Document:

Exhibit 10.2

                         EXECUTIVE EMPLOYMENT AGREEMENT
                         ------------------------------

     THIS  EXECUTIVE  EMPLOYMENT AGREEMENT (the "Agreement") is made and entered
into  by  and  between  COMMERCE  PLANET,  INC.,  a  Utah corporation (hereafter
"Employer"  or  "Commerce"), and CHARLIE GUGLIUZZA (hereafter "Employee") and is
effective as of date stated below.  Employer and Employee may for convenience of
reference  be  collectively  referred  to  as  "Parties".

     R  E  C  I  T  A  L  S:

WHEREAS,  Employer  is  a publicly traded media company offering media products,
lead  generation  services  and  marketing  tools  to  its  client partners; and

WHEREAS,  Employee  desires  to become employed by Employer as its President and
the  Parties  desire  to  confirm  the  terms  of  the employment of Employee by
Employer  as  herein  set  forth  and hereby enter into this Agreement effective
September  1,  2006  (hereafter  the  "Effective  Date"),  which Agreement shall
supersede  any  and  all  prior  agreements  between  the  Parties;  and

NOW,  THEREFORE,  the  Parties  agree  as  follows:

1.     EMPLOYMENT.  Employer  shall employ Employee as the President of Commerce
       ----------
in  accordance  with the terms and conditions herein set forth and in accordance
with  Employer's  policies,  and  consistent  with  the  laws  of  the  State of
California.

     Employee  will work on a full-time basis (five days per week, eight hours a
day),  in  fulfilling  the duties assigned to him hereunder and will continue to
spend  as  much  time  as  needed  to fulfill his duties in a successful manner.
Employee  currently  works  from  a  remote  office  in  Rancho Santa Margarita,
California.  Employee  will  continue  to  work both onsite at the Santa Barbara
Corporate  Office  and  remotely.

2.     JOB DUTIES.  Employee's duties shall include, but are not limited to, the
       ----------
following:
The  President  will  be responsible for overseeing the day to day operations of
Commerce.  The President will insure that directives from the Board of Directors
through  the  CEO are implemented to achieve maximum profitability in Commerce's
operations. The President will oversee the operations of Commerce and its wholly
owned  subsidiaries.  The  President will work to further the efforts of the CEO
and  develop  the  necessary  infrastructure  to  continue  profitable  growth.

2.1   EXEMPT STATUS.  Employee shall perform such duties as are necessary to the
      -------------
administration  and  management  of  Employer's  business  and  has  control and
supervision  of  that  business  during  his  employment  for  Commerce.  It  is
understood  that  while  Employee reports and shall be responsible to the CEO of
Employer,  or  designee, Employee has discretion to perform such functions as he
deems  reasonably  necessary to the successful operation of Employer's business.
Accordingly,  the Parties understand and agree that Employee is "exempt" on both
an  executive and administrative basis under applicable California wage and hour
laws.

     3.     TERM  AND  TERMINATION.
            ----------------------

The  initial term of Employee's employment under this Agreement will commence on
the  Effective Date and end on the first anniversary of that date (such one-year
period  is the "Initial Term").  The Initial Term, together with any extensions,
is  referred  to  herein  as  the  "Term."

This Agreement shall be subject to termination upon the occurrence of any of the
following  events:

<PAGE>

     (a)     At  any  time  Employer  and  Employee mutually agree in writing to
terminate  this  Agreement.

(b)     On  the  death  or  legal  incapacity  of  Employee.

(c)     If  Employee is "disabled" as defined below and if Employee's disability
continues  for  a period of more than three (3) months, his employment hereunder
will  automatically  terminate with or without formal notice from Employer.  For
purposes  of  this  Agreement,  "disability"  shall  be defined as an Employee's
inability through physical or mental illness or other cause to fully and capably
engage  in  the  management  of Employer's business operations and/or to perform
Employee's  obligation  herein  set  forth.

(d)     Employer  may  terminate  this  Agreement  and  Employee's  employment
hereunder,  for  "cause"  as  herein defined, upon sixty (60) days prior written
notice.  For  the purposes of this Agreement, "cause" shall be defined as any of
the  following:

     i)      Employee's  misappropriation  of  assets,  properties,  or funds of
Employer;  or

iii)     Employee's  conviction  of,  or  plea of guilty or nolo contendere to a
felony  or  misdemeanor  involving  moral  turpitude.

iii)     Any  conduct that will reasonably tend to degrade Employee     or bring
Employer  into  public  hatred, contempt, or ridicule,     or tend to offend the
community  in which Employee     represents Employer, or to prejudice Employer's
position  in     the  community.  Employee acknowledges and agrees that     this
provision  is necessary to protect the profitability of     Employer's business.

(e)     In  the  event  that Employee voluntarily terminates his employment with
Employer,  Employee  shall  be entitled to receive such salary, wages, and bonus
which  have  accrued  through  the  effective  date  of  termination.

     3.1  AGREEMENT  SURVIVES  COMBINATION OR DISSOLUTION.  This Agreement shall
          -----------------------------------------------
not  be  terminated by Employer's voluntary or involuntary dissolution or by any
merger  in  which  Employer  is not the surviving or resulting entity, or on any
transfer  of all or substantially all of Employer's assets.  In the event of any
such  merger  or  transfer  of assets, the provisions of this Agreement shall be
binding  on  and  inure  to  the benefit of the surviving business entity or the
business  entity  to  which  such  assets  shall  be  transferred.

     4.     COMPENSATION.
            ------------

<PAGE>

4.1  ANNUAL  SALARY.  Employer  shall  pay  to  Employee during the term of this
Agreement  or  any  extension  thereof, as consideration for Employee's full and
faithful  performance  of his duties hereunder, an annual salary of $350,000 per
annum  for  the  Initial  Term  and for each Renewal Period thereafter.  Payment
shall  be made on a pro rata basis in accordance with Employer's then applicable
payroll  procedures.

          4.2   CASH  BONUS.  As additional compensation, Employee shall receive
a  bonus equal to five (5%) of Commerce's adjusted net profits under the payment
terms  below,  for  the  duration  of  Executive's  term  with  Commerce.

iv.     ADJUSTED NET PROFITS - Calculated by taking Commerce's actual net income
and  adding  back  the  following  expenses:

a.     Investor  Relations
b.     Expenses  associated  with  the  conversion  of  Commerce's  debentures.
c.     All  expenses  associated with payment of the Executive Compensation Plan
including  cash  bonus  and  stock  issuance.

v.     PAYMENT  DUE  DATE  -  Payment  will  be due upon the close of the second
quarter  of the year and upon the fourth quarter of the year.  All payments will
be made no later than five (5) business days after the filing of Commerce's"10Q"
or  "10K"  of  the  corresponding quarter.  The effective start date for payment
eligibility will be the same date as execution of this Agreement by all parties.

vi.     PAYMENT  AMOUNT  - Of the total amount due and payable upon the close of
the  second  quarter,  fifty  percent  (50%)  will  be  held in a reserve escrow
account.  The  balance of the reserve will be released to Employee no later than
five  (5) business days after the filing of the 10K including the results of the
fourth quarter, assuming that the last two quarters adjusted net profits are not
thirty (30%) percent less than the first two quarters of the year.  The reserved
funds  will  be  returned  to  Commerce  in  the  event that there is a negative
variation  greater  than  thirty  percent  (30%)  within  the  net  profits.

In  addition  to  the  reserve  amount  being  due,  the bonus for the final two
quarters  of the year will be due and payable in their full amount with no funds
held in reserve no later than five (5) business days after the filing of the 10K
which  includes  the  results  of  the  fourth  quarter.

     4.3   OWNERSHIP  BONUS.  As additional consideration for the services to be
provided  hereunder  Employee  will  be  issued  an  additional 5 percent of the
presently  issued  shares of Employer upon execution of this Agreement. Employee
will  enjoy all immediate benefits of stock ownership including, but not limited
to,  voting  rights and dividend participation. This ownership will be issued in
Commerce's  common  stock.

i.     NATURE  OF  OWNERSHIP  -  The  ownership interest will vest in full as of
December  31,  2006.  However,  if  the  employment  of  Employee is voluntarily
terminated  by

<PAGE>

Employee  within  one  (1) year after September 1, 2006, Employer shall have the
option to purchase from Employee his shares for that sum which is equal to $1.00
times  the number of shares that are to be repurchased.  This option shall lapse
proportionately  upon  a  daily  basis  throughout  the one year period and will
entirely  expire  at  the  end  of  such  one  year  period.

          4.4  INITIAL TERM SALARY DUE IF EMPLOYEE TERMINATED WITHOUT CAUSE - In
the  event  Employee is terminated without cause (as defined above) by Employer,
Employee shall be entitled to receive any and all of his annual salary (referred
to  in  Paragraph  4.1 above) which is still due and owing under this Agreement.
Said  amount  shall be calculated from the date of Employee's termination to the
end  of  the  Initial Term of this Agreement and shall be paid no later than one
(1) month after Employee's termination date in a single lump-sum payment.  In no
event  is  this amount to be less than six (6) months of his annual salary which
equals  One  Hundred  Seventy-Five  Thousand  Dollars  ($175,000) as a severance
payment.

          4.5 SEVERANCE PAYMENT - In the event Employee is terminated with cause
(as  defined  above)  by Employer, Employee shall be entitled to receive six (6)
months  of  his  annual  salary  which  equals One Hundred Seventy-Five Thousand
Dollars  ($175,000)  as  a  severance  payment.  Said  amount  shall  be paid to
Employee  no  later  than  one  (1) month after Employee's termination date in a
single  lump-sum  payment.

     5.     VACATION.  Employee  shall  be  entitled  to  take  up to four weeks
            --------
(twenty  working  days)  paid  vacation  leave  during  each  calendar  year.

6.     SICK  LEAVE.  Employee  shall  be  entitled  to take up to two weeks (ten
       ------------
working  days)  of  paid  sick  leave  during  each  calendar  year.

     7.     HEALTH  INSURANCE.  Employee  and  Employee's  dependants  shall  be
            -----------------
provided with health insurance coverage or reimbursement at no cost to Employee.

     8.     HOUSING  ALLOWANCE.  Employee  will  be  entitled  to  a  three
            -------------------
thousand-five  hundred  ($3,500) dollar per month housing allowance in the event
that  Employee  works at the Santa Barbara Corporate Office in excess of two (2)
days  per  week.

     9.     VEHICLE  &  RELATED  EXPENSES.  During  the  Term of this Agreement,
            -----------------------------
Employer  shall  reimburse  Employee's  monthly  car payment in an amount not to
exceed  $1,100.00  per  month.  Employer  will  also  pay  for  fuel and related
maintenances  and  repairs  for  Employee's vehicle.  Employer acknowledges that
Employee  primarily  utilizes  his  vehicle  for  work-related  purposes.

     10.     WORK-RELATED  EXPENDITURES. Employee will be provided a credit card
             --------------------------
on  behalf  of  Commerce  to  be  utilized for work-related expenses incurred by
Employee  in  promoting  the  business  of  Employer, including expenditures for
entertainment,  gifts, and travel. An expense report based upon adequate records
and  other  documentary evidence will be required to be submitted by Employee to
Commerce  prior  to reimbursement of Employee's expenditures. Employee will also
be  entitled  to  reimbursement  in  the  event  he  is  required  to  utilize a
non-Employer  issued  credit  card  for  work-related  expenses.

<PAGE>

     11.     OTHER  BENEFITS.  Employee  will  be entitled to participate in any
             ---------------
other  employee benefit plans which the Board of Directors of Employer may elect
to  provide  for  other employees of Commerce or Commerce's affiliated companies
and/or  divisions.

     12.     CONFIDENTIAL INFORMATION/EMPLOYER'S OWNERSHIP OF INTANGIBLES.  Upon
             ------------------------------------------------------------
termination  of his employment hereunder, Employee shall not be entitled to keep
or use any documents, files, property or information of any description acquired
by  Employee  pursuant to the performance of his duties herein and pertaining to
Employer's business, including, but not limited to, vendor information, accounts
receivable,  customer  lists,  business  and financial information, trade names,
trademarks,  service marks, or related matters, including but not limited to the
name  "Commerce".

Employee  agrees  that  he  will not, during or after the term of the Agreement,
furnish  or make accessible to any person, firm, corporation or other entity any
financial  information,  receipts,  business information, customer lists, vendor
information,  or  other  proprietary  or trade secret data (whether technical or
non-technical)  acquired  by  him  from Employer, from Employer's principals, or
from  his  co-employees,  without  the prior written consent of Employer, unless
such  information  is or shall have become public knowledge, other than by being
divulged  or  made  accessible  by  Employee.

     13.     AMENDMENTS  TO  AGREEMENT.  The  terms of Employee's employment for
             -------------------------
Employer  are  described in full in this Agreement, and there are no other terms
not contained in this Agreement. Any changes in the terms of employment shall be
deemed  valid  only  if  they  are  in  writing  and  signed  by  an  authorized
representative  of  Commerce  and  by  Employee.

     14.     NOTICES.  In  the  event that any notices are sent by either of the
             -------
parties  to  the  other,  such notices shall be in writing, and shall be sent by
registered  or  certified  mail,  return  receipt  requested,  as  follows:

<PAGE>

If  to  Employer:

          COMMERCE  PLANET,  INC.
          C/O  MICHAEL  HILL
          CEO
          30  S.  La  Patera  Lane,  Suite  7
          Goleta,  CA  93117

If  to  Employee:

          CHARLIE  GUGLIUZZA
          17  Chardonnay  Drive
          Ladera  Ranch,  CA  92694

     15.     ASSIGNMENT.  This  Agreement  shall  inure to the benefit of and be
             ----------
binding upon the Employer, its successors and assigns, and upon Employee and his
heirs,  executors,  administrators,  and legal representatives.  Notwithstanding
the  foregoing,  this  Agreement shall not be assignable by Employee or Employer
without  the prior written consent of the other party hereto; provided, however,
that Employer may assign all of its rights and interests under this Agreement to
any  of  its  affiliates.

     16.     GOVERNING LAW.  This Agreement shall be governed in all respects by
             -------------
the laws of the State of California.  Any and all litigation or arbitration will
occur  in  the  State  of  California,  County  of  Santa  Barbara.

     17.     ARBITRATION  -  Any  disputes  arising  from this Agreement will be
             -----------
subject to binding [JUDICIAL ARBITRATION] in the State of California, subject to
the  provisions  of  the  code  of civil procedure section 1141.10 et.sec.  Both
parties understand that by agreeing to this provision they waive their rights to
civil  litigation  and  will  submit  to  and  be  bound  by the decision of the
arbitrating  body.

18.     ATTORNEYS FEES - The parties also hereby agree that the prevailing party
        --------------
in  any
suit, action or proceeding arising out of or relating to this Agreement shall be
entitled  to reimbursement of all fees, costs and expenses, including legal fees
and  court  costs  from  the  non-prevailing  party.

     19.     COMPLETE  DOCUMENT - The terms of this Agreement written, verbal or
             ------------------
otherwise  are  all  reflected  within the pages of this document.  Any previous
understandings  will  be superseded by the terms of this Agreement. Both parties
understand  and  agree that this Agreement and the terms herein are the complete
and  sole  understandings  between  the  two  parties.

     20.     SEVERABILITY  -  If  any  of  the  terms  or provisions within this
             ------------
Agreement  are  deemed  to be invalid by a court of law or other governing body,
the  other  surviving provisions will remain in full force and effect.  Standard
contracts  law and industry business practices consistent with that of Employer,
will  be  implemented to replace and supplement any failed provisions or missing
bodies  of  law.
                       Signatures Appear on Following Page

<PAGE>

EMPLOYER                              EMPLOYEE
--------                              --------

COMMERCE  PLANET,  INC.

BY  /S/  MICHAEL  HILL                   BY  /S/  CHARLIE  GUGLIUZZA
    ------------------                       -----------------------
         MICHAEL  HILL                         CHARLIE  GUGLIUZZA
         CEO

DATE                                     DATEExhibit 10.1

     

      
        

      

    

    Back
      to Form 8-K

    Exhibit
      10.1

     

     

    

      ATTESTATION

      

       

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

       

      

      
        	
                3/17/06

                (Date)

              	
                /s/
                  Todd S. Farha

                (Signature)

                 

              
	 	
                Todd
                  S. Farha

                (Print
                  Name in Full)

                 

              
	 	
                President
                  and CEO

                (Title)

              
	
                /s/
                  Rebecca McNeely

                (Notary
                  Seal and Signature)

              	 

      

      

      

      I
        Diane
        Daniels,
        attest
        that DOHMH has reviewed this executed contract and that it follows the latest
        model contract provided to us by the New York State Department of
        Health.

      

      
        	
                4/6/06

              	
                /s/
                  Diane Daniels

              
	
                (Date)

              	
                (Signature)

                 

                Diane
                  Daniels

              
	 	
                (Print
                  Name in Full)

                 

                Assistant
                  Counsel

              
	
                /s/
                  Alice Rothbaum 

                (Notary
                  Seal and Signature)

              	
                (title)

              

      

    

     

     

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    

      MEDICAID
        ADVANTAGE

      MODEL
        CONTRACT

      

      

      2006

       

      

       

      New
        York
        City Model

       

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      AGREEMENT
        BETWEEN

      

       

      The
        City
        of New York 

       

      And
        

       

      WellCare
        of New York, Inc.

       

      This
        Agreement is made by and between

       

      The
        City
        of New York 

       

      Acting
        through,

       

      Department
        of Health and Mental Hygiene ["DOHMH"] 

       

      Located
        at

       

      161
        William Street, 5th
        floor

       

      New
        York,
        NY 1003 8

       

      And

       

      WellCare
        of New York, Inc.

       

      Located
        At

       

      11
        West
        19th
        Street,
        2nd
        floor

      New
        York,
        NY 10011

      

      

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      

      RECITALS

       

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

       

      WHEREAS,
        pursuant to Article 44 of the Public Health Law (PHL), the New York State
        Department of Health (SDOH) is authorized to issue Certificates of Authority
        to
        establish Health Maintenance Organizations (HMOs), PHL Section 4400 et seq.,
        and
        Prepaid Health Services Plans (PHSPs), PHL Section 4403-a; and

       

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

       

      WHEREAS,
        the Contractor is a corporation organized under the laws of New York State
        and
        is certified under Article 44 of the State Public Health Law or Article 43
        of
        the NYS Insurance Law; and

       

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

       

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

       

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

       

      WHEREAS,
        the Contractor offers a comprehensive health services plan and represents
        that
        it is able to make provision for furnishing the Medicare Plan Benefit Package
        (
        Medicare Part C benefit), the Medicare Voluntary Prescription Drug Benefit
        (Medicare Part D prescription drug

       

       

      

       

      Medicaid
        Advantage Contract 

      RECITALS
        

      New
        York
        City 2006 

      Page
        2 of
        3

       

      

      benefit)
        and the Medicaid Advantage Product as defined in this Agreement and has proposed
        to provide these products to Eligible Persons as defined in this Agreement
        residing in the geographic area specified in Appendix M; and

       

      WHEREAS,
        Chapter 364-j (5)(d) of the SSL authorizes the local department of social
        services in a city with a population of over two million to contract with
        managed care providers who meet the qualifications for participation in the
        Medicaid Managed care program and since in the City of New York such authority
        has been delegated the DOHMH;

       

      NOW
        THEREFORE,
        the
        parties agree as follows:

       

      

       

      

      Medicaid
        Advantage Contract

      RECITALS

      New
        York
        City 2006

      Page
        3 of
        3

       

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

         

        

          Table
            of Contents for Medicaid Advantage Model Contract

           

          Recitals

           

          Section
            1 Definitions

           

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

          2.1 Term

          2.2 Amendments

          2.3 Approvals

          2.4 Entire
            Agreement

          2.5 Renegotiation

          2.6 Assignment
            and Subcontracting

          2.7 Termination

          a. DOHMH
            Initiated Termination

          b. Contractor
            and DOHMH Initiated Termination

          c. Contractor
            Initiated Termination

          d. Termination
            Due to Loss of Funding

          2.8 Close-Out
            Procedures

          2.9 Rights
            and Remedies

          2.10 Notices

          2.11 Severability

           

          Section
            3 Compensation

          3.1 Capitation
            Payments

          3.2 Modification
            of Rates During Contract Period

          3.3 Rate
            Setting Methodology

          3.4 Payment
            of Capitation

          3.5 Denial
            of
            Capitation Payments

          3.6 SDOH
            Right to Recover Premiums

          3.7 Third
            Party Health Insurance Determination

          3.8 Contractor
            Financial Liability

          3.9 Tracking
            Services Provided by Indian Health Clinics

           

          Section
            4 Service
            Area

           

          Section
            5 Eligibility
            For Enrollment in Medicaid Advantage

          5.1 Eligible
            to Enroll in the Medicaid Advantage Program

          5.2 Not
            Eligible to Enroll in the Medicaid Advantage Program

          5.3 Change
            in
            Eligibility Status

           

          Section
            6 Enrollment

          6.1 Enrollment
            Requirements

          6.2 Equality
            of Access to Enrollment

          6.3 Enrollment
            Decisions

          6.4 Prohibition
            Against Conditions on Enrollment

           

          

           

          

           

          

          Medicaid
            Advantage Contract 

          TABLE
            OF
            CONTENTS 

          New
            York
            City 2006 

          1

           

          

          Table
            of Contents for Medicaid Advantage Model Contract

           

          6.5 Effective
            Date of Enrollment

          6.6 Contractor
            Liability

          6.7 Roster

          6.8 Automatic
            Re-Enrollment

          6.9 Failure
            to Enroll in Contractor's Medicare Advantage Product

          6.10 Medicaid
            Managed Care Enrollees Who Will Gain Medicare Eligibility

          6.11 Newborn
            Enrollment

           

          Section
            7 RESERVED

           

          Section
            8 Disenrollment

          8.1 Disenrollment
            Requirements

          8.2 Disenrollment
            Prohibitions

          8.3 Disenrollment
            Requests

          a. Routine
            Disenrollment Requests 

          b. Non-routine
            Disenrollment Requests

          8.4 Contractor
            Notification of Disenrollments

          8.5 Contractor's
            Liability

          8.6 Enrollee
            Initiated Disenrollment

          8.7 Contractor
            Initiated Disenrollment

          8.8 LDSS
            Initiated Disenrollment

           

          Section
            9 Guaranteed
            Eligibility

          9.1 General
            Requirements

          9.2 Right
            to
            Guaranteed Eligibility

          9.3 Covered
            Services During Guaranteed Eligibility

          9.4 Disenrollment
            During Guaranteed Eligibility

           

          Section
            10 Benefit
            Package, Covered and Non-Covered Services

          10.1 Contractor
            Responsibilities

          10.2 SDOH
            and
            LDSS Responsibilities

          10.3 Benefit
            Package and Non-Covered Services Descriptions

          10.4 Adult
            Protective Services

          10.5 Court-Ordered
            Services

          10.6 Family
            Planning and Reproductive Health Services

          10.7 Emergency
            and Post Stabilization Care Services

          10.8 Medicaid
            Utilization Thresholds (MUTS)

          10.9 Services
            for Which Enrollees Can Self-Refer 

          a. Diagnosis
            and Treatment of Tuberculosis 

          b. Family
            Planning and Reproductive Health Services 

          c. Article
            28 Clinics Operated by Academic Dental Centers

          10.10 Coordination
            with Local Public Health Agencies

          10.11 Public
            Health Services

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

          

          

          

          

           

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          b. Immunizations
            

          c. Prevention
            and Treatment of Sexually Transmitted Diseases

          10.12 Adults
            with Chronic Illnesses and Physical or Developmental Disabilities

          10.13 Persons
            Requiring Ongoing Mental Health Services

          10.14 Member
            Needs Relating to HIV

          10.15 Persons
            Requiring Chemical Dependence Services

          10.16 Native
            Americans

          10.17 Urgently
            Needed Services

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

          

          10.19 Coordination
            of Services

          

          Section
            11 Marketing

          11.1 Marketing
            Requirements

           

          Section
            12 Member
            Services

          12.1 General
            Functions

          12.2 Translation
            and Oral Interpretation

          12.3 Communicating
            with the Visually, Hearing and Cognitively Impaired

           

          Section
            13 Enrollee
            Notification

          13.1 General
            Requirements

          13.2 Member
            ID
            Cards

          13.3 Member
            Handbooks

          13.4 Enrollee
            Rights

           

          Section
            14 Organization
            Determinations, Actions, and Grievance System

          14.1 General
            Requirements

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

            

          

          14.3 Medicaid
            Advantage Action and Grievance System Additional Provisions

          14.4 Notification
            of Medicaid Advantage Action and Grievance System Procedures

          14.5 Complaint,
            Complaint Appeal and Action Appeal Investigation determinations

           

          Section
            15 Access
            Requirements

           

          

          Section
            16 Quality
            Management and Performance Improvement

           

          Section
            17 Monitoring
            and Evaluation

          17.1 Right
            To
            Monitor Contractor Performance

          17.2 Cooperation
            During Monitoring And Evaluation

          17.3 Cooperation
            During On-Site Reviews

          17.4 Cooperation
            During Review of Services by External Review Agency

          

          

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          Section
            18 Contractor
            Reporting Requirements

          18.1 General
            Requirements

          18.2 Time
            Frames for Report Submissions

          18.3 SDOH
            Instructions for Report Submissions

          18.4 Liquidated
            Damages

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

          18.6 Reporting
            Requirements

          18.7 Ownership
            and Related Information Disclosure

          18.8 Public
            Access to Reports

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

          

          18.10
            Conflict of Interest Disclosure

          18.11
            Physician Incentive Plan Reporting

           

          Section
            19 Records
            Maintenance and Audit Rights

          19.1 Maintenance
            of Contractor Performance Records

          19.2 Maintenance
            of Financial Records and Statistical Data

          19.3 Access
            to
            Contractor Records

          19.4 Retention
            Periods

           

          Section
            20 Confidentiality

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

            
              20.2
                Confidentiality
                of Medical Records

            

            
              20.3
                Length
                of
                Confidentiality Requirements

            

          

           

          Section
            21 Participating
            Providers

          21.1 General
            Requirements

          21.2 Medicaid
            Advantage Network Requirements

          21.3 SDOH
            Exclusion or Termination of Providers

          21.4 Payment
            in Full

          21.5 Dental
            Networks

           

          Section
            22 Subcontracts
            and Provider Agreements for Medicaid Only Covered Services

          22.1 Written
            Subcontracts

          22.2 Permissible
            Subcontracts

          22.3 Provision
            of Services Through Provider Agreements

          22.4 Approvals

          22.5 Required
            Components

          22.6 Timely
            Payment

          22.7 Physician
            Incentive Plan

          

          Section
            23 Americans
            With Disabilities Act Compliance Plan 

           

          Section
            24 Fair
            Hearings

          

          

          

          

          

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          24.1 Enrollee
            Access to Fair Hearing Process

          24.2 Enrollee
            Rights to a Fair Hearing

          24.3 Contractor
            Notice to Enrollees

          24.4 Aid
            Continuing

          24.5 Responsibilities
            of SDOH

          24.6 Contractor's
            Obligations

           

          Section
            25 External
            Appeal

          25.1 Basis
            for
            External Appeal

          25.2 Eligibility
            for External Appeal

          25.3 External
            Appeal Determination

          25.4 Compliance
            with External Appeal Laws and Regulations

          25.5 Member
            Handbook

           

          Section
            26 Intermediate
            Sanctions

          26.1 General
            Practices

          26.2 Unacceptable
            Practices

          26.3 Intermediate
            Sanctions

          26.4 Enrollment
            Limitations

          26.5 Due
            Process

          

          Section
            27 Environmental
            Compliance 

           

          Section
            28 Energy
            Conservation

           

          Section
            29 Independent
            Capacity of Contractor Section 30 No
            Third
            Party Beneficiaries

           

          Section
            31 Indemnification

          31.1 Indemnification
            by Contractor

          31.2 Indemnification
            by DOHMH

           

          Section
            32 Prohibition
            on Use of Federal Funds for Lobbying

          32.1 Prohibition
            of Use of Federal Funds for Lobbying

          32.2 Disclosure
            Form to Report Lobbying

          32.3 Requirements
            of Subcontractors

           

          Section
            33 Non-Discrimination

           

          
            33.1
              Equal
              Access to Benefit Package

            
              33.2
                Non-Discrimination

            

            
              33.3
                Equal
                Employment Opportunity

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

              

            

          

           

          

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          Section
            34 Compliance
            with Applicable Laws and Regulations

          34.1 Contractor
            and DOHMH Compliance with Applicable Laws

          
            34.2
              Nullification
              of Illegal, Unenforceable, Ineffectiveor
              Void
              Contract Provisions

          

          34.3 Certificate
            of Authority Requirements

          34.4 Notification
            of Changes in Certificate of Incorporation

          34.5 Contractor's
            Financial Solvency Requirements

          34.6 Non-Liability
            ofEnrollees for Contractor's Debts

          34.7 DOHMH
            Compliance with Conflict of Interest Laws

          34.8 Compliance
            Plan

          

          Section
            35 New
            York
            State Standard Contract Clauses and New York City Standard Clauses Signature
            Page

          

          

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          APPENDICES

          

          
            	 	
                    A.

                  	
                    New
                      York State Standard Clauses 

                  

          

          
            	 	
                    B.

                  	
                    Certification
                      Regarding Lobbying

                  

          

          
            	 	
                    C.

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

                  

          

          
            	 	
                    D.

                  	
                    New
                      York State Department of Health Medicaid Advantage Marketing
                      Guidelines

                  

          

          
            	 	
                    E.

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

                  

          

          
            	 	
                    F.

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

                  

          

          
            	 	
                    G.

                  	
                    RESERVED

                  

          

          
            	 	
                    H.

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

                  

          

          
            	 	
                    I.

                  	
                    RESERVED

                  

          

          
            	 	
                    J.

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

                  

          

          
            	 	
                    K.

                  	
                    Medicare
                      and Medicaid Advantage Products and Non-Covered
                      Services

                  

          

          
            	 	
                    L.

                  	
                    Approved
                      Capitation Payment Rates

                  

          

          
            	 	
                    M.

                  	
                    Service
                      Area

                  

          

          
            	 	
                    N.

                  	
                    New
                      York City Specific Contracting
                      Requirements

                  

          

          
            	 	
                    O.

                  	
                    RESERVED

                  

          

          
            	 	
                    P.

                  	
                    RESERVED

                  

          

          
            	 	
                    Q.

                  	
                    RESERVED

                  

          

          
            	 	
                    R.

                  	
                    New
                      York City Standard Clauses

                  

          

          

          

          

          

          

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    1.
      DEFINITIONS

     

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

     

    "Court-Ordered
      Services" means those services that the Contractor is required to provide to
      Enrollees pursuant to orders of courts of competent jurisdiction, provided
      however, that such ordered services are within the Contractor's Medicare and
      Medicaid Advantage Benefit Packages.

     

    "Days"
      means
      calendar days except as otherwise stated.

     

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

     

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

     

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

     

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

     

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

     

    "Eligible
      Person"
      means a
      person whom the LDSS, state or federal government determines to be eligible
      for
      Medicaid and who meets all the other conditions for enrollment in the Medicaid
      Advantage Program as set forth in Section 5.1 of this Agreement.

     

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

     

    "Emergency
      Medical Condition"
      means a
      medical or behavioral condition, the onset of which is sudden, that manifests
      itself by symptoms of sufficient severity, including severe pain, that a prudent
      layperson, possessing an average knowledge of medicine and health, could
      reasonably expect the absence of immediate medical attention to result
      in:

    (i)
      placing the health of the person afflicted with such condition in serious
      jeopardy, or in the case of a behavioral condition, placing the health of the
      person or others in serious jeopardy; or (ii) serious impairment to such
      person's bodily functions; or (iii) serious dysfunction of any bodily organ
      or
      part of such person; or (iv) serious disfigurement of such person.

     

    

     

    Medicaid
      Advantage Contract 

    SECTION
      1

    (DEFINITIONS)
      

    New
      York
      City 2006 

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    "Emergency
      Services"
      means
      covered services that are needed to treat an Emergency Medical Condition.
      Emergency services include health care procedures, treatments or services needed
      to evaluate or stabilize an Emergency Medical Condition including psychiatric
      stabilization and medical detoxification from drugs or alcohol.

     

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

     

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

     

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

     

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

     

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

     

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

     

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

     

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

     

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

     

    

     

    Medicaid
      Advantage Contract 

    SECTION
      1

    (DEFINITIONS)

    New
      York
      City 2006 

    1-2

     

    

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

     

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

     

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

     

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

     

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

     

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

     

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

     

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

     

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

     

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

     

    

     

    Medicaid
      Advantage Contract 

    SECTION
      1

    (DEFINITIONS)
      

    New
      York
      City 2006 

    1-3

     

    

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

     

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

     

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

     

    "Nonconsensual
      Enrollment"
      means
      Enrollment of an Eligible Person, in a Medicaid Advantage Product, without
      the
      consent of the Eligible Person or consent of a person with the legal authority
      to act on behalf of the Eligible Person at the time of Enrollment.

     

    "Non-Participating
      Provider"
      means a
      provider of medical care and/or services with which the Contractor has no
      Provider Agreement.

     

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

     

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

     

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

     

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

     

    "Post-stabilization
      Care
      Services" means covered services, related to an Emergency Medical Condition,
      that are provided after an Enrollee is stabilized in order to maintain the
      stabilized condition, or to improve or resolve the Enrollee's
      condition.

     

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

     

     

    

    Medicaid
      Advantage Contract

    SECTION
      1

    (DEFINITIONS)
      

    New
      York
      City 2006 

    1-4

     

    

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

     

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

     

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

     

     

    

    Medicaid
      Advantage Contract

    SECTION
      1

    (DEFINITIONS)

    New
      York
      City 2006

    1-5

    

    
      	
              2.

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

            

    

     

    2.1 Term

     

    
      	 	
              a)

            	
              This
                Agreement is effective April 1, 2006 and shall remain in effect until
                December 31, 2006 or until the execution of an extension, renewal
                or
                successor Agreement between the Contractor and the DOHMH approved
                by the
                SDOH, the Department of Health and Human Services (DHHS), and any
                other
                entities as required by law or regulation, whichever occurs
                first.

            

    

     

    
      	 	
              b)

            	
              This
                Agreement shall not be automatically renewed at its expiration. The
                parties to the Agreement shall have the option to renew this Agreement
                for
                four additional one (1) year terms, subject to the approval of the
                SDOH,
                the DHHS, and any other entities as required by law or
                regulation.

            

    

     

    
      	 	
              c)

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

            

    

     

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

     

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

     

    
      	 	
              d)

            	
              Notwithstanding
                the foregoing, this Agreement will automatically terminate, in its
                entirety, should federal financial participation for the Medicaid
                Advantage program expire.

            

    

     

    2.2 Amendments

     

    
      	 	
              a)

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

            

    

     

    
      	 	
              b)

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

            

    

     

    

     

    Medicaid
      Advantage Contract
      

    SECTION
      2

    (AGREEMENT
      TERM, AMENDMENTS, EXTENSIONS, AND GENERAL 

    CONTRACT
      ADMINISTRATION PROVISIONS) 

    New
      York
      City 2006 

    2-1

    

    
      	 	
              c)

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

            

    

     

    2.3 Approvals

     

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

     

    2.4 Entire
      Agreement

     

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

     

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

    2) Appendix
      R, Local Standard Clauses for all New York City Contracts;

    3) Appendix
      N, New York City Specific Requirements

    4) The
      body
      of this Agreement;

    5) The
      appendices attached to the body of this Agreement, other than Appendices A,
      R
      and N;

    6) The
      Contractor's approved:

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

    SDOH
      and
      DOHMH

    ii) Action
      and Grievance System Procedures on file with SDOH 

    iii) ADA
      Compliance Plan on file with SDOH and DOHMH

     

    2.5 Renegotiation

     

    The
      parties to this Agreement shall have the right to renegotiate the terms and
      conditions of this Agreement in the event applicable local, state or federal
      law, regulations or policy are altered from those existing at the time of this
      Agreement in order to be in continuous compliance therewith. This Section shall
      not limit the

     

    

     

    Medicaid
      Advantage Contract

    SECTION
      2

    (AGREEMENT
      TERM, AMENDMENTS, EXTENSIONS, AND GENERAL 

    CONTRACT
      ADMINISTRATION PROVISIONS) 

    New
      York
      City 2006 

    2-2

    

    right
      of
      the parties to this Agreement from renegotiating or amending other terms and
      conditions of this Agreement. Such changes shall only be made with the consent
      of the parties and the prior approval of the SDOH and the DHHS.

     

    
      	
              2.6

            	
              Assignment
                and Subcontracting

            

    

     

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

     

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

     

    
      	
              2.7

            	
              Termination

            

    

     

    a) DOHMH
      Initiated Termination

     

    i) DOHMH
      shall have the right to terminate this Agreement, in whole or in part if the
      Contractor:

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

    B) has
      engaged in an unacceptable practice under 18 NYCRR, Part 515, that affects
      the
      fiscal integrity of the Medicaid program

     

     

    Medicaid
      Advantage Contract
      

    SECTION
      2

    (AGREEMENT
      TERM, AMENDMENTS, EXTENSIONS, AND

    GENERAL
      CONTRACT ADMINISTRATION PROVISIONS) 

    New
      York
      City 2006 

    2-3

    

    or
      engaged in an unacceptable practice pursuant to Section 26.2 of this
      Agreement;

    

    
      	 	
              C)

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

            

    

    
      	 	
              D)

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

            

    
      	
            	
              E)

            	
              becomes
                insolvent;

            

    

    
      	 	
              F)

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

            

    

    
      	 	
              G)

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

            

    

    
      	 	
              H)

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

            

    

     

    
      	 	
              ii)

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

            

    

     

    
      	 	
              iii)

            	
              If
                SDOH suspends, limits or revokes Contractor's Certificate of Authority
                under PHL § 4404, this Agreement shall expire on the date the Contractor
                ceases to have authority to serve the geographic area of the LDSS.
                No
                hearing will be required if the Agreement expires due to SDOH suspension,
                limitation or revocation of the Contractor's Certificate of Authority
                or
                if the Contractor's contract with CMS to offer the Medicare Advantage
                Product is terminated or not
                renewed.

            

    

     

    
      	iv)  	
              Prior
                to the effective date of the termination the DOHMH shall notify Enrollees
                of the termination, or delegate responsibility for such notification
                to
                the Contractor, and such notice shall include a statement that Enrollees
                may disenroll immediately from the Contractor's Medicaid Advantage
                Product.

            

    

     

    

     

    Medicaid
      Advantage Contract

    SECTION
      2

    (AGREEMENT
      TERM, AMENDMENTS, EXTENSIONS,

    AND
      GENERAL CONTRACT ADMINISTRATION PROVISIONS)

    New
      York
      City 2006

    2-4

    

     

     

    b) Contractor
      and DOHMH Initiated Termination

     

    
      	 	
              i)

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

            

    

     

    
      	 	
              ii)

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

            

    

     

    
      	 	
              iii)

            	
              In
                such events, the party exercising its right shall give the other
                party and
                SDOH written notice specifying the reason for and the effective date
                of
                termination, which shall not be less time than will permit an orderly
                disenrollment of Enrollees from the Contractor's Medicaid Advantage
                Product. However, in the event that this Agreement is terminated
                due to
                the Contractor's failure to renew its contract with CMS to offer
                the
                Medicare Advantage Product, or that the Contractor's Medicare Advantage
                contract with CMS otherwise expires or terminates, this Agreement
                shall
                terminate on the effective date of the termination of the Contractor's
                contract with CMS.

            

    

     

    c)
      Contractor Initiated Termination

     

    
      	 	
              i)

            	
              The
                Contractor shall have the right to terminate this Agreement in the
                event
                that DOHMH materially breaches the Agreement or fails to comply with
                any
                term or condition of this Agreement that is not cured within twenty
                (20)
                days, or to such longer period as the parties may agree, of the
                Contractor's written request for compliance. The Contractor shall
                give
                DOHMH and SDOH written notice specifying the reason for and the effective
                date of the termination, which shall not be less time than will permit
                an
                orderly disenrollment of Enrollees from the Contractor's Medicaid
                Advantage Product.

            

    

     

    
      	 	
              ii)

            	
              In
                the event that the Contractor's obligations are materially changed
                by
                modifications to this Agreement and its Appendices by SDOH or DOHMH
                and
                the Contractor does not agree to such material changes, the Contractor
                shall have the right to terminate this Agreement. In such event.
                Contractor shall give DOHMH and SDOH written notice within thirty
                (30)
                days of notification of changes to the Agreement
                or

            

    

    

     

    

    Medicaid
      Advantage Contract 

    SECTION
      2

    (AGREEMENT
      TERM, AMENDMENTS, EXTENSIONS,

    AND
      GENERAL CONTRACT ADMINISTRATION PROVISIONS)

    New
      York
      City 2006 

    2-5

    

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

     

    
      	 	
              iii)

            	
              The
                Contractor shall have the right to terminate this Agreement if the
                Contractor is unable to provide the Medicaid Advantage Benefit Package
                pursuant to this Agreement because of a natural disaster and/or an
                act of
                God to such a degree that Enrollees cannot obtain reasonable access
                to
                Medicaid Only Covered Services within the Contractor's organization,
                and,
                after diligent efforts, the Contractor cannot make other provisions
                for
                the delivery of such services. The Contractor shall give DOHMH and
                SDOH
                written notice of any such termination that
                specifies:

            

    

     

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

    B) the
      Contractor's attempts to make other provision for the delivery of Medicaid
      Only
      Covered Services; and

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

     

    d) Termination
      Due To Loss of Funding

     

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

     

    2.8 Close-Out
      Procedures

     

    
      	 	
              a)

            	
              Upon
                termination or expiration of this Agreement and in the event that
                it is
                not scheduled for renewal, the Contractor shall comply with close-out
                procedures that the Contractor develops in conjunction with DOHMH
                and that
                the DOHMH, and the SDOH have approved. The close-out procedures shall
                include the following:

            

    

     

     

    

    Medicaid
      Advantage Contract 

    SECTION
      2

    (AGREEMENT
      TERM, AMENDMENTS, EXTENSIONS, 

    AND
      GENERAL CONTRACT ADMINISTRATION PROVISIONS) 

    New
      York
      City 2006 

    2-6

    

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

     

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

     

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

     

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

     

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

     

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

     

    2.9 Rights
      and Remedies

     

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

     

     

     

    

    Medicaid
      Advantage Contract 

    SECTION
      2

    (AGREEMENT
      TERM, AMENDMENTS, EXTENSIONS, 

    AND
      GENERAL CONTRACT ADMINISTRATION PROVISIONS) 

    New
      York
      City 2006 

    2-7

    

    2.10 Notices

     

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

     

    For
      DOHMH:

    New
      York
      City Department of Health and Mental Hygiene

    125
      Worth
      Street, CN #
      29C

    New
      York,
      NY 10013

    ATTN:
      Assistant Commissioner

    Division
      of Health Care Access and Improvement

     

    For
      SDOH:

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

     

    For
      the
      Contractor:

    WellCare
      of New York, Inc. 11 West 19th
      Street,
      2nd
      floor
      New York, NY 10011 ATTN: Chief Executive Officer

     

    2.11  Severability

     

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

     

    Medicaid
      Advantage Contract SECTION 2

    (AGREEMENT
      TERM, AMENDMENTS, EXTENSIONS, AND 

    GENERAL
      CONTRACT ADMINISTRATION PROVISIONS) 

    New
      York
      City 2006 

    2-8

    

    3. COMPENSATION

     

    3.1 Capitation
      Payments

     

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

     

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

     

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

     

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

     

    3.2 Modification
      of Rates During Contract Period

     

    a) Any
      technical modification to Capitation Rates during the term of this Agreement
      as
      agreed to by the Contractor, including but not limited to, changes in
      reinsurance or the Medicaid Advantage Benefit Package, shall be deemed
      incorporated into this Agreement without further action by the parties, upon
      approval by SDOH, and upon written notice by SDOH to the DOHMH.

     

    b) Any
      other
      modification to Capitation Rates, as agreed to by SDOH and the Contractor,
      during the term of the Agreement shall be deemed incorporated into this
      Agreement without further action by the parties upon approval of such
      modifications by the SDOH and the State Division of the Budget, and upon written
      notice by SDOH to the DOHMH.

     

    c) In
      the
      event that SDOH and the Contractor fail to reach agreement on modifications
      to
      the monthly Capitation Rates, the SDOH will provide formal written notice to
      the
      Contractor and DOHMH of the amount and effective date of the modified Capitation
      Rates approved by the State Division of the Budget. The Contractor shall have
      the option of terminating this Agreement if such approved modified Capitation
      Rates are not acceptable. In such case, the Contractor shall give written notice
      to the SDOH and the DOHMH within thirty (30) days of the date of the formal
      written notice of the modified Capitation Rates from SDOH specifying the reasons
      for and effective date of termination. The effective date of termination shall
      be ninety (90) days from the date of the Contractor's written notice, unless
      the
      SDOH determines that an orderly disenrollment to Medicaid fee-for-service or
      transfer to another MCO's Medicaid Advantage Product can be accomplished in
      fewer days. During the period commencing with the effective date of the SDOH
      modified Capitation Rates through the effective date of termination of the
      Agreement,

     

    

     

    

     

    Medicaid
      Advantage Contract

     SECTION
      3 (COMPENSATION) 

    New York
      City
      2006 

    3-1

     

    

    the
      Contractor shall have the option of continuing to receive capitation payments
      at
      the expired Capitation Rates or at the modified Capitation Rates approved by
      SDOH and State Division of the Budget for the rate period.

     

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

     

    3.3 Rate
      Setting Methodology

     

    
      	 	
              a)

            	
              Capitation
                Rates shall be determined prospectively and shall not be retroactively
                adjusted to reflect actual fee-for-service data or plan experience
                for the
                time period covered by the rates.

            

    

     

    
      	 	
              b)

            	
              Capitated
                rates in effect as of April 1, 2006 and thereafter, shall be certified
                to
                be actuarially sound in accordance with 42 CFR § 438.6 (c
                ).

            

    

     

    
      	 	
              c)

            	
              Notwithstanding
                the provisions set forth in Section 3.3 (a) and (b) above, the DOHMH
                reserves the right to terminate this Agreement pursuant to Section
                2.7 of
                this Agreement, upon determination by SDOH that the aggregate monthly
                Capitation Rates are not cost
                effective.

            

    

     

    3.4 Payment
      of Capitation

     

    
      	 	
              a)

            	
              The
                monthly capitation payments for each Enrollee are due to the Contractor
                from the Effective Date of Enrollment until the Effective Date of
                Disenrollment of the Enrollee or termination of this Agreement, whichever
                occurs first. The Contractor shall receive a full month's capitation
                payment for the month in which Disenrollment occurs. The Roster generated
                by SDOH with any modification communicated electronically or in writing
                by
                the LDSS or the Enrollment Broker prior to the end of the month in
                which
                the Roster is generated, shall be the Enrollment list for purposes
                of
                eMedNY premium billing and payment, as discussed in Section 6.7 and
                Appendix H.

            

    

     

    
      	 	
              b)

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

            

    

     

     

     

    Medicaid
      Advantage Contract 

    SECTION
      3

    (COMPENSATION)

    New
      York
      City 2006 

    3-2

     

    3.5 Denial
      of
      Capitation Payments

     

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

     

    3.6 SDOH
      Right to Recover Premiums

     

    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.

     

    3.7 Third
      Party Health Insurance Determination

     

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

    

     

    Medicaid
      Advantage Contract

    SECTION
      3

    (COMPENSATION)
      

    New
      York
      City 2006 

    3-3

    

    3.8 Contractor
      Financial Liability

     

    Contractor
      shall not be financially liable for any services rendered to an Enrollee prior
      to his or her Effective Date of Enrollment in the Contractor's Medicaid
      Advantage Product.

     

    3.9 Tracking
      Services Provided by Indian Health Clinics

     

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

    

     

    Medicaid
      Advantage Contract

    SECTION
      3

    (COMPENSATION)
      

    New
      York
      City 2006 

    3-4

    

    
      	
              4.

            	
              SERVICE
                AREA

            

    

     

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

     

    

     

    

     

    Medicaid
      Advantage Contract 

    SECTION
      4

    (SERVICE
      AREA) 

    New
      York
      City 2006

    4-1

     

    

    5. ELIGIBILITY
      FOR ENROLLMENT IN MEDICAID ADVANTAGE

     

    5.1 Eligible
      to Enroll in the Medicaid Advantage Program

     

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

     

    
      	 	
              i)

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

            

    

     

    
      	 	
              ii)
                

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

            

    

     

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

            

    

    
       

      
        	
              	iv)	
                
                   Must
                    be 21 years of age or older;
                    and

                

              

      

      
         

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

                  

                

        

      

    

     

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

     

    5.2 Not
      Eligible to Enroll in the Medicaid Advantage Program

     

    Persons
      meeting the following criteria are not eligible to enroll in the Contractor's
      Medicaid Advantage Product:

     

    a)
       Individuals
      who are medically determined to have End Stage Renal Disease (ESRD) at the
      time
      of enrollment, unless such individuals meet the exceptions to Medicare Advantage
      eligibility rules for persons who have ESRD as found in Section 20.2.2 of the
      Medicare Managed Care Manual.

     

    b)
       Individuals
      who are only eligible for the Qualified Medicare Beneficiary (QMB), Specified
      Low Income Medicare Beneficiary (SLIMB) or the Qualified Individual-1 (QI-1)
      and
      are not otherwise eligible for Medical Assistance.

     

    c)
       Individuals
      who become eligible for Medical Assistance only after spending down a portion
      of
      their income.

     

    

    

    Medicaid
      Advantage Contract 

    SECTION
      5

    (ELIGIBLE,
      EXEMPT AND EXCLUDED POPULATIONS)

    New
      York
      City 2006 

    5-1

    

    
      	 	
              d)
                

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

            

    

    

      
        	 	
                e)

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

                

              

      

    

     

    
      	 	
              f)
                

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

            

    

     

    
      	 	
              g)
                

            	
              Individuals
                with access to comprehensive private health care coverage, except
                for
                Medicare, including those already enrolled in an MCO. Such health
                care
                coverage purchased either partially or in full, by or on behalf of
                the
                individual, must be determined to be cost effective by the local
                social
                services district.

            

    

     

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

     

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

     

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

     

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

    1)  
      Individuals enrolled in the Restricted Recipient Program. 

     

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

     

    
      	 	
              n)
                

            	
              Individuals
                admitted to a Hospice program prior to time of enrollment (if an
                Enrollee
                enters a Hospice program while enrolled in the Contractor's plan,
                he/she
                may remain enrolled in the Contractor's plan to maintain continuity
                of
                care with his/her PCP).

            

    

     

    
      	 	
              o)
                

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

            

    

     

    

     

    

     

    

    Medicaid
      Advantage Contract 

    SECTION
      5

    (ELIGIBLE,
      EXEMPT AND EXCLUDED POPULATIONS)

    New
      York
      City 2006

    5-2

    

    p)
       Individuals
      with a "County of Fiscal Responsibility" code of 98 (OMRDD in eMedNY) will
      be
      excluded until program features are approved by the State and operational at
      the
      local district level to permit these individuals to voluntarily enroll in
      Medicaid managed care.

     

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

     

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

     

    
      	 	
              s)
                

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

            

    

     

    5.3 Change
      in
      Eligibility Status

     

    
      	 	
              a)

            	
              The
                Contractor must report to the LDSS any change in status of its Enrollees,
                which may impact the Enrollee's eligibility for Medicaid or Medicaid
                Advantage, within five (5) business days of such information becoming
                known to the Contractor. This information includes, but is not limited
                to:
                change of address; incarceration; permanent placement in a nursing
                home or
                other residential institution or program rendering the individual
                ineligible for enrollment in Medicaid Advantage; death; and disenrollment
                from the Contractor's Medicare Advantage Product as defined in this
                Agreement.

            

    

     

    
      	 	
              b)

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

            

    

     

     

    

    Medicaid
      Advantage Contract

    SECTION
      5

    (ELIGIBLE,
      EXEMPT AND EXCLUDED POPULATIONS)

    New
      York
      City 2006 

    5-3

    

    6. ENROLLMENT

     

    6.1 Enrollment
      Requirements

     

    The
      LDSS
      and the Contractor agree to conduct enrollment of Eligible Persons in accordance
      with the policies and procedures set forth in Appendix H of this Agreement
      as if
      set forth fully herein.

     

    6.2 Equality
      of Access to Enrollment

     

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

     

    6.3 Enrollment
      Decisions

     

    An
      Eligible Person's decision to enroll in the Contractor's Medicaid Advantage
      Product shall be voluntary. However, as a condition of eligibility for Medicaid
      Advantage, individuals may only enroll in the Contractor's Medicaid Advantage
      Product if they also enroll in the Contractor's Medicare Advantage Product
      as
      defined in this Agreement.

     

    6.4 Prohibition
      Against Conditions on Enrollment

     

    Unless
      otherwise required by law or this Agreement, neither the Contractor nor LDSS
      shall condition any Eligible Person's enrollment in the Medicaid Advantage
      Program upon the performance of any act or suggest in any way that failure
      to
      enroll may result in a loss of Medicaid benefits.

     

    6.5 Effective
      Date of Enrollment

     

    
      	 	
              a)

            	
              At
                the time of enrollment, the Contractor and the LDSS must notify the
                Enrollee of the expected Effective Date of
                Enrollment.

            

    

     

    
      	 	
              b)

            	
              To
                the extent practicable, such notification must precede the Effective
                Date
                of Enrollment.

            

    

     

    
      	 	
              c)

            	
              In
                the event that the actual Effective Date of Enrollment changes, the
                Contractor and the LDSS must notify the Enrollee of the
                change.

            

    

     

    Medicaid
      Advantage Contract 

    SECTION
      6
      (ENROLLMENT) 

    New
      York
      City 2006

    6-1

    

    
      	 	
              d)

            	
              An
                Enrbllee's Effective Date of Enrollment shall be the first day of
                the
                month on which the Enrollee's name appears on the Prepaid Capitation
                Plan
                Roster and is enrolled in the Contractor's Medicare Advantage Product
                for
                that month.

            

    

     

    6.6 Contractor
      Liability

     

    As
      of the
      Effective Date of Enrollment, and until the Effective Date of Disenrollment
      from
      the Contractor's product, the Contractor shall be responsible for the provision
      and cost of the Medicaid Advantage Benefit Package as described in Appendix
      K-2
      of this Agreement for Enrollees whose names appear on the Prepaid Capitation
      Plan Roster.

     

    6.7 Roster

     

    
      	 	
              a)

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

            

    

     

    
      	 	
              b)

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

            

    

     

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

     

    6.8 Automatic
      Re-Enrollment

     

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

     

    

     

    

    Medicaid
      Advantage Contract 

    SECTION
      6

    (ENROLLMENT)
      

    New
      York
      City 2006 6-2

    

    
      	 	
              i)

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

            

    

    
      	 	
              ii)

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

            

    

     

    6.9 Failure
      to Enroll in the Contractor's Medicare Advantage Product

     

    If
      an
      Enrollee's enrollment in the Contractor's Medicare Advantage Product is rejected
      by CMS, the Contractor must notify the local social services district within
      five (5) business days of learning of CMS' rejection of the enrollment. In
      such
      instances, the LDSS shall delete the Enrollee's enrollment in the Contractor's
      Medicaid Advantage Product retroactive to the Effective Date of
      Enrollment.

     

    6.10 Medicaid
      Managed Care Enrollees Who Will Gain Medicare Eligibility

     

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

     

    6.11 Newborn
      Enrollment

     

    
      	 	
              a)

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

            

    

     

    
      	 	
              b)

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

            

    

     

    
      	 	
              c)

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

            

    

    

    

    Medicaid
      Advantage Contract 

    SECTION
      6

    (ENROLLMENT)

    New
      York
      City 2006 

    6-3

     

    

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

            

    

    

     

    

    

    

    

    

    Medicaid
      Advantage Contract 

    SECTION
      6

    (ENROLLMENT)
      

    New
      York
      City 2006 

    6-4

     

    

    7. RESERVED

    

    

    

    

    

    

    

    

    Medicaid
      Advantage Contract 

    SECTION
      7

    (LOCK-IN
      PROVISIONS)

    New
      York
      City 2006 

    7-1

    

    8. DISENROLLMENT

     

    8.1 Disenrollment
      Requirements

     

    
      	 	
              a)

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

            

    

     

    
      	 	
              b)

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

            

    

     

    8.2 Disenrollment
      Prohibitions

     

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

     

    
      	 	
              i)

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

            

    

     

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

     

    iii) the
      Capitation Rate payable to the Contractor.

     

    8.3 Disenrollment
      Requests

     

    a) Routine
      Disenrollment Requests

     

    The
      LDSS
      or the Enrollment Broker is responsible for processing routine Disenrollment
      requests to take effect on the first (1st)
      day of
      the next month, to the extent possible. In no event shall the Effective Date
      of
      Disenrollment be later than the first (1st)
      day of
      the second (2nd)
      month
      after the month in which an Enrollee requests a Disenrollment.

     

    b) Non-Routine
      Disenrollment Requests

     

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

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

    

     

    

    Medicaid
      Advantage Contract 

    SECTION
      8

    (DISENROLLMENT)
      

    New
      York
      City 2006 

    8-1

     

    

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

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

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

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

     

    8.4 Contractor
      Notification of Disenrollments

     

    
      	 	
              a)

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

            

    

     

    
      	 	
              b)

            	
              In
                the event that the LDSS intends to retroactively disenroll an Enrollee
                on
                a date prior to the first day of the month of the disenrollment request,
                the LDSS shall consult with the Contractor prior to Disenrollment.
                Such
                consultation shall not be required in cases where it is clear that
                the
                Contractor was not a risk for the provision of the Medicaid Advantage
                Benefit Package for any portion of the retroactive
                period.

            

    

     

    
      	 	
              c)

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

            

    

     

    8.5 Contractor's
      Liability

     

    
      	 	
              a)

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

            

    

     

    

    Medicaid
      Advantage Contract 

    SECTION
      8

    (DISENROLLMENT)
      

    New
      York
      City 2006 

    8-2

     

    

    8.6 Enrollee
      Initiated Disenrollment

     

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

     

    8.7 Contractor
      Initiated Disenrollment

     

    
      	 	
              a)

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

            

    

     

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

    ii) The
      Enrollee disenrolls from the Contractor's Medicare Advantage Product
      as defined in this Agreement;

    iii) The
      Enrollee dies;

    iv) The
      Enrollee's status changes such that he/she is no longer eligible to
      participate in Medicaid Advantage as described in Section 5 of this
      Agreement.

     

    
      	 	
              b)

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

            

    

     

    
      	 	
              i)

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

            

    

    
      	 	
              ii)

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

            

    

    
      	 	
              iii)

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

            

    

     

    
      	 	
              c)

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

            

    

    

    

    

    Medicaid
      Advantage Contract 

    SECTION
      8

    (DISENROLLMENT)
      

    New
      York
      City 2006 

    8-3

     

    

    
      	 	
              d)

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

            

    

     

    8.8 LDSS
      Initiated Disenrollment

     

    
      	 	
              a)

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

            

    

     

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

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

    iii) the
      Guaranteed Eligibility period ends (See Section 9) and an Enrollee is
      no
      longer eligible for any Medicaid benefits; or iv) an Enrollee is no longer
      the
      financial responsibility of the LDSS; or v) an Enrollee becomes ineligible
      for
      Enrollment pursuant to Section 5.2 of
      this
      Agreement, as appropriate.

    

    

    

    Medicaid
      Advantage Contract 

    SECTION
      8

    (DISENROLLMENT)
      

    New
      York
      City 2006 

    8-4

     

    

    9. GUARANTEED
      ELIGIBILITY

    

    9.1 General
      Requirements

     

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

     

    9.2 Right
      to
      Guaranteed Eligibility

     

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

     

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

     

    
      	 	
              i)

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

            

    

     

    
      	 	
              ii)

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

            

    

     

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

     

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

     

    

     

    Medicaid
      Advantage Contract 

    SECTION
      9

    (GUARANTEED
      ELIGIBILITY) 

    New
      York
      City 2006 

    9-1

     

    

    9.3 Covered
      Services During Guaranteed Eligibility

     

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

     

    9.4 Disenrollment
      During Guaranteed Eligibility

     

    
      	 	
              a)

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

            

    

     

    
      	 	
              b)

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

            

    

     

     

     

    

    Medicaid
      Advantage Contract

    SECTION
      9

    (GUARANTEED
      ELIGIBILITY) 

    New
      York
      City 2006 

    9-2

    

    10. BENEFIT
      PACKAGE, COVERED AND NON-COVERED SERVICES

     

    10.1 Contractor
      Responsibilities

     

    a) The
      Contractor agrees to provide the Medicare Advantage Benefit Package, as
      described in Appendix K-l of this Agreement, to Enrollees of the Contractor's
      Medicaid Advantage Product subject to any exclusions or limitations imposed
      by
      federal or state law during the period of this Agreement. Such services and
      supplies shall be provided in compliance with the requirements of the
      Contractor's Medicare Advantage Coordinated Care Plan contract with CMS and
      all
      applicable federal statutes, regulations and policies.

     

    b) The
      Contractor agrees to provide the Medicaid Advantage Benefit Package, as
      described in Appendix K-2 of this Agreement, to Enrollees of the Contractor's
      Medicaid Advantage Product subject to any exclusions or limitations imposed
      by
      federal or state law during the period of this Agreement. Such services and
      supplies, shall be provided in compliance with the requirements of this
      Agreement, the State Medicaid Plan established pursuant to Section 363-a of
      the
      State Social Services Law, and all applicable federal and state statutes,
      regulations and policies.

     

    10.2 SDOH
      and
      LDSS Responsibilities

     

    SDOH
      and
      LDSS shall assure that Medicaid services covered under the Medicaid
      fee-for-service program as described in Appendix K-3 of this Agreement which
      are
      not covered in the Medicare or Medicaid Advantage Benefit Packages are available
      to, and accessible by, Medicaid Advantage Enrollees.

     

    10.3 Benefit
      Package and Non-Covered Services Descriptions

     

    The
      Medicare and Medicaid Advantage Benefit Packages and Non-Covered Services agreed
      to by the Contractor and the LDSS are contained in Appendix K, which is hereby
      made a part of this Agreement as if set forth fully herein.

     

    10.4 Adult
      Protective Services

     

    The
      Contractor shall cooperate with LDSS in the implementation of 18 NYCRR Part
      457
      and any subsequent amendments thereto with regard to medically necessary health
      and mental health services and all Court Ordered Services for adults to the
      extent such services are included in the Contractor's Medicare and Medicaid
      Advantage Benefit Packages as described in Appendix K of this Agreement. The
      Contractor is responsible for payment of those services as covered by the
      Medicare and Medicaid Advantage Benefit Packages, even when provided by
      Non-Participating Providers. Non-Participating Providers will be reimbursed
      at
      the Medicaid fee schedule.

     

     

    

    Medicaid
      Advantage Contract

    SECTION
      10

    (BENEFIT
      PACKAGE, COVERED AND NON-COVERED SERVICES) 

    New
      York
      City 2006 

    10-1

    

    10.5 Court-Ordered
      Services

     

    
      	 	
              a)

            	
              The
                Contractor shall provide any Medicare and Medicaid Advantage Benefit
                Package services to Enrollees as ordered by a court of competent
                jurisdiction, regardless of whether such services are provided by
                a
                Participating Provider or by a Non-Participating Provider in compliance
                with such court order. The Non-Participating Providers shall be reimbursed
                by the Contractor at the Medicaid fee schedule. The Contractor is
                responsible for court-ordered services to the extent that such
                court-ordered services are included in the Contractor's Medicare
                and
                Medicaid Advantage Benefit Packages as described in Appendix K of
                this
                Agreement.

            

    

     

    
      	 	
              b)

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

            

    

     

    10.6 Family
      Planning and Reproductive Health Services

     

    a) Nothing
      in this Agreement shall restrict the right of Enrollees to receive

    Family
      Planning and Reproductive Health Services, as defined in Appendix C of
      this
      Agreement, which is hereby made a part of this Agreement as if set forth
      fully herein.

     

    
      	 	
              i)

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

            

    

     

    
      	 	
              b)

            	
              The
                Contractor shall permit Enrollees to exercise their right to obtain
                Family
                Planning and Reproductive Health Services from either the Contractor,
                if
                Family Planning and Reproductive Health Services are provided by
                the
                Contractor, or from any appropriate Medicaid enrolled Non-Participating
                family planning Provider, without a referral from the Enrollee's
                PCP and
                without approval by the Contractor.

            

    

     

    
      	 	
              c)

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

            

    

     

    

    Medicaid
      Advantage Contract 

    SECTION
      10

    (BENEFIT
      PACKAGE, COVERED AND NON-COVERED SERVICES)

    New
      York
      City 2006 

    10-2

    

    
      	 	
              d)

            	
              If
                Contractor does not provide Family Planning and Reproductive Health
                Services to its Enrollees, the Contractor shall comply with Part
                C.3' of
                Appendix C of this Agreement, including assuring that Enrollees are
                fully
                informed of their rights.

            

    

     

    10.7 Emergency
      and Post Stabilization Care Services

     

    
      	 	
              a)

            	
              The
                Contractor shall provide Emergency and Post Stabilization Care Services
                in
                accordance with applicable federal and state requirements, including
                42
                CFR§422.113.

            

    

     

    
      	 	
              b)

            	
              The
                Contractor shall ensure that Enrollees are able to access Emergency
                Services twenty four (24) hours per day, seven (7) days per
                week.

            

    

     

    
      	 	
              c)

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

            

    

     

    
      	 	
              d)

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

            

    

     

    
      	 	
              e)

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

            

    

     

    10.8 Medicaid
      Utilization Thresholds (MUTS)

     

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

     

    

     

    Medicaid
      Advantage Contract

    SECTION
      10

    (BENEFIT
      PACKAGE, COVERED AND NON-COVERED SERVICES) 

    New
      York
      City 2006 

    10-3

    

    10.9 Services
      for Which Enrollees Can Self-Refer

     

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

     

    
      	 	
              a)

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

            

    

     

    
      	 	
              b)

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

            

    

     

    
      	 	
              c)

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

            

    

     

    10.10 Coordination
      with Local Public Health Agencies

     

    The
      Contractor will coordinate its public health-related activities with the Local
      Public Health Agency (LPHA) consistent with the SDOH MCO and Public Health
      Guidelines. Coordination mechanisms and operational protocols for addressing
      public health issues will be negotiated with the LPHA and customized to reflect
      local public health priorities. Negotiations must result in agreements regarding
      required Contractor activities related to public health as set forth in Appendix
      N of this Agreement as if set forth fully herein.

     

    10.11 Public
      Health Services

     

    a) Tuberculosis
      Screening, Diagnosis and Treatment; Directly Observed

    Therapy
      (TB\DOT):

    
      	 	
              i)

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

            

    

    
      	 	
              ii)

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

            

    

    
      	 	
              iii)

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

            

    

    
      	 	
              iv)

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

            

    

    
      	 	
              v)

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

            

    

     

     

    Medicaid
      Advantage Contract

    SECTION
      10

    (BENEFIT
      PACKAGE, COVERED AND NON-COVERED SERVICES) 

    New
      York
      City 2006 

    10-4

    

    
      	 	
              A.

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

            

    

    
      	 	
              B.

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

            

    

    
      	 	
              C.

            	
              The
                LPHA is responsible for: 1) giving notification to the Contractor
                before
                delivering TB-related services, unless these services are ordered
                by a
                court of competent jurisdiction; and 2) making reasonable efforts
                to
                verify with the Enrollee's PCP that he/she has not already provided
                TB
                care and treatment, and 3) providing documentation of services rendered
                along with the claim.

            

    

    
      	 	
              D.

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

            

    

    
      	 	
              E.

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

            

    

    
      	 	
              F)

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

            

    

     

    
      	 	
              vi)

            	
              The
                Contractor will not be financially liable for Directly Observed Therapy
                (DOT) costs. While all other clinical management of tuberculosis
                is
                covered by the Contractor, TB/DOT, where applicable, may be billed
                to any
                SDOH approved fee-for-service Medicaid provider. The Contractor agrees
                to
                make all reasonable efforts to ensure coordination with DOT providers
                regarding clinical care and services. Enrollees may use any Medicaid
                fee-for-service TB/DOT provider.

            

    

     

    
      	 	
              vii)

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

            

    

     

    b) Immunizations

    
      	 	
              i)

            	
              The
                Contractor will be required to reimburse the Local Public Health
                Agency
                when Enrollees self-refer to Local Public Health Agencies for
                immunizations covered by Contractor's Medicare Advantage
                Plan.

            

    

    

    

     

    Medicaid
      Advantage Contract 

     

    SECTION
      10

    (BENEFIT
      PACKAGE, COVERED AND NON-COVERED SERVICES) 

    New
      York
      City 2006 

    10-5

    

    
      	 	
              ii)

            	
              The
                LPHA is responsible for making reasonable efforts to (1) determine
                the
                Ehrollee's managed care membership status; and (2) ascertain the
                Enrollee's immunization status. Reasonable efforts shall consist
                of client
                interviews, medical records, and, when available, access to the
                Immunization Registry. When an Enrollee presents a membership card
                with a
                PCP's name, the LPHA is responsible for calling the PCP. If the LPHA
                is
                unable to verify the immunization status from the PCP or learns that
                immunization is needed, the LPHA is responsible for delivering the
                service
                as appropriate, and the Contractor will reimburse the LPHA at the
                negotiated rate or in the absence of a negotiated rate, at rates
                determined by SDOH.

            

    

     

    c) Prevention
      and Treatment of Sexually Transmitted Diseases

     

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

     

    10.12 Adults
      with Chronic Illnesses and Physical or Developmental Disabilities

     

    a) The
      Contractor will implement all of the following to meet the needs of
      its

    adult
      Enrollees with chronic illnesses and physical or developmental

    disabilities:

    
      	 	
              i)

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

            

    

    
      	 	
              ii)

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

            

    

    
      	 	
              A)

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

            

    

    
      	 	
              B)

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

            

    

    
      	 	
              C

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

            

    

     

    Medicaid
      Advantage Contract

     

    SECTION
      10

    (BENEFIT
      PACKAGE, COVERED AND NON-COVERED SERVICES) 

    New
      York
      City 2006 

    10-6

    

    
      	 	
              D)

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

            

    

    
      	 	
              iii)

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

            

    

    
      	 	
              iv)

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

            

    

    
      	 	
              v)

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

            

    

     

    10.13 Persons
      Requiring Ongoing Mental Health Services

     

    a) The
      Contractor will implement all of the following for its Enrollees
      with

    chronic
      or ongoing mental health service needs:

    
      	 	
              i)

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

            

    

    
      	 	
              ii)

            	
              Satisfactory
                case management systems or satisfactory case
                management.

            

    

    
      	 	
              iii)

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

            

    

    
      	 	
              iv)

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

            

    

     

    10.14 Member
      Needs Relating to HIV

     

    
      	 	
              a)

            	
              To
                adequately address the HIV prevention needs of uninfected Enrollees,
                as
                well as the special needs of individuals with HIV infection who do
                enroll
                in managed care, the Contractor shall have in place all of the
                following:

            

    

    
      	 	
              i)

            	
              Anonymous
                testing may be furnished to the Enrollee without prior approval by
                the
                Contractor and may be conducted at anonymous testing sites available
                to
                clients. Services provided for HIV treatment may only be obtained
                from the
                Contractor during the period the Enrollee is enrolled in the Contractor's
                plan.

            

    

    
      	 	
              ii)

            	
              Methods
                for promoting HIV prevention to all Plan Enrollees. HIV prevention
                information, both primary, as well as secondary should
                be

            

    

     

    

     

    

     

    Medicaid
      Advantage Contract 

     

    SECTION
      10

    (BENEFIT
      PACKAGE, COVERED AND NON-COVERED SERVICES)

    New
      York
      City 2006 

    10-7

    

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

    
      	 	
              iii)

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

            

    

    
      	 	
              iv)

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

            

    

    
      	 	
              v)

            	
              A
                network of providers sufficient to meet the needs of its Enrollees
                with
                HIV. Satisfaction of the network requirement may be accomplished
                by
                inclusion of HIV specialists within the network or the provision
                of HIV
                specialist consultation to non-HIV specialists serving as PCPs for
                persons
                with HIV infection; inclusion of Designated AIDS Center Hospitals
                or other
                hospitals experienced in HIV care in the
                Contractor's

            

    

     

    

     

    Medicaid
      Advantage Contract

     

    SECTION
      10

    (BENEFIT
      PACKAGE, COVERED AND NON-COVERED SERVICES)

    New
      York
      City 2006

    10-8

    

    network;
      and contracts or linkages with providers funded under the Ryan White CARE Act.
      The Contractor shall inform the providers in its network how to obtain
      information about the availability of Experienced HIV Providers and HIV
      Specialist PCPs

    
      	 	
              vi)

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

            

    

    
      	 	
              vii)

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

            

    

    
      	 	
              viii)

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

            

    

     

    10.15 Persons
      Requiring Chemical Dependence Services

     

    a) The
      Contractor will have in place all of the following for its
      Enrollees

    requiring
      Chemical Dependence Services:

    
      	 	
              i)

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

            

    

    
      	 	
              ii)

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

            

    

    
      	 	
              iii)

            	Satisfactory case management
              systems.

    
      	 	
              iv)

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

            

    

    
      	 	
              v)

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

            

    

     

    

     

    Medicaid
      Advantage Contract 

     

    SECTION
      10

    (BENEFIT
      PACKAGE, COVERED AND NON-COVERED SERVICES) 

    New
      York
      City 2006 

    10-9

    

     

     

    10.16 Native
      Americans

     

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

     

    10.17 Urgently
      Needed Services

     

    The
      Contractor is financially responsible for Urgently Needed Services.

     

    
      	 	
              10.18

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

            

    

     

    
      	 	
              a)

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

            

    

     

    
      	 	
              b)

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

            

    

     

    10.19 Coordination
      of Services

     

    a) The
      Contractor shall coordinate care for Enrollees with:

    

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

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

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

      iv) WIC;

      v) programs
        funded through the Ryan White CARE Act;

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

      vii) Prenatal
        Care Assistance Program (PCAP) Providers;

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

      
        ix)
specialized
          providers of long term care for people with developmental
          disabilities.

      

      

       

      

       

      

       

      Medicaid
        Advantage Contract 

      SECTION
        10

      (BENEFIT
        PACKAGE, COVERED AND NON-COVERED SERVICES)

      New
        York
        City 2006 

      10-10

    

     

     

     

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

            

    

     

     

     

    

    Medicaid
      Advantage Contract 

    SECTION
      10

    (BENEFIT
      PACKAGE, COVERED AND NON-COVERED SERVICES) 

    New
      York
      City 2006 

    10-11

    

    11. MARKETING

     

    11.1 Marketing
      Requirements

     

    a) The
      Contractor agrees to follow the Medicare Advantage Marketing

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

     

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

            

    

     

    

     

    

    Medicaid
      Advantage Contract 

    SECTION
      11

    (MARKETING)
      

    New
      York
      City 2006 

    11-1

     

    

    12. MEMBER
      SERVICES

     

    12.1 General
      Functions

     

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

     

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

     

    i) Explaining
      the benefits and covered services offered under the Medicare and Medicaid
      Advantage Products, including applicable conditions and limitations, and any
      conditions associated with the receipt or use of benefits.

     

    ii) Explaining
      the rules for obtaining Medicare and Medicaid Advantage Benefit Package services
      and additional services available to the Enrollee through use of his/her
      Medicaid benefit card.

     

    iii) Providing
      information on: the providers from whom Enrollees may obtain Medicare and
      Medicaid Advantage Benefit Package Services, any out-of-area coverage provided
      by the plan, and coverage of emergency services and urgently needed
      care.

     

    iv) Fielding
      and responding to Enrollee questions and complaints regarding the Contractor's
      Medicare and Medicaid Advantage Products and benefits, and advising Enrollees
      of
      the prerogative to complain at any time to the CMS regarding the Medicare
      Advantage Product, and to the SDOH and LDSS, regarding the Medicaid Advantage
      Product.

     

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

     

    vi) Advising
      Enrollees of the Contractor's applicable complaint and appeals programs,
      utilization review processes, and the Enrollee's rights to a fair hearing or
      external review.

     

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

     

    

    

     

    Medicaid
      Advantage Contract 

    SECTION
      12

    (MEMBER
      SERVICES) 

    New
      York
      City 2006 

    12-1

     

    

    12.2 Translation
      and Oral Interpretation

     

    
      	 	
              a)

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

            

    

     

    
      	 	
              b)

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

            

    

     

    
      	 	
              c)

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

            

    

     

    12.3 Communicating
      with the Visually, Hearing and Cognitively Impaired

     

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

    

    

    

    

    

    Medicaid
      Advantage Contract 

    SECTION
      12 

    (MEMBER
      SERVICES) 

    New
      York
      City 2006 

    12-2

     

    

    13. ENROLLEE
      NOTIFICATION

     

    13.1 General
      Requirements

     

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

     

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

     

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

     

    d) Medicaid
      Advantage post enrollment notices and materials shall include, but not be
      limited to the following:

     

    Provider
      Directories

    Member
      ID
      Cards

    Member
      Handbooks

    Notice
      of
      the Effective Date of Enrollment

    Notice
      of
      the Effective Date of Benefit Package Changes

    Notice
      of
      Termination, Service Area Changes and Network Changes

    Summary
      of Benefits

     

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

     

    13.2 Member
      ID
      Cards

     

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

     

    13.3 Member
      Handbooks

     

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

     

    

     

    

     

    

    Medicaid
      Advantage Contract 

    SECTION
      13

    (ENROLLEE
      NOTIFICATION) New York City 2006

    13-1

     

    

    13.4 Enrollee
      Rights

     

    a) The
      Contractor shall, in compliance with the requirements of 42 CFR

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

     

    
      	 	
              b)

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

            

    

     

    i) receive
      information about the Contractor and managed care;

     

    
      	 	
              ii)

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

            

    

     

    
      	 	
              iii)

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

            

    

     

    
      	 	
              iv)

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

            

    

     

    
      	 	
              v)

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

            

    

     

    
      	 	
              vi)

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

            

    

     

    
      	c)  	
              The
                Contractor's policies and procedures must require that neither the
                Contractor nor its Participating Providers adversely regard an Enrollee
                who exercises his/her rights in 13.4(b)
                above.

            

    

     

     

     

    

    Medicaid
      Advantage Contract 

    SECTION
      13 

    (ENROLLEE
      NOTIFICATION)

    New
      York
      City- 2006 

    13-2

     

    

    14. ORGANIZATION
      DETERMINATIONS, ACTIONS AND GRIEVANCE SYSTEM

     

    
      	 	
              14.1

            	
              General
                Requirements

            

    

     

    a) The
      Contractor agrees to comply with, and shall establish and maintain written
      Organization Determination and Action procedures and a comprehensive Grievance
      system, as described in Appendix F, which is hereby made a part of this
      Agreement as if set forth fully herein, that complies with:

     

    i) all
      procedures and requirements of 42 CFR Subpart M of Part 422 and Chapter 13
      of
      CMS's Medicare Managed Care Manual for services that the Contractor determines
      are a Medicare only benefit.

     

    ii) all
      procedures and requirements of 42 CFR Subpart M of Part 422 and Chapter 13
      of
      CMS's Medicare Managed Care Manual for services the Contractor determines to
      be
      a benefit covered under both Medicare and Medicaid, except that:

    A) the
      Contractor will determine whether services are Medically Necessary as that
      term
      is defined in this Agreement; and

    B) when
      the
      Contractor intends to reduce, suspend, or terminate a previously authorized
      service within an authorization period, the notification provisions of paragraph
      F.2(4)(a) of Appendix F of this Agreement shall apply.

     

    iii)  all
      procedures and requirements of the Medicaid Advantage Action and Medicaid
      Advantage Grievance System requirements described in Appendix F of this
      Agreement and 42 CFR Section 438.400 et. seq., for services that the Contractor
      determines are a Medicaid only benefit. With respect to Medicaid-only services,
      nothing herein shall release the Contractor from its responsibilities under
      PHL
§ 4408-a or PHL Article 49 and 10 NYCRR Part 98 that are not otherwise expressly
      established in Appendix F of this Agreement.

     

    b) For
      services that the Contractor determines are a benefit under both Medicare and
      Medicaid, the Contractor agrees to offer Enrollees the right to pursue either
      the Medicare appeal procedures or the Medicaid Advantage Action Appeal and
      Grievance System in the manner described and provided for in Appendix F of
      this
      Agreement.

     

    
      	 	
              14.2

            	
              Filing
                and Modification of Medicaid Advantage Action and Grievance Systems
                Procedures

            

    

     

    a) The
      Contractor's Action and Grievance System Procedures governing services
      determined by the Contractor to be a Medicaid only benefit and services
      determined by the Contractor to be a benefit under both Medicare and Medicaid
      shall be, approved by the SDOH, and kept on file with the Contractor/DOHMH
      and
      SDOH.

    

    Medicaid
      Advantage Contract 

    SECTION
      14

    (COMPLAINT
      AND APPEAL PROCEDURE) 

    New
      York
      City 2006 

    14-1

     

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

     

    14.3 Medicaid
      Advantage Action and Grievance System Additional Provisions

     

    
      	 	
              a)

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

            

    

     

    
      	 	
              b)

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

            

    

     

    
      	 	
              c)

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

            

    

     

    
      	 	
              d)

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

            

    

     

    
      	 	
              e)

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

            

    

     

    
      	 	
              f)

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

            

    

     

    

    Medicaid
      Advantage Contract 

    SECTION
      14

    (COMPLAINT
      AND APPEAL PROCEDURE) 

    New
      York
      City 2006 

    14-2

    

    14.4 Notification
      of Medicaid Advantage Action and Grievance System Procedures

     

    
      	 	
              a)

            	
              The
                Contractor's specific Action and Grievance System Procedures 'for
                services
                determined by the Contractor to be a Medicaid only benefit and services
                determined by the Contractor to be a benefit under both Medicare
                and
                Medicaid shall be described in the Contractor's Medicaid Advantage
                member
                handbook and shall be made available to all Medicaid Advantage
                Enrollees.

            

    

     

    
      	 	
              b)

            	
              The
                Contractor will advise Enrollees of their right to a fair hearing
                as
                appropriate and comply with the procedures established by SDOH for
                the
                Contractor to participate in the fair hearing process, as set forth
                in
                Section 24 of this Agreement. Such procedures shall include the provision
                of a Medicaid notice in accordance with 42 CFR Sections 438.210 and
                438.404.

            

    

     

    
      	 	
              c)

            	
              The
                Contractor will also advise Enrollees of their right to an External
                Appeal, related to services determined by the Contractor to be a
                Medicaid
                only benefit or services determined by the Contractor to be a benefit
                under both Medicare and Medicaid, in accordance with Section 25 of
                this
                Agreement.

            

    

     

    
      	 	
              d)

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

            

    

     

    
      	 	
              i)

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

            

    

     

    
      	 	
              ii)

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

            

    

     

    
      	 	
              iii)

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

            

    

     

    
      	 	
              iv)

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

            

    

     

    
      	 	
              v)

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

            

    

     

    
      	 	
              vi)

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

            

    

     

    

    Medicaid
      Advantage Contract 

    SECTION
      14

    (COMPLAINT
      AND APPEAL PROCEDURE) 

    New
      York
      City 2006 

    14-3

    

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

     

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

     

    14.5 Complaint,
      Complaint Appeal and Action Appeal Investigation Determinations

     

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

     

    

     

    

    Medicaid
      Advantage Contract 

    SECTION
      14

    (COMPLAINT
      AND APPEAL PROCEDURE) 

    New
      York
      City 2006 

    14-4

    

    15. ACCESS
      REQUIREMENTS

     

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

     

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

     

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

     

    

    

    Medicaid
      Advantage Contract 

    SECTION
      15

    (EQUALITY
      OF ACCESS AND TREATMENT) 

    New
      York
      City 2006 

    15-1

    

    16. QUALITY
      MANAGEMENT AND PERFORMANCE IMPROVEMENT

     

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

     

    16.2 The
      Contractor agrees to conduct a Chronic Care Improvement Program (CCIP) relevant
      to its membership as directed by CMS and to submit the annual report on the
      CCIP
      to CMS and SDOH.

     

    16.3 The
      Contractor agrees to conduct performance improvement projects and to measure
      performance using standard measures required by CMS, and to report results
      to
      CMS and SDOH. Standard Measures will include, but not be limited
      to:

     

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

     

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

     

    • Health
      Outcomes Survey (HOS).

     

    

    

    Medicaid
      Advantage Contract 

    SECTION
      16

    (QUALITY
      ASSURANCE)

     New
      York City 2006 

    16-1

     

    

    17. MONITORING
      AND EVALUATION

     

    17.1 Right
      to
      Monitor Contractor Performance

     

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

     

    17.2 Cooperation
      During Monitoring and Evaluation

     

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

     

    17.3 Cooperation
      During On-Site Reviews

     

    The
      Contractor shall cooperate with SDOH and/or its designee, DOHMH and DHHS in
      any
      on-site review of the Contractor's operations.

     

    17.4 Cooperation
      During Review of Services by External Review Agency

     

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

     

    

     

    

    Medicaid
      Advantage Contract

    SECTION
      17

    (MONITORING
      AND EVALUATION)

    New
      York
      City 2006

    17-1

    

    18. CONTRACTOR
      REPORTING REQUIREMENTS

     

    18.1 General
      Requirements

     

    a) The
      Contractor must maintain a health information system that collects, analyzes,
      integrates and reports data. The system must be sufficient to provide the data
      necessary to comply with the requirements of this Agreement.

     

    b) The
      Contractor must take steps to ensure that data entered into the system,
      particularly that received from Participating Providers, is accurate and
      complete.

     

    c) The
      Contractor must make collected information available to CMS and SDOH, as
      requested under this Agreement.

     

    18.2 Time
      Frames for Report Submissions

     

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

     

    18.3 SDOH
      Instructions for Report Submissions

     

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

     

    18.4 Liquidated
      Damages

     

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

     

    

     

    Medicaid
      Advantage Contract 

    SECTION
      18

    (CONTRACTOR
      REPORTING REQUIREMENTS)

    New
      York
      City 2006 

    18-1

    

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

     

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

     

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

     

    18.6 Reporting
      Requirements

     

    
      	 	
              a)

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

            

    

     

    i) Annual
      Financial Statements:

     

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

     

    ii) Quarterly
      Financial Statements:

     

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

     

    iii) Other
      Financial Reports:

     

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

     

    iv) Encounter
      Data:

     

    The
      Contractor shall prepare and submit encounter data on a monthly basis to SDOH
      through SDOH's designated Fiscal Agent. Each provider is

     

    

     

    Medicaid
      Advantage Contract 

    SECTION
      18

    (CONTRACTOR
      REPORTING REQUIREMENTS) 

    New
      York
      City 2006 

    18-2

    

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

     

    v) Quality
      of Care Performance Measures:

     

    The
      Contractor shall prepare and submit reports to SDOH, as specified by CMS for
      the
      Medicare Advantage Program including Medicare HEDIS results and Medicare CAHPS.
      Reports should be duplicative of reports submitted to CMS, and separate reports
      for the dual eligible population are not required.

     

    vi) Complaint,
      Complaint Appeals and Action Appeals Reports:

     

    
      	 	
              A)

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

            

    

     

    
      	 	
              B)

            	
              The
                Contractor also agrees to provide on a quarterly basis, via the Summary
                Complaint form on the HPN, the total number of Complaints, Complaint
                Appeals and Action Appeals subject to PHL §4408-a and related to Medicaid
                Only Covered Services and services determined by the Contractor to
                be a
                benefit under both Medicare and Medicaid that have been unresolved
                for
                more than forty-five (45) days. The Contractor shall maintain records
                on
                these and other Complaints, Complaint Appeals and Action Appeals
                pursuant
                to Appendix F of this Agreement.

            

    

     

    
      	 	
              C)

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

            

    

     

    vii) Fraud
      and
      Abuse Reporting Requirements:

     

    
      	 	
              A)

            	
              The
                Contractor must submit quarterly, via the HPN Complaint reporting
                format,
                the number of Complaints of fraud or abuse made to the Contractor
                related
                to Medicaid Only Covered Services that warrant preliminary investigation
                by the Contractor.

            

    

     

    

     

    Medicaid
      Advantage Contract

    SECTION
      18

    (CONTRACTOR
      REPORTING REQUIREMENTS)

    New
      York
      City 2006 

    18-3

    

     

     

    
      	 	
              B)

            	
              The
                Contractor must also submit to the SDOH the following on' an ongoing
                basis
                for each confirmed case of fraud or abuse it identifies through
                Complaints, organizational monitoring, contractors, subcontractors,
                providers, beneficiaries, Enrollees, etc related to Medicaid Only
                Covered
                Services:

            

    

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

    2) The
      source that identified the fraud or abuse;

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

    4) A
      description of the fraud or abuse;

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

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

    7) Other
      data/information as prescribed by SDOH.

     

    
      	 	
              C)

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

            

    

     

    viii) Participating
      Provider Network Reports:

     

    The
      Contractor shall submit electronically to the HPN, an updated provider network
      report on a quarterly basis for providers of Medicaid Only Covered Services
      as
      defined in this Agreement and described in Appendix K-2. The Contractor shall
      submit an annual notarized attestation that the providers listed in each
      submission have executed an agreement with the Contractor to serve Contractor's
      Medicaid Enrollees. The report submission must comply with the Managed Care
      Provider Network Data Dictionary. Networks must be reported separately for
      each
      county in which the Contractor operates.

     

    ix) Quality
      Assessment and Performance Improvement Projects

     

    The
      Contractor will submit reports to SDOH on all quality assessment and performance
      improvement projects directed by CMS for the Medicare Advantage Program,
      including the annual report on the Contractor's Chronic Care Improvement
      Program. Reports should be duplicative of reports submitted to CMS, and separate
      reports for the dual eligible population are not required.

     

    

     

    

    Medicaid
      Advantage Contract 

    SECTION
      18

    (CONTRACTOR
      REPORTING REQUIREMENTS) 

    New
      York
      City 2006 

    18-4

    

    x) Additional
      Reports:

     

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

     

    18.7 Ownership
      and Related Information Disclosure

     

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

     

    18.8 Public
      Access to Reports

     

    Any
      data,
      information, or reports collected and prepared by the Contractor and submitted
      to NYS authorities in the course of performing their duties and obligation
      under
      this program will be deemed to be owned by the State of New York subject to
      and
      consistent with the requirements of Freedom of Information Law. This provision
      is made in consideration of the Contractor's use of public funds in collecting
      and preparing such data, information, and reports.

     

    
      	 	
              18.9

            	
              Certification
                Regarding Individuals Who Have Been Debarred Or Suspended By Federal,
                State, or Local Government Contractor will certify to the SDOH initially
                and immediately upon changed circumstances from the last such
                certification that it does not knowingly have an individual who has
                been
                debarred or suspended by the federal, state or local government,
                or
                otherwise excluded from participating in procurement
                activities:

            

    

     

    
      	 	
              a)

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

            

    

     

    
      	 	
              b)

            	
              as
                a party to an employment, consulting or other agreement with the
                Contractor for the provision of items and services that are significant
                and material to the Contractor's obligations in the Medicaid managed
                care
                program, consistent with requirements of SSA § 1932
                (d)(l).

            

    

    

     

    Medicaid
      Advantage Contract 

    SECTION
      18

    (CONTRACTOR
      REPORTING REQUIREMENTS) 

    New
      York
      City 2006

    18-5

    

    18.10 Conflict
      of Interest Disclosure

     

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

     

    18.11 Physician
      Incentive Plan Reporting

     

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

     

    

    Medicaid
      Advantage Contract

    SECTION
      18

    (CONTRACTOR
      REPORTING REQUIREMENTS) 

    New
      York
      City 2006 

    18-6

    

    19. RECORDS
      MAINTENANCE AND AUDIT RIGHTS

     

    19.1 Maintenance
      of Contractor Performance Records

     

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

     

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

     

    ii)  all
      financial records and statistical data that 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 and expenses
      incurred under this Agreement;

     

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

     

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

     

    19.2 Maintenance
      of Financial Records and Statistical Data

     

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

     

    19.3 Access
      to
      Contractor Records

     

    The
      Contractor shall provide 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) of such records. The Contractor shall
      give access to such records on two (2) business days prior written notice,
      during normal business hours, unless otherwise provided or permitted by
      applicable laws, rules, or regulations.

     

    Medicaid
      Advantage Contract

     SECTION
      19

    (RECORDS
      MAINTENANCE AND AUDIT RIGHTS) 

    New
      York
      City 2006 

    19-1

    

    19.4 Retention
      Periods

     

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

     

    

    Medicaid
      Advantage Contract 

    SECTION
      19

    (RECORDS
      MAINTENANCE AND AUDIT RIGHTS) 

    New
      York
      City 2006 

    19-2

    

    20. CONFIDENTIALITY

     

    
      	 	
              20.1

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

            

    

     

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

     

    
      	 	
              20.2

            	
              Confidentiality
                of Medical Records

            

    

     

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

     

    
      	 	
              20.3

            	
              Length
                of Confidentiality Requirements

            

    

     

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

    

    

     

    Medicaid
      Advantage Contract 

    SECTION
      20 

    (CONFIDENTIALITY)
      

    New
      York
      City 2006

    20-1

     

    

    21. PARTICIPATING
      PROVIDERS

     

    21.1 General
      Requirements

     

    a) The
      Contractor agrees to comply with all applicable requirements and standards
      set
      forth at 42 CFR Section 422.112, Subpart C; Part 422, Subpart E; Section
      422.504(a)(6) and 422.504(i), Subpart K; Part 423, subpart C and other
      applicable federal laws and regulations related to MCO relationships with
      providers and with related entities, contractors and subcontractors for services
      in the Contractor's Medicare Advantage Product.

     

    b) The
      Contractor agrees to comply with all applicable requirements and standards
      set
      forth at PHL Article 44, 10 NYCRR Part 98, and other applicable federal and
      state laws and regulations related to MCO relationships with providers and
      with
      related entities, contractors and subcontractors for services in the
      Contractor's Medicaid Advantage Product.

     

    21.2 Medicaid
      Advantage Network Requirements

     

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

     

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

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

     

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

     

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

     

    e) The
      Contractor shall not include in its network any provider who has been sanctioned
      or prohibited from participation in Federal health care programs under either
      Section 1128 or Section 1128A of the SSA, or who has had his/her license
      suspended by the New York State Education Department or the SDOH Office of
      Professional Medical Conduct.

     

    

     

    Medicaid
      Advantage Contract 

    SECTION
      21

    (PROVIDER
      NETWORK AND AGREEMENTS) 

    New
      York
      City 2006 

    21-1

    

    21.3 SDOH
      Exclusion or Termination of Providers

     

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

     

    21.4 Payment
      in Full

     

    Contractor
      must limit participation to providers who agree that payment received from
      the
      Contractor for services included in the Medicare and Medicaid Advantage Benefit
      Package is payment in full for services provided to Enrollees, except for the
      collection of applicable co-payments from Enrollees as provided by
      law.

     

    21.5 Dental
      Networks

     

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

     

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

     

    

    Medicaid
      Advantage Contract 

    SECTION
      21

    (PROVIDER
      NETWORK AND AGREEMENTS) 

    New
      York
      City 2006 

    21-2

    

    
      	
              22.

            	
              SUBCONTRACTS
                AND PROVIDER AGREEMENTS FOR MEDICAID ONLY COVERED
                SERVICES

            

    

     

    22.1 Written
      Subcontracts

     

    
      	 	
              a)

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

            

    

     

    
      	 	
              b)

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

            

    

     

    
      	 	
              c)

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

            

    

     

    22.2 Permissible
      Subcontracts

     

    Contractor
      may subcontract for provider services as set forth in Section 2.6 and 21 of
      this
      Agreement, for management services and for other services as are acceptable
      to
      the SDOH. The Contractor must evaluate the prospective subcontractor's ability
      to perform the activities to be delegated.

     

    22.3 Provisions
      of Services through Provider Agreements

     

    All
      medical care and/or services covered under this Agreement, with the exception
      of
      Emergency Services, Family Planning and Reproductive Health Services, and
      services for which Enrollees can self refer, shall be provided through Provider
      Agreements with Participating Providers.

     

    22.4 Approvals

     

    
      	 	
              a)

            	
              Provider
                Agreements related to Medicaid Only Covered Services shall require
                the
                approval of SDOH as set forth in PHL § 4402 and 10 NYCRR Part
                98.

            

    

     

    
      	 	
              b)

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

            

    

     

    
      	 	
              c)

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

            

    

     

    

     

    Medicaid
      Advantage Contract 

    SECTION
      22 

    (PROVIDER
      AGREEMENTS) 

    New
      York
      City 2006 

    22-1

    

    

    

    

    

    22.5 Required
      Components

     

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

    
      	 	
              i)

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

            

    

    ii) that
      the
      work performed by the subcontractor must be in accordance

    with
      the
      terms of this Agreement; and

    
      	 	
              iii)

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

            

    

     

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

     

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

     

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

     

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

     

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

     

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

     

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

    

    

    Medicaid
      Advantage Contract

    SECTION
      22

    (PROVIDER
      AGREEMENTS)

    New
      York
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    22.6 Timely
      Payment

     

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

     

    22.7 Physician
      Incentive Plan

     

    
      	 	
              a)

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

            

    

     

    
      	 	
              b)

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

            

    

     

    
      	 	
              c)

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

            

    

     

    

    Medicaid
      Advantage Contract 

    SECTION
      22 

    (PROVIDER
      AGREEMENTS) 

    New
      York
      City 2006 

    22-3

     

    

    
      	23.  	
              AMERICANS
                WITH DISABILITIES ACT COMPLIANCE
                PLAN

            

    

    

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

     

    24. FAIR
      HEARINGS

     

    24.1 Enrollee
      Access to Fair Hearing Process

     

    Enrollees
      in the Contractor's Medicaid Advantage Product may access the fair hearing
      process related to services determined by the Contractor to be a Medicaid only
      benefit or services determined by the Contractor to be a benefit under both
      Medicare and Medicaid in accordance with applicable federal and state laws
      and
      regulations. The Contractor must abide by and participate in New York State's
      Fair Hearing Process and comply with determinations made by a fair hearing
      officer.

     

    24.2 Enrollee
      Rights to a Fair Hearing

     

    Enrollees
      in the Contractor's Medicaid Advantage Product may request a fair hearing
      regarding adverse LDSS determinations concerning enrollment, disenrollment
      and
      eligibility, and regarding the denial, termination, suspension or reduction
      of a
      service determined by the Contractor to be a Medicaid only benefit or a benefit
      under both Medicare and Medicaid. For issues related to disputed services,
      Enrollees must have received an adverse determination from the Contractor or
      its
      approved utilization review agent either overriding a recommendation to provide
      services by a Participating Provider or confirming the decision of a
      Participating Provider to deny those services. An Enrollee may also seek a
      fair
      hearing for a failure by the Contractor to act with reasonable promptness with
      respect to such services. Reasonable promptness shall mean compliance with
      the
      time frames established for review of grievances and utilization review in
      Sections 44 and 49 of the Public Health Law, the grievance system requirements
      of 42 CFR Part 438 and Appendix F of this Agreement.

     

    24.3 Contractor
      Notice to Enrollees

     

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

     

    

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      Advantage Contract 

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      York
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              b)

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

            

    

     

    24.4 Aid
      Continuing

     

    
      	 	
              a)

            	
              Contractor
                shall be required to continue the provision of services determined
                by the
                Contractor to be a Medicaid only benefit or a benefit under both
                Medicare
                and Medicaid that are the subject of the fair hearing to an Enrollee
                (hereafter referred to as "aid continuing") if so ordered by the
                OAH under
                the following circumstances:

            

    

     

    i) Contractor
      has or is seeking to reduce, suspend or terminate such service

    or
      treatment currently being provided;

    
      	 	
              ii)

            	
              Enrollee
                has filed a timely request for a fair hearing with OAH; and iii)
                There is
                a valid order for the service or treatment from a
                Participating

            

    

    Provider.

     

    
      	 	
              b)

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

            

    

     

    
      	 	
              c)

            	
              If
                the services and/or benefits in dispute have been terminated, suspended
                or
                reduced and the Enrollee requests a fair hearing in a timely manner,
                the
                Contractor shall, at the direction of either SDOH or LDSS, restore
                the
                disputed services and/or benefits consistent with the provisions
                of
                Section 24.4 of this Agreement.

            

    

     

    24.5 Responsibilities
      of SDOH

     

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

     

    24.6 Contractor's
      Obligations

     

    
      	 	
              a)

            	
              Contractor
                shall appear at all scheduled fair hearings concerning its clinical
                determinations and/or Contractor-initiated Disenrollments to present
                evidence as justification for its determination or submit written
                evidence
                as justification for its determination regarding the disputed benefits
                and/or services. If Contractor will not be making a personal appearance
                at
                the fair hearing, the written material must be submitted to OAH and
                Enrollee or Enrollee's representative at least three (3) business
                days
                prior to the scheduled hearing. If the hearing is scheduled fewer
                than
                three (3) business days after the
                request,

            

    

     

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      Advantage Contract 

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    Contractor
      must deliver the evidence to the hearing site no later than one (1) business
      day
      prior to the hearing, otherwise Contractor must appear in person.
      Notwithstanding the above provisions, Contractor may be required to make a
      personal appearance at the discretion of the hearing officer and/or
      SDOH.

     

    
      	 	
              b)

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

            

    

     

    
      	 	
              c)

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

            

    

     

    
      	 	
              d)

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

            

    

     

    
      	 	
              e)

            	
              If
                SDOH, through its Complaint investigation process, or OAH, by a
                determination after a fair hearing, directs Contractor to provide
                a
                service that was initially denied by Contractor, Contractor may either
                directly provide the service, arrange for the provision of that service
                or
                pay for the provision of that service by a Non-Participating Provider.
                If
                the services were not furnished during the period in which the fair
                hearing was pending, the Contractor must authorize and furnish the
                disputed services promptly and as expeditiously as the Enrollee's
                health
                condition requires.

            

    

     

    
      	 	
              f)

            	
              Contractor
                agrees to abide by changes made to this Section of the Agreement
                with
                respect to the fair hearing. Service Authorization, Action, Action
                Appeal,

            

    

    

    

    

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      Advantage Contract 

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    Complaint
      and Complaint Appeal processes by SDOH in order to comply with any amendments
      to
      applicable state or federal statutes or regulations.

     

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

     

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

     

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

     

    25. EXTERNAL
      APPEAL

     

    25.1 Basis
      for
      External Appeal

     

    Enrollees
      in the Contractor's Medicaid Advantage Product are eligible to request an
      External Appeal when one or more health care service determined by the
      Contractor to be a Medicaid only benefit or a benefit under both Medicare and
      Medicaid has been denied by the Contractor on the basis that the service(s)
      is
      not medically necessary or is experimental or investigational.

     

    25.2 Eligibility
      for External Appeal

     

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

    

    

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      Advantage Contract 

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    25.3 External
      Appeal Determination

     

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

     

    25.4 Compliance
      with External Appeal Laws and Regulations

     

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

     

    25.5 Member
      Handbook

     

    The
      Contractor shall describe its Action and utilization review policies and
      procedures, including a notice of the right to an External Appeal together
      with
      a description of the External Appeal process and the timeframes for External
      Appeal in the Medicaid Advantage Handbook.

     

    26. INTERMEDIATE
      SANCTIONS

     

    26.1 General

     

    Contractor
      is subject to the imposition of sanctions as authorized by 42 CFR 422, Subpart
      0. In addition, for the Medicaid Advantage Program, the Contractor is subject
      to
      the imposition of sanctions as authorized by state and federal law and
      regulation, including the SDOH's right to impose sanctions for unacceptable
      practices as set forth in 18 NYCRR Part 515 and civil and monetary penalties
      as
      set forth in 18 NYCRR Part 516 and 43 CFR § 438.700, and such other sanctions
      and penalties as are authorized by local laws and ordinances and resultant
      administrative codes, rules and regulations related to the Medical Assistance
      Program or to the delivery of the contracted for services.

     

    26.2 Unacceptable
      Practices

     

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

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

    ii) Imposing
      premiums or charges on Enrollees that are in excess of the premiums
      or charges permitted under the Medicaid Advantage Program.

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

       

    

    

     

    

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      Advantage Contract 

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    iv) Misrepresenting
      or falsifying information that the Contractor furnishes to
      an'
      Enrollee, Eligible Persons, Prospective Enrollees, health care providers,
      the State or to CMS. v) Failing to comply with the requirements for Physician
      Incentive Plans, as set forth in 42 CFR §§ 422.208 and 422.210.

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

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

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

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

       

    

    26.3 Intermediate
      Sanctions

     

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

     

    i) Civil
      and
      monetary penalties.

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

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

       

    

     

    26.4 Enrollment
      Limitations

     

    
      	 	
              a)

            	
              The
                DOHMH shall have the right, upon consultation with and notice to
                the SDOH,
                to limit, suspend, or terminate Enrollment activities by the Contractor
                and/or enrollment into the Contractor's Medicaid Advantage Product
                upon
                ten (10) days written notice to the Contractor. The written notice
                shall
                specify the action(s) contemplated and the reason(s) for such action(s)
                and shall provide the Contractor with an opportunity to submit additional
                information that would support the conclusion that limitation, suspension
                or termination of Enrollment activities or Enrollment in the Contractor's
                plan is unnecessary. Nothing in this paragraph limits other remedies
                available to the DOHMH under this
                Agreement.

            

    

     

    
      	 	
              b)

            	
              The
                SDOH shall have the right, upon notice to the DOHMH and LDSS, to
                limit,
                suspend or terminate Enrollment activities by the Contractor and/or
                Enrollment into the Contractor's Medicaid Advantage Product upon
                ten (10)
                days written notice to the Contractor. The written notice shall specify
                the action(s) contemplated and the reason(s) for such action(s) and
                shall
                provide the Contractor with an opportunity to submit additional
                information that would support the conclusion that limitation, suspension
                or termination of Enrollment activities or Enrollment in the Contractor's
                Medicaid Advantage

            

    

     

    

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      Advantage Contract 

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    Product
      is unnecessary. Nothing in this paragraph limit other remedies available to
      SDOH
      or the DOHMH under this Agreement.

     

    26.5 Due
      Process

     

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

     

    27. ENVIRONMENTAL
      COMPLIANCE

     

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

     

    28. ENERGY
      CONSERVATION

     

    The
      Contractor shall comply with any applicable mandatory standards and policies
      relating to energy efficiency that are contained in the State Energy
      Conservation regulation issued in compliance with the Energy Policy and
      Conservation Act of 1975 (Pub. L. 94-165) and any amendment to the
      Act.

     

    29. INDEPENDENT
      CAPACITY OF CONTRACTOR

     

    The
      parties agree that the Contractor is an independent Contractor, and that the
      Contractor, its agents, officers, and employees act in an independent capacity
      and not as officers or employees ofLDSS, DOHMH, SDOH or the DHHS..

     

    30. NO
      THIRD PARTY BENEFICIARIES

     

    Only
      the
      parties to this Agreement and their successors in interest and assigns have
      any
      rights or remedies under or by reason of this Agreement.

     

    31.
      INDEMNIFICATION

     

    31.1 Indemnification
      by Contractor

     

    a) The
      Contractor shall indemnify, defend, and hold harmless the SDOH and the DOHMH,
      and their officers, agents, and employees and the Enrollees and their eligible
      dependents from

     

    
      	 	
              i)

            	
              any
                and all claims and losses accruing or resulting to any and all
                Contractors, subcontractors, materialmen, laborers, and any other
                person,

            

    

     

     

    

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      Advantage Contract 

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    firm,
      or
      corporation furnishing or supplying work, services, materials, or supplies
      in
      connection with the performance of this Agreement

     

    
      	 	
              ii)

            	
              any
                and all claims and losses accruing or resulting to any person, firm,
                or
                corporation that may be injured or damaged by the Contractor, its
                officers, agents, employees, or subcontractors, including Participating
                Providers, in connection with the performance of this
                Agreement;

            

    

     

    
      	 	
              iii)

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

            

    

     

    b) The
      DOHMH
      will provide the Contractor with prompt written notice of any claim made against
      the DOHMH, and the Contractor, at its sole option, shall defend or settle said
      claim. The DOHMH shall cooperate with the Contractor to the extent necessary
      for
      the Contractor to discharge its obligation under Section 31.1.

     

    c) The
      Contractor shall have no obligation under this section with respect to any
      claim
      or cause of action for damages to persons or property solely caused by the
      negligence of DOHMH, or their employees, or agents.

     

    31.2 Indemnification
      by DOHMH

     

    The
      DOHMH
      shall indemnify and hold harmless the Contractor and its officers, agents,
      and
      employees from any loss or damage resulting from actions by the DOHMH pursuant
      to the terms of Appendix R, Section 6.3 herein.

     

    32. PROHIBITION
      ON USE OF FEDERAL FUNDS FOR LOBBYING

     

    32.1 Prohibition
      of Use of Federal Funds for Lobbying

     

    The
      Contractor agrees, pursuant to 31 U.S.C. § 1352 and 45 CFR Part 93, that no
      Federally appropriated funds have been paid or will be paid to any person by
      or
      on behalf of the Contractor for the purpose of influencing or attempting to
      influence an officer or employee of any agency, a Member of Congress, an officer
      or employee of Congress, or an employee of a Member of Congress in connection
      with the award of any Federal contract, the making of any federal grant, the
      making of any Federal loan, the entering into of any cooperative agreement,
      or
      the extension, continuation, renewal, amendment, or modification of any Federal
      contract, grant, loan, or cooperative agreement. The Contractor agrees to
      complete and submit the "Certification Regarding Lobbying", Appendix B attached
      hereto and incorporated herein, if this Agreement exceeds $100,000.

     

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      Advantage Contract 

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    32.2 Disclosure
      Form to Report Lobbying

     

    If
      any
      funds other than Federally appropriated funds have been paid or will'be paid
      to
      any person for the purpose of influencing or attempting to influence an officer
      or employee of any agency, a Member of Congress, an officer or employee of
      Congress, or an employee of a Member of Congress in connection with the award
      of
      any Federal contract, the making of any Federal grant, the making of any Federal
      loan, the entering into of any cooperative agreement, or the extension,
      continuation, renewal, amendment, or modification of any Federal contract,
      grant, loan, or cooperative agreement, and the Agreement exceeds $100,000,
      the
      Contractor shall complete and submit Standard Form-LLL "Disclosure Form to
      Report Lobbying," in accordance with its instructions.

     

    32.3 Requirements
      of Subcontractors

     

    The
      Contractor shall include the provisions of this section in its subcontracts,
      including its Provider Agreements. For all subcontracts, including Provider
      Agreements, that exceed $100,000, the Contractor shall require the
      subcontractor, including any Participating Provider to certify and disclose
      accordingly to the Contractor.

     

    33. NON-DISCRIMINATION

     

    33.1 Equal
      Access to Benefit Package

     

    Except
      as
      otherwise provided in applicable sections of this Agreement the Contractor
      shall
      provide the Medicaid Advantage Benefit Package to all Enrollees in the same
      manner, in accordance with the same standards, and with the same priority as
      Enrollees of the Contractor enrolled under any other contracts.

     

    33.2 Non-Discrimination

     

    The
      Contractor shall not discriminate against Eligible Persons or Enrollees on
      the
      basis of age, sex, race, creed, physical or mental handicap/developmental
      disability, national origin, sexual orientation, type of illness or condition,
      need for health services, or Capitation Rate that the Contractor will receive
      for such Eligible Persons or Enrollees.

     

    33.3 Equal
      Employment Opportunity

     

    Contractor
      must comply with Executive Order 11246, entitled "Equal Employment Opportunity"
      as amended by Executive Order 11375, and as supplemented in Department of Labor
      regulations.

     

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

     

    The
      Contractor shall not prohibit, restrict or discourage enrolled Native Americans
      from receiving care from or accessing Medicaid reimbursed health services from
      or through a tribal health or urban Indian health facility or
      center.

     

    34. COMPLIANCE
      WITH APPLICABLE LAWS AND REGULATIONS

     

    34.1 Contractor
      and DOHMH Compliance with Applicable Laws

     

    Notwithstanding
      any inconsistent provisions in this Agreement, the Contractor and DOHMH shall
      comply with all applicable requirements of the State Public Health Law; the
      State Insurance Law; the State Social Services Law; and state regulations
      related to the aforementioned state statutes. Such state laws and regulations
      shall not be deemed to be applicable to the extent that they are pre-empted
      by
      federal laws. The Contractor also shall comply with Titles XVIII and XIX of
      the
      Social Security Act and regulations promulgated thereunder, including but not
      limited to 43 CFR Part 422 and Part 423; Title VI of the Civil Rights Act of
      1964 and 45 C.F.R. Part 80, as amended; Section 504 of the Rehabilitation Act
      of
      1973 and 45 C.F.R. Part 84, as amended; Age Discrimination Act of 1975 and
      45
      C.F.R. Part 91, as amended; the ADA; Title XIII of the Federal Public Health
      Services Act, 42 U.S.C. § 300e et seq., and the regulations promulgated there
      under; the Health Insurance Portability and Accountability Act of 1996 (P.L.
      104-191) and related regulations; and all other applicable legal and regulatory
      requirements in effect at the time that this Agreement is signed and as adopted
      or amended during the term of this Agreement. The parties agree that this
      Agreement shall be interpreted according to the laws of the State of New
      York.

     

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

     

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

     

    34.3 Certificate
      of Authority Requirements

     

    The
      Contractor must satisfy conditions for issuance of a certificate of authority,
      including proof of financial solvency, as specified in 10 NYCRR Part
      98.

     

    34.4 Notification
      of Changes in Certificate of Incorporation

     

    The
      Contractor shall notify DOHMH of any amendment to its Certificate of
      Incorporation in the same manner as and simultaneously with the notice given
      to
      SDOH pursuant to 10 NYCRR Part 98.

     

    Medicaid
      Advantage Contract 

    SECTION
      23 -SECTION 35 

    New
      York
      City 2006 

    -10-

     

    

    34.5 Contractor's
      Financial Solvency Requirements

     

    The
      Contractor, for the duration of this Agreement, shall remain in compliance
      with
      all applicable state requirements for financial solvency for MCOs participating
      in the Medicaid Program. The Contractor shall continue to be financially
      responsible as defined in PHL § 4403 (l)(c) and shall comply with the contingent
      reserve fund and escrow deposit requirements of 10 NYCRR Part 98 and must meet
      minimum net worth requirements established by SDOH and the State Insurance
      Department. The Contractor shall make provision, satisfactory to SDOH, for
      protections for SDOH, LDSS and the Enrollees in the event of HMO or
      subcontractor insolvency, including but not limited to, hold harmless and
      continuation of treatment provisions in all provider agreements which protect
      SDOH, DOHMH, LDSSs and Enrollees from costs of treatment and assures continued
      access to care for Enrollees.

     

    34.6 Non-Liability
      of Enrollees for Contractor's Debts

     

    Contractor
      agrees that in no event shall the Enrollee become liable for the Contractor's
      debts as set forth in SSA § 1932(b)(6).

     

    34.7 DOHMH
      Compliance with Conflict of Interest Laws

     

    DOHMH
      and
      its employees shall comply with Article 18 of the General Municipal Law and
      all
      other appropriate provisions of New York State law, local laws and ordinances
      and all resultant codes, rules and regulations pertaining to conflicts of
      interest.

     

    34.8 Compliance
      Plan

     

    The
      Contractor agrees to implement a compliance plan in accordance with the
      requirements of 42 CFR § 422.503(b)(4) (vi) and 42 CFR § 438.608.

     

    
      	
              35.

            	
              NEW
                YORK STATE STANDARD CONTRACT CLAUSES AND NEW YORK CITY STANDARD
                CLAUSES

            

    

     

    The
      parties agree to be bound by the standard clauses for all New York State
      contracts and standard clauses, if any, for local government contracts contained
      in Appendix A and R, respectively, attached to and incorporated into this
      Agreement as if set forth fully herein, and any amendment thereto.

    

    

    Medicaid
      Advantage Contract 

    SECTION
      23 -SECTION 35 

    New
      York
      City 2006 

    -11-

     

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    This
      Agreement is effective April 1, 2006 and shall remain in effect until December
      31, 2006 or until the execution of an extension, renewal or successor agreement
      as provided for in the Agreement.

    
       

      In
        Witness Whereof, the parties have duly executed this Agreement on the dates
        appearing below their respective signatures.

       

      
        	
                By
                  /s/ Todd S. Farha

              	 	
                By: /s/ 
                  Illegible   

              
	
                Contractor

              	 	
                New
                  York City Department of Health and Mental Hygiene

              
	
                 

                Date
                  3/17/06

              	 	
                 

                Date: 
                  4/04/06

              

      

       

      

       

      Approval
        as to form and certification as to legal authority was granted by the
        Corporation Counsel on: March
        8, 2006.

      

      

      

      Medicaid
        Advantage Contract 

      SIGNATURE
        PAGE

      New
        York
        City 2006

       

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      

      STATE
        OF
        FLORIDA

      SS:

      

      COUNTY
        OF
        HILLSBOROUGH

      

      

      On
        this
        17 day of March 2006, Todd S. Farha came before me 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/
                  Rebecca McNealy

              
	
                NOTARY
                  PUBLIC

              

      

       

      

       

      STATE
        OF
        NEW YORK)

       

      SS:

       

      COUNTY
        OF
        NEW YORK

       

      On
        this 4 day of April, 2006, Thomas
        Frieden   came before me, to me known and known to be
        the Commissioner  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.

      

      

      
        	 
	
                Frank
                  Lane          

                NOTARY
                  PUBLIC

              

      

       

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    
      APPENDIX
        A

       

       

       

      New
        York State Standard Clauses

       

       

       

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

       

      STANDARD
        CLAUSES FOR NYS CONTRACTS

       

      The
        parties to the attached contract, license, lease, amendment or other agreement
        of any kind (hereinafter, "the contract" or "this contract") agree to be
        bound
        by the following clauses which are hereby made a part of the contract (the
        word
        "Contractor" herein refers to any party other than the State, whether a
        contractor, licenser, licensee, lessor, lessee or any other party):

       

      1.
        EXECUTORY
        CLAUSE.
        In
        accordance with Section 41 of the State Finance Law, the State shall have
        no
        liability under this contract to the Contractor or to anyone else beyond
        funds
        appropriated and available for this contract.

      

      2.
        NON-ASSIGNMENT CLAUSE.
        In
        accordance with Section 138 of the State Finance Law, this contract may not
        be
        assigned by the Contractor or its right, title or interest therein assigned,
        transferred, conveyed, sublet or otherwise disposed of without the previous
        consent, in writing, of the State and any attempts to assign the contract
        without the State's written consent are null and void. The Contractor may,
        however, assign its right to receive payment without the State's prior written
        consent unless this contract concerns Certificates of Participation pursuant
        to
        Article 5-A of the State Finance Law.'.

      

      3.
        COMPTROLLER'S
        APPROVAL.
        In
        accordance with Section 112 of the State Finance Law (or, if this contract
        is
        with the State University or City University of New York, Section 355 or
        Section
        6218 of the Education Law), if this contract exceeds $15,000 (or the minimum
        thresholds agreed to by the Office of the State Comptroller for certain S.U.N.Y.
        and C.U.N.Y. contracts), or if this is an amendment for any amount to a contract
        which, as so amended, exceeds said statutory amount, or if, by this contract,
        the State agrees to give something other than money when the value or reasonably
        estimated value of such consideration exceeds $10,000, it shall not be valid,
        effective or binding upon the State until it has been approved by the State
        Comptroller and filed in his office. Comptroller's approval of contracts
        let by
        the Office of General Services is required when such contracts exceed $30,000
        (State Finance Law Section 163.6.a).

      

      4.
        WORKERS'
        COMPENSATION BENEFITS.
        In
        accordance with Section 142 of the State Finance Law, this contract shall
        be
        void and of no force and effect unless the Contractor shall provide and maintain
        coverage during the life of this contract for the benefit of such employees
        as
        are required to be covered by the provisions of the Worker;;' Compensation
        Law.

       

      5.
        NON-DISCRIMINATION
        REQUIREMENTS.
        To the
        extent required by Article 15 of the Executive Law (also known as the Human
        Rights Law) and all other State and Federal statutory and constitutional
        non-discrimination provisions, the Contractor will not discriminate against
        any
        employee or applicant for employment because of race, creed, color, sex,
        national origin, sexual orientation, age, disability, genetic predisposition
        or
        carrier status, or marital status. Furthermore, in accordance with Section
        220-e
        of the Labor Law, if this is a contract for the construction, alteration
        or
        repair of any public building or public work or for the manufacture, sale
        or
        distribution of materials, equipment or supplies, and to the extent that
        this
        contract shall be performed within the State of New York, Contractor agrees
        that
        neither it not its subcontractors shall, by reason of race, creed, color,
        disability, sex, or national origin: (a) discriminate in hiring against any
        New
        York State citizen who is qualified and available to perform the work; or
        (b)
        discriminate against or intimidate any employee hired for the performance
        of
        work under this contract. If this is a building service contract as defined
        in
        Section 230 of the Labor Law, then, in accordance with Section 239 thereof,
        Contractor agrees that neither it nor its subcontractors shall by reason
        of
        race, creed, color, national origin, age, sex or disability: (a) discriminate
        in
        hiring against any New York State citizen who is qualified and available
        to
        perform the work; or (b) discriminate against or intimidate any employee
        hired
        for the performance of work under this contract. Contractor is subject to
        fines
        of $50.00 per person per day for any violation of Section 220-e or
        Section

       

       

      Page
        1

      

      

      239
        as
        well as possible termination of this contract and forfeiture of all moneys
        due
        hereunder for a second or subsequent violation.

       

      6.
        WAGE
        AND HOURS PROVISIONS.
        If this
        is a public work contract covered by Article 8 of the Labor Law or a building
        service contract covered by Article 9 thereof, neither Contractor's employees
        nor the employees of its subcontractors may be required or permitted to work
        more than the number of hours or days stated in said statutes, except as
        otherwise provided in the Labor Law and as set forth in prevailing wage and
        supplement schedules issued by the State Labor Department. Furthermore,
        Contractor and its subcontractors must pay at least the prevailing wage rate
        and
        pay or provide the prevailing supplements, including the premium rates for
        overtime pay, as determined by the State Labor Department in accordance with
        the
        Labor Law.

       

      7.
        NON-COLLUSIVE
        BIDDING CERTIFICATION.
        In
        accordance with Section 139-d of the State Finance Law, if this contract
        was
        awarded based upon the submission of bids, Contractor warrants, under penalty
        of
        perjury, that its bid was arrived at independently and without collusion
        aimed
        at restricting competition. Contractor further warrants that, at the time
        Contractor submitted its bid, an authorized and responsible person executed
        and
        delivered to the State a non-collusive bidding certification on Contractor's
        behalf.

      

      8.
        INTERNATIONAL
        BOYCOTT PROHIBITION.
        In
        accordance with Section 220-f of the Labor Law and Section 139-h of the State
        Finance Law, if this contract exceeds $5,000, the Contractor agrees, as a
        material condition of the contract, that neither the Contractor nor any
        substantially owned or affiliated person, firm, partnership or corporation
        has
        participated, is participating, or shall participate in an international
        boycott
        in violation of the federal Export Administration Act of 1979 (50 USC App.
        Sections 2401 et seq.) or regulations thereunder. If such Contractor, or
        any of
        the aforesaid affiliates of Contractor, is convicted or is otherwise found
        to
        have violated said laws or regulations upon the final determination of the
        United States Commerce Department or any other appropriate agency of the
        United
        States subsequent to the contract's execution, such contract, amendment or
        modification thereto shall be rendered forfeit and void. The Contractor shall
        so
        notify the State Comptroller within five (5) business days of such conviction,
        determination or disposition of appeal (2NYCKR 105.4).

      

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

      

      10.
        RECORDS.
        The
        Contractor shall establish and maintain complete and accurate books, records,
        documents, accounts and other evidence directly pertinent to performance
        under
        this contract (hereinafter, collectively, "the Records"). The Records must
        be
        kept for the balance of the calendar year in which they were made and for
        six
        (6) additional years thereafter. The State Comptroller, the Attorney General
        and
        any other person or entity authorized to conduct an examination, as well
        as the
        agency or agencies involved in this contract, shall have access to the Records
        during normal business hours at an office of the Contractor 

      

      May,
        2003

      

      

      STANDARD
        CLAUSES FOR NYS CONTRACTS APPENDIX A

       

      within
        the State of New York or, if no such office is available, at a mutually
        agreeable and reasonable venue within the State, for the term specified above
        for the purposes of inspection, auditing and copying. The State shall take
        reasonable steps to protect from public disclosure any of the Records which
        are
        exempt from disclosure under Section 87 of the Public Officers Law (the
        "Statute") provided that: (i) the Contractor shall timely inform an appropriate
        State official, in writing, that said records should not be disclosed; and
        (ii)
        said records shall be sufficiently identified; and (iii) designation of said
        records as exempt under the Statute is reasonable. Nothing contained herein
        shall diminish, or in any way adversely affect, the State's right to discovery
        in any pending or future litigation.

      

      11.
        IDENTIFYING
        INFORMATION AND PRIVACY NOTIFICATION,
        (a)
        FEDERAL EMPLOYER IDENTIFICATION NUMBER and/or FEDERAL SOCIAL SECURITY NUMBER.
        All invoices or New York State standard vouchers submitted for payment for
        the
        sale of goods or services or the lease of real or personal property to a
        New
        York State agency must include the payee's identification number, i.e., the
        seller's or lessor's identification number. The number is either the payee's
        Federal employer identification number or Federal social security number,
        or
        both such numbers when the payee has both such numbers. Failure to include
        this
        number or numbers may delay payment. Where the payee does not have such number
        or numbers, the payee, on its
        invoice
        or New York State standard voucher, must give the reason or reasons why the
        payee does not have such number or numbers.

      (b)
        PRIVACY
        NOTIFICATION. (1) The authority to request the above personal information
        from a
        seller of goods or services or a lessor of real or personal property, and
        the
        authority to maintain such information, is found in Section 5 of the State
        Tax
        Law. Disclosure of this information by the seller or lessor to the State
        is
        mandatory. The principal purpose for which the information is collected is
        to
        enable the State to identify individuals, businesses and others who have
        been
        delinquent in filing tax returns or may have understated their tax liabilities
        and to generally identify persons affected by the taxes administered by the
        Commissioner of Taxation and Finance. The information will be used for tax
        administration purposes and for any other purpose authorized by
        law.

      (2)
        The
        personal information is requested by the purchasing unit of the agency
        contracting to purchase the goods or services or lease the real or personal
        property covered by this contract or lease. The information is maintained
        in New
        York State's Central Accounting System by the Director of Accounting Operations,
        Office of the State Comptroller, AESOB, Albany, New York 12236.

      

      12.
        EQUAL
        EMPLOYMENT OPPORTUNITIES FOR MINORITIES AND WOMEN.
        In
        accordance with Section 312 of the Executive Law, if this contract is: (i)
        a
        written agreement or purchase order instrument, providing for a total
        expenditure in excess of $25,000.00, whereby a contracting agency is committed
        to expend or does expend funds in return for labor, services, supplies,
        equipment, materials or any combination of the foregoing, to be performed
        for,
        or rendered or furnished to the contracting agency; or (ii) a written agreement
        in excess of S100,000.00 whereby a contracting agency is committed to expend
        or
        does expend funds for the acquisition, construction, demolition, replacement,
        major repair or renovation of real property and improvements thereon; or
        (iii) a
        written agreement in excess of $100,000.00 whereby the owner of a Slate assisted
        housing project is committed to expend or does expend funds for the acquisition,
        construction, demolition, replacement, major repair or renovation of real
        property and improvements thereon for such project, then:

      

      (a)
        The
        Contractor will not discriminate against employees or applicants for employment
        because of race, creed, color, national origin, sex, age, disability or marital
        status, and will undertake or continue existing programs of affirmative action
        to ensure that minority group members and women are afforded equal employment
        opportunities without discrimination. Affirmative action shall mean
        recruitment,

       

       

      Page
        2

      

       

      employment,
        job assignment, promotion, upgrading?, demotion, transfer, layoff, or
        termination and rates of pay or other forms of compensation;

       

      (b)
        at
        the request of the contracting agency, the Contractor shall request each
        employment agency, labor union, or authorized representative of workers with
        which it has a collective bargaining or other agreement or understanding,
        to
        furnish a written statement that such employment agency, labor union or
        representative will not discriminate on the basis of race, creed, color,
        national origin, sex, age, disability or marital status and that such union
        or
        representative will affirmatively cooperate in the implementation of the
        contractor's obligations herein; and

      

      (c)
        the
        Contractor shall state, in all solicitations or advertisements for employees,
        that, in the performance of the State contract, all qualified applicants
        will be
        afforded equal employment opportunities without discrimination because of
        race,
        creed, color, national origin, sex, age, disability or marital
        status.

       

      Contractor
        will include the provisions of "a", "b", and "c" above, in every subcontract
        over $25,000.00 for the construction, demolition, replacement, major repair,
        renovation, planning or design of real property and improvements thereon
        (the
        "Work") except where the Work is for the beneficial use of the Contractor.
        Section 312 does not apply to: (i) work, goods or services unrelated to this
        contract; or (ii) employment outside New York State; or (iii) banking services,
        insurance policies or the sale of securities. The State shall consider
        compliance by a contractor or subcontractor with the requirements of any
        federal
        law concerning equal employment opportunity which effectuates the purpose
        of
        this section. The contracting agency shall determine whether the imposition
        of
        the requirements of title provisions hereof duplicate or conflict with any
        such
        federal law and if such duplication or conflict exists, the contracting agency
        shall waive the applicability of Section 312 to the extent of such duplication
        or conflict. Contractor will comply with all duly promulgated and lawful
        rules
        and regulations of the Governor's Office of Minority and Women's Business
        Development pertaining hereto.

      

      13.
        CONFLICTING
        TERMS.
        In the
        event of a conflict between the terms of the contract (including any and
        all
        attachments thereto and amendments thereof) and the terms of this Appendix
        A,
        the terms of this Appendix A shall control.

      

      14.
        GOVERNING
        LAW.
        This
        contract shall be governed by the laws of the State of New York except where
        the
        Federal supremacy clause requires otherwise.

      

      15.
        LATE
        PAYMENT.
        Timeliness of payment and any interest to be paid to Contractor for late
        payment
        shall be governed by Article I)-A of the State Finance Law to the extent
        required by law.

      

      16.
        NO
        ARBITRATION.
        Disputes
        involving this contract, including the breach or alleged breach thereof,
        may not
        be submitted to binding arbitration (except where statutorily authorized),
        but
        must, instead, be heard in a court of competent jurisdiction of the State
        of New
        York.

      

      17.
        SERVICE
        OF PROCESS.
        In
        addition to the methods of service allowed by the State Civil Practice Law
&
Rules ("CPLR"), Contractor hereby consents to service of process upon it
        by
        registered or certified mail, return receipt requested. Service hereunder shall
        be complete upon Contractor's actual receipt of process or upon the State's
        receipt of the return thereof by [he United States Postal Service as refused
        or
        undeliverable. Contractor must promptly notify the State, in writing, of
        each
        and every change of address to which service of process can be made. Service
        by
        the State to the last known address shall be sufficient. Contractor will
        have
        thirty (30) calendar days after service hereunder is complete in which to
        respond.

       

       

      May,2003

       

      

      STANDARD
        CLAUSES FOR NYS CONTRACTS APPENDIX A

      

      

      18.
        PROHIBITION
        ON PURCHASE OF TROPICAL HARDWOODS.
        The
        Contractor certifies and warrants that all wood products to be used under
        this
        contract award will be in accordance with, but not limited to, the
        specifications and provisions of State Finance Law §165. (Use of Tropical
        Hardwoods) which prohibits purchase and use of tropical hardwoods, unless
        specifically exempted, by the State or any governmental agency or political
        subdivision or public benefit corporation. Qualification for an exemption
        under
        this law will be the responsibility of the contractor to establish to meet
        with
        the approval of the State.

      In
        addition, when any portion of this contract involving the use of woods, whether
        supply or installation, is to be performed by any subcontractor, the prime
        Contractor will indicate and certify in the submitted bid proposal that the
        subcontractor has been informed and is in compliance with specifications
        and
        provisions regarding use of tropical hardwoods as detailed in §165 State Finance
        Law. Any such use must meet with the approval of the State; otherwise, the
        bid
        may not be considered responsive. Under bidder certifications, proof of
        qualification for exemption will be the responsibility of the Contractor
        to meet
        with the approval of the State.

       

      19.
        MACBRIDE
        FAIR EMPLOYMENT PRINCIPLES.
        In

      accordance
        with: the MacBride Fair Employment Principles (Chapter 807 of the Laws of
        1992),
        the Contractor hereby stipulates that the Contractor either (a) has no-business
        operations in Northern Ireland, or (b) shall take lawful steps in good faith
        to
        conduct any business operations in Northern Ireland in accordance with the
        MacBride Fair Employment Principles (as described in Section 165 of the New
        York
        State Finance Law), and shall permit independent monitoring of compliance
        with
        such principles.

      

      20.
        OMNIBUS
        PROCUREMENT ACT OF 1992.
        It is
        the policy of New York State to maximize opportunities for the participation
        of
        New York State business enterprises, including minority and women-owned business
        enterprises as bidders, subcontractors and suppliers on its procurement
        contracts.

      

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

      

      NYS
        Department of Economic Development Division for Small Business 30 South Pearl
        St
        - 7th
        Floor
        Albany, New York 12245 Telephone: 518-292-5220

      

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

       

      NYS
        Department of Economic Development

      Division
        of Minority and Women's Business Development

      30
        South
        Pearl St - 2nd Floor

      Albany,
        New York 12245

      http://www.empire.state.ny.us

       

      The
        Omnibus Procurement Act of 1992 requires that by signing this bid proposal
        or
        contract, as applicable, Contractors certify that whenever the total bid
        amount
        is greater than $1 million:

      

      (a)
        The
        Contractor has made reasonable efforts to encourage the participation of
        New
        York State Business Enterprises as suppliers and subcontractors, including
        certified minority and women-owned business enterprises, on this project,
        and
        has retained the documentation of these efforts to be provided upon request
        to
        the Slate;

      

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

      

       

      

      Page
        3

      

       

      (c)
        The
        Contractor agrees to make reasonable efforts to provide notification to New
        York
        State residents of employment opportunities on this project through listing
        any
        such positions with the Job Service Division of the New York State Department
        of
        Labor, or providing such notification in such manner as is consistent with
        existing collective 

      

      

      bargaining
        contracts or agreements. The Contractor agrees to document these efforts
        and to
        provide said documentation to the State upon request; and

       

      (d)
        The
        Contractor acknowledges notice that the State may seek to obtain offset credits
        from foreign countries as a result of this contract and agrees to cooperate
        with
        the State in these efforts.

       

      21.
        RECIPROCITY
        AND SANCTIONS PROVISIONS.
        Bidders
        are hereby notified that if their principal place of business is located
        in a
        country, nation, province, state or political subdivision that penalizes
        New
        York State vendors, and if the goods or services they offer will be
        substantially produced or performed outside New York State, the Omnibus
        Procurement Act 1994 and 2000 amendments (Chapter 684 and Chapter 383,
        respectively) require that they be denied contracts which they would otherwise
        obtain. NOTE: As of May 15, 2002, the list of discriminatory jurisdictions
        subject to this provision includes the states of South Carolina, Alaska,
        West
        Virginia, Wyoming, Louisiana and Hawaii. Contact NYS Department of Economic
        Development for a current list of jurisdictions subject to this
        provision.

       

      22.
        PURCHASES
        OF APPAREL.
        In
        accordance with State Finance Law 162 (4-a), the State shall not purchase
        any
        apparel from any vendor unable or unwilling to certify that: (i) such apparel
        was manufactured in compliance with all applicable labor and occupational
        safety
        laws, including, but not limited to, child labor laws, wage and hours laws
        and
        workplace safety laws, and (ii) vendor will supply, with its bid (or, if
        not a
        bid situation, prior to or at the time of signing a contract with the State),
        if
        known, the names and addresses of each subcontractor and a list of all
        manufacturing plants to be utilized by the bidder.

       

      

       

       

      May
        2003

       

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      

        APPENDIX
          B CERTIFICATION REGARDING LOBBYING

         

        The
          undersigned certifies, to the best of his or her knowledge, that:

         

        1.
          No
          Federal appropriated funds have been paid or will be paid to any person
          by or on
          behalf of the Contractor for the purpose of influencing or attempting to
          influence an officer or employee of any agency, a Member of Congress, an
          officer
          or employee of a Member of Congress in connection with the award of any
          Federal
          loan, the entering into of any cooperative agreement, or the extension,
          continuation, renewal, amendment, or modification of any Federal contract,
          grant, loan, or cooperative agreement.

         

        2.
          If any
          funds other than Federal appropriated funds have been paid or will be paid
          to
          any person for the purpose of influencing or attempting to influence an
          officer
          or employee of any agency, a Member of Congress in connection with the
          award of
          any Federal contract, the making of any Federal grant, the making of any
          Federal
          loan, the entering into of any cooperative agreement, or the extension,
          continuation, renewal, amendment, or modification of any Federal contract,
          grant, loan, or cooperative agreement, and the Agreement exceeds $100,000,
          the
          Contractor shall complete and submit Standard Form -LLL "Disclosure Form
          to
          Report Lobbying", in accordance with its instructions.

         

        3.
          The
          Contractor shall include the provisions of this section in all provider
          Agreements

        under
          this Agreement and require all Participating providers whose Provider Agreements
          exceed $100,000 to certify and disclose accordingly to the
          Contractor.

         

        This
          certification is a material representation of fact upon which reliance
          was place
          when this transaction was made or entered into. Submission of this certification
          is a prerequisite for making or entering into this transaction pursuant
          to
          U.S.C. Section 1352. The failure to file the required certification shall
          subject the violator to a civil penalty of not less than $10,000 and not
          more
          than $100,000 for each such failure.

         

        

        
          	
                   

                  DATE:  3/17/06       

                
	 
	
                   

                  SIGNATURE:  /s/
                    Todd S. Farha    

                
	 
	
                   

                  TITLE: 
                    President and Chief Executive Officer    

                
	 
	
                   

                  ORGANIZATION:
                     WellCare
                    of New York, Inc.   

                

        

         

        
          Medicaid
            Advantage Contract 

          APPENDIX
            B

          New
            York
            City 2006 

          B-2

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

         

        

          Appendix
            C

          

          

          

          

          New
            York State Department of Health 

          Requirements
            for the Provision of Free Access to 

          Family
            Planning and Reproductive Health Services

           

           

          
            	 	
                    C.I
                      

                  	
                    Definitions
                      and General Requirements for the Provision of Family Planning
                      and
                      Reproductive Health
                      Services

                  

          

           

          
            	 	
                    C.2

                  	
                    Requirements
                      for MCOs that Provide Family Planning and Reproductive Health
                      Services

                  

          

           

          
            	 	
                    C.3

                  	
                    Requirements
                      for MCOs That Do Not Provide Family Planning and Reproductive
                      Health
                      Services

                  

          

          

          

          

          Medicaid
            Advantage Contract 

          APPENDIX
            C.

          New
            York
            City 2006 

          C-l

           

          

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

          C.I

          Definitions
            and General Requirements for the Provision of Family Planning and Reproductive
            Health Services

           

          1. Family
            Planning and Reproductive Health Services

           

          
            	 	
                    a)

                  	
                    Family
                      Planning and Reproductive Health Services mean the offering,
                      arranging and
                      furnishing of those health services which enable Enrollees,
                      including
                      minors who may be sexually active, to prevent or reduce the
                      incidence of
                      unwanted pregnancies.

                  

          

           

          
            	 	
                    i)

                  	
                    Family
                      Planning and Reproductive Health Services include the following
                      medically-necessary services, related drugs and supplies which
                      are
                      furnished or administered under the supervision of a physician,
                      licensed
                      midwife or certified nurse practitioner during the course of
                      a Family
                      Planning and Reproductive Health visit for the purpose
                      of:

                  

          

           

          
            	 	
                    A)

                  	
                    contraception,
                      including all FDA-approved birth control methods, devices such
                      as
                      insertion/removal of an intrauterine device (IUD)or insertion/removal
                      of
                      contraceptive implants, and injection procedures involving
                      Pharmaceuticals
                      such as Depo-Provera;

                  

          

           

          B) emergency
            contraception and follow up;

           

          C) sterilization;

           

          
            	 	
                    D)

                  	
                    screening,
                      related diagnosis, and referral to a Participating Provider
                      for
                      pregnancy;

                  

          

           

          
            	 	
                    E)

                  	
                    medically-necessary
                      induced abortions, which are procedures, either medical or
                      surgical, that
                      result in the termination of pregnancy. The determination of
                      medical
                      necessity shall include positive evidence of pregnancy, with
                      an estimate
                      of its duration.

                  

          

           

          
            	 	
                    ii)

                  	
                    Family
                      Planning and Reproductive Health Services include those education
                      and
                      counseling services necessary to render the services
                      effective.

                  

          

           

          
            	 	
                    iii)

                  	
                    Family
                      Planning and Reproductive Health Services include medically-necessary
                      ordered contraceptives and
                      pharmaceuticals:

                  

          

           

          
            	 	
                    A)

                  	
                    The
                      Contractor is responsible for pharmaceuticals and medical supplies
                      such as
                      IUDS and Depo-Provera that must be furnished or administered
                      under the
                      supervision of a physician, licensed midwife, or certified
                      nurse
                      practitioner during the course of a Family Planning and Reproductive
                      Health visit and for those prescription drugs included in the
                      Contractor's
                      Medicare Part D Prescription Drug Benefit. Over the counter
                      drugs are not
                      the responsibility of

                  

          

           

           

          

          Medicaid
            Advantage Contract 

          APPENDIX
            C 

          New
            York
            City 2006 

          C-2

           

          

          the
            Contractor and are to be obtained when covered on the New York State
            list of
            Medicaid reimbursable drugs by the Enrollee from any appropriate eMedNY-enrolled
            health care provider of the Enrollee's choice.

           

          
            	 	
                    b)

                  	
                    When
                      clinically indicated, the following services may be provided
                      as a part of
                      a Family Planning and Reproductive Health
                      visit:

                  

          

           

          
            	 	
                    i)

                  	
                    Screening,
                      related diagnosis, ambulatory treatment and referral as needed
                      for
                      dysmenorrhea, cervical cancer, or other pelvic
                      abnormality/pathology.

                  

          

           

          
            	 	
                    ii)

                  	
                    Screening,
                      related diagnosis and referral for anemia, cervical cancer,
                      glycosuria,
                      proteinuria, hypertension and breast disease.

                     

                  

          

          
            	 	
                    iii)

                  	
                    Screening
                      and treatment for sexually transmissible
                      disease.

                  

          

          iv) HIV
            blood
            testing and pre- and post-test counseling. 

          

          2. Free
            Access to Services for Enrollees

           

          
            	 	
                    a)

                  	
                    Free
                      Access means Enrollees may obtain Family Planning and Reproductive
                      Health
                      Services, and HIV blood testing and pre-and post-test counseling
                      when
                      performed as part of a Family Planning and Reproductive Health
                      encounter,
                      from either the Contractor, if it provides such services in
                      its Medicare
                      Advantage Benefit Package, or from any appropriate eMedNY-enrolled
                      health
                      care provider of the Enrollee's choice. No referral from the
                      PCP or
                      approval by the Contractor is required to access such
                      services.

                  

          

           

          
            	 	
                    b)

                  	
                    The
                      Family Planning and Reproductive Health Services listed above
                      are the only
                      services which are covered under the Free Access policy. Routine
                      obstetric
                      and/or gynecologic care, including hysterectomies, pre-natal,
                      delivery and
                      post-partum care are not covered under the Free Access policy,
                      and are the
                      responsibility of the Contractor.

                  

          

          

          

          

          Medicaid
            Advantage Contract APPENDIX C 

          New
            York
            City 2006

          C-3

           

           

          C.2

           

          Requirements
            for MCOs that Provide Family Planning and Reproductive Health
            Services

           

          1. Notification
            to Enrollees

           

          a)  If
            the
            Contractor provides Family Planning and Reproductive Health Services,
            the
            Contractor must notify all Enrollees of reproductive age at the time
            of
            Enrollment about their right to obtain Family Planning and Reproductive
            Health
            Services and supplies without referral or approval. The notification
            must
            contain the following:

           

          i) Information
            about the Enrollee's right to obtain the full range of Family Planning
            and
            Reproductive Health Services, including HIV counseling and testing when
            performed as part of a Family Planning and Reproductive Health encounter,
            from
            the Contractor's Participating Provider without referral, approval or
            notification.

           

          ii) Enrollees
            must receive notification that they also have the right to obtain Family
            Planning and Reproductive Health Services in accordance with the Medicaid
            Free
            Access policy as defined in C.I of this Appendix.

           

          iii) A
            current
            list of qualified Participating Family Planning Providers who provide
            the full
            range of Family Planning and Reproductive Health Services within the
            Enrollee's
            geographic area, including addresses and telephone numbers. The Contractor
            may
            also provide Enrollees with a list of qualified Non-Participating providers
            who
            accept Medicaid and who provide the full range of these services.

           

          iv) Information
            that the cost of the Enrollee's Family Planning and Reproductive care
            will be
            fully covered, including when an Enrollee obtains such services in accordance
            with the Medicaid Free Access policy.

           

          2. Billing
            Policy

           

          
            	 	
                    a)

                  	
                    The
                      Contractor must notify its Participating Providers that all
                      claims for
                      Family Planning and Reproductive Health Services must be billed
                      to the
                      Contractor and not the Medicaid fee-for-service
                      program.

                  

          

           

          b)  Non-Participating
            Providers will bill Medicaid fee-for-service.

           

          

          Medicaid
            Advantage Contract 

          APPENDIX
            C 

          New
            York
            City 2006 

          C-4

           

          

          3. Consent
            and Confidentiality

           

          a) The
            Contractor will comply with federal, state, and local laws, regulations
            and
            policies regarding informed consent and confidentiality and ensure Participating
            Providers comply with all of the requirements set forth in Sections 17
            and 18 of
            the PHL and 10 NYCRR Section 751.9 and Part 753 relating to informed
            consent and
            confidentiality.

           

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

           

          4. Informing
            and Standards

           

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

           

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

          

          

          

          Medicaid
            Advantage Contract 

          APPENDIX
            C 

          New
            York
            City 2006 

          C-5

          

          C.3

           

          Requirements
            for MCOs That Do Not Provide Family Planning and Reproductive Health
            Services

           

          1. Requirements

           

          
            	 	
                    a)

                  	
                    The
                      Contractor agrees to comply with the policies and procedures
                      stated in the
                      SDOH-approved statement described in Section 2
                      below.

                  

          

           

          
            	 	
                    b)

                  	
                    Within
                      ninety (90) days of signing this Agreement, the Contractor
                      shall submit to
                      the SDOH a policy and procedure statement that the Contractor
                      will use to
                      ensure that its Enrollees are fully informed of their rights
                      to access a
                      full range of Family Planning and Reproductive Health Services,
                      using the
                      following guidelines. The statement must be sent to the Director,
                      Office
                      of Managed Care, NYS Department of Health, Corning Tower, Room
                      2001,
                      Albany, NY 12237.

                  

          

           

          
            	 	
                    c)

                  	
                    SDOH
                      may waive the requirement in (b) above if such approved statement
                      is
                      already on file with SDOH and remains
                      unchanged.

                  

          

           

          2. Policy
            and Procedure Statement

           

          
            	 	
                    a)

                  	
                    The
                      policy and procedure statement regarding Family Planning and
                      Reproductive
                      Health Services must contain the
                      following:

                  

          

           

          i) Enrollee
            Notification

           

          
            	 	
                    A)

                  	
                    A
                      statement that the Contractor will inform Prospective Enrollees,
                      new
                      Enrollees and current Enrollees
                      that:

                  

          

           

          
            	 	
                    I)

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

                  

          

           

          
            	 	
                    II)

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

                  

          

           

          
            	 	
                    III)

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

                  

          

           

          

          Medicaid
            Advantage Contract 

          APPENDIX
            C 

          New
            York
            City 2006 

          C-6

           

          

          
            	 	
                    IV)

                  	
                    HIV
                      counseling and testing services are available through the Contractor
                      and
                      are also available as part of a Family Planning and Reproductive
                      Health
                      encounter when furnished by a fee-for-service Medicaid provider
                      to
                      Medicaid Advantage Enrollees; and that anonymous counseling
                      and testing
                      services are available from SDOH, Local Public Health Agency
                      clinics and
                      other New York City or county
                      programs.

                  

          

           

          
            	 	
                    B)

                  	
                    A
                      statement that this information will be provided in the following
                      manner:

                  

          

           

          
            	 	
                    I)

                  	
                    Through
                      the Contractor's written Marketing materials, including the
                      Member
                      Handbook. The Member Handbook and Marketing materials will
                      indicate that
                      the Contractor has elected not to cover certain Family Planning
                      and
                      Reproductive Health Services, and will explain the right of
                      all Medicaid
                      Advantage Enrollees to secure such services through fee-for-service
                      Medicaid from any provider/clinic which offers these services
                      and who
                      accepts Medicaid.

                  

          

           

          
            	 	
                    II)

                  	
                    Orally
                      at the time of Enrollment and any time an inquiry is made regarding
                      Family
                      Planning and Reproductive Health
                      Services.

                  

          

           

          
            	 	
                    III)

                  	
                    By
                      inclusion on any web site of the Contractor which includes
                      information
                      concerning its Medicaid Advantage product. Such information
                      shall be
                      prominently displayed and easily
                      navigated.

                  

          

           

          
            	 	
                    C)

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

                  

          

           

          
            	 	
                    D)

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

                  

          

           

          
            	 	
                    I)

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

                  

          

           

          
            	 	
                    II)

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

                  

          

          

          Medicaid
            Advantage Contract 

          APPENDIX
            C

          New
            York
            City 2006

          C-7

          

          
            	 	
                    III)

                  	
                    Each
                      Medicaid Advantage Enrollee and Prospective Enrollee who calls
                      will be
                      mailed a copy of the SDOH approved letter explaining the Enrollee's
                      right
                      to receive these non-covered services, and an SDOH approved
                      list of Family
                      Planning Providers who participate in Medicaid in the Enrollee's
                      community. These materials will be mailed within two (2) business
                      days of
                      the contact.

                  

          

           

          
            	 	
                    IV)

                  	
                    Enrollees
                      can call the Contractor's member services number for further
                      information
                      about how to obtain these non-covered services. Medicaid Advantage
                      Enrollees can also call the New York State Growing-Up-Healthy
                      Hotline
                      (1-800-522-5006) to request a copy of the list of Medicaid
                      Family Planning
                      Providers.

                  

          

           

          
            	 	
                    E)

                  	
                    The
                      procedure for maintaining a manual log of all requests for
                      such
                      information, including the date of the call, the Enrollee's
                      client
                      identification number (CIN), and the date the SDOH approved
                      letter and
                      SDOH or DOHMH approved list were mailed, where applicable.
                      The Contractor
                      will review this log monthly and upon request, submit a copy
                      to
                      SDOH.

                  

          

           

          ii) Participating
            Provider and Employee Notification

           

          
            	 	
                    A)

                  	
                    A
                      statement that the Contractor will inform its Participating
                      Providers and
                      administrative personnel about Family Planning and Reproductive
                      Health
                      policies under Medicaid Advantage Free Access, as defined in
                      C.I of this
                      Appendix, HIV counseling and testing; reimbursement for Family
                      Planning
                      and Reproductive Health encounters; Enrollee Family Planning
                      and
                      Reproductive Health education and
                      confidentiality.

                  

          

           

          
            	 	
                    B)

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

                  

          

           

          
            	 	
                    C)

                  	
                    The
                      procedure(s) for informing the Contractor's Participating primary
                      care
                      providers, family practice physicians, obstetricians, and gynecologists
                      that the Contractor has elected not to cover certain Family
                      Planning and
                      Reproductive Health Services, but that routine obstetric and/or
                      gynecologic care, including hysterectomies, pre-natal, delivery
                      and
                      post-partum care are covered; and that Participating Providers
                      may
                      provide, make referrals, or arrange for non-covered services
                      in accordance
                      with Medicaid Advantage Free Access policy, as defined in C.I
                      of this
                      Appendix.

                  

          

           

          

          Medicaid
            Advantage Contract

          APPENDIX
            C

          New
            York
            City 2006 

          C-8

          

          
            	 	
                    D)

                  	
                    A
                      description of the mechanisms to inform the Contractor's Participating
                      Providers that:

                  

          

           

          
            	 	
                    I)

                  	
                    if
                      they also participate in the fee-for-service Medicaid program
                      and they
                      render non-covered Family Planning and Reproductive Health
                      Services to
                      Medicaid Advantage Enrollees, they do so as a fee-for-service
                      Medicaid
                      practitioner, independent of the
                      Contractor.

                  

          

           

          
            	 	
                    E)

                  	
                    A
                      description of the mechanisms to inform Participating Providers
                      that, if
                      requested by the Enrollee, or, if in the provider's best professional
                      judgment, certain Family Planning and Reproductive Health Services
                      not
                      offered through the Contractor are medically indicated in accordance
                      with
                      generally accepted standards of professional practice, an appropriately
                      trained professional should so advise the Enrollee and
                      either:

                  

          

           

          
            	 	
                    I)

                  	
                    offer
                      those services to Medicaid Advantage Enrollees on a fee-for-service
                      basis
                      as an eMedNY-enrolled provider, or

                  

          

           

          
            	 	
                    II)

                  	
                    provide
                      Medicaid Advantage Enrollees with a copy of the SDOH approved
                      list of
                      Medicaid Family Planning Providers,
                      or

                  

          

           

          
            	 	
                    III)

                  	
                    give
                      Enrollees the Contractor's member services number to call to
                      obtain the
                      list of Medicaid Family Planning
                      Providers.

                  

          

           

          
            	 	
                    F)

                  	
                    A
                      statement that the Contractor acknowledges that the exchange
                      of medical
                      information, when indicated in accordance with generally accepted
                      standards of professional practice, is necessary for the overall
                      coordination of Enrollees' care and assist Primary Care Providers
                      in
                      providing the highest quality care to the Contractor's Enrollees.
                      The
                      Contractor must also acknowledge that medical record information
                      maintained by Participating Providers may include information
                      relating to
                      Family Planning and Reproductive Health Services provided under
                      the
                      fee-for-service Medicaid program.

                  

          

           

          iii) Quality
            Assurance Initiatives

           

          
            	 	
                    A)

                  	
                    A
                      statement that the Contractor will submit any materials to
                      be furnished to
                      Enrollees and providers relating to access to non-covered Family
                      Planning
                      and Reproductive Health Services to SDOH, Office of Managed
                      Care for its
                      review and approval before issuance. Such materials include,
                      but are not
                      limited to, Member Handbooks, provider manuals, and Marketing
                      materials.

                  

          

           

          
            	 	
                    B)

                  	
                    A
                      description of monitoring mechanisms the Contractor will use
                      to assess the
                      quality of the information provided to
                      Enrollees.

                  

          

           

          

           

          

          Medicaid
            Advantage Contract

          APPENDIX
            C 

          New
            York
            City 2006 

          C-9

           

          

          
            	 	
                    C)

                  	
                    A
                      statement that the Contractor will prepare a monthly list of
                      Medicaid
                      Advantage Enrollees who have been sent a copy of the SDOH approved
                      letter
                      and the SDOH approved list of Family Planning providers. This
                      information
                      will be available to SDOH upon
                      request.

                  

          

           

          
            	 	
                    D)

                  	
                    A
                      statement that the Contractor will provide all new employees
                      with a copy
                      of these policies. A statement that the Contractor's orientation
                      programs
                      will include a thorough discussion of all aspects of these
                      policies and
                      procedures and that annual retraining programs for all employees
                      will be
                      conducted to ensure continuing compliance with these
                      policies.

                  

          

           

          3. Consent
            and Confidentiality

           

          a) The
            Contractor must comply with federal, state, and local laws, regulations
            and
            policies regarding informed consent and confidentiality and ensure that
            Participating Providers comply with all of the requirements set forth
            in
            Sections 17 and 18 of the PHL and 10 NYCRR § 751.9 and Part 753 relating to
            informed consent and confidentiality.

           

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

          

          

          

          

          Medicaid
            Advantage Contract 

          APPENDIX
            C 

          New
            York
            City 2006 

          C-10

           

          

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

          Appendix
            D

          

          

          New
            York State Department of Health

          Medicaid
            Advantage Marketing Guidelines

          

          

          

           

          

          Medicaid
            Advantage Contract 

          APPENDIX
            D 

          New
            York
            City 2006 

          D-l

           

          

          MEDICAID
            ADVANTAGE MARKETING GUIDELINES

           

          I. Purpose

           

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

           

          II. Marketing
            Materials

           

          A. Definitions

           

          
            	 	
                    1.

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

                  

          

           

          
            	 	
                    2.

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

                  

          

           

          B. Marketing
            Material Requirements

           

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

           

          
            	 	
                    1.

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

                  

          

           

          
            	 	
                    2.

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

                  

          

          

          

          Medicaid
            Advantage Contract 

          APPENDIX
            D

          New
            York
            City 2006 

          D-2

           

          

          be
            translated include those key materials, such as informational brochures,
            that
            are produced for routine distribution, and which are included within
            the MCO's
            marketing plan. SDOH will determine the need for other than English translations
            based on county specific census data or other available measures.

           

          
            	 	
                    3.

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

                  

          

           

          C. Prior
            Approvals

           

          
            	 	
                    1.

                  	
                    The
                      CMS and SDOH will jointly review and approve Medicaid Advantage
                      marketing
                      videos, materials for broadcast (radio, television, or electronic),
                      billboards, mass transit (bus, subway or other livery) and
                      statewide/regional print advertising 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 

          New
            York
            City 2006 

          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.

          

          

          

          

          Medicaid
            Advantage Contract APPENDIX D 

          New
            York
            City 2006 

          D-4

           

          

          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.

           

          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

                  

          

           

          

          Medicaid
            Advantage Contract 

          APPENDIX
            D 

          New
            York
            City 2006 

          D-5

           

          

          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.

           

          
            	 	
                    g.

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

                  

          

           

          2. Compensation
            for Dedicated Medicaid Advantage Marketing Staff

           

          The
            Contractor shall not offer compensation to Medicaid Advantage dedicated
            Marketing Representatives, including salary increases or bonuses, based
            solely
            on the number of individuals they enroll in Medicaid Advantage. However,
            the
            Contractor may base compensation of these Marketing Representatives on
            periodic
            performance evaluations which consider enrollment productivity as one
            of several
            performance factors during a performance period, subject to the following
            requirements:

           

          
            	 	
                    a.

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

                  

          

           

          
            	 	
                    b.

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

                  

          

           

          
            	 	
                    c.

                  	
                    The
                      Contractor may not award bonuses more frequently than quarterly,
                      or for an
                      annual amount that exceeds ten percent (10%) of his/her total
                      annual
                      compensation;

                  

          

           

          
            	 	
                    d.

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

                  

          

           

          3. Prohibition
            of Cold Call Marketing Activities

           

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

          

          

          

          

          Medicaid
            Advantage Contract 

          APPENDIX
            D 

          New
            York
            City 2006 

          D-6

           

          

          4. Marketing
            in Emergency Rooms or Other Patient Care Areas

           

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

           

          5. Enrollment
            Incentives

           

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

           

          E. General
            Marketing Restrictions

           

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

           

          
            	 	
                    1.

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

                  

          

           

          
            	 	
                    2.

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

                  

          

           

          
            	 	
                    3.

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

                  

          

           

          
            	 	
                    4.

                  	
                    Contractors
                      may not require participating providers to distribute plan
                      prepared
                      communications to their patients, including communications
                      which compare
                      the benefits of different health plans, unless the materials
                      have the
                      concurrence of all

                  

          

          

          Medicaid
            Advantage Contract 

          APPENDIX
            D 

          New
            York
            City 2006

          D-7

           

          

          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.

                  

          

           

          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.

                  

          

           

          
            	 	
                    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

          New
            York
            City 2006 

          D-8

           

          

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

          Appendix
            E

          

          

          New
            York State Department of Health

          Medicaid
            Advantage

          Model
            Member Handbook

          

          

          

          

          

          

          

          

          Medicaid
            Advantage Contract

          APPENDIX
            E

          New
            York
            City 2006

          E-l

           

          

          Introduction

           

          Managed
            care organizations (MCOs) under contract to provide a Medicaid Advantage
            Product
            to Dually Eligible beneficiaries must provide Enrollees with a Medicaid
            Advantage member handbook which is consistent with the current model
            Medicaid
            Advantage member handbook provided by SDOH and approved by the CMS Regional
            Office and the SDOH. This model handbook is to be issued by the Contractor
            to
            Enrollees in addition to the handbook or Explanation of Coverage (EOC)
            required
            by CMS for Medicare Advantage. The model member handbook may be revised
            based on
            changes in the law and the changing needs of the program. Handbooks must
            be
            approved by the CMS Regional Office and the SDOH prior to printing and
            distribution by the Contractor.

           

          General
            Format

           

          Member
            handbooks must be written in a style and reading level that will accommodate
            the
            reading skills of Medicaid recipients. In general the writing should
            not exceed
            a fourth to sixth-grade reading level, taking into consideration the
            need to
            incorporate and explain certain technical or unfamiliar terms to assure
            accuracy. The text must be printed in at least twelve (12) point font.
            The SDOH
            reserves the right to require evidence that a handbook has been tested
            against
            the sixth-grade reading-level standard. Member handbooks must be available
            in
            languages other than English whenever at least five percent (5%) of the
            Prospective Enrollees in any county in the Contractor's service area
            speak that
            particular language and do not speak English as a first language.

           

          Model
            Medicaid Advantage Handbook

           

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

          

          

          

          

          

          

          

          Medicaid
            Advantage Contract APPENDIX E 

          New
            York
            City 2006 

          E-2

           

           

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

           

          APPENDIX
            F

          

          

          New
            York State Department of Health 

          Medicaid
            Advantage Action and Grievance System Requirements

           

          F.I General
            Requirements

           

          F.2 Medicaid
            Advantage Action Requirements

           

          F.3 Medicaid
            Advantage Grievance System Requirements

          

          

          

          

          

          

          

          

          Medicaid
            Advantage Contract

          APPENDIX
            F 

          New
            York
            City 2006 

          F-l

           

          

          F.I
            

          General
            Requirements

           

          1. Organization
            Determinations

           

          a) Organization
            Determinations means any decision by or on behalf of a MCO regarding
            payment or
            services to which an Enrollee believes he or she is entitled. For the
            purposes
            of this Agreement, Organization Determinations are synonymous with Action,
            as
            defined by this Appendix.

           

          b) Organization
            Determinations regarding services determined by the Contractor to be
            benefits
            covered solely by Medicare shall be conducted in accordance with the
            procedures
            and requirements of 42 CFR Subpart M of Part 422, and the Medicare Managed
            Care
            Manual.

           

          c) Organization
            Determinations regarding services determined by the Contractor to be
            benefits
            covered by Medicare and Medicaid shall be conducted in accordance with
            the
            procedures and requirements of 42 CFR Subpart M of Part 422 and the Medicare
            Managed Care Manual, except that:

          i) the
            Contractor will determine whether services are Medically Necessary as
            that

          term
            is
            defined in this Agreement; and 

          ii) when
            the
            Contractor intends to reduce, suspend, or terminate a previously authorized
            service within an authorization period, the notification provisions of
            paragraph
            F.2(4)(a) of this Appendix shall apply.

           

          d) Organization
            Determinations regarding services determined by the Contractor to be
            solely
            covered by Medicaid shall be conducted in accordance with Appendix F.I
            of this
            Agreement, and Articles 44 and 49 of the PHL, and 10 NYCRR Part 98, not
            otherwise expressly established herein.

           

          2. Notices,
            Action Appeals, Complaints and Complaint Appeals

           

          a) Services
            determined by the Contractor to be benefits solely covered by Medicare
            are
            subject to the Medicare Advantage Complaint and Appeals Process. In these
            cases,
            the Contractor will follow such procedures to notify Enrollees, and providers
            as
            applicable, regarding Organization Determinations and offer the Enrollee
            Medicare appeal rights.

           

          b) Services
            determined by the Contractor to be solely covered by Medicaid are subject
            to the
            Medicaid Advantage Grievance System. In these cases, the Contractor will
            follow
            such procedures to notify Enrollees and providers regarding Organization
            Determinations and offer Action Appeal, Complaint, and Complaint Appeals
            rights
            in accordance with Appendices F.2 and F.3 of this Agreement and the requirements
            of Articles 44 and 49 of the PHL, and 10 NYCRR Part 98, not otherwise
            expressly
            established herein.

          

          

          

          Medicaid
            Advantage Contract 

          APPENDIX
            F

          New
            York
            City 2006 

          F-2

          

          c) For
            Organization Determinations regarding services determined by the Contractor
            to
            be a benefit under both Medicare and Medicaid, the Contractor must offer
            Enrollees the right to pursue either the Medicare appeal procedures or
            the
            Medicaid Advantage Action Appeals, Complaint, and
            Complaint Appeals procedures.

           

          i) As
            part
            of, or attached to, the appropriate Organization Determination notice,
            the
            Contractor must provide Enrollees with a notice that informs the Enrollee
            of his
            or her appeal rights under both the Medicare and Medicaid Advantage programs,
            and of their right to select either the Medicare or Medicaid Advantage
            appeals
            process, and instructions to make such selection. Such notice shall inform
            the
            Enrollee that:

          A) if
            he or
            she chooses to pursue the Medicare appeal procedures to challenge a service
            denial, suspension, reduction, or termination, the Enrollee may not pursue
            a
            Medicaid Advantage appeal and may not file a Fair Hearing request with
            the
            state; and

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

           

          ii) The
            Contractor will enclose with the notice described in (i) above the notice
            of
            Action and other attachments as may be required by Appendix F.2 (5)(a)(iii).
            However, the notice of Action need not duplicate information provided
            in the
            Organization Determination notice it is attached to.

           

          iii) If
            the
            Enrollee files an appeal, but fails to select either the Medicare or
            Medicaid
            Advantage procedure, the default procedure will be the Medicaid Advantage
            procedure.

          

          

          

          Medicaid
            Advantage Contract
            

          APPENDIX
            F 

          New
            York
            City 2006 

          F-3

           

          

          F.2

           

          Medicaid
            Advantage Action Requirements

           

          1. Definitions

           

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

           

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

           

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

           

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

           

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

           

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

           

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

           

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

           

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

           

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

           

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

          

          

          

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          2. General
            Requirements

          

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

           

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

           

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

           

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

           

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

           

          3. Timeframes
            for Service Authorization Determinations

           

          

           

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

           

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

           

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

           

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

          

          

          

          

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                    i)

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

                  

          

           

          
            	 	
                    ii)

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

                  

          

           

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

           

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

           

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

           

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

           

          
            	 	
                    4.

                  	
                    Timeframes
                      for Notices of Actions Other Than Service Authorizations
                      Determinations

                  

          

           

          
            	 	
                    a)

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

                  

          

          i) the
            period of advance notice is shortened to five (5) days in cases of
            confirmed

          Enrollee
            fraud; or 

          ii) the
            Contractor may mail notice not later than date of the Action for the
            following:

          A) the
            death
            of the Enrollee;

          
            	 	
                    B)

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

                  

          

          
            	 	
                    C)

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

                  

          

          
            	 	
                    D)

                  	
                    the
                      Enrollee's address is unknown and mail directed to the Enrollee
                      is
                      returned stating that there is no forwarding
                      address;

                  

          

          

          

          

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                    E)

                  	
                    the
                      Enrollee has been accepted for Medicaid services by another
                      jurisdiction;

                  

          

          or
            

          F) the
            Enrollee's physician prescribes a change in the level of medical
            care.

           

          b) The
            Contractor must mail written notice to the Enrollee on the date of the
            Action
            when the Action is denial of payment, in whole or in part, except as
            provided in
            paragraph F.2 6(b) below.

           

          c) When
            the
            Contractor does not reach a determination within the Service Authorization
            Determination timeframes described above, it is considered an Adverse
            Determination, and the Contractor must send notice of Action to the Enrollee
            on
            the date the timeframes expire.

           

          5. Format
            and Content of Notices

           

          a) The
            Contractor shall ensure that all notices are in writing, in easily understood
            language and are accessible to non-English speaking and visually impaired
            Enrollees. Notices shall include that oral interpretation and alternate
            formats
            of written material for Enrollees with special needs are available and
            how to
            access the alternate formats.

           

          i) 
            Notice
            to the Enrollee that the Enrollee's request for an expedited review has
            been
            denied shall include that the request will be reviewed under standard
            timeframes, including a description of the timeframes.

           

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

          A) the
            reason for the extension;

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

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

          

          D) the
            revised date by which the MCO will make its determination;

          E) the
            right
            of the Enrollee to file a Complaint (as defined in Appendix F.3 ofthis
            Agreement)regarding the extension;

          F) the
            process for filing a Complaint with the Contractor and the timeframes
            within
            which a Complaint determination must be made;

          G) the
            right
            of an Enrollee to designate a representative to file a Complaint on behalf
            of
            the Enrollee; and 

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

           

          iii) Notice
            to
            the Enrollee of an Action shall include:

          A) the
            description of the Action the Contractor has taken or intends to
            take;

          B) the
            reasons for the Action, including the clinical rationale, if any;

          C) the
            Enrollee's right to file an Action Appeal (as defined in Appendix F.3
            of this
            Agreement), including:

          

          

          

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                    I)

                  	
                    The
                      fact that the Contractor will not retaliate or take any discriminatory
                      action against the Enrollee because he/she filed an Action
                      Appeal.

                  

          

          II) 
The
            right
            of the Enrollee to designate a representative to file Action Appeals
            on his/her
            behalf;

          D) the
            process and timeframe for filing an Action Appeal with the Contractor,
            including
            an explanation that an expedited review of the Action Appeal can be requested
            if
            a delay would significantly increase the risk to an Enrollee's health,
            a
            toll-free number for filing an oral Action Appeal and a form, if used
            by the
            Contractor, for filing a written Action Appeal;

          E) a
            description of what additional information, if any, must be obtained
            by the
            Contractor from any source in order for the Contractor to make an Appeal
            determination;

          F) the
            timeframes within which the Action Appeal determination must be made;
            

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

          H) the
            notice entitled "Managed Care Action Taken" for denial of benefits or
            for
            termination or reduction in benefits, as applicable, containing the Enrollee's
            fair hearing and aid continuing rights. 

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

          
            	 	
                    I)

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

                  

          

          
            	 	
                    II)

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

                  

          

          
            	 	
                    III)

                  	
                    a
                      statement that the Enrollee may be eligible for, and timeframes
                      for filing
                      an External Appeal, including that if so eligible, the Enrollee
                      may
                      request an External Appeal after first filing an expedited
                      Action Appeal
                      with the Contractor and receiving notice that the Contractor
                      upholds its
                      adverse determination, or after filing standard Action Appeal
                      with the
                      Contractor and receiving the Contractor's final adverse determination,
                      or
                      after the Contractor and the Enrollee agree to waive the internal
                      Action
                      Appeal process.

                  

          

           

          6. Contractor
            Obligation to Notice

           

          a) The
            Contractor must provide written Notice of Action to Enrollees and providers
            in
            accordance with the requirements of this Appendix, including, but not
            limited
            to, the following circumstances (except as provided for in paragraph
            6(b)
            below):

           

          i) the
            Contractor makes a coverage determination or denies a request for a referral,
            regardless of whether the Enrollee has received the benefit;

           

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

          

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                    iii)
                      

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

                  

          

           

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

           

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

           

          
            	 	
                    vi)

                  	
                    the
                      Contractor denies a claim because it has determined that the
                      Enrollee was
                      not eligible for Medicaid Advantage coverage on the date of
                      service;

                  

          

           

          
            	 	
                    vii)

                  	
                    the
                      Contractor denies a claim for service rendered by a Participating
                      Provider
                      due to lack of a referral;

                  

          

           

          viii) the
            Contractor denies a claim because it has determined it is not the appropriate
            payor; or

           

          
            	 	
                    ix)

                  	
                    the
                      Contractor denies a claim due to a Participating Provider billing
                      for
                      Benefit Package services not included in the Provider Agreement
                      between
                      the Contractor and the Participating
                      Provider.

                  

          

           

          b) The
            Contractor is not required to provide written Notice of Action to Enrollees
            in
            the following circumstances:

           

          
            	 	
                    i)

                  	
                    When
                      there is a prepaid capitation arrangement with a Participating
                      Provider
                      and the Participating Provider submits a fee-for-service claim
                      to the
                      Contractor for a service that falls within the capitation
                      payment;

                  

          

           

          
            	 	
                    ii)

                  	
                    if
                      a Participating Provider of the Contractor itemizes or "unbundles"
                      a claim
                      for services encompassed by a previously negotiated global
                      fee
                      arrangement;

                  

          

           

          
            	 	
                    iii)

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

                  

          

           

          
            	 	
                    iv)

                  	
                    if
                      the claim is for a service that is carved-out of the Benefit
                      Package and
                      is provided to an Enrollee through Medicaid fee-for-service,
                      however, the
                      Contractor should notify the provider to submit the claim to
                      Medicaid;

                  

          

           

          
            	 	
                    v)

                  	
                    if
                      the Contractor makes a coding adjustment to a claim (up-coding
                      or
                      down-coding) and its Provider Agreement with the Participating
                      Provider
                      includes a provision allowing the Contractor to make such
                      adjustments;

                  

          

           

          
            	 	
                    vi)

                  	
                    if
                      the Contractor has paid the negotiated amount reflected in
                      the Provider
                      Agreement with a Participating Provider for the services provided
                      to the
                      Enrollee and denies the Participating Provider's request for
                      additional
                      payment; or

                  

          

          

          

          

          

          

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                    vii)

                  	
                    if
                      the Contractor has not yet adjudicated the claim. If the Contractor
                      has
                      pended the claim while requesting additional information, a
                      notice is not
                      required until the coverage determination has been
                      made.

                  

          

          

          

          

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          F.3

           

          Medicaid
            Advantage Grievance System Requirements

           

          1. Definitions

           

          a) A
            Grievance System means the Contractor's Medicaid Advantage Complaint
            and Appeal
            process, and includes a Complaint and Complaint Appeal process, a process
            to
            appeal Actions, and access to the State's fair hearing system.

           

          b) For
            the
            purposes of this Agreement, a Complaint means an Enrollee's expression
            of
            dissatisfaction with any aspect of his or her care other than an Action.
            A
            "Complaint" means the same as a "grievance" as defined by 42 CFR §438.400
            (b).

           

          c)
            An
            Action Appeal means a request for a review of an Action.

           

          d)
            A
            Complaint Appeal means a request for a review of a Complaint
            determination.

           

          e)
            An
            Inquiry means a written or verbal question or request for information
            posed to
            the Contractor with regard to such issues as benefits, contracts, and
            organization rules. Neither Enrollee Complaints nor disagreements with
            Contractor determinations are Inquiries.

           

          2. Grievance
            System - General Requirements

           

          a)
            The
            Contractor shall describe its Grievance System in the Member Handbook,
            and it
            must be accessible to non-English speaking, visually, and hearing impaired
            Enrollees. The handbook shall comply with The Member Handbook Guidelines
            (Appendix E) of this Agreement.

           

          b)
            The
            Contractor will provide Enrollees with any reasonable assistance in completing
            forms and other procedural steps for filing a Complaint, Complaint Appeal
            or
            Action Appeal, including, but not limited to, providing interpreter services
            and
            toll-free numbers with TTY/TDD and interpreter capability.

           

          c)
            The
            Enrollee may designate a representative to file Complaints, Complaint
            Appeals
            and Action Appeals on his/her behalf.

           

          d)
            The
            Contractor will not retaliate or take any discriminatory action against
            the
            Enrollee because he/she filed a Complaint, Complaint Appeal or Action
            Appeal.

          

          

          

          

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          e)
            The
            Contractor's procedures for accepting Complaints, Complaint Appeals and
            Action
            Appeals shall include:

           

          i)
            toll-free telephone number;

           

          ii)
            designated staff to receive calls;

           

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

           

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

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

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

           

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

          i)
            A
            denial of an Action Appeal based on lack of medical necessity. ii) A
            Complaint
            regarding denial of expedited resolution of an Action Appeal. iii) A
            Complaint,
            Complaint Appeal, or Action Appeal that involves clinical issues.

           

          3. 
            Action Appeals Process

           

          a)
            The
            Contractor's Action Appeals process shall indicate the following regarding
            resolution of Appeals of an Action:

           

          i)
            The
            Enrollee, or his or her designee, will have no less than sixty (60) business
            days and no more than 90 days from the date of the notice of Action to
            file an
            Action Appeal. An Enrollee filing an Action Appeal within ten (10) days
            of the
            notice of Action or by the intended date of an Action, whichever is later,
            that
            involves the reduction, suspension, or termination of previously approved
            services may request "aid continuing" in accordance with Section 24.4
            of this
            Agreement.

           

          ii)
            The
            Enrollee may file a written Action Appeal or an oral Action Appeal. Oral
            Action
            Appeals must be followed by a written, signed. Action Appeal. The Contractor
            may
            provide a written summary of an oral Action Appeal to the Enrollee (with
            the
            acknowledgement or separately) for the Enrollee to review, modify if
            needed,
            sign and return to the Contractor. If the Enrollee or provider requests
            expedited resolution of the Action Appeal, the oral Action Appeal does
            not need
            to be confirmed in writing.

          

          

          

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          The
            date
            of the oral filing of the Action Appeal will be the date of the Action
            Appeal
            for the purposes of the timeframes for resolution of Action Appeals.
            Action
            Appeals resulting from a Concurrent Review must be handled as an expedited
            Action Appeal.

           

          iii)
            The
            Contractor must send a written acknowledgement of the Action Appeal,
            including
            the name, address and telephone number of the individual or department
            handling
            the Action Appeal, within fifteen (15) days of receipt. If a determination
            is
            reached before the written acknowledgement is sent, the Contractor may
            include
            the written acknowledgement with the notice of Action Appeal determination
            (one
            notice).

           

          iv)
            The
            Contractor must provide the Enrollee reasonable opportunity to present
            evidence,
            and allegations of fact or law, in person as well as in writing. The
            Contractor
            must inform the Enrollee of the limited time to present such evidence
            in the
            case of an expedited Action Appeal. The Contractor must allow the Enrollee
            or
            his or her designee, both before and during the Action Appeals process,
            to
            examine the Enrollee's case file, including medical records and any other
            documents and records considered during the Action Appeals process. The
            Contractor will consider the Enrollee, his or her designee, or legal
            estate
            representative of a deceased Enrollee a party to the Action Appeal.

           

          v)
            The
            Contractor must have a process for handling expedited Action Appeals. Expedited
            resolution of the Action Appeal must be conducted when the Contractor
            determines
            or the provider indicates that a delay would seriously jeopardize the
            Enrollee's
            life or health or ability to attain, maintain, or regain maximum function.
            The
            Enrollee may request an expedited review of an Action Appeal. If the
            Contractor
            denies the Enrollee's request for an expedited review, the Contractor
            must
            handle the request under standard Action Appeal resolution timeframes,
            make
            reasonable efforts to provide prompt oral notice of the denial to the
            Enrollee
            and send written notice of the denial within two (2) days of the denial
            determination.

           

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

           

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

          

          

          

          

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            Advantage Contract 

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            York
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          4. Timeframes
            for Resolution of Action Appeals

           

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

           

          i)
            The
            Contractor will resolve Action Appeals as fast as the Enrollee's condition
            requires, and no later than thirty (30) days from the date of the receipt
            of the
            Action Appeal.

           

          ii)
            The
            Contractor will resolve expedited Action Appeals as fast as the Enrollee's
            condition requires, within two (2) business days of receipt of necessary
            information and no later than three (3) business days of the date of
            the receipt
            of the Action Appeal.

           

          iii)
            Timeframes for Action Appeal resolution, in either (i) or (ii) above,
            may be
            extended for up to fourteen (14) days if:

          A)
            the
            Enrollee, his or her designee, or the provider requests an extension
            orally or
            in writing; or

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

           

          iv)
            The
            Contractor will make a reasonable effort to provide oral notice to the
            Enrollee,
            his or her designee, and the provider where appropriate, for expedited
            Action
            Appeals at the time the Action Appeal determination is made.

           

          v)
            The
            Contractor must send written notice to the Enrollee, his or her designee,
            and
            the provider where appropriate, within two (2) business days of the Action
            Appeal determination.

           

          5. Action
            Appeal Notices

           

          a)
            The
            Contractor shall ensure that all notices are in writing and in easily
            understood
            language and are accessible to non-English speaking and visually impaired
            Enrollees. Notices shall include that oral interpretation and alternate
            formats
            of written material for Enrollees with special needs are available and
            how to
            access the alternate formats.

           

          i)
            Notice
            to the Enrollee that the Enrollee's request for an expedited Action Appeal
            has
            been denied shall include that the request will be reviewed under standard
            Action Appeal timeframes, including a description of the timeframes.
            This notice
            may be combined with the acknowledgement.

           

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

          
            	 	
                    A)

                  	
                    the
                      reason for the extension;

                  

          

          

          

          

          

          

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            Advantage Contract
            

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

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

          D)
            the
            revised date by which the MCO will make its determination;

          E)
            the
            right of the Enrollee to file a Complaint regarding the extension;

          F)
            the
            process for filing a Complaint with the Contractor and the timeframes
            within
            which a Complaint determination must be made;

          G)
            the
            right of an Enrollee to designate a representative to file a Complaint
            on behalf
            of the Enrollee; and 

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

           

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

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

          B)
            Date
            the Action Appeal process was completed;

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

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

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

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

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

          II)
            the
            Enrollee's coverage type;

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

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

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

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

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

          and

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

          

          

          

          

          

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            Advantage Contract

          APPENDIX
            F 

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            York
            City 2006 

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          6. 
            Complaint Process

           

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

           

          
            	 	
                    i)

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

                  

          

           

          
            	 	
                    ii)

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

                  

          

           

          
            	 	
                    iii)

                  	
                    Complaints
                      shall be reviewed by one or more qualified
                      personnel.

                  

          

           

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

           

          7.
             Timeframes
            for Complaint Resolution by the Contractor

           

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

           

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

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

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

          

          

          

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            Advantage Contract 

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            F 

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            York
            City 2006

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          8. Complaint
            Determination Notices

           

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

           

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

          A)
            the
            detailed reasons for the determination;

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

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

           

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

           

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

           

          9. Complaint
            Appeals

           

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

           

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

           

          ii)
            Within fifteen (15) business days of receipt of the Complaint Appeal,
            the
            Contractor shall provide written acknowledgment of the Complaint Appeal,
            including the name, address and telephone number of the individual designated
            to
            respond to the Appeal. The Contractor shall indicate what additional
            information, if any, must be provided for the Contractor to render a
            determination.

           

           

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            Advantage Contract 

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            F 

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            York
            City 2006 

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          iii)
            Complaint Appeals of clinical matters must be decided by personnel qualified
            to
            review the Appeal, including licensed, certified or registered health
            care
            professionals who did not make the initial determination, at least one
            of whom
            must be a clinical peer reviewer, as defined by PHL §4900(2)(a).

           

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

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

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

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

           

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

          A)
            the
            detailed reasons for the determination;

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

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

          D)
            instructions for any further Appeal, if applicable.

           

          10. Records

           

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

           

          i)
            date
            the Complaint was filed;

           

          ii),
            copy
            of the Complaint, if written;

           

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

           

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

           

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

           

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

           

          

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            Advantage Contract 

          APPENDIX
            F 

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            York
            City 2006 

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          vii)
            necessary documentation to support any extensions;

           

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

           

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

           

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

          

          

          

          

          

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            Advantage Contract 

          APPENDIX
            F 

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            York
            City 2006 

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          APPENDIX
            G

           

          

           

          Reserved

          

          

          

          

          

          

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            Advantage Contract 

          APPENDIX
            G

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            York
            City 2006

          G-l

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

          APPENDIX
            H

           

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

          

          

          

          

          

          

          

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            Advantage Contract

          APPENDIX
            H 

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            York
            City 2006 

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          Appendix
            H SDOH Guidelines

          For
            the Processing of Medicaid Advantage Enrollments and
            Disenrollments

           

          1.
            General

           

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

           

          2.
            Enrollment

           

          a)
            SDOH Responsibilities:

           

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

           

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

           

          b)
            LDSS Responsibilities:

           

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

           

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

           

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

           

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

           

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            Advantage Contract

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

           

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

           

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

           

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

           

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

           

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

           

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

           

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

           

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

          

          

          

          

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            Advantage Contract 

          APPENDIX
            H 

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            York
            City 2006 

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          A)
            LDSS
            directly enters data into PCP Subsystem; or

           

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

           

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

           

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

           

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

           

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

           

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

           

          A)
            Enrollment Confirmation Notice: This notice indicates the Effective Date
            of
            Enrollment, the name of the Medicaid Advantage Product and the individual
            who is
            being enrolled. This notice must also include a statement advising the
            individual that if his/her Medicare Advantage enrollment is denied by
            CMS, the
            individual's Medicaid Advantage Enrollment will be voided retroactively
            back to
            the Effective Date of Enrollment, hi 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.

          

          

          

          

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            Advantage Contract 

          APPENDIX
            H 

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            York
            City 2006

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          c)
            Contractor Responsibilities:

           

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

           

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

           

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

           

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

           

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

           

          vi)
            If an
            Enrollee's Enrollment in the Contractor's Medicare Advantage Product
            is rejected
            by CMS, the Contractor must notify the LDSS within five (5) business
            days of
            learning of CMS' rejection of the Enrollment.

          

          

          

          

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            Advantage Contract 

          APPENDIX
            H 

          New
            York
            City 2006 

          H-5

           

          

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

           

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

           

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

           

          3.
            Newborn Enrollments:

           

          a)
            SDOH Responsibilities:

           

          i)
            The
            SDOH will update WMS with information on the newborn received from hospitals
            or
            birthing centers, consistent with the requirements of Section 366-g of
            the
            Social Services Law as amended by Chapter 412 of the Laws of 1999.

           

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

           

          b)
            LDSS Responsibilities:

           

          i)
            The
            LDSS is responsible for granting Medicaid eligibility for newboms 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 unboms to all WMS cases that
            include a
            pregnant woman as soon as the pregnancy is medically verified. (NYS
            DSS Administrative Directive 85 ADM-33)

           

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

           

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

           

          

           

          

           

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            Advantage Contract

          APPENDIX
            H

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            York
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          v)
            The
            LDSS may develop a transmittal form to be used for unbom/newbom 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 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 monthly to the Contractor and LDSS, at the time of the first
            monthly
            roster production; a Disenrollment Report listing those Enrollees from
            the
            previous month's roster who were disenrolled, transferred to another
            MCO, or
            whose Enrollments were deleted from the file. Notification to the Contractor
            and
            LDSSs will be accomplished via paper transmission, magnetic media, or
            the
            HPN.

           

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

           

          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

           

          

           

          

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            Advantage Contract 

          APPENDIX
            H 

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            York
            City 2006

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          and
            LDSS
            a second Roster which contains any additional Enrollees that the LDSS
            has added
            for Enrollment for the current month. The SDOH will also include any
            additions
            to the error report that have occurred since the initial error report
            was
            generated.

           

          c)
            LDSS Responsibilities:

           

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

           

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

           

          d)
            Contractor Responsibilities:

           

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

           

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

           

          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.

           

          

           

          Medicaid
            Advantage Contract

          APPENDIX
            H 

          New
            York
            City 2006 

          H-8

          

           

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

           

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

           

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

           

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

           

          vi)
            The
            LDSS is responsible for disenrolling Enrollees automatically upon death,
            Disenrollment from the Contractor's Medicare Acrvantage 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

          New
            York
            City 2006 

          H-9

          

          viii)
            The
            LDSS is responsible for ensuring that Retroactive Disenrollments are
            used only
            when absolutely necessary. Circumstances warranting a retroactive Disenrollment
            are rare and include when an individual is deemed to have been non-consensually
            enrolled in the Contractor's Medicaid Advantage Product, is enrolled
            when
            ineligible for Enrollment, or when an Enrollee enters or resides in a
            residential institution under circumstances which render the individual
            ineligible; is incarcerated; is retroactively disenrolled from the Contractor's
            Medicare Advantage Product, or dies - as long as the Contractor was not
            at risk
            for provision of Benefit Package services for any portion of the retroactive
            period. Payment of subcapitation does not constitute "provision of Benefit
            Package services." The LDSS is responsible for notifying the Contractor
            of the
            retroactive disenrollment prior to the action. The LDSS is responsible
            for
            finding out if the Contractor has made payments to providers on behalf
            of the
            Enrollee prior to Disenrollment. After this information is obtained,
            the LDSS
            and Contractor will agree on a retroactive Disenrollment or prospective
            Disenrollment date.

           

          In
            all
            cases of retroactive Disenrollment, including Disenrollments effective
            the first
            day of the current month, the LDSS is responsible for sending notice
            to the
            Contractor at the time of Disenrollrnent, of the Contractor's responsibility
            to
            submit to the SDOH's Fiscal Agent voided premium claims for any full
            months of
            retroactive Disenrollment where the Contractor was not at risk for the
            provision
            of Benefit Package services during the month. However, failure by the
            LDSS to so
            notify the Contractor does not affect the right of the SDOH to recover
            the
            premium payment as authorized by Section 3.6 of this Agreement.

          

          

          

          Medicaid
            Advantage Contract

          APPENDIX
            H 

          New
            York
            City 2006

          H-10

           

          

          ix)
            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 ofwaivered services through
                      the Long
                      Term Home Health Care Program (LTHHCP), including when an Enrollee
                      is
                      admitted to a hospital that 1) is certified by Medicare as
                      a long-term
                      care hospital and 2) has an average length of stay for all
                      patients
                      greater than ninety-five (95) days as reported in the Statewide
                      Planning
                      and Research Cooperative System (SPARCS) Annual Report
                      2002.

                  	
                     

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

                  
	
                     

                    •
                      Individual enrolled while ineligible for enrollment

                  	
                     

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

                  
	
                     

                    •
                      Non-consensual Enrollment

                  	
                     

                    •
                      Retroactive to the first day of the month of

                     

                    Enrollment

                  
	
                     

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

                  	
                     

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

                  
	
                     

                    •
                      Urgent medical need

                  	
                     

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

                  
	
                     

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

                  	
                     

                    •
                      Retroactive to the first day of the month of

                     

                    the
                      request

                  
	
                     

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

                  	
                     

                    •
                      First day of the month the duplicate Enrollment
                      began.

                  

          

           

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

          

          

          

          

          Medicaid
            Advantage Contract APPENDIX H

          New
            York
            City 2006

          H-ll

           

          

          Service
            Area but not outside, of the City of New York (e.g., move from one borough
            to
            another), will not be involuntarily disenrolled, but must request a
            Disenrollment or transfer. These Disenrollments will be performed on
            a routine
            basis unless there is an urgent medical need to expedite the
            Disenrollment.

           

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

           

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

           

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

           

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

           

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

           

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

           

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

           

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

           

          

          Medicaid
            Advantage Contract APPENDIX H 

          New
            York
            City 2006

          H-12

           

          

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

           

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

           

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

           

          b)
            Contractor Responsibilities:

           

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

           

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

           

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

           

          iv)
            With
            respect to Contractor-initiated Disenrollments:

           

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

          

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

          

           

          

          Medicaid
            Advantage Contract 

          APPENDIX
            H 

          New
            York
            City 2006 

          H-13

           

          

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

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

           

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

           

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

           

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

           

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

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

          

          

          

          

          Medicaid
            Advantage Contract

          APPENDIX
            H 

          New
            York

          City
            2006

          H-14

           

           

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

           

          

          APPENDIX
            I

           

          Reserved

          

          

          

          

          Medicaid
            Advantage Contract APPENDIX I

          New
            York
            City 2006

          1-1

           

           

           

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

          

            APPENDIX
              J

             

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

             

            

             

            

             

            

             

            

             

            APPENDIX
              J 

            October
              1,2005

             

            J-l

             

            I.
              OBJECTIVES 

            

            Title
              II
              of the Americans With Disabilities Act (ADA) and Section 504 of the
              Rehabilitation Act of 1973 (Section 504) provides that no qualified
              individual
              with a disability shall, by reason of such disability, be excluded
              from
              participation in or denied access to the benefits of services, programs
              or
              activities of a public entity, or be subject to discrimination by such
              an
              entity. Public entities include State and local government and ADA
              and Section
              504 requirements extend to all programs and services provided by State
              and local
              government. Since MMC and FHPlus are government programs, health services
              provided through MMC and FHPlus Programs must be accessible to all
              that qualify
              for them.

            

            Contractor
              responsibilities for compliance with the ADA are imposed under Title
              II and
              Section 504 when, as a Contractor in a MMC or FHPlus Program, a Contractor
              is
              providing a government service. If an individual provider under contract
              with
              the Contractor is not accessible, it is the responsibility of the Contractor
              to
              make arrangements to assure that alternative services are provided.
              The
              Contractor may-determine it is expedient to make arrangements with
              other
              providers, or to describe reasonable alternative means and methods
              to make these
              services accessible through its existing Participating Providers. The
              goals of
              compliance with ADA Title II requirements are to offer a level of services
              that
              allows people with disabilities access to the program in its entirety,
              and the
              ability to achieve the same health care results as any Enrollee.

            

            Contractor
              responsibilities for compliance with the ADA are also imposed under
              Title III
              when the Contractor functions as a public accommodation providing services
              to
              individuals (e.g. program areas and sites such as Marketing, education,
              member
              services, orientation. Complaints and Appeals). The goals of compliance
              with ADA
              Title III requirements are to offer a level of services that allows
              people with
              disabilities full and equal enjoyment of the goods, services, facilities
              or
              accommodations that the entity provides for its customers or clients.
              New and
              altered areas and facilities must be as accessible as possible. Whenever
              Contractors engage in new construction or renovation, compliance is
              also
              required with accessible design and construction standards promulgated
              pursuant
              to the ADA as well as State and local laws. Title III also requires
              that public
              accommodations undertake "readily achievable barrier removal" in existing
              facilities where architectural and communications barriers can be removed
              easily
              and without much difficulty or expense.

            

            The
              State
              uses MCO Qualification Standards to qualify MCOs for participation
              in the MMC
              and FHPlus Programs. Pursuant to the State's responsibility to assure
              program
              access to all Enrollees, the Plan Qualification Standards require each
              MCO to
              submit an ADA Compliance Plan that describes in detail how the MCO
              will make
              services, programs and activities readily accessible and useable by
              individuals
              with disabilities. In the event that certain program sites are not
              readily
              accessible, the MCO must describe reasonable alternative methods for
              making the
              services or activities accessible and usable.

            

            

            

            APPENDIX
              J 

            October
              1.2005

            J-2

             

            

            The
              objectives of these guidelines are threefold:

            •
To
              ensure that Contractors take appropriate steps to measure access and
              assure
              program accessibility for persons with disabilities;

            •
To
              provide a framework for Contractors as they develop a plan to assure
              compliance
              with the Americans with Disabilities Act (ADA); and

            •
To
              provide standards for the review of the Contractor Compliance
              Plans.

            

            These
              guidelines include a general standard followed by a discussion of specific
              considerations and suggestions of methods for assuring compliance.
              Please be
              advised that, although these guidelines and any subsequent reviews
              by State and
              local governments can give the Contractor guidance, it is ultimately
              the
              Contractor's obligation to ensure that it complies with its Contractual
              obligations, as well as with the requirements of the ADA, Section 504,
              and other
              federal, state and local laws. Other federal, state and local statutes
              and
              regulations also prohibit discrimination on the basis of disability
              and may
              impose requirements in addition to those established under ADA. For
              example,
              while the ADA covers those impairments that "substantially" limit one
              or more of
              the major life activities of an individual. New York City Human Rights
              Law
              deletes the modifier "substantially".

            

            II.
              DEFINITIONS

             

            A.
              "Auxiliary aids and services" may include qualified interpreters, note
              takers,
              computer-aided transcription services, written materials, telephone
              handset
              amplifiers, assistive listening systems, telephones compatible with
              hearing
              aids, closed caption decoders, open and closed captioning, telecommunications
              devices for Enrollees who are deaf or hard of hearing (TTY/TDD), video
              test
              displays, and other effective methods of making aurally delivered materials
              available to individuals with hearing impairments; qualified readers,
              taped
              texts, audio recordings, Braille materials, large print materials,
              or other
              effective methods of making visually delivered materials available
              to
              individuals with visual impairments.

            

            B.
              "Disability" means a mental or physical impairment that substantially
              limits one
              or more of the major life activities of an individual; a record of
              such
              impairment; or being regarded as having such an impairment.

            
 

            III.
              SCOPE OF CONTRACTOR COMPLIANCE PLAN

            

            The
              Contractor Compliance Plan must address accessibility to services at
              Contractor's program sites, including both Participating Provider sites
              and
              Contractor facilities intended for use by Enrollees.

            

            

            IV.
              PROGRAM ACCESSIBILITY

            

            Public
              programs and services, when viewed in their entirety must be readily
              accessible
              to and useable by individuals with disabilities. This standard includes
              physical
              access, non-discrimination in policies and procedures and communication.
              Communications with individuals with disabilities are required to be
              as

            

            

            APPENDIX
              J 

            October
              1.2005

            J-3

            

            effective
              as communications with others. The Contractor Compliance Plan must
              include a
              detailed description of how Contractor services, programs, and activities
              are
              readily accessible and usable by individuals with disabilities. In
              the event
              that full physical accessibility is not readily available for people
              with
              disabilities, the Contractor Compliance Plan will describe the steps
              or actions
              the Contractor will take to assure accessibility to services equivalent
              to those
              offered at the inaccessible facilities.

            

            IV
              PROGRAM ACCESSIBILITY

            

            A.
              PRE-ENROLLMENT MARKETING AND EDUCATION 

            

            STANDARD
              FOR COMPLIANCE

            

            Marketing
              staff, activities and materials will be made available to persons with
              disabilities. Marketing materials will be made available in alternative
              formats
              (such as Braille, large print, and audiotapes) so that they are readily
              usable
              by people with disabilities.

            

            SUGGESTED
              METHODS FOR COMPLIANCE

            

            1.
              Activities held in physically accessible location, or staff at activities
              available to meet with person in an accessible location as
              necessary

            2.
              Materials available in alternative formats, such as Braille, large
              print, audio
              tapes

            3.
              Staff
              training which includes training and information regarding attitudinal
              barriers
              related to disability

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

            5.
              Enrollee health promotion material/activities targeted specifically
              to persons
              with disabilities (e.g. secondary infection prevention, decubitus prevention,
              special exercise programs, etc.)

            6.
              Policy
              statement that Marketing Representatives will offer to read or summarize
              to
              blind or vision impaired individuals any written material that is typically
              distributed to all Enrollees

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

            

            

            COMPLIANCE
              PLAN SUBMISSION

            

            

            1.
              A
              description of methods to ensure that the Contractor's Marketing presentations
              (materials and communications) are accessible to persons with auditory,
              visual
              and cognitive impairments

            2.
              A
              description of the Contractor's policies and procedures, including
              Marketing
              training, to ensure that Marketing Representatives neither screen health
              status
              nor ask questions about health status or prior health care services

            

             

            APPENDIX
              J 

            October
              1.2005 

            J-4

            

            IV.
              PROGRAM ACCESSIBILITY

            

            B.
              MEMBER SERVICES DEPARTMENT

            

            Member
              services functions include the provision to Enrollees of information
              necessary
              to make informed choices about treatment options, to effectively utilize
              the
              health care resources, to assist Enrollees in making appointments,
              and to field
              questions and Complaints, to assist Enrollees with the Complaint
              process.

            

            Bl.
              ACCESSIBILITY

            

            STANDARD
              FOR COMPLIANCE

            Member
              Services sites and functions will be made accessible to and usable
              by, people
              with disabilities.

            

            SUGGESTED
              METHODS FOR COMPLIANCE
              (include, but are not limited to those identified below):

            1.
              Exterior routes of travel, at least 36" wide, from parking areas or
              public
              transportation stops into the Contractor's facility

            2.
              If
              parking is provided, spaces reserved for people with disabilities,
              pedestrian
              ramps at sidewalks, and drop-offs

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

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

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

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

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

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

            9.
              Availability of activities and educational materials tailored to specific
              conditions/illnesses and secondary conditions that affect these populations
              (e.g. secondary infection prevention, decubitus prevention, special
              exercise
              programs, etc.)

            10.
              Contractor staff trained in the use of telecommunication devices for
              Enrollees
              who are deaf or hard of hearing (TTY/TDD) as well as in the use of
              NY Relay for
              phone communication

            11.
              New
              Enrollee orientation available in audio or by interpreter services

            12.
              Policy that when member services staff receive calls through the NY
              Relay, they
              will offer to return the call utilizing a direct TTY/TDD connection

             

            

            APPENDIX
              J 

            October
              1.2005 

            J-5

            

            COMPLIANCE
              PLAN SUBMISSION

            1.
              A
              description of accessibility to the Contractor's -member services department
              or
              reasonable alternative means to access member services for Enrollees
              using
              wheelchairs (or other mobility aids)

            2.
              A
              description of the methods the Contractor's member services department
              will use
              to communicate with Enrollees who have visual or hearing impairments,
              including
              any necessary auxiliary aid/services for Enrollees who are deaf or
              hard of
              hearing, and TTY/TDD technology or NY Relay service available through
              a
              toll-free telephone number

            3.
              A
              description of the training provided to the Contractor's member services
              staff
              to assure that staff adequately understands how to implement the requirements
              of
              the program, and of these guidelines, and are sensitive to the needs
              of persons
              with disabilities

            

            IV.
              PROGRAM ACCESSIBILITY

            

            B2.
              IDENTIFICATION OF ENROLLEES WITH DISABILITIES 

            

            STANDARD
              FOR COMPLIANCE

            The
              Contractor must have in place satisfactory methods/guidelines for identifying
              persons at risk of, or having, chronic diseases and disabilities and
              determining
              their specific needs in terms of specialist physician referrals, durable
              medical
              equipment, medical supplies, home health services etc. The Contractor
              may not
              discriminate against a Prospective Enrollee based on his/her current
              health
              status or anticipated need for future health care. The Contractor may
              not
              discriminate on the basis of disability, or perceived disability of
              an Enrollee
              or their family member. Health assessment forms may not be used by
              the
              Contractor prior to Enrollment. Once a MCO has been chosen, a health
              assessment
              form may be used to assess the person's health care needs.

            

            

            

            SUGGESTED
              METHODS FOR COMPLIANCE

            1.
              Appropriate post Enrollment health screening for each Enrollee, using
              an
              appropriate health screening tool

            2.
              Patient profiles by condition/disease for comparative analysis to national
              norms, with appropriate outreach and education

            3.
              Process for follow-up of needs identified by initial screening; e.g.
              referrals,
              assignment of case manager, assistance with scheduling/keeping
              appointments

            4.
              Enrolled population disability assessment survey

            5.
              Process for Enrollees who acquire a disability subsequent to Enrollment
              to
              access appropriate services

            

            

            APPENDIX
              J 

            October
              1.2005 

            J-6

            

            COMPLIANCE
              PLAN SUBMISSION

            

            A
              description of how the .Contractor will identify special health care,
              physical
              access or communication needs of Enrollees on a timely basis, including
              but not
              limited to the health care needs of Enrollees who:

            

            •
are
              blind or have visual impairments, including the type of auxiliary aids
              and
              services required by the Enrollee

            •
are
              deaf or hard of hearing, including the type of auxiliary aids and services
              required by the Enrollee

            •
have
              mobility impairments, including the extent, if any, to which they can
              ambulate

            •
have
              other physical or mental impairments or disabilities, including cognitive
              impairments

            •
have
              conditions which may require more intensive case management

            

            IV.
              PROGRAM ACCESSIBILITY

            

            B3.
              NEW ENROLLEE ORIENTATION 

            

            STANDARD
              FOR COMPLIANCE

            

            Enrollees
              will be given information sufficient to ensure that they understand
              how to
              access medical care through the Contractor. This information will be
              made
              accessible to and usable by people with disabilities.

            

            SUGGESTED
              METHODS FOR COMPLIANCE

            

            1.
              Activities held in physically accessible location, or staff at activities
              available to meet with person in an accessible location as
              necessary

            2.
              Materials available in alternative formats, such as Braille, large
              print, audio
              tapes

            3.
              Staff
              training which includes sensitivity training related to disability
              issues
              (Resources and technical assistance are available through the NYS Office
              of
              Advocate for Persons with Disabilities - V/TTY (800) 522-4369; and
              the NYC
              Mayor's Office for People with Disabilities - (212) 788-2830 or TTY
              (212)788-283
              8)

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

            5.
              Include in written/audio materials available to all Enrollees information
              regarding how and where people with disabilities can access help in
              getting
              services, for example help with making appointments or for arranging
              special
              transportation, an interpreter or assistive communication devices

            6.
              Staff/resources available to assist individuals with cognitive impairments
              in
              understanding materials

            

             

            APPENDIX
              J 

            October
              1.2005

            J-7

             

            

            COMPLIANCE
              PLAN SUBMISSION

            

            1.
              A
              description of how the Contractor will advise Enrollees with disabilities,
              during the new Enrollee orientation on how to access care

            2.
              A
              description of how the Contractor will assist new Enrollees with disabilities
              (as well as current Enrollees who acquire a disability) in selecting
              or
              arranging an appointment with a Primary Care Practitioner (PCP)

            •
This
              should include a description of how the Contractor will assure and
              provide
              notice to Enrollees who are deaf or hard of hearing, blind or who have
              visual
              impairments, of their right to obtain necessary auxiliary aids and
              services
              during appointments and in scheduling appointments and follow-up treatment
              with
              Participating Providers

            •
In
              the
              event that certain provider sites are not physically accessible to
              Enrollees
              with mobility impairments, the Contractor will assure that reasonable
              alternative site and services are available

            3.
              A
              description of how the Contractor will determine the specific needs
              of an
              Enrollee with or at risk of having a disability/chronic disease, in
              terms of
              specialist physician referrals, durable medical equipment (including
              assistive
              technology and adaptive equipment), medical supplies and home health
              services
              and will assure that such contractual services are provided

            4.
              A
              description of how the Contractor will identify if an Enrollee with
              a disability
              requires on-going mental health services and how the Contractor will
              encourage
              early entry into treatment

            5.
              A
              description of how the Contractor will notify Enrollees with disabilities
              as to
              how to access transportation, where applicable

            

            IV.
              PROGRAM ACCESSIBILITY

            

            B4.
              COMPLAINTS, COMPLAINT APPEALS AND ACTION APPEALS STANDARD FOR
              COMPLIANCE

            The
              Contractor will establish and maintain a procedure to protect the rights
              and
              interests of both Enrollees and the Contractor by receiving, processing,
              and
              resolving Complaints, Complaint Appeals and Action Appeals in an expeditious
              manner, with the goal of ensuring resolution of Complaints, Complaint
              Appeals,
              and Action Appeals and access to appropriate services as rapidly as
              possible.

            All
              Enrollees must be informed about the Grievance System within their
              Contractor
              and the procedure for filing Complaints, Complaint Appeals and Action
              Appeals.
              This information will be made available through the Member Handbook,
              SDOH
              toll-free Complaint line (1-(800) 206-8125) and the Contractor's Complaint
              process annually, as well as when the Contractor denies a benefit or
              referral.
              The Contractor will inform Enrollees of the Contractor's Grievance
              System;
              Enrollees' right to contact the LDSS or SDOH with a Complaint, and
              to file a
              Complaint Appeal, 

            

            

            

            APPENDIX
              J

            October
              1,2005

            J-8

            

            Action
              Appeal or request a fair hearing; the right to appoint a designee to
              handle a
              Complaint, Complaint Appeal or Action Appeal; and the toll free Complaint
              line.
              The Contractor will maintain designated staff to take and process Complaints,
              Complaint Appeals and Action Appeals, and be responsible for assisting
              Enrollees
              in Complaint, Complaint Appeal or Action Appeal resolution.

            The
              Contractor will make all information regarding the Grievance System
              available to
              and usable by people with disabilities, and will assure that people
              with
              disabilities have access to sites where Enrollees typically file Complaints
              and
              requests for Complaint Appeals and Action Appeals.

            

            SUGGESTED
              METHODS FOR COMPLIANCE

            1.
              Toll-free Complaint phone line with TDD/TTY capability

            2.
              Staff
              trained in Complaint process, and able to provide interpretive or assistive
              support to Enrollee during the Complaint process

            3.
              Notification materials and Complaint forms in alternative formats for
              Enrollees
              with visual or hearing impairments

            4.
              Availability of physically accessible sites, e.g. member services department
              sites

            5.
              Assistance for individuals with cognitive impairments

            

            COMPLIANCE
              PLAN SUBMISSION

            1.
              A
              description of how the Contractor's Complaint, Complaint Appeals and
              Action
              appeal procedures shall be accessible for persons with disabilities,
              including:

            •
              procedures for Complaints, Complaint Appeals and Action Appeals to
              be made in
              person at sites accessible to persons with mobility impairments

            •
              procedures accessible to persons with sensory or other impairments
              who wish to
              make verbal Complaints, Complaint Appeals or Action Appeals, and to
              communicate
              with such persons on an ongoing basis as to the status or their Complaints
              and
              rights to further appeals

            •
              description of methods to ensure notification material is available
              in
              alternative formats for Enrollees with vision and hearing
              impairments

            2.
              A
              description of how the Contractor monitors Complaints, Complaint Appeals
              and
              Action Appeals related to people with disabilities. Also, as part of
              the
              Compliance Plan, the Contractor must submit a summary report based
              on the
              Contractor's most recent year's Complaints, Complaint Appeals and Action
              Appeals
              data.

            

            IV.
              PROGRAM ACCESSIBILITY

            

            C.
              CASE MANAGEMENT 

            

            STANDARD
              FOR COMPLIANCE

            

            The
              Contractor must have in place adequate case management systems to identify
              the
              service needs of all Enrollees, including Enrollees with chronic illness
              and
              Enrollees with disabilities, and ensure that medically necessary covered
              benefits are delivered on a timely basis. These systems must include
              procedures
              for standing referrals, specialists as PCPs, and referrals to specialty
              centers
              for Enrollees who require specialized medical 

            

            

            appendix
              J

            October
              1,2005

            J-9

            

            care
              over
              a prolonged period of time (as determined by a treatment plan approved
              by the
              Contractor in consultation with the primary care provider, the designated
              specialist and the Enrollee or his/her designee), out-of-network referrals
              and
              continuation of existing treatment relationships with out-of-network
              providers
              (during transitional period).

            

            SUGGESTED
              METHODS FOR COMPLIANCE

            1.
              Procedures for requesting specialist physicians to function as PCP

            2.
              Procedures for requesting standing referrals to specialists and/or
              specialty
              centers, out-of-network referrals, and continuation of existing treatment
              relationships

            3.
              Procedures to meet Enrollee needs for; durable medical equipment, medical
              supplies, home visits as appropriate

            4.
              Appropriately trained Contractor staff to function as case managers
              for special
              needs populations, or sub-contract arrangements for case management
              

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

            

            COMPLIANCE
              PLAN SUBMISSION

            

            1.
              A
              description of the Contractor case management program for people with
              disabilities, including case management functions, procedures for qualifying
              for
              and being assigned a case manager, and description of case management
              staff
              qualifications

            2.
              A
              description of the Contractor's model protocol to enable Participating
              Providers, at their point of service, to identify Enrollees who require
              a case
              manager

            3.
              A
              description of the Contractor's protocol for assignment of specialists
              as PCP,
              and for standing referrals to specialists and specialty centers, out-of-network
              referrals and continuing treatment relationships

            4.
              A
              description of the Contractor's notice procedures to Enrollees regarding
              the
              availability of case management services, specialists as PCPs, standing
              referrals to specialists and specialty centers, out-of-network referrals
              and
              continuing treatment relationships

            

            IV.
              PROGRAM ACCESSIBILITY

            

            D.
              PARTICIPATING PROVIDERS 

            

            STANDARD
              FOR COMPLIANCE

            The
              Contractor's network will include all the provider types necessary
              to furnish
              the Benefit Package, to assure appropriate and timely health care to
              all
              Enrollees, including those with chronic illness and/or disabilities.
              Physical
              accessibility is not limited to entry to a provider site, but also
              includes
              access to services within the site, e.g., exam tables and medical
              equipment.

            

            APPENDIX
              J

            October
              1,2005

            J-10

            

            SUGGESTED
              METHODS FOR COMPLIANCE

            

            1.
              Process for the Contractor to evaluate provider network to ascertain
              the degree
              of provider accessibility to persons with disabilities, to identify
              barriers to
              access and required modifications to policies/procedures

            2.
              Model
              protocol to assist Participating Providers, at their point of service,
              to
              identify Enrollees who require case manager, audio, visual, mobility
              aids, or
              other accommodations

            3.
              Model
              protocol for determining needs of Enrollees with mental
              disabilities

            4.
              Use of
              Wheelchair Accessibility Certification Form (see attached)

            5.
              Submission of map of physically accessible sites

            6.
              Training for providers re: compliance with Title III of ADA, e.g. site
              access
              requirements for door widths, wheelchair ramps, accessible diagnostic/treatment
              rooms and equipment; communication issues; attitudinal barriers related
              to
              disability, etc. (Resources and technical assistance are available
              through the
              NYS Office of Advocate for Persons with Disabilities -V/TTY (800) 522-4369;
              and
              the NYC Mayor's Office for People with Disabilities - (212) 788-2830
              or TTY
              (212) 788-2838).

            7.
              Use of
              NYS Office of Persons with Disabilities (OAPD) ADA Accessibility Checklist
              for
              Existing Facilities and NYC Addendum to OAPD ADA Accessibility Checklist
              as
              guides for evaluating existing facilities and for new construction
              and/or
              alteration.

            

            COMPLIANCE
              PLAN SUBMISSION

            

            1.
              A
              description of how the Contractor will ensure that its Participating
              Provider
              network is accessible to persons with disabilities. This includes the
              following:

            •
              Policies and procedures to prevent discrimination on the basis of disability
              or
              type of illness or condition

            •
              Identification of Participating Provider sites which are accessible
              by people
              with mobility impairments, including people using mobility devices.
              If certain
              provider sites are not physically accessible to persons with disabilities,
              the
              Contractor shall describe reasonable, alternative means that result
              in making
              the provider services readily accessible

            •
              Identification of Participating Provider sites which do not have access
              to sign
              language interpreters or reasonable alternative means to communicate
              with
              Enrollees who are deaf or hard of hearing; and for those sites, a description
              of
              reasonable alternative methods to ensure that services will be made
              accessible

            
              	 	
                      •
                        

                    	
                      Identification
                        of Participating Providers which do not have adequate communication
                        systems for Enrollees who are blind or have vision impairments
                        (e.g.
                        raised symbol and lettering or visual signal appliances),
                        and for those
                        sites, a description of reasonable alternative methods to
                        ensure that
                        services will be made accessible

                    

            

            2.
              A
              description of how the Contractor's specialty network is sufficient
              to meet the
              needs of Enrollees with disabilities

            

            APPENDIX
              J 

            October
              1,2005 

            J-ll

            

            3.
              A
              description of methods to ensure the coordination of out-of-network
              providers to
              meet the needs of the Enrollees with disabilities

            •
This
              may include the implementation of a referral system to ensure that
              the health
              care needs of Enrollees with disabilities are met appropriately

            •
The
              Contractor shall describe policies and procedures to allow for the
              continuation
              of existing relationships with out-of-network providers, when in the
              best
              interest of the Enrollee with a disability

            4.
              Submission of the ADA Compliance Summary Report or Contractor statement
              that
              data submitted to SDOH on the Health Provider Network (HPN) files is
              an accurate
              reflection of each network's physical accessibility.

            

            IV.
              PROGRAM ACCESSIBILITY

            E.
              POPULATIONS WITH SPECIAL HEALTH CARE NEEDS 

            STANDARD
              FOR COMPLIANCE

            The
              Contractor will have satisfactory methods for identifying persons at
              risk of, or
              having, chronic disabilities and determining their specific needs in
              terms of
              specialist physician referrals, durable medical equipment, medical
              supplies,
              home health services, etc. The Contractor will have satisfactory systems
              for
              coordinating service delivery and, if necessary, procedures to allow
              continuation of existing relationships with out-of-network provider
              for course
              of treatment.

            

            SUGGESTED
              METHODS FOR COMPLIANCE

            1.
              Procedures for requesting standing referrals to specialists .and/or
              specialty
              centers, specialist physicians to function as PCP, out-of-network referrals,
              and
              continuation "of existing relationships with out-of-network providers
              for course
              of treatment

            2.
              Linkages with behavioral health agencies, disability and advocacy organizations,
              etc.

            3.
              Adequate network of providers and sub-specialists (including pediatric
              providers
              and sub-specialists) and contractual relationships with tertiary
              institutions

            4.
              Procedures for assuring that these populations receive appropriate
              diagnostic
              work-ups on a timely basis

            5.
              Procedures for assuring that these populations receive appropriate
              access to
              durable medical equipment on a timely basis

            6.
              Procedures for assuring that these populations receive appropriate
              allied health
              professionals (Physical, Occupational and Speech Therapists, Audiologists)
              on a
              timely basis

            7.
              State
              designation as a Well Qualified Plan to serve the OMRDD population
              and
              look-alikes 

            

            APPENDIX
              J 

            October
              1,2005 

            J-l2

            

            COMPLIANCE
              PLAN SUBMISSION

            

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

             

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

             

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

             

            V.
              ADDITIONAL ADA RESPONSIBILITIES FOR PUBLIC ACCOMMODATIONS

             

            Please
              note that Title III of the ADA applies to all non-governmental providers
              of
              health care. Title III of the Americans with Disabilities Act prohibits
              discrimination on the basis of disability in the full and equal enjoyment
              of
              goods, services, facilities, privileges, advantages or accommodations
              of any
              place of public accommodation. A public accommodation is a private
              entity that
              owns, leases or leases to, or operates a place of public accommodation.
              Places
              of public accommodation identified by the ADA include, but are not
              limited to/
              stores (including pharmacies) offices (including doctors' offices),
              hospitals,
              health care providers, and social service centers.

             

            New
              and
              altered areas and facilities must be as accessible as possible. Barriers
              must be
              removed from existing facilities when it is readily achievable, defined
              by the
              ADA as easily accomplishable without much difficulty or expense. Factors
              to be
              considered when determining if barrier removal is readily achievable
              include the
              cost of the action, the financial resources of the site involved, and,
              if
              applicable, the overall financial resources of any parent corporation
              or entity.
              If barrier removal is not readily achievable, the ADA requires alternate
              methods
              of making goods and services available. New facilities must be accessible
              unless
              structurally impracticable.

             

            Title
              III
              also requires places of public accommodation to provide any auxiliary
              aids and
              services that are needed to ensure equal access to the services it
              offers,
              unless a fundamental alteration in the nature of services or an undue
              burden
              would result. Auxiliary aids include, but are not limited to, qualified
              sign
              interpreters, assistive listening systems, readers, large print materials,
              etc.
              Undue burden is defined as "significant difficulty or expense". The
              factors to
              be considered in determining "undue burden" include, but are not limited
              to, the
              nature and cost of the action required and the overall financial resources
              of
              the provider. "Undue burden" is a higher standard than "readily achievable"
              in
              that it requires a greater level of effort on the part of the public
              accommodation.

            

            

            

            

            APPENDIX
              J

            October
              1,2005 

            J-13

            

             

            Please
              note also that the ADA is not the only law applicable for people with
              disabilities. In some cases, State or local laws require more than
              the ADA. For
              example. New York City's Human Rights Law, which also prohibits discrimination
              against people with disabilities, includes people whose impairments
              are not as
              "substantial" as the narrower ADA and uses the higher "undue burden"
              ("reasonable") standard where the ADA requires only that which is "readily
              achievable". New York City's Building Code does not permit access waivers
              for
              newly constructed facilities and requires incorporation of access features
              as
              existing facilities are renovated. Finally, the State Hospital code
              sets a
              higher standard than the ADA for provision of communication (such as
              sign
              language interpreters) for services provided at most hospitals, even
              on an
              outpatient basis.

             

            

            APPENDIX
              J

            October
              1,2005 

            J-14

             

            
 

            
              
                
                

              

              
                
                

                
                  

                

              

              
                
                

              

            

            APPENDIX
              K

            

            Medicare
              and Medicaid Advantage Products And Non-Covered Services

            

            

            

            

            

            

            Medicaid
              Advantage Contract 

            APPENDIX
              K

            New
              York
              City 2006 

            K-l

          

        

      

      

         

        APPENDIX
          K.l

         

        MEDICARE
          ADVANTAGE PRODUCT

         

        

        
          	
                  Medicare
                    Advantage Benefit Package for Dual Eligibles-
                    Upstate Counties

                
	
                  Category
                    of Service

                	
                  Included
                    in Medicare Capitation

                
	
                  Inpatient
                    Hospital Care Including Substance Abuse and Rehabilitation
                    Services

                	
                  Up
                    to 365 days per year (366 days for leap year). $3 00 per stay
                    co-payment

                
	
                  Inpatient
                    Mental Health

                	
                  Medically
                    necessary care. $300 per stay co-payment. 190-day lifetime limit
                    in a
                    psychiatric hospital.

                
	
                  Skilled
                    Nursing Facility

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

                
	
                  Home
                    Health

                	
                  Medically
                    necessary intermittent skilled nursing care, home health aide
                    services and
                    rehabilitation services. $10 per visit co-payment.

                
	
                  PCP
                    Office Visits

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

                
	
                  Specialist
                    Office Visits

                	
                  Specialist
                    office visits. Subject to $20 co-payment for each specialist
                    office
                    visit.

                
	
                  Chiropractic

                	
                  Manual
                    manipulation of the spine to correct subluxation provided by
                    chiropractors
                    or other qualified providers. Subject to $20
                    co-payment.

                
	
                  Podiatry

                	
                  Medically
                    necessary foot care, including care for medical conditions affecting
                    lower
                    limbs, subject to $20 co-payment. Visits for routine foot care
                    up to 4
                    visits per year, not subject to co-payment.

                
	
                  Outpatient
                    Mental Health

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

                
	
                  Outpatient
                    Substance Abuse

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

                
	
                  Outpatient
                    Surgery

                	
                  Medically
                         necessary visits to an ambulatory surgery center or outpatient
                    hospital
                    facility. $35 per visit to ambulatory surgery or outpatient
                    hospital.

                
	
                  Ambulance

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

                

        

         

         

         

        Medicaid
          Advantage Contract 

        APPENDIX
          K

        New
          York
          City 2006 

        K-3

         

        

        
          	
                   

                  Medicare
                    Advantage Benefit Package for Dual Eligibles - Upstate
                    Counties

                
	
                  Category
                    of Service

                	
                  Included
                    in Medicare Capitation

                
	 	
                  which
                    require the provision of emergency services while the enrollee
                    is being
                    transported. Includes transportation to a hospital emergency
                    room
                    generated by a "Dial 911". $50 co-

                
	
                  Emergency
                    Room

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

                
	
                  Urgent
                    Care

                	
                  Urgently
                    needed care in most cases outside the plan's service area. Subject
                    to $20
                    co-payment.

                
	
                  Outpatient
                    Rehabilitation (OT, PT, Speech)

                	
                  Occupational
                    therapy, physical therapy and speech and language therapy subject
                    to $20
                    co-payment.

                
	
                  Durable
                    Medical Equipment (DME)

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

                
	
                  Prosthetics

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

                
	
                  Diabetes
                    Monitoring

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

                
	
                  Diagnostic
                    Testing

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

                
	
                  Bone
                    Mass Measurement

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

                
	
                  Colorectal
                    Screening

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

                
	
                  Immunizations

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

                
	
                  Mammograms

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

                
	
                  Pap
                    Smear and Pelvic Exams

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

                
	
                  Prostate
                    Cancer Screening

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

                

        

        

        

        Medicaid
          Advantage Contract 

        APPENDIX
          K 

        New
          York
          City 2006

        K-4

         

        
          	
                  Medicare
                    Advantage Benefit Package for Dual Eligibles -
                    Upstate Counties

                
	
                  Category
                    of Service

                	
                  Included
                    in Medicare Capitation

                
	
                  Outpatient
                    Drugs

                	
                  Medicare
                    Part B covered prescription drugs and other drugs obtained by
                    a provider
                    and administered in a physician office or clinic setting covered
                    by
                    Medicaid.

                
	
                  Hearing
                    Services

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

                
	
                  Vision
                    Care Services

                	
                  Services
                    of optometrists, ophthalmologists and ophthalmic dispensers including
                    eyeglasses, medically necessary contact lenses and poly-carbonate
                    lenses,
                    artificial eyes (stock or custom-made), low vision aids and low
                    vision
                    services. Coverage includes the replacement of lost or destroyed
                    glasses.
                    Coverage also includes the repair or replacement of parts. Coverage
                    also
                    includes examinations for diagnosis and treatment for visual
                    defects
                    and/or eye disease. Examinations for refraction are limited to
                    every two
                    (2) years unless otherwise justified as medically necessary.
                    Eyeglasses do
                    not require changing more frequently than every two (2) years
                    unless
                    medically necessary or unless the glasses are lost, damaged or
                    destroyed.
                    No prerequisite of cataract surgery. No co-payment

                
	
                  Routine
                    Physical Exam I/year

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

                
	
                  Health/Wellness
                    Education

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

                
	
                  Additional
                    Part C Benefits, if any

                	 
	
                  Medicare
                    Part D Prescription Drug Benefit as Approved by CMS

                	 

        

         

         

        Medicaid
          Advantage Contract 

        APPENDIX
          K 

        New
          York
          City 2006

        K-5

         

        

        
          	
                   

                  Medicare
                    Advantage Benefit Package for Dual Eligibles

                   

                  NYC,
                    Nassau, Suffolk, Westchester, Rockland, Orange and Putnam
                    Counties

                
	
                  Category
                    of Service

                	
                  Included
                    in Medicare Capitation

                
	
                  Inpatient
                    Hospital Care Including Substance Abuse and Rehabilitation
                    Services

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

                
	
                  Inpatient
                    Mental Health

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

                
	
                  Skilled
                    Nursing Facility

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

                
	
                  Home
                    Health

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

                
	
                  PCP
                    Office Visits

                	
                  Primary
                    care doctor office visits. No co-payment.

                
	
                  Specialist
                    Office Visits

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

                
	
                  Chiropractic

                	
                  Manal
                    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 9 II". No
                    co-payment.

                

        

        

        

        

        Medicaid
          Advantage Contract 

        APPENDIX
          K 

        New
          York
          City 2006

        K-6

         

        

        
          	
                   

                  Medicare
                    Advantage Benefit Package for Dual Eligibles

                   

                  NYC,
                    Nassau, Suffolk, Westchester, Rockland, Orange and Putnam
                    Counties

                
	
                  Category
                    of Service

                	
                  Included
                    in Medicare Capitation

                
	
                  Emergency
                    Room

                   

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

                
	
                  Urgent
                    Care

                   

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

                
	
                  Outpatient
                    Rehabilitation (OT, PT, Speech)

                   

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

                
	
                  Durable
                    Medical Equipment (DME)

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

                
	
                  Prosthetics

                   

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

                
	
                  Diabetes
                    Monitoring

                   

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

                
	
                  Diagnostic
                    Testing

                   

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

                
	
                  Bone
                    Mass Measurement

                   

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

                
	
                  Colorectal
                    Screening

                   

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

                
	
                  Immunizations

                   

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

                
	
                  Mammograms

                   

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

                
	
                  Pap
                    Smear and Pelvic Exams

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

                
	
                  Prostate
                    Cancer Screening

                   

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

                
	
                  Outpatient
                    Drugs

                   

                	
                  Medicare
                    Part B covered prescription drugs and other drugs obtained by
                    a provider
                    and administered in a physician office or clinic setting covered
                    by
                    Medicaid.

                
	
                  Hearing
                    Services

                   

                	
                  Medicare
                    and Medicaid hearing services and products
                    when

                

        

         

        Medicaid
          Advantage Contract APPENDIX K New York City 2006 K-7

         

        

        
          	
                   

                  Medicare
                    Advantage Benefit Package for Dual Eligibles

                   

                  NYC,
                    Nassau, Suffolk, Westchester, Rockland, Orange and Putnam
                    Counties

                
	
                  Category
                    of Service

                	
                  Included
                    in Medicare Capitation

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

                
	
                  Vision
                    Care Services

                	
                  Services
                    of optometrists, ophthalmologists and ophthalmic dispensers including
                    eyeglasses, medically necessary contact lenses and poly-carbonate
                    lenses,
                    artificial eyes (stock or custom-made), low vision aids and low
                    vision
                    services. Coverage includes the replacement of lost or destroyed
                    glasses.
                    Coverage also includes the repair or replacement of parts. Coverage
                    also
                    includes examinations for diagnosis and treatment for visual
                    defects
                    and/or eye disease. Examinations for refraction are limited to
                    every two
                    (2) years unless otherwise justified as medically necessary.
                    Eyeglasses do
                    not require changing more frequently than every two (2) years
                    unless
                    medically necessary or unless the glasses are lost, damaged or
                    destroyed.
                    No prerequisite of cataract services. No co-payment.

                
	
                  Routine
                    Physical Exam I/year

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

                
	
                  Health/Wellness
                    Education

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

                
	
                  Additional
                    Part C Benefits, if any

                	 
	
                   

                  Medicare
                    Part D Prescription Drug Benefit as Approved by CMS

                	 

        

        

        

        

        

        Medicaid
          Advantage Contract 

        APPENDIX
          K 

        New
          York
          City 2006 

        K-8

         

        

         

        APPENDIX
          K.2

         

        MEDICAID
          ADVANTAGE PRODUCT

         

        
          	
                   

                  Medicaid
                    Advantage Benefit Package for Dual Eligibles -
                    Upstate Counties

                
	
                  Category
                    of Service

                	
                  Included
                    in Medicaid Capitation

                
	
                  Inpatient
                    Hospital Care Including Substance Abuse and Rehabilitation
                    Services

                	
                  Elimination
                    of $300 per stay co-payment.

                
	
                  Inpatient
                    Mental Health

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

                
	
                  Home
                    Health

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

                
	
                  PCP
                    Office Visits

                	
                  Elimination
                    of $10 co-payment

                
	
                  Specialist
                    Office Visits

                	
                  Elimination
                    of $20 co-payment

                
	
                  Podiatry

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

                
	
                  Outpatient
                    Mental Health

                	
                  Elimination
                    of $20 co-payment

                
	
                  Outpatient
                    Substance Abuse

                	
                  Elimination
                    of $20 co-payment

                
	
                  Outpatient
                    Surgery

                	
                  Elimination
                    of $35 co-payment

                
	
                  Ambulance

                	
                  Elimination
                    of $50 co-payment

                
	
                  Emergency
                    Room

                	
                  Elimination
                    of $50 co-payment

                
	
                  Urgent
                    Care

                	
                  Elimination
                    of $20 co-payment

                
	
                  Outpatient
                    Rehabilitation (OT, PT, Speech)

                	
                  Elimination
                    of $20 co-payment

                
	
                  Dental
                    (Optional
                    benefit)

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

                
	
                  Routine
                    Physical Exam I/year

                	
                  Elimination
                    of $10 co-payment

                
	
                  Transportation
                    - Routine (Optional
                    benefit)

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

                
	
                  Private
                    Duty Nursing

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

                

        

         

        Medicaid
          Advantage Contract 

        APPENDIX
          K-

        New
          York
          City 2006 

        K-9

         

        

        
          	
                   

                  Medicaid
                    Advantage Benefit Package for Dual Eligibles

                   

                  NYC,
                    Nassau, Suffolk,.Westchester, Rockland, Orange and Putnam
                    Counties

                
	
                  Category
                    of Service

                	
                  Included
                    in Medicaid Capitation

                
	
                  Inpatient
                    Mental Health

                	
                  Days
                    in excess of the 190-day lifetime maximum.

                
	
                  Home
                    Health

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

                
	
                  Specialist
                    Office Visits

                	
                  Elimination
                    of $ 10 co-payment.

                
	
                  Podiatry

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

                
	
                  Outpatient
                    Mental Health

                	
                  Elimination
                    of $20 co-payment.

                
	
                  Outpatient
                    Substance Abuse

                	
                  Elimination
                    of $20 co-payment.

                
	
                  Emergency
                    Room

                	
                  Elimination
                    of $50 co-payment

                
	
                  Urgent
                    Care

                	
                  Elimination
                    of $ 10 co-payment.

                
	
                  Outpatient
                    Rehabilitation (OT, PT, Speech)

                	
                  Elimination
                    of $10 co-payment.

                
	
                  Dental
                    (Optional
                    benefit outside of NYC)

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

                
	
                  Transportation
                    - Routine (Optional
                    benefit outside of NYC)

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

                
	
                  Private
                    Duty Nursing

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

                

        

         

        Medicaid
          Advantage Contract 

        APPENDIX
          K 

        New
          York
          City 2006

        K-10

         

        

        DESCRIPTION
          OF MEDICAID ONLY SERVICES IN MEDICAID ADVANTAGE BENEFIT
          PACKAGE:

         

        Inpatient
          Mental Health Over 190-Day Lifetime Limit

         

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

         

        Non-Medicare
          Covered Home Health Services

         

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

         

        Private
          Duty Nursing Services

         

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

         

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

         

        Dental
          Services (optional benefit outside of NYC)

         

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

         

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

         

        Medicaid
          Advantage Contract 

        APPENDIX
          K 

        New
          York
          City 2006

        K-ll

         

        

        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 ofNYC)

         

        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 to Medicaid covered services that
          are
          not part of the Contractor's Benefit Package.

         

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

         

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

         

        Medicaid
          Advantage Contract 

        APPENDIX
          K 

        New
          York
          City 2006

        K-12

         

        

         

        APPENDIX
          K.3

         

        NON
          COVERED SERVICES

         

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

         

        Services
          Covered by Direct Reimbursement from Original Medicare

         

        •
Hospice
          services provided to Medicare Advantage members

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

         

        Services
          Covered by Medicaid Fee for Service

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

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

        •
          Personal Care Services

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

        •
          Methadone Maintenance Treatment Programs

        •
Certain
          Mental Health Services, including

        o
          Intensive Psychiatric Rehabilitation Treatment Programs

        o
          Day
          Treatment

        o
          Continuing Day Treatment

        o
          Case
          Management for Seriously and Persistently Mentally 111 (sponsored by state
          or
local
          mental health units) o Partial Hospitalizations o Assertive Community Treatment
          (ACT) o Personalized Receiving 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 Program Optional Benefits

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

         

        •
          Non-Emergency Transportation Services

         

        •
Dental
          Service

         

        These
          services are mandatory in NYC.

         

        Medicaid
          Advantage Contract 

        APPENDIX
          K 

        New
          York
          City 2006 

        K-13

         

        

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

         

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

         

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

         

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

         

        3.
          Personal Care Agency Services

         

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

         

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

         

        Medicaid
          Advantage Contract 

        APPENDIX
          K 

        New
          York
          City 2006 

        K-14

         

        

        4.
          Skilled Nursing Facility Days Not Covered by Medicare

         

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

         

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

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

         

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

         

        6.
          Out of Network Family Planning Services

         

        As
          described in Section 10.6 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 Care services means those
          health services which enable Enrollees, including minors, who may be sexually
          active to prevent or reduce the incidence of unwanted pregnancy. These
          include:
          diagnosis and all medically necessary treatment, sterilization, screening
          and
          treatment for sexually transmissible diseases and screening for disease
          and
          pregnancy.

         

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

         

        7.
          Dental (when not in benefit package)

         

        (see
          description in Appendix K-2)

        8.
          Non-Emergency Transportation (when not in benefit package) (see
          description in Appendix K-2)

         

        9.
          Methadone Maintenance Treatment Program (MMTP)

         

        Consists
          of drug detoxification, drug dependence counseling, and rehabilitation
          services
          which include chemical management of the patient with methadone. Facilities
          that
          provide methadone

         

        Medicaid
          Advantage Contract 

        APPENDIX
          K 

        New
          York
          City 2006 

        K-15

         

        

        maintenance
          treatment do so as their principal mission and are certified by the Office
          of
          Alcohol and Substance Abuse Services (OASAS) under Title 14 NYCRR, Part
          828.

         

        10.
          Certain Mental Health Services

         

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

         

        a.
          Intensive Psychiatric Rehabilitation Treatment Programs (IPRT)

         

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

         

        b.
          Day
          Treatment

         

        A
          combination of diagnostic, treatment, and rehabilitative procedures which,
          through supervised and planned activities and extensive client-staff
          interaction, provides the services of the clinic treatment program, as
          well as
          social training, task and skill training and socialization activities.
          Services
          are expected to be of six (6) months duration. These services are certified
          by
          OMH under 14 NYCRR, Part 587.

         

        c.
          Continuing Day Treatment

         

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

         

        This
          waiver is in select counties for children and adolescents who would otherwise
          be
          admitted to an institutional setting if waiver services were not provided.
          The
          services include individualized care coordination, respite, family support,
          intensive in-home skill building, and crisis response.

         

        d.
          Case
          Management for Seriously and Persistently Mentally 111 Sponsored by State
          or
          Local Mental Health Units

         

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

         

        Medicaid
          Advantage Contract 

        APPENDIX
          K 

        New
          York
          City 2006 

        K-16

         

        

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

         

        e.
          Partial Hospitalization Not Covered by Medicare

         

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

         

        f.
          Assertive Community Treatment (ACT)

         

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

         

        g.
          Personalized Recovery Oriented Services (PROS)

         

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

         

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

         

        a.
          OMH
          Licensed CRs*

         

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

         

        b.
          Family-Based Treatment*

         

        Rehabilitative
          services in family-based treatment programs are intended to provide treatment
          to
          seriously emotionally disturbed children and youth to promote their successful
          functioning and integration into the natural family, community, school
          or
          independent living situations. Such services are provided in consideration
          of a
          child's developmental stage. Those children determined eligible for admission
          are placed in surrogate family homes for care and treatment.

         

        Medicaid
          Advantage Contract 

        APPENDIX
          K 

        New
          York
          City 2006 

        K-17

         

        

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

         

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

         

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

         

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

         

        b.
          Day
          Treatment

         

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

         

        c.
          Medicaid Service Coordination (MSC)

         

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

         

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

         

        Medicaid
          Advantage Contract 

        APPENDIX
          K 

        New
          York
          City 2006 

        K--18

         

        

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

         

        d.
          Home
          And Community Based Services Waivers (HCBS)

         

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

         

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

         

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

         

        13.
          Comprehensive Medicaid Case Management (CMCM)

         

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

         

        14.
          Directly Observed Therapy for Tuberculosis Disease

         

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

         

        Medicaid
          Advantage Contract 

        APPENDIX
          K 

        New
          York
          City 2006

         K-19

         

        

        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 individualized health care
          plan,
          ongoing implementation and coordination of the health care plan, and
          transportation.

         

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

         

        18.
          Personal Emergency Response Services (PERS)

         

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

         

        Medicaid
          Advantage Contract 

        APPENDIX
          K 

        New
          York
          City 2006 

        K-20

         

         

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

         

        

          Wellcare
            of New York, Inc

           

          Dual
            Eligible Medicaid Managed Care Rates

           

          

          
            	
                    MMSI
                      ID#: 02645710

                  	 	
                    Effective
                      Date: 01/01/06

                  
	
                    Region:
                      NYC

                  	 	 
	
                    County:
                      NYC

                  	 	 
	
                    Rate
                      Code

                  	
                    Premium
                      Group

                  	
                    Rate
                      Amount

                  
	
                    2370

                  	
                    DUALLY
                      ELIGIBLE SSI 21-64 MALE/FEMALE

                  	
                    $44.45

                  
	
                    2371

                  	
                    DUALLY
                      ELIGIBLE SSI 65+ MALE/FEMALE

                  	
                    $46.04

                  
	
                     

                    Optional
                      Benefits Offered:

                  
	
                     

                    R Dental

                    R Non-Emergent
                      Transportation

                     

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

                  

          

           

        

        

          
 

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

          APPENDIX
            M 

           

           

          Service
            Area

          

          

          

          Medicaid
            Advantage Contract 

          APPENDIX
            M 

          New
            York
            City 2006 

          M-l

           

          

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

          WellCare
            of New York, Inc.

           

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

           

          New
            York

           

          Medicaid
            Advantage Contract 

          APPENDIX
            M 

          New
            York
            City 2006
            

          M-2

           

          

           

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

           

           

          Appendix
            N 

           

          New
            York City Specific Contracting Requirements

           

           

           

           

           

          APPENDIX
            M 

          New
            York
            City 2006 

          N-l

           

          

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

          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

           

          APPENDIX
            N 

          New
            York
            City 2006 

          N-2

           

          

           

          N.I
            

          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

           

          .
            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.

           

          APPENDIX
            N 

          New
            York
            City 2006 

          N-3

           

          

          N.2

           

          Coordination
            with DOHMH on Public Health Initiatives

           

          1.
            Coordination with DOHMH

           

          a)
            The
            Contractor shall provide the DOHMH with existing information 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 §§ 1103-1107 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.
            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 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 age appropriate anticipatory guidance iv) Domestic
            violence

           

          APPENDIX
            N 

          New
            York
            City 2006 

          N-4

           

          

          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)
            Injury prevention including guidance on preventing falls and
            poisoning

          xv)
            Preserving oral function and oral health

          xvi)
            Stroke recognition

           

          4.
            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.

           

          5.
            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.

           

          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.

           

          6.
            Medical Directors

           

          APPENDIX
            N 

          New
            York
            City 2006 

          N-5

           

          

          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 ofMCO 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.

           

          7.
            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.

           

          b)
            The
            Contractor shall select one condition annually from the TCNY initiative
            and
            perform the following:

           

          i)
            Identify Enrollees with the condition using information from multiple
            sources
            (e.g., utilization data, including hospitalizations and ER visits; provider
            referrals; new Enrollee screenings; self-referrals by Enrollees) and
            maintain
            such information in a patient registry; and

           

          APPENDIX
            N 

          New
            York
            City 2006 

          N-6

           

          

          ii)
            Develop and submit to DOHMH for approval a proposal to evaluate the
            effectiveness of Contractor interventions for this condition by tracking
            service
            utilization and assessing health outcomes.

           

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

          

           

          

          APPENDIX
            N

          New
            York
            City 2006 

          N-7

           

          

          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 as
            follows:

           

          i)
            For
            Enrollees discharged from a hospital or RHCF and for whom personal care
            a-gency
            services have been requested by the hospital/RHCF discharge planner,
            the thirty
            (30) day period shall commence with the day following the Enrollee's
            discharge
            from the hospital or RHCF. Transitional home health services shall not
            be
            available if the Enrollee: was hospitalized less than thirty (30) days,
            was in
            receipt of personal care agency services prior to his/her admission to
            the
            hospital or RHCF, and requires the same level and hours of personal care
            agency
            services upon discharge. ii) For Enrollees who have been receiving Medicare
            or
            Medicaid Advantage covered 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.

           

          c)
            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 Ml 1Q, requires physician orders, signed by the licensed
            physician, to be received by HRA within thirty (30) calendar days of
            the
            physician's examination.

           

          APPENDIX
            N 

          New
            York
            City 2006 

          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! 8.6(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 18.6(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.

           

           

          APPENDIX
            N 

          New
            York
            City 2006

          N-9

          

           

           

          

           

          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 MEedicaid community office.

           

          2.
            Contractor shall not market in h-omeless shelters.

           

           

          Appendix
            N

          New
            York
            City 2006 

          N-10

           

          

           

          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 ofnon-consenusal Enrollment; or the Enrollee is certified
            blind or
            disabled and meets an exemption criteria. If approved, the HRA will manually
            process the Disenrollment.

           

           

          APPENDIX
            N 

          New
            York
            City 2006 

          N-ll

           

          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 disenrollmerit.

           

          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.

           

          APPENDIX
            N 

          New
            York
            City 2006 

          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.

           

          

           

          APPENDIX
            N

          New
            York
            City 2006

          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
            form 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.

           

           

           

          APPENDIX N 

          New
            York
            City 2006 

          N-14

           

          

           

          Schedule
            1 of Appendix N 

           

          DOHMH
            Public Health Services Fee Schedule

           

           

          
            	
                    SERVICE

                  	
                    FEE

                  
	
                    TB
                      CLINIC

                  	
                    $125.00

                  
	
                    IMMUNIZATION

                  	
                    $
                      50.00

                  
	
                    HP/
                      COUNSELING AND TESTING

                  	
                    $
                      96.47

                  
	
                    VISIT
                      HIV COUNSELING AND NO TESTING

                  	
                    $90.12

                  
	
                    HIV
                      POST TEST COUNSELING

                  	
                    $
                      72.54

                  
	
                    Visit
                      Negative Result Visit Positive Result

                  	
                    $90.12

                  
	
                    LAB
                      TESTS

                  	
                    $
                      12.27

                  
	
                    HP/
                      1 (ELISA Test) HIV Antibody, Confirmatory (Western Blot)

                  	
                    $
                      26.75

                  
	
                    DENTAL
                      SERVICES

                  	
                    $
                      108.00

                  

          

          

          

           

          

          

          

          

          

          

          APPENDIX
            N

          New
            York
            City 2006 

          N-15

           

          

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

          APPENDIX
            O

          Reserved

          

          

          Medicaid
            Advantage Contract

          APPENDIX
            0

          New
            York
            City 2006

          0-1

           

          

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

           

          APPENDIX
            P

           

          Reserved

          

          

          APPENDIX
            P

          New
            York
            City 2006

          P-l

           

          

           

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

          

          APPENDIX
            Q

          

          

          Reserved

          

          

          

          Medicaid
            Advantage Contract

          APPENDIX
            Q

          New
            York
            City 2006

          Q-l

           

          

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

           

          APPENDIX
            R

           

          New
            York
            City Standard Clauses

           

           

          R.1
            General Provisions Governing Contracts for Consultants, Professional
            and
            Technical Services (Not-For-Profit Entities)

           

          R.2
            General Provisions Governing Contracts for Consultants, Professional
            and
            Technical Services (For-Profit Entities)

           

           

           

          Medicaid
            Advantage Contract 

          APPENDIX
            R 

          New
            York
            City 2006

           R-l

         

         

         

         

        APPENDIX
          R

         

         

        New
          York City Standard Local Clauses

         

         

         

        R.I
          General
          Provisions Governing Contracts for Consultants, Professional and Technical
          Services (Not-For-Profit Entities)

         

        R.2
          General
          Provisions Governing Contracts for Consultants, Professional and Technical
          Services (For-Profit Entities)

        

         

        

        

        APPENDIX
          R October 1, 2005

        R-l

        

         

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

         

         

        

          APPENDIX
            R 1

           

          GENERAL
            PROVISIONS GOVERNING CONTRACTS FOR CONSULTANTS, PROFESSIONAL AND TECHNICAL
            SERVICES (Not-For-Profit
            entities)

        

        

          
            	
                    CONTENTS

                  	
                    Page

                  	
                     

                  	
                     

                  	
                     

                  	
                    
                      Page

                    

                  
	
                    ARTICLE
                      1.

                  	
                    DEFINITIONS

                  	
                    2

                  	
                     

                  	
                    6.5

                  	
                    Waiver

                  	
                    12

                  
	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                    6.6

                  	
                    Notice

                  	
                    12

                  
	
                    ARTICLE
                      2.

                  	
                    REPRESENTATIONS
                      AND WARRANTIES

                  	
                    2

                  	
                     

                  	
                    6.7

                  	
                    All
                      Legal Provisions Deemed Included

                  	
                    12

                  
	
                    2.1

                  	
                    Procurement
                      of Agreement 

                  	
                    2

                  	
                     

                  	
                    6.8

                  	
                    Severability

                  	
                    12

                  
	
                    2.2

                  	
                    Conflict
                      of interest

                  	
                    2

                  	
                     

                  	
                    6.9

                  	
                    Political
                      Activity

                  	
                    12

                  
	
                    2.3

                  	
                    Fair
                      Practices

                  	
                    2

                  	
                     

                  	
                    6.10

                  	
                    Modification

                  	
                    12

                  
	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                    6.11

                  	
                    Paragraph
                      Headings

                  	
                    13

                  
	
                    ARTICLE
                      3.

                  	
                    AUDIT
                      BY DEPARTMENT 

                    AND
                      CITY

                  	
                     

                    3

                  	
                     

                  	
                    6.12

                  	
                    No
                      removal of records from premises

                  	
                    13

                  
	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                    6.13

                  	
                    Inspection
                      at site

                  	
                    13

                  
	
                    ARTICLE
                      4.

                  	
                    CONVENANTS
                      OF THE CONTRACTOR 

                  	
                     

                    3

                  	
                     

                  	
                    6.14

                  	
                    Pricing

                  	
                    13

                  
	
                    4.1

                  	
                    Employees

                  	
                    3

                  	
                     

                  	
                    ARTICLE
                      7.

                  	
                    MERGER

                  	
                    13

                  
	
                    4.2

                  	
                    Independent
                      Contractor Status

                  	
                    4

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  
	
                    4.3

                  	
                    Insurance

                  	
                    4

                  	
                     

                  	
                    ARTICLE
                      8. 

                  	
                    CONDITIONS
                      PRECEDENT

                  	
                    13

                  
	
                    4.4

                  	
                    Protection
                      of City Property.

                  	
                    6

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  
	
                    4.5

                  	
                    Confidentiality

                  	
                    6

                  	
                     

                  	
                    ARTICLE
                      9.

                  	
                    PPB
                      RULES

                  	
                    14

                  
	
                    4.6

                  	
                    Books
                      and Records

                  	
                    6

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  
	
                    4.7

                  	
                    Retention
                      of Records

                  	
                    6

                  	
                     

                  	
                    ARTICLE
                      10.

                  	
                    STATE
                      LABOR LAW AND CITY ADMINISTRTIVE 

                    CODE

                  	
                    14

                  
	
                    4.8

                  	
                    Compliance
                      with Law

                  	
                    6

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  
	
                    4.9

                  	
                    Investigation
                      Clause

                  	
                    6

                  	
                     

                  	
                    ARTICLE
                      11.

                  	
                    FORUM
                      PROVISION

                  	
                    15

                  
	
                    4.10

                  	
                    Assignment

                  	
                    8

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  
	
                    4.11

                  	
                    Subcontracting

                  	
                    8

                  	
                     

                  	
                    ARTICLE
                      12.

                  	
                    EQUAL
                      EMPLOYMENT OPPORTUNITY

                  	
                    15

                  
	
                    4.12

                  	
                    Publicity

                  	
                    9

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  
	
                    4.13

                  	
                    Participation
                      in an International Boycott

                  	
                    9

                  	
                     

                  	
                    ARTICLE
                      13.

                  	
                    NO
                      DAMAGE FOR DELAY

                  	
                    16

                  
	
                    4.14

                  	
                    Inventions,
                      Patents, and Copyrights

                  	
                    9

                  	
                     

                  	
                    ARTICLE
                      14.

                  	
                    CONSULTANT
                      REPORT INFORMATION

                  	
                    16

                  
	
                    4,15

                  	
                    Infringements

                  	
                    9

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  
	
                    4.16

                  	
                    Anti-Trust

                  	
                    10

                  	
                     

                  	
                    ARTICLE
                      15.

                  	
                    RESOLUTION
                      OF DISPUTES

                  	
                    17

                  
	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                    15.4

                  	
                    Presentation
                      of Dispute to Agency head

                  	
                    17

                  
	
                    ARTICLE
                      5.

                  	
                    TERMINATION

                  	
                    10

                  	
                     

                  	
                    15.5

                  	
                    Presentation
                      of dispute to the controller

                  	
                    18

                  
	
                    5.1

                  	
                    Termination
                      of Agreement

                  	
                    10

                  	
                     

                  	
                    15.6

                  	
                    Contract
                      Dispute Resolution Board

                  	
                    19

                  
	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                    15.7

                  	
                    Petition
                      to Contract Dispute Resolution Board

                  	
                    19

                  
	
                    ARTICLE
                      6.

                  	
                    MISCELLANEOUS

                  	
                    11

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  
	
                    6.1

                  	
                    Conflict
                      of Laws

                  	
                    11

                  	
                     

                  	
                    ARTICLE
                      16.

                  	
                    PROMPT
                      PAYMENT

                  	
                    20

                  
	
                    6.2

                  	
                    General
                      Release

                  	
                    11

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  
	
                    6.3

                  	
                    Claims
                      and Actions Thereon

                  	
                    11

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  
	
                    6.4

                  	
                    No
                      Claims Against Officers, Agents, or Employees

                  	
                     

                    11

                  	
                     

                  	 	 	 

          

        

         

         

         

         

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

        

        ARTICLE
          1. DEFINITIONS

        As
          used
          throughout this Agreement, the following terms shall have the meaning set
          forth
          below:

        a.
          "City"
          shall
          mean the City of New York, its departments and political
          subdivisions.

         

        b.
          "Comptroller"
          shall
          mean the Comptroller of the City of New York.

         

        c.
          "Department"
          or
          "Agency"
          shall
          mean the DEPARTMENT OF HEALTH. AND MENTAL HYGIENE

         

        d.
          "Commissioner"
          or
          "Administrator"
          shall
          mean the COMMISSIONER OF HEALTH AND MENTAL

         

        HYGIENE
          or his
          duly authorized representative. The term "duly authorized representative"
          shall
          include any

         

        person
          or
          persons acting within the limits of his or her authority.

         

        e.
          "Law"
          or
          "Laws" shall include but not be limited to the New York City Charter, the
          New
          York City AdministrativeCode, a local law of the City of New York, and
          any
          ordinance, rule or regulation having the Force of law.
          

        f.
          "Contractor"or"ConsuItant" shall
          mean
          VENDOR

         

        ARTICLE
          2. REPRESENTATIONS AND WARRANTIES

        2.1
          PROCUREMENT
          OF AGREEMENT

        A.
          The
          Contractor represents and warrants that no person or selling agency has
          been
          employed or retained to solicit or secure this Agreement upon an agreement
          or
          understanding for a commission, percentage, brokerage fee, contingent fee
          or any
          other compensation. The Contractor further represents and warrants that
          no
          payment, gift or thing of value has been made, given or promised to obtain
          this
          or any other agreement between the parties. The Contractor makes such
          representations and warranties to induce the City to enter into this Agreement
          and the City relies upon such representations and warranties in the execution
          hereof.

        B.
          For a
          breach or violation of such representations or warranties, the Administrator
          shall have the right to annul this Agreement without liability, entitling
          the
          City to recover all monies paid hereunder and the Contractor shall not
          make
          claim for, or be entitled to recover, any sum or sums due under this Agreement.
          This remedy, if effected, shall not constitute the sole remedy afforded
          the City
          for the falsity or breach, nor shall it constitute a waiver of the City's
          right
          to claim damages or refuse payment or to take any other action provided
          for by
          law or pursuant to this Agreement.

         

        2.2
          CONFLICT
          OF INTEREST

        The
          Contractor represents and warrants that neither it nor any of its directors,
          officers, members, partners or employees, has any interest nor shall they
          acquire any interest, directly or indirectly, which would or may conflict
          in any
          manner or degree with the performance or rendering of the services herein
          provided. The Contractor further represents and warrants that in the performance
          of this Agreement no person having such interest or possible interest shall
          be
          employed by it. No elected official or other officer or employee of the
          City or
          Department, nor any person whose salary is payable, in whole or in part,
          from
          the City Treasury, shall participate in any decision relating to this Agreement
          which affects his or her personal interest or the interest of any corporation,
          partnership or association in which he or she is, directly or indirectly,
          interested; nor shall any such person have any interest, direct or indirect,
          in
          this Agreement or in the proceeds thereof.

         

        2.3
          FAIR
          PRACTICES

        The
          Contractor and each person signing on behalf of any contractor represents
          and
          warrants and certifies, under penalty of perjury, that to the best of its
          knowledge and belief:

          
A.
          The
          prices in this contract have been arrived at independently without collusion,
          consultation, communication, or

        agreement,
          for the purpose of restricting competition, as to any matter relating to
          such
          prices with any other bidder or with any competitor;

        B.
          Unless
          otherwise required by law, the prices which have been quoted in this contract
          and on the proposal submitted by the Contractor have not been knowingly
          disclosed by the Contractor prior to the proposal opening, directly or
          indirectly, to any other bidder or to any competitor; and

        C.
          No
          attempt has been made or will be made by the Contractor to induce any other
          person, partnership or corporation to submit or not to submit a proposal
          for the
          purpose of restricting competition. The fact that the Contractor (a) has
          published price lists, rates, ortariffs covering items being procured,
          (b) has
          informed prospective customers of proposed

        

        NFP.W/P.L.

        -2-

        

        

        or
          pending publication of new or revised price lists for such items, or © has sold
          the same items to other customers at the same prices being bid, does not
          constitute, without more, a disclosure within the meaning of the
          above.

         

        ARTICLE
          3. AUDIT BY THE DEPARTMENT AND CITY

        3.1
          All
          vouchers or invoices presented for payment to be made hereunder, and the
          books,
          records and accounts upon which said vouchers or invoices are based are
          subject
          to audit by the Department and by the Comptroller of the City of New York
          pursuant to the powers and responsibilities as conferred upon said Department
          and said Comptroller by the New York City Charter and Administrative Code
          of the
          City of New York, as well as all orders and regulations promulgated pursuant
          thereto.

         

        3.2
          The
          Contractor shall submit any and all documentation and justification in
          support
          of expenditures or fees under this Agreement as may be required by said
          Department and said Comptroller so that they may evaluate the reasonableness
          ofthe charges and shall make its records available to the Department and
          to the
          Comptroller as they consider necessary.

         

        3.3
          All
          books, vouchers, records, reports, canceled checks and any and all similar
          material may be subject to periodic inspection, review and audit by the
          State of
          New York, Federal Government and other persons duly authorized by the City.
          Such
          audit may include examination and review ofthe source and application of
          all
          funds whether from the City, any State, the Federal Government, private
          sources
          or otherwise.

         

        3.4
          The
          contractor shall not be entitled to final payment under the Agreement until
          all
          requirements have been satisfactorily met.

         

        ARTICLE
          4. COVENANTS OF THE CONTRACTOR

        4.1
          EMPLOYEES

        A.
          All
          experts or consultants or employees ofthe Contractor who are employed by
          the
          Contractor to perform work under this contract are neither employees ofthe
          City
          nor under contract to the City and the Contractor alone is responsible
          for their
          work, direction, compensation and personal conduct while engaged under
          this
          Agreement. Nothing in this contract shall impose any liability or duty
          on the
          City for the acts, omissions, liabilities or obligations ofthe Contractor
          any
          person, firm company, agency, association, expert, consultant, independent
          contractor, specialist, trainee, employee, servant, or agent, or for taxes
          of
          any nature including but not limited to unemployment insurance, workmen's
          compensation, disability benefits and social security, or, except as
          specifically stated in this contract, to any person, firm or
          corporation.

        

        B.
          The
          Contractor shall be solely responsible for all physical injuries or death
          to its
          agents, servants, or employees or to any other person or damage to any
          property
          sustained during its operations and work on the project under this agreement
          resulting from any act of omission or commission or error in judgment of
          any of
          its officers, trustees, employees, agents, servants, or independent contractors,
          and shall hold harmless and indemnify the City from liability upon any
          and all
          claims for damages on account of such injuries or death to any such person
          or
          damages to property on account of any neglect, fault or default ofthe
          Contractor, its officers, trustees, employees, agents, servants, or independent
          contractors. The Contractor shall be solely responsible for the safety
          and
          protection of all of its employees whether due to the negligence, fault
          or
          default ofthe Contractor or not.

         

        C.
          Workmen's
          Compensation and Disability Benefits

        If
          this
          Agreement be of such a character that the employees engaged thereon are
          required
          to be insured by the provision of Chapter 615 ofthe Laws of 1922, known
          as the
          "Workmen's Compensation Law" and acts amendatory thereto, the Agreement
          shall be
          void and of no effect unless the Contractor shall secure compensation for
          the
          benefit of, and keep insured during the life of this Agreement such employees
          in
          compliance with the provisions of said law, inclusive of Disability Benefits,;
          and, shall furnish the Department with two (2) certificates of these insurance
          coverages.

         

        D.
          Unemployment
          Insurance

        Unemployment
          Insurance coverage shall be obtained and provided by the Contractor for
          its
          employees.

        

        NFP.W/P.L.
          

        -3-

         

        

        

        E.
          Minimum
          Wage 

        Except
          for those employees whose minimum wage is required to be fixed pursuant
          to
          Section 220 of the Labor Law of the State of New York, all persons employed
          by
          the Contractor in the performance of this Agreement shall be paid, without
          subsequent deduction or rebate, unless expressly authorized by law, not
          less
          than the minimum wage as prescribed by law. Any breach or violation of
          the
          foregoing shall be deemed a breach or violation of a material provision
          of this
          Agreement.

         

        4.2
          INDEPENDENT
          CONTRACTOR STATUS

        The
          Contractor and the Department agree that the Contractor is an independent
          contractor, and not an employee of the Department or the City of New York,
          and
          that in accordance with such status as independent contractor, the Contractor
          covenants and agrees that neither it nor its employees or agents will hold
          themselves out as, nor claim to be, officers or employees of the City ofNew
          York, or of any department, agency or unit thereof, by reason hereof, and
          that
          they will not, by reason hereof, make any claim, demand or application
          to or for
          any right or privilege applicable to an officer or employee of the City
          ofNew
          York, including, but not limited to, Workmen's Compensation coverage.
          Unemployment Insurance Benefits, Social Security coverage or employee retirement
          membership or credit.

         

        4.3
          INSURANCE

        A.
          INSURANCE
          REQUIREMENTS FOR CONTRACTORS

        Contractors
          shall procure and maintain for the duration of the contract insurance against
          claims for injuries to persons or damages to property which may arise from
          or in
          connection with the performance of the work hereunder by the Contractor,
          his
          agents, representatives, employees or subcontractors. All required insurance
          policies shall be maintained with companies that may lawfully issue the
          required
          policy and have an A.M. Best rating of at least A-7 or a Standard and Poor's
          rating of at least AA, unless prior written approval is obtained from the
          Mayor's Office of Operations. The cost of such insurance shall be included
          in
          the Contractor's bid.

         

        a.
          Minimum
          Scope of Insurance

        Coverage
          shall be at least as broad as:

        1.
          Insurance Services Office form number GL 0002 (1/73) covering Comprehensive
          General Liability and Insurance Services Office form number GL 0404 covering
          Broad Form Comprehensive General Liability; or Insurance Services Office
          Commercial General Liability coverage ("occurrence" form CG 0001).(ED
          11/85).

        2.Insurance
          Services Office form number CA 0001 (Ed. 1/78) covering Automobile Liability,
          code 1 "any auto" and endorsements CA 2232 and CA 0112.

        3.
          Workers' Compensation insurance as required by Labor Code of the State
          ofNew
          York and Employers Liability insurance.

         

        b.
          Minimum
          Limits of Insurance

        Contractor
          shall maintain limits no less than:

        1.
          Comprehensive General Liability: $1,000,000.00 combined single limit per
          accident for bodily injury and property damage.

        2-Professional
          liability: 1 Million Dollars per occurrence; Three Million Dollars
          Aggregate.

        3.
          Workers' Compensation and Employers Liability: Workers' Compensation limits
          as
          required by the Labor Code of the State of New York Employers Liability
          limits
          of $1,000,000.00 per accident. Pursuant to Section 57 of the NYS Workers'
          Compensation Law, the vendor has submitted proof of workers' compensation
          and
          disability benefits coverage to the agency.

        

         

        

        NFP.W/P.L.
          

        -4-

         

        

        

        c.
          Deductibles
          and Self-Insured Retentions

        Any
          deductibles and self-insured retentions must be declared to and approved
          by the
          Agency. At the option of the Agency, either: the insurer shall reduce or
          eliminate such deductibles or self-insured retentions as respects and Agency,
          its officers, officials and employees; or the Contractor shall procure
          a bond
          guaranteeing payment of losses and related investigations, claim administration
          and defense expenses.

         

        1.
          General Liability and Automobile Liability Coverages

         

        a.
          The
          City, its officers, officials and employees are to be covered as insured
          as
          respects: liability arising out of activities performed by or on behalf
          of the
          Contractor; products and completed operations of the Contractor; premises
          owned,
          leases or used by the Contractor; or automobiles owned, leased, hired or
          borrowed by the Contractor. The coverage shall contain no special limitations
          on
          the scope of protection afforded to the City, its officers, officials and
          employees.

        b.
          The
          Contractor's insurance coverage shall be primary insurance as respect the
          City,
          its officers, officials, and employees. Any other insurance or self-insurance
          maintained by the Agency, its officers, officials and employees shall be
          excess
          of and not contribute with the Contractor's insurance.

        c.
          Any
          failure to comply with reporting provisions of the policies shall not affect
          coverage provided to the Agency, its officers, officials, and
          employees.

        d.
          The
          Contractor's insurance shall apply separately to each insured against whom
          claim
          is made or suit is brought, except with respect to the limits of the insurers
          liability.

         

        2.
          Workers' Compensation and Employers Liability Coverage

        The
          insurer shall agree to waive all rights of subrogation against the Agency,
          its
          officers, officials, and employees for losses arising from work performed
          by the
          Contractor for Agency. -

         

        3.
          All
          Coverages

         

        Each
          insurance policy required by this clause shall be endorsed to state that
          coverage shall not be suspended, voided, cancelled by either party, reduced
          in
          coverage or in limits except after sixty (60) days prior written notice
          by
          certified mail, return receipt requested, has been given to the
          City.

         

        d.
          Acceptability
          of Insurers

        Insurance
          is to be placed with insurers with an A.M. Best rating of at least A-7
          or a
          Standard and Poor's rating of at least AA, unless prior written approval
          is
          obtained from the Mayor's Office of Operations.

         

        e.
          Verification
          of Coverage

        Contractor
          shall furnish the City with Certificates of Insurance effecting coverage
          required by this clause.' The Certificates for each insurance policy are
          to be
          signed by a person authorized by that insurer to bind coverage on its behalf.
          The Certificates are to be on forms provided by the Agency and are to be
          received and approved by the Agency before work commences. The Agency reserves
          the right to obtain complete, certified copies of all required insurance
          policies, at any time.

         

        f.
          Subcontractors

        Contractor
          shall include all subcontractors as insured under its policies or shall
          furnish
          separate Certificates for each subcontractor. All coverages for subcontractors
          shall be subject to all of the requirements stated herein.

         

        B.
          In the
          event that any claim is made or any action is brought against the City
          arising
          out of negligent or careless acts of an employee of the Contractor, either
          within or without the scope of his employment, or arising out of Contractor's
          negligent performance of this Agreement, then the City shall have the right
          to
          withhold further payments hereunder for the purpose of set-off in sufficient
          sums to cover the said claim or action. The rights and remedies of the
          City
          provided for in this clause shall not be exclusive and are in addition
          to any
          other rights and remedies provided by law or this Agreement, 

        

         

        NFP.W/P.L.

        -5-

        

        

         

        4.4
          PROTECTION
          OF CITY PROPERTY

         

        A.
          The
          Contractor assumes the risk of, and shall be responsible for, any loss
          or damage
          to City property, including property and equipment leased by the City,
          used in
          the performance of this Agreement; and caused, either directly or indirectly
          by
          the acts, conduct, omissions or lack of good faith of the Contractor, its
          officers, managerial personnel and employees, or any person, firm, company,
          agent or others engaged by the Contractor as expert, consultant, specialist
          or
          subcontractor hereunder.

         

        B.
          In the
          event that any such City property is lost or damaged, except for normal
          wear and
          tear, then the City shall have the right to withhold further payments hereunder
          for the purpose of set-off, in sufficient sums to cover such loss or
          damage.

         

        C.
          The
          Contractor agrees to indemnify the City and hold it harmless from any and
          all
          liability or claim for damages due to any such loss or damage to any such
          City
          property described in subsection A above.

        

        D.
          The
          rights and remedies of the City provided herein shall not be exclusive
          and are
          in addition to any other rights and remedies provided by law or by this
          Agreement.

         

        4.5
          CONFIDENTIALITY

        All
          of
          the reports, information or data, furnished to or prepared, assembled or
          used by
          the Contractor under this Agreement are to be held confidential, and prior
          to
          publication, the Contractor agrees that the same shall not be made available
          to
          any individual or organization without the prior written approval of the
          Department.

         

        4.6
          BOOKS
          AND RECORDS

        The
          Contractor agrees to maintain separate and accurate books, records, documents
          and other evidence and accounting procedures and practices which sufficiently
          and properly reflect all direct and indirect costs of any nature expended
          in the
          performance of this Agreement.

         

        4.7
          RETENTION
          OF RECORDS

        The
          Contractor agrees to retain all books, records, and other documents relevant
          to
          this Agreement for six years after the final payment or termination of
          this
          Agreement, whichever is later. City, State and Federal auditors and any
          other
          persons duly authorized by the Department shall have full access to and
          the
          right to examine any of said materials during said period.

         

        4.8
          COMPLIANCE
          WITH LAW

        Contractor
          shall render all services under this Agreement in accordance with the applicable
          provisions of federal, state and local laws, rules and regulations as are
          in
          effect at the time such services are rendered.

         

        4.9
          INVESTIGATION
          CLAUSE

        1.
          The
          parties to this agreement agree to cooperate fully and faithfully with
          any
          investigation, audit or inquiry conducted by a State of New York (State)
          or City
          of New York (City) governmental agency or authority that is empowered directly
          or by designation to compel the attendance of witnesses and to examine
          witnesses
          under oath, or conducted by the Inspector General of a governmental agency
          that
          is a party in interest to the transaction, submitted bid, submitted proposal,
          contract, lease, permit, or license that is the subject of the investigation,
          audit or inquiry.

        2(a)
          If
          any person who has been advised that his or her statement, and any information
          from such statement, will not be used against him or her in any subsequent
          criminal proceeding refuses to testify before a grand jury or other governmental
          agency or authority empowered directly or by designation to compel the
          attendance of witnesses and to examine witnesses under oath concerning
          the award
          of or performance under any transaction,

        

        

        NFP.W/P.L.
          

        -6-

         

        

        

        agreement,
          lease, permit, contract, or license entered into with the City, the State,
          or
          any political subdivision or public authority thereof, or the Port Authority
          of
          New York and New Jersey, or any local development corporation within the
          City,
          or any public benefit corporation organized under the laws of the State
          of New
          York, or;

         

        (b)
          If
          any person refuses to testify for a reason other than the assertion of
          his or
          her privilege against self-incrimination in an investigation, audit or
          inquiry
          conducted by a City or State governmental agency or authority empowered
          directly
          or by designation to compel the attendance of witnesses and to take testimony
          under oath, or by the Inspector General of the governmental agency that
          is a
          party in interest in, and is seeking testimony concerning the award of,
          or
          performance under, any transaction, agreement, lease, permit, contract
          . or
          license entered into with the City, the State, or any political subdivision
          thereof or any local development corporation within the City, then;

        

        3(a)
          The
          commissioner or agency head whose agency is a party in interest to the
          transaction, submitted bid, submitted proposal, contract, lease, permit,
          or
          license shall convene a hearing, upon not less than five (5) days written
          notice
          to the parties involved, to determine if any penalties should attach for
          the
          failure of a person to testify.

        

        3(b)
          If
          any non-governmental party to the hearing requests an adjournment, the
          commissioner or agency head who convened the hearing may, upon granting
          the
          adjournment, suspend any contract, lease, permit, or license pending the
          final
          determination pursuant to paragraph 5 below without the City incurring
          any
          penalty or damages for delay or otherwise.

        

        4.
          The
          penalties which may attach after a final determination by the commissioner
          or
          agency head may include but shall not exceed:

        

        (a)
          The
          disqualification for a period not to exceed five (5) years from the date
          of an
          adverse determination for any person, or any entity of which such person
          was a
          member at the time the testimony was sought, from submitting bids for,
          or
          transacting business with, or entering into or obtaining any contract,
          lease,
          permit or license with or from the City; and/or

        

        (b)
          The
          cancellation or termination of any and all such existing City contracts,
          leases,
          permits or licenses that the refusal to testify concerns and that have
          not been
          assigned as permitted under this agreement, nor the proceeds of which pledged,
          to an unaffiliated and unrelated institutional lender for fair value prior
          to
          the issuance of the . notice scheduling the hearing, without the City incurring
          any penalty or damages on account of such cancellation or termination;
          monies
          lawfully due for goods delivered, work done, rentals, or fees accrued prior
          to
          the cancellation or termination shall be paid by the City.

        

        5.
          The
          commissioner or agency head shall consider and address in reaching his
          or her
          determination and in assessing an appropriate penalty the factors in paragraphs
          (a) and (b) below. He or she may also consider, if relevant and appropriate,
          the
          criteria established in paragraphs (c) and (d) below in addition to any
          other
          information which may be relevant and appropriate:

        

        (a)
          The
          party's good faith endeavors or lack thereof to cooperate fully and faithfully
          with any governmental investigation or audit, including but not limited
          to the
          discipline, discharge, or disassociation of any person failing to testify,
          the
          production of accurate and complete books and records, and the forthcoming
          testimony of all other members, agents, assignees or fiduciaries whose
          testimony
          is sought.

         

        (b)
          The
          relationship of the person who refused to testify to any entity that is
          a party
          to the hearing, including, but not limited to, whether the person whose
          testimony is sought has an ownership interest in the entity and/or the
          degree of
          authority and responsibility the person has within the entity.

         

        NFP.W/P.L.
          

        -7-

         

        

        

        (c)
          The
          nexus of the testimony sought to the subject entity and its contracts,
          leases,
          permits or licenses with the City.

        

        (d)
          The
          effect a penalty may have on an unaffiliated and unrelated party or entity
          that
          has a significant interest in an entity subject to penalties under 4 above,
          provided that the party or entity has given actual notice to the commissioner
          or
          agency head upon the acquisition of the interest, or at the hearing called
          for
          in 3(a) above gives notice and proves that such interest was previously
          acquired. Under either circumstance the party or entity must present evidence
          at
          the hearing demonstrating the potential adverse impact a penalty will have
          on
          such person or entity.

        

        6.
          The
          term "license" or "permit" as used herein shall be defined as a license,
          permit,
          franchise or concession not granted as a matter of right.

         

        (a)
          The
          term "person" as used herein shall be defined as any natural person doing
          business alone or associated with another person or entity as a partner,
          director, officer, principal or employee.

        

        b)
          The
          term "entity" as used herein shall be defined as any firm, partnership,
          corporation, association, or person that receives monies, benefits, licenses,
          leases, or permits from or through the City or otherwise transacts business
          with
          the City.

        

        (c)
          The
          term "member" as used herein shall be defined as any person associated
          with
          another person or entity as a partner, director, officer, principal or
          employee.

        

        7.
          . In
          addition to and notwithstanding any other provision of this agreement the
          Commissioner or agency head may in his or her sole discretion terminate
          this
          agreement upon not less than three (3) days written notice in the event
          contractor fails to promptly report in writing to the Commissioner of
          Investigation of the City of New York any solicitation of money, goods,
          requests
          for future employment or other benefit or thing of value, by or on behalf
          of any
          employee of the City or other person, firm, corporation or entity for any
          purpose which may be related to the procurement or obtaining of this agreement
          by the contractor, or affecting the performance of this contract.

         

        4.10 ASSIGNMENT

        A.
          The
          Contractor shall not assign, transfer, convey or otherwise dispose of this
          Agreement or of Contractor's rights, obligations, duties, in whole or in
          part,
          or of its right to execute it, or its right, title or interest in it or
          any part
          thereof, or assign, by power of attorney or otherwise, any of the notices
          due or
          to become due under this contract, unless the prior written consent of
          the
          Administrator shall be obtained. Any such assignment, transfer, conveyance
          or
          other disposition without such consent shall be void.

        

        B.
          Failure of the Contractor to obtain any required consent to any assignment,
          shall be cause for termination for cause, at the option of the Administrator;
          and if so terminated, the City shall thereupon be relieved and discharged
          from
          any further liability and obligation to the Contractor, its assignees or
          transferees, and all monies that may become due under the contract shall
          be
          forfeited to the City except so much thereof as may be necessary to pay
          the
          Contractor's employees.

        

        C.
          The
          provisions of this clause shall not hinder, prevent, or affect an assignment
          by
          the Contractor for the benefit of its creditors made pursuant to the laws
          of the
          State of New York.

        

        D.
          This
          Agreement may be assigned by the City to any corporation, agency or
          instrumentality having authority to accept such assignment.

         

        4.11
          SUBCONTRACTING

        A.
          The
          Contractor agrees not to enter into any subcontracts for the performance
          of its
          obligations, in whole or in part, under this Agreement without the prior
          written
          approval of the Department. Two copies of each such proposed
          subcontract

         

        NFP.W/P.L.

         -8-

         

        

        

        shall
          be
          submitted to the Department with the Contractor's written request for approval.
          All such subcontracts shall contain provisions specifying:

        1.
          that
          the work performed by the subcontractor must be in accordance with the
          terms of
          the Agreement between the Department and the Contractor,

        2.
          that
          nothing contained in such agreement shall impair the rights of the
          Department,

        3.
          that
          nothing contained herein, or under the Agreement between the Department
          and the
          Contractor, shall create any contractual relation between the subcontractor
          and
          the Department, and

        4.
          that
          the subcontractor specifically agrees to be bound by the confidentiality
          provision set forthin
          this
          Agreement between the Department and the Contractor.

        B.
          The
          Contractor agrees that it is fully responsible to the Department for the
          acts
          and omissions of the subcontractors and of persons either directly or indirectly
          employed by them as it is for the acts and omissions of persons directly
          employed by it.

        

        C.
          The
          aforesaid approval is required in all cases other than individual
          employer-employee contracts. 

        

        D.
          The
          Contractor shall not in any way be relieved of any responsibility under
          this
          Contract by any subcontract.

         

        4.12
          PUBLICITY

        A.
          The
          prior written approval of the Department is required before the Contractor
          or
          any of its employees, servants, agents, or independent contractors may,
          at any
          time, either during or after completion or termination of this Agreement,
          make
          any statement to the press or issue any material for publication through
          any
          media of communication bearing on the work performed or data collected
          under
          this Agreement.

        

        B.
          If the
          Contractor publishes a work dealing with any aspect of performance under
          this
          Agreement, or of the results and accomplishments attained in such performance,
          the Department shall have a royalty free, non-exclusive and irrevocable
          license
          to reproduce, publish or otherwise use and to authorize others to use the
          publication.

         

        4.13
          PARTICIPATION
          IN AN INTERNATIONAL BOYCOTT

        A.
          The
          Contractor agrees that neither the Contractor nor any substantially-owned
          affiliated company is participating or shall participate in an international
          boycott in violation of the provisions of the Export Administration Act
          of 1979,
          as amended, or the regulations of the United States Department of Commerce
          promulgated thereunder.

        

        B.
          Upon
          the final determination by the Commerce Department or any other agency
          of the
          United States as to, or conviction of the Contractor or a substantially-owned
          affiliated company thereof, participation in an international boycott in
          violation of the provisions of the Export Administration Act of 1979, as
          amended, or the regulations promulgated thereunder, the Comptroller may,
          at his
          option, render forfeit and void this contract.

         

        C.
          The
          Contractor shall comply in all respects, with the provisions of Section
          6-114 of
          the Administrative Code of the City of New York and the rules and regulations
          issued by the Comptroller thereunder.

         

        4.14
          INVENTIONS.
          PATENTS AND COPYRIGHTS

        A.
          Any
          discovery or invention arising out of or developed in the course of performance
          of this Agreement shall be promptly and fully reported to the Department,
          and if
          this work is supported by a federal grant of funds, shall be promptly and
          fully
          reported to the Federal Government for determination as to whether patent
          protection on such invention shall be sought and how the rights in the
          invention
          or discovery, including rights under any patent issued thereon, shall be
          disposed of and administered in order to protect the public
          interest.

        

        B.
          No
          report, document or other data produced in whole or in part with contract
          funds
          shall be copyrighted by the Contractor nor shall any notice of copyright
          be
          registered by the Contractor in connection with any report, document or
          other
          data developed for the contract.

        

        NFP.W/P.L.
          

        -9-

         

        

        

        C.
          In no
          case shall subsections A and B of this section apply to, or prevent the
          Contractor from asserting or protecting its rights in any report, document
          or
          other data, or any invention which existed prior to or was developed or
          discovered independently from the activities directly related to this
          Agreement.

         

        4.15
          INFRINGEMENTS

        The
          Contractor shall be liable to the Department and hereby agrees to indemnify
          and
          hold the Department harmless for any damage or loss or expense sustained
          by the
          Department from any infringement by the Contractor of any copyright, trademark
          or patent rights of design, systems, drawings, graphs, charts, specifications
          orprinted matter furnished orused by the Contractor in the performance
          of this
          Agreement.

        

        4.16
          ANTI-TRUST

        The
          Contractor hereby assigns, sells, and transfers to the City all right,
          title and
          interest in and to any claims and causes of action arising under the anti-trust
          laws of the State of New York or of the United States relating to the particular
          goods or services purchased or procured by the City under this
          Agreement.

         

        ARTICLES.
          TERMINATION

        5.1
          TERMINATION
          OF AGREEMENT

         

        A.
          The
          Department and/or City shall have the right to terminate this Agreement,
          inwhole
          or
          in part:

        1.
          Under
          any right to terminate as specified in any section of this
          Agreement.

        2.
          Upon
          the failure of the Contractor to comply with any of the terms and conditions
          of
          this Agreement.

        3.
          Upon
          the Contractor's becoming insolvent.

        4.
          Upon
          the commencement under the Bankruptcy Act of any proceeding by or against
          the
          Contractor, either voluntarily or involuntarily. -

        5.
          Upon
          the Commissioner's determination, termination is in the best interest of
          the
          City.

        

        B.
          The
          Department or City shall give the Contractor written notice of any termination
          of this Agreement specifying therein the applicable provisions of subsection
          A
          of this section and the effective date thereof which shall not be less
          than ten
          (10) days from the date the notice is received.

        

        C.
          The
          Contractor shall be entitled to apply to the Department to have this Agreement
          terminated by said Department by reason of any failure in the performance
          of
          this Agreement (including any failure by the Contractor to make progress
          in the
          prosecution of work hereunder which endangers such performance), if such
          failure
          arises out of causes beyond the control and without the fault or negligence
          of
          the Contractor. Such causes may include, but are not restricted to: acts
          of God
          or of the public enemy; acts of the Government in either its sovereign
          or
          contractual capacity; fires; floods; epidemics; quarantine restrictions;
          strikes; freight embargoes; or any other cause beyond the reasonable control
          of
          the Contractor. The determination that such failure arises out of causes
          beyond
          the control and without the fault or negligence of the Contractor shall
          be made
          by the Department which agrees to exercise reasonable judgment therein.
          If such
          a determination is made and the Agreement terminated by the Department
          pursuant
          to such application by the Contractor, such termination shall be deemed
          to be
          without cause.

        

        D
          Upon
          termination of this Agreement the Contractor shall comply with the Department
          or
          City close-out procedures, including but not limited to:

        

        1.
          Accounting for and refund to the Department or City, within thirty (30)
          days,
          any unexpended funds which have been paid to the Contractor pursuant to
          this
          agreement.

        2.
          Furnishing within thirty (30) days an inventory to the Department or City
          of all
          equipment, appurtenances and property purchased through or provided under
          this
          Agreement carrying out any Department or City directive concerning the
          disposition thereof.

        3.
          Not
          incurring or paying any further obligation pursuant to this Agreement beyond
          the
          termination date. Any obligation necessarily incurred by the Contractor
          on
          account of this Agreement prior to receipt of notice of termination and
          falling
          due after such date shall be paid by the Department or City in accordance
          with
          the terms of this Agreement. In no event shall the word "obligation as
          used
          herein,,"

         

        NFP.W/P.L.

         -10-

         

        

        

        be
          construed as including any lease agreement, oral or written, entered into
          between the Contractor and its landlord.

        4.
          Turn
          over to the Department or City or its designees all books, records, documents
          and material specifically relating to this Agreement.

        5.
          Submit, within ninety (90) days, a final statement and report relating
          to this
          Agreement. The report shall be made by a certified public accountant or
          a
          licensed public accountant.

         

        E.
          In the
          event the Department or City shall terminate this Agreement, in whole or
          in
          part, as provided in paragraphs 1,2, 3, or 4 of subsection A of this section,
          the Department or City may procure, upon such terms and in such manner
          as deemed
          appropriate, services similar to those so terminated, and the Contractor
          shall
          continue the performance of this Agreement to the extent not terminated
          hereby.

         

        F.
          Not
          withstanding any other provisions of this contract, the Contractor shall
          not be
          relieved of liability to the City for damages sustained by the City by
          virtue of
          Contractor's breach of the contract, and the City may withhold payments
          to the
          Contractor for the purpose of set-off until such time as the exact amount
          of
          damages due to the City from the Contractor is determined.

         

        G.
          The
          provisions of the Agreement regarding confidentiality of information shall
          remain in full force and effect following any termination.

         

        H.
          The
          rights and remedies of the City provided in this section shall not be exclusive
          and are in addition to all other rights and remedies provided by law or
          under
          this Agreement.

         

        ARTICLE
          6. MISCELLANEOUS

         

        6.1
          CONFLICT
          OF LAWS

        All
          disputes arising out of this Agreement shall be interpreted and decided
          in
          accordance with the laws of the State of New York.

         

        6.2
          GENERAL
          RELEASE

        The
          acceptance by the Contractor or its assignees of the final payment under
          this
          contract, whether by voucher, judgment of any court of competent jurisdiction
          or
          any other administrative means, shall constitute and operate as a general
          release to the City from any and all claims of and liability to the Contractor
          arising out of the performance of this contract.

         

        6.3
          CLAIMS
          AND ACTIONS THEREON

        A.
          No
          action at law or proceeding in equity against the City or Department shall
          lie
          or be maintained upon any claim based upon this Agreement or arising out
          of this
          Agreement or in any way connected with this Agreement unless the Contractor
          shall have strictly complied with all requirements relating to the giving
          of
          notice and of information with respect to such claims, all as herein
          provided.

        B.
          No
          action shall lie or be maintained against the City by Contractor upon any
          claims
          based upon this Agreement unless such action shall be commenced within
          six (6)
          months after the date of filing in the Office of the Comptroller of the
          City of
          the certificate for the final payment hereunder, or within six (6) months
          of the
          termination or conclusion of this Agreement, or within six (6) months after
          the
          accrual of the Cause of Action, whichever first occurs.

        C.
          In the
          event any claim is made or any action brought in any way relating to the
          Agreement herein, the Contractor shall diligently render to the Department
          and/or the City of New York without additional compensation any and all
          assistance which the Department and/or the City of New York may require
          of the
          Contractor.

         

        D.
          The
          Contractor shall report to the Department in writing within three (3) working
          days of the initiation by or against the Contractor of any legal action
          or
          proceeding in connection with or relating to this Agreement.

         

        NFP.W/P.L.
          -11-

         

        

        

        6.4
          NO
          CLAIM AGAINST OFFICERS. AGENTS OR EMPLOYEES

        No
          claim
          whatsoever shall be made by the Contractor against any officer, agent or
          employee of the City for, or on account of, anything done or omitted in
          connection with this contract.

         

        6.5
          WAIVER

        Waiver
          by
          the Department of a breach of any provision of this Agreement shall not
          be
          deemed to be a waiver of any other or subsequent breach and shall not be
          construed to be a modification of the terms of the Agreement unless and
          until
          the same shall be agreed to in writing by the Department or City as required
          and
          attached to the original Agreement.

         

        6.6
          NOTICE

        The
          Contractor and the Department hereby designate the business addresses
          hereinabove specified as the places where all notices, directions or
          communications from one such party to the other party shall be delivered,
          or to
          which they shall be mailed. Actual delivery of any such notice, direction
          or
          communication to a party at the aforesaid place, or delivery by certified
          mail
          shall be conclusive and deemed to be sufficient service thereof upon such
          party
          as of the date such notice, direction or communication is received by the
          party.
          Such address may be changed at any time by an instrument in writing executed
          and
          acknowledged by the party making such change and delivered to the other
          party in
          the manner as specified above. Nothing in this section shall be deemed
          to serve
          as a waiver of any requirements for the service of notice or process in
          the
          institution of an action or proceeding as provided by law, including the
          Civil
          Practice Law and Rules.

         

        6.7
          ALL
          LEGAL PROVISIONS DEEMED INCLUDED

        It
          is the
          intent and understanding of the parties to this Agreement that each and
          every
          provision of law required to be inserted in this Agreement shall be and
          is
          inserted herein. Furthermore, it is hereby stipulated that every such provision
          is to be deemed to be inserted herein, and if, through mistake or otherwise,
          any
          such provision is not inserted, or is not inserted in correct form, then
          this
          Agreement shall forthwith upon the application of either party be amended
          by
          such insertion so as to comply strictly with the law and without prejudice
          to
          the rights of either party hereunder.

         

        6.8
          SEVERABILITY

        If
          this
          Agreement contains any unlawful provision not an essential part of the
          Agreement
          and which shall not appear to have been a controlling or material inducement
          to
          the making thereof, the same shall be deemed of no effect and shall upon
          notice
          by either party, be deemed stricken from the Agreement without affecting
          the
          binding force of the remainder.

         

        6.9
          POLITICAL
          ACTIVITY

        There
          shall be no partisan political activity or any activity to further the
          election
          or defeat of any candidate for public, political or party office as part
          of or
          in connection with this Agreement, nor shall any of the funds provided
          under
          this Agreement be used for such purposes.

         

        6.10
          MODIFICATION

        This
          Agreement may be modified by the parties in writing in a manner not materially
          affecting the substance hereof. It may not be altered or modified
          orally.

         

        A.
          CONTRACT
          CHANGES

        Changes
          may be made to this contract only as duly authorized by the Agency Chief
          Contracting Officer of his or her designee. Vendors deviating from the
          requirements of an original purchase order or contract without a duly authorized
          change order document, or written contract modification or amendment, do
          so at
          their own risk. All such duly authorized changes, modifications and amendments
          will be reflected in a written change order and become a part of the original
          contract. Contract changes will be made only for work necessary to complete
          the
          work included in the original scope of the contract, and for non-material
          changes to the scope of the contract. Changes are not permitted for any
          material
          alteration in the scope of the work. Changes may include any one or more
          of the
          following:

        - Specification
          changes to account for design errors or omissions;

         

        NFP.W/P.L.
          -12-

         

        

        

        
          	 	
                  -

                	
                  changes
                    in contract amount due to authorized additional or omitted work.
                    Any such
                    changes require appropriate price and cost analysis to determine
                    reasonableness. In addition, except for non-construction requirements
                    contracts, all changes that cumulatively exceed the greater often
                    percent
                    of the original contract amount or $100,000 shall be approved
                    by the City
                    Chief Procurement Officer;

                

        

        
          	 	
                  -

                	
                  Extensions
                    of a contract term for good and sufficient cause for a cumulative
                    period
                    not to exceed one year from the date of expiration of this current
                    contract. Requirements contracts shall be subject to this
                    limitation;

                

        

        
          	 	
                  -

                	
                  Changes
                    in delivery location;

                

        

        - Changes
          in shipment method; and 

        - Any
          other
          change not inconsistent with §4-02 of the P.P.B. Rules (ed. 9/00), or any
          successor Rule.

        

        The
          Contractor may be entitled to a price adjustment for extra work performed
          pursuant to a written change order. If any part of the contract work is
          necessarily delayed by a change order, the Contractor may be entitled to
          an
          extension of time for performance. Adjustments to price shall be validated
          for
          reasonableness by using appropriate price and cost analysis.

         

        6.11
          PARAGRAPH
          HEADINGS

        Paragraph
          headings are inserted only as a matter of convenience and for reference
          and in
          no way define, limit or describe the scope or intent of this contract and
          in no
          way affect this contract.

         

        6.12
          NO
          REMOVAL OF RECORDS FROM PREMISES

        Where
          performance of this Agreement involves use by the Contractor of Departmental
          papers, files, data or records at Departmental facilities or offices, the
          Contractor shall not remove any such papers, files, data or records, therefrom
          without the prior approval of the Department's designated official.

         

        6.13
          INSPECTION
          AT SITE

        The
          Department shall have the right to have representatives of the Department
          or of
          the City or of the State or Federal governments present at the site of
          the
          engagement to observe the work being performed.

         

        6.14
          PRICING

        A.
          The
          Contractor shall when ever required during the contract, including but
          not
          limited to the time of bidding, submit cost or pricing data and formally
          certify
          that, to the best of its knowledge and belief, the cost or pricing date
          submitted was accurate, complete, and current as of a specified date. The
          Contractor shall be required to keep its submission of cost and pricing
          date
          current until the contract has been completed.

        B.
          The
          price of any change order or contract modification subject to the conditions
          of
          paragraph A, shall be adjusted to exclude any significant sums by which
          the City
          finds that such price was based on cost or price data furnished by the
          supplier
          which was inaccurate, incomplete, or not current as of the date agreed
          upon
          between the parties.

        C.
          Time
          for Certification.
          The
          Contractor must certify that the cost or pricing data submitted are accurate,
          complete and current as of a mutually determined date.

        D.
          Refusal
          to Submit Data.
          When any
          contractor refuses to submit the required data to support a price, the
          Contracting Officer shall not allow the price.

        E.
          Certificate
          of Current Cost or Pricing Data. Form of Certificate.
          In those
          cases when cost or pricing data is required, certification shall be made
          using a
          certificate substantially similar to the one contained in Chapter 4 of
          the PPB
          rules and such certification shall be retained in the agency contract
          file.

         

        ARTICLE
          7. MERGER

        This
          written Agreement contains all the terms and conditions agreed upon by
          the
          parties hereto, and no other agreement, oral or otherwise, regarding the
          subject
          matter of this Agreement shall be deemed to exist or to bind any of the
          parties
          hereto, or to vary any of the terms contained herein.

         

        NFP.W/P.L.
          -13-

         

        

        

        ARTICLE
          8. CONDITIONS PRECEDENT

        This
          contract shall neither be binding nor effective unless:

        A.
          Approved by the Mayor pursuant to the provisions of Executive Order No.
          42,
          dated October 9, 1975, in the event the

        Executive
          Order requires such approval; and 

        B.
          Certified by the Mayor (Mayor's Fiscal Committee created pursuant to Executive
          Order No. 43, dated October 14,1975) that performance thereof will be in
          accordance with the City's financial plan; and 

        C.
          Approved by the New York State Financial Control Board (Board) pursuant
          to the
          New York State Financial Emergency Act for the City of New York, as amended,
          (the "Act"), in the event regulations of the Board pursuant to the Act
          require
          such approval.

         

        D.
          It has
          been authorized by the Mayor and the Comptroller shall have endorsed his
          certificate that there remains unexpended and unapplied a balance of the
          appropriation of funds applicable thereto sufficient to pay the estimated
          expense of carrying out this Agreement. The requirements of this section
          of the
          contract shall be in addition to, and not in lieu of, any approval or
          authorization otherwise required for this contract to be effective and
          for the
          expenditure of City funds.

         

        ARTICLE
          9. PPB RULES

        This
          contract is subject to the Rules of the Procurement Policy Board of the
          City of
          New York effective August 1, 1990, as amended. In the event of a conflict
          between said Rules and a provision of this contract, the Rules shall take
          precedence.

         

        ARTICLE
          10. STATE LABOR LAW AND CITY ADMINISTRATIVE CODE

        1.
          As
          required by New York State Labor Law Section 220-e:

        a.
          That
          in the hiring of employees for the performance of work under this contract
          or
          any subcontract hereunder, neither the Contractor, Subcontractor, nor any
          person
          acting on behalf of such Contractor or Subcontractor, shall by reason of
          race,
          creed, color, sex or national origin discriminate against any citizen of
          the
          State of New York who is qualified and available to perform the work to
          which
          the employment relates;

        b.
          That
          neither the Contractor, subcontractor, nor any person on his behalf shall,
          in
          any manner, discriminate against or intimidate any employee hired for the
          performance of work under this contract on account of race, creed, color,
          sex or
          national origin;

        c.
          That
          there may be deducted from the amount payable to the Contractor by the
          City
          under this contract a penalty of five dollars for each person for each
          calendar
          day during which such person was discriminated against or intimidated in
          violation of the provisions of this contract; and 

        d.
          That
          this contract may be canceled or terminated by the City and all monies
          due or to
          become due hereunder may be forfeited, for a second or any subsequent violation
          of the terms or conditions of this section of the contract.

        e.
          The
          aforesaid provisions of this section covering every contract for or on
          behalf of
          the State or a municipality for the manufacture, sale or distribution of
          materials, equipment or supplies shall be limited to operations performed
          within
          the territorial limits of the State of New York.

         

        2.
          As
          required by New York City Administrative Code Section 6-108:

        a.
          It
          shall be unlawful for any person engaged in the construction, alteration
          or
          repair of buildings or engaged in the construction or repair of streets
          or
          highways pursuant to a contract with the City or engaged in the manufacture,
          sale or distribution of materials, equipment or supplies pursuant to a
          contract
          with the City to refuse to employ or to refuse to continue in any employment
          any
          person on account of the race, color or creed of such person.

        b.
          It
          shall be unlawful for any person or any servant, agent or employee of any
          person, described in subdivision (a) above, to ask, indicate or transmit,
          orally
          or in writing, directly or indirectly, the race, color, creed or religious
          affiliation of any person employed or seeking employment from such person,
          firm
          or corporation.

        c.
          Disobedience of the foregoing provisions shall be deemed a violation of
          a
          material provision of this contract.

        d.
          Any
          person, or the employee, manager or owner of or officer of such firm or
          corporation who shall violate any of the provisions of this section shall,
          upon
          conviction thereof, be punished by a fine of not more than one hundred
          dollars
          or by imprisonment for not more than thirty days, or both.

        

        NFP.W/P.L.

        -14-

        

        

        ARTICLE
          11. FORUM PROVISION CHOICE OF LAW. CONSENT TO JURISDICTION AND
          VENUE

        This
          Contract shall be deemed to be executed in the City of New York, State
          of New
          York. regardless of the domicile of the Contractor, and shall be governed
          by and
          construed in accordance with the laws of the State of New York. The parties
          agree that any and all claims asserted by or against the City arising under
          this
          Contract or related thereto shall be heard and determined either in the
          courts
          of the United States located in New York City ("Federal Courts") or in
          the
          courts of the State of New York ("New York State Courts") located in the
          City
          and County of New York. To effect this Agreement and intent, the Contractor
          agrees:

        a.
          If the
          City initiates any action against the Contractor in Federal Court or in
          New York
          State Court, service of process may be made on the Contractor either in
          person,
          wherever such Contractor may be found, or by registered mail addressed
          to the
          Contractor at its address as set forth in this Contract, or to such other
          address .as the Contractor may provide to the City in writing; and

        b.
          With
          respect to any action between the City and the Contractor in New York State
          Court, the Contractor hereby expressly waives and relinquishes any rights
          it
          might otherwise have (I) to move to dismiss on grounds of forum non
          conveniens;
          (ii) to
          remove to Federal Court; and (iii) to move for a change of venue to a New
          York
          State Court outside New York County.

        c.
          With
          respect to any action between the City and the Contractor in Federal Court
          located in New York City, the Contractor expressly waives and relinquishes
          any
          right it might otherwise have to move to transfer the action to a United
          States
          Court outside the City of New York.

        d.
          If the
          Contractor commences any action against the City in a court located other
          than
          in the City and State
          of New
          York,
          upon request of the City, the Contractor shall either consent to a transfer
          of
          the action to a court of competent jurisdiction located in the City and
          State
          ofNew York or, if the court where the action is initially brought will
          not or
          cannot transfer the action, the Contractor shall consent to dismiss such
          action
          without prejudice and may thereafter reinstitute the action in a court
          of
          competent jurisdiction in New York City. If any provision(s) of this Article
          is
          held unenforceable for any reason, each and all other provision(s) shall
          nevertheless remain in full force and effect.

         

        ARTICLE
          12. EQUAL EMPLOYMENT OPPORTUNITY

        This
          contract is subject to the requirements of Executive Order No. 50 (1980)
          as
          revised ("E.O. 50") and the Rules and Regulations promulgated thereunder.
          No
          contract will be awarded unless and until these requirements have been
          complied
          with in their entirety. By signing this contract, the contractor agrees
          that
          it:

        1.
          will
          not engage in any unlawful discrimination against any employee or applicant
          for
          employment because of race, creed, color, national origin, sex age, disability,
          marital status or sexual orientation with respect to all employment decisions
          including, but not limited to, recruitment, hiring, upgrading, demotion,
          downgrading, transfer, training, rates of pay or other forms of compensation,
          layoff, termination, and all other terms and conditions of
          employment;

        2.
          the
          contractor agrees that when it subcontracts it will not engage in any unlawful
          discrimination in the selection of subcontractors on the basis of the owner's
          race, color, creed, national origin, sex, age, disability, marital status
          or
          sexual orientation;

        3.
          will
          state in all solicitations or advertisements for employees placed by or
          on
          behalf of the contractor that all qualified applicants will receive
          consideration for employment without unlawful discrimination based on race,
          creed, color, national origin, sex, age, disability, marital status or
          sexual
          orientation, or that it is an equal employment opportunity
          employer;

        4.
          will
          send to each labor organization or representative of workers with which
          it has a
          collective bargaining agreement or other contract or memorandum of
          understanding, written notification of its equal employment opportunity
          commitments under E. 0. 50 and the rules and regulations promulgated thereunder;
          and

        5.
          will
          furnish all information and reports including an Employment Report before
          the
          award of the contract which are required by E. 0. 50, the rules and regulations
          promulgated thereunder, and orders of the Director of the Bureau of Labor
          Services ("Bureau"), and will permit access to its books, records and accounts
          by the Bureau for the purposes of investigation to ascertain compliance
          with
          such rules, regulations, and orders. The contractor understands that in
          the
          event of its noncompliance with nondiscrimination clauses of this contract
          or
          with any of such rules, regulations, or orders, such noncompliance shall
          constitute a material breach of the contract and noncompliance with the
          E. 0. 50
          and the rules and regulations promulgated thereunder. After a hearing held
          pursuant to the rules of the Bureau, the Director may direct the imposition
          by
          the contracting agency held of any or all of the following
          sanctions:

        (i)
          disapproval of the contractor;

         

        NFP.W/P.L.
          -15-

         

        

        

        (ii)
          suspension or termination of the contract;

        (iii)
          declaring the contractor in default; or '

        (iv)
          in
          lieu of any of the foregoing sanctions, the Director may impose an employment
          program. The Director of the Bureau may recommend to the contracting agency
          head
          that a Board of Responsibility be convened for purposes of declaring a
          contractor who has repeatedly failed to comply with E.O. 50 and the rule
          and
          regulations promulgated thereunder to be nonresponsible. The contractor
          agrees
          to include the provisions of the foregoing paragraphs in every subcontract
          or
          purchase order in excess of $50,000 to which it becomes a party unless
          exempted
          by E.O. 50 and the rules and regulations promulgated thereunder, so that
          such
          provisions will be binding upon each subcontractor or vendor. The contractor
          will take such action with respect to any subcontract or purchase order
          as may
          be directed by the Director of the Bureau of Labor Services as a means
          of
          enforcing such provisions, including sanctions for noncompliance. The contractor
          further agrees that it will refrain from entering into any contract or
          contract
          modification subject to E.O. 50 and the rules and regulations promulgated
          thereunder with a subcontractor who is not in compliance with the requirements
          of E.O. 50 and the rules and regulations promulgated thereunder.

         

        ARTICLE
          13. NO DAMAGE FOR DELAY

        The
          Contractor agrees to make no claim for damages for delay in the performance
          of
          this Contract occasioned by any act or omission to act of the City or any
          of its
          representatives, and agrees that any such claim shall be fully compensated
          for
          by an extension of time to complete performance of the work as provided
          herein.

         

        ARTICLE
          14. CONSULTANT REPORT INFORMATION

        A
          copy of
          each consultant report submitted by a consultant to any City official or
          to any
          officer, employee, agent or representative of a City department, agency,
          commission or body or to any corporation, association or entity whose expenses
          are paid in whole or in part from the City treasury shall be furnished
          to the
          Commissioner of the department to which such report was submitted or, if
          not a
          City department, then to the chief controlling officer or officers of such
          other
          office or entity. A copy of such report shall also be furnished to the
          Director
          of the Mayor's Office of Construction for matters related to construction
          or to
          the Director of the Mayor's Office of Operations for all other
          matters.

         

        ARTICLE
          15. RESOLUTION OF DISPUTES

        15.1
          All
          disputes between the City and the Contractor of the kind delineated in
          this
          section that arise under, or by virtue of this Contract shall be finally
          resolved in accordance with the provisions of this section and Section
          4-09 of
          the Rules of the Procurement Policy Board ("PPB Rules"), and any successor
          Rule.
          The procedure for resolving all disputes of the kind delineated herein
          shall be
          the exclusive means of resolving any such disputes.

        

        a.
          This
          section shall not apply to disputes concerning matters dealt with in other
          sections of the PPB Rules or to disputes involving patents, copyrights,
          trademarks, or trade secrets (as interpreted by the courts of New York
          State)
          relating to proprietary rights in computer software.

        

        b.
          For
          construction and construction-related services this section shall apply
          only to
          disputes about the scope of work delineated by the Contract, the interpretation
          of Contract Documents, the amount to be paid for extra work or disputed
          work
          performed in connection with the Contract, the conformity of the Contractor's
          work to the Contract, and the acceptability and quality of the Contractor's
          work; such disputes arise when the Engineer makes a determination with
          which the
          Contractor disagrees.

        

        15.2
          All
          determinations required by this section shall be made in writing, clearly
          stated, with a reasoned explanation for the determination based on the
          information and evidence presented to the party making the determination.
          Failure to make such determination within the time period required by this
          section shall be deemed a non-determination without prejudice that will
          allow
          appeal to the next level.

         

        15.3
          During such time as any dispute is being presented, heard, and considered
          pursuant to this section, the contract terms shall remain in full force
          and
          effect and the Contractor shall continue to perform work in accordance
          with the
          Contract and as directed by the Agency Chief Contracting Officer or Engineer.
          Failure of the Contractor to continue the work as directed shall constitute
          a
          waiver by the Contractor of any and all claims being presented pursuant
          to this
          section and a material breach of Contract.

        

        NFP.W/P.L.
          

        -16-

         

        

        

        15.4
          Presentation
          of Dispute to Agency Head.

         

        (A)
          Notice of Dispute and Agency Response. The Contractor shall present its
          dispute
          in writing ("Notice of Dispute") to the Agency Head within the time specified
          herein or, if no time is specified, within thirty (30) days of receiving
          notice
          of the determination or action that is the subject of the dispute. This
          notice
          requirement shall not be read to replace any other notice requirements
          contained
          in the Contract. The Notice of Dispute shall include all the facts, evidence,
          documents, or other basis upon which the Contractor relies in support of
          its
          position, as well as a detailed computation demonstrating how any amount
          of
          money claimed by the Contractor in the dispute was arrived at. Within thirty
          (30) days after receipt of the detailed written submission, the Agency
          Chief
          Contracting Officer or, in the case of construction or construction-related
          services, the Engineer shall submit to the Agency Head all materials he
          or she
          deems pertinent to the dispute. Following initial submissions to the Agency
          Head, either party may demand of the other the production of any document
          or
          other material the demanding party believes may be relevant to the dispute.
          The
          requested party shall produce all relevant materials that are not otherwise
          protected by a legal privilege recognized by the courts of New York State.
          Any
          question of relevancy shall be determined by the Agency Head whose decision
          shall be final. Wilful failure of the Contractor to produce any requested
          material whose relevancy the Contractor has not disputed, or whose relevancy
          has
          been affirmatively determined, shall constitute a waiver by the Contractor
          of
          its claim.

        

        (B)
          Agency Head Inquiry. The Agency Head shall examine the material and may,
          in his
          or her discretion, convene an informal conference with the Contractor and
          the
          Agency Chief Contracting Officer and, in the case of construction or
          construction-related services, the Engineer to resolve the issue by mutual
          consent prior to reaching a determination. The Agency Head may seek such
          technical or other expertise as he or she shall deem appropriate, including
          the
          use of neutral mediators, and require any such additional material from
          either
          or both parties as he or she deems fit. The Agency Head's ability to render,
          and
          the effect of, a decision hereunder shall not be impaired by any negotiations
          in
          connection with the dispute presented, whether or not the Agency Head
          participated therein. The Agency Head may or, at the request of any party
          to the
          dispute, shall compel the participation of any other contractor with a
          contract
          related to the work of this Contract, and that contractor shall be bound
          by the
          decision of the Agency Head. Any contractor thus brought into the dispute
          resolution proceeding shall have the same rights to make presentations
          and to
          seek review as the Contractor initiating the dispute.

        

        (C)
          Agency Head Determination. Within thirty (30) days after the receipt of
          all
          materials and information, or such longer time as may be agreed to by the
          parties, the Agency Head shall make his or her determination and shall
          deliver
          or send a copy of such determination to the Contractor and Agency Chief
          Contracting Officer and, in the case of construction or construction-related
          services, the Engineer, together with a statement concerning how the decision
          may be appealed.

        

        (D)
          Finality of Agency Head Decision. The Agency Head's decision shall be final
          and
          binding on all parties, unless presented to the Contract Dispute Resolution
          Board pursuant to this section. The City may not take a petition to the
          Contract
          Dispute Resolution Board. However, should the Contractor take such a petition,
          the City may seek, and the Board may render, a determination less favorable
          to
          the Contractor and more favorable to the City than the decision of the
          Agency
          Head.

        

        15.5
          Presentation
          of Dispute to the Comptroller.
          Before
          any dispute may be brought by the Contractor to the Contract Dispute Resolution
          Board, the Contractor must first present its claim to the comptroller for
          his or
          her review, investigation, and possible adjustment.

        

        (A)
          Time,
          Form, and Content of Notice. Within thirty (30) days of its receipt of
          a
          decision by the Agency Head, the Contractor shall submit to the Comptroller
          and
          to the Agency Head a Notice of Claim regarding its dispute with the Agency.
          The
          Notice of Claim shall consist of(i) a brief written statement of the substance
          of the dispute, the amount of money, if any, claimed and the reason(s)
          the
          Contractor contends the dispute was wrongly decided by the Agency Head;
          (ii) a
          copy of the written decision of the Agency Head, and (iii) a copy of all
          materials submitted by the Contractor to the Agency, including the Notice
          of
          Dispute. The Contractor may not present to the Comptroller any material
          not
          presented to the Agency Head, except at-the request of the
          Comptroller.

        (B)
          Agency Response. Within thirty (30) days of receipt of the Notice of Claim,
          the
          Agency shall make available to the Comptroller a copy of all material submitted
          by the Agency to the Agency Head in connection with the dispute. The Agency
          may
          not present to the Comptroller any material not presented to the Agency
          Head
          except at the request of the Comptroller.

        

        NFP.W/P.L.
          

        -17-

         

        

        

        (C)
          Comptroller Investigation. The Comptroller may investigate the claim in
          dispute
          and, in the course of such investigation, may exercise all powers provided
          in
          sections 7-201 and 7-203 of the New York City Administrative Code. In addition,
          the Comptroller may demand of either party, and such party shall provide,
          whatever additional material the Comptroller deems pertinent to the claim,
          including original business records of the Contractor. Wilful failure of
          the
          Contractor to produce within fifteen (15) days any material requested by
          the
          Comptroller shall constitute a waiver by the Contractor of its claim. The
          Comptroller may also schedule an informal conference to be attended by
          the
          Contractor, Agency representatives, and any other personnel desired by
          the
          Comptroller.

         

        (D)
          Opportunity of Comptroller to Compromise or Adjust Claim. The Comptroller
          shall
          have forty-five (45) days from his or her receipt of all materials referred
          to
          in 5. (C) to investigate the disputed claim. The period for investigation
          and
          compromise may be further extended by agreement between the Contractor
          and. the
          Comptroller, to a maximum of ninety (90) days from the Comptroller's receipt
          of
          all the materials. The Contractor may not present its petition to the Contract
          Dispute Resolution Board until the period for investigation and compromise
          delineated in this paragraph has expired. In compromising or adjusting
          any claim
          hereunder, the Comptroller may not revise or disregard the terms of the
          Contract
          between the parties.

         

        15.6
          Contract
          Dispute Resolution Board.
          There
          shall be a Contract Dispute Resolution Board composed of:

        A.
          the
          chief administrative law judge of the Office of Administrative Trials and
          Hearings ("OATH") or his/her designated OATH administrative law judge,
          who shall
          act as chairperson, and may adopt operational procedures and issue such
          orders
          consistent with this section as may be necessary in the execution of the
          Contract Dispute Resolution Board's functions, including, but not limited
          to,
          granting extensions of time to present or respond to submissions;

        

        B.
          the
          City Chief Procurement Officer or a designee; or in the case of disputes
          involving construction, the Director of the Office of Construction or his/her
          designee; any designee shall have the requisite background to consider
          and
          resolve the merits of the dispute and shall not have participated personally
          and
          substantially in the particular matter that is the subject of the dispute
          or
          report to anyone who so participated, and

         

        C.
          a
          neutral person with appropriate expertise. This person shall be selected
          by the
          presiding administrative lawjudge from a prequalified panel of individuals,
          established and administered by OATH, with appropriate background to act
          as
          decision-makers in a dispute. Such individuals may not have a contract
          or
          dispute with the City or be an officer or employee of any company or
          organization that does, or regularly represents persons, companies, or
          organizations having disputes with the City.

         

        15.7
          Petition
          to Contract Dispute Resolution Board.
          In the
          event the claim has not been settled or adjusted by the Comptroller within
          the
          period provided in this section, the Contractor, within thirty (30) days
          thereafter, may petition the Contract Dispute Resolution Board to review
          the
          Agency Head determination.

        

        (A)
          Form
          and Content of Petition by Contractor. The Contractor shall present its
          dispute
          to the Contract Dispute Resolution Board in the form of a Petition, which
          shall
          include (i) a brief written statement of the substance of the dispute,
          the
          amount of money, if any, claimed and the reason(s) the Contractor contends
          that
          the dispute was wrongly decided by the Agency Head; (ii) a copy of the
          written
          decision of the Agency Head; (iii) copies of all materials submitted by
          the
          Contractor to the Agency; (iv) a copy of the written decision of the
          Comptroller, if any, and (v) copies of all correspondence with, or written
          material submitted by the Contractor to, the Comptroller's Office. The
          Contractor shall concurrently submit four complete sets of the Petition:
          one to
          the Corporation Counsel (Attn: Commercial and Real Estate Litigation Division),
          and three to the Contract Dispute Resolution Board at oath's
          offices
          with proof of service on the Corporation Counsel. In addition, the supplier
          shall submit a copy of the statement of the substance of the dispute, cited
          in
          (i) above to both the Agency Head and the Comptroller.

         

        (B)
          Agency Response. Within thirty (30) days of its receipt of the Petition
          by the
          Corporation Counsel, the Agency shall respond to the brief written statement
          of
          the Contractor and make available to the Board at oath's
          offices
          and one to the Contractor, all material it submitted to the Agency Head
          and
          Comptroller. Extensions of time for submittal of the agency response shall
          be
          given as necessary upon a showing of good cause or, upon the consent of
          the
          parties, for an initial period of up to thirty (30) days.

         

        (C)
          Further Proceedings. The Board shall permit the Contractor to present its
          case
          by

         

        NFP.W/P.L.

         -18-

         

        

        

        the
          submission of memoranda, briefs, and oral argument. The Board shall also
          permit
          the Agency to present its case in response to the Contractor by the submission
          of memoranda, briefs, and oral argument. If requested by the Corporation
          Counsel, the Comptroller shall provide reasonable assistance in the preparation
          of the Agency's case. Neither the Contractor nor the Agency may support
          its case
          with any documentation or other material that was not considered by the
          Comptroller, unless requested by the Board. The Board, at its discretion,
          may
          seek such technical or other expertise as it shall deem appropriate and
          may
          seek, on its own or upon application of a party, any such additional material
          from any party as it deems fit. The Board, in its discretion, may combine
          more
          than one dispute between the parties of concurrent resolution.

         

        (D)
          Contract Dispute Resolution Board Determination. Within forty-five (45)
          days of
          the conclusion of all written submissions and oral arguments, the Board
          shall
          render a written decision resolving the dispute. In an unusually complex
          case,
          the Board may render its decision in a longer period of time, not to exceed
          ninety (90) days, and shall so advise the parties at the commencement of
          this
          period. The Board's decision must be consistent with the terms of the Contract.
          In reaching its decision, the Board shall accord no precedential significance
          to
          prior decisions of the Board involving other non-related contracts.

        

        (E)
          Notification of Contract Dispute Resolution Board Decision. The Board shall
          send
          a copy of its decision to the Contractor, the Agency Chief Contracting
          Officer,
          the Corporation Counsel, the Comptroller, and in the case of construction
          or
          construction-related services, the Engineer. A decision in favor of the
          Contractor shall be subject to the prompt payment provisions of the PPB
          Rules.
          The Required Payment Day shall be thirty (30) days after the date the parties
          are formally notified of the Board's decision.

        

        (F)
          Finality of Contract Dispute Resolution Board Decision. The Board's decision
          shall be final and binding on all parties. Any party may seek review of
          the
          Board's decision solely in the form of a challenge, made within four (4)
          months
          of the date of the Board's decision, in a court of competent jurisdiction
          of the
          State ofNew York, County of New York, pursuant to Article 78 of the Civil
          Practice Law and Rules. Such review by the court shall be limited to the
          question of whether or not the Board's decision was made in violation of
          lawful
          procedure, was affected by an error of law, or was arbitrary and capricious
          or
          an abuse of discretion. No evidence or information shall be introduced
          or relied
          upon in such proceeding that was not presented to the Board in accordance
          with
          Section 4-09 of the PPB Rules.

        

        15.8
          Any
          termination, cancellation, or alleged breach of the Contract prior to or
          during
          the pendency of any proceedings pursuant to this section shall not affect
          or
          impair the ability of the Agency Head or Contract Dispute Resolution Board
          to
          make a binding and final decision pursuant to this section.

         

        ARTICLE
          16. PROMPT PAYMENT

        The
          Prompt Payment provisions set forth in Chapter 4, Section 4-06 of the
          Procurement Policy Board Rules in effect at the time for this solicitation
          will
          be applicable to payments made under this contract. The provisions require
          the
          payment to the contractors of interest on payments made after the required
          payment date except as set forth in Section 4-06 of the Rules;

        

        The
          contractor must submit a proper invoice to receive payment, except where
          the
          contract provides that the contractor will be paid at predetermined intervals
          without having to submit an invoice for each scheduled payment.

        

        Determinations
          of interest due will be made in accordance with the provisions of the
          Procurement Policy Board Rules and General Municipal Law Section
          3-a.

         

        NFP.W/P.L.
          

        -19-

        

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

        

          APPENDIX
            R2

           

          GENERAL
            PROVISIONS GOVERNING CONTRACTS FOR CONSULTANTS, PROFESSIONAL AND TECHNICAL
            SERVICES (For-Profit Entities)

           

          

           

           

          
            
              	 CONTENTS	 PAGE
	
                      ARTICLE
                        1.

                    	
                      DEFINITIONS

                    	
                      1

                    
	
                      ARTICLE
                        2.

                    	
                      REPRESENTATIONS
                        AND WARRANTIES 

                    	
                      1

                    
	
                      ARTICLE
                        3. 

                    	
                      AUDIT
                        BY THE DEPARTMENT AND CITY 

                    	
                      2

                    
	
                      ARTICLE
                        4. 

                    	
                      COVENANTS OF
                        THE CONTRACTOR 

                    	
                      3

                    
	
                      ARTICLE
                        5.

                    	
                      TERMINATION
                        

                    	
                      10

                    
	
                      ARTICLE
                        6

                    	
                      MISCELLANEOUS
                        

                    	
                      12

                    
	
                      ARTICLE
                        7. 

                    	
                      MERGER
                        

                    	
                      15

                    
	
                      ARTICLE
                        8.

                    	
                      CONDITIONS
                        PRECEDENT 

                    	
                      15

                    
	
                      ARTICLE
                        9.

                    	
                      PPB
                        RULES 

                    	
                      15

                    
	
                      ARTICLE
                        10.

                    	
                      STATE
                        LABOR LAW AND CITY ADMINISTRATIVE CODE

                    	
                      15

                    
	
                      ARTICLE
                        11.

                    	
                      FORUM
                        PROVISION

                    	
                      16

                    
	
                      ARTICLE
                        12

                    	
                      EQUAL
                        EMPLOYMENT OPPORTUNITY

                    	
                      17

                    
	
                      ARTICLE
                        13

                    	
                      NO
                        DAMAGE FOR DELAY

                    	
                      18

                    
	
                      ARTICLE
                        14

                    	
                      CONSULTANT
                        REPORT INFORMATION

                    	
                      18

                    
	
                      ARTICLE
                        15. 

                    	
                      RESOLUTION
                        OF DISPUTES

                    	
                      18

                    
	
                      ARTICLE
                        16.

                    	
                      PROMPT
                        PAYMENT

                    	
                      22

                    
	
                      ARTICLE
                        17.

                    	
                      MACBRIDE
                        PRINCIPLES ADMINISTRATIVE CODE

                    	
                      22

                    

            

          

           

           

          ARTICLE
            1. DEFINITIONS

          As
            used
            throughout this Agreement, the following a-ms shall have the meaning
            set forth
            below:

          a.
            "City"
            shall
            mean the City of New York, its

          departments
            and political subdivisions.

          b.
            "Comptroller"
            shall
            mean the Comptroller

          of
            the
            City of New York. 

          c. 
            "Department"
            or
            "Agency" shall mean the DEPARTMENT
            OF HEALTH AND MENTAL HYGIENE

          d.
            "Commissioner"
            or
            "Administrator
            shall
            mean the COMMISSIONER OF HEALTH AND MENTAL HYGIENE or his duly authorized
            representative. The term "duly authorized representative" shall include
            any
            person or persons acting within the limits of his or her authority.

          e.
            "Law"
            or
            "Laws"
            shall
            include but not be limited to the New York City Charter, the New York
            City
            Administrative Code, a local law of the City of New York, and any ordinance,
            rule or regulation having the force of law.

          f.
            "Contractor"or"ConsuItant"
            shall
            mean WellCare of New York, Inc.

           

          ARTICLE
            2. REPRESENTATIONS AND WARRANTIES

          

          2.1
            PROCUREMENT
            OF AGREEMENT  

          A.
            The
            Contractor represents and warrants that no person or selling agency has
            been
            employed or retained to solicit or secure this Agreement upon an agreement
            or
            understanding for a commission, percentage, brokerage fee, contingent
            fee or any
            other compensation. The Contractor further represents and warrants that
            no
            payment, gift or thing of value has been made, given or promised to obtain
            this
            or any other agreement between the parties. The Contractor makes such
            representations and warranties to induce the City to enter into
            this
            Agreement and the City relies upon such representations and warranties
            in the
            execution hereof.

          

          B.
            For a
            breach or violation of such representations or warranties, the Administrator
            shall have the right to annul this Agreement without liability, entitling
            the
            City to recover all monies paid hereunder and the Contractor shall not
            make
            claim for, or be entitled to recover, any sum or sums due under this
            Agreement.
            This remedy, if effected, shall not constitute the sole remedy afforded
            the City
            for the falsity or breach, nor shall it constitute a waiver of the City's
            right
            to claim damages or refuse payment or to take any other action provided
            for by
            law or pursuant to this Agreement.

           

          2.2
            CONFLICT OF INTEREST

          The
            Contractor represents and warrants that neither it nor any of its directors,
            officers, members, partners or employees, has any interest nor shall
            they
            acquire any interest, directly or indirectly, which would or may conflict
            in any
            manner or degree with the performance or rendering of the services herein
            provided. The Contractor further represents and warrants that in the
            performance
            of this Agreement no person having such interest or possible interest
            shall be
            employed by it. No elected official or other officer or employee of the
            City or
            Department, nor any person whose salary is payable, in whole or in part,
            from
            the City Treasury, shall participate in any decision relating to this
            Agreement
            which affects his or her personal interest or the interest of any corporation,
            partnership or association in which he or she is, directly or indirectly,
            interested; nor shall any such person have any interest, direct or indirect,
            in
            this Agreement or in the proceeds thereof.

          

          2.3
            FAIR PRACTICES

          The
            Contractor and each person signing on behalf of any contractor represents
            and
            warrants and certifies, under penalty of perjury, that to the best of
            its
            knowledge and belief:

          

          A.
            The
            prices in this contract have been arrived at independently without collusion,
            consultation, communication, or agreement, for the purpose of restricting
            competition, as to any matter relating to such prices with any other
            bidder or
            with any competitor;

          B.
            Unless
            otherwise required by law, the prices which have been quoted in this
            contract
            and on the proposal submitted by the Contractor have not been knowingly
            disclosed by the Contractor prior to the proposal opening, directly or
            indirectly, to any other bidder or to any competitor; and 

          C.
            No
            attempt has been made or will be made by the Contractor to induce any
            other
            person, partnership or corporation to submit or not to submit a proposal
            for the
            purpose of restricting competition. 

          

          The
            fact
            that the Contractor (a) has published price lists, rates, or tariffs
            covering
            items being procured, (b) has informed prospective customers of proposed
            or
            pending publication of new or revised price lists for such items, or
            (c) has
            sold the same items to other customers at the same prices being bid,
            does not
            constitute, without more, a disclosure within the meaning of the
            above.

           

          ARTICLE
            3. AUDIT BY THE DEPARTMENT AND CITY

           

          

          3.1
            All
            vouchers or invoices presented for payment to be made hereunder, and
            the books,
            records and accounts upon which said vouchers or invoices are based are
            subject
            to audit by the Department and by the Comptroller of the City of New
            York
            pursuant to the powers and responsibilities as conferred upon said Department
            and said Comptroller by the New York City Charter and Administrative
            Code of the
            City of New York, as well as all orders and regulations promulgated pursuant
            thereto.

          3.2
            The
            Contractor shall submit any and all documentation and justification in
            support
            of expenditures or fees under this Agreement as may be required by said
            Department and said Comptroller so that they may evaluate the reasonableness
            of
            the charges and shall make its records available to the Department and
            to the
            Comptroller as they consider necessary.

          

           

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          -2-

           

          
 

          3.3
            All
            books, vouchers, records, reports, canceled checks and any and all similar
            material may be subject to periodic inspection, review and audit by the
            State of
            New York, Federal Government and other persons duly authorized by the
            City. Such
            audit may include examination and review of the source and application
            of all
            funds whether from the City, any State, the Federal Government, private
            sources
            or otherwise.

          3.4
            The
            contractor shall not be entitled to final payment under the Agreement
            until all
            requirements have been satisfactorily met.

           

          ARTICLE
            4. COVENANTS OF THE CONTRACTOR

          

          4.1
            EMPLOYEES

          

          A.
            All
            experts or consultants or employees of the Contractor who are employed
            by the
            Contractor to perform work under this contract are neither employees
            of the City
            nor under contract to the City and the Contractor alone is responsible
            for their
            work, direction, compensation and personal conduct while engaged under
            this
            Agreement. Nothing in this contract shall impose any liability or duty
            on the
            City for the acts, omissions, liabilities or obligations of the Contractor
            any
            person, firm company, agency, association, expert, consultant, independent
            contractor, specialist, trainee, employee, servant, or agent, or for
            taxes of
            any nature including but not limited to unemployment insurance, workmen's
            compensation, disability benefits and social security, or, except as
            specifically stated in this contract, to any person, firm or
            corporation.

          

          B.
            The
            Contractor shall be solely responsible for all physical injuries or death
            to its
            agents, servants, or employees or to any other person or damage to any
            property
            sustained during its operations and work on the project under this agreement
            resulting from any act of omission or commissioner error in judgment
            of any of
            its officers, trustees, Employees, agents, servants, or independent contractors
            and shall hold harmless, and indemnify the city from liability upon any
            and all
            claims for damages on account of such injuries or death to any such person
            or
            damages to property on account for any neglect, fault or default of the
            contractor, its officers trustees, employees, agents, servants, or independent
            contractors. The Contractor shall be solely responsible for the safety
            and
            protection of all of its employees whether due to the negligence, fault
            or
            default of the contractor or not.

          

          C. Workmen’s
            Compensation and Disability Benefits: 

          If
            this
            agreement be of such a character that the employees engages thereon are
            required
            to be insured by the provision of Chapter 615 of the Laws of 1992, known
            as the
“Workmen’s Compensation Law” and acts amendatory thereto, the agreement shall be
            void and of no effect unless the Contractor shall secure compensation
            for the
            benefit of, and keep such insured during the life of this agreement such
            employees compliance with the provisions of said law, inclusive of Disabilities
            Benefits; and shall furnish the Department with two (2) certificates
            of these
            insurance coverages.

          

          
            	D.  	
                    Unemployment
                      Insurance: 

                  

          

          Unemployment
            Insurance coverage shall be obtained and provided by the contractor for
            its
            employees

          

          E. Minimum
            Wage

          Except
            for those employees whose minimum wage is required to be fixed pursuant
            to
            Section 220 of the Labor Law of the State of New York, all persons employees
            by
            the contractor in the performance of this agreement shall be paid, without
            subsequent deduction or rebate, unless expressly authorized by the law,
            not less
            than the minimum wage as prescribed by law. Any breach or violation of
            the
            foregoing shall be deemed a breach or violation of a material provision
            of this
            Agreement.

           

          

           

          

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          -3-

           

          4.2
            INDEPENDENT CONTRACTOR STATUS The
            Contractor and the Department agree that the Contractor is an independent
            contractor, and not an employee of the Department or the City of New
            York, and
            that in accordance with such status as independent contractor, the Contractor
            covenants and agrees that neither it nor its employees or agents will
            hold
            themselves out as, nor claim to be, officers or employees of the City
            of New
            York, or of any department, agency or unit thereof, by reason hereof,
            and that
            they will not, by reason hereof, make any claim, demand or application
            to or for
            any right or privilege applicable to an officer or employee of the City
            of New
            York, including, but not limited to, Workmen's Compensation coverage.
            Unemployment Insurance Benefits, Social Security coverage or employee
            retirement
            membership or credit. 

           

          4.3
            INSURANCE

          A.
            Insurance
            Requirements for Contractors 

          Contractors
            shall procure and maintain for the duration of the contract insurance
            against
            claims for injuries to persons or damages to property which may arise
            from or in
            connection with the performance of the work hereunder by the Contractor,
            his
            agents, representatives, employees or subcontractors. All required insurance
            policies shall be maintained with companies that may lawfully issue the
            required
            policy and have an A.M. Best rating of at least A-7 or a Standard and
            Poor's
            rating of at least AA, unless prior written approval is obtained from
            the
            Mayor's Office of Operations. The cost of such insurance shall be included
            in
            the Contractor's bid.

          

          a.
            Minimum
            Scope of Insurance

          Coverage
            shall be at least as broad as:

          

          
            	1.  	
                    Insurance
                      Services Office form number GL 0002 (1/73) covering Comprehensive
                      General
                      Liability and Insurance Services Office form number GL 0404
                      covering Broad
                      Form Commercial General Liability; Insurance General Liability;
                      or
                      Insurance Services Office Commercial General Liability coverage
                      ("occurrence" form CG 0001).(ED
                      11/85).

                  

          

          
            	2.  	
                    Insurance
                      Services Office form number CA 0001 (Ed. 1/78) covering Automobile
                      Liability, code 1 "any auto" and endorsements CA 2232 and CA
                      0112.
                      

                  

          

          
            	3.  	
                    Workers'
                      Compensation insurance as required by Labor Code of the State
                      of New York
                      and Employers Liability insurance. 

                  

          

          
            	b.  	
                    Minimum
                      Limits of Insurance Contractor
                      shall maintain limits no less than:

                  

          

          1. Comprehensive
            General Liability:

          $1,000,000.00
            combined single limit per accident for bodily injury and property
            damage.

          2. 
            Professional liability: 1 Million Dollars per occurrence; Three Million
            Dollars
            Aggregate.

          3. Workers'
            Compensation and Employers Liability: Workers' Compensation limits as
            required
            by the Labor Code of the State of New York Employers Liability limits
            of
            $1,000,000.00 per accident. Pursuant to Section 57 of the NYS Workers'
            Compensation Law, the vendor has submitted proof of workers' compensation
            and
            disability benefits coverage to the agency.

          c. Deductibles
            and Self-Insured Retentions. Any
            deductibles and self-insured retentions must be declared to and approved
            by the
            Agency. At the option of the Agency, either: the insurer shall reduce
            or
            eliminate such deductibles or self-insured retentions as respects the
            Agency,
            its officers, officials and employees; or the Contractor shall procure
            a bond
            guaranteeing payment of losses and related investigations, claim administration
            and defense expenses.

          1. General
            Liability and Automobile Liability Coverages

           

           

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          -4-

           

          

          

          a.
             The
            City,
            its officers, officials and employees are to be covered as insured as
            respects:
            liability arising out of activities performed by or on behalf of the
            Contractor;
            products and completed operations of the Contractor; premises owned,
            leases or
            used by the Contractor; or automobiles owned, leased, hired or borrowed
            by the
            Contractor. The coverage shall contain no special limitations on the
            scope of
            protection afforded to the City, its officers, officials and employees.
            

          

          b. The
            Contractor's insurance coverage shall be primary insurance as respect
            the City,
            its officers, officials, and employees. Any other insurance or self-insurance
            maintained by the Agency, its officers, officials and employees shall
            be excess
            of and not contribute with the Contractor's insurance. 

          

          
            	c.  	
                    Any
                      failure to comply with reporting provisions of the policies
                      shall not
                      affect coverage provided to the Agency, .its officers, officials,
                      and
                      employees. 

                  

          

          

          
            	d.  	
                    The
                      Contractor's insurance shall apply separately to each insured
                      against whom
                      claim is made or suit is brought, except with respect to the
                      limits of the
                      insurers liability. 

                  

          

          

          
            	2.  	
                    Workers
                      Compensation and Employers Liability
                      Coverage

                  

          

          The
            insurer shall agree to waive all rights of subrogation against the Agency,
            its
            officers, officials, and employees for losses /rising from work performed
            by the
            Contractor for Agency. 

          

          3.
            All
            Coverages

          Each
            insurance policy required by this clause shall be endorsed to state that
            coverage shall not be suspended, voided, canceled by either party, reduced
            in
            coverage or in limits except after sixty (60) days prior written notice
            by
            certified mail, return receipt requested, has been given to the City.
            

          

          
            	d.  	
                    Acceptability
                      of Insurers 

                  

          

          Insurance
            is to be placed with insurers with a Best's rating of no less than an
            A.M. Best
            rating of at least A-7 or a Standard and Poor's rating of at least AA,
            unless
            prior written approval is obtained from the Mayor's Office of
            Operations.

          

          
            	e.  	
                    Verification
                      of Coverage Contractor
                      shall furnish the City with Certificates of Insurance effecting
                      coverage
                      required by this clause. The Certificates for each insurance
                      policy are to
                      be signed by a person authorized by that insurer to bind coverage
                      on its
                      behalf. The Certificates are to be on forms provided by the
                      Agency and are
                      to be received and approved by the Agency before work commences.
                      The
                      Agency reserves the right to obtain complete, certified copies
                      of all
                      required insurance policies, at any time.

                  

          

          

          
            	f.  	
                    Subcontractors

                  

          

          Contractor
            shall include all subcontractors as insured under its policies or shall
            furnish
            separate Certificates for each subcontractor. All coverages for subcontractors
            shall be subject to all of the requirements stated herein.

          

          
 

          

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          -5-

           

          

          B.
            In the
            event that any claim is made or any action is brought against the City
            arising
            out of negligent or careless acts of an employee of the Contractor, either
            within or without the scope of his employment, or arising out of Contractor's
            negligent performance of this Agreement, then the City shall have the
            right to
            withhold further payments hereunder for the purpose of set-off in sufficient
            sums to cover the said claim or action. The rights and remedies of the
            City
            provided for in this clause shall not be exclusive and are in addition
            to any
            other rights and remedies provided by law or this Agreement.

          

          4.4
            PROTECTION OF CITY PROPERTY

          

          A.
            The
            Contractor assumes the risk of, and shall be responsible for, any loss
            or damage
            to City property, including property and equipment leased by the City,
            used in
            the performance of this Agreement; and caused, either directly or indirectly
            by
            the acts, conduct, omissions or lack of good faith of the Contractor,
            its
            officers, managerial personnel and employees, or any person, firm, company,
            agent or others engaged by the Contractor as expert, consultant, specialist
            or
            subcontractor hereunder.

          B.
            In the
            event that any such City property is lost or damaged, except for normal
            wear and
            tear, then the City shall have the right to withhold further payments
            hereunder
            for the purpose of set-off, in sufficient sums to cover such loss or
            damage.

          C.
            The
            Contractor agrees to indemnify the City and hold it harmless from any
            and all
            liability or claim for damages due to any such loss or damage to any
            such City
            property described in subsection A above.

          D.
            The
            rights and remedies of the City provided herein shall not be exclusive
            and are
            in addition to any other rights and remedies provided by law or by this
            Agreement.

          

           

          4.5
            CONFIDENTIALITY

          All
            of
            the reports, information or data, furnished to or prepared, assembled
            or used by
            the Contractor under this Agreement are to be held confidential, and
            prior to
            publication, the Contractor agrees that the same shall not be made available
            to
            any individual or organization without the prior written approval of
            the
            Department.

           

          4.6
            BOOKS
            AND RECORDS

          The
            Contractor agrees to maintain separate and accurate books, records, documents
            and other evidence and accounting procedures and practices which sufficiently
            and properly reflect all direct and indirect costs of any nature expended
            in the
            performance of this Agreement.

          

          4.7
            RETENTION
            OF RECORDS

          The
            Contractor agrees to retain all books, records, and other documents relevant
            to
            this Agreement for six years after the final payment or termination of
            this
            Agreement, whichever is later. City, State and Federal auditors and any
            other
            persons duly authorized by the Department shall have full access to and
            the
            right to examine any of said materials during said period.

          

          4.8
            COMPLIANCE
            WITH LAW

          Contractor
            shall render all services under this Agreement in accordance with the
            applicable
            provisions of federal, state and local laws, rules and regulations as
            are in
            effect at the time such services are rendered.

          

          4.9
            INVESTIGATION CLAUSE

           

          

           

          1. The
            parties to this agreement agree to cooperate fully and faithfully with
            any
            investigation, audit or ' inquiry conducted by a State of New York (State)
            or
            City of New York (City) governmental agency or authority that is empowered
            directly or by designation to compel the attendance of witnesses and
            to examine
            witnesses under oath, or conducted by the Inspector General of a governmental
            agency that is a party in interest to the transaction, submitted bid,
            submitted
            proposal, contract, lease, permit, or license that is the subject of
            the
            investigation, audit or inquiry.

           

          2.

           

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          -6-

           

          

           

          (a)
            If
            any person who has been advised that his or her statement, and any information
            from such statement, will not be used against him or her in any subsequent
            criminal proceeding refuses to testify before a grand jury or other governmental
            agency or authority empowered directly or by designation to compel the
            attendance of witnesses and to examine witnesses under oath concerning
            the award
            of or performance under any transaction, agreement, lease, permit, contract,
            or
            license entered into with the City, the State, or any political subdivision
            or
            public authority thereof, or the Port Authority of New York and New Jersey,
            or
            any local development corporation within the City, or any public benefit
            corporation organized under the laws of the State of New York, or;

           

          

          2.

          (b)
            If
            any person refuses to testify for-a reason other than the assertion of
            his or
            her privilege against self-incrimination in an investigation, audit or
            inquiry
            conducted by a City or State governmental agency or authority empowered
            directly
            or by designation to compel the attendance of witnesses and to take testimony
            under oath, or by the Inspector General of the governmental agency that
            is a
            party in interest in, and is seeking testimony concerning the award of,
            or
            performance under, any transaction, agreement, lease, permit, contract,
            or
            license entered into with the City, the State, or any political subdivision
            thereof or any local development corporation within the City, then;

           

          3.

          (a)
            The
            commissioner or agency head whose agency is a party in interest to the
            transaction, submitted bid, submitted proposal, contract, lease, permit,
            or
            license shall convene a hearing, upon not less than five (5) days written
            notice
            to the parties involved, to determine if any penalties should attach
            for the
            failure of a person to testify.

          

          3. 

          (b)
            If
            any non-governmental party to the hearing requests an adjournment, the
            commissioner or agency head who convened the hearing may, upon granting
            the
            adjournment, suspend any contract, lease, permit, or license pending
            the final
            determination pursuant to paragraph 5 below without the City incurring
            any
            penalty or damages for delay or otherwise.

          

          4.
            The
            penalties which may attach after a final determination by the commissioner
            or
            agency head may include but shall not exceed:

          

          (a)
            The
            disqualification for a period not to exceed five (5) years from the date
            of an
            adverse determination for any person, or any entity of which such person
            was a
            member at the time the testimony was sought, from submitting bids for,
            or
            transacting business with, or entering into or obtaining any contract,
            lease,
            permit or license with or from the City; and/or

          (b)
            The
            cancellation or termination of any and all such existing City contracts,
            leases,
            permits or licenses that the refusal to testify concerns and that have
            not been
            assigned as permitted under this agreement, nor the proceeds of which
            pledged,
            to an unaffiliated and unrelated institutional lender for fair value
            prior to
            the issuance of the notice scheduling the hearing, without the City incurring
            any penalty or damages on account of such cancellation or termination;
            monies
            lawfully due for goods delivered, work done, rentals, ' or fees accrued
            prior to
            the cancellation or termination shall be paid by the City.

          

          5.
            The
            commissioner or agency head shall consider and address in reaching his
            or her
            determination and in assessing an appropriate penalty the factors in
            paragraphs
            (a) and (b) below. He or she may also consider, if relevant and appropriate,
            the
            criteria established in paragraphs (c) and (d) below in addition to any
            other
            information which may be relevant and appropriate:

          

           

          Profit.w/P.L.

           

          -7-

          

          (a)
            The
            party's good faith endeavors or lack thereof to cooperate fully and faithfully
            with any governmental investigation or audit, including but not limited
            to the
            discipline, discharge, or disassociation of any person failing to testify,
            the
            production of accurate and complete books and records, and the forthcoming
            testimony of all other members, agents, assignees or fiduciaries whose
            testimony
            is sought.

          (b)
            The
            relationship of the person who refused to testify to any entity that
            is a party
            to the hearing, including, but not limited to, whether the person whose
            testimony is sought has an ownership interest in the entity and/or the
            degree of
            authority and responsibility the person has within the entity.

          (c)
            The
            nexus of the testimony sought to the subject entity and its contracts,
            leases,
            permits or licenses with the City.

          (d)
            The
            effect a penalty may have on an unaffiliated and unrelated party or entity
            that
            has a significant interest in an entity subject to penalties under 4
            above,
            provided that the party or entity has given actual notice to the commissioner
            or
            agency head upon the acquisition of the interest, or at the hearing called
            for
            in 3 (a) above gives notice and proves that such interest was previously
            acquired. Under either circumstance the party or entity must present
            evidence at
            the hearing demonstrating the potential adverse impact a penalty will
            have on
            such person or entity.

           

          6.

          (a)
            The
            term "license" or "permit" as used herein shall be defined as a license,
            permit,
            franchise or concession not granted as a matter of right.

          (b)
            The
            term "person" as used herein shall be defined as any natural person doing
            business alone or associated with another person or entity as a partner,
            director, officer, principal or employee.

          (c)
            The
            term "entity" as used herein shall be defined as any firm, partnership,
            corporation, association, or person that receives monies, benefits, licenses,
            leases, or permits from or through the City or otherwise transacts business
            with
            the City.

          (d)
            The
            term "member" as used herein shall be defined as any person associated
            with
            another person or entity as a partner, director, officer, principal or
            employee,

          

          7.
            In
            addition to and notwithstanding any other provision of this agreement
            the
            Commissioner or agency head may in his or her sole discretion terminate
            this
            agreement upon not less than three (3) days written notice in the event
            contractor fails to promptly report in writing to the Commissioner of
            Investigation of the City of New York any solicitation of money, goods,
            requests
            for future employment or other benefit or thing of value, by or on behalf
            of any
            employee of the City or other person, firm, corporation or entity for
            any
            purpose which may be related to the procurement or obtaining of this
            agreement
            by the contractor, or affecting the performance of this contract. 

          

          4.10
            ASSIGNMENT

          A.
            The
            Contractor shall not assign, transfer, convey or otherwise dispose of
            this
            Agreement or of Contractor's rights, obligations, duties, in whole or
            in part,
            or of its right to execute it, or its right, title or interest in it
            or any part
            thereof, or assign, by power of attorney or otherwise, any of the notices
            due or
            to become due under this contract, unless the prior written consent of
            the
            Administrator shall be obtained. Any such assignment, transfer, conveyance
            or
            other disposition ' without such consent shall be void. 

          B.
            Failure of the Contractor to obtain any required consent to any assignment,
            shall be cause for termination for cause, at the option of the Administrator;
            and if so terminated, the City shall thereupon be relieved and discharged
            from
            any further liability and obligation to the Contractor, its assignees
            or
            transferees, and all monies that may become due under the contract shall
            be
            forfeited to the City

          

          

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          -8-

          

          except
            so
            much thereof as may be necessary to pay the Contractor's employees.

          C.
            The
            provisions of this clause shall not hinder, prevent, or affect an assignment
            by
            the Contractor for the benefit of its creditors made pursuant to the
            laws of the
            State of New York. 

          D.
            This
            Agreement may be assigned by the City to any corporation, agency or
            instrumentality having authority to accept such assignment.

          

          4.11
            SUBCONTRACTING

          A.
            The
            Contractor agrees not to enter into any subcontracts for the performance
            of its
            obligations, in whole or in part, under this Agreement without the prior
            written
            approval of the Department. Two copies of each such proposed subcontract
            shall
            be submitted to the Department with the Contractor's written request
            for
            approval. All such subcontracts shall contain provisions
            specifying:

          1.
            that
            the work performed by the subcontractor must be in accordance with the
            terms of
            the Agreement between the Department and the Contractor,

          2.
            that
            nothing contained in such agreement shall impair the rights of the
            Department,

          3.
            that
            nothing contained herein, or under the Agreement between the Department
            and the
            Contractor, shall create any contractual relation between the subcontractor
            and
            the Department, and

          4.
            that
            the subcontractor specifically agrees to be bound by the confidentiality
            provision set forth in this Agreement between the Department and the
            Contractor.

          B.
            The
            Contractor agrees that it is fully responsible to the Department for
            the acts
            and omissions of the subcontractors and of persons either directly or
            indirectly
            employed by them as it is for the acts and omissions of persons directly
            employed by it.

          C.
             The
            aforesaid approval is required in all cases other than individual
            employer-employee contracts. 

          D.
             The
            Contractor shall not in any way be relieved of any responsibility under
            this
            Contract by any subcontract. 

          

          4.12 PUBLICITY

          A.
             The
            prior
            written approval of the Department is required before the Contractor
            or any of
            its employees, servants, agents, or independent contractors may, at any
            time,
            either during or after completion or termination of this Agreement, make
            any
            statement to the press or issue any material for publication through
            any media
            of communication bearing on the work performed or data collected under
            this
            Agreement.

          B.
             If
            the
            Contractor publishes a work dealing with any aspect of performance under
            this
            Agreement, or of the results and accomplishments attained in such performance,
            the Department shall have a royalty free, non-exclusive and irrevocable
            license
            to reproduce, publish or otherwise use and to authorize others to use
            the
            publication

          

          4.13.
            PARTICIPATION
            IN AN INTERNATIONAL BOYCOTT 

          A.
             The
            Contractor agrees that neither the Contractor nor any substantially-owned
            affiliated company is participating or shall participate in an international
            boycott in violation of the provisions of the Export Administration Act
            of 1979,
            as amended, or the regulations of the United States Department of Commerce
            promulgated thereunder. 

          B.
            Upon
            the final determination by the Commerce Department or any other agency
            of the
            United States as to, or conviction of the Contractor or a

          

           

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          substantially-owned
            affiliated company thereof, participation in an international boycott
            in
            violation of the provisions of the Export Administration Act of 1979,
            as
            amended, or the regulations promulgated thereunder, the Comptroller may,
            at his
            option, render forfeit and void this contract.

          C.
            The
            Contractor shall comply in all respects, with the provisions of Section
            6-114 of
            the Administrative Code of the City of New York and the rules and regulations
            issued by the Comptroller thereunder.

          

          4.14
            INVENTIONS.
            PATENTS AND COPYRIGHTS

          A.
            Any
            discovery or invention arising out of or developed in the course of performance
            of this Agreement shall be promptly and fully reported to the Department,
            and if
            this work is supported by a federal grant of funds, shall be promptly
            and fully
            reported to the Federal Government for determination as to whether patent
            protection on such invention shall be sought and how the rights in the
            invention
            or discovery, including rights under any patent issued thereon, shall
            be
            disposed of and administered in order to protect the public
            interest.

          B.
            No
            report, document or other data produced in whole or in part with contract
            funds
            shall be copyrighted by the Contractor nor shall any notice of copyright
            be
            registered by the Contractor in connection with any report, document
            or other
            data developed for the contract.

          C.
            In no
            case shall subsections A and B of this section apply to, or prevent the
            Contractor from asserting or protecting its rights in any report, document
            or
            other data, or any invention which existed prior to or was developed
            or
            discovered independently from the activities directly related to this
            Agreement.

          

          4.15
            INFRIGEMENTS

          The
            Contractor shall be liable to the Department and hereby agrees to indemnify
            and
            hold the Department harmless for any damage or loss or expense sustained
            by the
            Department from any infringement by the Contractor of any copyright,
            trademark
            or patent rights of design, systems, drawings, graphs, charts, specifications
            or
            printed matter furnished or used by the Contractor in the performance
            of this
            Agreement. 

          

          4.16
            ANTI-TRUST

           

          The
            Contractor hereby assigns, sells, and transfers to the City all right,
            title and
            interest in and to any claims and causes of action arising under the
            anti-trust
            laws of the State of New York or of the United States relating to the
            particular
            goods or services purchased or procured by the City under this
            Agreement.

           

          ARTICLE
            5. TERMINATION

           

          

          5.1
            TERMINATION
            OF AGREEMENT 

          A.
            The
            Department and/or City shall have the right to terminate this Agreement,
            in
            whole or in part:

          1.
            Under
            any right to terminate as specified in any section of this
            Agreement.

          2.
            Upon
            the failure of the Contractor to comply with any of the terms and conditions
            of
            this Agreement.

          3.
            Upon
            the Contractor's becoming insolvent.

          4.
            Upon
            the commencement under the Bankruptcy Act of any proceeding by or against
            the
            Contractor, either voluntarily or involuntarily.

          5.
            Upon
            the Commissioner's determination, termination is in the best interest
            of the
            City.

          B.
            The
            Department or City shall give the Contractor written notice of any termination
            of this Agreement specifying therein the applicable provisions of subsection
            A
            of this section and the effective date thereof which shall not be

          

           

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          less
            than
            ten (10) days from the date the notice is

           

          received.

          C.
            The
            Contractor shall be entitled to apply to the Department to have this
            Agreement
            terminated by said Department by reason of any failure in the performance
            of
            this Agreement (including any failure by the Contractor to make progress
            in the
            prosecution of work hereunder which endangers such performance), if such
            failure
            arises out of causes beyond the control and without the fault or negligence
            of
            the Contractor. Such causes may include, but are not restricted to: acts
            of God
            or of the public enemy; acts of the Government in either its sovereign
            or
            contractual capacity; fires; floods; epidemics; quarantine restrictions;
            strikes; freight embargoes; or any other cause beyond the reasonable
            control of
            the Contractor. The determination that such failure arises out-of causes
            beyond
            the control and without the fault or negligence of the Contractor shall
            be made
            by the Department which agrees to exercise reasonable judgment therein.
            If such
            a determination is made and the Agreement terminated by the Department
            pursuant
            to such application by the Contractor, such termination shall be deemed
            to be
            without cause.

          D.
             Upon
            termination of this Agreement the Contractor shall comply with the Department
            or
            City close-out procedures, including but not limited to:

          1.
            Accounting for and refund to the Department or City, within thirty (30)
            days,
            any unexpended funds which have been paid to the Contractor pursuant
            to this
            agreement.

          2.
            Furnishing within thirty (30) days an inventory to the Department or
            City of all
            equipment, appurtenances and property purchased through or provided under
            this
            Agreement carrying out any Department or City directive concerning the
            disposition thereof. 

          
            	3.  	
                    Not
                      incurring or paying any further obligation pursuant to this
                      Agreement
                      beyond the termination date. Any obligation necessarily incurred
                      by the .
                      Contractor on account of this Agreement prior to receipt of
                      notice of
                      termination and falling due after such date shall be paid by
                      the
                      Department or City in accordance with the terms of this Agreement.
                      In no
                      event shall the word "obligation," as used herein, be construed
                      as
                      including any lease agreement, oral or written, entered into
                      between the
                      Contractor and its landlord. 

                  

          

          
            	4.  	
                    Turn
                      over to the Department or City or its designees all books,
                      records,
                      documents and material specifically relating to this
                      Agreement.

                  

          

          5.
            Submit, within ninety (90) days, a final statement and report relating
            to this
            Agreement. The report shall be made by a certified public accountant
            or a
            licensed public accountant.

          E.
            In the
            event the Department or City shall terminate this Agreement, in whole
            or in
            part, as provided in paragraphs 1, 2, 3, or 4 of subsection A of this
            section,
            the Department or City may procure, upon such terms and in such manner
            as deemed
            appropriate, services similar to those so terminated, and the Contractor
            shall
            continue the performance of this Agreement to the extent not terminated
            hereby.

          F.
            Not
            withstanding any other provisions of this contract, the Contractor shall
            not be
            relieved of liability to the City for damages sustained by the City by
            virtue of
            Contractor's breach of the contract, and the City may withhold payments
            to the
            Contractor for the purpose of set-off until

          

           

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          such
            time
            as the exact amount of damages due to the City from the Contractor is
            determined.

          G.
            The
            provisions of the Agreement regarding confidentiality of information
            shall
            remain in full force and effect following any termination.

          H.
            The
            rights and remedies of the City provided in this section shall not be
            exclusive
            and are in addition to all other rights and remedies provided by law
            or under
            this Agreement.

           

          ARTICLE
            6. MISCELLANEOUS

          

          6.1
            CONFLICT OF LAWS

          All
            disputes arising out of this Agreement shall be interpreted and decided
            in
            accordance with the laws of the State of New York.

          

          6.2
            GENERAL RELEASE

          The
            acceptance by the Contractor or its assignees of the final payment under
            this
            contract, whether by voucher, judgment of any court of competent jurisdiction
            or
            any other administrative means, shall constitute and operate as a general
            release to the City from any and all claims of and liability to the Contractor
            arising out of the performance of this contract.

          

          6.3
            CLAIMS
            AND ACTIONS THEREON

          A.
            No
            action at law or proceeding in equity against the City or Department
            shall lie
            or be maintained upon any claim based upon this Agreement or arising
            out of this
            Agreement or in any way connected with this Agreement unless the Contractor
            shall have strictly complied with all requirements relating to the giving
            of
            notice and of information with respect to such claims, all as herein
            provided.

          B.
            No
            action shall lie or be maintained against the City by Contractor upon
            any claims
            based upon this Agreement unless such action shall be commenced within
            six (6)
            months after the date of filing in the Office of the Comptroller of the
            City of
            the certificate for the final payment hereunder, or within six (6) months
            of the
            termination or conclusion of this Agreement, or within six (6) months
            after the
            accrual of the Cause of Action, whichever first occurs.

           

          C.
            In the
            event any claim is made or any action brought in any way relating to
            the
            Agreement herein, the Contractor shall diligently render to the Department
            and/or the City of New York without additional compensation any and all
            assistance which the Department and/or the City of New York may require
            of the
            Contractor.

          D.
            The
            Contractor shall report to the Department in writing within three (3)
            working
            days of the initiation by or against the Contractor of any legal action
            or
            proceeding in connection with or relating to this Agreement.

          

          6.4
            NO
            CLAIM AGAINST OFFICERS. AGENTS OR EMPLOYEES 

          No
            claim
            whatsoever shall be made by the Contractor against any officer, agent
            or
            employee of the City for, or on account of, anything done or omitted
            in
            connection with this contract.

          

          6.5
            WAIVER

          Waiver
            by
            the Department of a breach of any provision of this Agreement shall not
            be
            deemed to be a waiver of any other or subsequent breach and shall not
            be
            construed to be a modification of the terms of the Agreement unless and
            until
            the same shall be agreed to in writing by the Department or City as required
            and
            attached to the original Agreement.

          

          6.6
            NOTICE

          The
            Contractor and the Department hereby designate the business addresses
            hereinabove specified as the places where all notices, directions or
            communications from one such party to the other party shall be delivered,
            or to
            which they shall be mailed. Actual delivery of any such notice, direction or
            communication to a party at the

          

          Profit.w/P.L.

          -12-

          

          aforesaid
            place, or delivery by certified mail shall be conclusive and deemed to
            be
            sufficient service thereof upon such party as of the date such notice,
            direction
            or communication is received by the party. Such address may be changed
            at any
            time by an instrument in writing executed and acknowledged by the party
            making
            such change and delivered to the other party in the manner as specified
            above.
            Nothing in this section shall be deemed to serve as a waiver of any requirements
            for the service of notice or process in the institution of an action
            or
            proceeding as provided by law, including the Civil Practice Law and
            Rules.

          

          6.7
            ALL LEGAL PROVISIONS DEEMED INCLUDED

          It
            is the
            intent and understanding of the parties to this Agreement that each and
            every
            provision of law required to be inserted in this Agreement shall be and
            is
            inserted herein. Furthermore, it is hereby stipulated that every such
            provision
            is to be deemed to be inserted herein, and if, through mistake or otherwise,
            any
            such provision is not inserted, or is not inserted in correct form, then
            this
            Agreement shall forthwith upon the application of either party be amended
            by
            such insertion so as to comply strictly with the law and without prejudice
            to
            the rights of either party hereunder.

          

          6.8
            SEVERABILITY

          If
            this
            Agreement contains any unlawful provision not an essential part of the
            Agreement
            and which shall not appear to have been a controlling or material inducement
            to
            the making thereof, the same shall be deemed of no effect and shall upon
            notice
            by either party, be deemed stricken from the Agreement without affecting
            the
            binding force of the remainder.

          

          6.9
            POLITICAL ACTIVITY

          There
            shall be no partisan political activity or any activity to further the
            election
            or defeat of any candidate for public, political or party office as part
            of or
            in connection with this Agreement, nor shall any of the funds provided
            under
            this Agreement be used for such purposes.

          

          6.10
            MODIFICATION

          This
            Agreement may be modified by the parties in writing in a manner not materially
            affecting the substance hereof. It may not be altered or modified
            orally.

           

          A.
            CONTRACT
            CHANGES
            Changes
            may be made to this contract only as duly authorized by the Agency Chief
            Contracting Officer of his or her designee. Vendors deviating from the
            requirements of an original purchase order or contract without a duly
            authorized
            change order document, or written contract modification or amendment,
            do so at
            their own risk. All such duly authorized changes, modifications and amendments
            will be reflected in a written change order and become a part of the
            original
            contract. Contract changes will be made only for work necessary to complete
            the
            work included in the original scope of the contract, and for non-material
            changes to the scope of the contract. Changes are not permitted for any
            material
            alteration in the scope of the work. Changes may include any one or more
            of the
            following:

          -
            Specification changes to account for design errors or omissions;

          -
            changes
            in contract amount due to authorized additional or omitted work. Any
            such
            changes require appropriate price and cost analysis to determine reasonableness.
            In addition, except for non-construction requirements contracts, all
            changes
            that cumulatively exceed the greater often percent of the original contract
            amount or $100,000 shall be approved by the City Chief Procurement
            Officer;

          -
            Extensions of a contract term for good and sufficient cause for a cumulative
            period not to exceed one year from the date of expiration of this current
            contract. Requirements contracts shall be subject to this
            limitation;

          -
            Changes
            in delivery location;

           

          -
            Changes
            in shipment method; and

          -
            Any
            other change not inconsistent with

          

          Profit.w/P.L.
            

          -13-

           

          

          §
5-02
            of
            the P.P.B. Rules (ed. 9/99), or any successor Rule.

          

          The
            Contractor may be entitled to a price adjustment for extra work performed
            pursuant to
            a
            written change order. If any part of the contract work is necessarily
            delayed by
            a change order, the Contractor may be entitled to an extension of time
            for
            performance. Adjustments to price shall be validated for reasonableness
            by using
            appropriate price and cost analysis.

          

          6.11
            PARAGRAPH
            HEADINGS

          Paragraph
            headings are inserted only as a matter of convenience and for reference
            and in
            no way define, limit or describe the scope or intent of this contract
            and in no
            way affect this contract.

          

          6.12
            NO
            REMOVAL OF RECORDS FROM PREMISES

          Where
            performance of this Agreement involves use by the Contractor of Departmental
            papers, files, data or records at Departmental facilities or offices,
            the
            Contractor shall not remove any such papers, files, data or records,
            therefrom
            without the prior approval of the Department's designated official.

          

          

          6.13
            INSPECTION
            AT SITE

          The
            Department shall have the right to have representatives of the Department
            or of
            the City or of
            the
            State or Federal governments present at the site of the engagement to
            observe
            the work being performed.

          

          6.14
            PRICING

          A.
             The
            Contractor shall when ever required during the contract, including but
            not
            limited to the time of bidding, submit cost or pricing data and formally
            certify
            that, to the best of its knowledge and belief, the cost or pricing date
            submitted was accurate, complete, and current as of a specified date.
            The
            Contractor shall be required to keep its submission of cost and pricing
            date
            current until the contract has been completed.

          B.
            The
            price of any change order or contract modification subject to the conditions
            of
            paragraph A, shall be adjusted to exclude any significant sums by which
            the City
            finds that such price was based on cost or price data furnished by the
            supplier
            which was inaccurate, incomplete, or not current as of the date agreed
            upon
            between the parties. 

          

          
            	C.  	
                    Time
                      for Certification.
                      The Contractor must certify that the cost or pricing data submitted
                      are
                      accurate, complete and current as of a mutually determined
                      date

                  

          

          D. Refusal
            to Submit Data.
            When any
            contractor refuses to submit the required data to support a price, the
            Contracting Officer shall not allow the price. 

          E. Certificate
            of Current Cost or Pricing Data.

          Form
            of Certificate.
            In those
            cases when cost or pricing data is required, certification shall be made
            using a
            certificate substantially similar to the one contained in Chapter 4 of
            the PPB
            rules and such certification shall be retained in the agency contract
            file.

          

          ARTICLE
            7. MERGER

          

          This
            written Agreement contains all the terms and conditions agreed upon by
            the
            parties hereto, and no other agreement, oral or otherwise, regarding
            the subject
            matter of tills Agreement shall be deemed to exist or to bind any of
            the parties
            hereto, or to vary any of the terms contained herein.

          

          ARTICLE
            8. CONDITIONS PRECEDENT

          This
            contract shall neither be binding nor effective unless:

          A.
             Approved
            by the Mayor pursuant to the provisions of Executive Order No. 42, dated
            October
            9, 1975, in the event the Executive Order requires such approval;
            and

          

          Profit.w/P.L.
            

          -14-

          

           

          

          
            	
                    B.
                      

                  	
                    Certified
                      by the Mayor (Mayor's Fiscal Committee created pursuant to
                      Executive Order
                      No. 43, dated October 14, 1975) that performance thereof will
                      be in
                      accordance with the City's financial plan; and

                  

          

          C.
             Approved
            by the New York State Financial Control Board (Board) pursuant to the
            New York
            State Financial Emergency Act for the City of New York, as amended, (the
            "Act"),
            in the event regulations of the Board pursuant to the Act require such
            approval.

          D.
             It
            has
            been authorized by the Mayor and the Comptroller shall have endorsed
            his
            certificate that there remains unexpended and unapplied a balance of
            the
            appropriation of funds applicable thereto sufficient to pay the estimated
            expense of carrying out this Agreement.

          

          The
            requirements of this section of the contract shall be in addition to,
            and not in
            lieu of, any approval or authorization otherwise required for this contract
            to
            be effective and for the expenditure of City funds.

           

          ARTICLE
            9. PPB RULES

          This
            contract is subject to the Rules of the Procurement Policy Board of the
            City of
            New York effective August 1, 1990, as amended. In the event of a conflict
            between said Rules and a provision of this contract, the Rules shall
            take
            precedence.

           

          ARTICLE
            10. STATE LABOR LAW AND CITY ADMINISTRATIVE CODE

          1.
            As
            required by New York State Labor Law Section 220-e:

          a.
            That
            in the hiring of employees for the performance of work under this contract
            or
            any subcontract hereunder, neither the Contractor, Subcontractor, nor
            any person
            acting on behalf of such Contractor or Subcontractor, shall by reason
            of race,
            creed, color, sex or national origin discriminate against any citizen
            of the
            State of New York who is qualified and available to perform the work
            to which
            the employment relates;

          b.
             That
            neither the Contractor, subcontractor, nor any person on his behalf shall,
            in
            any manner, discriminate against or intimidate any employee hired for
            the
            performance of work under this contract on account of race, creed, color,
            sex or
            national origin;

          c.
            That
            there may be deducted from the amount payable to the Contractor by the
            City
            under this contract a penalty of five dollars for each person for each
            calendar
            day during which such person was discriminated against or intimidated
            in
            violation of the provisions of this contract; and

          d.
            That
            this contract may be canceled or terminated by the City and all monies
            due or to
            become due hereunder may be forfeited, for a second or any subsequent
            violation
            of the terms or conditions of this section of the contract.

          e.
            The
            aforesaid provisions of this section covering every contract for or on
            behalf of
            the State or a municipality for the manufacture, sale or distribution
            of
            materials, equipment or supplies shall be limited to operations performed
            within
            the territorial limits of the State of New York.

          2.
            As
            required by New York City Administrative Code Section 6-108:

          a.
            It
            shall be unlawful for any person engaged in the construction, alteration
            or
            repair of buildings or engaged in the construction or repair of streets
            or
            highways pursuant to a contract with the City or. engaged in the manufacture,
            sale or distribution of' materials, equipment or supplies pursuant to
            a contract
            with the City to refuse to employ or to refuse to continue in any employment
            any
            person on account of the race, color or creed of such person.

          b.
            It
            shall be unlawful for any person or any servant, agent or employee of
            any
            person, described in subdivision (a) above, to ask, indicate or transmit,
            orally
            or in writing, directly or indirectly, the race, color, creed or religious
            affiliation of any person employed or seeking employment from such person,
            firm
            or corporation.

          

           

          Profit.w/P.L.
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          c.
            Disobedience of the foregoing provisions shall be deemed a violation
            of a
            material provision of this contract.

          d.
            Any
            person, or the employee, manager or owner of or officer of such firm
            or
            corporation who shall violate any of the provisions of this section shall,
            upon
            conviction thereof, be punished by a fine of not more than one hundred
            dollars
            or by imprisonment for not more than thirty days, or both.

           

          ARTICLE
            11. FORUM PROVISION

          Choice
            of Law, Consent to Jurisdiction and Venue This
            Contract shall be deemed to be executed in the City of New York, State
            of New
            York, regardless of the domicile of the Contractor, and shall be governed
            by and
            construed in accordance with the laws of the State of New York.

          The
            parties agree that any and all claims asserted by or against the City
            arising
            under this Contract or related thereto shall be heard and determined
            either in
            the courts of the United States located in New York City ("Federal Courts")
            or
            in the courts of the State of New York ("New York State Courts") located
            in the
            City and County of New York. To effect this Agreement and intent, the
            Contractor
            agrees:

          a.
            If the
            City initiates any action against the

          Contractor
            in Federal Court or in New York State Court, service of process may be
            made on
            the Contractor either in person, wherever such Contractor may be found,
            or by
            registered mail addressed to the Contractor at its address as set forth
            in this
            Contract, or to such other address as the Contractor may provide to the
            City in
            writing; and

          b.
            With
            respect to any action between the City and the Contractor in New York
            State
            Court, the Contractor hereby expressly waives and relinquishes any rights
            it
            might otherwise have (I) to move to dismiss on grounds of forum non
            conveniens;
            (ii) to
            remove to Federal Court; and (iii) to move for a change of venue to a
            New York
            State Court outside New York County.

          c.
            With
            respect to any action between the City and the Contractor in Federal
            Court
            located in New York City, the Contractor expressly waives and relinquishes
            any
            right it might otherwise have to move to transfer the action to a United
            States
            Court outside the City of New York.

          d.
            If the
            Contractor commences any action against the City in a court located other
            than
            in the City and State of New York, upon request of the City, the Contractor
            shall either consent to a transfer of the action to a court of competent
            jurisdiction located in the City and State of New York or, if the court
            where
            the action is initially brought will not or cannot transfer the action,
            the
            Contractor shall consent to dismiss such action without prejudice and
            may
            thereafter reinstitute the action in a court of competent jurisdiction
            in New
            York City. If any provision(s) of this Article is held unenforceable
            for any
            reason, each and all other provision(s) shall nevertheless remain in
            full force
            and effect.

           

          ARTICLE
            12. EQUAL EMPLOYMENT OPPORTUNITY

          This
            contract is subject to the requirements of Executive Order No. 50 (1980)
            as
            revised ("E.O. 50") and the Rules and Regulations promulgated thereunder.
            No
            contract will be awarded unless and until these requirements have been
            complied
            with in their entirety. By signing this contract, the contractor agrees
            that
            it:

          1.
            will
            not engage in any unlawful discrimination against any employee or applicant
            for
            employment because of race, creed, color, national origin, sex age, disability,
            marital status or sexual orientation with respect to all employment decisions
            including, but not limited to, recruitment, hiring, upgrading, demotion,
            downgrading, transfer, training, rates of pay or other forms of compensation,
            layoff, termination, and all other terms and conditions of
            employmEnt;

          2.
            the
            contractor agrees that when it subcontracts it will not engage in any
            unlawful
            discrimination in

           

          

          Profit.w/P.L.

          16-

           

          the
            selection of subcontractors on the basis of the owner's race, color,
            creed,
            national origin, sex, age. disability, marital status or sexual
            orientation;

          3.
            will
            state in all solicitations or advertisements for employees placed by
            or on
            behalf of the contractor that all qualified applicants will receive
            consideration for employment without unlawful discrimination based on
            race,
            creed, color, national origin, sex, age, disability, marital status or
            sexual
            orientation, or that it is an equal employment opportunity
            employer;

          4.
            will
            send to each labor organization or representative of workers with which
            it has a
            collective bargaining agreement or other contract or memorandum of
            understanding, written notification of its equal employment opportunity
            commitments under E. 0. 50 and the rules and regulations promulgated
            thereunder;
            and

          5.
            will
            furnish all information and reports including an Employment Report before
            the
            award of the contract which are required by E-. 0. 50, the rules and
            regulations
            promulgated thereunder, and orders of the Director of the Bureau of Labor
            Services ("Bureau"), and will permit access to its books, records and
            accounts
            by the Bureau for the purposes of investigation to ascertain compliance
            with
            such rules, regulations, and orders. The contractor understands that
            in the even
            of its noncompliance with nondiscrimination clauses of this contract
            or with any
            of such rules, regulations, or orders, such noncompliance shall constitute
            a
            material breach of the contract and noncompliance with the E. 0. 50 and
            the
            rules and regulations promulgated thereunder. After a hearing held pursuant
            to
            the rules of the Bureau, the Director may direct the imposition by the
            contracting agency held of any or all of the following sanctions:

          (I)
            disapproval of the contractor;

          (ii)
            suspension or termination of the contract;

          (iii)
            declaring the contractor in default; or (iv) in lieu of any of the foregoing
            sanctions, the Director may impose an employment program.

          The
            Director of the Bureau may recommend to the contracting agency head that
            a Board
            of Responsibility be convened for purposes of declaring a contractor
            who has
            repeatedly failed to comply with E.O. 50 and the rule and regulations
            promulgated thereunder to be nonresponsible. The contractor agrees to
            include
            the provisions of the foregoing paragraphs in every subcontract or purchase
            order in excess of $50,000 to which it becomes a party unless exempted
            by E.O.
            50 and the rules and regulations promulgated thereunder, so that such
            provisions
            will be binding upon each subcontractor or vendor. The contractor will
            take such
            action with respect to any subcontract or purchase order as may be directed
            by
            the Director of the Bureau of Labor Services as a means of enforcing
            such
            provisions, including sanctions for noncompliance.

          The
            contractor further agrees that it will refrain from entering into any
            contract
            or contract modification subject to E.O. 50 and the rules and regulations
            promulgated thereunder with a subcontractor who is not in compliance
            with the
            requirements of E.O. 50 and the rules and regulations promulgated
            thereunder.

           

          ARTICLE
            13. NO DAMAGE FOR DELAY

          The
            Contractor agrees to make no claim for damages for delay in the performance
            of
            this Contract occasioned by any act or omission to act of the City or
            any of its
            representatives, and agrees that any such claim shall be fully compensated
            for
            by an extension of time to complete performance of the work as provided
            herein.

           

          ARTICLE
            14. CONSULTANT REPORT INFORMATION

           

          A
            copy of
            each consultant report submitted by a consultant to any City official
            or to any
            officer, employee, agent or representative of a City department, agency,
            commission or body or to any

           

          

           

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          corporation,
            association or entity whose expenses are paid in whole or in part from
            the City
            treasury shall be furnished to the Commissioner of the department to
            which such
            report was submitted or, if not a City department, then to the chief
            controlling
            officer or officers of such other office or entity. A copy of such report
            shall
            also be furnished to the Director of the Mayor's Office of Construction
            for
            matters related to construction or to the Director of the Mayor's Office
            of
            Operations for all other matters.

           

          ARTICLE
            15. RESOLUTION OF DISPUTES

           

          15.1 All
            disputes between the City and the Contractor of the kind delineated in
            this
            section that arise under, or by virtue of, this Contract shall be finally
            resolved in accordance with the provisions of this section and Section
            5-11 of
            the Rules of the Procurement Policy Board ("PPB Rules"). The procedure
            for
            resolving all disputes of the kind delineated herein shall be the exclusive
            means of resolving any such disputes.

           

          a.
            This
            section shall not apply to disputes concerning matters dealt with in
            other
            sections of the PPB Rules or to disputes involving patents, copyrights,
            trademarks, or trade secrets (as interpreted by the courts of New York
            State)
            relating to proprietary rights in computer software.

           

          b.
            For
            construction and construction-related services this section shall apply
            only
            to

          disputes
            about the scope of work delineated by the Contract, the interpretation
            of
            Contract Documents, the amount to be paid for extra work or disputed
            work
            performed in connection with the Contract, the conformity of the Contractor's
            work to the Contract, and he acceptability and quality of the Contractor's
            work;
            such disputes arise when the Engineer makes a determination with which
            the
            Contractor disagrees.

          5.2
            All
            determinations required by this section shall be made in writing, clearly
            stated, with a reasoned explanation for the determination based on the
            information and evidence presented to the party making the determination.
            Failure to make such determination within the time period required by
            this
            section shall be deemed a non-determination without prejudice that will
            allow
            appeal to the next level.

           

          15.3
            During such time as any dispute is being presented, heard, and considered
            pursuant to this section, the contract terms shall remain in full force
            and
            effect and the Contractor shall continue to perform work in accordance
            with the
            Contract and as directed by the Agency Chief Contracting Officer or Engineer.
            Failure of the Contractor to continue the work as directed shall constitute
            a
            waiver by the Contractor of any and all claims being presented pursuant
            to this
            section and a material breach of Contract.

           

          15.4 Presentation
            of Dispute to Agency Head.

           

          (A)
            Notice of Dispute and Agency Response. The Contractor shall present its
            dispute
            in writing ("Notice of Dispute") to the Agency Head within the time specified
            herein or, if no time is specified, within thirty (30) days of receiving
            notice
            of the determination or action that is the subject of the dispute. This
            notice
            requirement shall not be read to replace any other notice requirements
            contained
            in the Contract. The Notice of Dispute shall include all the facts, evidence,
            documents, or other basis upon which the Contractor relies in support
            of its
            position, as well as a detailed computation demonstrating' how any amount
            of
            money claimed by the Contractor in the dispute was arrived at. Within
            thirty
            (30) days after receipt of the detailed written submission, the Agency
            Chief
            Contracting Officer or, in the case of construction or construction-related
            services, the Engineer shall submit to the Agency Head all materials
            he or she
            deems pertinent to the dispute. Following initial submissions to the
            Agency
            Head, either party may demand of the other the production of any document
            or
            other material the demanding party believes may be relevant to the dispute.
            The
            requested party shall produce all relevant materials

           

           

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          that
            are
            not otherwise protected by a legal privilege recognized by the courts
            of New
            York State. Any question of relevancy shall be determined by the Agency
            Head
            whose decision shall be final. Wilful failure of the Contractor to produce
            any
            requested material whose relevancy the Contractor has not disputed, or
            whose
            relevancy has been affirmatively determined, shall constitute a waiver
            by the
            Contractor of its claim.

           

          (B)
            Agency Head Inquiry. The Agency Head shall examine the material and may,
            in his
            or her discretion, convene an informal conference with the Contractor
            and the
            Agency Chief Contracting Officer and, in the case of construction or
            construction-related services, the Engineer to resolve the issue by mutual
            consent prior to reaching a determination. The Agency Head may seek such
            technical or other expertise as he or she shall deem appropriate, including
            the
            use of neutral mediators, and require any such additional material from
            either
            or both parties as he or she deems fit. The Agency Head's ability to
            render, and
            the effect of, a decision hereunder shall not be impaired by any negotiations
            in
            connection with the dispute presented, whether or not the Agency Head
            participated therein. The Agency Head may or, at the request of any party
            to the
            dispute, shall compel the participation of any other contractor with
            a contract
            related to the work of this Contract, and that contractor shall be bound
            by the
            decision of the Agency Head. Any contractor thus brought into the dispute
            resolution proceeding shall have the same rights to make presentations
            and to
            seek review as the Contractor initiating the dispute.

           

          (C)
            Agency Head Determination. Within thirty (30) days after the receipt
            of all
            materials and information, or such longer time as may be agreed to by
            the
            parties, the Agency Head shall make his or her determination and shall
            deliver
            or send a copy of such determination to the Contractor and Agency Chief
            Contracting Officer and, in the case of construction or construction-related
            services, the Engineer, together with a statement concerning how the
            decision
            may be appealed.

          

          (D)
            Finality of Agency Head Decision. The Agency Head's decision shall be
            final and
            binding on all parties, unless presented to the Contract Dispute Resolution
            Board pursuant to this section. The City may not take a petition to the
            Contract
            Dispute Resolution Board. However, should the Contractor take such a
            petition,
            the City may seek, and the Board may render, a determination less favorable
            to
            the Contractor and more favorable to the City than the decision of the
            Agency
            Head.

           

          15.5
            Presentation of Dispute to the Comptroller. Before any dispute may be
            brought by
            the Contractor to the Contract Dispute Resolution Board, the Contractor
            must
            first present its claim to the comptroller for his or her review, investigation,
            and possible adjustment.

           

          (A)
            Time,
            Form, and Content of Notice. Within thirty

          (3
            0)
            days of its receipt of a decision by the Agency Head, the Contractor
            shall
            submit to the Comptroller and to the Agency Head a Notice of Claim regarding
            its
            dispute with the Agency. The Notice of Claim shall consist of (i) a brief
            written statement of the substance of the dispute, the amount of money,
            if any,
            claimed and the reason(s) the Contractor contends the dispute was wrongly
            decided by the Agency Head; (ii) a copy of the written decision of the
            Agency
            Head, and (iii) a copy of all materials submitted by the Contractor to
            the
            Agency, including the Notice of Dispute. The Contractor may not present
            to the
            Comptroller any material not presented to the Agency Head, except at-the
            request
            of the Comptroller.

           

          (B)
            Agency Response. Within thirty (30) days of receipt of the Notice of
            Claim, the
            Agency shall make available to the Comptroller a copy of all material
            submitted
            by the Agency to the Agency Head in connection with the dispute. The
            Agency may
            not present to the Comptroller any material not presented to the Agency
            Head
            except at the request of the Comptroller.

           

          (C)
            Comptroller Investigation. The Comptroller may investigate the claim
            in dispute
            and, in the course of such

           

           

          

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          investigation,
            may exercise all powers provided in sections 7-201 and 7-203 of the New
            York
            City Administrative Code. In addition, the Comptroller may demand of
            either
            party, and such party shall provide, whatever additional material the
            Comptroller deems pertinent to the claim, including original business
            records of
            the Contractor. Wilful failure of the Contractor to produce within fifteen
            (15)
            days any material requested by the Comptroller shall constitute a waiver
            by the
            Contractor of its claim. The Comptroller may also schedule an informal
            conference to be attended by the Contractor, Agency representatives,
            and any
            other personnel desired by the Comptroller.

           

          (D)
            Opportunity of Comptroller to Compromise or Adjust Claim. The Comptroller
            shall
            have forty-five (45) days from his or her receipt of all materials referred
            to
            in 5. (C) to investigate the disputed claim. The period for investigation
            and
            compromise may be further extended by agreement between the Contractor
            and the
            Comptroller, to a maximum of ninety (90) days from the Comptroller's
            receipt of
            all the materials. The Contractor may not present its petition to the
            Contract
            Dispute Resolution Board until the period for investigation and compromise
            delineated in this paragraph has expired. In compromising or adjusting
            any claim
            hereunder, the Comptroller may not revise or disregard the terms of the
            Contract
            between the parties.

           

          15.6
            Contract Dispute Resolution Board. There shall be a Contract Dispute
            Resolution
            Board composed of:

           

          (a)
            the
            chief administrative law judge of the Office of Administrative Trials
            and
            Hearings ("OATH") or his/her designated OATH administrative law judge,
            who shall
            act as chairperson, and may adopt operational procedures and issue such
            orders
            consistent with this section as may be necessary in the execution of
            the
            Contract Dispute Resolution Board's functions, including, but not limited
            to,
            granting extensions of time to present or respond to submissions;

          

          (b)
            the
            City Chief Procurement Officer or a designee; or in the case of disputes
            involving construction, the Director of the Office of Construction or
            his/her
            designee; any designee shall have the requisite background to consider
            and
            resolve the merits of the dispute and shall not have participated personally
            and
            substantially in the particular matter that is the subject of the dispute
            or
            report to anyone who so participated, and

           

          (c)
            a
            neutral person with appropriate expertise. This person shall be selected
            by the
            presiding administrative law judge from a prequalified panel of individuals,
            established and administered by OATH, with appropriate background to
            act as
            decision-makers in a dispute. Such individuals may not have a contract
            or
            dispute with the City or be an officer or employee of any company or
            organization that does, or regularly represents persons. companies, or
            organizations having disputes with the City.

           

          15.7
            Petition to Contract Dispute Resolution Board. In the event the claim
            has not
            been settled or adjusted by the Comptroller within the period provided
            in this
            section, the Contractor, within thirty (30) days thereafter, may petition
            the
            Contract Dispute Resolution Board to review the Agency Head
            determination.

           

          (A)
            Form
            and Content of Petition by Contractor. The Contractor shall present its
            dispute
            to the Contract Dispute Resolution Board in the form of a Petition, which
            shall
            include (i) a brief written statement of the substance of the dispute,
            the
            amount of money, if any, claimed and the reason(s) the Contractor contends
            that
            the dispute was wrongly decided by the Agency Head; (ii) a copy of the
            written
            decision of the Agency Head; (iii) copies of all materials submitted
            by the
            Contractor to the Agency; (iv) a copy of the written decision of the
            Comptroller, if any, and (v) copies of all correspondence with, or written
            material submitted by the Contractor to, the Comptroller's Office. The
            Contractor shall concurrently submit four complete sets of the Petition:
            one to
            the Corporation Counsel (Attn: Commercial and

          

           

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          Real
            Estate Litigation Division), and three to the Contract Dispute Resolution
            Board
            at oath's
            offices
            with proof of service on the Corporation Counsel. In addition, the supplier
            shall submit a copy of the statement of the substance of the dispute,
            cited in
            (i) above to both the Agency Head and the Comptroller.

           

          (B)
            Agency Response. Within thirty (30) days of its receipt of the Petition
            by the
            Corporation Counsel, the Agency shall respond to the brief written statement
            of
            the Contractor and make available to the Board at oath's
            offices
            and one to the Contractor, all material it submitted to the Agency Head
            and
            Comptroller. Extensions of time for submittal of the agency response
            shall be
            given as necessary upon a showing of good cause or, upon the consent
            of the
            parties, for an initial period of up to thirty (30) days.

           

          (C)
            Further Proceedings. The Board shall permit the Contractor to present
            its case
            by

          the
            submission of memoranda, briefs, and oral argument. The Board shall also
            permit
            the Agency to present its case in response to the Contractor by the submission
            of memoranda, briefs, and oral argument. If requested by the Corporation
            Counsel, the Comptroller shall provide reasonable assistance in the preparation
            of the Agency's case. Neither the Contractor nor the Agency may support
            its case
            with any documentation or other material that was not considered by the
            Comptroller, unless requested by the Board. The Board, at its discretion,
            may
            seek such technical or other expertise as it shall deem appropriate and
            may
            seek, on its own or upon application of a party, any such additional
            material
            from any party as it deems fit. The Board, in its discretion, may combine
            more
            than one dispute between the parties of concurrent resolution.

          

          (D)
            Contract Dispute Resolution Board Determination. Within forty-five (45)
            days of
            the conclusion of all written submissions and oral arguments, the Board
            shall
            render a written decision resolving the dispute. In an unusually complex
            case,
            the Board may render its decision in a longer period of time, not to
            exceed
            ninety (90) days, and shall so advise the parties at the commencement
            of this
            period. The Board's decision must be consistent with the terms of the
            Contract.
            In reaching its decision, the Board shall accord no precedential significance
            to
            prior decisions of the Board involving other non-related contracts.

           

          (E)
            Notification of Contract Dispute Resolution Board Decision. The Board
            shall send
            a copy of its decision to the Contractor, the Agency Chief Contracting
            Officer,
            the Corporation Counsel, the Comptroller, and in the case of construction
            or
            construction-related services, the Engineer. A decision in favor of the
            Contractor shall be subject to the prompt payment provisions of the PPB
            Rules.
            The Required Payment Day shall be thirty (30) days after the date the
            parties
            are formally notified of the Board's decision.

           

          (F)
            Finality of Contract Dispute Resolution Board Decision. The Board's decision
            shall be final and binding on all parties. Any party may seek review
            of the
            Board's decision solely in the form of a challenge, made within four
            (4) months
            of the date of the Board's decision, in a court of competent jurisdiction
            of the
            State of New York, County of New York, pursuant to Article 78 of the
            Civil
            Practice Law and Rules. Such review by the court shall be limited to
            the
            question of whether or not the Board's decision was made in violation
            of lawful
            procedure, was affected by an error of law, or was arbitrary and capricious
            or
            an abuse of discretion. No evidence or information shall be introduced
            or relied
            upon in such proceeding that was not presented to the Board in' accordance
            with
            Section 5-11 of the PPB Rules.

           

          15.8
            Any
            termination, cancellation, or alleged breach of the Contract prior to
            or during
            the pendency of any proceedings pursuant to this section shall not affect
            or
            impair the ability of the Agency Head or Contract Dispute Resolution
            Board to
            make a binding and final decision pursuant to this section.

           

          ARTICLE
            16. PROMPT PAYMENT

           

          The
            Prompt Payment provisions set forth in Chapter 5,

           

          

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          Section
            5-07 of the Procurement Policy Board Rules in effect at the time for
            this
            solicitation will be applicable to payments made under this contract.
            The
            provisions require the payment to the contractors of interest on payments
            made
            after the required payment date except as set forth in subdivisions c(3)
            and
            d(2), (3), (4) and (5) of Section 5-07 of the Rules.

           

          The
            contractor must submit a proper invoice to receive payment, except where
            the
            contract provides that the contractor will be paid at predetermined intervals
            without having to submit an invoice for each scheduled payment.

           

          Determinations
            of interest due will be made in accordance with the provisions of the
            Procurement Policy Board Rules and General Municipal Law Section
            3-a.

           

          ARTICLE
            17.

          MACBRIDE
            PRINCIPLES PROVISIONS FOR NEW YORK CITY CONTRACTORS

           

          ARTICLE
            I. MACBRIDE PRINCIPLES NOTICE TO ALL PROSPECTIVE
            CONTRACTORS

          Local
            Law
            No. 34 of 1991 became effective on September 10, 1991 and added section
            6-115.1
            to the Administrative Code of the City of New York. The local law provides
            for
            certain restrictions on City contracts to express the opposition of the
            people
            of the City of New York to employment discrimination practices in Northern
            Ireland and to encourage companies doing business in Northern Ireland
            to promote
            freedom of workplace opportunity.

          Pursuant
            to Section 6-115. ^prospective contractors for contracts to provide goods
            or
            services involving an expenditure of an amount greater than ten thousand
            dollars, or for construction involving an amount greater than fifteen
            thousand
            dollars, are asked to sign a rider in which they covenant and represent,
            as a
            material condition of their contract, that any business in Northern Ireland
            operations conducted by the contractor and any individual or legal entity
            in
            which the contractor holds a ten percent or greater ownership interest
            and any
            individual or legal entity that holds a ten percent or greater ownership
            interest in the contractor will be conducted in accordance with the MacBride
            Principles of nondiscrimination in employment.

          Prospective
            contractors are not required to agree to these conditions. However, in
            the case
            of contracts let by competitive sealed bidding, whenever the lowest responsible
            bidder has not agreed to stipulate to the conditions set forth in this
            notice
            and another bidder who has agreed to stipulate to such conditions has
            submitted
            a bid within five percent of the lowest responsible bid for a contract
            to supply
            goods, services or construction of comparable quality, the contracting
            entity
            shall refer such bids to the Mayor, the Speaker or other officials, as
            appropriate, who may determine, in accordance with applicable law and
            rules,
            that it is in the best interest of the city that the contract be awarded
            to
            other than the lowest responsible bidder pursuant to Section 313 (b)(2)
            of the
            City Charter.

          In
            the
            case of contracts let by other than competitive sealed bidding, if a
            prospective
            contractor does not agree to these conditions, no agency, elected official
            or
            the Council shall award the contract to that bidder unless the entity
            seeking to
            use the goods, services or construction certifies in writing that the
            contract
            is necessary for the entity to perform its functions and there is no
            other
            responsible contractor who will supply goods, services or construction
            of
            comparable quality at a comparable price.

           

          PART
            A

          In
            accordance with section 6-115.1 of the Administrative Code of the City
            of New
            York, the contractor stipulates that such contractor and any individual
            or legal
            entity in which the contractor holds a ten percent or greater ownership
            interest
            and any individual or legal entity that holds a ten percent or greater
            ownership
            interest in the contractor either (a) have no business operations in
            Northern
            Ireland, or (b) shall take lawful steps in good faith to conduct any
            business
            operations they have in Northern Ireland in accordance with the MacBride
            Principles, and shall permit independent monitoring of their compliance
            with
            such principles.

           

           

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          PART
            B

           

          For
            purposes of this section, the following terms shall have the following
            meanings:

          1.
            "MacBride Principles" shall mean those principles relating to nondiscrimination
            in employment and freedom of workplace opportunity which require employers
            doing
            business in Northern Ireland to:

          (1)
            increase the representation of individuals from under represented religious
            groups in the work force, including managerial, supervisory, administrative,
            clerical and technical jobs;

          (2)
            take
            steps to promote adequate security for the protection of employees from
            under
            represented religious groups both at the workplace and while traveling
            to and
            from work;

          (3)
            ban
            provocative religious or-political emblems from the workplace;

          (4)
            publicly advertise all job openings and make special recruitment efforts
            to
            attract applicants from under represented religious groups;

          (5)
            establish layoff, recall and termination procedures which do not in practice
            favor a particular religious group;

          (6)
            abolish all job reservations, apprenticeship restrictions and different
            employment criteria which discriminate on the basis of religion;

          (7)
            develop training programs that will prepare substantial numbers of current
            employees from under represented religious groups for skilled jobs, including
            the expansion of existing programs and the creation of new programs to
            train,
            upgrade and improve the skills of workers from under represented religious
            groups;

          (8)
            establish procedures to assess, identify and actively recruit employees
            from
            under represented religious groups with potential for further advancement;
            and

          (9)
            appoint a senior management staff member to oversee affirmative action
            efforts
            and develop a timetable to ensure their full implementation.

          

          ARTICLE
            II. ENFORCEMENT OF ARTICLE I.

          The
            contractor agrees that the covenants and representation in Article I
            above are
            material conditions to this contract. In the event the contracting entity
            receives information that the contractor who made the stipulation required
            by
            this section is in violation thereof, the contracting entity shall review
            such
            information and give the contractor an opportunity to respond. If the
            contracting entity finds that a violation has occurred, the entity shall
            have
            the right to declare the contractor in default and/or terminate this
            contract
            for cause and procure the supplies, services or work from another source
            in any
            manner the entity deems proper. In the event of such termination, the
            contractor
            shall pay to the entity, or the entity in its sole discretion may withhold
            from
            any amounts otherwise payable to the contractor, the difference between
            the
            contract price for the uncompleted portion of this contract and the cost
            to the
            contracting entity of completing performance of this contract either
            itself or
            by engaging another contractor or contractors. In the case of a requirements
            contract, the contractor shall be liable for such difference in price
            for the
            entire amount of supplies required by the contracting entity for the
            uncompleted
            term of its contract. In the case of a construction contract, the contracting
            entity shall also have the right to hold the contractor in partial or
            total
            default in accordance with the default provisions of this contract, and/or
            may
            seek debarment or suspension of the contractor. The rights and remedies
            of the
            entity hereunder shall be in addition to, and not in lieu of, any rights
            and
            remedies the entity has pursuant to this contract or by operation of
            law.

           

           

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