Document:

Exhibit 4.5

Execution Copy

EXCHANGE AGREEMENT

between

VOTORANTIM CELULOSE E PAPEL S.A.

and

INTERNATIONAL PAPER INVESTMENTS (HOLLAND) B.V.

on

September 19, 2006

EXCHANGE AGREEMENT

          By this EXCHANGE AGREEMENT (this “Agreement”) between, on one side, VOTORANTIM CELULOSE E PAPEL S.A., a company (sociedade por ações) organized under the laws of the Federative Republic of Brazil, with head offices in the City of São Paulo, State of São Paulo, at Al. Santos, 1357, 6th floor, enrolled with the Legal Entities Taxpayers’ Registry (CNPJ/MF) under No. 60.643.228/0001-21, herein represented in accordance with its bylaws (“VCP”), and, on the other side, INTERNATIONAL PAPER INVESTMENTS (HOLLAND) B.V., a company organized under the laws of The Netherlands, with head offices at Rokin 55, 1012 KK, in the city of Amsterdam, enrolled with the Legal Entities Taxpayers’ Registry (CNPJ/MF) under No 05.501.662/0001-69, herein represented in accordance with its corporate documents
(“IP”).

          W I T N E S S E T H:

          WHEREAS, IP and/or its Affiliates is the legal holder and registered owner of an eucalyptus plantation in the Brazilian state of Mato Grosso do Sul (the “Forest”) and other existing assets related to the construction of a pulp mill adjacent to the Forest, which are part of the Chamflora Assets (as defined below);

          WHEREAS, VCP is the legal holder and registered owner of an eucalyptus plantation and an integrated pulp and printing and writing paper plant in the city of Luiz Antônio, State of São Paulo and related assets, including the LA Establishment (as defined below);

          WHEREAS, VCP wishes to own, operate, develop, exploit and further improve the Chamflora Assets and IP wishes to own, operate, develop, exploit and further improve the LA Establishment;

          WHEREAS, in furtherance of the desire expressed in the preceding whereas clause, IP and VCP wish to exchange the Chamflora Assets for the LA Assets (as defined below);

          WHEREAS, as an inducement for IP to agree to this exchange of assets, VCP agrees to segregate the LA Assets into a newly-formed, operational company;

          WHEREAS, as an inducement for VCP to agree to this exchange of assets, IP will transfer certain remaining Chamflora Assets to Chamflora;

          NOW, THEREFORE, in consideration of the foregoing and the mutual covenants and agreements set forth herein, the Parties hereto agree as follows:

ARTICLE 1
 DEFINITIONS

          SECTION 1.01.  Definitions.  (a) The following terms, as used herein, have the following meanings:

          “Affiliate” means, with respect to any Person, any other Person directly or indirectly Controlling, Controlled by, or under common Control with such Person;

          “Agreement” means this Exchange Agreement and the schedules attached hereto;

           “AMCHAM CA” means the Centro de Arbitragem of the Câmara Americana de Comércio, the arbitration chamber of the American Chamber of Commerce;

          “Biotechnology Property Rights” means specific germplasm (eucalyptus and pine), such as commercial clones, test clones, clone banks, commercial plantations from seed, progeny trials and seed production areas, and research practices currently applied specifically to each of the LA Establishment and Chamflora, as the case may be; and know-how pertaining to the manufacturing and production processes and techniques and research and development information for the eucalyptus and pine plantings (commercial and experimental) as they are currently grown in each of the LA Establishment and Chamflora, as the case may be,  plantations as they are currently grown in each of the LA Establishment and Chamflora, as the case may be, proprietary process. It does not include corporate germplasms and research projects which are not exclusive to Chamflora and the LA Establishment; 

          “Brazilian GAAP” means generally accepted accounting principles in Brazil;

          “Business Day” means any day other than a Saturday, Sunday, or other day on which commercial banks in the City of São Paulo, State of São Paulo are authorized by law to close;

          “CADE” means Conselho Administrativo de Defesa Econômica, the Brazilian antitrust authority;

          “Chamflora” means Chamflora - Três Lagoas Agroflorestal Ltda., a company (sociedade limitada) organized under the laws of the Federative Republic of Brazil, with head offices in the City of Três Lagoas, State of Mato Grosso do Sul, at Rodovia MS 395, Km 20, enrolled with the Legal Entities Taxpayers’ Registry (CNPJ/MF) under No. 36.785.418/0001-07;

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          “Chamflora Assets” means the Forest and the Chamflora Related Assets, as described in Schedule 1.01(a) hereto;

          “Chamflora Biotechnology Property Rights” has the meaning set forth in Section 4.15 of this Agreement;

          “Chamflora Financial Statements” has the meaning set forth in Section 4.07 of this Agreement;

          “Chamflora Contracts” means the agreements to be entered into by Chamflora and existing on the Closing Date for the construction of the Project Mill and the acquisition of additional land to develop eucalyptus plantations;

          “Chamflora Operating Systems” has the meaning set forth in Section 4.14 of this Agreement;

          “Chamflora Permits” has the meaning set forth in Section 4.12 of this Agreement;

          “Chamflora Related Assets” means the real estate properties in connection with the Forest, the rights under the Chamflora Contracts, environmental licenses and applications, tax benefit agreements, project designs and engineering, Chamflora Intellectual Property Rights, Chamflora Operating Systems, and Chamflora Biotechnology Rights and all other rights and assets related to the Project Mill, including all real estate property registrations (“matrículas”) and total area, quality and age of trees, and all other existing assets related to the Forest;

          “Chamflora Reorganization” means the steps necessary to transfer to Chamflora the Chamflora Assets in a way that, on or prior to the Closing Date, Chamflora shall be the legal holder and registered owner of the Chamflora Assets;

          “Chamflora’s Quotas” means 100% of the quotas of the capital stock of Chamflora;

          “Claim” has the meaning set forth in Section 9.07 of this Agreement;

          “Closing” has the meaning set forth in Section 3.01 of this Agreement;

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          “Closing Date” has the meaning set forth in Section 3.01 of this Agreement;

          “Confidential Information” has the meaning set forth in Section 7.02 of this Agreement;

          “Control” means, in respect of any Person, the possession, directly or indirectly, of the power to permanently direct or cause the direction of the management and policies of such Person, whether through the ownership of voting securities or by voting agreement, contract or otherwise, and the terms “Controlled” and “Controlling” will be construed accordingly;

          “Environmental Laws” means, as in effect on the date hereof, all laws, rules, regulations, judgments, injunctions, orders or decrees relating to pollution or protection of the environment, including, without limitation, laws relating to the release or threatened release of Waste and Discharge into the indoor or outdoor environment (including, without limitation, ambient air, surface water, groundwater, land, surface and sub-surface strata) or otherwise relating to the manufacture, processing, distribution, use, treatment, storage, release, transport or handling of Waste and Discharge;

          “Environmental Permits” has the meaning set forth in Section 4.18 of this Agreement;

          “Forest” means Chamflora’s eucalyptus plantation in the Brazilian state of Mato Grosso do Sul;

          “Governmental Authority” means any government, governmental entity, regulatory authority, department, commission, board, agency or instrumentality, any recognized stock exchange and any court, arbitrator, tribunal, whether foreign or domestic with jurisdiction over the Parties;

          “Insurance Policies” has the meaning set forth in Section 5.19 of this Agreement;

          “LA Intellectual Property Rights” means, in relation to the LA Establishment all (i) inventions, whether or not patentable, including, without limitation, the paper packaging equipment  and related technology, (ii) copyrights (whether or not registered) and registrations and applications for registration thereof, including all derivative works, moral rights, renewals, extensions, reversions or restorations associated with such copyrights, regardless of the medium of fixation or means of expression; and (iii) computer software, databases, technology, and related information to the maintenance of the activity of the LA Establishment, formulae, algorithms, models, user interfaces, inventions, source codes, object codes, methodologies and all related information;

          “IP” has the meaning set forth in the preamble of this Agreement;

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          “IP Indemnified Parties” has the meaning set forth in Section 9.02 of this Agreement;

          “IP Paper Machine” means a paper machine of approximately 200,000 to 250,000 tonnes per year, adjacent and integrated with the Project Mill, to be built by IP, at IP’s option and cost;

          “LA Assets” means, except as otherwise provided for herein, the assets, rights and obligations pertaining to the LA Establishment, including the eucalyptus plantations, the industrial facilities, together with its fixed and operating assets, the real estate properties in connection therewith, environmental licenses and applications, accounts receivables, accounts payables, inventories of raw materials and inventory in process, finished goods (excluding any branded products), LA Operating Systems,  LA Biotechnology Property Rights and other current assets and current liabilities related to the LA Establishment, but excluding the LA Excluded Assets;

          “LA Biotechnology Property Rights” has the meaning set forth in Section 5.15 of this Agreement;

          “LA Company” means the company to be organized by VCP under the laws of the Federative Republic of Brazil and that, on the Closing Date, shall be the legal holder and registered owner of the LA Assets;

          “LA Company Financial Information” has the meaning set forth in Section 5.07;

          “LA Company Quotas” means 100% of the quotas of the capital stock of the LA Company;

          “LA Distributors” has the meaning set forth in Section 6.07(b) of this Agreement;

          “LA Employees” has the meaning set forth in Section 5.17 of this Agreement;

          “LA Environmental Permits” has the meaning set forth in Section 5.18 of this Agreement;

          “LA Excluded Assets” means (i) the sales representatives/agents of the LA Establishment, (ii) KSR, VCP’s distribution company, (iii) all domestic and international brands, including, but not limited to, the brands “Copimax”, “Printmax”, “Mascote” and “Regatta”, (iv) VCP’s international offices, and (v) the assets that are not to be transferred as described in Section 5.21;

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          “LA Operating Systems” has the meaning set forth in Section 5.14 of this Agreement;

          “LA Permits” has the meaning set forth in Section 5.12 of this Agreement;

          “LA Reorganization” means the steps necessary in order to convey the LA Assets into the LA Company on or prior to the Closing Date;

          “Lien” means any mortgage, lien, pledge, charge, security interest, encumbrance, title defect, objections, rights of first refusal, options or other restriction of any kind, or any other right in favor of or claim by, any third party of whatsoever nature;

          “Losses” has the meaning set forth in Section 9.01 of this Agreement;

          “LA Establishment” means the establishment currently owned by VCP containing the eucalyptus plantation and the integrated pulp and printing and writing paper plant in the city of Luiz Antônio, State of São Paulo and related assets, such as the industrial facilities, including its fixed and operating assets, real estate properties in connection therewith, environmental licenses and applications and other assets further described in Schedule 5.21 attached hereto, as well as the LA Operating Systems, LA Intellectual Property Rights and LA Biotechnology Property Rights;

          “Option Paper Machine” has the meaning set forth in Section 2.04(b) of this Agreement;

          “Paper Machine Agreements” has the meaning set forth in Section 2.04(a) of this Agreement;

          “Paper Machine Notice” has the meaning set forth in Section 2.04(a) of this Agreement;

          “Parties” means VCP and IP; and “Party” means any of them;

          “Person” means an individual, corporation, partnership, limited liability company, association, trust or other entity or organization, including a government or political subdivision or an agency or instrumentality thereof;

          “Project Mill” means a pulp mill to be built in the region of the City of Três Lagoas, in the State of Mato Grosso do Sul, with an annual capacity of approximately 1,000,000 tonnes, pursuant to the existing project, as well as any future assets and rights under agreements related to its construction;

          “Quotas” means Chamflora Quotas and the LA Company Quotas;

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           “Representative” means, with respect to a Person, its respective officers, directors, advisors or representatives;

           “Taxes” means all taxes, charges, fees, levies or other assessments imposed by any taxing authority, including, without limitation, income, gross receipts, sales, use, goods and services, capital transfer, profits, license, withholding, payroll, employment, employer health, social contributions, social security, excise, severance, occupation, property, or other taxes, customs duties, fees, assessments or charges of any kind whatsoever, together with any interest and any penalties, additions to tax or additional amounts, including any amounts payable as a result of the application of monetary correction or any other similar factor imposed by any taxing authority;

           “Tax Returns” means any report, return, document, declaration, schedule, or any other information or filing required to be supplied, including by electronic means or otherwise, to any Governmental Authority or jurisdiction with respect to Taxes including, without limitation, any amendments thereto;

           “US$” means the United States dollar;

           “VCP” means Votorantim Celulose e Papel S.A.;

           “VCP Indemnified Parties” has the meaning set forth in Section 9.01 of this Agreement;

           “Waste and Discharge” means petroleum and petroleum products, by-products or breakdown products, radioactive materials, asbestos-containing materials, and any other chemicals, materials or substances regulated as toxic or hazardous or as pollutant, contaminant, discharge, emission or waste under any applicable Environmental Laws;

ARTICLE 2
 CORPORATE REORGANIZATIONS, EXCHANGE OF Q UOTAS AND OTHER TRANSACTIONS

           SECTION 2.01.  Corporate Reorganizations. As an inducement for IP to exchange the Chamflora Assets for the LA Assets, VCP hereby agrees to carry out a corporate reorganization in order to convey the LA Assets into the newly-formed LA Company until the Closing Date.  IP, in turn, shall carry out a corporate reorganization in order to have only and all of the Chamflora Assets in Chamflora on the Closing Date.

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          SECTION 2.02 Exchange of Quotas.  On the terms and subject to the conditions set forth in this Agreement, IP agrees to exchange with VCP, on the Closing Date, all the title and interest in the Chamflora Quotas, free and clear of any and all Liens, for all the title and interest in the LA Company Quotas, free and clear of any and all Liens, provided that Chamflora shall be the owner of the Chamflora Assets and the LA Company shall be the owner of the LA Assets, pursuant to the terms and conditions of this agreement. 

          SECTION 2.03.  No consideration. The Parties agree that the exchange of Quotas provided in Section 2.02 above will occur without the payment of any consideration from one Party to the other. 

          SECTION 2.04. IP Paper Machine. (a) If IP informs VCP, in writing, within 45 (forty-five) days as of the date hereof, of its decision to build the IP Paper Machine (the “Paper Machine Notice”), including the production capacity and technical specifications thereof, then, as of the date of the Paper Machine Notice: (i) the Slush Pulp Supply Agreement and the Utilities Supply Agreement, separately executed between IP and VCP on the date hereof, shall enter into full force and effect and (ii) the other ancillary agreements, which terms and conditions are attached as exhibits to the Slush Pulp Supply Agreement and the Utilities Supply Agreement shall be executed and shall enter into full force and effect (all such agreements jointly referred to as the “Paper Machine Agreements”). 

          (b) IP shall also have an option to build a second paper machine of 200,000 to 250,000 tonnes per year (the “Option Paper Machine”), also at IP’s option and cost, upon delivery of written notice within 3 (three) years from the Closing Date, provided, however, that IP shall deliver such notice to VCP at least 24 (twenty four) months prior to the start-up date of the Option Paper Machine, unless otherwise agreed by the Parties, that will also be supplied by the Project Mill under similar terms and conditions as those contained in the Paper Machine Agreements. 

          (c) In case IP provides the Paper Machine Notice to VCP regarding its intention to build the IP Paper Machine, then the real estate property described in Schedule 2.04(c) attached hereto, where the IP Paper Machine, the Option Paper Machine and IP offices shall be constructed by IP, and the related access roads, shall not be part of the Chamflora Assets. 

          (d) In case IP fails to provide VCP with the Paper Machine Notice, then VCP shall be released from any obligation related to the IP Paper Machine or to the Option Paper Machine. 

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ARTICLE 3
 CLOSING

          SECTION 3.01.  Closing.  Subject to the terms and conditions set forth herein, the exchange of the Quotas (the “Closing”) shall take place at the offices of Mattos Filho, Veiga Filho, Marrey Jr. e Quiroga, at Alameda Joaquim Eugênio de Lima, 447, in the City of São Paulo, State of São Paulo, immediately after the fulfillment and/or waiver of all conditions to closing set forth in Article 8 below, provided that Closing shall occur, no later than February 1, 2007, unless another date or place is agreed in writing by the Parties (the day on which the Closing occurs shall be for purposes of this Agreement the “Closing Date”).

          SECTION 3.02.  Deliveries at Closing.  At the Closing:

          (a) IP shall deliver, or cause any of its Affiliates to deliver, to VCP, the duly signed Amendment to the Articles of Association of Chamflora providing for the transfer of Chamflora Quotas to VCP;

          (b) VCP shall deliver, or cause any of its Affiliates to deliver, to IP, the duly signed Amendment to the Articles of Association of the LA Company providing for the transfer of the LA Company Quotas to IP;

          (c) IP shall deliver, or cause any of its Affiliates to deliver, to VCP, with respect to Chamflora, each as valid as of the Closing Date, the Clearance Certificate of Federal Taxes and Contributions and the Overdue Taxes Clearance Certificate issued by the Federal Revenue Office (Certidão de Quitação de Tributos e Contribuições Federais e de Dívida Ativa), the Debt Clearance Certificate issued by the National Institute of Social Security (Certidão Negativa de Débito do Instituto Nacional de Seguridade Social - INSS), the Certificate of Good Standing towards the Employment Guarantee Fund (Certidão de Regularidade de Situação do Fundo de Garantia por Tempo de Serviço – FGTS) and the Clearance Certificate from the Office of Attorney General of the National Treasury (Certidão Negativa de Inscrição de
Dívida Ativa da União); 

          (d) VCP shall deliver, or cause any of its Affiliates to deliver, to IP, with respect to the LA Company, each as valid as of the Closing Date, the Clearance Certificate of Federal Taxes and Contributions and the Overdue Taxes Clearance Certificate issued by the Federal Revenue Office (Certidão de Quitação de Tributos e Contribuições Federais e de Dívida Ativa), the Debt Clearance Certificate issued by the National Institute of Social Security (Certidão Negativa de Débito do Instituto Nacional de Seguridade Social - INSS), the Certificate of Good Standing towards the Employment Guarantee Fund (Certidão de Regularidade de Situação do Fundo de Garantia por Tempo de Serviço – FGTS) and the Clearance Certificate from the Office of Attorney General of the National Treasury (Certidão Negativa de Inscrição de
Dívida Ativa da União);

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          (e) IP shall deliver, or cause any of its Affiliates to deliver, to VCP, the resignations (effective as of the Closing Date) of all of the officers of Chamflora;

          (f) VCP shall deliver, or cause any of its Affiliates to deliver, to IP, the resignations (effective as of the Closing Date) of all of the officers of the LA Company;

          (g) VCP shall deliver to LA Company and LA Company shall deliver to VCP duly signed counterparts of the Wet Lap Pulp Supply Agreement (as defined in Section 8.02 below), to which IP hereby expressly consents.

ARTICLE 4
 REPRESENTATIONS AND WARRANTIES WITH RESPECT TO
 CHAMFLORA, THE CHAMFLORA ASSETS AND IP

          IP represents and warrants to VCP that each of the following representations and warranties will be on the Closing Date, true and correct and in full force and effect:

          SECTION 4.01.  Existence and Power.  Chamflora is a company duly organized, validly existing and in good standing under the laws of the Federative Republic of Brazil and has all material corporate powers, governmental licenses, authorizations, permits, consents and approvals required to own the Chamflora Assets.  On the Closing Date, Chamflora will be duly organized, validly existing and in good standing under the laws of the Federative Republic of Brazil and will have all material corporate powers, governmental licenses, authorizations, permits, consents and approvals required to own the Chamflora Assets.

          SECTION 4.02.  Authorization, Binding Effect.  The execution, delivery and performance by IP of this Agreement and the consummation of the transactions contemplated hereby are within IP’s powers.  IP is duly authorized by all necessary corporate action to execute, deliver, perform and consummate the transactions contemplated in this Agreement.  This Agreement constitutes a valid and binding agreement upon IP and is enforceable against IP in accordance with its terms.

          SECTION 4.03.  Governmental Authorization.  The execution, delivery and performance by IP of this Agreement and the consummation of the transactions contemplated hereby require no action, approval, consent or declaration by or in respect of, notice or filing with, any Governmental Authority, agency or official other than the filing with CADE. 

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          SECTION 4.04.  Noncontravention.  The execution, delivery and performance by IP of this Agreement and the consummation of the transactions contemplated herein do not and will not (i) violate the organizational documents or bylaws of IP, (ii) assuming any filing required by the antitrust authorities is properly made, violate any material applicable law, rule, regulation, judgment, injunction, order or decree, (iii) require any consent or other action by any Person, constitute a default, or give rise to any right of termination, cancellation, vesting or acceleration of any right or obligation of IP or Chamflora, or to a loss of any benefit to which Chamflora is entitled under any provision of any law, agreement or other instrument, or (iv) result in the creation or imposition of any Lien on any Chamflora Asset or in the Chamflora Quotas.

          SECTION 4.05.  Capital Stock and Ownership of Shares.  On the Closing Date, all the quotas of the capital stock of Chamflora shall be validly issued, totally subscribed and paid in, non-assessable and directly or indirectly owned by IP, and there will be no (i) other outstanding quotas issued by Chamflora or other ownership interests of Chamflora, or (ii) options or other rights to acquire from Chamflora or from IP or other obligation of Chamflora to issue any quotas of capital stock or other ownership interests of Chamflora.  On the Closing Date, there will be no outstanding obligations of Chamflora to repurchase, redeem or otherwise acquire any quotas of capital stock of Chamflora.

          SECTION 4.06.  Subsidiaries.  IP, directly or indirectly, owns 100% of Chamflora’s capital stock and Chamflora does not own any securities or other ownership interest in any Person, or any other investment in any Person, whether by means of a share purchase, capital contribution or otherwise. On the Closing Date, Chamflora shall not own any securities or other ownership interest in any Person, or any other investment in any Person, whether by means of a share purchase, capital contribution or otherwise.

          SECTION 4.07.  Financial Statements.  Schedule 4.07 attached hereto contains a true copy of the unaudited financial statements of Chamflora for the fiscal year ended on December 31, 2005, and the same documents dated as of May 31, 2006 (the “Chamflora Financial Statements”), which have been prepared in accordance with the Brazilian GAAP and consistent with the companies’ past practices.  The Chamflora Financial Statements are true, correct and complete, can be reconciled with the books and records of Chamflora in all material aspects and fairly reflect the financial situation of Chamflora on such dates, as well as the results of Chamflora’s activities in the relevant time periods, no transactions out of the ordinary course of business having occurred.

          SECTION 4.08.  Chamflora Assets.  (a) Chamflora has good and marketable, legitimate title, free and clear of any Liens, or, in the case of leased property and assets, has valid leasehold interests, in all Chamflora Assets.  None of such Chamflora Assets is subject to any Lien, except for Liens created by operation of law (“reserva legal” and “área de preservação permanente”).

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           (b) The properties and assets owned, leased or subleased or licensed to Chamflora, or which it otherwise has the right to use, constitute all of the properties and assets used or held for use in connection with the operation of Chamflora and are adequate to conduct such operation as currently conducted.  All of the Chamflora properties and assets are in good working condition and repair, ordinary wear and tear excepted, and have been maintained in a manner consistent with generally accepted industry practice;

           (c) The Chamflora Contracts are and shall be valid and enforceable in accordance with their terms.

          SECTION 4.09.  Absence of Certain Changes.  As from May 31, 2006, IP has conducted the business of Chamflora in the ordinary and usual course of business.  In addition, as from May 31, 2006 up to the date hereof, there has been:

           (i) no physical damage, destruction, loss or abandonment of any material asset or property of Chamflora;

           (ii) except as listed in Schedule 4.09(ii) hereto attached, no acquisition, sale, assignment, transfer, lease, sublease, license or other disposal of any material asset or property of Chamflora;

           (iii) no material change in the management practices of Chamflora;

           (iv) no creation of any Liens on all or any portion of any material asset or property of Chamflora;

           (v) no material amendment, modification, alteration, failure to renew or termination of any material contract of Chamflora;

           (vi) no waiver of any material rights of Chamflora or any cancellation of any material claims, debts or accounts receivable owing to Chamflora, other than in the ordinary course of business;

           (vii) no entering into any form of financial agreement related Chamflora;

           (viii) no revaluation of any tangible or intangible assets of Chamflora;

           (ix) no litigation, which has had or could have a material adverse effect on Chamflora or its financial condition;

           (x) no material loss;

           (xi) no material adverse change in Chamflora’s financial condition, business, operations or prospects; and

           (xii) no commitment by IP to do any of the foregoing.

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          SECTION 4.10.  Contracts.  The agreements related to the Chamflora Assets presently in force, which are listed in Schedule 4.10 attached hereto, were, and the Chamflora Contracts shall have been, on the Closing Date, entered into and executed in the ordinary course of business, represent all material agreements currently in force, conform to all the required legal formalities and are valid, binding and in full force and effect and are enforceable against each of the parties thereto.  There is no event, occurrence, condition or act (including the Closing of the transaction contemplated herein) which, with the giving of notice or the lapse of time or both would become a default under the terms and conditions of such agreements. 

          SECTION 4.11.  Litigation.  (a) Except as disclosed in Schedule 4.11 attached hereto, there is no claim, action, suit, investigation or proceeding (or any basis therefor) pending against Chamflora or any of the Chamflora Assets before any court or arbitrator or any Governmental Authority.

          (b) There is no claim, action, suit, litigation, investigation or proceeding (or any basis therefor) outstanding or pending against Chamflora, any of the Chamflora Assets or IP before any court or arbitrator or any Governmental Authority that would prevent IP from entering into or implementing the transactions contemplated in this Agreement.

          SECTION 4.12.  Licenses and Permits.  Schedule 4.12 and Schedule 4.18 attached hereto correctly describes each license, franchise, permit, certificate, approval or other similar authorization affecting, or relating in any way to the Chamflora Assets,  including those currently held by IP or its Affiliates that are related to the Project Mill which will be held by Chamflora on the Closing Date (the “Chamflora Permits”).  Each Chamflora Permit is valid and in full force and effect, there is no material default under, and no condition exists that with notice or lapse of time or both would constitute a default under, any Chamflora Permit and none of the Chamflora Permits will be terminated or impaired or become terminable, in whole or in part, as a result of the transactions contemplated hereby.

          SECTION 4.13.  Intellectual Property Rights.  Schedule 4.13 hereto attached contains a true and complete list of all Intellectual Property Rights owned by Chamflora and all Intellectual Property Rights used by Chamflora by license or other agreement.  Such Intellectual Property Rights represent all items of intellectual property necessary to permit Chamflora to conduct its operations as currently conducted.  There is no claim, action, suit, investigation or proceeding (or any basis therefor) pending against the use of any such Intellectual Property Rights.

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          SECTION 4.14.  Chamflora Operating Systems.  Schedule 4.14 hereto attached contains a true and complete list of all systems used by IP in the operations of Chamflora, including, without limitation, the SAP system] (the “Chamflora Operating Systems”).  Chamflora has all the licenses necessary to own and operate the Chamflora Operating Systems.  The Chamflora Operating Systems represent all systems necessary to permit Chamflora to conduct its operations as currently conducted.  There is no claim, action, suit, investigation or proceeding (or any basis therefor) pending against the use of the Chamflora Operating Systems.

          SECTION 4.15.  Chamflora Biotechnology Property Rights.  Schedule 4.15 hereto attached contains a true and complete list of all Biotechnology Property Rights owned by Chamflora and all Biotechnology Property Rights used by Chamflora by license or other agreement (the “Chamflora Biotechnology Property Rights”).  The Chamflora Biotechnology Property Rights represent all items of Biotechnology necessary to permit Chamflora to conduct its operations as currently conducted.  There is no claim, action, suit, investigation or proceeding (or any basis therefor) pending against the use of any such Chamflora Biotechnology Property Rights.

          SECTION 4.16.  Taxes.  Chamflora has filed in a timely manner with the appropriate Governmental Authorities all Tax Returns required to be filed by them and all such Tax Returns are true, complete and correct in all material respects; all Taxes required to be paid by Chamflora (including Taxes required to be deducted or withheld and paid over to a taxing authority) have been timely paid in full or are reflected as Tax reserve on the Financial Statements of Chamflora.  Schedule 4.16 attached hereto lists all tax incentives so far granted to IP and Chamflora in connection with the Chamflora Assets, none of which will be reduced, qualified or otherwise affected by this Agreement or the consummation of the transactions contemplated herein.

          SECTION 4.17.  Employee Matters.  Except as otherwise indicated in Schedule 4.17, (a) Chamflora is not a party to any collective bargaining agreement with any labor union, confederation or association, (b) there are no discussions, negotiations, demands or proposals that are pending or have been conducted or made with or by any labor union, confederation or association and (c) there are no pending labor disputes, strikes or work stoppages against Chamflora.  Except as otherwise indicated in Schedule 4.17, Chamflora is not a party to, or sponsors, maintains or contributes to, or is required to contribute to, any bonus, deferred compensation, incentive compensation, stock purchase, stock option, severance or termination pay, hospitalization or other medical, life or other insurance, supplemental unemployment benefits, profit-sharing, pension, or retirement plan, program,
agreement or arrangement.  Except as otherwise indicated in Schedule 4.17, all the labor obligations of Chamflora, including any labor obligation derived from law or collective agreements (such as salaries, bonus, and their accessory benefits), and all the social security contributions and labor union contributions of Chamflora, have been duly calculated, declared and paid.

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          SECTION 4.18.  Environmental Matters.  Chamflora has been in compliance, in all material respects, with all applicable Environmental Laws, and therefore there is no environmental remediation pending or, to the best of IP’s knowledge, threatened regarding the Chamflora Assets.  IP has been granted all permits required to be granted under Environmental Laws for the Chamflora Assets in their current stage (“Environmental Permits”).  Schedule 4.18(a) hereto lists the Environmental Permits held by IP and its Affiliates and Chamflora.  No deadline for the application of the additional Environmental Permits required to build and operate the Project Mill will have expired on the Closing Date.  Except as indicated in Schedule 4.18(b), there are no judicial or administrative pending claims or fines or payments of any nature by any
Governmental Authority or any other person in respect of Environmental Laws affecting Chamflora or the Chamflora Assets.

          SECTION 4.19.  Insurance.  The Chamflora Assets that are covered by insurance are, as of the date hereof, and will be, until the Closing Date, covered by insurance policies protecting general liability, in accordance with standard industry practice.

          SECTION 4.20.  Chamflora Assets.  Schedule 1.01(a) contains a complete list of all of the Chamflora Assets. On the Closing Date, Chamflora shall have all unencumbered right, title and interest to the Chamflora Assets.

          SECTION 4.21.  No Undisclosed Liabilities.  There are no liabilities of Chamflora of any kind whatsoever, whether accrued, contingent, absolute, determined, determinable or otherwise, and there is no existing condition, situation or set of circumstances that could reasonably be expected to result in such a liability, other than liabilities provided for in the Chamflora Financial Statements or liabilities disclosed in any of the Schedules attached hereto.

          SECTION 4.22. IP ́s representations. (a) IP is duly organized, validly existing and in good standing under the laws of the Federative Republic of Brazil. (b) The execution, delivery and performance by IP of this Agreement and the consummation of the transactions contemplated hereby are within the powers of IP.  IP is duly authorized by all necessary corporate action on the part of IP.  This Agreement constitutes a valid and binding agreement upon IP and is enforceable against IP in accordance with its terms. (c) The execution, delivery and performance by IP of this Agreement and the consummation of the transactions contemplated hereby require no action, approval, consent or declaration by or in respect of, notice or filing with, any Governmental Authority, agency or official other than the filing with CADE. (d) The execution, delivery and performance by IP of this
Agreement and the consummation of the transactions contemplated herein do not and will not (i) violate the organizational documents or bylaws of IP, (ii) assuming any filing required by the antitrust authorities properly made, violate any applicable material law, rule, regulation, judgment, injunction, order or decree or (iii) violate any contract, agreement or obligation entered into by IP on or prior to the date hereof.

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          (e) There is no action, suit, investigation or proceeding pending against, or to the knowledge of IP threatened against or affecting, IP before any court or arbitrator or any Governmental Authority, which in any manner challenges or seeks to prevent, alter or materially delay the transaction contemplated by this Agreement. (f) In entering into this Agreement, IP acknowledges that (a) it has conducted an independent due diligence investigation, review and analysis of the LA Establishment, and (b) except for the specific representations and warranties contained herein, IP has relied solely upon the aforementioned investigation, review and analysis and not on any factual representations and warranties of VCP (and of its respective Representatives). (g) IP has the financial capacity whether through its own resources or through committed credit facilities from reputable financial institutions to fulfill all of
its obligations under this Agreement.  The fulfillment of all obligations assumed by IP in this Agreement is not subject to any financing condition.

          SECTION 4.23.  No Other Representations and Warranties.  Except for the representations and warranties contained in this Article 4, IP does not make any representation or warranty, express or implied, to VCP, as to any matter.

ARTICLE 5
 REPRESENTATIONS AND WARRANTIES
 WITH RESPECT TO THE LA ESTABLISHMENT AND THE LA COMPANY

          VCP represents and warrants to IP that each of the following representations and warranties is, and will be on the Closing Date, true and correct and in full force and effect:

          SECTION 5.01.  Existence and Power.  VCP is a company duly organized, validly existing and in good standing under the laws of the Federative Republic of Brazil and has all material corporate powers, governmental licenses, authorizations, permits, consents and approvals required to own and operate the LA Establishment.  On the Closing Date, the LA Company will be duly organized, validly existing and in good standing under the laws of the Federative Republic of Brazil and will have all material corporate powers, governmental licenses, authorizations, permits, consents and approvals required to own and operate the LA Establishment.

          SECTION 5.02.  Authorization, Binding Effect.  The execution, delivery and performance by VCP of this Agreement and the consummation of the transactions contemplated herein are within VCP’s powers.  VCP is duly authorized by all necessary corporate action to execute, deliver, perform and consummate the transactions contemplated in this Agreement.  This Agreement constitutes a valid and binding agreement upon VCP and is enforceable against VCP in accordance with its terms.

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          SECTION 5.03.  Governmental Authorization.  The execution, delivery and performance by VCP of this Agreement and the consummation of the transactions contemplated hereby require no action, approval, consent or declaration by or in respect of, notice or filing with, any Governmental Authority, agency or official other than the filing with CADE.

          SECTION 5.04.  Noncontravention.  The execution, delivery and performance by VCP of this Agreement and the consummation of the transactions contemplated herein do not and will not (i) violate the organizational documents or bylaws of VCP, (ii) assuming any filing required by the antitrust authorities is properly made, violate any material applicable law, rule, regulation, judgment, injunction, order or decree, (iii) require any consent or other action by any Person, constitute a default, or give rise to any right of termination, cancellation, vesting or acceleration of any right or obligation of VCP affecting the LA Establishment, or to a loss of any benefit to which the LA Establishment is entitled (or a loss of any benefit to which the LA Company will be entitled as of the Closing Date) under any provision of any law, agreement or other instrument, or
(iv) result in the creation or imposition of any Lien on any of the assets of the LA Establishment (or in the Luiz Antonio Quotas, as of the Closing Date).

          SECTION 5.05.  Capital Stock and Ownership of Shares.  On the Closing Date, all the quotas of the capital stock of the LA Company shall be validly issued, totally subscribed and paid in, non-assessable and directly owned by VCP, and there will be no (i) other outstanding quotas issued by the LA Company or other ownership interests of the LA Company, or (ii) options or other rights to acquire from the LA Company or from VCP or other obligation of the LA Company to issue any quotas of capital stock or other ownership interests of the LA Company.  On the Closing Date, there will be no outstanding obligations of the LA Company to repurchase, redeem or otherwise acquire any quotas of capital stock of the LA Company.

          SECTION 5.06.  Subsidiaries.  Upon completion of the Reorganization, the LA Company shall not own any securities or other ownership interest in any Person, or any other investment in any Person, whether by means of a share purchase, capital contribution or otherwise.

          SECTION 5.07. Pro Forma Financial Information. Schedule 5.07 attached hereto contains a true copy of unaudited pro forma financial information of the LA Establishment for the fiscal year ended December 31, 2005, and the period ended on June 30, 2006 (the “LA Company Financial Information”).  The LA Company Financial Information has been extracted from VCP’s management information, which has been prepared on a basis consistent with VCP’s past practices. To the best knowledge of VCP management, the LA Company Financial Information are true and correct, can be reconciled with the books and records of VCP in connection with the LA Establishment and fairly present, in all material aspects, the current assets, current liabilities, fixed assets and results of operations of the LA Establishment as of the date and for the period indicated therein. 
Since June 30, 2006, no transactions out of the ordinary course of business have occurred.

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LA EstablishmentLA Company Financial InformationLA EstablishmentLA Establishment.

          SECTION 5.08.  Assets.  (a) VCP has (and, on the Closing Date, the LA Company shall have) good and marketable, legitimate title, free and clear of any Liens, or, in the case of leased properties and assets, has valid leasehold interests, in all LA Assets, and none of such LA Assets is subject to any Lien, except for Liens created by operation of law (“reserva legal” and “área de preservação permanente”). 

          (b) The properties and assets owned, leased or subleased or licensed to the LA Establishment, or which it otherwise has the right to use, constitute all of the properties and assets used or held for use in connection with the operation of the LA Establishment and are adequate to conduct such operation as currently conducted.  All of the LA Establishment properties and assets are in good working condition and repair, ordinary wear and tear excepted, and have been maintained in a manner consistent with generally accepted industry practice.

          SECTION 5.09.  Absence of Certain Changes.  As from June 30, 2006, VCP has conducted the LA Establishment in the ordinary and usual course of business.  In addition, as from June 30, 2006 up to the date hereof, there has been:

          (i) no physical damage, destruction, loss or abandonment of any material asset or property of the LA Establishment;

          (ii) no acquisition, sale, assignment, transfer, lease, sublease, license or other disposal of any material asset or property of the LA Establishment;

          (iii) no material change in the management practices of the LA Establishment, including changes in prices, distribution channels, product mix, sales policies, geographic limits (export/domestic) etc.;

          (iv) no creation of any Liens on all or any portion of any material asset or property of the LA Establishment;

          (v) except as listed in Schedule 5.09(v) hereto attached, no material amendment, modification, alteration, failure to renew or termination of any material contract of the LA Establishment;

          (vi) no waiver of any material rights of the LA Establishment or any cancellation of any material claims, debts or accounts receivable owing to the LA Establishment, other than in the ordinary course of business;

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          (vii) no entering into any form of financial agreement related to the LA Establishment;

          (viii) no revaluation of any tangible or intangible assets of the LA Establishment;

          (ix) no litigation, which has had or could have a material adverse effect on the LA Establishment or its financial condition;

          (x) no material loss;

          (xi) no material adverse change in the LA Establishment’ financial condition, business, operations or prospects; 

          (xii) no commitment by VCP to do any of the foregoing.

          SECTION 5.10.  Contracts.  The agreements related to the LA Establishment presently in force, including service agreements, which are listed in Schedule 5.10(a) attached hereto, were entered into and executed in the ordinary course of business, represent all material agreements currently in force, conform to all the required legal formalities and are valid, binding and in full force and effect and are enforceable against each of the parties thereto.  Except as provided for in Schedule 5.10(b), there is no event, occurrence, condition or act (including the Closing of the transaction contemplated herein) which, with the giving of notice or the lapse of time or both would become a default under the terms and conditions of such agreements. The LA Company shall have, on the Closing Date, all required contracts to operate the LA Establishment. 

          SECTION 5.11.  Litigation.  (a) Except as disclosed in Schedule 5.11 attached hereto, there is no claim, action, suit, investigation or proceeding (or any basis therefor) pending against the LA Establishment (and, as of the Closing Date, against the LA Company) before any court or arbitrator or any Governmental Authority, nor any related provisions and judicial deposits, which provisions and judicial deposits shall be transferred to the LA Company along with the litigation pertaining to the LA Establishment.

          (b) There is no claim, action, suit, litigation, investigation or proceeding (or any basis therefor) outstanding or pending against VCP and/or the LA Establishment (and, as of the Closing Date, against the LA Company) before any court or arbitrator or any Governmental Authority that would prevent VCP from entering into or implementing the transactions contemplated in this Agreement.

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          SECTION 5.12.  Licenses and Permits.  Schedule 5.12(a) attached hereto correctly describes each license, franchise, permit, certificate, approval or other similar authorization affecting, or relating in any way to, the LA Establishment (the “ LA Permits”).  Except as otherwise indicated in Schedule 5.12(b), each LA Permit is valid and in full force and effect and will remain valid and in full force and effect on the closing Date. There is no material default under, and no condition exists that with notice or lapse of time or both would constitute a default under, any LA Permit and none of the LA Permits will be terminated or impaired or become terminable, in whole or in part, as a result of the transactions contemplated hereby.  The LA Company shall have on the Closing Date all of the material licenses, franchises, permits, certificates, approvals
or other similar authorization necessary to operate the LA Establishment as currently operated.

          SECTION 5.13.  Intellectual Property Rights.  The LA Establishment owns or has the right to use all of the Intellectual Property Rights necessary to permit VCP to conduct the operation of the LA Establishment as currently conducted.  There is no claim, action, suit, investigation or proceeding (or any basis therefor) pending against the use of any such Intellectual Property Rights.

          SECTION 5.14.  LA Operating Systems.  Schedule 5.14 hereto attached contains a true and complete list of all systems used by VCP in the operation of the LA Establishment, including SAP, the middleware software for the paper production control, other software and manual operation systems, including processes and spreadsheets (the “LA Operating Systems”).  VCP has (and, as of the Closing Date, the LA Company shall have) all the licenses necessary to own and operate the LA Operating Systems.  The LA Operating Systems represent all systems necessary to permit VCP to conduct the operation of the LA Establishment as currently conducted.  There is no claim, action, suit, investigation or proceeding (or any basis therefor) pending against the use of the LA Operating Systems.

          SECTION 5.15.  LA Biotechnology Property Rights.  Schedule 5.15hereto attached contains a true and complete list of all Biotechnology Property Rights owned by the LA Establishment and to be transferred to LA Company and all Biotechnology Property Rights used by the LA Establishment by license or other agreement (the “LA Biotechnology Property Rights”).  The LA Biotechnology Property Rights represent all items of Biotechnology necessary to permit VCP to conduct the operation of the LA Establishment as currently conducted.  There is no claim, action, suit, investigation or proceeding (or any basis therefor) pending against the use of any such LA Biotechnology Property Rights. 

          SECTION 5.16.  Taxes.  VCP has (and, as of the Closing Date, the LA Company will have) filed in a timely manner with the appropriate Governmental Authorities all Tax Returns required to be filed by it and all such Tax Returns are true, complete and correct in all material respects; all Taxes required to be paid by VCP (and, as of the Closing Date, LA Company) (including Taxes required to be deducted or withheld and paid over to a taxing authority) have been (and will be, as of the Closing Date, in the case of the LA Company) timely paid in full or are reflected as Tax reserve on the financial statements of VCP, except in the event that the failure to do so will not impact, in any way, any of the assets of the LA Establishment. 

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          SECTION 5.17.  Employee Matters.  (a) Schedule 5.17(a) sets forth an accurate and complete list of the names and titles of all employees of the LA Establishment, either working in the mills, forest operations, or in the São Paulo or any other office, including any such employee who is on disability leave or any other leave of absence (all such employees, other than those listed in Schedule 5.17 (a1) the “LA Employees”).

          (b) Schedule 5.17(b) hereto attached contains a true copy of the collective bargaining agreement with any labor union, confederation or association pertaining to the LA Employees of the LA Establishment.  Such collective bargaining agreement is valid, in full force and effective, and conforms to all the required legal formalities.  There are no discussions, negotiations, demands or proposals that are pending or have been conducted or made with or by any labor union, confederation or association pertaining to the LA Employees of the LA Establishment.

          (c) There is no liability of any kind with respect to amounts withheld or deducted amounts from LA Employees’ earnings, for the period ending on the date hereof (and, upon the Closing of the transaction, on the Closing Date).  VCP is in compliance with all Brazilian federal, state, municipal and other applicable laws and regulations relating to the employment of labor, including all such laws, regulations and orders relating to wages and hours, labor relations, civil rights, safety and health, workers’ compensation, and social security and other taxes, except in the event that the failure to do so will not impact, in any way, any of the assets of the LA Establishment.

          (d) As of the Closing Date, all the labor obligations of the LA Company, including any labor obligation derived from law or collective agreements (such as salaries, bonus, and their accessory benefits), and all the social security contributions and labor union contributions of the LA Company, shall have been duly calculated, declared and paid.

          (e) Except as disclosed in Schedule 5.17(e), as of the Closing Date, the LA Company shall not be a party to, or sponsor, maintain or contribute to, or be required to contribute to, any bonus, deferred compensation, incentive compensation, stock purchase, stock option, severance or termination pay, hospitalization or other medical, life or other insurance, supplemental unemployment benefits, profit-sharing, pension, or retirement plan, program, agreement or arrangement. The transition of the participants of VCP’s pension plan into IP’s pension plan will be determined between the parties by mutual consent until the Closing Date.

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          (f) There is no (and has not been during the last five years) labor strike, slow down, stoppage or other material labor difficulty, actual or threatened, against or affecting the LA Establishment. 

          SECTION 5.18.  Environmental Matters.  Each of VCP and LA Company has been (and, as of the Closing Date, LA Company shall be) in compliance, in all material respects, with all applicable Environmental Laws affecting in any way the LA Establishment, and therefore there is no environmental remediation pending or, to the best of VCP’s knowledge, threatened regarding the LA Establishment. Schedule 5.18(a) hereto lists the LA Environmental Permits held by VCP.  Except as indicated in Schedule 5.18(b), VCP and LA Company have been granted all permits and other licenses or authorizations required to be granted under Environmental Laws for the LA Establishment (“LA Environmental Permits”) and there are no judicial or administrative pending claims or fines or payments of any nature by any Governmental Authority or any other person in respect of
Environmental Laws affecting VCP and the LA Establishment or LA Company. 

          SECTION 5.19.  Insurance.  Schedule 5.19 hereto attached describes all of the insurance policies relating to the operations, properties and assets of the LA Establishment in effect as of the date hereof (“Insurance Policies”).  All of such Insurance Policies are (i) in full force and effect; (ii) are underwritten by financially sound and reputable insurers, (iii) are sufficient for all applicable requirements of law; and (iv) secure coverage in amounts and against all risks that are normal and customary for the operation of the LA Establishment.  All of such Insurance Policies will remain in full force and effect in accordance with their terms and will not terminate or lapse by reason of any of the transactions contemplated hereby, or shall be replaced with substantially equivalent new policies.  VCP is not in default in any material
respect with respect to its obligations under any of such Insurance Policies, except in the event that such default will not impact, in any way, any of the assets of the LA Establishment.

          SECTION 5.20.  No Undisclosed Liabilities.  There are no liabilities of the LA Establishment of any kind whatsoever, whether accrued, contingent, absolute, determined, determinable or otherwise, to be transferred to the LA Company, and there is no existing condition, situation or set of circumstances that could reasonably be expected to result in such a liability, other than liabilities provided for in the LA Company Financial Informationor liabilities disclosed in any of the Schedules attached hereto.

          SECTION 5.21.  LA Establishment.  Schedule 5.21 contains a complete list of all of the assets and rights within the LA Establishment. On the Closing Date, the LA Company shall have all right, title and interest to the LA Assets. The corporate activities of technology research and the forest research laboratories will not be transferred to the LA Company. Schedule 5.21 hereto lists the professionals involved in research activities who shall remain with VCP.  

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The forest research laboratories and the research nursery shall also continue to be operated by VCP under a free lease for a period of 2 (two) years from the Closing Date, after which the physical space and the buildings shall return to the LA Company. Corporate genetic materials planted in the LA Establishment, except for the ones listed in Schedule 5.15, shall be removed by VCP within 60 (sixty) days as of this date, along with seedlings that the Luiz Antonio nursery is producing for other regions.  The Cara Preta Farm shall maintain the normal seedling production to supply the commercial plantations of the LA Establishment. IP also acknowledges that asbestos cement is used in the Cloning Garden of the Cara Preta Nursery Farm.

          SECTION 5.22. VCP ́s representations. (a) VCP is duly organized, validly existing and in good standing under the laws of the Federative Republic of Brazil. (b) The execution, delivery and performance by VCP of this Agreement and the consummation of the transactions contemplated hereby are within the powers of VCP.  VCP is duly authorized by all necessary corporate action on the part of VCP.  This Agreement constitutes a valid and binding agreement upon VCP and is enforceable against VCP in accordance with its terms. (c) The execution, delivery and performance by VCP of this Agreement and the consummation of the transactions contemplated hereby require no action, approval, consent or declaration by or in respect of, notice or filing with, any Governmental Authority, agency or official other than the filing with CADE. (d) The execution, delivery and performance by VCP of
this Agreement and the consummation of the transactions contemplated herein do not and will not (i) violate the organizational documents or bylaws of VCP, (ii) assuming any filing required by the antitrust authorities properly made, violate any applicable material law, rule, regulation, judgment, injunction, order or decree or (iii) violate any contract, agreement or obligation entered into by VCP on or prior to the date hereof. (e) There is no action, suit, investigation or proceeding pending against, or to the knowledge of VCP threatened against or affecting, VCP before any court or arbitrator or any Governmental Authority, which in any manner challenges or seeks to prevent, alter or materially delay the transaction contemplated by this Agreement. (f) In entering into this Agreement, VCP acknowledges that (a) it has conducted an independent due diligence investigation, review and analysis of the Chamflora Assets, and (b) except for the specific representations and warranties contained herein,
VCP has relied solely upon the aforementioned investigation, review and analysis and not on any factual representations and warranties of VCP (and of its respective Representatives). (g) VCP has the financial capacity whether through its own resources or through committed credit facilities from reputable financial institutions to fulfill all of its obligations under this Agreement.  The fulfillment of all obligations assumed by VCP in this Agreement is not subject to any financing condition.

          SECTION 5.23.  No Other Representations and Warranties.  Except for the representations and warranties contained in this Article 5, VCP does not make any representation or warranty, express or implied, to IP, as to any matter.

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ARTICLE 6
 ACTIONS BETWEEN SIGNING AND CLOSING

          SECTION 6.01.  Chamflora Reorganization.  (a) IP shall take all steps necessary in order to carry out the Chamflora Reorganization prior to the Closing Date.  IP agrees to indemnify and hold VCP, its shareholders and Representatives harmless from and against and in respect of any and all damages, claims and/or losses resulting from the Chamflora Reorganization.  

          (b) IP shall take all acts necessary to ensure that no assets, liabilities, business, operations or interests other than those related to the Chamflora Assets remain with Chamflora as a result of the Chamflora Reorganization. 

          (c) Between the date of this Agreement and the Closing Date, IP agrees to inform VCP on a bi-weekly basis of the conduct of the Chamflora Reorganization and shall provide VCP with copies of the documentation of the Chamflora Reorganization after their registration in the applicable Board of Trade, as VCP may reasonably request.

          SECTION 6.02.  Ordinary Course of Business.  (a) During the period from the date hereof until the Closing Date, IP shall cause Chamflora to conduct its business in the ordinary and usual course of business.  In addition to the above, IP shall not take any action that leads to:

          (i) physical damage, destruction, loss or abandonment of any material Chamflora Asset;

          (ii) acquisition, sale, assignment, transfer, lease, sublease, license or other disposal of any material Chamflora Asset;

          (iii) creation of any Liens on all or any portion of any material Chamflora Asset;

          (iv) a material amendment, modification, alteration, failure to renew or termination of any material contract in connection with the Chamflora Assets;

          (v) the potential or actual cancellation or alteration of any of the Permits or Environmental Permits;

          (vi) a waiver of any material rights of Chamflora or any cancellation of any material claims, debts or accounts receivable owing to Chamflora, other than in the ordinary course of business;

          (vii) any form of financial agreement related to Chamflora, other than inter company financing entered into with the prior written consent of VCP;

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          (viii) revaluation of any tangible or intangible assets of Chamflora;

          (ix) litigation which could have a material adverse effect on Chamflora or its financial condition;

          (x) a material loss; or

          (xi) a material adverse change in Chamflora’s financial condition, business, operations or prospects.

          (b) IP shall take all necessary measures to continue the process to obtain the required Environmental Permits for Chamflora.  IP shall consult and agree with VCP prior to any final measure to be taken.

          SECTION 6.03.  LA Reorganization.  (a) VCP shall take all steps necessary in order to carry out the LA Reorganization prior to the Closing Date.  As a result of the LA Reorganization, the LA Establishment shall have been conveyed to the LA Company.  VCP agrees to indemnify and hold IP, its shareholders and Representatives harmless from and against and in respect of any and all damages, claims and/or losses resulting from the VCP Reorganization.  

          (b) VCP shall take all acts necessary to ensure that (i) no assets, business, operations or interests other than those related to the LA Establishment and listed in Schedule 5.21 hereto attached are conveyed to the LA Company as a result of the LA Reorganization. 

          (c) Between the date of this Agreement and the Closing Date, VCP agrees to inform IP on a bi-weekly basis of the conduct of the LA Reorganization and shall provide IP with copies of the documentation of the LA Reorganization after their registration in the applicable Board of Trade, as IP may reasonably request.

          SECTION 6.04.  Ordinary Course of Business.  (a) During the period from the date hereof until the Closing Date, VCP shall conduct the operation of the LA Establishment in the ordinary and usual course of business.  In addition to the above, VCP shall not take any action that may lead to:

          (i) physical damage, destruction, loss or abandonment of any material asset or property of the LA Establishment;

          (ii) acquisition, sale, assignment, transfer, lease, sublease, license or other disposal of any material asset or property of the LA Establishment;

          (iii) a material change in the management practices of the LA Establishment, including changes in prices, distribution channels, product mix, sales policies, geographic limits (export/domestic) etc.;

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          (iv) the creation of any Liens on all or any portion of any material asset or property of the LA Establishment;

          (v) a material amendment, modification, alteration, failure to renew or termination of any material contract of the LA Establishment;

          (vi) a waiver of any material rights of the LA Establishment or any cancellation of any material claims, debts or accounts receivable owing to the LA Establishment, other than in the ordinary course of business;

          (vii) any form of financial agreement related to the LA Establishment;

          (viii) revaluation of any tangible or intangible assets of the LA Establishment;

          (ix) litigation which could have a material adverse effect on the LA Establishment or its financial condition;

          (x) a material loss; 

          (xi) termination of employment relationships with a key personnel of the LA Establishment, other than voluntary termination or termination for cause; 

          (xii) a change in the historical practice with respect to working capital of the LA Establishment; or

          (xiii) a material adverse change in the LA Establishment financial condition, business, operations or prospects,

provided however, that VCP shall be entitled to withdraw from LA Company the amount of cash or cash equivalents of LA Company existing on the Closing Date, subject to Section 9.09 below.

          SECTION 6.05. Representatives.  (a) In good faith and in order to ensure  a successful and smooth transition after the exchange between IP and VCP with respect to the LA Establishment and Chamflora, as of the date of this Agreement and until the Closing Date, IP and VCP may each appoint representatives to observe the day-to-day business activities of the LA Establishment and Chamflora, which representatives shall have access to the books and records of Chamflora or the LA Company (as the case may be), and the LA Establishment, but excluding any books, records or databases which are shared by the LA Establishment with other VCP plants or operations, until such information is segregated to reflect only the LA Establishment, and may consult, make inquiries and request reasonable information to VCP’s and IP’s officers.

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          (b) Such representatives shall call the attention of VCP’s and IP’s officers for maintenance issues and other operational problems detected in relation to the ordinary course of business of the LA Establishment, the LA Company and Chamflora, and shall be allowed to take action to prevent the aggravation of or to solve such issues and problems, should VCP or IP (as the case may be) fail to remedy the situation.

          SECTION 6.06.  Environmental Matters. The Parties acknowledge that VCP has applied for and is in the process of obtaining the applicable operating license for the LA Establishment for a production capacity of up to 360,000 tonnes of pulp per year. The Parties hereby agree that  VCP shall be fully responsible for obtaining such license. In addition to such license and considering the current production capacity status of the LA Establishment, prior to the Closing Date, VCP shall apply for an amendment or a new license, as applicable, authorizing the production of up to 410,000 tonnes of pulp per year. VCP shall also be fully responsible for requesting and obtaining such license, provided that prior to taking any measure to obtain such license, VCP shall inform the procedure to be adopted to IP and obtain IP’s consent to such procedure (which consent shall not be
unreasonably withheld). The consent by IP in relation to such procedure shall not create any liability to IP.  

          SECTION 6.07. Distributors Supply Commitment. (a) From the date hereof, LA Company or the LA Establishment, as the case may be, shall maintain the supply of cut size uncoated paper (“Cut Size Paper”) to the market. Such commitment will be communicated to distributors through the LA Company or the LA Establishment, as the case may be. 

          (b) LA Company or the LA Establishment, as the case may be, is committed to endeavor its best efforts to secure the continuance of the Cut Size Paper supply, through the execution of distribution agreements or otherwise, with distributors, including those listed in Schedule 6.07(b) hereto (“LA Distributors”), which list does not include all current distributors of the LA Establishment. Such distribution agreements shall be substantially in the form of the draft of the Distribution Agreement attached hereto as Schedule 6.07(b).

          (c) VCP shall not, directly or indirectly, for a period of 2 (two) years from the Closing Date, distribute any Cut Size Paper through any of the LA Distributors nominated in Schedule 6.07(b).

          SECTION 6.08.  Supply and Services Agreements.  (a) VCP shall have assigned to the LA Company the rights and agreements (or shall have caused LA Company to enter into new agreements) necessary for LA Company to maintain the current supplies and services from third parties to the LA Establishment, including the supply of energy from CPFL Energia, as described below,  as well as of other raw materials such as ozone, oxygen, caustic soda and hydrogen peroxide and precipitated calcium carbonate (PCC) with other suppliers under no less favorable terms and conditions than those currently existing. 

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To the extent VCP may not assign to LA Company the current energy supply agreement with CPFL nor to cause LA Company to enter into a new agreement with the same price and conditions, then, the existing energy supply agreement with VCP for the LA Establishment will be maintained until its termination and LA Company will fully reimburse VCP of the cost thereunder. After such termination, LA Company shall negotiate the energy supply agreements in the best possible terms. (b) VCP shall have assigned to the LA Company the service agreements (or shall have caused LA Company to enter into new agreements) necessary for LA Company to maintain the current services from third parties to the LA Establishment.

          SECTION 6.09.  Employees. VCP shall have caused the LA Employees to be legally and validly transferred to the LA Company, except for those LA Employees who voluntarily terminate their employment relationships or those who are terminated for cause. 

          SECTION 6.10.  Operating Systems. VCP shall have taken all necessary and desirable measures in order to cause the LA Company to be the legal owner and duly licensed user of all Operating Systems on a stand alone basis and under substantially the same conditions as the Operating Systems that are currently used in the LA Establishment. IP and VCP shall create a technical commission which shall define, within 2 (two) months from the date hereof, the procedures for the transition of the Operating Systems of the LA Company from VCP to IP.  IP acknowledges that VCP will not begin the transfer and/or segregation of the LA Operating Systems to the LA Company until December 31, 2006. VCP will endeavor its best efforts to ensure that such transition is completed within 6 (six) months as from the Closing Date. To the extent that the Operating Systems are not transferred within the
above term, IP shall have the right to continue to use and operate the Operating Systems until such transition is completed. 

          SECTION 6.11.  Chamflora Project Mill Construction.  (a) Pursuant to the terms of this Agreement and the existing plans and agreements to construct the Project Mill on the land owned by Chamflora, from the execution of this Agreement until the Closing Date, Chamflora shall, upon VCP’s written request:

	
  
 
  	
  
(i) initiate   the negotiation for the construction of the Project Mill, including placing   orders with suppliers for the necessary equipment and entering into   appropriate agreements and making advance payments;
  
	
   
  	
  
 
  
	
  
 
  	
  
(ii) acquire   and negotiate the acquisition of additional land;
  
	
  
 
  	
  
 
  
	
  
 
  	
  
(iii)   transfer any portion of Chamflora’s cash related to the Project Mill   construction to a third party elected by VCP to be responsible for the   engineering, procurement, construction and management of the Project Mill.
  

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          (b) Considering the estimated costs related to the construction of the Project Mill, Chamflora shall enter into agreements and acquire from third unrelated parties, assets, rights, services, land and other assets related to the Project Mill in the amount of US$1,150,000,000 (one billion, one hundred and fifty million dollars).  to be funded by IP or its Affiliates within 60 (sixty) days as of the date hereof, provided that the funding date will be determined and informed to VCP in writing within 10 (ten) days from the date hereof. 

          SECTION 6.12. Transition Services. IP and VCP shall negotiate mutually acceptable terms under which VCP will provide to the LA Company the following administrative services for a term of 60 (sixty) days subject to renewal upon mutual agreement: invoicing, payroll, debt collection, operating systems, among others. 

          SECTION 6.13. Delivery of pending Schedules. VCP agrees to deliver to IP the schedules related to the LA Establishment listed in Schedule 6.13(a) within 6 (six) days of the date hereof. 

ARTICLE 7
 COVENANTS OF ALL PARTIES

          SECTION 7.01.  Best Efforts; Further Assurances.  Subject to the terms and conditions of this Agreement, the Parties hereto shall take, or cause to be taken, all actions and to do, or cause to be done, all things necessary under applicable laws and regulations to consummate the transactions contemplated by this Agreement.  The Parties agree to execute and deliver all such documents, certificates, agreements and other writings and to take such other actions as may be necessary or desirable in order to consummate or implement expeditiously the transactions contemplated by this Agreement.

          SECTION 7.02.  Confidentiality.  (a) From and after the date hereof, the Parties agree jointly and severally to hold, and to cause their Affiliates and respective Representatives to hold, in confidence, all confidential documents and information concerning the Chamflora Assets, the LA Establishment and/or the Parties, including without limitation, certain non-public information about the proposed or potential business strategy, operations, financial matters and other matters relating to the Chamflora Assets, the LA Establishment and/or the Parties (the “Confidential Information”), except to the extent that such information can be shown to have been (i) in the public domain through no fault of any of the Parties or (ii) later lawfully acquired by any of the Parties from other sources without any breach of any law, regulation, order or confidentiality
obligation.  Confidential Information may only be disclosed in the event that any of the Parties is compelled to disclose such Confidential Information by law, rule, regulation, order or decree enacted by a Governmental Authority to which such Party is subject or as a result of judicial or administrative process in connection with any action, suit, proceeding or investigation.  In any event Confidential Information is disclosed, the disclosing Party shall previously inform the other Party and agree upon the contents of such disclosure.

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          (b) From and after the date hereof, the Parties agree to hold, and to cause their Affiliates and respective Representatives to hold, in confidence, any and all information regarding the terms and conditions of this Agreement.  The terms and conditions of this Agreement may only be disclosed in the event that any of the Parties is compelled to disclose such information by law, rule, regulation, order or decree enacted by a Governmental Authority to which the Party is subject or as a result of judicial or administrative process in connection with any action, suit, proceeding or investigation.  In any event the terms and conditions of this Agreement are disclosed, the disclosing Party shall previously inform the other Party and agree upon the contents of such disclosure.

          SECTION 7.03.  Public Announcements.  The Parties agree to consult with each other before issuing any press release or making any public statement with respect to this Agreement or the transactions contemplated hereby and will not issue any such press release or make any such public statement prior to agree on the content of such press release or public announcement.

          SECTION 7.04.  (a) The transactions contemplated in this Agreement do not represent any change in the Parties’ commercial relationship or any change in any of the Parties’ business competitive strategy toward the other Party or the other competitors in the pulp and paper markets in Brazil.

          (b) Notwithstanding the above, VCP agrees not to, directly or through any of its Affiliates, either alone or together with or on behalf of any other Person, build, own, finance, manage or operate an uncoated freesheet paper machine in the City of Três Lagoas or in the region comprised of a 100 kilometers radius around the Project Mill for as long as IP owns the IP Paper Machine (or the Option Paper Machine, if applicable), provided that VCP shall have the right to attract potential investors to the Project Mill, as long as they are not, directly or indirectly, engaged in the uncoated printing and writing paper or packaging paper businesses. 

          SECTION 7.05.  CADE Submission.  (a) The Parties agree to make the appropriate filing with CADE jointly pursuant to applicable antitrust laws within 15 (fifteen) Business Days following the execution of this Agreement to obtain CADE’s approval of the transactions contemplated by this Agreement.  The Parties agree to respond, as promptly as practicable, to any inquiries received from the notified authorities and to supply any additional information and documentary material that may be requested by such notified authorities. 

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          (b) VCP agrees to bear all risks arising from the CADE’s decision in relation to the transfer of Chamflora.  In case CADE does not approve such transaction, VCP shall be entitled to (i) dispute the decision in good faith through appropriate administrative or legal proceedings, bearing all the costs arising therefrom, or (ii) divest all of Chamflora Quotas; and VCP shall hold IP harmless and indemnified from any and all damages, claims and/or losses arising out of any such decision taken by VCP hereunder.  In case CADE requires the divestiture of the Chamflora Assets or any portion thereof, VCP shall be restricted from selling the Chamflora Assets or any portion thereof without having first offered the Chamflora Assets (or Chamflora Quotas, as the case may be) to IP under the same terms and conditions of a third party bona fide offer.

          (c) IP agrees to bear all risks arising from the CADE’s decision in relation to the transfer of the LA Company.  In case CADE does not approve any of such transactions, IP shall be entitled to (i) dispute the decision in good faith through appropriate administrative or legal proceedings, bearing all the costs arising therefrom, or (ii) divest all of the LA Company quotas after the Quota exchange herein provided; and IP shall hold VCP harmless and indemnified from any and all damages, claims and/or losses arising out of any such decision taken by IP hereunder.  In case CADE requires the divestiture of the LA Establishment or any portion thereof, IP shall be restricted from selling the LA Establishment or any portion thereof without having first offered the LA Establishment (or the LA Company Quotas, as the case may be) to VCP under the same terms and conditions of a third party bona fide
offer.

          (d) In case CADE imposes any restriction to the supply of pulp in accordance with the Pulp Supply Agreement, VCP and IP shall negotiate in good faith an appropriate action in response to CADE’s restriction.  In the event that the Parties are not able to reach an agreement as to such appropriate action within 30 (thirty) days after the date they were notified of the CADE’s decision, the provisions of Article 11 shall apply.

          (e) VCP and IP shall cooperate in obtaining any information required for the CADE filing and to supply any information requested by any of the antitrust authorities.

          (f) Notwithstanding the above, VCP agrees that IP or any Affiliate thereof shall not be required to buy back Chamflora Quotas, unwind the transactions, suffer any other impact resulting from the CADE’s decision or otherwise be adversely affected by any decision taken by VCP hereunder.

          (g) Notwithstanding the above, IP agrees that VCP or any Affiliate thereof shall not be required to buy back the LA Company Quotas, unwind the transactions, suffer any other impact resulting from the CADE’s decision or otherwise be adversely affected by any decision taken by IP hereunder.

          (h) VCP and IP shall bear equally the costs of the joint submission provided for in item (a) above.

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          SECTION 7.06.  IP Project Support regarding the Chamflora Assets.  (a) IP is committed to provide VCP with IP personnel in order to provide (i) the support and assistance required to enable the VCP’s team to accelerate their familiarity with the Project Mill’s design and status; (ii) the support as necessary to ensure that the Project Mill construction schedule is maintained; (iii) continuation of the engineering and construction support, as requested and mutually agreed until the Closing Date; and (iv) continuous activities in securing the construction permit and the installation license for the site, up to the time of issuance of the construction permit, at no cost to VCP.

          (b) IP will work with VCP to develop a management and oversight framework for obtaining the construction permit and the installation license.

          (c) IP will endeavor its best efforts to assist VCP in obtaining tax benefits similar to those accorded to IP.

          (d) IP will also endeavor its best efforts to provide further engineering and project support, as requested by VCP, beyond this time frame on a fee based structure.

          SECTION 7.07.  Non Solicitation.  VCP shall not, for a period of two (2) years counted as from the Closing Date, directly or indirectly solicit for employment or employ any of the LA Employees, provided that VCP shall not be prevented from hiring any LA Employee as a result of a response to a general published solicitation or any LA Employee who has not been employed by the LA Company for the preceding six (6) months.

          SECTION 7.08.  Intercompany Loan.  Chamflora shall repay any outstanding intercompany loan with IP and Affiliates within 30 (thirty) days as from the Closing Date, provided that such loans have been extended in connection with the funding of the Project Mill, land acquisition and the forest operations and have been previously consented in writing by VCP. 

          SECTION 7.09.  Biotechnology Property Rights.  IP and VCP hereby agree not to transfer or reveal to any third parties their Biotechnology Property Rights exchanged hereunder without the other Party’s prior written consent. In addition, each of VCP and IP will retain the right to access and continue to use their respective Biotechnology Property Rights exchanged hereunder according to a formal plan to be submitted by VCP and IP to each other within 60 (sixty) days after the Closing Date. 

          SECTION 7.10.  LA Permits. VCP shall continue to support the ongoing actions, at its own cost, to obtain the LA Permits to the extent the LA Permits are not valid or existing on the Closing Date, until the date when they are obtained by LA Company, and IP and LA Company shall take all actions required to obtain such LA Permits.

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ARTICLE 8
 CONDITIONS TO CLOSING

          SECTION 8.01.  VCP ́s Conditions to Close.  The obligations of VCP to carry out its respective actions at Closing is subject to the fulfillment of the following conditions (unless waived in writing by VCP, to the extent possible):

          (i) Covenants.  The covenants contained in this Agreement to be complied with by IP on or before the Closing, including those provided for in Article 6, shall have been complied with in all material respects, except the obligations under Article 3 that shall have been complied with in all respects.

          (ii) No Order.  No Governmental Authority shall have enacted, issued, promulgated, enforced or entered any law, rule, regulation, judgment, injunction, order or decree (whether temporary, preliminary or permanent) which is in effect and has the effect of making the transactions contemplated by this Agreement illegal or otherwise restraining or prohibiting consummation of such transactions.

          (iii) Chamflora.  Chamflora shall be the lawful owner of the Chamflora Assets, as listed in Schedule 1.01.

          (iv) No Material Change in Chamflora Assets Condition.  None of the events under Section 6.02 shall have occurred, and the Chamflora Assets must all be substantially in the same condition as per Schedule 1.01 hereto and no fact or event may have arisen resulting from the disclosure in Schedule 4.18(b) restricting or impeding the use of the Chamflora Assets for their contemplated purposes.

          (v) Chamflora Company Financial Statements.  IP shall have delivered to VCP the unaudited financial statements of Chamflora as of nearest possible date to the Closing Date, which must only reflect the Chamflora Assets and shall fairly reflect the financial situation of Chamflora on such date, as well as the results of activities in the relevant time periods. 

          (vi) The representations and Warranties of IP set forth in Article 4 of this Agreement shall remain valid and in full force in all its materials aspects on the Closing Date. 

          SECTION 8.02.  IP ́s Conditions to Close.  The obligation of IP to carry out its respective actions at Closing is subject to the fulfillment of the following conditions (unless waived in writing by IP, to the extent possible):

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          (i) Covenants.  The covenants contained in this Agreement to be complied with by VCP on or before the Closing, including those provided for in Article 6, shall have been complied with in all material respects, except the obligations under Article 3 that shall have been complied with in all respects.

          (ii) No Order.  No Governmental Authority shall have enacted, issued, promulgated, enforced or entered any law, rule, regulation, judgment, injunction, order or decree (whether temporary, preliminary or permanent) which is in effect and has the effect of making the transactions contemplated by this Agreement illegal or otherwise restraining or prohibiting consummation of such transactions.

          (iii) Retained Employees.  VCP shall have delivered a list of the employees of Chamflora who shall remain in their positions after the Closing.

          (iv) LA Company.  The LA Company shall be the lawful owner of the LA Establishment, as listed in Schedule 5.21.

          (v) No Material Change in the LA Establishment Conditions.  None of the events under Section 6.04 shall have occurred and the assets of the LA Establishment must all be substantially in the same condition as per Schedule 5.21 hereto.

          (vi) LA Company Financial Statements.  VCP shall have delivered to IP the unaudited financial statements of the LA Company as of the nearest possible date to the Closing Date, which must contain the assets of the LA Establishment listed in Schedule 5.21 attached hereto and shall fairly reflect the financial situation of the LA Company on such date, as well as the results of activities in the relevant time periods. 

          (vii) Distributors Supply Commitment. VCP shall have caused the LA Company or the LA Establishment, as the case may be, to maintain the supply of the Cut Size Paper to the market through the execution of distribution agreements or otherwise pursuant to Section 6.07(b) hereof.

          (viii) Supply and Services Agreement.  VCP shall have caused the LA Company to comply with Section 6.08 hereof.

          (ix) Employees.  The LA Employees shall have been transferred to the LA Company pursuant to Section 6.09 hereof. 

          (x) Operating Systems.  Subject to Section 6.10, the LA Company shall be the legal owner and duly licensed user of all Operating Systems on a stand alone basis and under substantially the same conditions of the Operating Systems as currently used in the LA Establishment.

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          (xi) Wet Lap Pulp Supply Agreement. LA Company and VCP shall have entered into the Wet Lap Pulp Supply Agreement, in the form of Schedule 8.02 hereto attached.

          (xii) The representations and Warranties of VCP set forth in Article 5 of this Agreement shall remain valid and in full force in all its materials aspects on the Closing Date. 

ARTICLE 9
 INDEMNIFICATION

          SECTION 9.01.  Indemnification by IP.  Subject to Sections 9.03 and 9.04 below, IP agrees to indemnify and hold VCP and its Affiliates and its shareholders and Representatives (the “VCP Indemnified Parties”), harmless from any and all liability, loss, damage, claims, awards, judgments, costs and expenses (including reasonable fees and expenses of attorneys) (“Losses”) incurred or suffered by any of the VCP Indemnified Parties in connection with, relating to or as a result of (i) any breach of any representations and warranties given by IP in Article 4 hereof; and/or (ii) any breach by IP of any covenant or agreement contained in this Agreement; and/or (iii) any and all debts and liabilities of any kind (tax, labor, civil, environmental etc.), including but not limited to those related to judicial or administrative procedures,
resulting from any act or omission, fact, event or circumstance related to the Chamflora Assets that occurred on or prior to the Closing Date, which have not been recorded in the Chamflora Financial Statements or disclosed in the Schedules hereto attached.

          SECTION 9.02.  Indemnification by VCP.  Subject to Sections 9.03 and 9.05 below, VCP agrees to indemnify and hold IP and its Affiliates and its shareholders and Representatives (the “IP Indemnified Parties”), harmless from any and all Losses incurred or suffered by any of the IP Indemnified Parties in connection with, relating to or as a result of (i) any breach of any representations and warranties given by VCP in Article 5 hereof; and/or (ii) any breach by VCP of any covenant or agreement contained in this Agreement; and/or (iii) any and all debts and liabilities of any kind (tax, labor, civil, environmental etc.), including but not limited to those related to judicial or administrative procedures, resulting from any act or omission, fact, event or circumstance related to the LA Establishment or the LA Company that occurred on or prior to the Closing
Date, which have not been recorded in the LA Company Financial Informationor disclosed in the Schedules hereto attached. 

          SECTION 9.03.  Survival of Indemnification Obligations.  (a) The right to claim for any indemnification due under this Agreement shall remain in full force and effect for the following terms:

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          (i) with respect to any and all Losses resulting from Tax related liabilities, for a maximum period of 5 (five) years as of the date hereof, except for homologation Taxes (“tributos de lançamento por homologação”), which right to claim shall remain in full force and effect for 10 (ten) years as of the date hereof, provided that such Tax related Loss results from acts or omissions, facts, events or circumstances of which the taxable event or origin occurred up to and including the date hereof;

          (ii) with respect to any and all Losses resulting from labor related liabilities, for a maximum period of 2 (two) years as of the date hereof, provided that such labor related Loss results from acts or omissions, facts, events or circumstances occurred up to and including the date hereof;

          (iii) with respect to any and all Losses resulting from environmental related liabilities, for a maximum period of 5 (five) years as of the date hereof, provided that such other Loss results from acts or omissions, facts, events or circumstances occurred up to and including the date hereof; and

          (iv) with respect to any and all Losses resulting from civil, commercial or liabilities of any other nature, for a maximum period of 3 (three) years as of the date hereof, provided that such other Loss results from acts or omissions, facts, events or circumstances occurred up to and including the date hereof.

          (b) For the avoidance of doubt, the indemnification obligation set forth in this Article 9 shall encompass all Losses that are the subject matter of claims filed within the time limits established in Section 9.03(a) above, notwithstanding the fact that the obligation to make payments or disbursements only becomes enforceable after such dates.

          SECTION 9.04.  Limits on Indemnification.  (a) Subject to Section 9.04(b) below, IP’s total indemnification liability to the VCP Indemnified Parties pursuant to Section 9.01 with respect to Losses indemnifiable under this Agreement shall be limited to the maximum amount of US$20,000,000.00 (twenty million United States dollars).  The Parties agree that IP’s indemnification obligation towards any of the Indemnified Parties for Losses under this Section 9.04(a) shall be triggered only if and when the amount of such Losses exceeds US$1,000,000.00 (one million United States dollars), provided, however, that, with respect to labor related Losses, if the aggregate amount of such Losses exceeds such figure, including therein any Losses resulting from the labor claims disclosed in Schedule 4.11 hereto attached, IP shall only be liable for the amounts that
exceed that figure.

          (b) IP’s total indemnification liability to the Indemnified Parties with respect to environmental related Losses indemnifiable under this Agreement shall be limited to the maximum amount of US$40,000,000.00 (forty million United States dollars).  The Parties agree that IP’s indemnification obligation towards any of the Indemnified Parties for environmental related Losses under this Section 9.04(b) shall be triggered only if and when the amount of such Losses exceeds US$1,000,000.00 (one million United States dollars), provided, however, that if the aggregate amount of such environmental related Losses exceeds such figure, IP shall only be liable for the amounts that exceed that figure.

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          (c) The indemnification liability limits set forth in this Section 9.04 do not apply to breaches of the representation and warranties with respect to existence and power of IP, ownership and transferability of the Quotas and ownership to the Chamflora Assets, which shall not be subject to any limitation.

          SECTION 9.05.  Limits on Indemnification.  (a) Subject to Section 9.05(b) and (c) blow, VCP’s total indemnification liability to the IP Indemnified Parties with respect to Losses indemnifiable under this Agreement shall be limited to the maximum amount of US$ 50,000,000.00 (fifty million United States dollars). The Parties agree that VCP’s indemnification obligation towards any of the Indemnified Parties for Losses under this Section 9.05(a) shall be triggered only if and when the amount of such Losses exceeds US$1,000,000.00 (one million United States dollars), provided, however, that, with respect to labor related Losses, if the aggregate amount of such Losses exceeds such figure, VCP shall only be liable for the amounts that exceed that figure. 

          (b) VCP`s total indemnification liability to the IP Indemnified  Parties with respect to environmental related Losses indemnifiable under this Agreement shall be limited to the maximum amount of US$70,000,000.00 (seventy million United States dollars). The Parties agree that VCP`s indemnification obligation towards any of the Indemnified Parties for environmental related Losses under this Section 9.05(b) and Section 9.08 below shall be triggered only if and when the amount of such Losses exceeds US$1,000,000.00 (one million United States dollars), provided, however, that if the aggregate amount of such environmental related Losses exceeds such figure, VCP shall only be liable for the amounts that exceed that figure.

          (c) The indemnification liability limits set forth in this Section 9.05 do not apply to breaches of the representation and warranties with respect to existence and power of VCP, ownership and transferability of the Quotas and ownership to the assets and liabilities pertaining to the LA Establishment, which shall not be subject to any limitation.

          SECTION 9.06.  (a) VCP’s Obligations from Businesses other than the LA Establishment.  IP or the LA Company shall not be, in any event, liable for any obligation related to any past, existing or future businesses of VCP other than the LA Establishment, which shall remain under the responsibility of VCP, including, but not limited to, tax, labor or environmental obligations.  For the avoidance of doubt, if IP or the LA Company is compelled to pay for any such obligation of VCP, VCP shall indemnify and hold IP or the LA Company harmless, without any limit of time and value.  If VCP does not indemnify IP or the LA Company within 30 (thirty) days from the date of the request, VCP shall pay a 12% (twelve percent) interest per annum from the date of the request until the date of the actual payment.

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          (b) IP’s Obligations from Businesses other than Chamflora.  VCP or Chamflora shall not be, in any event, liable for any obligation related to any past, existing or future businesses of IP other than Chamflora, which shall remain under the responsibility of IP, including, but not limited to, tax, labor or environmental obligations.  For the avoidance of doubt, if VCP or Chamflora is compelled to pay for any such obligation of IP, IP shall indemnify and hold VCP or Chamflora harmless, without any limit of time and value.  If IP does not indemnify VCP or Chamflora within 30 (thirty) days from the date of the request, IP shall pay a 12% (twelve percent) interest per annum from the date of the request until the date of the actual payment. 

          SECTION 9.07.  Indemnification Procedures.  In the event that any action, suit, proceeding, demand, assessment or other notice of claim (“Claim”) is at any time instituted against or made upon any Indemnified Party for which indemnification may be due from IP or VCP pursuant to Sections 9.01 and 9.02 above, as the case may be, such Indemnified Party shall notify IP or VCP, as the case may be, in writing as soon as reasonably practical, which notice shall contain a description of the Claim and its subject matter in reasonable detail.  IP or VCP, as the case may be, may either decide to present a defense or counterclaim or pay the amount sought under the Claim.  In the event that IP or VCP, as the case may be, does not present a defense, counterclaim or pay the amount sought under the Claim within the two thirds of the period available for the
presentation of the relevant defense, IP or VCP, as the case may be, may assume the defense of the Claim.  In the event the Indemnified Party is obliged by a final court decision to pay any amount relating to any Claim for which IP or VCP, as the case may be, is liable, IP or VCP shall fund or reimburse such amount to the Indemnified Party within 30 (thirty) days counted as of the receipt, by IP, of written notification with evidence of such fact.

          SECTION 9.08. Specific Indemnification by VCP for Operating License. VCP further agrees to indemnify the IP Indemnified Parties, within the limits set forth in Section 9.05(b) above, from any and all Losses and for any criminal liability or charges resulting from any liability incurred by IP and/or the LA Company arising from the lack or insufficiency of the operating license of the LA Establishment for the production capacity of up to 410,000 tonnes of pulp per year incurred at any time before or after the Closing Date, until VCP has completed the whole licensing process, that is, the approval of Preliminary Environmental Report (RAP), if required, and the granting of the Previous, Installation and Operation Licenses to manufacture 410,000 tonnes of pulp per year, provided, however, that VCP`s indemnification obligation under this clause will only be enforceable if (a) the
LA Company pulp production has not exceeded 410,000 tonnes per year; and (b) there has not been any damage (physical, biological or to human health) to the LA Establishment after the Closing Date that impairs VCP’s ability to complete the licensing process of the LA Establishment. 

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          SECTION 9.09. Closing Date Balance Sheet Reimbursement. (a) IP shall cause LA Company to prepare an audited balance sheet as of the Closing Date, which will be delivered to IP and VCP within 75 days as from the Closing Date. In case such balance sheet reflects a difference in the sum of the accounts receivable, and inventory minus accounts payable, when compared to the same calculation based on the LA Company Financial Information (Section 5.07), then any negative difference will be reimbursed by VCP to LA Company, and any positive difference will be reimbursed by LA Company to VCP, within 5 (five) Business Days counted from the delivery of such audited closing date balance sheet. (b) In addition, on the same date provided above, VCP shall reimburse IP for the amount equal to the percentage of 5.25% per year applied on a pro rata basis to the amount of funding described in Section
6.11 as from the date of funding into Chamflora to the Closing Date, plus the amount of capital increases of Chamflora since May, 31, 2006 until the date hereof.

          SECTION 9.10. Ebitda Confirmation. VCP shall prior to Closing Date deliver to IP a letter confirming the Ebitda of the LA Establishment for the first semester of 2006 (according to Schedule 5.07), duly audited by PriceWaterhouseCoopers (the “Audited Ebitda”). In case the amount corresponding to the audited Ebitda is 20% lower than the Ebitda provided for in the LA Pro Forma Financial Information, the parties shall negotiate in good faith in order to reach an agreement to settle the above mentioned negative difference. If the parties fail to reach an agreement within 15 days after the delivery of the Audited Ebitda, IP shall be entitled to request the installation of an arbitration procedure as set forth in Section 11.01. The purpose of such arbitration shall be the determination of any Losses incurred by IP in connection with such negative difference. Any
indemnification award in favor of IP shall be limited to the amount of US$80,000,000 (eighty million dollars). For the avoidance of any doubt, any indemnification award as provided in this Section shall not be taken into consideration for the purposes of Section 9.05. 

ARTICLE 10
 TERMINATION

          SECTION 10.01.  Right to Terminate.  This Agreement may be terminated at any time prior to the Closing without liability or penalty to any of the Parties:

          (i) by the mutual written consent of the Parties; 

          (ii) by either Party in the event that any Governmental Authority shall have issued an order, decree or ruling or taken any other action restraining or otherwise prohibiting the transactions contemplated by this Agreement and such order, decree, ruling or other action shall have become final and unappealable;

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          (iii) by cause by any of the Parties if the other party is in material breach of any obligation of this Agreement that is not mitigated within a period of 10 (ten) days counted from the date that such breach is identified and informed to the party that is in breach;

          (iv) by VCP if the Conditions to Closing provided for in Section 8.01 hereof are not fulfilled or waived in writing until April 1, 2007.;

          (v) by IP (a) if the Conditions to Closing provided for in Section 8.02 hereof are not fulfilled or waived in writing until April 1, 2007. 

          SECTION 10.02.  Effects of Termination.  In the event of termination of this Agreement as provided in Section 10.01, this Agreement shall immediately become void and there shall be no liability on the part of any Party to this Agreement, except that:

          (i) the obligations under Sections 7.02, 7.03 and Article 11 will survive; and

          (ii) nothing in this Article 10 shall relieve either Party from liability for any breach, failure to perform or comply with this Agreement which has given the right to the other Party to exercise the right of termination pursuant to Section 10.1 of this Agreement;

          (iii) VCP shall reimburse IP for any expense and indemnify and hold the IP Indemnified Parties harmless from any and all Losses (including, without limitation, Losses claimed by third parties as a result of actions taken by IP to terminate agreements contemplated in Section 6.11, which were entered into pursuant to VCP’s written request, due to termination of this Agreement) incurred or suffered by any of the IP Indemnified Parties in connection with, relating to or as a result of any actions performed by the IP Indemnified Parties pursuant to VCP ́s written approval, without any of the time, threshold and total amount limitations set forth above for other indemnification obligations of VCP, to the extent Closing does not occur for any reason other than a willful breach by or negligence of IP under the terms of this Agreement. 

          In addition, IP shall have no liability for any contracts or agreements entered into pursuant to Section 6.11 by VCP’s written request, regardless of termination of this Agreement.

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          SECTION 10.03.  Remedies.  (a) At any time prior to the Closing, either Party may:

          (i) extend the time for the performance of any of the obligations or other acts of the other Party;

          (ii) waive any inaccuracies in the representations and warranties contained in this Agreement or in any document delivered pursuant to this Agreement; or

          (iii) waive compliance with any of the agreements or conditions contained in this Agreement.

          (b) This Agreement may only be terminated prior to Closing and in accordance with Section 10.01 of this Agreement.  After the Closing has taken place, the indemnification rights provided for in Article 9 of this Agreement shall be the sole and ultimate remedy available to the Parties with respect to any breach of the representations and warranties of the Parties in this Agreement, and/or any breach of any covenant or other term in this Agreement.

ARTICLE 11

DISPUTE RESOLUTION

          SECTION 11.01.  Arbitration.  (a) Any dispute arising between the Parties in connection with this Agreement, its interpretation, validity, performance, enforceability, breach or termination, shall be settled in an amicable way by the Parties by direct negotiations held in good faith for a term not exceeding 30 (thirty) calendar days.

          (b) If, upon expiration of the 30-days period, the Parties have not reached an amicable settlement, the dispute must be submitted to the decision of an arbitration panel and shall be finally settled under the rules of the AMCHAM CA.

          (c) The arbitrators shall be in the number of 3 (three).  VCP shall appoint 1 (one) arbitrator and IP shall appoint 1 (one) arbitrator.  The Parties designated arbitrators shall appoint the third arbitrator, who will be the chairman of the arbitration panel.

          (d) The arbitration shall be conducted in accordance with the AMCHAM CA rules.

          (e) The arbitration shall take place in the city of São Paulo and shall be conducted in the Portuguese language.

          (f) To the fullest extent permitted by law, the Parties waive their right to file any remedies against (including, but not limited to) the arbitration award and any defenses against its enforcement.  The arbitration award shall be final and binding for the Parties.  Specifically for purposes of any injunction procedure, whether of preventive, provisional or permanent nature, or even for purposes of the enforcement of the arbitration award, the Parties hereby elect the jurisdiction of the Central Courts of the City of São Paulo, State of São Paulo, with the exclusion of any other jurisdictions, no matter how privileged they may be.

41

ARTICLE 12
 MISCELLANEOUS

          SECTION 12.01.  Binding Effect.  This Agreement will be binding and inure to the benefit of the Parties and their respective legal successors.

          SECTION 12.02.  Assignability.  The rights and obligations set forth in this Agreement must not be assigned by any of the Parties, except (i) that IP is entitled to assign all of its rights and obligations arising from this Agreement to an Affiliate, provided that such Affiliate has agreed, in writing, to be bound to the terms and conditions of this Agreement; and (ii) with the written consent of the other Parties.

          SECTION 12.03.  Severability.  In case any term or provision set forth in this Agreement is considered invalid, illegal or not applicable, due to any legal provision or final court decision, all the other conditions and provisions hereto will remain in full force and effect.  In case any term or provision is considered invalid, illegal or inapplicable, the Parties will negotiate, in good faith, the amendment of this Agreement, so as to effect the original intent of the Parties hereto as closely as possible.

          SECTION 12.04.  Waiver; Amendment.  (a) No failure of delay in exercising any right, power or privilege hereunder will be considered as a waiver thereof, nor will any single or partial exercise thereof prevent the future exercise thereof or the exercise of any other right, power or privilege.  The rights and legal measures set forth herein will be cumulated and will not prevent any other rights or legal measures set forth in the law or in this Agreement.

          (b) Any provision of this Agreement may only be amended or waived if through written form and signed by all the Parties hereto.

          SECTION 12.05.  Notices.  All notices and communications required or allowed pursuant to this Agreement, will be made in written form, in English, and will be sent by registered mail, by fax (receipt confirmed) or e-mail (receipt confirmed), to the following addresses:

	
  
 
  	
  
If to VCP:
  
	
  
 
  	
  
 
  
	
  
 
  	
  
Votorantim   Celulose e Papel S.A.
  
	
  
 
  	
  
Al. Santos,   1357, 6th floor
  
	
  
 
  	
  
São Paulo,   SP  01470-908
  
	
  
 
  	
  
Attn.: Chief   Executive Officer
  

42

	
  
 
  	
  
if to IP:
  
	
  
 
  	
  
 
  
	
   
  	
  
International   Paper do Brasil Ltda.
  
	
  
 
  	
  
Attn.: Chief   Executive Officer
  
	
  
 
  	
  
Rodovia   SP-340, km 171
  
	
  
 
  	
  
Mogi Guaçu,   SP 13840-970
  
	
  
 
  	
  
Brazil
  
	
  
 
  	
  
 
  
	
  
 
  	
  
with copy   to:
  
	
  
 
  	
  
International   Paper do Brasil Ltda.
  
	
  
 
  	
  
Attn.:   General Counsel
  
	
  
 
  	
  
Rodovia   SP-340, km 171
  
	
  
 
  	
  
Mogi Guaçu,   SP 13840-970
  
	
   
  	
  
Brazil
  

          The Parties are entitled to amend, by means of written communication, pursuant to this Section 12.05, the addresses above.

          SECTION 12.06.  Expenses.  All costs and expenses incurred in connection with this Agreement and the transactions contemplated hereby will be paid by the Party incurring such cost or expense.

          SECTION 12.07.  Conversion Rate.  Any amounts in this Agreement expressed in United States dollars shall be converted into Reais by the average of the purchase and sale rates for United States dollars published by the Central Bank of Brazil on the Business Day immediately prior to the date on which any payment is due or conversion is to be made in accordance with the terms of this Agreement through the SISBACEN data system under rate PTAX 800, option 5 – L – Taxas para Contabilidade.

          SECTION 12.08.  Headings.  The headings of the sections of this Agreement are included for convenience purposes and will not in any way affect the meaning or the interpretation of this Agreement.

          SECTION 12.09.  Counterparts; Third Party Beneficiaries.  This Agreement may be signed in any number of counterparts, each of which will be an original, with the same effect as if the signatures thereto and hereto were upon the same instrument.  This Agreement will become effective when each Party hereto will have received a counterpart hereof signed by the other Party hereto.  No provision of this Agreement is intended to confer upon any Person other than the Parties hereto any rights or remedies hereunder.

43

          SECTION 12.10.  Entire Agreement.  This Agreement (including the Schedules hereto) constitute the entire agreement between the Parties with respect to the subject matter of this Agreement.

          SECTION 12.11.  Language.  This Agreement was negotiated and is signed in two original copies in the English language. The Parties agree to jointly arrange and approve a translation into Portuguese of this Agreement within 10 (ten) days counted from the date hereof. In any of the Parties identifies any discrepancy between the Portuguese and the English version of this agreement, at any time, the Parties agree to amend the Portuguese version in way to reflect as much as possible the intent of the English language. 

          SECTION 12.12.  Applicable Law.  This Agreement is governed and interpreted in accordance with the laws of the Federative Republic of Brazil.

IN WITNESS WHEREOF, the Parties hereto have caused this Agreement to be duly executed by their respective authorized officers, as of the day and year below, in the presence of the two witnesses named below.

São Paulo, September 19, 2006.

	
  

  	
  
 
  	
  

  
	
  Votorantim   Celulose e Papel S.A.
  	
  
 
  	
  
International Paper Investments 
   (Holland) B.V.
  
	
  
 
  	
  
 
  	
  
 
  
	
  
Witnesses:
  	
  
 
  	
  
 
  
	
  
 
  	
  
 
  	
  
 
  
	
  
1)   ____________________
  	
  
 
  	
  
2)   ____________________
  
	
  
Name:
  	
  
 
  	
  
Name:
  
	
  
ID:
  	
  
 
  	
  
ID:
  

44Exhibit 10.1

    Back
      to Form 8-K
      

    

    Exhibit
      10.1

     

     

    

      APPENDIX
        X 

      [Amendment
        Number 3]

       

      

      
        	
                 

                Agency
                  Code 12000 

              	
                 

                Contract
                  No. C020454

              
	
                 

                Period
                  1/1/07
                  - 9/30/08

              	
                 

                Funding
                  Amount for Period Based
                  on approved capitation rates

              

      

       

       

       

      This
        is
        an AGREEMENT between THE STATE OF NEW YORK, acting by and through The
        New York State Department of Health,
        having
        its principal office at Corning
        Tower, Room 2001. Empire State Plaza, Albany NY 12237.
        (hereinafter referred to as the STATE), and WellCare
        of New York. Inc.
        (hereinafter referred to as the CONTRACTOR), to modify Contract
        Number C020454
        as set
        forth below. The effective date of these modifications is January 1,
        2007.

       

      1.
        The
        attached "Table of Contents" will be applicable for the period beginning
        January
        1. 2007.

       

      2.
        Amend
        Section 10.13 "Emergency Services" to read as follows:

       

      10.13
        Emergency Services

       

      a)
        The
        Contractor shall maintain coverage utilizing a toll free telephone number
        twenty-four (24) hours per day seven (7) days per week, answered by a live
        voice, to advise Enrollees of procedures for accessing services for Emergency
        Medical Conditions and for accessing Urgently Needed Services. Emergency
        mental
        health calls must be triaged via telephone by a trained mental health
        professional.

       

      b)
        The
        Contractor shall advise its Enrollees how to obtain Emergency Services when
        it
        is not feasible for Enrollees to receive Emergency Services from or through
        a
        Participating Provider. The Contractor agrees to inform its Enrollees that
        access to Emergency Services is not restricted and that Emergency Services
        may
        be obtained from a Non-Participating Provider without penalty.

       

      c)
        The
        Contractor agrees to bear the cost of Emergency Services provided to Enrollees
        by Participating or Non-Participating Providers.

       

      d)
        The
        Contractor agrees to cover and pay for services as follows:

       

      i)
        Participating Providers

       

      A)
        Payment by the Contractor for general hospital emergency department services
        provided to an Enrollee by a Participating Provider shall be at the rate
        or
        rates of payment specified in the contract between the Contractor and the
        hospital. Such contracted rate or rates shall be paid without regard to whether
        such services meet the definition of Emergency Medical Condition.

       

      B)
        Payment by the Contractor for physician services provided to an Enrollee
        by a
        Participating Provider while the Enrollee is receiving general hospital
        emergency department services shall be at the rate or rates of payment specified
        in the contract between the Contractor and the physician. Such contracted
        rate
        or rates shall be paid without regard to whether such services meet the
        definition of Emergency Medical Condition.

       

      

      APPENDIX
        X 

      MMC/FHPlus
        Contract Amendment 

      January
        1, 2007 

      Page
        l

      

      ii)
        Non-Participating Providers

       

      A)
        Payment by the Contractor for general hospital emergency department services
        provided to an Enrollee by a Non-Participating Provider shall be at the Medicaid
        fee-for-service rate, inclusive of the capital component, in effect on the
        date
        that the service was rendered without regard to whether such services meet
        the
        definition of Emergency Medical Condition.

       

      B)
        Payment by the Contractor for physician services provided to an Enrollee
        by a
        Non-Participating Provider while the Enrollee is receiving general hospital
        emergency department services shall be at the Medicaid fee-for-service rate
        in
        effect on the date the service was rendered without regard to whether such
        services meet the definition of Emergency Medical Condition.

       

      e)
        The
        Contractor agrees that it will not require prior authorization for services
        in a
        medical or behavioral health emergency. Nothing herein precludes the Contractor
        from entering into contracts with providers or facilities that require providers
        or facilities to provide notification to the Contractor after Enrollees present
        for Emergency Services and are subsequently stabilized. The Contractor may
        not
        deny payments to a Participating Provider or a Non-Participating Provider
        for
        failure of the Emergency Services provider or Enrollee to give such
        notice.

       

      f)
        The
        Contractor agrees to abide by requirements for the provision and payment
        of
        Emergency Services and Post-stabilization Care Services which are specified
        in
        AppendixG,
        which is
        hereby made a part of this Agreement as if set forth fully herein.

       

      3.
        Amend
        Section 10.22 "Member Needs Relating to HTV" to read as
        follows:

       

      10.22
        Member Needs Relating to HIV

       

      a)
        The
        Contractor must inform MMC Enrollees newly diagnosed with HTV infection or
        AIDS,
        who are known to the Contractor, of their enrollment options including the
        ability to return to the Medicaid fee-for-service program or to disenroll
        from
        the Contractor's MMC product and to enroll into HTV SNPs, if such plan is
        available.

       

      b)
        The
        Contractor will inform Enrollees about HIV counseling and testing services,
        including Rapid HIV Testing, available through the Contractor's Participating
        Provider network; HIV counseling and testing services available when performed
        as part of a Family Planning and Reproductive Health encounter; and anonymous
        counseling and testing services available from SDOH, Local Public Health
        Agency
        clinics and other county programs. Counseling and testing rendered outside
        of a
        Family Planning and Reproductive Health encounter, as well as services provided
        as the result of an HTV+ diagnosis, will be furnished by the Contractor in
        accordance with standards of care.

       

      c)
        The
        Contractor agrees that anonymous testing may be furnished to the Enrollee
        without prior approval by the Contractor and may be conducted at anonymous
        testing sites. Services provided for HIV treatment may only be obtained from
        the
        Contractor during the period the Enrollee is enrolled in the Contractor's
        MMC or
        FHPlus product.

       

      APPENDIX
        X

      MMC/FHPlus
        Contract Amendment
        

      January
        1, 2007 

      Page
        2

      

       

      d)
        The
        Contractor shall implement policies and procedures consistent with CDC
        recommendations as published in the MMWR where consistent with New York State
        laws and SDOH Guidance for HIV Counseling & Testing and New Laboratory
        Reporting Requirements, including:

       

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

       

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

       

      iii)
        Policies and procedures that require Participating Providers to provide HIV
        counseling and recommend HTV testing to pregnant women in their care. Such
        policies and procedures shall be updated to reflect the most current CDC
        recommendations as published in the MMWR where consistent with New York State
        laws and SDOH Guidance on HIV Counseling and Testing. The HIV counseling
        and
        testing provided shall be done in accordance with Article 27-F of the PHL.
        Such
        policies and procedures shall also direct Participating Providers to refer
        any
        HTV positive women in their care to clinically appropriate services for both
        the
        women and their newborns.

       

      iv)
        A
        network of providers sufficient to meet the needs of its Enrollees with HIV.
        Satisfaction of the network requirement may be accomplished by inclusion
        of HIV
        specialists within the network or the provision of HIV specialist consultation
        to non-HTV specialists serving as PCPs for persons with HP/ infection; inclusion
        of Designated AIDS Center Hospitals or other hospitals experienced in HIV
        care
        in the Contractor's network; and contracts or linkages with
        providers funded under the Ryan White CARE Act. The Contractor shall inform
        Participating Providers about how to obtain information about the availability
        of Experienced HTV Providers and HTV Specialist PCPs.

       

      

       

      APPENDIX
        X

      MMC/FHPlus
        Contract Amendment 

      January
        1, 2007

      Page
        3

      

       

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

       

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

       

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

       

      4.
        Amend
        Section 18.3 "SDOH Instructions for Report Submissions" to read as
        follows:

       

      18.3
        SDOH
        Instructions for Report Submissions

       

      SDOH
        will
        provide Contractor with instructions for submitting the reports required
        by SDOH
        in Section 18.5 of this Agreement, including time frames, and requisite formats.
        The instructions, time frames and formats may be modified by SDOH upon sixty
        (60) days written notice to the Contractor.

       

      5.
        Delete
        Section 18.4 "Liquidated Damages. " and renumber Sections 18.5 "Notification
        of
        Changes in Report Due Dates, Requirements or Formats:" 18.6 "Reporting
        Requirements:" 18.7 "Ownership and Related Information Disclosure:" 18.8
        "Public
        Access to Reports;" 18.9 Professional Discipline: 18.10 "Certification Regarding
        Individuals Who Have Been Debarred Or Suspended By Federal, State, or Local
        Government;" 18.11 "Conflict of Interest Disclosure;" and 18.12 "Physician
        Incentive Plan Reporting," as Sections 18.4, 18.5, 18.6, 18.7, 18.8, 18.9,
        18.10. and 18.11 respectively.

       

      APPENDIX
         X

      MMC/FHPlus
        Contract Amendment 

      January
        1, 2007 

      Page
        4

      

       

      6.
        Add
        a
        new Section 22.7 "Recovery of Overpayments to Providers" to read as
        follows:

       

      22.7
        Recovery of Overpayments to Providers

       

      Consistent
        with the exception language in Section 3224-b of the Insurance Law,' the
        Contractor shall retain the right to audit participating providers' claims
        for a
        six year period from the date the care, services or supplies were provided
        or
        billed, whichever is later, and to recoup any overpayments discovered as
        a
        result of the audit. Th: s six year limitation does not apply to situations
        in
        which fraud may be involved or in which the provider or an agent of the provider
        prevents or obstructs the Contractor's auditing.

       

      7.
        Renumber
        Sections 22.7 "Restrictions on Disclosure:" 22.8 "Transfer of Liability;"
        22.9
        "Termination
        of Health Care Professional Agreements," 22.10 "Health Care Professional
        Hearings:" 22.11 "Non-Renewal of Provider Agreements;" 22.12 "Notice of
        Participating Provider Termination:" and 22.13 "Physician Incentive Plan:"
        as
        Sections 22.8, 22.9. 22.10. 22.11. 22.12.. 22.13. and 22.14
        respectively.

       

      8.
        The
        attached Appendix F "New York State Department of Health Action and Grievance
        System Requirements for MMC and FHPlus Programs" will be applicable for the
        period beginning January 1.2007.

       

      9.
        The
        attached Appendix G "SDOH Requirements for the Provision of Emergency Care
        and
        Services" will be applicable for the period beginning January 1.
        2007.

       

      10.
        The
        attached Appendix K "Prepaid Benefit Package Definitions of Covered and
        Non-Covered Services" will be applicable for the period beginning January
        1,
        2007.

       

      11.
        The attached Schedule 2 of Appendix M "LDSS Election of Enrollment in
        Medicaid Managed Care For Foster Care Children and Homeless Persons" will
        be
        applicable for the period beginning January
        1. 2007.

       

      12.
        Add
        a
        Section 13 "Provisions Related to New York State Procurement Lobbying Law"
        and a
        Section 14 "Provisions Related to New York State Information Security Breach
        and
        Notification Act" to Appendix R "Additional Specifications for the MMC and
        FHPlus Agreement" to read as follows:

       

      13.
        Provisions Related to New York State Procurement Lobbying Law

       

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

       

      14.
        Provisions Related to New York State Information Security Breach and
        Notification Act

       

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

       

      APPENDIX
        X

      MMC/FHPlus
        Contract Amendment 

      January
        1,2007 

      Page
        5

       

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

       

      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/
                  Todd Farha

              	
                 

                By:
                  /s/ Donna Frescatore

              
	
                 

                Printed
                  Name: Todd Farha

              	
                 

                Printed
                  Name: Donna Frescatore

              
	
                 

              	
                 

              
	
                Title: President & CEO

              	
                Title:
                  Deputy Director

                 

              
	 Date: December
                15, 2006	
                 Date: 12/27/2006

                 

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

      

       

       

      STATE
        OF
        FLORIDA

       

      County
        of
        Hillsborough

      On
        the
15th
        day
        of December 2006, before me personally appeared Todd S. Farha, to me
        known, who being by me duly sworn, did depose, that he/she resides at 345
        Bayshore Blvd. Tampa, FL, that he/she is the is the President and CEO
        of WellCare of New York, Inc., 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)

       

      /s/
        Andrea Rosa

       

      Title:

       

      Date:

       

      STATE
        COMPTROLLER'S SIGNATURE

       

      APPENDIX
        X

      MMC/FHPlus
        Contract Amendment 

      January
        1,2007 

      Page
        6

       

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

       

      Table
        of Contents for Model Contract

       

      Recitals

       

      Section
        1
        Definitions

       

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

      2.1
        Term

      2.2
        Amendments

      2.3
        Approvals

      2.4
        Entire Agreement

      2.5
        Renegotiation

      2.6
        Assignment and Subcontracting

      2.7
        Termination

      a.
        SDOH
        Initiated Termination

      b.
        Contractor and SDOH Initiated Termination

      c.
        Contractor Initiated Termination

      d.
        Termination Due to Loss of Funding

      2.8
        Close-Out Procedures

      2.9
        Rights and Remedies

      2.10
        Notices

      2.11
        Severability

       

      Section
        3
        Compensation

      3.1
        Capitation Payments

      3.2
        Modification of Rates During Contract Period

      3.3
        Rate
        Setting Methodology

      3.4
        Payment of Capitation

      3.5
        Denial of Capitation Payments

      3.6
        SDOH
        Right to Recover Premiums

      3.7
        Third
        Party Health Insurance Determination

      3.8
        Payment for Newborns

      3.9
        Supplemental Maternity Capitation Payment

      3.10
        Contractor Financial Liability

      3.11
        Inpatient Hospital Stop-Loss Insurance for Medicaid Managed Care (MMC) Enrollees
        

      3.12
        Mental Health and Chemical Dependence Stop-Loss for MMC Enrollees

      3.13
        Residential Health Care Facility Stop-Loss for MMC Enrollees

      3.14
        Stop-Loss Documentation and Procedures for the MMC Program

      3.15
        Family Health Plus (FHPlus) Reinsurance

      3.16
        Tracking Visits Provided by Indian Health Clinics — Applies to MMC Program
        Only

       

      Section
        4
        Service Area

       

      Section
        5 Reserved

       

      TABLE
        OF
        CONTENTS

      January
        1,2007 

      1

      

      Table
        of Contents for Model Contract

       

      

       

      Section
        6
        Enrollment

      6.1
        Populations Eligible for Enrollment

      6.2
        Enrollment Requirements

      6.3
        Equality of Access to Enrollment

      6.4
        Enrollment Decisions

      6.5
        Auto
        Assignment - For MMC Program Only

      6.6
        Prohibition Against Conditions on Enrollment

      6.7
        Newborn Enrollment

      6.8
        Effective Date of Enrollment

      6.9
        Roster

      6.10
        Automatic Re-Enrollment

       

      Section
        7
        Lock-In Provisions

      7.1
        Lock-In Provisions in MMC Mandatory Counties and for Family Health
        Plus

      7.2
        Disenrollment During a Lock-In Period

      7.3
        Notification Regarding Lock-In and End of Lock-In Period

      7.4
        Lock-In and Change in Eligibility Status

       

      Section
        8
        Disenrollment

      8.1
        Disenrollment Requirements

      8.2
        Disenrollment Prohibitions

      8.3
        Disenrollment Requests

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

      8.4
        Contractor Notification of Disenrollments

      8.5
        Contractor's Liability

      8.6
        Enrollee Initiated Disenrollment

      8.7
        Contractor Initiated Disenrollment

      8.8
        LDSS
        Initiated Disenrollment

       

      Section
        9
        Guaranteed Eligibility

      9.1
        General Requirements

      9.2
        Right
        to Guaranteed Eligibility

      9.3
        Covered Services During Guaranteed Eligibility

      9.4
        Disenrollment During Guaranteed Eligibility

       

      Section
        10 Benefit Package Requirements

      10.1
        Contractor Responsibilities

      10.2
        Compliance with State Medicaid Plan and Applicable Laws

      10.3
        Definitions

      10.4
        Child Teen Health Program/Adolescent Preventive Services

      10.5
        Foster Care Children - Applies to MMC Program Only

      10.6
        Child Protective Services

      10.7
        Welfare Reform - Applies to MMC Program Only

      10.8
        Adult Protective Services

      10.9
        Court-Ordered Services

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      10.10
        Family Planning and Reproductive Health Services

      10.11
        Prenatal Care 10.12 Direct Access

      10.13
        Emergency Services

      10.14
        Medicaid Utilization Thresholds (MUTS)

      10.15
        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

      10.16
        Second Opinions for Medical or Surgical Care

      10.17
        Coordination with Local Public Health Agencies

      10.18
        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
        -
        Applies to MMC Program Only

      10.19
        Adults with Chronic Illnesses and Physical or Developmental
        Disabilities

      10.20
        Children with Special Health Care Needs

      10.21
        Persons Requiring Ongoing Mental Health Services

      10.22
        Member. Needs Relating to HIV

      10.23
        Persons Requiring Chemical Dependence Services

      10.24
        Native Americans

      10.25
        Women, Infants, and Children (WIC)

      10.26
        Urgently Needed Services

      10.27
        Dental Services Provided by Article 28 Clinics Operated by Academic Dental
        Centers Not Participating in Contractor's Network- Applies to MMC
        Program Only

      10.28
        Hospice Services

      10.29
        Prospective Benefit Package Change for Retroactive SSI Determinations -Applies
        to MMC Program Only

      10.30
        Coordination of Services

       

      Section
        11 Marketing

      11.1
        Information Requirements

      11.2
        Marketing Plan

      11.3
        Marketing Activities

      11.4
        Prior Approval of Marketing Materials and Procedures

      11.5
        Corrective and Remedial Actions

       

      Section
        12 Member Services

      12.1
        General Functions

      12.2
        Translation and Oral Interpretation

      12.3
        Communicating with the Visually, Hearing and Cognitively Impaired

       

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      Section
        13 Enrollee Rights and Notification 

      13.1
        Information Requirements

      13.2
        Provider Directories/Office Hours for participating Providers

      13.3
        Member ID Cards

      13.4
        Member Handbooks

      13.5
        Notification of Effective Date of Enrollment

      13.6
        Notification of Enrollee Rights

      13.7
        Enrollee's Rights

      13.8
        Approval of Written Notices i

      13.9
        Contractor's Duty to Report Lack of Contact

      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 Action and Grievance System 

      14.1
        General Requirements 

      14.2
        Actions

      14.3
        Grievance System

      14.4
        Notification of Action and Grievance System Procedures

      14.5
        Complaint, Complaint Appeal and Action Appeal Investigation
        Determinations

      

      Section
        15 Access
        Requirements

      15.1
        General Requirement

      15.2
        Appointment Availability Standards

      15.3
        Twenty-Four (24) Hour Access

      15.4
        Appointment Waiting Times

      15.5
        Travel Time Standards

      15.6
        Service Continuation

      a.
        New
        Enrollees

      b.
        Enrollees Whose Health Care Provider Leaves Network

      15.7
        Standing Referrals

      15.8
        Specialist as a Coordinator of Primary Care

      15.9
        Specialty Care Centers 15.10 Cultural Competence

      

      Section
        16 Quality Assurance

      16.1
        Internal Quality Assurance Program

      16.2
        Standards of Care

      

      Section
        17 Monitoring
        and Evaluation

      17.1
        Right To Monitor Contractor Performance

      17.2
        Cooperation During Monitoring And Evaluation :

      17.3
        Cooperation During On-Site Reviews

      17.4
        Cooperation During Review of Services by External Review Agency

       

      

       

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      Section
        18 Contractor Reporting Requirements 

      18.1
        General Requirements

      18.2
        Time
        Frames for Report Submissions

      18.3
        SDOH
        Instructions for Report Submissions :

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

      18.5
        Reporting Requirements

      18.6
        Ownership and Related Information Disclosure

      18.7
        Public Access to Reports

      18.8
        Professional Discipline

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

      18.10
        Conflict of Interest Disclosure

      18.11
        Physician Incentive Plan Reporting

       

      Section
        19 Records Maintenance and Audit Rights

      19.1
        Maintenance of Contractor Performance Records

      19.2
        Maintenance of Financial Records and Statistical Data

      19.3
        Access to Contractor Records

      19.4
        Retention Periods

       

      Section
        20 Confidentiality

      20.1
        Confidentiality of Identifying Information about Enrollees, Potential Enrollees,
        and Prospective Enrollees

      20.2
        Medical Records of Foster Children

      20.3
        Confidentiality of Medical Records

      20.4
        Length of Confidentiality Requirements

       

      Section
        21 Provider Network

      21.1
        Network Requirements

      21.2
        Absence of Appropriate Network Provider

      21.3
        Suspension of Enrollee Assignments to Providers

      21.4
        Credentialing

      21.5
        SDOH
        Exclusion or Termination of Providers

      21.6
        Application Procedure

      21.7
        Evaluation Information

      21.8
        Choice/Assignment of Primary Care Providers (PCPs)

      21.9
        Enrollee PCP Changes

      21.10
        Provider Status Changes

      21.11
        PCP
        Responsibilities

      21.12
        Member to Provider Ratios

      21.13
        Minimum PCP Office Hours 

      a.
        General Requirements 

      b.
        Waiver
        of Minimum Hours

      21.14
        Primary Care Practitioners

      a.
        General Limitations 

      b.
        Specialists and Sub-specialists as PCPs

       

      

       

      

       

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      c.
        OB/GYN
        Providers as PCPs 

      d.
        Certified Nurse Practitioners as PCPs

      21.15
        PCP
        Teams 

      a.
        General Requirements

      b.
        Registered Physician Assistants as Physician Extenders 

      c.
        Medical Residents and Fellows

      21.16
        Hospitals

      a.
        Tertiary Services 

      b.
        Emergency Services 

      21.17
        Dental Networks

      21.18
        Presumptive Eligibility Providers

      21.19
        Mental Health and Chemical Dependence Services Providers

      21.20
        Laboratory Procedures

      21.21
        Federally Qualified Health Centers (FQHCs)

      21.22
        Provider Services Function

      21.23
        Pharmacies - Applies to FHPlus Program Only

       

      Section
        22 Subcontracts and Provider Agreements

      22.1
        Written Subcontracts

      22.2
        Permissible Subcontracts

      22.3
        Provision of Services Through Provider Agreements

      22.4
        Approvals 

      22.5
        Required Components

      22.6
        Timely Payment

      22.7
        Recovery of Overpayments to Providers

      22.8
        Restrictions on Disclosure

      22.9
        Transfer of Liability

      22.10
        Termination of Health Care Professional Agreements

      22.11
        Health Care Professional Hearings

      22.12
        Non-Renewal of Provider Agreements

      22.13
        Notice of Participating Provider Termination

      22.14
        Physician Incentive Plan

       

      Section
        23 Fraud and Abuse

      23.1
        General Requirements

      23.2
        Prevention Plans and Special Investigation Units

       

      Section
        24 Americans with Disabilities Act (ADA) Compliance Plan

       

      Section
        25 Fair Hearings

      25.1
        Enrollee Access to Fair Hearing Process

      25.2
        Enrollee Rights to a Fair Hearing

      25.3
        Contractor Notice to Enrollees

      25.4
        Aid
        Continuing

      25.5
        Responsibilities of SDOH

      25.6
        Contractor's Obligations

      

      

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      Section
        26 External Appeal

      26.1
        Basis for External Appeal 

      26.2
        Eligibility For External Appeal

      26.3
        External Appeal Determination

      26.4
        Compliance With External Appeal Laws and Regulations

      26.5
        Member Handbook

       

      Section
        27 Intermediate Sanctions

      27.1
        General

      27.2
        Unacceptable Practices

      27.3
        Intermediate Sanctions

      27.4
        Enrollment Limitations

      27.5
        Due
        Process

       

      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
        Indemnification by Contractor

      32.2
        Indemnification by SDOH

       

      Section
        3
        3 Prohibition on Use of Federal Funds for Lobbying

      33.1
        Prohibition of Use of Federal Funds for Lobbying

      33.2
        Disclosure Form to Report Lobbying

      33.3
        Requirements of Subcontractors

       

      Section
        34 Non-Discrimination

      34.1
        Equal Access to Benefit Package

      34.2
        Non-Discrimination

      34.3
        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 SDOH 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

       

      

       

      

       

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      35.8
        Non-Liability of Enrollees For Contractor's Debts

      35.9
        SDOH
        Compliance With Conflict of Interest Laws

      35.10
        Compliance With Public Health Law (PHL) Regarding External Appeals

       

      Section
        36 New York State Standard Contract Clauses

      

      

      

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      APPENDICES

      

      A.
        New
        York State Standard Clauses 

      B.
        Certification Regarding Lobbying 

      B-l.
        Certification Regarding MacBride Fair Employment Principles

      C.
        New
        York State Department of Health Requirements 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 Action and Grievance System Requirements
        for the
        MMC and FHPlus Programs

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

      H.
        New
        York State Department of Health Requirements for the Processing of Enrollments
        and Disenrollments in the MMC and FHPlus Programs

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

      J.
        New
        York State Department of Health Guidelines for Contractor Compliance with
        the
        Federal ADA

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

      L.
        Approved Capitation Payment Rates

      M.
        Service Area, Benefit Options and Enrollment Elections

      N.
        RESERVED

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

      P.
        Facilitated Enrollment and Federal Health Insurance Portability and
        Accountability Act (HIPAA) Business Associate Agreements

      Q.
        RESERVED

      R.
        Additional Specifications for the MMC and FHPlus Agreement

       

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      X.
        Modification Agreement Form

      

      

      

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      APPENDIX
        F

       

      New
        York State Department of Health Action and Grievance System Requirements
        for MMC
        and FHPlus Programs

      

      

      F.I
        Action Requirements 

      F.2
        Grievance System Requirements

      APPENDIX
        F

      January
        1, 2007

      F-l

      

      F.1

       

      Action
        Requirements

       

      1. Definitions

       

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

      

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

       

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

       

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

       

      c)
        Adverse Determination means a denial of a Service Authorization Request by
        the
        Contractor or an approval of a Service Authorization Request in an amount,
        duration, or scope that is less than requested.

       

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

       

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

       

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

       

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

       

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

       

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

       

      vi)
        in
        rural areas, as defined by 42 CFR §412.62(f)(a), where enrollment in the MMC
        program is mandatory and there is only one MCO, the denial of an Enrollee's
        request to obtain services outside the MCO's network pursuant to 42 CFR
§438.52(b)(2)(ii).

      

      

      APPENDIX
        F 

      January
        1,2007

      F-2

       

      

       

       

      2.
        General Requirements

       

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

       

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

       

      ii)
        Any
        Action taken by the Contractor regarding medical necessity or experimental
        or
        investigational services must be made by a clinical peer reviewer as defined
        by
        PHL §4900(2)(a).

       

      iii)
        Adverse Determinations, other than those regarding medical necessity or
        experimental/investigational services, must be made by a licensed, certified
        or
        registered health care professional when such determination is based on an
        assessment of the Enrollee's health status or of the appropriateness of the
        level, quantity or delivery method of care. This requirement applies to Service
        Authorization Requests including but not limited to: services included in
        the
        Benefit Package, referrals and out-of-network services.

       

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

       

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

       

      3.
        Timeframes for Service Authorization Determinations

       

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

      

      

      

      APPENDIX
        F 

      January
        1,2007

      F-3

       

      

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

       

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

       

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

       

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

       

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

       

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

       

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

       

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

       

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

       

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

       

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

       

      APPENDIX
        F

      January
        1, 2007

      F-4

      

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

       

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

      

      A)
        the
        death of the Enrollee;

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

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

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

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

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

       

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

       

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

       

      5.
        Format and Content of Notices

       

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

       

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

       

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

      A)
        the
        reason for the extension;

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

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

      D)
        the
        right of the Enrollee to file a Complaint (as defined in Appendix F.2 of
        this
        Agreement)regarding the extension;

      

      

      APPENDIX
        F 

      January
        1, 2007 

      F-5

       

      

      E)
        the
        process for filing a Complaint with the Contractor and the timeframes within
        which a Complaint determination must be made;

      F)
        the
        right of an Enrollee to designate a representative to file a
        Complaint on
        behalf
        of the Enrollee; and 

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

       

      iii)
        Notice to the Enrollee of an Action shall include:

      

      A)
        the
        description of the Action the Contractor has taken or intends to
        take;

      B)
        the
        reasons for the Action, including the clinical rationale, if any;

      C)
        the
        Enrollee's right to file an Action Appeal (as defined in Appendix
        F.2 of this
        Agreement), including:

      I)
        The
        fact that the Contractor will not retaliate or take any discriminatory action
        against the Enrollee because he/she filed an Action Appeal. 

      II)
        The
        right of the Enrollee to designate a representative to file Action Appeals
        on
        his/her behalf;

      D)
        the
        process and timeframe for filing an Action Appeal with the Contractor, including
        an explanation that an expedited review of the Action Appeal can be requested
        if
        a delay would significantly increase the risk to an Enrollee's health, a
        toll-free number for filing an oral Action Appeal and a form, if used by
        the
        Contractor, for filing a written Action Appeal;

      E)
        a
        description of what additional information, if any, must be obtained by the
        Contractor from any source in order for the Contractor to make an Appeal
        determination;

      F)
        the
        timeframes within which the Action Appeal determination must be
        made;

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

      H)
        the
        notice entitled "Managed Care Action Taken" for denial of benefits or for
        termination or reduction in benefits, as applicable, containing the Enrollee's
        fair hearing and aid continuing rights.

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

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

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

      III)
        a
        statement that the Enrollee may be eligible for an External Appeal.

       

      6.
        Contractor Obligation to Notice

       

      a)
        The
        Contractor must provide written Notice of Action to Enrollees and providers
        in
        accordance with the requirements of this Appendix, including, but not limited
        to, the following circumstances (except as provided for in paragraph 6(b)
        below):

       

      

      APPENDIX
        F

      January
        1, 2007

      F-6

       

      

      i)
        the
        Contractor makes a coverage determination or denies a request for a referral,
        regardless
        of whether the Enrollee has received the benefit;

       

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

       

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

       

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

       

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

       

      vi)
        the
        Contractor denies a claim because it has determined that the Enrollee was
        not
        eligible for MMC or FHPlus coverage on the date of service;

       

      vii)
        the
        Contractor denies a claim for service rendered by a Participating Provider
        due
        to lack of a referral;

       

      viii)
        the
        Contractor denies a claim because it has determined it is not the appropriate
        payor; or

       

      ix)
        the
        Contractor denies a claim due to a Participating Provider billing for Benefit
        Package services not included in the Provider Agreement between the Contractor
        and the Participating Provider.

       

      b)
        The
        Contractor is not required to provide written Notice of Action to Enrollees
        in
        the following circumstances:

       

      i)
        When
        there is a prepaid capitation arrangement with a Participating Provider and
        the
        Participating Provider submits a fee-for-service claim to the Contractor
        for a
        service that falls within the capitation payment;

       

      ii)
        if a
        Participating Provider of the Contractor itemizes or "unbundles" a claim
        for
        services encompassed by a previously negotiated global fee
        arrangement;

       

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

       

      iv)
        if
        the claim is for a service that is carved-out of the MMC Benefit Package
        and is
        provided to a MMC Enrollee through Medicaid fee-for-service, however, the
        Contractor should notify the provider to submit the claim to
        Medicaid;

       

      v)
        if the
        Contractor makes a coding adjustment to a claim (up-coding or down-coding)
        and
        its Provider Agreement with the Participating Provider includes a provision
        allowing the Contractor to make such adjustments;

      

       

      

      APPENDIX
        F 

      January
        1,2007 

      F-7

       

      

      vi)
        if
        the Contractor has paid the negotiated amount reflected in the Provider
        Agreement with a Participating Provider for the services provided to the
        Enrollee and denies the Participating Provider's request for additional payment;
        or

       

      vii)if
        the Contractor has not yet adjudicated the claim. If the Contractor has pended
        the claim while requesting additional information, a notice is not required
        until the coverage determination has been made.

       

      

      APPENDIX
        F

      January
        1,2007

      F-8

      

      F.2

       

      Grievance
        System Requirements

       

      1.
        Definitions

       

      a)
        A
        Grievance System means the Contractor's Complaint and Appeal process, and
        includes a Complaint and Complaint Appeal process, a process to appeal Actions,
        and access to the State's fair hearing system.

       

      b)
        For
        the purposes of this Agreement, a Complaint means an Enrollee's
        expression of dissatisfaction
        with any aspect of his or her care other than an Action. A "Complaint" means
        the
        same as a "grievance" as defined by 42 CFR §438.400 (b).

       

      c)
        An
        Action Appeal means a request for a review of an Action.

       

      d)
        A
        Complaint Appeal means a request for a review of a Complaint determination.

       

      e)
        An
        Inquiry means a written or verbal question or request for information posed
        to
        the Contractor with regard to such issues as benefits, contracts, and
        organization rules. Neither Enrollee Complaints nor disagreements with
        Contractor determinations are Inquiries.

       

      2.
        Grievance System - General Requirements

       

      a)
        The
        Contractor shall describe its Grievance System in the Member Handbook, and
        itmust
        be
        accessible to non-English speaking, visually, and hearing impaired Enrollees.
        The handbook shall comply with Section 13.4 and The Member Handbook Guidelines
        (Appendix E) of this Agreement.

       

      b)
        The
        Contractor will provide Enrollees with any reasonable assistance in completing
        forms and other procedural steps for filing a Complaint, Complaint Appeal
        or
        Action Appeal, including, but not limited to, providing interpreter services
        and
        toll-free numbers with TTY/TDD and interpreter capability.

       

      c)
        The
        Enrollee may designate a representative to file Complaints, Complaint Appeals
        and Action Appeals on his/her behalf.

       

      d)
        The
        Contractor will not retaliate or take any discriminatory action against the
        Enrollee because he/she filed a Complaint, Complaint Appeal or Action
        Appeal.

       

      

      APPENDIX
        F

      January
        1, 2007

      F-9

       

      

      e)
        The
        Contractor's procedures for accepting Complaints, Complaint Appeals and Action
        Appeals shall include:

       

      i)
        toll-free telephone number;

       

      ii)
        designated staff to receive calls;

       

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

       

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

      

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

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

       

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

       

      i)
        A
        denial Action Appeal based on lack of medical necessity.

       

      ii)
        A
        Complaint regarding denial of expedited resolution of an Action
        Appeal.

       

      iii)
        A
        Complaint, Complaint Appeal, or Action Appeal that involves clinical
        issues.

       

      3.
        Action
        Appeals Process

      

      a)
        The
        Contractor's Action Appeals process shall indicate the following regarding
        resolution of Appeals of an Action:

       

      i)
        The
        Enrollee, or his or her designee, will have no less than sixty (60) business
        days from the date of the notice of Action to file an Action Appeal. An Enrollee
        filing an Action Appeal within 10 days of the notice of Action or by the
        intended date of an Action, whichever is later, that involves the reduction,
        suspension, or termination of previously approved services may request "aid
        continuing" in accordance with Section 25.4 of this Agreement.

       

      ii)
        The
        Enrollee may file a written Action Appeal or an oral Action Appeal. Oral
        Action
        Appeals must be followed by a written, signed, Action Appeal. The Contractor
        may
        provide a written summary of an oral Action Appeal to the Enrollee (with
        the
        acknowledgement or separately) for the Enrollee to review,

      

      

      APPENDIX
        F 

      January
        1, 2007 

      F-10

       

      

      modify
        if
        needed, sign and return to the Contractor. If the Enrollee or provider requests
        expedited resolution of the Action Appeal, the oral Action Appeal does  not
        need to be confirmed in writing. The date of the oral filing of the Action
        Appeal will be the date of the Action Appeal for the purposes of the timeframes
        for resolution of Action Appeals. Action Appeals resulting from a Concurrent
        Review must be handled as an expedited Action Appeal.

       

      iii)
        The
        Contractor must send a written acknowledgement of the Action Appeal within
        fifteen (15) days of receipt. If a determination is reached before the written
        acknowledgement is sent, the Contractor may include the written acknowledgement
        with the notice of Action Appeal determination (one notice).

       

      iv)
        The
        Contractor must provide the Enrollee reasonable opportunity to present evidence,
        and allegations of fact or law, in person as well as in writing. The Contractor
        must inform the Enrollee of the limited time to present such evidence in
        the
        case of an expedited Action Appeal. The Contractor must allow the Enrollee
        or
        his or her designee, both before and during the Action Appeals process, to
        examine the Enrollee's case file, including medical records and any other
        documents and records considered during the Action Appeals process. The
        Contractor will consider the Enrollee, his or her designee, or legal estate
        representative of a deceased Enrollee a party to the Action Appeal.

       

      v)
        The
        Contractor must have a process for handling expedited Action Appeals. Expedited
        resolution of the Action Appeal must be conducted when the Contractor determines
        or the provider indicates that a delay would seriously jeopardize the Enrollee's
        life or health or ability to attain, maintain, or regain maximum function.
        The
        Enrollee may request an expedited review of an Action Appeal. If the Contractor
        denies the Enrollee's request for an expedited review, the Contractor must
        handle the request under standard Action Appeal resolution timeframes, make
        reasonable efforts to provide prompt oral notice of the denial to the Enrollee
        and send written notice of the denial within two (2) days of the denial
        determination.

       

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

       

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

       

      APPENDIX
        F

      January
        1, 2007

      F-ll

      

      4.
        Timeframes for Resolution of Action Appeals

       

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

       

      i)
        The
        Contractor will resolve Action Appeals as fast as the Enrollee's condition
        requires, and no later than thirty (30) days from the date of the receipt
        of the
        Action Appeal.

       

      ii)
        The
        Contractor will resolve expedited Action Appeals as fast as the Enrollee's
        condition requires, within two (2) business days of receipt of necessary
        information and no later than three (3) business days of the date of the
        receipt
        of the Action Appeal.

       

      iii)
        Timeframes for Action Appeal resolution may be extended for up to fourteen
        (14)
        days if:

      

      A)
        the
        Enrollee, his or her designee, or the provider requests an extension orally
        or
        in writing; or

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

       

      iv)
        The
        Contractor will make a reasonable effort to provide oral notice to the Enrollee,
        his or her designee, and the provider where appropriate, for expedited Action
        Appeals at the time the Action Appeal determination is made.

       

      v)
        The
        Contractor must send written notice to the Enrollee, his or her designee,
        and
        the provider where appropriate, within two (2) business days of the Action
        Appeal determination.  

      

      5.
        Action Appeal Notices

       

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

       

      i)
        Notice
        to the Enrollee that the Enrollee's request for an expedited Action Appeal
        has
        been denied shall include that the request will be reviewed under standard
        Action Appeal timeframes, including a description of the timeframes. This
        notice
        may be combined with the acknowledgement.

       

      APPENDIX
        F

      January
        1, 2007

      F-12

      

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

      A)
        the
        reason for the extension;

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

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

      D)
        the
        right of the Enrollee to file a Complaint regarding the extension;

      E)
        the
        process for filing a Complaint with the Contractor and the timeframes within
        which a Complaint determination must be made;

      F)
        the
        right of an Enrollee to designate a representative to
        file a
        Complaint on behalf of the Enrollee; and 

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

       

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

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

      B)
        Date
        the Action Appeal process was completed; 

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

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

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

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

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

      II)
        the
        Enrollee's coverage type;

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

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

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

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

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

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

       

      APPENDIX
        F

      January
        1,2007

      F-13

      

       

      6.
        Complaint Process

       

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

       

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

       

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

       

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

       

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

       

      7.
        Timeframes for Complaint Resolution by the Contractor

      

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

       

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

       

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

      

      

      APPENDIX
        F 

      January
        1,2007 

      F-14

       

      

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

       

      8.
        Complaint Determination Notices

       

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

       

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

      A)
        the
        detailed reasons for the determination;

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

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

       

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

       

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

       

      9.
        Complaint Appeals

       

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

       

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

       

      ii)
        Within fifteen (15) business days of receipt of the Complaint Appeal, the
        Contractor shall provide written acknowledgement of the Complaint Appeal,
        including the name, address and telephone number of the individual designated
        to
respond
        to the Appeal. The Contractor shall indicate what additional information,
        if
        any, 

       

      APPENDIX
        F

      January
        1,2007

      F-15

      

      iii)
        Complaint Appeals of clinical matters must be decided by personnel qualified
        toreview
        the Appeal, including licensed, certified or registered healthcare
        professionals
        who did not make the initial determination, at least one
        of
        whom must
        be a
        clinical peer reviewer, as defined by PHL §4900(2)(a).

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

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

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

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

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

      A)
        the
        detailed reasons for the determination;

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

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

      D)
        instructions for any further Appeal, if applicable.

       

      10. Records

       

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

       

      i)
        date
        the Complaint was filed;

       

      ii)
        copy
        of the Complaint, if written;

       

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

       

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

       

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

       

      APPENDIX
        F

      January
        1,2007 

      F-16

      

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

       

      vii)
        necessary documentation to support any extensions;

       

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

       

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

       

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

      

      APPENDIX
        F 

      January
        1,2007

      F-17

      

      APPENDIX
        G

      

      

      SDOH
        Requirements for the Provision of Emergency Care and
        Services

      

      

      

      

      

      

      

      APPENDIX
        G

      January
        1, 2007

      G-l

      

      SDOH
        Requirements for the Provision of Emergency Care and
        Services

       

      1. Definitions

       

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

       

      i)
        placing the health of the person afflicted with such condition in serious
        jeopardy or, in the case of a pregnant woman, the health of the woman or
        her
        unborn child or, in the case of a behavioral condition, placing the health
        of
        the person or others in serious jeopardy; or

       

      ii)
        serious impairment to such person's bodily functions; or

       

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

       

      iv)
        serious disfigurement of such person.

       

      b)
        "Emergency Services"
        means
        covered inpatient and outpatient health care procedures, treatments or services
        that are furnished by a provider qualified to furnish these services and
        that
        are needed to evaluate or stabilize an Emergency Medical Condition including
        psychiatric stabilization and medical detoxification from drugs or
        alcohol.

       

      c)
        "Post-stabilization Care
        Services" means covered services, related to an emergency medical condition,
        that are provided after an Enrollee is stabilized in order to maintain the
        stabilized condition, or, under the circumstances described in Section 5
        below,
        to improve or resolve the Enrollee's condition.

       

      2.
        Coverage and Payment of Emergency Services

       

      a)
        The
        Contractor must cover and pay for Emergency Services regardless of whether
        the
        provider that furnishes the services has a contract with the
        Contractor.

       

      b)
        The
        Contractor shall cover and pay for services as follows:

       

      i)
        Participating Providers

       

      A)
        Payment by the Contractor for general hospital emergency department services
        provided to an Enrollee by a Participating Provider shall be at the rate
        or
        rates of payment specified in the contract between the Contractor
        and

      

      

      APPENDIX
        G 

      January
        1,2007 

      G-2

       

      

      the
        hospital. Such contracted rate or rates shall be paid without regard to whether
        such services meet the definition of Emergency Medical Condition.

       

      B)
        Payment by the Contractor for physician services provided to an Enrollee
        by a
        Participating Provider while the Enrollee is receiving general hospital
        emergency department services shall be at the rate or rates of payment specified
        in the contract between the Contractor and the physician. Such contracted
        rate
        or rates shall be paid without regard to whether such services meet the
        definition of Emergency Medical Condition.

       

      ii)
        Non-Participating Providers

       

      A)
        Payment by the Contractor for general hospital emergency department services
        provided to an Enrollee by a Non-Participating Provider shall be at the Medicaid
        fee-for-service rate, inclusive of the capital component, in effect on the
        date
        that the service was rendered without regard to whether such services meet
        the
        definition of Emergency Medical Condition.

       

      B)
        Payment by the Contractor for physician services provided to an Enrollee
        by a
        Non-Participating Provider while the Enrollee is receiving general hospital
        emergency department services shall be at the Medicaid fee-for-service rate in
        effect on the date the service was rendered without regard to whether such
        services meet the definition of Emergency Medical Condition.

       

      c)
        The
        Contractor must advise Enrollees that they may access Emergency Services
        at any
        Emergency Services provider.

       

      d)
        Prior
        authorization for treatment of an Emergency Medical Condition is never
        required.

       

      e)
        The
        Contractor may not deny payment for treatment obtained in either of the
        following circumstances:

       

      i)
        An
        Enrollee had an Emergency Medical Condition, including cases in which the
        absence of immediate medical attention would not have had the outcomes specified
        in the definition of Emergency Medical Condition above.

       

      ii)
        A
        representative of the Contractor instructs the Enrollee to seek Emergency
        Services.

       

      f)
        A
        Contractor may not:

       

      i)
        limit
        what constitutes an Emergency Medical Condition based on lists of diagnoses
        or
        symptoms; or

       

      ii)
        refuse to cover emergency room services based on the failure of the provider
        or
the
        Enrollee to give the Contractor notice of the emergency room
        visit.

       

      APPENDIX
        G 

      January
        1,2007 

      G-3

       

      

       

      g)
        An
        Enrollee who has an Emergency Medical Condition may not be held liable for
        payment of subsequent screening and treatment needed to diagnose the specific
        condition or stabilize the patient. .

       

      h)
        The
        attending emergency physician, or the provider actually treating the Enrollee,
        is responsible for determining when the Enrollee is sufficiently stabilized
        for
        transfer or discharge, and that determination is binding on the Contractor
        for
        payment.

       

      3.
        Coverage and Payment of Post-stabilization Care Services

       

      a)
        The
        Contractor is financially responsible for Post-stabilization Care Services
        furnished by a provider within or outside the Contractor's network
        when:

       

      i)
        they
        are pre-approved by a Participating Provider, as authorized by the Contractor,
        or other authorized Contractor representative;

       

      ii)
        they
        are not pre-approved by a Participating Provider, as authorized by the
        Contractor, or other authorized Contractor representative, but administered
        to
        maintain the Enrollee's stabilized condition within one (1) hour of a request
        to
        the Contractor for pre-approval of further Post-stabilization Care
        Services;

       

      iii)
        they
        are not pre-approved by a Participating Provider, as authorized by the
        Contractor, or other authorized Contractor representative, but administered
        to
        maintain, improve or resolve the Enrollee's stabilized condition
        if:

      

      A)
        The
        Contractor does not respond to a request for pre-approval within one
        (l)hour;

       

      B)
        The
        Contractor cannot be contacted; or

       

      C)
        The
        Contractor's representative and the treating physician cannot reach an agreement
        concerning the Enrollee's care and a plan physician is not available for
        consultation. In this situation, the Contractor must give the treating physician
        the opportunity to consult with a plan physician and the treating physician
        may
        continue with care of the patient until a plan physician is reached or one
        of
        the criteria in 3(b) is met.

       

      iv)
        The
        Contractor must limit charges to Enrollees for Post-stabilization Care Services
        to an amount no greater than what the organization would charge the Enrollee
        if
        he or she had obtained the services through the Contractor.

       

      b)
        The
        Contractor's financial responsibility to the treating emergency provider
        for
        Post-stabilization Care Services it has not pre-approved ends when:

       

      i)
        A plan
        physician with privileges at the treating hospital assumes responsibility
        for
        the Enrollee's care;

       

      

      APPENDIX
        G 

      January
        1,2007 

      G-4

       

      

      ii)
        A
        plan physician assumes responsibility for the Enrollee's care through
        transfer;

       

      iii)
        A
        Contractor representative and the treating physician reach an agreement
        concerning the Enrollee's care or

       

      iv)
        The
        Enrollee is discharged. 

       

      4.
        Protocol for Acceptable Transfer Between Facilities

       

      a)
        All
        relevant COBRA requirements must be met.

       

      b)
        The
        Contractor must provide for an appropriate (as determined by the
        emergency department physician) transfer method/level with personnel as
        needed.

       

      c)
        The
        Contractor must contact/arrange for an available, accepting physician and
        patient bed at the receiving institution.

       

      d)
        If a
        patient is not transferred within eight (8) hours to an appropriate inpatient
        setting after the decision to admit has been made, then admission at the
        original facility is deemed authorized.

       

      5.
        Emergency Transportation

       

      When
        emergency transportation is included in the Contractor's Benefit Package,
        the
        Contractor shall reimburse the transportation provider for all emergency
        ambulance services without regard to final diagnosis or prudent layperson
        standards.

      

      APPENDIX G

      January
        1,2007

      G-5

      

      APPENDIX
        K

       

      PREPAID
        BENEFIT PACKAGE DEFINITIONS OF COVERED AND NON-COVERED
        SERVICES

       

      K.1
        Chart
        of Prepaid Benefit Package

      -
        Medicaid Managed Care Non-SSI (MMC Non-SSI)

      -
        Medicaid Managed Care SSI (MMC SSI)

      -
        Medicaid Fee-for-Service (MFFS)

      -
        Family
        Health Plus (FHPlus)

       

      K.2
        Prepaid Benefit Package Definitions of Covered Services

       

      K.3
        Medicaid Managed Care Definitions of Non-Covered Services

       

      K.4
        Family Health Plus Non-Covered Services

      

      

      

      

      

      

      APPENDIX
        K

      January
        1, 2007

      K-1

      

      APPENDIX
        K

      

      PREPAID
        BENEFIT PACKAGE DEFINITIONS OF COVERED AND NON-COVERED
        SERVICES

      

      1. General

       

      a)
        The
        categories of services in the Medicaid Managed Care and Family Health
        Plus Benefit Packages, including optional covered services, shall be
        provided by the Contractor to MMC Enrollees and FHPlus Enrollees, respectively,
        when medically necessary under the terms of this Agreement. The definitions
        of
        covered and non-covered services herein are in summary form; the full
        description and scope of each covered service as established by the New York
        Medical Assistance Program are set forth in the applicable NYS Medicaid Provider
        Manual, except for the Eye Care and Vision benefit for FHPlus Enrollees which
        is
        described in Section 19 of Appendix K.2.

       

      b)
        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, and emergency services, emergency transportation. Family Planning
        and Reproductive Health services, 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.

       

      c)
        This
        Appendix contains the following sections:

       

      i)
        K.1 -
        "Chart of Prepaid Benefit Package" lists the services provided by the
        Contractor to all Medicaid Managed Care Non-SSI Enrollees, Medicaid Managed
        Care
        SSI Enrollees, Medicaid fee-for-service coverage for carved out and wraparound
        benefits, and Family Health Plus Enrollees.

       

      ii)
        K.2 -
        "Prepaid Benefit Package Definitions Of Covered Services" describes the covered
        services, as numbered in K.I. Each service description applies to both MMC
        and
        FHPlus Benefit Package unless otherwise noted.

       

      iii)
        K.3
        - "Medicaid Managed Care Definitions of Non-Covered Services" describes services
        that are not covered by the MMC Benefit Package. These services are covered
        by
        the Medicaid fee-for-service program unless otherwise noted.

       

      iv)
        K.4 -
        "Family Health Plus Non-Covered Services" lists the services that are not
        covered by the FHPlus Benefit Package. There is no Medicaid fee-for-service
        coverage available for any service outside of the FHPlus Benefit
        Package.

       

      APPENDIX
        K

      January
        1, 2007 

      K-2

      

      K.1

      PREPAID
        BENEFIT PACKAGE

      

      
        	
                 

                *

              	
                 

                Covered
                  Services

              	
                 

                MMC
                  Non-SSI

              	
                 

                MMC
                  SSI

              	
                 

                MFFS

              	
                 

              	
                 

                FHPlus**

              
	
                 

                1.

              	
                 

                Inpatient
                  Hospital Services

              	
                 

                Covered,
                  unless admit date precedes Effective Date of Enrollment [see § 6.8 of this
                  Agreement]

              	
                 

                Covered,
                  unless admit date precedes Effective Date of Enrollment [see § 6.8 of this
                  Agreement]

              	
                 

                Stay
                  covered only when admit date precedes Effective Date of Enrollment
                  [see
                  §6.8 of this Agreement]

              	
                 

              	
                 

                Covered,
                  unless admit date precedes Effective Date of Enrollment [see §6.8 of this
                  Agreement]

              
	
                 

                2.

              	
                 

                Inpatient
                  Stay Pending Alternate Level of Medical Care

              	
                 

                Covered

              	
                 

                Covered

              	
                 

              	
                 

              	
                 

                Covered

              
	
                 

                3.

              	
                 

                Physician
                  Services

              	
                 

                Covered

              	
                 

                Covered

              	
                 

              	
                 

              	
                 

                Covered

              
	
                 

                4.

              	
                 

                Nurse
                  Practitioner Services

              	
                 

                Covered

              	
                 

                Covered

              	
                 

              	
                 

              	
                 

                Covered

              
	
                 

                5.

              	
                 

                Midwifery
                  Services

              	
                 

                Covered

              	
                 

                Covered

              	
                 

              	
                 

              	
                 

                Covered

              
	
                 

                6.

              	
                 

                Preventive
                  Health Services

              	
                 

                Covered

              	
                 

                Covered

              	
                 

              	
                 

              	
                 

                Covered

              
	
                 

                7.

              	
                 

                Second
                  Medical/Surgical Opinion

              	
                 

                Covered

              	
                 

                Covered

              	
                 

              	
                 

              	
                 

                Covered

              
	
                 

                8.

              	
                 

                Laboratory
                  Services

              	
                 

                Covered

              	
                 

                Covered

              	
                 

                HIV
                  phenotypic, virtual phenotypic and genotypic drug resistance
                  tests

              	
                 

              	
                 

                Covered

              
	
                 

                9.

              	
                 

                Radiology
                  Services

              	
                 

                Covered

              	
                 

                Covered

              	
                 

              	
                 

              	
                 

                Covered

              
	
                 

                10.

              	
                 

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

              	
                 

                Pharmaceuticals
                  and medical supplies routinely furnished or administered as part
                  of a
                  clinic or office visit, except Risperdal Consta [see Appendix K.3,
                  2. b)
                  xi) of this Agreement]

              	
                 

                Pharmaceuticals
                  and medical supplies routinely furnished or administered as part
                  of a
                  clinic or office visit, except Risperdal Consta [see Appendix
                  K.3,2.b)xi)of this Agreement]

              	
                 

                Covered
                  outpatient drugs from the list of Medicaid reimbursable prescription
                  drugs, subject to any applicable co-payments

              	
                 

              	
                 

                Covered,
                  may be limited to generic. Vitamins (except to treat an illness
                  or
                  condition), OTCs and medical supplies are not covered

              
	
                 

                11.

              	
                 

                Smoking
                  Cessation Products

              	
                 

              	
                 

              	
                 

                Covered

              	
                 

              	
                 

                Covered

              
	
                 

                12.

              	
                 

                Rehabilitation
                  Services

              	
                 

                Covered

              	
                 

                Covered

              	
                 

              	
                 

              	
                 

                Covered
                  for short term inpatient, and limited to 20 visits per calendar
                  year for
                  outpatient PT and OT

              
	
                 

                13.

              	
                 

                EPSDT
                  Services/Child Teen Health Program (C/THP)

              	
                 

                Covered

              	
                 

                Covered

              	
                 

              	
                 

              	
                 

                Covered

              

      

      

      APPENDIX
        K

      January
        1, 2007

      K-3

      *
        See K.2
        for Scope of Benefits

      

      Note:
        if
        cell is blank, there is no coverage

      

      **
        No
        Medicaid fee-for service-wrap around is available. Subject to applicable
        (o-pays.

      

      

      
        	
                 

                *

              	
                 

                Covered
                  Services

              	
                 

                MMC
                  Non-SSI

              	
                 

                MMC
                  SSI

              	
                 

                MFFS

              	
                 

              	
                 

                FHPlus
                  **

              
	
                 

                14.

              	
                 

                Home
                  Health Services

              	
                 

                Covered

              	
                 

                Covered

              	
                 

              	
                 

              	
                 

                Covered
                  for 40 visits in lieu of a skilled nursing facility stay
                  or hospitalization, plus 2 post partum home visits for high risk
                  women

              
	
                 

                15

              	
                 

                Private
                  Duty Nursing Services

              	
                 

                Covered

              	
                 

                Covered

              	
                 

              	
                 

              	
                 

                Not
                  Covered

              
	
                 

                16

              	
                 

                Hospice

              	
                 

              	
                 

              	
                 

                Covered

              	
                 

              	
                 

                Covered

              
	
                 

                17.

              	
                 

                Emergency
                  Services

                 

                 

                 

                Post-Stabilization
                  Care Services (see also Appendix G of this Agreement)

              	
                 

                Covered
                  

                 

                 

                 

                Covered
                  

                 

                 

              	
                 

                Covered
                  

                 

                 

                 

                Covered
                  

                 

                 

              	
                 

              	
                 

              	
                 

                Covered
                  

                 

                 

                 

                Covered
                  

                 

                 

              
	
                 

                18.

              	
                 

                Foot
                  Care Services

              	
                 

                Covered

              	
                 

                Covered

              	
                 

              	
                 

              	
                 

                Covered

              
	
                 

                19.

              	
                 

                Eye
                  Care and Low Vision Services

              	
                 

                Covered

              	
                 

                Covered

              	
                 

              	
                 

              	
                 

                Covered

              
	
                 

                20.

              	
                 

                Durable
                  Medical Equipment (DME)

              	
                 

                Covered

              	
                 

                Covered

              	
                 

              	
                 

              	
                 

                Covered

              
	
                 

                21.

              	
                 

                Audiology,
                  Hearing Aids Services & Products

              	
                 

                Covered
                  except for hearing aid batteries

              	
                 

                Covered
                  except for hearing aid batteries

              	
                 

                Hearing
                  aid batteries

              	
                 

              	
                 

                Covered,
                  including hearing aid batteries

              
	
                 

                22.

              	
                 

                Family
                  Planning and Reproductive Health Services

              	
                 

                Covered
                  if included in Contractor's Benefit Package as per Appendix M of
                  this
                  Agreement

              	
                 

                Covered
                  if included in Contractor's Benefit Package as per Appendix M of
                  Agreement

              	
                 

                Covered
                  pursuant to Appendix C of Agreement

              	
                 

              	
                 

                Covered
                  if included in Contractor's Benefit Package as per Appendix M of
                  this
                  Agreement or through the DTP Contractor

              
	
                 

                23.

              	
                 

                Non-Emergency
                  Transportation

              	
                 

                Covered
                  if included in Contractor's Benefit Package as per Appendix M of
                  this
                  Agreement

              	
                 

                Covered
                  if included in Contractor's Benefit Package as per Appendix M of
                  this
                  Agreement

              	
                 

                Covered
                  if not included in Contractor's Benefit Package

              	
                 

              	
                 

                Not
                  covered, except for transportation to C/THP services fir 19 and
                  20 year
                  olds

              
	
                24

              	
                Emergency
                  Transportation

              	
                Covered
                  if included in Contractor's Benefit Package as per Appendix M of
                  this
                  Agreement

              	
                Covered
                  if included in Contractor's Benefit Package as per Appendix M of
                  this
                  Agreement

              	
                Covered
                  if not included in Contractor's Benefit Package

              	
                 

              	
                Covered

              

      

      

      APPENDIX
        K

      January
        1,2007

      K-4

      

      *
        See K.2
        for Scope of Benefits

      **
        No
        Medicaid fee-for service-wrap around is available. Subject to applicable
        co-pays.

      

      Note:
        If
        cell is blank, there is no coverage.

      

       

      
        	
                 

                *

              	
                 

                Covered
                  Services

              	
                 

                MMC
                  Non-SSI

              	
                 

                MMCSSI

              	
                 

                MFFS

              	
                 

              	
                 

                FHPlus
                  **

              
	
                 

                25.

              	
                 

                Dental
                  Services

              	
                 

                Covered
                  if included in Contractor's Benefit Package as per Appendix M of
                  this
                  Agreement, except orthodontia

              	
                 

                Covered
                  if included in Contractor's Benefit Package as per Appendix M of
                  this
                  Agreement, except orthodontia

              	
                 

                Covered
                  if not included in the Contractor's Benefit Package, Orthodontia
                  in all
                  instances

              	
                 

              	
                 

                Covered,
                  if included in Contractor's Benefit Package as per Appendix M of
                  this
                  Agreement,
                  excluding orthodontia

              
	
                 

                26.

              	
                 

                Court-Ordered
                  Services

              	
                 

                Covered,
                  pursuant to court order (see also §10.9 of this

                 

                Agreement)

              	
                 

                Covered,
                  pursuant to court order (see also §10.9 of this Agreement)

              	
                 

              	
                 

              	
                 

                Covered,
                  pursuant to court order (see also § 0.9 of this
                  Agreement)

              
	
                 

                27.

              	
                 

                Prosthetic/Onhotic
                  Services/Orthopedic Footwear

              	
                 

                Covered

              	
                 

                Covered

              	
                 

              	
                 

              	
                 

                Covered,
                  except orthopedic shoes

              
	
                 

                28.

              	
                 

                Mental
                  Health Services

              	
                 

                Covered

              	
                 

              	
                 

                Covered
                  for SSI Enrollees

              	
                 

              	
                 

                Covered
                  subject to calendar year benefit limit of 30 days inpatient, 60
                  visits
                  outpatient, combined with chemical dependency services

              
	
                 

                29.

              	
                 

                Detoxification
                  Services

              	
                 

                Covered

              	
                 

                Covered

              	
                 

              	
                 

              	
                 

                Covered

              
	
                 

                30.

              	
                 

                Chemical
                  Dependence Inpatient Rehabilitation and Treatment Services

              	
                 

                Covered
                  subject to stop loss

              	
                 

              	
                 

                Covered
                  for SSI recipients

              	
                 

              	
                 

                Covered
                  subject to calendar year benefit limit 30 days combined with mental
                  health
                  services

              
	
                 

                31

              	
                 

                Chemical
                  Dependence Outpatient

              	
                 

              	
                 

              	
                 

                Covered

              	
                 

              	
                 

                Covered
                  subject to calendar year benefit limits of 60 visits combined with
                  mental
                  health services

              
	
                 

                32.

              	
                 

                Experimental
                  and/or Investigational) Treatment

              	
                 

                Covered
                  on a case by case basis

              	
                 

                Covered
                  on a case by case basis

              	
                 

              	
                 

              	
                 

                Covered
                  on a case by case basis

              
	
                 

                33.

              	
                 

                Renal
                  Dialysis

              	
                 

                Covered

              	
                 

                Covered

              	
                 

              	
                 

              	
                 

                Covered

              
	
                34.

              	
                Residential
                  Health Care Facility Services (RHCF)

              	
                Covered,
                  except for individuals in permanent placement

              	
                Covered,
                  except for individuals in permanent placement

              	
                 

              	
                 

              	
                 

              

      

      

      APPENDIX
        K

      January
        1,2007

      K-5

      *
        See K.2
        for Scope of Benefits

      **
        No
        Medicaid fee-for service wrap around is available. Subject to applicable
        co-pays.

      

      Note:
        If
        cell is blank, there is
        no
        coverage

       

      K.2

      PREPAID
        BENEFIT PACKAGE DEFINITIONS OF COVERED SERVICES

       

      Service
        definitions in this Section pertain to both MMC and FHPlus unless otherwise
        indicated.

       

      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). Contractor will not be responsible for hospital stays that commence
        prior to the Effective Date of Enrollment (see Section 6.8 of this Agreement),
        but will be responsible for stays that commence prior to the Effective Date
        of
        Disenrollment (see Section 8.5 of this Agreement). 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.

       

      2.
        Inpatient Stay Pending Alternate Level of Medical Care

       

      Inpatient
        stay pending alternate level of medical care, or continued care in a hospital,
        Article 31 mental health facility, or skilled nursing facility pending placement
        in an alternate lower medical level of care, consistent with the provisions
        of
        18 NYCRR § 505.20 and 10 NYCRR Part 85.

       

      3.
        Physician Services

       

      a)
        "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:

       

      i)
        within
        the scope of practice of medicine as defined in law by the New York State
        Education Department; and

       

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

       

      b)
        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.

       

      c)
        The
        following are also included without limitations:

      

      

      APPENDIX K

      January
        1, 2007

      K-6

       

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

       

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

       

      iii)
        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;

       

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

       

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

       

      vi)
        annual preventive health visits for adolescents;

       

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

       

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

       

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

       

      4.
        Certified Nurse Practitioner Services

       

      a)
        Certified 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.

       

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

       

      i)
        Child/Teen Health Program(C/THP) services which are comprehensive primary
        health
        care services provided to persons under twenty-one (21) (see Item 13 of this
        Appendix and Section 10.4 of this Agreement);

       

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

       

      

      APPENDIX
        K

      January
        1,2007

      K-7

       

      

      5.
        Midwifery Services

      SSA
§
        1905 (a)(17), Education Law § 695 l(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.

       

      6.
        Preventive Health Services

       

      a)
        Preventive health services means care and services to avert disease/illness
        and/or its consequences. There are three (3) levels of preventive health
        services: 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.

       

      b)
        The
        Contractor must offer the following preventive health services essential
        for
        promoting and preventing illness:

       

      i)
        General health education classes.

      ii)
        Pneumonia and influenza immunizations for at risk populations.

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

      iv)
        Childbirth education classes. 

      v)
        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. 

      vi)
        Nutrition counseling, with targeted outreach for diabetics and pregnant women.
        vii) Extended care coordination, as needed, for pregnant women. viii)HIV
        counseling and testing.

       

      7.
        Second Medical/Surgical Opinions

       

      The
        Contractor will allow Enrollees to obtain second opinions for diagnosis of
        a
        condition, treatment or surgical procedure by a qualified physician or
        appropriate specialist, including one affiliated with a specialty care center,
        m
        the event that the Contractor determines that it does not have a Participating
        Provider in its network with appropriate training and experience qualifying
        the
        Participating Provider to provide a second opinion, the Contractor shall
        make a
        referral to an appropriate Non-Participating Provider. The Contractor shall
        pay
        for the cost of the services associated with obtaining a second opinion
        regarding medical or surgical care, including diagnostic and evaluation
        services, provided by the Non-Participating Provider.

       

      APPENDIX K

      January
        1, 2007

      K-8

       

      

      8.
        Laboratory Services 

      18
        NYCRR
§ 505.7(a)

      

      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.

       

      b)
        All
        laboratory testing sites providing services under this Agreement 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 NYS Medicaid Provider
        Manual.

       

      c)
        For
        MMC only: coverage for HIV phenotypic, HP/ virtual phenotypic and HIV genotypic
        drug resistance tests are covered by Medicaid fee-for-service.

       

      9.
        Radiology Services

      18
        NYCRR
§ 505.17(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.

       

      10.
        Prescription and Non-Prescription (OTC) Drugs, Medical Supplies and Enteral
        Formulas

       

      a)
        For
        Medicaid fee-for-service only: Medically necessary prescription and
        non-prescription (OTC) drugs, medical supplies and enteral formula are covered
        when' ordered by a qualified provider.

       

      b)
        MMC
        Enrollees are covered for prescription drugs through the Medicaid
        fee-for-service program. Pharmaceuticals and medical supplies routinely
        furnished or administered as part of a clinic or office visit are covered
        by the
        MMC Program. Self-administered injectable drugs (including those administered
        by
        a family member) and injectable drugs administered during a home care visit
        are
        covered by Medicaid fee-for-service if the drug is on the list of Medicaid
        reimbursable prescription drugs or covered by the Contractor, subject to
        medical
        necessity, if the drug is not on the list of Medicaid reimbursable prescription
        drugs.

       

      APPENDIX K

      January
        1, 2007 

      K-9

       

      

      c)
        For
        Family Health Plus only:

       

      i)
        Prescription drugs are covered, but may be limited to generic medications
        where
        medically acceptable. All medications used for preventive and therapeutic
        purposes are covered, as well as family planning or contraceptive medications
        or
        devices.

       

      ii)
        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. Vitamins are not covered
        except when necessary to treat a diagnosed illness or condition.

       

      iii)
        Experimental investigational drugs are generally excluded, except where approved
        in the course of experimental/investigational treatment.

       

      iv)
        Drugs
        prescribed for cosmetic purposes are excluded.

       

      v)
        Over-the-counter items are excluded with the exception of diabetic supplies,
        including insulin and smoking cessation agents. Non-prescription (OTC) drugs
        and
        medical supplies are not covered.

       

      11.
        Smoking Cessation Products

       

      a)
        MMC
        Enrollees are covered for smoking cessation products through the Medicaid
        fee-for-service program.

       

      b)
        For
        Family Health Plus only: At least two courses of smoking cessation therapy
        per
        person per year, as medically necessary are covered. A course of therapy
        is
        defined as no more than a ninety (90)-day supply, (an original prescription
        and
        two (2) refills, even if less than a thirty (30)-day supply is dispensed
        in any
        fill). Duplicate e use of one agent is not allowed (i.e., same drug/same
        dosage
        form/same strength). Both prescription and over-the-counter therapies/agents
        are
        covered; this includes nicotine patches, inhalers, nasal sprays, gum, and
        Zyban
        (bupropion).

       

      12.
        Rehabilitation Services

      18
        NYCRR§505.11

       

      a)
        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

       

      

      APPENDIX
        K

      January
        1,2007

      K-10

       

       

      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. For the MMC Program, 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.

       

      b)
        For
        Family Health Pins only: Outpatient visits for physical and occupational
        therapy
        is limited to twenty (20) visits per calendar year. Coverage for speech therapy
        services is limited to those required for a condition amenable to significant
        clinical improvement within a two month period.

       

      13.
        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
        including outreach, education, appointment scheduling, administrative case
        management and transportation assistance.

       

      14.
        Home Health Services

      18
        NYCRR
§ 505.23(a)(3)

       

      a)
        Home
        health care services are provided to Enrollees in their homes by home health
        agency certified under Article 36 of the PHL (Certified Home Health Agency
        -
        CHHA). Home health services mean the following services when prescribed by
        a
        Provider and provided to a Enrollee in his or her home:

       

      i)
        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;

       

      ii)
        Physical therapy, occupational therapy, or speech pathology and audiology
        services; and

       

      iii)
        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.

      

      

      APPENDIX
        K 

      January
        1, 2007

      K-ll

       

      b)
        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.

       

      c)
        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. 

       

      d)
        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.

       

      e)
        For
        Family Health Plus only: coverage is limited to forty (40) home health care
        visits per calendar year in lieu of a skilled nursing facility stay or
        hospitalization. Post partum home visits apply only to high risk mothers.
        For
        the purposes of this Section, visit is defined as the delivery of a discreet
        service (e.g. nursing, OT, PT, ST, audiology or home health aide). Four (4)
        hours of home health aide services equals one visit.

       

      15.
        Private Duty Nursing Services - For MMC Program Only

       

      a)
        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, must be provided in the MMC Enrollee's home and can be provided
        through an improved certified home health agency, a licensed home care agency,
        or a private Practitioner.

       

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

       

      16.
        Hospice Services

       

      a)
        Hospice Services means a coordinated hospice program of home and inpatient
        services which provide non-curative medical and support services for Enrollees
        certified by a physician to be terminally ill with a life expectancy of six
        (6)
        months or less.

       

      b)
        Hospice services include palliative and supportive care provided to an Enrollee
        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. Hospices must be certified under Article 40
        of the
        New York
        State 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 Enrollee and the Enrollee's family. Family members
        are
        eligible for up to [five visits for bereavement counseling.

       

      
        APPENDIX
          K 

        January
          1, 2007

        K-l2

      

       

      c)
        Medicaid Managed Care Enrollees receive coverage for hospice services through
        me
        Medicaid fee-for-service program.

       

      17.
        Emergency Services 

       

      a)
        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. See also Appendix
        G
        of this Agreement.

       

      b)
        Post
        Stabilization Care Services means services related to an emergency medical
        condition that are provided after an Enrollee is stabilized in order to maintain
        the stabilized condition, or to improve or resolve the Enrollee's condition.
        These- services are covered pursuant to Appendix G of this
        Agreement.

       

      18.
        Foot Care Services

       

      a)
        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.

       

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

       

      c)
        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

      January
        1,2007 

      K-13

       

      

      19. Eye
        Care and Low Vision Services

      18
        NYCRR
§505.6(b)(l-3) SSL §369-ee (l)(e)(xii)

       

      a)
        For
        Medicaid Managed Care only:

       

      i)
        Emergency, preventive and routine eye care services are covered. 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. Eye care coverage includes the replacement of lost
        or
        destroyed eyeglasses. The replacement of a complete pair of eyeglasses must
        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 must duplicate
        the
        original prescription and frames. Repairs to, and replacements of, frames
        and/or
        lenses must be rendered as needed. 

       

      ii)
        If
        the Contractor does not provide upgraded eyeglass frames or additional features
        (such as scratch coating, progressive lenses or photo-gray lenses) as part
        of
        its covered vision benefit, the Contractor cannot apply the cost of its covered
        eyeglass benefit to the total cost of the eyeglasses the enrollee wants and
        bill
        only the difference to the Enrollee. The Enrollee can choose to purchase
        the
        upgraded frames and/or additional features by paying the entire cost of the
        eyeglasses as a private customer. For example, if the Contractor covers standard
        bifocal eyeglasses and the Enrollee wants no-line bifocal eyeglasses, the
        Enrollee must choose between taking the standard bifocal eyeglasses or paying
        the full price of the no-line bifocal eyeglasses (net just the difference
        between the cost of the bifocal lenses and the no-line lenses). The Enrollee
        must be informed of this fact by the vision care provider at the time that
        that
        the glasses are ordered.

       

      iii)
        Examinations for diagnosis and treatment for visual defects and/or eye disease
        are provided only as necessary and as required by the Enrollee's particular
        condition. Examinations which include refraction are limited to one every
        twenty
        four (24) months unless otherwise justified as medically necessary.

       

      iv)
        Eyeglasses do not require changing more frequently than once every twenty
        four
        (24) months unless medically indicated, such as a change in correction greater
        than 1/2 diopter, or unless the glasses are lost, damaged, or
        destroyed.

       

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

       

      vi)
        MMC
        Enrollees may self-refer to any Participating Provider of vision services
        (optometrist or ophthalmologist) for refractive vision services not more
        frequently than once every twenty four (24) months, or if otherwise justified
        as
        medically necessary or if eyeglasses are lost, damaged or destroyed as described
        above.

       

      

      APPENDIX
        K

      January
        1,2007 

      K-14

       

      b)
        For
        Family Health Plus only:

      i)
        Covered Services include emergency vision care and the following preventive
        and
        routine vision care provided once in any twenty four (24) month
        period:

      A)
        one
        eye examination;

      B)
        either: one pair of prescription eyeglass lenses and a frame,
        or
        prescription contact lenses when medically necessary; and

      C)
        one
        pair of medically necessary occupational eyeglasses.

       

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

       

      iii)
        FHPlus Enrollees may self-refer to any Participating Provider of vision services
        (optometrist or ophthalmologist) for refractive vision services not more
        frequently than once every twenty-four (24) months.

       

      iv)
        If
        the Contractor does not provide upgraded frames or additional features, that
        the
        Enrollee wants (such as scratch coating, progressive lenses or photo-gray
        lenses) as part of its covered vision benefit, the Contractor cannot apply
        the
        cost of its covered eyeglass benefit to the total cost of the eyeglasses
        the
        Enrollee wants and bill only the difference to the Enrollee. The Enrollee
        can
        choose to purchase the upgraded frames and/or additional features by paying
        the
        entire cost of the eyeglasses as a private customer. For example, if the
        Contractor covers standard bifocal eyeglasses and the Enrollee wants no-line
        bifocal eyeglasses, the Enrollee must choose between taking the standard
        bifocal
        glasses or paying the full price for the no-line bifocal eyeglasses (not
        just
        the difference between the cost of bifocal lenses and no-line lenses). The
        Enrollee must be informed of the fact by the vision care provider at the
        time
        that the glasses are ordered.

       

      v)
        Contact lenses are covered only when medically necessary. Contact lenses
        shall
        not be covered solely because the FHPlus Enrollee selects contact lenses
        in lieu
        of receiving eyeglasses.

       

      vi)
        Coverage does not
        include
        the replacement of lost, damaged or destroyed eyeglasses.

       

      vii)
        The
        occupational vision benefit for FHPlus Enrollees covers the cost of job-related
        eyeglasses if that need is determined by a Participating Provider through
        special testing done in conjunction with a regular vision examination. Such
        examination shall determine whether a special pair of eyeglasses would improve
        the performance of job-related activities. Occupational eyeglasses can be
        provided in addition to regular glasses hut are available only in conjunction
        with a regular vision benefit once in any twenty-four (24) month period.
        FHPlus
        Enrollees may purchase an upgraded frame or lenses for occupational eyeglasses
        by paying the entire cost as a private customer. Sun-sensitive and polarized
        lens ' options are not available for occupational eyeglasses.

       

      APPENDIX K

      January
        1,2007 

      K-15

       

       

       

       

      20.
        Durable Medical Equipment (DME)

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

       

      a)
        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 individial's use.
        Where equipment is intended for use by only one (1) person, it may be either
        custom made or customized.

       

      b)
        Coverage includes equipment servicing but excludes disposable medical
supplies.

       

      21.
        Audiology, Hearing Aid Services and Products

      18
        NYCRR
§505.31 (a)(l)(2) and Section 4.7 of the NYS Medicaid 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 healing 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.

       

      d)
        Hearing aid batteries:

       

      i)
        For
        Family Health Plus only: Hearing aid batteries are covered as part of the
        prescription drug benefit.

       

      ii)
        For
        Medicaid Managed Care only: Hearing aid batteries are
        covered
        through the Medicaid fee-for-service program.

      

      

      APPENDIX
        K 

      January
        1,2007 

      K-16

       

      22.
        Family Planning and Reproductive Health Care 

       

      a)
        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, as specified in Appendix C of this Agreement.

       

      b)
        HIV
        counseling and testing is included in coverage when provided as part of a
        Family
        Planning and Reproductive Health visit.

       

      c)
        All
        medically necessary abortions are covered, as specified in Appendix C of
        this
        Agreement.

       

      d)
        Fertility' services are not covered.

       

      e)
        If the
        Contractor excludes Family Planning and Reproductive Health services from
        its
        Benefit Package, as specified in Appendix M of this Agreement, the Contractor
        is
        required to comply with the requirements of Appendix C.3 of this Agreement
        and
        still provide the following services:

       

      i)
        screening, related diagnosis, ambulatory treatment, and referral to
        Participating Provider as needed for dysmenorrhea, cervical cancer or other
        pelvic abnormality/pathology;

       

      ii)
        screening, related diagnosis, and referral to Participating Provider for
        anemia,
        cervical cancer, glycosuria, proteinuria, hypertension, breast disease and
        ,
        pregnancy.

       

      23.
        Non-Emergency Transportation

       

      a)
        Transportation expenses are covered for MMC Enrollees when transportation
        is
        essential in order for a MMC 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 Medicaid fee-for-service). Non-emergent
        transportation' guidelines may be developed in conjunction with the LDSS,
        based
        on the LDSS' approved transportation plan.

       

      b)
        Transportation services means transportation by ambulance, ambulette fixed
        wing
        or airplane transport, invalid coach, taxicab, livery, public transportation,
        or
        other means appropriate to the MMC Enrollee's medical condition; and a
        transportation attendant to accompany the MMC 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 MMC Enrollee's family.

       

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

      

      

      APPENDIX
        K

      January
        1, 2007 

      K-17

       

       

      d)
        Non-emergency transportation is covered for FHPlus Enrollees that are nineteen
        (19) or twenty (20) years old and are receiving C/THP services.

       

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

       

      24.
        Emergency Transportation

      

      a)
        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 Services while the Enrollee
        is being transported.

       

      b)
        Emergency Services means the health care procedures, treatments or services
        needed to evaluate or stabilize an Emergency Medical Condition including,
        but
        not limited to, the treatment of trauma, bums, respiratory, circulatory and
        obstetrical emergencies.

       

      c)
        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.
        Contractor shall reimburse the transportation provider for all emergency
        ambulance services without regard for final diagnosis or prudent layperson
        standard.

       

      25.
        Dental Services

       

      a)
        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. Orthodontic services
        are
        not covered.

       

      b)
        Dental
        surgery performed in an ambulatory or inpatient setting is the responsibility
        of
        the Contractor whether dental services are included in the Benefit Package
        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. The
        Contractor shall set up procedures to prior approve dental services provided
        in
        inpatient and ambulatory settings.

       

      APPENDIX
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      January
        1,2007 

      K-18

      

       

       

      c)
        For
        Medicaid Managed Care only:

      

      i)
        As
        described in Sections 10.15 and 10.27 of this Agreement, Enrollees may
        self-refer to Article 28 clinics operated by academic dental centers to obtain
        covered dental services if dental services are included in the Benefit Package.
        

      ii)
        Professional services of a dentist for dental surgery performed in an ambulatory
        or inpatient setting are billed Medicaid fee-for-service if the Contractor
        does
        not include dental services in the benefit package.

       

      d)
        For
        Family Health Plus only: professional services of a dentist for dentel surgery
        performed in an ambulatory or inpatient setting are not covered.

       

      26.
        Court Ordered Services 

       

      Court
        ordered services are those services ordered by a court of competent jurisdiction
        which are performed by or under the supervision of a physician, dentist,
        or
        other provider qualified under State law to furnish medical, dental, behavioral
        health (including treatment for mental health and/or alcohol and/or substance
        abuse or dependence), or other covered services. The Contractor is responsible
        for payment of those services included in the benefit package.

       

      27.
        Prosthetic/Orthotic Orthopedic Footwear

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

       

      a)
        Prosthetics are those appliances or devices 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 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)
        Medicaid Managed Care: 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.

      

      28.
        Mental Health Services 

       

      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 PHL.

       

      APPENDIX
        K 

      January
        1,2007 

      K-19

       

      

      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 the New York State Office
        of
        Mental Health (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.

       

      c)
        Family
        Health Plus Enrollees have a combined mental health/chemical dependency benefit
        limit of thirty (30) days inpatient and sixty (60) outpatient visits per
        calendar year.

       

      d)
        MMC
        SSI Enrollees obtain all mental health services through the Medicaid
        fee-for-service program.

       

      29.
        Detoxification Services

       

      a)
        Medically Managed Inpatient Detoxification

       

      These
        programs provide medically directed twenty-four (24) 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 § 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.

       

      b)
        Medically Supervised Withdrawal

       

      i)
        Medically Supervised Inpatient Withdrawal

       

      These
        programs offer treatment for moderate withdrawal on an inpatient basis. Services
        must include medical supervision and direction under the supervision of a
        physician in the treatment for moderate withdrawal. Specific services must
        include, but are not limited to: medical assessment within twenty four (24)
        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
§
816.7.

       

      APPENDIX
        K

      January
        1,2007 

      K-20

       

      ii)
        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 under Title 14 NYCRR
§816.7.

       

      c)
        For
        Medicaid Managed Care only: all detoxification and withdrawal services are
        a
        covered benefit for all Enrollees, including those categorized as SSI or
        Sill-related. Detoxification Services in Article 28 inpatient hospital
        facilities are subject to the inpatient hospital stop-loss provisions specified
        in Section 3.11 of this Agreement.

       

      30.
        Chemical Dependence Inpatient Rehabilitation and Treatment
        Services

       

      a)
        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 the New York State Office of Alcoholism
        and Substance Abuse Services (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.
        

       

      b)
        Family
        Health Plus Enrollees have a combined mental health/chemical dependency benefit
        limit of thirty (30) days inpatient and sixty (60) outpatient visits per
        calendar year.

       

      31.
        Outpatient Chemical Dependency Services

       

      a)
        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.

       

      APPENDIX
        K

      January
        1,2007

      K-21

       

      

      b)
        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 §822.9.

       

      c)
        Outpatient Chemical Dependence for Youth Programs

       

      Outpatient
        Chemical Dependence for Youth Programs (OCDY) licensed under Tide 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.

       

      d)
        Medicaid Managed Care Enrollees access outpatient chemical dependency services
        through the Medicaid fee-for-service program.

       

      32.
        Experimental or Investigational Treatment

       

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

       

      b)
        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 the PHL under the following
        conditions:

       

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

       

      ii)
        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 Contractor, or

       

      C)
        for
        which there exists a clinical trial, and

       

      iii)
        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
        1,2007

      K-22

       

      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

       

      iv)
        The
        specific health service or procedure recommended by the attending physician
        would otherwise be covered except for the Contractor's determination that
        the
        health service or procedure is experimental or investigational.

       

      33.
        Renal Dialysis

       

      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.

       

      34.
        Residential Health Care Facility (RHCF) Services - For MMC Program
        Only

       

      a)
        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, twenty-four (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 MMC Enrollee:

       

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

       

      ii)
        Whose
        assessed health care needs, in the professional judgment of the MMC Enrollee's
        physician or a medical team: 

       

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

       

      B)
        cannot
        be met satisfactorily in the MMC 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

       

      C)
        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 MMC Enrollee in such setting in or near
        his
        or her community.

      APPENDIX
        K 

      January
        1, 2007
        

      K-23

       

      

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

       

      c)
        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 MMC Enrollees who are
        not in
        Permanent Placement Status as determined by LDSS.

      

      

      APPENDIX
        K

      January
        1,2007

      K-24

       

      

       

      K.3
        

       

      Medicaid
        Managed Care Prepaid Benefit Package 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:

       

      1.
        Medical Non-Covered Services

       

      a)
        Personal Care Agency Services 

       

      i)
        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 me 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).

       

      ii)
        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 to develop a
        plan
        of care.

       

      b)
        Residential Health Care Facilities (RHCF)

       

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

       

      c)
        Hospice Program

       

      i)
        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.

       

      ii)
        Hospices are organizations which must be certified under Article 40 of the
        PHL.
        All services must be provided by qualified employees and volunteers of
        the

      

      

      APPENDIX
        K 

      January
        1,2007 

      K-25

       

      

      hospice
        or by qualified staff through contractual arrangements to tile 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.

       

      iii)
        If
        an Enrollee 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.

       

      d)
        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 :ire items other than drugs, prosthetic or orthotic appliances,
        or DME
        which have beer, 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.

      

      2.
        Non-Covered Behavioral Health Services 

       

      a)
        Chemical Dependence Services

       

      i)
        Outpatient Rehabilitation and Treatment Services

       

      A)
        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 OASAS under 14 NYCRR  Part 828.

       

      B)
        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.

      

      

      APPENDIX
        K 

      January
        1,2007 

      K-26

       

      C)
        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 ,1 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 § 822.9. 

       

      D)
        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.

       

      ii)
        Chemical Dependence Services Ordered by the LDSS

       

      A)
        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:

       

      I)
        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

       

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

       

      B)
        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).

       

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

       

      D)
        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

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        1,2007 

      K-27

       

      b)
        Mental
        Health Services

       

      i)
        Intensive Psychiatric Rehabilitation Treatment Programs (BPRT)

       

      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.

       

      ii)
        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 Pan 587.

       

      iii)
        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.

       

      iv)
        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.

       

      v)
        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.

      

      

      APPENDIX
        K 

      January
        1,2007 

      K-28

       

      vi)
        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 Item 3 - "Other
        Non-Covered Services".

       

      vii)
        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.

       

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

       

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

       

      ix)
        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.

       

      x)
        Personalized Recovery Oriented Services (PROS)

       

      PROS,
        licensed and reimbursed pursuant to 14 NYCRR 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.

      

      

      APPENDIX
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      xi)
        Risperdal Consta, an injectable mental health drug used for management of
        patients with schizophrenia, furnished as part of a clinic or office
        visit.

       

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

       

      i)
        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.

       

      ii)
        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 :are and treatment.

       

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

       

      d)
        Office
        of Mental Retardation and Developmental Disabilities (OMRDD)
        Services

       

      i)
        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.

      

      

      APPENDIX
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        1,2007 

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      ii)
        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.

       

      iii)
        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
        Item 3
        "Other Non-Covered Services."

       

      iv)
        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 § 1915(c) waiver from
        DHHS.

       

      v)
        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

      

      

      APPENDIX
        K

      January
        1,2007 

      K-31

       

      coordination,
        respite and assistive technologies. Care at Home waiver services are authorized
        pursuant to a SSA § 1915(c) waiver from DHHS.

       

      3.
        Other
        Non-Covered Services

       

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

       

      i)
        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 and Mental Hygiene; Erie County - The Department of
        Youth
        Services; Jefferson County -the Office of Community Services; and Ulster
        County
        - the Department of Social Services).

       

      ii)
        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 eMedNY 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, through its Participating Providers, 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 (EFSP). 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.

       

      iii)
        SDOH
        will instruct the locally designated early intervention agencies on how to
        identify an Enrollee and the need to contact the Contractor or the
        Participating  Provider to coordinate service provision.

       

      b)
        Preschool Supportive Health Services-Children Three (3) Through Pour (4)
        Years
        of Age

       

      i)
        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.

       

      APPENDIX
        K

      January
        1,2007 

      K-32

      

       

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

       

      iii)
        The
        PSHSP services will be identified on eMedNY by unique rate code; 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.

       

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

       

      i)
        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.

       

      ii)
        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.

       

      iii)
        The
        SSHSP services are identified on eMedNY 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.

       

      d)
        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 tie 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 must 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.

       

      e)
        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

       

      

       

      APPENDIX
        K

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        1,2007

      K-33

       

      

      prescribed
        medication regimen. While the clinical management of tuberculosis is included
        in
        the Benefit Package, TB/DOT where applicable, can be billed directly to eMedNY
        by any SDOH approved Medicaid fee-for-service TB/DOT Provider. The Contractor
        remains responsible for communicating, cooperating and coordinating clinical
        management of TB with the TB/DOT Provider.

       

      f)
        AIDS
        Adult Day Health Care

       

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

       

      g)
        HIV
        COBRA Case Management

       

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

       

      h)
        Adult
        Day Health Care

       

      i)
        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.

       

      ii)
        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.

      

      

      APPENDIX
        K 

      January
        1,2007

      K-34

      

      

      

       

      i)
        Personal Emergency Response Services (PERS)

       

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

       

      j)
        School-Based Health Centers

       

      A
        School-Based Health Center (SBHC) is an Article 28 extension clinic that
        islocated
        in a school and provides students with primary and preventive physical
        andmental
        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.

       

      

       

      

      APPENDIX
        K

      January
        1,2007 

      K-35

       

      

       

      K.4

       

      Family
        Health Plus Non-Covered Services

       

      1. Non-Emergent
        Transportation Services (except for 19 and 20 year olds receiving
        C/THP

       

      Services)

      2. Personal
        Care Agency Services

      3. Private
        Duty Nursing Services

      4. Long
        Term
        Care - Residential Health Care Facility Services

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

      6. Alcohol
        and .Substance Abuse (ASA) Services Ordered by the LDSS

      7. Office
        of
        Mental Health/ Office of Mental Retardation and Developmental Disabilities
        Services

      8. School
        Supportive Health Services

      9. Comprehensive
        Medicaid Case Management (CMCM)

      10. Directly
        Observed Therapy for Tuberculosis Disease

      11. AIDS
        Adult Day Health Care

      12. HIV
        COBRA
        Case Management

      13. Home
        and
        Community Based Services Waiver

      14. Methadone
        Maintenance Treatment Program

      15. Day
        Treatment

      16. IPRT

      17. Infertility
        Services

      18. Adult
        Day
        Health Care

      19. School
        Based Health Care Services

      20. Personal
        Emergency Response Systems

      

      

      APPENDIX
        K

      January
        1, 2007

      K-36

       

      

      Schedule
        2 of Appendix M

       

      LDSS
        Election of Enrollment in Medicaid Managed Care For Foster Care Children
        and
        Homeless Persons

       

      1.
        Effective January 1, 2007, in the Contractor's service area, Medicaid Eligible
        Persons in the following categories will be eligible for Enrollment in the
        Contractor's Medicaid Managed Care product at LDSS's option as described
        in (a)
        and (b) as follows, and indicated by an "X" in the chart below:

       

      a)
        Options for foster care children in the direct care of LDSS:

       

      i)
        Children in LDSS direct care are mandatorily enrolled in MMC (mandatory counties
        only);

      ii)
        Children in LDSS direct care are enrolled in on a case by case basis in MMC
        (mandatory or voluntary counties);

      iii)
        All
        foster care children are Excluded from Enrollment in MMC (mandatory or voluntary
        counties).

       

      b)
        Options for homeless persons living in shelters outside of New York
        City:

       

      i)
        Homeless persons are mandatorily enrolled in MMC (mandatory counties
        only);

      ii)
        Homeless persons are enrolled in on a case by case basis in MMC (mandatory
        or
voluntary
        counties);

      iii)
        All
        homeless persons are Excluded from Enrollment in MMC (mandatory or voluntary
        counties).

       

      c) In
        the schedule below, an entry of "N/A" means not applicable for the purposes
        of
        this Agreement.

      

        
          	
                  Contractor:
                    WellCare of New York, hie.

                
	
                  County

                	
                  Foster
                    Care Children

                	
                  Homeless
                    Persons

                
	
                  Mandatorily
                    Enrolled

                	
                  Enrolled
                    on Case by Case Basis

                	
                  Excluded
                    from Enrollment

                	
                  Mandatorily
                    Enrolled

                	
                  Enrolled
                    on Case by Case Basis

                	
                  Excluded
                    from Enrollment

                
	
                  Albany

                	 	
                  x

                	 	 	
                  x

                	 
	
                  Columbia

                	 	
                  x

                	 	 	
                  x

                	 
	
                  Dutchess

                	 	
                  x

                	 	 	
                  x

                	 
	
                  Greene

                	
                  x

                	 	 	
                  x

                	 	 
	
                  Orange

                	 	
                  x

                	 	 	
                  x

                	 
	
                  Rensselaer

                	 	
                  x

                	 	 	
                  x

                	 
	
                  Rockland

                	 	
                  x

                	 	 	
                  x

                	 
	
                  Ulster

                	 	
                  x

                	 	 	
                  x

                	 

        

      

       

       

       

      APPENDIX M

      January
        1, 2007

      M-4

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