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exhibit10-6.htm

    
      
        

      

    

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      to Form 8-K

    Exhibit
      10.6

     

    
      Wellcare
        of Florida, Inc. d/b/a Staywell
        Healh Plan of Florida

      Medicaid
        Reform HMO Contract 

    

    
       

      AHCA
        CONTRACT NO. FAR009 

      AMENDMENT
        NO. 8

      

      THIS
        CONTRACT, entered into
        between the STATE OF FLORIDA,
        AGENCY FOR HEALTH CARE ADMINISTRATION, hereinafter referred to as the
        "Agency" and WELLCARE OF
        FLORIDA, INC., D/B/A STAYWELL HEALTH PLAN OF FLORIDA, hereinafter
        referred to as the "Vendor", is hereby amended as
        follows: 

      

      
        	
                1.

              	
                Standard
                  Contract, Section II, Item A, Contract Amount, the first sentence
                  is
                  hereby revised to now read as follows:

              

      

      

      
        	
                 

              	
                To
                  pay for contracted services according to the conditions of Attachment
                  I in
                  an amount not to exceed $260,332,646.00 (an increase of $26,554,643.00),
                  subject to availability of funds. 

              

      

      

      
        	
                2.

              	
                Attachment
                  I, Scope of Services, Section C, Method of Payment, Item 1, General,
                  the
                  first paragraph is hereby revised to now read as follows:
                  

              

      

      

      
        	
                 

              	
                Notwithstanding
                  the payment amounts which may be computed with the rate tables
                  specified
                  in Tables 2 thru 8, the sum of total capitation payments under
                  this
                  Contract shall not exceed the total Contract amount of $260,332,646.00
                  (an
                  increase of $26,554,643.00). 

              

      

      

      
        	
                3.

              	
                Attachment
                  I, Scope of Services, is hereby amended to include Exhibits 3-B,
                  5-C, 6-C,
                  and 9-B, attached hereto and made a part of the Contract. All references
                  in the Contract to Exhibits 3-A, 5-B, 6-B, and 9-A, shall hereinafter
                  instead refer to Exhibits 3-B, 5-C, 6-C, and 9-B.
                  

              

      

      

      
        	
                4.

              	
                This
                  Amendment shall have an effective date of January 1, 2008, or the
                  date on
                  which other parties execute the Amendment which ever is later.
                  

              

      

      

      All
        provisions in the Contract and any attachments thereto in conflict with this
        Amendment shall be and are hereby changed to conform with this
        Amendment.

       

      All
        provisions not in conflict with this Amendment are still in effect and are
        to be
        performed at the level specified in the Contract.

       

      This
        Amendment and all its attachments are hereby made a part of the
        Contract.

       

      This
        Amendment cannot be executed unless all previous amendments to this Contract
        have been fully executed.

      

      

      

      REMAINDER
        OF PAGE INTENTIONALLY LEFT BLANK

       

      AHCA
        Contract No. FAR009, Amendment No. 8, Page 1 of 2 

      
        
          
             

            

          

          
          

        

        
          
          

          
            

          

        

        
          
          

          
            Wellcare
              of Florida, Inc. d/b/a Staywell
              Healh Plan of Florida

            Medicaid
              Reform HMO Contract 

          

        

      

      

      IN
        WITNESS WHEREOF, the
        parties hereto have caused this seven (7) page amendment (which includes
        all
        attachments hereto) to be executed by their officials thereunto duly
        authorized. 

      

      
        	
                WELLCARE
                  OF FLORIDA, INC. D/B/A  STAYWELL HEALTH PLAN OF
                  FLORIDA

              	
                STATE
                  OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION

              
	
                SIGNED BY:   /s/  Todd
                  S.
                  Farha 

              	
                SIGNED
                  BY:   /s/  Illegible
                  

                (for)

              
	
                NAME: Todd
                  S.
                  Farha                                
                  

              	
                NAME: Andrew
                  C. Agwunobi, M.D.

              
	
                TITLE:  President
                  and CEO

              	
                TITLE: Secretary

              
	
                DATE:
                  1/2/08

              	
                DATE:
                  1/3/08

              

      

      

      

      List
        of Attachments/Exhibits included as part of this
        Amendment:                                              
        

      

      
        	 Specify Type      	 Letter/Number 
                	Description
	 Exhibit    	3-B     	Comprehensive
                and Catostrophic Component Captation Rates (2 Pages) 
	
                Exhibit

              	
                5-C

              	
                Capitation
                  Rates SSI Medicare Part B Only and SSI Medicare Parts A & B Enrollees
                  for All Medicaid Reform Counties (1 Page)

              

      

      
        	
                Exhibit

              	
                6-C

              	
                Capitation
                  Rates for HIV/AIDS Populations for Each Medicaid Reform County
                  (1 Page)
                  

              
	Exhibit	9-B 	Kick
                Payment Amounts for Covered Obstetrical Delivery Services (1 Page)
                

      

      

                                                            
        

      

      

      
        	
                REMAINDER
                  OF PAGE INTENTIONALLY LEFT BLANK

              

      

      
        
          
            AHCA
              Contract No. FAR009, Amendment No. 8, Page 2 of 2

            

          

          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      EXHIBIT
        3-B

      COMPREHENSIVE
        COMPONENT AND
        CATASTROPHIC COMPONENT CAPITATION RATES

       

      Jan
        1, 2008 

      TABLE
        2                 

      

      Area:
        10                                
County: Broward

      

      

      ESTIMATED
        HEALTH PLAN RATES (NOT FOR USE UNLESS APPROVED BY CMS)

      

      
        	
                Age
                    Range 

              	
                FY0708
                  

                 Discounted
                  

                Reform
                  rates 

                Under
                  Current Methodology 

              	
                Percentage
                  of Current Methodology 

              	
                50%
                  of Current Methodology 

              	
                Preliminary
                  FY0708 Base rates for Risk Adjusted Methodology 

              	
                Budget
                  Neutrality Factor 

              	
                FY0708
                  Base rates for Risk Adjusted Methodology after Budget Neutrality
                  

              	
                Percentage
                  of Risk Adjusted Methodology 

              	
                50%
                  of Risk Adjusted Methodology 

              	
                Final
                  Rates (with Enhanced Benefit Adjustment) 

              
	
                a
                  

              	
                b
                  

              	
                c
                  

              	
                d
                  

              	
                e
                  

              	
                f
                  

              	
                g
                  

              	
                h
                  

              	
                i
                  

              	
                j
                  

              
	
                Eligibility
                  Category: 

              	
                Children
                  and Family

              	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 
	
                 Month
                  0-2 All 

              	 	 	 	 	 	 	 	 	
                $
                  892.28 

              
	
                Month
                  3-11 All 

              	 	 	 	 	 	 	 	 	
                $
                  205.04 

              
	
                1-5
                  All 

              	
                $106.14
                  

              	
                50%
                  

              	
                $53.07
                  

              	
                $117.69
                  

              	
                1.07460
                  

              	
                $126.47
                  

              	
                50%
                  

              	
                $63.23
                  

              	
                $
                  112.09 

              
	
                6-13
                  All 

              	
                $82.94
                  

              	
                50%
                  

              	
                $41.47
                  

              	
                $117.69
                  

              	
                1.07460
                  

              	
                $126.47
                  

              	
                50%
                  

              	
                $63.23
                  

              	
                $
                  100.91 

              
	
                14-20
                  Female 

              	
                $115.00
                  

              	
                50%
                  

              	
                $57.50
                  

              	
                $117.69
                  

              	
                1.07460
                  

              	
                $126.47
                  

              	
                50%
                  

              	
                $63.23
                  

              	
                $
                  116.36 

              
	
                14-20
                  Male 

              	
                $79.98
                  

              	
                50%
                  

              	
                $39.99
                  

              	
                $117.69
                  

              	
                1.07460
                  

              	
                $126.47
                  

              	
                50%
                  

              	
                $63.23
                  

              	
                $
                  99.49 

              
	
                21-54
                  Female 

              	
                $202.08
                  

              	
                50%
                  

              	
                $101.04
                  

              	
                $117.69
                  

              	
                1.07460
                  

              	
                $126.47
                  

              	
                50%
                  

              	
                $63.23
                  

              	
                $
                  158.33 

              
	
                21-54
                  Male 

              	
                $146.71
                  

              	
                50%
                  

              	
                $73.35
                  

              	
                $117.69
                  

              	
                1.07460
                  

              	
                $126.47
                  

              	
                50%
                  

              	
                $63.23
                  

              	
                $
                  131.64 

              
	
                55+
                  All 

              	
                $325.58
                  

              	
                50%
                  

              	
                $162.79
                  

              	
                $117.69
                  

              	
                1.07460
                  

              	
                $126.47
                  

              	
                50%
                  

              	
                $63.23
                  

              	
                $
                  217.84 

              
	 	 	 	 	 	 	 	 	 	 
	
                Composite
                  Based on Total Casemonths 

              	
                $108.91
                  

              	 	 	 	 	
                $126.47
                  

              	 	
                $0.00
                  

              	
                $
                  113.43 

              
	 	 	 	 	 	 	 	 	 	 
	
                Eligibility
                  Category: 

              	
                Aged
                  and Disabled 

              	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 
	
                Month
                  0-2 All 

              	 	 	 	 	 	 	 	 	
                $
                  17,528.17 

              
	
                Month
                  3-11 All 

              	 	 	 	 	 	 	 	 	
                $
                  3,534.94 

              
	
                1-5
                  All 

              	
                $631.27
                  

              	
                50%
                  

              	
                $315.63
                  

              	
                $813.28
                  

              	
                1.06682
                  

              	
                $867.63
                  

              	
                50%
                  

              	
                $433.81
                  

              	
                $
                  722.31 

              
	
                6-13
                  All 

              	
                $355.68
                  

              	
                50%
                  

              	
                $177.84
                  

              	
                $813.28
                  

              	
                1.06682
                  

              	
                $867.63
                  

              	
                50%
                  

              	
                $433.81
                  

              	
                $
                  589.51 

              
	
                14-20
                  All 

              	
                $343.79
                  

              	
                50%
                  

              	
                $171.90
                  

              	
                $813.28
                  

              	
                1.06682
                  

              	
                $867.63
                  

              	
                50%
                  

              	
                $433.81
                  

              	
                $
                  583.78 

              
	
                21-54
                  All 

              	
                $930.27
                  

              	
                50%
                  

              	
                $465.13
                  

              	
                $813.28
                  

              	
                1.06682
                  

              	
                $867.63
                  

              	
                50%
                  

              	
                $433.81
                  

              	
                $
                  866.40 

              
	
                55+
                  All 

              	
                $965.71
                  

              	
                50%
                  

              	
                $482.85
                  

              	
                $813.28
                  

              	
                1.06682
                  

              	
                $867.63
                  

              	
                50%
                  

              	
                $433.81
                  

              	
                $
                  883.48 

              
	 	 	 	 	 	 	 	 	 	 
	
                Composite
                  Based on Total Casemonths 

              	
                $758.94
                  

              	 	 	 	 	
                $867.63
                  

              	 	
                $0.00
                  

              	
                $
                  783.84 

              

      

      

      

      REMAINDER
        OF PAGE INTENTIONALLY LEFT BLANK

      
        
          
            AHCA
              Contract No. FAR009, Exhibit 3-B, Page 1 of 2

          

          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      EXHIBIT
        3-B

      COMPREHENSIVE
        COMPONENT AND
        CATASTROPHIC COMPONENT CAPITATION RATES

      

      TABLE
        2

      

      Jan
        1,
        2008

      Area:
        4                                
        County: Duval, Baker,
        Clay, Nassau

      

      

      ESTIMATED
        HEALTH PLAN RATES (NOT FOR USE UNLESS APPROVED BY CMS)

      

      

      
        	
                Age
                  Range

              	
                FY0708
                  Discounted Reform rates Under Current Methodology

              	
                Percentage
                  of Current Methodology

              	
                50%
                  of Current Methodology

              	
                Preliminary
                  FY0708 Base rates for Risk Adjusted Methodology

              	
                Budget
                  Neutrality Factor

              	
                FY0708
                  Base rates for Risk Adjusted Methodology after Budget
                  Neutrality

              	
                Percentage
                  of Risk Adjusted Methodology

              	
                50%
                  of Risk Adjusted Methodology

              	
                  Final
                  Rates (with Enhanced Benefit Adjustment) 

              
	
                a

              	
                b

              	
                c

              	
                d

              	
                e

              	
                f

              	
                g

              	
                h

              	
                I

              	
                          j
                  

              
	
                Eligibility
                  Category:

              	
                Children
                  and Family 

              	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 
	
                Month
                  0-2 All

              	 	 	 	 	 	 	 	 	
                $
                  926.73 

              
	
                Month
                  3-11 All

              	 	 	 	 	 	 	 	 	
                $
                  215.12 

              
	
                1-5
                  All

              	
                $113.17

              	
                50%

              	
                $56.58

              	
                $124.53

              	
                1.04120

              	
                $129.66

              	
                50%

              	
                $64.83

              	
                $
                  117.02 

              
	
                6-13
                  All

              	
                $82.75

              	
                50%

              	
                $41.37

              	
                $124.53

              	
                1.04120

              	
                $129.66

              	
                50%

              	
                $64.83

              	
                $
                  102.36 

              
	
                14-20
                  Female

              	
                $119.81

              	
                50%

              	
                $59.91

              	
                $124.53

              	
                1.04120

              	
                $129.66

              	
                50%

              	
                $64.83

              	
                $
                  120.22 

              
	
                14-20
                  Male

              	
                $81.70

              	
                50%

              	
                $40.85

              	
                $124.53

              	
                1.04120

              	
                $129.66

              	
                50%

              	
                $64.83

              	
                $
                  101.85 

              
	
                21-54
                  Female

              	
                $218.13

              	
                50%

              	
                $109.06

              	
                $124.53

              	
                1.04120

              	
                $129.66

              	
                50%

              	
                $64.83

              	
                $
                  167.60 

              
	
                21-54
                  Male

              	
                $158.54

              	
                50%

              	
                $79.27

              	
                $124.53

              	
                1.04120

              	
                $129.66

              	
                50%

              	
                $64.83

              	
                $
                  138.88 

              
	
                55+
                  All

              	
                $350.55

              	
                50%

              	
                $175.28

              	
                $124.53

              	
                1.04120

              	
                $129.66

              	
                50%

              	
                $64.83

              	
                $
                  231.41 

              
	 	 	 	 	 	 	 	 	 	 
	
                Composite
                  Based on Total Casemonths

              	
                $119.40

              	 	 	 	 	
                $129.66

              	 	
                $0.00

              	
                $
                  120.02 

              
	
                Eligibility
                  Category:

              	
                Aged
                  and Disabled 

              	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 
	
                Month
                  0-2 All

              	 	 	 	 	 	 	 	 	
                $
                  14,558.96 

              
	
                Month
                  3-11 All

              	 	 	 	 	 	 	 	 	
                $
                  2,969.69 

              
	
                1-5
                  All

              	
                $537.41

              	
                50%

              	
                $268.70

              	
                $657.05

              	
                1.05080

              	
                $690.42

              	
                50%

              	
                $345.21

              	
                $
                  591.69 

              
	
                6-13
                  All

              	
                $312.13

              	
                50%

              	
                $156.06

              	
                $657.05

              	
                1.05080

              	
                $690.42

              	
                50%

              	
                $345.21

              	
                $
                  483.13 

              
	
                14-20
                  All

              	
                $296.53

              	
                50%

              	
                $148.27

              	
                $657.05

              	
                1.05080

              	
                $690.42

              	
                50%

              	
                $345.21

              	
                $
                  475.61 

              
	
                21-54
                  All

              	
                $790.16

              	
                50%

              	
                $395.08

              	
                $657.05

              	
                1.05080

              	
                $690.42

              	
                50%

              	
                $345.21

              	
                $
                  713.49 

              
	
                55+
                  All

              	
                $809.32

              	
                50%

              	
                $404.66

              	
                $657.05

              	
                1.05080

              	
                $690.42

              	
                50%

              	
                $345.21

              	
                $
                  722.72 

              
	 	 	 	 	 	 	 	 	 	 
	
                Composite
                  Based on Total Casemonths

              	
                $623.67

              	 	 	 	 	
                $690.42

              	 	
                $0.00

              	
                $
                  633.26 

              

      

      

      REMAINDER
        OF PAGE INTENTIONALLY LEFT BLANK

      
        
          
            AHCA
              Contract No. FAR009, Exhibit 3-B, Page 2 of 2

            

            

          

          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      EXHIBIT
        5-C

      CAPITATION
        RATES

      SSI
        MEDICARE PART B ONLY

      AND

      SSI
        MEDICARE PARTS A AND B ENROLLEES

      FOR
        ALL
        MEDICAID REFORM COUNTIES

      
        TABLE
          4

      

       

      Area:
        10                                           
County: Broward

      

      
        ESTIMATED
          HEALTH PLAN RATES (NOT FOR USE UNLESS APPROVED BY CMS) 

         

      

      
        	 	
                Under
                  Age 65

              	
                Age
                  65 & Over

              
	
                SSI/Parts
                  A & B

              	
                $149.01

              	
                $100.91

              
	
                SSI/Part
                  B Only

              	
                $244.40

              	
                $244.40

              

      

       

       

       

      
        	
                Area:  4

              	
                County:
                  Duval,
                  Baker, Clay, and Nassau

              

      

       

      
        ESTIMATED
          HEALTH PLAN RATES (NOT FOR USE UNLESS APPROVED BY CMS) 

         

      

      
      

      
        	 	
                Under
                  Age 65

              	
                Age
                  65 & Over

              
	
                 SSI/Parts
                  A & B

              	
                 $156.46

              	
                 $105.72

              
	
                 SSI/Part
                  B Only

              	
                 $362.68

              	
                 $362.68

              

      

      

      

      

      

      REMAINDER
        OF PAGE INTENTIONALLY LEFT BLANK

      
        
          
            AHCA
              Contract No. FAR009, Exhibit 5-C, Page 1 of 1

          

          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      EXHIBIT
        6-C

      CAPITATION
        RATES FOR HIV/AIDS POPULATIONS FOR EACH MEDICAID REFORM
        COUNTY

      

      

      
        	
                 

              	
                TABLE
                  5 

              

      

      

      
        	
                Area:
                  10

              	
                County:
                  __Broward_________
                  

              

      

      

      

      ESTIMATED
        HEALTH PLAN RATES (NOT FOR USE UNLESS APPROVED BY CMS)

      
        	 	
                Capitation
                  Rate

              
	
                HIV
                  (no medicare)

              	
                $1,933.92

              
	
                AIDS
                  (no medicare)

              	
                $3,629.23

              
	
                HIV-SSI/Parts
                  A & B, SSI Part B Only

              	
                $   271.50

              
	
                AIDS-SSI/Parts
                  A & B, SSI Part B Only

              	
                $   579.63

              

      

      

      

      
        	
                Area:
                  4

              	
                County:
                  Duval,
                  Baker,
                  Clay, and Nassau

              

      

      

      

      ESTIMATED
        HEALTH PLAN RATES (NOT FOR USE UNLESS APPROVED BY CMS)

      
        	 	
                Capitation
                  Rate

              
	
                HIV
                  (no medicare)

              	
                $1,196.17

              
	
                AIDS
                  (no medicare)

              	
                $2,354.82

              
	
                HIV-SSI/Parts
                  A & B, SSI Part B Only

              	
                $   162.15

              
	
                AIDS-SSI/Parts
                  A & B, SSI Part B Only

              	
                $   346.18

              

      

      

      

      REMAINDER
        OF PAGE INTENTIONALLY LEFT BLANK

      

      
        
          
            AHCA
              Contract No. FAR009, Exhibit 6-C, Page 1 of 1

          

          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      EXHIBIT
        9-B

      KICK
        PAYMENT AMOUNTS FOR COVERED OBSTETRICAL DELIVERY SERVICES

       

      

        

        

        TABLE
          8

        

        
          	
                  Area:
                    10

                	
                  County:
                    Broward

                

        

        

        
          	
                  CPT
                    Code

                	
                  Obstetrical
                    Delivery CPT Code Description

                	
                  Payment
                    Amount

                
	
                  59409

                	
                  Vaginal
                    delivery only

                	
                   

                   

                  $3,950.67

                
	
                  59410

                	
                  Vaginal
                    delivery including postpartum care

                
	
                  59515

                	
                  Cesarean
                    delivery including postpartum care

                
	
                  59612

                	
                  Vaginal
                    delivery only, after previous cesarean delivery

                
	
                  59614

                	
                  Vaginal
                    delivery only, after previous cesarean delivery including postpartum
                    care

                
	
                  59622

                	
                  Cesarean
                    delivery only, following attempted vaginal delivery after previous
                    cesarean delivery including postpartum
                    care

                

        

        

        
          	
                  Area:
                    04

                	
                  County:
                    __Duval,
                    Baker,
                    Clay, Nassau_ 

                

        

        

        
          	
                  CPT
                    Code

                	
                  Obstetrical
                    Delivery CPT Code Description

                	
                  Payment
                    Amount

                
	
                  59409

                	
                  Vaginal
                    delivery only

                	
                   

                   

                  $3,936.56

                
	
                  59410

                	
                  Vaginal
                    delivery including postpartum care

                
	
                  59515

                	
                  Cesarean
                    delivery including postpartum care

                
	
                  59612

                	
                  Vaginal
                    delivery only, after previous cesarean delivery

                
	
                  59614

                	
                  Vaginal
                    delivery only, after previous cesarean delivery including postpartum
                    care

                
	
                  59622

                	
                  Cesarean
                    delivery only, following attempted vaginal delivery after previous
                    cesarean delivery including postpartum
                    care

                

        

        

        
          
            
              AHCA
                Contract No. FAR009, Exhibit 9-B, Page 1 of 1exhibit10-7.htm

    
      

    

    Back
      to Form 8-K

    Exhibit
      10.7

     

    

    
      MEDICAID
        MANAGED CARE MODEL CONTRACT

    

    
      

       

      Amendment
        of Agreement

    

    
      Between

    

    
      City
        of
        New York

    

    
      And

    

    
      WellCare
        of New York, Inc.

    

    
      

       

      This
        Amendment, effective April 1, 2007, amends the Medicaid Managed Care Model
        Contract (hereinafter referred to as the "Agreement") made by and between
        the
        City of New York acting through the New York City Department of Health and
        Mental Hygiene (hereinafter referred to as "DOHMH" or "LDSS") and WellCare
        of
        New York, Inc. (hereinafter referred to as ''Contractor" or
        "MCO").

    

    
      

       

      WHEREAS,
the
        parties entered
        into an Agreement effective October 1, 2005, amended April 1, 2006 and January
        1, 2007, for the purpose of providing prepaid case managed health services
        to
        Medical Assistance recipients residing in New York City; and

    

    
      

       

      WHEREAS,
the
        parties desire to
        amend said Agreement to modify certain provisions to reflect current
        circumstances and intentions, and as authorized in Section 2.1 of the Agreement,
        to extend the term of the Agreement until September 30, 2009;

    

    
      

       

      NOW
        THEREFORE, effective April
        1, 2007, it is mutually agreed by the parties to amend this Agreement as
        follows:

    

    
      

       

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

    

    
      

       

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

    

    
      

       

      3.6   SDOH
        Right to Recover Premiums

    

    
      

       

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

    

    
      

       

      April
        1,
        2007 Amendment 

      1

    

    

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

    

    
      

       

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

    

    
      

       

      a) The
        Contractor shall maintain and shall require its subcontractors, including
        its
        Participating

    

    
      

       

      Providers,
        to maintain appropriate records relating to Contractor performance under
        this

    

    
      

       

      Agreement,
        including:

    

    
      

       

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

    

    
      

       

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

    

    
      

       

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

    

    
      

       

      iv)
        all
        documents concerning duplicate CINs;

    

    
      

       

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

    

    
      

       

      b) The
        Contractor shall maintain all Access NY Health Care (DOH-4220), Medicaid
        Choice,
        and SDOH enrollment applications (DOH-4097) and recertification forms completed
        by the Contractor or its subcontractors in fulfilling its responsibilities
        related to Facilitated Enrollment as set forth in Appendix P of this
        Agreement.

    

    
      

       

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

    

    
      

       

      4.   Amend
        Section 19.3, "Access
        to Contractor Records," to read as follows:

    

    
      

       

      19.3   Access
        to Contractor Records

    

    
      

       

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

    

    
       

    

    
      

    

    
      April
        1,
        2007 Amendment

    

    
      2

    

    

    
      5.   Amend
        C.l, 1. a)
        iii B) of
        Appendix C, "New York State Department of Health Requirements for the
        Provision of Family
        Planning and Reproductive Health," to read as follows:

    

    
      

       

      B)
        For
        FHPlus Enrollees - The Contractor, if it includes such services in its Benefit
        Package is responsible for covering contraceptives, including emergency
        contraceptives, provided by a Participating pharmacy or a participating provider
        or clinic. The Contractor is responsible for prescription contraceptives
        consistent with the pharmacy benefit package as described in Appendix K,
        as well
        as for contraceptives obtained and administered by a provider in an office
        or
        clinic setting. When the Contractor does not provide Family Planning and
        Reproductive Health Services, the Designated Third Party Contractor that
        covers
        such services for FHPlus Enrollees is responsible for contraceptives, including
        emergency contraceptives, provided by a Participating pharmacy or a
        participating provider or clinic. The Designated Third Party Contractor is
        responsible for prescription contraceptives consistent with the pharmacy
        benefit
        package as described in Appendix K, as well as for contraceptives obtained
        and
        administered by a provider in an office or clinic setting. The Contractor
        or the
        Designated Third Party Contractor must cover at least one of every type of
        the
        following methods of contraception:

    

    
      

       

      I)  Oral

    

    
      II) Oral,
        emergency

    

    
      III)
         Injectable

    

    
      IV) Transdermal

    

    
      V) 
        Intravaginal

    

    
      VI) Intravaginal,
        systemic

    

    
      VII) Implantable

    

    
      

       

      6.   The
        attached Appendix H,
        "New York State Department of Health Requirements for the Processing
        of Enrollments
        and Disenrollments in the MMC and FHPlus Programs," is substituted for the
        period beginning
        April 1, 2007.

    

    
      

       

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

    

    
      

       

      April
        1,
        2007 Amendment 

      3

    

    
      

       

      

    

    
      This
        Amendment is effective April 1, 2007 and the Agreement, including the
        modifications made by this Amendment and previous Amendments, shall remain
        in
        effect until September 30, 2009 or until an extension, renewal or successor
        Agreement is entered into as provided for in the Agreement.

    

    
      

       

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

      

    

    
      

       

      

    

    
      	
              
              

              
                
                

                CONTRACTOR

              

            	
              
                CITY
                  OF NEW YORK

              

              
              

            
	
              
              

              By:    /s/  Todd
                S. Farha

            	
              
              

              By:   
                /s/  Andrew
                Rein

            
	
              
              

              Todd
                Farha

            	
              
              

              Andrew
                Rein

              
              

            
	
              
              

              Title:
                President & CEO

            	
              
              

              Title:
                Chief Operating Officer

              Executive
                Deputy Commissioner

              
              

            
	
              
              

              WellCare
                of New York,
                Inc.

              Contractor
                Name

              
              

            	
              
              

              (NYC
                DOHMH)

            
	
              
              

              Date:
                10/31/07

            	
              
              

              Date:
                12/5/07

            

    

    
      

       

      

    

    
      

    

    
      

    

    
      April
        1,
        2007 Amendment

    

    
      4

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    
      STATE
        OF
        FLORIDA

    

    
      COUNTY
        OF
        HILLSBOROUGH

    

    
      

    

    
      On
        this
        31 day of October, 2007, Todd Farha came before me, to me known and known
        to be
        the President & CEO of WellCare of New York, Inc., who is duly authorized to
        execute the foregoing instrument on behalf of said corporation and s/he
        acknowledged to me that s/he executed the same for the purpose therein
        mentioned.

    

    

    
        /s/  Sara
        L. Gallo

    

    
      Notary
        Public

    

    
      

    

    
      

    

    
      

    

    
      STATE
        OF
        NEW YORK

    

    
      COUNTY
        OF
        NEW YORK

    

    
      

    

    
      On
        this 5
        day of December, 2007, Andy Rein came before me, to me known and known to
        be
        Chief Operating Officer/ Executive Deputy Commissioner in the New York City
        Department of Health and Mental Hygiene, who is duly authorized to execute
        the
        foregoing instrument on behalf of the City and s/he acknowledged to me that
        s/he
        executed the same for the purpose therein mentioned.

    

    
      

    

    
      

    

    
        /s/
        Frank
        Lane

    

    
      Notary
        Public

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    
      APPENDIX
        H

    

    
      

       

      New
        York
        State Department of Health Requirements

    

    
      for
        the
        Processing of Enrollments and Disenrollments

    

    
      in
        the
        MMC and FHPlus Programs

    

    
      

       

       

       

       

      APPENDIX
        H

    

    
      April
        1,
        2007

    

    
      H-l

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    
      SDOH
        Requirements

    

    
      for
        the Processing of Enrollments and Disenrollments

    

    
      in
        the MMC and FHPlus Programs

    

    
      

       

      1.
        General

    

    
      

       

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

    

    
      

       

      2.
        Enrollment

    

    
      

       

      a)  SDOH
        Responsibilities:

    

    
      

       

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

    

    
      

       

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

    

    
      

       

      b) LDSS
        Responsibilities:

    

    
      

       

      i)   The
        LDSS has the primary responsibility for the Enrollment
        process.

    

    
      

       

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

    

    
      

       

      iii)
        The
        LDSS is responsible for coordinating the Medicaid and FHPlus application
        and
        Enrollment processes.

    

    
      

       

      iv)
        The
        LDSS is responsible for providing pre-enrollment information to Eligible
        Persons, consistent with Sections 364-j(4)(e)(iv) and 369-ee of the SSL,
        and the
        training of persons providing Enrollment counseling to Eligible
        Persons.

    

    
      

       

      v)
        The
        LDSS is responsible for informing Eligible Persons of the availability of
        MCOs
        and HIV SNPs offering MMC and/or FHPlus products and the scope of services
        covered by each.

    

    
      

       

       

      APPENDIX
        H

    

    
      April
        1,
        2007

    

    
      H-2

    

     

     

    

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

    

    
      

       

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

    

    
      

       

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

    

    
      

       

      ix)
        The
        LDSS is responsible for the timely processing of managed care Enrollment
        applications, Exemptions, and Exclusions.

    

    
      

       

      x)
        The
        LDSS is responsible for determining the status of Enrollment applications.
        Applications will be enrolled, pended or denied. The LDSS will notify the
        Contractor of the denial of any Enrollment applications that the Contractor
        assisted in completing and submitting to the LDSS under the circumstances
        described in 2(c)(i) of this Appendix.

    

    
      

       

      xi)
        The
        LDSS is responsible for determining the Exemption and Exclusion status of
        individuals determined to be eligible for Medicaid under Title 11 of the
        SSL.

    

    
      

       

      A) Exempt
        means an individual eligible for Medicaid under Title 11 of the SSL determined
        by the LDSS or the SDOH to be in a category of persons, as specified in Section
        364-j of the SSL and/or New York State's Operational Protocol for the
        Partnership Plan, that are not required to participate in the MMC Program;
        however, individuals designated as Exempt may elect to voluntarily
        enroll.

    

    
      

       

      B)  Excluded
        means an individual eligible for Medicaid under Title 11 of the SSL determined
        by the LDSS or the SDOH to be in a category of persons, as specified in Section
        364-j of the SSL and/or New York State's Operational Protocol for the
        Partnership Plan, that are precluded from participating in the MMC
        Program.

    

    
      

       

      xii)
        Individuals eligible for Medicaid under Title 11 of the SSL in the following
        categories will be eligible for Enrollment in the Contractor's MMC product
        at
        the LDSS's option, as indicated in Schedule 2 of Appendix M.

    

    
      

       

      A)
        Foster
        care children in the direct care of LDSS;

    

    
      

       

      APPENDIX
        H

    

    
      April
        1,
        2007

    

    
      H-3

    

     

     

    B)
      Homeless persons living in shelters outside of New York City.

    
      

       

      xiii)
        The
        LDSS is responsible for entering individual Enrollment form data and
        transmitting that data to the State's Prepaid Capitation Plan (PCP) Subsystem.
        The transfer of Enrollment information may be accomplished by any of the
        following:

    

    
      

       

      A) LDSS
        directly enters data into PCP Subsystem; or

    

    
      

       

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

    

    
      

       

      C) LDSS
        electronically transfers data, via a dedicated line or Medicaid Eligibility
        Verification System (MEVS) to the PCP Subsystem.

    

    
      

       

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

    

    
      

       

      A) For
        mandatory MMC program only - Initial Notification Letter: This letter informs
        Eligible Persons about the mandatory MMC program and the time frames for
        choosing a MCO offering a MMC product. Included with the letter are managed care
        brochures, an Enrollment form, and information on their rights and
        responsibilities under this program, including the option for HIV/AIDS infected
        individuals who are categorically exempt from the mainstream MMC program
        to
        enroll in an HIV SNP on a voluntary basis in LDSS jurisdictions where HIV
        SNPs
        exist.

    

    
      

       

      B) For
        mandatory MMC program only - Reminder Letter: A letter to all Eligible Persons
        in a mandatory category who have not responded by submitting a completed
        Enrollment form within thirty (30) days of being sent or given an Enrollment
        packet.

    

    
      

       

      C) For
        MMC program - Enrollment Confirmation Notice for MMC Enrollees: This notice
        indicates the Effective Date of Enrollment, the name of the MCO and all
        individuals who are being enrolled. This notice should also be used for case
        additions and re-enrollments into the same MCO. There is no requirement that
        an
        Enrollment Confirmation Notice be sent to FHPlus Enrollees.

    

    
      

       

      D) Notice
        of Denial of Enrollment: This notice is used when an individual has been
        determined by LDSS to be ineligible for Enrollment into the MMC or FHPlus
        program. This notice must include fair hearing rights. This notice is not
        required when Medicaid or FHPlus eligibility is being denied (or
        closed).

    

    
      

       

      E) For
        MMC program only - Exemption Request Forms: Exemption forms are provided
        to MMC Eligible Persons upon request if they wish to apply for
        an

    

    
      

       

      APPENDIX
        H

    

    
      April
        1,
        2007

    

    
      H-4

    

     

     

     

    
      Exemption.
        Individuals precoded on the system as meeting Exemption or Exclusion criteria
        do
        not need to complete an Exemption, request form. This notice is required
        for
        mandatory MMC Eligible Persons.

    

    
      

       

      F)
        For
        MMC program only - Exemption and Exclusion Request Approval or Denial: This
        notice is designed to inform a recipient who applied for an exemption or
        who
        failed to provide documentation of exclusion criteria when requested by the
        LDSS
        of the LDSS's disposition of the request, including the right to a fair hearing
        if the request for exemption or exclusion is denied. This notice is required
        for
        voluntary and mandatory MMC Eligible Persons.

    

    
      

       

      c)  Contractor
        Responsibilities:

    

    
      

       

      i)
        To the
        extent permitted by law and regulation, the Contractor may accept Enrollment
        forms from Potential Enrollees for the MMC program, provided that the
        appropriate education has been provided to the Potential Enrollee by the
        LDSS
        pursuant to Section 2(b) of this Appendix. In those instances, the Contractor
        will submit resulting Enrollments to the LDSS, within a maximum of five (5)
        business days from the day the Enrollment is received by the Contractor (unless
        otherwise agreed to by SDOH and LDSS).

    

    
      

       

      ii)
        The
        Contractor must notify new MMC and FHPlus Enrollees of their Effective Date
        of
        Enrollment. In the event that the actual Effective Date of Enrollment is
        different from that previously given to the Enrollee, the Contractor must
        notify
        the Enrollee of the actual date of Enrollment. This may be accomplished through
        a Welcome Letter. To the extent practicable, such notification must precede
        the
        Effective Date of Enrollment.

    

    
      

       

      iii)
        The
        Contractor must notify the LDSS within five (5) business days of such
        information becoming known to the Contractor of any Medicaid or FHPlus Enrollees
        whose eligibility for those programs was established based on false information
        contained in applications completed by the Contractor or its subcontractors
        in
        fulfilling its responsibilities related to Facilitated Enrollment as set
        forth
        in Appendix P of this Agreement. Such information may include, but is not
        limited to, household income and/or resources (as defined in Subpart 360-4
        of 18
        NYCRR), household size, or address. The foregoing responsibility supplements
        those set forth in Sections 23.1 and 23.2 of this Agreement.

    

    
      

       

      iv)
        The
        Contractor must report any changes that affect or may affect the eligibility
        status of its enrolled members to the LDSS within five (5) business days
        of such
        information becoming known to the Contractor. This includes, but is not limited
        to, address changes, verification of pregnancy, incarceration, third party
        insurance, etc.

    

    
      

       

      APPENDIX
        H

    

    
      April
        1,
        2007

    

    
      H-5

    

     

    

    
      v)
        The
        Contractor, within five (5) business days of identifying cases where a person
        may be enrolled in the Contractor's MMC or FHPlus product under more than
        one
        CIN, must convey that information in writing to the LDSS.

    

    
      

       

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

    

    
      

       

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

    

    
      

       

      3.
        Newborn Enrollments

    

    
      

       

      a)
        The
        Contractor agrees to enroll and provide coverage for eligible newborn children
        effective from the time of birth.

    

    
      

       

      b) SDOH
        Responsibilities:

    

    
      

       

      i)
        The
        SDOH will update WMS with information on the newborn received from hospitals,
        consistent with the requirements of Section 366-g of the SSL as amended by
        Chapter 412 of the Laws of 1999.

    

    
      

       

      ii)
        Upon
        notification of the birth by the hospital or birthing center, the SDOH will
        update WMS with the demographic data for the newborn and enroll the newborn
        in
        the mother's MCO if the newborn is not already enrolled, the mother's MCO
        offers
        a MMC product, and the newborn is not identified as SSI or SSI-related and
        therefore Excluded from the MMC Program pursuant to Section 2(b)(xi) of this
        Appendix. The newborn will be retroactively enrolled back to the first (1st)
        day of
        the month of birth. Based on the transaction date of the Enrollment of the
        newborn on the PCP subsystem, the newborn will appear on either the next
        month's
        Roster or the subsequent month's Roster. On Rosters for upstate and NYC,
        the
        "PCP Effective From Date" will indicate the first day of the month of birth,
        as
        described in 01 OMM/ADM 5 "Automatic Medicaid Enrollment for Newborns." If
        the
        newborn's Enrollment is not completed by this process, the LDSS is responsible
        for Enrollment (see (c)(iv) below).

    

    
      

       

      c) LDSS
        Responsibilities:

    

    
      

       

      i)
        Grant
        Medicaid eligibility for newborns for one (1) year if born to a woman eligible
        for and receiving Medicaid or FHPlus on the date of the newborn's
        birth.

    

    
      

       

      ii)
        The
        LDSS is responsible for adding eligible unborns to all WMS cases that include
        a
        pregnant woman as soon as the pregnancy is medically
        verified.

    

    
      

       

      APPENDIX
        H

    

    
      April
        1,
        2007

    

    
      H-6

    

     

    

    
      iii)
        In
        the event that the LDSS learns of an Enrollee's pregnancy prior to the
        Contractor, the LDSS is responsible for establishing Medicaid eligibility
        and
        enrolling the unborn in the Contractor's MMC product. If the Contractor does
        not
        offer a MMC product, the pregnant woman will be asked to select a MCO offering
        a
        MMC product for the unborn. If a MCO offering a MMC product is unavailable,
        or
        if Enrollment is voluntary in the LDSS jurisdiction and an MCO is not chosen
        by
        the mother, the newborn will be eligible for Medicaid fee-for-service coverage,
        and such information will be entered on the WMS.

    

    
      

       

      iv)
        The
        LDSS is responsible for newborn Enrollment if enrollment is not successfully
        completed under the "SDOH Responsibilities" process as outlined in 2(b)(ii)
        above.

    

    
      

       

      Contractor
        Responsibilities:

    

    
      

       

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

    

    
      

       

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

    

    
      

       

      iii)
        In
        districts that use an Enrollment Broker, the Contractor shall not submit
        electronic Enrollments of newborns to the Enrollment Broker, because this
        will
        interfere with the retroactive Enrollment of the newborn back to the first
        (1st)
        day of
        the month of birth. For newborns whose mothers are not enrolled in the
        Contractor's MMC or FHPlus product and who were not pre-enrolled into the
        Contractor's MMC product as unborns, the Contractor may submit electronic
        Enrollment of the newborns to the Enrollment Broker. In such cases, the
        Effective Date of Enrollment will be prospective.

    

    
      

       

      iv)
        In
        voluntary MMC counties, the Contractor will accept Enrollment applications
        for
        unborns if that is the mothers' intent, even if the mothers are not and/or
        will
        not be enrolled in the Contractor's MMC or FHPlus product. In all counties,
        when
        a mother is ineligible for Enrollment or chooses not to enroll, the Contractor
        will accept Enrollment applications for pre-enrollment of unborns who are
        eligible.

    

    
      

       

      v)
        The
        Contractor is responsible for provision of services to a newborn and payment
        of
        the hospital or birthing center bill if the mother is an Enrollee at the
        time of
        the newborn's birth, even if the newborn is not yet on the Roster, unless
        the
        Contractor does not offer a MMC product in the mother's county of fiscal
        responsibility
        or the newborn is Excluded from the MMC Program pursuant to Section 2(b)(xi)
        of
        this Appendix.

    

    
      

       

      APPENDIX
        H

    

    
      April
        1,
        2007

    

    
      H-7

    

     

    
      

       

      vi)
        Within fourteen (14) days of the date on which the Contractor becomes aware
        of
        the birth, the Contractor will issue a letter, informing parent(s) about
        the
        newborn's Enrollment and how to access care, or a member identification
        card.

    

    
      

       

      vii)
        In
        those cases in which the Contractor is aware of the pregnancy, the Contractor
        will ensure that enrolled pregnant women select a PCP for their infants prior
        to
        birth.

    

    
      

       

      viii)
        The
        Contractor will ensure that the newborn is linked with a PCP prior to discharge
        from the hospital or birthing center, in those instances in which the Contractor
        has received appropriate notification of birth prior to
        discharge.

    

    
      

       

      4.  Auto-Assignment
        Process (Applies to Mandatory MMC Program Only):

    

    
      

       

      a)  This
        section only applies to a LDSS where CMS has given approval and the LDSS
        has
        begun mandatory Enrollment into the Medicaid Managed Care Program. The details
        of the auto-assignment process are contained in Section 12 of New York State's
        Operational Protocol for the Partnership Plan.

    

    
      

       

      b)  
        SDOH Responsibilities:

    

    
      

       

      i)
        The
        SDOH, LDSS or Enrollment Broker will assign MMC Eligible Persons not pre-coded
        in WMS as Exempt or Excluded, who have not chosen a MCO offering a MMC product
        in the required time period, to a MCO offering a MMC product using an algorithm
        as specified in §364-j(4)(d) of the SSL.

    

    
      

       

      ii)
        SDOH
        will ensure the auto-assignment process automatically updates the PCP Subsystem,
        and will notify MCOs offering MMC products of auto-assigned individuals
        electronically.

    

    
      

       

      iii)
        SDOH
        will notify the LDSS electronically on a daily basis of those individuals
        for
        whom SDOH has selected a MCO offering a MMC product through the Automated
        PCP
        Update Report. Note: This does not apply in Local Districts that utilize
        an
        Enrollment Broker.

    

    
      

       

      c) LDSS
        Responsibilities:

    

    
      

       

      i)   The
        LDSS is responsible for tracking an individual's choice
        period.

    

    
      

       

      ii)
        As
        with Eligible Persons who voluntarily choose a MCO's MMC product, the LDSS
        is
        responsible for providing notification to assigned individuals regarding
        their
        Enrollment status as specified in Section 2 of this Appendix.

    

    
      

       

      d) 
        Contractor Responsibilities:

    

    
      

       

      APPENDIX
        H

    

    
      April
        1,
        2007

    

    
      H-8

    

     

    i)
      The
      Contractor is responsible for providing notification to assigned individuals
      regarding their Enrollment status as specified in Section 2 of this
      Appendix.

    
      

      5. Roster
        Reconciliation:

    

    
      a) All
        Enrollments are effective the first of the month.

    

    
      b) SDOH
        Responsibilities:

    

    
      

       

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

    

    
      

       

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

    

    
      

       

      B) SDOH
        shall send the Contractor and LDSS monthly, at the time of the first monthly
        roster production, a Disenrollment Report listing those Enrollees from the
        previous month's roster who were disenrolled, transferred to another MCO,
        or
        whose Enrollments were deleted from the file. Notification to the Contractor
        and
        LDSS will be accomplished via paper transmission, magnetic media, or the
        HPN.

    

    
      

       

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

    

    
      

       

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

    

    
      

       

      c) 
        LDSS Responsibilities:

    

    
      

       

      i)
        The
        LDSS is responsible for notifying the Contractor electronically or in writing
        of
        changes in the Roster and error report, no later than the end of the month.
        (Note: To the extent practicable the date specified must allow for timely
        notice
        to Enrollees regarding their Enrollment status. The Contractor and the LDSS
        may
        develop protocols for the purpose of resolving Roster discrepancies that
        remain
        unresolved beyond the end of the month.)

    

    
      

       

      APPENDIX
        H

    

    
      April
        1,
        2007

    

    
      H-9

    

     

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

    
      

       

      d)  Contractor
        Responsibilities:

    

    
      

       

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

    

    
      

       

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

    

    
      

       

      6.  Disenrollment:

    

    
      

       

      a)  LDSS
        Responsibilities:

    

    
      

       

      i)
        The
        LDSS is responsible for accepting requests for Disenrollment directly from
        Enrollees and may not require Enrollees to approach the Contractor for a
        Disenrollment form. Where an LDSS is authorized to mandate Enrollment, all
        requests for Disenrollment must be directed to the LDSS or the Enrollment
        Broker. The LDSS and the Enrollment Broker must utilize the State-approved
        Disenrollment forms.

    

    
      

       

      ii)
        Enrollees may initiate a request for an expedited Disenrollment to the LDSS.
        The
        LDSS will expedite the Disenrollment process in those cases where an Enrollee's
        request for Disenrollment involves an urgent medical need, a complaint of
        non­consensual Enrollment or, in local districts where homeless individuals
        are exempt, homeless individuals in the shelter system. If approved, the
        LDSS
        will manually process the Disenrollment through the PCP Subsystem. MMC Enrollees
        who request to be disenrolled from managed care based on their documented
        HIV,
        ESRD, or SPMI/SED status are categorically eligible for an expedited
        Disenrollment on the basis of urgent medical need.

    

    
      

       

      iii)
        The
        LDSS is responsible for processing routine Disenrollment requests to take
        effect
        on the first (1st)
        day of
        the following month if the request is made before the fifteenth (15th)
        day of
        the month. In no event shall the Effective Date of Disenrollment be later
        than
        the first (1st)
        day of
        the second month after the month in which an Enrollee requests a
        Disenrollment.

    

    
      

       

       

      APPENDIX
        H

    

    
      April
        1,
        2007

    

    
      H-10

    

     

    

    
      iv)
        The
        LDSS is responsible for disenrolling Enrollees automatically upon death or
        loss
        of Medicaid or FHPlus eligibility. All such Disenrollments will be effective
        at
        the end of the month in which the death or loss of eligibility occurs or
        at the
        end of the last month of Guaranteed Eligibility, where
        applicable.

    

    
      

       

      v)
        The
        LDSS is responsible for informing Enrollees of their right to change Contractors
        if there is more than one available including any applicable Lock-In
        restrictions. Enrollees subject to Lock-In may disenroll after the grace
        period
        for Good Cause as defined below. The LDSS is responsible for determining
        if the
        Enrollee has Good Cause and processing the Disenrollment request in accordance
        with the procedures outlined in this Appendix. The LDSS is responsible for
        providing Enrollees with notice of their right to request a fair hearing
        if
        their Disenrollment request is denied. Such notice must include the reason(s)
        for the denial. An Enrollee has Good Cause to disenroll if:

    

    
      

       

      A)  The
        Contractor has failed to furnish accessible and appropriate medical care
        services
        or supplies to which the Enrollee is entitled under the terms of the
contract
        under which the Contractor has agreed to provide services.
        This

    

    
      

       

      includes,
        but is not limited to the failure to:

    

    
      I) provide
        primary care services;

    

    
      II) arrange
        for in-patient care, consultation with specialists, or laboratory and
        radiological services when reasonably necessary;

    

    
      III) arrange
        for consultation appointments;

    

    
      IV) coordinate
        and interpret any consultation findings with emphasis on continuity of medical
        care;

    

    
      V) arrange
        for services with qualified licensed or certified providers;

    

    
      VI) coordinate
        the Enrollee's overall medical care such as periodic immunizations and diagnosis
        and treatment of any illness or injury; or

    

    

    
      

       

      B) 
        The Contractor cannot make a Primary Care Provider available to the Enrollee
        within the time and distance standards prescribed by SDOH; or

    

    
      

       

      C) The
        Contractor fails to adhere to the standards prescribed by SDOH and such failure
        negatively and specifically impacts the Enrollee; or

    

    
      

       

      D) The
        Enrollee moves his/her residence out of the Contractor's service area or
        to a
        county where the Contractor does not offer the product the Enrollee is eligible
        for; or

    

    
      

       

      E)  The
        Enrollee meets the criteria for an Exemption or Exclusion as set forth in
        2(b)(xi) of this Appendix; or

    

    
      

       

      F) It
        is determined by the LDSS, the SDOH, or its agent that the Enrollment was
        not
        consensual; or

    

    
      

       

      APPENDIX
        H

    

    
      April
        1,
        2007

    

    
      H-ll

    

     

    G)
      The
      Enrollee, the Contractor and the LDSS agree that a change of MCOs would be
      in
      the best interest of the Enrollee; or

    
      

       

      H)
        The
        Contractor is a primary care partial capitation provider that does not have
        a
        utilization review process in accordance with Title I of Article 49 of the
        PHL
        and the Enrollee requests Enrollment in an MCO that has such a utilization
        review process; or

    

    
      

       

      I)
        The
        Contractor has elected not to cover the Benefit Package service that an Enrollee
        seeks and the service is offered by one or more other MCOs in the Enrollee's
        county of fiscal responsibility; or

    

    
      

       

      J)   The
        Enrollee's medical condition requires related services to be performed at
        the
        same time but all such related services cannot be arranged by the Contractor
        because the Contractor has elected not to cover one of the services the Enrollee
        seeks, and the Enrollee's Primary Care Provider or another provider determines
        that receiving the services separately would subject the Enrollee to unnecessary
        risk; or

    

    
      

       

      K)
        An
        FHPlus Enrollee is pregnant.

    

    
      

       

      vi)
        An
        Enrollee subject to Lock-In may initiate Disenrollment for Good Cause by
        filing
        an oral or written request with the LDSS.

    

    
      

       

      vii)
        The
        LDSS is responsible for promptly disenrolling an MMC Enrollee whose MMC
        eligibility or health status changes such that he/she is deemed by the LDSS
        to
        meet the Exclusion criteria. The LDSS will provide the MMC Enrollee with
        a
        notice of his or her right to request a fair hearing.

    

    
      

       

      viii)
        In
        instances where an MMC Enrollee requests Disenrollment due to MMC Exclusion,
        the
        LDSS must notify the MMC Enrollee of the approval or denial of
        exclusion/Disenrollment status, including fair hearing rights if Disenrollment
        is denied.

    

    
      

       

      ix)
        The
        LDSS is responsible for ensuring that retroactive Disenrollments are used
        only
        when absolutely necessary. Circumstances warranting a retroactive Disenrollment
        are rare and include when an Enrollee is determined to have been
        non-consensually enrolled in a MCO; he or she enters or resides in a residential
        institution under circumstances which render the individual Excluded from
        the
        MMC program; is incarcerated; is an SSI infant less than six (6) months of
        age;
        is simultaneously in receipt of comprehensive health care coverage from an
        MCO
        and is enrolled in either the MMC or FHPlus product of the same MCO; or he
        or
        she has died - as long as the Contractor was not at risk for provision of
        Benefit Package services for any portion of the retroactive period. Payment
        of
        subcapitation does not constitute "provision of Benefit Package services."
        Notwithstanding the foregoing, the SDOH always has the right to recover
        duplicate MMC or FHPlus premiums paid for persons enrolled under more than
one
        Client Identification Number (CIN) in the Contractor's MMC or FHPlus product
        whether or not the Contractor has made payments to
        providers. 

    

    
      

       

      APPENDIX
        H

    

    
      April
        1,
        2007

    

    
      H-12

    

     

     

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

    

    
      

       

      xi)
        The
        LDSS is responsible for notifying the Contractor of the retroactive
        Disenrollment prior to the action. The LDSS is responsible for finding out
        if
        the Contractor has made payments to providers on behalf of the Enrollee prior to
        Disenrollment. After this information is obtained, the LDSS and Contractor
        will
        agree on a retroactive Disenrollment or prospective Disenrollment date. In
        all
        cases of retroactive Disenrollment, including Disenrollments effective the
        first
        day of the current month, the LDSS is responsible for sending notice to the
        Contractor at the time of Disenrollment, of the Contractor's responsibility
        to
        submit to the SDOH's Fiscal Agent voided premium claims within thirty (30)
        business days of notification from the LDSS for any full months of retroactive
        Disenrollment where the Contractor was not at risk for the provision of Benefit
        Package services during the month. Notwithstanding the foregoing, the SDOH
        always has the right to recover duplicate MMC or FHPlus premiums paid for
        persons enrolled under more than one Client Identification Number (CIN) in
        the
        Contractor's MMC or FHPlus product whether or not the Contractor has made
        payments to providers. Failure by the LDSS to notify the Contractor does
        not
        affect the right of the SDOH to recover the premium payment as authorized
        by
        Section 3.6 of this Agreement or for the State Attorney General to bring
        legal
        action to recover any overpayment.

    

    
      

       

      APPENDIX
        H

    

    
      April
        1,
        2007

    

    
      H-13

    

     

    

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

       

    

    

    
      	
              
                Reason
                  for Disenrollment

                 

              

            	 	
              
                Effective
                  Date of Disenrollment

              

            
	
              
                A)
                  Infants weighing less than 1200 grams at birth and other infants
                  under six
                  (6) months of age who meet the criteria for the SSI or SSI related
                  category

                 

              

            	 	
              
                First
                  Day of the month of birth or the month of onset of disability,
                  whichever
                  is later

              

            
	
              
                B)
                  Death of Enrollee

                 

              

            	 	
              
                First
                  day of the month after death

              

            
	
              
                C)
                  Incarceration

              

            	 	
              
                First
                  day of the month of incarceration (note-Contractor is at risk for
                  covered
                  services only to the date of incarceration and is entitled to the
                  capitation payment for the month of incarceration)

                 

              

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

                 

              

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

              

            
	
              
                E)
                  Individual's effective date of Enrollment or

              

              
                autoassignment
                  into a MMC product occurred while meeting institutional criteria
                  in (D)
                  above

                 

              

            	 	
              
                Effective
                  Date of Enrollment in the Contractor's Plan

              

            
	
              
                F)
                  Non-consensual Enrollment

                 

              

            	 	
              
                Retroactive
                  to the first day of the month of Enrollment

              

            
	
              
                G)
                  Enrollee moved outside of the District/County of Fiscal
                  Responsibility

              

            	 	
              
                First
                  day of the month after the update of the system with the new address1

                 

              

            
	
              
                H)
                  Urgent medical need

              

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

                 

              

            
	
              
                I)
                  Homeless Enrollees in Medicaid Managed Care residing in the shelter
                  system
                  in NYC or in other districts where homeless individuals are
                  exempt

                 

              

            	 	
              
                Retroactive
                  to the first day of the month of the request

              

            
	
              
                J)
                  Individual is simultaneously in receipt of comprehensive health
                  care
                  coverage from an MCO and is Enrolled in either the MMC or FHPlus
                  product
                  of the same MCO

                 

              

            	 	
              
                First
                  day of the month after simultaneous coverage
                  began

              

            
	
              
                K)
                  An Enrollee with more than one Client Identification Number (CIN)
                  is
                  enrolled in an MCO's MMC or FHPlus product under more than one
                  of the
                  CINs

              

            	 	
              
                First
                  day of the month the duplicate Enrollment
                  began

              

            

    

    
      

       

       

      1
        In
        counties outside of New York City, LDSSs should work together to ensure
        continuity of care through the Contractor if the Contractor's service area
        includes the county to which the Enrollee has moved and the Enrollee, with
        continuous eligibility, wishes to stay enrolled in the Contractor's MMC or
        FHPlus product. In New York City, Enrollees, not in guaranteed status, who
        move
        out of the Contractor's Service Area but not outside of the City of New York
        (e.g., move from one borough to another), will not be involuntarily disenrolled,
        but must request a Disenrollment or transfer. These Disenrollments will be
        performed on a routine basis unless there is an urgent medical need to expedite
        the Disenrollment.

    

    
      

       

       

       

      APPENDIX
        H

    

    
      April
        1,
        2007

    

    
      H-14

    

     

    

    
      xiii)
        The
        LDSS is responsible for rendering a determination and responding within thirty
        (30) days of the receipt of a fully documented request for Disenrollment,
        except
        for Contractor-initiated Disenrollments where the LDSS decision must be made
        within fifteen (15) days. The LDSS, to the extent possible, is responsible
        for
        processing an expedited Disenrollment within two (2) business days of its
        determination that an expedited Disenrollment is warranted.

    

    
      

       

      xiv)
        The
        Contractor must respond timely to LDSS inquiries regarding Good Cause
        Disenrollment requests to enable the LDSS to make a determination within
        thirty
        (30) days of the receipt of the request from the Enrollee.

    

    
      

       

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

    

    
      

       

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

    

    
      

       

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

    

    
      

       

      C)  End
        of Lock-In Notice: Where Lock-In provisions are applicable, Enrollees must
        be
        notified sixty (60). days before the end of their Lock-In Period. The SDOH
        or
        its designee is responsible for notifying Enrollees of this provision in
        applicable LDSS jurisdictions.

    

    
      

       

      D)  Notice
        of Change to Guarantee Coverage: This notice will advise the Enrollee that
        his
        or her Medicaid or FHPlus eligibility is ending and how this affects his
        or her
        Enrollment in a MCO's MMC or FHPlus product. This notice contains pertinent
        information regarding Guaranteed Eligibility benefits and dates of coverage.
        If
        an Enrollee is not eligible for Guarantee, this notice is not
        necessary.

    

    
      

       

      xvi)
        The
        LDSS may require that a MMC Enrollee that has been disenrolled at the request
        of
        the Contractor be returned to the Medicaid fee-for-service program. In the
        FHPlus program, a FHPlus Enrollee disenrolled at the request of the Contractor,
        may choose another MCO offering a FHPlus product. If the FHPlus Enrollee
        does
        not choose, or there is not another MCO offering FHPlus in the LDSS
        jurisdiction, the case will be closed.

    

    
      

       

       

      APPENDIX
        H

    

    
      April
        1,
        2007

    

    
      H-15

    

     

     

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

    
      

       

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

    

    
      

       

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

    

    
      

       

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

    

    
      

       

      b)  Contractor
        Responsibilities:

    

    
      

       

      i)
        In
        those instances where the Contractor directly receives Disenrollment forms,
        the
        Contractor will forward these Disenrollments to the LDSS for processing within
        five (5) business days (or according to Section 6 of this Appendix). During
        pulldown week, these forms may be faxed to the LDSS with the hard copy to
        follow.

    

    
      

       

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

    

    
      

       

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

    

    
      

       

      APPENDIX
        H

    

    
      April
        1,
        2007

    

    
      H-16

    

     

    

    
      iv)
        Pursuant to Section 8.7 of this Agreement, the Contractor may initiate an
        involuntary Disenrollment if the Enrollee engages in conduct or behavior
        that
        seriously impairs the Contractor's ability to furnish services to either
        the
        Enrollee or other Enrollees, provided that the Contractor has made and
        documented reasonable efforts to resolve the problems presented by the
        Enrollee.

    

    
      

       

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

    

    
      

       

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

    

    
      

       

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

    

    
      

       

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

    

    
      

       

      ix)
        The
        Contractor will not consider an Enrollee disenrolled without confirmation
        from
        the LDSS or the Roster (as described in Section 5 of this
        Appendix).

    

    
      

       

      APPENDIX
        H

    

    
      April
        1,
        2007

    

    
      H-17

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