Document:

EX-10.48.1

MEDICAID MANAGED CARE MODEL CONTRACT

Amendment of Agreement

Between

The City of New York

And

CarePlus, LLC

This Amendment, effective January 1, 2005, amends the Medicaid Managed Care Model Contract
(hereinafter referred to as the “Agreement”) made by and between the City of New York acting
through the New York City Department of Health and Mental Hygiene (hereinafter referred to as
"DOHMH” or “LDSS”) and  CarePlus, LLC  (hereinafter referred to as “MCO”
or “Contractor”).

WHEREAS, the parties entered into an Agreement effective October 1, 2004 for the purpose of
providing prepaid case managed health services to Medical Assistance recipients residing in New
York City; and

WHEREAS, the parties desire to amend said Agreement to modify certain provisions to reflect
current circumstances and intentions;

NOW THEREFORE, effective January 1, 2005, it is mutually agreed by the parties to amend this
Agreement as follows:

The attached “Table of Contents for Model Contract” is substituted for the period
beginning January 1, 2005.

Add to Section 1, Definitions, a definition for “Permanent Placement Status,” to read as

follows:

“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
on medical evidence affirming the individual’s need for permanent RHCF placement.

Amend Section 3.1 (c), “Capitation Payments,” to read as follows:

	 	c)	 	The monthly capitation payments and the Supplemental Newborn Capitation Payment and the
Supplemental Maternity Capitation Payment to the Contractor shall constitute full and
complete payments to the Contractor for all services that the Contractor provides pursuant to
this Agreement subject to stop-loss provisions set forth in Section 3.11, 3.12, and 3.13 of
this Agreement.

January 1, 2005 Amendment

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Add a new Section 3.13, “Residential Health Care Facility Stop-Loss,” to
read as follows: 3.13 Residential Health Care Facility Stop-Loss

The Contractor will be compensated for medically necessary and clinically appropriate
Medicaid reimbursable inpatient Residential Health Care Facility services as defined in
Appendix K in excess of sixty (60) days during a calendar year at the lower of the
Contractor’s negotiated rates or Medicaid rate of payment.

Add a new Section 3.14, “Stop-Loss Procedures and Documentation,” to read as
follows: 3.14 Stop-Loss Procedures and Documentation

The Contractor must follow procedures and documentation requirements in accordance
with the New York State Department of Health stop-loss policy and procedure manual.
Payments made for stop-loss claims that do not conform to SDOH requirements are
subject to recoupment.

Renumber Sections 3.13, “Enrollment Limitations,” and 3.14, “Tracking Visits Provided
by Indian Health Clinics,” as Sections 3.15, and 3.16 respectively.

Amend Section 18.2, “SDOH Instructions for Report Submissions” to read as follows:

SDOH, with prior notice to the LDSS, will provide Contractor with instructions for submitting the
reports required by Section 18.5 (a) through (m), including time frames, and requisite formats.
The instructions, time frames and formats may be modified by SDOH with prior notice to the LDSS,
and thereafter upon sixty (60) days written notice to the Contractor. The LDSS, with prior notice
to SDOH, shall provide the Contractor with instructions for submitting the reports required by
Section 18.5(n), including time frames and requisite formats.

Amend Section 18.4, “Notification of Changes in Report Due Dates, Requirements or
Formats" to read as follows:

SDOH or LDSS may extend due dates, or modify report requirements or formats upon a written
request by the Contractor to the SDOH or LDSS with a copy of the request to the other agency,
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
SDOH with regard to annual and quarterly statements, complaint reports, audits, encounter data,
change of ownership, clinical studies, QARR, and provider network reports. The determination to
grant a modification or extension of time shall be made by the LDSS with respect to reports
required by Sections 18.5 (m) and (n) of the Agreement.

Amend “Reporting Requirements,” Section 18.5 (c), “Other Financial Reports” to read
as follows:

c) 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 §§ 98.11, 98.16 and
98.17 and applicable Insurance Law §§ 304, 305, 306, and 310. The LDSS reserves the right to
require Contractor to submit such relevant financial reports and documents related to the
financial condition of the MCO to the LDSS, as set forth in Section 18.5(n) of this
Agreement.

Amend “Reporting Requirements,” Section 18.5 (f), “Complaint Reports” to read as
follows: f) Complaint Reports:

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 received during the,, preceding
quarter on the Health Provider Network (“HPN”).

January 1, 2005 Amendment

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2

The Contractor also agrees to provide on a quarterly basis, via the HPN, the
total number of complaints that have been unresolved for more than forty-five (45) days. The
Contractor shall maintain records on these and other complaints which shall include all
correspondence related to the complaint, and an explanation of disposition. These records
shall be readily available for review by the SDOH or LDSS upon request.

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

The LDSS reserves the right to require the Contractor to submit a hardcopy of complaint
reports in Section 18.5(n) of this Agreement.

Amend Section 32.2, “Indemnification by LDSS,” to read as follows:

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

The attached Appendix K, “Prepaid Benefit Package Definitions of Covered and
Non-Covered Services,” is substituted for the period beginning January 1, 2005.

Schedule A of Appendix K, “Prepaid Benefit Package Coverage Status of Optional Covered
Services,” as included in the executed Agreement effective October 1, 2004, remains
unchanged.

January 1, 2005 Amendment

3

This Amendment is effective January 1, 2005, and the Agreement, including the modifications
made by this Amendment, shall remain in effect until September 30, 2005 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 Amendment to the Agreement on the dates
appearing below their respective signatures below.

	 	 	 	 	 
	For the Contractor:	 	For the LDSS:
	By /s/ K Ajmani	 	By
	Karin Ajmani
	(Printed Name)	 	(Printed Name)
	Title President & CEO	 	Title
	Date	 	Date

January 1, 2005 Amendment

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I:IDATAIINTERGOVICONTRACT\05AMDRHCIAMENDMNT\AM 105nyc.DOC Last revised 11/26/04

January 1, 2005 Amendment

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Table of Contents for Model Contract

Recitals

	 	 	 	 	 
	Section 1

	 	Definitions
	 	

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

	 
	 	 	 	 
	
 
	 	Administration Provisions

2.1

2.2

2.3

2.4

2.5

2.6

2.7
	 	

Term

Amendments and Extensions

Approvals

Entire Agreement

Renegotiation

Assignment and Subcontracting

Termination

a. LDSS Initiated Termination of Contract

b. Contractor and LDSS Initiated Termination

c. Contractor Initiated Termination

d. Termination Due to Loss of Funding

	 	 	 	 	 
	
 
	 	2.8

2.9

2.10

2.11
	 	Close-Out Procedures

Rights and Remedies

Notices

Severability
	 
	 	 	 	 
	Section 3

	 	Compensation

3.1

3.2

3.3

3.4

3.5

3.6

3.7

3.8

3.9

3.10

3.11

3.12
	 	

Capitation Payments

Modification of Rates During Contract Period

Rate Setting Methodology

Payment of Capitation

Denial of Capitation Payments

SDOH Right to Recover Premiums

Third Party Health Insurance Determination

Payment for Newborns

Supplemental Maternity Capitation Payment

Contractor Financial Liability

Inpatient Hospital Stop-Loss Insurance

Mental Health and Chemical Dependence Stop-Loss

	 	 	 	 	 
	 	 	3.13 Residential Health Care Facility Stop-Loss

	 
	 	 	 	 
	
 
	 	3.14

3.15

3.16
	 	Stop-Loss Procedures and Documentation

Enrollment Limitations

Tracking Visits Provided by Indian Health Clinics
	 
	 	 	 	 
	Section 4

	 	Service Area
	 	

	 
	 	 	 	 
	Section 5	 	Eligible, Exempt and Excluded Populations

	 
	 	 	 	 
	
 
	 	5.1

5.2

5.3

5.4

5.5
	 	Eligible Populations

Exempt Populations

Excluded Populations

Family Health Plus

Family Enrollment

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January 1, 2005

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Table of Contents for Model Contract

	 	 	 	 	 
	Section 6

	 	Enrollment

6.1

6.2

6.3

6.4

6.5

6.6

6.7

6.8

6.9

6.10
	 	

Enrollment Guidelines

Equality of Access to Enrollment

Enrollment Decisions

Auto Assignment

Prohibition Against Conditions on Enrollment

Family Enrollment

Newborn Enrollment

Effective Date of Enrollment

Roster

Automatic Re-Enrollment
	 
	 	 	 	 
	Section 7

	 	Lock-In Provisions

7.1

7.2

7.3

7.4
	 	

Lock-In Provisions in Voluntary Counties

Lock-In Provisions in Mandatory Counties and New York City

Disenrollment During Lock-In Period

Notification Regarding Lock-In and End of Lock-In Period
	 
	 	 	 	 
	Section 8

	 	Disenrollment

8.1

8.2

8.3

8.4
	 	

Disenrollment Guidelines

Disenrollment Prohibitions

Reasons for Voluntary Disenrollment

Processing of Disenrollment Requests

a. Routine Disenrollment

b. Expedited Disenrollment

c. Retroactive Disenrollment

	 	 	 
	8.5

8.6

8.7

	 	Contractor Notification of Disenrollments

Contractor’s Liability

Enrollee Initiated Disenrollment

a. Disenrollment for Good Cause

	 	 	 	 	 
	
 
	 	8.8

8.9
	 	Contractor Initiated Disenrollment

LDSS Initiated Disenrollment
	 
	 	 	 	 
	Section 9

	 	Guaranteed Eligibility
	 	

	 
	 	 	 	 
	Section 10	 	Benefit Package, Covered and Non-Covered Services

	 
	 	 	 	 
	
 
	 	10.1

10.2

10.3
	 	Contractor Responsibilities

Compliance with State Medicaid Plan and Applicable Laws

Definitions

	 	 	 
	10.4 Provision of Services Through Participating and Non-Participating Providers

	 
	 	 
	10.5

10.6

10.7

10.8

10.9

10.10

10.11

10.12

10.13

10.14

10.15

	 	Child Teen Health Program / Adolescent Preventive Services

Foster Care Children

Child Protective Services

Welfare Reform

Adult Protective Services

Court-Ordered Services

Family Planning and Reproductive Health Services

Prenatal Care

Direct Access

Emergency Services

Medicaid Utilization Thresholds (MUTS)

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2

Table of Contents for Model Contract

10.16 Services for Which Enrollees Can Self-Refer

a. Mental Health and Chemical Dependence Services

b. Vision Services

c. Diagnosis and Treatment of Tuberculosis

d. Family Planning and Reproductive Health Services

e. Article 28 Clinics Operated by Academic Dental Centers

	 	 	 
	10.17

10.18

10.19

	 	Second Opinions for Medical or Surgical Care

Coordination with Local Public Health Agencies

Public Health Services

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

b. Immunizations

c. Prevention and Treatment of Sexually Transmitted Diseases

d. Lead Poisoning

	 	 	 
	10.20

10.21

10.22

10.23

10.24

10.25

10.26

10.27

	 	Adults with Chronic Illnesses and Physical or Developmental Disabilities

Children with Special Health Care Needs

Persons Requiring Ongoing Mental Health Services

Member Needs Relating to HIV

Persons Requiring Chemical Dependence Services

Native Americans

Women, Infants, and Children (WIC)

Urgently Needed Services

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

10.29 Coordination of Services

10.30 Prospective Benefit Package Change for Retroactive SSI Determinations

	 	 	 	 	 
	Section 11

	 	Marketing

11.1

11.2

11.3

11.4

11.5
	 	

Marketing Plan

Marketing Activities

Prior Approval of Marketing Materials, Procedures, Subcontracts

Marketing Infractions

LDSS Option to Adopt Additional Marketing Guidelines
	 
	 	 	 	 
	Section 12

	 	Member Services

12.1

12.2

12.3
	 	

General Functions

Translation and Oral Interpretation

Communicating with the Visually, Hearing and Cognitively Impaired
	 
	 	 	 	 
	Section 13

	 	Enrollee Notification

13.1

13.2

13.3

13.4

13.5

13.6

13.7

13.8

13.9
	 	

Provider Directories/Office Hours for Participating Providers

Member ID Cards

Member Handbooks

Notification of Effective Date of Enrollment

Notification of Enrollee Rights

Enrollee’s Rights to Advance Directives

Approval of Written Notices

Contractor’s Duty to Report Lack of Contact

Contractor Responsibility to Notify Enrollee of Expected Effective Date

of Enrollment

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Table of Contents for Model Contract

13.10 LDSS Notification of Enrollee’s Change in Address

	 	13.11	 	Contractor Responsibility to Notify Enrollee of Effective
Date of Benefit Package Change	 

	 	13.12	 	Contractor Responsibility to Notify Enrollee of Termination,
Service Area Changes and Network Changes

	 	 	 	 	 
	Section 14	 	Complaint and Appeal Procedure

	 
	 	 	 	 
	
 
	 	14.1

14.2

14.3

14.4
	 	Contractor’s Program to Address Complaints

Notification of Complaint and Appeal Program

Guidelines for Complaint and Appeal Program

Complaint Investigation Determinations
	 
	 	 	 	 
	Section 15

	 	Access Requirements

15.1

15.2

15.3

15.4
	 	

Appointment Availability Standards

Twenty-Four (24) Hour Access

Appointment Waiting Times

Travel Time Standards

a. Primary Care

b. Other Providers

15.5 Service Continuation

a. New Enrollees

b. Enrollees Whose Health Care Provider Leaves Network

	 	 	 	 	 	 	 
	
 
	 	15.6

15.7

15.8
	 	Standing Referrals

Specialist as a Coordinator of Primary Care

Specialty Care Centers
	 
	 	 	 	 	 	 
	Section 16

	 	Quality Assurance

16.1

16.2
	 	

Internal Quality Assurance Program

Standards of Care
	 
	 	 	 	 	 	 
	Section 17

	 	Monitoring and Evaluation

17.1

17.2

17.3

17.4
	 	

Right To Monitor Contractor Performance

Cooperation During Monitoring And Evaluation

Cooperation During On-Site Reviews

Cooperation During Review of Services by External Review Agency
	 
	 	 	 	 	 	 
	Section 18	 	Contractor Reporting Requirements
	 
	 	 	 	 	 	 
	
 
	 	 	18.1	 	 	Time Frames for Report Submissions

18.2 SDOH Instructions for Report Submissions 18.3
Liquidated Damages

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

a. Annual Financial Statements

b. Quarterly Financial Statements

c. Other Financial Reports

d. Encounter Data

e. Quality of Care Performance Measures

f. Complaint Reports

g. Fraud and Abuse Reporting Requirements

h. Participating Provider Network Reports

i. Appointment Availability/Twenty-Four Hour (24) Access and

Availability Surveys

j. Clinical Studies

k. Independent Audits

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4

Table of Contents for Model Contract

1. New Enrollee Health Screening Completion Report

m. Additional Reports

n. LDSS Specific Reports

	 	 	 
	18.6

18.7

18.8

18.9

	 	Ownership and Related Information Disclosure

Revision of Certificate of Authority

Public Access to Reports

Professional Discipline

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

	 	 	 
	
 
	 	18.11 Conflict of Interest Disclosure

18.12 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 Medicaid Recipients and
Applicants

	 	 	 	 	 
	Section 21

	 	20.2

20.3

20.4

Participating Providers

21.1
	 	Medical Records of Foster Children

Confidentiality of Medical Records

Length of Confidentiality Requirements

Network Requirements

a. Sufficient Number

b. Absence of Appropriate Network Provider

c. Suspension of Enrollee Assignments to Providers

d. Notice of Provider Termination

21.2 Credentialing

a. Licensure

b. Minimum Standards

c. Credentialing/Recredentialing Process

d. Application Procedure

	 	 	 
	21.3

21.4

21.5

21.6

21.7

21.8

21.9

21.10

21.11

	 	SDOH Exclusion or Termination of Providers

Evaluation Information

Payment In Full

Choice/Assignment of PCPs

PCP Changes

Provider Status Changes

PCP Responsibilities

Member to Provider Ratios

Minimum Office Hours

a. General Requirements

b. Medical Residents

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	 	 	Table of Contents for Model Contract
	21.12

	 	Primary Care Practitioners

a. General Limitations

b. Specialists and Sub-specialists as PCPs

c. OB/GYN Providers as PCPs

d. Certified Nurse Practitioners as PCPs

e. Registered Physician’s Assistants as Physician Extenders

21.13 PCP Teams

a. General Requirements

b. Medical Residents

21.14 Hospitals

a. Tertiary Services

b. Emergency Services

	 	 	 	 	 
	
 
	 	21.15

21.16

21.17

21.18

21.19

21.20
	 	Dental Networks

Presumptive Eligibility Providers

Mental Health and Chemical Dependence Services Providers

Laboratory Procedures

Federally Qualified Health Centers (FQHCs)

Provider Services Function
	 
	 	 	 	 
	Section 22	 	Subcontracts and Provider Agreements

	 
	 	 	 	 
	
 
	 	22.1

22.2

22.3

22.4

22.5

22.6

22.7

22.8

22.9

22.10

22.11

22.12
	 	Written Subcontracts

Permissible Subcontracts

Provision of Services Through Provider Agreements

Approvals

Required Components

Timely Payment

Restrictions on Disclosure

Transfer of Liability

Termination of Health Care Professional Agreements

Health Care Professional Hearings

Non-Renewal of Provider Agreements

Physician Incentive Plan
	 
	 	 	 	 
	Section 23

	 	Fraud and Abuse Prevention Plan
	 	

	 
	 	 	 	 
	Section 24	 	Americans With Disabilities Act Compliance Plan

	 
	 	 	 	 
	Section 25

	 	Fair Hearings

25.1

25.2

25.3

25.4

25.5

25.6
	 	

Enrollee Access to Fair Hearing Process

Enrollee Rights to a Fair Hearing

Contractor Notice to Enrollees

Aid Continuing

Responsibilities of SDOH

Contractor’s Obligations
	 
	 	 	 	 
	Section 26

	 	External Appeal

26.1

26.2

26.3

26.4
	 	

Basis for External Appeal

Eligibility For External Appeal

External Appeal Determination

Compliance With External Appeal Laws and Regulations

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January I, 2005

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Table of Contents for Model Contract

	 	 	 	 	 
	Section 27

	 	Intermediate Sanctions
	 	

	 
	 	 	 	 
	Section 28

	 	Environmental Compliance
	 	

	 
	 	 	 	 
	Section 29

	 	Energy Conservation
	 	

	 
	 	 	 	 
	Section 30

	 	Independent Capacity of Contractor
	 	

	 
	 	 	 	 
	Section 31

	 	No Third Party Beneficiaries
	 	

	 
	 	 	 	 
	Section 32

	 	Indemnification

32.1

32.2
	 	

Indemnification by Contractor

Indemnification by LDSS
	 
	 	 	 	 
	Section 33	 	Prohibition on Use of Federal Funds for Lobbying

	 
	 	 	 	 
	
 
	 	33.1

33.2

33.3
	 	Prohibition of Use of Federal Funds for Lobbying

Disclosure Form to Report Lobbying

Requirements of Subcontractors
	 
	 	 	 	 
	Section 34

	 	Non-Discrimination

34.1

34.2

34.3
	 	

Equal Access to Benefit Package

Non-Discrimination

Equal Employment Opportunity

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

	 	 	 	 	 	 	 
	Section 35	 	Compliance with Applicable Laws
	 
	 	 	 	 	 	 
	
 
	 	 	35.1	 	 	Contractor and LDSS Compliance With Applicable Laws

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

	 	 	 
	
 
	 	35.3 Certificate of Authority Requirements

35.4 Notification of Changes In Certificate of Incorporation

35.5 Contractor’s Financial Solvency Requirements

35.6 Compliance With Care For Maternity Patients

35.7 Informed Consent Procedures for Hysterectomy and Sterilization

35.8 Non-Liability of Enrollees For Contractor’s Debts

35.9 LDSS Compliance With Conflict of Interest Laws

35.10 Compliance With PHL Regarding External Appeals
	 
	 	 
	Section 36

	 	New York State Standard Contract Clauses

Section 37 Insurance
Requirements Signature Page

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	 	 	 	Table of Contents for Model Contract
APPENDICES	 

A. New York State Standard Clauses and Local Standard Clauses, if applicable

B. Certification Regarding Lobbying

	 	C.	 	New York State Department of Health Guidelines for the Provision of Family Planning and
Reproductive Health Services	 

D. New York State Department of Health Marketing Guidelines

E. New York State Department of Health Member Handbook Guidelines

	 	F.	 	New York State Department of Health Medicaid Managed Care Complaint and Appeals
Requirements	 

	 	G.	 	New York State Department of Health Guidelines for the Provision of Emergency Care and
Services	 

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

I. New York State Department of Health Guidelines for Use of Medical Residents

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

K. Prepaid Benefit Package Definitions of Covered and Non-Covered Services

L. Approved Capitation Payment Rates

M. Service Area

N. Contractor-County Specific Agreements

A.

11

TABLE OF CONTENTS

January 1, 2005

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APPENDIX K

PREPAID BENEFIT PACKAGE

DEFINITIONS OF COVERED AND

12

NON-COVERED SERVICES

APPENDIX K

January 1, 2005

K- I

APPENDIX K

PREPAID BENEFIT PACKAGE

DEFINITIONS OF COVERED AND NON-COVERED SERVICES

The categories of services in the Medicaid Managed Care Benefit Package, when listed as
covered services shall be provided by the Contractor to Enrollees when medically necessary under
the terms of this Agreement. The definitions of covered and non-covered services therein are in
summary form; the full description and scope of each Medicaid covered service as established by the
New York Medical Assistance Program are set forth in the applicable MMIS Provider Manual.

All care provided by the Contractor, pursuant to this Agreement, must be provided, arranged, or
authorized by the Contractor or its Participating Providers with the exception of most behavioral
health services to SSI or SSI related beneficiaries (see Benefit Package K-2), and emergency
services, emergency transportation, family planning, mental health and chemical dependence
assessments (one (1) of each per year), court ordered services, and services provided by Local
Public Health Agencies as described in Section 10 of this Agreement.

This Appendix contains the following two (2) charts:

K-1 A summary of services provided by the Contractor to all Non-SSI Enrollees.

K-2 A summary of services provided by the Contractor to all SSI Enrollees.

Also included:

	 	 	 	Prepaid Benefit Package Definitions of Covered Services A)
Medical Services	 

1. Inpatient Hospital Services

1 a. Inpatient Stay Pending Alternate Level of Medical Care

2. Professional Ambulatory Services

3. Physician Services

4. Home Health Services

5. Private Duty Nursing Services

6. Emergency Room Services

7. Services of Other Practitioners‘

8. Eye Care and Low Vision Services

9. Laboratory Services

10. Radiology Services

11. Early Periodic Screening Diagnosis and Treatment (EPSDT)

Services Through the Child Teen Health Program (C/THP) and

Adolescent Preventive Services

12. Durable Medical Equipment (DME)

13. Audiology, Hearing Aid Services and Products

14. Preventive Care

15. Prosthetic/Orthotic Orthopedic Footwear

16. Renal Dialysis

17. Experimental or Investigational Treatment

18. Residential Health Care Facility (RHCF) Services

B) Behavioral Health Services

1 Chemical Dependence Services

a) Detoxification Services

i) Medically Managed Inpatient Detoxification

ii) Medically Supervised Withdrawal

	 	b)	 	Chemical Dependence Inpatient
Rehabilitation and Treatment Services	 

c) Chemical Dependence Assessment Self-Referral

APPENDIX K

January 1, 2005

K-2

13

2. Mental Health Services

a) Inpatient Services

b) Outpatient Services

C) Other Covered Services

1. Federally Qualified Health Center (FQHC) Services

	 	II.	 	Optional Covered Services (at discretion of LDSS and/or Contractor) [See Schedule A of
Appendix K for Coverage Status]	 

A) Family Planning and Reproductive Health Care

B) Dental Services

C) Transportation Services

1. Non-Emergency Transportation

2. Emergency Transportation

III. Definitions of Non-Covered Services

A) Medical Non-Covered Services

1. Personal Care Agency Services

2. Residential Health Care Facilities (RHCF)

3. Hospice Program

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

B) Non-Covered Behavioral Health Services

1. Chemical Dependence Services

a) Outpatient Rehabilitation and Treatment Services

i) Methadone Maintenance Treatment Program (MMTP)

	 	ii)	 	Medically
Supervised Ambulatory Chemical Dependence
Outpatient Clinic Programs	 

	 	iii)	 	Medically
Supervised Chemical Dependence Outpatient
Rehabilitation Programs	 

iv) Outpatient Chemical Dependence for Youth Programs

b) Chemical Dependence Services Ordered by the LDSS

2. Mental Health Services

	 	a)	 	Intensive Psychiatric
Rehabilitation Treatment Programs (IPRT)	 

b) Day Treatment

c) Continuing Day Treatment

	 	d)	 	Day Treatment Programs
Serving Children

	 	e)	 	Home and Community
Based Services Waiver for Seriously Emotionally Disturbed
Children	 

f) Case Management

g) Partial Hospitalization

	 	h)	 	Services Provided
through OMH Designated Clinics for Children With a
Diagnosis of Serious Emotional Disturbance (SED)	 

	 	i)	 	Assertive Community
Treatment (ACT)

	 	j)	 	Personalized Recovery
Oriented Services (PROS)

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

a) OMH Licensed CRs

b) Family-Based Treatment

APPENDIX K

January 1, 2005

K- 3

14

	 	4.	 	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	 

b) Day Treatment

c) Medicaid Service Coordination (MSC)

d) Home and Community Based Services Waivers (HCBS)

	 	e)	 	Services Provided Through
the Care at Home Program (OMRDD)	 

C) Other Non-Covered Services

	 	1.	 	The Early Intervention Program (EIP) -
Children Birth to Two (2) Years of Age

2. Preschool Supportive Health Services — Children Three (3)

Through Four (4) Years of Age

3. School Supportive Health Services — Children Five (5) Through

Twenty-One (21) Years of Age

4. Comprehensive Medicaid Case Management (CMCM)

5. Directly Observed Therapy for Tuberculosis Disease

6. AIDS Adult Day Health Care

7. HIV COBRA Case Management

8. Fertility Services

9. Adult Day Health. Care

10. Personal Emergency Response Systems (PERS)

11. School-Based Health Centers

	 	IV.	 	Schedule A of Appendix K, Prepaid Benefit Package, Coverage Status of Optional Covered
Services

APPENDIX K

January I, 2005

15

K- 4

APPENDIX K-1

MANAGED CARE PLAN PREPAID BENEFIT PACKAGE

	 	 	 	 	 	 	 	 	 
	Covered Services
	 	Managed Care Plan Scope of Benefit                                                                   	 	Covered by Medicaid Fee-For-Service
	 	 	 	 	 
	 
	 	Up to 365 medically necessary days per year (366 for leap year) in accordance
	 	 	 	 
	 
	 	with the stop-loss provisions of Section 3.10 of this Agreement. Includes inpatient
	 	 	 	 
	 
	 	detoxification services provided in Article 28 hospitals for all Enrollees. Inpatient
	 	 	 	 
	Inpatient Hospital Services
	 	dental services are covered. (See dental definition)
	 	 	 	 
	 	 	 	 	 	 	 
	 
	 	Continued care in a hospital pending placement in an alternate lower medical level
	 	 	 	 
	Inpatient Stay Pending Alternate
	 	of care, consistent with the provisions of 18 NYCRR.505.20 and 10 NYCRR, Part
	 	 	 	 
	Level of Medical Care
	 		85.		 	 	 	 
	 
	 	 	 	 	 	 	 	 
	 
	 	Provided through ambulatory care facilities including hospital outpatient
	 	 	 	 
	 
	 	departments, D&T centers, and emergency rooms. Services include medical,
	 	 	 	 
	 
	 	surgical, preventive, primary, rehabilitative, specialty care, mental health, family
	 	 	 	 
	 
	 	planning, C/THPservices and ambulatory dental surgery. Covered as needed
	 	 	 	 
	Professional Ambulatory Services
	 	based on medical necessity.
	 	 	 	 
	 	 	 	 	 	 	 
	 
	 	Care or service to avert disease/illness and/or its consequences. Preventive care
	 	 	 	 
	 
	 	includes primary care, secondary care and tertiary care. Coverage includes general
	 	 	 	 
	 
	 	health education classes, smoking cessation classes, childbirth education classes,
	 	 	 	 
	 
	 	parenting classes and nutrition counseling (with targeted outreach to persons with
	 	 	 	 
	 
	 	diabetes and pregnant women). HIV counseling and testing is a covered service for
	 	 	 	 
	Preventive Health Services
	 	all Enrollees.
	 	 	 	 
	 	 	 	 	 	 	 
	 
	 	Covered when medically necessary as ordered by a qualified medical professional,                     
	 	HIV phenotypic, HIV virtual phenotypic and HIV

	 
	 	and when listed in the Medicaid fee schedule. Coverage excludes HIV                                  
	 	genotypic drug resistance tests with a Provider's

	Laboratory Services
	 	phenotypic, HIV virtual phenotypic and HIV genotypic drug resistance tests.                          
	 	order.

	 	 	 	 	 
	_
	 	Covered when medically necessary as ordered by a qualified medical professional,
	 	 	 	 
	Radiology Services
	 	and when ordered and provided by a qualified medical professional/practitioner.
	 	 	 	 
	 	 	 	 	 	 	 
	 
	 	EPSDT is a package of early and periodic screening, including inter-periodic
	 	 	 	 
	 
	 	screens and, diagnostic and treatment services that are offered to all Medicaid                      
	 	Services not included in the managed care Benefit

	EPSDT Services/Child Teen
	 	eligible children under twenty-one (21) years of age known in New York State as                      
	 	Package ordered by the child's physician based on

	Health Program (C/THP)
	 	the Child Teen Health Program (C/THP).                                                               
	 	the results of a screening.

	 	 	 	 	 

APPENDIX K

January 1, 2005

K-5

	 	 	 	 	 
	Covered Services	 	Managed Care Plan Scope of Benefit	 	Covered by Medicaid Fee-For-Service
	Home Health Services	 	Home health care services include medically necessary nursing, home health aide	 	Services rendered by a personal
	 	 	services, equipment and appliances, physical therapy, speech/language pathology,	 	care agency which are approved by
	 	 	occupational therapy, social work services or nutritional services provided by a	 	the Local Social Services District
	 	 	home health care agency pursuant to an established care plan. Personal care	 	when ordered by the Enrollee's
	 	 	tasks performed by a home health aide in connection with a home health care	 	Primary Care Provider (PCP). The
	 	 	agency visit, and pursuant to an established care plan, are covered.	 	district will determine the
	 	 	 	 	applicant's need for personal care
	 	 	 	 	agency services and coordinate a
	 	 	 	 	plan of care with the personal care
	 	 	 	 	agency.
	Private Duty Nursing Services	 	Covered service when medically necessary in accordance with the ordering	 	 
	 	 	physician, registered physician assistant or certified nurse practitioner's	 	 
	 	 	written	 	 
	 	 	treatment plan.	 	 
	Emergency Room Services

	 	Covered for emergency conditions, medical or behavioral, the onset of which is

sudden, manifesting 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 medical attention to result in

(a) placing the health of the person afflicted with such condition in serious

jeopardy, or in the case of a behavioral condition placing the health of such

person or others in serious jeopardy; (b) serious impairment of such person’s

bodily functions; (c) serious dysfunction of any bodily organ or part of such

person; or (d) serious disfigurement of such person. Emergency services include

health care procedures, treatments or services, including psychiatric

stabilization and medical detoxification from drugs or alcohol that are provided

for an emergency medical condition. A medical assessment (triage) is covered for

non-emergent conditions.
	 	

	 
	 	 	 	 
	Foot Care Services

	 	Foot care when the Enrollee’s (any age) physical condition poses a hazard due to

the presence of localized illness, injury or symptoms involving the foot, or

when performed as a necessary and integral part of otherwise covered services

such as

the diagnosis and treatment of diabetes, ulcers, and infections.
	 	

	 
	 	 	 	 
	Eye Care and Low Vision Services

	 	Eye care includes the services of an ophthalmologist; optometrist and an

ophthalmic dispenser and coverage for contact lenses, polycarbonate lenses,

artificial eyes and replacement of lost or destroyed glasses (including repairs)

when medically necessary.

Artificial eyes are covered as ordered by a Contractor’s Participating Provider.
	 	

APPENDIX K

January 1, 2005

K-6

	 	 	 	 	 
	Covered Services Managed Care Plan Scope of Benefit	Covered by Medicaid Fee-For-Service
	 	 	DME are devices and equipment other than medical/surgical supplies, enteral	 	 
	 	 	formula, and prosthetic or orthotic appliances. Covered when medically necessary	 	 
	 	 	as ordered by a Contractor's Participating Provider and procured from a	 	Excluded services, such as disposable
	Durable Medical Equipment	 	Participating Provider. Coverage excludes disposable medical/surgical supplies	 	medical/surgical supplies and enteral formula with a
	(DME)	 	and enteral formula.	 	Provider's order.
	 	 	Provided when medically necessary to alleviate disability caused by the loss or	 	 
	 	 	impairment of hearing. Hearing aid products include hearing aids, earmolds,	 	Excluded services, such as hearing aid batteries
	Hearing Aids Services	 	special fittings, and replacement parts. Coverage excludes hearing aid batteries.	 	with a Provider's order.
	Family Planning and

Reproductive Health Services

See Schedule A of Appendix K

for Coverage Status

	 	Family planning means the offering, arranging, and furnishing of those health

services which enable individuals, including minors, who may be sexually active,

to prevent or reduce the incidence of unintended pregnancies and includes the

screening, diagnosis and treatment, as medically necessary, for sexually

transmissible diseases, sterilization services and screening for pregnancy.

Reproductive health services also includes all medically necessary abortions.
	 	

Enrollees may always obtain family planning and

HIV testing and counseling services, when part of a

family planning visit, outside of the plan’s network

from any Provider that accepts Medicaid.

APPENDIX K

January 1, 2005

K-7

	 	 	 	 	 
	Covered Services	 	Managed Care Plan Scope of Benefit	 	Covered by Medicaid Fee-For-Service
	
 
	 	Non-Emergency Transportation:
	 	

	Transportation Services

Non-Emergency Transportation

See Schedule A of Appendix

K for Coverage Status

Emergency Transportation

See Schedule A of Appendix

K for Coverage Status

	 	Transportation expenses are covered when transportation is essential in order for an

Enrollee to obtain necessary medical care and services which are covered under this

Benefit Package (or by fee-for-service Medicaid for carved-out services).

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 or 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.

For Enrollees with disabilities, the method of transportation must reasonably

accommodate their needs, taking into account the severity and nature of the

disability.

Emergency Transportation

Emergency transportation can only be provided by an ambulance service. Emergency

transportation is covered for Enrollees suffering from severe, life-threatening or

potentially disabling conditions which require the provision of emergency medical

services while the Enrollee is being transported.
	 	

For Contractors that do not cover

transportation services, these

services are paid for

fee-for-service. Non-emergent

transportation requests should be

referred to the LDSS.

For Contractors that cover

non-emergency transportation in the

Benefit Package, transportation

costs to MMTP services may be

reimbursed by Medicaid

fee-for-service in accordance with

the LDSS transportation polices in

local districts where there is a

systematic method to discretely

identify and reimburse such

transportation costs.
	 
	 	 	 	 
	
 
	 	Optional Benefit Package dental services include:
	 	

	Dental Services

See Schedule A of Appendix K

for Coverage Status

	 	• Medically necessary preventive, prophylactic and other routine dental care,

services and supplies and dental prosthetics required to alleviate a serious health

condition, including one which affects employability.

As described in Sections 10.16 and 10.28 of this Agreement, Enrollees may self-refer

to Article 28 clinics operated by academic dental centers to obtain covered dental

services.

All Contractors must cover the following, even if dental services is not a plan

covered benefit:

• Ambulatory or inpatient surgical services (subject to prior authorization by the

Contractor).

Coverage excludes the professional services of the dentist if dental services are not

covered by the Contractor’s Benefit Package.
	 	

Routine exams, orthodontic services

and appliances, dental office

surgery, fillings, prophylaxis,

provided to Enrollees of plans not

electing to cover dental services.

Orthodontic services are always

covered by fee-forservice.

APPENDIX K

January 1, 2005

K-8

	 	 	 	 	 
	 Covered Services Managed Care Plan Scope of Benefit	Covered by Medicaid Fee-For-Service
	Court-Ordered Services

	 	Coverage includes such services ordered by a court of competent jurisdiction if the

services are in the Contractor’s Benefit Package.
	 	

	 

	 	 
	 	

	 
	 	 	 	 
	Prosthetic/Orthotic

Services/Orthopedic Footwear

	 	Covered when medically necessary as ordered by the Contractor’s Participating

Provider.
	 	

	 

	 	 
	 	

	 
	 	 	 	 
	Mental Health Services

	 	Covered when medically necessary, in accordance with the stop-loss provisions as

described in Section 3.12 of this Agreement. Enrollees must be allowed to self-

refer for one (1) mental health assessment from a Contractor’s Participating

Provider in a twelve (12) month period. In the case of children, such self-referrals

may originate at the request of a school guidance counselor or similar source.
	 	All services in excess of twenty (20) outpatient

visits and thirty (30) inpatient days in accordance

with the stop-loss provisions in Section 3.12 of this

Agreement. Contractor continues to reimburse

mental health service providers and coordinate care.

The Contractor is reimbursed for payment through

the stop-loss provisions.
	 

	 	 
	 	 
	 
	 	 	 	 
	Detoxification Services

	 	Covered when medically necessary on either an inpatient or outpatient basis. Such

services are referred to as “Medically Managed Detoxification Services” when

provided in facilities licensed under Title 14 NYCRR Part 816.6 or Article 28 of

the Public Health Law; and “Medically Supervised Inpatient and Outpatient

Withdrawal Services” when provided in facilities licensed under Title 14 NYCRR

Part 816.7.
	 	

Medically Supervised Inpatient and Outpatient

Withdrawal Services, when ordered by the LDSS

under Welfare Reform (as indicated by “code 83”).
	 

	 	 
	 	 
	 
	 	 	 	 
	Chemical Dependence Inpatient

Rehabilitation and Treatment

Services

	 	Covered when medically necessary in accordance with the stop-loss provisions

described in Section 3.12 of this Agreement.
	 	Chemical Dependence Inpatient Rehabilitation and

Treatment Services when ordered by the LDSS

under Welfare Reform (as indicated by “code 83”)
	 

	 	 
	 	 
	 
	 	 	 	 
	Chemical Dependence

Assessment Self-Referral

	 	Enrollees must be allowed to self refer for one (1) assessment from a Contractor’s

participating provider in a twelve (12) month period.
	 	

	 

	 	 
	 	

	 
	 	 	 	 
	Experimental and/or

Investigational Treatment

	 	Covered on a case by case basis in accordance with the provisions of Section 4910

of the New York State P.H.L.
	 	

	 

	 	 
	 	

	 
	 	 	 	 
	Renal Dialysis

	 	Renal dialysis is covered when medically necessary as ordered by a qualified

medical professional. Renal dialysis may be provided in an inpatient hospital

setting, in an ambulatory care facility, or in the home on recommendation from a

renal dialysis center.
	 	

	 

	 	 
	 	

	 
	 	 	 	 
	Residential Health Care Facility

(RHCF) Services

	 	Residential Health Care Facility Services means inpatient nursing home services

provided by facilities licensed under New York State Public Health Law, including

AIDS nursing facilities. Covered services include the following health care

services: medical supervision, 24-hour per day nursing care, assistance with the

activities of daily living, physical therapy, occupational therapy, and

speech/language pathology services and other services as specified in the New

York State Public Health Law and Regulations for residential health care facilities

and AIDS nursing facilities. RHCF Services are subject to the stop-loss provisions

specified in Section 3.13 of this Agreement.
	 	

	 

	 	 
	 	

APPENDIX K

January 1, 2005

16

K-9

K-2

MANAGED CARE PLAN PREPAID HEALTH ONLY BENEFIT PACKAGE

For SSI and SSI Related Recipients

	 	 	 	 	 
	Covered Services	 	Managed Care Plan Scope of Benefit	 	Covered by Medicaid Fee-For-Service
	Inpatient Hospital Services

	 	Up to 365 medically necessary days per year (366 for leap year) in accordance

with the stop-loss provisions of Section 3.10 of this Agreement. Includes inpatient

detoxification services provided in Article 28 hospitals for all Enrollees. Inpatient

dental services are covered.
	 	

	 

	 	 
	 	

	 
	 	 	 	 
	Inpatient Stay Pending Alternate

Level of Medical Care

Professional Ambulatory Services

	 	Continued care in a hospital pending placement in an alternate lower

medical level

of care, consistent with the provisions of 18 NYCRR 505.20 and 10 NYCRR, Part

85.

Provided through ambulatory care facilities including hospital outpatient

departments, D&T centers, and emergency rooms. Services include medical,

surgical, preventive, primary, rehabilitative, specialty care, family planning,

C/THP services and ambulatory dental surgery. Covered as needed based on

medical necessity.
	 	

Mental Health and Chemical Dependence services.
	 

	 	 
	 	 
	 
	 	 	 	 
	EPSDT Services/ Child Teen

Health Program (C/THP)

	 	EPSDT is a package of early and periodic screening, including inter-periodic

screens and diagnostic and treatment services that are offered to all Medicaid

eligible children under twenty-one (21) years of age, known in New York State as

the Child Teen Health Plan (C/THP).
	 	

Services not included in the managed care Benefit

Package ordered by the child’s physician based on

the results of a screening.
	 

	 	 
	 	 
	 
	 	 	 	 
	Preventive Health Services

	 	Care and services to avert disease/illness and/or its consequences. Preventive care

includes primary care, secondary care and tertiary care. Coverage includes general

health education classes, smoking cessation classes, childbirth education classes,

parenting classes and nutrition counseling (with targeted outreach to persons with

diabetes and pregnant women). HIV counseling and testing is a covered

service for

all Enrollees.
	 	

	 

	 	 
	 	

	 
	 	 	 	 
	Home Health Services

	 	Home health care services include medically necessary nursing, home health aide

services, equipment and appliances, physical therapy, speech/language pathology,

occupational therapy, social work services or nutritional services provided by a

home health care agency pursuant to an established care plan. Personal care tasks

performed by a home health aide in connection with a home health care agency

visit, and pursuant to an established care plan, are covered.
	 	Services rendered by a personal care agency which

are approved by the Local Social Services District

when ordered by the Enrollee’s Primary Care

Provider (PCP). The district will determine the

applicant’s need for personal care agency services

and coordinate with the personal care agency a plan

of care.
	 

	 	 
	 	 

APPENDIX K

. January 1, 2005

K-10

	 	 	 	 	 
	Covered Services Managed Care Plan Scope of Benefit	Covered by Medicaid Fee-For-Service
	Private Duty Nursing Services

	 	Covered service when medically necessary in accordance with the ordering

physician, registered physician assistant or certified nurse practitioner’s written

treatment plan.
	 	

	 

	 	 
	 	

	 
	 	 	 	 
	Emergency Room Services

	 	Covered for emergency conditions, medical or behavioral, the onset of which is

sudden, manifesting 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 medical attention to result in (a)

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

or in the case of a behavioral condition placing the health of such person or others

in serious jeopardy; (b) serious impairment of such person’s bodily functions; (c)

serious dysfunction of any bodily organ or part of such person; or (d) serious

disfigurement of such person, Emergency services include health care procedures,

treatments or services, including psychiatric stabilization and medical

detoxification from drugs or alcohol that are provided for an emergency medical

condition. A medical assessment (triage) is covered for non-emergent conditions.
	 	

	 

	 	 
	 	

	 
	 	 	 	 
	Foot Care Services

	 	Foot care when the Enrollee’s (of any age) physical condition poses a hazard due

to the presence of localized illness, injury or symptoms involving the foot, or when

performed as a necessary and integral part of otherwise covered services such as

the diagnosis and treatment of diabetes, ulcers, and infections.
	 	

	 

	 	 
	 	

	 
	 	 	 	 
	Eye Care and Low Vision

Services

	 	Eye care includes the services of an ophthalmologist, optometrist and an

ophthalmic dispenser and coverage for contact lenses, polycarbonate lenses,

artificial eyes and replacement of lost or destroyed glasses (including repairs)

when medically necessary.

Artificial eyes are covered as ordered by the Contractor’s Participating Provider.
	 	

	 

	 	 
	 	

APPENDIX K

January 1, 2005

K-11

	 	 	 	 	 
	Covered Services Managed Care Plan Scope of Benefit	Covered by Medicaid Fee-For-Service
	
 
	 	Optional Benefit Package dental services include:
	 	

	Dental Services

See Schedule A of Appendix K

for Coverage Status

	 	• Medically necessary preventive, prophylactic and other routine dental care,

services and supplies and dental prosthetics required to alleviate a serious

health condition, including one which affects employability.

As described in Sections 10.16 and 10.28 of this Agreement, Enrollees may self-

refer to Article 28 clinics operated by academic dental centers to obtain covered

dental services.

All Contractors must cover the following, even if dental services is not a plan

covered benefit:

• Ambulatory or inpatient surgical services (subject to prior authorization by the

Contractor).
	 	

Routine exams, orthodontic services and appliances,

dental office surgery, fillings, prophylaxis, provided

to Enrollees of MCOs not electing to cover dental

services.
	 
	 	 	 	 
	
 
	 	Coverage excludes the professional services of the dentist if dental services are not

covered by the Contractor’s Benefit Package.
	 	

	
 
	 	 
	 	

	 
	 	 	 	 
	Family Planning and

	 	Family planning means the offering, arranging, and furnishing of those health
	 	Enrollees may always obtain family planning and
	 
	 	 	 	 
	Reproductive Health Services

	 	services which enable individuals, including minors, who may be sexually active,
	 	HIV testing and counseling services, when part of a
	 
	 	 	 	 
	See Schedule A of Appendix K

	 	to prevent or reduce the incidence of unintended pregnancies and includes the

screening, diagnosis and treatment, as medically necessary, for sexually
	 	family planning visit, outside of the Contractor’s

network from any Provider that accepts Medicaid.
	 
	 	 	 	 
	for Coverage Status

	 	transmissible diseases, sterilization services and screening for pregnancy.

Reproductive health services also includes all medically necessary abortions.
	 	

	 

	 	 
	 	

APPENDIX K

January 1, 2005

K-12

	 	 	 	 	 
	Covered Services	 	Managed Care Plan Scope of Benefit	 	Covered by Medicaid Fee-For-Service
	 	 	Non-Emergency Transportation:	 	 
	Transportation

Services Non-Emergency

Transportation:

See Schedule A of Appendix

K for Coverage Status

Emergency Transportation:

See Schedule A of Appendix K

for Coverage Status

	 	Transportation expenses are covered when transportation is essential in

order for an Enrollee to obtain necessary medical care and services which

are covered under this Benefit Package (or by fee-for-service Medicaid for

carved-out services). 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 or

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.

For Enrollees with disabilities, the method of transportation must

reasonably accommodate their needs, taking into account the severity and

nature of the disability.

Emergency Transportation

Emergency transportation can only be provided by an ambulance service.

Emergency transportation is covered for Enrollees suffering from severe,

life-threatening or potentially disabling conditions which require the

provision of emergency medical services while the Enrollee is being

transported.
	 	

For Contractors that do not cover

transportation services, these

services are paid for

fee-for-service. Non-emergent

transportation requests should be

referred to the LDSS.

For Contractors that cover

non-emergency transportation in the

Benefit Package, transportation

costs to MMTP services may be

reimbursed by Medicaid

fee-for-service in accordance with

the LDSS transportation polices in

local districts where there is a

systematic method to discretely

identify and reimburse such

transportation costs.
	 
	 	 	 	 
	Laboratory Services

	 	Covered when medically necessary as ordered by a medical professional, and

when listed in the Medicaid fee schedule. Coverage excludes HIV

phenotypic,

HIV virtual phenotypic and HIV genotypic drug resistance tests.
	 	HIV phenotypic, HIV virtual

phenotypic and HIV genotypic drug

resistance tests with a Provider’s

order.
	
 
	 	 	 	 
	 
	 	 	 	 
	Radiology Services

	 	Covered when medically necessary as ordered by a medical professional, and

when ordered and provided by a qualified medical professional/practitioner.
	 	

	 
	 	 	 	 
	Durable Medical Equipment (DME)

	 	DME are devices and equipment other than medical/surgical supplies enteral

formula, and prosthetic or orthotic appliances. Covered when medically

necessary as ordered by the Contractor’s Participating Provider and

procured from a Participating Provider. Coverage excludes disposable

medical/surgical supplies and enteral formula.
	 	Excluded services, such as

disposable medical/surgical supplies

and enteral formula with a

Provider’s order.

PPENDIX K

January 1, 2005

K-13

	 	 	 	 	 
	Covered Services Managed

	 	Care Plan Scope of Benefit Covered
	 	by Medicaid Fee-For-Service
	 

	 	 
	 	 
	 
	 	 	 	 
	Hearing Aid Services

	 	Provided when medically necessary to alleviate disability caused by the loss or

impairment of hearing. Hearing aid products include hearing aids, earmolds,

special fittings, and replacement parts. Coverage excludes hearing aid batteries.
	 	

Excluded services, such as hearing aid batteries

with a Provider’s order.
	 

	 	 
	 	 
	 
	 	 	 	 
	Court-Ordered Services

	 	Coverage includes such services ordered by a court of competent jurisdiction if the

services are in the Contractor’s Benefit Package.
	 	

	 

	 	 
	 	

	 
	 	 	 	 
	Prosthetic/Orthotic Services/Orthotic

Footwear

	 	Covered when medically necessary as ordered by a managed care plan qualified

medical professional.
	 	

	 

	 	 
	 	

	 
	 	 	 	 
	Renal Dialysis

	 	Renal dialysis is covered when medically necessary as ordered by a qualified

medical professional. Renal dialysis may be provided in an inpatient hospital

setting, in an ambulatory care facility, or in the home on recommendation from a

renal dialysis center.
	 	

	 

	 	 
	 	

	 
	 	 	 	 
	Experimental and/or

Investigational Treatment

	 	Covered on a case by case basis in accordance with the provisions of Section 4910

of the New York State P.H.L.
	 	

	 

	 	 
	 	

	 
	 	 	 	 
	Detoxification Services

	 	Covered when medically necessary on either an inpatient or outpatient basis. Such

services are referred to as “Medically Managed Detoxification Services” when

provided in facilities licensed under Title 14 NYCRR Part 816.6 or Article 28 of

the Public Health Law; and “Medically Supervised Inpatient and Outpatient

Withdrawal Services” when provided in facilities licensed under Title 14 NYCRR

Part 816.7.
	 	

	 

	 	 
	 	

	 
	 	 	 	 
	Residential Health Care Facility

(RHCF) Services

	 	Residential Health Care Facility Services means inpatient nursing home services

provided by facilities licensed under New York State Public Health Law, including

AIDS nursing facilities. Covered services include the following health care

services: medical supervision, 24-hour per day nursing care, assistance with the

activities of daily living, physical therapy, occupational therapy, and

speech/language pathology services and other services as specified in the New

York State Public Health Law and Regulations for residential health care facilities

and AIDS nursing facilities. RHCF Services are subject to the stop-loss provisions

specified in Section 3.13 of this Agreement.
	 	

	 

	 	 
	 	

APPENDIX K

January 1, 2005

K-14

17

	 	I.	 	PREPAID BENEFIT PACKAGE DEFINITIONS OF COVERED SERVICES	 

A. Medical Services

1. Inpatient Hospital Services

Inpatient hospital services, as medically necessary, shall include, except as otherwise
specified, the care, treatment, maintenance and nursing services as may be required, on an
inpatient hospital basis, up to 365 days per year (366 days in leap year). Among other services,
inpatient hospital services encompass a full range of necessary diagnostic and therapeutic care
including medical, surgical, nursing, radiological, and rehabilitative services. Services are
provided under the direction of a physician, certified nurse practitioner, or dentist.

la. Inpatient Stay Pending Alternate Level of Medical Care

Inpatient stay pending alternate level of medical care, or continued care in a hospital pending
placement in an alternate lower medical level of care, consistent with the provisions of 18 NYCRR
505.20 and 10 NYCRR, Part 85.

2. Professional Ambulatory Services

Outpatient hospital services are provided through ambulatory care facilities. Ambulatory care
facilities include hospital outpatient departments (OPD), diagnostic and treatment centers (free
standing clinics) and emergency rooms. These facilities may provide those necessary medical,
surgical, and rehabilitative services and items authorized by their operating certificates.
Outpatient services (clinic) also include preventive, primary medical, specialty, mental health,
C/THP and family planning services provided by ambulatory care facilities.

Hospital OPDs and D&T centers may perform ordered ambulatory services. The purpose of ordered
ambulatory services is to make available to the Participating Provider those services needed to
complement the provision of ambulatory care in his/her office. Examples are: diagnostic testing
and radiology.

3. Physician Services

“Physicians’ services,” whether furnished in the office, the Enrollee’s home, a hospital, a
skilled nursing facility, or elsewhere, means services furnished by a physician:

	 	(1)	 	within the scope of practice of medicine or osteopathy as defined in law by
the New York State Education Department; and

	 	(2)	 	by or under the personal supervision of an individual licensed and currently
registered by the New York State Education Department to practice medicine or
osteopathy.

Physician services include the full range of preventive care services, primary care medical
services and physician specialty services that fall within a physician’s scope of practice under
New York State law.

The following are also included without limitations:

	 	•	 	pharmaceuticals and medical supplies routinely furnished or administered as part of a clinic or office visit;

	 	•	 	physical examinations, including those which are necessary for employment, school, and camp;

	 	•	 	physical and/or mental health, or chemical dependence examinations of children and
their parents as requested by the LDSS to fulfill its statutory responsibilities for the
protection of children and adults and for children in foster care;	 

	 	•	 	health and mental health assessments for the purpose of making recommendations
regarding a Enrollee’s disability status for Federal SSI applications;	 

	 	•	 	health assessments for the Infant /Child Assessment Program (ICHAP);	 

	 	•	 	annual preventive health visits for adolescents;	 

	 	•	 	new admission exams for school children if required by the LDSS;	 

APPENDIX K

January 1, 2005

K-15

	 	•	 	health screening, assessment and treatment of refugees, including completing
SDOH/LDSS required forms;	 

	 	•	 	Child/Teen Health Program (C/THP) services which are comprehensive primary health care
services provided to children under twenty-one (21) years of age (see Section 10 of this
Agreement).

4. Home Health Services

	 	18	 	NYCRR
505.23(a)(3)	 

Home health care services are provided to Enrollees in their homes by a home health agency
certified under Article 36 of the New York State P.H.L. (Certified Home Health Agency — CHHA).
Home health services mean the following services when prescribed by a Provider and provided to a
Medicaid managed care Enrollee in his or her home:

	 	•	 	nursing services provided on a part-time or intermittent basis by a CHHA
or, if there is no CHHA that services the county/district, by a registered
professional nurse or a licensed practical nurse acting under the direction
of the Enrollee’s PCP;

	 	•	 	physical therapy, occupational therapy, or speech pathology and audiology
services; and

home health services provided by a person who meets the training requirements
of the SDOH, is assigned by a registered professional nurse to provide home
health aid services in accordance with the Enrollee’s plan of care, and is
supervised by a registered professional nurse from a CHHA or if the Contractor
has no CHHA available, a registered nurse, or therapist.

Personal care tasks performed by a home health aide incidental to a certified home health care
agency visit, and pursuant to an established care plan, are covered.

Services include care rendered directly to the Enrollee and instructions to his/her family or
caretaker such as teacher or day care provider in the procedures necessary for the Enrollee’s
treatment or maintenance.

The Contractor must provide up to two (2) post partum home visits for high risk infants and/or
high risk mothers, as well as to women with less than a forty-eight (48) hour hospital stay after
a vaginal delivery or less than a ninety-six (96) hour stay after a cesarean delivery. Visits
must be made by a qualified health professional (minimum qualifications being an RN with
maternal/child health background), the first visit to occur within forty-eight (48) hours of
discharge.

5. Private Duty Nursing Services

Private duty nursing services shall be 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 only 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 physicians, or certified nurse practitioner’s written treatment plan.

6. Emergency Room Services

Emergency conditions, medical or behavioral, the onset of which is sudden, manifesting 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 medical attention
to result in (a) placing the health of the person afflicted with such condition in serious
jeopardy, or in the case of a behavioral condition placing the health of such person or others in
serious jeopardy; (b) serious impairment of such person’s bodily functions; (c) serious
dysfunction of any bodily organ or part of such person; or (d) serious disfigurement of such
person are covered. 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. A medical assessment (triage) is covered for
non-emergent conditions.

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K-16

7. Services of Other
Practitioners a) Nurse Practitioner
Services

Nurse practitioner services include preventive services, the diagnosis of illness and physical
conditions, and the performance of therapeutic and corrective measures, within the scope of the
certified nurse practitioner’s licensure and collaborative practice agreement with a licensed
physician in accordance with the requirements of the NYS Education Department.

The following services are also included in the certified nurse practitioner’s scope of
services, without limitation:

	 	•	 	Child/Teen Health Program(C/THP) services which are comprehensive primary health care
services provided to children under twenty-one (21) (see page 20 of this Appendix and
Section 10.5 of this Agreement);	 

• Physical examinations including those which are necessary for employment, school and camp.

	 	b.	 	Rehabilitation
Services	 

18 NYCRR 505.11

Rehabilitation services are provided for the maximum reduction: of physical or mental
disability and restoration of the Enrollee to his or her best functional level. Rehabilitation
services include care and services rendered by physical therapists, speech-language pathologists
and occupational therapists. Rehabilitation services may be provided in an Article 28 inpatient
or outpatient facility, an Enrollee’s home, in an approved home health agency, in the office of a
qualified private practicing therapist or speech pathologist, or for a child in a school,
pre-school or community setting, or in a Residential Health Care Facility (RHCF) as long as the
Enrollee’s stay is classified as a rehabilitative stay and meets the requirements for covered
RHCF services as defined herein. Rehabilitation services provided in Residential Health Care
Facilities are subject to the stop-loss provisions specified in Section 3.13 of this Agreement.
Rehabilitation services are covered as medically necessary, when ordered by the Contractor’s
Participating Provider.

c. Midwifery Services

SSA §1905 (a)(17), Education Law §6951(i).

Midwifery services include the management of normal pregnancy, childbirth and postpartum care as
well as primary preventive reproductive health care to essentially healthy women as specified in a
written practice agreement and shall include newborn evaluation, resuscitation and referral for
infants. The care may be provided on an inpatient or outpatient basis including in a birthing
center or in the Enrollee’s home as appropriate. The midwife must be licensed by the NYS Education
Department.

	 	d.	 	Clinical Psychological
Services	 

18 NYCRR 505.18(a)

Clinical psychological services include psychological evaluation, testing and therapeutic
treatment for personality or behavior disorders.

e. Foot Care Services

Covered services must include routine foot care when any Enrollee’s (regardless of age) physical
condition poses a hazard due to the presence of localized illness, injury or symptoms involving
the foot, or when performed as a necessary and integral part of otherwise covered services such
as the diagnosis and treatment of diabetes, ulcers, and infections.

Services provided by a podiatrist for persons under twenty-one (21) must be covered upon referral
of a physician, registered physician’s assistant, certified nurse practitioner or certified
midwife.

Routine hygienic care of the feet, the treatment of corns and calluses, the trimming of nails,
and other hygienic care such as cleaning or soaking feet, is not covered in the absence of a
pathological condition.

APPENDIX K

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K-17

18

	 	8.	 	Eye Care and Low Vision
Services	 

18 NYCRR §505.6(b)(1-3)

Eye care includes the services of ophthalmologists, optometrists and ophthalmic dispensers, and
includes eyeglasses, medically necessary contact lenses and polycarbonate lenses, artificial eyes
(stock or custom-made), low vision aids and low vision services. Eyecare coverage includes the
replacement of lost or destroyed eyeglasses. The replacement of the complete pair of eyeglasses
should duplicate the original prescription and frames. Coverage also includes the repair or
replacement of parts in situations where the damage is the result of causes other than defective
workmanship. Replacement parts should duplicate the original prescription and frames. Repairs to,
and replacements of, frames and/or lenses must be rendered as needed.

MCOs that allow upgrades of eyeglass frames or additional features, cannot apply the eyeglass
benefit towards the cost and bill the difference to the Enrollee. However, if the Contractor does
not include upgraded eyeglasses or additional features such as scratchcoating, progressive
lenses, or photogray lenses, the Enrollee may choose to purchase the upgraded frame or feature by
paying the entire cost as a private customer.

Examinations for diagnosis and treatment for visual defects and/or eye disease is provided only as
necessary and as required by the Enrollee’s particular condition. Examinations which include
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
indicated, such as a change in correction greater than 1/2 diopter, or unless the glasses are lost,
damaged, or destroyed.

An ophthalmic dispenser fills the prescription of an optometrist or opthalmologist and supplies
eyeglasses or other vision aids upon the order of a qualified practitioner.

Enrollees may self-refer to any Participating Provider of vision services (optometrist or
opthalmologist) for refractive vision services.

	 	9.	 	Laboratory Services
18 NYCRR §505.7(a)	 

Laboratory services include medically necessary tests and procedures ordered by a qualified
medical professional and listed in the Medicaid fee schedule for laboratory services, with the
exception of HIV phenotypic, HIV virtual phenotypic and HIV genotypic drug resistance tests, which
are not included in the Benefit Package and are covered by Medicaid fee-for-service.

All laboratory testing sites providing services under this Contract must have a permit issued by
the New York State Department of Health and a Clinical Laboratory Improvement Act (CLIA)
certificate of waiver, a physician performed microscopy procedures (PPMP) certificate, or a
certificate of registration along with a CLIA identification number. Those laboratories with
certificates of waiver or a PPMP certificate may perform only those specific tests permitted under
the terms of their waiver. Laboratories with certificates of registration may perform a full range
of laboratory tests for which they have been certified. Physicians providing laboratory testing
may perform only those specific limited laboratory procedures identified in the Physician’s MMIS
Provider Manual.

10. Radiology Services

18 NYCRR§505 .1 7(c)(7)(d)

Radiology services include medically necessary services provided by qualified practitioners in the
provision of diagnostic radiology, diagnostic ultrasound, nuclear medicine, radiation oncology,
and magnetic resonance imaging (MRI). These services may only be performed upon the order of a
qualified practitioner.

APPENDIX K

January 1, 2005

K-18

	 	11.	 	Early Periodic Screening Diagnosis and Treatment (EPSDT) Services Through the Child Teen
Health Program (C/THP) and Adolescent Preventive Services 18 NYCRR §508.8

Child/Teen Health Program (C/THP) is a package of early and periodic screening, including
inter-periodic screens and, diagnostic and treatment services that New York State offers all
Medicaid eligible children under twenty-one (21) years of age. Care and services shall be provided
in accordance with the periodicity schedule and guidelines developed by the New York State
Department of Health. The care includes necessary health care, diagnostic services, treatment and
other measures (described in § 1905(a) of the Social Security Act) to correct or ameliorate
defects, and physical and mental illnesses and conditions discovered by the screening services
(regardless of whether the service is otherwise included in the New York State Medicaid Plan). The
package of services includes administrative services designed to assist families obtain services
for children that include outreach, education, appointment scheduling, administrative case
management and transportation assistance.

12. Durable Medical Equipment (DME)

18 NYCRR §505.5(a)(1) and Section 4.4 of the MMIS DME, Medical and Surgical Supplies and
Prosthetic and Orthotic Appliances Provider Manual

Durable Medical Equipment (DME) are devices and equipment, other than medical/surgical supplies,
enteral formula, and prosthetic or orthotic appliances, and have the following characteristics:

(i) can withstand repeated use for a protracted period of time;

(ii) are primarily and customarily used for medical purposes;

(iii) are generally not useful to a person in the absence of illness or injury; and

	 	(iv)	 	are usually not fitted, designed or fashioned for a particular
individual’s use. Where equipment is intended for use by only one (1) person, it
may be either custom made or customized.	 

DME must be ordered by a qualified practitioner and procured from a Participating Provider.

13. Audiology, Hearing Aid Services and Products

18 NYCRR §505.31 (a)(1)(2) and Section 4.7 of the MMIS Hearing Aid Provider Manual

	 	a)	 	Hearing aid services and products are provided in compliance with Article 37-A of the
General Business Law when medically necessary to alleviate disability caused by the loss or
impairment of hearing. Hearing aid services include: selecting, fitting and dispensing of
hearing aids, hearing aid checks following dispensing of hearing aids, conformity evaluation,
and hearing aid repairs.

	 	b)	 	Audiology services include audiometric examinations and testing, hearing aid evaluations and
hearing aid prescriptions or recommendations, as medically indicated.

	 	c)	 	Hearing aid products include hearing aids, earmolds, special fittings, and replacement parts
(hearing aid batteries are excluded from the Benefit Package, but are covered by Medicaid
fee-for-service as part of the prescription benefit).

14. Preventive Care

Preventive care means care and services to avert disease/illness and/or its consequences. There
are three (3) levels of preventive care: 1) primary, such as immunizations, aimed at preventing
disease; 2) secondary, such as disease screening programs aimed at early detection of disease; and
3) tertiary, such as physical therapy, aimed at restoring function after the disease has occurred.
Commonly, the term “preventive care” is used to designate prevention and early detection programs
rather than restorative programs.

The following preventive services are also included in the managed care Benefit Package. These
preventive services are essential for promoting wellness and preventing illness. MCOs must offer
the following :

	 	•	 	General health education classes.

	 	•	 	Pneumonia and influenza immunizations for at risk populations.

	 	•	 	Smoking cessation classes, with targeted outreach for adolescents and pregnant women.

	 	•	 	Childbirth education classes.

APPENDIX K

January 1, 2005

K-I9

	 	•	 	Parenting classes covering topics such as bathing, feeding, injury prevention,
sleeping, illness prevention, steps to follow in an emergency, growth and development,
discipline, signs of illness, etc.

	 	•	 	Nutrition counseling, with targeted outreach for diabetics and pregnant women.

	 	•	 	Extended care coordination, as needed, for pregnant women.

	 	•	 	HIV counseling and testing.

15. Prosthetic/Orthotic Orthopedic Footwear

Section 4.5, 4.6 and 4.7 of the MMIS DME, Medical and Surgical Supplies and Prosthetic and
Orthotic Appliances Provider Manual

a. Prosthetics are those appliances or devices ordered for an Enrollee by a Participating
Provider which replace or perform the function of any missing part of the body. Artificial eyes
are covered as part of the eye care benefit.

b. Orthotics are those appliances or devices, ordered for an Enrollee by a qualified practitioner
which are used for the purpose of supporting a weak or deformed body part or to restrict or
eliminate motion in a diseased or injured part of the body.

c. Orthopedic Footwear means shoes, shoe modifications, or shoe additions which are used to
correct, accommodate or prevent a physical deformity or range of motion malfunction in a diseased
or injured part of the ankle or foot; to support a weak or deformed structure of the ankle or
foot, or to form an integral part of a brace.

16. Renal Dialysis

Renal dialysis is covered when medically necessary as ordered by a qualified medical
professional. Renal dialysis may be provided in an inpatient hospital setting, in an ambulatory
care facility, or in the home on recommendation from a renal dialysis center.

17. Experimental or Investigational Treatment

Experimental and investigational treatment is covered on a case by case basis.

Experimental or investigational treatment for life-threatening and/or disabling illnesses may also
be considered for coverage under the external appeal process pursuant to the requirements of
Section 4910 of New York State P.H.L. under the following conditions:

	 	(1)	 	The Enrollee has had coverage of a health care service denied on the basis that such service
is experimental and investigational, and

	 	(2)	 	The Enrollee’s attending physician has certified that the Enrollee has a life-threatening or
disabling condition or disease:

(a) for which standard health services or procedures have been ineffective or would be
medically inappropriate, or

(b) for which there does not exist a more beneficial standard health service or procedure
covered by the health care plan, or

(c) for which there exists a clinical trial, and

	 	(3)	 	The Enrollee’s provider, who must be a licensed, board-certified or board-eligible
physician, qualified to practice in the area of practice appropriate to treat the
Enrollee’s life-threatening or disabling condition or disease, must have recommended
either:	 

APPENDIX K

January 1, 2005

K-20

	 	(a)	 	a health service or procedure that, based on two (2) documents from the
available medical and scientific evidence, is likely to be more beneficial to the
Enrollee than any covered standard health service or procedure; or	 

(b) a clinical trial for which the Enrollee is eligible; and

	 	(4)	 	The specific health service or procedure recommended by the attending physician would
otherwise be covered except for the MCO’s determination that the health service or procedure
is experimental or investigational.	 

18. Residential Health Care Facility (RHCF) Services

Residential Health Care Facility (RHCF) Services means inpatient nursing home services provided
by facilities licensed under Article 28 of the New York State Public Health Law, including AIDS
nursing facilities. Covered services includes the following health care services: medical
supervision, 24-hour per day nursing care, assistance with the activities of daily living,
physical therapy, occupational therapy, and speech/language pathology services and other services
as specified in the New York State Health Law and Regulations for residential health care
facilities and AIDS nursing facilities. These services should be provided to an Enrollee:

	 	(a)	 	Who is diagnosed by a physician as having one or more clinically determined
illnesses or conditions that cause the Enrollee to be so incapacitated, sick,
invalid, infirm, disabled, or convalescent as to require at least medical and
nursing care; and	 

	 	(b)	 	Whose assessed health care needs, in the professional judgment of the
Enrollee’s physician or a medical team:	 

	 	i)	 	do not require care or active treatment of the Enrollee in a
general or special hospital;

ii) cannot be met satisfactorily in the Enrollee’s own home or home substitute

through provision of such home health services, including medical and other

health and health-related services as are available in or near his or her

community; and

	 	iii)	 	cannot be met satisfactorily in the physician’s office, a
hospital clinic, or other ambulatory care setting because of the
unavailability of medical or other health and health-related services for the
Enrollee in such setting in or near his or her community.

The Contractor is also responsible for respite days and bed hold days authorized by the
Contractor.

The Contractor is responsible for all medically necessary and clinically appropriate inpatient
Residential Health Care,, Facility services authorized by the Contractor up to a sixty
(60) day calendar year stop-loss for Enrollees who are not in Permanent Placement Status as
determined by LDSS.

B. Behavioral Health Services

These services include Chemical Dependence and Mental Health Services.

• Chemical Dependence Services:

For all Enrollees not categorized as SSI or SSI related, Chemical Dependence Services in the
Benefit Package include inpatient treatment services including inpatient rehabilitation and
treatment services programs, Detoxification Services (Medically Managed Inpatient
Detoxification and Medically Supervised Inpatient and Outpatient Withdrawal Services) and
self-referral for assessment as described below.

For all Enrollees categorized as SSI or SSI related, the Benefit Package includes
Detoxification Services (Medically Managed Inpatient Detoxification and Medically Supervised
Inpatient and Outpatient Withdrawal Services). All other Chemical Dependence Services,
including Chemical Dependence Inpatient Rehabilitation and Treatment, are covered on a
Medicaid fee-for-service basis for the SSI population.

APPENDIX K

January 1, 2005

K-21

• Mental Health Services:

The Mental Health Services listed below are in the Benefit Package for all Enrollees not
categorized as SSI or SSI related. For Enrollees who are categorized as SSI or SSI related, all
Mental Health Services are covered on a Medicaid fee-for-service basis.

1. Chemical Dependence Services a.
Detoxification Services

i) Medically Managed Inpatient Detoxification

These programs provide medically directed twenty-four hour care on an inpatient basis to
individuals who are at risk of severe alcohol or substance abuse withdrawal, incapacitated, a
risk to self or others, or diagnosed with an acute physical or mental co-morbidity. Specific
services include, but are not limited to: medical management, bio-psychosocial assessments,
stabilization of medical psychiatric / psychological problems, individual and group
counseling, level of care determinations and referral and linkages to other services as
necessary. Medically Managed Detoxification Services are provided by facilities licensed by
OASAS under Title 14 NYCRR Part 816.6 and the Department of Health as a general hospital
pursuant to Article 28 of the Public Health Law or by the Department of Health as a general
hospital pursuant to Article 28 of the Public Health Law.

	 	ii)	 	Medically Supervised Withdrawal (a) Medically
Supervised Inpatient Withdrawal	 

These programs offer treatment for moderate withdrawal on an inpatient basis. Services must
include medical supervision and direction under the care of a physician in the treatment for
moderate withdrawal. Specific services must include, but are not limited to: medical
assessment within twenty four hours of admission; medical supervision of intoxication and
withdrawal conditions; bio-psychosocial assessments; individual and group counseling and
linkages to other services as necessary. Maintenance on methadone while a patient is being
treated for withdrawal from other substances may be provided where the provider is
appropriately authorized. Medically Supervised Inpatient Withdrawal services are provided by
facilities licensed under Title 14 NYCRR Part 816.7.

(b) Medically Supervised Outpatient Withdrawal

These programs offer treatment for moderate withdrawal on an outpatient basis. Required
services include, but are not limited to: medical supervision of intoxication and withdrawal
conditions; bio-psychosocial assessments; individual and group counseling; level of care
determinations; discharge planning; and referrals to appropriate services. Maintenance on
methadone while a patient is being treated for withdrawal from other substances may be
provided where the provider is appropriately authorized. Medically Supervised Outpatient
Withdrawal services are provided by facilities licensed by Title 14 NYCRR Part 816.7.

All detoxification and withdrawal services are a covered benefit for all Enrollees, including
those categorized as SSI or SSI related.

Detoxification Services in Article 28 inpatient hospital facilities are subject to the
stop-loss provisions specified in Section 3.11 of this Agreement.

b. Chemical Dependence Inpatient Rehabilitation and Treatment Services

Services provided include intensive management of chemical dependence symptoms and medical
management of physical or mental complications from chemical dependence to clients who cannot be
effectively served on an outpatient basis and who are not in need of medical detoxification or
acute care. These services can be provided in a hospital or free-standing facility. Specific
services can include, but are not limited to: comprehensive admission evaluation and treatment
planning; individual group, and family counseling; awareness and relapse prevention; education
about self-help groups; assessment and referral services; vocational and educational assessment;
medical and psychiatric consultation; food and housing; and HIV and AIDS education. These
services may be provided by facilities licensed by OASAS to provide: Chemical Dependence
Inpatient Rehabilitation and Treatment Services under Title 14 NYCRR Part 818. Maintenance on
methadone while a patient is being treated for withdrawal from other substances may be provided
where the provider is appropriately authorized.

APPENDIX K

January 1, 2005

K-22

MCOs will be reimbursed for qualifying inpatient days of chemical dependence inpatient
treatment beyond thirty (30) days according to stop-loss provisions contained in Section 3.12
of this Agreement.

c. Chemical Dependence Assessment Self-Referral

Enrollees must be allowed to self refer for one (1) assessment from a Contractor’s
participating provider in a twelve (12) month period.

2. Mental Health Services

Mental Health Services are subject to the stop-loss provisions specified in Section 3.12 of this
Agreement.

a. Inpatient Services

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

b. Outpatient Services

Outpatient services including but not limited to: assessment, stabilization, treatment planning,
discharge planning, verbal therapies, education, symptom management, case management services,
crisis intervention and outreach services, chlozapine monitoring and collateral services as
certified by OMH. Services may be provided in-home, office or the community. Services may be
provided by licensed OMH providers or by other providers of mental health services including
clinical psychologists and physicians. For further information regarding service coverage consult
the following MMIS Provider Manuals: Clinic, Ambulatory Services for Mental Illness (Clinic
Treatment Program), Clinical Psychology, and Physician (Psychiatric Services).

Enrollees must be allowed to self-refer for one (1) mental health assessment from a Contractor’s
Participating Provider in a twelve (12) month period. In the case of children, such self-referrals
may originate at the request of a school guidance counselor or similar source.

Services provided through OMH designated clinics for Enrollees with a clinical diagnosis of SED
are covered by Medicaid fee-for-service.

C. Other Covered Services

1. Federally Qualified Health Center (FQHC) Services

FQHC services include physician services, services and supplies covered under SSA §1861(s)(2) (A).
Services include primary health, referral for supplemental health services, health education,
patient case management, including outreach, counseling, referral and follow-up services (see 42
USC §254c(a) & (b)).

APPENDIX K

January 1,2005

19

K-23

Prepaid Benefit Package

II. Optional Covered Services (at Discretion of LDSS and/or Contractor)

A. Family Planning and Reproductive Health Care

Family Planning and Reproductive Health Care services means 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 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.

If the Contractor excludes family planning from its Benefit Package, the Contractor is still
required to provide the following services:

i) screening, related diagnosis, ambulatory treatment, and referral to Participating Provider as

	 	 	 
	ii)

	 	needed for dysmenorrhea, cervical cancer or other pelvic abnormality/pathology;

screening, related diagnosis, and referral to Participating Provider for anemia, cervical cancer,

glycosuria, proteinuria, hypertension, breast disease and pregnancy.

B. Dental Services

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

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

As described in Sections 10.16 and 10.28 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 MMIS; 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.	 

	 	C.	 	Transportation
Services	 

18 NYCRR §505.10

a. Non-Emergency Transportation

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

APPENDIX K

January 1, 2005

K-24

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 Benefit Package, transportation
costs to MMTP services may be reimbursed by Medicaid fee-for-service in accordance with the LDSS
transportation polices 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.

b. Emergency Transportation

Emergency transportation can only be provided by an ambulance service including air ambulance
service. Emergency ambulance transportation means the provision of ambulance transportation 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
medical services while the Enrollee is being transported.

Emergency medical services means the provision of initial urgent medical care including, but not
limited to, the treatment of trauma, bums, respiratory, circulatory and obstetrical emergencies.

Emergency ambulance transportation is transportation to a hospital emergency room generated by a
“Dial 911” emergency system call or some other request for an immediate response to a medical
emergency. Because of the urgency of the transportation request, insurance coverage or other
billing provisions are not addressed until after the trip is completed. When the Contractor is
capitated for this benefit, emergency transportation via 911 or any other emergency call system is
a covered benefit and the Contractor is responsible for payment.

APPENDIX K

January 1, 2005

K-25

Prepaid Benefit Package

III. Definitions of Non-Covered Services

The following services are excluded from the Contractor’s Benefit Package, but are covered, in
most instances, by Medicaid fee-for-service:

A. MEDICAL NON-COVERED SERVICES

1. 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. Enrollee’s 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 Benefit Package. 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.

2. Residential Health Care Facilities (RHCF)

Services provided in a Residential Health Care Facility (RHCF) to an individual who is determined
by the LDSS to be in Permanent Placement Status in the RHCF are not covered.

3. Hospice Program

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. 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 Medicaid fee-for-service.

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

Coverage for drugs dispensed by community pharmacies, over the counter drugs, medical/surgical
supplies and enteral formula are not included in the Benefit Package and 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.

APPENDIX K

January 1, 2005

K-26

20

B. Non-Covered Behavioral Health Services

1. Chemical Dependence Services

a. Outpatient Rehabilitation and Treatment Services

i). Methadone Maintenance Treatment Program (MMTP)

Consists of drug detoxification, drug dependence counseling, and rehabilitation services which
include chemical management of the patient with methadone. Facilities that provide methadone
maintenance treatment do so as their principal mission and are certified by the Office of Alcohol
and Substance Abuse Services (OASAS) under Title 14 NYCRR, Part 828.

ii). Medically Supervised Ambulatory Chemical Dependence Outpatient Clinic Programs

Medically Supervised Ambulatory Chemical Dependence Outpatient Clinic Programs are licensed under
Title 14 NYCRR Part 822 and provide chemical dependence outpatient treatment to individuals who
suffer from chemical abuse or dependence and their family members or significant others.

iii): Medically Supervised Chemical Dependence Outpatient Rehabilitation Programs

Medically Supervised Chemical Dependence Outpatient Rehabilitation Programs provide full or
half-day services to meet the needs of a specific target population of chronic alcoholic persons
who need a range of services which are different from those typically provided in an alcoholism
outpatient clinic. Programs are licensed by as Chemical Dependence Outpatient Rehabilitation
Programs under Title 14 NYCRR Part 822.9.

iv). Outpatient Chemical Dependence for Youth Programs

Outpatient Chemical Dependence for Youth Programs (OCDY) licensed under Title 14 NYCRR Part 823,
establishes programs and service regulations for OCDY programs. OCDY programs offer discrete,
ambulatory clinic services to chemically-dependent youth in a treatment setting that supports
abstinence from chemical dependence (including alcohol and substance abuse) services.

b. Chemical Dependence Services Ordered by the LDSS

The Contractor is not responsible for the provision and payment of Chemical Dependence Inpatient
Rehabilitation and Treatment Services ordered by the LDSS and provided to Enrollees who have:

	 	•	 	been assessed as unable to work by the LDSS and are mandated to receive
Chemical Dependence Inpatient Rehabilitation and Treatment Services as a condition
of eligibility for Public Assistance or Medicaid, or

	 	•	 	have been determined to be able to work with limitations (work
limited) and are simultaneously mandated by the district into Chemical Dependence
Inpatient Rehabilitation and Treatment Services (including alcohol and substance
abuse treatment services )pursuant to work activity requirements.	 

The Contractor is not responsible for the provision and payment of Medically Supervised
Inpatient and Outpatient Withdrawal Services ordered by the LDSS under Welfare Reform (as
indicated by Code 83).

The Contractor is responsible for the provision and payment of Medically Managed Detoxification
Services in this Agreement.

If the Contractor is already providing an Enrollee with Chemical Dependence Inpatient
Rehabilitation and Treatment Services and Detoxification Services and the LDSS is satisfied
with the level of care and services, then the Contractor will continue to be responsible for
the provision and payment of these services.

APPENDIX K

January 1,2005

K-27

2. Mental Health Services

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.

d. Day Treatment Programs Serving Children

Day treatment programs are characterized by a blend of mental health and special education
services provided in a fully integrated program. Typically these programs include: special
education in small classes with an emphasis on individualized instruction, individual and group
counseling, family services such as family counseling, support and education, crisis
intervention, interpersonal skill development, behavior modification, art and music therapy.

e. Home and Community Based Services Waiver for Seriously Emotionally Disturbed Children

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.

f. Case Management

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

Please note: See generic definition of Comprehensive Medicaid Case Management (CMCM) under OTHER
NON-COVERED SERVICES.

g. Partial Hospitalization

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.

	 	h.	 	Services Provided Through OMH Designated Clinics for Children With A Diagnosis of Serious
Emotional Disturbance (SED)

APPENDIX K

January 1, 2005

K-28

These are services provided by designated OMH clinics to children and adolescents with a
clinical diagnosis of SED.

i. 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.

j. 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.

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

a. OMH Licensed CRs*

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

b. Family-Based Treatment*

Rehabilitative services in family-based treatment programs are intended to provide treatment to
seriously emotionally disturbed children and youth to promote their successful functioning and
integration into the natural family, community, school or independent living situations. Such
services are provided in consideration of a child’s developmental stage. Those children determined
eligible for admission are placed in surrogate family homes for care and treatment.

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

4. 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.

APPENDIX K

January 1, 2005

K-29

c. Medicaid Service Coordination (MSC)

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

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

Please note: See generic definition of Comprehensive Medicaid Case Management (CMCM) under OTHER
NON-COVERED SERVICES.

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.

C. Other Non-Covered Services

1. The Early Intervention Program (EIP) — Children Birth to Two (2) Years of Age

This program provides early intervention services to certain children, from birth through two (2)
years of age, who have a developmental delay or a diagnosed physical or mental condition that has
a high probability of resulting in developmental delay. All managed care providers must refer
infants and toddlers suspected of having a delay to the local designated Early Intervention
agency in their area. (In most municipalities, the County Health Department is the designated
agency, except: New York City — the Department of Health, Mental Retardation and Alcoholism
Services; Erie County — The Department of Youth Services; Jefferson County — the Office of
Community Services; and Ulster County — the Department of Social Services).

Early intervention services provided to this eligible population are categorized as Non-Covered.
These services, which are designed to meet the developmental needs of the child and the needs of
the family related to enhancing the child’s development, will be identified on MMIS by unique rate
codes by which only the designated early intervention agency can claim reimbursement. Contractor
covered and authorized services will continue to be provided by the Contractor. Consequently, the
Contractor will be expected to refer any enrolled child suspected of having a developmental delay
to the locally designated early intervention agency in their area and participate in the
development of the Child’s Individualized Family Services Plan (IFSP). Contractor’s participation
in the development of the IFSP is necessary in order to coordinate the provision of early
intervention services and services covered by the Contractor.

Additionally, the locally designated early intervention agencies will be instructed on how to
identify a managed care Enrollee and the need to contact the Contractor to coordinate service
provision.

APPENDIX K

January 1, 2005

K-30

2. Preschool Supportive Health Services-Children Three (3) Through Four (4) Years of Age

The Preschool Supportive Health Services Program (PSHSP) enables counties and New York City to
obtain Medicaid reimbursement for certain educationally related medical services provided by
approved preschool special education programs for young children with disabilities. The Committee
on Preschool Special Education in each school district is responsible for the development of an
Individualized Education Program (IEP) for each child evaluated in need of special education and
medically related health services.

PSHSP services rendered to children three (3) through four (4) years of age in conjunction with an
approved IEP are categorized as Non-Covered.

The PSHSP services will be identified on MMIS by unique rate codes through which only counties and
New York City can claim reimbursement. In addition, a limited number of Article 28 clinics
associated with approved pre-school programs are allowed to directly bill Medicaid fee-for-
service for these services. Contractor covered and authorized services will continue to be
provided by the Contractor.

3. School Supportive Health Services-Children Five (5) Through Twenty-One (21) Years of Age

The School Supportive Health Services Program (SSHSP) enables school districts to obtain Medicaid
reimbursement for certain educationally related medical services provided by approved special
education programs for children with disabilities. The Committee on Special Education in each
school district is responsible for the development of an Individualized Education Program (IEP)
for each child evaluated in need of special education and medically related services.

SSHSP services rendered to children five (5) through twenty-one (21) years of age in conjunction
with an approved IEP are categorized as Non-Covered.

The SSHSP services are identified on MMIS by unique rate codes through which only school districts
can claim Medicaid reimbursement. Contractor covered and authorized services will continue to be
provided by the Contractor.

4. Comprehensive Medicaid Case Management (CMCM)

A program which provides “social work” case management referral services to a targeted population
(e.g.: pregnant 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 EMEVS and informed on the need to contact the Contractor to coordinate service
provision.

5. 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.

6. 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 service 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.

APPENDIX K

January 1, 2005

K-31

7. 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.

8. Fertility Services Fertility services are not covered by the Benefit Package nor by Medicaid
fee-for-service.

9. 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 while or in part
satisfactorily by delivery of appropriate services in such program.

10. 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.

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.

11. School-Based Health Centers

A School-Based Health Center (SBHC) is an Article 28 extension clinic that is located in a school
and provides students with primary and preventive physical and mental health care services, acute
or first contact care, chronic care, and referral as needed. SBHC services include comprehensive
physical and mental health histories and assessments, diagnosis and treatment of acute and chronic
illnesses, screenings (e.g., vision, hearing, dental, nutrition, TB), routine management of chronic
diseases (e.g., asthma, diabetes), health education, mental health counseling and/or referral,
immunizations and physicals for working papers and sports.

21

APPENDIX K

January 1, 2005

K-32

Amendment to Medicaid Managed Care Model Contract — Effective 1/1/05

Residential Health Care Clarifications & Miscellaneous Revisions

	 	 	 	 	 	 	 	 	 	 	 	 	 
	Contract	 	 	 	 	 	 
	Section	 	Topic / Reason for Change	 	Contract Language Change	 	Status
	Sect. 1
	 	Definitions                                  	 	"Permanent Placement Status" means the status of an individual	 	 	 	 
	 
	 	"Permanent Placement Status"	 	in a
	 	 	 	 
	 
	 	Newly added definition                       
	 	 	—	 	 	 	 	 
	 
	 	 	 	 	 	Residential Health Care Facility (RHCF when the LDSS determines
	 	 	 	 
	 
	 	 	 	 	 	that
	 	 	 	 
	 
	 	 	 	 	 	the individual is not expected to return home based on medical
	 	 	 	 
	 
	 	 	 	 	 	evidence affirming the individual’s need for permanent RHCF
	 	 	 	 
	 
	 	 	 	 	 	placement.
	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	c) The monthly capitation payments and the Supplemental Newborn	 	 	 	 
	 
	 	 	 	 	 	Capitation Payment and the Supplemental Maternity Capitation
	 	 	 	 
	 
	 	Capitation Payments                          
	 	Payment to the Contractor shall constitute full and complete
	 	 	 	 
	 
	 	Conforming reference change                  
	 	payments to the Contractor for all services that the Contractor
	 	 	 	 
	 
	 	associated with addition of new              
	 	provides pursuant to this Agreement subject to stop-loss
	 	 	 	 
	 
	 	Section 3.13, Residential Health             
	 	provisions set forth in Section 3.11, and 3.12, and 3.13 of
	 	 	 	 
	Sect. 3.1 (c)
	 	Care Facility Stop-Loss                      
	 	this Agreement.
	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	3.13 Residential Health Care Facility Stop-Loss	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	The Contractor will be compensated for medically
	 	 	 	 
	 
	 	 	 	 	 	necessary and clinically appropriate Medicaid
	 	 	 	 
	 
	 	 	 	 	 	reimbursable inpatient Residential Health Care
	 	 	 	 
	 
	 	 	 	 	 	Facility services as defined in Appendix K in
	 	 	 	 
	 
	 	 	 	 	 	excess of sixty (60) days during a calendar year at
	 	 	 	 
	 
	 	 	 	 	 	the lower of the Contractor's negotiated rates or
	 	 	 	 
	Sect. 3.13
	 	Residential Health Care Facility             
	 	 	—	 	 	 	 	 
	(New item)
	 	Stop-Loss                                    
	 	Medicaid rate of payment.
	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 

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Amendment to Medicaid Managed CareModel Contract — Effective 1/1/05

Residential Health Care Clarifications & Miscellaneous Revisions

	 	 	 	 	 	 	 	 	 	 	 	 	 
	Contract	 	 	 	 	 	 
	Section	 	Topic / Reason for Change	 	Contract Language Change	 	Status
	 
	 	 	 	 	 	3.14 Stop-Loss Procedures and Documentation	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	The Contractor must follow procedures and
	 	 	 	 
	 
	 	 	 	 	 	documentation requirements in accordance with the
	 	 	 	 
	 
	 	 	 	 	 	New York State Department of Health stop-loss
	 	 	 	 
	 
	 	 	 	 	 	policy and procedure manual. Payments made for
	 	 	 	 
	 
	 	 	 	 	 	stop-loss claims that do not conform to SDOH
	 	 	 	 
	Sect. 3.14
	 	Stop-Loss Procedures and                    
	 	 	—	 	 	 	 	 
	(New Item)
	 	Documentation                               
	 	requirements are subject to recoupment.
	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 
	Sections 3.13
and 3.14
Renumber
Sections 3.13,
“Enrollment
Limitations,”
	 	Enrollment Limitations
	 	 	 	 	 	 	 	 
	and 3.14,
	 	Tracking Visits Provided by
	 	 	 	 	 	 	 	 
	“Tracking Visits
	 	Indian Health Clinics
	 	 	 	 	 	 	 	 
	Provided by
	 	Conforming numbering change
	 	 	 	 	 	 	 	 
	Indian Health
	 	associated with addition of new
	 	 	 	 	 	 	 	 
	Clinics,” as
	 	Section 3.13, Residential Health
	 	 	 	 	 	 	 	 
	Sections 3.15,
	 	Care Facility Stop-Loss and new
	 	 	 	 	 	 	 	 
	and 3.16
	 	Section 3.14 Stop-Loss
	 	 	 	 	 	 	 	 
	respectively.
	 	Procedures and Documentation                
	 	Renumber original Sections 3.13 and 3.14 as indicated.
	 	 	 	 
	 	 	 	 	 	 	 	 	 

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Amendment to Medicaid Managed Care Model Contract — Effective 1/1/05

Residential Health Care Clarifications & Miscellaneous Revisions

	 	 	 	 	 	 	 
	Contract	 	 	 	 	 	 
	Section	 	Topic / Reason for Change	 	Contract Language Change	 	Status
	 	 	 	 	SDOH, with prior notice	 	 
	 	 	 	 	to the LDSS, will provide	 	 
	 	 	 	 	Contractor with	 	 
	 	 	 	 	instructions for	 	 
	 	 	 	 	submitting the reports	 	 
	 	 	 	 	required by Section 18.5	 	 
	 	 	 	 	(a) through (nmm),	 	 
	 	 	 	 	including time frames,	 	 
	 	 	 	 	and requisite formats.	 	 
	 	 	 	 	The instructions, time	 	 
	 	 	 	 	frames and formats may be	 	 
	 	 	 	 	modified by SDOH with	 	 
	 	 	 	 	prior notice to the LDSS,	 	 
	 	 	 	 	and thereafter upon sixty	 	 
	 	 	 	 	(60) days written notice	 	 
	 	 	 	 	to the Contractor. The	 	 
	 	 	 	 	LDSS, with prior notice	 	 
	 	 	 	 	to SDOH, shall provide	 	 
	 	 	 	 	the Contractor with	 	 
	 	 	 	 	instructions for	 	 
	 	 	 	 	submitting the reports;	 	 
	 	 	 	 	required by Section	 	 
	 	 	SDOH Instructions for Report	 	18.5(en)S	 	 
	 	 	Submissions	 	including time frames and	 	 
	Section 18.2	 	Technical correction	 	requisite formats.	 	 
	Section 18.4

	 	Notification of Changes in Report

Due Dates, Requirements or

Formats

Technical correction
	 	SDOH or LDSS may extend

due dates, or modify

report requirements or

formats upon a written

request by the Contractor

to the SDOH or LDSS with

a copy of the request to

the other agency, 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 SDOH with

regard to annual and

quarterly statements,

complaint reports,

audits, encounter data,

change of

ownership, clinical

studies, QARR, and

provider network reports.

The determination to

grant a modification or

extension of time shall

be made by the LDSS with

respect to No Contact,

PCP auto assignment, and

reports required by

Sections 18.5 (am) and

(en) of the Agreement.
	 	

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	Contract	 	 	 	 	 	 
	Section	 	Topic / Reason for Change	 	Contract Language Change	 	Status
	
 
	 	 	 	c) Other Financial Reports:
	 	

	Section 18.5 (c)

	 	Reporting Requirements — Other

Financial Reports:

Technical correction
	 	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 §§ 98.11,

98.16 and 98.17 and applicable Insurance Law §§ 304, 305,

306 and 310. The LDSS reserves the right to require Contractor

to submit such relevant financial reports and documents related

to the financial condition of the MCO to the LDSS, as set forth in

Section 18.5(en) of this Agreement.
	 	

	 

	 	 
	 	 
	 	

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	Section	 	Topic / Reason for Change	 	Contract Language Change	 	Status
	
 
	 	 	 	f) Complaint Reports:
	 	

	Section 18.5 (f)

	 	Reporting Requirements -

Complaint Reports

Technical correction
	 	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

received during the preceding quarter on the Health

Provider Network (“HPN”).

The Contractor also agrees to provide on a quarterly

basis, via the HPN, the total number of complaints that

have been unresolved for more than forty-five (45)

days. The Contractor shall maintain records on these

and other complaints which shall include all correspondence

related to the complaint, and an explanation of disposition.

These records shall be readily available for review by the

SDOH or LDSS upon request.

Nothing in this Section is intended to limit the right of the SDOH

and the LDSS to obtain information immediately from a Contractor

pursuant to investigating a particular Enrollee or provider

complaint.

The LDSS reserves the right to require the Contractor to submit a

hardcopy of complaint reports in Section 18.5(en) of this

Agreement.
	 	

	 

	 	 
	 	 
	 	

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	Contract	 	 	 	 	 	 
	Section	 	Topic / Reason for Change	 	Contract Language Change	 	Status
	Section 32.2
	 	Indemnification by LDSS                      
	 	32.2 Indemnification by LDSS	 	Change in NYC model
	 
	 	Note: This change will only be               	 	The LDSS shall indemnify and hold harmless the Contractor                             
	 	only.
	 
	 	in the contracts between NYC                 	 	and its officers, agents, and employees from any and all claims
	 	 	 	 
	 
	 	and its participating MCOs.                  	 	for damages any lose or  damages resulting from actions by the
	 	 	 	 
	 
	 	Change requested by NYC                      	 	 	—	 	 	 	 	 
	 
	 	Department of Law.                           	 	LDSS or  their Contractors in their connection with under this
	 	 	 	 
	 
	 	 	 	 	 	Agreement, for performance except such the Contractor, its
	 	 	 	 
	 
	 	 	 	 	 	negligence or culpable act of officers, agents, employees, or
	 	 	 	 
	 
	 	 	 	 	 	subcontractors, including Participating Providers pursuant to
	 	 	 	 
	 
	 	 	 	 	 	the terms of Appendix A Part IL Section 6.3 herein.
	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 
	App. K
Table of
Contents
	 	Residential Health Care Facility
	 	 	 	 	 	 	 	 
	(Add New Item)
	 	(RHCF) Services                              
	 	18. Residential Health Care Facility (RHCF) Services	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 

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	Section	 	Topic / Reason for Change	 	Contract Language Change	 	Status
	
 
	 	 	 	Managed Care Plan Scope of Benefit

Residential Health Care Facility

Services means inpatient nursing

home services provided by

facilities licensed under New York

State Public Health Law, including

AIDS nursing facilities. Covered

services include the following

health care services: medical

supervision, 24-hour per day
	 	

	
 
	 	 	 	 
	 	

	App. K

Appendix K-1

and K-2 charts

(Add New Item

to end of each

chart, under

“Managed Care

Plan Scope of

Benefit”

column)

	 	Residential Health Care Facility

(RHCF) Services

Clarify the range of covered

services and Contractor

responsibility
	 	nursing care, assistance with the

activities of daily living,

physical therapy, occupational

therapy, and speech/language

pathology services and other

services as specified in the New

York State Public Health Law and

Regulations for residential health

care facilities and AIDS nursing

facilities. RHCF Services are

subject to the stop-loss

provisions specified in Section

3.13 of this Agreement.
	 	

	
 
	 	 	 	 
	 	

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	Section	 	Topic / Reason for Change	 	Contract Language Change	 	Status
	 
	 	 	 	 	 	b. Rehabilitation Services
	 	 	 	 
	 
	 	 	 	 	 	18 NYCRR 505.11	 	 	 	 
	 
	 	 	 	 	 	Rehabilitation services are provided for the maximum reduction of
	 	 	 	 
	 
	 	 	 	 	 	physical or mental disability and restoration of the Enrollee to his or
	 	 	 	 
	 
	 	 	 	 	 	her best functional level. Rehabilitation services include
	 	 	 	 
	 
	 	 	 	 	 	care and services rendered by physical therapists, speech-language
	 	 	 	 
	 
	 	 	 	 	 	pathologists and occupational therapists. Rehabilitation services may be
	 	 	 	 
	App. K, I.
	 	 	 	 	 	provided in an Article 28 inpatient or outpatient facility, an
	 	 	 	 
	Prepaid Benefit
	 	 	 	 	 	Enrollee's home, in an approved home health agency, in the office of a
	 	 	 	 
	Package
	 	 	 	 	 	qualified
	 	 	 	 
	Definitions of
	 	 	 	 	 	private practicing therapist or speech pathologist, or for a
	 	 	 	 
	Covered
	 	 	 	 	 	child in a school, pre-school or community setting, or in a Residential
	 	 	 	 
	Services, A.
	 	 	 	 	 	Health Care Facility (RHCF) as long as  the Enrollee's stay is
	 	 	 	 
	Medical
	 	 	 	 	 	classified as a rehabilitative stay and meets the requirements for
	 	 	 	 
	Services,
	 	 	 	 	 	covered RHCF services as defined herein.
	 	 	 	 
	#7. Services of
	 	 	 	 	 	 	—	 	 	 	 	 
	Other
	 	 	 	 	 	Rehabilitation services provided in Residential Health Care Facilities
	 	 	 	 
	Practitioners,
	 	 	 	 	 	are subject to the stop-loss provisions specified in Section 3.13 of
	 	 	 	 
	b.)
	 	 	 	 	 	this Agreement. Rehabilitation services are covered as medically
	 	 	 	 
	Rehabilitation
	 	 	 	 	 	necessary, when ordered by the
	 	 	 	 
	Services
	 	Rehabilitation Services               
	 	 	—	 	 	 	 	 
	 
	 	 	 	 	 	Contractor's Participating Provider.
	 	 	 	 

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	Contract	 	 	 	 	 	 
	Section	 	Topic / Reason for Change	 	Contract Language Change	 	Status
	 
	 	 	 	 	 	18. Residential Health Care Facility (RHCF) Services	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	Residential Health Care Facility (RHCF) Services means inpatient nursing
	 	 	 	 
	 
	 	 	 	 	 	home services provided by facilities licensed wider Article 28 of the New
	 	 	 	 
	 
	 	 	 	 	 	York State Public Health Law, including AIDS nursing facilities. Covered
	 	 	 	 
	 
	 	 	 	 	 	services includes the following health care services: medical supervision,
	 	 	 	 
	 
	 	 	 	 	 	24-hour per day nursing care, assistance with the activities of daily	 	 	 	 
	 
	 	 	 	 	 	living, physical therapy, occupational therapy, and speech/language
	 	 	 	 
	 
	 	 	 	 	 	pathology services and other services as specified in the New York State
	 	 	 	 
	 
	 	 	 	 	 	Public Health Law and Regulations for residential health care facilities
	 	 	 	 
	 
	 	 	 	 	 	and AIDS nursing facilities. These services should be provided to an
	 	 	 	 
	 
	 	 	 	 	 	Enrollee:
	 	 	 	 
	 
	 	 	 	 	 	a. Who is diagnosed by a physician as having one or more clinically
	 	 	 	 
	 
	 	 	 	 	 	determined illnesses or conditions that cause the Enrollee to be so
	 	 	 	 
	 
	 	 	 	 	 	incapacitated, sick, invalid, infirm, disabled, or convalescent as to
	 	 	 	 
	 
	 	 	 	 	 	require at least medical and nursing care; and
	 	 	 	 
	 
	 	 	 	 	 	b. Whose assessed health care needs, in the professional
	 	 	 	 
	 
	 	 	 	 	 	judgment of the Enrollee's physician or a medical team:
	 	 	 	 
	 
	 	 	 	 	 	i. do not require care or active treatment of the Enrollee in a
	 	 	 	 
	 
	 	 	 	 	 	general or special hospital;
	 	 	 	 
	 
	 	 	 	 	 	ii. cannot be met satisfactorily in the Enrollee's own home or home
	 	 	 	 
	 
	 	 	 	 	 	substitute through provision of such home health services, including
	 	 	 	 
	 
	 	 	 	 	 	medical and other health and health-related services as are available in or
	 	 	 	 
	 
	 	 	 	 	 	near his or her community; and
	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	iii. cannot be met satisfactorily in the physician's office, a hospital
	 	 	 	 
	 
	 	 	 	 	 	clinic, or other ambulatory care setting because of the unavailability of
	 	 	 	 
	 
	 	 	 	 	 	medical or other health and health-related services for the Enrollee in
	 	 	 	 
	 
	 	 	 	 	 	such, setting in or near his or her community.
	 	 	 	 
	 
	 	 	 	 	 	The Contractor is also responsible for respite days and bed hold days
	 	 	 	 
	 
	 	 	 	 	 	authorized by the Contractor.
	 	 	 	 
	App. K, I. Prepaid
	 	Residential Health Care               
	 	 	—	 	 	 	 	 
	Benefit Package
	 	Facility (RHCF) Services              
	 	The Contractor is responsible for all medically necessary and clinically
	 	 	 	 
	Definitions of
	 	Clarify the range of                  
	 	appropriate inpatient Residential Health Care Facility services authorized
	 	 	 	 
	Covered Services,
	 	covered services and                  
	 	by the Contractor up to a sixty (60) day calendar year stop-loss for
	 	 	 	 
	A. Medical Services
	 	Contractor responsibility             
	 	Enrollees who are not in Permanent Placement Status as determined by LDSS.
	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 

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	Section	 	Topic / Reason for Change	 	Contract Language Change	 	Status
	App. K

Section III,

Non-Covered

Services; 2.

Other Non-

Covered

Services

	 	Residential Health Care Facilities

(RHCF)

Clarify that permanent residency

in a RHCF is not a covered

service in the Medicaid managed

care benefit package.
	 	2. Residential Health Care Facilities (RHCF)

Residency Services provided in a Residential

Health Care Facility (RHCF) to an individual

who is determined by the LDSS to be in

Permanent Placement Status in the RHCF is

are not covered (see 1.8 NYCRR 1.4

Rehabilitation in §360 (k)) services such a

setting by are covered as medically

necessary when ordered the Contractor’s

Participating Provider.
	 	

	
 
	 	 	 	 
	 	

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31EX-10.49

DOH

 STATE OF NEW YORK DEPARTMENT OF HEALTH

Coming Tower

zlarbara A. DeBuono, M.D., M.P.H. Commissioner

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

Dennis P. Whalen

Executive Deputy Commissioner

S.CONTAugust 26, 1998

Mr. Michael Wasserman General
Counsel CarePlus Health Plan 3
West 35th Street New York, NY
10001

Dear Mr. Wasserman:

Enclosed please find two copies of your contract for participation in the expanded Child
Health Plus program. The Department has developed a uniform contract for all participating
insurers. However, the changes you have requested have been incorporated into the contract. The
contract period is July 1, 1998 through December 31, 1999. Due to the size of the document, your
proposal and any required proposal amendments are not included in this mailing. Your proposal will
be included as Appendix C of the contract once forwarded to the Attorney General and Office of the
State Comptroller for final approval. Since your proposal did not contain the required standard
contract bid insert form and proof of worker’s compensation and disability insurance, you should
forward this information with your signed contract.

Both copies of the contract must contain original, notarized signatures. The attached
Appendix X should also be signed and notarized. The copies should be forwarded to Ms. Gabrielle
Armenia of my staff at the address below as soon as possible for completion of the contract
approval process:

New York State Department of Health

Bureau of Health Economics

Empire State Plaza, Corning Tower

Room 1119

Albany, NY 12237-0722

If you have any questions regarding the contract, please contact Ms. Armenia at (518)
473-7883. Thank you in advance for your cooperation in this matter.

Sincerely

/s/ Suzanne Moore

	 	 	 	Suzanne Moore, Ph.D. Director	 

Bureau of Health Economics

Enclosures

1

MISCELLANEOUS/CONSULTANT SERVICES

	 	 	 
	STATE AGENCY:

	 	. NYS COMPTROLLER’S NUMBER:
	Department of Health

	 	C-015473

Bureau of Health Economics ESP — Tower Building — Room
1110

	 	 	 
	Albany, NY 12237-0722

CONTRACTOR (Name and Address):

	 	ORIGINATING AGENCY CODE: 12000

TYPE OF PROGRAM:

S.CONT CarePlus Health Plan

3 West 35th Street

New York, NY 10001

Child Health Plus Insurance Program

	 	 	 
	CHARITIES REGISTRATION NUMBER: INITIAL

N/A

	 	CONTRACT PERIOD

FROM: July 1, 1998
	 
	 	 
	FEDERAL TAX IDENTIFICATION NUMBER:

	 	TO: December 31, 1999

13-3865627

FUNDING AMOUNT FOR INITIAL MUNICIPALITY NO. (if applicable): PERIOD

N/A $ 13,156,633

STATUS:

CONTRACTOR IS ( ) IS NOT( ) A

SECTARIAN ENTITY

CONTRACTOR IS ( ) IS NOT ( ) A

NOT-FOR-PROFIT ORGANIZATION

CONTRACTOR IS ( ) IS NOT ( ) A N Y STATE BUSINESS ENTERPRISE

FROM: TO:

FROM: TO:

FROM: TO:

BID OPENING DATE: February 14, 1997

APPENDICES ATTACHED AND PART OF THIS AGREEMENT

	 	 	 
	X APPENDIX A

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

	 	

	X APPENDIX A-2

	 	Program Specific Clauses
	 

	 	

	X APPENDIX B

	 	Request for Proposal(RFP)
	 

	 	

	X APPENDIX B-1

	 	RFP — Questions and Answers from Bidders’ Conference
	 

	 	

	X APPENDIX B-2

	 	RFP — Standard Contract/Bid Insert Form
	 

	 	

	 	 	 
	X APPENDIX D Schedul

	 	e of Deliverables
	 

	 	

	X APPENDIX E

	 	Financial Information
	 

	 	

	X APPENDIX F

	 	Payment and Reporting Schedules
	 

	 	

	X APPENDIX G-1

	 	Proof of Workers’ Compensation Coverage
	 

	 	

	X APPENDIX G-2

	 	Proof of Disability Insurance Coverage
	 

	 	

	X APPENDIX X

	 	Modification Agreement Form (to accompany
	 

	 	

	
 
	 	modified appendices for changes in term or consideration

on an existing period or for renewal periods)

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

S.CONTCONTRACTOR

By:

Printed Name

Title:

Date:

Contract No.

STATE AGENCY

By:

Printed Name

Title:

Date:

.State Agency Certification:

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

	 	 	 	 	 
	STATE OF NEW YORK
	 	 	)	 
	 
	 	) SS.:
	County of 
	 	 	)	 
	 
	 	 	 	 

On the day of , 19 , before me personally appeared , to me known, who being by me duly sworn, did
depose and say that he/she resides at that he/she is the of the , the corporation described herein
which executed the foregoing instrument, and that he/she

	 	 	 
	signed his/her name thereto by order of the board of directors of said corporation.

	 
	 	 
	(Notary)

	 	

	 

	 	

	ATTORNEY GENERAL’S SIGNATURE

Title:

	 	STATE COMPTROLLER’S SIGNATURE

Title:
	 

	 	

2

Date: Date:STATE OF NEW YORK

AGREEMENT

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

WITNESSETH:

WHEREAS, the STATE has formally requested contractors to submit bid proposals for the project
described in Appendix B for which bids were opened on the date noted on the face pages of this
AGREEMENT; and

WHEREAS, the STATE has determined that the CONTRACTOR is the successful bidder, and the
CONTRACTOR covenants that it is willing and able to undertake the services and provide the
necessary materials, labor and equipment therewith;

NOW THEREFORE, in consideration of the terms hereinafter mentioned and also the covenants and
obligations moving to each party hereto from the other, the parties hereto do hereby agree as
follows:

I. Conditions of Agreement

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

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

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

D. To modify the AGREEMENT within an existing PERIOD, the parties shall revise or complete the
appropriate appendix form(s). Any change in the amount of consideration to be paid, or change in
the term; is subject to the approval of the Office of the State Comptroller. Any other
modifications shall be processed in accordance with agency guidelines as stated in Appendix A-2.

E. The CONTRACTOR shall perform all services to the satisfaction of the STATE. The CONTRACTOR shall
provide services and meet the program objectives summarized in the Proposal/Program Workplan
(Appendix C) in accordance with: provisions of the AGREEMENT; relevant laws, rules and regulations,
administrative and fiscal guidelines; and where applicable, operating certificates for facilities
or licenses for an activity or program.

F. If the CONTRACTOR enters into subcontracts for the performance of work pursuant to this
AGREEMENT, the CONTRACTOR shall take full responsibility for the acts and omissions of its
subcontractors. Nothing in the subcontract shall impair the rights of the STATE under this
AGREEMENT. No contractual relationship shall be deemed to exist between the subcontractor and the
STATE.

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

H. For the purposes of this AGREEMENT, the terms Request For Proposal and RFP include all
Appendix B documents as marked on the face page hereof.

II. Payment and Reporting

A. The CONTRACTOR, to be eligible for payment., shall submit to the STATE’s designated payment
office (identified in Appendix F) any appropriate documentation as required by the Payment and
Reporting Schedule (Appendix F) and by agency fiscal guidelines, in a manner acceptable to the
STATE.

B. ‘The STATE shall make payments and any reconciliations in accordance with the Payment and
Reporting Schedule (Appendix F). The STATE shall pay the CONTRACTOR, in consideration of contract
services for a given PERIOD, a sum not to exceed the amount noted on the face page hereof.
or in the respective Appendix designating the payment amount for that given
PERIOD. This sum shall not duplicate reimbursement from other sources for CONTRACTOR costs and
services provided pursuant to this AGREEMENT.

C. The CONTRACTOR shall meet the audit requirements specified by the STATE.

Terminations

A. This AGREEMENT may be terminated at any time upon mutual written consent of the STATE and the
CONTRACTOR.

B. The STATE may terminate the AGREEMENT immediately, upon written notice of termination to the
CONTRACTOR, if the CONTRACTOR fails to comply with the terms and conditions of this AGREEMENT
and/or with any laws, rules, regulations, policies or procedures affecting this AGREEMENT.

C. The STATE may also terminate this AGREEMENT for any reason in accordance with provisions set
forth in Appendix A-2.

D. Written notice of termination, where required, shall be sent by personal messenger service or
by certified mail, return receipt requested. The termination shall be effective in accordance with
the terms of the notice.

E. Upon receipt of notice of termination, the CONTRACTOR agrees to cancel, prior to the effective
date of any prospective termination, as many outstanding obligations as possible, and agrees not
to incur any new obligations after receipt of the notice without approval by the STATE.

F. The STATE shall be responsible for payment on claims pursuant to services provided and costs
incurred pursuant to terms of the AGREEMENT. In no event shall the STATE be liable for expenses
and obligations arising from the. program(s) in this AGREEMENT after the termination date.

IV. Indemnification

A. The CONTRACTOR shall be solely responsible and answerable in damages for any and all accidents
and/or injuries to persons (including death) or property arising out of or related to the services
to be rendered by the CONTRACTOR or its subcontractors pursuant to this AGREEMENT. The CONTRACTOR
shall indemnify and hold harmless the STATE and its officers and employees from claims, suits,
actions, damages and costs of every nature arising out of the provision of services pursuant to
this AGREEMENT.

B. The CONTRACTOR is an independent contractor and may neither hold it self out nor claim to be an
officer, employee or subdivision of the STATE nor make any claim, demand or application to or for
any right based upon any different status.

V. Property

A. Any equipment, furniture, supplies or other property purchased. pursuant to this AGREEMENT is
deemed to be the property of the STATE except-as may otherwise be governed by Federal or State
laws, rules or regulations, or as stated in Appendix A-2.

VI. Safeguards for Services and Confidentiality

B. Services performed pursuant to this AGREEMENT are secular in nature and shall be performed in a
manner that does not discriminate on the basis of religious belief, or promote or discourage
adherence to religion in general or particular religious beliefs,

C. Funds provided pursuant to this AGREEMENT shall not be used for any partisan political
activity, or for activities that may influence legislation or the election or defeat of any
candidate for public office.

D. Information relating to individuals who may receive services pursuant to this AGREEMENT shall
be maintained and used only for the purposes intended under the contract and in conformity with
applicable provisions of laws and regulations, or specified in Appendix A-2.

3

APPENDIX A

STANDARD CLAUSES FOR

ALL NEW YORK STATE 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.

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 515,000 (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 510,000, 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 I 63.6.a).

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

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

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.

2. 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.

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

4. 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.

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

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

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

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

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

(a) The Contractor will not discriminate against employees or applicants for employment because of
race, creed, color, national origin, sex, age, disability or marital status, and will undertake or
continue existing programs of affirmative action to ensure that minority group members and women
are afforded equal employment opportunities without discrimination. Affirmative action shall mean
recruitment, employment, job assignment, promotion, upgradings, demotion, transfer, layoff, or
termination and rates of pay or other forms of compensation;

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

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

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

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

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

15. LATE PAYMENT. Timeliness of payment and any interest to be paid to Contractor for late
payment shall be governed by Article 11-A of the State Finance Law to the extent required by law.

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

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

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 §I65. (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.

18. 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 suck principles.

19. 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 — 7i° 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 SI million:

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

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

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

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.

4

CARE PLUS HEALTH PLAN

APPENDIX A-2

PROGRAM SPECIFIC CLAUSES

I. DEFINITIONS

A. “Subscriber” shall mean the parent, legally responsible adult, individual or head of
household who enters into a contractual agreement with the CONTRACTOR to obtain health
care coverage on behalf of his/her child or children or his or herself.

B. “Enrollee” shall mean an eligible child as defined in Section 2510 (4) of the
Public Health Law.

C. “Premiums” shall mean the amounts to be paid to the CONTRACTOR for a specified period
of time for health care coverage provided to enrollees eligible for insurance under
provisions of this AGREEMENT.

D. “RFP” shall refer to the document issued by the STATE in December 1996 which is found in
Appendix B.

E. “Subsidy Payment” shall mean the STATE’s share of the premium cost for health care
coverage provided to enrollees, under provisions of this AGREEMENT, eligible for a subsidy
pursuant to criteria specified in the authorizing legislation and the RFP.

F. “Subcontractor” shall refer to any entities which will provide services under
contractual arrangement to the CONTRACTOR for the sole purposes of performing some or
all of the CONTRACTOR’s responsibilities under provisions of this agreement.

G. “Proposal” shall refer to the document submitted by the CONTRACTOR in response to the
RFP issued by the New York State Department of Health in December 1996, as amended and
revised and approved by the STATE prior to the effective date of this AGREEMENT and the
Questions and Answers from the January 10, 1997 Bidder’s Conference.

H. “Benefit Contract” shall mean the contract between the CONTRACTOR and subscriber
approved by the New York State Insurance Department which details the provision of
health care coverage.

I. “Health Care Services” shall mean the services of physicians, optometrists, nurses,
nurse practitioners, midwives and other related professional personnel which are
provided on an inpatient or outpatient basis, including routine well-child visits;
diagnosis and treatment of illness and injury; inpatient hospital medical or surgical
care; laboratory tests; diagnostic x-rays; prescription drugs; diabetic supplies and
equipment; diabetic education and home visits; maternity care; radiation therapy;
chemotherapy; hemodialysis; ambulatory surgery; durable medical equipment; physical
therapy; emergency room services; home health care services; and outpatient alcohol,
substance abuse and mental health services as defined in the RFP, Questions and
Answers and the CONTRACTOR’s proposal as amended.

J. “Child Health Plus Contract Manager” shall refer to the individual responsible for the
oversight and monitoring the Child Health Plus Program on behalf of the New York State
Department of Health.

K. “Family Contribution” shall mean a premium payment made on behalf of an eligible
child for enrollment in the Child Health Plus program as defined in the RFP.

L. “Department of Health Policy Advisory Memoranda” shall mean Department issued memoranda
that clarify policy issues.

M. “The STATE” shall mean the people of the state of New York, acting by and through the
Commissioner of Health.

II. PAYMENT TO CONTRACTOR

A. Amount

1. The STATE, acting through the Health Care Initiatives Pool Administrator, shall reimburse the
CONTRACTOR on a subsidy payment basis for an amount up to, and not to exceed, the amount for. the
period indicated in the budget/ financial information (Appendix E). Payment shall be based upon
the CONTRACTOR’s submission and the STATE’s acceptance of those deliverables identified in
Appendix D (Schedule of Deliverables), identified herein. Notwithstanding any other provisions of
this AGREEMENT, in no event .shall the amount paid to the CONTRACTOR exceed the total budget
amount as stated in Appendix E.

2. The STATE agrees to review said deliverables in a timely fashion and specifically to notify the
CONTRACTOR in writing through the Child Health Plus Contract Manager, within sixty (60) business
days of receipt of the deliverables, if the STATE finds cause for rejection. The rejection notice
shall specify those exact portions of the deliverables that are deemed unsatisfactory and the
manner in which they deviate from the CONTRACTOR’s responsibilities as set forth in this
AGREEMENT.

3. The STATE’s failure to notify the CONTRACTOR promptly of the STATE’s rejection of a deliverable
shall constitute the STATE’s acceptance of said deliverable.

4. The STATE’s acceptance of a deliverable shall not be delayed unreasonably. A deliverable that
is resubmitted due to an initial rejection by the STATE shall be processed as an initial submittal
as outlined in this Section.

5. The State share of the premium payment shall be the only payment made by the STATE and there
will be no additional payment for the following types of activities: administering and marketing
the Child Health Plus program; enrolling children; issuing health insurance contracts; providing
and. coordinating the provision of health care services to enrollees; performing utilization
review and quality of care activities in conformance with the RFP and Proposal; performing billing
and claims procedures and collecting and submitting data as set forth in this AGREEMENT; and for
reimbursing any subcontractor.

6. The CONTRACTOR shall submit, to the STATE’s designated payment office, those deliverables
identified in Appendices D and F of this AGREEMENT. All monthly voucher bills and electronic mail
transmissions submitted by the CONTRACTOR pursuant to this AGREEMENT shall be submitted to the
STATE no later than the tenth business day of the month. The State reserves the right to process
vouchers received later than the tenth business day of the said month during subsequent months.

2.

5

7. The STATE shall notify the Health Care Initiatives Pool Administrator by the
first day of the following month (or the first business day following the first day of the
following month if the first day falls on a weekend or holiday) to reimburse the CONTRACTOR for
vouchers for which payment is being claimed, subject to the review procedures specified in Appendix
F.

8. All vouchers submitted by the CONTRACTOR pursuant to this AGREEMENT shall be submitted to
the STATE no later than sixty (60) days after the end date of the period for which reimbursement
is being claimed, unless the STATE has granted an extension for late submission of premium billing
and vouchers. In no event shall the amount received by all Child Health Plus Program CONTRACTORS
exceed the budgeted amount approved by the STATE.

9. The CONTRACTOR shall be entitled to receive payments for work, projects and services
rendered as detailed and described in this AGREEMENT and the CONTRACTOR’s Proposal (Appendix c)
which is attached.

10. The STATE agrees to pay its share of the premium unless this AGREEMENT is canceled or
terminated prior to its expiration date in accordance with the terms and provisions hereof. In the
event of cancellation, the CONTRACTOR shall be reimbursed for the STATE’s share of premium costs
per enrollee in effect up to the effective date of the termination of this AGREEMENT.

11. The STATE shall retain 10 percent of the last month’s premium to be paid to the
CONTRACTOR (December, 1999 payment period) until such time as all deliverables, including the
final report, specified in this AGREEMENT are completed and approved by the STATE.

12. The CONTRACTOR shall be entitled to enroll as many members as may be accommodated by the
amount of maximum annual funds received from the STATE as provided in Appendix E. The CONTRACTOR
shall monitor the number of enrollees so as not to exceed the maximum funding provided as set
forth in Appendix E, and the STATE shall not be obligated to pay more than the maximum funds as
set forth in Appendix E even in the event that the CONTRACTOR enrolls more members than can be
accommodated by the maximum funds set forth in Appendix E.

13. The maximum annual funding under this AGREEMENT may be modified by the STATE based upon
written request by the CONTRACTOR or on need as determined by the STATE. The STATE shall provide
the CONTRACTOR with a written notice of the effective date of modification of the maximum annual
funding. A modification which results in an increase in the maximum annual funding of a CONTRACTOR
may result in a like or commensurate decrease(s) from other Child Health Plus CONTRACTORS.

14. The CONTRACTOR shall notify the STATE in writing in a timely manner when current enrollment and
pending applications indicate that the CONTRACTOR shall reach ninety percent (90%) of its maximum
allocation of funding within or by the end of the annual funding allocation period. After receipt
of notice from the CONTRACTOR, the STATE shall respond within twenty (20) business days to the
CONTRACTOR to provide direction, such as but not limited to., whether the CONTRACTOR is to begin a
wait list at ninety percent . (90%) or continue to accept applications. If the CONTRACTOR is
directed to begin a wait list, the CONTRACTOR and the STATE shall mutually agree in writing upon a
plan of action for implementation of a wait. list. However, at a minimum, the CONTRACTOR
shall include the following factors in this plan of action:

	 	•	 	Intended start date of the wait list;

	 	•	 	Effective enrollment date when enrollment will be limited;

	 	•	 	Justification of need for limiting enrollment;

	 	•	 	Affected plan/catchment areas;

	 	•	 	Description of any public media campaign, including copies of any media releases, to
announce establishment of a wait list;	 

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

	 	•	 	Plan for referring applicants to other Child Health Plus plans in shared service areas.	 

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

B. Terms

1. For purposes of this AGREEMENT, the CONTRACTOR’s service area shall consist
of the following counties:

Kings, Queens and Richmond.

The CONTRACTOR may request approval to expand and

enhance its existing provider network to provide services under Child Health Plus
to areas of New York State for which the CONTRACTOR is certified as a Corporation
or Health Maintenance Organization licensed under Article 43 of the Insurance Law
and/or a Health Maintenance Organization or Comprehensive Health Service
Organization certified under Article 44 of the Public Health Law; however, in no
event may the CONTRACTOR provide services to an expanded service area beyond that
currently authorized under contract without prior written approval from the Child
Health Plus Contract Manager. -

2. The CONTRACTOR and its participating providers shall comply with the codes,
rules and regulations of the New York State Department of Health and the New York
State Insurance Department, with appropriate articles of Public Health Law and New
York State Insurance Law and with all other pertinent federal, STATE and local
laws and regulation, guidelines, policy, and/or Advisory Memoranda issued by the
STATE.

3. Any modifications to existing or new subcontract arrangements to
perform activities relative to service provided under this AGREEMENT
must be submitted in writing and approved by the STATE before they may
be implemented.

The CONTRACTOR agrees not to enter into any agreements with third party organizations for the
performance of its obligations, in whole or in part, under this AGREEMENT without the STATE’s
prior written approval of such third parties and the scope of the work to be performed by
them. The STATE’s approval of the scope of work and the subcontractor does not relieve the
CONTRACTOR of its obligation to perform fully under this contract. The responsibilities of
the CONTRACTOR and any subcontractors will be limited to those specified in the subcontracts.

All subcontracts entered into by the CONTRACTOR to provide program services for Child Health Plus
under this AGREEMENT shall contain provisions specifying:

1. that the work performed by the subcontractor must be in accordance with the terms of
this AGREEMENT;

2. that nothing contained in such AGREEMENT shall impair the rights of the
STATE; and

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

4. The prior review of the STATE is required before the CONTRACTOR or any of its employees,
agents or independent contractors at any time, either during or after termination of, or
cessation of the services required by this AGREEMENT, issue any written statement to the
media or issues any material for publication through any medium of communication bearing on
the work performed relating to financial results, enrollment, outcomes, utilization
patterns, and/or health status under this AGREEMENT. Any data related to the implementation
or outcome of the programs funded pursuant to this AGREEMENT used for publication in trade
or scientific medium shall require prior review by the STATE. Subsidies received pursuant to
Chapter 639 of the Laws of 1996 shall be acknowledged.

5. No report, document or other data produced in whole or in part with the funds provided under
this AGREEMENT may be copyrighted by the CONTRACTOR without consent by the STATE, nor shall any
notice of copyright be registered by the CONTRACTOR in connection with any report, document or
other data developed pursuant to this AGREEMENT. All information and data developed under this
AGREEMENT shall be the property of the STATE.

6. The CONTRACTOR shall provide the STATE with reports of progress or other deliverables pursuant
to this AGREEMENT. All required reports or other work products developed under this AGREEMENT
shall be completed as provided and agreed upon in the proposal (Appendix C), schedule of
deliverables (Appendix D) and the payment and reporting schedule (Appendix F) in a manner
satisfactory and acceptable to the STATE in order for the CONTRACTOR to receive payment.

7. All data relating to the design, implementation and outcome of the Child Health Plus program,
as specified in this AGREEMENT, shall be made available to the STATE for a period of twenty-four
(24) months following termination of coverage provided under this AGREEMENT. The data shall
include data collected under this AGREEMENT including marketing and enrollment outcomes,
demographic characteristics of the enrollees, utilization data of enrollees and data directly
related to the reporting requirements contained in Appendix F. The data collected are considered
to. be patient and provider specific and shall be held to all confidentiality controls pursuant to
STATE regulatory and statutory requirements.

8. The STATE reserves the right to require the CONTRACTOR to immediately cease enrollment if the
STATE determines that such action is necessary for the good of the program.

III. CONTRACTOR’S RESPONSIBILITIES

The CONTRACTOR shall be responsible for the administration and implementation of the Child
Health Plus program for those children deemed eligible to participate. The project shall be
implemented in conjunction with any subcontract designated in the program proposal/workplan,
Appendix C, attached hereto and made a part hereof. As set forth in the CONTRACTOR’s proposal
(Appendix. C), the responsibilities of the CONTRACTOR shall include, but not be limited to, the
following:

A. Marketing

1. The CONTRACTOR shall implement a marketing plan that is consistent with the RFP. The
marketing plan must be submitted to the State’s Contract Manager for approval prior to
implementation. Any subsequent change to the marketing plan must be submitted to the DOH
at least thirty (30) days prior to implementation and must be approved by the State’s
Contract Manager prior to implementation of such plan or change.

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

3. The CONTRACTOR shall use its own Child Health Plus enrollment application form to
collect information on each applicant during the enrollment and application process
which contains all information necessary to make an eligibility determination subject
to approval by the New York Sate Insurance Department. The enrollment application may
contain an insert agreed to, and/or provided by the STATE to collect supplemental data
if the STATE determines collection of such supplemental data is necessary.

4. The CONTRACTOR shall refer the parent, guardian or legally responsible adult of children whose
household gross income and family size meet criteria which indicate a strong potential for
Medicaid eligibility to the appropriate agency for application to the Medicaid program. The
CONTRACTOR shall use the State Issued “Child Health Plus Medicaid Referral Form” to determine
which children to refer for application to the Medicaid Program. The CONTRACTOR shall provide such
families with a brochure provided by the STATE describing the Medicaid application process.
Documentation of these referrals must be maintained in enrollment files and shall be made
available for review by the STATE during site visits.

B. Issuance of Health Insurance

1. The CONTRACTOR shall issue a benefit contract for each enrollee consistent with the
benefit structure and premiums detailed in its Proposal, as modified and approved by
the New York State Department of Health (DOH) and the State Insurance Department (SID).
Such contract and premiums shall be subject to the approval of the New York State
Department of Health and the State Insurance Department and shall meet all appropriate
statutory and regulatory requirements imposed by the New York State Department of
Health and the State Insurance Department.

2. The CONTRACTOR shall issue an identification card to each enrollee which
identifies the Child Health Plus program.

3. Any subcontractor that is responsible for providing health insurance coverage to Child
Health Plus enrollees shall do so by utilizing the CONTRACTOR’s existing benefit package
or may issue an individual benefit package, subject to written approval by the STATE, to
each eligible Child Health Plus enrollee consistent with the benefit package and premiums
currently in effect as approved by the STATE for the CONTRACTOR.

4. Any such individual benefit contract issued by a., subcontractor shall be
subject to approval of the New York State Department of Insurance and shall meet all
appropriate statutory and regulatory requirements imposed by the New York State
Departments of Health and Insurance.

C. Benefit Package.

The CONTRACTOR shall be responsible for the provision of health services to each enrollee
consistent with the benefit package identified in the RFP, the CONTRACTOR’s proposal and
the Benefit Contract as approved by the New York State Insurance Department and consistent
with subsequent STATE issued regulations, guidelines, policy and/or Advisory Memoranda.

D. Payment to Health Care Providers

	 	1.	 	The CONTRACTOR shall be responsible for the processing of all claims from
providers rendering care to program enrollees.	 

E. Premium Determination and Payment

1. The STATE’s subsidy shall be limited to the amount indicated in Appendix E.

	 	2.	 	The STATE’s subsidy shall constitute the total monetary obligation of the
STATE under this AGREEMENT.

	 	3.	 	Premiums set forth in Appendix E shall be-in effect at least through December
31, 1998. Subscribers shall be responsible for payment of the family premium
contribution to the CONTRACTOR and shall be responsible for copayments as set forth in
the Benefit contract.

	 	4.	 	Premiums approved with the proposal will be valid at least through December
31, 1998. Premiums may be modified periodically under the Child Health Plus program
subject to approval of a request from the CONTRACTOR through the New York State
Department of Health and the State Insurance Department. Applications for adjustments
must be submitted at least 90 days prior to the requested effective date of the change
and will be subject to approval by the New York State Department of Health and the
State Insurance Department. Payment shall be adjusted to cover any premium
modifications approved by the New York State Department of Health and the State
Insurance Department. In the absence of an approved premium modification by the
Department of Health and the State Insurance Department., the premium contained herein
or any subsequent premium (whichever is in effect), shall continue as the premium for
the STATE’s subsidy through December 31, 1999. The New York State Department of Health
maintains the right to eliminate an insurer from the Child Health Plus program if
agreement on the premium cannot be reached.

	 	5.	 	The CONTRACTOR shall be responsible for collecting premiums and family
premium contributions to be paid for by subscribers on behalf of an enrolled child or
children in advance of the period of coverage.

	 	6.	 	The CONTRACTOR shall prepare and submit to the STATE, in accordance with
Appendix F of this AGREEMENT and on a monthly basis, voucher bills and adjustments on
such forms and in such detail as the STATE shall require. Monthly voucher bills shall
be based on the actual number of children eligible for a subsidy enrolled in the
program during the month for which payment is being claimed.

	 	7.	 	Monthly voucher bills shall include the period for which reimbursement is
being claimed, the plan identifier (name), contract number, application number, last
name, first name, middle initial, social security number (if available), date of
birth, sex, house number or post office box number, street, city, county, zip code,
original effective date of coverage, termination date of coverage, STATE share of the
monthly premium, current enrollment/recertification date, telephone number,
household/family     identifier, whether or not the child entered the program though the
presumptive eligibility process and the payment category. Proof of income as well as
other eligibility criteria should be maintained by the contractors for purposes of
site visit and reconciliation of premium payments by the STATE.

	 	8.	 	All adjustments shall include a listing by enrollee of any, change in
enrollment occurring in that period. The report shall include the period for which
adjustment is being billed, the plan identifier (name), contract number, social
security number (if available), the last name, first name, middle initial, from and to
date and the adjustment to the STATE share of the monthly premium. All adjustments
shall be submitted in accordance with timeframes provided herein and procedures
provided by the STATE.

	 	9.	 	The CONTRACTOR shall monitor enrollment levels such that the amount of STATE
subsidy authorized for a given year is not exceeded.

F. Utilization Review and Ouality of Care Program

1. Utilization review programs shall be made consistent with the provisions of the RFP and
the CONTRACTOR’s Proposal, subject to existing STATE or federal requirements, as may be
amended by STATE law and/or regulations.

2. Quality of care review provisions shall be consistent with the provisions of the
CONTRACTOR’s Proposal and the RFP subject to STATE requirements.

3. The STATE reserves the right to monitor and conduct a separate quality of care review
audit of services provided to enrollees participating in the Child Health Plus program.

4. The CONTRACTOR will be required to address deficiencies relating to results of Quality
Assurance and utilization reviews in cooperation with the STATE and Quality Assurance
CONTRACTORS if applicable to ensure appropriate compliance in provision of benefits to
enrollees under the Child Health Plus program.

5. The providers are responsible for complying with all quality of care assurances as
stipulated in FEDERAL and STATE regulations and statute.

G. Evaluation and Data Submittal

The CONTRACTOR shall:

1. Prepare and submit to the STATE, progress reports detailing marketing and
enrollment outcomes, demographic characteristics of enrollees and utilization data, on
such forms and in such detail as the STATE shall require. The progress reports shall
include, in aggregate, the data elements specified in Appendix F.

2. Make the requested data available pursuant to the provisions of Appendix F.

3. Have access to, and establish an account with the STATE electronic mail network and
obtain STATE approved electronic mail software and hardware for electronic submission of
monthly voucher bills, adjustments and data reports via the STATE electronic mail network.

4. Furnish or make available accounts, records, or other information pertaining solely to
this AGREEMENT as required to substantiate any estimate, expenditures or reports as
requested by the STATE or the Office of the State Comptroller, as may be necessary for
auditing purposes regarding this AGREEMENT, or to verify that expenditures were made only
for the purposes authorized by this AGREEMENT. Audits performed of the CONTRACTOR’s records
shall be conducted in accordance with regulations set forth in the federal “Office of
Management and Budget Circular A-110.” Reports, disclosures, comments and opinions required
under this attachment shall be so noted in the audit report.

5. The CONTRACTOR shall assure the STATE and its authorized representatives ready access
to all project sites and all enrollment, financial, clinical or other records and reports
relating to the project. The STATE shall have full access upon five days notice and at
reasonable times. during normal business hours to all patient medical records consistent
with all legal requirements regarding patient privacy and confidentiality and consistent
with the STATE’s regulatory authority to gain access to such information.

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

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

8. The CONTRACTOR shall provide the STATE with reports of progress or other specific work
products pursuant to this AGREEMENT in a timely manner subject to a schedule agreed upon
by the parties herein or required by the STATE. All required reports or other work
products developed under this AGREEMENT must be completed as provided by the agreed upon
or required work schedule in order for the CONTRACTOR to be eligible for payment.

9. The CONTRACTOR shall accept responsibility for compensating the STATE for financial
errors which are found to be the responsibility of the CONTRACTOR which are revealed in
an audit and sustained after completion of the New York State Comptroller’s normal
audit procedure.

10. The CONTRACTOR shall accept responsibility for compensating the STATE for any premiums
paid on behalf of an enrollee who the CONTRACTOR inappropriately determined eligible for
and enrolled in the Child Health Plus program as revealed during a site visit, desk audit,
or other method performed by the STATE.

11. The CONTRACTOR shall maintain all necessary and appropriate insurance coverage
to protect itself under this AGREEMENT.

12. The relationship of the CONTRACTOR to the STATE is that of an independent contractor.
The CONTRACTOR shall conduct itself in a manner consistent with its status as an
independent contractor, shall neither hold itself out as nor claim to be an officer or
employee of the STATE, and shall not make any claim, demand, or application to or for any
right of the STATE, including but not limited to worker’s compensation coverage,
unemployment insurance benefits, social security-coverage or retirement
membership or credit.

13. In the event an enrollee moves outside of the CONTRACTOR’s catchment area to a
different area within the STATE, the CONTRACTOR shall refer the enrollee to the Child
Health Plus CONTRACTOR(S) which (is/are) responsible for providing services for the Child
Health Plus Program in the area to which the enrollee moves.

H. Presumptive Eligibility

1. The CONTRACTOR shall use the presumptive eligibility process established for the Child
Health Plus program. Presumptive eligibility provides coverage for a child who appears
eligible based upon a completed and signed application but is lacking documentation
necessary to support the application pending a full eligibility determination. An enrollee
is presumptively eligible for a maximum of 60 days after the initial date of enrollment.
Only one period of presumptive eligibility per enrollee per plan is permitted. At the end
of the presumptive eligibility period, all required documentation must have been provided
to maintain and support the enrollee’s continued coverage. Presumptive. eligibility shall
not be available during the recertification process. The continuous 12 month period of
enrollment is inclusive of the 60 day presumptive eligibility period and shall not be
extended to reflect an enrollee’s coverage under the presumptive eligibility period.
Failure to meet presumptive eligibility requirements shall be cause for termination of
Child Health Plus benefits at midnight the last day of the month of the presumptive
eligibility period.

IV. STATE RESPONSIBILITIES

It shall be the obligation of the STATE to:

A. Monitor and evaluate the CONTRACTOR’s performance and compliance with this
AGREEMENT.

B. Review in a timely manner policies and procedures related to the enrollment, marketing,
provider network, payment process and change in premiums, which are submitted by the
CONTRACTOR, and certify that they are consistent with STATE policy.

C. Review and evaluate all reports, to ensure that all deliverables required by
this AGREEMENT are fulfilled.

D. Approve, in advance of project implementation, all subcontractor arrangements
(identified in the. Proposal as participating in Child Health Plus) entered into by
the CONTRACTOR for the sole purpose of carrying out the responsibilities of this
AGREEMENT.

E. Approve any additional subcontractor arrangements to be entered into by the CONTRACTOR
for the sole purpose of carrying out the responsibilities of this AGREEMENT prior to the
CONTRACTOR entering into such an arrangement.

F. Pay the CONTRACTOR at premium rates set ‘forth in Appendix E or any subsequent premium
rate approved by the New York State Department of Health and the State Insurance
Department.

G. Conduct annual site visits of enrollment files and enrollment/disenrollment procedures
and program reviews and desk audits as it deems necessary to determine compliance with
this AGREEMENT.

	 	H.	 	Provide the CONTRACTOR with brochures describing the Medicaid program
and the application process.	 

I. Provide the CONTRACTOR with all reporting forms and reports necessary for
compliance with the requirements set forth in this AGREEMENT.

J. Provide the CONTRACTOR with all required forms and software necessary to
transmit monthly voucher bills, adjustments and other data reports using the
STATE electronic mail network.

K. Review and approve requests made by the CONTRACTOR to expand and enhance the
existing provider network of the CONTRACTOR to provide services under Child Health Plus
to areas of New York State for which the CONTRACTOR is certified as a Corporation or
Health Maintenance Organization licensed under Article 43 of the Insurance Law and/or a
Health Maintenance Organization or Comprehensive Health Service Organization certified
under Article 44 of the Public Health Law.

L. Modify (increase or decrease) maximum annual funding of CONTRACTOR based on written
request by the CONTRACTOR or on need as determined by the STATE.

M. Recoupment from Medicaid by the Child Health Plus` program, any premiums
paid by the Child Health Plus program on behalf of children who subsequently become
enrolled in Medicaid.

V. Patient Confidentiality

A. The provisions of this AGREEMENT shall in no way violate. or compromise existing STATE
and federal statutes and/or regulations designed to protect patient confidentiality. The
CONTRACTOR shall adopt policies and procedures which fully guard patient confidentiality
and which are acceptable to the STATE.

VI. Termination of AGREEMENT

A. This AGREEMENT may be canceled at any time by the STATE giving the CONTRACTOR not less
than sixty (60) days written notice that on or after a date therein specified, this AGREEMENT
shall be deemed terminated and canceled.

B. The STATE may cancel this AGREEMENT at any time without prior notice for the following
reasons: if the STATE determines the CONTRACTOR is adhering to enrollment procedures, which result
in a pattern and practice of inappropriate enrollment; deficiencies in Quality Assurance;
termination of participation in the STATE’s Medicaid Managed Care initiative; or if it is
determined that the CONTRACTOR does not meet the financial requirements as specified in statute.

C. Any delay by, or failure or inability of the CONTRACTOR to complete this AGREEMENT, either
in whole or in part, in accordance with provisions, specifications, and/or schedules contained
herein shall be excused and a reasonable time for performance pursuant to this AGREEMENT shall be
extended to include the period of such delay or nonperformance, if caused by or resulting from
fire, explosion, accident, labor dispute, flood, war, riot, acts of God, legal action including
injunction, present or future law, governmental order, rule or regulation, or any other reasonable
cause beyond the CONTRACTOR’S immediate and direct control. It is agreed, however, that a cause
itemized or referred to above shall not excuse a delay, failure or inability to the CONTRACTOR to
perform if such cause arose as a result of the negligence or willful act or omission of the
CONTRACTOR which in the exercise of reasonable judgment, could. have been avoided by the
CONTRACTOR. Pending the restoration, settlement or resolution of the cause for delay, failure or.
inability of the CONTRACTOR to perform, the CONTRACTOR shall continue to perform those obligations
of this AGREEMENT which are not related or subject to such cause.

D. The CONTRACTOR shall notify the STATE of circumstances resulting in the inability of
the CONTRACTOR to perform activities and services required under this AGREEMENT. If
circumstances result in the CONTRACTOR’S inability to perform services, sixty (60) days notice
of termination should be provided by the CONTRACTOR to the STATE with notice to insured persons
of conclusion of coverage under this AGREEMENT and the availability of conversion rights
pursuant to the Benefit Contract.

E. If the AGREEMENT between the STATE and CONTRACTOR is terminated for any reason, the
CONTRACTOR must work in conjunction with the STATE to develop a plan to transition enrollees to
another CONTRACTOR in their catchment area. This plan must include notifying each enrollee of the
names and telephone numbers of other CONTRACTORS in the catchment area.

VII. Third Party Insurance

The CONTRACTOR will make diligent efforts to determine whether enrollees have third party
health insurance (TPHI) and must attempt to coordinate benefits with, and collect TPHI
recoveries from, other insurers. The CONTRACTOR may use the Prepaid Capitation Plan roster
as one method to determine TPHI information. The CONTRACTOR will be permitted to retain
100 percent of any reimbursement for benefit package services obtained from TPHI.
Capitation rates will reflect a deduction for anticipated TPHI recoveries. In no instance
may enrollees be held responsible for disputes over these recoveries.

6

STATE OF NEW YORK

DEPARTMENT OF HEALTH

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

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

Dennis P. Whalen

Executive Deputy Commissioner

	 	 	 
	Date: Jan. 15

	 	, 2002
	 
	 	 
	Contract:

	 	C105473
	 
	 	 
	Contractor:

	 	CarePlus Health Plan

Contract Period: Jan. 1, 1998 – Dec. 31, 2002

Attached is your copy of the approved contract. The Contract number must appear on all
vouchers and correspondence.

Reports of the Expenditures and Budget Statements should be submitted as outlined in the
Contract.

In accordance with the contract, properly completed vouchers and/or programmatic questions
should be addressed to the State’s designated payment office. as stated in the Contract.

Failure of the contracting Agency to comply with payment provisions as set forth in the
approved Contract may result in non-payment.

An additional supply of vouchers to be used in submitting claims maybe obtained by written
request from the Office of the State Comptroller, Supply Room, Alfred E. Smith State Office
Building, Albany, New York 12236.

New York State Department of Health Contract Unit

7

CONTRACT AMENDMENT 2002

APPENDIX X

	 	 	 	 	 
	Agency Code 12000	 	Contract No. C-015473
	Period 7/1/98 - 12/31/02	 	Funding Amount for Period $111,356,633

This is an AGREEMENT between THE STATE OF NEW YORK, acting by and through the Department
of Health, having its principal office at Corning Tower, Empire State Plaza,
Albany, NY, (hereinafter referred to as the STATE), and CarePlus Health Plan
(hereinafter referred to as the CONTRACTOR), for modification of Contract Number C015473
as provided in attached revisions to Section I.B. of the Agreement, and Appendices A-2, E and
H and to extend the period of the contract through December 31, 2002 subject to the enactment
of legislation by the New York State Legislature extending certain provisions of Chapter 2 of the
Laws of 1998.

All other provisions of said AGREEMENT shall remain in full force and effect.

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

	 	 	 	 	 
	CONTRACTOR ISIGNATURE

	 	STATE AGENCY SIGNATURE
	 	

	 
	 	 	 	 
	By: /s/ K Ajmani

	 	By: /s/ Judith Arnold
	 	

	 
	 	 	 	 
	 	 	 

	 
	 	 	 	 
	Karin Ajmani

	 	Judith Arnold
	 	

	 
	 	 	 	 
	 	 	 

	 
	 	 	 	 
	Printed Name

	 	Printed Name
	 	

	 
	 	 	 	 
	Title: Executive Director

	 	Title: Deputy Commissioner
	 	

	 

	 	

	 	

	 
	 	 	 	 
	 	 	Division of Planning, Policy, and Resource Development

	 
	 	 	 	 
	Date: 11/30/2001

	 	Date:
	 	12/3/01
	 

	 	 	 	 

	 	 	 	State Agency Certification:

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

	 	 	 	 	 
	STATE OF NEW YORK
	 	 	)	 
	 
	 	) SS.:
	County of New York )
{r}
	 	 	 	 

On the 30th  day of  November  2001 before me personally
appeared  Karin Ajmani ,to me known, who being by me duly sworn, did
depose and say that he/she resides at  New York, NY , 

that he/she is the  Executive Director  of  Care Plus Health Plan  ,
the corporation

described herein which executed the foregoing instrument, and that he/she signed his/her name
thereto by order of the board of directors of said corporation.

Evelyn Huang

Notary Public State of New York

No. 31-6001118

Qualified in New York County

Commission Expires 3-6-2002

Title:

Date:

STATE OF NEW YORK

AGREEMENT

Section I.B.1. is revised to read as follows: I.
Conditions of Agreement

B.1. This AGREEMENT is extended through December 31, 2002, subject to the enactment of legislation
by the New York State Legislature extending certain provisions of Chapter 2 of the Laws of 1998
governing the Child Health Plus Program.

APPENDIX A-2

Program Specific Clauses

Section III.E.3 is revised to read as follows:

Section III. CONTRACTOR’S RESPONSIBILITIES E.
Premium Determination and Payment

	 	3.	 	Premiums set forth in Appendix E shall be in effect at least through December 31, 2002.
Subscribers shall be responsible for payment of the family premium contribution to the
CONTRACTOR and shall be responsible for copayments as set forth in the Benefit contract and
consistent with subsequent STATE and FEDERAL legislation, regulations, guidelines, policy
and/or Advisory Memoranda. Effective January 1, 1999, all copayments are eliminated and any
provisions regarding copayments will no longer have any force and effect.

APPENDIX E

Financial Information

Sections A is revised to read as follows:

A. CarePlus Health Plan shall receive, for the period January 1, 2002 through December 31,
2002, an amount up to, but not to exceed, $ 39,800,000 to provide and administer a Child
Health Plus program for uninsured children in the counties identified in Appendix A-2, Section
II.B.1 of this AGREEMENT or as modified by the STATE. Payment of this amount is based on the
CONTRACTOR meeting the responsibilities provided in this AGREEMENT.

Additional Premium Information: For Periods on
or after July 1, 2000:

The total monthly premium shall be: $ 110.22

The State share of the total monthly premium shall be $ 110.22 or the total
monthly premium for children in families with gross household income less than 160% of
the federal poverty level and children who are American Indians or Alaskan Natives
(AUAN).

The State share of the total monthly premium shall be $ 101.22 or the total monthly
premium minus $9 for children in families with gross household income between 160% and 222%
of the federal poverty level with a maximum of $27 per month per family. The State share is
the total monthly premium less $9 for each of the first three children. For additional
children, the State share is the total monthly premium.

The State share of the total monthly premium shall be $ 95.22 or the total monthly
premium minus $15 for children in families with gross household income between 223% and 250%
of the federal poverty level with a maximum of $45 per month per family. The State share is
the total monthly premium less $15 for each of the first three children. For additional
children, the State share is the total monthly premium.

In the absence of an approved premium modification by the Department of Health and State
Insurance Department, the premium above or subsequent premium approved (whichever is in effect)
shall continue as the State’s subsidy through December 31, 2002.

APPENDIX H

Additional Program Specific Clauses

	 	 	 	 	 	 	 
	The following section is revised as follows: H. Audit Procedures
	 	 	 	 
	 
	 	 	 	 	 	 
	 
	 	 

	 	•	 	Initial Audit — The initial audit will be a sampling of randomly selected files by category (such as new enrollees, re-enrollments,
presumptive enrollments or other category identified to be necessary) reviewed to ensure the propriety of enrollment and
eligibility in the Child Health Plus program, and, as determined by the STATE to be necessary, ensure compliance with the
requirements of Title 1-A of Article 25 of the Public Health Law, contractual provisions, advisory memoranda issued by the
Commissioner, Title XXI of the federal Social Security Act and implementing regulations, and requirements set forth in the State
Child Health Plan established pursuant to Title XXI of the federal Social Security Act.

	 	•	 	Verbal Review of the Findings by the Auditor — Verbal review of the findings by the auditor will be done to provide immediate
feedback of audit findings during the initial audit; to identify the need, if any, for a second audit (based upon a fatal error
rate of 10% or greater of the files reviewed) and to identify the need for a plan of correction and the areas to be addressed (a
plan of correction is required if any errors are detected). For purposes of these audits, a fatal error is one in which an enrollee
was found to be ineligible or enrolled inappropriately for any period.

	 	•	 	Initial Audit Report — The initial audit report will finalize the findings of the initial audit which shall be transmitted to the
audited CONTRACTOR within 30 days of the audit by certified mail. Such report will request a plan of correction, which is
acceptable to the STATE, to be submitted within 30 days of receipt of the initial audit report, and advise of the need of a second
audit if the fatal error rate is 10% or greater of the files reviewed, or if the plan or correction is not acceptable or submitted
within the thirty day period.

	 	•	 	Second Stage Audit — The second stage audit shall be performed if the fatal error rate of the initial audit is 10% or greater of
the files reviewed and shall be done no earlier than three (3) months after submission of the plan of correction. The second audit
will be done on a statistically valid sample and will include an extrapolation of the results to the population in accordance with
generally accepted auditing standards and accepted statistical sampling methodology.
DOH
	 
	 	 	 	STATE of NEW YORK
DEPARTMENT OF HEALTH
Corning Tower            The Governor Nelson A. Rockefeller Empire State PlazaAlbany, New York 12237
	 
	 	 	 	Ionia C. Novello, M.D., M.P.H. Dennis P. Whalen
Commissioner            Executive Deputy Commissioner
DATE: Feb. 11, 2000
	 
	 	 	 	CONTRACT #: C015473

CONTRACTOR: CAREPLUS HEALTH PLAN CONTRACT PERIOD: Jul. 01,
1998 — Dec. 31, 2000

Attached is your copy of the approved contract. The Contract
number must appear on all vouchers and correspondence.

Reports of the Expenditures and Budget Statements should be submitted as
outlined in the Contract.

In accordance with the contract, properly completed vouchers and/or
programmatic questions should be addressed to the State’s designated payment office
as stated in the Contract.

Failure of the contracting Agency to comply with payment provisions as set
forth in the approved Contract may result in non-payment.

An additional supply of vouchers to be used in submitting claims may be
obtained by written request from the Office of the State Comptroller, Supply Room,
Alfred E. Smith State Office Building, Albany, New York 12236.

New York State Department of Health Contract
Unit

	 	 	 	 	 	 	 	 	 
	Agency Code 12000	Contract No. C-015473
	Period	 	I / I /99-12/31 /00	 	Funding Amount for Period $30,456,633

This is an AGREEMENT between THE STATE OF NEW YORK, acting by. and through the
Department of Health, having its principal office at Coming Tower, Empire
State Plaza. Albany. NY, (hereinafter referred to as the STATE), and 
Care Plus Health Plan  (hereinafter referred to as the CONTRACTOR),
for modification of Contract Number C-015473 as provided in attached revisions to
Section I.C. of the Agreement, and Appendices A-2,D, E, H and J and to extend the
period of the contract to December 31, 2000.

All other provisions of said AGREEMENT shall remain in full force and effect.

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

	 	 	 	 	 
	CONTRACTOR ISIGNATURE

	 	STATE AGENCY SIGNATURE
	 	

	 
	 	 	 	 
	By: /s/ K Ajmani

	 	By: /s/ Judith Arnold
	 	

	 
	 	 	 	 
	 	 	 

	 
	 	 	 	 
	Karin Ajmani

	 	Judith Arnold
	 	

	 
	 	 	 	 
	 	 	 

	 
	 	 	 	 
	Printed Name

	 	Printed Name
	 	

	 
	 	 	 	 
	Title: Executive Director

	 	Title: Deputy Commissioner
	 	

	 

	 	

	 	

	 
	 	 	 	 
	 	 	Division of Planning, Policy, and Resource Development

	 
	 	 	 	 
	Date: 12/20/99

	 	Date:
	 	1/4/2000
	 

	 	 	 	 

	 	 	 	State Agency Certification:

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

	 	 	 	 	 
	STATE OF NEW YORK
	 	 	)	 
	 
	 	) SS.:
	County of New York )
{r}
	 	 	 	 

On the 20th day of  December  2002 before me
personally appeared  Karin Ajmani ,to me known, who being
by me duly sworn, did depose and say that he/she resides at  New York,
NY , 

that he/she is the  Executive Director  of  Care Plus Health Plan
 , the corporation

described herein which executed the foregoing instrument, and that he/she signed
his/her name thereto by order of the board of directors of said corporation.

Title:

8

STATE OF NEW YORK

AGREEMENT

Section I.B. is revised to read as
follows: I. Conditions of Agreement

B.1. This AGREEMENT is subject to enactment of authorizing and extending legislation by the New
York State Legislature effective January 1, 2000. The enactment of such authorizing legislation
will hereby extend all provisions of the AGREEMENT from December 31, 1999 to December 31, 2000.

2. The maximum compensation for the contract term of this AGREEMENT shall not exceed the amount
specified on the face page hereof, subject to available funding as enacted by the New York State
Legislature effective January 1, 2000 and continued appropriations through the contract term.

MODIFICATIONS TO APPENDIX A-2

Program Specific Clauses

Section II.A.2 is revised to read as follows:

II. PAYMENT TO CONTRACTOR A.
Amount

2. The STATE agrees to review said deliverables in a timely fashion and specifically to notify
the CONTRACTOR in writing through the Child Health Plus Contract Manager, within sixty (60)
business days of receipt of the deliverables, if the STATE finds cause for rejection. The
rejection notice shall specify those exact portions of the deliverables that are deemed
unsatisfactory and the manner in which they deviate from the CONTRACTOR’s responsibilities as set
forth in this AGREEMENT.

The CONTRACTOR must submit corrected, acceptable deliverables within 30 days of the date of
the STATE’s written notification. If the CONTRACTOR fails to submit acceptable deliverables
within 30 days, the DEPARTMENT may reduce the CONTRACTOR’s subsidy payment by up to a total of
two percent each month for a period beginning on the first day of the calendar month following
the expiration of the 30 days noted above and continuing until the last day of the calendar month
in which the acceptable deliverable is submitted.

Sections III.E.4, H.1 and H.2 are revised to read as follows:
Section III. CONTRACTOR’S RESPONSIBILITIES E.
Premium Determination and Payment,

4. Premiums may be modified periodically under the Child Health Plus program subject to approval of
a request from the CONTRACTOR through the New York State Department of Health and the State
Insurance Department. Applications for adjustments must be submitted at least 90 days prior to the
requested effective date of the change and will be subject to approval by the New York State
Department of Health and the State Insurance Department. Payment shall be adjusted to cover any
premium modifications approved by the New York State Department of Health and the State Insurance
Department. In the absence of an approved premium modification by the Department of Health and the
State Insurance Department, the premium contained herein or any subsequent premium (whichever is in
effect), shall continue as the premium for the STATE’s subsidy through December 31, 2000. The New
York ‘State Department of Health maintains the right to eliminate an insurer from the Child Health
Plus program if agreement on the premium cannot be reached.

H. Presumptive Eligibility

1. The CONTRACTOR shall use the presumptive eligibility process established for the Child Health
Plus program. Presumptive eligibility provides coverage for a child who appears eligible based upon
a completed and signed application but is lacking documentation necessary to support the
application pending a full eligibility determination. An enrollee is presumptively eligible for a
maximum of two (2) calendar months after the initial date of enrollment. Necessary documentation
shall be accepted by the CONTRACTOR through the last day of the second month of the presumptive
eligibility period. Presumptive eligibility shall not be available during the recertification
process. The continuous 12 month period of enrollment is inclusive of the two month presumptive
eligibility period. Failure to meet presumptive eligibility requirements shall be cause for
termination of Child Health Plus benefits at midnight the last day of the month of the presumptive
eligibility period.

2. Effective January 1, 1999 and subject to the availability of federal financial participation
(FFP) under Title XIX of the Social Security Act, any child under age 19 whose family’s net
household income does not exceed 192% or, effective July 1, 2000, 208% of the non-farm federal
poverty level or the gross equivalent of such net income shall be presumed eligible for Child
Health Plus coverage.

The presumptive eligibility period shall continue until the earlier of the date a Medicaid or Child
Health Plus eligibility determination is made or sixty (60) days after the presumptive eligibility
period begins. If a child is determined to not be eligible for Medicaid prior to the last day of
the sixty (60) day presumptive eligibility, such child may continue to be presumed eligible for
Child Health Plus until the earlier of the date a Child Health . Plus eligibility determination is
made or the last day of the sixty (60) days presumptive eligibility period. A presumptive
eligibility period may be extended in the event a Medicaid eligibility determination is not made ,
within the sixty (60) day period through no fault of the applicant, as long as all the required
documentation has been submitted within the sixty (60) day period. The CONTRACTOR or facilitated
enroller will be required by the STATE to collect documentation of a pending Medicaid application.
Subsequent to the sixty (60) day period, it is the responsibility of the enroller (CONTRACTOR or
facilitated enroller, depending on with whom the family applied) to follow-up on the status of the
applicant’s Medicaid application with the appropriate local district of social services (LDSS)
office on a monthly basis, commencing on or about the 120th day following the completion of the
Child Health Plus application. If the child is determined to be ineligible for Medicaid, the
CONTRACTOR will be required by the STATE to collect documentation of such denial. In no case will
the presumptive eligibility period be extended beyond a twelve month period.

A child enrolled in Child Health Plus who screens as Medicaid eligible upon recertification in
Child Health Plus may continue to be eligible for Child Health Plus under this subparagraph 2,
until a Medicaid determination is made, provided all required documentation has been submitted.

This subparagraph 2 shall have no force and effect and presumptive eligibility under this
subparagraph 2 shall not be available on and after the date presumptive eligibility in Medicaid
becomes effective and is available pursuant to the Social Services Law. Once presumptive
eligibility in Medicaid is effective, a child who screens as Medicaid eligible at initial
enrollment and/or recertification in Child Health Plus may not be presumptively enrolled in Child
Health Plus and the CONTRACTOR will be required by the STATE to collect documentation of a Medicaid
denial or disenrollment in order to presumptively enroll a child in Child Health Plus.

9

APPENDIX D

SCHEDULE OF DELIVERABLES

(Revised and Restated)

	 	 	 
	Relevant Dates

Ongoing

	 	

Marketing Plans

a. Design and develop marketing materials as approved by DOH.

b. Implement marketing strategies specified in the proposal/workplan and
consistent with subsequently issued STATE guidelines.

c. Coordinate marketing and outreach activities consistent with the
designated STATE Outreach CONTRACTOR and the STATE Mass Media Marketing
Campaign.

Ongoing Enrollment Activities

a. Design and finalize revised enrollment process and forms.

b. Hire enrollment staff as necessary.

c. Develop and finalize eligibility determination mechanisms.

d. Implement enrollment process. The CONTRACTOR may process new enrollment
applications in accordance with its own internal processing schedule.
However, the cut off date for processing new applications effective the first
day of the following month can be no earlier than the 20th day of the
previous month and for recertification, any application received through the
last day of the twelve (12) month enrollment period must be processed as a
recertification effective the first day of the following month

e. Participate in the development and implementation of the Medicaid linkage
and referral process with State and local agencies in order to maximize the
use of Medicaid for eligible children. The referral process shall include use
of the Medicaid screening and referral form provided by the STATE, a copy of
which must be maintained in the enrollment file, use of the joint Medicaid,
WIC and Child Health Plus enrollment form when implemented, electronic
submission of the Medicaid Referral Data File which documents the referrals
made to Medicaid, and cooperation in the implementation of the facilitated
enrollment process for Medicaid and Child Health Plus.

f. Participate in the monthly match process to eliminate duplicate
enrollment in Child Health Plus and Medicaid. The STATE may recoup
premiums from the CONTRACTOR when a Medicaid/Child Health Plus
duplicate is identified and not disenrolled from Child Health Plus
within the specified timeframe.

g. Capture data on marketing and enrollment outcomes.

h. Capture data on demographic characteristics of enrollees.

Ongoing Quality Assurance

a. Adapt and finalize quality assurance and utilization review
mechanisms.

b. Maintain quality assurance and utilization review mechanisms
in accordance with STATE issued guidelines and/or advisory
memoranda in cooperation with STATE designated CONTRACTORS and
provide requested data to STATE and any designated CONTRACTORS.

Ongoing Billing/Electronic Mail

a. Implement billing processing systems such that:

The CONTRACTOR shall prepare and submit to the STATE monthly
voucher bills and adjustments pursuant to this AGREEMENT through
the electronic mail system.

Ongoing Insurance Coverage/Miscellaneous

a. Provide insurance coverage for enrollees.

b. Implement project such that health services are provided
to enrollees. Continue enrollment and marketing programs as needed in
cooperation with other STATE CONTRACTORS and the DOH Mass Media
Marketing Campaign as directed by the STATE.

c. Initiate the collection of utilization data on enrollees.

d. Monitor program enrollment to ensure that enrollment does not reach a
number that would result in exceeding the annual funding allocation as
specified in Appendix G.

e. Meet data requirements of an independent evaluator as needed.

f. Capture data on prior insurance status of applicants.

Ongoing Reporting Requirements

a. Initiate subsidy process with STATE. Thereafter, the submittal of
monthly voucher bills and supporting documentation shall be on a monthly
basis, pursuant to this AGREEMENT.

b. Cost and utilization data reports shall be submitted at least on a
semi-annual and annual basis, based on a calendar year, due seventy five
(75) days after the close of the second quarter and one hundred and
twenty(120) days after the close of the calendar year, respectively,
using the forms and format supplied by the STATE.

c. Submit other reports as required by Appendix I.

d. Conform with additional reporting requirements imposed by the STATE which
are based on need or as legislatively mandated.

12/31/2000 Conclusion of insurance coverage for enrollees unless

continuation of the Child Health Plus program is approved by the New
York State Legislature.

	 	 	 	1/1/01 Initiate conversion cove rage as stipulated in the request for applications,
application/workplan and benefit contract	 

3/31/01 Final report due from the CONTRACTOR.

	 	 	 	12/31/02 Data relating to the Child Health Plus program shall be maintained and retained by the
CONTRACTOR until this date. Enrollee specific data for disenrolled children shall be retained
for six years from the date of disenrollment or two years following termination of the
program, whichever is shorter.

MODIFICATIONS TO APPENDIX E

Financial Information

The following new paragraphs are being added to this Appendix, as follows:

A. Care Plus Health Plan shall receive, for the period January 1, 2000 through December 31, 2000,
an amount up to, but not to exceed, $17,300,000 to provide and administer a Child Health Plus
program for uninsured children in the counties identified in Appendix A-2, Section II.B.1 of this
AGREEMENT or as modified by the STATE. Payment of this amount is based on the CONTRACTOR meeting
the responsibilities provided in this AGREEMENT.

B. The maximum compensation for the contract term of this AGREEMENT shall. not exceed
the amount specified on the fact page hereof, subject to available funding as enacted by the New
York State Legislature effective January 1, 2000 and continued appropriations through the contract
term.

Additional Premium Information: For
Periods on or after July 1, 2000:

	 	•	 	The total monthly premium shall be: $108.89.	 

	 	•	 	The State share of the total monthly premium shall be
$108.89 or the total monthly premium for children in
families with gross household income less than 160% of the
federal poverty level.	 

The State share of the total monthly premium shall be $99.89 or the total monthly premium
minus $9 for children in families with gross household income between 160% and 222% of the
federal poverty level with a maximum of $27 per month per family. The State share is the
total monthly premium less $9 for each of the first three children. For additional
children, the State share is the total monthly premium.

	 	•	 	The State share of the total monthly premium shall be $93.89 or the total monthly premium
minus $15 for children in families with gross household income between 223% and 250% of the
federal poverty level with a maximum of $45 per month per family. The State share is the total
monthly premium less $15 for each of the first three children. For additional children, the
State share is the total monthly premium.

	 	•	 	

10

MODIFICATIONS TO
APPENDIX H Additional Program
Specific Clauses
    	 

Section B is revised to read as follows:

B. Premium Contributions

	 	•	 	Effective July 1, 2000, the family premium contribution for children whose gross
household income is between 223%-250% of the non-farm federal poverty level is $15 per
child, with a family maximum of $45 per month.	 

A new Section K is added to read as follows:

K. Annual Recertification

1. The CONTRACTOR shall, via the recertification letter, advise the family that the
application and all documentation must be received by the CONTRACTOR three (3) weeks prior to the
CONTRACTOR’s cut-off date to avoid the risk of a lapse in coverage.

2. The CONTRACTOR shall review and act upon the recertification application and
documentation within 7 to 10 days to allow time for any requests for further information to be
made and time for response by the family prior to the cut-off date.

3. The CONTRACTOR shall reinstate a child in the Child’Health Plus program without a new
application if their recertification application and/or required documentation is submitted
after the recertification cut-off date, but before the plan’s cut-off date for the following
month. The enrollee will have a one-month lapse in coverage but will not be required to reapply
to the program.

11

1.APPENDIX •4

CHILD HEALTH PLUS BENEFITS PACKAGE

(No Pre-Existing Condition Limitations Permitted)

	 	 	 	 	 	 	 
	General Coverage	 	Scope of Coverage	 	Level of Coverage	 	Copayments/Deducbbles
	Pediatric Health

	 	Well child care visits in accordance
	 	Includes all services related to visits. Includes immunizations, well child
	 	No copayments or
	 
	 	 	 	 	 	 
	Promotion Visits

	 	with visitation schedule established by

American Academy of Pediatrics,

and/or the New York State
	 	care, health education, tuberculin testing (mantoux), hearing testing,

dental and developmental screening, clinical laboratory and radiological

tests, eye screening, lead screening, and reproducjive health services,
	 	deductibles.

	
 
	 	 
	 	 
	 	

	 
	 	 	 	 	 	 
	
 
	 	Department of Health recommended
	 	with direct access to such reproductive health services.
	 	

	
 
	 	 	 	 
	 	

	 
	 	 	 	 	 	 
	
 
	 	immunization schedule.
	 	

	 	

	
 
	 	 
	 	

	 	

	 	 	 	 	 	 	 
	General Coverage Scope of Coverage	Level of Coverage	Copayments/Deductibles
	
 
	 	 	 	No benefits will be provided for any out-of-hospital days, or if inpatient

care was not necessary; no benefits are provided after discharge;

benefits are paid in full for accommodations in a semi-private room. A

private room will be covered if medically warranted, Includes 365 days

per year coverage for inpatient hospital services and services provided by

physicians and other professional personnel for covered inpatient

services: bed and board, including special diet and nutritional therapy:
	 	

	Inpatient Hospital

Medical or Surgical

No copayments or

Care

	 	As a registered bed patient for

treatment of an illness, injury or

condition which cannot be treated on

an outpatient basis. The hospital must

be a short-term, acute care facility

and New York State licensed.

        .
	 	general, special and critical care nursing services, supplies and

equipment related to surgical operations, recovery facilities,, anesthesia,

and facilities for intensive or special care; oxygen and other inhalation

therapeutic services and supplies; drugs and medications that are not

experimental; sera, biologicals, vaccines, intravenous preparations,

dressings, casts, and materials for diagnostic studies; blood products,

except when participation in a volunteer blood replacement program is

available to the insured or covered person, and services and equipment

related to their administration; facilities, services, supplies and equipment

related to physical medicine and occupational therapy and rehabilitation;

facilities, services; supplies and equipment related to diagnostic studies

and the monitoring of physiologic functions, including but not limited to

laboratory, pathology, cardiographic, endoscopic, radiologic and electro-

encephalographic studies and examinations; facilities, services, supplies

and equipment related to radiation and nuclear therapy; facilities,

services, supplies and equipment related to emergency medical care;

chemotherapy; any additional medical, surgical, or related services,

supplies and equipment that customarily furnished by the hospital.
	 	

deductibles.
	 
	 	 	 	 	 	 
	Inpatient Mental Health

and Alcohol and

Substance Abuse

Services

	 	Services to be provided in a facility

operated by OMH under Sec. 7.17 of

the Mental Hygiene Law, or a facility

issued an operating certificate

pursuant to Article 23 or Article 31 of

the Mental Hygiene Law or a general

hospital as defined in Article 28 of the

Public Health Law.
	 	

A combined 30 days per calendar year for inpatient mental health

services, inpatient detoxification and inpatient rehabilitation.

I
	 	

No co-payments or

deductibles
	 

	 	 
	 	 
	 	 

	 	 	 	 	 	 	 
	General Coverage Scope o

	 	f Coverage '' Leve
	 	l of Coverage Copayme
	 	nts/Deductibles
	 

	 	 
	 	 
	 	 
	 
	 	 	 	 	 	 
	Professional Services

for Diagnosis and

Treatment of Illness

and Injury .

	 	Provides services on ambulatory basis

by a covered provider for medically

necessary diagnosis and treatment of

sickness and injury and other

conditions. Includes all services

related to visits. Professional services

are provided on outpatient basis and

inpatient basis.
	 	

No limitations. Includes wound dressing and casts to immobilize fractures

for the immediate treatment of the medical condition. Injections and

medications provided at the time of the office visit or therapy will be

covered. Includes audiometric testing where deemed medically

necessary.
	 	

No copayments or

deductibles.
	 

	 	 
	 	 
	 	 
	 
	 	 	 	 	 	 
	Outpatient Surgery

	 	Procedure performed within the

provider’s office will be covered as

well as "ambulatory surgery

procedures” which may. be performed

in a hospital-based ambulatory surgery

service or a freestanding ambulatory

surgery center.
	 	

The utilization review process must ensure that the ambulatory surgery is

appropriately provided.
	 	

No copayments or

deductibles.
	 

	 	 
	 	 
	 	 
	 
	 	 	 	 	 	 
	Diagnostic and

Laboratory Tests

	 	Prescribed ambulatory clinical

laboratory tests and diagnostic x-rays.
	 	No limitations.
	 	No copayments or

deductibles.
	 

	 	 
	 	 
	 	 

	 	 	 	 	 	 	 
	General Coverage Scope of Coverage	Level of Coverage	Copayments/Deductibles
	Durable Medical

Equipment, Prosthetic

Appliances and Orthotic

Devices

	 	Durable Medical Equipment means

devices and equipment ordered by a

practitioner for the treatment of a

specific medical condition which

a) can withstand repeated

use for a protracted

period of. time;

b) are primarily and customarily used for

medical purposes;

c) are generally not useful

in the absence of illness or injury;

and

d) are usually not fitted,

designed or fashioned

for a particular person’s use.

DME intended for use by one person

may be custom-made or customized.

Prosthetic Appliances are those appliances and

devices ordered by a qualified practitioner which

replace any missing part of the body.

Orthotic Devices are those devices

which are used to support a weak or

deformed body member or to restrict

or eliminate motion in a diseased or

injured part of the body.
	 	

Includes hospital beds and accessories, oxygen and oxygen supplies,

pressure pads, volume ventilators, therapeutic ventilators, nebulizers and

other equipment for respiratory care, traction equipment, walkers,

wheelchairs and accessories, commode chairs, toilet rails, apnea

monitors, patient lifts, nutrition infusion pumps, ambulatory infusion pumps

and other miscellaneous DME.

DME coverage includes equipment servicing (labor and parts).

Examples include. but are not limited to:
	 	

No Copayments or

deductibles.
	
 
	 	 	 	 
	 	

	 
	 	 	 	 	 	 
	
 
	 	 	 	Fitted/Customized Not Fitted/Customized

Leg brace Cane

Prosthetic arm Wheelchair

Footplate Crutches

Covered without limitation except that there is no coverage for cranial

prostheses (i.e. wigs) and dental prostheses, except those made

necessary due to accidental injury to sound, natural teeth and provided

within twelve months of the accident, and except for dental prostheses

needed in treatment of a congenital abnormality or as part of

reconstructive surgery.

No limitations on orthotic devices except that devices prescribed solely

for use during sports are not covered.
	 	

	 	 	 	 	 	 	 
	General Coverage Scope of Coverage	Level of Coverage	Copaymentt/Deductibles
	 	 	Ambulatory radiation therapy,	 	No limitations. These therapies must be medically necessary and under	 	 
	 	 	chemotherapy, injections and	 	the supervision of referral of a licensed physician. Short term physical	 	 
	 	 	medications provided at time of	 	and occupational therapies will be covered when ordered by a physician.	 	 
	 	 	therapy (i.e. chemotherapy) will also	 	No procedure or services considered experimental will be reimbursed.	 	 
	 	 	be covered.	 	Determination of the need for services and whether home based or facility	 	No copayments or
	Therapeutic Services.	 	Hemodialysis	 	based treatment is appropriate.	 	deductibles.
	Speech and Hearing

Services including

hearing aids.

	 	Hearing examinations to determine the

need for corrective action and speech

therapy performed by an audiologist,

language pathologist, a speech

therapist and/or otolaryngologist.
	 	One hearing examination per calendar year is covered. If an auditory

deficiency requires additional hearing exams and follow up exams, these

exams will be covered. Hearing aids, including batteries and repairs, are

covered. If medically necessary, more than one hearing aid will be

covered

Covered speech therapy services are those required for a condition

amenable to significant clinical improvement within a two month period,

beginning with the first day of therapy.
	 	

No copayments or

deductibles.
	 
	 	 	 	 	 	 
	Pre-surgical Testing.

        .

	 	All tests (laboratory, x-ray, etc.)

necessary prior to inpatient or

outpatient surgery.
	 	Benefits are available if a physician orders the tests: proper diagnosis and

treatment require the tests; and the surgery takes place within seven days

after the testing. If surgery is canceled because of pre-surgical test

findings or as a result of a Second Opinion on Surgery, the cost of the

tests will be covered.
	 	

No copayments or

deductibles.
	 

	 	 
	 	 
	 	 
	 
	 	 	 	 	 	 
	Second Surgical

Opinion

	 	Provided by a qualified physician.
	 	No limitations.
	 	No copayments or

deductibles.
	 

	 	 
	 	 
	 	 
	 
	 	 	 	 	 	 
	Second Medical

Opinion.

	 	Provided by an appropriate specialist,

including one affiliated with a specialty

care center.
	 	A second medical opinion is available in the event of a positive or negative

diagnosis of cancer, a recurrence of cancer, or a recommendation of a

course of treatment of cancer.
	 	

No copayments or

deductibles.
	 

	 	 
	 	 
	 	 
	 
	 	 	 	 	 	 
	Outpatient visits for

mental health and for

the diagnosis and

treatment of alcoholism

and substance abuse.

	 	

Services must be provided by certified

and/or licensed professionals.
	 	

A combined 60 outpatient visits per calendar year. Visits may be for

family therapy related to the alcohol or substance abuse.
	 	

No copayments or

deductibles.
	 

	 	 
	 	 
	 	 

	 	 	 	 	 	 	 
	General Coverage Scope o

	 	f Coverage “’ Leve
	 	l of Coverage. Copayme
	 	nts/Deductibles
	 

	 	 
	 	 
	 	 
	 
	 	 	 	 	 	 
	Home Health Care

Services

	 	The care and treatment of a covered

person who is under the. care of a

physician but only if hospitalization or

confinement in a skilled nursing facility

would otherwise have been required if

home care was not provided and the

plan covering the home health service

is established and provided in writing

by such physician.
	 	Home care shall be provided by a certified home health agency

possessing a valid certificate of approval issued pursuant to article thirty-

six of the public health law. Home care shall consist of one. or more of

the following: part-time or intermittent home health aide services which

consist primarily of caring for the patient, physical, occupational, or

speech therapy if provided by the home health agency and medical

supplies, drugs and medications prescribed by a physician, and laboratory

services by or on behalf of a certified home health agency to the extent

such items would have been covered or provided under the contract if the

covered person had been hospitalized or confined in a skilled nursing

facility. The contact must provide forty such visits in any calendar year, if

such visits are medically necessary.
	 	

No copayments or

deductibles.
	 

	 	 
	 	 
	 	 
	 
	 	 	 	 	 	 
	Prescription and Non-

prescription Drugs.

	 	Prescription and non-prescription

medications must be authorized by a

professional licensed to write

prescriptions.
	 	Prescriptions must be medically necessary. May be limited to generic

medications where medically acceptable. Includes family planning or

contraceptive medications or devices. All medications used for preventive

and therapeutic purposes will be covered. Vitamins are not covered

except when necessary to treat a diagnosed illness or condition.

Coverage includes enteral formulas for home use for which a physician or

other provider authorized to prescribe has issued a written order. Enteral

formulas for the treatment of specific diseases shall be distinguished from

nutritional supplements taken electively. Coverage for certain inherited

diseases of amino acid and organic acid metabolism shall include

modified solid food products that are low-protein or which contain

modified protein. Coverage for such modified solid food products shall

not exceed $2500 per calendar year.
	 	

No copayments or

deductibles.
	 

	 	 
	 	 
	 	 

	 	 	 	 	 	 	 
	General Coverage Scope o

	 	f Coverage Level o
	 	f Coverage Copayme
	 	nts/Deductibles
	 

	 	 
	 	 
	 	 
	 
	 	 	 	 	 	 
	
 
	 	For services to treat an emergency

condition in hospital facilities. For the

purpose of this provision, “emergency

condition” means a medical or

behavioral condition, the onset of

which is sudden, that manifests itself

by symptoms of sufficient severity,

including severe pain, that a prudent

layperson, possessing an average

knowledge of medicine and health,

could reasonably expect the absence

of immediate medical attention to

result in :
	 	

	 	

	Emergency Medical

Services

	 	(A) placing the health of the person

afflicted with such condition in

serious jeopardy, or in the case of

a behavioral condition placing the

health of such person or others in

serious jeopardy, or

(B) serious impairment to such

person’s bodily functions;

(C) serious dysfunction of any bodily

organ or part of such person; or

(D) serious disfigurement of such

person.
	 	

No limitations.
	 	

No copayment or

deductibles.
	 

	 	 
	 	 	 	 

	 	 	 	 	 	 	 
	General Coverage Scope o

	 	f Coverage Level o
	 	f Coverage Copayme
	 	nts/Deductibles
	 

	 	 
	 	 
	 	 
	 
	 	 	 	 	 	 
	Maternity Care

	 	Inpatient hospital coverage for at least

48 hours after childbirth for any

delivery other than a C-Section and in

at least 96 hours following a C-

Section. Also coverage of parent

education, assistance and training in

breast and bottle feeding and any

necessary maternal and newborn

clinical assessments. The mother

shall have the option to be discharged

earlier than the 48/96 hours, provided

that at least one home care visit is

covered post-discharge. Prenatal,

labor and delivery care is covered.
	 	

No limitations; (however subsidized children requiring maternity care

services will be referred to Medicaid):

        .
	 	

No copayments or

deductibles.
	 

	 	 
	 	 	 	 
	 
	 	 	 	 	 	 
	Diabetic Supplies and

Equipment.

	 	Coverage includes insulin, blood

glucose monitors, blood glucose

monitors for legally blind, data

management systems, test strips for

monitors and visual reading, urine test

strips, insulin, injection aids,

cartridges for legally blind, syringes,

insulin pumps and appurtenances

thereto, insulin infusion devices, oral

agents.
	 	

As prescribed by a physician or other licensed health care provider legally

authorized to prescribe under title eight of the education law.
	 	

No copayments or

deductibles.
	 

	 	 
	 	 
	 	 
	 
	 	 	 	 	 	 
	Diabetic Education and

Home Visits.

	 	Diabetes self-management education

(including diet); reeducation or

refresher. Home visits for diabetic

monitoring and/or education.
	 	Limited to visits medically necessary where a physician diagnoses a

significant change in the patient’s symptoms or conditions which

necessitate changes in a patient’s self-management or where reeducation

is necessary. May be provided by a physician or other licensed health

care provider legally authorized to prescribe under title eight of thei

education law, or their staff, as part of an office visit for diabetes

diagnosis or treatment, or by a certified diabetes nurse educator, certified

diagnosis nutritionist, certified dietician or registered dietician upon the

referral of a physician or other licensed health care provider legally

authorized to prescribe under title eight of the education law and may be

limited to group settings wherever practicable.
	 	

No copayments or

deductibles.
	 

	 	 
	 	 
	 	 

	 	 	 	 	 	 	 
	General Coverage Scope of Coverage	- ''• Level of Coverage	Copayments/Deductibles
	
 
	 	 	 	The vision examination may include, but is not limited to:
	 	

	Emergency, Preventive

and Routine Vision

Care.

	 	Vision examinations performed by a

physician, or optometrist for the

purpose of determining the need for

corrective lenses, and if needed, to

provide a prescription.
	 	- case history

• external examination of the eye and external or internal

- examination of the eye

- ophthalmoscopic exam

- determination of refractive status

• binocular balance

tonometry tests for glaucoma

• gross visual fields and color vision testing

• summary findings and recommendations for corrective lenses
	 	

No copayments or

deductibles.
	 
	 	 	 	 	 	 
	
 
	 	Prescribed Lenses

Frames

Contact Lenses
	 	At a minimum, quality, standard prescription lenses provided by a

physician, optometrist or optician are to be covered once in any twelve

month period, unless required more frequently with appropriate

documentation. The lenses may be glass or plastic lenses.

At a minimum, standard frames adequate to hold lenses will be covered

once in any twelve month period, unless required more frequently with

appropriate documentation.

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

Covered when medically necessary
	 	

	 
	 	 	 	 	 	 
	 
	 	 	 	 

12

Level of Coverage

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

Includes procedures which help prevent oral disease from occurring, including but IQt
limited’to:

- prophylaxis: scaling and polishing the teeth at 6 month intervals.

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

• Sealants on unrestored permanent molar teeth.

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

- dental examinations, visits and consultations covered once within 6 consecutive
period (when primary teeth erupt).

	 	•	 	x-ray, full mouth x-rays at 36 month intervals, if necessary, bitewing x-rays at 6-12 month
intervals, or panoramic x-rays at 36 month intervals if necessary; and other x-rays as
required (once primary teeth erupt).	 

	 	 	 	- All necessary procedures for simple extractions and other routine dental surgery not
requiring hospitalization including:	 

- preoperative care

 — postoperative care

• In office conscious sedation

- Amalgam, composite restorations and stainless steel crowns — Other restorative
materials appropriate for children

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

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

Fixed: fixed bridges are not covered unless

	 	1)	 	required for replacement of a single upper anterior (central/lateral
incisor or cuspid) in a patient with an otherwise	 

	 	 	 	 	 	 	 
	General Coverage Scope of Coverage	Level of Coverage	Copayments/Deductibles
	Emergency, Preventive

and Routine Dental

Care (continued)

	 	Prosthodontics (continued)
	 	full complement of natural, functional and/or restored teeth;

2) required for cleft-palate treatment or stabilization;

3) required, as demonstrated by medical documentation, due to the

presence of any neurologic or physiologic condition that would

preclude the placement of a removable prosthesis.

NOTE: Refer to the Medicaid Management Information System (MMIS)

Dental Provider Manual for a more detailed description of services.
	 	

No copayments or

deductibles.

13

CHILD HEALTH-PLUS
EXCLUSIONS . The following
services will not be covered:

	 	•	 	Experimental medical or surgical procedures.	 

	 	•	 	Experimental drugs.	 

	 	•	 	Drugs which can be bought without prescription, except as defined.	 

	 	•	 	Private duty nursing.	 

	 	•	 	Hospice services.	 

Home health care, except as defined.

Care in connection with the detection and correction by manual or mechanical means of
structural imbalance, distortion or subluxation

in the human body for the purpose of removing nerve interference and the effects
thereof, where such interference is the result of or related to distortion,
misalignment or subluxation of or in the vertebral column.

	 	•	 	Services in a skilled nursing facility or rehabilitation facility.

	 	•	 	Cosmetic, plastic, or reconstructive surgery, except as defined.

	 	•	 	In vitro fertilization, artificial insemination or other means of conception and infertility services.

	 	•	 	Services covered by another payment source.

	 	•	 	Durable Medical Equipment and Medical Supplies, except as defined.

	 	•	 	Transportation.

	 	•	 	Personal or comfort items.

	 	•	 	Orthodontia Services.

• Services which are not medically necessary.

14

DOH STATE OF NEW YORK

 DEPARTMENT OF HEALTH

Corning Tower

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

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

Dennis P. Whalen

Executive Deputy Commissioner

August 22, 2000

Ms. Karen Ajmani
Executive Director
CarePlus Health Plan
3 W. 35th
Street

New York, NY 10001

Dear Ms. Ajmani:

Enclosed you will find a contract amendment that increases your maximum
funding allocation for the period ending December 31, 2000. This is necessary
as the funding level in your current contract is soon to be exhausted. The
maximum funding allocation, as described in Appendix E of your contract for
the period January 1, 2000 through December 31, 2000 has been increased to
$27,700,000.

In order to modify the total 7/1/98 — 12/31/00 contract amount, a
Contract Amendment (Appendix X) is required. Therefore, we have enclosed two
copies of an Appendix X with the increased 7/1/98 through 12/31/00 amount.

Please sign, notarize and return both copies of the enclosed
Contract Amendment (Appendix X) as soon as possible. Please return both
amendments to:

Peter C. Endryck

NYS Child Health Plus Program
NYS Department of Health Room
1119, Corning Tower Empire
State Plaza

Albany, New York 12237-0004

15

-2-

Please return these documents as soon as possible to avoid any lapse in payment. If you have
any questions regarding this matter, please contact Peter Endryck or Debbie Carriero (518)
473-7883. Thank you for your continued support of the Child Health Plus Program.

S.CONT

Linda Stackman

Associate Director

Division of Planning, Policy and Resource Development

16

APPENDIX X

	 	 	 
	Agency Code 12000

Period- 7/1/98 — I2/31/00

	 	Contract No. C-015473

Funding Amount for Period $40,856,633

This is an AGREEMENT between THE STATE OF NEW YORK, acting by and through the
Department of Health, having its principal office at Corning Tower,
Empire State Plaza. Albany, NY, (hereinafter referred to as the STATE), and New
York Care Plus Insurance, (hereinafter referred to as the CONTRACTOR), for
modification of Contract Number C-015473 as amended in the attached Appendix E.

All other provisions of said AGREEMENT shall remain in full force and effect.

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

	 	 	 
	CONTRACTOR ISIGNATURE

	 	STATE AGENCY SIGNATURE
	 
	 	 
	By: /s/ K Ajmani

	 	By:
	 

	 	 
	 
	 	 
	Karin Ajmani

	 	Judith Arnold
	 

	 	 
	Printed Name

	 	Printed Name
	 
	 	 
	Title: Executive Director

	 	Title: Deputy Commissioner
	 

	 	

	
 
	 	Division of Planning, Policy, and Resource Development
	 
	 	 
	Date: 8/23/00

	 	Date:
	 

	 	 

	 	 	 	State Agency Certification:

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

	 	 	 	 	 
	STATE OF NEW YORK
	 	 	)	 
	 
	 	) SS.:
	County of New York )
{r}
	 	 	 	 

On the 23rd  day of  August  2000 before me
personally appeared  Karin Ajmani ,to me known, who being
by me duly sworn, did depose and say that he/she resides at  New York,
NY , that he/she is the  Executive Director  of  Care Plus
Health Plan  , the corporation described herein which executed the foregoing
instrument, and that he/she signed his/her name thereto by order of the board of
directors of said corporation.

17

Evelyn Huang

Notary Public State of New York

No. 31-6001118

Qualified in New York County

Commission Expires 3-6-2002

Title:APPENDIX E

Financial Information

Paragraph A is revised to read as follows:

A. New York Care Plus Insurance shall receive, for the period January 1, 2000 through December 31,
2000, an amount up to, but not to exceed, $27,700,000 to provide and administer a Child Health Plus
program for uninsured children in the counties identified in Appendix A-2, Section II.B.l of this
AGREEMENT or as modified by the STATE. Payment of this amount is based on the CONTRACTOR meeting
the responsibilities provided in this AGREEMENT.

18

APPENDIX X

	 	 	 
	Agency Code 12000

Period 7/1/98 — 12/31/00

	 	Contract No. C-015473

Funding Amount for Period $40,856,633

This is an AGREEMENT between THE STATE OF NEW YORK, acting by and through the Department
of Health, having its principal office at Corning Tower, Empire State Plaza, Albany.
NY, (hereinafter referred to as the STATE), and New York Care Plus Insurance,
(hereinafter referred to as the CONTRACTOR), for modification of Contract Number C-015473 as
amended in the attached Appendix E.

All other provisions of said AGREEMENT shall remain in full force and effect.

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

	 	 	 
	CONTRACTOR ISIGNATURE

	 	STATE AGENCY SIGNATURE
	 
	 	 
	By: /s/ K Ajmani

	 	By:
	 

	 	 
	 
	 	 
	Karin Ajmani

	 	Judith Arnold
	 

	 	 
	Printed Name

	 	Printed Name
	 
	 	 
	Title: Executive Director

	 	Title: Deputy Commissioner
	 

	 	

	
 
	 	Division of Planning, Policy, and Resource Development
	 
	 	 
	Date: 8/23/00

	 	Date:
	 

	 	 
	 
	 	 
	
 
	 	State Agency Certification:

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

	 	 	 	 	 	 	 	 	 
	STATE OF NEW YORK
	 	 	 	 	 	 	)	 
	) SS.:
	 	 	 	 	 	 	 	 
	County of
	 	New York  )
	 	 	 	 
	 	 	 	 	 	 	 

On the 23rd  day of  August  2000 before me personally
appeared  Karin Ajmani ,to me known, who being by me duly sworn, did
depose and say that he/she resides at  New York, NY , that he/she is the 
Executive Director  of  Care Plus Health Plan  , the corporation described
herein which executed the foregoing instrument, and that he/she signed his/her name thereto by
order of the board of directors of said corporation.

Evelyn Huang

Notary Public State of New York

No. 31-6001118

Qualified in New York County

Commission Expires February 1,

Title:

Date:

19

APPENDIX E

Financial Information

Paragraph A is revised to read as follows:

A. New York Care Plus Insurance shall receive, for the period January 1, 2000 through December 31,
2000, an amount up to, but not to exceed, $27,700,000 to provide and administer a Child Health Plus
program for uninsured children in the counties identified in Appendix A-2, Section II.B.1 of this
AGREEMENT or as modified by the STATE. Payment of this amount is based on the CONTRACTOR meeting
the responsibilities provided in this AGREEMENT.

20

DOH STATE OF NEW YORK

DEPARTMENT OF HEALTH

	 	 	 	 	 
	Corning TowerThe Governor Nelson A. Rockefeller Empire State PlazaAlbany, New York 12237

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

Commissioner

DATE:

	 	Aug. 09, 2000
	 	Dennis P. Whalen

Executive Deputy Commissioner

	 
	 	 	 	 
	CONTRACT #:

	 	C015473
	 	

	 
	 	 	 	 
	CONTRACTOR:

	 	CAREPLUS HEALTH PLAN
	 	

CONTRACT PERIOD: Jul. 01, 1998-Dec. 31, 2000

Attached is your copy of the approved contract. The Contract number must appear on
all vouchers and correspondence.

Reports of the Expenditures and Budget Statements should be submitted as
outlined in the Contract.

In accordance with the contract, properly completed vouchers and/or programmatic
questions should be addressed to the State’s designated payment office as stated in
the Contract.

Failure of the contracting Agency to comply with payment provisions as set
forth in the approved Contract may result in non-payment.

An additional supply of vouchers to be used in submitting claims may be obtained
by written request from the Office of the State Comptroller, Supply Room, Alfred E.
Smith State Office Building, Albany, New York 12236.

New York State Department of Health Contract
Unit

	 	 	 
	Agency Code 12000

Period 7/1/98-12/31/00

	 	APPENDIX X

Contract No. C-015473

Funding for the Period: NO CHANGE

This is an AGREEMENT between THE STATE OF NEW YORK, acting by and through the
Department of Health, having its principal office at Corning Tower, Empire State
Plaza, Albany, NY, (hereinafter referred to as the STATE), Care Plus Health
Plan, (hereinafter referred to as the CONTRACTOR), for modification of Contract Number
C.015473 as amended in attached Appendices A-2, D, and F.

All other provisions of said AGREEMENT shall remain in full force and effect.

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

	 	 	 	 	 
	CONTRACTOR SIGNATURE

	 	STATE AGENCY SIGNATURE
	 	

	 
	 	 	 	 
	By: /s/ K Ajmani

	 	By: /s/ Judith Arnold
	 	

	 
	 	 	 	 
	 	 	 

	 
	 	 	 	 
	Karin Ajmani

	 	Judith Arnold
	 	

	 
	 	 	 	 
	 	 	 

	 
	 	 	 	 
	Printed Name

	 	Printed Name
	 	

	 
	 	 	 	 
	Title: Executive Director

	 	Title: Deputy Commissioner
	 	

	 

	 	

	 	

	 
	 	 	 	 
	 	 	Division of Planning, Policy, and Resource Development

	 
	 	 	 	 
	Date: 6/9/00

	 	Date:
	 	6/15/00
	 

	 	 	 	 

	 	 	 	State Agency Certification:

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

	 	 	 	 	 
	STATE OF NEW YORK )

	 	) SS.:
	County of
	 	New York  )
	 	 	 

On the  6th  day of  June  2000 before me personally
appeared  Karin Ajmani ,to me known, who being by me duly sworn, did
depose and say that he/she resides at  New York, NY , that he/she is the 
Executive Director  of  Care Plus Health Plan  , the corporation described
herein which executed the foregoing instrument, and that he/she signed his/her name thereto by
order of the board of directors of said corporation.

Title:

Date:

21

MODIFICATIONS TO APPENDIX
A-2 Additions to Program Specific Clauses Section I.
DEFINITIONS

	 	N.	 	“Facilitated Enrollment” shall mean the simplified, user friendly enrollment
infrastructure established by the STATE to assist families in applying for the Medicaid
or Child Health Plus programs or the Special Supplemental Food Program for Women, Infants
and Children (WIC) using the “Growing Up Healthy” joint application.	 

	 	O.	 	“Facilitator" shall mean an individual who assists families in completing the
Growing Up Healthy application, screens children for Medicaid, Child Health Plus and WIC
eligibility, conducts the Medicaid face-to-face interview, assists in collecting required
documentation, assists in the health plan selection process, and refers individuals to WIC
sites.	 

	 	P.	 	“Community-Based Facilitated Enrollment Lead Organization” shall mean an entity other than a
health plan that contracts with the STATE to provide the facilitated enrollment infrastructure
to community-based facilitators (which may include subcontracts with numerous community-based
organizations) and provides support and technical assistance to community-based facilitators,
reviews applications for completeness and quality, forwards applications and documentation to
the appropriate eligibility determining entity, and serves as the interface between the
community-based organizations and the health plans and the community-based organizations and
the local districts of social services (LDSS).

Section III. CONTRACTOR’S RESPONSIBILITIES I.
Health Plan Facilitated Enrollment

A CONTRACTOR which performs facilitated enrollment for the Child Health Plus and Medicaid
programs must:

1. Provide facilitated enrollment in each county of the CONTRACTOR’S Child Health Plus
service area in a manner approved by the State. The CONTRACTOR is not required to
dedicate facilitators in each county of their service area but must have the service”
available in every county of their service area.

2. Place facilitators at sites that are accessible and convenient to the population being
served. Sites must include a range of locations and types of sites that will attract as
many families as possible (e.g. community centers) and facilitators must be designated to
target vulnerable and hard-to-reach populations (e.g. non-English speaking). The CONTRACTOR
shall provide the STATE with a list of the fixed enrollment sites at which it intends to
offer facilitated enrollment, including the days and hours during which facilitators will
be available at the sites. The CONTRACTOR shall update the list on a monthly basis. Nothing
herein shall prevent the CONTRACTOR from offering facilitated enrollment at additional
sites not provided on the above referenced list, or if circumstances warrant, from
modifying the previously scheduled fixed enrollment activities.

3. Provide facilitators during evenings and weekends. Hours of operation shall demonstrate
an understanding of what is convenient to working families in the community.

4. Hire or designate existing staff as facilitators who are culturally and
linguistically reflective of the population being served.

5. Comply with procedures that have been established by the LDSS in accordance with
Medicaid ADM-2 and approved by the STATE to assure that facilitators are authorized to
perform the Medicaid face-to-face interview.

6. Ensure that facilitators perform the following functions:

a) assist families in completing the Growing Up Healthy

application;

b) appropriately screen children for Child Health Plus or Medicaid program
eligibility;

c) explain documentation requirements for Child: Health PIus and
Medicaid and assist families in obtaining such documentation;

d) complete the Medicaid face-to-face interview in accordance with Medicaid
requirements, policies and procedures;

e) follow-up with families to complete the application process;

f) assist families in selecting either a Child Health Plus or

Medicaid managed care health plan. As part of this function, facilitators are required to
inquire about existing provider relationships, identify the health plans in which such
providers participate to the extent such information is available to the CONTRACTOR, and
describe the full choice of health plans available to the family;

g) refer potentially eligible children to the WIC program;

h) educate families about managed care and how to access benefits in a managed care
environment; and

i) distribute Child Health Plus, Medicaid and WIC information materials developed
by the STATE.

7. Develop procedures to review applications completed with the assistance of the
CONTRACTOR’S facilitators for quality and completeness. All applications completed with the
assistance of the CONTRACTOR’S facilitators must be reviewed for quality and completeness prior to
being submitted to the appropriate, eligibility determining entity. These procedures shall include
mechanisms for identifying and rectifying deficiencies with application quality and completeness.
The CONTRACTOR shall submit such procedures to the STATE for review and approval within 30 days of
the effective date of the contract amendment.

8. Comply with LDSS established procedures for transmitting Medicaid
applicant‘s managed health care plan choice to enrollment brokers or LDSS offices.

9. Submit completed applications to the appropriate LDSS or to Child Health Plus insurer.
The CONTRACTOR is required to comply with LDSS established procedures developed in
accordance with ADM-2 and approved by the STATE regarding the delivery and processing of
completed applications.

10. Follow up if necessary [on each application] with the appropriate LDSS or Child Health
Plus insurer to ensure that the applications are being processed.

11. Assist families of children enrolled. in a Child Health Plus plan who approach a
facilitator of the CONTRACTOR in recertifying for programs prior to expiration of their
12-month enrollment period. This includes providing families with the location and hours
of facilitators available in the community to assist in the recertification process.

	 	12.	 	Provide specific information on the progress of each facilitated enrollment application that
the CONTRACTOR’S facilitators provided assistance on using an Internet-based system developed
by the STATE for that purpose. The required information shall be continually updated by the
CONTRACTOR to ensure timely and accurate tracking of applications, including the dates and
dispositions of applications as they are processed. Specifically, the requirement to
continually update the information shall ensure that the endof-month status of all
applications is reflected in the Internet-based system no later than the tenth day following
the end of the month.

	 	13.	 	Assure that all facilitators participate in the STATE-sponsored training program or other
training approved by the STATE, including use of the “trainthe-trainer” approach.

	 	14.	 	Assure that the ratio of children enrolled in Medicaid who received application assistance
from the CONTRACTOR to children enrolled in Child Health Plus who received application
assistance from the CONTRACTOR is not less than the historical ratio for the
CONTRACTOR‘S service area. The historical ratio will be based on the most recently
available administrative data for a one-year period prior to the start of facilitated
enrollment, as determined by the STATE.

15. Maintain confidentiality of applicant and enrollee information in accordance with
protocols developed by the CONTRACTOR and approved by the STATE. Information obtained on the
Growing Up Healthy Application and information concerning the determination of eligibility for
Medicaid may be shared by the CONTRACTOR, its subcontractors conducting facilitated enrollment
and the programs and agencies identified in Section H of the Application, provided that the
applicant has given appropriate written authorization on the Application and provided that the
release is for the purposes of determining eligibility or evaluating the success of the program.

The CONTRACTOR agrees that there will be no further disclosure of Medicaid Confidential Data (MCD)
without prior, written approval of the New York State Department of Health, Medicaid
Confidentiality Data Review Committee (MCDRC). The CONTRACTOR will require and ensure that any
approved agreement, contract or document contains a statement that the subcontractor or other
party may not further disclose the MCD without the prior written approval of the New York State
Department of Health, MCDRC.

The CONTRACTOR must assure that all persons performing activities under this contract receive
appropriate training in confidentiality and that procedures are in place to sanction any such
person for violations of confidentiality.

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

16. Upon notice by the STATE, comply with any federal or state law, regulation and
administrative guidance which may supplement or supersede the provisions set forth in this
AGREEMENT.

17. The CON’1’RACTOR may terminate its facilitated enrollment responsibilities which will
result in removal of the premium add-on associated with those functions by providing at least 60
days written notice to the STATE.

15.

22

Section IV. STATE RESPONSIBILITIES.

Monitor and evaluate the CONTRACTOR’S performance of facilitated enrollment in accordance with the
terms and conditions specified in the CONTRACT. If the CONTRACTOR is found to be out of compliance
with the terms and conditions required under facilitated enrollment, the STATE may terminate the
CONTRACTOR‘S responsibilities relating to facilitated enrollment and remove the premium
add-on associated with those functions. The STATE will give the CONTRACTOR at least 60 days notice
if the facilitated enrollment responsibilities are terminated.

MODIFICATIONS TO APPENDIX D

Additions to Schedule of Deliverables

Facilitated Enrollment

1. Hire or designate staff who will act as facilitators in accordance with State
guidelines.

2. Select sites, days and hours of operation for facilitated enrollment activities in
accordance with STATE requirements.

3. Comply with procedures that have been established by the LDSS in accordance with Medicaid
ADM-2 and approved by the State to assure that facilitators are authorized to perform the
Medicaid face-to-face interview.

4. Establish protocols for reviewing applications completed with the assistance of facilitators
for quality and completeness.

5. Comply with procedures that have been established by the LDSS in accordance with Medicaid
ADM-2 and approved by the State for the exchange of applications, documentation and follow-up
information between facilitators and LDSS and Child Health Plus insurers.

6. Comply with established procedures for transmitting Medicaid managed care plan choices to an
enrollment broker or LDSS.

7. Collect data related to the facilitated enrollment program in. accordance with STATE
requirements and transmit such data to the STATE over the Internet.

8. Establish protocols to maintain confidentiality of applicant and enrollee
information.

9. Update facilitated enrollment data on a monthly basis by the tenth day following the end of
the month.

1.

23

MODIFICATIONS TO APPENDIX F

Additions to Payment and Reporting Schedule

Section II. REPORTING REQUIREMENTS

Facilitated Enrollment Report - Provide specific information on the progress of each
facilitated enrollment application using. an Internet-based system developed by the STATE for that
purpose. The required information shall be continually updated by the CONTRACTOR to ensure timely
and accurate tracking of applications, including the dates and dispositions of applications as they
are processed. In particular, the CONTRACTOR must ensure that the Internet-based system accurately
reflects the end-of-month status of all applications by the tenth day following the end of the
month. CONTRACTOR shall also submit quarterly reports that contain narrative information regarding
facilitated enrollment within thirty (30) days of the end of the reporting period.

	 	 	 
	DOH STATE OF NEW YORK

 DEPARTMENT OF HEALTH

	 	

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

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

Commissioner

	 	Dennis P. Whalen

Executive Deputy Commissioner

January 28, 2002

Ms. Evelyn Huang, General
Counsel CarePlus Health Plan

21 Penn Plaza

360 West 31st Street, 5`h Floor

New York, New York 10001

Dear Ms. Huang:

Enclosed is a contract amendment that adds to the Child Health Plus benefit
package non-airborne, pre-hospital emergency medical services provided by an
ambulance service.

In order to revise the benefit package, a Contract Amendment (Appendix X) is
required. Therefore, we have enclosed two copies of Appendix X along with the
applicable appendices to modify the benefit package. Please sign, notarize and
return both copies of the enclosed Contract Amendment (Appendix X) as soon as
possible. Please return both amendments to:

Gabrielle L. Armenia, Plan Program Manager
NYS Child Health Plus Program

ESP, Corning Tower, Room 1656

Albany, NY 12237-0004

If you have any questions regarding this matter, please contact Ms. Armenia
at (518) 473-0566. Thank you for your continued support of the Child Health Plus
Program.

Sincerely

/s/ Linda Stackman

Linda Stackman

Associate Director

Division of Planning, Policy and Resource Development

Enclosure

24

APPENDIX X

	 	 	 	 	 
	Agency Code 12000	 	Contract No. C-015473
	Period 7/ 1 /98 - 12/31/02	 	Funding Amount for Period No Change

This is an AGREEMENT between THE STATE OF NEW YORK, acting by and through the Department of
Health, having its principal office at Corning Tower, Empire State Plaza, Albany, NY,
(hereinafter referred to as the STATE), and CarePlus Health Plan (hereinafter referred to
as the CONTRACTOR), for modification of Contract Number C015473 by adding the attached
provisions to the existing appendices A-2 and I.

All other provisions of said AGREEMENT shall remain in full force and effect.

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

	 	 	 
	CONTRACTOR ISIGNATURE

	 	STATE AGENCY SIGNATURE
	 
	 	 
	By: /s/ K Ajmani

	 	By:
	 

	 	 
	 
	 	 
	Karin Ajmani

	 	Judith Arnold
	 

	 	 
	Printed Name

	 	Printed Name
	 
	 	 
	Title: Executive Director

	 	Title: Deputy Commissioner
	 

	 	

	
 
	 	Division of Planning, Policy, and Resource Development
	 
	 	 
	Date: 1/31/2002

	 	Date:
	 

	 	 

	 	 	 	State Agency Certification:

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

	 	 	 	 	 
	STATE OF NEW YORK
	 	 	)	 
	 
	 	) SS.:
	County of New York )
{r}
	 	 	 	 

On the 31st  day of January  2002 before me personally appeared
 Karin Ajmani ,to me known, who being by me duly sworn, did depose and
say that he/she resides at  New York, NY , 

that he/she is the  Executive Director  of  Care Plus Health Plan  ,
the corporation

described herein which executed the foregoing instrument, and that he/she signed his/her name
thereto by order of the board of directors of said corporation.

Evelyn Huang

Notary Public State of New York

No. 31-6001118

Qualified in New York County

Commission Expires 3-6-2002

Title:

APPENDIX A-2

PROGRAM SPECIFIC CLAUSES

The following provision is hereby added:
I. DEFINITIONS

1. Effective February 1, 1999, “Health Care Services” shall mean the services of physicians,
optometrists, nurses, nurse practitioners, midwives and other related professional personnel which
are provided on an inpatient or outpatient basis, including routine well-child visits; diagnosis
and treatment of illness and injury; inpatient hospital medical or surgical care; laboratory tests;
diagnostic x-rays; prescription drugs and nonprescription drugs; diabetic supplies and equipment;
diabetic education and home visits; maternity care; radiation therapy; chemotherapy; hemodialysis;
ambulatory surgery; durable medical equipment; physical therapy; emergency room services; home
health care services; outpatient and inpatient mental health, alcohol and substance abuse services;
preventive and routine vision care (including eyeglasses); speech and hearing services; routine and
preventive dental services; and effective March 1, 2002, non-air-borne, pre-hospital emergency
medical services when such services are provided by an ambulance service.

25

APPENDIX J

CHILD HEALTH PLUS BENEFITS PACKAGE

The following provision is hereby added:

	 	 	 	 	 	 	 
	General

Coverage

	 	Scope of

Coverage
	 	Level of Coverage
	 	Copayments/

Deductibles
	 

	 	 
	 	 
	 	 
	 
	 	 	 	 	 	 
	Ambulance

services

	 	Prehospital

emergency

medical

services,

including

prompt

evaluation

and

treatment

of an

emergency

condition

and/or

non-airborne

transportati

on to

a hospital.
	 	-Services must be provided by an ambulance service issued a

certificate to operate pursuant to section 3005 of the Public

Health Law.

-Evaluation and treatment services must be for an emergency

condition defined as a medical or behavioral condition, the

onset of which is sudden, that manifests itself by symptoms

of sufficient severity, including severe pain, that a prudent

layperson, possessing an average knowledge of medicine and

health, could reasonably expect the absence of immediate

medical attention to result in (i) placing the health of the

person afflicted with such condition in serious jeopardy; (ii)

serious impairment to such person’s bodily functions; (iii)

serious dysfunction of any bodily organ or part of such

person; or (iv) serious disfigurement of such person.

-Coverage for non-airborne emergency transportation is

based on whether a prudent layperson, possessing an average

knowledge of medicine and health, could reasonably expect

the absence of such transportation to result in (i) placing the

health of the person afflicted with such condition in serious

jeopardy; (ii) serious impairment to such person’s bodily

functions; (iii) serious dysfunction of any bodily organ or part

of such person; or (iv) serious disfigurement of such person.
	 	

No

copayment

or

deductible.
	 

	 	 
	 	 
	 	 

	 	 	 	 	 
	 	 	 	 	APPENDIX X
	Agency Code 12000	 	Contract No. C-015473
	Period 7/ 1 /98 - 12/31/02	 	Funding Amount for Period No Change

This is an AGREEMENT between THE STATE OF NEW YORK, acting by and through the Department of
Health, having its principal office at Corning Tower, Empire State Plaza, Albany. NY,
(hereinafter referred to as the STATE), and CarePlus Health Plan (hereinafter referred to
as the CONTRACTOR), for modification of Contract Number C015473 by adding the attached
provisions to the existing appendices A-2 and J.

All other provisions of said AGREEMENT shall remain in full force and effect.

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

	 	 	 
	CONTRACTOR ISIGNATURE

	 	STATE AGENCY SIGNATURE
	 
	 	 
	By: /s/ K Ajmani

	 	By:
	 

	 	 
	 
	 	 
	Karin Ajmani

	 	Judith Arnold
	 

	 	 
	Printed Name

	 	Printed Name
	 
	 	 
	Title: Executive Director

	 	Title: Deputy Commissioner
	 

	 	

	
 
	 	Division of Planning, Policy, and Resource Development
	 
	 	 
	Date: 1/31/2002

	 	Date:
	 

	 	 

	 	 	 	State Agency Certification:

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

	 	 	 	 	 
	STATE OF NEW YORK
	 	 	)	 
	 
	 	) SS.:
	County of New York )
{r}
	 	 	 	 

On the 31st  day of January  2002 before me personally appeared
 Karin Ajmani ,to me known, who being by me duly sworn, did depose and
say that he/she resides at  New York, NY , 

that he/she is the  Executive Director  of  Care Plus Health Plan  ,
the corporation described herein which executed the foregoing instrument, and that he/she signed
his/her name thereto by order of the board of directors of said corporation.

Evelyn Huang

Notary Public State of New York

No. 31-6001118

Qualified in New York County

Commission Expires 3-6-2002

Title:

APPENDIX A-2

PROGRAM SPECIFIC CLAUSES

The following provision is hereby added:
1. DEFINITIONS

1. Effective February 1, 1999, “Health Care Services” shall mean the services of physicians,
optometrists, nurses, nurse practitioners, midwives and other related professional personnel which
are provided on an inpatient or outpatient basis, including routine well-child visits; diagnosis
and treatment of illness and injury; inpatient hospital medical or surgical care; laboratory tests;
diagnostic x-rays; prescription drugs and nonprescription drugs; diabetic supplies and equipment;
diabetic education and home visits; maternity care; radiation therapy; chemotherapy; hemodialysis;
ambulatory surgery; durable medical equipment; physical therapy; emergency room services; home
health care services; outpatient and inpatient mental health, alcohol and substance abuse services;
preventive and routine vision care (including eyeglasses); speech and hearing services; routine and
preventive dental services; and effective March 1, 2002, non-air-borne, pre-hospital emergency
medical services when such services are provided by an ambulance service.

26

APPENDIX J

CHILD HEALTH PLUS BENEFITS PACKAGE

The following provision is hereby added:

	 	 	 	 	 	 	 
	General

Coverage

	 	Scope of

Coverage
	 	Level of Coverage
	 	Copayments/

Deductibles
	 

	 	 
	 	 
	 	 
	 
	 	 	 	 	 	 
	Ambulance

services

	 	Prehospital

emergency

medical services,

including prompt

evaluation and

treatment of an

emergency

condition and/or

non-airborne

transportation to

a hospital.
	 	-Services must be provided by an ambulance service issued a

certificate to operate pursuant to section 3005 of the Public

Health Law.

-Evaluation and treatment services must be for an emergency

condition defined as a medical or behavioral condition, the

onset of which is sudden, that manifests itself by symptoms

of sufficient severity, including severe pain, that a prudent

layperson, possessing an average knowledge of medicine and

health, could reasonably expect the absence of immediate

medical attention to result in (i) placing the health of the

person afflicted with such condition in serious jeopardy; (ii)

serious impairment to such person’s bodily functions; (iii)

serious dysfunction of any bodily organ or part of such

person; or (iv) serious disfigurement of such person.

-Coverage for non-airborne emergency transportation is

based on whether a prudent layperson, possessing an average

knowledge of medicine and health, could reasonably expect

the absence of such transportation to result in (i) placing the

health of the person afflicted with such condition in serious

jeopardy; (ii) serious impairment to such person’s bodily

functions; (iii) serious dysfunction of any bodily organ or part

of such person; or (iv) serious disfigurement of such person.
	 	

No copayment or

deductible.
	 

	 	 
	 	 
	 	 

	 	 	 	STATE OF NEW’YORK
AGREEMENT	 

Section I.B.1. is revised to read as
follows: I. Conditions of Agreement

B.1. This AGREEMENT is extended through December 31, 2003 subject to the enactment of legislation
by the New York State Legislature extending certain provisions of Chapter 2 of the Laws of 1998, as
amended by section 55. of Chapter 1 of the Laws of 2002, governing the Child Health Plus
Program.

27

APPENDIX E

Financial Information

Sections A is revised to read as follows:

A. CarePlus Health Plan shall receive, for the period April 1, 2003 through December 31,
2003, an amount up to, but not to exceed, $26,500,000, to provide and administer
a Child Health Plus program for uninsured children in the counties identified in Appendix
A-2, Section II.B.1 of this AGREEMENT or as modified by the STATE. Payment of this amount is based
on the CONTRACTOR meeting the responsibilities provided in this AGREEMENT.

Additional Premium Information:

The total monthly premium shall be: $ 110.70

The State share of the total monthly premium shall be $ 110.70 or the total
monthly premium for children in families with gross household income less than 160% of
the federal poverty level and children who are American Indians or Alaskan Natives
(AI/AN)

The State share of the total monthly premium shall be $ 101.70 or the total monthly
premium minus $9 for children in families with gross household income between 160% and 222%
of the federal poverty level with a maximum of $27 per month per family. The State share is
the total monthly premium less $9 for each of the first three children. For additional
children, the State share is the total monthly premium.

The State share of the total monthly premium shall be $ 95.70 or the total
monthly premium minus $15 for children in families with gross household income between 223%
and 250% of the federal poverty level with a maximum of $45 per month per family. The State
share is the total monthly premium less $15 for each of the first three children. For
additional children, the State share is the total monthly premium.

In the absence of an approved premium modification by the Department of Health and State.
Insurance Department, the premium above or subsequent premium approved (whichever is in effect)
shall continue as the State’s subsidy through December 31, 2003.

28

APPENDIX A-2 Program Specific Clauses

Sections I.R and I.S are added to read as follows:
I. DEFINITIONS

R. “Knowledge, Information and Data System (KIDS)” shall mean the database health plans use to
report information regarding individual children enrolled in the Child Health Plus program.

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

R.

29

The following Section II.A.6 is revised upon implementation of the Knowledge,
Information and Data Systems (KIDS):

II. PAYMENT TO CONTRACTOR

6. The CONTRACTOR shall update the KIDS database to reflect the actual number of children
enrolled in the program during the month for which payment is claimed by the CONTRACTOR to the
STATE. The KIDS database shall include information on each enrolled child as required by the Meta
Data Repository. Changes in a child’s enrollment status must be reported no later

than the seventh (71) business day of the month for which payment is being claimed in
order for the CONTRACTOR to receive the appropriate subsidy payment that month. The KIDS system
will generate a standard voucher to be downloaded by the CONTRACTOR through the Health Provider
Network (HPN) which reflects the information contained in the KIDS system. Such standard voucher
shall be used by the CONTRACTOR for all children eligible for a subsidy
payment and shall be submitted to the STATE no later, than the 1 Oda business day of
the month

for which payment is being claimed. Vouchers must be signed by an authorized representative of the
CONTRACTOR and accompanied by a brief cover letter that identifies a name and phone number of a
person authorized to speak on behalf of the CONTRACTOR if questions arise.

The following Section ll.B.1 is revised as follows:
B. Terms

	 	1.	 	For purposes of this AGREEMENT, the CONTRACTOR’S service area shall consist of the
following counties: Kings, New York, Queens and Richmond	 

The CONTRACTOR may request approval to expand and enhance its existing provider network to provide
services under Child Health Plus to areas of New York State for which the ‘CONTRACTOR is certified
as a Corporation or Health Maintenance Organization licensed under Article 43 of the Insurance Law
and/or a Health Maintenance Organization or Comprehensive Health Service Organization certified
under Article 44 of the Public Health Law; however, in no event may the CONTRACTOR provide
services. to an expanded service area beyond the currently authorized under contract without prior
written approval from the Child Health Plus Contract Manager.

30

The following Sections II.B:9, 10 and 11 are added to read as follows:

9. The CONTRACTOR shall make available any necessary data or program information; as requested
by the STATE, such that the STATE may, in a timely manner, investigate and resolve suspected and
apparent instances of fraud and abuse in accordance with federal regulations.

10. Certification for Contracts and Proposals

By signing this AGREEMENT, the CONTRACTOR certifies the accuracy, completeness, and truthfulness
of information in contracts and proposals, inclining information on subcontractors, and
all other related documents.

11. Contract and Payment Requirements Including Certification of Payment Related
Information

A. By signing this AGREEMENT, the CONTRACTOR certifies that it will provide to the STATE:

1. Enrollment information and other information required by the STATE; and

2. Access for the State, Centers for Medicare and Medicaid Services (CMS) or the Office of

the Inspector General (OIG) to enrollee health claims data and payment data, in

conformance with appropriate privacy protections in the STATE.

B. By signing this AGREEMENT, the CONTRACTOR

1. Attests to the accuracy, completeness and truthfulness of claims and payment data,
under penalty of perjury; and

2. Guarantees that it will not avoid costs for services by referring enrollees to
publicly supported health care resources.

Section III.C is revised to read as follows:
III. CONTRACTOR’S RESPONSIBILITIES C.
Benefit Package

The CONTRACTOR shall be responsible for the provision of health care services to each
enrollee consistent with the benefit package identified in theRFP, the CONTRACTOR’S proposal and
the Benefit Contract as approved by the New York State Insurance Department and consistent with
subsequent STATE legislation, regulations, guidelines, policy and/or Advisory Memoranda.

31

The CONTRACTOR must provide immunizations according to the “Childhood
Immunization Schedule of the United States” as recommended by the Advisory Committee on
Immunization Practices (ACIP). The CONTRACTOR must furnish newly recommended vaccines
to enrollees within 90 days of publication in the Morbidity and Mortality Weekly Report,
available on the Centers for Disease Control and Prevention website at
www.cdc.gov/mmwr.

Section III.D.2 is added to read as follows:

D. Payment to Health Care Providers

	 	2.	 	The CONTRACTOR will not charge enrollees any cost-sharing amounts for
emergency room services provided at a non participating facility beyond applicable
copayments.	 

Section III.E.3 and 5 are revised to read as follows:

E. Premium Determination and Payment

	 	3.	 	Premiums set forth in Appendix E shall be in effect at least through December 31,
2003.. Subscribers shall be responsible for payment of the family premium contribution to
the CONTRACTOR and shall be responsible for copayments as set forth in
the Benefit contract and consistent with subsequent STATE and FEDERAL
legislation, regulations, guidelines; policy and/or Advisory Memoranda     Effective
January 1, 1999, all copayments are eliminated and any provisions regarding copayments
will no longer have any force and effect.

	 	5.	 	The CONTRACTOR shall be responsible for collecting premiums and family
contributions to be paid for by subscribers on behalf of an enrolled child or children
in advance of the period of coverage. The CONTRACTOR must give enrollees
reasonable notice of and an opportunity to pay past due family contributions prior
to. disenrollment. CONTRACTOR must provide enrollees with an
opportunity to show that family income has declined prior to disenrollment and must
provide enrollees with an opportunity for impartial review to address disenrollment in
accordance with administrative guidance . provided by the STATE.	 

32

The following Sections III.E.6 and 7 are revised upon implementation of
the Knowledge, Information and Data Systems (KIDS):

	 	6.	 	The CONTRACTOR shall submit to the STATE on a monthly basis, vouchers and
adjustments on forms developed by the STATE and available through the KIDS system. The
monthly voucher shall reflect the information contained in the KIDS system and must be used
by the CONTRACTOR for all children eligible for a subsidy payment who are enrolled
in the program during the month for which payment is being claimed.

	 	7	 	. The CONTRACTOR shall submit to the STATE. standard vouchers signed by an
authorized representative of the CONTRACTOR no later than the tenth
(10th) business day of the month for which payment is being claimed. Each
voucher must be — accompanied by a brief cover letter that identifies a name and phone
number of a person authorized to speak on behalf of the CONTRACTOR if
questions arise.

Sections III. I, J, K, L and M are added to read
as follows: I. Application and Enrollment

1. The CONTRACTOR shall distribute information to potential enrollees, applicants
and enrollees, regarding:

a. The types of benefits and amount, duration and scope of benefits available;

b. Cost-sharing requirements;

c. The names and locations of current participating providers;

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

e. Information on physician incentive plans; and

f. Review processes available to applicants and enrollees.

This information shall be provided to the CONTRACTOR by the STATE and the
CONTRACTOR shall distribute it to potential enrollees, applicants and enrollees to
assist families in making informed decisions about their health plans, professionals and
facilities.

2. The CONTRACTOR shall distribute a public schedule to be provided by the STATE which
contains information on:

a. Current cost-sharing charges;

b. Enrollee groups subject to the charges;

c. Cumulative cost-sharing maximums;

d. Mechanisms for making payments for required charges; and

e. The consequences for an applicant or enrollee who does not pay a charge, including
disenrollment protections.

a.

33

The public schedule must be available to: enrollees at the time of enrollment
and reenrollment after recertification and. when cost-sharing charges and cumulative
cost-sharing maximums are revised; applicants at the time of application; all participating
providers; and the general public in accordance with administrative guidance provided by the STATE.

3. At the time of application, the CONTRACTOR must inform applicants, in writing and orally if
appropriate, about the application. and eligibility requirements, the time frame for determining
eligibility and the right to review eligibility determinations in a form and manner to be developed
by the State.

4. At the time of application, the CONTRACTOR must inform each applicant about their
right to a full Medicaid eligibility determination and the medically needy spend down program, in
a form and manner to be developed by the STATE.

5. The CONTRACTOR shall process applications received by the 20’ of the month for
an enrollment effective date of the first day of the following month. In no instance shall
the CONTRACTOR determine eligibility any later than 45 days after receipt of a
complete application.

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

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

J. Civil Rights Assurance

The CONTRACTOR must comply with all applicable civil rights requirements, including:

a. Title VI of the Civil Rights Act of 1964;

b. Title II of the Americans with Disabilities Act of 1990;

c. Section 504 of the Rehabilitation Act of 1973;

d. Age Discrimination Act of 1975;

e. 45 CFR parts 80, 84 and 91; and

f. 28 CFR part 35.

a.

34

K. Sanctions and Related Penalties

	 	1.	 	The CONTRACTOR shall not make payments for any item or service furnished, ordered, or
prescribed to any provider excluded from participating in the Medicare and Medicaid programs.

2. The CONTRACTOR must comply with and may be subject to the following:

a. 42 CFR Part 455, Subpart B (Disclosure of information by providers and fiscal
agents).

b. Social Security Act (SSA) *1124 (42 USC §1320a-3) (Disclosure of ownership and
related information).

c. SSA §1126(42 USC §1320a-5) (Disclosure by institutions, organizations, and
agencies of owners and certain other individuals who have been convicted of certain
offenses).

d. SSA §1128 (42 USC §1320a-7 (Exclusion of certain individuals and entities from
participationin Medicare and State health care programs).

e. SSA §1128A (42 USC § 1320a-7a) (Civil monetary penalties).

f. SSA §1128B (42 USC §1320a-7b) (Criminal penalties for acts involving federal
health care programs). .

g. SSA §1128E (42 USC §1320a-7e) (Health care fraud and abuse data collection
program).

L. Fraud and Abuse Protections

The CONTRACTOR must have procedures designed to safeguard against fraud and abuse. .
Such procedures must:

1. Comply with all applicable Federal and State standards;

2. Prohibit conducting unsolicited personal contact with potential enrollees by the
CONTRACTOR’s employees to influence enrollment with the CONTRACTOR; and

1.

35

3. Include mechanisms for the CONTRACTOR to report to the
State information on . violations of law by subcontractors or enrollees of the
CONTRACTOR and other individuals.

M. Integrity of Professional Advice to Enrollees,

The CONTRACTOR must comply with the following:

	 	1.	 	42 CFR section 422.206 (a) which prohibits interference with health care
professionals’ advice to enrollees and requires that professionals provide information
about treatment in an appropriate manner; and

	 	2..	 	42 CFR sections 422.208 and 422.210 which place limitations
on physician incentive plans and require the disclosure of information related to those
physician incentive plans, respectively.

The following Sections N.P and Q are added to read as follows: IV.
STATE RESPONSIBILITIES

P. Provide the CONTRACTOR with information, for distribution to potential enrollees,
applicants and enrollees, regarding the types of benefits and amount, duration and scope of.
benefits available, cost-sharing requirements, a description of the procedures relating to an
enrollment cap or waiting list including the process for decicli g which children will
be given priority for enrollment, how children will be informed of their status on a waiting
list and the circumstances under which enrollment will reopen, if an enrollment cap or waiting
list is in effect, physician incentive plans and review processes available to applicants and
enrollees.

Q. Provide the CONTRACTOR with a public schedule that includes information on current
cost-sharing charges, enrollee groups subject to the charges, cumulative cost-sharing maximums,
mechanisms for making payments for required charges and the consequences for an applicant or
enrollee who’ does not, pay a charge, including disenrollment protections.

The following Section IV.J is revised and Section N.R is added upon implementation
of the Knowledge, Information and Data Systems (KIDS):

J. Provide the CONTRACTOR with all required forms and software necessary to
transmit adjustments and enrollment transactions using the KIDS system.

R. Through the KIDS system, provide the CONTRACTOR with a standard monthly voucher to
be downloaded through the HPN, which reflects the information contained in the KIDS
system and which shall be used by the CONTRACTOR for all children eligible for subsidy
who are enrolled in the program during the month for which payment is being claimed.

P.

36

APPENDIX D

	 	 	 
	Schedule of Deliverables

Letters (i) and (j) are added to read as follows: Ongoing

	 	

Enrollment Activities

i. The CONTRACTOR shall inform each applicant about their right to
a full Medicaid eligibility determination and the medically needy spend down
program at the time of application.

j. The CONTRACTOR shall give enrollees reasonable notice of and an
opportunity to pay past due family contribution prior to disenrollment.
CONTRACTOR must provide enrollees with an opportunity to show that family
income has declined prior to disenrollment and must provide
enrollees with an opportunity for impartial review to address
disenrollment in accordance with administrative guidance provided by the
STATE.

i.

37

Appendix F Payment
and Reporting Schedule

The following Section I.F is revised upon implementation of the Knowledge, Information and Data
Systems (KIDS):

I. Payment and Reporting Terms and Conditions

	 	F.	 	By no later than the seventh (76”) business day of the month for
which payment is being claimed, the CONTRACTOR shall update the KIDS
database to reflect accurate information on the actual number of children enrolled in
the program during the month for which payment is claimed by the CONTRACTOR
to the STATE. The KIDS database shall include information on each enrolled child
as required by the Meta Data Repository. The KIDS system will generate a standard
voucher to be downloaded by the CONTRACTOR through the HPN which reflects
the information contained in the KIDS system. Such standard voucher shall be used by
the CONTRACTOR to receive payment for all children eligible for a subsidy
payment and shall be submitted to the STATE no later than the tenth
(loth) business day of the month for which payment is being
claimed. Vouchers must be signed by an authorized representative of the
CONTRACTOR and accompanied by a brief cover letter that identifies a name
and phone number of a person authorized to speak on behalf of the CONTRACTOR if
questions arise. The CONTRACTOR shall submit vouchers to the State’s
designated payment office located in the New York State Department of Health.

The following paragraph replaces the existing paragraph on the Annual Marketing Plan:

II. Reporting Requirements

Annual Marketing Plan - An addendum to the currently approved Medicaid managed
care/Family Health Plus Marketing plan which includes specific marketing activities and
strategies aimed at reaching eligible children. The content of the marketing plan
must be consistent with that required by the Office of Managed Care (OMC) as defined in
ADM 38. This plan is due 60 days prior to the beginning of the calendar year and
must be submitted simultaneously to the OMC and Child Health Plus contract managers.

The following report is added:

Screen and Enroll Report — A report that includes the number and percent of
children applying for Child Health Plus who are screened potentially eligible for Medicaid,
the number of those screened potentially eligible for Medicaid who are determined to be
eligible versus the number not eligible and the number of children ultimately determined
not to be eligible for Medicaid whose applications for Child Health Plus are processed.
This report is due on a monthly basis by the tenth (10`h) business day
of the month.

38

Effective with the implementation of the Knowledge, Information and Data System (KIDS),
the following replaces Section II of Appendix F:

II. Reporting Requirements

The CONTRACTOR is responsible for submitting reports to the STATE as defined in Appendix G of the
RFP (Appendix B) ‘contained herein. Additional reporting requirements may be imposed based on need
or state or federal legislative requirements. The following are the reports currently required:

Six Month Operations Report — Enrollment summary by income and age group,
disenrollment information, Statement of Revenue and Expenses, and Utilization/Visit
data. This report is due 75 days after the close of the second quarter.

Annual Operations Report — The same data requirements as the Six Month
Operations Report. This report is due 120 days after the close of the calendar year.

Annual Certified Financial Statements — Certified financial statements shall be
prepared in accordance with the requirements of the Federal Office of Management and Budget
(OMB) circular number A-133. This report is due within. one month of completion of but not
later than nine months after the close of the plan’s fiscal year or the date
specified in OMB circular A-133.

Monthly Voucher — Monthly voucher, including adjustments, if necessary. This report
is due by the tenth business day of the month.

Annual Marketing Plan — An addendum to the currently approved Medicaid managed
care/Family Health Plus Marketing plan which includes specific marketing activities and
strategies aimed at reaching eligible: children. The content of the marketing plan must be
consistent with that required by the Office of Managed Care (OMC) as defined in ADM 38.
This plan is due 60 days prior to the beginning of the calendar year and must be submitted
simultaneously to the OMC and Child Health Plus contract managers.

Quality Assurance Report — A report of quality performance data which is consistent
with the New York State Department of Health Quality Assurance Reporting Requirements
(QARR) data specifications as required by Section IlI.G.14 of Appendix A-2. This report is
due on an annual basis in the month of June. The STATE, through the Office of
Managed Care, will notify plans regarding the exact due date for this report.

Facilitated Enrollment Report — Provide specific information on the progress of
each facilitated enrollment application using an Internet-based system developed by the
STATE for that purpose. The required information shall be continually updated by the
CONTRACTOR to ensure timely and accurate tracking of applications, including the dates
and dispositions of applications as they are processed. In particular, the CONTRACTOR
must ensure that the Internet. based system accurately reflects the end-

39

of-month status of all applications by the tenth business day following the
end. of the month when the application was taken. CONTRACTOR shall also submit
quarterly reports that contain narrative information regarding facilitated enrollment within
thirty (30) days of the end of the reporting period.

Screen and Enroll Report A report that includes the number and percent of children applying
for Child Health Plus who are screened potentially eligible for Medicaid, the number of those
screened potentially eligible for Medicaid who are determined to be eligible versus the number not
eligible and the number of children ultimately determined not to be eligible for Medicaid whose
applications for Child Health Plus are processed. This report is due on a monthly basis by the
tenth (10th) business day of the month.

Final Report - The following is required if a plan ceases to do business under the
contract. The final report must detail all aspects of the program including the
CONTRACTOR‘S experience in the marketing and enrollment process, the provision of health
insurance benefits and how program funds were utilized. This report is due 90 days after
the close of the contract period.

40

Appendix H

Additional Program Specific Clauses

The following Sections D and K.4 , 5 and 6 are added as follows:
D. Co-payments/Cost Sharing

	 	•	 	The CONTRACTOR will not charge enrollees any cost sharing beyond applicable
family contributions.	 

K. Annual Recertification

4. Effective April 1, 2003, at recertification, the CONTRACTOR will give each parent and/or legally
responsible adult who is a member of the child(ren)’s household and whose income is
available to the child(ren), the option to provide their social security number in lieu of income
documentation in accordance with administrative guidance issued by the STATE. If the parent/
responsible adult chooses not to provide their social security number(s), the CONTRACTOR will
collect appropriate income documentation in accordance with administrative guidance issued by the
STATE. The CONTRACTOR shall not require the provision of social security numbers as a
condition of a child’s enrollment or eligibility for the program.

5. Effective April 1, 2003, the CONTRACTOR shall provide a two-month
presumptive period at recertification in accordance with administrative guidance issued by the
STATE.

41

STATE OF NEW YORK

DEPARTMENT OF HEALTH

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

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

Dennis P. Whalen

Executive Deputy Commissioner

	 	 	 
	DATE: Jan. 28

CONTRACT #:

	 	, 2004

C015473

CONTRACTOR: CAREPLUS HEALTH PLAN CONTRACT PERIOD: Jul. 01, 1998
-Jun. 30, 2004

Attached is your copy of the approved contract. The Contract number must appear on
all vouchers and correspondence.

Reports of the Expenditures and Budget Statements should be submitted as outlined
in the Contract.

In accordance with the contract, properly completed vouchers and/or programmatic
questions should be addressed to the State’s designated payment office as stated in the
Contract.

Failure of the contracting. Agency to comply with payment provisions as set
forth in the approved Contract may result in non-payment.

An additional supply. of vouchers to be used in submitting claims may be obtained
by written request from the Office of the State Comptroller, Supply Room, 110 State
Street, 2nd Floor, Albany, New York 12236. .

New York State Department of Health Contract
Unit

42

Page 2

Please note the following new information regarding payments:

OSC now offers Electronic Payments. Payments formerly made by check can be made by
electronic funds transfer through the Automated Clearinghouse (ACH) network, and
with OSC optional e-mail notification service, you will receive advance notice of
your electronic payments. Additional information is available on-line at
http://www.osc.state.nv.us/epav/how.htm or by calling 518-474-4032.

43

H

STATE OF NEW YORK DEPARTMENT OF HEALTH

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

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

Dennis P. Whalen

Executive Deputy Commissioner

S.CONTDecember 4, 2003

Karin Ajmani

President

CarePlus Health Plan
21 Penn Plaza

360 West 31st 5th Fl.
New York, NY 10001

Dear Ms. Ajmani:

Enclosed is your Child Health Plus contract amendment for CarePlus Health Plan for the period
January 1, 2004 to June 30, 2004.

Please sign and notarize both copies of the enclosed contract amendment (Appendix X) as
soon as possible. Please return both amendments to me at:

NYS Child Health Plus Program ESP,
Coming Tower, Room 1621 Albany, NY
12237-0004

Please return these documents as soon as possible to avoid any lapse in payment. If you
have any questions regarding this matter, please contact me at (518) 473-0566. Thank you for
your continued support of the Child Health Plus Program.

Sincerely,

Gabrielle L. Armenia
Program Manager

NYS Child Health Plus Program

Enclosures

	 	 	 	 	 
	 	 	 	 	APPENDIX X
	Agency Code 12000	 	Contract No. C-015473
	Period 7/1/98 - 6/30/04	 	Funding Amount for Period $166,856,633

This is an AGREEMENT between THE STATE OF NEW YORK, acting by and through the
Department of Health, having its principal office at Corning Tower.
Empire State Plaza, Albany, NY, (hereinafter referred to as the STATE), and
CarePlus Health Plan (hereinafter referred to as the CONTRACTOR), for
modification of Contract Number C015473 as reflected in attached revisions to
the existing Section I.B.1 of the Agreement and Appendices E, F, I and J to extend the
period of the contract through June 30, 2004.

All other provisions of said AGREEMENT shall remain in full force and effect.

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

	 	 	 
	CONTRACTOR ISIGNATURE

	 	STATE AGENCY SIGNATURE
	 
	 	 
	By: /s/ K Ajmani

	 	By:
	 

	 	 
	 
	 	 
	Karin Ajmani

	 	Judith Arnold
	 

	 	 
	Printed Name

	 	Printed Name
	 
	 	 
	Title: President

	 	Title: Deputy Commissioner
	 

	 	

	
 
	 	Division of Planning, Policy, and Resource Development
	 
	 	 
	Date: 12/22/03

	 	Date:
	 

	 	 

	 	 	 	State Agency Certification:

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

	 	 	 	 	 
	STATE OF NEW YORK
	 	 	)	 
	 
	 	) SS.:
	County of New York )
{r}
	 	 	 	 

On the  22nd  day of  December  2003 before me
personally appeared  Karin Ajmani ,to me known, who being by me duly
sworn, did depose and say that he/she resides at  New York, NY ,that he/she is the
 President   of  CarePlus LLC  , the corporation described
herein which executed the foregoing instrument, and that he/she signed his/her name thereto by
order of the board of directors of said corporation.

Evelyn Huang

Notary Public State of New York

No. 31-6001118

Qualified in New York County

	 	 	 	Commission Expires March 13,
2006

44

STATE OF NEW YORK
AGREEMENT

Section I.B.1. is revised to read as follows: I. Conditions of
Agreement

BA. This AGREEMENT is extended through June 30, 2004.

45

APPENDIX E

Financial Information

Sections A is revised to read as follows:

A. CarePlus Health Plan shall receive, for the period January 1, 2004 through June 30,
2004, an amount up to, but not to exceed, $ 15,700,000 to provide and administer a Child
Health Plus program for uninsured children in the counties identified in Appendix A-2, Section
lI.B.1 of this AGREEMENT or as modified by the STATE. Payment of this amount is based on the
CONTRACTOR meeting the responsibilities provided in this AGREEMENT.

Additional Premium Information:

The total monthly premium shall be: $ 110.70

The State share of the total monthly premium shall be $ 110.70 or the total
monthly premium for children in families with gross household income less than 160% of
the federal poverty level and children who are American Indians or Alaskan Natives
(AUAN).

The State share of the total monthly premium shall be $ 101.70 or the total
monthly premium minus $9 for children in families with gross household income
between 160% and 222% of the federal poverty level with a maximum of $27 per month
per family. The State share is the total monthly premium less $9 for each of the
first three children. For additional children, the State share is the total monthly
premium.

The State share of the total monthly premium shall be $ 95.70 or the total
monthly premium minus $15 for children in families with gross household income
between 223% and 250% of the federal poverty level with a maximum of $45 per month
per family. The State share is the total monthly premium less $15 for each of the
first three children. For additional children, the State share is the total monthly
premium.

In the absence of an approved premium modification by the Department of Health and
State Insurance Department, the premium above or subsequent premium approved (whichever is
in effect) shall continue as the State’s subsidy through June 30, 2004.

46

APPENDIX F

Payment and Reporting Schedule

Section I[.F is revised to read as follows:
Annual Certified Financial Statements

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

For — profit Health Plan: Certified financial statements shall be prepared in accordance with
accounting principles generally accepted in the United States of America and must include a
supplementary report of Child Health Plus B revenue and expenses. This report must be submitted to
the Department no later than nine months after the close of the plan’s fiscal year.

The Department will impose penalties if the required fmancial statements are not submitted on
time, including withholding payments on any or all Department contracts, recovering payments
made under any or all DOH contracts, or terminating this AGREEMENT.

47

APPENDIX I

FEDERAL REQUIREMENTS

The following replaces the existing Appendix I: 1.
Administrative Rules and Audits:

	 	a.	 	If this contract is funded in whole or in part from federal funds,
the CONTRACTOR shall comply with the following federal grant requirements
regarding administration and allowable costs.	 

	 	i.	 	For a local or Indian tribal government, use the
principles in the common rule, “Uniform Administrative Requirements for
Grants and Cooperative Agreements to State and Local Governments,” and
Office of Management and Budget (OMB) Circular A-87, “Cost Principles
for State, Local and Indian Tribal Governments”.	 

	 	 	 	 	 
	ii.	 	For a nonprofit organization other than

	 
	 	 	 	 
	
 
	 	 ̈

 ̈
	 	an institution of higher education,

a hospital, or

	 	 	 	 ̈ an organization named in OMB Circular A-122, “Cost Principles for
Non-profit Organizations”, as not subject to that circular,	 

use the principles in OMB Circular A-110, “Uniform Administrative
Requirements for Grants and Agreements with Institutions of Higher
Education, Hospitals and Other Non-profit Organizations,” and OMB
Circular A-122.

	 	.	 	For an Educational Institution, use the
principles in OMB Circular A-110 and OMB Circular A-21, “Cost
Principles for Educational Institutions”.	 

	 	i.	 	For a hospital, use the principles in OMB Circular
A-110, Department of Health and Human Services, 45 CFR 74, Appendix E,
“Principles for Determining Costs Applicable to Research and Development
Under Grants and Contracts with Hospitals” and, if not covered for audit
purposes by OMB Circular A-133, “Audits of States Local Governments and
Non-profit Organizations”, then subject to program specific audit
requirements following Government Auditing Standards for financial audits.

	 	b.	 	If this contract is funded entirely from STATE funds, and if there are no
specific administration and allowable costs requirements applicable, CONTRACTOR
shall adhere to the applicable principles in “a” above.	 

48

	 	c.	 	The CONTRACTOR shall comply with the following grant requirements regarding
audits.	 

	 	i.	 	If the contract is funded from federal funds, and the
CONTRACTOR spends more than $300,000 in federal funds in their
fiscal year, an audit report must be submitted in accordance with OMB Circular
A-133.	 

	 	ii.	 	If this contract is funded from other than federal funds or if the
contract is funded from a combination of STATE and federal funds but federal
funds are less,than $300,000, and if the CONTRACTOR receives $300,000 or more in
total annual payments from the STATE, the CONTRACTOR shall submit to the STATE
after the end of the CONTRACTOR’s fiscal year an audit report. The audit report
shall be submitted to the STATE within thirty days after its completion but no
later than nine months after the end of the audit period. The audit report shall
summarize the business and financial transactions of the CONTRACTOR. The report
shall be prepared and certified by an independent accounting firm or other
accounting entity, which is demonstrably independent of the administration of the
program being audited. Audits performed of the CONTRACTOR’s records shall be
conducted in accordance with Government Auditing Standards issued by the
Comptroller General of the United States covering fmancial audits. This audit
requirement may be met through entity-wide audits, coincident with the
CONTRACTOR’s fiscal year, as described in OMB Circular A-133. Reports,
disclosures, comments and opinions required under these publications should be so
noted in the audit report.

	 	d.	 	For audit reports due on or after April 1, 2003, that are not received by the dates due, the
following steps shall be taken:

i. If the audit report is one or more days late, voucher payments shall be held until
a compliant audit report is received.

ii. If the audit report is 91 or more days late, the STATE shall recover payments for
all STATE funded contracts for periods for which compliant audit reports are not
received.

iii. If the audit report is 180 days or more late, the STATE shall terminate all
active contracts, prohibit renewal of those contracts and prohibit the execution of
future contracts until all outstanding compliant audit reports have been submitted.

	 	 	 	i.

49

2. The CONTRACTOR shall accept responsibility for compensating the STATE for any
exceptions which are revealed on an audit and sustained after completion of the normal audit
procedure.

	 	3.	 	FEDERAL CERTIFICATIONS: This section shall be applicable to this AGREEMENT only if any of
the funds made available to the CONTRACTOR under this AGREEMENT are federal funds.

a. LOBBYING CERTIFICATION

	 	1)	 	The CONTRACTOR acknowledges that as a recipient of federal
appropriated funds, it is subject to the limitations on the use of such funds
to influence certain Federal contracting and financial transactions, as
specified in Public Law 101-121, section 319, and codified in section 1352 of
Title 31 of the United States Code. In accordance with P.L. 101-121, section
319, 31 U.S.C. 1352 and implementing regulations, the CONTRACTOR affirmatively
acknowledges and represents that it is prohibited and shall refrain from using
Federal funds received under this AGREEMENT for the purposes of lobbying;
provided, however, that such prohibition does not apply in the case of a
payment of reasonable compensation made to an officer or employee of the
CONTRACTOR to the extent that the payment is for agency and legislative
liaison activities not directly related to the awarding of any Federal
contract, the making of any Federal grant or 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.
Nor does such prohibition prohibit any reasonable payment to a person in
connection with, or any payment of reasonable compensation to an officer or
employee of the CONTRACTOR if the payment is for professional or technical
services rendered directly in the preparation, submission or negotiation of
any bid, proposal, or application for a Federal contract, grant, loan, or
cooperative agreement, or an extension, continuation, renewal, amendment, or
modification thereof, or for meeting requirements imposed by or pursuant to
law as a condition for receiving that Federal contract, grant, loan or
cooperative agreement.

	 	2)	 	This section shall be applicable to this AGREEMENT only if
federal funds allotted exceed $100,000.	 

1)

50

a) The CONTRACTOR certifies, to the best of his or her knowledge and belief,
that:

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

 ̈ If any funds other than federal appropriated funds have been paid or will be paid to any
person for influencing or attempting to influence an officer or employee of any agency, a Member of
Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection
with this federal contract, grant, loan, or cooperative agreement, the CONTRACTOR shall complete
and submit Standard Form-LLL, “Disclosure Form to Report Lobbying” in accordance with its
instructions.

	 	b)	 	The CONTRACTOR shall require that the language of this certification be included in the
award documents for all sub-awards at all tiers (including subcontracts, sub-grants, and
contracts under grants, loans, and cooperative agreements) and that all sub-recipients shall
certify and disclose accordingly. This certification is a material representation of fact
upon which reliance was placed when this transaction was made or entered into. Submission of
this certification is a prerequisite for making or entering into this transaction imposed by
section 1352, title 31, U.S. Code. Any person who fails to file the required certification
shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for
each such failure.	 

	 	c)	 	The CONTRACTOR shall disclose specified information on any agreement with lobbyists whom
the CONTRACTOR will pay with other Federal appropriated funds by completion and submission
to the STATE of the Federal Standard Form-LLL, “Disclosure Form to Report Lobbying”, in
accordance with its instructions. This form may be obtained by contacting either the Office
of Management and Budget Fax Information Line at	 

b)

51

(202) 395-9068 or the Bureau of Accounts Management at (518)
474-1208. Completed forms should be submitted to the New York State Department
of Health, Bureau of Accounts Management, Empire State Plaza, Coming Tower
Building, Room 1315, Albany, 12237-0016.

	 	d)	 	The CONTRACTOR shall file quarterly updates on the use of lobbyists
if material changes occur, using the same standard disclosure form identified in
(c) above to report such updated information.

3) The reporting requirements enumerated in subsection (3) of this paragraph shall not
apply to the CONTRACTOR with respect to:

	 	a)	 	Payments of reasonable compensation made to its regularly
employed officers or employees;	 

	 	b)	 	A request for or receipt of a contract (other than a contract
referred to in clause (c) below), grant, cooperative agreement, subcontract
(other than a subcontract referred to in clause (c) below), or subgrant that
does not exceed $100,000; and	 

	 	c)	 	A request for or receipt of a loan, or a commitment providing for
the United States to insure or guarantee a loan, that does not exceed $150,000,
including a contract or subcontract to carry out any purpose for which such a
loan is made.

b. CERTIFICATION REGARDING ENVIRONMENTAL TOBACCO SMOKE:

Public Law 103-227, also known as the Pro-Children Act of 1994 (Act), requires that smoking
not be permitted in any portion of any indoor facility owned or leased or contracted for by an
entity and used routinely or regularly for the provision of health, day care, early childhood
development services, education or library services to children under the age of 18, if the
services are funded by federal programs either directly or through State or local governments,
by federal grant, contract, loan, or loan guarantee. The law also applies to children’s
services that are provided in indoor facilities that are constructed, operated, or maintained
with such federal funds. The law does not apply to children’s services provided in private
residences; portions of facilities used for inpatient drug or alcohol treatment; service
providers whose sole source of applicable federal funds is Medicare or Medicaid; or facilities
where WIC coupons are redeemed. Failure to comply with the provisions of the law may result

52

in the imposition of a monetary penalty of up to $1000 for each violation and/or the
imposition of an administrative compliance order on the responsible entity.

By signing this AGREEMENT, the CONTRACTOR certifies that it will comply with the requirements of
the Act and will not allow smoking within any portion of any indoor facility used for the
provision of services for children as defined by the Act. The CONTRACTOR agrees that it will
require that the language of this certification be included in any subawards which contain
provisions for children’s services and that all subrecipients shall certify accordingly.

c. CERTIFICATION REGARDING DEBARMENT AND SUSPENSION

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

Pursuant to the above-cited regulations, the New York State Department of Health (as a
participant in a primary covered transaction) may not knowingly do business with a person who is
debarred, suspended, proposed for debarment, or subject to other government-wide exclusion
(including any exclusion from Medicare and State health care program participation on or after
August 25, 1995), and the Department of Health must require its prospective contractors, as
prospective lower tier participants, to provide the certification in Appendix B to Part 76 of
Title 45 CFR, as set forth below:

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

53

Instructions for Certification

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

	 	b)	 	The certification in this clause is a material representation of fact upon which
reliance was placed when this transaction was entered into. If it is later determined
that the prospective lower tier participant knowingly rendered and erroneous
certification, in addition to other remedies available to the Federal Government the
department or agency with which this transaction originated may pursue available
remedies, including suspension and/or debarment.	 

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

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

	 	e)	 	The prospective lower tier participant agrees by submitting this proposal that, should the
proposed covered transaction be entered into, it shall not knowingly enter into any lower
tier covered transaction with a person who is proposed for debarment under 48 (:FR part 9,
subpart 9.4, debarred, suspended, declared ineligible, or voluntarily excluded from
participation in this covered transaction, unless authorized by the department or agency
with which this transaction originated.	 

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

	 	g)	 	A participant in a covered transaction may rely upon a certification of a prospective
participant in a lower tier covered transaction that it is not proposed for debarment under
48 CFR part 9, subpart 9.4,	 

54

debarred,suspended, ineligible, or voluntarily excluded from covered
transactions, unless it knows that the certification is erroneous. A
participant may decide the method and frequency by which it determines the
eligibility of its principals. Each participant may, but is not required to,
check the List of Parties Excluded from Federal Procurement and
Non-procurement Programs.

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

	 	i)	 	Except for transactions authorized under paragraph “e”
of these instructions, if a participant in a covered transaction knowingly
enters into a lower tier covered transaction with a person who is proposed
for debarment under 48 CFR part 9, subpart 9.4, suspended, debarred,
ineligible, or voluntarily excluded from participation in this
transaction, in addition to other remedies available to the Federal
Government, the department or agency with which this transaction
originated may pursue available remedies, including suspension and/or
debarment.	 

	 	2)	 	Certification Regarding Debarment, Suspension,
Ineligibility and Voluntary Exclusion — Lower Tier Covered Transactions	 

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

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

4. The STATE, its employees, representatives and designees, shall have the right at any time
during normal business hours to inspect the sites where services are performed and observe the
services being performed by the CONTRACTOR. The CONTRACTOR shall render all assistance and
cooperation to the STATE in making such inspections.

The surveyors shall have the responsibility for determining contract compliance as well as the
quality of service being rendered.

55

5. The CONTRACTOR will not discriminate in the terms, conditions and privileges of
employment, against any employee, or against any applicant for employment because of race, creed,
color, sex, national origin, age, disability, sexual orientation or marital status. The CONTRACTOR
has an affirmative duty to take prompt, effective, investigative and remedial action where it has
actual or constructive notice of discrimination in the terms, conditions or privileges of
employment against (including harassment of) any of its employees by any of its other employees,
including managerial personnel, based on any of the factors listed above.

6. The CONTRACTOR shall not discriminate on the basis of race, creed, color, sex, national
origin, age, disability, sexual orientation or marital status against any person seeking services
for which the CONTRACTOR may receive reimbursement or payment under this AGREEMENT.

7. The CONTRACTOR shall comply with all applicable federal, State and local civil rights and
human rights laws with reference to equal employment opportunities and the provision of
services.

8. The STATE may cancel this AGREEMENT at any time by giving the CONTRACTOR not less than thirty
(30) days written notice that on or after a date therein specified, this AGREEMENT shall be deemed
terminated and cancelled.

9. Other Modifications

	 	a.	 	Modifications of this AGREEMENT as specified below may be made
within an existing PERIOD by mutual written agreement of both parties:	 

	 	 	 
	 ̈

 ̈

 ̈

	 	Appendix B — Budget line interchanges;

Appendix C — Section 11, Progress and Final Reports;

Appendix D — Program Workplan.

	 	b.	 	To make any other modification of this AGREEMENT within an existing
PERIOD, the parties shall revise or complete the appropriate appendix form(s),
and a Modification Agreement (Appendix X is the blank form to be used), which
shall be effective only upon approval by the Office of the State Comptroller.	 

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

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

	 	 	 	 ̈

56

 ̈ Certificate of Workers’ Compensation
Insurance, on the Workers’ Compensation Board form C-105.2 or
the State Insurance Fund Form U- 26.3 (naming the Dept. of
Health, Corning Tower Rm. 1315, Albany 12237- 0016), or
    	 

	 	 	 	 ̈ Affidavit Certifying That Compensation Has Been Secured, form
SI-12 or form GSI 105.2, or	 

	 	 	 	 ̈ Statement That Applicant Does Not Require Workers’ Compensation
or Disability Benefits Coverage, form 105.21, completed for
workers’ compensation; and	 

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

 ̈ Certificate of Disability Benefits Insurance, form DB-120.1, or

	 	 	 	 ̈ Notice of Qualification as Self Insurer Under Disability
Benefits Law, form DB-155, or	 

	 	 	 	 ̈ Statement That Applicant Does Not Require Workers’ Compensation
or Disability Benefits Coverage, form 105.21, completed for
disability benefits insurance.	 

11. Additional clauses as may be required under this AGREEMENT are annexed hereto as appendices
and are made a part hereof if so indicated on the face page of this AGREEMENT.

57

Appendix J

Child Health Plus B

Benefits Package

No Pre-Existing Condition Limitations Permitted

No Co-payments or Deductibles

January 1, 2004

	 	 	 	 	 
	General Coverage	 	Scope of Coverage	 	Level of Coverage
	Pediatric Health

Promotion Visits

	 	Well child care visits in accordance with

visitation schedule

established by American Academy of Pediatrics,

and the

Advisory Committee on Immunization Practices

recommended immunization schedule.
	 	Includes all services related to visits. Includes immunizations which must be provided

within

90 days from publication in the Morbidity and Mortality Weekly Report, well child

care, health

education, tuberculin testing (mantoux), hearing testing, dental and developmental

screening,

clinical laboratory and radiological tests, eye screening, lead screening, and

reproductive

health services, with direct access to such reproductive health services.
	 

	 	 
	 	 
	 
	 	 	 	 
	
 
	 	 	 	No benefits will be provided for any out-of-hospital days, or if inpatient care was not

necessary; no benefits are provided after discharge; benefits are paid in full for

accommodations in a semi-private room. A private room will be covered if medically

warranted. Includes 365 days per year coverage for inpatient hospital services and

services

provided by physicians and other professional personnel for covered inpatient

services: bed

and board, including special diet and nutritional therapy: general, special and

critical care

nursing services, supplies and equipment related to surgical operations, recovery

facilities,

anesthesia, and facilities for intensive or special care; oxygen and other inhalation

therapeutic

services and supplies; drugs and medications that are not experimental; sera,

biologicals,

vaccines, intravenous preparations, dressings, casts, and materials for diagnostic

studies;

blood products, except when participation in a volunteer blood replacement program is

available to the insured or covered person, and services and equipment related to their

administration; facilities, services, supplies and equipment related to physical

medicine and

occupational therapy and rehabilitation; facilities, services, supplies and equipment

related to

diagnostic studies and the monitoring of physiologic functions, including but not

limited to

laboratory, pathology, cardiographic, endoscopic, radiologic and
	 
	 	 	 	 
	Inpatient Hospital or

Medical or Surgical

Care

	 	electro-encephalographic

As a registered bed patient for treatment of

an illness,

injury or condition which cannot be treated on an

outpatient basis. The hospital must be a

short-term, acute

care facility and New York State licensed.
	 	

studies and examinations; facilities, services, supplies and equipment related to

radiation and

nuclear therapy; facilities, services, supplies and equipment related to emergency

medical

care; chemotherapy; any additional medical, surgical, or related services, supplies and

equipment that are customarily furnished by the hospital.
	 

	 	 
	 	 

	 	 	 	 	 
	General Coverage Scope of Coverage	Level of Coverage
	Inpatient Mental

Health and Alcohol

and Substance Abuse

Services

	 	Services to be provided in a facility operated by OMH

under sec. 7.17 of the Mental Hygiene Law, or a

facility

issued an operating certificate pursuant to Article

23 or

Article 31 of the Mental Hygiene Law or a general

hospital

as defined in Article 28 of the Public Health Law.
	 	

A combined 30 days per calendar year for inpatient mental health services, inpatient

detoxification and inpatient rehabilitation.
	 

	 	 
	 	 
	 
	 	 	 	 
	Professional Services

for Diagnosis and

Treatment of Illness

and Injury

	 	Provides services on ambulatory basis by a covered

provider for medically necessary diagnosis and

treatment

of sickness and injury and other conditions. Includes

all

services related to visits. Professional services are

provided on outpatient basis and inpatient basis.
	 	No limitations. Includes wound dressing and casts to immobilize fractures for the

immediate

treatment of the medical condition. Injections and medications provided at the time

of the

office visit or therapy will be covered. Includes audiometric testing where deemed

medically

necessary.
	 

	 	 
	 	 
	 
	 	 	 	 
	Hospice Services and

Expenses

	 	Coordinated hospice program of home and inpatient

services which provide non-curative medical and

support

services for persons certified by a physician to be

terminally ill with a life expectancy of six months

or less.
	 	Hospice services include palliative and supportive care provided to a patient to

meet the

special needs arising out of physical, psychological, spiritual, social and

economic stress

which are experienced during the final stages of illness and during dying and

bereavement.

Hospice organizations must be certified under Article 40 of the NYS Public Health

Law. All

services must be provided by qualified employees and volunteers of the hospice or by

qualified staff through contractual arrangements to the extent permitted by federal

and state

requirements. All services must be provided according to a written plan of care

which reflects

the changing needs of the patient/family. Family members are eligible for up to

five visits for

bereavement counseling.
	 

	 	 
	 	 
	 
	 	 	 	 
	Outpatient Surgery

	 	Procedure performed within the provider’s office will

be

covered as well as “ambulatory surgery procedures”

which

may be performed in a hospital-based ambulatory

surgery

service or a freestanding ambulatory surgery center.
	 	

The utilization review process must ensure that the ambulatory surgery is

appropriately

provided.
	 

	 	 
	 	 
	 
	 	 	 	 
	Diagnostic and

Laboratory Tests

	 	Prescribed ambulatory clinical laboratory tests and

diagnostic x-rays.
	 	

No limitations.
	 

	 	 
	 	 

	 	 	 	 	 	 	 	 	 
	General	 	 	 	 
	Coverage	 	Scope of Coverage	 	Level of Coverage
	 
	 	 	 	 	 	Includes hospital beds and accessories, oxygen and oxygen

	 
	 	Durable Medical Equipment means devices and                 	 	supplies, pressure pads, volume

	 
	 	equipment ordered by a practitioner for the                 	 	ventilators, therapeutic ventilators, nebulizers and other

	 
	 	treatment of a                                              
	 	equipment for respiratory care,

	 
	 	specific medical condition which:                           
	 	traction equipment, walkers, wheelchairs and accessories, commode

	 
	 	Can withstand repeated use for a protracted                 
	 	chairs, toilet rails,

	 
	 	period of time;                                             
	 	apnea monitors, patient lifts, nutrition infusion pumps,

	 
	 	Are primarily and customarily used for medical              
	 	ambulatory infusion pumps and other

	 
	 	purposes;                                                   
	 	miscellaneous DME.

	 
	 	Are generally not useful in the absence of                  
	 	DME coverage includes equipment servicing (labor and parts).

	Durable Medical
	 	illness                                                     
	 	Examples include, but are not

	Equipment (DME),
	 	or injury; and                                              
	 	limited to:

	Prosthetic
	 	© Are usually not fitted, designed or fashioned	 	Fitted/Customized leg brace Not fitted/Customized cane

	Appliances
	 	for                                                         
	 	Prosthetic arm Wheelchair

	and Orthotic Devices
	 	a particular person's use.                                  
	 	Footplate Crutches

	 
	 	DME intended for use by one person may be
	 	 	 	 
	 
	 	custom-
	 	 	 	 
	 
	 	made or customized.
	 	 	 	 
	 
	 	 	 	 	 	 
	 
	 	Prosthetic Appliances are those appliances and              
	 	Covered without limitation except that there is no coverage for

	 
	 	devices                                                     
	 	cranial prosthesis (Le. wigs)

	 
	 	ordered by a qualified practitioner which                   
	 	and dental prosthesis, except those made necessary due to

	 
	 	replace any                                                 
	 	accidental injury to sound,

	 
	 	missing part of the body.                                   
	 	natural teeth and provided within twelve months of the accident,

	 
	 		—		 	and except for dental

	 
	 	 	 	 	 	prosthesis needed in treatment of congenital abnormality or as

	 
	 	 	 	 	 	part of reconstructive surgery.

	 
	 	Orthotic Devises are those devices which are                
	 	No limitations on orthotic devices except that devices prescribed

	 
	 	used to                                                     
	 	solely for use during sports

	 
	 	support a weak or deformed body member or to                
	 	are not covered.

	 
	 	restrict or,                                     
	 		—	
	 
	 	eliminate motion in a diseased or injured part
	 	 	 	 
	 
	 	of the body.
	 	 	 	 
	Therapeutic Services
	 	Ambulatory radiation therapy, chemotherapy,                 
	 	No limitations. These therapies must be medically necessary and

	 
	 	injections                                                  
	 	under the supervision or

	 
	 	and medications provided at time of therapy (Le.            
	 	referral of a licensed physician. Short term physical and

	 
	 	chemotherapy) will also be covered.                         
	 	occupational therapies will be

	 
	 		—		 	covered when ordered by a physician. No procedure or services

	 
	 	 	 	 	 	considered experimental will

	 
	 	 	 	 	 	be reimbursed.
	 
	 	 	 	 	 	 
	 
	 	Hemodialysis                                                
	 	Determination of the need for services and whether home-based or

	 
	 		—		 	facility-based treatment is

	 
	 	 	 	 	 	appropriate.

	 
	 	 	 	 	 	 
	 
	 	 	 	 	 	One hearing examination per calendar year is covered. If an

	 
	 	 	 	 	 	auditory deficiency requires

	 
	 	 	 	 	 	additional hearing exams and follow-up exams, these exams will be

	 
	 	 	 	 	 	covered. Hearing aids,

	 
	 	 	 	 	 	including batteries and repairs, are covered. If medically

	 
	 	Hearing examinations to determine the need for              
	 	necessary, more than one hearing

	 
	 	corrective                                                  
	 	aid will be covered.

	 
	 	action and speech therapy performed by an                   
	 	Covered speech therapy services are those required for a condition

	Speech and Hearing
	 	audiologist,                                                
	 	amenable to significant

	Services Including
	 	language pathologist, a speech therapist and/or             
	 	clinical improvement within a two-month period, beginning with the

	Hearing Aids
	 	otolaryngologist.                                           
	 	first day of therapy.

	 
	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	Benefits are available if a physician orders the tests: proper

	 
	 	 	 	 	 	diagnosis and treatment require

	 
	 	 	 	 	 	the tests; and the surgery takes place within seven days after the

	 
	 	 	 	 	 	testing. If surgery is

	 
	 	All tests (laboratory, x-ray, etc.) necessary               
	 	canceled because of pre-surgical test findings or as a result of a

	 
	 	prior to                                                    
	 	Second Opinion on Surgery,

	Pre-Surgical Testing
	 	inpatient or outpatient surgery.                            
	 	the cost of the tests will be covered.

	 	 	 	 	 

	 	 	 	 	 
	General Coverage Scope of Coverage	Level of Coverage
	Second Surgical	 	 	 	 
	Opinion

	 	Provided by a qualified physician.
	 	No limitations.
	 

	 	 
	 	 
	 
	 	 	 	 
	Second Medical

Opinion

	 	Provided by an appropriate.

specialist, including one

affiliated with a specialty care center.
	 	A second medical opinion is available in the event of a positive or

negative diagnosis of

cancer, a recurrence of cancer, or a recommendation of a course of

treatment of cancer.
	 

	 	 
	 	 
	 
	 	 	 	 
	Outpatient Visits for

Mental Health and for

the Diagnosis and

Treatment of

Alcoholism and

Substance Abuse

	 	

Services must be provided by certified and/or

licensed

professionals.
	 	

A combined 60 outpatient visits per calendar year. Visits may

include family therapy for

alcohol, drug and/or mental health as long as such therapy is

directly related to the enrolled

child’s alcohol, drug and/or mental health treatment.
	 

	 	 
	 	 
	 
	 	 	 	 
	Home Health Care

Services

	 	The care and treatment of a covered person who

is under

the care of a physician but only if

hospitalization or

confinement in a skilled nursing facility

would otherwise

have been required if home care was not

provided and the

plan covering the home health service is

established and

provided in writing by such physician.
	 	Home care shall be provided by a certified home health agency

possessing a valid certificate

of approval issued pursuant to Article 36 of the Public Health Law.

Home care shall consist of

one or more of the following: part-time or intermittent home health

aide services which consist

primarily of caring for the patient, physical, occupational, or

speech therapy if provided by the

home health agency and medical supplies, drugs and medications

prescribed by a physician,

and laboratory services by or on behalf of a certified home health

agency to the extent such

items would have been covered or provided under the contract if the

covered person had

been hospitalized or confined in a skilled nursing facility. The

contract must provide 40 such

visits in any calendar year, if such visits are medically necessary.
	 

	 	 
	 	 
	 
	 	 	 	 
	Prescription and Non-

Prescription Drugs

	 	Prescription and non-prescription medications

must be

authorized by a professional licensed to write

prescriptions.
	 	Prescriptions must be medically necessary. May be limited to

generic medications where

medically acceptable. Includes family planning or contraceptive

medications or devices. All

medications used for preventive and therapeutic purposes will be

covered. Vitamins are not

covered except when necessary to treat a diagnosed illness or

condition. Coverage includes

enteral formulas for home use for which a physician or other

provider authorized to prescribe

has issued a written order. Enteral formulas for the treatment of

specific diseases shall be

distinguished from nutritional supplements taken electively.

Coverage for certain inherited

diseases of amino acid and organic acid metabolism shall include

modified solid food

products that are low-protein or which contain modified protein.

Coverage for such modified

solid food products shall not exceed $2500 per calendar year.
	 

	 	 
	 	 

	 	 	 	 	 
	General Coverage Scope of Coverage	Level of Coverage
	
 
	 	For services to treat an emergency condition in

hospital

facilities. For the purpose of this provision,

“emergency

condition” means a medical or behavioral

condition, the

onset of which is sudden, that manifests itself

by

symptoms of sufficient severity, including

severe pain, that

a prudent layperson, possessing an average

knowledge of

medicine and health, could reasonably expect the

absence

of immediate medical attention to result in:
	 	

	Emergency Medical

Services

	 	o Placing the health of the person

afflicted with

such condition in serious jeopardy, or in the

case

of a behavioral condition placing the health of

such person br others in serious jeopardy;

© Serious impairment to such person’s bodily

functions;

Serious dysfunction of any bodily organ or part

of such person; or

Serious disfigurement of such person.
	 	

No limitations.
	 

	 	 
	 	 

	 	 	 	 	 
	General	 	 	 	 
	Coverage	 	Scope of Coverage	 	Level of Coverage
	 	 	 	 	Services must be provided by an ambulance service issued a certificate to operate
	 	 	 	 	pursuant
	 	 	 	 	to Section 3005 of the Public Health Law.
	 	 	 	 	Evaluation and treatment services must be for an emergency condition defined as a
	 	 	 	 	medical
	 	 	 	 	or behavioral condition, the onset of which is sudden, that manifests itself by
	 	 	 	 	symptoms of
	 	 	 	 	sufficient severity, including severe pain, that a prudent layperson, possessing an
	 	 	 	 	average
	 	 	 	 	knowledge of medicine and health, could reasonably expect the absence of immediate
	 	 	 	 	medical attention to result in:
	 	 	 	 	o Placing the health of the person afflicted with such condition in
	 	 	 	 	serious jeopardy, or
	 	 	 	 	in the case of a behavioral condition placing the health of such person or others in
	 	 	 	 	serious jeopardy;
	 	 	 	 	Serious impairment to such person's bodily functions;
	 	 	 	 	Serious dysfunction of any bodily organ or part of such person; or
	 	 	 	 	o Serious disfigurement of such person.
	 	 	 	 	Coverage for non-airborne emergency transportation is based on whether a prudent
	 	 	 	 	layperson, possessing an average knowledge of medicine and health, could reasonable
	 	 	 	 	expect the absence of such transportation to result in:
	 	 	Pre-hospital emergency medical services,	 	o Placing the health of the person afflicted with such condition in
	 	 	including	 	serious jeopardy;
	 	 	prompt evaluation and treatment of an emergency	 	Serious impairment to such person's bodily functions;
	Ambulance	 	condition and/or non-airborne transportation	 	o Serious dysfunction of any bodily organ or part of such person; or
	Services	 	to a hospital.	 	 
	Serious disfigurement of such person.	 	 
	 	 	Inpatient hospital coverage for at least 48	 	 
	 	 	hours after	 	 
	 	 	childbirth for any delivery other than a	 	 
	 	 	C-Section and in at	 	 
	 	 	least 96 hours following a C-section. Also	 	 
	 	 	coverage of	 	 
	 	 	parent education, assistance and training in	 	 
	 	 	breast and	 	 
	 	 	bottle feeding and any necessary maternal and	 	 
	 	 	newborn	 	 
	 	 	clinical assessments. The mother shall have	 	 
	 	 	the option to	 	 
	 	 	be discharged earlier than the 48/96 hours,	 	 
	 	 	provided that	 	 
	 	 	at least one home care visit is covered	 	No limitations; (however subsidized children requiring maternity care services will
	 	 	post-discharge.	 	be referred
	Maternity Care	 	Prenatal, labor and delivery is covered.	 	to Medicaid).
	Diabetic Supplies

and

	 	Coverage includes insulin, blood glucose

monitors, blood
	 	As prescribed by a physician or other licensed health care provider legally

authorized to
	 
	 	 	 	 
	Equipment

	 	glucose monitors for visually impaired, data

management

systems, test strips for monitors and visual

reading, urine

test strips, insulin, injection aids,

cartridges for visually

impaired, syringes, insulin pumps and

appurtenances

thereto, insulin infusion devices, oral agents.
	 	

prescribe under title eight of the education law.
	 

	 	 
	 	 

58

Child Health Plus B

Benefit Package Exclusions

	 	 	 
	
 
	 	The following services will NOT be covered:
	 
	 	 
	
 
	 	

	 	•	 	Experimental medical or surgical procedures.	 

	 	•	 	Experimental drugs.	 

	 	•	 	Drugs which can be bought without prescription, except as defined.	 

	 	•	 	Prescription drugs and biologicals and the administration of these drugs and biologicals that are furnished
for the purpose of causing or assisting in causing the death, suicide, euthanasia or mercy killing of a
person.	 

	 	•	 	Private duty nursing.	 

	 	•	 	Home health care, except as defined.	 

	 	•	 	Care in connection with the detection and correction by manual or mechanical means of structural imbalance,
distortion or subluxation in the human body for the purpose of removing nerve interference and the effects
thereof, where such interference is the result of or related to distortion, misalignment or subluxation of
or in the vertebral column.	 

	 	•	 	Services in a skilled nursing facility or rehabilitation facility.	 

	 	•	 	Cosmetic, plastic, or reconstructive surgery, except as defined.	 

	 	•	 	In vitro fertilization, artificial insemination or other means of conception and infertility services.	 

	 	•	 	Services covered by another payment source.	 

	 	•	 	Durable Medical Equipment and Medical Supplies, except as defined.	 

	 	•	 	Transportation, except as defined.	 

	 	•	 	Personal or comfort items.	 

	 	•	 	Orthodontia Services.	 

	 	•	 	Services which are not medically necessary.	 

59

STATE OF- NEW YORK

DEPARTMENT OF HEALTH

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

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

Dennis P. Whalen

Executive Deputy Commissioner

	 	 	 
	DATE: Sep. 08

	 	, 2004
	 
	 	 
	CONTRACT #:

	 	C015473
	 
	 	 
	CONTRACTOR:

	 	CAREPLUS HEALTH PLAN

CONTRACT PERIOD: Jul. 01, 1998 — Dec. 31, 2004

Attached is your copy of the approved contract. The Contract number must appear on all
vouchers and correspondence.

Reports of the Expenditures and Budget Statements should be submitted as outlined-in
the Contract.

In accordance with the contract, properly completed vouchers and/or programmatic
questions should be addressed to the State’s designated payment office as stated in the
Contract.

Failure of the contracting Agency to, comply with payment provisions asset forth in
the approved Contract may result in non-payment.

An additional supply of vouchers to be used in submitting claims may be obtained by
written request from the Office of the State Comptroller, Supply Room, 110 State Street,
2nd Floor, Albany, New York 12236.

New York State Department of Health Contract Unit

60

Please note the following new information regarding payments:. .

OSC now offers Electronic Payments. Payments formerly made by check east be. made by
electronic funds transfer. through the Automated Clearinghouse (A network, and
with OSC optional e-mail notification service, you will receive advance notice: of your
electronic payments:. Additional information is available on-line at
Irttp://rvww.ose.state.nv.usfenar/how.htm or by calling 518-474-4032’.

	 	 	 	 	 
	Agency Code 12000

Period

	 	7/1/1998 to 12/31/04
	 	APPENDIX X

Contract No. C-015473

Funding Amount for Period $183,356,633.00

This is an AGREEMENT between THE STATE OF NEW YORK, acting by and through the Department
of Health, having its principal office at Corning Tower, Empire State Plaza, Albany,
NY, (hereinafter referred to as the STATE), and Care Plus, LLC (hereinafter referred to as the
CONTRACTOR), for modification of Contract Number C-015473 as reflected in the attached provisions
to Section I.B.I. of the Agreement and Appendices E and L, and to extend the period of the contract
through December 31, 2004.

All other provisions of said AGREEMENT shall remain in full force and effect.

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

	 	 	 	 	 
	CONTRACTOR ISIGNATURE

	 	STATE AGENCY SIGNATURE
	 	

	 
	 	 	 	 
	By: /s/ K Ajmani

	 	By:
	 	/s/ Judith Arnold
	 

	 	 
	 	 
	 
	 	 	 	 
	Karin Ajmani

	 	Judith Arnold
	 	

	 
	 	 	 	 
	 	 	 

	 
	 	 	 	 
	Printed Name

	 	Printed Name
	 	

	 
	 	 	 	 
	Title: President

	 	Title: Deputy Commissioner
	 	

	 

	 	

	 	

	 
	 	 	 	 
	 	 	Division of Planning, Policy, and Resource Development

	 
	 	 	 	 
	Date: 6/2/04

	 	Date:
	 	6/21/04
	 

	 	 	 	 

	 	 	 	State Agency Certification:

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

	 	 	 	 	 
	STATE OF NEW YORK
	 	 	)	 
	 
	 	) SS.:
	County of New York )
{r}
	 	 	 	 

On the  2nd  day of  June  2004 before me personally
appeared  Karin Ajmani ,to me known, who being by me duly sworn, did
depose and say that he/she resides at  New York, NY , 

that he/she is the  President   of  CarePlus LLC  , the
corporation described herein which executed the foregoing instrument, and that he/she signed
his/her name thereto by order of the board of directors of said corporation.

Evelyn Huang

Notary Public State of New York

No. 31-6001118

Qualified in New York County

Commission Expires March 13, 2006

61

STATE OF NEW YORK AGREEMENT

Section I.B.1. is revised to read as follows: I. Conditions of Agreement

B.1. This AGREEMENT is extended through December 31, 2004.

62

APPENDIX E

Financial Information

Sections A is revised to read as follows:

A. Care Plus, LLC shall receive, for the period July 1, 2004 through December 31, 2004, an amount
up to, but not to exceed, $16,500,000.00 to provide and administer a Child Health Plus
program for uninsured children in the counties identified in Appendix A-2, Section II.B. l of this
AGREEMENT or as modified by the STATE. Payment of this amount is based on the
CONTRACTOR meeting the responsibilities provided in this AGREEMENT.

Additional Premium Information:

The total monthly premium shall be: $ 110.70

The State share of the total monthly premium shall be $ 110.70 or the total monthly premium
for children in families with gross household income less than 160% of the federal poverty
level and children who are American Indians or Alaskan Natives (AI/AN)

The State share of the total monthly premium shall be $ 101.70 or the total monthly premium
minus $9 for children in families with gross household income between 160% and 222% of the
federal poverty level with a maximum of $27 per month per family. The State share is the
total monthly premium less $9 for each of the first three children. For additional children,
the State share is the total monthly premium.

The State share of the total monthly premium shall be $ 95.70 or the total monthly premium
minus $15 for children in families with gross household income between 223% and 250% of the
federal poverty level with a maximum of $45 per month per family. The State share is the
total monthly premium less $15 for each of the first three children. For additional
children, the State share is the total monthly premium.

In the absence of an approved premium modification by the Department of Health and State
Insurance Department, the premium above or subsequent premium approved (whichever is in
effect) shall continue as the State’s subsidy through December 31, 2004.

63

Appendix L

Privacy and Confidentiality

Section II is revised as follows:

II. Effective April 14, 2003, the CONTRACTOR shall comply with the following
agreement:

Federal Health Insurance Portability and Accountability Act (HIPAA)

Business Associate Agreement (“Agreement”)

This Business Associate Agreement between the New York State Department of Health and Care
Plus, LLC, hereinafter referred to as the Business Associate, is effective on April 14,
2003 to December 31, 2004.

64

STATE OF NEW YORK DEPARTMENT OF HEALTH Coming Tower The Governor
Nelson A. Rockefeller Empire State Plaza Albany, New York 12237

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

Dennis P. Whalen

Executive Deputy Commissioner

May 27, 2004

Evelyn Huang Care
Plus

21 Penn Plaza

360 W 31st St., 5th Floor

New York, NY 10001

Dear Ms. Huang:

Enclosed is your Child Health Plus contract amendment for Care Plus for the period
July 1, 2004 to December 31, 2004.

Please sign and notarize both copies of the enclosed contract amendment (Appendix
X) as soon as possible. Please return both amendments to me at:

NYS Child Health Plus Program
ESP, Corning Tower, Room 1621
Albany, NY 12237-0004

Please return these documents as soon as possible to avoid any lapse in payment.
If you have any questions regarding this matter, please contact me at (518) 473-0566.
Thank you for your continued support of the Child Health Plus Program.

Sincerely,

Gabrielle L. Armenia
Program Manager

NYS Child Health Plus Program

Enclosures

	 	 	 	 	 
	Agency Code 12000

Period

	 	7/1/1998 to 12/31/04
	 	APPENDIX X

Contract No. C-015473

Funding Amount for Period $183,356,633.00

This is an AGREEMENT between THE STATE OF NEW YORK, acting by and through the Department of
Health, having its principal office at Corning Tower, Empire State Plaza, Albany,
NY, (hereinafter referred to as the STATE), and Care Plus, LLC (hereinafter referred to as
the CONTRACTOR), for modification of Contract Number C-015473 as reflected in the attached
provisions to Section I.B.I. of the Agreement and Appendices E and L, and to extend the period
of the contract through December 31, 2004.

All other provisions of said AGREEMENT shall remain in full force and effect.

IN WITNESS WHEREOF, the parties hereto have executed this AGREEMENT as of the dates appearing under
their signatures. CONTRACTOR ISIGNATURE STATE AGENCY SIGNATURE

	 	 	 	 	 
	By: /s/ K Ajmani

	 	By:
	 	/s/ Judith Arnold
	 

	 	 
	 	 
	 
	 	 	 	 
	Karin Ajmani

	 	Judith Arnold
	 	

	 
	 	 	 	 
	 	 	 

	 
	 	 	 	 
	Printed Name

	 	Printed Name
	 	

	 
	 	 	 	 
	Title: President

	 	Title: Deputy Commissioner
	 	

	 

	 	

	 	

	 
	 	 	 	 
	 	 	Division of Planning, Policy, and Resource Development

	 
	 	 	 	 
	Date: 6/2/04

	 	Date:
	 	6/21/04
	 

	 	 	 	 

	 	 	 	State Agency Certification:

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

	 	 	 	 	 
	STATE OF NEW YORK
	 	 	)	 
	 
	 	) SS.:
	County of New York )
{r}
	 	 	 	 

On the  2nd  day of  June  2004 before me personally
appeared  Karin Ajmani ,to me known, who being by me duly sworn, did
depose and say that he/she resides at  New York, NY , 

that he/she is the  President   of  CarePlus LLC  , the
corporation described herein which executed the foregoing instrument, and that he/she signed
his/her name thereto by order of the board of directors of said corporation.

Evelyn Huang

Notary Public State of New York

No. 31-6001118

Qualified in New York County

Commission Expires March 13, 2016

STATE COMPTROLLER SIGNATURE

65

STATE OF NEW YORK AGREEMENT

Section I.B.1. is revised to read as follows: I. Conditions of Agreement

B.1. This AGREEMENT is extended through December 31, 2004.

66

APPENDIX E

Financial Information

Sections A is revised to read as follows:

A. Care Plus, LLC shall receive, for the period July 1, 2004 through December 31, 2004, an amount
up to, but not to exceed, $16,500,000.00 to provide and administer a Child Health Plus program for
uninsured children in the counties identified in Appendix A-2, Section II.B.1 of this AGREEMENT or
as modified by the STATE. Payment of this amount is based on the CONTRACTOR meeting the
responsibilities provided in this AGREEMENT.

Additional Premium Information:

The total monthly premium shall be: $ 110.70

The State share of the total monthly premium shall be $ 110.70 or the total monthly premium
for children in families with gross household income less than 160% of the federal poverty
level and children who are American Indians or Alaskan Natives (AI/AN)

The State share of the total monthly premium shall be $ 101.70 or the total monthly premium
minus $9 for children in families with gross household income between 160% and 222% of the
federal poverty level with a maximum of $27 per month per family; The State share is the
total monthly premium less $9 for each of the first three children. For additional children,
the State share is the total monthly premium.

The State share of the total monthly premium shall be $ 95.70 or the total monthly premium
minus $15 for children in families with gross household income between 223% and 250% of the
federal poverty level with a maximum of $45 per month per family. The State share is the
total monthly premium less $15 for each of the first three children. For additional
children, the State share is the total monthly premium.

In the absence of an approved premium modification by the Department of Health and State
Insurance Department, the premium above or subsequent premium approved (whichever is in effect)
shall continue as the State’s subsidy through December 31, 2004.

67

Appendix L

Privacy and Confidentiality

Section II is revised as follows:

II. Effective April 14, 2003, the CONTRACTOR shall comply with the following
agreement:

Federal Health Insurance Portability and Accountability Act (HIPAA)

Business Associate Agreement (“Agreement”)

	 	 	 	This Business Associate Agreement between the New York State Department of Health and Care
Plus, LLC, hereinafter referred to as the Business Associate, is effective on April
14, 2003 to December 31, 2004.

68

DOH STATE OF NEW
YORK
    	 

DEPARTMENT OF HEALTH

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

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

Commissioner

	 	Dennis P. Whalen

Executive Deputy Commissioner

November 24, 2004

Evelyn Huang

General Counsel

Care Plus Health Plan

21 Penn Plaza, 360 W. 31st St,
5th Floor New York, NY .10001

Dear. Ms. Huang:

Enclosed is your Child Health Plus contract amendment for Care Plus
Health Plan for the period January 1, 2005 through June 30, 2005.

Please sign and notarize both copies of the enclosed comma
amendment (Appendix X) and sign the Waiver of Interest Payment form as
soon as possible. Please return both amendments and the form to me at:

NYS Child Health Plus
Program ESP, Corning
Tower, Room 1621 Albany,
NY 12237-0004

Please return these documents as soon as possible to avoid any
lapse in payment If you have any questions regarding this matter,
please contact me at (518) 473-0566. Thank you for your continued
support of the Child Health Plus Program.

Sincerely,

Gabrielle L.
Armenia Program
Manager

NYS Child Health Plus Program

69

EnclosuresAPPENDIX X

Agency Code: 12000 Contract Number: 0-015473

Period: July 1, 1998 through
June 30, 2005 Fending Amount
for Period: 8198,606,633

This is an AGREEMENT between THE STATE OF NEW YORK, acting by and through the
Department of Health, having its principal office at Coming Tower.
Empire State Plate. Albany, NY, (hereinafter referred to as the STATE), and
Care Plus Health Plan thereinafter referred to as the CONTRACTOR), for modification
of Contract Number C-015473 as reflected in the attached provisions to Section
1.8.1. of the Agreement and Appendices E and L. and to extend the period
‘litho contract through June 30, 2005.

CONTRACTOR acknowledges that the STATE Is currently developing a replacement
contract document to govern services provided to Child Health Plus enrollees. If
that replacement contract between the CONTRACTOR and the STATE Is in
place prior to Juno 30, 2005, this CONTRACT will be cancelled upon approval of the
replacement contract. Any extension to this CONTRACT beyond dune 30, 2005 must be
done via written amendment approved by the Office of the State Comptroller.

All other provisions of said AGREEMENT shall remain in fall force and effect.

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

	 
	 	 	 	 
	CONTRACTOR SIGNATURE

	 	STATE AGENCY SIGNATURE
	 	

	 
	 	 	 	 
	By:

	 	 	 	By

Judith Arnold Printed Name Printed Name

Title: Deputy Commissioner

Division of Planning, Policy and Resource
Development

Date: Data:

State Agency Certification:

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

STATE OF NEW YORK )

) SS.: County of ._._)

	 	 	 
	On theday ofz0, before me personally appeared

	 	, to me known,
	 

	 	

	who being by me duty sworn, did depose and say that he/she resides at

	 	, that he/she is the

of the the corporation described herein which executed the foregoing
instrument; and that ha/she signed his/her name thereto by order of the board of
directors of said corporation.

	 	 	 
	(Notary)

	 	STATE COMPTROLLER SIGNATURE

‘lids:

Date:

70

STATE OF NEW YORK

AGREEMENT

Section I.U. is revised to read as follows:

I. Conditions of Agreement

B1. This AGREEMENT is extended through June 30, 2005 or until the start data of it
new contract between the STATE and the

CONTRACTOR governing services provided to Child Health Plus enrollees, whichever date
occurs first.

71

APPENDIX E

Financial Information

Section A is revised to read as follows:

A. Can Plus Health Plan shall receive, for the period January 1,
2005 through June 30, 2005, an amount up to, but not to exceed,
IS 250,000 to provide and administer it Child Health Plus program
for uninsured children in the counties identified hi Appendix A-2, Section II,B.1
of this AGREEMENT or as modified by the STATE Payment of this amount is based on
the CONTRACTOR meeting the responsibilities provided in this AGREEMENT.

Additional Premium Information:

The total monthly premium shall be: $110.70

The State share of the total monthly premium shall be $ 110.70 or the total
monthly premium for children in families with gross household income loss
than 160% of the federal poverty level and children who are American
Indians or Alaskan Natives (AI/AN).

Tice State share of the total monthly premium shall be 5 101,70 or the total
monthly premium minus $9 for children in families with gross household income
between 160°rtr and 222% of the federal poverty level with, a
maximum of $27 per month per family. The State share is the total monthly
premium loss $9 for each of the first three children. For additional children,
the State share is the total monthly premium.

The Store share of the total monthly premium shall be $ 95.70 or the total
monthly premium minus $15 for children in families with gross household income
between 223% and 25045 of the federal poverty level with a maximum of $45 per
month per family. The State share is the total monthly premium less $15 for
each of the first three children. For additional children, the State share is
this total monthly premium_

In the absence of an approved premium modification by the Department of Health
and State Insurance Department, the premium above or subsequent premium approved
(whichever is in ease) shall continue as the State’s subsidy through June 30,
2005.

72

Appendix L

Privacy and Confidentiality

	 	 	 
	Section fl b revised as follows:

	 
	 	 
	II.

	 	Effective April 14, 2003, the CONTRACTOR shall comply with the following agreement:

Federal Health Insurance Portability and Accountability Act (HIPAA)

Business Associate Agreement (`Agreement"}

This Business Associate Agreement between the New York Slate Department of Health
and Care Pius Health Plan, hereinafter referred to as the business Associate, is
effective an April 14.2OO3 to June 30. 2005,

	 	 	 
	 	 	S.NEXTAPPENDIX X
	Agency Code: ’WOO

	 	Contract Number: 0.015473

Period: July I,1998 through
June 30, 200S Funding
Amount for Period:
S198,6O6,633

This is an AGREEMENT between THE STATE OF NEW YORK, acting by and through the
Anent of Health, having its principal office at Coming Tower Empire
State Plaza. Albany,, NY (hereinafter referred to as the STATE), and
Care Plus Health Plan (hereinafter referred to as the CONTRACTOR), for modification
of Contract Number 0415473 as reflected in the attached provisions to Section L8.1.
of the Agreement and Appendices E and L, and to extend the period of the contract
through June 30, 2003.

CONTRACTOR acknowledges that the STATE is currently developing a replacement
contract document to govern services provided to Child Health Plus enrollees. If
that replacement contract between the CON’T’RACTOR and the STATE is in place prior
to June 30, 2005, this CONTRACT will be. cancelled upon approval of the replacement
contract. Any extension to this CONTRACT beyond June 30, 2005 must be done via
written amendment approved by the Office of the State Comptroller.

All other provisions of said AGREEMENT shall remain in full force and effect.

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

	 	 	 
	CONTRACTOR SIGNATURE

By:

	 	STATE AGENCY SIGNATURE

By:
	 

	 	 

Printed Name

Judith Arnold Printed Name

Title: Title: Deputy Commissioner

Division of Planning, Policy and Resource
Development

Date: Date: State Agency Certification:

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

	 	 	 	 	 
	STATE OF NEW YORK
	 	 	)	 
	 
	 	) SS.:
	County of New York )
{r}
	 	 	 	 

On the   day of   20  before me personally appeared 
 , to me known, who being by me duly sworn, did depose and say that he/she resides at 
 , that he/she is the     of   , the corporation

described herein which executed the foregoing instrument, and that he/she signed his/her name
thereto by order of the board of directors of said corporation.

Title:

73

STATE OF NEW YORK

AGREEMENT

Section I. B.1 .is
revised to read as follows:
I. Conditions of Agreement

B.1. This AGREEMENT is extended through June 30, 2005 or until the start date of a
new contract between the STATE and the CONTRACTOR governing services provided to
Child Health Plus enrollees, whichever date occurs fast.

74

APPENDIX E

Financial Information

Section A is revised to read as follows:

A. Care Plus Health Plan shall receive, for the period January 1, 2005 through
June 30, 2005, an amount up to, but not to exceed, $15,250,000 to provide and
administer a Child Health Plus program for uninsured children in the counties
identified in Appendix A•2, Section 11.13.1 of this AGREEMENT or as modified by
the STATE. Payment of this amount is based an the CONTRACTOR meeting the
responsibilities provided in this AGREEMENT.

Additional Premium Information

The total monthly premium shell be: $ 110.70

The State share of the total monthly premium shall be $ 11030 or the total
monthly premium for children in families with gross household income less
than 160% of the federal poverty level and children who are American
Indians or Alaskan Natives (AUAN).

The State share of the total monthly premium shall be $ 101.70 or the total
monthly premium minus $9 for children in families with gross household
Income, between i 60% and 222% of the federal poverty level with a maximum of
$27 per month per family. The State share is the total monthly premium less
$9 Oar each of the first three children. For additional children, the State
share is the total monthly premium.

The State share of the total monthly premium shall be $ 95.70 or the total
monthly premium minus $15 for child= in families with gross household income
between 223% and 250% of the federal poverty level with a maximum of $4$    per
month per family. Tice State share Is the total monthly premium less $15 for
each of the first three children. For additional children, the
State share is the total monthly premium.

in the absence of an approved premium modification by the Department of
Health and State Insurance Department, the premium above or subsequent premium
approved (whichever is in effect) shall continue as the State’s subsidy through
June 30, 2005.

	 	 	 
	 	 	S.NEXTAppendix L
	
 
	 	Privacy and Confidentiality
	 
	 	 
	Section I1 is revised as follows:

	 
	 	 
	I1.

	 	Effective April 14, 2003, the CONTRACTOR shall comply with the following agreement

Federal Health Insurance Portability and Accountability Act (HIPAA)

Business Associate Agreement (“Age amen°)

This Business Associate Agreement between the New York State Department of Health
and Cara Plus Health Plan, hereinafter referred to as the Business Associate, is
effective on April 14. 2043 to June 30, 2005,

S.CONT

STATE OF NEW YORK

DEPARTMENT OF HEALTH

Corning Tower

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

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

Dennis P. Whalen

Executive Deputy Commissioner

December 12, 2000

Ms. Karin Ajmani

Executive Director

CarePlus Health Plan

21 Penn Plaza

360 West 31st Street, 5th
Floor New York, NY 10001

Dear Ms. Ajmani:

Enclosed is the Child Health Plus contract extension for the period January 1, 2001 to
December 31, 2001 for CarePlus Health Plan.

In order to extend the contract, a Contract Amendment (Appendix X) is required.
Therefore, we have enclosed two copies of an Appendix X along with the contract extension.

Please sign, notarize and return both copies of the enclosed Contract Amendment
(Appendix X) as soon as possible. Please return both amendments to:

Gabrielle L. Armenia

NYS Child Health Plus Program
NYS Department of Health

Room 1629, ESP, Corning Tower
Albany, NY 12237-0004

Please return these documents as soon as possible to avoid any lapse in payment. If you
have any questions regarding this matter, please contact Gabrielle Armenia at (518) 474-5449.
Thank you for your continued support of the Child Health Plus Program.

S.CONT

Linda Stockman

Associate Director

Division of Planning, Policy and Resource Development

75

CONTRACT AMENDMENT EXTENSION 2001

APPENDIX X

	 	 	 
	Agency Code 12000

Period 7/1/98 — 12/31/01

	 	Contract No. C-015473

Funding Amount for Period $71,556,633

This is an AGREEMENT between THE STATE OF NEW YORK, acting by and through the
Department of Health, having its principal office at Corning Tower, Empire
State Plaza, Albany, NY, (hereinafter referred to as the STATE), and CarePlus Health Plan
(hereinafter referred to as the CONTRACTOR), for modification of Contract Number C-015473 as
provided in attached revisions to Section I.B. of the Agreement, and Appendi(x)(ces) A-2, D,E,F
and K to extend the period of the contract through December 31, 2001 subject to the enactment of
legislation by the New York State Legislature extending certain provisions of Chapter 2 of the
Laws of 1998.

All other provisions of said AGREEMENT shall remain in full force and effect.

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

	 	 	 
	CONTRACTOR SIGNATURE

	 	STATE AGENCY SIGNATURE
	 
	 	 
	By: /s/ K Ajmani

	 	By:
	 

	 	 
	 
	 	 
	Karin Ajmani

	 	Judith Arnold
	 

	 	 
	Printed Name

	 	Printed Name
	 
	 	 
	Title: Executive Director

	 	Title: Deputy Commissioner
	 

	 	

	
 
	 	Division of Planning, Policy, and Resource Development
	 
	 	 
	Date: 12/13/2000

	 	Date:
	 

	 	 

	 	 	 	State Agency Certification:

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

	 	 	 	 	 
	STATE OF NEW YORK
	 	 	)	 
	 
	 	) SS.:
	County of New York )
{r}
	 	 	 	 

On the 13th  day of  December  2000 before me personally
appeared  Karin Ajmani ,to me known, who being by me duly sworn, did
depose and say that he/she resides at  New York, NY , 

that he/she is the  Executive Director  of  Care Plus Health Plan  ,
the corporation

described herein which executed the foregoing instrument, and that he/she signed his/her name
thereto by order of the board of directors of said corporation.

Evelyn Huang

Notary Public State of New York

No. 31-6001118

Qualified in New York County

Commission Expires 3-6-2002

Title:

76

STATE OF NEW YORK

AGREEMENT

Section I.B.1. is revised to read as follows: I.
Conditions of Agreement

B. 1. This AGREEMENT is extended through December 31, 2001, subject to the enactment of legislation
by the New York State Legislature extending certain provisions of Chapter 2 of the Laws of 1998
governing the Child Health Plus Program.

APPENDIX A-2

Program Specific Clauses

Section I. Q is added to read as follows:
Section I. DEFINITIONS

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

Section II.B.3. is revised to read as follows:
Section II. PAYMENT TO CONTRACTOR B.
Terms

3. Any modifications to existing or new subcontract arrangements to perform activities relative to
service provided under this AGREEMENT must be submitted in writing and approved by the STATE
before they may implemented. The CONTRACTOR agrees not to enter into any agreements with third
party organizations for the performance of its obligations, in whole or in part, under this
AGREEMENT without the STATE’s prior written approval of such third parties and the scope of the
work to be performed by them. The STATE’s approval of the scope of work and the subcontractor does
not relieve the CONTRACTOR of its obligation to perform fully under this contract. The
responsibilities of the CONTRACTOR and any subcontractors will be limited to those specified in
the subcontracts.

All subcontracts entered into by the CONTRACTOR to provide program services for Child
Health Plus under this AGREEMENT shall contain provisions specifying: that the work performed by
the subcontractor must be in accordance with the terms of this AGREEMENT;

1. that nothing contained in such AGREEMENT shall impair the rights of
the STATE; and

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

A current and final copy of each subcontract must be submitted to and approved by the
CONTRACTOR’S Child Health Plus Contract Manager at the New York State Department of Health.

Section III.E.3 and 4 are revised to read as follows: Section
III. CONTRACTOR’S RESPONSIBILITIES E. Premium
Determination and Payment

3. Premiums set forth in Appendix E shall be in effect at least through December 31, 2001.
Subscribers shall be responsible for payment of the family premium contribution to the CONTRACTOR
and shall be responsible for copayments as set forth in the Benefit contract and consistent with
subsequent STATE and FEDERAL legislation, regulations, guidelines, policy and/or Advisory
Memoranda. Effective January 1, 1999, all copayments are eliminated and any provisions regarding
copayments will no longer have any force and effect.

4. Premiums may be modified periodically under the Child Health Plus program subject to
approval of a request from the CONTRACTOR through the New York State Department of Health and the
State Insurance Department. Applications for adjustments must be submitted at least 90 days prior
to the requested effective date of the change and will be subject to approval by the New York
State Department of Health and the State Insurance Department. Payment shall be adjusted to cover
any premium modifications approved by the New York State Department of Health and the State
Insurance Department. In the absence of an approved premium modification by the Department of
Health and the State Insurance Department, the premium contained herein or any subsequent premium
(whichever is in effect) shall continue as the premium for the STATE’S subsidy through the
duration of the contract. The New York State Department of Health maintains the right to eliminate
an insurer from the Child Health Plus program if agreement on the premium cannot be reached.

Section III.E.10 is added to read as follows:

10. Pursuant to PHL section 2510(9)( c )(i), as amended by section 61 of Chapter 419 of the
Laws of 2000, the CONTRACTOR is required to exempt eligible American Indian and Alaskan Native
(AI/AN) children from the family contributions required in the Child Health Plus program. To
determine eligibility for this cost sharing exemption, CONTRACTOR is required to collect at least
one of the following documents:

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

	 	•	 	Documentation of roll or band number.

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

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

	 	•	 	A birth certificate indicating heritage.

Section III. G. 14 is added to read as follows: G.
Evaluation and Data Submittal The CONTRACTOR SHALL:

14. Quality Assurance Report — Plans must provide quality performance data which is
consistent with the New York State Department of Health Quality Assurance Reporting
Requirements (QARR) data specifications, on an annual basis for the Child Health Plus
population. Some of the general QARR data categories which are required to be collected
include membership, utilization, quality, access, member satisfaction and general plan
management.

Plans must provide audited quality performance data which is consistent with the New
York State Department of Health Quality Assurance Reporting Requirements (QARR) data
specifications, on an annual basis for the Child Health Plus population. Plans must contract
with a National Committee on Quality Assurance (NCQA) certified auditor for a full audit of
the QARR data. The audited data must be submitted to the Department of Health on the date
established by the New York State Department of Health Office of Managed Care. Section
III.H.2. is revised to read as follows:

H. Presumptive and Temporary Enrollment

2. Subject to the availability of federal financial participation (FFP) under Title XXI of the
Social Security Act, any child under age 19 whose family’s net household income does not exceed
208% of the non-farm federal poverty level or the gross equivalent of such net income shall be
presumed temporarily eligible for Child Health Plus coverage (hereinafter referred to as
“temporary enrollment”).

The eligibility period for temporary enrollment shall continue until the earlier of the date a
Medicaid or Child Health Plus eligibility determination is made or two (2) months after such
eligibility period begins. If a child is determined to not be eligible for Medicaid prior to the
last day of the two (2) month temporary enrollment period, such child may continue to be
presumptively enrolled in Child Health Plus as described in subparagraph 1 above until the earlier
of the date a Child Health Plus eligibility determination is made or the last day of the two (2)
month presumptive eligibility period. Temporary enrollment shall be granted to an enrollee only
once in a twelve-month period. A temporary enrollment period may be extended in the event a
Medicaid eligibility determination is not made within the two (2) month period through no fault of
the applicant, as long as all the required documentation has been submitted within the two (2)
month period. The CONTRACTOR or facilitator will be required by the STATE to collect documentation
of a pending Medicaid application. Subsequent to the two (2) month period, it is the responsibility
of the CONTRACTOR or facilitator, depending on with whom the family applied, to follow up on the
status of the applicant’s Medicaid application with the appropriate local district of social
services (LDSS) office on a monthly basis, commencing on or about the 120th day following the
completion of the Child Health Plus application. If the child is determined to be ineligible for
Medicaid, the CONTRACTOR will be required by the STATE to collect documentation of such denial. In
no case will the temporary enrollment period be extended beyond a twelve-month period.

A child enrolled in Child Health Plus who screens as Medicaid eligible upon recertification in
Child Health Plus may continue to be eligible for Child Health Plus under this subparagraph 2
until a Medicaid determination is made, provided all required documentation is collected and the
Medicaid application has been submitted to the appropriate LDSS.

This subparagraph 2 shall have no force and effect and temporary enrollment under this subparagraph
2 shall not be available on and after the date presumptive eligibility in Medicaid becomes
effective and is available pursuant to the Social Services Law. Once presumptive eligibility in
Medicaid is effective, a child who screens as Medicaid eligible at initial enrollment and/or
recertification in Child Health Plus may not be temporarily enrolled in Child Health Plus and the
CONTRACTOR will be required by the STATE to collect documentation of a Medicaid denial or
disenrollment in order to presumptively enroll a child in Child Health Plus.

APPENDIX D

SCHEDULE OF DELIVERABLES

Expiration

of authorized funding

First day following end of authorized funding

Three months following

end of contract

Two years following the end of contract

Conclusion of insurance coverage for enrollees unless continuation of the Child Health Plus
program is approved by the New York State Legislature.

Initiate conversion coverage as stipulated in the request for applications,
application/workplan and benefit contract.

Final report due from the CONTRACTOR

Data relating to the Child Health Plus program shall be maintained and retained by the CONTRACTOR
until this date. Enrollee specific data for disenrolled children shall be retained for six years
from the date of disenrollment or two years following termination of the program, whichever is
shorter.

APPENDIX F

PAYMENT AND REPORTING SCHEDULES

Section I.E. is revised to read as follows:

I. Payment and Reporting Terms and Conditions

E. The CONTRACTOR will provide the STATE with the reports of progress or other specific work
products pursuant to this AGREEMENT as described in this Appendix F, below. In addition, a final
report must be submitted by the CONTRACTOR no later than three months following end of contract.
All required reports or other work products developed under this AGREEMENT must be completed as
provided by the agreed upon work schedule in a manner satisfactory and acceptable to the STATE. in
order for the CONTRACTOR to be eligible for payment.

Section II is amended to add a new reporting requirement to read as follows:

II. Reporting Requirements

Quality Assurance Report — A report of quality performance data which is consistent
with the New York State Department of Health Quality Assurance Reporting Requirements (QARR) data
specifications as required by section III. G. 14 of Appendix A-2. This report is due on an annual
basis in the month of June with the exact date to be determined by the Office of Managed Care.

Appendix K

Additional Program Specific Clauses

Section B is revised to read as follows: B.
Premium Contributions

	 	•	 	Effective October 1, 1997, there is no family premium contribution for children whose gross
household income is at or below 150% of the non-farm federal poverty level.

	 	•	 	Effective January 1, 1999, there is no family premium contribution for children whose
gross household income is less than 160% of the non-farm federal poverty level and, effective
August 1, 2000, for children who are American Indians or Alaskan Natives (AI/AN).

	 	•	 	Effective January 1, 1999, the family premium contribution for children whose gross
household income is between 160% — 222% of the non-farm federal poverty level is $9 per
child, with a family maximum of $27 per month.

	 	•	 	Effective January 1, 1999, the family premium contribution for children whose gross
household income is between 223% — 230% of the non-farm federal poverty level is $15 per
child, with a family maximum of $45 per month.

	 	•	 	Effective July 1, 2000, the family premium contribution for children whose gross
household income is between 223% — 250% of the non-farm federal poverty level is $15 per
child, with a family maximum of $45 per month.	 

APPENDIX E

Financial Information

Sections A and B are revised to read as follows:

A. CarePlus Health Plan shall receive, for the period January 1, 2001 through December 31, 2001,
an amount up to, but not to exceed, $30,700,000 to provide and administer a Child Health Plus
program for uninsured children in the counties identified in Appendix A-2, Section II.B.1 of this
AGREEMENT or as modified by the STATE. Payment of this amount is based on the CONTRACTOR meeting
the responsibilities provided in this AGREEMENT.

B. The maximum compensation for the contract term of this AGREEMENT shall not exceed the amount
specified on the fact page hereof; contingent on the availability of funds as enacted by the New
York State Legislature and continued appropriations through the contract term.

Additional Premium Information: For Periods on or after July 1, 2000:

	 	•	 	The total monthly premium shall be: $110.22

	 	•	 	The State share of the total monthly premium shall be
$110.22 or the total monthly premium for children in
families with gross household income less than 160% of the
federal poverty level and children who are American Indians
or Alaskan Natives (AI/AN).

	 	•	 	The State share of the total monthly premium shall be
$101.22 or the total monthly premium minus $9 for children
in families with gross household income between 160% and
222% of the federal poverty level with a maximum of $27 per
month per family. The State share is the total monthly
premium less $9 for each of the first three children. For
additional children, the State share is the total monthly
premium.

	 	•	 	The State share of the total monthly premium shall be $95.22
or the total monthly premium minus $15 for children in
families with gross household income between 223% and 250%
of the federal poverty level with a maximum of $45 per month
per family. The State share is the total monthly premium
less $15 for each of the first three children. For
additional children, the State share is the total monthly
premium.

In the absence of an approved premium modification by the Department of Health and State Insurance
Department, the premium above or subsequent premium approved (whichever is in effect) shall
continue as the State’s subsidy through December 31, 2001. RE: CarePLus Health Plan LLC 1-IMO
Reinsurance Page 5 of 5 — Binder

Until ;txch time as we deem, the above items to be acceptable, we reserve our
right to modify the above renewal binder.

The Undersigned, an authorized representative of CarePlus Health Plan, LLC

	 	1.	 	acknowledges that he/she has read this binder in its entirety and
understand the terms and conditions set forth in this binder.	 

2. accepts and agrees to all of the terms and conditions set forth in this binder; and

	 	3.	 	acknowledges that thin; binder, together with the Application and
Policy, constitute the entire agreement between the Underwriter
and CarePlus Health Plan, LLC concerning the tams and conditions under which
coverage will be provided.	 

This binder is expressly conditioned on the Underwriter’s receipt of this binder, properly
executed by an authorized representative of CarePlus Health Plan, LLC. In the event that the
Underwriter does not receive this binder properly executed on behalf of CarePlus Health
Plan, LLC, this binder will be void ab initio.

	 	 	 
	/s/ Tracy M. Gregg

	 	/s/ K Ajmani
	 

	 	 
	 
	 	 
	Senior — Underwriter

	 	Executive Director
	 

	 	 
	Title

	 	Title

77

January 6, 2003 Refer to:

Deborah A. Kozemko, JD Supervising
Insurance Attorney

Evelyn Huang

General Counsel

CarePlus Health Plan

360 West 31st Street, 5th
Floor New York, NY 10001

Re: Child Health Plus

Amendment — Hospice Services File: 2003012501

Dear Ms. Huang:

The Amendment submitted under your letter dated December 31, 2002 is approved as of this
date.

A stamped copy is attached for your records.

Very truly yours,

Thomas C. Zyra Co-Chief, Health
Bureau

DAKlrcw

cc: Mr. Endryck (DOH) Enclosure

78

Amendment to the Child Health Plus subscriber
contact Addition to page 15- Other Cover Services Add
Section 8 — Hospice Services

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

Family members are eligible for up to five visits for bereavement counseling.

APPROVED

State of New York

JAN O 3 2002

79

Gregory V. Sevio

Superintended of Insurance

APPENDIX A

STANDARD CLAUSES FOR ALL

NEW YORK STATE 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 Artlde 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 $10,000 (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.

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

5. NON-DISCRIMINATION REOUIREMENTS. In accordance with 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, age, disability 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 nor its subcontractors shall, by reason of race, creed, color, disability, sex, or
national origin: (a) discriminate in hiring against any New York State citizen who is qualified and
available to perform the work; or (b) discriminate against or intimidate any employee hired for the
performance of work under this contract. If this is a building service contract as defined in
Section 230 of the Labor Law, then, in accordance with Section 239 thereof, Contractor agrees that
neither it nor its subcontractors shall, by reason of race, creed, color, national origin, age, sex
or disability: (a) discriminate in hiring against any New York State citizen who is qualified and
available to perform the work; or (b) discriminate against or intimidate any employee hired for the
performance of work under this contract. Contractor is subject to fines of $50.00 per person per
day for any violation of Section 220-e or Section 239 as well as possible termination of this
contract and forfeiture of all moneys due hereunder for a second or subsequent violation.

6. WAGE AND HOURS PROVISIONS. if this is a public work contract covered by Artide 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 REQUIREMENT. 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

1.

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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 BOYCQTT 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 fire (5) business days of such conviction,
determination or disposition of appeal (2NYCRR 105.4).

9. SET-OFF RIGHTS. The State shall have all of its common law, equitable and statutory
rights of set-off. These rights shall include, but not be limited to, the State’s option to
withhold for the purposes of set-off any moneys due to the Contractor under this contract up to any
amounts due and owing to the State with regard to this contract, any other contract with any State
department or agency, including any contract for a term commencing prior to the term of this
contract, plus any amounts due and owing to the State for any other reason including, without
limitation, tax delinquencies, fee delinquendes 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 sbt (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 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 indude 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 prindpal 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.

81

(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 State Accounts, Office of the State Comptroller, AESOB, Albany, New York 12236.

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

(a) The Contractor will not discriminate against employees or applicants for employment because of
race, creed, color, national origin, sex, age, disability or marital status, and will undertake or
continue existing programs of affirmative action to ensure that minority group members and women
are afforded equal employment opportunities without discrimination. Affirmative action shall mean
recruitment, employment, job assignment, promotion, upgradings, demotion, transfer, layoff, or
termination and rates of pay or other forms of compensation;

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

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

Contractor will indude 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 Oil) banking services,
insurance policies or the sale of securities. The State shall consider compliance by a contractor
or subcontractor with the requirements of any federal law concerning equal employment opportunity
which effectuates the purpose of this section. The contracting agency shall determine whether the
imposition of the requirements of the provisions hereof duplicate or conflict with any such
federal law and if such duplication or conflict exists, the contracting agency shall waive the
applicability of Section 312 to the extent of such duplication or conflict. Contractor will comply
with all duly promulgated and lawful rules and regulations of the Governor’s Office of Minority
and Women’s Business Development pertaining hereto.

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

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

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

82

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 BE Rules (“CPLR”), Contractor hereby consents to service of process upon it by
registered or certified mail, return receipt requested. Service hereunder shall be complete upon
Contractor’s actual receipt of process or upon the State’s receipt of the return thereof by the
United States Postal Service as refused or undeliverable. Contractor must promptly notify the
State, in writing, of each and every change of address to which service of process can be made.
Service by the State to the last known address shall be sufficient. Contractor will have thirty
(30) calendar days after service hereunder is complete in which to respond.

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 5165. (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

One Commerce Plaza

Albany, New York 12245

Phone: (518) 474-7756 Fax: (518) 486-7577

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

NYS Department of Economic Development

Minority and Women’s Business Development
Div. One Commerce Plaza

Albany, New York 12245

Phone: (518) 473-0582 Fax: (518) 473-0665

certify that whenever the total bid amount is greater than $1 million:

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

(b) The Contractor has complied with the Federal Equal Opportunity Act of 1972 (P.1. 92-261), as
amended;

(c) The Contractor agrees to make reasonable efforts to provide notification to New York State
residents of employment opportunities on this project through listing any such positions with the
job Service Division of the New York State Department of Labor, or providing such notification in
such manner as is consistent with existing collective bargaining contracts or agreements. The
Contractor agrees to document these efforts and to provide said documentation to the State upon
request; and

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

21. RECIPROCITY AND SANCTIONS PROVISIONS Bidders are hereby notified that if their
principal place of business is located in a state 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 amendments (Chapter 684, Laws of 1994) require that they be denied
contracts which they would otherwise obtain. (Contact the NYS Division for Small Business at (518)
474-7756 for a current list of States subject to this provision.)

Revised December, 1996

83

APPENDIX E

FINANCIAL INFORMATION

CarePlus Health Plan shall receive, for the period effective the date of this contract
through December 31, 1998, an amount up to, but not to exceed, the sum of $1,367,313
to provide and administer a Child Health Plus program for uninsured children in the
counties identified in Appendix A-2, Section II B 1 of this AGREEMENT or as modified
by the STATE. Premiums may be modified periodically under the Child Health Plus
program subject to approval of a request from the CONTRACTOR through the New York
State Department of Health and the State Insurance Department. In the absence of an
approved premium modification by the New York State Department of Health and the State
Insurance Department, the premium contained herein or any subsequent premium
(whichever is in effect), shall continue as the premium for the STATE’s subsidy
through December 31, 1999:. Payment of this amount is based on the CONTRACTOR meeting
the responsibilities provided in this AGREEMENT.

CarePlus Health Plan shall receive, for the period of January 1, 1999 through
December 31, 1999, an amount up to, but not to exceed, the sum of $11,789,320 to
provide and administer a Child Health Plus program for uninsured children in the
counties identified in Appendix A-2, Section II B 1 of this AGREEMENT or as modified
by the STATE. Payment of this amount is based on the CONTRACTOR meeting the
responsibilities provided in this AGREEMENT.

	 	 	 	 	 
	Premium Information:

	 	•	 	The total monthly premium for Kings, Queens and Richmond counties shall be: $89.56.	 

• The State Share of the total monthly premium shall be $89.56 or the total
monthly premium for children in families with gross household income equal to or less
than 150% of the federal poverty level.

• The State Share of the total monthly premium shall be $80.46 or the total
monthly premium minus $9 for children in families with gross household income between
151 and 159% of the federal poverty level.

• The State Share of the total monthly premium shall be $ 76.56 or the total
monthly premium minus $13 for children in families      with gross household income between
160 and 222% of the federal poverty level.

•

84

85

The following Appendix L is added:

Appendix L

Privacy and Confidentiality

I. The CONTRACTOR shall comply with all applicable Federal and State laws, including the Health
Insurance Portability and Accountability Act (HIPAA) regarding the confidentiality and disclosure
of information about enrollees. This includes individual medical records and any other health and
enrollment information that identifies a particular enrollee.

The Contractor must comply with the following:

	 	1.	 	In accordance with 42 CFR Part 431, subpart F, the CONTRACTOR is prohibited
from disclosing information concerning applicants and enrollees unless such disclosure
is directly connected with the administration of the program, including (a)
establishing eligibility, (b) determining the level of family contribution based on the
household’s income and the applicable Federal Poverty Level (FPL); (c) providing
services for enrollees; and (d) investigation or prosecution related to administration
of the program;

2. The CONTRACTOR must maintain information in a timely and accurate manner;

3. The CONTRACTOR must specify and make available to any enrollee requesting it (a) the
purpose for which information is maintained or used, and (b) to whom and for what purposes
information will be disclosed outside the State; and

4. Except as provided in Federal and State law, the CONTRACTOR must ensure that each
enrollee may request a copy of his or her records/information and receive such
records/information in a timely manner and that an enrollee may request that his or her
records/information be supplemented or corrected.

II. Effective April 14, 2003, the CONTRACTOR shall comply with the following
agreement:

Federal Health Insurance Portability and Accountability Act (HIPAA)

Business Associate Agreement (“Agreement”)

This Business Associate Agreement between the New York State Department of Health and
CarePlus Health Plan, hereinafter referred to as the Business Associate, is effective on
April 14 2003 to December 31. 2003.

86

I. Definitions: The terms used, but not otherwise defined, in this agreement shall
have the same meaning as those terms in the federal Health Insurance Portability and
Accountability Act of 1996 ("HIPAA”) and its implementing regulations, including those
at 45 CFR Parts 160 and 164.

II. Obligations and Activities of CarePlus Health Plan, the Business Associate:

	 	(a)	 	The Business Associate agrees to not use or further disclose Protected Health
Information other than as permitted or required by this Agreement or as required by
law.	 

	 	(b)	 	The Business Associate agrees to use the appropriate safeguards to prevent use or
disclosure of the Protected Health Information other than as provided for by this
Agreement.	 

	 	(c)	 	The Business Associate agrees to mitigate, to the extent practicable, any harmful
effect that is known to the Business Associate of a use or disclosure of Protected Health
Information by the Business Associate in violation of the requirements of this Agreement.

	 	(d)	 	The Business Associate agrees to report to the Covered Program, any use or disclosure
of the Protected Health Information not provided for by this Agreement, as soon as
reasonably practicable of which it becomes aware.

	 	(e)	 	The Business Associate agrees to ensure that any agent, including a subcontractor,
to whom it provides Protected Health Information received from, or created or received
by the Business Associate on behalf of the Covered Program agrees to the same
restrictions and conditions that apply through this Agreement to the Business Associate
with respect to such information.	 

The Covered Program does not routinely receive PHI, therefore The Business Associate, agrees to
directly implement on behalf of the Covered Program, the HIPAA Privacy authorization requirements
(45 CFR 164.508), verifications requirements (45 CFR 164.514 (h)), and individual rights under 45
CFR part 160 and 164 including:

	 	i.	 	Responding to request for restrictions to use and disclosures of PHI, other than those
that would constrain the CHP B program access for purposes of handling complaints or
conducting audits, and adhering to any agreed upon restrictions to meet the requirements
of 45 CFR 164.522 (a)	 

	 	ii.	 	Respond to requests and accommodate reasonable requests for confidential
communications to meet the requirements of 45CFR 164.522(b).	 

	 	iii.	 	Providing access to Protected Health Information in a Designated Record Set, to an
Individual in order to meet the requirements under 45 CFR 164.524, if the business associate
has protected health information in a designated record set.

	 	iv.	 	Making any amendment(s) to Protected Health Information or appending
the necessary information pursuant to an amendment request in a designated record
set at the request of an Individual, if the business associate has protected health
information in a designated record set.

	 	v.	 	Documenting such disclosures of Protected Health Information and
information related to such disclosures as would be required to respond to a
request by an Individual for an accounting of disclosures of Protected Health
Information in accordance with 45 CFR 164.528.	 

	 	vi.	 	Providing to the Individual information collected in accordance with
this Agreement, to respond to a request by an Individual for an accounting of
disclosures of Protected Health Information in accordance with 45 CFR 164.528.	 

	 	 	 	(g) The Business Associate agrees, to maintain and retain
the necessary documentation for the processes listed in (f) including policies and
procedures and communications that are provided in writing or required to be documented
for a minimum of six (6) years.

	 	(h)	 	The Business Associate agrees to make internal practices, books, and records relating
to the use and disclosure of Protected Health Information received from, or created or
received by the Business Associate on behalf of, the Covered Program available to the
Covered Program, or to the Secretary of Health and Human Services, in a time and manner
designated by the Covered Program or the Secretary, for purposes of the Secretary
determining the Covered Program’s compliance with the Privacy Rule.

	 	III.	 	Permitted Uses and Disclosures by Business
Associate (a) General Use and Disclosure Provisions	 

Except as otherwise limited in this Agreement, the Business Associate may use or
disclose Protected Health Information to perform functions, activities, or services
for, or on behalf of, the Covered Program as specified in the agreement to which
this is an addendum, provided that such use or disclosure would not violate the
Privacy Rule if done by Covered Program.

(b) Specific Use and Disclosure Provisions:

	 	(1)	 	Except as otherwise limited in this Agreement, the Business Associate
may disclose Protected Health Information for the proper management and
administration of the Business Associate, provided that disclosures are required
by law, or Business Associate obtains reasonable assurances from the person to
whom the information is disclosed that it will remain confidential and used or
further disclosed only as required by law or for the purpose for which it was
disclosed to the person, and the person notifies the Business Associate of any
instances of which it is aware in which the confidentiality of the information has
been breached.	 

	 	(2)	 	Except as otherwise limited in this Agreement, Business Associate may
use Protected Health Information to provide Data Aggregation services to Covered
Program as permitted by 42 CFR 164.504(e)(2)(i)(B). Data Aggregation includes the
combining of protected information created or received by a business associate
through its activities under this contract with other information gained from
other sources.

N. Obligations of Covered Program

Provisions for the Covered Program to Inform the Business Associate of Privacy Practices

	 	(a)	 	The Covered Program shall notify the Business Associate of any limitation(s)
in its notice of privacy practices of the Covered Program in accordance with 45 CFR
164.520, to the extent that such limitation may affect the Business Associate’s use
or disclosure of Protected Health Information.	 

V. Permissible Requests by Covered Program

The Covered Program shall not request the Business Associate to use or disclose Protected
Health Information in any manner that would not be permissible under the Privacy Rule if done
by Covered Program, except if the Business Associate will use or disclose protected health
information for, and the ‘contract includes provisions for, data aggregation or management
and administrative activities of Business Associate.

VI. Term and Termination

	 	(a)	 	Term. The Term of this Agreement shall be effective as of the date noted in this
Appendix L of this agreement, at the end of which time all of the Protected Health
Information provided by Covered Program to Business Associate, or created or received by
Business Associate on behalf of Covered Program, shall be retained by the Business
Associate for a minimum of six (6) years.

	 	(b)	 	Termination for Cause. Upon the Covered Program’s knowledge of a material breach by
Business Associate, Covered Program may provide an opportunity for the Business Associate
to cure the breach or end the violation and may terminate this Agreement if the Business
Associate does not cure the breach or end the violation within the time specified by
Covered Program, or may immediately terminate this Agreement if the Business Associate
has breached a material term of this Agreement and cure is not possible.

(c) Effect of Termination.

	 	(1)	 	As noted in section VI above, upon termination of this Agreement, for any
reason, the Business Associate shall retain all Protected Health Information
received from the Covered Program, or created or received by the Business Associate
on behalf of the Covered Program for a minimum of six (6) years. This provision
shall apply to Protected Health Information that is in the possession of
subcontractors or agents of the Business Associate.

VII. Violations

	 	(a)	 	It is further agreed that any violation of this agreement may cause irreparable harm
to the STATE, therefore the STATE may seek any other remedy, including an injunction or
specific performance for such harm, without bond, security or necessity of demonstrating
actual damages.

	 	(b)	 	The business associate shall indemnify and hold the STATE harmless against all
claims and costs resulting from acts/omissions of the business associate in connection
with the business associate’s obligations under this agreement.

Miscellaneous

	 	(a)	 	Regulatory References. A reference in this Agreement to a section in the HIPAA
Privacy Rule means the section as in effect or as amended, and for which compliance is
required.	 

	 	(b)	 	Amendment. The Parties agree to take such action as is necessary to amend this
Agreement from time to time as is necessary for Covered Program to comply with the
requirements of the Privacy Rule and the Health Insurance Portability and Accountability
Act, Public Law 104-191.

	 	(c)	 	Survival. The respective rights and obligations of the Business Associate under
Section VI (c) of this Agreement shall survive the termination of this Agreement.	 

	 	(d)	 	Interpretation. Any ambiguity in this Agreement shall be resolved in favor of a
meaning that permits the Covered Program to comply with the HIPAA Privacy Rule.	 

	 	(e)	 	If anything in this agreement conflicts with a provision of any other agreement on
this matter, this agreement is controlling.

	 	(f)	 	HIV/AIDS. If HIV/AIDS information is to be disclosed under this agreement, the
business associate acknowledges that it has been informed of the confidentiality
requirements of Public Health Law Article 27-F.	 

	 	(g)	 	Nothing in this Agreement shall prohibit the Business Associate from using and
disclosing PHI in its capacity as a Covered Entity, provided such use and disclosure is
fully compliant with the Privacy Rule.

/s/Judith Arnold  /s/ K Ajmani

	 	 	 	Signature of covered program Signature of the business associate

Date:  4/14/03 Date:  3/28/03

87

APPENDIX I

FEDERAL AUDIT REQUIREMENTS

I. Administrative Rules and Audits:

	 	a.	 	If this contract is funded in whole or in part from federal funds, the
CONTRACTOR shall comply with the following federal grant requirements regarding
administration, allowable costs and audits.	 

	 	•	 	For a local or Indian tribal government, use the principles in the common
rule, `“Uniform Administrative Requirements for Grants and Cooperative
Agreements to State and Local Governments," Office of Management and
Budget (OMB) Circular A-87, “Cost Principles for State and Local Governments”
and OMB Circular A-128, “Audits of State and Local Governments.”

	 	•	 	For a private nonprofit organization other than
n an institution of higher education,
n a hospital, or

	 	 	 	n an organization named in OMB Circular A-122 as not subject to that
circular,	 

use the principles in OMB Circular A-110, “Uniform Administrative
Requirements for Grants and Other Agreements with Institutions of Higher
Education, Hospitals and Other Nonprofit Organizations,” OMB Circular A-122,
“Cost Principles for Nonprofit Organizations” and OMB Circular A-133,
“Audits of Institutions of Higher Education and Other Non-Profit
Institutions.”

	 	•	 	For an Educational Institution, use the principles in OMB Circular A-110, OMB
Circular A-21, “Cost Principles for Educational Institutions” and OMB Circular
A-133.

	 	•	 	For a hospital, use the principles in OMB Circular A-110, Department of
Health and Human Services, 45 CFR 74, Appendix E, “Principles for Determining
Cost Applicable to Research and Development Under Grants and Contracts with
Hospitals” and, if not covered by OMB Circulars A-128 or A-I33 for audit
purposes, then subject to program specific audit requirements following
Government Auditing Standards for financial audits.

	 	•	 	

88

b. If this contract is funded entirely from other than federal
funds and if the CONTRACTOR receives $100,000 or more in total annual payments from
the STATE, the CONTRACTOR shall submit to the STATE after the end of the
CONTRACTOR‘s fiscal year an audit report. The audit report shall be
submitted to the STATE within thirty days after its completion but no later than
thirteen months after the end of the audit period. The audit report shall summarize
the business and financial transactions of the CONTRACTOR. The report shall be
prepared and certified by an independent accounting firm or other accounting entity
which is demonstrably independent of the administration of the program being audited.
Audits performed of the CONTRACTOR’s records shall be conducted in accordance with
Government Auditing Standards issued by the Comptroller General of the United States
covering financial audits. This audit requirement may be met through entity-wide
audits, coincident with the CONTRACTOR’s fiscal year, as described in Office of
Management and Budget Circulars A-128 or A-133. Reports, disclosures, comments and
opinions required under these publications should be so noted in the audit report.

	 	c.	 	“For Profit” entities shall use program specific audit requirements for
following , government auditing standards. (GAGAS).

	 	2.	 	The CONTRACTOR will accept responsibility for compensating the STATE for any exceptions
which are revealed on an audit and sustained after completion of the normal audit
procedure.	 

	 	3.	 	FEDERAL CERTIFICATIONS: This section shall be applicable to this AGREEMENT only if any of
the funds made available to the CONTRACTOR under this AGREEMENT are federal funds.

a. LOBBYING CERTIFICATION

	 	1.	 	If the CONTRACTOR is a tax-exempt organization under Section
501 (c)(4) of the Internal Revenue Code, the CONTRACTOR certifies that it
will not engage in lobbying activities of any kind regardless of how funded.	 

	 	2.	 	The CONTRACTOR acknowledges that as a recipient of federal
appropriated funds, it is subject to the limitations on the use of such funds
to influence certain Federal contracting and financial transactions, as
specified in Public Law 101-121, section 319, and codified in section 1352 of
Title 31 of the United States Code. In accordance with P.L. 101-121, section
319, 31 U.S.C. 1352 and implementing regulations, the CONTRACTOR affirmatively
acknowledges and represents that it is prohibited and shall refrain from using
Federal funds received under this AGREEMENT for the purposes of lobbying;
provided, however, that such prohibition does not apply in the case of a
payment of reasonable

1.

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compensation made to an officer or employee of the CONTRACTOR to the
extent that the payment is for agency and legislative liaison activities not directly
related to the awarding of any Federal contract, the making of any Federal grant or 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.
Nor does such prohibition prohibit any reasonable payment to a person in connection with,
or any payment of reasonable compensation to an officer or employee of the CONTRACTOR if
the payment is for professional or technical services rendered directly in the
preparation, submission or negotiation of any bid, proposal, or application for a Federal
contract, grant, loan, or cooperative agreement, or an extension, continuation, renewal,
amendment, or modification thereof, or for meeting requirements imposed by or pursuant to
law as a condition for receiving that Federal contract, grant, loan or cooperative
agreement.

	 	3.	 	This section shall be applicable to this AGREEMENT only if federal funds
allotted exceed $100,000.	 

The CONTRACTOR:

a) Certifies, to the best of his or her knowledge and belief, that:

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

	 	 	 	 ̈ If any funds other than federal appropriated funds have been paid or will
be paid to any person for influencing or attempting to influence an officer
or employee of any agency, a Member of Congress, an officer or employee of
Congress, or an employee of a Member of Congress in connection with this
federal contract, grant, loan, or cooperative agreement, the CONTRACTOR
shall complete and submit Standard Form-LLL, “Disclosure Form to Report
Lobbying” in accordance with its instructions.

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	 	 	 	 ̈ The CONTRACTOR shall require that the language of this
certification be included in the award documents for all subawards at all
tiers (including subcontracts, subgrants, and contracts under grants, loans
and cooperative agreements) and that all subrecipients shall certify and
disclose accordingly. This certification is a material representation of
fact upon which reliance was placed when this transaction was made or
entered into. Submission of this certification is a prerequisite for making
or entering into this transaction imposed by section 1352, title 31, U.S.
Code. Any person who fails to file the required certification shall be
subject to a civil penalty of not less than $10,000 and not more than
$100,000 for each such failure.

	 	b)	 	Shall disclose specified information on any agreement with lobbyists whom the
CONTRACTOR will pay with other Federal appropriated funds by completion and submission
to the STATE of the Federal Standard Form-LLL, “Disclosure Form to Report Lobbying”,
in accordance with its instructions. This form may be obtained by contacting either
the Office of Management and Budget Fax Information Line at (202) 395-9068 or the
Bureau of Accounts Management at (518) 474-1208. Completed forms should be submitted
to the New York State Department of Health, Bureau of Accounts Management, Empire
State Plaza, Corning Tower Building, Room 1315, Albany, 12237-0016.

	 	c)	 	Shall file quarterly updates on the use of lobbyists if material changes
occur, using the same standard disclosure form identified in (b) above to report
such updated information.	 

	 	2.	 	The reporting requirements enumerated in subsection (3) of this paragraph shall not apply to
the CONTRACTOR with respect to:

	 	a)	 	Payments of reasonable compensation made to its regularly employed
officers or employees;	 

	 	b)	 	A request for a receipt of a contract (other than a contract referred to in
clause (c) below), grant, cooperative agreement, subcontract (other than a
subcontract referred to in clause (c) below), or subgrant that does not exceed
$100,000; and	 

	 	c)	 	A request for or receipt of a loan, or a commitment providing for the
United States to insure or guarantee a loan, that does not exceed $150,000,
including a contract or subcontract to carry out	 

a)

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any purpose for which such a loan is made.

	 	b.	 	CERTIFICATION REGARDING ENVIRONMENTAL TOBACCO SMOKE: Public Law 103-227,
also known as the Pro-Children Act of 1994 (Act), requires that smoking not be
permitted in any portion of any indoor facility owned or leased or contracted for
by an entity and used routinely or regularly for the provision of health, day care,
early childhood development services. education or library services to children
under the age of 18, if the services are funded by Federal programs either directly
or through State or local governments, by Federal grant, contract, loan, or loan
guarantee. The law also applies to children’s services that are provided in indoor
facilities that are constructed, operated, or maintained with such federal funds.
The law does not apply to children’s services provided in private residences;
portions of facilities used for inpatient drug or alcohol treatment; service
providers whose sole source of applicable Federal funds is Medicare or Medicaid; or
facilities where WIC coupons are redeemed. Failure to comply with the provisions of
the law may result in the imposition of a monetary penalty of up to $1000 for each
violation and/or the imposition of an administrative compliance order on the
responsible entity.	 

By signing this AGREEMENT, the CONTRACTOR certifies that it will comply with the
require thents of the Act and will not allow smoking within any portion of any
indoor facility used for the provision of services for children as defined by the
Act.

The CONTRACTOR agrees that it will require that the language of this
certification be included in any subawards which contain provisions for
children’s services and that all subrecipients shall certify accordingly.

	 	4.	 	The STATE, its employees, representatives and designees, shall have the right at any time
during normal business hours to inspect the sites where services are performed and observe
the services being performed by the CONTRACTOR. The CONTRACTOR shall render all assistance
and cooperation to the STATE in making such inspections. The surveyors shall have the
responsibility for determining contract compliance as well as the quality of service being
rendered.	 

	 	5.	 	The CONTRACTOR will not discriminate in the terms, conditions and privileges of
employment, against any employee, or against any applicant for employment because of
race, creed, color, sex, national origin, age, disability or marital status. The .
CONTRACTOR has an affirmative duty to take prompt, effective, investigative and remedial
action where it has actual or constructive notice of discrimination in the terms,
conditions or privileges of employment against (including harassment of) any of its
employees by any of its other employees, including managerial personnel, based on any of
the factors listed above.	 

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