     

    A planned
combination of diagnostic, treatment and rehabilitation services provided to
developmentally disabled individuals in need of a broad range of services, but
who do not need intensive twenty-four (24) hour care and medical supervision.
The services provided as identified in the comprehensive assessment may include
nutrition, recreation, self-care, independent living, therapies, nursing, and
transportation services. These services are generally provided in an
Intermediate Care Facility (ICF) or a comparable setting. These services are
certified by OMRDD under Part 690 of 14 NYCRR.

     

    c.    
Medicaid Service Coordination (MSC)

     

    Medicaid
Service Coordination (MSC) is a Medicaid State Plan service provided by OMRDD
which assists persons with developmental disabilities and mental retardation to
gain access to necessary services and supports appropriate to the needs of the
needs of the individual. MSC is provided by qualified service coordinators and
uses a person centered planning process in developing, implementing and
maintaining an Individualized Service Plan (ISP) with and for a person with
developmental disabilities and mental retardation. MSC promotes the concepts of
a choice, individualized services and consumer satisfaction.

     

    MSC is
provided by authorized vendors who have a contract with OMRDD, and who are paid
monthly pursuant to such contract. Persons who receive MSC must not permanently
reside in an ICF for persons with developmental disabilities, a developmental
center, a skilled nursing facility or any other hospital or Medical Assistance
institutional setting that provides service coordination. They must also not
concurrently be enrolled in any other comprehensive Medicaid long term service
coordination program/service, including the Care at Home
Waiver.

    
      
        
          Medicaid
Advantage Contract

          APPENDIX
K

          NYC
January 1, 2008

          K-15 

        

      

      
         

        
          

        

      

      
         

      

    

     

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

     

    d.    Home
And Community Based Services Waivers (HCBS)

     

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

     

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

     

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

     

    13.           Comprehensive
Medicaid Case Management (CMCM)

     

    A program
which provides "social work" case management referral services to a targeted
population (e.g.: teens, mentally ill). A CMCM case manager will assist a client
in accessing necessary services in accordance with goals contained in a written
case management plan. CMCM programs do not provide services directly, but refer
to a wide range of service providers. The nature of these services include:
medical, social, psycho-social, education, employment, financial, and mental
health. CMCM referral to community service agencies and/or medical providers
requires the case manager to work out a mutually agreeable case coordination
approach with the agency/medical providers. Consequently, if an Enrollee of the
Contractor is participating in a CMCM program, the Contractor should work
collaboratively with the CMCM case manager to coordinate the provision of
services covered by the Contractor. CMCM programs will be instructed on how to
identify a managed care Enrollee on eMedNY so that the program can contact the
Contractor or to coordinate service provision.

     

    14.           Directly
Observed Therapy for Tuberculosis Disease

     

    Tuberculosis
directly observed therapy (TB/DOT) is the direct observation of oral ingestion
of TB medications to assure patient compliance with the physician's prescribed
medication regimen. While the clinical management of tuberculosis is covered in
the Benefit Package, TB/DOT where applicable, can be billed directly to MMIS by
any SDOH approved fee-for­service Medicaid TB/DOT Provider. The Contractor
remains responsible for communicating, cooperating and coordinating clinical
management of TB with the TB/DOT Provider.

    
      
        
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    15.           AIDS
Adult Day Health Care

     

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

     

    16.           HIV
COBRA Case Management

     

    The HIV
COBRA (Community Follow-up Program) Case Management Program is a program that
provides intensive, family-centered case management and community follow-up
activities by case managers, case management technicians, and community
follow-up workers. Reimbursement is through an hourly rate billable to Medicaid.
Reimbursable activities include intake, assessment, reassessment, service plan
development and implementation, monitoring, advocacy, crisis intervention, exit
planning, and case specific supervisory case-review conferencing.

     

    17.           Adult
Day Health Care

     

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

     

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

     

    18.           Personal
Emergency Response Services (PERS)

     

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

    
      
        
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          APPENDIX
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      Appendix
N

      New York
City Specific Contracting Requirements

      
 

      
        
          
            
              Medicaid
Advantage Contract

              APPENDIX
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              N-1 

            

          

          
             

            
              

            

          

          
             

          

        

      

    

     

    Appendix
N

    New
York City Specific Contracting Requirements

     

    1.           
 General

     

    
      	
               
      

            	
              a)

            	
              In
      New York City, the Contractor will comply with all provisions of the main
      body and other Appendices of this Agreement, except as otherwise expressly
      established in this Appendix.

            

    

     

    
      	
               
      

            	
              b)

            	
              This
      Appendix sets forth New York City Specific Contracting Requirements and
      contains the following sections:

            

    

    
 

    
      	
               

            	 N.1	
              Compensation
      for Public Health Services

            
	
               

            	 N.2	
              Coordination
      with DOHMH on Public Health Initiatives

            
	
               

            	 N.3	
              Benefits

            
	
               

            	 N.4	
              Additional
      Reporting Requirements

            
	
               

            	 N.5	
              New
      York City Additional Medicaid Advantage Marketing
    Guidelines

            
	
               

            	 N.6	
              Guidelines
      for Processing Enrollments and Disenrollments in New York
    City

            
	
               

            	 N.7	
              New
      York City Transportation Policy Guidelines

            
	
               

            	 Schedule
      1	
              DOHMH
      Public Health Services Fee
Schedule

            

    

    
      
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          APPENDIX
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    N.1

     

    Compensation
for Public Health Services

     

    
      	
              1.

            	
              The
      Contractor shall reimburse DOHMH at the rates contained in Schedule 1 of
      this Appendix for Enrollees who receive the following services from DOHMH
      facilities, except in those instances where DOHMH may bill Medicaid
      fee-for-service.

            

    

    

    a)            
Diagnosis and/or treatment of TB

    b)            HIV
counseling and testing that is not part of an STD or TB visit

    c)            
Adult immunizations

    d)           
Dental services

    e)            
STD lab test (s)

     

    
      	
              2.

            	
              Notwithstanding
      Sections 10.11 (a) (v) (C) and (b) (ii) of this Agreement, the following
      requirements
      concerning Contractor notification and documentation of services shall
      apply in New York City:

            

    

     

    
      	
               
      

            	
              a)

            	
              DOHMH
      shall confirm the Enrollee's membership in the Contractor's Medicaid
      Advantage product on the date of service through EMEDNY prior to billing
      for these services.

            

    

    
      	
               
      

            	
              b)

            	
              DOHMH
      must submit claims for services provided to Enrollees no later than one
      year from the date of service.

            

    

    
      	
               
      

            	
              c)

            	
              The
      Contractor shall not require pre-authorization, notification to the
      Contractor or contacts with the PCP for the above mentioned
      services.

            

    

    
      	
               
      

            	
              d)

            	
              DOHMH
      shall make reasonable efforts to notify the Contractor that it has
      provided the above mentioned services to an
  Enrollee.

            

    

    
      
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      N.2

    

     

    Coordination
with DOHMH on Public Health Initiatives

     

    1.          Coordination
with DOHMH

    

    
      	
               
      

            	
              a)

            	
              The
      Contractor shall provide the DOHMH with existing infoimation requested by
      DOHMH to conduct epidemiological
investigations.

            

    

     

    2.           Provider
Reporting Obligations

    

    
      	
               
      

            	
              a)

            	
              The
      Contractor shall make reasonable efforts to assure timely and accurate
      compliance by Participating Providers with public health reporting
      requirements relating to communicable disease and conditions mandated in
      the New York City Health Code pursuant to 24 RCNY §§ 11.03-11.07 and
      Article 21 of the NYS Public Health
Law.

            

    

    

    
      	
               
      

            	
              b)

            	
              "Reasonable
      efforts" shall include:

            

    

     

    
      	
               
      

            	
              i)

            	
              educating
      Participating Providers on treatment guidelines and instructions for
      reporting included in the NYC DOHMH Compendium of Public Health
      Requirements and
      Recommendations.

            

    

    
      	
               
      

            	
              ii)

            	
              Including
      reporting requirements in the Contractor's provider manual or other
      written instructions or guidelines.

            

    

    
      	
               
      

            	
              iii)

            	
              letters
      from the Contractor to Participating Providers who generated claims that
      suggest that an Enrollee may have a reportable disease or condition,
      encouraging such providers to report and providing information on how to
      report.

            

    

     

    
      	
               
      

            	
              iv)

            	
              Other
      methods for follow up with Participating Providers, subject to DOHMH
      approval, may be employed.

            

    

     

    3.           Standing
Orders

    

    The
Contractor shall encourage participating providers.who employ registered nurses
to implement standing orders for influenza and pneumococcal
vaccines.

     

    4.           Enrollee
Outreach/Education

    

    
      	
               
      

            	
              a)

            	
              The
      Contractor shall provide health education to Enrollees on an on-going
      basis through methods such as distribution of Enrollee newsletters, health
      education classes or individual counseling on preventive health and public
      health topics. Each topic below shall be covered at least once every two
      years.

            

    

     

    
      	
               
      

            	
              i)

            	
              HIV/AIDS

            

    

       
A)         Encourage Enrollee
counseling and testing

    
      	
               
      

            	
              B)

            	
              Inform
      Enrollees as to availability of sterile needles and
    syringes

            

    

    
      
          
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Advantage Contract

          APPENDIX
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January 1, 2008

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              ii)

            	
              STDs

            

    

    
      	
               
      

            	
              A)

            	
              Inform
      Enrollees that confidential STD services are available at DOHMH facilities
      for non-enrolled sexual and needle-sharing partners at no
      charge

            

    

     

    
      	
               
      

            	
              iii)

            	
              Injury
      prevention, including guidance on preventing falls and poisoning, and
      other age appropriate anticipatory
guidance

            

    

     

    
      	
               
      

            	
              iv)

            	
              Domestic
      violence

            

    

     

    
      	
               
      

            	
              v)

            	
              Smoking
      cessation

            

    

     

    
      	
               
      

            	
              vi)

            	
              Asthma

            

    

     

    
      	
               
      

            	
              vii)

            	
              Immunization-
      influenza and pneumococcal

            

    

     

    
      	
               
      

            	
              viii)

            	
              Mental
      health services

            

    

     

    
      	
               
      

            	
              ix)

            	
              Diabetes

            

    

     

    
      	
               
      

            	
              x)

            	
              Screening
      for Cancer

            

    

     

    
      	
               
      

            	
              xi)

            	
              Chemical
      Dependence

            

    

     

    
      	
               
      

            	
              xii)

            	
              Physical
      fitness and nutrition

            

    

     

    
      	
               
      

            	
              xiii)

            	
              Cardiovascular
      disease and hypertension

            

    

     

    
      	
               
      

            	
              xiv)

            	
              Preserving
      oral function and oral health

            

    

     

    
      	
               
      

            	
              xv)

            	
              Stroke
      recognition

            

    

    

    5.           Provider
Education

    

    
      	
               
      

            	
              a)

            	
              DOHMH
      shall prepare a public health compendium ("Compendium") with public health
      guidelines, protocols, and recommendations which it shall make available
      directly to Participating Providers and to the
  Contractor.

            

    

    

    
      	
               
      

            	
              b)

            	
              The
      Contractor shall adapt public health guidance from the Compendium for its
      internal protocols, practice manuals and
  guidelines.

            

    

    

    
      	
               
      

            	
              c)

            	
              The
      Contractor will assist DOHMH in its efforts to disseminate electronic
      materials to its Participating Providers by providing electronic addresses
      if known by

            	
              -

            

    

    
      	
               
      

            	
              Contractor
      (fax and/or e-mail) for its Participating Providers, updated semi-
      annually.

            

    

    

    
      	
               
      

            	
              d)

            	
              The
      Contractor shall promote the use of rapid HIV testing among its
      Participating Providers.

            

    

     

    
      	
              6.

            	
              MCO
      Staff Responsibilities and Training

            

    

     

    
      	
              a)

            	
              Domestic
      Violence

            

    

     

    
      	
               
      

            	
              i)

            	
              The
      Contractor shall designate a domestic violence coordinator who
      can:

            

    

    

    
      	
               
      

            	
              A)

            	
              Provide
      technical assistance to Participating Providers in documenting cases of
      domestic violence;

            

    

    

    
      	
               
      

            	
              B)

            	
              Provide
      referrals to Enrollees or their Participating Providers, to obtain
      protective, legal and or supportive social services;
  and

            

    

    

    
      	
               
      

            	
              C)

            	
              Provide
      consultative assistance to other staff within the Contractor's
      organization.

            

    

    
      
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Advantage Contract

          APPENDIX
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              ii)

            	
              The
      Contractor shall distribute a directory of resources for victims of
      domestic violence to appropriate staff, such as member services staff or
      case managers.

            

    

     

    
      	
              7.

            	
              Medical
      Directors

            

    

     

    
      	
               
      

            	
              a)

            	
              The
      Contractor's Medical Director shall participate in Medical Directors'
      Meetings with the medical directors of the other MCOs participating in the
      MMC Program in New York City and representatives of the New York City
      Department of Health and Mental Hygiene. The purpose of the Medical
      Directors' Meetings shall be to share public health information and data;
      recommend that certain public health information be disseminated by the
      MCOs to their Participating Providers; discuss public health strategies
      and outreach efforts and potential collaborative projects; encourage the
      development of MCO policies that support public health strategies; and
      provide a vehicle for communication between the MCOs participating in the
      MMC Program and the various bureaus and divisions of the NYC Department of
      Health and Mental Hygiene.

            

    

     

    
      	
               
      

            	
              b)

            	
              The
      Contractor's Medical Director shall attend all periodic meetings, which
      shall not exceed one every two months. In the event that the Medical
      Director is unable to attend a particular meeting, the Contractor will
      designate an appropriate substitute to attend the
  meeting.

            

    

     

    
      	
               
      

            	
              c)

            	
              DOHMH,
      following consultation with the Medical Directors, may create workgroups
      on particular public health topics. The Contractor's Medical Director may
      participate. in any or all of the workgroups, but shall participate in at
      least one of the designated
workgroups.

            

    

     

    
      	
              8.

            	
              Take
      Care New York

            

    

     

    
      	
              a)

            	
              The
      Contractor shall:

            

    

     

    
      	
               
      

            	
              i)

            	
              Educate
      Enrollees regarding prevention and treatment of diseases and conditions
      included in the Take Care New York initiative
  (TCNY);

            

    

     

    
      	
               
      

            	
              ii)

            	
              Disseminate
      TCNY health passports or materials containing similar content approved by
      DOHMH to Enrollees;

            

    

     

    
      	
               
      

            	
              iii)

            	
              Disseminate
      reminders to obtain recommended health screenings at age appropriate
      intervals to Enrollees; and

            

    

     

    
      	
               
      

            	
              iv)

            	
              Educate
      Participating Providers on recommended clinical guidelines regarding
      prevention and treatment/management of diseases and conditions described
      in the TCNY initiative.

            

    

    
      
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Advantage Contract

          APPENDIX
N

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January 1, 2008

          N-6   

        

      

      
         

        
          

        

      

      
         

      

    

    
      	
               
      

            	
              b)

            	
              The
      Contractor shall, upon request by DOHMH, participate in one or more TCNY
      workgroups or other activities sponsored by the
  DOHMH.

            

    

     

    9.           Participation
in DOHMH public health detailing campaigns

     

    
      	
               
      

            	
              a)

            	
              The
      Contractor shall participate in a minimum of 1 DOHMH public health
      detailing campaign (e.g. depression screening, colonoscopy or other
      condition affecting the Medicaid Advantage population) in high-need
      neighborhoods designated by DOHMH including the South Bronx, East and
      Central Harlem, and North and Central Brooklyn by providing DOHMH with a
      list of affiliated network providers that would benefit from such
      detailing and a description of the criteria used to select these
      providers.

            

    

     

    
      	
               
      

            	
              b)

            	
              For
      one detailing campaign selected by the Contractor, the Contractor shall
      collaborate with the Department in an evaluation of the impact of that
      detailing on provider practice in the detailed
  neighborhood

            

    

    
      
          
Medicaid
Advantage Contract

          APPENDIX
N

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January 1, 2008

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    N.3

    Benefits

     

    1.           Transitional
Home Health Services Pending Placement in Personal Care Agency
Services

     

    
      	
               
      

            	
              a)

            	
              Transitional
      home health services are home health services as defined in Appendix K of
      this Agreement provided by the Contractor to a Medicaid Advantage Enrollee
      while the Human Resources Administration's determination regarding a
      request for the provision of personal care agency services to the Enrollee
      is pending. Transitional home health services are available to Medicaid
      Advantage Enrollees in addition to the home health care services otherwise
      covered under the Medicare and Medicaid Advantage Benefit Packages as
      medically necessary.

            

    

     

    
      	
               
      

            	
              b)

            	
              The
      Contractor shall be responsible for providing transitional home health
      services to Medicaid Advantage Enrollees for up to a thirty (30) day
      period.

            

    

     

    
      	
               
      

            	
              c)

            	
              For
      Medicaid Advantage Enrollees discharged from a hospital or RHCF and for
      whom personal care agency services have been requested by the
      hospital/RHCF discharge planner, the thirty (30) day period shall commence
      with the day following the Medicaid Advantage Enrollee's discharge from
      the hospital or RHCF.

            

    

     

    
      	
               
      

            	
              d)

            	
              For
      Medicaid Advantage Enrollees who have been receiving home health care
      services in the community and for whom personal care agency services have
      been ordered by the Enrollee's physician, the thirty (30) day period shall
      commence with the day following the last day that the Contractor approved
      home health care services to be medically
  necessary.

            

    

     

    
      	
               
      

            	
              e)

            	
              Transitional
      home health services shall not be available if the Medicaid Advantage
      Enrollee was in receipt of personal care agency services prior to his/her
      admission to a hospital or RHCF and both of the following circumstances
      exist:

            

    

     

    
      	
               
      

            	
              1)

            	
              The
      Medicaid Advantage Enrollee was in a hospital and/or RHCF for a cumulative
      total of fewer than thirty (30) consecutive days;
  and

            

    

     

    
      	
               
      

            	
              2)

            	
              The
      Medicaid Advantage Enrollee requires the same level and hours of personal
      care agency services upon
discharge.

            

    

     

    
      	
               
      

            	
              f)

            	
              The
      Contractor shall provide reasonable assistance as requested regarding the
      completion of forms required by the Human Resources Administration to
      initiate the review of a request for personal care agency services. Such
      form, commonly referred to as the M11Q, requires physician orders, signed
      by the licensed physician, to be received by HRA within thirty (30)
      calendar days of the physician's
examination.

            

    

    
      
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Advantage Contract

          APPENDIX
N

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January 1, 2008

          N-8   

        

      

      
         

        
          

        

      

      
         

      

    

    N.4

    Additional
Reporting Requirements

     

    
      	
              1.

            	
              DOHMH,
      will provide Contractor with instructions for submitting the reports
      required by paragraphs 4(c), below. These instructions shall include time
      frames, and requisite formats. The instructions, time frames and formats
      may be modified by DOHMH upon sixty (60) days written notice to the
      Contractor.

            

    

     

    
      	
              2.

            	
              The
      Contractor shall submit reports that are required to be submitted to DOHMH
      by this Agreement electronically.

            

    

     

    
      	
              3.

            	
              The
      Contractor shall pay liquidated damages of $500 to DOHMH for any report
      required by paragraphs 4(c) below which is materially incomplete, contains
      material misstatements or inaccurate information or is not submitted on
      time in the requested format. The DOHMH shall not impose liquidated
      damages for a first time infraction by the Contractor unless DOHMH deems
      the infraction to be a material misrepresentation of fact or the
      Contractor fails to cure the first infraction within a reasonable period
      of time upon notice from the DOHMH. Liquidated damages may be waived at
      the sole discretion of DOHMH.

            

    

     

    4.       
     The Contractor shall submit the following reports
to DOHMH:

     

    
      	
               
      

            	
              a)

            	
              The
      Contractor shall provide DOHMH with all reports submitted to SDOH pursuant
      to Sections 18.5(a)(i), (ii), (vi) and (vii) of this
      Agreement.

            

    

     

    
      	
               
      

            	
              b)

            	
              Upon
      request by DOHMH, the Contractor shall submit to DOHMH reports submitted
      to SDOH pursuant to Section 18.5(a) (iii) of this
    Agreement.

            

    

     

    
      	
               
      

            	
              c)

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

            

    

    
      
         Medicaid
Advantage Contract

          APPENDIX
N

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January 1, 2008

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    N.5

    New York City Additional
Medicaid Advantage Marketing Guidelines

     

    
      	
              1.

            	
              Contractor
      may not market Medicaid Advantage within a two block perimeter of an HRA
      facility.
      Additionally, when a Medicaid community office is located in a hospital
      facility, Contractor may not market Medicaid Advantage within 60 feet of
      the Medicaid community
office.

            

    

     

    
      	
              2.

            	
              Contractor
      shall not market in homeless
shelters.

            

    

    
      
         Medicaid
Advantage Contract

          APPENDIX
N

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January 1, 2008

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    N.6

     

    Guidelines
for Processing Enrollments and Disenrollments

    in
New York City

     

    
      	
              1.

            	
              Notwithstanding
      any contrary provisions in Appendix H, in New York City, Enrollment error
      reports are generated by the Enrollment Broker to the Contractor generally
      within 24-48 hours of Contractor Enrollment submissions and the Contractor
      is able to resubmit corrections via the Enrollment Broker before Roster
      pulldown. Changes in Enrollee eligibility or Enrollment status that occur
      prior to production of the monthly Roster are reported by the State to the
      Contractor with their rosters. Changes in Enrollee eligibility status that
      occur subsequent to production of the monthly Roster shall be reported by
      the Enrollment Broker by means of the electronic bulletin board. Reports
      of Disenrollments processed by the Enrollment Broker shall be reported to
      the Contractor as they occur by means of the electronic bulletin board.
      Reports of Disenrollments processed by HRA shall be reported to the
      Contractor manually as they occur or through the HPN. In the event that
      the electronic bulletin board notification process is not available for
      any reason, the Contractor shall use EMEDNY to verify loss of
      eligibility.

            

    

     

    
      	
              2.

            	
              With
      respect to Section 5 (a) (vi) of Appendix H of this Agreement, in the
      event that an Enrollee loses Medicaid eligibility, the PCP Enrollment is
      left on the system and removed thereafter by SDOH if no eligibility
      reinstatement occurs.

            

    

     

    
      	
              3.

            	
              Section
      3 (c ) (ii) of Appendix H of this Agreement is not applicable in New York
      City. The Contractor shall not send verification of the infant's
      demographic data to the HRA unless thirty days has expired since the date
      of birth and the Contractor has not received confirmation via the HPN of a
      successful Enrollment through the automated Enrollment system. When the
      thirty days has expired the Contractor shall, within 10 days, send
      verification of the infant's demographic data to the HRA including: the
      mother's name and CIN; and the newborn's name, CIN, sex and date of birth.
      Upon receipt of the data, if the Enrollment does not appear on the system,
      HRA will process the retroactive
Enrollment.

            

    

     

    
      	
              4.

            	
              In
      New York City, Enrollees may initiate a request for an expedited
      Disenrollment to the HRA. The HRA will expedite the Disenrollment process
      in those cases where: an Enrollee's request for Disenrollment involves an
      urgent medical need; the Enrollee is a homeless individual residing in the
      shelter system in New York City; the Enrollee has HIV, ESRD, or a SPMI/SED
      condition; the request involves a complaint of non­consenusal
      Enrollment; or the Enrollee is certified blind or disabled and meets an
      exemption criteria. If approved, the IRA will manually process the
      Disenrollment.

            

    

    
      
         Medicaid
Advantage Contract

          APPENDIX
N

          NYC
January 1, 2008

          N-11  

        

      

      
         

        
          

        

      

      
         

      

    

     

    
      	
              5.

            	
              Notwithstanding
      Section 5 (a) (viii) of Appendix H of this Agreement, in New York City,
      further notification by HRA is not required prior to retroactive
      Disenrollment in the following
instances:

            

    

    
    

     

    
      	
               
      

            	
              (a)

            	
              death
      or incarceration of an Enrollee;

            

    

     

    
      	
               
      

            	
              (b)

            	
              an
      Enrollee has duplicate CINs and is enrolled in a Contractor's Medicaid
      Advantage Product or FHPlus product under more than one of the CINs;
      or

            

    

     

    
      	
               
      

            	
              (c)

            	
              where
      there has been communication between the Contractor and HRA or the
      Enrollment Broker regarding the date of
  disenrollment.

            

    

    

    
      	
               
      

            	
              Consistent
      with 5 (a) (viii) of Appendix H of this Agreement, the LDSS remains
      responsible for sending a notice to the Contractor at the time of
      Disenrollment of the Contractor's responsibility to submit to the SDOH's
      Fiscal Agent voided premium claims for any full months of retroactive
      Disenrollment where the Contractor was not at risk for the provision of
      Benefit Package Services. Such notice shall be completed by the LDSS to
      include: the Disenrollment Effective Date, the reason for the retroactive
      Disenrollment, and the months for which premiums must be repaid. The
      Contractor has 10 days to notify the LDSS should it refute the
      Disenrollment Effective Date, based on a belief that the Contractor was at
      risk for the provision of Benefit Package Services for any month for which
      recoupment of premium has been requested. However failure by the LDSS to
      so notify the Contractor does not affect the right of SDOH to recover
      premium payment as authorized by Section 3.6 of this
      Agreement.

            

    

    

    
      	
              6.

            	
              In
      New York City, the LDSS will only accept Medicaid Advantage plan
      Enrollments submitted
      to the Enrollment Broker via the bulletin board with the exception of
      consumers currently enrolled in a mainstream plan. For consumers enrolled
      in a mainstream plan, Enrollment applications will only be accepted when
      submitted to the Enrollment Broker via paper
      application.

            

    

    
    

    
      
         Medicaid
Advantage Contract

          APPENDIX
N

          NYC
January 1, 2008

          N-12   

        

      

      
         

        
          

        

      

      
         

      

    

    

    N.7

    New York City Transportation Policy
Guidelines

     

    
      	
              1.

            	
              The
      Medicaid Managed Care Program contractual Benefit Package in New York City
      includes non emergency transportation to all medical care and services
      that are covered under the Medicare and Medicaid program, regardless of
      whether the specific medical service is included in the Benefit Package or
      paid for on a fee-for-service basis, except for transportation costs to
      Methadone Maintenance Treatment Programs. The transportation obligation
      includes the cost of meals and lodging incurred when going to and
      returning from a provider of medical care and services when distance and
      travel time require these costs.

            

    

     

    
      	
              2.

            	
              Generally,
      the Contractor may provide transportation by giving or reimbursing the
      Enrollee subway/bus tokens for the round trip for their medical care and
      services, if public transportation is available for such care and
      services. The Contractor is not required to provide transportation if the
      distance to the medical appointment is so short that the Enrollee would
      customarily walk to perform other routine errands. The Contractor may
      adopt policies requiring a minimum distance between an Enrollee's
      residence and the medical appointment, which may not be greater than ten
      blocks; however, the policy must provide transportation for Enrollees
      living a lesser distance upon a showing of special circumstances such as a
      physical disability on a case-by-case
basis.

            

    

     

    
      	
              3.

            	
              If
      the Enrollee has disabilities or medical conditions which prevent him or
      her from utilizing
      public transportation, the Contractor must provide accessible
      transportation which is appropriate to the disability or condition such as
      livery, ambulette, or taxi. The Contractor may require pre-authorization
      of non-public transportation except for emergency
      transportation.

            

    

     

    
      	
               
      

            	
              a)

            	
              The
      Contractor shall provide livery transportation under the following
      circumstances, unless the Enrollee requires transportation by ambulette or
      ambulance:

            

    

     

    
      	
               
      

            	
              i)

            	
              The
      Enrollee is able to travel independently but due to a debilitating
      physical or mental condition, cannot use the mass transit
      system.

            

    

    
      	
               
      

            	
              ii)

            	
              The
      Enrollee is traveling to and from a location that is inaccessible by mass
      transit.

            

    

    
      	
               
      

            	
              iii)

            	
              The
      Enrollee cannot access the mass transit system due to temporary severe
      weather, which prohibits use of the normal mode of
      transportation.

            

    

     

    
      	
               
      

            	
              b)

            	
              The
      Contractor shall provide ambulette transportation under the following
      circumstances, unless the Enrollee requires transportation by
      ambulance:

            

    

     

    
      	
               
      

            	
              i)

            	
              The
      Enrollee requires personal assistance from the driver in entering/exiting
      the Enrollee's residence, the ambulette and the medical
      facility.

            

    

     

    
      
         Medicaid
Advantage Contract 

          APPENDIX
N

          NYC
January 1, 2008

          N-13   

        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    
      	
               
      

            	
              ii)

            	
              The
      Enrollee is wheelchair-bound (non-collapsible or requires a specially
      configured vehicle).

            

    

     

    
      	
               
      

            	
              iii)

            	
              The
      Enrollee has a mental impairment and requires the personal assistance of
      the ambulette driver.

            

    

     

    
      	
               
      

            	
              iv)

            	
              The
      Enrollee has a severe, debilitating weakness or is mentally disoriented as
      a result of medical treatment and requires the personal assistance of the
      ambulette driver.

            

    

     

    
      	
               
      

            	
              v)

            	
              The
      Enrollee has a disabling physical condition that requires the use of a
      walker, cane, crutch or brace and is unable to use livery service or mass
      transportation.

            

    

     

    
      	
               
      

            	
              c)

            	
              The
      Contractor shall provide non-emergency ambulance transportation when the
      Enrollee must be transported on a stretcher and/or requires the
      administration of life support equipment by trained medical personnel. The
      use of non-emergency ambulance is indicated when the Enrollee's condition
      would prohibit any other fowl of
transport.

            

    

     

    
      	
              4.

            	
              Emergency
      transportation may only be provided by accessing 911 emergency ambulances.
      Urgent care transportation may be provided by any mode of transportation
      so long as such mode is appropriate for the medical condition or
      disability experienced by the
Enrollee.

            

    

     

    
      	
              5.

            	
              If
      an attendant is medically necessary to accompany the Enrollee to the
      medical appointment, the Contractor is responsible for the transportation
      of the attendant. A medically required attendant (authorized by the
      attending physician) may include a family member, friend, legal guardian
      or home health worker. When a child travels to medical care and services,
      and an attendant is required, the parent or guardian of the child may act
      as an attendant. In these situations, the costs of the transportation,
      lodging and meals of the parent or guardian may be reimbursable, and
      authorization of the attending physician is not
  required.

            

    

    
      
         Medicaid
Advantage Contract

          APPENDIX
N

          NYC
January 1, 2008

          N-14   

        

      

      
         

        
          

        

      

      
         

      

    

     

    Schedule
1 of Appendix N

     

    
      	
              SERVICE

            	
              FEE

            
	
               

              TB
      CLINIC

            	
              $125.00

            
	
              IMMUNIZATION

            	 
      
	
               

              Children
      under 19 years

            	
               

              17.85

            
	
               

              Adults
      19 years and older

            	
               

              CDC
      acquisition

              cost
      per dose

              +
      $2.00

              Administration
      fee

            
	
               

              HIV
      COUNSELING AND TESTING VISIT

            	
               

              $96.47

            
	
               

              HIV
      COUNSELING AND NO TESTING

            	
               

              $90.12

            
	
               

              HIV
      POST TEST COUNSELING

            	 
      
	
               

                        Visit
      Positive Result

            	
               

              $90.12

            
	
               

              LAB
      TESTS

            	 
      
	
                        HIV-1/HIV-2
      (Single Assay),

            	
              $15.17

            
	
               

                        HIV
      Antibody, Confirmatory (Western Blot)

            	
               

              $26.75

            
	
                        GC/Chlamydia
      Combo (GCT) Test

            	 
      
	
                             Chlamydia
      Trachomatis, Amplified Probe

            	
              $21.43

            
	
                             Technique

            	 
      
	
                             Neisseria
      Gonorrhoeae, Amplified Probe

            	
              $21.43

            
	
                             Technique

            	 
      
	
                        Culture
      Bacterial (GC Cultures)

            	
              $8.15

            
	
               

              DENTAL
      SERVICES

            	
               

              $108.00

            

    

    

    
      
         Medicaid
Advantage Contract

          APPENDIX
N

          NYC
January 1, 2008

          N-15

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